STAT: Health Care Has an ‘LMNO’ Problem

From STAT: By David A. Asch and Roy Rosin On inpatient medical services, it’s common to hear patients’ laboratory results presented with statements sounding like “CALCE-MAG-FOSS were normal.” The efficiency of this reporting is part of the secret handshake of one insider communicating with another. Contraction of three serum ions resembles children learning the alphabet through song: A, B, C, D are sung as discrete letters, but eventually LMNO spills out all at once as if it were one of the English alphabet’s 23 letters. Singing “elemeno” isn’t a problem unless children actually believe it’s a single letter. But often verbal constructions and other shortcuts are tightly linked with behaviors. Not only do some physicians report the results of serum calcium, magnesium, and phosphate simultaneously, they often order these tests together — a reflex where their behavior mirrors the contractions in their speech — even though there are many more reasons to check a calcium than a magnesium. The result here is needless tests and avoidable costs. We call this the LMNO problem: Contractions of language or contractions of behavior that reinforce each other. Once you recognize your first LMNO problem, you see them all over medicine. Many patients in our neurointensive care units receive tube feedings, and few of them were achieving their recommended calorie or protein targets, nutrition deficits that prolong care and delay recovery. One culprit was the order, “NPO after midnight.” Like LMNO, it rolls off the tongue, but in this case it also finds its way into the orders for any patient with a procedure planned the next day. For people who eat orally, NPO (nil per os, or nothing by mouth) after midnight really means “don’t give the patient breakfast.” Turning off tube feedings from midnight to 8 a.m. loses a third of a day’s intake in a setting where it’s hard to catch up later — worse if, as often happens, what was scheduled for 8 a.m. is postponed until 1 p.m. Procedures are safer when stomachs are empty, but for the many patients whose nutrition depends on liquid food delivered through a tube, the time between when feedings stop and a procedure begins has more consequence and needs more specificity. Read more from STAT.