Monday, October 28, 2013

Are we on our way to third-world medicine?

In a post last week, I discussed why elderly patients don't get out of bed and walk when hospitalized. I wrote that a major reason that staff does not have time to walk patients is that they are too busy documenting useless checkboxes on the electronic medical record.

The New York Times article about the negative effects of bed rest on the elderly which led me to comment stated that "hospital nurses seemed grateful" when the author offered to walk her father. She also mentioned that she had to supply a walker, robe and slippers.

My next question is "Could this be the first step toward third-world medicine?" [Pun intended.]

We've all heard stories about how in certain countries, families must provide hospitalized patients with bedding, food and basic hygiene.

A recent article about a family's experiences with a relative who had surgery in Cuba illustrates the point.

The author wrote, "Prior to the trip [to Cuba], my wife wisely purchased towels and two sets of sheets and pillowcases for her mother’s use during her hospital stay. In addition, we packed several aerosol cans of spray disinfectant, special soap used for sponge baths and a room air-freshener that plugs into to an electrical outlet.

Regarding the postoperative stay, he says, "The next two days for me was [sic] spent shuttling food and juice to the hospital for my wife and her mother."

"At the end of the third day, my mother-in-law had arranged to trade her used sheets and towels for a week’s supply of Vicodin and Percocet with another MD on staff."

Is this where we are headed?

First, families start walking the patients because the nurses are "too busy" to do it.

Next will we have to bring linens and food and barter for medications?

Maybe it won't be that difficult. The way it is now, a family member should be present at the bedside of any relative who might be sedated or confused to help prevent some of the thousands of medical errors that occur each day.

If someone is going to be sitting there on watch anyway, he might as well bring food and sheets and get the patient out of bed. Maybe we could enlist the relative to do some of the charting in the electronic medical record too.

Of course, there are always loose ends.

What happens if the patient has no relatives who are free to spend days in the hospital caring for the him or has no family at all?

Where is all that money that hospitals are making by overcharging everyone going?


DD said...

(From Medsurg Nursing 2011) Nurse to patient ratios have been shown to affect patient outcomes. Although California remains the only state with mandated nurse-patient ratios, 17 states have introduced similar legislation, calling for specific, minimum nurse-
patient ratios in both hospital and ambulatory units. Multiple studies have associated increased RN staffing with increases in patient safety, quality of care, and patient satisfaction, as well as a decrease in patient length of stay, and nurse burnout and turnover (Douglas, K. (2010). Ratios — If it were only that easy.
Nursing Economics, 28(2), 119-125). To accommodate mandatory staffing ratios, employers look for ways to save money, including decreased funding for supplies(e.g., equipment), environmental changes (e.g., upgrading to single patient rooms), and educational costs (e.g.,tuition reimbursement) (Buerhaus, P.I.(2010). What is the harm in imposing mandatory hospital nurse staffing regulations?
Nursing Economics, 28(2), 87-93. ).

To address your final comment on "where is all the money that hospitals are making..going?"
The Big multi-hospital university health system in my area also sets the salary range for nurses and physician extenders and those salaries are well below national averages--so we know the money does not go to those employees.Yet the CEO makes > $5 million a year. Also, the health system runs a lot of TV and print ads touting their high national ranking. Maybe instead of spending 100s of thousands on PR and millions on executive salaries, they should hire additional housekeeping staff and nurse assistants so patients can be properly bathed, toileted, fed, ambulated and rooms disinfected; this might decrease NOSOCOMIAL infections, pressure ulcers, falls etc. It seems like common sense to me.


RobertL39 said...

And then the nurse data-collectors can collect data on which family member was present, the quality and quantity of the items brought (which of course were screened by biomed engineering and the ID nurse beforehand), and provide a list of people with whom one might trade sheets and blankets for medication. Then hospitals can advertise the quality and quantity of family-brought items that their patients bring. Soon!
Parenthetically, it's astounding to me that hospital lawyers allow someone not affiliated with the hospital to get the patient out of bed. Think of the liability issues! "Nurse, you knew this patient was sedated, correct? And you let them out of bed with a relative of unknown strength and skill?" Yikes!

Jeffre said...

Maybe consult the Physical Therapist?

Skeptical Scalpel said...

DD, excellent points. Thanks for bringing them up. I recently blogged about what a waste hospital advertising is.

Robert, I did not think of the liability angle. You are so right.

Jeffre, good idea and we often consult PT. Unfortunately, they can only spent limited time with each patient because there are not enough therapists. Also in most hospitals PT is not open during evening shifts and on weekends except for a possible skeleton crew on Saturday mornings.

Anonymous said...

Not just hospitals, not just electronic records. Also, so-called skilled nursing facilities, the nursing homes, and their do nothing "case plans". My mother had PT in a nursing home twice after two hip replacement surgeries.

My dad and I tried to be there every minute we could because bad things happened when we weren't. For example, they lied to us about her medications, put her on Sereoquel when her doctor and I informed them, she should not be on it. They undermedicated her for pain. Gave her stuff, she was allergic to, and on and on. Literally lost her in the facility a couple of times and I had to search the whole building to find her.

PT would come by and put in her chart something like "won't respond to commands". This, coming after we repeatedly told them, she is nearly deaf, please make sure her hearing aides are in, which we figured out, they weren't doing. PT billed Medicare multiple times when they never even saw her and I know because I was there the whole day.

But what was really unconscionable was not taking care of her and trying to prevent us from doing so. They didn't want us to walk her, even though she needed it, and after awhile I did it any way and told them to try and stop me. Her doctor tried to intervene and they ignored him and did what they wanted. I'd get an order and they countermand it. Mostly because they didn't want, or didn't have the staff, to do it. I understand the no staff stuff, I was ok with that but not the interference, preventing us from participating in her care. That was worse than third world medicine.

Especially, when they didn't do the basics, such as turn her in bed before she could move on her on, or feed her when she needed to be handfed. They wanted us to consent to a feeding tube on the second day out of the hospital, I think because it took so much time to get her to eat anything.

The hospitals were just as bad. This is where I learned to be on my guard. After the first serious surgery, a hip replacement during a late Sunday afternoon, I left my mom alone at bedtime; I told all the nurses, she has Alzheimer's, she can't push the call button, she can't always communicate and tell you what she needs. I discussed her pain meds and was told she would get them at regular intervals. I talked to every one I could and they all reassured me. The next morning, my dad walked in and found her rocking up and down in bed and pounding her fists against the bed rails. No pain medicine from the time I left (11:00 p.m.) until the time he got there.

After that, someone was almost always with her. We were afraid to leave her alone. She was helpless.

In the nine years my dad and I cared for her, I learned a lot. I learned that hospitals and nursing homes were always the last resort and every effort should be made to keep her home. It was exhausting trying to keep up with what was going on in the hospital or nursing home and trying to fight for better care. Even though caring for her at home was exhausting and hard, the stress level I felt when Mom was at the hospital or nursing home was ten times what it was at home.

Mom lived eight years past the first time I heard a doctor say, prepare yourself, this is the end. During that time, I learned how little any one can predict about that terrible disease and how much you have to do on your own to take care of your family.

If I could contribute anything to any discussion about health care, I would say there is nothing wrong with family being allowed more input into care. There are certain things we can do and many things we will know better than any nurse or doctor. There ought to be more paid training for the families. A little training or information would assist us and reassure the professionals that we can do the job. If you love someone and that person is helpless, after awhile, you will just do what you have to do.

Anonymous said...

Yes, SS, where is the money going. All sorts of places. It helps lawyers, executives, and drug and device reps go on ski trips. It goes to fund fratricidal wars with Cigna and United Healthcare. (It helps advertise the cutting edge laser-guided robot.) It goes everywhere but where it should.

Anonymous said...

We are well on our way to 3rd world status in general.

A country that can't read, can't work, can't pick their own oranges, can't raise children, can't keep their pants on, can't keep the jobs from going overseas, can't defend their own borders, can't get or stay married, can't even save their own flag from burning -- but must go monkeying around with every Libyan/Syrian/Egyptian crisis -- and must consult an attorney before raising a pinky finger -- ??? what do you expect?

Kosch said...

If every family member wants to help in the patient's recovery, please be present! I love family input, it keeps my patients happy and they are most often the cajolers needed when I need a patient to get up after surgery.
PT is around once or twice a weekday shift, but god forbid a patient is not ready to move when PT shows up. It then becomes the nurse's job to get our patient's to get up and move.
I, and most nurses I work with, want to walk all of our patients for the entire shift. I know that this is the best time to assess them, this is the best time to allow them to assess themselves on their recovery; and finally, I also know that when I am walking them around our unit, I am able to educate my patient on the best way that they can heal when they leave our care.
When I find a hospital that will allow me to do this with every patient that comes to our floor, I will do whatever it takes to get myself hired there. Nurses aren't morons, we know what our patients need.
Unfortunately, a lot of our time is spent charting the minutiae that keeps the hospital from having to admit fault.
I am always searching for that hospital that strives to only break even.
I am not different from most nurses.
I wish more hospital administrators would read this blog.

Skeptical Scalpel said...

First anon, that is some story and I believe every word of it. You describe so many problems--attitude, communication, knowledge. I wonder if it is hopeless.

Second and third anons, thanks for commenting. No argument from me.

Kosch, we would get along really well. Thanks for your perspective and the kind words.

Anonymous said...

Yes, the care is moving toward third world status as DD describes above. Caring for the sick is a very labor intensive endeavor and one that hospitals/insurance co's are finding too expensive. The usual solution is to pass this work on to the rn. The problem is that more and more work is passed off this way and staff levels are decreasing. The US is starting to learn that you get what you pay for.

Anonymous said...

After multiple surgeries and multiple hospitalizations at multiple institutions, I've lowered my expectations. I would settle for getting important daily maintenance meds that were ordered in the ED at 9 PM sometime before 11 AM the next day...

I was also sent home from that hospital on a Friday afternoon with the world's shortest, vaguest discharge instructions and no prescription for a refill on my rescue inhaler, so while I believe you that you're typing a lot into the EMR, the information getting fed in there did not translate into actually helping the patient this last time.

I am so lucky to have family who are both willing and able, both physically and financially, to drop everything and come stay with me when I am sick. However, they live across the country, so I am also working on designating a dear friend as having POA/conservatorship so that I can have someone there in person advocating for me - that the hospital legally has to listen to - if I end up intubated or otherwise incapacitated . She and I have talked about the need to have someone there to advocate for me as much as possible, even if I am conscious. A patient who is in bed connected to monitors and IV's can not track down nurses or go home to get my own meds if it's something that the hospital doesn't have on formulary.

As a side note about formularies, I understand why they exist, but even if you don't see a difference in drug responses at the population level among members of a class, that doesn't mean that all drugs in that class are interchangeable; patients vary in their responses and ability to tolerate certain drugs.

Skeptical Scalpel said...

First anon, good comments. I have no solution.

Second anon, I hear you loud and clear. Many have confirmed what I have written. And it's not getting any better.

Anonymous said...

As an RN in a critical care setting, I encourage all patients and their families or friends advocating for their hospitalized loved ones to call the hospital administrator when they are not being heard. Maybe then patients will have their needs met safely and appropriately. Hospital administrators need to be called as many times and as feel as overwhelmed as the hospital staff, from physicians to housekeeping, to feel and understand our frustration and burnout.
I feel that the majority of staff providing direct patient care truly want the best for their patients and want to feel good about providing quality care. There is not enough staff or resources to compete with "hospital throughput", leading to 'turning and burning' of patients, in addition to hospital staff. Regulatory agencies and hospital administrators only care about the bottom line, money.
Administrative physicians and nurses that are not practicing at the bedside are out of touch. It should be mandated that they get out of their suits and into their scrubs once per week to maintain clinical competencies and keep a perspective of what patients and staff are experiencing. Only then can they be advocates for the reasons they have their administrative jobs in the first place, the patients and the hospital staff.

Skeptical Scalpel said...

Anon, I agree with everything you said. even if administrators don't keep up with their clinical skills, they should at least round on all the floors once a week. I've known many administrators who don't even know where the patient floors are and certainly don't know the nursing or other staff people.

Anonymous said...

Thank you. I use to believe that rounding the floors cut it, but it doesn't anymore. Administrators need to "feel" the pressure they are mandating in addition to the acuity of patients, their needs, and documenting in the "almighty" EHR's touted to be a safer way to deliver patient care. So, okay, twice a month versus one a week...

Skeptical Scalpel said...

OK, I'm good with twice a month.

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