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You can fool some of the people, some of the time, but not this time
AORN JOURNAL
SEPTEMBER 1986. VOL. 44. NO 3
Editorial You can fool some of the people, some of the time, but not this time
E
veryone likes to be asked their opinion, but no one likes their opinion ignored. And that is just what the federal government did-ignored the comments of nurses-when the Department of Health and Human Services, Health Care Financing Administration (HCFA), published the 1983 notice of proposed rulemaking (NPRM) concerning what conditions hospitals must meet to be certified for participation in Medicare or Medicaid. Every time HCFA officials publish proposed revisions of a regulation or condition, they do two things: they advise the readers that the revisions are intended to strengthen “patient health and safety,” and they state that consideration will be given to written comments or suggestions submitted by a certain date. In the case of the final regulations published in the Federal Regikter on June 17 of this year, they did neither. It is as though the government officials were so intent on projecting an image of belt-tightening that they lost sight of patient safety and, for the most part, ignored the comments of the professionals who are most concerned with quality patient care. After the 1983 NPRM was published, HCFA officials received more than 36,300 comments. According to the Federal Regkler, 85 comments were received from “professional medical and health care associations.” If, like AORN, those associations have memberships of thousands, those 85 comments should have been weighed accordingly in the decision-making process and not just viewed as 85 individual voices. After reading the final regulations, I believe comments that were contrary to HCFA’s predetermined 366
course of action were not considered. In the case of operating room circulating responsibilities, HCFA’s disregard for patient safety and for the comments submitted from nurses is blatant. As many of you know, the wording in the final regulations is quite different from the 1983 NPRM. Technicians and LPNs may now “assist in circulatory duties under the supervision of a qualified registered nurse who is immediately available to respond to emergencies.” Officials must have had blinders on to the thousands of comments submitted by nursing organizations and individual practitioners that addressed safe patient care in the operating room. In the comments section, HCFA officials summarized the comments of the surgical technologists, who objected to the 1983 NPRM that mandated their direct supervision by a registered nurse. Officials were convinced by surgical technologists and LPNs that they are “qualified through education and experience to perform these functions without supervision of a registered nurse.” Comments submitted by groups as large as the American Nurses’ Association and AORN, as well as other professional associations were not discussed. It seems to me that because those comments were contrary to HCFA’s predetermined goals, they were ignored. No one ever said that technologists or LPNs have no role in the care of the surgical patient. But to say that the reason for eliminating the requirement for direct supervision by an RN was to “strengthen patient health and safety” is absurd. And the regulations state just that. The HCFA officials assert that this approach
AORN JOURNAL
SEPTEMBER 1986, VOL. 44, NO 3
“will help protect patient health and safety by ensuring the ready availability of a registered nurse who has training and experience in all aspects of comprehensive skilled patient care.” If they were truly interested in patient safety, they would recognize-and mandate-that nurses, the professionals who have the skills to deliver comprehensive care, do just that. Nurses belong in the OR, and not in some unidentified place away from the patient. If the HCFA officials believe that this change
in the regulations makes the public believe the government is saving money while quality patient care is maintained, they are wrong. The final regulations do neither. The patients served by the Medicare and Medicaid programs are smarter than that. And the hospital and nursing administrators responsible for hiring appropriate professional staff are also smarter than that. PATNIESSNERPALMER,RN, MS EDITOR
Abdominal X-rays Not Needed for Stab Wounds
Rising Health Care Costs Will Continue
Routine roentgenograms for evaluating abdominal stab wounds should be eliminated, according to recommendations of a research report in the April Surgery, Gynecology, and Obstetrics. According to the report, abdominal x-rays make a negligible contribution to the wound diagnosis, are too expensive to use on a routine basis, and are not reliable. Researchers from the University of Texas Health Science Center at San Antonio reviewed medical records for all patients with abdominal stab wounds admitted to the medical center between Sept 1, 1981 and March 1, 1984. Of the 128 patients, 94 (73.5%)had x-rays taken. The x-rays showed abnormal results in eight patients (8.5%).Of those, seven had peritoneal injuries requiring surgery. However, all seven injuries were discovered during the physical examination; thus, the roentgenograms were not needed, researchers noted. According to the article, each roentgenogram cost $1 19, which was a total of $1 1,186 for the 94 patients studied. Dividing that number by the number of abnormal results (eight), produces a total of $1,398.25 per positive roentgenogram. Those figures, researchers said, indicate that roentgenograms are not a cost-effective treatment, especially considering that the abnormal roentgenograms did not help in diagnosis. Researchers also stated that there was a significant false-negative rate (49%)in this study.
Health care costs are rising and will continue to rise, according to an article in the July 11 issue of the Journal of the American Medical ihsociation. The article was written by a researcher from Columbia University, New York City. , According to the researcher, medical costs are determined by physicians, technology, and patients’ desire for the best possible care regardless of the price. Of those, he said, it is the physicians who control all diagnostic and therapeutic interventions and, thus, are the driving force behind price increases. Technology, according to the researcher, will also continue to push health care prices up, Patients want the most effective treatment, not the least costly treatment, he said. Another factor likely to keep prices from falling is the lack of a competitive health care market. Because 70%of health care costs are paid by the government and insurance, the health care industry is not subject to the same influences as a competitive market. Diagnosis related groups have reduced the cost of health care, he added, but they only represent a small portion of the overall costs.
368
SEPTEMBER 1986. VOL. 44. NO 3
Editorial You can fool some of the people, some of the time, but not this time
E
veryone likes to be asked their opinion, but no one likes their opinion ignored. And that is just what the federal government did-ignored the comments of nurses-when the Department of Health and Human Services, Health Care Financing Administration (HCFA), published the 1983 notice of proposed rulemaking (NPRM) concerning what conditions hospitals must meet to be certified for participation in Medicare or Medicaid. Every time HCFA officials publish proposed revisions of a regulation or condition, they do two things: they advise the readers that the revisions are intended to strengthen “patient health and safety,” and they state that consideration will be given to written comments or suggestions submitted by a certain date. In the case of the final regulations published in the Federal Regikter on June 17 of this year, they did neither. It is as though the government officials were so intent on projecting an image of belt-tightening that they lost sight of patient safety and, for the most part, ignored the comments of the professionals who are most concerned with quality patient care. After the 1983 NPRM was published, HCFA officials received more than 36,300 comments. According to the Federal Regkler, 85 comments were received from “professional medical and health care associations.” If, like AORN, those associations have memberships of thousands, those 85 comments should have been weighed accordingly in the decision-making process and not just viewed as 85 individual voices. After reading the final regulations, I believe comments that were contrary to HCFA’s predetermined 366
course of action were not considered. In the case of operating room circulating responsibilities, HCFA’s disregard for patient safety and for the comments submitted from nurses is blatant. As many of you know, the wording in the final regulations is quite different from the 1983 NPRM. Technicians and LPNs may now “assist in circulatory duties under the supervision of a qualified registered nurse who is immediately available to respond to emergencies.” Officials must have had blinders on to the thousands of comments submitted by nursing organizations and individual practitioners that addressed safe patient care in the operating room. In the comments section, HCFA officials summarized the comments of the surgical technologists, who objected to the 1983 NPRM that mandated their direct supervision by a registered nurse. Officials were convinced by surgical technologists and LPNs that they are “qualified through education and experience to perform these functions without supervision of a registered nurse.” Comments submitted by groups as large as the American Nurses’ Association and AORN, as well as other professional associations were not discussed. It seems to me that because those comments were contrary to HCFA’s predetermined goals, they were ignored. No one ever said that technologists or LPNs have no role in the care of the surgical patient. But to say that the reason for eliminating the requirement for direct supervision by an RN was to “strengthen patient health and safety” is absurd. And the regulations state just that. The HCFA officials assert that this approach
AORN JOURNAL
SEPTEMBER 1986, VOL. 44, NO 3
“will help protect patient health and safety by ensuring the ready availability of a registered nurse who has training and experience in all aspects of comprehensive skilled patient care.” If they were truly interested in patient safety, they would recognize-and mandate-that nurses, the professionals who have the skills to deliver comprehensive care, do just that. Nurses belong in the OR, and not in some unidentified place away from the patient. If the HCFA officials believe that this change
in the regulations makes the public believe the government is saving money while quality patient care is maintained, they are wrong. The final regulations do neither. The patients served by the Medicare and Medicaid programs are smarter than that. And the hospital and nursing administrators responsible for hiring appropriate professional staff are also smarter than that. PATNIESSNERPALMER,RN, MS EDITOR
Abdominal X-rays Not Needed for Stab Wounds
Rising Health Care Costs Will Continue
Routine roentgenograms for evaluating abdominal stab wounds should be eliminated, according to recommendations of a research report in the April Surgery, Gynecology, and Obstetrics. According to the report, abdominal x-rays make a negligible contribution to the wound diagnosis, are too expensive to use on a routine basis, and are not reliable. Researchers from the University of Texas Health Science Center at San Antonio reviewed medical records for all patients with abdominal stab wounds admitted to the medical center between Sept 1, 1981 and March 1, 1984. Of the 128 patients, 94 (73.5%)had x-rays taken. The x-rays showed abnormal results in eight patients (8.5%).Of those, seven had peritoneal injuries requiring surgery. However, all seven injuries were discovered during the physical examination; thus, the roentgenograms were not needed, researchers noted. According to the article, each roentgenogram cost $1 19, which was a total of $1 1,186 for the 94 patients studied. Dividing that number by the number of abnormal results (eight), produces a total of $1,398.25 per positive roentgenogram. Those figures, researchers said, indicate that roentgenograms are not a cost-effective treatment, especially considering that the abnormal roentgenograms did not help in diagnosis. Researchers also stated that there was a significant false-negative rate (49%)in this study.
Health care costs are rising and will continue to rise, according to an article in the July 11 issue of the Journal of the American Medical ihsociation. The article was written by a researcher from Columbia University, New York City. , According to the researcher, medical costs are determined by physicians, technology, and patients’ desire for the best possible care regardless of the price. Of those, he said, it is the physicians who control all diagnostic and therapeutic interventions and, thus, are the driving force behind price increases. Technology, according to the researcher, will also continue to push health care prices up, Patients want the most effective treatment, not the least costly treatment, he said. Another factor likely to keep prices from falling is the lack of a competitive health care market. Because 70%of health care costs are paid by the government and insurance, the health care industry is not subject to the same influences as a competitive market. Diagnosis related groups have reduced the cost of health care, he added, but they only represent a small portion of the overall costs.
368