ER Murse

How to tell if you have been Studerized - or something that sounds similar

2009-05-12T17:28:00.000-07:00

You’re a seasoned ED Nurse. You are respected by your peers. You are up to date with the latest medical advances, you treat your patients well, you’re a strong patient advocate and actively advocate for patient safety and the nursing profession even if it conflicts with some of your organizations priorities. You probably feel your operating at or near the expert level and have been evaluated that way for a number of years but I have news for you. Nurses are no longer graded on the Novice to Expert scale. They are now being categorized as Low, Medium, and High performers. So how do you know where you fit in and what’s behind this new evaluation system? Hold on, if you haven’t already you’re about to be Studerized or something that sounds similar but is much more painful, at least from what I’ve been told.

How can you tell if you’re on the road to Studerization. It starts out when your managers, CNE, CEO, ED MD Director, among others leave for a few days to a conference or management retreat. The retreats are usually held in resort places like Las Vegas, Phoenix, or Florida but have been branching out to other cities and even webinars. You are not told what it’s all about and you don’t care, you’re just happy to see them gone for a few days. When they return you notice an immediate change. They are using new lingo and talk like they have been indoctrinated into some sort of cult. They are very scripted. They use terms like “Hardwired”, “Fire Starter” “Best Practice” “Taking the organization to the next level” “Low Performers” and “Rounding.” Some of these I wrote about in a previous post titled annoying consultant speak They also talk about some charismatic character named Quint Studer. From conversations with a number of people who’ve attended the programs they sound like a combination of a Amway multilevel marketing seminar, manager training seminar, and Kool-Aid drinking cult gathering. There usually is an inspirational speaker to pump up the crowd. There are various levels and once students are immersed in the philosophy they are considered “Studerized”. A more advanced level is the “Fire Starter” which has a 15 point litmus test called “15 Sparks”. Hospitals can even win the prestigious Fire Starter Award after a visit from one of the Studer troopers.

Hospitals thought-out the nation are trying to improve their patient satisfaction scores and marketing share. I have written about that in a post on patient satisfaction scores out of balance and How has the patient satisfaction push effected your practice. They have turned to groups like Studer who give them the nuts and bolts of turning patients into customers and strategies to bump their satisfaction scores. I have listed my own strategies here.

Not long after the retreat new concepts start appearing into the work area. Some are founded in good ideas but are being done for marketing reasons and means to boost patient satisfaction scores rather than any interest in patient care. Some measures include.

Scripting: Nurses are no longer free to communicate the way that feels natural or based on the situation at hand but are given scripts to communicate with their patients. Coincidentally, or not, the scripts prompt the patient to answer their discharge surveys by injecting key phrases into the scripts that correspond with the questions on the survey. Would you like Fries with that?
Managing up: Encouraging staff to positively portray services and co-workers, doctors, ect during conversations and hand offs regardless if it is true or not. Hi, this is your Doctor, He is one of our best physicians, The patients really love him. Wink Wink
Hourly rounding: Rounding every hour and every half our for ER utilizing your best scripting language. Staff are required to fill out rounding documents and some facilities play the beach boys music “I get Around” every hour on the hour to remind staff. Even the Manager, CNE, and CEO round once a day and ask patients directly if your Nurse has been doing their rounding. I hope my patients are not sleeping when I round, I might get a write up for not performing my hourly’s.
Discharge Phone calls: Generally a good concept if done to check on patients but these calls are timed and scripted to plant answers to survey questions with the specific purpose of boosting patient satisfaction scores. Expect a call the day before your survey arrives provided you were not admitted, transferred, mental health, or someone who really needed to be in the ER.
Peer review: Having staff fill out 1 to 5 rating scales on each other in 5 different categories. Used to help classify people as low, medium, or high performers. If you dont participate your immediatly classified a low performer. Nice way of turning the staff against each other.
RME: Marketing measures disguised as ED through put measures that focus on turnover and catering to low acuity patients, oops, I mean customers. I have written on RME and similar programs here and here. The common thread it that they de-emphasize Triage and limit the practice of Nursing.

So where do you fall, Here are some characteristics of low, medium, and high performers from the Studer site. Funny thing, you could be a effective employee and Studer still recommends you be fired

“..In fact, I would even suggest that you terminate employees who get results but do not role model your organization’s standards of behavior, because they are so damaging to overall employee morale”.

One Chief Nursing officer at a Sutter Health Facility learned the hard way about the dangers of email. It exposed how managers are using groups like Studer target their staff following a quota system. She instructs each department manager to identify 3 low performers per unit “You know who they are” for moving up or out to improve Press Ganey scores. Read her leaked memo here. CNA gave a great response on the same memo.

So are you ready to be Studerized. Bend over.

Who is the right Union for RN’s - Update CNA-NNOC and SEIU truce

2008-12-10T00:00:00.000-08:00

UPDATE March 19th: CNA-NNOC and SEIU made nice and have agreed not to step on each others turf. Basically, they agreed not to raid each others contracts and SEIU recgonized CNA-NNOC as the correct bargaining group for RN's not currently orgainzed with SEIU. This is a big win for each side even if it threw the NUHW worksers under the bus. Read about the strory here
_______________________________________________________________
Origional Post:

A serious debate and some say war has been unfolding over who can provide the best representation to Nurses. One school of thought is that Nursing should be represented by the same Union that represents the entire hospital, from the housekeeper to the bedside RN and nearly everyone in between. The other side says RN’s power and ability to advocate for patients is diluted when their representative is not a organization dedicated to the Nursing profession. A third point of view wants no representation and wants to trust the employer. I won’t spend time commenting on the 3rd group who I consider hopelessly naive.

Now enter the major players. The Service Employees International Union (SEIU) is a nationwide union that represents more than 2 million workers in over 100 occupations from all sectors of the economy. SEIU has many divisions and locals, some exclusive to healthcare such as the United Healthcare Workers (UHW). In California UHW was a marriage of 2 large Unions, Local 250 in Northern California and Local 399 in Southern California. It’s not all one happy family within the SEIU-UHW marriage. Within SEIU and UHW’s web sites which are linked are charges and counter charges by both sides accusing each other of fraud, phony elections, inappropriate use of funds, and more. The other key player in this war is the California Nurses Association (CNA) and their national affiliate the National Nurses Organizing Committee (NNOC) which represent approximately 75000 Registered Nurses in many states. CNA is a member of the national AFL-CIO which is a voluntary federation of 56 national and international Labor Unions. CNA and NNOC are basically the same people wearing different hats depending if they are organizing California Nurses or Nurses in other states. CNA is much more homogenises than SEIU. They only represent Registered Nurses. Are all these affiliations clear as mud.

The unions have several things in common, primarily their politics which is various versions of left of center. Some way left. Each promote Healthcare Reform with CNA promoting single payer coverage or "Medicare for All" and SEIU promoting Universal Coverage with employer provided coverage and government assistance to those not employed. Each were Obama supporters and provided resources for various democratic causes and campaigns. Each Union supports the Employee Free Choice Act (EFCA) also known as Card Check. You can read about the case for EFCA here and the case against here. This is where the friendship and cooperation ends.

Throughout the Nation there are Hospitals were all non-exempt employees are represented by SEIU unions. Others have SEIU representing ancillary staff and CNA or one of the other smaller Nursing unions or employee associations representing Nurses mostly with good cooperation. Others have CNA for Nursing and no one for ancillary. The majority of Nurses outside California and a few other states are unrepresented by any Union. CNA and SEIU are in competition for the most lucrative members and both have nationwide campains to organize hospitals and Registered Nurses. Union dues generally run about 1-2 percent of an employee’s gross yearly pay. 1 percent is a larger sum from an RN than it is from a Housekeeper. Each side accuses the other of a variety of issues. CNA alleges that SEIU is a more management friendly union and has made numerous backdoor deals and relationships that are not in the best interest of employees as well as numerous episodes of corruption. Read a variety of allegations in CNA’s SEIU watch website. SEIU accuses CNA of raiding other Unions which they claim weakens all represented employees. You can read their claims at their sponsored site “Shame on CNA”. This fight has turned ugly on a number of occasions this spring at hospital organizing events in Ohio, Michigan, and Chicago where things became physical.

I have worked in Hospitals where Nurses have been represented by SEIU and others by CNA. I have also worked in management roles without representation. Currently I am a CNA member where union membership is a requirement of employment. I feel much more empowered both economically and as a patient advocate in a RN union than in a all inclusive union or being unrepresented. CNA successfully brought Nursing Ratio’s to California and successfully repelled Governor Arnold’s attempt to repeal them in 2005. CNA is on a nationwide campaign to get patient protections in the form of ratios to other states. SEIU opposed ratios in favor of more protections for LVN’s and Ancillary staff who they represent and fewer for RN’s. While working as a SEIU nurse I was very aware that Nursing did not have the same voice as I do now. Nurses are one of the few classes of employees where the market was demanding higher wages but were constrained because our union was attempting to be fair by bargaining for more across the board increases for all workers. So there you have it. ERMurse comes out squarely for RN’s having a RN union. I am also troubled by the numerous reports of corruption within SEIU. That being said, the current nasty public battle between unions damages all of us seeking effective union representation.

Flagrant Prescription Drug abusers doing the Perp Walk in California

2008-10-07T19:31:00.000-07:00

In a previous posting I wrote about the CURES program in California. Under this program every controlled substance dispensed, from the six pack of Vicodin given to go from your local ED to controlled medications dispensed by Pharmacies, is required to reported to the CURES program. CURES is administered by the California Department of Justice. Data collected include the dispenser, date, time, drug, amount, and person dispensed to. Health Care providers can currently obtain a written report on patients under their care on just what they have received from all the various sources. Soon this database will be available online instantly for Health Care providers. This information is also available to Law Enforcement upon their request for cause. The need for this level of monitoring has become necessary in light of the medical communities inability to police itself. The outcome of reckless prescribing was highlighted recently in a Archieves of Intermal Medicine article here.

In a recent press release the Attorney General announced the arrest of some of the most flagrant prescription drug violators. Here is one

California Attorney General Edmund G. Brown Jr. today announced a crackdown on rampant prescription drug fraud in California, including the top fifty abusers who average more than 100 doctor and pharmacy visits to collect massive quantities of addictive drugs like Valium, Vicodin, and Oxycontin.

“These prescription drug addicts are abusing the system, draining time and money from hundreds of doctors and pharmacies who are there to help real sick people, not con artists,” said Attorney General Brown. “On my order, California Department of Justice special agents launched a statewide search for the most aggressive prescription drug addicts. We want to end these dangerous cycles of fraud and abuse.”

Launched in June this year, the new crackdown has already led to the arrest of dozens of suspects, including Frankie Greer, 53, who visited 183 doctors and 47 pharmacies to feed a prescription drug habit that included some of the most dangerous painkillers in lethal combinations. In a one-year period, Greer sought out multiple doctors at hospital emergency rooms to prescribe her over 4,830 hydrocodone tablets, 2,210 oxycodone tablets, 156 Oxycotin, along with a variety of additional addictive painkillers.

Think Frankie was consuming all those drugs. Probably selling as many as she took for herself. The loose prescribing habits driven by the patient satisfaction push and the fear of being accused of not treating the firth vital sign have provided a steady supply and a nice income for many of our ED patients.

Now I am no fan of Jerry Brown, California’s Attorney General and former Governor, known as Governor Moonbeam. He is way left of my leanings but he has it right on this subject.

Drinking the RME Kool-Aid at ENA’s annual conference

2008-09-30T23:04:00.000-07:00

Just got back from the Emergency Nurses Association’s annual conference in Minneapolis. Overall a pretty good conference if you avoided the Keynote addresses. A disappointment was the numerous presentations and posters touting the wonders of the process being pushed by several ED groups and Hospital bean counters called RME. Rapid Medical (Mediocre) Evaluation which also goes by several other names such as Triage Bypass, Provider is Triage, Door to Doc, among others depending on which ED Physician group is pushing it. All are basically the same thing. While pieces of the process can streamline care (immediate bedding, bedside registration) here are the claims that are made by the RME’ers that any thinking Nurse should question.

If we adopt RME we will be able to pay for more Nurses with the all the money we Save. Right!!!!! Well, that’s not my experience. I work in one of these facilities and staffing has stayed the same and the moment there is a lull the manager is trying to send staff home because the census is low. So, reduce your standards to move people through, stack them in chairs to utilize more space, pressure the Doc's to do a substandard exam, and as soon as you discharge them go home your not needed. Now that’s efficiency. Remember, work smarter not harder. I have an idea. How about not counting patients who dont get a Nurse in the Nursing hours of care. Most patients are alotted around 2 hours of care credit for budgeting. What if they never get a Nurse. No, that would be way to honest.

Patient should not have to tell their story more than once. Don’t trouble the patient with having to repeat their story more than once. This is team Triage and we get all the facts on the first try because the Story Never Changes!!!!! More Kool-Aid please. What do you call the Nurse in Team Triage? Scribe

You don’t need to have a Primary Nurse assessment. What the heck for. They don’t do that down at the Wall Mart Clinic, why should the ED. And what a wonderful way of dodging the Nursing ratios in California.

Patients do not need to get undressed. What the heck for. You never find anything when you examine the skin, back, or any other covered part. What a waste of time. Yum, Good Kool-Aid. I cant wait for our next round of survey results. Can you say Bump!!

Nurses are more satisfied. Which ones? The ones who view Nursing as a series of tasks rather than a process and don’t assess their patients or understand a Nurse Patient relationship probably will. You know them, the ones who make up discharge vital signs and always have their chart complete even though you never heard any of those questions asked. Yep, that’s them. There are certainly plenty of them around. Managers will also like it. Nothing makes them tingle like good numbers.

Patients can be quickly categorized with minimal or no triage. Put on your Blinders and only focus on the complaint they tell you. It keeps the problem simple. Patients always articulate an accurate complaint and totally understand their symptoms. Easy Peasy. You have an ear ache – Done, Your back hurts – take these, Done. Our Door to Provider times are awesome. Wow, why didn’t we think of this model 20 years ago.

Patients are more satisfied. Some probably will be. Most don’t recognize crappy care as long as its delivered with a smile and done quick. The Customer is always right.

So there you have it. Our professional organization (ENA) pumping up a process that shortchanges patient assessment and treatment from both Nurses and Physicians and cuts out important parts of the Nurses role to make the numbers look good. Brilliant recruiting strategy. I am so thrilled I think I will join for life right after I finish this Kool-Aid.

Annoying Consultant Speak

2008-08-19T21:36:00.000-07:00

In the past week I have sat through several process type meetings and must reflect on some of the most irritating consultant speak. Here are a few examples.

Rapid cycle process improvement
The model of improvement is applied in short test periods, using small samples of patients, and measures the effectiveness of the changes being tested. Based on what is learned, successful interventions are applied to other patients or other organizational activities or settings and unsuccessful ones are revised and tested again for effectiveness. You usually hear it when a new manager or director takes over from the outside or your existing manager goes to a conference. Murse’s Translation. I went to this cool seminar and heard this great idea and since I don’t really know anything about statistics or study design and we don’t have time to do a real study were going to implement this new process and if by the end of the day it works were going to do it throughout the hospital. Then were going to put it in a power point and present our great success to the CEO. I love the smell of a bonus in the morning.

Perfect is the enemy of Good Enough
The origins of this phrase are from the French Philosopher Voltaire. In modern times it seems to appear during crunch time of hospital IT projects. Go-Live is just a few months out. The team is feeling nervous and wants changes. The CIO calls a big meeting and gives a power point pep talk to get everyone "on the same page". Then it comes out, “You know, when it comes to rolling this out, Perfect is the Enemy of Good Enough. Murse’s translation: “Lets put some lipstick on this pig and roll her out. Stop you’re bitching, the users will just have to deal with the issues”. Ok, we know its never going to be perfect but can I ask: Did you use that same term when applying for your job when asked to describe yourself? How about when you proposed to your significant other, or do you say it to your kids just before finals or the big game? Doubt it. I’ve decided that at the next EMR Go Live that I support I will wear a team t-shirt that says, Perfect is the enemy of good enough! How about that on a team shirt. The users will be impressed.

Studerized
Being Studerized is similar a baptism in the Studer Group philosophy. I suspect there is Cool Aid being served at this baptism. Hospitals thought-out the country are sending their staff to various vacation resorts for $1200 a pop, not counting lodging and travel for the 2 day Studerization. By the end you are a customer service expert. Patients become Customers. You become experts in scripting the survey and how to change the patients perception of the visit. You are eager to go back to your hospital and implement the Three Levels of Studerizaiton. When you get back you will be filling out report cards on each other and identifying your departments high, middle, and low performers. Hope I’m not in the low group. Wow, I’m pumped. Pass the Cool Aid.

I'll update this list from time to time, shouldn't be hard I have more meetings this week.

Spike in medications deaths. Could it beeeeeee ……. Satan – or perhaps “The Fifth Vital Sign”

2008-07-28T21:49:00.000-07:00

In a article to be published in the Archieves of Internal Medicine next week an alarming spike in the number of accidental deaths from prescription drug use related to “medication errors" is reported. The Article by David P. Phillips, a sociologist at the University of California, San Diego is the most recent in a series of research he has done on the subject of drug abuse, suicide, and societal trends.

“Deaths from medication mistakes at home increased from 1,132 deaths in 1983 to 12,426 in 2004. Adjusted for population growth, that amounts to an increase of more than 700 percent during that time. In contrast, there was only a 5 percent increase in fatal medication errors away from home, including hospitals, and not involving alcohol or street drugs”

"By 2004, fatal medication errors were responsible for far more years of potential life lost than were all accidents from firearms, falls, fire and flames, drowning and non-medication poisonings combined," Phillips said

So what type of medications are we primarily talking about here. You guessed it, Opioid pain medications like Methadone, Oxycodone, Vicodin, and Fentanyl. Throw in a benzo, an antidepressant, perhaps a glass of wine and out go the lights.

Similar data is being reported by the Centers for Disease Control. According to the federal Centers for Disease Control and Prevention, unintentional poisoning deaths – 95% of which are drug overdoses – increased from 12,186 in 1999 to 20,950 in 2004.

During testimony at a Senate Judiciary committee in March of 2008 Leonard J. Paulozzi, M.D., M.P.H stated

When these more specific drugs were tabulated, we found that street drugs were not behind the increase. The increase from 1999 to 2004 was driven largely by opioid analgesics, with a smaller contribution from cocaine, and essentially no contribution from heroin. The number of deaths in the narcotics category that involved prescription opioid analgesics increased from 2,900 in 1999 to at least 7,500 in 2004, an increase of 160% in just 5 years.[1] By 2004, opioid painkiller deaths numbered more than the total of deaths involving heroin and cocaine in this category.

He went on to say

All available evidence suggests that these deaths are related to the increasing use of prescription drugs, especially opioid painkillers, among people during the working years of life. A CDC study showed a correlation on the state level between usage of opioid painkillers and drug overdose death rates.[2] Perhaps because of differences in marketing or physician prescribing practices

What can be done

It is important that state prescription drug monitoring programs share data with law enforcement officials for the purpose of investigating the unlawful diversion or misuse of certain controlled substances. For example, some state prescription drug monitoring programs are administered by a law enforcement agency in conjunction with a state board of pharmacy

This recommendations falls in line with what California is implementing through the CURES program which will give providers instant online access to all scheduled drugs obtained via prescription by a patient. Law enforcement also has access to this data as needed. I recently posted about that program here

What is going on here is a direct result of politicizing medicine by the pain rights movement and the organizations (Joint Commission and others) that have mandated liberal pain management into guidelines and enforcement standards. More recently the push to promote patient satisfaction in Healthcare organizations has resulted in liberalizing of prescribing opioid medications to make patients happy. Whatever happened to do no harm? Medicine has lost its way. These numbers should serve as a wake up call and re-examination of pain management practices and the whole concept of pain as the fifth vital sign.

California takes a big step forward in fighting prescription drug abuse

2008-07-02T19:27:00.000-07:00

In 2005 California expanded the CURES program to include all Schedule II-IV prescriptions dispensed. These medications have to be reported to the State Attorney Generals office who maintains a database of medications dispensed. This includes controlled substances directly dispensed from, Pharmacies, Doctors offices, clinics, and Emergency Departments that give out the to-go six pack of Vicodin when patients present after pharmacies are closed. Reports to the CURES program are done using a direct dispensing log that is faxed weekly to the CURES program.

Medical Providers and Pharmacist have been able to tap into this database by requesting an activity report on patients under their care. What they get is a print-out of every controlled Rx filled by the patient regardless of the source. In the past this report took several days to weeks to obtain. It was little use for the Provider who is trying to figure out if the person in front of them is filling multiple scripts from multiple sources. It worked well for ongoing care of repeat patients. I have seen it work well with some of our regular patients who return like clockwork to the ED several times a month. When confronted with the report of scripts they have filled recently and neglected to mention when listing their medications most give up knowing they have been had and you don’t see them again.

Soon the availability of activity reports will be online instantly via the California Attorney Generals web site. Instant access to a patients controlled substance prescription activity will give providers knowledge if they being lied to, used, played, to feed a habit or supply someone with an income who is reselling their meds. For those with legitimate pain conditions who are not seeking medication from multiple sources it should help them by removing the cloud of suspicion that follows them when seeking pain relief.

This effort is being funded partially by the Troy and Alana Pack Foundation founded by Bob Pack who’s 7 and 10 year old children were killed by a driver under the influence of prescription drugs obtained from multiple doctors. The Wall Street Journal recently had an article about the program.

Its about time.

Technology protections for Nurses and why they are necessary

2008-05-28T13:12:00.000-07:00

Recent employment contracts between the California Nurses Association (CNA) and a number of California Hospitals have contained model language to protect Nursing Practice from being degraded by the implementation of Technology, primarily Electronic Medical Records. When initially proposed this language did not receive much attention but as nearly everyone is in some phase of implementing an Electronic Charting system its getting attention now. I'm not a banner carrier for CNA as their positions are very much to the left of mine which I have noted here but on a few issues, ratio's and this language, they are right on. I am a big supporter of EMR’s if they are designed correctly. That’s a big if. Here are a few experts from one contract.

“Deployment of technology shall not limit the Registered Nurses in the performance of functions that are part of the Nursing Process, including full exercise of clinical judgment in assessment, evaluation, planning, and implementation of care; nor from acting as patient advocate”.

“Technology is intended to enhance, not degrade nursing skills”

Here are some of the ways that Nursing practice is being limited with the use of Electronic Charting.

Charting by Exception: The assumption of Charting by Exception is that patients follow a predictable course and unless there is deviation from the norm nothing needs to be charted. The is in direct contradiction to the “If it was not charted it was not done” assumption that many Nurses live by. Charting by exception is certainly not limited to computer charting but tends to creep in as systems are implemented to ease the transition by selling the point that look how much less you have to chart.

Limitations of access to key areas of the chart: All EMR systems have security settings that allow hospitals to determine who can see what. Some Hospitals have designed their systems to keep Nursing from viewing the notes of others or specific types of results. The most common examples are the limitation on the viewing of sensitive areas such as Psych notes or HIV status, all important information to the patients Primary Nurse.

Lack of basic Nursing Functions within the system: One of the major Hospital EMR systems, Cerner, does not even contain a Care Planning Module. Cerner has been around for years. Supposedly they are developing one. Nurses using the system either have to keep their Care Plans on paper, manually type them out every time, or use the Problem List function which is not a Care Plan. Some Cerner users keep Care Plan templates in word documents and cut and paste them into blank notes as their work around. Being an ED Nurse, I am no fan of care plans but they are a key Nursing function on the floors and a regulatory requirement by JCAHO and most boards of nursing.

Limitation of Nursing access to educational materials: One ED EMR System (T-Systems) is very role based which means your view and access to the application is very dependent on your role. Not a problem in theory if the system designers know all the complexities of the various roles. The problem is the developers over at T-System (and the hospitals that purchase their product) do not recognize that one of the main professional responsibilities of Nurses is to provide good discharge education. This education goes beyond what the ED Physician may select in the system as the discharge instructions for the patient. Nursing does not have access to the Exit Writer instruction module that is a part of T-System.

Limited generic charting choices: Some forms of charting limit the Nurse’s ability to document in a coherent way. An example is Flowsheet documentation or Templated charting with fixed choices, many that are very generic and difficult to fit into complex patient situations. The underlying issue here is the desire to make all data reportable, actionable in alerts, or graphable. Its also the way programmers think. Structured data can be reported off and trigger alerts while free text data is very hard to report off of. Some data needs to be structured such as the Patients Medications, Allergies, Height, Weight, I&O’s, ect. Other data such as observations of patients behavior, patient statements, or responses to procedures are better left to free text and make little sense when forced into fixed choices.

Compromising Triage in the ED: When a patient enters the ED the first contact should be with a Triage Nurse who will determine the patients acuity and disposition. Many EMR systems require the patient to be registered in the registration (ADT) system prior to them being visible in the EMR system. So, until the patient see’s a registration person the Nurse cannot document. Most facilities do not allow the Nurse to create the patient in the EMR system out of fear they will create duplicate patients or otherwise get it wrong. It’s a battle with nearly every EMR implementation. While a quick registration can be very quick there is an interface that the data must cross from the ADT to the EMR and most ADT systems are prone to downtime.

CNA sees the move to Electronic Charting as part of the deskilling of Nursing by reducing Nursing to a series of tasks rather than a process. Whether that is one of the intents of some EMR's or just a result of poorly designed EMRs is not very clear. CNA’s technology contract language provides important protections and deserves a serious look to any Employee Organization that represents Nurses during contract negotiations.

Disparities in Healthcare and Staff Discipline at UC Hospitals

2008-04-14T22:50:00.000-07:00

The University of California Hospitals have been involved for many years in studying and pointing out the Disparities in Health care delivery and access in America between ethnic groups, genders, and other perceived disadvantaged groups. All have the same theme, disadvantaged or people of color get worse health care given the same conditions. All one has to do is Google “Disparities in Health care” and UC California and you will be treated to a whole host of studies, articles, talks, or seminars where UC researchers, mainly physicians, point out these disparities. UC seems to have taken the lead in many respects in pointing out the problem. That being said, one would think they would set an example within their own institution on equality. The tremendous body of research and the recent revelation about the disparities in disciplinary action between UC Physicians and non physicians for patient privacy breaches at UCLA Medical Center reminds me of that old saying about people in glass houses and throwing stones.

In case anyone missed it, a number of employees at UCLA Medical Center were caught recently peeking into the electronic records of Britney Spears and other celebrities. This has not been an isolated event as media reports and the citation and plan of correction from the California Department of Public Health revel that it has been going on for some time on a rather large scale. In regards to the Spears case, California Health Line reported ..

The Department of Public Health said 53 employees, including 14 doctors, at UCLA Medical Center breached Spears' records on two occasions. None of the physicians quit or were fired, while 18 other employees resigned, retired or were dismissed after the violations were discovered, according to UCLA data.

I guess I am not surprised by hypocrisy in one of the ivory towers of Academic Healthcare but I am surprised that they would hand a gift to the cases of workers that were fired. If the fired workers unions cannot capitalize on the inequity in treatment to the benefit of those fired then they are not representing their workers well. For a disciplinary action to prevail in arbitration with public or unionized employees it must be based on “Just Cause”. Over the years Arbitrators in hearing disciplinary cases have agreed that to establish Just Cause there are 7 tests that should be met. One of the 7 tests is equal treatment or discipline for similar offenses. It also can open Pandora’s box to a discrimination case if the person treated less equal is a member of a minority group or other protected class.

UC has an explanation for the treatment inequity. Physicians are peer reviewed in disciplinary cases. Everyone else deals with HR. They acknowledge that Physicians historically have been treated more leniently. Should they be? One could make a case that the the expectations and thus penalties for physicians should be higher than less educated staff.

David Feinberg, CEO of the UCLA Hospital System, said, "Historically, doctors have been treated in a way that may be more lenient than nonphysicians, and we will address that."

In their attempt to address the problem of privacy breaches and how to respond equitably to all offenders Gene Brock, UC Chancellor, has set up a committee of 11 people from various UC campus to come up with recommendations. 7 of the 11 are Physicians leaders, the rest are HR or Public Information staff. No Nurses or ancillary staff leaders. More stones for their glass houses.

RME: Rapid Mediocre Evaluation

2008-02-14T10:32:00.000-08:00

Rapid Medical Evaluation is one of the latest buzz words for programs promoted used by ED Physician groups to promote faster ED throughput and market their groups to hospitals. Its similar to “Provider is Triage”, “Triage Bypass”, and “Door to Doc” programs some of which I have written about before and so have others here. RME is proprietary to a California ED group, California Emergency Physicians (CEP).

The premise goes something like this. Patients presenting to the ED can be rapidly divided into 2 groups the sick and less sick based on a quick look rather than a full triage. This is done by bringing every patient upon presentation immediatly back to a intake area staffed with a physician or more commonly a PA and a Nurse or in some cases only a PA, tech, and unit clerk. After a quick focused interview by the provider the patient is put into one of the 2 categories. The sick group goes to the main ED for treatment. The less sick group may either be discharged on the spot or sent off to various areas for lab or radiology studies. The less sick group does not own a bed and rarely gets undressed. The less sick group is not assigned to a Nurse in most cases. They move about the hospital similar to the way you would move from area to area in a clinic setting basically on their own and once all the results are in they are dispo’ed. The benefits reported are quicker door to provider times, fewer Left Without Being Seen patients, and more revenue for the hospitals and ED groups.

Some of this sounds good but lets peel back the onion and look beyond the marketing aspects and flashy improvement of ED metric’s that some of these programs report. Since these programs are primarily focused on the low acuity patients do they really do anything about ED overcrowding. The primary reason ED’s are in crisis is not a large volume of low acuity patients. If there is a back up of low acuity patients waiting to get into fast track is that a crisis that endangers patient safety, usually not. It’s the high acuity patients and the difficulties in dispositioning those patients that is the majority of the problem. Lack of inpatient beds or staff, lack of specialist coverage, lack of primary care, and an aging population being the main culprits. ENA has a well refrenced position statement on ED overcrowding that examines the issue.

None of these programs are consistent with national standards for Triage which usually gets eliminated or stripped down when RME is implemented. Both ENA and ACEP have endorsed a 5 level triage system. ENA and ACEP have a joint position statement here. ENA at their 2007 meeting specifically endorsed either the 5 level Canadian Triage Acuity System (CTAS) or the Emergency Severity Index (ESI) Historically ED triage systems have been 3 level and the research has shown that the 3 level systems have poor reliability and predictive value where as the 5 level systems have good predictive value. So now were supposed to believe that a 2 level system is the way to go. Perhaps the biggest flaw is the assumption that the majority of ED visits can be can be reduced to a quick look and a 3 minute interview a couple of tests, a quick prescription (likely not indicated) and disposition out the door. Many low acuity presentations are obvious but you will get burned by practicing like most are. Elderly and special needs populations even when presenting with a minor stated complaint need an history, physical exam, vital signs, and Nursing assessment.

Administrators see these programs as a way to reduce Nursing hours. CEP claims in their web site that the less sick patients do not need to be assigned to a Nurse. Kind of an end run around the California Nursing Ratio’s

“A corollary of RME to rapid care is the more efficient utilization of nurses and the elimination of many nurse hours that are required for compliance with many regulated state and healthcare system nurse:patient ratios. For example, by seeing, caring for and discharging a patient directly, and eliminating the need to count that patient as being in a bed in the ED, significant nurse hours may be reduced in the ED. Nurses find professional satisfaction with a career in an efficiently run ED, thus lowering hospital recruitment and retention costs”

So if patients only need ancillary testing they wont get counted in the Nursing Ratio’s? The promoters want it both ways. They want to end the Nurse Patient relationship with the less sick patients but in the real world a Nurse gets assigned many of the tasks to process the patient in and out and most regulatory agencies require some form of Nurse involvement. I have news for CEP. If a Nurse assess, gives medication (even Tylenol), performs a treatment, draws blood, performs a breathing treatment, or discharges a patient a Nurse Patient relationship is established and the patient is counted in the ratio’s, at least in California. You can not reduce Nursing to a series of tasks as much as you’d like to.

But what about the numbers, these programs produce great numbers! Yes, some do, especially if you don’t have a good understanding of statistics and view all patients as equal. The focus in the promotion is 3 primarily ED metric’s, LWBS, Door to Provider, and Patient Satisfaction scores with Patient Satisfaction scores being one of the biggest drivers. Because most high acuity patients get excluded from the satisfaction surveys the scores represents a skewed representation of what an ED does. The published metric's I have seen at the links here and others are relatively short duration measurements with no outcome studies. They avoid the subject of return ED visits rates, missed findings, morbidity and mortality from doing an inadequate exam or work-up or having the patient seen by a PA instead of a MD, or the negative effects of eliminating an effective Triage system. If you discharge patients before they have a chance to leave without being seen your LWBS rate will decline. You can drive down the door to provider time by putting the provider at the front end of the process but what does this do for the back end high acuity patients. Patients generally will be happier if waits are reduced, even if the care is sloppy. And finally, most of these programs are implemented simultaneously with other process changes such as bedside registration, expanded fast track capacity and hours, and immediate bedding which have been shown to be very effective. My experience is that the credit for the improvement is claimed by the RME type processes promoters when it would more accurately go to the bedside registration, expanded fast track, and immediate bedding processes The rest is window dressing and mediocre care designed to sell the services of the ED group promoting it and buff satisfaction scores.

MAB: Managing Assaultive Behavior - in the Trauma Room

2008-01-18T10:47:00.000-08:00

Lots of debate and discussion over at Kevin MD over the lawsuit in New York from a construction worker who alleges a forced rectal exam when he went to the ED for a head injury.

The story from the New York Times goes something like this. A construction worker gets hit in the head by a falling object on the job and suffers a head laceration and injury. He walks into New York Presbyterian / Cornell Medical Center for treatment. In the course of his evaluation the Trauma service attempted to perform a rectal exam. The patient objected then resisted. While being held down for the rectal exam he struck one of the Doctors. At that point he appears to have been chemically sedated and intubated. The patient upon his release was charged with assault and battery on the physician, a charge that has since been dropped. The patient is alleging the forced rectal exam violated his rights and is suing for assault and battery, false imprisonment, emotional distress and various damages. The suit has survived the preliminary challenges and is set to go to trial. Its not possible to tell from the article if the patient was alert enough to refuse or not.

I way’ed in, no pun intended, in the comments on Kevin MD and got support as well as a lot of criticism. There was a lot of discussion around the fact that the digital rectal exam in trauma is not very sensitive for anything, read here, and whether the patient was competent to refuse. The pro forced rectal argument was basically that if you have a head injury your not competent and we trauma doctors can do anything we deem necessary and of course, the rectal is absolutely necessary, forced or otherwise.

The whole thing brought back to the battles when I worked in a large Academic Medical Center that had a high volume of trauma cases. Many patients get caught in the trauma net. A large percentage are mechanism only or alert and stable patients. Attendings came for the trauma alert patients who had potential to go immediately to the OR, but most patients were attended to by the Trauma Service PG1-PG4 level who were poorly supervised. The codes were run straight from the trauma cookbook but with a locker room type (and sometimes a gang bang) atmosphere. After the primary survey, exposure, establishment of a BP and IV lines the secondary survey started. After the anterior of the patient was assessed they were log rolled onto their side. The examine resident felt down the spine for pain and step offs and with amazing stealth and about 1 second notice to the patient performed the rectal checking for tone and blood. If the patient resisted, depending on the team and assertiveness of the Nursing staff who objected, the trauma interns and residents held the patient down and the rectal proceed even if meant forcing the cheeks apart to get it. The backboard was removed and the patient was then log rolled back onto their back and any additional lines were placed and a Foley was inserted. Again, if the patient resisted the Foley they got restrained and if they resisted to much they got chemically restrained and intubated. Many of these sedations and intubations were punative in my opinion.

All the above would be fine with a critical patient or someone obviously altered and unable to make an informed choice but many trauma patients are fully alert and competent and stable. Landing on the Trauma Service does not in and of itself make one incompetent. Having a gash on your head also does not make one automatically incompetent. To the Trauma Service I worked with it didn’t matter there was no distinguishing between the obviously unstable patient and those that were alert and stable. There was an end justifies the means mentality that I see from the comments on Kevin MD is not limited to the place I worked.

So how did I manage assaultive behavior in the Trauma Room when the assault was being performed by the Trauma Service. I tried all the conventional means of writing the people up, talking to them, applying humor, advising the patient they had the right to refuse if it was appropriate, documenting the behavior with names in the chart, everything short of physically intervening. The behavior would change briefly with some but only until the next group rotated onto trauma service and it would start all over again. I wish Mr Persaud luck in his suit not because I feel he deserves a big payday but because a message needs to be sent.

Who are the real Villains in the Nataline Sarkisyan case.

2008-01-09T12:50:00.000-08:00

Ever hear the expression, Don’t let the facts get in the way of a good story. In the case of the well publicized death of a 17 year old from LA who while being treated for Leukemia went into Liver failure and was “denied” a transplant by CIGNA Insurance, that appears have happened. I won’t rehash the entire story as it is all over the media and has entered the health care debate at State and National levels. One candidate, John Edwards, has made it part of his campaign and advocates of “Single Payer” which is code for “Government run and taxpayer financed Health care” are using Nataline’s case as their poster child for the cause. The father appeared at a rally the other day and was quoted as saying “CIGNA killed Nataline”. The family has retained infamous looser lawyer, Mark Geragos, in their almost certain lawsuit against CIGNA. He and others are requesting that CIGNA execs be charged with murder.

Maggie Mahar has written one of the most balanced pieces on this issue titled “Bad cases make bad law” its an eye opener for those who haven't looked at this in depth.

“The fact that Nataline’s case had gone sour on her doctors’ watch might have made them less than objective. I’m not suggesting that the doctors were worried about a malpractice suit: following bone marrow transplants, patients are very susceptible to complications. There is no indication that the physicians caring for her did anything wrong. Nevertheless, at least one prominent palliative care specialist has told me that sometimes she has to protect patients from surgeons who want to try to repair a failed procedure —with yet another surgery. “They can’t bear the failure—they want to make it right. This is what they have been trained to do.” But they are not necessarily thinking about what is best for the patient”.

Two things stood out to me in this story. Those being were, is this patient even a candidate for a liver transplant and if she was why did not UCLA do the operation rather than wait for insurance approval. CIGNA had approved her bone marrow transplant which was unsuccessful. UCLA certainly did not need CIGNA’s approval for the transplant operation, only for the payment. Looking over the exclusion criteria for liver transplants from 2 other facilities that have good reputations in the transplant area I noted that this patient was not a candidate. Sanford who’s criteria is listed here and California Pacific Medical Center in San Francisco who’s criteria is listed here both exclude patients with non-hepatic malignancies. I could not find UCLA’s criteria in any searches.

I nominate the following as the Villains in this case

1. UCLA medical center for raising this families hopes when she would not of been a candidate for the operation at most transplant centers. They get a double nomination for not performing the operation if they felt it could of saved this girls life. A hospital does not need approval from a 3rd party insurer to perform a lifesaving operation. Considering the narrow window of availability of livers and this patients grave condition If UCLA felt she could have benefited they should have performed the operation immediately upon the availability of a donor liver and appealed the denial. Instead UCLA asked the family for a $75000 deposit to do the procedure which they did not have. Most appeals eventually end up getting paid. Even if they were not paid UCLA could have performed the case as charity care and been the good guys. UCLA is infamous for its excessive end of life care with no better results than more conservative like institutions. This is likely being driven by their excess bed capacity and a high percentage of specialist. Its all well documented here in this study by Drartmouth University.

2. The organizations promoting single payer who are exploiting this case and the family for the cause. In particular, one that I am a member of, the California Nurses Association. They have done a lot for nurses at the bargaining table and getting Nursing Ratios but their political agenda is way to Micheal Moorish. I cannot remember CNA ever soliciting its members on whether they even support single payer before devoting our dues money to that cause. Emails to their leadership expressing an opposite point of view are ignored. CNA members are some of the highest paid nurses in the country. That would not of happened under single payer where government sets the reimbursement.

3. Politicians and slimball lawyers led by slimball in chief John Edwards. Politicians do not normally piss me off, Edwards is an exception. He made his millions by suing OB doctors in cerebral palsy cases for not doing c-sections. He used junk science and courtroom theatrics imitating a fetus stuck inside the mother yelling to get out to sway juries. Note to Edwards, most recent research has shown that CP is not related to delayed C-sections but lets not let facts get in the way of a good story, especially when big money is at stake. Edwards, the champion of the poor, is well known for giving speeches on poverty in America for 50,000 a pop. One recently for none other than the University of California at Davis. You’d think the University of California would have better things to do with taxpayers and students money, apparently not.

I hate to be in a position defending an Insurance company. I generally despise them and as Maggie Mahar states

“Meanwhile there are so many clear-cut problems in our for-profit private insurance industry that should be investigated in a court of law. I would like to see states take insurers to court for the way they “cherry-pick” their customers, shunning the sick, and raising premiums on customers who become seriously ill. Often, insurers scour their records looking for some scrap of evidence that the patients’ illness may have been caused by a pre-existing condition. Insurers also write policies in such a way that it is very difficult to know, for certain, what will be covered—and they advertise “super-saver” policies that contain so many holes that they don’t even deserve to called “insurance.”

Another tip for the single payer crowd would be pick your battles. Being wrong and going public with it in such a high profile case and trying to capitalize on other peoples tragedies ruins your credibility for legitimate issues.

And the Winner of the LWBS sweepsakes is....

2008-01-08T20:52:00.000-08:00

A simple litature search on the subject of patients who leave without being seen from Emergency Departments reveals a lot of information about the characteristics of patients who LWBS, factors associated with it, and methods to reduce it. Most of the articles do not cite individual facilities rates as its sensitive information that some facilities closely guard. In California its public record available on a State web site with a little sleuthing. The biggest single factor, to no ones surprise, is wait times. My experience is that community hospital ED's have rates less than 5 percent and larger urban medical centers are between 5 and 10 percent.

This week, the Sacramento Business Journal wrote a good article on patients who LWBS. They disclosed rates of local area hospitals (cart above - click to enlarge). And the winner is, UC Davis Medical Center, with a rate of 20.1 percent. No else even came close. This is not a new trend for UCDMC. They have hovered at or around that rate for years.

So what is your LWBS rate and why do you think UCDMC has tolerated theirs?

How has the Patient Satisfaction push effected your practice

2007-12-10T15:08:00.000-08:00

In the past 2 years Patient Satisfaction scores have led to a major change in priorities in Emergency Departments. I have written about some of the ways ED’s are changing here. Many feel the patient survey is biased toward the less sick (read Ron Elfenbein's editorial in ep monthly) patient because it excludes admits and transfers and is based on relatively a small percentage of returns from very low acuity patients. Regardless, survey results are on the Web and in the newspaper which can lead to a major competitive advantage or disadvantage depending on where you fall. Perception is more important than reality in our sound bite world. Nothing evidences that more than some of the consulting groups offering seminars on how to change the patients perception (not the care itself) of their experience. Have you been studerized? Another example is the willingness of some hospitals, Sutter Health Alta Bates Hospital in this case, to target 3 employees from each unit who are "Not onboard with our service expectations" for disciplinary action to improve their Press Ganey scores.

Perceptions aside, has this emphasis changed practice for the better or worse in Emergency Departments? Below is an unscientific survey for “Providers” regarding how the patient satisfaction push in Emergency Departments has effected your practice in the past 2 years. I am starting with Providers but will follow-up with Nurses and Managers. I have weighted the score based on things generally considered good practice based on my experience. Do not consider, for the sake of clarity, other factors that have changed in the past 2 years such as new research, guidelines, institutional policies, and legal climate, only consider the effect of the Patient Satisfaction scores in your answers. Only Yes Answers get scored. Everyone starts at 0. Now lets take the test.

1. Do you see patients sooner than you did 2 years ago (quicker door to provider time)? Add 5
2. Do you cut short exams or procedures to achieve seeing new patients sooner? Subtract 5
3. Do you spend more time with your patients than you did 2 years ago? Add 5
4. Are you more likely to keep the patient informed of delays and explain procedures? Add 5
5. Are you more likely to troubleshoot delays in admission and testing to reduce the patients waiting time to admission and improve ED flow? Add 5
6. Do you provide a higher level of personal service to those who are included in the survey as opposed to those who are excluded? Subtract 10
7. Are you more likely to prescribe antibiotics upon patient request when the clinical indications suggest a viral etiology of infection or otherwise are not indicated? Subtract 10
8. Are you more likely to prescribe narcotic pain medication, stronger narcotic pain medication, or a larger quantity upon patient request when the indication is weak or a NSAID would be the better medication choice? Subtract 10
9. Are you more likely to order expensive tests such as CT Scans or MRI’s upon patient request when the indication is weak? Subtract 5
10. Are you more likely to directly dispense take home medications from the ER upon patient request, especially narcotics? Subtract 5
11. Are you more likely to tolerate disrespectful behavior or verbal abuse to avoid a complaint or negative survey? Subtract 5
12. Are you more likely to encourage or pressure Nursing or Ancillary staff to tolerate disrespectful behavior or verbal abuse to avoid a complaint or negative survey* Subtract 10
13. Are you more likely to avoid educating patients about negative health behaviors to avoid offending them and getting a negative survey? Subtract 5
14. Are you more likely to pressure Nursing to avoid educating patients about negative health behaviors to avoid offending them?* Subtract 10
15. Are you less likely to report suspected conditions such as domestic violence, child, or elder abuse to avoid angering patients and risking a negative survey?* Subtract 15

Now add up your score. Here is Murse's take on how the patient satisfaction push has effected your practice.

+5 to +20 – You are the bomb. Come work in my ED. You truly care about doing what is best for your patients and have not been pressured to make bad decisions to get a better score. You are ethical. The Nurses love working with you. Its not very likely that you’re the director of your ED group.

0 – You’re a solid practioner but you probably have been asleep for 2 years or on an extended sabbatical or trek in Tibet. Nothing effects you. Your probably the type that does not even look up from the desk when a patient is totally going off just on the other side. You operate at one speed regardless of the activity in the department. Also not likely influenced by bean counters or Pharmaceutical reps. Probably wears the same type cloths and prescribes the same type of medications you did 15 years ago. You could be an Attending in many academic medical centers riding out your tenure to retirement. The Nurses ignore you except to look at your cool vacation photo’s that you frequently load up on the department computer and show even during busy times.

-5 to -15 – You don’t like confrontation especially from bean counters or demanding patients. Have a little bit of a backbone problem. Perhaps your testicals have not fully descended if your male. Your not dangerous but just a little bit irritating. You give wishy washy answers to keep everyone happy. You like being peoples friend and generally are but are not someone to go to for support.

> - 15 – You would sell your sole to the devil. You sell out your peers for political expediency. Your either trying to impress some bean counter with the bump in scores at the expense of safe practice or you or your ER group is getting a financial bonus for improving their patient satisfaction scores which drives your actions. You probably do unnecessary procedures under the cover of poorly supported guidelines to increase your reimbursement. You likely prescribe every new expensive medication after sucking up freebie trips and dinners from the Pharmaceutical rep. You just might be the Director of your ED group. The Nurses dislike you.

*If yes to any of these questions then mandatory failure regardless of final score. Some Nurse is likely to drop a dime to on you to the State Licensing Board if you ever screw up.

Trauma Center Designation battle in Sacramento gets ugly - Updated

2007-11-12T22:42:00.000-08:00

There once was an urban legend that Trauma Center designation does not pay, in fact, was a big money drain on a Hospital. That’s not true in Sacramento as two hospitals, each affiliated with large chains, go nuclear on each other battling for designation as Sacramento Counties 3rd Level II Trauma Center. Whether trauma pays or is a drain on a hospital boils down to the old real estate saying, location, location, location. If you serve an poor inner city crowd with a high percentage of penetrating trauma your going to loose money. If you have a better payer mix and are located in the burbs or along a commuter corridor then there is big money to be made. Basically, blunt trauma pays, penetrating does not. The two hospitals, Methodist, a member of CHW, and Kaiser South Sacramento, a part of the Kaiser family of hospitals. are right across the street from one another. They are located at the South end of town along the commuter corridor into Sacramento and also in proximity of some of Sacramento’s knife and gun club neighborhoods.

In October of 2006 Sacramento County issued an RFP for a South County Level II Trauma Center. Methodist and Kaiser applied. There was lots of publicity, visits by the American College of Surgeons (ACS), full page newspaper adds by both sides, letter writing campaigns, and lots of buzz. The competition gradually turned bitter with both hospitals questioning openly in the media the others ability to provide the service as well as their motivations. An interesting cast of characters began to line up, mostly on the side of Methodist hospital. Those pulling for Methodist included UC Davis Medical Center, Sacramento’s Level I trauma center, as well as several Insurances companies (Blue Shield and HealthNet) who claim that Methodist would be better since they have contracts with them and Kaiser does not.

In April the ACS gave their nod to Kaiser. That was followed by the same recommendation from Sacramento County staff. The decision was quickly protested by Methodist and things got even uglier. The County hired a EMS - Trauma consultant, the Abaris Group, to review the entire process. The consultant came to the same conclusion that Kaiser was substantially better prepared at nearly all levels and in fact appeared ready to move to implement a Trauma facility before the 2010 date called for in the RFP. One would think that would be the end of it but Methodist and friends battle on with a final decision to be announced by the Sacramento County Board of Supervisors in late November.

One would wonder what is motivating the players here. With Kaiser its simple. They have approximately half of the working insured in the Sacramento area (the people who drive to work every day) and an overall market share of about 35 percent. They have no Trauma facility so whenever one of their members gets caught by the wide net of the Trauma System, mostly as the result of blunt motor vehicle Trauma, ambulances transport them to a trauma facility and Kaiser pays full price. Not only that, their patients are virtual hostages of these facilities who will not transfer them to a Kaiser facility until they have been stabilized (that’s code for captured most of the available charges) because it would be sending patients to a lower level of care, ie non trauma center. Kaiser is hemorrhaging dollars mostly to UC Davis Medical Center that charges some of the highest rates in the nation for Trauma care. Kaiser seems to be willing to take their share of the knife and gun club to stop the financial bleeding . UCDMC is supporting Methodist so the Kaiser cash machine keeps paying off, even if they have to share a little with a CHW facility, better than loosing the full boat.

Methodist wants in on the action and is being a little more sneaky, in my opinion. They seem to be making their case based on who is supporting them and making the public claim that Kaiser would abandon the uninsured rather than making the investment in their facility and staff to be competitive. That’s almost funny as CHW does not have the greatest reputation for taking care of the uninsured. The main ED at Methodist has only an 8 beds plus a number more in their fast Track. The Hospital is old and they do not have a reputation for treating their ED staff well. It shows as turnover is high and most ED Nurses are Travelers. They claim that they will have their facility remodeled and ready by 2010. Kaiser by contrast has a relatively modern, much larger ED and stable staff. The cat snuck out of the bag a little more when Methodist announced the purchase of land further south in a nice area for a new hospital site. Conveniently out of range of the knife and gun club but still in the heart of the commuter crowd. Nah, Methodist would not take their Trauma designation and run to the burbs would they? Medical redlining, not Methodist. Methodist further had the curtain pulled back on them when it was revealed in the media 2 days ago that they had not passed their April JACHO accreditation visit having received only conditional accreditation. That never surfaced during any of the discussions and testimony over who would be best equipped to get the Trauma Center nod.

The whole thing reminds me of my dog I had as a kid. He challenged almost any dog, no matter how big from a distance or when I was standing by as backup but he would turn tail and run when it was obvious his opponent was superior. I think its time for Methodist to learn that lesson. Stay tuned for updates.

Update: December 11
Kaiser gets the nod 3-2 from Sacramento County Board of Supervisors. The competition got real ugly in the final stretch with an aggressive media campaign and letters from one of the Sisters of Mercy that got placed on car windshields at churches throughout the area. Note to Methodist: People judge you by the company you keep. The endorsement of large insurance companies and the Academic Medical Center with an obvious conflict of interest was a bad stratagy.

Templated Charting - The Slippery Slope to Fraudulant Documentation

2007-10-12T13:24:00.000-07:00

The other day at work I was taking care of a patient that was in an MVC. She was in spinal precautions and complained of neck, and leg pain. Our ED Physician came in and did his exam from the door way holding his Tablet PC marking off items into the Electronic T-sheet while he asked a few basic questions. He was in and out in less than a minute. Out of curiosity, I reviewed his documentation and not surprisingly there was a comprehensive assessment documented. Abdominal findings, lungs sounds, heart sounds, pupils and ocular movements, neuro exam, all beautifully documented in a long paragraph and all normal. Not bad for an exam conducted from the doorway. I watched without comment throughout the day and noticed the same general exam pattern on most of his patients and the same comprehensive documentation of his exams. About one half of the Docs in this ED practice operate in a similar way although he is the worst. Others actually perform the exams they document and coincidental, have the longest door to provider times. They are being pressured to speed up their times. Exams do take time. This same Physician above is the promoter of Triage Bypass policy being promoted at the ED I work. He claims that asking patients the same questions and doing the same exam he will do (or not do) in Triage is an unnecessary delay and negatively effects patient satisfaction scores. So now when beds are open were rushing patients back with nothing more than an eyeball assessment to make them happy and get them to the Doctor who does a 1 minute exam from the doorway and fudges the chart. Guess what, our patient satisfaction numbers are way up and our length of stay is down. Administration is happy.

Fudging charting is not isolated to Physicians and Electronic Documentation. Another ED I occasionally work at I see nurses regularly check off on the paper T-Sheet items that were not done. I even see some make up phony discharge vital signs rather than take the time to do them. I recently had a discussion with my Charge Nurse who audits charts prior to the end of the shift. She was all over me because I was not checking off the boxes which said ID Band confirmed, Bed in low position, Side rails up x 2, patient gowned, blanket provided, and including discharge vitals. I told her, the patient was a Fast Track patient and discharged within minutes of arrival, I didn’t do all those things. Doesn’t matter she said, “Just check the boxes or we get dinged”. I told her to go ahead and ding me, make my day. I’d rather get dinged for not checking boxes than falsifying a chart. My stand is being viewed as I'm just being difficult.

The question that this begs is whether the problem is with the individuals or the tool. My opinion is a poorly designed tool facilitates shortcuts in certain individuals who are either lazy, dishonest, or very uninformed about what they are charting. Templated charting, either paper or electronic, can cross the line rapidly into fraudulent charting in those individuals. I don’t think they view it as fraud and are able to rationalize their actions because they feel they are only documenting to satisfy a regulatory requirement. In the case of documenting items not done to obtain a higher billing level there is no question in my mind that fraud is occurring.

A good article, here, at AIS Health.com list some of the issues with templated electronic documentation.

"Physicians love electronic medical record (EMR) templates because they make documentation faster and easier, but abuses, such as cloning and "exploding" notes, are jeopardizing reimbursement and compliance, experts say. If too much information is replicated from one EMR to the next, there is little to distinguish patient encounters, and that undermines physician attempts to establish medical necessity — the foundation of Medicare reimbursement — and perhaps implicates quality of care."

My first example I listed is an example of an exploding note. Basically, an electronic template is pulled up for a specific complaint, a few mouse clicks is all it takes to default all values to normal and a beautiful paragraph is produced based on programming code behind the scenes listing all the elements of a comprehensive normal exam. To change the defaults you need to click a few more times either selecting common abnormal values or free text the abnormal finding in. The path of least resistance is the former.

"Cloning can work for elements of the history, but cannot and should not be used for the history of present illness, the exam or the medical decision-making portion," the compliance officer says."

Cloning refers to pulling data forward from previous visits or from another persons note, usually via copy and paste, into your note and signing it as yours. Very helpful for a long history which does not change but problematic for a physical exam that you did not do. In Academic Medical Centers its common for the Student to do the exam, the Resident pulls forward the note as theirs and on rounds the Attending does the same and signs it electronically.

Templated charting both paper and electronic has caught the attention of many in the HIM community. The American Health Information Management Association has a good paper on Guidelines for EHR Documentation to prevent Fraud. The article list many types of documentation problems and recommendations and the appendix gives real case examples.

“Electronic documentation tools offer exciting new time-saving and validity checking features designed to enhance communication for all health record users. They address traditional, well-known requirements for documentation principles, while supporting expansive new HIM capabilities. However, use of these features without appropriate management and guidelines may cause invalid auto population of data fields, manufactured documentation to enhance expected reimbursement, and other undesirable outcomes”

What is the solution? It’s certainly not to stop using templated charting or electronic charting. It won’t be long before everyone is doing it. A strong set of standards for EMR design and training is essential. Charting tools that require structured data for most exam documentation would help. Rules against copying notes of others and calling them yours and the clear understanding that if you have charted something you did not do you have committed fraud. You can report fraud here. Templated charting, if used correctly, prompts the individual to perform complete exams and documentation and can enhance patient safety.

Change of shift at Emergiblog

2007-09-20T09:09:00.000-07:00

Some great posts included including my most recent on patient satisfaction scores

http://ermurse.blogspot.com/2007/09/ed-patient-satisfacion-scores-out-of.html

ED Patient Satisfacion Scores - Out of Balance

2007-09-04T22:39:00.000-07:00

A few months ago I ran a post titled Top Ten ways to improve your Patient Satisfaction Scores where I listed some of the disturbing methods being undertaken to improve patient satisfaction scores in Emergency Departments. Is anyone else bothered by the constant drum beat from administration that seems to have a single minded focus on satisfaction scores to the exclusion of almost everything else? I have seen Managers in tears when the monthly report cards come out and their scores for their departments have not risen or perhaps even dipped a point or two. Many Managers who until recently were at the top of their careers suddenly are pushed out over the issue. Why is this so important now? Easy, it’s being tied to reimbursement, CEO bonuses, and it’s now listed on the web which gets featured in many community newspapers. In the typical 2-4 Hospital town it can become a major competitive advantage or disadvantage. That would be fine if the scores reflected the critical mission of an Emergency Department. I do not believe they do.

Now before everyone gets their panties in a bunch I am not advocating against a satisfied patient. That would be like being against mom and apple pie. What I am advocating for is balance. The surveys focus seems to lack balance and does not recognize that Emergency Departments primary focus should be emergencies. Lets look at the survey and who it targets, and more importantly, who gets excluded. The National Quality Measures Clearinghouse forms the basis of the Press Ganey or other organizations who produce patient satisfaction surveys sent to ED Patients. Here is a survey section on ED satisfaction and who gets excluded is described below.

“Patients with an emergency department (ED) visit during the reporting period who answered at least one question in the "Overall Assessment" section of the Emergency Department Survey. Deceased patients, patients admitted to hospital through the ED, patients who leave the ED against medical advice, patients who leave the ED without being seen, and patients transferred to another hospital/institution are not eligible”

So the Critical Care patient who you and half the department bust your ass to stabilize, admit, or transfer does not get surveyed, at least for their ED stay. Some hospital surveys do include these patients for their own purposes but they are excluded from the reported scores used for like hospital comparison of Emergency Department questions. In fact, putting a lot of resources into your critical patient can detract from and increase waits for the non-critical patient, the ones who get surveyed, many of which don’t need to be there. We all know that wait times are highly correlated to patient satisfaction. That is why Hospitals have changed their focus and are catering to the lower acuity patients with programs such as expanded Fast Tracks, Provider is Triage, Triage Bypass, liberal prescription practices, and other sometimes short sighted practices that sacrifice solid principles and safety for expediency. Critical care and educating staff to do well at it in many ED's has assumed a lower priority.

I have a suggestion. The survey should be weighted based on the patients acuity. Critical patients surveys would be weighted heavily and patients with clinic conditions should receive much less weight. So if I get high rating from one acute MI that should mean as much as 5 clinic patients. If that were to happen you would see administration put much more emphasis into expanded training and education with a focus on critical thinking and skills rather than over serving a patient population who want boutique treatment with no waiting.

Remote CPOE error and the relationship to Critical Thinking Nurses

2007-08-07T08:44:00.000-07:00

In recent past post on several blogs I, along with numerous others, engaged in some back and forth banter about the appropriateness of Nurses questioning Dr’s treatment orders. I remember one of the quotes of someone, I presume an MD, who expressed strong feelings about having his judgment questioned by a Nurse, “Because I’m the Doctor, that’s why” and other comments to the effect of What Medical School did you go to blah blah blah. A couple examples of this attitude mostly in the comments on posts here, and here. I have had similar discussions in my various workplaces over the years with a few MD’s who expressed similar opinions. Fortunately they are in the minority. Most Physicians value Nursing input and recognize the benefits to themselves as well as patients.

I ran across an interesting article in the newsletter from the Institute for Safe Medication Practices that puts this argument in perspective for me.

From the May 31, 2007 issueProblem: ISMP received a report from a hospital where a medical resident had prescribed a NORCURON (vecuronium) infusion for the wrong patient via a computerized prescriber order entry (CPOE) system in a remote location. She meant to order the infusion for a ventilated patient in ICU but accidentally prescribed the drug for a patient on a medical unit.

ERMurse’s opinion on how this could of happened. Most EMR systems have features called Patient Lists which are very valuable for staff seeing patients in multiple locations especially in large facilities. For example, all patients assigned to a particular admitting service populate the Service List and individual practitioners can create their own lists adding patients manually. They work from these list extensively. In the electronic world a lot of work can be done remotely from the patients location. I suspect the Resident simply picked the wrong person from the list and the system did not have enough strategically placed visual cues in the list or on each screen of the patient record for the Resident to recognize the error. The placement on the list of appropriate patient identifiers and location can help in orientation to what patient you have accessed. Once in the record, did each screen have a prominent view across the top that displayed the patients name and location. Some EMR systems do, others once you pick a patient and begin wading through the various order and documentation screens you loose orientation of which patients record your on. Busy people get interrupted frequently and can resume work thinking they are on one patient and are actually on another. Simple design decisions and consistency of design in an EMR can keep the clinicians oriented to the correct patient or not.

An inexperienced resident pharmacist processed the order and prepared the infusion, failing to recognize that a neuromuscular blocking agent should never be sent to a medical unit where patients are not intubated and on ventilators. The resident pharmacist affixed two labels to the bag: one noting that the infusion was a high-alert medication, and the other stating that the drug was a “paralyzing agent.” The pharmacy technician who delivered the infusion did not think to question why the medication had been pre-scribed for a patient on the medical unit. An independent double-check was required for this medication before administration, so two nurses verified the drug, pump settings, and patient.

You think those 2 Nurses left something out? They did the 5 rights of med checking, well sort of. You can verify the order, route, patient, dose, and time and make this error if you do not possess the critical thinking skills to understand (or research) what your giving and why your giving it. My initial gut reaction is that all the people involved in the chain are incompetent. That may be the case but knowing the culture of the institution or floor is an important consideration in determining how this happened. Do the Nurses view themselves as independent licensed professionals with a duty to know their patients conditions and reasons for treatments and feel free to question Physicians on care issues or do they view themselves simply as being there to follow orders without understanding or questioning. A surprising number of Nurses practice this way. I do believe there is a cultural element in Nurses who do not critically think. In some cases it is the culture of the institution that discourages critical thinking, in others I believe it is a reflection of the culture of the Nurses and where they were trained which in my experience is more common among some foreign trained Nurses.

The infusion was started, after which the patient began walking to the bathroom. He fell to the floor once paralysis began to set in, but fortunately, he was able to call out for help. The resident physician was called, along with the rapid response team. When the team arrived and asked what happened, one of the nurses questioned whether the “new drug” she had just hung could be responsible. Realizing the problem, the physician immediately stopped the infusion.

Talk about a Shit your pants moment when that Doc looked up and saw Vec hanging on a Med Surg patient. I would have loved to have been a fly on the wall to see the expressions on the faces in that room.

The prescribing error escaped the attention of at least five staff members–the physician, pharmacist, pharmacy technician, and two nurses. The error was also able to get through the system despite safeguards such as warning labels and double-checks. It is also likely that the nurses working on the medical unit, where the drug had never been used, had little knowledge of Norcuron, its indication, its paralytic effect, and the need for mechanical ventilation, despite the warning label…..

Most likely, the problem was not that the nurses did not carry out an independent double-check according to a typical process used in many hospitals–independently comparing the “five rights” against the physician’s orders or a verified MAR.In fact, the nurses followed the physician’s orders perfectly. What is missing in the double-checking process is a cognitive review of the appropriateness of the drug, dose, and route of administration.

That’s why you look up meds your not familiar with and question any order that does not fit the picture. Getting back to the “Because I’m the Doctor” attitude I have only one thing to say, Be careful for what you ask for in how you would like Nurses follow your orders and not question your judgment. The result might not be in your best interest or the patients.

Change of Shift: This week with a Highly Trained Monkey

2007-07-26T19:21:00.000-07:00

Musings of a Highly Trained Monkey: Change of Shift: Volume Two, Number Three

Great collection of posts including mine with a nice touch of color.

A Vital Sign with concerning unintended consequences

2007-07-24T12:35:00.000-07:00

Great post over at Aggravated Surgery Doc about the on the Downside of the 5th Vital Sign on how the PC infiltration of pain management policy caused poor patient outcomes and placed patients at higher risk. He makes valid points that political pressure has lead to more aggressive use of IV narcotic pain management instead of IM or other management thus putting patients at risk.

“In that milieu, a physician who prefers to prescribe IM narcotics can be accosted for using up valuable nursing resources, and assailed for not being sensitive enough to patients' pain. Of course, given that scenario, it was only a matter of time before some self-important regulatory agency got involved in the business of pain management”

“Fast forward a few years to 2001, when the Death Star of American Medicine decides it should be the arbiter of all things pain-related --- JCAHO published its report on Pain Management Standards. Basically, it mandated that hospitals establish policies for assessing and treating pain, particularly postoperative pain“

In my mind the crux of the issue is whether the pain scale is an accurate means of pain assessment (that’s a big NO!!!!!) and are people being harmed from more aggressive pain management (YEP!!!). A study published in the May 2007 Journal of the American College of Surgeons titled Kindness Kills: The Negative Impact of Pain as the Fifth Vital Sign documents cases of preventable death directly related to pain management in surgical patients and how they have increased in the period after JCAHO’s rules. More concern here from Anaesthesiologist.

The study and experiences above relate mostly to surgical patients. My experience has been in the ER. I have seen numerous near misses (patients needing reversal) and am aware of a few clean kills related to over aggressive pain management in a busy ED without the depth in Staffing to provide sufficient monitoring of the practice. I have seen numerous people who “Have a Ride” lie or sneak out and drive after being well medicated. I call in a report and turn in a DMV form when I see it happen. How do we measure how many people that has knocked off over the years on the roads by one of these "Customers". Wont ever be measured and the reports will be anecdotal so it will be ignored in the pain management debate.

I see this problem as getting worse and now being driven by the desire to produce high patient satisfaction scores which is reflected by improper intervention in medical decisions by non medical Hospital Administrators. Kim wrote about that recently here and couldn't’t have said it better below. When a patient does not get their fix, I mean, appropriate pain management, that being IV or IM Demoral or Dilaudid with a mixer x 2 and Rx of Vicodin #30 as well as a six pack of Vicodin to go being they came in after the Pharmacies are closed, they tend to complain.

“The patient is pissed. Excuse me, I mean the patient is experiencing anger at the unwillingness of the physician to administer what they want to be given. The patient is so angry that they take it all the way up to the head administrator of the hospital. In person.The administrator is concerned. Although the Admin is neither an RN nor MD, they do see an unhappy patient/client/health care recipient who feels they were treated inappropriately. This needs to be addressed. A meeting is called to address the patient’s issues. The bottom line: the patient gets what they want. Every time they come in, from anyone who happens to be on duty. This message is relayed back to the ER and the physician who did not treat the patient per the patient’s request is reprimanded. The patient is now given exactly what they ask for every time they come in by every doctor in the department”.

I may add that if the Nurse shows the least bit of a perceived judgmental attitude when carrying out the fix, I mean the order, they can expect a complaint and a negative evaluation, or worse from managers who are running scared over complaints. A judgmental attitude could be the Nurse inquiring about daily use of other medications, legal or illegal, that may potentate their ordered fix, I mean pain management, giving the big whopping dose of Dilaudid to slow (I put anything more than 1 mg IV on a pump over 20 min which has been called punitive), pressing the "Customer" to show they have a driver, or any type of attempted discharge education or suggestion related to their pain management practices.

If this practice has not hit your ER yet, consider yourself lucky for now.

Stroke Centers, Marketing or Medicine

2007-07-11T15:22:00.000-07:00

You are out shopping on a hot summer day when you suddenly become a little dizzy. It comes and goes and you start having a minor headache and then your vision gets a little fuzzy. Your getting worried. In the back of your mind you remember that health fair you went to and the people at the booth sponsored by the local Hospital talking about signs and symptoms of stroke. Could this be a stroke? Possibly heat related or a migraine? You also remember what they told you. You must get to the hospital within 3 hours of the start of your symptoms to get the miracle clot busting drug if it is a Stroke. You tell your spouse and off you go to your local Hospital which has been certified as a Stroke Center by JCAHO.

Once in the Emergency Room your taken right back, people crowd around, off come your cloths, someone puts an IV in your arm and you’re rushed off for a Head CT. When you return you get an EKG, more blood tests and a lot of questions. A cheery young lady comes in and says she is the Stroke Coordinator. She talks with you and gives you some handouts and asks more questions. Then someone brings a big machine into the room and does an ultrasound of your heart and neck. Your symptoms seem to have subsided but you are admitted to the Hospital just as a precaution. The ER Doctor is still not sure if you had a TIA or some other problem. Since your better you don’t need the miracle clot buster drug. Good thing.

The response to a potential stroke patient is modeled much like the response to a trauma patient entering a Trauma Center. These patients go to the top of the priority list and command the resources of the facility. The goal initially is to identify rapidly if the potential stroke patient is a candidate for TPA. A wide net is cast where most every patient with any acute neurological presentation gets entered into the Stroke Protocol. Some communities have implemented EMS destination protocols so potential Stroke patients are routed to a Stroke Center. San Francisco did this and the response of the hospitals was the all became or have applied to be Stroke Centers.

So is all this good medicine or marketing to increase patient volume and charge for a lot of expensive procedures? The good medicine argument is subject to much debate just as TPA’s use for ischemic strokes is controversial. Grunt Doc in recent posts here and here sheds light on the controversy, mainly in response to a recent Wall Street Journal Article that promotes TPA. The main Emergency Medicine organizations have taken positions that TPA not be considered standard of care for Ischemic Stroke but be an option in certain cases. AAEM’s position statement can be viewed here The movement towards Stroke Centers seems to have steamrolled over the concerns of Emergency Physicians and is moving ahead at a brisk pace. A list of current Stroke Centers can be viewed here. The ED I work at is a Stroke Center. Some of the ED MD’s are very reluctant to give TPA but know its not a good career move for them or their ED group to not give it on a qualified candidate. So they do it. ED Physicians are in a no-win situation. They are likely to get sued for giving or not giving TPA if the outcome is not good.

The marketing aspect of Stroke Centers is closely tied to the marketing of TPA. The creation of, or at least the illusion of, TPA as the Standard of Care for Ischemic Stroke seems to be the strategy with an aggressive media campaign as well as involvement with the American Heart Association in setting standards. Genentech who makes TPA has promoted the establishment of Stroke Centers and has made it one of their marketing goals.

The “Stroke Center” paradigm provides a way to segment hospitals by their treatment patterns and shed light on how to overcome barriers to treating with TPA. Source:Genentech Stroke Assessment Market Research, 02/2003 – 07/2003

Genentech also offers educational grants to assist Stroke Centers in defraying the cost of educating their staff in stroke care. The American Heart Association, long criticized for recommending TPA’s use due to conflicts of interest of its Leadership, some with financial ties to Genentech and weak supporting data for TPA use in stroke, also is very involved in the Stroke Center concept and assists hospitals in getting Stroke programs started.

Genentech knows that promoting Stroke Centers will increase the use of TPA. One study showed an dramatic increase in TPA use at Stroke Centers versus non centers but no decrease in mortality or length of hospital stay associated with TPA. The real data out there does seem to support a modest decrease in long term disability when TPA is used according to strict criteria although some studies have actually shown an increase in mortality with TPA use. My suggestion would be to place this illustration on the TPA consent form which basically says, you may have less disability but your likelihood of a fatal hemorrhage is increased, and if your symptoms are not due to a stroke but some other neurological disorder you assume all the risk and none of the benefit, you make the call.

The Hospital I work holds Stroke Fairs catering to senior citizens. They have speakers go to community events and organizations. More than once I have seen or read material distributed or articles in the local newspaper or directly heard reference to getting to the hospital early to get the “miracle clot busting drug”. Is this information helpful? accurate? The education on lifestyle changes and symptom recognition is very helpful but I have big concerns about the promotion of TPA and minimization of risks. Again, perhaps the above chart which was produced by AAEM should accompany the handouts.

So are Stroke Centers good medicine or marketing? My opinion, some good medicine (the education and rehab portion) and a lot of marketing and optimistic claims. The whole thing kinds of smells bad to me. As a Nurse when tasked to give TPA for stroke I make sure that the patient and family are fully informed, repeated several times, that while the treatment may eventually reduce disability it also might kill you. As far as the Stroke Center cheer leading, I just hold my nose.

Should the University of California Invest in Nurses or Lawyers…. Hmmmm!! Updated Aug 07

2007-07-03T11:06:00.000-07:00

Dan Walters, a columnist with the Sacramento Bee has a reputation for calling government on the carpet for its wasteful spending and misdirected priorities. California corners the market on government waste and misdirected priorities and the University of California tops the list within California government. Their mis-management of public money is infamous. Just a few examples, here, here, and here.

Walters comments here on the recent decision of the University of California at Irvine to open a new law school despite a recommendation by the California Post secondary Education Commission’s not to citing an ample supply of lawyers in California, approximately 200,000. Roughly the same number as practicing Registered Nurses in the State. The full report of the Commission can be viewed here. Walters suggests Nursing education would be a better use of public resources.

It's another illustration of the fundamental dysfunctionality of California's government, its chronic inability to relate to real-world issues and prioritize its limited resources. UC's regents and administrators want to establish a new law school at Irvine because it would, in their view, enhance the school's prestige and, by extension, their own, not to meet any true educational or societal need…….

The Legislature's budget analyst, Elizabeth Hill, issued a report on the state's looming shortage of nurses in May, noting that the University of California, in a study by its San Francisco medical school, forecast a demand for registered nurses in 2014 that's 40,000 higher than the current forecast of supply, given retirement and other factors.

Hill recommended several steps, including supplemental funding to expand nursing education programs and removal of artificial barriers to expansion. The issuance of her report was virtually simultaneous with another event -- a vote by UC regents to authorize UC Irvine to hire a founding dean for its proposed law school at an annual salary of $233,200 to $364,300. It was the regents' figurative thumb of the nose to CPEC and its position

Some would argue the University is not tasked with “vocational education” which is normally handled by the States Community College System. Without even addressing the Vocation vs Profession argument the Nursing shortage in California is closely related to the number of Nursing programs available to students which is closely related to the number of qualified advanced degree Nurses to teach those students. Would it not be a better use of taxpayer money for the UC system to try to address the real issues facing the public rather than producing a surplus of Attorneys and building their Ivory Towers.

I cant wait for the sequel. The inevitable audit of how UC spent its millions of Stem Cell monies.

UPDATE August 07: UC Davis just announced the start-up of a new Nursing Program. Could I be wrong about UC liking lawyers more than Nurses. Nahhhh. They got a 100 million dontation to get it started. Regardless of the motives I'm glad to see more training in the pipeline.

A Sigh of Relief

2007-06-09T19:02:00.000-07:00

Hope it lasts but I am not counting on it. The Joint commission just (in April) suspended its rule requiring prospective review prior to giving medications in the Emergency Department provided the following conditions are met, pending further study. Here is the entire ruling, an exert below.

However, The Joint Commission will now permit organizations to implement the two exceptions in Standard MM 4.10, EP 1 more broadly in order to minimize treatment delays and patient back-up. To clarify this position, each exception is addressed below emphasizing its implementation in the ED:

Exception 1: “…unless a licensed independent practitioner controls the ordering, preparation, and administration of the medication.”Implementation: When using this exception, medications ordered by a licensed independent practitioner in the ED can be processed, including administration of the medication, by a registered nurse or other licensed staff with medication administration responsibilities (e.g. respiratory therapist) in accordance with law and regulation. A licensed independent practitioner will not be required to remain at the bedside when the medication is administered. However, the licensed independent practitioner must remain available to provide immediate intervention should a patient experience an adverse medication event.

Exception 2: “…in urgent situations when the resulting delay would harm the patient, including situations in which the patient experiences a sudden change in clinical status.”Implementation: When using this exception, urgent care situations will be defined by the licensed independent practitioner who is providing care to the patient

So what does this mean for the ED’s? Read the entire update but looks like as long as your Doc is in the ED or an Emergency exists when the medication is given you do not need prospective review prior. At least not until further “field studies” are done. Kim had a good take on this rule here.

The Joint Commission will host a free audio conference on Standard MM 4.10 on Wednesday, July 18, beginning at 8:30 a.m. PT/ 9:30 a.m. MT/ 10:30 a.m. CT/ 11:30 a.m. ET. Registration information will be sent to accredited hospitals and critical access hospitals via list-serve approximately one week prior to the call. To sign up to receive registration information, go to your organization’s extranet site on The Joint Commission Connect.
Please direct questions to the Standards Interpretation Group at 630-792-5900, option 6, or through the online submission form at http://www.jointcommission.org/Standards/OnlineQuestionForm/

My opinion, Any reprieve is good and Nurses need to keep active and pressure their organizations to oppose harmful regulations. The requirement was not reality based and does not work for ED’s. ENA has been out front on this issue opposing the completely unreasonable requirement. Where has CNA been? Probably busy hyping the upcoming release of “SICKO” to promote their agenda of Government run Healthcare. CNA needs to get a clue and start representing Nurses instead of political agenda’s.

ER Doc reacts to Nursing Ratio’s and Unionization

2007-05-31T16:11:00.000-07:00

Posted at Backstage Pass ER Doctor blogs on the down side, as she sees it, of California’s Nursing Ratios effect on Emergency Departments and patient care. A lot of this is venting but worthy of ED Nurses review and consideration. I have seen this opinion expressed widely among my EM Physician Colleagues. Organized initiatives such as diminishing the RN’s role in Triage and other corner cutting measures are a reflection of it. So the question, Is there a backlash forming against Nursing's success in healthcare and patient advocacy and job protections? I'm feeling it!!

5.12.2007
Nursing ratios
4:1 nursing ratio...sounds like a good idea on the surface.But I tell you what - if you're in the ED waiting room, dying of a brain bleed; or if you're sitting in triage with an open fracture in excruciating pain, you'd appreciate one tenth of a nurse if it meant basic treatment......

...."Basically, nursing ratios are not good for the patients when there are already not enough nurses.......unless, of course, you're one of the first 4 to arrive".
Posted by ER doctor at 11:05 AM

I have been on both sides of this issue, formally against ratios while in ED Nursing Management, and now very much for them working at the Staff Level. I am convinced I am on the right side now, more evidence here. I made comments on ED Doctor's post regarding my support of ratios and got an interesting comment that followed. Worth a read.

ER Doctor in this post and another on Nursing Unionization express anger that Physicians and their organizations did not take an earlier stance on this issue and others and are not organized like the Nurses which advocates the balance of power to Nursing. Hey, thanks for the complement or at least acknowledgement that were kicking your butts. Were used it. We have to every day just to keep things flowing and our patients safe. Hopefully, after you vent you will realize that our advocacy is to your benefit and patients benefit. Yes, some Nurses do take advantage of the ratio's but the overall effect is good for patients. I do sense your anger and see some of your points. Others are just plain wrong like a RN can be cooked up from scratch in 2 years.

In another post ED Doctor writes

5.23.2007
Letter to my peers on unionizing
(I will kindly *not* include myself in this)Doctors are stupid, because they have allowed this to happen.Still living in an era of the rich, private practice mentality...not accepting the fact that most physicians today are employees in one way or another. And instead of turning up their noses to unionizing, perhaps they should realize that they are now more like the average worker. They've allowed the nursing union to be the be the sole legislative voice on healthcare policy, to their detriment, and to the detriment of their patients.As the nursing union shouts "patient advocacy," they are trying to implement healthcare policy that actually hurts the poorest, sickest, neediest members of our society (I'll elaborate as needed). The whole while, the AMA/CMA (made up of mostly people who are completely out of touch with young physicians) asks for money, but does nothing to help their cause. Time after time, taking "no position" on matters that make a huge difference with regard to modern physician's issues. Case in point - the Governor's proposed tax on doctors and hospitals. The doctor's are getting fucked, and there is no unified voice advocating on their behalf. Therefore, patients are getting fucked, and healthcare is a complete mess. And where are the doctors? Where is their voice. What solutions are *they* offering?Doctors need to change their thinking, hold the medical societies accountable, (or refuse to join), participate in the legislative process, and drop the arrogance against unionizing. Or we can all prepare for complete chaos as healthcare continues to fall apart, without a legitimate beacon of leadership. As the doctors bury their heads in their arrogant asses, allow everyone else to take control, and then wonder why they are (directly) paying for a shitty healthcare system, run by nurses/chiropractors/optometrists/herbalists/and the 'people at the healthfood store.'Get a clue.

Posted by ER doctor at 1:50 PM 4 comments
Labels: Issues

Nurses need to be aware that a Physician backlash is taking place and be prepared to defend our practice and ability to perform patient advocacy.

Top Ten ways to raise your Emergency Department Satisfaction scores

2007-05-14T17:18:00.000-07:00

So you’re a Hospital CEO, Emergency Physician Director, or ED Manager. Your latest patient satisfaction scores are lower than your competitor Hospital across town and your in a panic. The results are in the newspaper. Your job is on the line. Try this Nurse’s tried and true top 10 list of how to raise your scores in a hurry. Get your staff on board, here is how.

10. Prescribe Tylenol and other OTC meds: Patients love it because it will mean that their health coverage might cover the cost (at least publicly funded plans will). What’s a little ink on a prescription pad if it moves you up a notch on the survey.
9. Make the Nurses Apologize: Remember, the customer is always right. No matter how dysfunctional and disruptive their behavior apologize if anything upsets them. Smoking in the bathroom, cussing at the Nurses, no problem. If the Nurses refuse have the supervisor apologize and offer the patient a free drink voucher in the cafateria for not meeting their expectations. You can deal with this obvious case of insubordination later.
8. “MR CEO Take down these walls”: Eliminate secure entrances and relax visiting policies. They are only there because those damm Nurses are control freaks. Let the family in and make ER care a group event. Now isn’t everyone happy. More people to practice your scripts on (see #1). Besides, the odds are in your favor you wont have a security event. At least during your tenure as CEO, Director, or Manager. Here is one facility that was not so lucky.
7. Don’t spend to much energy on those excluded from the survey: Quietly leak out who is excluded from the survey (most institutional and mental health patients, and transfered patients in case you are curious) so staff can direct their energies appropriately. Hey, even a demanding CEO knows that you can only kiss so much butt per shift. The key is kissing the right butts.
6. Valet parking: If cost is an issue, lay off your ER Techs, or if you feel bad about that just change their job description, have them put on a suit and park those cars.
5. Prescribe antibiotics for every cough and ear ache: Again, the customer is always right and we dont treat patients, we treat customers. They didn’t drive all this way to get told a viral illness will not benifit from antibiodics and to take Motrin, drink lots of fluids, avoid second hand smoke, and rest. No, give them an antibiotic. Who cares about the treatment guidelines, this one is not measured. They will get better regardless in a couple of days and no doubt will attribute it to the antibiotic. And give them the good stuff, Cipro, makes them feel special and gives you bonus points come survey time. Also good for many bioterrorism events.
4. Hire Travel Nurses: The best thing about Travel Nurses is there easy to get rid of. Yes they are expensive but so is orientation, training, benefits, continuing education, step raises, and all the other stuff that your staff nurses have come to expect. Travel Nurses are not interested in the politics, problems, and shortcomings of the institution, or patient advocacy. They will come to work and not complain, generally be nice, and do as they are told. If they dont, send them packing.
3. Minimize threatening patient education: Crutch walking, wound care instructions, fever control, all great stuff but don’t let those Nurses get to proactive in educating patients. You can loose survey points if some Nurse talks to much about the dangers of smoking, obesity, shaking your child, or any other threatening subject. If the Nurses don’t comply limit their ability to give instructions by eliminating those handouts or use a electronic record that gives instruction control to the Doctor (like Tsystem). After all, Doctor does know best.
2. Provider is Triage: Replace your Triage Nurse with a Midlevel Provider. Your Midlevel can treat and street in a 1 minute Triage exam most of your common complaints as long as they do not engage in any meaningful conversation and follow items 10, 7, 5, and 3 as above. The Nurse, should you choose to keep one in Triage, can stand behind the Provider and quietly scribe the notes. You can call it "Team Triage" and tell them how importnat they are to the "Team". You’ll need a good generic checklist type H&P intake form (I recommend Tsystem or equivalent). The more complex patients will be assigned to the ER for the MD to see. But guess what, you can reduce your ER’s Door To Provider time to nearly zero on all patients by having your PA scribble down some preliminary orders before handing the patient over. Who cares if they ever get done. This is chart buffing at its finest.
1. Scripting to the Test: Teach your staff to memorize the test questions that patients get on their survey so you can have them script their conversation and prompt the patient to remember specifics when filling out their survey. “I am closing the curtain to protect your privacy Mr Jones” will score high on the question “The Nurse paid attention to my privacy needs? “Thank you for choosing Acme Medical Center for your care provider”. This one will get you a more likely to recommend. Not only does scripting guide the patient in completing their survey, it eliminates unnecessary Nurse conversation.

The sad part of this list is the items cited are becoming common practice at many Healthcare organizations.