Wednesday, May 12, 2010

There's been a story in the papers lately about staff at the Olive View - UCLA hospital (jointly run by Los Angeles County and UCLA) who ran what's been described as a "hair and nail salon" in a neonatal ICU. Disappointing story; apparently, the fumes of acetone and other chemicals (in an apparent NEONATAL ICU !!) weren't enough to convince the hospital administration that this salon needed to be shut down. It took pressure from the Joint Committee on the Accreditation of Hospitals (JCAH) to get this salon shut down.

I wasn't sure that this was more than an isolated story ... until further investigation indicated that the story involved elements of standard University of California practices. Perhaps most shocking, the "neonatal ICU" at which this occurred, though being run like a neonatal ICU, and though accepting patients for long term ICU treatment, was not actually a legitimate ICU. The hospital had an intermediate critical care facility, without the staffing or certification of an ICU (even before a hair and nail salon was set up). They used, and presumably billed for, this intermediate critical care facility as an ICU. It's a lot like the UC Irvine / UC San Diego sham liver transplant program, in which a transplant program that didn't actually have the staffing (no full time transplant surgeon, nor transplant-qualified anesthesiologists) was claimed to be a legitimate, and fundable, transplant program. Yet another example of billing for a service, but not actually providing the complete service.

There are two possibilities for the babies who were intubated, and who were put into this sham ICU. One: the babies were actually sick enough to need a real ICU ... which was not actually provided. Two: the babies were not actually sick enough to need an ICU ... but the babies were intubated, subjected to ICU procedures, and the medical staff (and billing office!) just pretended to run an ICU around the not-sick babies. I really haven't yet figured out which possibility is worse.

Not to worry. The most likely event is that both possibilities were actualized. After all, this facility was short of ICU-trained personnel, and was apparently using non-ICU personnel instead. It's likely that, on the margin, the non-ICU personnel would not be able to differentiate between children who needed an ICU (and wouldn't get one anyway), and children who should not have been in an ICU. If the staff could not differentiate between these groups, probably some more-healthy-than-usual kids would likely have wound up in the fake ICU. Some sick kids, who might have benefited from a real ICU, probably wound up not even getting admitted to the fake ICU.

Has anyone out there ever seen a child getting an IV? They are often scared beyond fear. They are scared of the needle, of having their skin broken, of the restraints necessary to hold them as the IV goes in. Still, putting an IV into children is a fairly common occurrence; parents and medical personnel try to ignore the screaming, the crying, the abject terror they are causing, and convince themselves that whatever is being done is being done for the good of the child. And often, whatever is being done is, in fact, being done for the good of the child.

Except in this case. The Olive-View UCLA medical center did everything they could to justify billing for ICU care, including putting in IVs, intubating babies, and all the other billable procedures associated with ICU care ... but didn't actually provide the ICU nor ICU staffing. In this case, the procedures they did weren't part of a legitimate ICU treatment plan, but the procedures that generated billings continued. Providing an actual ICU to medically justify those procedures somehow got left out. I wonder how the staff of this fake ICU explained to parents that they (the staff) were doing all that could be done for the babies, all the while knowing that there was no actual ICU nor ICU staffing.

And, of course, there's the recurrent omertà that seems to enable the "culture of noncompliance with the law." I mean really; intubating a bunch of babies, who were or were not sick enough to be in an actual ICU, and pretending to keep them in an ICU, and apparently billing for ICU services, while not actually providing an ICU ... and no one talks until the JCAH comes investigating parent's complaints that this "ICU" has a hair and nail salon running in the back? Once again: wow. Simply wow.

Also, there are allegations of leaks of confidential patient information. That's apparently pretty routine for UCLA.

The patterns of continued misconduct, consistent with what the NIH apparently called "a culture of noncompliance with the law," continue. I certainly don't expect those patterns to change, though I am disappointed each time those patterns make the news.

Addendum: I've been waiting for some analysis of the death rate differential between the patients of this "ICU" and the patients in a real ICU. As far as I know, no such death rate differential has been published. There's a few possible reasons for that. I think the most likely reason is that this facility, as described above, probably had both the really sick babies who needed an ICU, and some not-so-sick babies who did not need an ICU. The really sick babies would be more likely to die in the fake ICU than in a real ICUs, and the not-so-sick babies would be less likely to die (since they weren't so sick to start with) than the patients in a real ICU. In this situation, the average death rate for the fake ICU could therefore be the same as the average death rate for a real ICU. A simple mortality comparison would thus show that the fake ICU was as safe as a real ICU ... and would be wrong.

If the fake ICU actually had a higher mortality rate than a real ICU (which seems likely, especially since the fake ICU was staffed by people who ran a hair and nail salon in the back), then theres a number of small boxes filled with small decomposing corpses under the ground in the Los Angeles area due to this recurrent U. of California pattern of charging for a service, claiming to provide the service, and not actually providing the service.

So, has anyone done an illness-normalized study of mortality rates for the fake Olive View UCLA ICU? I haven't seen one. Here's a reason, relating to my time working for the U. of California, that I don't think such a study will be done:

During my medical internship, I rotated through the Long Beach VA Medical Center, run by U. California, Irvine. While I was there, one of the cardiology fellows finished work on a paper that was supposed to be about mortality markers for CCU stays. During data analysis, this fellow accidentally documented that the post-angioplasty mortality rate for that facility was approximately three times the mortality rate for the main UC Irvine hospital. Same patient population, same surgeons in many cases, same equipment, same ORs in many cases ... and the patients who got post PTCA care at the VA died at three times the rate of those who did not. My recollection is that it was a 1.8% mortality vs. a .6% mortality. The nationally quoted "standard" mortality was, IIRC, .4%.

You know those boxes I mentioned a few paragraphs up? The boxes filled with decomposing corpses under the ground around a U. of California hospital? Those boxes were known to exist in this case. Not speculation. Actual scientific finding.

Thing is, that finding apparently doomed publication. The paper was never published, and, I was advised by another cardiology fellow, never would be submitted for publication. "You just can't publish things like that, you know," is the phrase I remember being used. From what I understand, the fellow involved allowed the knowledge developed by the creation of this paper to be quashed, in exchange for being allowed to continue in the UC Irvine cardiology fellowship program. It's my guess that documentation of those outrageously high mortality rates at a facility run by the University of California would have led to an investigation as to the cause of those mortality rates, and that the investigation might have led to discovery of outrageously lax credentialing and oversight procedures such as was the case at Olive View UCLA.

Back to the Olive View UCLA "ICU." It's certainly believable to me that a similar set of concerns might have led to either failure to study the mortality rates at that "ICU," or to quash publication of those rates were they ever documented.

Just a thought.

(this posting altered after publication)


Anonymous said...

Prevention is better than cure.............................................................

Anonymous said...

很用心的部落格 路過留言支持 ............................................................