Fixing: Healthcare & Drowning

Sometimes, I believe that the best way to assess someone's understanding of healthcare is by observing whether they claim they can fix healthcare or, even worse, assert that they know how to fix it. In the realm of healthcare, a true understanding reveals that our healthcare system isn't easily fixable, and attempts to do so often make it more dysfunctional. Those who consider themselves "fixers" tend to seek quick solutions that may address one issue but neglect or even exacerbate the broader problems that result from their workarounds.

As I promised, in the upcoming weeks, I will shift the focus towards strategies that prevent further deterioration and instead foster continuous improvement within our healthcare system. To me, this process commences by encouraging those who believe they possess a "fix" to expand their perspectives and contemplate how we can enhance outcomes, reduce costs, and mend the many facets of healthcare that are more disrupted by "fixes" than genuinely resolved.

For this week, let's begin to explore a broader perspective and how healthcare and us "fixers" need to look at the much bigger picture if we are to improve outcomes, costs and improve equity.

Healthcare is drowning. If we're not drowning, we're definitely underwater in so many ways. I want to help fix healthcare, prevent drowning. It's tragically ironic that comparing these two "cases" can elucidate the challenges before us and make us ponder if or how we could approach healthcare differently.

As a pediatric emergency physician who has too often witnessed the tragedy of drowning and "near-drowning" (children who survive but have lasting brain injury), it's absolutely devastating. If you are not familiar with the data on drowning in children, I would encourage you to ponder this disturbing data.

CDC Trends on drowning in children:

• Children aged 1–4 years had the highest rates of unintentional drowning deaths over the past two decades.
• After declining from 1999 through 2003, the unintentional drowning death rate for non-Hispanic black children remained stable from 2003 through 2019.
• Unintentional drowning death rates among children were highest in rural counties compared with urban counties from 1999 through 2019.
• During 2018–2019, the highest percentage of unintentional drowning deaths occurred in bathtubs for children aged under 1 year, in swimming pools for those aged 1–4 and 5–13, and in natural bodies of water for those aged 14–17.

Even more devastating is that drowning is declared by most experts to be 100% preventable.

100% Preventable

Yes, it's 100% preventable. The question then is why are people, especially children, still dying from preventable injury? How could this be when we have state-of-the-art emergency departments and intensive care units? How could I or we not save these children? Ten years of training, highly skilled staff, every gizmo at my disposal, and incredible pediatric intensivists and resources are at our hands. Yet we fail, we see ongoing disparities in who survives, and kids are continue to die.

Should we train more? Do we need artificial intelligence? Should I blame the electronic medical record? Maybe it's hospital administrators or the insurers' fault? Perhaps we need an app or a medical device to help?

When I look at our drowning healthcare system, I struggle to illustrate to non-clinicians why despite their good intentions, their efforts are not working. They struggle to understand why our lives are shortening, outcomes worsening, and costs rising. We invest so much in our tertiary and quaternary hospitals, training specialist physicians, building new buildings, and buying technology, yet we are still drowning.

Does anyone stop for a second and wonder why? As I consider ways to "fix healthcare" and the well-intentioned people throwing out ideas, gizmos, and gadgets that will fix this or that, I often think of the children who have drowned and come to my emergency department or never even made it to the emergency department. These tragedies are real and intense for all involved and absolute devastation for families. These "cases" have changed my mindset on how to fix healthcare. I dare you to think differently as well.

What if we thought about our hospitals and health systems like a child who has drowned? Would we think and act and invest differently? Would we better understand when someone tells us that our health outcomes are really not decided in the ED or the hospital? Would we better understand primary care and the need for community and prevention? Or will we just keep investing in workarounds or hope-filled offerings that don't move the needle on outcomes? Will we just continue to gnash our teeth and wail when bad things eventually happen and keep on happening?

As we dive into the insights of drowning, I encourage you to think about this in the terms of our overall healthcare system.

The facts on the survival or outcome of drowning have little to nothing to do with the care delivered in the ED or the hospital.

Important predictors for survival of drowning itself, either with mild or severe neurological deficits, include: the duration of submersion, the need for advanced life support at the site of the accident, the duration of CPR, and the establishment of spontaneous breathing and circulation on arrival at the ER.

There you have it, the outcome of a drowning is really the first 5 minutes. In these first few minutes, the outcome of the child or adult will be determined. Highly unlikely that even first responders can get there in 5 minutes. The outcome has often been decided by the time they even arrive. In healthcare, we talk about social determinants of health. Well, here you go.

When is the child found? How long have they been down? Do bystanders know CPR? Do they start CPR? Are they able to regain a pulse?

Do they have access to pre-hospital providers who can help take over and add to the child's care? Do these pre-hospital providers have the experience and training to stabilize, treat, and transport this child to the next level of care? Is the next level nearby?

So let's stop here. If you were going to improve outcomes from drowning, where would you focus? Would you invest in hospitals and ICUs, electronic health records? Would you work hard in the ER to improve skills? Would you spend most of your time on pre-hospital training? Would you focus on the revenues that could be produced by caring for these children in the ER or intensive care unit?

My guess is if you looked at this logically, you would likely be appalled at any and all of these suggestions. But isn't there a little bit of truth as to where this is where our current focus is on our drowning healthcare system? While we build up the fortresses on the hospital and hospital system, we really miss out on where the outcomes are impacted, in our homes and communities.

So if you are committed to preventing drowning, this is how you would do it. You would focus on what helps and do more of this and ignore what doesn't and not invest in it. What lessons can we learn from drowning prevention?

Realize a child can drown in any body of water. While it would be great to eliminate water, kids will be around tubs, 5-gallon buckets, swimming pools, lakes, and so on. Regulating or rule-making won't help. You can't outlaw water. Lesson: The risk and benefits of water are present in our communities and need our attention. It's pretty clear that different populations and geographies have different risks of drowning. Perhaps targeting intervention to high-risk groups is even more important.

Put a barrier around this body of water. For pools, the only thing that really helps is a complete 4-sided fence with a self-latching gate. The house is not the fourth side, and gates are too often left open. Also, realize that your community or neighbor's pool offers the same threat to children. Kids don't just drown at home; they drown in their communities. Communities need to act. You might consider a community rule to make your child safe by mandating 4-sided fences (realizing this will be a fight because safety isn't offered as important as aesthetics). Lesson: Our health and well-being rely on not only ourselves but also impact those around us. We need to be cognizant of the entire community to promote better health.

Question what else could help and look for what works and not just what you're told will work or will give you a false sense of better. These workarounds may appear to help but too often fail. Pool sensors fail with too many false alarms and are often ignored. Pool covers are rarely closed all the way and too often are soft, and kids can drown in the puddles of water on top. Life jackets work, arm floats don't. Lesson: We should pay attention to what works and stop trying to add things that are more likely to make us spend more but not provide better outcomes. Workarounds or replacements for personal care and supervision of our health don't help.

Supervise your children. Easier said than done, which is why you must realize 1 and 2 and recognize how quickly your distraction can become a tragedy. In reality, kids can drown with lifeguards, in a bucket, or tub, and while you answer the phone, attend parties, and even with babysitters busy texting. Be responsible for your own behaviors and your children's safety. Lesson: no shortcuts to paying attention to the risks to your child, their health, and ensuring they are safe and well.

Know CPR. Educate yourself on what you need to do if you have a pool or, better yet, if you have a child. Invest in your education to ensure you can act quickly and swiftly. No time for Dr. Google or a call to your doctor here. Primary care and community should offer access to education and understanding on prevention. Lesson: we all need to better understand how, when, and where to intervene long before bad things happen. Prevention, care management, compliance with medications, and our behaviors will influence our outcomes.

Teach others. It's critical that others in your community have the same knowledge, ability, and awareness to ensure our kids are safer from drowning. Leaving this to others, hoping someone else will or should make this difference, too often ends in bad outcomes. Lesson: healthcare starts at home but really needs collective community efforts to not only educate and advocate but act for total better overall health.

Don't ignore the underserved or high-risk populations. Not everyone has the same resources or abilities to meet these needs. Data and population health tools can help identify high-risk patients and areas where we can better focus efforts to "prevent" drowning. Lesson: the same is true for healthcare. Broad brushes or sweeping legislation rarely capture the needs of all communities or people. We should target our interventions to those most in need and where we can make the biggest difference over the long term.

What do you think? Would a different mindset help us prevent drowning? Could we shift healthcare to this way of thinking? Prevention, education, population, community as our focus, or will we continue with treatment, admission, poor outcomes, and workarounds?

more to ponder..

WHO - drowning

Neurologic outcome

Pool Safety

Pediatric unintentional drowning deaths

Stop Drowning Now Site

Continuity