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Why Don’t Doctors Round With Nurses Anymore?

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Whenever possible I make a point of rounding on patients with their nurses present. I rely on nurses to be my eyes and ears when I’m not at the bedside. I need their input to confirm patient self-reports of everything from bowel and bladder habits to pain control, not to mention catching early warning signs of infection, mental status changes, or lapses in safety awareness. Oftentimes patients struggle to recall bathroom details, and they can inadvertently downplay pain control needs if they don’t happen to be in pain when I visit them. A quick check with their nurse can clarify (for example) that they are asking for pain medicine every 2 hours, that they have missed therapy due to somnolence, that their wound incision looks more red, and/or that they haven’t had a bowel movement in a dangerously long time. All critical details that I wouldn’t necessarily know from talking to the patient alone. Some of this information is not accurately captured in the electronic medical record either.

On a recent trip to a new facility, I asked the head nurse when change of shift occurred. She was visibly perplexed and asked why I wanted to know. I explained that I planned to attend nursing sign out so that I’d be up to date on how my patients were doing. She raised her eyebrows to their vertical limit and responded, “I haven’t seen a doctor do nursing rounds in 30 years.”

That was one of the saddest things I’d heard in a long time. How is it that one of the fundamental features of medical care (doctors and nurses visiting patients together) has gone the way of the dinosaur? Most of my colleagues say they don’t round with nurses because they “don’t have time for that stuff” or that they can “flag down a nurse when there’s an issue” without needing scheduled communication. While I can sympathize with the fear of yet another “time suck” during a busy hospital day, I believe that rounding with nurses can actually save time, reduce medical errors, and head off developing problems at earlier stages (e.g. wound infections, intestinal obstructions, delirium, over/under medication and unwanted medication side effects).

You may think that coordinating nursing rounds with medical rounds is an insurmountable logistical nightmare, and if you have patients scattered throughout various floors of a hospital, that will certainly make things more difficult. But I have found ways to overcome these barriers, and highly recommend them to my peers:

1. Attend nursing sign out at change of shift if possible. Do not disrupt their hand-off process, but ask for clarification (or offer clarification) at key points during patient presentation.

2. Listen to the change of shift recording. Some nurses have their night shift team record their observations and findings in lieu of a 1:1 hand-off process during busy morning hours. This has its advantages and disadvantages. The good thing is that relaying information becomes asynchronous (i.e., like email vs a phone call – you don’t have to be present to get the info), the bad thing is that you can’t ask for clarification from the person delivering the information. If the nurses know in advance that the patient’s doctor is also listening in, they will leave targeted medical questions and concerns for you on the recording.

3. Do your rounds at times when medications are most commonly delivered. You will be more likely to run into a nurse in the patient’s room and can coordinate conversations as well as perform skin checks together.

4. Communicate with nurses (between rounds) when you are about to order a series of tests or dramatically change medication regimens. Explain why you’re doing it so they will be able to plan to execute your orders more efficiently (i.e. before the patient leaves for a radiologic study, etc.) This open communication will be appreciated and will be reciprocated (and may help to spark interest in joining you for regular rounds).

5. Invite nurses to round with YOU. If you can’t join their change of shift, consider having them join your medical rounds. You’ll need to negotiate this carefully as the goal is to streamline rounding processes, not double them.

A recent study published in the New England Journal of Medicine described a sign out process that reduced medical errors by 30%. This communication strategy involved 1:1 transfer of information about patients in a structured team environment (including nurses in some physician meetings). I anticipate that further investigation will reveal that interdisciplinary rounding (with nurses and doctors together) is a critical piece of the error reduction process. For all our advances in technology and digital information tracking, “old school” doctor-nurse rounds may prove to be more important in reducing errors and keeping our patients safe than other far more costly (and exasperating) interventions.

How Not To Interrupt Patients But Also Get The Information You Need In A Timely Manner

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Much has been made about physicians’ tendencies to interrupt patients. Studies have shown that patients are permitted 12-18 seconds of talk time before they are redirected (or interrupted) by their doctor. This leads to patients feeling that the physician didn’t listen or didn’t care. I believe that there is a way to solve the problem without wasting time or being rude. I have used this technique with great success over the years and it works especially well in the inpatient setting, when beginning a formal “history and physical exam.” In three simple words:

Physician goes first.

Before I enter the patient’s room, I perform a careful review of their medical records and imagine what it must have been like for them to experience the events leading up to our meeting. I reconstruct the emotional time line in my head and figure out which pieces of information I need to complete my assessment and plan. Then when I meet the patient (often for the first time) I begin by greeting them warmly and then telling them what I have gleaned from their medical records, and how I think they may have felt during the process leading up to their hospitalization. This establishes that I have taken the time to get to know their background, that I genuinely care about how they’ve been dealing with things emotionally, and that I am determined to correct the record if there are any gaps or errors. I then rely on the patient to fill in the details or clarify results that are unclear.

This strategy saves the patient from having to review historical information that the physician already knows about (which usually leads to the classic interruption at second 12-18 of the interaction), and provides structure for patient participation and input. It establishes trust with the new physician, and conveys empathy. It corrects the medical record when necessary, and maximizes the efficiency of the information exchange. To drive home the concept, let me provide you with two hypothetical conversations with “Mrs. Smith” – in the first case the physician will approach her in the traditional manner, and in the second, with the “physician goes first” method.

Establishing the “chief complaint” with Mrs. Smith – Traditional method

Dr. Jones: (entering hospital room where Mrs. Smith is sitting alone in her bed in no acute distress): “Good morning, Mrs. Smith. I’m Dr. Jones, the attending physician for this unit. What brings you here today?”

Mrs. Smith: (eyeing Dr. Jones with some degree of confusion). “Well, I just had surgery, and I guess I’m still a bit weak so they said I needed to come to rehab but I still don’t really understand why I had to change rooms. Did you know I had surgery? Yes, I was walking my dog on the sidewalk and he pulled a little too hard to lurch at a squirrel and the next thing I knew I was on the ground and my hip was hurting and I was all scraped up and I saw this man in the distance who started running towards me and then I think I passed out and when I got to the hospital, I don’t know, they were worried I had a seizure and then they did a CAT scan and then when I….”

Dr. Jones: “I see. But what I need to know from you now is what is your chief complaint. In other words, why are you here in the rehab unit?”

Mrs. Smith: “Well aren’t you the doctor? You’re supposed to tell me what to do when I’m here aren’t you?”

Dr. Jones: “Yes, of course. But I was hoping you could tell me in your own words.”

Mrs. Smith: Sighs heavily. “Well, I’m here because I fell down and broke my hip and then they found out that I hit my head too and then I guess they were trying to figure out if they needed to put a drain in or just give me seizure pills and I’m not sure how they decided but I don’t remember a drain so I guess… Isn’t all this in my records somewhere? Can’t you figure out what happened?”

Dr. Jones: “Yes, it’s all in your chart but…”

Mrs. Smith: “Well then why don’t you just read it instead of asking a poor old lady with a bad headache to tell you what happened all over again. Everyone keeps asking me for the same old story and I’m just so tired…”

Dr. Jones: “So you’re here in rehab because you’re tired?”

Mrs. Smith: “Well, I guess that’s it.”

Establishing the chief complaint with Mrs. Smith – “Physician goes first” method:

Dr. Jones: “Hello Mrs. Smith, I’m Dr. Jones, the rehab physician who will be taking care of you on this floor. I read through your chart very carefully and learned that you fell down on the sidewalk when walking your dog about a week ago. It looks as if you broke your hip as well as hit your head during the fall. I see that you had your hip repaired surgically, and that fortunately you didn’t need any treatment for your head injury because it didn’t bleed very much internally, but as a precaution you were given some anti-seizure medicine. I imagine that this sudden hospitalization was an unwelcome surprise for you – there you were just walking your dog on a normal day, minding your own business and whammo – now you’re here in the hospital with me!? Well, my goal is to get you back home as soon as you’re ready and steady enough. What is your main goal for rehab?”

Mrs. Smith: “Yes, well it certainly was a shock to get the wind knocked out of me. You hear about little old ladies falling down and breaking a hip but I never thought it could happen to me. Now all I need to do is be able to walk safely so I can go home.”

Dr. Jones: “Well, the good news is that you were very active prior to your fall so I bet you’ll do very well here because you have a good baseline fitness level. My goal is to help control your pain so you can make the fastest gains possible. I bet your hip bothers you and you may have headaches too.”

Mrs. Smith: “Yes, well that’s just it. I’m in quite a bit of pain when I stand up but I’m afraid of becoming a drug addict so I try not to take the pills…”

As you can see, the second conversation was much more successful in establishing a relationship with the patient and getting to the meat of what the doctor needs to know (the patient’s primary goal, her pain level, and what the barrier to treatment might be) without the frustration caused by traditional “open ended questions” and lack of structure – leading to interruptions and perceived lack of caring on the part of the physician.

In my experience, doing a little up front chart review and taking the lead in the first patient encounter results in a dramatic decrease in wasted time and need for redirection. So in the case of avoiding rude patient interruptions – taking the conversation lead may be the best bet.

This is an unusual case where putting the patient first involves letting them talk second.

Medical Errors Reduced By 30% When Doctors Required To Speak To One Another At Shift Change

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I have spent many blog hours bemoaning the inadequate communication going on in hospitals today. Thanks to authors of a new study published in the New England Journal of Medicine, I have more objective data for my ranting. A prospective intervention study conducted at 9 academic children’s hospitals (and involving 10,740 patients over 18 months) revealed that requiring resident physicians to adopt a formal “hand off” process at shift change resulted in a 30% reduction of medical errors.

What was the intervention exactly? Details are available via mail order from the folks at Boston Children’s Hospital. It may take me a few weeks to get my hands on the curriculum (which was supported by a grant from the Department of Health and Human Services). I’m not sure how complex the new handoff initiative is in practice (or if it’s something that could be replicated without government-approved formality) but one thing is certain: disciplined physician communication saves lives.

I myself (without a grant from HHS or a NEJM study to back my assertions – ahem) proposed a set of comprehensive communication practices that can help to reduce medical errors in the hospital. My list involves more than peer hand-offs, but also nursing communication, EMR documentation strategies, and reliance on pharmacists for medication reconciliation and review. It is more than just an information exchange protocol for shift-changes, it is a lifestyle choice.

I applaud the I-PASS Handoff Study for its rigorous, evidence-based approach to implementing communication interventions among pediatric residents in children’s hospitals. I am stunned by how effective this one intervention has been – but a part of me is saddened that we practically had to mandate the obvious before it got done. What will it take for physicians to adopt safer communications strategies for inpatient care? I’m guessing that for many of us, it will involve enrollment in a workshop with hospital administration-driven requirements for participation.

For others of us – regular communication with staff, patients, and peers already defines our medical practice. But because (apparently?) we are not in the majority, we’ll just carry on our instinctual carefulness and wait for the rest to catch up. At least now we know that there is a path forward regarding improving communication skills and transfer of patient information. If we have to force doctors to look up from their iPhones and sit around a table and speak to one another – then so be it. The process may improve our lives while it saves those of our patients.

Hospital Pharmacists: Protecting Patients From Electronic Medical Record Errors May Be Their Most Important New Role

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Most hospitalized patients and families don’t realize that life-threatening medication errors are regularly thwarted by pharmacists. They are truly the unsung heroes of patient care. I just finished a locum tenens assignment at a hospital that uses EPIC as their electronic medical records system, and I was stunned by the impossibly complex medication reconciliation process. Each time a patient is admitted to the hospital, or transferred to another part of the hospital, a physician must review, approve, and re-order their medications. While this may seem like a good way to insure that medication errors are avoided, it actually has the exact opposite effect.

Because EPIC keeps lists of home meds, discontinued meds, and current meds available for review and reactivation, it takes little more than one misplaced check box to order the wrong dose or type of medication. Physicians who transfer a patient to another service can indicate their intended medication list and keep it “on hold” for the receiving physician to review and approve. Unfortunately, the software’s tab system is so complex that it’s extremely difficult to find that list and activate it. Lost in a sea of admissions tasks and order boxes in different fonts, colors, and drop down menus, one often accidentally reviews and approves discontinued types and doses of medicines. The only protection against such errors is the hospital pharmacist.

With each new admission to the inpatient rehabilitation unit, I had to resort to calling a pharmacist for help. I was terrified that I would accidentally insert medication errors into the patient’s order set by carrying forward discontinued meds. The long-suffering pharmacists explained to me that “most physicians make medication order errors in EPIC with each admission.” They said that they regularly had to talk physicians out of throwing their computer out the window in a state of extreme frustration. They also said that their EPIC user environment looked very different (and less confusing) than what the physicians used, so that they couldn’t even provide real-time phone guidance regarding order entry process.

The scary thing is that EPIC has the largest market share of any EMR in the United States. It is also (in my experience) the most prone to medical errors due to its overly complex medication reconciliation process. I have used other EMRs that have far simpler and more intelligent medication order entry processes. Soarian (Sieman’s EMR, just sold to Cerner) has, for example, an outstanding order entry system. So my complaint is not that “all EMRs are bad” – it’s that some have particularly flawed designs that are causing real harm to untold millions of patients. We just haven’t documented the harm yet. I tremble at the thought of what we’d find.

Until electronic medication reconciliation is made safer, pharmacists will be working overtime to correct records and protect patients from carry over errors. I thank my lucky stars that I have had vigilant, determined pharmacists by my side as I cared for very complex, sick patients who were exceptionally vulnerable to dosing errors. There has never been a more important time to exercise caution when entering hospital medication orders, or to express your appreciation for pharmacists. Without their help we might all be experiencing medication errors of EPIC proportions.

EMRs And The Dangers Of Digital Dependency And Drop-Down Medicine

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Electronic medical records (EMRs) now play a part in the daily documentation routine for most physicians. While improvements in access to patient data, legibility of notes, and ease of order entry are welcome enhancements, there is a significant downside to EMRs as well. Although I’ve blogged about my frustrations with nonsensical, auto-populated notes and error carry-forward, there is a more insidious problem with reliance on EMRs: digital dependency.

The idea of digital dependency first occurred to me during a conversation with a young medical resident at a hospital where we share patients. I was bemoaning the fact that I was being forced to use hospital-designed templates for admission notes, rather than a dictation system or carefully crafted note of my own choosing. She looked at me, wide-eyed and said:

“You’ve worked without templates? How do you even know where to begin? Can you really dictate an entire note off the top of your head? I couldn’t live without templates.”

As I stared back at her with an equal amount of bewilderment, I slowly realized that her thinking had been honed for drop-down menus and check boxes. Over time, she had lost the ability to construct narratives, create a cohesive case for her diagnostic impressions, and justify her patient plan of action. To this bright, highly trained mind, clinical reasoning was an exercise in multiple choice selection. Her brain had been optimized for the demands of an EMR template, and mine was a relic of the pre-EMR era. I was witnessing a fundamental cognitive shift in the way that medicine was practiced.

The problem with “drop-down medicine” is that the advantages of the human mind are muted in favor of data entry. Physicians in this model essentially provide little benefit over a computer algorithm. Intuition, clinical experience, sensory input (the smell of pseudomonas, the sound of pulmonary edema, the pulsatile mass of an aneurysm) are largely untapped.  We lose our need for team communication because “refer to my EMR note” is the way of the future. Verbal sign-outs are a thing of the past it seems, as those caring for the same patient rely on their digital documentation to serve in place of human interaction.

My advice to the next generation of physicians is to limit your dependency on digital data. Like alcohol, a little is harmless or possibly healthy, but a lot can ruin you. Leverage the convenience of the EMR but do not let it take over your brain or your patient relationships. Pay attention to what your senses tell you during your physical exam, take a careful history, listen to family members, discuss diagnostic conundrums with your peers, and always take the time for verbal sign outs. Otherwise, what advantage do you provide to patients over a computer algorithm?

Am I a curmudgeon who is bristling against forward progress, or do I have a reasonable point? Judging from the fact that my young peers copy and paste my assessment and plans into their progress notes with impressive regularity, I’d say that templatized medicine still can’t hold a candle to thoughtful prose. Even the digitally dependent know this. :-)

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

Click here for a musical take on over-testing.

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