Categories
Life In The Hospital

Why COVID-19 Has Made Me More Efficient

A funny thing happened last month… I realized that I’ve been feeling a lot more rested in the past 6 months. So I asked myself the 5 “whys” to sequentially drill down on the question:

  • Why #1? Because I was getting to bed earlier
  • Why #2? Because I wasn’t doing as much work at home in the evening
  • Why #3? Because I was getting all of my work done at the hospital.
  • Why #4? Because I had more free time during the workday
  • Why #5? Because COVID-19 created free time

How did this happen? COVID-19 has eliminated a lot of non-productive workday time, has shortened the duration of a lot of activities, and has allowed us to multi-task.

Eliminating non-productive time

I spend a lot of time in meetings. Before COVID-19, I was on 30 hospital committees. The coronavirus outbreak has added 6 more regular workgroups and lots of ad hoc meetings. In the past, each of these meetings cost me about 5 minutes each way to get from my office to the meeting room if the meeting is in my hospital and about 25 minutes each way to drive, park, and walk to a meeting room if the meeting is on the campus of OSU. That adds up to many hours every month. COVID-19 has given me all of that time back. Now, getting to and from a meeting involves just the click of the mouse and I am instantly transported via computer to wherever my next meeting is. No elevator rides, no stairwells, no car rides.

Making meetings more efficient

When you go to a meeting in a conference room, there seems to be tacit agreement by all attendees that they are obligated to fill the entire allotted time for the meeting. And so, a meeting scheduled for 1-hour almost always lasts for a full 60 minutes. There are meeting presenters who inevitably use 50 words for a 5 word statement. There is usually minutes taken to get the AV presentations started or download PowerPoint files. And then there are the attendees who feel that the are obligated to ask questions or interject their thoughts and keep doing so until the meeting is out of time.

With virtual meetings, most of that goes away. Meeting attendees are less inclined to drone on with marginally relevant comments (often because they are only half paying attention to the meeting while doing other things on their computer). Presenters tend to be more succinct on video. Many attendees will pose their questions to typed in “chat” boxes on the virtual meeting programs rather than ask them verbally. And all it takes to pull up a PowerPoint file is a single click of the “share screen” button on the program. For these reasons, a lot of meetings that were previously 60 minutes are all of a sudden only lasting 25 minutes.

Multi-tasking during meetings

In the past, it was considered rude to be checking your email or doing paperwork during a meeting held in a conference room. But with virtual meetings, the other attendees can’t tell if your email account is pulled up on your computer or whether you are working on your electronic medical record inbasket during the meeting. In most meetings, there are presentations that are relevant to you and there are presentations that are irrelevant. Now, rather than daydreaming about what you want to have for dinner during the presentation on proposed changes to the color of surgical scrubs used in the OR, you can get on-line and order dinner for pick-up. Overall, 20-30% of meeting time can now be devoted to catching up on email and paperwork.

Telemedicine is quicker

In general, it takes me less time to do an outpatient visit by telemedicine than it does by an in-person office visit. There is no physical examination required. It is easier to type your progress note while you are simultaneously on the computer with the patient. And patients seem to want to talk less on a video chat than in an exam room. As a consequence, I don’t get behind on my clinic schedule nearly as much as I did in the pre-COVID era.

More working lunches

Being particularly paranoid about opportunities for viral transmission, I now avoid cafeterias, break rooms, and lounges. Indeed, we have found that hospital staff are more likely to acquire COVID-19 in these locations than from direct care of COvID-19 patients. Instead, I pack a lunch and eat it in the safety of my own office, generally while on the computer doing work.

COVID-19 has brought economic hardships but it has also brought a paradigm-shift in business practices that have resulted in improved operational efficiencies in the workplace, especially for physicians. I now have about 2 hours a day of extra time during my workday that I previously did not have before COVID-19. As a consequence, I’m getting more sleep than anytime in the past 40 years.

October 2, 2020

Categories
Life In The Hospital

Hospital Power Outages

Perhaps no buildings are more dependent on electrical power than our hospitals. Almost everything that we do to heal and to cure ultimately depends on a reliable power supply and when that supply is interrupted, hospitals shift into disaster mode. I’ve been through several hospital power outages over the past 30 years, ranging from a few minutes to many hours; this is what I have learned.

Where does the hospital get its power?

Fortunately, there are multiple redundant power sources in hospitals, from the main power feed from the local electrical grid, to back up generators, to back up batteries on pieces of equipment. In an optimal situation, a hospital will have 2 independent feeds from different parts of the electrical grid so that if there is a regional power failure affecting one area, power can be drawn from the second feed to ensure a steady electrical stream.

Most hospitals will also have a back-up generator, often run off of diesel fuel, that can kick in within seconds of a loss of electricity from the regional power grid. However, the back-up generators can usually only supply a fraction of the normal power needs. This results in “emergency power” circuits in the hospital that are usually indicated by red electrical sockets (as opposed to the standard white sockets that are connected to the regular power grid).

Hospital electrical systems are unique

Despite the systems of back-up power, sometimes power can be lost. One of the reasons for this is that most hospitals are made of buildings of varying ages. We tend to add-on to existing buildings or build attached buildings as patient demand grows, rather than raze the old hospital building and then build an entirely new one. This leaves us with electrical components of varying ages and the hospital’s electrical system is only as good as its oldest components. Additionally, the amount of power a hospital consumes is enormous and so fuses can often weigh 200 pounds or more, making emergency repairs more difficult and time consuming.

So what do you do when the power goes out?

One of the first priorities is to activate the hospital’s disaster command center that is used to coordinate responses too disasters. Most hospitals will do 2 or more mock disaster drills each year to practice for disasters. The disaster that you get is usually not the one that you practiced for but by doing drills, you can ensure that your communication channels and key response personnel are in place and can adapt to the specific needs of each unique disaster.

Intensive Care Units. The first priority is to ensure that life support equipment has power. This includes mechanical ventilators in the ICUs, dialysis machines, and operating room equipment. Modern ventilators have back-up batteries but older ventilators may not work when the power goes out so hospital staff need to immediately go and check on mechanically ventilated patients. An ambu-bag should be brought to every room with a ventilator being used. If telemetry monitors no longer work, then a nurse or respiratory therapist should be assigned 1:1 for ICU patients. There should be a flashlight in every room. If a sustained power outage is anticipated, then moving patients to a different part of the hospital that can serve as a surrogate ICU may be required. Ideally, this should be location that has existing cardiac monitors and medical gases such as the surgical post-op recovery room, the endoscopy suite, and the cardiac cath lab recovery area. It can be very helpful to bring in additional nursing staff, respiratory therapists, and physicians. When we had a recent power outage involving our ICU, we moved patients to the surgical recovery area and brought in 2 extra critical care physicians. One physician was in charge of logistics and maintained a white board in the recovery area to list which patients were going to different recovery room bays, which ones had ventilators, which ones had chest tubes with pleurovacs (needing wall suction), etc. This physician triaged the order of patient movement, directing which patient should be moved first and grouped patients together for optimized nursing and respiratory care.

Operating Rooms. Operating rooms are unique. Usually, there will be sufficient power available on the emergency power (red power socket) system to complete a surgery but air handlers may be on regular power with the result that an operating room may quickly exceed approved temperature or humidity thresholds. Therefore, assessment of temperature and humidity controls of each operating room need to be assessed to determine if they are working and if not, then surgeries in those ORs may need to be canceled. Usually, a surgical procedure that has already been started can be completed before temperature and humidity thresholds are exceeded; however, if a very long surgery is underway and the air handler for that OR goes out, then it may become necessary to complete a portion of the surgery, close, and then bring the patient back for a staged procedure the following day. Although this can result in significant surgeon and patient dissatisfaction, it is better than risking a surgical infection if thresholds are exceeded. Be sure to check refrigerators and freezers in the OR area because supplies like frozen bone grafts require very specific low temperatures.

Nursing units. Most patients on regular medical/surgical floors are not connected to life support equipment as occurs in the ICUs. However, a sustained power outage can affect patient comfort. Having lots of bottled water and extra blankets is helpful. Patients’ medical conditions can change so if the elevator power is out, it may be necessary to use stair sleds to transport patients off of a floor. Most hospitals maintain a supply of stair sleds but staff often are not experienced in using them. It is a good idea to practice use of these sleds during disaster drills.

Elevators. Each elevator needs to be assessed to determine who is in them when power is lost. Elevators with patients being transported between floors should be prioritized for rescue. Elevators containing staff and visitors can be assigned a lower priority for rescue. Be sure to get a cell phone number for someone in each elevator to keep in your command center.

Emergency Department. If power loss is anticipated to continue, then the ER should be placed on “divert status” which directs emergency squads to take patients to other hospitals in the area. You do not want patients with myocardial infarction, stroke, or trauma coming to the ER if you are not able to assess or treat them.

Pharmacy. The first task for pharmacy is to ensure that patients can get needed medications. Many hospitals will use a Pyxis system to keep medications on individual nursing units. If the Pyxis machines lose power and cannot be opened, then medications will need to be brought up from the pharmacy. The second step for the pharmacy is to preserve medication inventory. Most medications have specific temperature thresholds. Medications in freezers or refrigerators may need to be moved to alternative locations. If air handlers to the pharmacy area are affected, then temperatures should be monitored to ensure that thresholds for shelf medications not exceeded. Arrangements may need to be made for medication compounding at another location.

Laboratory. The hospital lab is particularly vulnerable when there is power loss. There are reagents in freezers and in refrigerators that can have very specific temperature thresholds. These reagents can be very expensive so prioritizing moving these freezers and refrigerators to emergency power sockets or portable generators is necessary. When we had to do this, we found that having a lot of extension cords in our facilities department really paid off (you can never have too many extension cords in a power failure!). Refrigerated blood products in the blood banking areas also need immediate attention. The chemistry and hematology analyzers have fairly strict temperature and humidity thresholds – as long as these thresholds are not exceeded, then the analyzers simply lie dormant until power is restored but if thresholds are exceeded, then the analyzers may be down for days while reagents are replaced, controls are run, and analyzers are checked and serviced. We brought portable air chillers into our lab that ran off of emergency power to ensure proper ambient air temperature when we lost power. This is especially important in the lab where freezers and refrigerators running on emergency power can generate a lot of heat that can quickly warm up the lab area. Once power is restored, it may take several hours to get the lab analyzers back on-line. It is very useful to have a contingency plan for the lab with a courier system and an alternative lab that can run samples. Don’t forget about blood gas analyzers – these generally have a back up battery supply and can continue to run for a short time in the event of a power loss. Because these machines can generally also do hemoglobin and basic chemistry tests, they can be an important resource and should be prioritized to connect to emergency power or a portable generator.

Fire safety. If power loss results in the hospital’s fire alarm system being off line, then you should contact the fire marshal. In most communities, it is the fire marshal (and not the hospital’s administrative staff) who decides whether or not a building needs to be evacuated due to power loss. If the fire alarm system is not functioning, then a “fire spotter” will need to be assigned to each floor of the hospital. This is a hospital staff member who is equipped with a flashlight and a cellphone or other communication device whose sole job is to constantly patrol that floor for fire or smoke and can report directly to the command center.

Radiology. CT scanners and MRIs are particularly susceptible to power loss. When these systems go down, it can take 1-2 hours to bring them back on-line and even longer if one of their fuses blow at the time of the power outage. This may require bringing in management-level personnel who are experienced with rebooting these devices. Most hospitals utilize portable x-ray machines that can run off of batteries. This can at least allow for basic x-rays to be performed. Power loss may result in an inability to transmit the images to the hospital’s PACS system for review by a radiologist but at least there is usually a monitor on the portable devices that permits x-ray review by an on-site physician.

Cardiac catheterization laboratory. The cath lab has equipment, medications, and supplies that have specific thresholds and attention to temperature and humidity in these areas is necessary so that medications and equipment can be relocated if thresholds are reached. Additionally, the imaging equipment in a cath lab can take a long time to reboot. Bringing in your hospital’s clinical engineering personnel is essential for bringing cath lab equipment, radiology equipment, and other electronic equipment back on-line.

Inventory. All kinds of supplies in the hospital have specific temperature and humidity thresholds. A typical hospital will have about $1 million of supplies in the operating rooms alone. If temperature or humidity thresholds are approached, then it may be necessary to relocate these supplies to other locations to prevent losses.

Food services. Patients need to eat and if the power to the kitchen goes out, then alternative food sources need to be identified. There are portable kitchens in mobile trailers that can be brought on-site to do food preparation. It is a good idea to know who to call for portable kitchens as part of regular disaster planning so that one can be brought on-site quickly if needed. Food inventory in refrigerators and freezers requires attention and either needs to be relocated to meet temperature thresholds or need to be disposed of. Don’t forget about refrigerators in nursing units and procedure areas that contain snacks and drinks as these will also need to be disposed of if temperature thresholds are exceeded. If there is a sustained power outage, then hospital staff also need to eat, particularly all of those who are staying past their normal shifts to attend to patient care and safety. Bringing in pizza, bottled water, and snacks for nursing units can really help maintain morale. Calling in a couple of local retail food trucks can also help.

Central sterile supply. Sterilized surgical instruments will have specific thresholds and if sterilized packages get condensation in them, then they will need to be re-processed. Have a contingency location for surgical sets and case carts so that they can be maintained within thresholds.

Security. When power is lost to monitoring cameras and to public area lighting, there is increased demand on hospital security staff. It may take bringing in additional staff for patrolling parking areas at night and for patrolling hallways and waiting areas to ensure staff and visitor safety. Many access doors in hospitals will have electronic locks and badge readers. Be sure to send someone out to manually raise bars in gated parking lots to permit cars to enter and exit.

Electronic medical records. These often seem like the bane of physician existence but when they go off-line, it can paralyze patient care. Fortunately, most medical record systems get turned off for maintenance on a regular basis so hospitals have contingency plans for using paper charting for orders, progress notes, etc. It turns out that one of the hardest things to do when the electronic medical record goes down is to discharge patients, for example, from the emergency room.

Morgue. It is the last thing that anyone thinks about but don’t forget about the need to maintain low temperatures in the morgue if the air handlers are down. Options can include bringing in a portable refrigerated truck or identifying an alternative morgue location.

Equipment that you will need

Some of the items that I have found to be particularly useful to have during a power failure are extension cords, portable temperature/humidity monitors, and flashlights. Extension cords can allow you to re-route refrigerators, freezers, and essential electronic equipment to emergency power sockets or portable generators. Flashlights are useful everywhere. Portable temperature/humidity devices are a great way to tell if you are approaching thresholds in places like the operating rooms, pharmacy, lab areas, and central sterile supply. Ideally, bringing in infection control personnel and arming each of then with a hand-held temperature/humidity device allows for constant rounding and monitoring of these areas. It is also a good idea to document the temperature and humidity at regular intervals in each location so that once power is restored, it is easy to determine if thresholds were exceeded and for how long they were exceeded in order to determine what inventory needs to be disposed of. Hospitals will also maintain a stock of portable 2-way radios for communication. We use these but I have found that I use my cell phone primarily. If the power is out for more than a couple of hours, having cell phone chargers on had can be helpful.

Hopefully, your hospital will never have a power outage but every hospital needs to prepare and practice for how to respond in case power loss occurs.

January 18, 2020

Categories
Life In The Hospital

Controlling The Epidemic Of Outrage

Outrage is one of those human emotions that when used sparingly is useful to separate the most egregious violations of social norms from the constant background of minor social violations. This applies to whether you are working in a hospital or anywhere else. But in excess, outrage can be lethal to workplace culture. We live in an era when outrage surrounds us, whether it be Twitter-tantrums, toxic comments posted to news articles on-line, or angry pundits on TV news commentary shows. We have become saturated with outrage.

Outrage will burn you out

I recently listened to a podcast by a radiologist who had embraced the F.I.R.E. movement (Financial Independence, Retire Early). The radiologist had become burned out less than 10 years into his practice and viewed work purely as a means to retirement; in fact, he did not like his job and wanted to retire as soon as possible, preferably before age 45. After listening to him, I don’t think it was his job that he did not like, I think it was his life that he did not like. He said that he was able to tolerate continuing to work by stopping listening to commentaries on TV and stopping reading news feeds on-line. I think it was the constant barrage of TV and on-line outrage that had been making him unhappy and contributed to him being burned out.

Outrage is contagious

Outrage provokes a response in us when someone fans the fires of our opinions into a conflagration of anger and incredulousness. So what happens when you are told something that sets you into a fit of outrage? You tell it to your buddy sitting next to you in a bar. Or you re-tweet it to your Twitter followers. Or you send a link to a website to your family members. 15 years ago, the contagion of outrage spread slowly since you would have to wait until the next evening when you’d be meeting with your friend at the bar. Today, a pandemic of outrage can occur almost instantaneously via email and Twitter. It is said that 1 person infected with measles will then infect 9 non-immunized people on average. Today, one person infected with outrage can then infect a thousand people within an hour.

Outrage is addictive

We get rewarded for being an outrager. When we post something outrageous on a blog, we get more website visits. When we tweet something outrageous, we get more re-tweets and then other people tweet back equally outrageous tweets and pretty soon we are in a vicious Twitter cycle of  perpetual outrage, a growing vortex of fury burning through the internet. When a commentator says something outrageous on TV, he or she get more viewers. The attention feedback that we get for generating outrage has operantly conditioned us to generate more outrage. If you are listening to a news channel on cable TV, you will likely start daydreaming when the host is talking about a new fruitcake recipe but as soon as they bring on a far-right or far-left news pundit, you will snap back to attention. Outrage makes us feel alive.

Outrage is exhausting

Our emotions need balance, like Yin and Yang. If we spend too much time being outraged, then our emotions become out of balance. It takes a lot of psychological energy to be outraged and if you spend all of that energy being outraged, there’s little left over for all of the good things in life, like your profession or your family. Moreover, if you get all worked up being outraged all day, you can’t fall asleep that night and you end up being chronically sleep-deprived.

Outrage is poisonous

Sometimes, outrage can be unifying, to bring together a group of people for a common goal for the good. For example, when a community comes together after a particularly heinous crime. Or when a football team gets fired up to perform better after a particularly flagrant foul by the other team. But outrage can also be dividing. For example when it comes to politics and religion – both of which can intersect in hospital practice. And when outrage divides us, it can poison team-building efforts and derail interspecialty collaboration.

Outrage is distracting

When we become angry, our minds focus on that which made us angry and we can lose sight of our other tasks. This can foster mistakes and errors in judgment. Working while outraged is like driving while intoxicated.

Professional outragers versus amateur outragers

There are two types of professional outragers. There are those who get paid to be as outraged as possible – the radio political commentators whose voices’ raise as they incredulously mock people of the opposite political party. Then there are those who are paid to enable outrage in others – the TV news commentators who bring people with different opinions about a news item on their show and catalyze them into a shouting match on live TV. These are people whose job it is to be outraged or to create outrage and if they don’t, they lose their job.

Amateur outragers are different – they don’t get paid to be outraged or create outrage, they just do it because they enjoy it. These are the internet trolls who post demeaning comments on blogs and internet chat rooms. The are usually anonymous and for them outrage is a hobby rather than a career.

Fortunately, there are ways to lessen outrage in our hospitals and our workplaces.

  1. No tweeting on the job.
  2. Use work computers for work and not for surfing posted comments on websites.
  3. Keep waiting area and employee lounge televisions on cooking-related channels and home improvement channels; not on news channels
  4. Keep political campaign advertising out of the building
  5. Wait 10 minutes before responding to a “hate email” from someone who is enraged about something
  6. As leaders in the workplace, we need to ration our own outrage so that we set an example for the rest of the employees

I personally do not like being outraged and I have adapted my lifestyle to minimize outrage. I am not on Twitter. I read the local morning newspaper and then do not look at news shows or internet news feeds for the rest of the day. I avoid reading internet articles that encourage viewers to post comments. I flag “hate emails” to come back to later in the day or on the following day, after my emotions (and the email’s author’s emotions) have settled down. I don’t put our hospital’s amateur outragers on hospital committees. I don’t listen to news shows on the radio in the car. And maybe most importantly, I created this blog as a way of cleansing my soul when faced with events that could fester and ferment into outrage if I didn’t reflect on them and analyze them.

Save your outrage for the stuff that really matters and then use your outrage sparingly.

November 3, 2019

 

Categories
Life In The Hospital

You Can Solve All Quality Problems With A Policy, A CBL, Or A SmartPhrase

Anyone who has ever sat in a committee tasked with fixing a hospital quality issue knows that there are only three solutions that the committee can choose from. You can write a policy which will sit on a little known and even less used webpage on the hospital’s website. You can create a CBL, or Computer-Based Learning module, that are annual educational exercises for the hospital staff that are looked forward to with as much anticipation as a colonoscopy. Or, you can create a SmartPhrase to be used by the staff  in electronic medical record progress notes that will never be used but will allow the committee to win the congratulations of the hospital administration who have no idea what a SmartPhrase is but it sounds really important.

Here is how it works. One of the hospitalists submits an incident report to the hospital’s anonymous quality reporting website because the coffee pot in the physician’s lounge was left on for 3 hours resulting in coffee that tasted like burnt pencil shavings. A member of the quality department pulls up Center for Disease Control’s website and notes that there has been a recent CDC advisory that there has been an epidemic of bad coffee in physician lounges in hospitals all throughout the country. As a result, surgeons and anesthesiologists nationwide have stopped drinking hospital coffee with the result of pandemic caffeine-deficiency headaches. Your quality staff then pull up The Joint Commission Standards and learn that according to standard 7.5.B19.#!&.4, coffee pots in physician lounges should be maintained in a temperature range of 91 – 96 degree Centigrade and coffee should always be disposed of within 84 minutes of being brewed. The hospital is in its window for its quadrennial unannounced site survey by The Joint Commission and the word on the street is that this year, the site surveyors are carrying thermometers to measure the temperature of coffee in physician lounges. Recently, a hospital in Cleveland lost its accreditation and was dropped from Medicare because a surveyor found 92 minute-old coffee in a nursing station breakroom.

The hospital’s legal staff determines that bad coffee qualifies as a sentinel event and assembles a multidisciplinary committee to provide a solution to the problem to the hospital administration within 14 business days. The committee meets 3 times and determines that the event is egregious enough that it warrants the highest response possible, the so-called triple response, consisting not only of a new policy, but also a CBL and a new SmartPhrase. The committee provides the following recommendation to the Medical Staff Administrative Committee:

  1. A new policy regarding the use of coffee machines in physician lounges. The policy dictates that only physicians credentialed in coffee making are permitted to operate the coffee maker. Physicians wanting to be credentialed must show that they have performed at least 20 proctored coffee procedures during residency or show evidence of attending an AMA-approved coffee making simulation course. Physicians must maintain logs to show that they have brewed at least 10 pots of coffee every 2 years in order to maintain hospital privileges. The policy also dictates that coffee pots must have both visual and auditory alarms when left on beyond 84 minutes and that the hospitals Engineering Services Department maintain logs documenting that the alarms are checked on a weekly basis. The new policy can be found on pages 42,789 – 42,796 of the hospital’s policy manual.
  2. A new CBL about coffee maker equipment. The committee recognized that not all physicians will be credentialed in coffee making and that many non-credentialed physicians will be drinking coffee in the physician’s lounge. Therefore, it was determined that all physicians must complete an annual CBL about safe coffee practices. There was concern expressed by some committee members that physicians who are tea-drinkers or who are Mormon should not have to take the new CBL but the committee ultimately decided that because it was theoretically possible that tea-drinkers could convert to coffee-drinkers and Mormons could convert to Catholicism, that all physicians should be required to take the CBL with no exceptions. After viewing the CBL, physicians would be required to pass a 20-question test on safe coffee procedures in order to maintain their medical staff admitting privileges. Included would be information about the correct use of FDA-approved calibrated measuring spoons for dry coffee grounds, disposal of used coffee grounds in biohazard receptacles, management of acute lactose-intolerance due to milk and cream, and safe storage of Styrofoam coffee cups. The new CBL turned out to be quite timely since a previous CBL on correct operation of the stethoscope was being retired that year, leaving only 499 required CBLs, and the new CBL would keep the total number of required CBLs over the hospital-mandated minimal of 500 per year that the physicians need to complete.
  3. A SmartPhrase to prompt correct documentation of coffee making procedures in case of audit by regulatory agencies. The committee members had observed that SmartPhrases are used to great effect in the electronic medical record to document in the physician’s progress notes their review of problem lists, review of medication lists, review of reviews of system, and listing of all hemoglobin measurements that the patient has ever had in their entire life. In fact, the committee noted that 95% of all of the progress notes was information imported into the progress notes using SmartPhrases that was not relevant to the actual care of the patient but was inserted into the progress notes in case the patient’s chart was ever reviewed by Medicare as part of a billing audit. Because documentation of coffee making has absolutely nothing to do with patient care and would only add unnecessary documentation to the progress notes, it was felt that this would therefore be perfect use of a SmartPhrase. One member of the committee raised the question of also creating SmartPhrases for the 10-day weather forecast, the 12-month list Dow-Jones Industrial averages, and the latest edition of the Dear Abby column as these could also add to irrelevant information in the progress notes but it was concluded that this was beyond the scope of the committee.

The hospital administration gleefully accepted the committee’s recommendation and thus another pressing quality issue was resolved.

The sad reality is that hospitals often use the convenience of a new policy, a CBL, or a SmartPhrase in order to “solve” a quality issue. What most quality issues really require is improved communication among staff and a change in the culture of the staff. But creating a policy, CBL, or SmartPhrase is simple and lends themselves to easy documentation and audit. Changing culture and communication is hard and difficult to quantifiably document or audit.

October 26, 2018

Categories
Life In The Hospital

Leadership Means Listening

Whether you are a hospital medical director, an army major, a corporate CEO, or the President of the United States, you never have enough resources to do everything that you really want to do. Consequently, you can’t give everyone everything that they want. But you can listen and sometimes just listening is your most valuable and effective resource.

Children, citizens, and hospital employees often say that they want their voices heard. Effective parents listen. Effective politicians listen. And effective hospital leaders listen.

Here are some specific ways you can improve your listening skills.

  1. The first step in listening is to show up. You will understand what a person is saying better when you hear it in the environment that the person works in. Context is everything when it comes to listening. You can’t hear anyone if you spend your time behind a closed office door. Get out to the hospital wards, the doctor’s lounge, and the procedure areas.
  2. Be empathetic. Understanding and sharing the feelings of the other person will make that person perceive you as valuing that person and what they are experiencing. Ultimately, it will foster the perception that you are supportive of them.
  3. Control your emotions. Listening to criticism is exhausting and it is too easy to get annoyed, defensive, or angry when you feel like you are being criticized. Often, all that person wants is for someone to hear their complaint. Maintaining one’s composure can be difficult but ultimately makes the other person feel like you really listened to them.
  4. Don’t judge. Priests are great at this – they hear about the worst of human behavior and thought during confession and still remain completely dedicated to their parishioners.
  5. Listen to the words that are not spoken. Understanding the English language is easy; understanding body language can be more difficult. Sometime how someone says something is more important than the words that they actually speak.
  6. Don’t interrupt. We all like to hear ourselves talk and we often think that is what our employees and the physicians in the hospital want. A conversation is not a contest of who can get the most words in at the most strategic time. Different people express themselves at different paces and you need to be sure that the physicians have enough time to express their thoughts at their own pace.
  7. Ask a question about what they just told you. It will show that you are taking an interest in their ideas or concerns.
  8. Don’t forget to listen to yourself.

  9. Make eye contact. When you are looking at someone when you are listening to them, it creates more of a perception that you are focused on them and that you consider what they are saying is important. It makes them feel that they are appreciated.
  10. Don’t feel pressured to give advice too soon. A doctor once told me that the M.D. initials after our names stood for “make decisions” and as physicians, we are trained to get as much data as we need to make a diagnosis or therapeutic decision and then do it without belaboring that diagnosis or decision. As a leader, sometimes giving your employee a little more time allows him/her to draw their own conclusions and make their own decisions, which can be far more effective than if you just dictated that decision.
  11. Compliment the other person. By acknowledging that the issue that they are complaining about really is a problem and by telling them that they are doing a great job with the resources that they have, you show that you are truly interested in improving their work environment.
  12. Know their name. We have more than 1,000 physicians in our medical system and I can’t know them all by name but those that work regularly in my hospital, I make a point to know by name and by using their name in conversations, it shows that I value that physician.
  13. You can’t really listen to someone by an email. Same goes for a text message. Yeah, it is quick and convenient to send an email or a text but you can’t pick up on the nuances of how the words are spoken and the nuances of the non-verbal communication. If you take the time to call the person, or better yet, go and speak with them in person, you will not only learn more but you will better show that you value what that person is saying.
  14. Make a note. I know it is old-school, but I keep a clip of 3×5 cards in my pocket. When a physician tells me about an idea that they have or complains about an problem they are encountering, I write it down. Later, as it gets attended to or resolved, I cross it out. When the physician sees me write down a note about what they are telling me, it shows that I consider what they are saying important and to be attended to. Also, it helps keep me from forgetting about those issues when I finally have a  chance to do something about them later on.

Hearing is what you do with your ears. Listening is something that you do with your soul.

February 13, 2018

Categories
Life In The Hospital

Achieving Diversity In The Hospital

We are the stewards of our nation’s journey toward equality. The journey was charted in the Constitution by our country’s founding fathers. The journey has been continued by each generation of Americans. It has been steered by the Supreme Court’s interpretation of the constitution and by legislation enacted by Congress. We are closer to achieving equality now than we were in 1950, in an era of segregation. In 1950, we were closer than we were in 1900, in an era when women could not vote. In 1900, we were closer than we were in 1850, in an era of slavery. And I have no doubt that in 2050, we will be closer to equality than we are today.

But this journey is one that requires every American to be an active participant – achieving equality is not a spectator event. Our nation’s hospitals play an integral role in the journey toward equality. Although we are not there yet, we have come a long way in a short time. In 1959, Dr. Paul Cornely did a survey of segregation in our nation’s health system. In the North, 17% of hospitals were segregated. In the South, 94% were segregated – in 33%, African Americans were not admitted at all; in 50%, patients were racially segregated in different wards; and in the rest, there were other degrees of segregation. Nationwide, less than 10% of hospitals accepted African American interns or residents and 58% of medical schools did not admit African American students.

Two key laws virtually eliminated hospital desegregation almost overnight: the Civil Rights Act of 1964 and the Medicare Act of 1965. In less than 4 months, one thousand U.S. hospitals became desegregated. If hospitals did not comply, they were not eligible to receive Federal funds. These two pieces of legislation directly addressed explicit bias in medicine. But today, we more commonly face implicit bias, when we are not even aware of it. Implicit bias refers to the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. It was partially out of concern about implicit bias that led us to give our three daughters relatively androgynous first names, so that they would be less likely to be discriminated on with job applications. Some of the common areas of implicit bias include:

  1. Race/ethnicity
  2. Gender
  3. Socio-economic status
  4. Age
  5. Mental illness
  6. Obesity
  7. AIDS
  8. Brain-injured patients
  9. Intravenous drug users
  10. Disability

In our hospitals, the next step in our journey toward equality is to address this implicit bias. In many ways, this is a lot harder than addressing explicit bias. Most people have some degree of implicit bias and do not even realize it. However, there are a number of things that we can do:

  1. Increase awareness of implicit bias. The reality is that everyone has some implicit biases, it is the way that the human brain is wired. It is incumbent on us to recognize our own implicit biases so that we can improve our self-awareness of how this may inadvertently affect our decision making.
  2. Maintain a robust human resources department. You have to be able to investigate report of subtle or overt discrimination in order to prevent explicit bias from poisoning the workplace. This is harder to do with implicit bias but a good human resources office can help you considerably.
  3. Critically examine who gets promoted in the hospital. In the United States, we have approximately 3.9 million nurses. Of those, 90% are women and 10% are men. However, women make up 73% of healthcare managers and men make up 27%. So, does that mean that we are promoting too many male nurses into management positions or does it mean that too few men are going into nursing? In other words, should the percentage of managers mirror the demographics of the employees that they manage or should it mirror the demographics of the population in general? If opportunities are equal, then managers should be reflective of the employees that they manage.
  4. Avoid cognitive overload in the hospital. When our brains are overtaxed, we tend to revert to framing information in stereotypes. Cognitive overload can be created by inadequate staffing, productivity pressures, inadequate training, information overload, inadequate sleep, overcrowding, and high noise levels.
  5. Promote understanding of of the cultures of your patient populations. Much of implicit bias arises from the stereotypes created by an absence of knowledge about or understanding of those cultural difference between ourselves and others. 
  6. Continuously reinforce staff education about implicit bias. Case studies and videos are a great way of reminding staff of the common situations that implicit bias occurs. For example, two 25-year old men are brought into the emergency department stuporous and hypoventilating. One is African American and one is Caucasian. You have 1 dose of Narcan in your emergency department – which one do you give it to? If your first thought is to give it to the African American man, then you could have implicit bias about race and use of IV street drugs. In reality, in Ohio, 89% of people who die of opioid overdose are white.
  7. Establish outcome monitoring. In your hospital, does patient gender affect the decision of whether or not a patient gets a joint replacement? Does patient race affect how frequently screening colonoscopy is recommended? Does the insurance payor (Medicaid versus commercial) affect who gets flu shots? An effective electronic medical record can make monitoring patient populations for patterns of implicit bias much easier.
  8. Institute “Implicit Bias Rounds” in resident and medical student education. Morbidity and Mortality Conference has been a mainstay in doing a post-mortum examination of the factors that led to a patient’s death. Perhaps every residency program should have a regular “Morbidity and Implicit Bias Conference” as part of morning report 2 or 3 times a year to examine for any given patient what elements of implicit bias led to the patient’s illness or injury.
  9. Ensure that diversity in search committees for leadership positions. Part of implicit bias is the subconscious tendency to gravitate to those who we perceive as being similar to ourselves. If you are putting together a search committee for a department chairman and it is composed of a bunch of other chairmen who are all white men, then you are setting yourself up for group implicit bias.

Explicit bias and implicit bias are both bias. Explicit bias is usually easier to identify and easier to eliminate via rules and laws. Implicit bias is a lot more subtle and can’t be eliminated overnight as was done the the Civil Rights Act and the Medicare Act. Instead, elimination of implicit bias requires education and a change in healthcare culture. But as with all things, culture trumps policy and that change in culture will be what gets us farther along in our journey toward equality.

August 21, 2017

Categories
Life In The Hospital

What Is Your Leadership Style?

In 1995, New York Times columnist Daniel Goleman authored Emotional Intelligence, a book that popularized the idea that people who are able to recognize their own and other people’s emotions and then use that information to optimally manage relationships are more effective leaders. Goleman also examined leadership behaviors of executives and classified them into 6 leadership styles using different elements of emotional intelligence. Four of these styles are generally positive and two are generally negative. When you are working with physicians, no one leadership style works best in every situation.

Coercive

This is a top-down, bullying style where the leader demands immediate compliance with his or her directives and can be summed up by the phrase “Do what I tell you”. Subordinates are dissuaded from expressing their own ideas and there is a sense of lack of flexibility in the organization. This is not a style of leadership for the long-run of an organization but can be effective in the short-run when there is a crisis in the institution or when there is a group of problem employees. After the crisis is resolved, however, the coercive leader has a negative impact on the organization by undermining motivation and rewards.

Authoritative

Authoritative leaders are visionary and motivate subordinates to want to follow them. Their style can be summed up by the phrase “Come with me”. These leaders tend to not direct people in the specifics of how to do their job but rather on what the ultimate goal of the organization is, thus allowing people to devise their own means to that goal. This is one of the most effective leadership styles for most organizations, particularly when the organization has lost sight of its long-term mission. However, in hospitals, where the physicians are the subordinates, an authoritative hospital leader can sometimes come across as overbearing or out-of-touch, particularly when those physicians are more skilled or experienced than the leader.

Affiliative

These leaders create harmony and create emotional bonds by utilizing empathy and building relationships. It can be summed up by the phrase “People come first”. Communication skills are the greatest tool of these leaders. They use frequent positive feedback to motivate and build a sense of belonging. Although generally a positive leadership style, by exclusively relying on positive feedback, poor performance may go uncorrected. Furthermore, exclusive use of this leadership style can result in  people losing sight of the ultimate mission of the organization.

Democratic

These leaders strive to create consensus and their style can be summed up by the phrase “What do you think?” They seek input by their employees and use their actions to maintain high morale. By doing this, employees are better able to be realistic about what can and cannot be accomplished in the organization. However, in a committee, this leadership style can result in endless meetings where everyone is speaking their mind and nothing gets accomplished. This style works best when the leader needs ideas and guidance from employees and works best when the leader can subtly use it to make subordinates come to a desired conclusion on their own to make them feel empowered. It does not work in times of crisis or when the employees are not knowledgeable or competent in the issue at hand.

Pacesetting

These leaders set an example of high performance standards by being a high performer. They are often the hardest workers and set expectations for everyone else to work just as hard. This style can be summed up by the phrase “Do as I do, now”. The problem with this style is that most of the other employees can’t keep up with the highest performer and over time, these leaders can be exhausting. It can be used effectively in brief and selective situations in order to motivate highly skilled employees, for example, to meet an upcoming, important deadline.

Coaching

This style of leadership is best for developing people for the future by improving their performance or developing their individual strengths. These leaders are great listeners and use their communication skills to foster employees career growth. This style can be summed up by the phase “Try this”. These leaders will accept short-term failures if those failures result in better long-term performance. However, this is a very time intensive leadership style that requires the leader to do a lot of one-on-one personal mentoring and it can be hard to incorporate into a 60 or 70 hour work week. Furthermore, some employees are not able or willing to change their behaviors and in this situation, persisting with coaching can be frustrating and waste the leader’s time.

So, what is the best leadership style? Ideally, all 6, when used in the right situations.  No one style is best all of the time. This is especially true when you are leading physicians. Ideally, a hospital leader needs to primarily use authoritative, afflictive, democratic, and coaching styles most of the time. But, there can be occasions when coercive and pacesetting styles need to be used in moderation. The key is to try to match the style of leadership you employ to the specific situation. And the reality is that most of us cannot do all 6 styles but we do need to be able to recognize others who do have the leadership styles that we lack so that we can appoint them to leadership positions when that style would be the most effective one to use.

August 17, 2017

Categories
Life In The Hospital

When Physicians Reach Their “Use-By” Date

Everything in your kitchen has an expiration date. Doctors do too. If the lunch meat in your refrigerator goes too far beyond its “use-by” date, not only can you not use it, but it will smell up the rest of the food in the refrigerator. The same thing happens with doctors in the hospital. The difference is that the expiration date of that lunch meat is pretty predictable but the expiration date of a practicing physician is not so predictable. For some, it is in their 50’s, for others it is in their 60’s, and others in their 70’s. It really depends on the individual and on the specialty.

Over the decades, I’ve encountered a lot of physicians who were past their use-by date. Here are some examples of the spectrum of what happens when a physician approaches or goes past their career expiration – no names and some of the details have been changed a bit to protect identities.

The Master Clinician. This was a doctor who was revered by his colleagues, his residents, and his patients. When he told me he was going to retire at 62 years old, I couldn’t understand it. There was no case at morning report that he could not solve and he had clinical wisdom that was sought whenever his former trainees throughout the country had a case they couldn’t figure out. He told me that he wanted to go out at the top of his game so that he would always be remembered for the doctor and teacher he was when he was at his best rather than being remembered for being past his prime. And he was right – years later, he is still remembered for being one of the best.

The Gentleman. He was an old-school solo practitioner who ran a busy clinic, admitted his own patients to the hospital, and cared for his patients at several local nursing homes. Despite being nearly 70 years old, he worked long hours and rarely took a day off. But as inpatient demands changed with an emphasis on shorter hospital length of stay and as his patients got older with more complex and numerous medical problems, the younger hospitalists started to out-perform him. Eventually, I had to sit down with him and tell him that maybe it was time to cut back on inpatient care and let the young guys take over. He was very gracious and without an argument, gave up his inpatient admitting privileges to focus on his outpatient practice. It reminded me of the end of the movie, Major League, when the Cleveland Indians manager, Lou Brown, goes out to the pitcher’s mound to talk to aging pitcher Eddie Harris. Brown: “How’s it holding, Eddie? You look a little tired.” Harris: “I’m throwing every piece of junk I can think of at ’em, skipper.I got enough left for one more hitter.” Brown: “Nah.You pitched a hell of a game there. Take a seat, and we’ll see if we can get this guy out for you.” Harris: “All right.” Brown: “Good game, Eddie.”

The Surgeon. In his specialty, he was the best. Other surgeons came and went but he never left the institution. He was a lot like the master clinician, except in the operating room. He’d play country music in the OR while he was operating and he never lost his temper. He worked tirelessly and periodically when surgeons would resign, he’d work 7-days a week for months at a time… and never complained. He was a fixture at the hospital and surgery really defined his life. One day in his 60’s, he said he was going to retire and a couple of months later, he walked out of the hospital and never came back, not even to visit. He took up golf and a lot of the other things that he had never had time for when he was practicing but never set foot in the hospital again – it was like he turned off the lights and started an entirely new life.

The Consultant. She was a quiet and soft-spoken physician who never complained and always accepted the clinical assignments that no one else wanted to do. Everyone liked her and she provided great clinical service. She was a senior clinician who had seen every disease in her specialty and because of her experience, her management advice was like something from a Greek oracle. I started noticing that there was an envelope in the breast pocket of her white coat – she’d walk around with her stethoscope in one pocket, her rounding list in another pocket, and that envelope sticking out of the third pocket. So, one day I asked her, “Dr. Consultant, what is in that envelope that you’ve been carrying around for the past couple of years?” She said to me “Jim, that’s my resignation letter and I carry it with me so if one day, the bastards finally get to me, I can just hand it to them.”

The Victim. I had known The Victim for years. He had been one of my attending physicians when I was a resident. He was known for being eccentric and entertaining. But as the years went by, his behavior in the hospital went beyond eccentrics. His clinical judgment started to be questioned and the nurses couldn’t get hold of him at night with questions or problems with his inpatients. He was eventually asked to resign but he fought back. He recruited a union representative from the professor’s union and he hired an attorney. This led to a very ugly fight over maintaining hospital clinical privileges and after 2 years and hundreds of thousands of dollars in attorney fees on his part, he lost. A couple of years later, I read in the State Medical Board newsletter that he had lost his medical license due to alcoholism.

The Doctor Who Knew Only Medicine. He had been a fixture of medicine in our city for decades. He had practiced at the University for many years where he had re-invented himself by changing his specialty a couple of times as younger and more knowledgeable physicians were hired into his department. I had come to know him pretty well – like The Victim, he had been one of my attending physicians when I was in training. Eventually, he couldn’t reinvent himself anymore and went into private practice. Medicine was all he knew to do – his life was defined by being a doctor and not by anything else. After another 25 years in practice at a community hospital, he lost his admitting privileges due to his clinical practice not being up to date and questionable clinical judgment. He came to me in his 70’s and asked if he could get admitting privileges at our hospital. In looking into his recent evaluations at the community hospital, I knew that there was no chance that he would be granted clinical privileges out our hospital. I told him so but he kept asking me. We talked about retirement and I told him that he had provided service to the community for decades and maybe he deserved a rest and to do the things that he had never had time for before. The problem was that there was nothing other than medicine for him – it was all he had ever known and the only thing he could envision ever doing. He never did get privileges at our hospital.

The Monotone Physician. I encountered the Monotone Physician during my second year of medical school. He gave us several lectures about diseases in his specialty. He was a famous, internationally-known, white-haired University legacy. He had been at the University for decades and had written some of the standard textbooks in his field. But in the classroom, he moved slowly and lectured in a monotone that would put most students to sleep. He was completely unanimated. Many of the other medical students complained about him to the Dean and said that he was a boring and ineffective teacher. They had no patience with him said he was “over the hill” and should be replaced with someone else who was a better teacher. In private, they’d make fun of him. I never complained about him. Instead, I went to all of his lectures and watched and listened to him. I watched his gait when he’d walked into the lecture hall. I watched his facial movements (or lack thereof}. I listened to his monotone, emotionless voice. And I watched the tremor of his hands that he hid so well and that none of the other students ever noticed. And from him, I learned more about Parkinson’s disease than from my neurology lectures. I don’t think anyone else figured it out.

The Preceptor. After nearly 40 years of practice, he had seen at least one of every disease in the medical textbooks. Like the Master Clinician, he was a “doctor’s doctor” – the guy that other physicians would go to when they got sick. But he liked to travel and he liked spending time with his wife. It was getting hard to work 12-14 hours a day, answer patient phone calls at 2 AM, and round in the hospital every 3rd weekend. So he retired. A few months later, there were some resignations in his specialty and there weren’t enough physicians to cover all of the clinical and academic work. So, he came back as a clinic preceptor for the trainees in his specialty – he would work 3-4 days a week, not have to round on the weekend or take call, and could take a month or two off at a time to travel. Another generation of physicians learned from a master and he was able to have the best of both worlds in retirement.

The problem with physicians’ use-by dates is that most of the time, everyone else can see them but we, ourselves can’t. So, we often don’t realize when we are past our expiration date. It really requires enormous self-awareness and a willingness to pick up on cues from one’s peers. I’m just hoping that when my own use-by date is approaching, that one of my colleagues will have the courage and respect for me to let me know.

August 12, 2017

Categories
Life In The Hospital

When Patients Want To Video Physician Encounters

Last year, one of the emergency room physicians called me to ask my advice when one of his patients wanted to film himself being sutured and stream it live to Facebook. Today, one of the hospitalists contacted me because a patient wanted to video his hospital encounter for pain management. In the first case, the patient was looking to create “reality TV” for public entertainment. In the latter case, the patient was using the threat of public exposure in order to coerce the physician into prescribing narcotic medications.

The patient was admitted with a medical condition that can cause pain but is almost always associated with abnormal blood tests. In this case, all of the blood tests were normal and there were some suspicious discrepancies in the patient’s history that caused the physician to suspect opioid-seeking behavior on the part of the patient. In the past, we have had patients use all sorts of behaviors to get their physician to prescribe opioids. I’ve had patients threaten to call the State Medical Board about their physician. When his physician refused to prescribe oxycontin, one patient called the medical staff office to report that his physician was intoxicated (we immediately did an alcohol breath test – it was negative). But this was taking coercion to a new level.

It is pretty common for patients to ask to record their visits in the outpatient clinic and the vast majority of the time, it is for very appropriate reasons. Patients often have a hard time remembering all of the information that you’ve given them and they want to be sure that they get their medical instructions right. Sometimes, they have family members who will ask: “What did the doctor say?” and they want to be sure that they get it right. I was taken aback the first time that happened to me but now, I don’t find it intrusive – usually it is a way to improve my patients’ compliance with medical instructions and a way to be sure that everyone in the family hears the same thing. I admit, I am a little more cautious about what I say and how I say it… but then, maybe that is how I should always be.

From a legal standpoint, patients can record their conversations with you, even if they don’t tell you that they are recording you. In Ohio (as in most states), a conversation can be legally recorded as long as one party consents to it. This means that anyone can legally record a conversation with anyone else in secret. Video is treated pretty much the same as audio. The legal case of Smith versus the Cleveland Clinic in 2011 illustrates this. A patient died in the hospital and afterward, the family asked to meet with the hospital medical director and secretly recorded the conversation; the court ruled that the recording was admissible as evidence in the subsequent malpractice case. As the paparazzi will attest, it is perfectly legal to take photographs or videos of anyone as long as you are on public property. Hospitals are generally considered a public place, in this regard.

Should physicians wear body cameras?

Police are being pressured into wearing body cameras both because of the fear from some members of the public that the police are being abusive and because of the fear that many police officers feel that they are being inappropriately accused of being abusive. Jeremy Brown, MD, the director of the National Institutes of Health’s Office of Emergency Care Research, proposed that body cams should be standard equipment for emergency department physicians. I’ve been an expert witness for dozens of defense malpractice cases and can’t count the number of times the plaintiff will make an allegation about something totally outlandish that they claimed that the physician said with the astonished dependent physician’s response of “I never said that”.

So what should the physician do? Most of the time, an audio or video recording is a way of improving patient care and can be the physician’s friend, not foe. But this was a pretty unique situation where a patient took advantage of a physician being uncomfortable being filmed in order to pressure the physician into prescribing narcotics. Here are my suggestions:

  1. Treat every patient encounter as if it is being recorded. The reality is that patients are going to record your encounters, in secret and when you least expect it. Make your words count and never say disparaging things to patients whether you are being recorded or not.
  2. Someone is listening when the patient is under anesthesia. There are abundant cases of physicians sedating patients for procedures or surgeries and then saying sarcastic or insulting things about patients when they think the patient can’t hear only to learn in court that the patient turned his cell phone on to “record” before the procedure started or that one of the operating room staff was secretly recording the procedure. Don’t say anything about a patient when they are asleep that you wouldn’t say to them when they are awake.
  3. For most recordings, use them to your advantage in order to ensure that patients get your instructions right and to ensure that all of the family members hear the same thing about diagnosis, prognosis, treatment, etc.
  4. Although the patient can secretly record you, you can’t secretly record them. HIPAA laws prohibit you from mishandling personal health information. If a patient records an encounter with you and posts it to his/her Facebook account, there is not much you can do. But if you secretly record a patient encounter and post it to your Facebook account, get ready for court and possible jail time.
  5. Let patients know that recording your encounter with them can affect their care, possibly in a negative way. Stage fright is a very real thing. I’ve hosted more than 700 OMEN-TV shows and MedNet webcasts – I’m pretty comfortable being in front of the camera now but it wasn’t always that way and for the first few years, my heart would race and my stomach would have butterflies for the hour before the shows would start. Although some physicians could sew up a facial laceration just as well on-camera or off-camera, many physicians would get shaky hands on camera and that could result in a worse outcome. Would the Mona Lisa have turned out as well if da Vinci had a hundred people watching his every brushstroke? Maybe… but probably not.
  6. The doctor-patient relationship is built on a foundation of trust and so the doctor should let the patient know that non-consented recordings could be a violation of that trust and preclude you from providing care in the future.

The world has become a very small and very public place. We are recorded on some surveillance camera or another whenever we walk down a city block. People have their cell phone in holsters ready to draw at the first sign of anything newsworthy on our streets and our public places. When you walk into a grocery store or a bank, your picture has been taken. Like it or not, we are filmed by someone almost every day. The hospital has become no different.

May 31, 2017

Categories
Emergency Department Life In The Hospital

Should Hospital Security Officers Carry Narcan?

Two days ago, I was leaving the hospital and I heard the overhead announcement “Code Blue, front entrance to the hospital”. Nine times out of ten, this is because someone slipped and fell and a panicked visitor will run into the front lobby yelling something about cardiac arrest. But as I’ve mentioned in a previous post, you just don’t know until you know and so we treat every code blue as an emergency, regardless of its location.

Our hospital’s chief of cardiology and I arrived at the same time. There was a minivan at the front entrance of the hospital and an animatedly hysterical woman standing at the side with an unconscious young man in the front seat. We asked a couple of quick questions: “Does he have diabetes?”, “Does he have seizures?”, “Did he take any street drugs?”. The answers were no, no, and he “just smoked a little weed”. I took a quick check of his forearms – no needle marks.

He had a strong pulse and was breathing regularly but the best we could do was to get him to briefly open his eyes with stimulation. His pupils were small. We managed to get him out of his car and onto a patient cart. A quick oximetry check showed his oxygen saturation was 94%. We raced him to the emergency department which meant down a hallway, up one level in an elevator, and down another hallway. While we were in route, I called to the ER and spoke to our emergency department’s medical director, who happened to be on duty that evening. As we were wheeling the guy through the hospital, I told him to have a dose of intranasal Narcan ready when we arrived.

About 7 or 8 minutes after the code blue was first called, we got him into a room in the ER. By that time, he was pretty much unresponsive. Before vital signs, blood draws, or hooking him up to a cardiac monitor, he got a dose of Narcan sprayed into his nose. About a minute later, he sat up asking what was going on. He got opioids somehow – either he was snorting heroin or injecting in some unobtrusive part of the body that wasn’t easily visible. Marijuana laced with fentanyl or carfentanil is always something that we worry about but it is probably pretty uncommon.

But from an emergency response standpoint, it was pretty clear that the guy was going to die if nothing was done. In patient care areas, we keep a “crash cart” that is stocked with all of the medications that are needed to treat a patient during a cardiorespiratory arrest. But carts are not immediately available everywhere in the hospital, for example, in the driveway in front of the entrance to the building. Panicked people don’t always know to take someone with an urgent medical condition to the hospital’s emergency room, they may not even know where the emergency room is – they just drive up to the front of the hospital and yell for help. When someone has an opioid overdose, intranasal naloxone (Narcan) is life-saving and even a couple minutes delay can mean the difference between life and death. Narcan is the drug overdose equivalent of bystander CPR for cardiac arrests. So, it behooves us to have it immediately available to hospital first responders to “code blues”.

Ohio started Project DAWN as a way of getting naloxone into people who overdose on opioids as quickly as possible. In 2016, the Columbus EMS personnel administered intranasal naloxone 2,300 times. In a 6-month pilot program, 125 Columbus police officers were given intranasal naloxone to carry – they administered it 58 times and all but one of the people survived. So if city police carry intranasal Narcan, should hospital security staff carry it also?

Our hospital is currently debating this. On the one hand, a security officer responds to every code blue and they also patrol the hospital grounds, including the parking lot, where a lot of drug overdoses arrive. On the other hand, there are a lot of security officers that would need to be trained and it would require us to buy a lot of doses of intranasal naloxone to supply them all. The other option would be our nursing supervisors – there is only one of them on duty at any given time and they also respond to all code blue calls. Because of their nursing background, they would require a lot less training in administration and would likely be a lot more comfortable administering the medication. With fewer of them, it wold require a lot fewer doses to supply them. I’m not sure what the final decision will be but it is clear that we need to make intranasal naloxone more widely available, even in the hospital.

In cities, there has to be a fire hydrant every 400 feet. There has to be a smoke detector in every bedroom of your house. There should be one fire extinguisher for every 200 square feet of building space. We go to great efforts to prevent people from dying of fires. Last year, 104 Ohioans died from fire. But last year, 4,149 Ohioans died of unintentional drug overdose. That means that in Ohio, you are 40 times more likely to die of an accidental drug overdose than from a fire. How many lives could we save if intranasal Narcan was as easily available as fire hydrants and fire extinguishers?

The simplistic answer is that you get people to stop using heroin and other opioids. But as I’ve stated in a previous post, humans have a 5,000 year history with opioids and if history teaches us anything, it is that you can’t make heroin and other opioids go away by education, legislation, or moralization.

It is time to look at intranasal Narcan the way we look at automated electronic defibrillators (AEDs). Get them to where the people are who need them.

May 26, 2017