Sharps Safety

According to Gina Pugliese, R.N., director of the Premier Safety Institute, a sharps injury prevention program should include visible top management support, buying and using safety devices, proper training of the users of these devices, feedback from frontline workers, methods for collecting and analyzing data on injuries to target prevention efforts, and monitoring for compliance.

However, there are many problems associated with a sharps injury prevention program. Linda Chiarello, R.N., an epidemiologist with the CDC's Hospital Infection Program, Atlanta, cited four fundamental problems:

• Many types of needles and other sharps contribute to injuries: hypodermic, suture, butterfly, etc.
• Injuries occur in a variety of circumstances: during use, after use, during disposal, etc.
• Transmission risks vary by device type; e.g., hollow-bore needles transmit HIV more often than do scalpels.
• Not all injuries are preventable; for example, if no alternative device is available or no preventive work practice is currently recommended. Injury prevention "solutions" are no less complex, Chiarello said.
• Many devices with safety features are now available, but there's little data on efficacy, and one type of device cannot solve the problem.
• One device type can have multiple safety feature designs, which vary in the mode of activations.
• Some devices are used for multiple purposes, but some safety features limit the scope of those purposes.
• Implementation of a device does not guarantee acceptability and use.
• Incremental costs of devices with safety features can be substantial.

Payment Plan Expands Emergency Law

Several key terms under the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA) will have expanded meanings—as well as more precise ones—as of October 10 of this year.

Under changes published as part of the new outpatient prospective payment system (OPPS), EMTALA now includes an expanded definition of the term "comes to the ED [emergency department]" that spells out what constitutes an ED visit, said a representative of the National Heritage Insurance Company, a Part B carrier for upper New England.

In the April 7 PPS rule, the Health Care Financing Administration (HCFA) said an ED visit can happen in a hospital parking lot, driveway, or in off-campus hospital departments. HCFA further defined "campus" to include related facilities within 250 yards of a hospital's main buildings. The rule defines a "department" as a facility, organization, or physician office created or owned by a hospital. An off-campus department provides the same type of service as the hospital, and is under its name, ownership, and financial and administrative control.

Physician offices and other off-campus units should understand that lack of resources to treat a patient does not absolve them from EMTALA liabilities, if the main hospital has those resources. However, if an off-campus unit sends a patient to the main campus for treatment, it does not count as a transfer, and so the smaller unit does not have to stabilize the patient.

Disruptive Physicians Need Immediate Care

"Disruptive physicians have an adverse effect on patient care," says Spence Meighan, MD, FACP, president of Spence Meighan and Associates, a consulting firm in hospital medical staff relations. "The biggest issue is one of morale. People will say, 'If I behaved like that, I would be fired.' It is demoralizing to the staff, and in this day and age, the loss of any key nursing staff is a serious thing."

The Joint Commission on Accreditation of Healthcare Organizations encourages organizations to implement policies and procedures that deal with disruptive physicians. For example, standard MS.2 in the Medical Staff chapter of the Comprehensive Accreditation Manual for Hospitals states that each medical staff must develop and adopt bylaws, rules, and regulations to establish a framework for self-governance of medical staff activities and accountability to the governing body.

Further, medical staff bylaws must include provisions that abide by standard MS.2.3.3, which states that hospitals must have mechanisms for corrective action, including indications and procedures for automatic and summary suspension of an individual's medical staff membership or clinical privileges.

Experts agree that it is wise to take the necessary steps to document, control, and perhaps alter a physician's behavior before it is beyond repair. The Greeley Company suggests the following when dealing with disruptive physicians:

1. Define the expected behavior. According to Meighan, the starting point for dealing with the disruptive physician is a hospital/medical staff policy that clearly defines the professional characteristics expected from members of the medical staff. The policy should outline the steps to be taken when faced with behavior that contradicts those characteristics.
   A policy can include the following guidelines:
   • Complaints against members of the medical staff must be handled by the medical staff.
   • Any medical staff member, employee or agent of the hospital, or patient may file a complaint against a physician regarding disruptive conduct.
2. Identify the problem. Meighan says that one of the personality traits of a disruptive physician includes someone who works "25 hours a day to win." He developed a list of 34 characteristics or behaviors that define a disruptive physician.
3. Deal with the problem. Disruptive behavior should not be quantified. There should not be a "magic number" of incidents assigned to indicate when the hospital takes action. Instead, the policy should carefully outline the course of action to be taken.
   If the behavior is major—which includes sexual harassment, assault, or a physician flinging an instrument at a nurse in the operating room—it is considered an obvious violation resulting in the immediate suspension of the physician.
   Meighan says that by looking at the 34 behaviors your organization should apply a graduated process of intervention. These steps may include the following:
   • Meet with the physician
   • Restate what you deem as disruptive behavior
   • Resolve any reports of disruptive behavior
   • Document the disruptive behavior
   • Talk about revoking privileges
4. Take formal corrective action as a last step. The last step is to take legal action against the physician. However, this should be the last resort for a hospital. By setting up a very good medical staff leader with a commitment to handling this kind of situation, you may avoid a civil action.

The Disruptive Physician—Diagnosis and Management

A disruptive physician is a physician whose behavior is punctuated by repeated disruptive events.

Some characteristics

(Every instance is different, though many of the characteristics are the same.)

1. Does not establish harmonious relations with other members of the healthcare team. Does not get along with others.
2. Interferes with functioning of the team; makes it less effective.
3. Physicians may not know who their disruptive colleagues are. Nurses know. Physicians in authority know.
4. Threatens others; may threaten nurses with loss of job.
5. Disrupts department and other meetings.
6. Runs down hospital and colleagues to others in healthcare, patients, and the media.
7. Has no insight into the effects of his or her actions.
8. Has no conscience regarding behavior. Rarely apologizes.
9. Is never wrong.
10. Does not obey rules.
11. Rationalizes aberrant behaviors.
12. Manipulates and misrepresents.
13. Honesty is questionable.
14. Poses significant threat to patient care by disrupting functioning of the care team and by other means.
15. May justify actions on the grounds that he or she upholds higher standards than others.
16. History of problems with authority. May have no peers—only those above and below in the power structures.
17. Deals in power.
18. Subversive.
19. May be physically, emotionally, and sexually aggressive.
20. Commonly uses sarcasm with hospital staff. Demeaning.
21. Shouts, throws things.
22. Generates strong emotions among patients. Some patients will love the physician; others will hate him or her.
23. May be an excellent clinician or may be flawed.
24. Represents medical, legal dangers to the hospital and to colleagues.
25. Writes legally damaging progress notes.
26. More likely to have malpractice claims against him or her.
27. Angry. Hostile.
28. Threatens litigation.
29. Has a vendetta with the chief executive officer and/or anybody else in authority.
30. Has always been the way he or she is but until joining the hospital staff had concluded that disruptive tendencies should be hidden.
31. Changes jobs.
32. Does not respond appropriately to emergency or night calls.
33. Condition not usually amenable to psychiatric care.
34. Lots of issues occur which, if taken singly, would be of limited relevance but when taken together become highly significant.

Inspector General Proposes Medicaid Safeguards

The Department of Health and Human Services' Office of Inspector General (OIG) recently released three reports that evaluate Medicaid program safeguards and recommends opportunities for improvement. The reports were directed to the Health Care Financing Administration, which said it would share them with state Medicaid programs. The OIG's recommendations include:

PROACTIVE SAFEGUARDS:

• Identify and register all clearinghouses and third-party billers and improve safeguards to ensure that electronic claims are accepted only from authorized sites.
• Expand the use of Medicaid field offices to conduct onsite visits to verify the legitimacy of problematic providers.
• Strengthen laws to hold Medicaid providers liable for participating in any deception that allows others to use their credentials and business to harm Medicaid.

• Establish a system that identifies all third-party billers/agents and the physicians using their services.
• Give providers a list of critical errors on a denied claim.

• Improve the surveillance of providers with billing problems.
• Ensure that some post-payment audits are performed at random.
• Develop written procedures for handling suspected fraud and abuse.
• Make sure providers' remittance notices are not intercepted by third parties.

HCFA Compliance Letters

Nancy-Ann Min DeParle, administrator of the Health Care Financing Administration (HCFA), warned physicians that Medicare auditors will closely monitor two Current Procedural Terminology (CPT) codes used to report evaluation and management services.

The two codes are established patient code 99214, and subsequent hospital care code 99233. The codes accounted for a significant portion of the coding errors in the last two Medicare audits according to DeParle. She also said documentation for many of these services was only found to be sufficient to support services more appropriately described by CPT codes 99212 and 99231.

Curt Udell, president of EMPHYSYS, a physician compliance and billing firm, urges compliance officers for physician groups or outpatient clinics to immediately begin concurrent audits of CPT codes 99214 and 99233.

On the same day DeParle's letter to physicians was released, HCFA also released similar letters to durable medical equipment suppliers and home health agency providers. Each letter outlines specific compliance concerns for those industry segments. The letters are available on HCFA's Web site at www.hcfa.gov/medicare/mip/cfolettr.htm.

Prepare Now for Future Manpower Shortage

Healthcare providers are battling retailers, fast food outlets and the garment industry for workers, says Lynwood Brooks, a consultant who addressed the annual meeting of the American Society for Healthcare Human Resources Administration. "We're losing, because healthcare is a major mental drain."

Brooks applauds many hospitals for partnering with local high schools and vocational programs, but said national standards are needed to streamline and strengthen the education process. Students who change community college or vocational-technical programs often must retake courses because credits aren't transferable. "We need to continue forming those local program partnerships, but in a national program," he said.

One tool for fostering a standardized school-to-work curriculum is the National Health Science Career Path Model, developed with more than 1,500 providers, educators and professional organizations by the National Consortium on Health Science & Technology Education (NCHSTE). The program, described at www.nchste.org, offers some 160 lesson plans for teaching core healthcare skills to students in grades kindergarten through 12.

Brooks advises hospital clinical educators to become active partners in their local educational system, encouraging state and local decision-makers to adopt the NCHSTE standards.

Study: Internet will see 88.5 million health information seekers by 2005

By the middle of the decade, 88.5 million adults will be using the Internet to get health information, to shop for health products and to communicate with others about health, according to a study released by Cyber Dialogue Health Practice.

"The Future of e-Health" sees consumer demand for health care content already at critical mass with 36.7 million adults, and it will continue to grow for the next five years at about twice the overall online growth rate. According to the report, 11 million consumers are already shopping on the Net for health and beauty products and that number is projected to grow to 55 million by 2005. The study is based on interviews with 2,700 online and offline adults.

Expert Says Most Hospitals Unprepared for Chemical, Bioterrorism

Only about 15% of hospitals have the equipment or training to properly decontaminate victims in the event of a terrorist attack involving chemical or biological weapons, estimates a physician who trains hospitals to plan and prepare for the growing threat of terrorist attacks.

Henry Siegelson, an emergency physician at Emory University's Department of Emergency Medicine in Atlanta, told attendees at the summer meeting of the American Society for Healthcare Engineering, "I think every hospital employee from the CEO down should have to view a 15-minute video on medical preparedness for terrorism." He said hospital workers should be trained to remove the victims' clothes before they enter the hospital to prevent contamination of employees and other patients. If the patient was exposed to a liquid agent, he should then be put through a decontamination shower, Siegelson said.