Archive for September, 2009
Tonight’s dinner at Acme Regional features a somewhat soggy looking shepherd’s pie with even soggier miniature carrots, all served up on a flimsy plastic plate. Yum. I don’t think they could make food less appealing, even if they tried.
Maybe North York Gen has the answer — or at least that’s what they claim. They’ve just contracted out their food services to Compass Group, the largest food services company in the world. Incidentally, Compass Group has been implicated in a nasty United Nations bribery scandal and the UN has actually dropped them as a contractor.
Anyway, NYGH’s new contractor features “Steamplicity” food. This involves some sort of fancy machinery*, called a microwave, that hots up prepackaged food, no doubt supplied by the vendor at some outrageously high cost — no wait! It’s Michelina’s!.
And it evades the real issue: providing fresh, real, nutritious food to patients. I wonder if any hospital administrator has ever actually costed any of this out — and I mean the real costs, including impacts on patient morbidity and mortality rates.
*This is the description of “Steamplicity”. To be honest, it makes absolutely no sense to me at all. Especially the steam valve part.
Specially equipped pantries for food preparation will be located on each patient floor allowing food freshness to be maximized. The food is pressure cooked in microwaves using heatproof, pressure-resistant plastic packages with patented technology, which includes an innovative valve control system. Heating the water molecules within the food builds steam pressure, and the pressure is released gradually through the unique valve to cook the food. Throughout the food preparation and delivery process, systems are in place to ensure food safety and hygiene.
Hospital Food Bingo, anyone?
We sat in Observation and giggled and giggled — it was a slow morning, okay?
This guy, I have to say, has it good. Compared to the slop we give our patients in Canada — and I do mean slop, as in pig food, because hospital administrators see providing decent food to patients as a problem in livestock nutrition — the meals in Britain’s NHS look like cordon bleu.
But Notes from a Hospital Bed raises a serious issue. Hospital food sucks. I don’t mean it has the existential suckiness in way a salad from McDonald’s does because it’s (a) a stereotype of a salad, a salad imagined by marketers, and (b) it’s from McDonalds.* I mean it sucks in a deeply fundamental, dishonest way. It is shit pretending to be food. It reeks of of health care condescension and the seconds freezer at Almost Perfect.
Is it even ethical to be associated with hospital food, to pretend that eating it will put patients on the road to good health?
*Admittedly, and this is no cause for celebration, even a salad from McDonald’s would be a vast improvement over the crap du jour served at Canadian hospitals.
My old grey cat died today.
I thought he might when I went to work,
And paused by the couch where he lay
Panting, and stroked his matted fur, and when he mewed
I said good-bye.
I drove away, then got the call, “He’s gone —
I held him close when he died.”
And against the shining light of fall I cried
For an old grey cat we loved, perhaps too much, too well.
O God who minds the ways of men and mice,
And sees each sparrow fall (it’s said)
Have a thought, or care, or hope
For our old grey cat, well-loved, who’s dead.
10. We’re too busy.
9. We have too many vents.
8. We’re understaffed.
7. We have staff, but the patients are too heavy.
6. Two rooms are being waxed, so those beds aren’t available.
5. We need to do bed moves.
4. The patient is discharged/died, but he’s still in the bed, so your patient can’t come.
3. It’s too close to shift change.1
2. We want to see if your patient gets better.2
1. Your patient is too unstable for the ICU.3
1Which excludes 2 hours before and 2 hours prior to shift change, eight hours a day; if the ICU nurse is going on break, this can be easily be extended an hour.
2I have actually heard this. Meaning, “We want to see if the patient dies.”
Infection Control at Acme Regional Health hath decreed that known MRSA1 patients must have three clear swabs, done a week apart, in order to be declared free of MRSA. Well and good. MRSA is a very special form of nastiness. Except relatively few patients (unless you are condemned to that sinkhole known as designated as ALC2) are admitted for more than a few days, and almost none of them stay long enough to get three clear swabs.
There is, natch, absolutely no community follow-up on putative MRSA cases, i.e. no one thinks to repeat the swabs once patients are discharged.
Which means, in practice, once you are designated as MRSA positive, you will be MRSA positive forever. Even after you’ve been treated for MRSA — and MRSA gets treated aggressively.
Case in point: a patient comes in repeatedly for poorly controlled congestive heart failure; she gets a little IV diuretic, gets a whack of fluid off her lungs, and is sent home after a couple of days. She’s probably had eight admissions in as many months. Each time, because her chart is marked MRSA positive for a hospital-acquired infection we gave her maybe 10 years ago, we swab her, and every time, her swabs come back negative. Eight negative swabs in eight months — I am pretty confident that MRSA is the leastest of her problems.3
So in summary: we are probably wasting hundreds of thousands of dollars doing unnecessary MRSA screening, plus all the money wasted in putting these patients in contact isolation, extra nursing hours, gowns, gloves and so on, and not to mention the effect of isolation on patient morale, because we can’t figure an adequate way of doing community follow-up.
1Methicillin-resistant Staphylococcus aureus.
2Alternate Level of Care. Not actually acutely sick, but unable to actually go home because some debility or other. In other words, waiting for placement in (nonexistent) nursing home beds while simultaneously blocking acute care beds — and consequently Emerg beds. Probably the single greatest cause of long emergency department waits in Ontario.
3Unlike why she is bouncing in every 3 weeks in CHF.
My father-in-law had a cardiac cath today, so Mister Man drove himself and me (as the resident expert and chief hand holder) to Rollingindough General Hospital where they were doing the cath. Mister Man’s mother then promptly developed a weird epigastric pain which was probably anxiety induced, or maybe the result of too much spicy sausage the night before; but, being highly suspicious of weird epigatric pains, especially in women, I shuffled her off to Emerg.
All is well. Mister Man’s father’s left ventricle is all shot to hell, but it isn’t anything we didn’t know before; the mother-in-law is fine too.
The thing is, I spent the day shuttling between Emerg and the cath lab, and every time I stepped into the Emerg, and heard the familiar sounds and saw virtually the same equipment — I mean, emergency departments look pretty much the same anywhere — a huge wave of anxiety crashed in. I think I was having a bit of a panic attack.
This was really, really bizarre, because I don’t even work there. It was like I was having anxiety by proxy. Is there such a thing? Vicarious anxiety?
And do I actually have this much stress when I go on shift, but don’t notice it because it’s familiar?
Went to work the other day, found my assignment was in the treatment rooms, walked in and found I had five admitted patients: two fractured hips, a stabilized DKA1, and a couple of FTCs/FTTs2. All but one were over 80 and more or less unable to walk. So you know what sort of day I was going to have — and these were the least acute in the department, which had 27 admits in total. So. I was to provide nursing care for four total care patients, complete initial and ongoing assessments and vital signs, copy orders, ride herd on consultants, fling meds, do bed baths, test blood sugars before each meal (3 x 5 =15 glucometer readings), arrange for various and sundry diagnostics, you know, medical floor stuff, and in between, seeing various lumps and bumps in the other five beds. Which always turn out to be more complicated than the expected — needing IV starts, nebs x 3, complex dressings or some such.
Needless to say, the lumps and bumps took somewhat lower priority than the admitted patients.
So I was busy. Take a number, I hear you saying, the queue starts here. I’m not complaining, really. Sometimes it’s a bit of a break looking after predictable, routine patients: you get to provide some actual nursing care. No brains, no fuss, no muss.
The trouble is, this is becoming the usual, not the exception. I’m starting to see admitted patients discharged from the Emerg, as in going the course from ICU to Stepdown to Telemetry to Medicine to home with a script and a specialist’s appointment in two weeks.
The I had an epiphany: Acme Regional Health Centre doesn’t actually provide emergency services in the space they call the Emergency Department. What we provide is Outpatient Day Surgery, Home Care Evaluation and Ongoing Treatment, a medical/surgical ward, ICU/CCU services, Pre-op Clinic, Fracture Clinic, Ambulatory Care, Office space for Consultants, Psychiatric counselling and Inpatient Services, and a very special place for GPs (and Telehealth Ontario and nursing homes3) to dump patients. We only see a few Emergency patients on the side. Our real job is to be the catch-all and cover for the rest of Acme Regional Health Care. We fix what all the bits and pieces of our overloaded health care system can’t — and get precious little thanks for it.
So really (as a corollary) what’s the point of all the elaborate training and the alphabet soup of certifications I have — and not to mention the eons of experience as an Emerg RN? Is there any point to having Emergency nursing as a specialty when in fact we do very little real emerg nursing anymore?
And why did it take so long for me to figure it out?
2Failure to Cope/Failure to Thrive: a sort of catchall diagnosis, describing frail elderly patients, who can’t go home, usually because they (or their caregivers) have become physically or mentally incapable.
3One of my most petest of pet peeves are nursing homes who call EMS for their obviously failing patients despite utterly clear, written advance directives that state “No Patient Transfer to Hospital. Comfort measures only to be provided at nursing home.” And lo! They come anyway.
So I call them on it. The conversation usually goes like this:
Me: ”I’m calling from Acme Regional Emerg, I’m wanting to know why this patient was transferred here.”
Nursing Home RPN: Snarl, arrrrg, mutter argyfargblah, dehydrated, arf, waaaagh, not eating, waaarg mutter snarf, hiss.
Me: “You did realize that the patient had advanced directives not to be transferred?”
Nursing home RPN: “. . .”
Me: “I mean, was it you who signed the advanced directive form? “
Nursing home RPN: “We can’t provide appropriate care, snarl aarg, wargf, mutter.”
Imagine, a nursing home that can’t care for dying and/or debilitated patients.
If I had a dollar for every time I have had this conversation I would be somewhere else, like a beach waaaaaaaaay south.
Overheard at triage.
Triage nurse: Do you have any allergies?
Patient: No — wait, I am allergic to cats. But I guess I don’t have to worry about cats here.
[. . . pregnant pause. . .]
Triage nurse: None of the feline variety, anyway.
A Unified Field Theory to account for managerial ineptitude and general hosebaggery in hospitals. Ladies and gentlemen, I give you The Iron Law of Oligarchy:
Any large organization . . . is faced with problems of coordination that can be solved only by creating a bureaucracy. A bureaucracy, by design, is hierarchically organized to achieve efficiency—many decisions have to be made daily that cannot efficiently be made by large numbers of people. The effective functioning of an organization therefore requires the concentration of much power in the hands of a few. Those few, in turn—the oligarchy—will use all means necessary to preserve and further increase their power. . .
This process is further compounded, as delegation is necessary in any large organization, as thousands—sometimes hundreds of thousands—of members cannot make decisions via participatory democracy. This has been dictated by the lack of technological means for large numbers of people to meet and debate, and also by matters related to crowd psychology . . . that people feel a need to be led. Delegation, however, leads to specialization—to the development of knowledge bases, skills and resources among a leadership—which further alienates the leadership from the rank and file and entrenches the leadership in office.
Bureaucratization and specialization are the driving processes behind the Law. They create a specialized group of administrators in a hierarchical organization. Which, in turn, leads to the rationalization and routinization of authority and decision-making, a process described first and perhaps best by Max Weber, later by John Kenneth Galbraith, and to a lesser and more cynical extent by the Peter Principle.
The organizational characteristics that promote oligarchy are reinforced by certain characteristics of both leaders and members of organizations. People achieve leadership positions precisely because they have unusual political skill; they are adept at getting their way and persuading others of the correctness of their views Once they hold high office, their power and prestige is further increased. Leaders have access to, and control over, information and facilities that are not available to the rank-and-file. They control the information that flows down the channels of communication. Leaders are also strongly motivated to persuade the organization of the rightness of their views, and they use all of their skills, power and authority to do so.
Bonus points if you can think of ten ways that the Iron Law acts to the detriment of nursing practice in your workplace.
We’ve had a clutch of new emerg docs in the last few months, fresh, giggly, and just off the assembly line: they all still have that new doc smell. They’re all in awe of themselves and each other, being so amazingly smart and everything, which means (to them) the RNs must defer to their utter awesomeness, bow meekly, and generally kiss ass.
It’s very funny, really.
One of my best friends in the Emerg is Dianne, who has pink rhinestone-studded reading glasses, and takes no shit from anyone. New cocky doc comes up to her, all bright and shiny and urgent, and says, “You do know how to put on a polysporin dressing, don’t you?”
“What the hell?,” she asks, looking over the new doc like he’s an unpleasant present the cat brought in, and thinking, tete de merde. “What do you think? Sweetheart, I have pantyhose older than you.”
Oh well, he’ll learn. . .