Oximeters

Tom Benzoni benzonit at GMAIL.COM
Sun Feb 4 04:18:17 UTC 2018


Dr. Katz:
That sounds like a good study! We think we know that we induce considerable
variation in B/P measurement by not following these steps.
E.g., in ER, HR and B/P are routinely measured immediately on entry. So we
don't measure "base vitals," we measure "exercise recovery."

I believe you are pointing out that we will have great variation in results
when we use variation in measurement methods.
The importance of doing this simple procedure correctly as as important as
not checking the pressure on you tires when they are warm (unless there is
a problem.)

I'm concerned that sloppiness in simple matters makes a culture wherein
precision is not valued.
We then become lazy, ordering D-dimers on patients without PE (Pulmonary
Embolus) risk.
We then do CTAs on patients without PE by patient-oriented evidence.
We then prescribe anticoagulants to patients who can't benefit from them.
These patients then have intracranial bleeds.
And now we expect precision from the surgeon.
And all this without making a dent in deaths from PE.



tom

Fearing no insult, asking for no crown, receive with indifference both
flattery and slander, and do not argue with a fool. -Aleksandr Pushkin,
poet, novelist, and playwright (6 Jun 1799-1837)

On Feb 1, 2018, at 9:45, David Katz <d.katz at MAIL.UTORONTO.CA> wrote:

Wouldn’t an easier way to fix this problem be to reduce the number steps
needed to accurately check the BP?
Do we really know if all 11 steps are necessary?
I find it hard to believe that there are more steps to checking a blood
pressure than items on a central line checklist.
What is important is not that we achieve a specific number. What is
important is that we all do it the same way. Any procedure that includes 11
steps, with some of them being so mundane, is going to lead to wide variety
in practice.


David Katz MD FRCPC MSc
Adult Critical Care Medicine
Internal Medicine

On Jan 31, 2018, 9:49 PM -0500, hszerlip at gmail.com <hszerlip at GMAIL.COM>,
wrote:

Unfortunately most clinicians also
Fall short in taking BP. As our colleagues in other countries have learned,
BP is best taken automatically after the patient has been allowed to relax
and without a clinician in the room.

Harold Szerlip, MD
Director, Nephrology Division
Baylor University Medical Center, Dallas
Sent from my iPhone

On Jan 31, 2018, at 4:40 PM, robert bell <0000000296e45ec4-dmarc-
request at LIST.IMPROVEDIAGNOSIS.ORG> wrote:

Thanks Tom,

I checked on the JAMA Med Student blood pressure report - pretty awful.
Here is the link to the JAMA network summary.

https://jamanetwork.com/journals/jama/article-abstract/2653029?redirect=true

Only 1 out of 159 medical students scored 100% on all elements of the BP
challenge. Of the 11 elements the average score for all students was 4.1!

What does that say about the State of the Medical Industry!

Yes, it may be worse for the average HCP. I would be interested to
know what it would have been at foreign medical schools.

I agree with the idea of focussing on the small things first to establish a
culture. However I do think that culture needs some direction from above.

And with bottom line concern that is not always possible.

Would it be worthwhile to triage the main problems and focus on them with
or without help from other societies?  If we do not do this what will
happen?

Will more people be placed on BP medicines when they do not need it, with
this adding to the errors in diagnosis?

Thanks again for your fine replies.

Rob


On Jan 31, 2018, at 10:19 AM, Tom Benzoni <benzonit at gmail.com> wrote:

I'd focus on the rampant, low-level, constantly-tolerated, worked-around
errors.
These create an atmosphere wherein errors are ok.
Given human behavior, "We're ok with doing small jobs badly; we want big
jobs done right."is the philosophy of failure.
Big jobs are based on small jobs.

It's also simple math: the result of any process cannot be more precise
than the least precise of its components. (There are myriad sayings:
weakest link, slowest runner, etc.)

Excellence built into the system percolates up; it cannot drizzle down.

tom

On Wed, Jan 31, 2018 at 9:58 AM, Robert Bell <rmsbell200 at yahoo.com> wrote:

> Dear Tom,
>
> Thanks - appreciate your illuminating comments/thoughts. If all errors,
> including diagnostic, are at times inter-related how does the diagnostic
> error movement move forward? Focus on the commonest problems/combinations
> or focus on those that produce the greatest damage? Or all. A massive big
> challenge.
>
> Rob
>
>
> Sent from my iPad
>
> On Jan 31, 2018, at 8:04 AM, Tom Benzoni <benzonit at gmail.com> wrote:
>
> Dr. Bell:
> It's not well known, and is a double tragedy.
> Clinicians get beat up over endangering a patient when there was no
> expectant danger.
> This has the odd effect of causing interventions when none is warranted
> and making people less cognitive/aware.
> The way I know it is not well known: Hospitals have pages long protocols
> for procedural sedation, many written, in my not-very-humble opinion, to
> protect margins, and i've never seen this error discussed. (Don't make them
> aware; it's a marker I use for situational awareness.)
>
> You've only scratched the surface of errors in BP readings. JAMA had a
> recent paper discussing med student errors in measurement.
> Fortunately, they didn't study attendings or nurses in practice; it would
> have been worse.
> And nowhere so I see awareness that automated cuffs do not measure BP;
> they find first turbulent flow (approximately MAP) then, using proprietary
> algorithms, calculate a systolic and diastolic. Find that method in AHA
> guidelines?
> I helped write, many years ago, the original ACEP guidelines to NOT
> normalize/treat asymptomatic BP elevations found in the ER. (Full-on
> discussion behind that one separately.)
>
> If we tolerate this low level error systematically, how can we expect to
> address the large/few errors?
> High frequency-low consequence errors are arguably of greater import than
> low frequency-high consequence ones; driving to the airport caries greater
> risk of death than the flight itself.
>
> tom
>
>
> On Tue, Jan 30, 2018 at 10:21 PM, Robert Bell <
> 0000000296e45ec4-dmarc-request at list.improvediagnosis.org> wrote:
>
>> Thanks Tom,
>>
>> That is something to consider. How many HCPs know about that?
>>
>> What about, *Ipsilateral sphygmomanometer cuff - oximeter reading error*
>> !!
>>
>> And do not get me started on the frequency with which blood pressures are
>> taken with the wrong sphygmomanometer cuff size, and through clothing (some
>> times thick).
>>
>> I have in my postings to the list here always been interested in the
>> level of error in the things we do to help us with diagnoses. I strongly
>> believe that we need, to not only be improving our diagnostic abilities,
>> but also work to improve the errors of support tools at the same time. Both
>> need to be worked upon to get to our goal of significant reductions in
>> diagnostic error. That could be done with partnering with another society
>> or societies, more dedicated to standard errors, with time related goals to
>> help get there soon.
>>
>> Robert Bell
>>
>> On Tuesday, January 30, 2018, 2:57:56 PM MST, Tom Benzoni <
>> benzonit at GMAIL.COM> wrote:
>>
>>
>> Orthopedic changes do not effect them.
>> Skin thickness does not but we don't use these over callused areas.
>> They can read black skin. Melanin has a different spectral absorption.
>> Very cold extremities where the capillary beds are clamped down can cause
>> erroneous readings as can patients in extremis from end-stage myocardial
>> disease...but don't need a pulse ox there.
>> An interesting error source comes from blood pressure cuffs. Because the
>> cuffs are usually set to automatic, intermittent low readings occur not
>> from the patient but from temporary occlusion of the artery by the cuff if
>> on the ipsilateral arm. If you're not aware of this error source, you can
>> think the patient on whom you're doing a procedure is in trouble when
>> they're fine. And you might terminate the procedure or make an unnecessary
>> intervention on a well person.
>> What is that type of error?
>>
>> tom
>>
>> On Mon, Jan 29, 2018 at 11:49 PM, robert bell <
>> 0000000296e45ec4-dmarc-request at list.improvediagnosis.org> wrote:
>>
>> I was thinking also of the accuracy in elderly patients with
>> osteoarthritis, bent fingers, and soft skin versus hard thickened skin and
>> also the differences with different fingers.
>>
>> Yes, alarms are a problem.
>>
>> Rob Bell, M.D.
>> > On Jan 29, 2018, at 3:11 PM, Rory Jaffe <rjaffe at CHPSO.ORG> wrote:
>> >
>> > Interpretation is a big issue. Pulse oximetry is very insensitive to
>> hypoventilation when a patient is on supplemental O2. Also tends to have
>> lots of false alarms--the default limits are not very usable and ideally,
>> people would use patient-specific alarm limits.
>> >
>> > -----Original Message-----
>> > From: Grubenhoff, Joe [mailto:Joe.Grubenhoff@ CHILDRENSCOLORADO.ORG
>> <Joe.Grubenhoff at CHILDRENSCOLORADO.ORG>]
>> > Sent: Monday, January 29, 2018 8:55 AM
>> > To: IMPROVEDX at LIST. IMPROVEDIAGNOSIS.ORG
>> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> > Subject: [No SPF Record] Re: [IMPROVEDX] Oximeters
>> >
>> > Pretty accurate in my experience - the problem may be in how this
>> single value is interpreted in the context of the whole clinical picture:
>> >
>> >
>> >
>> > Effect of Oxygen Desaturations on Subsequent Medical Visits in Infants
>> Discharged From the Emergency Department With Bronchiolitis.
>> >
>> > Principi T, Coates AL, Parkin PC, Stephens D, DaSilva Z, Schuh S.
>> >
>> > JAMA Pediatr. 2016 Jun 1;170(6):602-8. doi:
>> 10.1001/jamapediatrics.2016. 0114.
>> >
>> >
>> >
>> > Effect of oximetry on hospitalization in bronchiolitis: a randomized
>> clinical trial.
>> >
>> > Schuh S, Freedman S, Coates A, Allen U, Parkin PC, Stephens D, Ungar W,
>> DaSilva Z, Willan AR.
>> >
>> > JAMA. 2014 Aug 20;312(7):712-8. doi: 10.1001/jama.2014.8637.
>> >
>> >
>> >
>> >
>> >
>> > On 1/29/18, 09:49, "Robert Bell" <0000000296e45ec4-dmarc-
>> request at LIST.IMPROVEDIAGNOSIS. ORG
>> <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> wrote:
>> >
>> >
>> >
>> >    How accurate are oximeters? Are the errors big enough to make wrong
>> decisions?
>> >
>> >
>> >
>> >    Rob Bell, M. D.
>> >
>> >
>> >
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>> ------------------------------
>>
>>
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>
>
>


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To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1

or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG



Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/


------------------------------


To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1

or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG



Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/


------------------------------


To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1

or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG



Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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