The checklist from hell

This one-page form illustrates much of what is wrong with medical care today.

Just imagine the amount of time it would take to complete all 11 steps. Wouldn't you love to hear what goes on in a "post Fall Huddle"?

Thanks to @anish_koka for tweeting the form.

Iatrogenic polyuria

Dr. William Reichert commented on a recent post of mine. I thought he told an interesting story and with his permission, I am featuring it here so more of you might see it.

He wrote

Some time ago, I was consulted on a patient because of excessive urination. The patent was putting out 4 or 5 five liters a day and nobody knew why. I checked out all the usual suspects, diabetic ketoacidosis, hyperglycemia, diabetes insipidus, etc. and all the medications listed on his chart. No diuretics. Finally, at my wit’s end, I entered the ICU room and noticed a number of med bags, some full, some empty hanging there on the IV pole. I checked each and discovered a bag labeled "dopamine” slowly dripping in.

I went to the nurse and asked how long the patient had been on dopamine. She said "He's not on dopamine." I said, "Come with me" and showed her that he was in fact getting low dose dopamine, a drug that behaves like a diuretic.

How does a 16-year-old boy receive 38 times the normal dose of an antibiotic?

If you are a doctor, nurse, patient, or just someone interested in patient safety, you should read a five-part story called "The Overdose: Harm in a Wired Hospital" excerpted from a book "The Digital Doctor" by Dr. Robert Wachter.

Dr. Wachter and the hospital are to be commended for publicizing this incident so others may learn from it. The hospital staff, the patient, and his mother, also deserve credit for allowing their stories to be told.

A synopsis does not do justice to this well-written account of the boy's near-death experience in a top hospital in San Francisco. In short, he somehow received a massive overdose of the antibiotic Septra despite the presence of a sophisticated electronic medical record and multiple systems in place that were supposed to prevent such a thing from happening.

After the patient recovered from receiving 38½ pills when he should have been given only one, a root cause analysis found numerous faulty system issues such as an electronic ordering program that was overly complex, a nurse "floating" to an unfamiliar floor, a satellite pharmacy that was too busy and susceptible to distractions, "alert fatigue" among hospital staff, and a culture, like that of most hospitals, that may have discouraged questioning both authority and the almighty computer.

The Midwife Delivers

The other day I reviewed a new medical reality television show called "Scrubbing In." I didn't like it very much.

A loyal reader, robertl39, commented that an antidote to "Scrubbing In" might be a show called "Call the Midwife."

It's about a midwife in the East End section of London in the 1950s. Fresh out of training, she joins a group of religious and lay midwives providing care for the indigent population.

The National Health Service had just been established, which led to improvements in the care of pregnant women.

I have watched the first two episodes. The show is everything that most medical TV shows are not. The story lines are compelling and tell a lot about the social climate of postwar England. The characters are interesting, engaging, and complex. You will laugh, and you will cry.

The midwives are heroic.

I can't say enough good things about this series. It's available online, and the first season is currently being rerun on PBS.

Since the episodes are in chronological order, it's best to start with Season 1, Episode 1.

Enjoy.

Review: "Scrubbing In," a new medical reality TV show

I don't watch much television except for some sports. But I feel it is my duty to comment on medical TV shows, which I generally hate. A few months ago, I reviewed two shows that, as I predicted, didn't last long. Their names were "Monday Mornings" and "Do No Harm."

A third show "Married to Medicine" is rumored to be coming back for a second season despite a storm of protests over the way it depicts black physicians and their spouses. You can read all of these reviews by entering "Medical TV shows" in the search field in my blog's upper right.

I should have known better, but something drove me to look at a new reality show on MTV called "Scrubbing In," which debuted last week.

A warning sign was that based upon only the show's trailer, both the American Nurses Association and the Canadian Nurses Association wrote to the network asking that the show be canceled because it depicts nurses in demeaning and unflattering ways.

I will spare you the details of the plot, such as it was. But here are a few highlights.

A group of travel nurses, mostly from Pittsburgh, to go to work at a hospital (which probably regrets its participation) in Orange County, California.

The cast features several extremely unlikable young women and a few equally unlikeable men. All are profane, unprofessional, and dishonor the nursing profession.

Most if not all of the women have had breast implant surgery and are not bashful about revealing that fact verbally and sartorially.

Two nurses, one male and one female, had to be removed from the orientation session at the hospital. Their California nursing licenses were held up because they both had prior arrests for DUI.

It's not clear what the show's title "Scrubbing In" has to do with anything, since all of the nurses who had licenses were working in the emergency department, not the operating room.

During the first 30 minutes of the show's premiere, which was all I could take, about 3 minutes took place in the hospital. The rest of the time was devoted to watching the ladies walk around in towels, swear, shower together (behind a curtain), and go on a "booze cruise" so they could all get acquainted.

There were some memorable lines however.

While taking off his shirt on the boat, one of the male nurses said, "Sun's out, guns out."

One of the nurses, discussing her prospects for the move to Orange County, said, "Nurses f--- doctors, and doctors f--- nurses."

And while in a car, one nurse says to the others, "Did you bring your vibrators?"

Not only is "Scrubbing In" the worst medical show I've ever seen, it might also be the worst television show in history.

It should be scrubbed.

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?

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?

Do BSN nurses provide better care?

A paper entitled "An increase in the number of nurses with baccalaureate degrees is linked to lower rates of postsurgery mortality" appeared in Health Affairs in March and  generated quite a lot of buzz on the Internet.

Its major finding was that hospitals in Pennsylvania that had 10% more nurses with BSN degrees were found to have 2.12 fewer deaths per 1000 postop patients than those that did not. The authors extrapolated this, saying that if all the hospitals they surveyed had the same percentage of BSN nurses as the best performers, 500 deaths may have been avoided.

The reduction in mortality rates was not significantly affected by staffing levels, skill mix or years of experience as a nurse.

The mechanism for the decrease in death rates was not explained but assumed to be better rates of "rescue" after the development of complications which also was significantly associated with the presence of more BSN nurses and not staffing levels, skill mix or years of experience as a nurse.

The abstract concludes, "The findings provide support for efforts to increase the production and employment of baccalaureate nurses."

The math in the paper is confusing. In 2006, 25,000 nurses responded and 1/3 (presumably about 8,333) of them were staff nurses in general hospitals. The information from those 8,333 nurses was the basis of the study. They go on to say that there were 134 hospitals with an average of 48 respondents. That computes to 6,432. That's a discrepancy of over 2000.

A cliché that is often used in comments about research papers is "the study raises more questions than it answers."

Here are a few. 

Could it be that the hospitals with improved mortality and rescue rates are simply better hospitals? And maybe BSN nurses are simply more likely to work at better hospitals. 

If 2/3 of the nurses who responded to the surveys are not working as staff nurses in general hospitals, just what are they doing? Going to committee meetings?

A nurse who commented on a recent post of mine about a national organization setting up a "Transition to Practice" fellowship for graduating surgical trainees who lack confidence in their skills said,

I could say the same about nursing school. Why are there suddenly nurse residencies and nurse fellowships? Because there is too little clinical time while in school. My nursing school has a name that you would recognize. Our med-surg clinical days were one half-day per week spent at the hospital, about 26 in total over 2 semesters. Peds and maternity, about 5 half-days each. I was lucky because I was on a general medicine unit and got to see a variety of patients. We all complained that our clinical time was inadequate. The preceptorship in the last semester consists of working eight shifts one-to-one with a staff RN. No wonder, then, that hospitals are not confident in the capability of new nurses to practice safely and effectively.

Why is it that over 100 hospitals have established "nursing residency" programs? Click here to see a list of them published by the University of Pennsylvania. 

Here are quotes from two hospital websites about their nursing residency programs.

The Nurse Residency Program at Mayo Clinic in Arizona is a full-time registered nurse position with a one-year orientation program that assists you in transitioning from a new graduate to a fully competent, professional nurse at Mayo Clinic.

Children’s National Medical Center’s Pediatric Nurse Residency program provides the novice nurse with the knowledge base and skill set needed to transition to competence in clinical nursing practice.

What they are saying is that at least some graduating nurses are not competent. This meshes well with recent findings that graduating surgical residents are not ready to practice independently.

Why can't we teach nurses how to nurse in school and docs how to doctor during residency?.