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Nurse Creates The Mother Lode of All Advance Directives.

Albany, NY -- Adrian Fleming knew all about the horrors that went on at her hospital everyday.  As a seasoned floor nurse at SunnyView Hospital for over 20 years, she had a front seat view of the face palms that threatened patient safety everyday. She also knew someday she would be a patient in her own hospital and with that fear in mind, set out to create the mother lode of all advance directives.

An advance directive is a written statement of a person's wishes regarding medical treatment created to ensure those wishes are carried out should the person be unable to communicate them to a doctor.

Her advance directive began as a collection of wishes and prayers and fears written on the back of sticky notes and used napkins, the communication method of choice between doctors and nurses.  After her first year on the job, Adrian had a large collection of random demands, each meticulously notarized by the hospital chaplain for authenticity.

Over the years, her collection of requests grew into a 17 page hardback nonfiction book titled Nobody Is Ever In a Fu*king Vegetative State:  What You Should Really Include In Your Advance Directive, an Amazon Times best seller.

An advance directive nobody will ever miss.
Then tragedy struck.  After twenty years of caring for patients, Adrian found herself hospitalized in the ICU,  seriously injured after hitting a light pole trying to avoid a barely gowned patient that just left AMA to buy cigarettes at a gas station across the street from her hospital.

Luckily, Adrian had her advance directive with her at all times; a barcode tattoo on her wrist, where she knew all the nurses would place her numerous armbands.

Unresponsive and intubated, but not in a vegetative state, Adrian's new grad nurse working in the ICU for the first time because seven nurses quit the week before after being accepted into nurse anesthetist school, scanned her wrist before placing the first of her seven  Joint Commission mandated arm bands. And what she found was a treasure of information on how to care for Adrian in the hospital.

Up on her computer popped a message that started, "Think of this as my birth plan for my ICU stay. I can hear everything you're saying.  As your guiding force, if you're thinking 'I would never let that happen to me, then don't let it happen to me either.'"

Then page after page of medical directives started flowing from the computer, as if a damn had broken upstream and a river of knowledge was released on the newby.  All in all, 496 legally binding demands were laid out for all the medical staff to adhere to.  Here are the top 10.

TOP 10 ADVANCE DIRECTIVE REQUESTS


1)  Don't let these surgeons operate on me Dr. XXXX, Dr. YYYY,  Dr. ZZZZ, Dr. XOXO, Dr XXY.   I don't care if they are the only ones on-call.  Transfer me AMA to another hospital if you have to (Names protected for publication).

2)  Don't even think about putting a Foley in me just because you don't wan't to clean me.  And that means no rectal tube either.  This is nonnegotiable.

3)  I don't want a CT scan to rule out shit that you and I both know I don't have if you just take the time to examine me.

4)  Don't put me on antibiotics because you can't tell if its CHF vs PE vs PNA vs COPD.  The xray is probably abnormal because of poor technique.

5)  If the radiologist says clinical correlation recommended, I don't want any other images read by that radiologist.    They are fired.

6)  Don't even think about consulting dermatology for any reason.   Instead, if it's wet make it dry and if it's dry make it wet.

7)  If you don't put me on VTE prevention dosing prophylaxis, I'm going to sue every...last...one...of...you, when I get a DVT.

8)  If I get c diff, it's because you didn't wash your f**cking hands.  I'm not a carrier, I can assure you.  That means I'm going to sue every...last...one...of...you.  Don't give me c diff.

9)  If I'm in isolation, I expect you to follow all the precautions, every time.  Not just the first 30 minutes of your shift.

10)  I am not hospice material.  Don't let the hospitalist tell you otherwise.


"You get a Foley. And you get a Foley. Everyone gets a Foley!"

You get a Foley. And you get a Foley. Everyone gets a Foley!



Top 10 Causes of DKA Hospitalization (ICD-10 Codes)

Most internists are taught the three most common causes of hospitalization for diabetic ketoacidosis (DKA) are infection, infection, infection.  In clinical reality, the three most likely causes of hospitalization for DKA are didn't take insulin, didn't take insulin and didn't take insulin.  With ICD-9, E15.1 could be used to code DKA Hospitalization Due to Noncompliance.  With ICD-10 coding rules, didn't take insulin is not specific enough to code the cause of DKA hospitalization.  The new ICD-10 codes provide a much more detailed look at the causes of DKA leading to hospitalization and will hopefully allow healthcare agencies an enormous amount of your personal data to improve public health.


TOP 10 CAUSES OF DKA HOSPITALIZATION (ICD-10 CODES)


1)  I forgot to take my insulin because I was Playing Pokemon GO. (E15.1)

2)  I forgot to take my insulin because I was twerking  and puking all night. (E15.2)

3)  I didn't to take my insulin because I was was nauseated and had abdominal pain and I was light headed and I wasn't eating and I didn't know what my sugar was.  (E15.3)

4)  I didn't take my insulin because I didn't f**king feel like it. (E15.4)

5)  I ran out of my insulin and couldn't even afford to buy a pack of cigarettes and I didn't have a friend to bum a bottle of insulin off of. (E15.5)

6)  I told everyone at the hospital I took my insulin just like I was supposed to but I actually haven't taken it for a week because I didn't f**king feel like it. (E15.4.6)

7)  Whether I took my insulin or not is none of your business and can I have some Dilaudid and a bag of Cheetos for my abdominal pain? (E15.7)

8)  I didn't take my insulin because the doctor who told me seven years ago I had diabetes didn't know what they were talking about. (E15.8)

9)  I didn't take my insulin because this sh*tty hospital wouldn't give me free insulin to take home when I was hospitalized last week. (E15.9)

10)  DKA hospitalization unknown because the childlike adolescent in their upper 20's who lives with their enabling parents refused to talk, gave nasty faces and slept with their boyfriend/girlfriend every night and then left AMA after eating a hearty breakfast.  (E15.10)

With ICD-10 exposing the top 10 causes of DKA hospitalization, make sure to provide insight for other readers with your experiences as well.  In the interest of public safety, please leave your experience with the causes of DKA hospitalization in the comments below so other healthcare professionals can gain a greater understanding of what to be on the lookout for when frequent flyer DKA patients come to the ER for hospitalization.

"So you have another DKA hospitalization this month.  Tell me again how you took all your insulin and have no idea why this happened, again."

So you have another DKA hospitalization this month. Tell me again how you took all your insulin and have no idea why this happened, again.



Top 10 Reasons Patients Skip Dialysis

The National Association of Noncompliant Dialysis Patients (NANDP), the largest noncompliant patient association in America, has released their 2016 Top 10 Reasons For Skipping Dialysis survey. Debuting in the top ten for the first time  in this annual survey  were Shopping on Amazon Prime Day and Playing Pokemon GO.

 "Amazon, Pokemon and Netflix are driving our chronic dialysis patients to an early grave,"  said Dr Stanley Cornsmith, M.D., Director of AMA Patient Satisfaction.  "I don't even want to think of what will happen once virtual reality goes mainstream.  We'll have hundreds of thousands of patients hospitalized because they thought they actually got dialyzed.

 Falling out of the top ten reasons for missing dialysis were I Was Eating and I Couldn't Get a Ride, which had been perennial powerhouses on the survey's top 10 list.

TOP 10 REASONS PATIENTS SKIP DIALYSIS

1. I just had dialysis two days ago.

2. I was shopping on  Amazon Prime Day.

3.  I had shit to do.

4.  My chiropractor does manipulation instead.

5.  They wouldn't let me smoke.

6.  I was too busy playing Pokemon Go.

7.  What is dialysis?

8.  I drink Plexus instead.

9.  I was Netflix Binging

10.  I was too short of breath to go.

(11).  Obamacare.

(12).  They wouldn't let me bring my therapy dog for emotional distress.

(13).  Changes mind on hospice hourly.


"The number of noncompliant dialysis patients is too damn high."

The number of noncompliant dialysis patients is too damn high.



Illinois Needs to Protect Consumers in Wake of Land of Lincoln Debacle

The liquidation of Land of Lincoln Health is just the first of mounting hurdles for Illinois consumers and small-business owners shopping for health insurance coverage in the Affordable Care Act marketplace.

Not only do Illinois consumers wait longer than others across the country to see annual rate increases, but they also have fewer resources to help navigate the marketplace. The state's budget morass means the two state agencies charged with protecting consumer interests and helping consumers connect with coverage options—the Department of Insurance and Get Covered Illinois—are underfunded and ill-prepared to serve the public.

Who will protect consumers' interests in the demise of Land of Lincoln? We keep hearing that the state's insurance department doesn't have the staff to provide information on rate increases to the public until Aug. 1 (even though the department received them from insurers in April). If regulators can't meet the requirements of the ACA in a timely manner, how will they manage the liquidation details for Land of Lincoln? Can consumers count on them to answer critical questions about their now-defunct Land of Lincoln plans?

Questions like: Should I keep paying my premiums to Land of Lincoln? (Yes, you should if you want to be eligible for the special enrollment period plan holders will be offered.) Will I be able to find another plan with my providers in the network at the same price point? What happens if I already met my deductible with Land of Lincoln? Will that carry over to the new plan? And, who will help me find a new plan? Because Get Covered grant funding to help consumers is gone, and insurance carriers reduced or eliminated broker commission for working with clients, Illinois consumers are left with fewer resources when faced with complex health insurance decisions.

We should all be watching how the Department of Insurance addresses the needs of Land of Lincoln policyholders. When Blue Cross & Blue Shield narrowed its networks offered in the marketplace, thousands migrated to Land of Lincoln because of its broader networks with academic medical centers like the University of Chicago. The loss of Land of Lincoln leaves consumers and small-business owners worrying about continuity of care—for themselves and their employees.

This development ensures one thing for the upcoming open enrollment season: Illinois consumers and small businesses will have even less choice, and fewer affordable options that cover a broader network of health care providers.

How the Department of Insurance responds to this crisis is important for all Illinois consumers. We only hope the Rauner administration redirects resources to make sure the Department of Insurance can do its job and do it well.


Barbara Otto and Michelle Thornton Health & Disability Advocates

Reprinted with permission from Crain's Chicago Business

18 Awesome Pokemon GO Medical Memes for Doctors and Nurses and Patients!

Pokemon GO, the augmented reality smart phone game, has taken the world by storm.  Millions of addicted players are roaming the streets, day and night, hunting pikachus with gross disregard for everyone around them.  And what better way to discuss how Pokemon GO has affected doctors, nurses and patients alike than 18 perfectly described medical memes explaining the many ways life is now different in a post Pokemon world.  Please enjoy these 18 original Happy Hospitalist Pokemon medical memes and feel free to add your own in the comments below.  Now stop reading and GO Pokemoning!


"Waiting for call light to get answered while everyone plays Pokemon GO."

WAITING FOR CALL LIGHT TO GET ANSWERED WHILE EVERYONE PLAYS POKEMON GO.


"The number of ER patients playing Pokemon GO is too damn high!"

THE NUMBER OF ER PATIENTS PLAYING POKEMON GO IS TOO DAMN HIGH.


"You said you weren't playing Pokemon GO when you called in sick three days this week.  The lie detector determined that was a lie."

YOU SAID YOU WEREN'T PLAYING POKEMON GO WHEN YOU CALLED IN SICK THREE DAYS THIS WEEK. THE LIE DETECTOR DETERMINED THAT WAS A LIE.


"You get discharged!  And you get discharged!  Everyone gets discharged! (when playing Pokemon Go))"

YOU GET DISCHARGED AND YOU GET DISCHARGE. EVERYONE GETS DISCHARGED WHEN PLAYING POKEMON GO


"Am I the only one around here not playing Pokemon GO?"

AM I THE ONLY ONE AROUND HERE NOT PLAYING POKEMON GO


"You brought your kid to the ER because he wouldn't stop playing Pokemon GO?  WTF!"

YOU BROUGHT YOUR KID TO THE ER BECAUSE HE WOULDN'T STOP PLAYING POKEMON GO. WTF.


"That face you make when ER patients check in playing Pokemon GO in triage."

THAT FACE YOU MAKE WHEN ER PATIENTS CHECK IN PLAYING POKEMON GO IN TRIAGE.


"You want Dilaudid for 12/10 pain, but you're playing Pokemon GO in my ER? No...No! No! No!"

YOU WANT DILAUDID FOR 12/10 PAIN, BUT YOU'RE PLAYING POKEMON GO IN MY ER. NO NO NO NO


"What if I told you playing Pokemon GO in the ER will automatically get you Tylenol for pain."

WHAT IF I TOLD YOU PLAYING POKEMON GO IN THE ER WILL AUTOMATICALLY GET YOU TYLENOL FOR PAIN.


"You came to the hospital for sepsis, but you want to come and go as you please to catch pikachus?"

YOU CAME TO THE HOSPITAL FOR SEPSIS BUT YOU WANT TO COME AND GO AS YOU PLEASE TO CATCH PIKACHUS?


"Came to the ER looking for Dilaudid but left AMA to play Pokemon GO instead."

CAME TO THE ER LOOKING FOR DILAUDID BUT LEFT AMA TO PLAY POKEMON GO INSTEAD


"If you could stop playing Pokemon GO in the ER that would be great."

IF YOU COUD STOP PLAYING POKEMON GO IN THE ER THAT WOULD BE GREAT.


"I see you caught 77 pikachus while your patient called 911 for help, but that's none of my business."

I SEE YOU CUAGHT 77 PIKACHUS WHEIL YOUR PATIENT CALLED 911 FOR HELP, BUT THAT'S NONE OF MY BUSINESS.


"Tell me again how you came to the ER with the worst headache ever, while playing Pokemon in the waiting room."

TELL ME AGAIN HOW YOU CAME TO THE ER WITH THE WORST HEADACHE EVER WHILE PLYING POKEMON IN THE WAITING ROOM.


"Prepare yourself.  Your doctors and nurses are too busy playing Pokemon GO."

PREPARE YOURSELF. YOUR DOCTORS AND NURSES ARE TOO BUSY PLAYING POKEMON GO.


"One does not simply claim 12/10 pain while in the ER playing Pokemon GO."

ONE DOES NOT SIMPLY CLAIM 12/10 PAIN WHILE IN THE ER PLAYING POKEMON GO.


"There's a pikachu in room 12 I need to catch.  But you have 6 patients to finish charting on."

THERE'S A PIKACHU IN ROOM 12 I NEED TO CATCH. BUT YOU HAVE 6 PATIENTS TO FINISH CHARTING ON.


"I don't always play Pokemon GO at the hospital.  But when I do, the patients with 12/10 pain are usually joining in."

I DON'T ALWAYS PLAY POKEMON GO AT THE HOSPITAL BUT WHEN I DO, THE PATIENTS WITH 12/10 PAIN ARE USUALLY JOINING IN.



NOTICE Act Could Do More for Patients


Starting August 6th, the Notice of Observation Treatment and Implication for Care Eligibility Act, or NOTICE Act, will go into effect. This new law requires hospitals to give written and verbal notice to Medicare beneficiaries who have been on observation status for more than 24 hours.

What is observation status? 

In a nutshell, observation status is a term hospitals use to bill Medicare. Observation status is based on a doctor’s medical determination. Doctors place patients on observation status if their condition is not serious enough for inpatient admission status, but still requires monitoring in case health worsens.

The NOTICE Act is a step in the right direction because patients are often unaware of their observation status or its potential consequences. Prior to the NOTICE Act, the only way to know your status was to ask. Part of the reasoning behind the law is that beneficiaries get hit with serious financial consequences including higher than expected hospital bills and that Medicare won’t cover skilled nursing care needed after discharge from the hospital. However, the law could do better to prevent those consequences.

The issue for many patients is that being on observation status also means they are classified as an outpatient, not an inpatient. That means that rules for Medicare Part B (outpatient services) and D (prescription medication coverage) apply to their hospitalization rather than part A (inpatient).

To understand this better, here is a chart comparing estimated costs. Let’s say a patient stays at the hospital for 4 days, and the care provided ends up costing $10,000. Keep in mind that costs can vary greatly depending on the type of care provided during that time.


Oftentimes, Medicare beneficiaries learn about their observation status when arranging for the skilled nursing facility care they need after discharge. These patients make the very valid assumption that because they are wearing hospital gowns, in a hospital bed, eating hospital food, meeting with nurses and taking tests administered by doctors that they are an inpatient. They learn their actual status, and its consequences, too late and have little recourse.

How could the law be improved?

An appeal process is needed.
The NOTICE Act ensures people know about their observation status and the financial consequences of this determination. And that’s it. They don’t know the medical reasons a doctor made the decision and they aren’t given any avenues to appeal this determination. Patients will be informed of their observation status and the possibility of higher medical costs, but have no recourse to fight the decision.

Use plain-language in the notice to ensure comprehension. 
The Medicare Outpatient Observation Notice, or MOON, used to inform patients about their observation status is not written using easy-to-understand language. In its current form, the MOON is written for a 12-grade reading level, a break from the common practice of writing consumer materials for no more than an 8th grade reading level.

Do you agree Medicare patients deserve more?

Tell the federal government. They are asking for your comments right now in response to the proposed rules. You can use this comment template or submit comments on your own. Submit your comments with these simple steps:

  • Go to the website where comments are submitted. Enter the phrase "Medicare Program: Hospital Inpatient Prospective Payment Systems" in the search box. The first hit will be the rule you want to comment on. Click the "Comment Now!" blue box. 
  • Use our comment template to show how people you know have been hurt by observation status and why changes need to be made by including personal information where indicated with yellow highlights. Adding specific examples of real people makes your case more compelling.
  • You can also write your own feedback directly in the comment box.

Go ahead, make your voice heard! The greater number of people that speak up, the more likely changes will be made.

How can you get ready? 

While the law could be improved, it will be implemented August 6th. Prepare for the changes by getting informed:
Going to the hospital is already stressful. Deciphering complex notices, understanding jargon and dealing with unexpected medical bills increases the strain. Armed with knowledge, you can act as a more effective advocate for yourself, your clients or patients, and loved ones so they can focus on their health and recovery.

Bryce Marable
Health Policy Analyst
Health & Disability Advocates

Health Care Changes for Small Businesses in 2016

It’s been about six years since the passage of the Affordable Care Act, but some provisions of the health care law that can improve health care options for small businesses are still being implemented – like employee choice. By learning about this addition and other aspects of the law, small business owners can empower themselves to make the best decisions regarding health coverage for themselves and their employees. In many ways, health care options for small businesses are remaining the same this year. For instance, the Small Business Health Options Program in Illinois will continue offering an array of cost-competitive insurance plans from which employers can choose. And as always, qualified small businesses that purchase health insurance through SHOP may receive federal tax credits to help offset the cost of coverage.

Employee Choice, a Positive New Change

There are several new features of the law being implemented this year, though. One of the biggest and most promising changes is the implementation of employee choice, which is now available in every state. Employee choice allows small business workers to choose from a number of plans from different insurance carriers. Under employee choice, workers choose which carrier they’d prefer to use, instead of business owners choosing for them. This option plays a key role in distinguishing SHOP from the outside health insurance market, and it’s popular among small business owners. In fact, Small Business Majority’s polling found two-thirds of small employers believe allowing employees to choose among multiple carriers is an important element of the health care marketplaces.

While employee choice is a great development for small businesses, options under Illinois’s employee choice program aren’t as robust as they could be. In some parts of Illinois, only one or two insurance providers are participating in SHOP. While employers can still choose different levels of coverage from participating providers, more providers will need to participate to boost options for small businesses.

Taking Advantage of the New Opportunities 

If your business has fewer than 51 full-time employees, you can enroll in SHOP at any time during the year to take advantage of employee choice. In order to begin the enrollment process now, entrepreneurs should visit www.getcoveredillinois.gov or the National Association of Health Underwriters to contact a health insurance broker who is trained and certified to enroll small businesses for SHOP Marketplace plans. Brokers are well-versed in the ins-and-outs of the ACA, and there’s often no extra cost to utilize their services.

While 2016 offers changes in Illinois’s small business health insurance landscape, small business owners shouldn’t be concerned. Changes like employee choice are a step in the right direction for entrepreneurs. The best bet is for employers to arm themselves with information; that way, they can choose health coverage that maximizes benefits for their business.

Geri Aglipay
Outreach Manager, Midwest Region and Greater Chicago
Small Business Majority 

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