It seems there is a "crisis" afoot in America's hospitals: in-hospital cardiac arrests. According to the American Heart Association (AHA)'s National Registry of Cardiopulmonary Resuscitation (NRCPR) investigators and now rocketed to the media to increase the fear factor:
In-hospital cardiac arrest is a major public health problem. During 2005 and 2006, more than 21 000 in-hospital cardiac arrests were reported to the AHA NRCPR from approximately 10% of the hospitals in the United States. The principal finding of this study was that survival to discharge following in-hospital cardiac arrest was lower during nights and weekends compared with day/evening times on weekdays, even after accounting for many potentially confounding patient, arrest event, and hospital factors.In an amazing move to justify their existence, the investigators' cardiac arrest database has identified the obvious: hospital wards staffed by the lowest numbers of individuals who have received the short-straw of night and weekend duty because of their junior status have poorer outcomes during cardiac arrests.
Well no kidding, ace. We needed a study to show this?
It seems so. Bureaucrats need to find things to "improve" in their ever-expanding quest to raise the cost of providing healthcare to our sick and injured while securing their fitful place in the Quality Assurance Hall of Fame.
But what was truly scary is not the problem; it was their solution proposed to fix this "major public health problem:"
Night staff proficiency in cardiac resuscitation could be enhanced by additional training, such as "mock codes" and cardiac resuscitation simulation training. Chronobiologic scheduling, naps, or use of medications such as modafinil may also improve nighttime staff performance.That's right. Dope the doctors and the nurses.
These investigators, at a loss to offer concrete staffing solutions, feel the use of drugs is the way to go. They reference two other studies: one in ER doctors and the other from sleep researchers touting the benefits of modafinil. Never mind that this drug prevents fitful sleep. It seems there is a move afoot amongst our clipboard-carrying colleagues to promote performance-enhancing drugs as a means to improve physician and nursing performance in all sorts of arenas.
I can see it now: George Mitchell will soon be hired by the hospitals' Bud Selig look-alike, Richard Umbdenstock, president and CEO of the American Hospital Association. Patients will be aghast at the findings. News media lights will shine. The scandal will be exposed. Performance enhancing drugs will "sully" the very game that is healthcare today. Doctors will be called before Congress, or worse: called to the witness stand to explain their drug-seeking behaviour to a jury of their peers.
Ridiculous, you say?
Not really. It is a sad commentary that there are really bozo's who think that the use of drugs should be condoned to improve outcomes in cardiac arrest.
That, my friends, makes my heart stop.
You made that up, right?
I mean... they can't possibly think that modafinil is the way to go, can they? My goodness, no wonder people just want a pill to cure all their ills... they're just following the advice of the PI gurus. Amazing. And sad. And scary.
...Or, how about just staffing those more dangerous periods with better qualified personnel (e.g. by paying some senior people a premium to be there)? Naw, that makes too much sense.
You hit the nail on the head about people with a database trying to justify it. There's a lot of these studies going around. It's really the media's fault for uncritically swallowing up anything that can be amped for fear factor. In an ideal world they'd be free to publish this and everyone would just ignore it. The fact that JAMA took it just shows that JAMA will take anything they think the media will pick up on.
My favorite quote by the lead author is "It may well be possible that there is a less-effective and less-efficient response at night."
In other exciting news, it may well be possible that worse nursing ratios give higher rates of bedside complications and having 1 intern managing 50 beds gives suboptimal results. I simply don't understand why hospitals don't have 1 nurse for every patient and a full staff of doctors at all times. Thankfully after this study, that will all be rectified (and we'll receive our daily modafinil).
It's not your performance managing cardiac arrests and the like that suffers at 4 am. During a code, your adrenal glands usually take over. It's the more mundane tasks that have more potential for error.
One of the biggest changes in ER medicine over the past 10 years is that we are more likely to be busy through the night. I rarely clean out the Er anymore, and I'm likely to be seeing patients until morning.
I have shift work sleep disorder, and I have taken Provigil almost daily for the past couple of years. If you're going to be up all night making life or death decisions, you might as well be awake. Some people are able to compensate for circadian shifts better than others, but the standard of care doesn't change just because you're a little sleepy.
Provigil is a miracle drug.
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