Commentary

Discharge summaries have become my pet peeve recently.

It’s not uncommon for a patient to be referred to me for outpatient follow-up, or for one of my own patients to be treated where I’m not on staff and then sent back to me afterward. When that occurs, I used to get a copy of the discharge summary to get an idea of what happened. (Note the "used to.") I certainly wouldn’t rely on it entirely, but it was helpful. Not anymore.

The modern discharge summary is worthless and sometimes downright dangerous. It’s often nonspecific and typically full of errors. Not minor errors, either, but big ones. I commonly see patients listed as having had procedures they didn’t undergo, test results that were someone else’s, and diagnoses and medications that aren’t even close.

Here’s a recent example (I’ve removed some information, but this is the basic idea): "The patient was admitted for dizziness. She was seen by neurology and had a brain MRI and labs. Discharge diagnosis is dizziness. Her medications were not changed."

That was it – a few sentences in one paragraph.

How much valuable information did you get from that? Absolutely none. All I see is that I need to get the MRI report and/or films, and possibly the other neurologist’s notes.

In years past, the summary was done by the patient’s own physician, who knew he or she would be referring to it in a few weeks when the patient came in for follow-up. So there was a vested interest in it being thorough and useful.

But today the reports are typically dictated by hospitalists. They may provide good care, but it’s often the case that they just picked up the patient for the first time. They likely have 18 other people to see, five admissions, and three discharge summaries to do and don’t have the time to do more than glance through the H&P and last few scribbled notes. As the day goes on, patients also tend to blur together, causing more errors.

The hospitalists simply don’t know patients as well as do the outpatient physicians who have been seeing them for years, and so fewer errors will be caught. I admit I’m guilty of turning some of my own patients over to inpatient physicians. All of us are busy. And I’m not knocking hospitalists, who do an often difficult part of medicine. But the loss of communication between these two branches of medicine is a sad loss for all of us – especially for our patients.

Perhaps the most irritating part is the generic statement I see at the bottom of many summaries: "This discharge summary may contain errors and omissions. Please refer to the full chart for complete information." This, sadly, is an admission that the document is worthless (which I doubt will stand up in court). I don’t often have access to the full chart, or time to comb through it in detail, when the patient comes in. Although I wouldn’t put all my faith in the summary, it’s nice when it give me a general idea of what I’m dealing with.

Once, a discharge summary was something useful – a succinct statement of events for the next doctor to use for guidance. Today, it’s become the kitchen mess piled up after a party. No one wants to do it, so a hurried, sloppy job is done, making more work for everyone else later.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Discharge summaries have become my pet peeve recently.

It’s not uncommon for a patient to be referred to me for outpatient follow-up, or for one of my own patients to be treated where I’m not on staff and then sent back to me afterward. When that occurs, I used to get a copy of the discharge summary to get an idea of what happened. (Note the "used to.") I certainly wouldn’t rely on it entirely, but it was helpful. Not anymore.

The modern discharge summary is worthless and sometimes downright dangerous. It’s often nonspecific and typically full of errors. Not minor errors, either, but big ones. I commonly see patients listed as having had procedures they didn’t undergo, test results that were someone else’s, and diagnoses and medications that aren’t even close.

Here’s a recent example (I’ve removed some information, but this is the basic idea): "The patient was admitted for dizziness. She was seen by neurology and had a brain MRI and labs. Discharge diagnosis is dizziness. Her medications were not changed."

That was it – a few sentences in one paragraph.

How much valuable information did you get from that? Absolutely none. All I see is that I need to get the MRI report and/or films, and possibly the other neurologist’s notes.

In years past, the summary was done by the patient’s own physician, who knew he or she would be referring to it in a few weeks when the patient came in for follow-up. So there was a vested interest in it being thorough and useful.

But today the reports are typically dictated by hospitalists. They may provide good care, but it’s often the case that they just picked up the patient for the first time. They likely have 18 other people to see, five admissions, and three discharge summaries to do and don’t have the time to do more than glance through the H&P and last few scribbled notes. As the day goes on, patients also tend to blur together, causing more errors.

The hospitalists simply don’t know patients as well as do the outpatient physicians who have been seeing them for years, and so fewer errors will be caught. I admit I’m guilty of turning some of my own patients over to inpatient physicians. All of us are busy. And I’m not knocking hospitalists, who do an often difficult part of medicine. But the loss of communication between these two branches of medicine is a sad loss for all of us – especially for our patients.

Perhaps the most irritating part is the generic statement I see at the bottom of many summaries: "This discharge summary may contain errors and omissions. Please refer to the full chart for complete information." This, sadly, is an admission that the document is worthless (which I doubt will stand up in court). I don’t often have access to the full chart, or time to comb through it in detail, when the patient comes in. Although I wouldn’t put all my faith in the summary, it’s nice when it give me a general idea of what I’m dealing with.

Once, a discharge summary was something useful – a succinct statement of events for the next doctor to use for guidance. Today, it’s become the kitchen mess piled up after a party. No one wants to do it, so a hurried, sloppy job is done, making more work for everyone else later.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Discharge summaries have become my pet peeve recently.

It’s not uncommon for a patient to be referred to me for outpatient follow-up, or for one of my own patients to be treated where I’m not on staff and then sent back to me afterward. When that occurs, I used to get a copy of the discharge summary to get an idea of what happened. (Note the "used to.") I certainly wouldn’t rely on it entirely, but it was helpful. Not anymore.

The modern discharge summary is worthless and sometimes downright dangerous. It’s often nonspecific and typically full of errors. Not minor errors, either, but big ones. I commonly see patients listed as having had procedures they didn’t undergo, test results that were someone else’s, and diagnoses and medications that aren’t even close.

Here’s a recent example (I’ve removed some information, but this is the basic idea): "The patient was admitted for dizziness. She was seen by neurology and had a brain MRI and labs. Discharge diagnosis is dizziness. Her medications were not changed."

That was it – a few sentences in one paragraph.

How much valuable information did you get from that? Absolutely none. All I see is that I need to get the MRI report and/or films, and possibly the other neurologist’s notes.

In years past, the summary was done by the patient’s own physician, who knew he or she would be referring to it in a few weeks when the patient came in for follow-up. So there was a vested interest in it being thorough and useful.

But today the reports are typically dictated by hospitalists. They may provide good care, but it’s often the case that they just picked up the patient for the first time. They likely have 18 other people to see, five admissions, and three discharge summaries to do and don’t have the time to do more than glance through the H&P and last few scribbled notes. As the day goes on, patients also tend to blur together, causing more errors.

The hospitalists simply don’t know patients as well as do the outpatient physicians who have been seeing them for years, and so fewer errors will be caught. I admit I’m guilty of turning some of my own patients over to inpatient physicians. All of us are busy. And I’m not knocking hospitalists, who do an often difficult part of medicine. But the loss of communication between these two branches of medicine is a sad loss for all of us – especially for our patients.

Perhaps the most irritating part is the generic statement I see at the bottom of many summaries: "This discharge summary may contain errors and omissions. Please refer to the full chart for complete information." This, sadly, is an admission that the document is worthless (which I doubt will stand up in court). I don’t often have access to the full chart, or time to comb through it in detail, when the patient comes in. Although I wouldn’t put all my faith in the summary, it’s nice when it give me a general idea of what I’m dealing with.

Once, a discharge summary was something useful – a succinct statement of events for the next doctor to use for guidance. Today, it’s become the kitchen mess piled up after a party. No one wants to do it, so a hurried, sloppy job is done, making more work for everyone else later.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I must admit that Shakespeare was not one of my favorite subjects at school. However, his words have relevance to some of my thoughts about vascular surgical issues. In a previous editorial I adopted his words to describe how, with the increasing representation of women and minorities, we have matured from a "Band of Brothers" to a "Band of Brothers and Sisters." Now, Shakespeare once again resonates with Hamlet’s inward-looking and existential "To be or not to be?"

For vascular surgeons are in an introspective mood as we re-evaluate our collaboration with other specialties to determine the best treatments for our patients. Increasingly we are developing our own guidelines, white papers, and position papers rather than appending our insights to initiatives originated by the American College of Cardiology. Whereas we were fundamental in the formation of the original "Trans-Atlantic Societal Consensus (TASC)¹," SVS as well as the European Society for Vascular Surgery (ESVS) and the World Federation of Vascular Societies (WFVS) have declined participation in further TASC iterations.

The fracturing of TASC began with controversy and strong differences of opinions raised by TASC IIb. Fundamental issues of process, governance, conflict of interest (COI), evidence base, and appropriate representation were raised and debated. In the end the SVS and other international vascular societies determined the TASC construct was not workable, and a new Global Vascular Guidelines initiative was born.

Under the co-leadership of Mike Conte (SVS), Andrew Bradbury (WFVS), and Philippe Kolh (ESVS), our surgical societies are developing practice guidelines reflecting the international consensus of vascular surgeons as well as other specialists directly involved in the care of vascular patients. This group is committed to an evidence-based approach and a strong COI policy that will hopefully insulate treatment algorithms from what many believed was the excessive influence of industry and "market forces" reflected in TASC IIb.

The proposed guidelines will no longer simply be lesion based. Rather, they will evaluate the patient and disease process, taking into account the potential benefit of both endo and open vascular procedures. It’s not that vascular surgeons are unsupportive of endo techniques. In fact many endo procedures have emerged from the inventive minds of vascular surgeons from all over the world. But only surgeons who can offer all treatment modalities can fully appreciate when an open procedure is still the best option, or that the disease process may be more benign than the planned treatment.

What we have gained and what have we lost by our withdrawal from communal involvement with other specialists is not altogether clear. Vascular surgeons have pioneered many of the major advances in our understanding and treatment of vascular diseases from the various bypass operations, through vascular lab testing to advances in endovascular therapy.

Nonetheless, we should not discount the contributions of our medical colleagues. Physicians from other disciplines pioneered endovascular therapies that many of our vascular surgeon predecessors claimed would never work. Medical management prevents thrombosis, keeps our patients alive and our bypasses and stents open. We must also acknowledge that there are many highly qualified physicians in other specialties who are equally devoted to improving the care of patients with vascular disease.

At present there are almost 5,000 U.S. vascular surgeons, and even more globally. Almost every developed nation has a vascular surgical society, and some even have a designated specialty of vascular surgery. Yet it seems we still do not have the numbers to be universally recognized for our expertise. However, our comprehensive training and knowledge have given us the self-assurance and confidence to claim that our specialty is uniquely qualified to take the leadership position in the management of vascular conditions.

So, "IIb, unquestionably, will not be" but, unlike Hamlet, we need not despair. TASC may have failed but we will not!

1) Eur. J. Vasc. Endovasc. Surg. 2007;33 Suppl 1:S1-75.

I must admit that Shakespeare was not one of my favorite subjects at school. However, his words have relevance to some of my thoughts about vascular surgical issues. In a previous editorial I adopted his words to describe how, with the increasing representation of women and minorities, we have matured from a "Band of Brothers" to a "Band of Brothers and Sisters." Now, Shakespeare once again resonates with Hamlet’s inward-looking and existential "To be or not to be?"

For vascular surgeons are in an introspective mood as we re-evaluate our collaboration with other specialties to determine the best treatments for our patients. Increasingly we are developing our own guidelines, white papers, and position papers rather than appending our insights to initiatives originated by the American College of Cardiology. Whereas we were fundamental in the formation of the original "Trans-Atlantic Societal Consensus (TASC)¹," SVS as well as the European Society for Vascular Surgery (ESVS) and the World Federation of Vascular Societies (WFVS) have declined participation in further TASC iterations.

The fracturing of TASC began with controversy and strong differences of opinions raised by TASC IIb. Fundamental issues of process, governance, conflict of interest (COI), evidence base, and appropriate representation were raised and debated. In the end the SVS and other international vascular societies determined the TASC construct was not workable, and a new Global Vascular Guidelines initiative was born.

Under the co-leadership of Mike Conte (SVS), Andrew Bradbury (WFVS), and Philippe Kolh (ESVS), our surgical societies are developing practice guidelines reflecting the international consensus of vascular surgeons as well as other specialists directly involved in the care of vascular patients. This group is committed to an evidence-based approach and a strong COI policy that will hopefully insulate treatment algorithms from what many believed was the excessive influence of industry and "market forces" reflected in TASC IIb.

The proposed guidelines will no longer simply be lesion based. Rather, they will evaluate the patient and disease process, taking into account the potential benefit of both endo and open vascular procedures. It’s not that vascular surgeons are unsupportive of endo techniques. In fact many endo procedures have emerged from the inventive minds of vascular surgeons from all over the world. But only surgeons who can offer all treatment modalities can fully appreciate when an open procedure is still the best option, or that the disease process may be more benign than the planned treatment.

What we have gained and what have we lost by our withdrawal from communal involvement with other specialists is not altogether clear. Vascular surgeons have pioneered many of the major advances in our understanding and treatment of vascular diseases from the various bypass operations, through vascular lab testing to advances in endovascular therapy.

Nonetheless, we should not discount the contributions of our medical colleagues. Physicians from other disciplines pioneered endovascular therapies that many of our vascular surgeon predecessors claimed would never work. Medical management prevents thrombosis, keeps our patients alive and our bypasses and stents open. We must also acknowledge that there are many highly qualified physicians in other specialties who are equally devoted to improving the care of patients with vascular disease.

At present there are almost 5,000 U.S. vascular surgeons, and even more globally. Almost every developed nation has a vascular surgical society, and some even have a designated specialty of vascular surgery. Yet it seems we still do not have the numbers to be universally recognized for our expertise. However, our comprehensive training and knowledge have given us the self-assurance and confidence to claim that our specialty is uniquely qualified to take the leadership position in the management of vascular conditions.

So, "IIb, unquestionably, will not be" but, unlike Hamlet, we need not despair. TASC may have failed but we will not!

1) Eur. J. Vasc. Endovasc. Surg. 2007;33 Suppl 1:S1-75.

I must admit that Shakespeare was not one of my favorite subjects at school. However, his words have relevance to some of my thoughts about vascular surgical issues. In a previous editorial I adopted his words to describe how, with the increasing representation of women and minorities, we have matured from a "Band of Brothers" to a "Band of Brothers and Sisters." Now, Shakespeare once again resonates with Hamlet’s inward-looking and existential "To be or not to be?"

For vascular surgeons are in an introspective mood as we re-evaluate our collaboration with other specialties to determine the best treatments for our patients. Increasingly we are developing our own guidelines, white papers, and position papers rather than appending our insights to initiatives originated by the American College of Cardiology. Whereas we were fundamental in the formation of the original "Trans-Atlantic Societal Consensus (TASC)¹," SVS as well as the European Society for Vascular Surgery (ESVS) and the World Federation of Vascular Societies (WFVS) have declined participation in further TASC iterations.

The fracturing of TASC began with controversy and strong differences of opinions raised by TASC IIb. Fundamental issues of process, governance, conflict of interest (COI), evidence base, and appropriate representation were raised and debated. In the end the SVS and other international vascular societies determined the TASC construct was not workable, and a new Global Vascular Guidelines initiative was born.

Under the co-leadership of Mike Conte (SVS), Andrew Bradbury (WFVS), and Philippe Kolh (ESVS), our surgical societies are developing practice guidelines reflecting the international consensus of vascular surgeons as well as other specialists directly involved in the care of vascular patients. This group is committed to an evidence-based approach and a strong COI policy that will hopefully insulate treatment algorithms from what many believed was the excessive influence of industry and "market forces" reflected in TASC IIb.

The proposed guidelines will no longer simply be lesion based. Rather, they will evaluate the patient and disease process, taking into account the potential benefit of both endo and open vascular procedures. It’s not that vascular surgeons are unsupportive of endo techniques. In fact many endo procedures have emerged from the inventive minds of vascular surgeons from all over the world. But only surgeons who can offer all treatment modalities can fully appreciate when an open procedure is still the best option, or that the disease process may be more benign than the planned treatment.

What we have gained and what have we lost by our withdrawal from communal involvement with other specialists is not altogether clear. Vascular surgeons have pioneered many of the major advances in our understanding and treatment of vascular diseases from the various bypass operations, through vascular lab testing to advances in endovascular therapy.

Nonetheless, we should not discount the contributions of our medical colleagues. Physicians from other disciplines pioneered endovascular therapies that many of our vascular surgeon predecessors claimed would never work. Medical management prevents thrombosis, keeps our patients alive and our bypasses and stents open. We must also acknowledge that there are many highly qualified physicians in other specialties who are equally devoted to improving the care of patients with vascular disease.

At present there are almost 5,000 U.S. vascular surgeons, and even more globally. Almost every developed nation has a vascular surgical society, and some even have a designated specialty of vascular surgery. Yet it seems we still do not have the numbers to be universally recognized for our expertise. However, our comprehensive training and knowledge have given us the self-assurance and confidence to claim that our specialty is uniquely qualified to take the leadership position in the management of vascular conditions.

So, "IIb, unquestionably, will not be" but, unlike Hamlet, we need not despair. TASC may have failed but we will not!

1) Eur. J. Vasc. Endovasc. Surg. 2007;33 Suppl 1:S1-75.

Death is no stranger to me. Like many my age, I have lost all my grandparents, but I also lost my dad early, when I was only 18. In my early 20s I saw death hundreds of times as an assistant to the medical examiner. Now, as part of my job, I routinely help families and patients approach this last and final stage of life.

Despite this familiarity, I somehow forget what the cold, harsh finality of death personally feels like; the incomprehensible irreversibility, the eerie emptiness. Patients often pass during the night, leaving me to find, the next day, their name off my list and their room being cleaned. I sign the death certificate and move on. It is, after all, part of my job.

Now and then death will touch me directly, and I am reminded anew what it is really like, beyond a "goals of care discussion" and a death certificate.

First there is the stunned knot in the stomach when you first hear the news; the pit of lost words and imploded emotions. Then comes the sadness followed by the unexpected and surreal work that has to be done. Emotions are briefly put on hold to "get things in order." Then, when all is said and done, you have to return to the empty nuances of life: work, bills, chores. You walk through the motions, trying to act the same. The world goes on.

©Nneirda/thinkstockphotos.com

Today I woke up to find that my friend and pet of 8 years had died in her sleep. She had been battling infections for a year and a half, had become incontinent, and was losing weight. I knew it was coming, I just didn’t know when. In evenings, I would find myself taking pause to look for respirations when she would rest in the shade. Then today, a day no different from any other, it just happened. Of course I knew instantly; there is such an indescribable difference between a lifeless body and one who still has even shallow breath. I just stood and stared. I told my wife and I watched the same helpless feelings pour over her.

This loyal rabbit, our friend, had been with me since I rescued her during medical school. At the time, I was not keen on owning any animal, let alone a little rabbit. But she needed rescuing and thus I adopted her. Then, through the loneliness of medical school clerkships and residency, she became my friend, often my only friend. She was a faithful companion that ran circles around my feet when I would come in the door after 30-hour shifts, and she would curl up next to me during post-call Netflix naps. When my wife moved to the United States in the middle of my residency, she was often her only companion for days at a time as I worked long hours in the ICU. She was with me through every relentless minute of studying for boards, sleeping quietly at my feet.

After we had a good cry came the cold requisite to "get things in order." We said our final good-byes just 2 hours ago, and we returned to the empty nuances of life: Fix the leaking faucet, eat dinner, do the dishes.

Working with patients who are sick and nearing the end of their lives can be part of our rhythm – monthly, weekly, or even daily. But for the patient and family, there is nothing rhythmic about it; death is a life event, perhaps the life event.

Quality of care can mean creating a temporal space of peace and honor, no matter the loss and however brief, that has a different tone from the rest of our day. It means never suggesting in word or deed that we are too busy to recognize the emptiness that the death will leave behind. It is understanding the initial thud that a palliative care/hospice referral makes on a loved-one’s soul. Even a novice physician or nurse should pause in recognition that though the hospital bed will be refilled and the hospital workload will continue, for families, nothing is ever quite the same.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

Death is no stranger to me. Like many my age, I have lost all my grandparents, but I also lost my dad early, when I was only 18. In my early 20s I saw death hundreds of times as an assistant to the medical examiner. Now, as part of my job, I routinely help families and patients approach this last and final stage of life.

Despite this familiarity, I somehow forget what the cold, harsh finality of death personally feels like; the incomprehensible irreversibility, the eerie emptiness. Patients often pass during the night, leaving me to find, the next day, their name off my list and their room being cleaned. I sign the death certificate and move on. It is, after all, part of my job.

Now and then death will touch me directly, and I am reminded anew what it is really like, beyond a "goals of care discussion" and a death certificate.

First there is the stunned knot in the stomach when you first hear the news; the pit of lost words and imploded emotions. Then comes the sadness followed by the unexpected and surreal work that has to be done. Emotions are briefly put on hold to "get things in order." Then, when all is said and done, you have to return to the empty nuances of life: work, bills, chores. You walk through the motions, trying to act the same. The world goes on.

©Nneirda/thinkstockphotos.com

Today I woke up to find that my friend and pet of 8 years had died in her sleep. She had been battling infections for a year and a half, had become incontinent, and was losing weight. I knew it was coming, I just didn’t know when. In evenings, I would find myself taking pause to look for respirations when she would rest in the shade. Then today, a day no different from any other, it just happened. Of course I knew instantly; there is such an indescribable difference between a lifeless body and one who still has even shallow breath. I just stood and stared. I told my wife and I watched the same helpless feelings pour over her.

This loyal rabbit, our friend, had been with me since I rescued her during medical school. At the time, I was not keen on owning any animal, let alone a little rabbit. But she needed rescuing and thus I adopted her. Then, through the loneliness of medical school clerkships and residency, she became my friend, often my only friend. She was a faithful companion that ran circles around my feet when I would come in the door after 30-hour shifts, and she would curl up next to me during post-call Netflix naps. When my wife moved to the United States in the middle of my residency, she was often her only companion for days at a time as I worked long hours in the ICU. She was with me through every relentless minute of studying for boards, sleeping quietly at my feet.

After we had a good cry came the cold requisite to "get things in order." We said our final good-byes just 2 hours ago, and we returned to the empty nuances of life: Fix the leaking faucet, eat dinner, do the dishes.

Working with patients who are sick and nearing the end of their lives can be part of our rhythm – monthly, weekly, or even daily. But for the patient and family, there is nothing rhythmic about it; death is a life event, perhaps the life event.

Quality of care can mean creating a temporal space of peace and honor, no matter the loss and however brief, that has a different tone from the rest of our day. It means never suggesting in word or deed that we are too busy to recognize the emptiness that the death will leave behind. It is understanding the initial thud that a palliative care/hospice referral makes on a loved-one’s soul. Even a novice physician or nurse should pause in recognition that though the hospital bed will be refilled and the hospital workload will continue, for families, nothing is ever quite the same.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

Death is no stranger to me. Like many my age, I have lost all my grandparents, but I also lost my dad early, when I was only 18. In my early 20s I saw death hundreds of times as an assistant to the medical examiner. Now, as part of my job, I routinely help families and patients approach this last and final stage of life.

Despite this familiarity, I somehow forget what the cold, harsh finality of death personally feels like; the incomprehensible irreversibility, the eerie emptiness. Patients often pass during the night, leaving me to find, the next day, their name off my list and their room being cleaned. I sign the death certificate and move on. It is, after all, part of my job.

Now and then death will touch me directly, and I am reminded anew what it is really like, beyond a "goals of care discussion" and a death certificate.

First there is the stunned knot in the stomach when you first hear the news; the pit of lost words and imploded emotions. Then comes the sadness followed by the unexpected and surreal work that has to be done. Emotions are briefly put on hold to "get things in order." Then, when all is said and done, you have to return to the empty nuances of life: work, bills, chores. You walk through the motions, trying to act the same. The world goes on.

©Nneirda/thinkstockphotos.com

Today I woke up to find that my friend and pet of 8 years had died in her sleep. She had been battling infections for a year and a half, had become incontinent, and was losing weight. I knew it was coming, I just didn’t know when. In evenings, I would find myself taking pause to look for respirations when she would rest in the shade. Then today, a day no different from any other, it just happened. Of course I knew instantly; there is such an indescribable difference between a lifeless body and one who still has even shallow breath. I just stood and stared. I told my wife and I watched the same helpless feelings pour over her.

This loyal rabbit, our friend, had been with me since I rescued her during medical school. At the time, I was not keen on owning any animal, let alone a little rabbit. But she needed rescuing and thus I adopted her. Then, through the loneliness of medical school clerkships and residency, she became my friend, often my only friend. She was a faithful companion that ran circles around my feet when I would come in the door after 30-hour shifts, and she would curl up next to me during post-call Netflix naps. When my wife moved to the United States in the middle of my residency, she was often her only companion for days at a time as I worked long hours in the ICU. She was with me through every relentless minute of studying for boards, sleeping quietly at my feet.

After we had a good cry came the cold requisite to "get things in order." We said our final good-byes just 2 hours ago, and we returned to the empty nuances of life: Fix the leaking faucet, eat dinner, do the dishes.

Working with patients who are sick and nearing the end of their lives can be part of our rhythm – monthly, weekly, or even daily. But for the patient and family, there is nothing rhythmic about it; death is a life event, perhaps the life event.

Quality of care can mean creating a temporal space of peace and honor, no matter the loss and however brief, that has a different tone from the rest of our day. It means never suggesting in word or deed that we are too busy to recognize the emptiness that the death will leave behind. It is understanding the initial thud that a palliative care/hospice referral makes on a loved-one’s soul. Even a novice physician or nurse should pause in recognition that though the hospital bed will be refilled and the hospital workload will continue, for families, nothing is ever quite the same.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

BOSTON – This year’s F. Stanley Crawford Critical Issues Forum, titled "Appropriate Use of Vascular Surgery Procedures: Do We Have a Problem?," was a response to the question of whether vascular surgeons are performing too many procedures and if enough evidence exists to support the ones that are being done, according to Dr. Peter F. Lawrence, incoming president of the SVS. Dr. Lawrence, who organized this year’s session, discussed how the issue of overuse and appropriateness has become a common theme in the media, in public policy discussions, and among medical societies.

"In Vascular Specialist, our newspaper, both Drs. Frank Veith and Russell Samson have written editorials about the overuse of vascular procedures. Dr. Veith titled his topic ‘The Blacksnake Phenomenon’ and pointed out that not everything that we find and identify needs to be treated."

Martin J. Allred

Dr. Lawrence chose and introduced five speakers charged with addressing the problem.

Dr. Robert M. Zwolak addressed the currently available data on vascular surgery procedures, focusing in particular on the Medicare procedural data derived from the Centers for Medicare & Medicaid Services. He pointed out several instances where the number of vascular procedures performed decreased tremendously over time, independent of reimbursement, including a remarkable 47% decrease in major amputations from 1996 to 2013. Open lower extremity bypass decreased, by 57%, to such a low level that it called into question the ability of the specialty to maintain excellence in performing the procedure. On the flip side, there was also a tremendous increase in certain procedures, including vein treatments, which grew more than 6,000% when reimbursement became available.

Dr. Michael D. Dake addressed the critical issue of optimizing multispecialty involvement in vascular procedures. In particular, he advocated a cooperative vs. adversarial approach. This included working together for common credentialing, institutional harmonization, and development of "care teams" for vascular diseases, such as already exist for transcatheter aortic valve replacement. He said SVS should take responsibility for promoting a "Big Tent approach" and become the overarching society dealing with all things vascular, including involvement in common credentialing and guidelines development.

Dr. Timothy Ferris discussed the various types of influence that hospital and physician practice organizations could have that impact appropriateness. In particular, he outlined a computer program that his own institution, Massachusetts General Hospital, Boston, developed that allows physicians to recognize and comply with guideline criteria generated through multispecialty consensus at the hospital. Within a few years, they found a tremendous increase in the number of procedures deemed appropriate. This information enabled them to influence insurance providers to waive the necessity of preauthorization, which often requires up to 30 people to fill out the paperwork.

Dr. Peter Gloviczki addressed the issue of practice guidelines as criteria for determining appropriateness. He reiterated their importance, but maintained that they were highly variable in their evidentiary basis, and that the quality of individual guidelines should always be considered so as to avoid a "herd mentality."

Dr. Samson topped off the forum with a discussion of the ethical issues related to frequency of procedures. He pointed out that personal integrity is critical and that the greatest potential risk of unethical behavior exists in outpatient centers. "The only time an intervention occurs is when a major complication sends a patient to a hospital or a negligent action results in a malpractice suit. As long as our government and insurers fail to determine what and where and who should be doing these procedures, I believe we will have unscrupulous doctors let loose on their unsuspecting prey." He said one of the ways to prevent this was to require that only board-certified and appropriately trained physicians be allowed to perform procedures.

[email protected]

BOSTON – This year’s F. Stanley Crawford Critical Issues Forum, titled "Appropriate Use of Vascular Surgery Procedures: Do We Have a Problem?," was a response to the question of whether vascular surgeons are performing too many procedures and if enough evidence exists to support the ones that are being done, according to Dr. Peter F. Lawrence, incoming president of the SVS. Dr. Lawrence, who organized this year’s session, discussed how the issue of overuse and appropriateness has become a common theme in the media, in public policy discussions, and among medical societies.

"In Vascular Specialist, our newspaper, both Drs. Frank Veith and Russell Samson have written editorials about the overuse of vascular procedures. Dr. Veith titled his topic ‘The Blacksnake Phenomenon’ and pointed out that not everything that we find and identify needs to be treated."

Martin J. Allred

Dr. Lawrence chose and introduced five speakers charged with addressing the problem.

Dr. Robert M. Zwolak addressed the currently available data on vascular surgery procedures, focusing in particular on the Medicare procedural data derived from the Centers for Medicare & Medicaid Services. He pointed out several instances where the number of vascular procedures performed decreased tremendously over time, independent of reimbursement, including a remarkable 47% decrease in major amputations from 1996 to 2013. Open lower extremity bypass decreased, by 57%, to such a low level that it called into question the ability of the specialty to maintain excellence in performing the procedure. On the flip side, there was also a tremendous increase in certain procedures, including vein treatments, which grew more than 6,000% when reimbursement became available.

Dr. Michael D. Dake addressed the critical issue of optimizing multispecialty involvement in vascular procedures. In particular, he advocated a cooperative vs. adversarial approach. This included working together for common credentialing, institutional harmonization, and development of "care teams" for vascular diseases, such as already exist for transcatheter aortic valve replacement. He said SVS should take responsibility for promoting a "Big Tent approach" and become the overarching society dealing with all things vascular, including involvement in common credentialing and guidelines development.

Dr. Timothy Ferris discussed the various types of influence that hospital and physician practice organizations could have that impact appropriateness. In particular, he outlined a computer program that his own institution, Massachusetts General Hospital, Boston, developed that allows physicians to recognize and comply with guideline criteria generated through multispecialty consensus at the hospital. Within a few years, they found a tremendous increase in the number of procedures deemed appropriate. This information enabled them to influence insurance providers to waive the necessity of preauthorization, which often requires up to 30 people to fill out the paperwork.

Dr. Peter Gloviczki addressed the issue of practice guidelines as criteria for determining appropriateness. He reiterated their importance, but maintained that they were highly variable in their evidentiary basis, and that the quality of individual guidelines should always be considered so as to avoid a "herd mentality."

Dr. Samson topped off the forum with a discussion of the ethical issues related to frequency of procedures. He pointed out that personal integrity is critical and that the greatest potential risk of unethical behavior exists in outpatient centers. "The only time an intervention occurs is when a major complication sends a patient to a hospital or a negligent action results in a malpractice suit. As long as our government and insurers fail to determine what and where and who should be doing these procedures, I believe we will have unscrupulous doctors let loose on their unsuspecting prey." He said one of the ways to prevent this was to require that only board-certified and appropriately trained physicians be allowed to perform procedures.

[email protected]

BOSTON – This year’s F. Stanley Crawford Critical Issues Forum, titled "Appropriate Use of Vascular Surgery Procedures: Do We Have a Problem?," was a response to the question of whether vascular surgeons are performing too many procedures and if enough evidence exists to support the ones that are being done, according to Dr. Peter F. Lawrence, incoming president of the SVS. Dr. Lawrence, who organized this year’s session, discussed how the issue of overuse and appropriateness has become a common theme in the media, in public policy discussions, and among medical societies.

"In Vascular Specialist, our newspaper, both Drs. Frank Veith and Russell Samson have written editorials about the overuse of vascular procedures. Dr. Veith titled his topic ‘The Blacksnake Phenomenon’ and pointed out that not everything that we find and identify needs to be treated."

Martin J. Allred

Dr. Lawrence chose and introduced five speakers charged with addressing the problem.

Dr. Robert M. Zwolak addressed the currently available data on vascular surgery procedures, focusing in particular on the Medicare procedural data derived from the Centers for Medicare & Medicaid Services. He pointed out several instances where the number of vascular procedures performed decreased tremendously over time, independent of reimbursement, including a remarkable 47% decrease in major amputations from 1996 to 2013. Open lower extremity bypass decreased, by 57%, to such a low level that it called into question the ability of the specialty to maintain excellence in performing the procedure. On the flip side, there was also a tremendous increase in certain procedures, including vein treatments, which grew more than 6,000% when reimbursement became available.

Dr. Michael D. Dake addressed the critical issue of optimizing multispecialty involvement in vascular procedures. In particular, he advocated a cooperative vs. adversarial approach. This included working together for common credentialing, institutional harmonization, and development of "care teams" for vascular diseases, such as already exist for transcatheter aortic valve replacement. He said SVS should take responsibility for promoting a "Big Tent approach" and become the overarching society dealing with all things vascular, including involvement in common credentialing and guidelines development.

Dr. Timothy Ferris discussed the various types of influence that hospital and physician practice organizations could have that impact appropriateness. In particular, he outlined a computer program that his own institution, Massachusetts General Hospital, Boston, developed that allows physicians to recognize and comply with guideline criteria generated through multispecialty consensus at the hospital. Within a few years, they found a tremendous increase in the number of procedures deemed appropriate. This information enabled them to influence insurance providers to waive the necessity of preauthorization, which often requires up to 30 people to fill out the paperwork.

Dr. Peter Gloviczki addressed the issue of practice guidelines as criteria for determining appropriateness. He reiterated their importance, but maintained that they were highly variable in their evidentiary basis, and that the quality of individual guidelines should always be considered so as to avoid a "herd mentality."

Dr. Samson topped off the forum with a discussion of the ethical issues related to frequency of procedures. He pointed out that personal integrity is critical and that the greatest potential risk of unethical behavior exists in outpatient centers. "The only time an intervention occurs is when a major complication sends a patient to a hospital or a negligent action results in a malpractice suit. As long as our government and insurers fail to determine what and where and who should be doing these procedures, I believe we will have unscrupulous doctors let loose on their unsuspecting prey." He said one of the ways to prevent this was to require that only board-certified and appropriately trained physicians be allowed to perform procedures.

[email protected]

Excessive wait times at VA hospitals have become front-page news. It is a complaint that I am very familiar with as a physician who has worked in the emergency department (ED) for a long time. And although the problems uncovered at the Phoenix VA Health Care System (where I currently work) and other health care centers involve bringing new patients into the system, not the hours spent waiting in the ED, our experience trying to reduce wait times may provide useful lessons as the VA seeks to reduce the backlog and see all its patients in a reasonable amount of time.

Overcrowding and long wait times are hardly unique to VA EDs, these are problems faced at most large hospitals. Today, the increasing use of the ED is driven by patient demand, changing benefits (insurance/entitlements), and shifting expectations. Many patients in the ED for nonemergent care do not have regular primary care providers. Others may be turning to the ED because of difficulty getting appointments to see a primary care provider. Some patients simply use the ED for convenience (it is open 24 hours a day after all) and because there are no copayments.

Emergency department providers have made many attempts to address wait times and overcrowding; however, these problems are complex, caused by rapidly shifting bottlenecks, making simple solutions challenging and difficult to resolve. Seemingly rational interventions aimed at reducing the wait times are frequently unsuccessful, a result of a rapidly changing and dynamic environment—you are only as fast as delays allow.

IDENTIFYING BOTTLENECKS

Capacity issues can cause bottlenecks in the ED and lead to overcrowding. The capacity of ED resources can vary widely over time. For example, radiology capacity at night depends on the radiology technician on call and how far the technician lives from the hospital (if there is no 24/7 in hospital coverage). Often, external issues can cause problems, such as if the clinics at the institution are closed (for federal holidays at the VA, for example); there is a primary care staff shortage (a nationwide problem); scheduling issues; or the clinic staff are in mandatory meetings. In these instances patients may directly or indirectly get diverted to the ED, slowing its flow.

Similarly, responsiveness or availability of specialists to offer consults can contribute to the time spent in the ED. In addition, the delay in getting patients into a hospital bed after being admitted can sometimes take many hours, tying up the already limited bed availability.

Physician and nursing capacity is even more complicated, because the volume of patients at any one time is unpredictable. Emergency department physicians have a variety of backgrounds and different skill sets; some can process patients more efficiently than can others. And the chemistry among the various staff working on a given shift can also shape capacity. Good team chemistry helps an ED work efficiently.

The demand placed on ED resources also varies, based on the patient mix over time. There are days where seemingly everyone needs a CT scan, which creates a bottleneck. There are other days when it is a trauma day when the X-rays and radiology techs rapidly get backed up. Then there are times when the CT scanner or MRI is down, or other technology issues create delays. All ED processes are interconnected. Unless you increase capacity for those days, the flow will be decreased and waste increased. Contributing further to the ED congestion is the recent trend in the health policy community and at the VA to shrink the ED resources while at the same time trying to improve patient satisfaction scores.

Many communities, like Phoenix, have seen significant shifts in veteran populations as aging veterans choose to move to retirement communities in the south and west. Even the seasonal fluctuations as aging veterans spend the winter months in warmer communities can impact the ED. Combining these trends with recently expanded eligibility standards in the VA system creates an imbalance in the flow of patients and strains the capacity at many facilities like ours. Without adjusting the capacity of the ED (and other departments) to handle more patients, setting new benchmarks to reduce veterans’ wait times is not workable.

Some EDs have experimented with streamlining processes using “lean” business management. Sources of waste and inefficiency are identified and alternate processes developed. The Phoenix VA ED has tried some of these techniques with some success. For example, we have decreased the wait times and fewer patients leave without being seen, while at the same time the patient volume has increased. We now have front-end initiation of a workup based on the presenting complaints. Thorough workups in the ED can be useful, especially if they prevent a costly hospitalization. However, these workups add to the demands placed on the ED’s precious commodity—the bed. 

Flexible Service Environment

The ED is a complex service environment with shifting bottlenecks. To reduce wait times, EDs need flexibility in hiring and shifting responsibilities, but unfortunately federal policies are not easily adaptable for addressing such shifting demands. It routinely takes 4 or more months to hire a new physician or a nurse once a job is offered, to say nothing of the time to recruit them in the first place. If a staff member leaves, typically the position is not filled for months. The VA credentialing and hiring process needs to be thorough but significantly streamlined with the salaries reflective of equal pay for equal work. Currently, this is not the case.

To be able to confront the crowding and long wait times in the ED, the VA needs to address the root causes of crowding. First and foremost, it means expanding access to nonemergent clinics, specialists, and primary care providers. Opening clinics after hours, weekends, and on holidays would be an easy first step with significant cost saving, compared with expansion. Second, the ED needs more resources, such as more beds and additional staff, including specialists (for example, a psychiatric team in the ED). Finally, the VA needs to facilitate the movement from the ED into a hospital for patients who are admitted.

Most important, ED teams must become more nimble and flexible. Lean business practices can help keep the overall process efficient by focusing on eliminating waste or non–value-added elements. A leaner, more flexible ED can not only reduce wait times but also give veterans more value, which is exactly what they deserve.

I have worked side-by-side with the men and women who bring the VA to life, putting in long hours, with diligent attention to the highest standards and a commitment to the mission. We have saved and changed the lives of many of the patients we serve; although it is not always easy for veterans to separate issues of access to care from those of the quality of that care. Though it can be a challenge to work in a VA ED, especially now, it can also be very fulfilling. 

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Excessive wait times at VA hospitals have become front-page news. It is a complaint that I am very familiar with as a physician who has worked in the emergency department (ED) for a long time. And although the problems uncovered at the Phoenix VA Health Care System (where I currently work) and other health care centers involve bringing new patients into the system, not the hours spent waiting in the ED, our experience trying to reduce wait times may provide useful lessons as the VA seeks to reduce the backlog and see all its patients in a reasonable amount of time.

Overcrowding and long wait times are hardly unique to VA EDs, these are problems faced at most large hospitals. Today, the increasing use of the ED is driven by patient demand, changing benefits (insurance/entitlements), and shifting expectations. Many patients in the ED for nonemergent care do not have regular primary care providers. Others may be turning to the ED because of difficulty getting appointments to see a primary care provider. Some patients simply use the ED for convenience (it is open 24 hours a day after all) and because there are no copayments.

Emergency department providers have made many attempts to address wait times and overcrowding; however, these problems are complex, caused by rapidly shifting bottlenecks, making simple solutions challenging and difficult to resolve. Seemingly rational interventions aimed at reducing the wait times are frequently unsuccessful, a result of a rapidly changing and dynamic environment—you are only as fast as delays allow.

IDENTIFYING BOTTLENECKS

Capacity issues can cause bottlenecks in the ED and lead to overcrowding. The capacity of ED resources can vary widely over time. For example, radiology capacity at night depends on the radiology technician on call and how far the technician lives from the hospital (if there is no 24/7 in hospital coverage). Often, external issues can cause problems, such as if the clinics at the institution are closed (for federal holidays at the VA, for example); there is a primary care staff shortage (a nationwide problem); scheduling issues; or the clinic staff are in mandatory meetings. In these instances patients may directly or indirectly get diverted to the ED, slowing its flow.

Similarly, responsiveness or availability of specialists to offer consults can contribute to the time spent in the ED. In addition, the delay in getting patients into a hospital bed after being admitted can sometimes take many hours, tying up the already limited bed availability.

Physician and nursing capacity is even more complicated, because the volume of patients at any one time is unpredictable. Emergency department physicians have a variety of backgrounds and different skill sets; some can process patients more efficiently than can others. And the chemistry among the various staff working on a given shift can also shape capacity. Good team chemistry helps an ED work efficiently.

The demand placed on ED resources also varies, based on the patient mix over time. There are days where seemingly everyone needs a CT scan, which creates a bottleneck. There are other days when it is a trauma day when the X-rays and radiology techs rapidly get backed up. Then there are times when the CT scanner or MRI is down, or other technology issues create delays. All ED processes are interconnected. Unless you increase capacity for those days, the flow will be decreased and waste increased. Contributing further to the ED congestion is the recent trend in the health policy community and at the VA to shrink the ED resources while at the same time trying to improve patient satisfaction scores.

Many communities, like Phoenix, have seen significant shifts in veteran populations as aging veterans choose to move to retirement communities in the south and west. Even the seasonal fluctuations as aging veterans spend the winter months in warmer communities can impact the ED. Combining these trends with recently expanded eligibility standards in the VA system creates an imbalance in the flow of patients and strains the capacity at many facilities like ours. Without adjusting the capacity of the ED (and other departments) to handle more patients, setting new benchmarks to reduce veterans’ wait times is not workable.

Some EDs have experimented with streamlining processes using “lean” business management. Sources of waste and inefficiency are identified and alternate processes developed. The Phoenix VA ED has tried some of these techniques with some success. For example, we have decreased the wait times and fewer patients leave without being seen, while at the same time the patient volume has increased. We now have front-end initiation of a workup based on the presenting complaints. Thorough workups in the ED can be useful, especially if they prevent a costly hospitalization. However, these workups add to the demands placed on the ED’s precious commodity—the bed. 

Flexible Service Environment

The ED is a complex service environment with shifting bottlenecks. To reduce wait times, EDs need flexibility in hiring and shifting responsibilities, but unfortunately federal policies are not easily adaptable for addressing such shifting demands. It routinely takes 4 or more months to hire a new physician or a nurse once a job is offered, to say nothing of the time to recruit them in the first place. If a staff member leaves, typically the position is not filled for months. The VA credentialing and hiring process needs to be thorough but significantly streamlined with the salaries reflective of equal pay for equal work. Currently, this is not the case.

To be able to confront the crowding and long wait times in the ED, the VA needs to address the root causes of crowding. First and foremost, it means expanding access to nonemergent clinics, specialists, and primary care providers. Opening clinics after hours, weekends, and on holidays would be an easy first step with significant cost saving, compared with expansion. Second, the ED needs more resources, such as more beds and additional staff, including specialists (for example, a psychiatric team in the ED). Finally, the VA needs to facilitate the movement from the ED into a hospital for patients who are admitted.

Most important, ED teams must become more nimble and flexible. Lean business practices can help keep the overall process efficient by focusing on eliminating waste or non–value-added elements. A leaner, more flexible ED can not only reduce wait times but also give veterans more value, which is exactly what they deserve.

I have worked side-by-side with the men and women who bring the VA to life, putting in long hours, with diligent attention to the highest standards and a commitment to the mission. We have saved and changed the lives of many of the patients we serve; although it is not always easy for veterans to separate issues of access to care from those of the quality of that care. Though it can be a challenge to work in a VA ED, especially now, it can also be very fulfilling. 

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Excessive wait times at VA hospitals have become front-page news. It is a complaint that I am very familiar with as a physician who has worked in the emergency department (ED) for a long time. And although the problems uncovered at the Phoenix VA Health Care System (where I currently work) and other health care centers involve bringing new patients into the system, not the hours spent waiting in the ED, our experience trying to reduce wait times may provide useful lessons as the VA seeks to reduce the backlog and see all its patients in a reasonable amount of time.

Overcrowding and long wait times are hardly unique to VA EDs, these are problems faced at most large hospitals. Today, the increasing use of the ED is driven by patient demand, changing benefits (insurance/entitlements), and shifting expectations. Many patients in the ED for nonemergent care do not have regular primary care providers. Others may be turning to the ED because of difficulty getting appointments to see a primary care provider. Some patients simply use the ED for convenience (it is open 24 hours a day after all) and because there are no copayments.

Emergency department providers have made many attempts to address wait times and overcrowding; however, these problems are complex, caused by rapidly shifting bottlenecks, making simple solutions challenging and difficult to resolve. Seemingly rational interventions aimed at reducing the wait times are frequently unsuccessful, a result of a rapidly changing and dynamic environment—you are only as fast as delays allow.

IDENTIFYING BOTTLENECKS

Capacity issues can cause bottlenecks in the ED and lead to overcrowding. The capacity of ED resources can vary widely over time. For example, radiology capacity at night depends on the radiology technician on call and how far the technician lives from the hospital (if there is no 24/7 in hospital coverage). Often, external issues can cause problems, such as if the clinics at the institution are closed (for federal holidays at the VA, for example); there is a primary care staff shortage (a nationwide problem); scheduling issues; or the clinic staff are in mandatory meetings. In these instances patients may directly or indirectly get diverted to the ED, slowing its flow.

Similarly, responsiveness or availability of specialists to offer consults can contribute to the time spent in the ED. In addition, the delay in getting patients into a hospital bed after being admitted can sometimes take many hours, tying up the already limited bed availability.

Physician and nursing capacity is even more complicated, because the volume of patients at any one time is unpredictable. Emergency department physicians have a variety of backgrounds and different skill sets; some can process patients more efficiently than can others. And the chemistry among the various staff working on a given shift can also shape capacity. Good team chemistry helps an ED work efficiently.

The demand placed on ED resources also varies, based on the patient mix over time. There are days where seemingly everyone needs a CT scan, which creates a bottleneck. There are other days when it is a trauma day when the X-rays and radiology techs rapidly get backed up. Then there are times when the CT scanner or MRI is down, or other technology issues create delays. All ED processes are interconnected. Unless you increase capacity for those days, the flow will be decreased and waste increased. Contributing further to the ED congestion is the recent trend in the health policy community and at the VA to shrink the ED resources while at the same time trying to improve patient satisfaction scores.

Many communities, like Phoenix, have seen significant shifts in veteran populations as aging veterans choose to move to retirement communities in the south and west. Even the seasonal fluctuations as aging veterans spend the winter months in warmer communities can impact the ED. Combining these trends with recently expanded eligibility standards in the VA system creates an imbalance in the flow of patients and strains the capacity at many facilities like ours. Without adjusting the capacity of the ED (and other departments) to handle more patients, setting new benchmarks to reduce veterans’ wait times is not workable.

Some EDs have experimented with streamlining processes using “lean” business management. Sources of waste and inefficiency are identified and alternate processes developed. The Phoenix VA ED has tried some of these techniques with some success. For example, we have decreased the wait times and fewer patients leave without being seen, while at the same time the patient volume has increased. We now have front-end initiation of a workup based on the presenting complaints. Thorough workups in the ED can be useful, especially if they prevent a costly hospitalization. However, these workups add to the demands placed on the ED’s precious commodity—the bed. 

Flexible Service Environment

The ED is a complex service environment with shifting bottlenecks. To reduce wait times, EDs need flexibility in hiring and shifting responsibilities, but unfortunately federal policies are not easily adaptable for addressing such shifting demands. It routinely takes 4 or more months to hire a new physician or a nurse once a job is offered, to say nothing of the time to recruit them in the first place. If a staff member leaves, typically the position is not filled for months. The VA credentialing and hiring process needs to be thorough but significantly streamlined with the salaries reflective of equal pay for equal work. Currently, this is not the case.

To be able to confront the crowding and long wait times in the ED, the VA needs to address the root causes of crowding. First and foremost, it means expanding access to nonemergent clinics, specialists, and primary care providers. Opening clinics after hours, weekends, and on holidays would be an easy first step with significant cost saving, compared with expansion. Second, the ED needs more resources, such as more beds and additional staff, including specialists (for example, a psychiatric team in the ED). Finally, the VA needs to facilitate the movement from the ED into a hospital for patients who are admitted.

Most important, ED teams must become more nimble and flexible. Lean business practices can help keep the overall process efficient by focusing on eliminating waste or non–value-added elements. A leaner, more flexible ED can not only reduce wait times but also give veterans more value, which is exactly what they deserve.

I have worked side-by-side with the men and women who bring the VA to life, putting in long hours, with diligent attention to the highest standards and a commitment to the mission. We have saved and changed the lives of many of the patients we serve; although it is not always easy for veterans to separate issues of access to care from those of the quality of that care. Though it can be a challenge to work in a VA ED, especially now, it can also be very fulfilling. 

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Excessive wait times at VA hospitals have become front-page news. It is a complaint that I am very familiar with as a physician who has worked in the emergency department (ED) for a long time. And although the problems uncovered at the Phoenix VA Health Care System (where I currently work) and other health care centers involve bringing new patients into the system, not the hours spent waiting in the ED, our experience trying to reduce wait times may provide useful lessons as the VA seeks to reduce the backlog and see all its patients in a reasonable amount of time.

Overcrowding and long wait times are hardly unique to VA EDs, these are problems faced at most large hospitals. Today, the increasing use of the ED is driven by patient demand, changing benefits (insurance/entitlements), and shifting expectations. Many patients in the ED for nonemergent care do not have regular primary care providers. Others may be turning to the ED because of difficulty getting appointments to see a primary care provider. Some patients simply use the ED for convenience (it is open 24 hours a day after all) and because there are no copayments.

Emergency department providers have made many attempts to address wait times and overcrowding; however, these problems are complex, caused by rapidly shifting bottlenecks, making simple solutions challenging and difficult to resolve. Seemingly rational interventions aimed at reducing the wait times are frequently unsuccessful, a result of a rapidly changing and dynamic environment—you are only as fast as delays allow.

IDENTIFYING BOTTLENECKS

Capacity issues can cause bottlenecks in the ED and lead to overcrowding. The capacity of ED resources can vary widely over time. For example, radiology capacity at night depends on the radiology technician on call and how far the technician lives from the hospital (if there is no 24/7 in hospital coverage). Often, external issues can cause problems, such as if the clinics at the institution are closed (for federal holidays at the VA, for example); there is a primary care staff shortage (a nationwide problem); scheduling issues; or the clinic staff are in mandatory meetings. In these instances patients may directly or indirectly get diverted to the ED, slowing its flow.

Similarly, responsiveness or availability of specialists to offer consults can contribute to the time spent in the ED. In addition, the delay in getting patients into a hospital bed after being admitted can sometimes take many hours, tying up the already limited bed availability.

Physician and nursing capacity is even more complicated, because the volume of patients at any one time is unpredictable. Emergency department physicians have a variety of backgrounds and different skill sets; some can process patients more efficiently than can others. And the chemistry among the various staff working on a given shift can also shape capacity. Good team chemistry helps an ED work efficiently.

The demand placed on ED resources also varies, based on the patient mix over time. There are days where seemingly everyone needs a CT scan, which creates a bottleneck. There are other days when it is a trauma day when the X-rays and radiology techs rapidly get backed up. Then there are times when the CT scanner or MRI is down, or other technology issues create delays. All ED processes are interconnected. Unless you increase capacity for those days, the flow will be decreased and waste increased. Contributing further to the ED congestion is the recent trend in the health policy community and at the VA to shrink the ED resources while at the same time trying to improve patient satisfaction scores.

Many communities, like Phoenix, have seen significant shifts in veteran populations as aging veterans choose to move to retirement communities in the south and west. Even the seasonal fluctuations as aging veterans spend the winter months in warmer communities can impact the ED. Combining these trends with recently expanded eligibility standards in the VA system creates an imbalance in the flow of patients and strains the capacity at many facilities like ours. Without adjusting the capacity of the ED (and other departments) to handle more patients, setting new benchmarks to reduce veterans’ wait times is not workable.

Some EDs have experimented with streamlining processes using “lean” business management. Sources of waste and inefficiency are identified and alternate processes developed. The Phoenix VA ED has tried some of these techniques with some success. For example, we have decreased the wait times and fewer patients leave without being seen, while at the same time the patient volume has increased. We now have front-end initiation of a workup based on the presenting complaints. Thorough workups in the ED can be useful, especially if they prevent a costly hospitalization. However, these workups add to the demands placed on the ED’s precious commodity—the bed. 

Flexible Service Environment

The ED is a complex service environment with shifting bottlenecks. To reduce wait times, EDs need flexibility in hiring and shifting responsibilities, but unfortunately federal policies are not easily adaptable for addressing such shifting demands. It routinely takes 4 or more months to hire a new physician or a nurse once a job is offered, to say nothing of the time to recruit them in the first place. If a staff member leaves, typically the position is not filled for months. The VA credentialing and hiring process needs to be thorough but significantly streamlined with the salaries reflective of equal pay for equal work. Currently, this is not the case.

To be able to confront the crowding and long wait times in the ED, the VA needs to address the root causes of crowding. First and foremost, it means expanding access to nonemergent clinics, specialists, and primary care providers. Opening clinics after hours, weekends, and on holidays would be an easy first step with significant cost saving, compared with expansion. Second, the ED needs more resources, such as more beds and additional staff, including specialists (for example, a psychiatric team in the ED). Finally, the VA needs to facilitate the movement from the ED into a hospital for patients who are admitted.

Most important, ED teams must become more nimble and flexible. Lean business practices can help keep the overall process efficient by focusing on eliminating waste or non–value-added elements. A leaner, more flexible ED can not only reduce wait times but also give veterans more value, which is exactly what they deserve.

I have worked side-by-side with the men and women who bring the VA to life, putting in long hours, with diligent attention to the highest standards and a commitment to the mission. We have saved and changed the lives of many of the patients we serve; although it is not always easy for veterans to separate issues of access to care from those of the quality of that care. Though it can be a challenge to work in a VA ED, especially now, it can also be very fulfilling. 

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Excessive wait times at VA hospitals have become front-page news. It is a complaint that I am very familiar with as a physician who has worked in the emergency department (ED) for a long time. And although the problems uncovered at the Phoenix VA Health Care System (where I currently work) and other health care centers involve bringing new patients into the system, not the hours spent waiting in the ED, our experience trying to reduce wait times may provide useful lessons as the VA seeks to reduce the backlog and see all its patients in a reasonable amount of time.

Overcrowding and long wait times are hardly unique to VA EDs, these are problems faced at most large hospitals. Today, the increasing use of the ED is driven by patient demand, changing benefits (insurance/entitlements), and shifting expectations. Many patients in the ED for nonemergent care do not have regular primary care providers. Others may be turning to the ED because of difficulty getting appointments to see a primary care provider. Some patients simply use the ED for convenience (it is open 24 hours a day after all) and because there are no copayments.

Emergency department providers have made many attempts to address wait times and overcrowding; however, these problems are complex, caused by rapidly shifting bottlenecks, making simple solutions challenging and difficult to resolve. Seemingly rational interventions aimed at reducing the wait times are frequently unsuccessful, a result of a rapidly changing and dynamic environment—you are only as fast as delays allow.

IDENTIFYING BOTTLENECKS

Capacity issues can cause bottlenecks in the ED and lead to overcrowding. The capacity of ED resources can vary widely over time. For example, radiology capacity at night depends on the radiology technician on call and how far the technician lives from the hospital (if there is no 24/7 in hospital coverage). Often, external issues can cause problems, such as if the clinics at the institution are closed (for federal holidays at the VA, for example); there is a primary care staff shortage (a nationwide problem); scheduling issues; or the clinic staff are in mandatory meetings. In these instances patients may directly or indirectly get diverted to the ED, slowing its flow.

Similarly, responsiveness or availability of specialists to offer consults can contribute to the time spent in the ED. In addition, the delay in getting patients into a hospital bed after being admitted can sometimes take many hours, tying up the already limited bed availability.

Physician and nursing capacity is even more complicated, because the volume of patients at any one time is unpredictable. Emergency department physicians have a variety of backgrounds and different skill sets; some can process patients more efficiently than can others. And the chemistry among the various staff working on a given shift can also shape capacity. Good team chemistry helps an ED work efficiently.

The demand placed on ED resources also varies, based on the patient mix over time. There are days where seemingly everyone needs a CT scan, which creates a bottleneck. There are other days when it is a trauma day when the X-rays and radiology techs rapidly get backed up. Then there are times when the CT scanner or MRI is down, or other technology issues create delays. All ED processes are interconnected. Unless you increase capacity for those days, the flow will be decreased and waste increased. Contributing further to the ED congestion is the recent trend in the health policy community and at the VA to shrink the ED resources while at the same time trying to improve patient satisfaction scores.

Many communities, like Phoenix, have seen significant shifts in veteran populations as aging veterans choose to move to retirement communities in the south and west. Even the seasonal fluctuations as aging veterans spend the winter months in warmer communities can impact the ED. Combining these trends with recently expanded eligibility standards in the VA system creates an imbalance in the flow of patients and strains the capacity at many facilities like ours. Without adjusting the capacity of the ED (and other departments) to handle more patients, setting new benchmarks to reduce veterans’ wait times is not workable.

Some EDs have experimented with streamlining processes using “lean” business management. Sources of waste and inefficiency are identified and alternate processes developed. The Phoenix VA ED has tried some of these techniques with some success. For example, we have decreased the wait times and fewer patients leave without being seen, while at the same time the patient volume has increased. We now have front-end initiation of a workup based on the presenting complaints. Thorough workups in the ED can be useful, especially if they prevent a costly hospitalization. However, these workups add to the demands placed on the ED’s precious commodity—the bed. 

Flexible Service Environment

The ED is a complex service environment with shifting bottlenecks. To reduce wait times, EDs need flexibility in hiring and shifting responsibilities, but unfortunately federal policies are not easily adaptable for addressing such shifting demands. It routinely takes 4 or more months to hire a new physician or a nurse once a job is offered, to say nothing of the time to recruit them in the first place. If a staff member leaves, typically the position is not filled for months. The VA credentialing and hiring process needs to be thorough but significantly streamlined with the salaries reflective of equal pay for equal work. Currently, this is not the case.

To be able to confront the crowding and long wait times in the ED, the VA needs to address the root causes of crowding. First and foremost, it means expanding access to nonemergent clinics, specialists, and primary care providers. Opening clinics after hours, weekends, and on holidays would be an easy first step with significant cost saving, compared with expansion. Second, the ED needs more resources, such as more beds and additional staff, including specialists (for example, a psychiatric team in the ED). Finally, the VA needs to facilitate the movement from the ED into a hospital for patients who are admitted.

Most important, ED teams must become more nimble and flexible. Lean business practices can help keep the overall process efficient by focusing on eliminating waste or non–value-added elements. A leaner, more flexible ED can not only reduce wait times but also give veterans more value, which is exactly what they deserve.

I have worked side-by-side with the men and women who bring the VA to life, putting in long hours, with diligent attention to the highest standards and a commitment to the mission. We have saved and changed the lives of many of the patients we serve; although it is not always easy for veterans to separate issues of access to care from those of the quality of that care. Though it can be a challenge to work in a VA ED, especially now, it can also be very fulfilling. 

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Excessive wait times at VA hospitals have become front-page news. It is a complaint that I am very familiar with as a physician who has worked in the emergency department (ED) for a long time. And although the problems uncovered at the Phoenix VA Health Care System (where I currently work) and other health care centers involve bringing new patients into the system, not the hours spent waiting in the ED, our experience trying to reduce wait times may provide useful lessons as the VA seeks to reduce the backlog and see all its patients in a reasonable amount of time.

Overcrowding and long wait times are hardly unique to VA EDs, these are problems faced at most large hospitals. Today, the increasing use of the ED is driven by patient demand, changing benefits (insurance/entitlements), and shifting expectations. Many patients in the ED for nonemergent care do not have regular primary care providers. Others may be turning to the ED because of difficulty getting appointments to see a primary care provider. Some patients simply use the ED for convenience (it is open 24 hours a day after all) and because there are no copayments.

Emergency department providers have made many attempts to address wait times and overcrowding; however, these problems are complex, caused by rapidly shifting bottlenecks, making simple solutions challenging and difficult to resolve. Seemingly rational interventions aimed at reducing the wait times are frequently unsuccessful, a result of a rapidly changing and dynamic environment—you are only as fast as delays allow.

IDENTIFYING BOTTLENECKS

Capacity issues can cause bottlenecks in the ED and lead to overcrowding. The capacity of ED resources can vary widely over time. For example, radiology capacity at night depends on the radiology technician on call and how far the technician lives from the hospital (if there is no 24/7 in hospital coverage). Often, external issues can cause problems, such as if the clinics at the institution are closed (for federal holidays at the VA, for example); there is a primary care staff shortage (a nationwide problem); scheduling issues; or the clinic staff are in mandatory meetings. In these instances patients may directly or indirectly get diverted to the ED, slowing its flow.

Similarly, responsiveness or availability of specialists to offer consults can contribute to the time spent in the ED. In addition, the delay in getting patients into a hospital bed after being admitted can sometimes take many hours, tying up the already limited bed availability.

Physician and nursing capacity is even more complicated, because the volume of patients at any one time is unpredictable. Emergency department physicians have a variety of backgrounds and different skill sets; some can process patients more efficiently than can others. And the chemistry among the various staff working on a given shift can also shape capacity. Good team chemistry helps an ED work efficiently.

The demand placed on ED resources also varies, based on the patient mix over time. There are days where seemingly everyone needs a CT scan, which creates a bottleneck. There are other days when it is a trauma day when the X-rays and radiology techs rapidly get backed up. Then there are times when the CT scanner or MRI is down, or other technology issues create delays. All ED processes are interconnected. Unless you increase capacity for those days, the flow will be decreased and waste increased. Contributing further to the ED congestion is the recent trend in the health policy community and at the VA to shrink the ED resources while at the same time trying to improve patient satisfaction scores.

Many communities, like Phoenix, have seen significant shifts in veteran populations as aging veterans choose to move to retirement communities in the south and west. Even the seasonal fluctuations as aging veterans spend the winter months in warmer communities can impact the ED. Combining these trends with recently expanded eligibility standards in the VA system creates an imbalance in the flow of patients and strains the capacity at many facilities like ours. Without adjusting the capacity of the ED (and other departments) to handle more patients, setting new benchmarks to reduce veterans’ wait times is not workable.

Some EDs have experimented with streamlining processes using “lean” business management. Sources of waste and inefficiency are identified and alternate processes developed. The Phoenix VA ED has tried some of these techniques with some success. For example, we have decreased the wait times and fewer patients leave without being seen, while at the same time the patient volume has increased. We now have front-end initiation of a workup based on the presenting complaints. Thorough workups in the ED can be useful, especially if they prevent a costly hospitalization. However, these workups add to the demands placed on the ED’s precious commodity—the bed. 

Flexible Service Environment

The ED is a complex service environment with shifting bottlenecks. To reduce wait times, EDs need flexibility in hiring and shifting responsibilities, but unfortunately federal policies are not easily adaptable for addressing such shifting demands. It routinely takes 4 or more months to hire a new physician or a nurse once a job is offered, to say nothing of the time to recruit them in the first place. If a staff member leaves, typically the position is not filled for months. The VA credentialing and hiring process needs to be thorough but significantly streamlined with the salaries reflective of equal pay for equal work. Currently, this is not the case.

To be able to confront the crowding and long wait times in the ED, the VA needs to address the root causes of crowding. First and foremost, it means expanding access to nonemergent clinics, specialists, and primary care providers. Opening clinics after hours, weekends, and on holidays would be an easy first step with significant cost saving, compared with expansion. Second, the ED needs more resources, such as more beds and additional staff, including specialists (for example, a psychiatric team in the ED). Finally, the VA needs to facilitate the movement from the ED into a hospital for patients who are admitted.

Most important, ED teams must become more nimble and flexible. Lean business practices can help keep the overall process efficient by focusing on eliminating waste or non–value-added elements. A leaner, more flexible ED can not only reduce wait times but also give veterans more value, which is exactly what they deserve.

I have worked side-by-side with the men and women who bring the VA to life, putting in long hours, with diligent attention to the highest standards and a commitment to the mission. We have saved and changed the lives of many of the patients we serve; although it is not always easy for veterans to separate issues of access to care from those of the quality of that care. Though it can be a challenge to work in a VA ED, especially now, it can also be very fulfilling. 

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Continuous positive airway pressure (CPAP) has long been considered the gold standard treatment for OSA. Recently, a variety of new treatment approaches have become available for mild and moderate OSA, including nasal resistance valves, nerve stimulators, and negative pressure devices. Nonetheless, CPAP remains unmatched in efficacy, as well as the frequency and severity of side effects associated with treatment. The main drawback of CPAP is the required use of a mask interface and pressurized air during sleep, which is uncomfortable for some patients.

This article will highlight recent work investigating issues associated with equipment choice for practitioners treating OSA patients with CPAP and discuss how proper equipment choices and educational programs can reduce common complaints associated with CPAP use.

Mask choice

Finding a suitable mask interface is one of the most critical aspects of achieving adequate treatment compliance. The four general styles to choose from are oronasal (full-mask), standard nasal (over the nose), nasal pillows (in the nose), and the rarely-used oral.

Most clinicians choose an initial mask after CPAP titration based on a combination of patient feedback and air leakage rates but may change the mask style after home implementation in order to improve patient tolerance. Unfortunately, many clinicians are unaware that CPAP levels may need to be adjusted after changing masks. Two studies have shown that oronasal masks require significantly more pressure to ensure adequate OSA treatment during CPAP titration compared with standard nasal and nasal pillows masks (Ebben et al. Sleep Med. 2012;13[6]:645; Borel et al. PLoS ONE. 2013;8[5]:e64382).

In a separate study in which nasal masks were replaced with oronasal masks, the apnea-hypopnea index (AHI) increased to greater than 10 events per hour in half of patients who had been previously titrated to less than five per hour with the nasal mask (Ebben et al. Sleep Med. 2014;15[6]:619). Caution should be used when making a mask change to ensure that adequate disease control is maintained.

Humidification

In the past few years, humidification has been routinely added to most CPAP machines in order to improve comfort. The benefit appears to come from a reduction in dryness related to regular CPAP use (Ruhle et al. Sleep Breath. 2011;15[3]:479). Some patients report that humidification is particularly helpful in the winter months, when indoor humidity is low. Heated humidification has been found to produce significantly more humidity and causes less insensible water loss from the respiratory tract compared with unheated units (Randerath et al. Eur J Respir. 2002;20[1]:183). Unfortunately, the humidifier significantly increases the size and weight of the treatment machine, though it can be removed for travel if desired. In addition, the humidifier requires additional maintenance; if not cleaned regularly, there is a risk of bacterial colonization of the humidification chamber (Chin et al. J Clin Sleep Med. 2013; 9[8]:747).

In some instances, patients may complain of excess water condensation in the hose, particularly in the presence of a cool sleeping environment. Some CPAP manufacturers now offer heated hoses, which can significantly reduce this condensation. A second option is to add an insulating hose cover to help maintain a higher internal temperature. Generally, these covers are a good choice if the cost of a heated hose is not covered by a patient’s insurance.

Pressure relief

A common complaint often heard from patients using CPAP is that the pressure feels too high, particularly when exhaling. In response, some equipment makers have developed pressure relief systems that allow an adjustable pressure drop during exhalation with standard CPAP units. These systems work by transiently reducing pressure during exhalation by a set amount, according to their proprietary algorithm (Dolan et al. Sleep and Breath. 2009;13:73). However, not all patients find this pressure relief effective at making CPAP easier to use. When tested empirically, pressure relief has not been consistently shown to improve CPAP compliance (Dolan et al. Sleep Breath. 2009;13[1]:73).

Compliance data monitoring

Many patients benefit from discussing and reviewing treatment efficacy at their follow-up visits. Most modern CPAP equipment allows for such data monitoring, that may include duration and specific times of machine use, leak rate, snoring periods, and residual respiratory events, subdivided into hypopneas and apneas. In some cases, the software can distinguish between central ("clear airway") and obstructive events using forced oscillation techniques to measure upper airway resistance. This information allows the clinician to adjust settings and ensure that treatment is optimized and used as prescribed.

Clinicians should familiarize themselves with the different reporting systems that provide these data, and train their office staff on using software to capture information for all CPAP users. Notably, the algorithms used to capture residual respiratory events are not completely accurate; identification of such events is based only on measures of flow.

While it is probably acceptable to take extreme values at face value, whether low or very high, the imprecision of the methodology makes it more difficult to reliably use middling values in a clinical setting. (Schwab et al. Am J Respir Crit Care Med. 2013;188[5]:613). If a patient remains symptomatic despite no evidence of residual respiratory events from the adherence data download, a retitration study should still be considered.

Educational programs

Adherence to CPAP has been shown to increase when providers engage patients in educational programs to enhance compliance and understanding of the potential health-care consequences of untreated OSA (Lai et al. Chest. 2014 May 8. doi: 10.1378/ chest.13-2228. [Epub ahead of print]).

Early education and continuous support provide reinforcement of the need for adherence to therapy, as well as an opportunity to personalize the treatment and adjust settings and equipment as needed for each individual patient. Although specific guidelines for the best timing of the educational intervention are still lacking, evidence suggests that long-term compliance with CPAP might be determined as early as 2 weeks after therapy is initiated (Aloia et al. J Clin Sleep Med. 2005;1[4]:346). Therefore, educational programs should be readily available for prospective and new CPAP users in order to enhance their understanding of OSA and knowledge about CPAP treatment and to provide them with a venue for reviewing and managing compliance-related issues. Such programs can be run by dedicated sleep technologists, respiratory therapists, or nurses in clinics where physician availability is more limited.

Summary

CPAP remains the most effective treatment for OSA, though adherence is a struggle for many patients. Identifying the best mask for a given patient, determining whether humidification or an expiratory pressure drop should be added and making early and frequent contact after prescription can all assist in improving long-term CPAP use. Regular review of adherence data with the patient is also important, modifying the therapy as necessary to optimize comfort, understanding that such changes may necessitate a subsequent pressure adjustment to maintain disease control.

Implementing a comprehensive approach to managing patients using CPAP therapy can impact compliance by reducing treatment-related complaints and improving comfort.

Dr. Ebben is Assistant Professor of Psychology in Clinical Neurology, Department of Neurology; and Dr. Krieger is Associate Clinical Professor, Departments of Medicine, Neurology, and Genetic Medicine; Weill Cornell Medical College of Cornell University, New York, New York.

Continuous positive airway pressure (CPAP) has long been considered the gold standard treatment for OSA. Recently, a variety of new treatment approaches have become available for mild and moderate OSA, including nasal resistance valves, nerve stimulators, and negative pressure devices. Nonetheless, CPAP remains unmatched in efficacy, as well as the frequency and severity of side effects associated with treatment. The main drawback of CPAP is the required use of a mask interface and pressurized air during sleep, which is uncomfortable for some patients.

This article will highlight recent work investigating issues associated with equipment choice for practitioners treating OSA patients with CPAP and discuss how proper equipment choices and educational programs can reduce common complaints associated with CPAP use.

Mask choice

Finding a suitable mask interface is one of the most critical aspects of achieving adequate treatment compliance. The four general styles to choose from are oronasal (full-mask), standard nasal (over the nose), nasal pillows (in the nose), and the rarely-used oral.

Most clinicians choose an initial mask after CPAP titration based on a combination of patient feedback and air leakage rates but may change the mask style after home implementation in order to improve patient tolerance. Unfortunately, many clinicians are unaware that CPAP levels may need to be adjusted after changing masks. Two studies have shown that oronasal masks require significantly more pressure to ensure adequate OSA treatment during CPAP titration compared with standard nasal and nasal pillows masks (Ebben et al. Sleep Med. 2012;13[6]:645; Borel et al. PLoS ONE. 2013;8[5]:e64382).

In a separate study in which nasal masks were replaced with oronasal masks, the apnea-hypopnea index (AHI) increased to greater than 10 events per hour in half of patients who had been previously titrated to less than five per hour with the nasal mask (Ebben et al. Sleep Med. 2014;15[6]:619). Caution should be used when making a mask change to ensure that adequate disease control is maintained.

Humidification

In the past few years, humidification has been routinely added to most CPAP machines in order to improve comfort. The benefit appears to come from a reduction in dryness related to regular CPAP use (Ruhle et al. Sleep Breath. 2011;15[3]:479). Some patients report that humidification is particularly helpful in the winter months, when indoor humidity is low. Heated humidification has been found to produce significantly more humidity and causes less insensible water loss from the respiratory tract compared with unheated units (Randerath et al. Eur J Respir. 2002;20[1]:183). Unfortunately, the humidifier significantly increases the size and weight of the treatment machine, though it can be removed for travel if desired. In addition, the humidifier requires additional maintenance; if not cleaned regularly, there is a risk of bacterial colonization of the humidification chamber (Chin et al. J Clin Sleep Med. 2013; 9[8]:747).

In some instances, patients may complain of excess water condensation in the hose, particularly in the presence of a cool sleeping environment. Some CPAP manufacturers now offer heated hoses, which can significantly reduce this condensation. A second option is to add an insulating hose cover to help maintain a higher internal temperature. Generally, these covers are a good choice if the cost of a heated hose is not covered by a patient’s insurance.

Pressure relief

A common complaint often heard from patients using CPAP is that the pressure feels too high, particularly when exhaling. In response, some equipment makers have developed pressure relief systems that allow an adjustable pressure drop during exhalation with standard CPAP units. These systems work by transiently reducing pressure during exhalation by a set amount, according to their proprietary algorithm (Dolan et al. Sleep and Breath. 2009;13:73). However, not all patients find this pressure relief effective at making CPAP easier to use. When tested empirically, pressure relief has not been consistently shown to improve CPAP compliance (Dolan et al. Sleep Breath. 2009;13[1]:73).

Compliance data monitoring

Many patients benefit from discussing and reviewing treatment efficacy at their follow-up visits. Most modern CPAP equipment allows for such data monitoring, that may include duration and specific times of machine use, leak rate, snoring periods, and residual respiratory events, subdivided into hypopneas and apneas. In some cases, the software can distinguish between central ("clear airway") and obstructive events using forced oscillation techniques to measure upper airway resistance. This information allows the clinician to adjust settings and ensure that treatment is optimized and used as prescribed.

Clinicians should familiarize themselves with the different reporting systems that provide these data, and train their office staff on using software to capture information for all CPAP users. Notably, the algorithms used to capture residual respiratory events are not completely accurate; identification of such events is based only on measures of flow.

While it is probably acceptable to take extreme values at face value, whether low or very high, the imprecision of the methodology makes it more difficult to reliably use middling values in a clinical setting. (Schwab et al. Am J Respir Crit Care Med. 2013;188[5]:613). If a patient remains symptomatic despite no evidence of residual respiratory events from the adherence data download, a retitration study should still be considered.

Educational programs

Adherence to CPAP has been shown to increase when providers engage patients in educational programs to enhance compliance and understanding of the potential health-care consequences of untreated OSA (Lai et al. Chest. 2014 May 8. doi: 10.1378/ chest.13-2228. [Epub ahead of print]).

Early education and continuous support provide reinforcement of the need for adherence to therapy, as well as an opportunity to personalize the treatment and adjust settings and equipment as needed for each individual patient. Although specific guidelines for the best timing of the educational intervention are still lacking, evidence suggests that long-term compliance with CPAP might be determined as early as 2 weeks after therapy is initiated (Aloia et al. J Clin Sleep Med. 2005;1[4]:346). Therefore, educational programs should be readily available for prospective and new CPAP users in order to enhance their understanding of OSA and knowledge about CPAP treatment and to provide them with a venue for reviewing and managing compliance-related issues. Such programs can be run by dedicated sleep technologists, respiratory therapists, or nurses in clinics where physician availability is more limited.

Summary

CPAP remains the most effective treatment for OSA, though adherence is a struggle for many patients. Identifying the best mask for a given patient, determining whether humidification or an expiratory pressure drop should be added and making early and frequent contact after prescription can all assist in improving long-term CPAP use. Regular review of adherence data with the patient is also important, modifying the therapy as necessary to optimize comfort, understanding that such changes may necessitate a subsequent pressure adjustment to maintain disease control.

Implementing a comprehensive approach to managing patients using CPAP therapy can impact compliance by reducing treatment-related complaints and improving comfort.

Dr. Ebben is Assistant Professor of Psychology in Clinical Neurology, Department of Neurology; and Dr. Krieger is Associate Clinical Professor, Departments of Medicine, Neurology, and Genetic Medicine; Weill Cornell Medical College of Cornell University, New York, New York.

Continuous positive airway pressure (CPAP) has long been considered the gold standard treatment for OSA. Recently, a variety of new treatment approaches have become available for mild and moderate OSA, including nasal resistance valves, nerve stimulators, and negative pressure devices. Nonetheless, CPAP remains unmatched in efficacy, as well as the frequency and severity of side effects associated with treatment. The main drawback of CPAP is the required use of a mask interface and pressurized air during sleep, which is uncomfortable for some patients.

This article will highlight recent work investigating issues associated with equipment choice for practitioners treating OSA patients with CPAP and discuss how proper equipment choices and educational programs can reduce common complaints associated with CPAP use.

Mask choice

Finding a suitable mask interface is one of the most critical aspects of achieving adequate treatment compliance. The four general styles to choose from are oronasal (full-mask), standard nasal (over the nose), nasal pillows (in the nose), and the rarely-used oral.

Most clinicians choose an initial mask after CPAP titration based on a combination of patient feedback and air leakage rates but may change the mask style after home implementation in order to improve patient tolerance. Unfortunately, many clinicians are unaware that CPAP levels may need to be adjusted after changing masks. Two studies have shown that oronasal masks require significantly more pressure to ensure adequate OSA treatment during CPAP titration compared with standard nasal and nasal pillows masks (Ebben et al. Sleep Med. 2012;13[6]:645; Borel et al. PLoS ONE. 2013;8[5]:e64382).

In a separate study in which nasal masks were replaced with oronasal masks, the apnea-hypopnea index (AHI) increased to greater than 10 events per hour in half of patients who had been previously titrated to less than five per hour with the nasal mask (Ebben et al. Sleep Med. 2014;15[6]:619). Caution should be used when making a mask change to ensure that adequate disease control is maintained.

Humidification

In the past few years, humidification has been routinely added to most CPAP machines in order to improve comfort. The benefit appears to come from a reduction in dryness related to regular CPAP use (Ruhle et al. Sleep Breath. 2011;15[3]:479). Some patients report that humidification is particularly helpful in the winter months, when indoor humidity is low. Heated humidification has been found to produce significantly more humidity and causes less insensible water loss from the respiratory tract compared with unheated units (Randerath et al. Eur J Respir. 2002;20[1]:183). Unfortunately, the humidifier significantly increases the size and weight of the treatment machine, though it can be removed for travel if desired. In addition, the humidifier requires additional maintenance; if not cleaned regularly, there is a risk of bacterial colonization of the humidification chamber (Chin et al. J Clin Sleep Med. 2013; 9[8]:747).

In some instances, patients may complain of excess water condensation in the hose, particularly in the presence of a cool sleeping environment. Some CPAP manufacturers now offer heated hoses, which can significantly reduce this condensation. A second option is to add an insulating hose cover to help maintain a higher internal temperature. Generally, these covers are a good choice if the cost of a heated hose is not covered by a patient’s insurance.

Pressure relief

A common complaint often heard from patients using CPAP is that the pressure feels too high, particularly when exhaling. In response, some equipment makers have developed pressure relief systems that allow an adjustable pressure drop during exhalation with standard CPAP units. These systems work by transiently reducing pressure during exhalation by a set amount, according to their proprietary algorithm (Dolan et al. Sleep and Breath. 2009;13:73). However, not all patients find this pressure relief effective at making CPAP easier to use. When tested empirically, pressure relief has not been consistently shown to improve CPAP compliance (Dolan et al. Sleep Breath. 2009;13[1]:73).

Compliance data monitoring

Many patients benefit from discussing and reviewing treatment efficacy at their follow-up visits. Most modern CPAP equipment allows for such data monitoring, that may include duration and specific times of machine use, leak rate, snoring periods, and residual respiratory events, subdivided into hypopneas and apneas. In some cases, the software can distinguish between central ("clear airway") and obstructive events using forced oscillation techniques to measure upper airway resistance. This information allows the clinician to adjust settings and ensure that treatment is optimized and used as prescribed.

Clinicians should familiarize themselves with the different reporting systems that provide these data, and train their office staff on using software to capture information for all CPAP users. Notably, the algorithms used to capture residual respiratory events are not completely accurate; identification of such events is based only on measures of flow.

While it is probably acceptable to take extreme values at face value, whether low or very high, the imprecision of the methodology makes it more difficult to reliably use middling values in a clinical setting. (Schwab et al. Am J Respir Crit Care Med. 2013;188[5]:613). If a patient remains symptomatic despite no evidence of residual respiratory events from the adherence data download, a retitration study should still be considered.

Educational programs

Adherence to CPAP has been shown to increase when providers engage patients in educational programs to enhance compliance and understanding of the potential health-care consequences of untreated OSA (Lai et al. Chest. 2014 May 8. doi: 10.1378/ chest.13-2228. [Epub ahead of print]).

Early education and continuous support provide reinforcement of the need for adherence to therapy, as well as an opportunity to personalize the treatment and adjust settings and equipment as needed for each individual patient. Although specific guidelines for the best timing of the educational intervention are still lacking, evidence suggests that long-term compliance with CPAP might be determined as early as 2 weeks after therapy is initiated (Aloia et al. J Clin Sleep Med. 2005;1[4]:346). Therefore, educational programs should be readily available for prospective and new CPAP users in order to enhance their understanding of OSA and knowledge about CPAP treatment and to provide them with a venue for reviewing and managing compliance-related issues. Such programs can be run by dedicated sleep technologists, respiratory therapists, or nurses in clinics where physician availability is more limited.

Summary

CPAP remains the most effective treatment for OSA, though adherence is a struggle for many patients. Identifying the best mask for a given patient, determining whether humidification or an expiratory pressure drop should be added and making early and frequent contact after prescription can all assist in improving long-term CPAP use. Regular review of adherence data with the patient is also important, modifying the therapy as necessary to optimize comfort, understanding that such changes may necessitate a subsequent pressure adjustment to maintain disease control.

Implementing a comprehensive approach to managing patients using CPAP therapy can impact compliance by reducing treatment-related complaints and improving comfort.

Dr. Ebben is Assistant Professor of Psychology in Clinical Neurology, Department of Neurology; and Dr. Krieger is Associate Clinical Professor, Departments of Medicine, Neurology, and Genetic Medicine; Weill Cornell Medical College of Cornell University, New York, New York.