Friday, October 25, 2013

Hospitalized elderly patients spend too much time in bed. Why?

43 minutes—that’s the median length of time a hospitalized elderly patient spends standing or walking daily, reports a New York Times story. Not only that, the study from which the 43 minutes number came also noted that elderly spend 83% of their hospitalizations lying in bed.

The paper was a study of the activity of elderly patients who spent about 6 hours per day on their feet before they were admitted. Failure to walk around in the hospital had significant negative effects on the activity levels of patients for as long as two years after discharge from the hospital.

That brings up the question, why didn't they walk more?

According to the Times, "Even when physicians recognize the hazards of immobility and write orders that include ambulation, overworked staff can’t always find the time."

Ah, the real question is, why can't they find the time?

I'll tell you why. They are too busy documenting unnecessary garbage in the electronic medical record (EMR).

Here's an example of what I am referring too. This was tweeted on June 2, 2013:

"@Apathetic_Cynic: Check da box @docgrumpy: Intubated, GCS of 3 x 2 weeks. Today someone documented counseling pt to quit smoking" 

If you don't speak Twitter, here's the translation:

A doctor who calls himself Apathetic Cynic retweeted what a another doctor (docgrumpy) wrote which said that a comatose patient who was completely unresponsive for two weeks in an ICU was documented to have received smoking cessation counseling.

Of course, the patient could not possibly have understood such counseling. It likely never happened. But the box in the EMR was properly checked, and all is right with the bean counters.

A paper from the Journal of General Internal Medicine found that interns spent 12% of their time with pts. That's 8 minutes per hour. "Computer use occupied 40% of interns' time," much of it spent documenting.

Ask any nurse, and he will tell you that the EMR demands ever-increasing amounts of documentation such that the documentation itself is now the endpoint. On hospital I am familiar with has a 7-page nursing assessment section that must be completed for any admitted patient.

Here are the sections that need to be filled out.

Cognition, verbalization, hearing, vision, educational barriers, pain assessment, restraint information, health history, advance directive, alcohol and drug use history, smoking history, diabetes mellitus, discharge planning (self-management of health, latex allergy screening, nutrition assessment, room service appropriate, urinary elimination habits , bowel elimination habits, activities of daily living/mobility, fall risk assessment, legal contact information, living situation and primary care giver, abuse, opt out/visitor restriction, suicide assessment, psycho-social concerns, spiritual needs, allergies, vital signs, height/weight, respiratory, cardiovascular, peripheral vascular, venous access, tubes and drains, neuromuscular, skin-Braden scale, skin assessment, skin co-morbidities, HEENT, gastrointestinal.

How long do you suppose that takes? There is a fair amount of redundancy too. For example, nutritional assessment will be done by the nutritionist. A complete history and physical should be done by the physician (or maybe not, because she has a lot of documenting to do too). Discharge planning is done by case managers and social workers. Contact information is obtained by the admitting office.

And guess what? A number of these nursing assessments must be documented every shift.

Now do you wonder why the staff doesn't have time to get  the patients up and walking?


Anonymous said...

I spend 2-3 hours EXTRA at the end of my ER shifts documenting. I don't get paid for this. I get paid to see patients and I can't do them any justice if my primary concern is checking boxes to ensure a level 5 chart. Maybe when medicine has me burned out and cynical, maybe then I'll get home to my family on time. But not yet.

Skeptical Scalpel said...

I feel your pain. The sad part is that no one reads all those check boxes but the people auditing the chart for check boxes that aren't completed.

RuggerMD said...

So how to we change or reverse this trend?

Skeptical Scalpel said...

More nurses, fewer check boxes, get rid of 75% of the EMR. It'll never happen.

Anonymous said...

Was there ever a golden age? I remember as an intern (pre-EMR) waiting 30 mins for a nurse to help with an LP. -- and the the spinal fluids got lost on transit to the lab.

I am getting to the "get off my lawn" stage of my career. But honestly, the clinical care now is better then in 1990.

How many more nurses do we need? Here in San Francisco we pay them 6 figures shortly after hire. Many pediatricians and other docs make less

Skeptical Scalpel said...

Good points. I should have said we need more nurses who are unencumbered by "documentation' issues.

In the 1970s, nurses spent far more time with patients. The head nurse (now called "nurse manager") used to round with the doctors, even residents. She knew all the patients and what there problems were. Now the patient's own nurse often knows little about the patient, why he is getting certain meds, or even where the patient is. "He might be having a test off the floor. Ask the unit secretary."

Henna said...

Skep, as a nurse I agree completely about spending too much time documenting things that won't be read. I will offer another, much more prosaic, reason for why patients don't get up and around. Why in the world would anyone stand up and leave their room in one of our gowns? And where would they go? Even if a patient wears a second gown over the back, or a bathrobe, he doesn't feel comfortable going around the unit dressed like that. For ladies especially, not wearing underwear is enough to make them stay well tucked under the covers. No elderly patient cares to venture farther than the nurses' station dressed like that.
The corridors of our units are filled. At my hospital, we keep one side free but the presence of Dynamaps, computer stations, a linen cart, busy staff members and perhaps that elusive manual BP equipment does not invite patients to walk.
We nurses (and doctors) could do better at educating our patients about the importance of ambulation. Elderly patients in particular have a deeply ingrained idea that they are in the hospital to rest and really shouldn't be up--"If you're sick, you should stay in bed!" Family members often reinforce that concept.
In this baseball town, the custom in our academic hospitals is for the charge nurse to round with the doctors. The charge does have a good idea why each patient is there. Staffing mix in virtually all hospitals here is 70% RN, 30% techs, and I would expect any nurse to know why the patient is getting certain meds.
To Anon 2 above, maybe I should move to San Francisco. New nurses here start at about $20/hour.

artiger said...

I consider myself fortunate; our rural hospital has nurses that are something of a throwback, even with the headaches of documentation. I can call up there about a patient, and if whoever answers the phone doesn't know, he/she will promptly find someone who does.

Skeptical Scalpel said...

Henna, good stuff. Sounds like you and Artiger work in good places.

Anonymous said...

Henna, I think you hit it. Where do patients walk, esp. in their ridiculous gowns?

About pay in SF, it is tough to make it on just 100K.

Anonymous said...

The average rental in San Francisco is $3000.

Anonymous said...

If my postsurgical elderly patient spent 45 minutes standing or walking daily, I would jump over the hospital roof with joy. In my decade of practice as a general surgeon, I am lucky to see 10-15 minutes of vertical, and often I have to lay down the law and drag the patient out of bed myself. Nurses, PT, etc, usually don't give a hang. I have seen plenty of hospitals that allow an elderly patient (surgical or medical admission -- patient was ambulatory and independent prior to hospitalization) to lay in bed for several days straight -- foley catheter helps facilitate the bedridden scenario. The patient loses the ability to walk, and sometimes never gets it back. Nursing home is the next step, of course (if the patient survives the hospitalization and doesn't get DVT, pneumonia, atelectasis, decub.)
The excuse is, the staff is busy. Well, anyone can get something done if they really want to get it done (just ask the pre-2004 surgical resident.) The staff really doesn't care, from what I have seen. I can order Flagyl 500 mg IV TID, and heads will roll if the patient doesn't get Flagyl TID; but just let me write "ambulate TID in halls with assistance", and my order gets treated as a big joke. There is no accountability, and nobody means business.
In the last 10 years, I have never seen an elderly patient s/p laparotomy or laparoscopy die on my watch, if 1) they were extubated at the end of the case or within 24 hours approximately, and 2) if they were compliant with standing up and walking when I said so. I haven't seen pneumonia or respiratory failure; I have seen one PE (bilateral mastectomy pt that I should have given heparin/Lovenox in retrospect); I have seen no clinically evident DVT (or even postop MI/CHF/cardiac arrest.) I was taking plenty of ER call; it's not that I was cherry picking low risk patients.
Of course EMR will only make things worse. Solution is, throw the Washington DC communists into the Potomac (and as SS says, it will never happen.)

Skeptical Scalpel said...

Anons, thanks for commenting. SF is pretty expensive. I have had similar experiences with post-op patients being left in bed for days despite orders. Getting them into a chair doesn't accomplish much either.

Anonymous said...

As a lawyer, I can assure you that sometimes people do indeed read those check boxes very carefully to look for indicators of a patient's overall condition. We know that sometimes no one is paying attention to what they check, but we still have to rely on them as accurate descriptions.

Skeptical Scalpel said...

Anon, thanks for mentioning that. A careless check in a box by a nurse can be disastrous if a suit is brought. At least when they wrote notes on paper, you could read them. Now what they write and check is buried a a sea of distracting and useless information.

Chris Porter MD said...

Hospitals need a 'staff workflow advocate' along the lines of the 'patient advocate'. Presently it's nobody's job description to push back against the many whose job description is layering on more documentation requirements.

Skeptical Scalpel said...

Chris, that's a good idea, but I doubt that any hospital administrator would pay for it. You would think that the VP for nursing would be an advocate for the nurses. Apparently not.

Mary said...

From a non-medical perspective...Earlier this year my MIL was in the hospital following valve repair surgery. There was so much going on all the time that getting her to walk was nearly impossible. It was always, "Wait until after X occurs." By that time, Y was waiting in the wings to occur. At one point we took her to the bathroom and she went down to her knees. After that she wasn't to get up without staff. Viscous cycle. The good news for her was when we took her home we made a "course" in the house and nagged her into walking once an hour. She recovered well but if she hadn't had us.....

Skeptical Scalpel said...

Mary, thanks for commenting. I'm beginning to see a pattern here.

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Skeptical Scalpel said...

On the right side of this page near the top, you will find spaces where you can enter your information and subscribe to posts and/or receive email notification.

Anonymous said...

I did an audition rotation few yrs back at Northwestern community hosp as a med student. Even though I was part of the surgical team, I knew everyone who was rounding in the morning. Particularly, this critical care/pulmo doc who had a zoo of people rounding w him. Why I noticed him? He always had the nurse who was overseeing majority of his pts round with his team. The MS's listened to her, residents listened, he was a control freak. He wanted to know everything about his pt by the minute. How was the pt last night? He was the only doc I met rounding w a nurse in my med career. He demands it and I saw it had a psychological effect because it empowered the nurses, made them feel important and part of the team. What I realized is that his nurses worked harder, spent more time w the pt, and everyone was always on the same page. I asked him why he had to have a nurse w the team. He said I get paged less and my pts feel like they are getting the best care because staff is all communicating w each other. We end up spending more time w the pt because i delegate what the nurse should be looking for, what the MS should be doing, and resident. I changed my approach as a MS and resident because of him. I speak w the nurse about my pt, I listen to them. Since I am valuing their opinion and time spent with the pt, he/she will spend more time making sure they understand that pt. When I become an attending, I think I might try this too and have a nurse round w the team. It is sort of cumbersome, but since he has been doing it for yrs the nurses just know this is their role when dealing w his pts. Sorry, very tired this morning, very redundant. #residentproblems #nosleep

Skeptical Scalpel said...

Anon, thanks for commenting. Rounding with a patient's nurse is great.

Unfortunately, most nurses are so busy checking boxes that they don't have time to round with every doctor who comes to the floor. And the same nurse is never assigned to more than one or two of a specific doctor's patients. You could round with the head nurse, sorry--nurse manager, but she is always at a meeting.

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