Archive for category Parade of the Blindingly Obvious

Doctors Are From Mars, Nurses Are From — Oh, To Hell With It

News flash! From Fierce Medical News, here’s the shocking headline:

Docs, nurses miscommunicate on respect, job role

When you guys pick yourselves off the floor from laughing, here’s the money quote:

In particular, the survey found differing views of how doctors treat nurses. According to 42 percent of nurse leaders, physician abuse or disrespect of nurses was common, whereas only 13 percent of physician leaders said it was common. Fifty-eight percent of nurse leaders considered disrespect for nurses uncommon, while 88 percent of physician leaders said it was uncommon at their healthcare organizations.

“I do believe nurses and physicians are on two different pages when it comes to communication,” Pam Kadlick, vice president of patient care and chief nursing officer for Ohio’s Mercy St. Anne Hospital, said in a HealthLeaders Media article. “Nurses have a tendency to give a very detailed report, more than what a physician may want to hear; hence, the physician may interrupt, seem to be abrupt, even rude at times.”

But most physicians don’t consider such behavior to be disrespectful, she noted.

You’re telling me abuse of nurses is all about physicians being insensitive, maybe, and nurses having too many hurt fee-fees? Really? And nurses are supposed to be surprised that physicians “don’t consider such behavior to be disrespectful?”

Why does this sound like a ’80s sitcom?

Why does this sound like this report is trying to validate abusive physician behaviour?

You can only shake your head. And you just know, somewhere, in a darkened office maybe, in an obscure corner of a mega health care corporation, a manager is reading this report and exclaiming, “I knew nurses were to blame!”

I will very happily concede abusive behaviour of all kinds has declined markedly in my own time as a nurse, though I will say I work in an institution that enforces a zero tolerance policy against abusive behaviour. Moreover, the physicians I work with, shoulder to shoulder, are lovely and professional, and there is a true sense of collaboration. This makes for excellent patient care.

However, by no means is this true everywhere. So let’s not pretend the brow-beating, the mocking, the chart-throwing, the patronizing  — to be blunt, treating nurses like you wouldn’t treat your mother, daughter, wife, bank clerk, Wal-Mart greeter, housekeeper, or dog — still doesn’t go on. Denial will never fix the problem, either from physicians — or nurses.

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Long Emergency Department Admissions Shorten Lives

Via, another study showing prolonged emergency department stays are less than optimal:

There were 41,256 admissions from the ED. Mortality generally increased with increasing boarding time, from 2.5% in patients boarded less than 2 hours to 4.5% in patients boarding 12 hours or more (p < 0.001). Mean hospital LOS also showed an increase with boarding time (p < 0.001), from 5.6 days (SD ± 11.4 days) for those who stayed in the ED for less than 2 hours to 8.7 days (SD ± 16.3 days) for those who boarded for more than 24 hours. The increases were still apparent after adjustment for comorbid conditions and other factors.

In other words, two consequences from lengthy Emergency department admissions: first, you are about twice as likely to die if you are admitted for more than twelve hours, and secondly, if you stay for longer than 24 hours (and survive, of course) you’re likely to be hospitalized for three extra days.

Clearly something bad happens when patients are admitted in EDs for long periods of time. The study’s authors identify a few reasons for this. Care for admitted emergency department patients are poorly prioritized by both physicians and nurses; a preference bias occurs because less acute patients tend to get beds more quickly (a phenomenon which is a frequent occurrence in my hospital as “easy” patients go off-service to Paeds or Post-Partum or General Surg); there are also delays in the getting appropriate treatment started, which negatively affects mortality.

I would add the obvious, that expecting Emergency departments to run as Emergency departments and simultaneously as ICU/Post-Op/Med-Surg/Urology/Gyne/Surgical Outpatients/Paediatric unit(s) is probably not a reasonable expectation, if for the simple reason acutely ill new ED patients will always take priority over admitted patients, except when those patients are actively crashing. Additionally EDs are not set up to take care of admitted patients. We are not given the resources to do the job properly.

I don’t expect this study would surprise anyone who has actually worked in an Emergency department. We’re used to seeing patients decompensating before our eyes. What it does is give us ammunition. When some manager tells me, “I’m not going to do those bed moves for that patient because you only have seven admits — which I have actually heard fall out of a manager’s mouth — I can cheerfully reply, “You’re increasing the risk of that patient dying to 1 in 20.” When the ICU tells me to wait till after lunch, I can counter with “You are increasing the patient’s overall length of stay with every hour’s delay.” Most importantly it adds a sense of moral urgency. Get the patients upstairs, or increase the risk of killing them. It’s pretty simple.

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Andrea Horwath has a Complaint about the Health Care System.

For my American friends and readers, we’re having a provincial election here in Ontario. Since health care is deemed a provincial responsibility (though funded extensively by the federal government), it’s naturally a hot topic of discussion. At the televised leader’s debate a couple of days ago, New Democrat leader Andrea Horwath managed to step in it, just a little, by suggesting Emergency Department staff at Hamilton General Hospital treated her son inappropriately or even incompetently after he injured his elbow skateboarding. “He went to an emergency ward in my community,” she said. “They didn’t do anything for his fractured elbow. They sent him home, said it doesn’t really need anything, they can’t afford a cast, and go home and somebody will help you figure out how to put a sling on it.”

Unlike St. Joseph’s Health Care Centre in Toronto, which took a pasting in the Toronto media after an elderly man made allegations of abuse, Hamilton General pushed back:

Despite her clarification Wednesday, some hospital staffers felt Horwath’s comments were unfair, said Jeff Vallentin spokesperson for Hamilton Health Sciences.
“All I know is there are lots of folks (working here) concerned about the comments … some feel it’s an unfair representation of the hospital.”
He added that no one has made an official complaint about Leonetti’s visit to the ER.


The hospital’s chief of emergency medicine would not speak on the specifics of the Horwath case, but said it is common for elbow fractures not to be put in a cast.
Dr. Bill Krizmanich works in emergency at McMaster University and said there are many degrees of fracture, from a hairline to a full-out break, and each is treated differently. The elbow is a very complicated joint because of its range of movement and the treatment depends on the severity of the injury.
The most common elbow injury from skateboarding is a radial head fracture, which normally heals permanently in about four to six weeks with very few future problems.
“In those, we don’t splint and we don’t cast. It heals on its own … (and) early mobilization of joints is helpful.”

At the end of it all, Andrea Horwath walked backed her comments, somewhat: her intent, she claims, wasn’t to attack staff but to highlight systemic problems. “The example,” she says, “was meant to illustrate that people are disappointed with the service they’re getting at the hospitals. In the event, it turns it turns out Horwath was not even with her 18-year-old son during the visit; her retelling of the story was at best second-hand — and 18-year-olds are not known for taking direction well.

I guess, to be charitable, Horwath was trying to personalize a complex issue, i.e. validating through personal anecdote reports of poor care at Ontario hospitals. Unfortunately, the leader of the party of the Left managed to fall into the  trap of repeating the same tired meme (ironically!), beloved of right-wing politicians and pundits that Canadian public health care is The Pit From Whence Few Return Alive.

We all have stories of poor treatment by health care institutions, and I am sure this is a commonality of both Canadian and American health care systems. My own story relates to being seen in the ED of Belleville General (I was passing through) presenting with sudden onset of severe headache. I was treated badly by the Emergency physician who plainly thought I was some drug-seeking tourist from The Big Smoke. (The nursing staff, I hasten to add, were superb and professional.)

But anecdotal evidence, while having the power of making the complex real and personal, is also the worst kind of evidence. It’s pretty difficult to generalize conclusions from anecdotes. Even if Horwath’s story is true and my story is true, you can’t point to a larger conclusion, as Horwath does, that “people disappointed with the service they’re getting at the hospitals.”  It’s logically faulty. In any case, the larger point it isn’t actually true, and illustrates nicely the problem of using anecdotal evidence for anything: more often then not you’re going to be caught with your pants down. Statistics Canada has the data.

Patients very or somewhat satisfied with health care services, by region, 2007

Source: Statistics Canada. Patient satisfaction with any health care services received in past 12 months, by sex, household population aged 15 and over, Canada, provinces and territories, occasional (CANSIM Table 105-4080). Ottawa: Statistics Canada, 2008

In Ontario, 86% of people were either very or somewhat satisfied with the health care received. Is there room for improvement? Absolutely, and I am a bit worried about the gap between “somewhat” and “very”, which the StatsCan study does not elaborate upon. If we’re going to talk reasonably about health care reform, let us at least speak rationally, and use evidence and best practices. Bashing health care agencies and professionals isn’t helpful, especially when (I suspect) large number of health care professionals are sympathetic to the New Democrat message.

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Not Charted, Not Done — And The Patient Suffers

I was seconded a little while ago for a couple of weeks to do administrative duties, among which were some chart audits. This is where we pulled old Emergency Department charts and compared them to a check-list of essential criteria for having sound documentation. We looked at whether initial nursing assessments were complete. Were vital signs taken according to policy? Were the orders signed off? Were discharge instructions given? The list was long, and almost each check-off represented a point where a nurse could be called to account for poor practice

For reasons of  liability, accountability, and most importantly, patient safety and continuity of care, good charting is a nursing essential. Why? Because the chart is the principal way health care professionals communicate with each other. We all make clinical decisions based on the information found in the chart, and if information is missing or inaccurate, we may jeopardize patient care.

And frankly, in the never-ending Quest for Good Charting, we collectively sucked.* I’m not talking about whether nurses were completing Form 5435-xy-125 documenting the chain of custody of the patient’s lower plate, either. There were some pretty egregious examples. No initial vitals signs charted on some charts. No assessment of peripheral capillary refill on children. No chest assessments on patients with presenting with cough and dypsnea. A patient in hypertensive crisis given an antihypertensive with no follow-up blood pressure documented. I was actually embarrassed for my colleagues — and myself. To be clear, I am not suggesting that the nursing care was ever as poor as these charts might suggest, though the blood pressure chart did give me pause. But it’s also an old maxim that “if it isn’t charted, it isn’t done.”

The missing piece of information which bothered me the most was the lack of charted pain evaluation, and unfortunately in this instance, I could show pain was not being assessed at all. Let me explain. Lay people who have travelled in the land of health care are probably familiar with this question: “On a scale of one to ten, with ten being the worst possible pain, how would you rate your pain?” This question is important, and not only for the obvious reasons of providing effective pain control. In the Canadian Triage Acuity Scale (CTAS) system, the pain scale forms a crucial element of determining a triage score and in turn, priority of care, because the level of pain is correlated to the severity of the patient’s condition.

Alarmingly, many of the charts audited had no triage pain assessment, meaning the triage score was unreliable. Patients presenting with chief complaints of back pain, for example, were routinely triaged as “4,”  that is “Less Urgent,” without any pain assessment being done at all. A pain scale of  8/10 would bump these patients to CTAS 2 (Emergent),  which of course determines a whole other priority for care. I understand why the chief complaint of “back pain” did not receive adequate pain assessment: patients presenting with such are often unfairly labelled as drug seeking. Trouble is, I can think of many problems which present as back pain, that are unrelated to either mechanical injury — which can be serious enough —  or drug seeking behaviour, ranging from renal calculi to dissecting aortic aneurysm.

The point is, poor charting on the part of nurses can lead to bad patient outcomes. Part of the problem is that nurses are overwhelmed by the documentation they are required to managed. Charts are full of administrative trivia unrelated to the actual provision of health care, yet nurses are expected to treat this flood of paper as being as important as documenting the care itself. (I know this situation is far better in Canada than the United States, where charts take on encyclopedic length before ever leaving the ED.) When nurses face ever-increasing workloads, higher patient acuities  and volumes, and the consequential time constraint, the choice is often literally between actually saving lives and writing it down in the chart in an adequate manner. Guess which wins.

But in the end is the plea of “I don’t have the time for good charting” really a good excuse, especially when licences are potentially on the line? This is to say, nurse managers must be pro-active in insisting their staff are given the space to chart properly, and front-line nurses must be equally clear good charting is not optional. Yet, to be honest, in reading though the charts during the audit, I sensed that a lot of nursing care was routinized, that there wasn’t much critical thinking going on between the lines — what wasn’t charted was, in fact, never done. For good patient care, this is the greatest danger of all.


*Note to any educators: an hour or two of chart auditing is guaranteed to cure the most recalcitrant nurse of poor charting. I think of myself as a reasonably conscientious charter, having worked in the U.S., but even for me, it was a real kick in the pants.

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Some Days You Just Gotta Post Links

Sorry. No new content today. Just links. Sore brain.

  • Unions step up fight against pay freeze: “Women who care for the elderly in publicly funded nursing homes in Toronto make, on average, 2.5 per cent of the compensation paid to CEOs like Tim Lukenda at Extendicare,” Stewart said. “Mr. Lukenda made $1.5 million including bonuses last year. Is the CEO really worth 50 times more than the woman providing care?”
  • Some preemie babies ‘give up’ to blunt repeated pain: “Premature babies are repeatedly exposed to painful invasive procedures, yet only 36 per cent of premature babies in Canada get pain relief, according to Celeste Johnston, a McGill University nursing professor and expert in neonatal pain.”

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Three Million Dollars I Will Never See

Another float in the Parade of the Blindingly Obvious:

A 3 year, 3 million dollar study into how nurses and other health care providers can reduce the time they spend on administrative tasks or retrieving medical supplies , so they can spend more time with their patients is underway in Saskatchewan.

Um, how about 1) hiring staff to perform administrative tasks, because paying me $42 an hour for data entry is probably not a good use of resources, and 2) moving supplies to where I actually do my work and ensuring the supply carts are well-organized and stocked.

Can I have my $3 million now?

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