Computers, Measures, and Patients
Helmut Meisl MD FACEP
With great interest, I read Dr Susan Nedza’s article in the March 2016 QIPS Newsletter. Since my wife and I have become greater consumers of health care (I do not like the word consumers, let us say patients), we have experienced medicine from the “Other Side.”
What we have observed is a disconnect between the actual treatment of the patient and the adherence to protocols and mandatory documentation. I will give a few examples, granted all subjective. My visit to the ED a few years ago for chest pain brought out the myocardial infarction routine/protocol from nursing, before seeing the ED physician even though the pain was totally atypical for myocardial ischemia. A brief history and physical would have sufficed, and saved costs. Here, 2 words triggered a rigid response and protocol, without thinking about what the patient might actually have.
Another example was when my wife developed vomiting after surgery. I pressed the patient cord to request an anti-nauseant for her, but with no response. After waiting some time, I finally wandered outside to the nursing station, expecting to see the staff chatting idly and to chastise them for this. However I saw all furiously pounding at the computer screens entering information. I interrupted one with my request and she said she would look into it. Then later there was still no medication, and again I walked out and now all the nurses were in “Report” and that someone would come after “Report.” Here is all of this information entered into computers, but the old traditional report is being used to communicate. In my wandering of the hallways, I rarely ever found nursing staff in the rooms caring for patients, but usually in front of computer screens. There is more time spent documenting care, rather than actually providing it. What is put in the record is often care that is marginally provided or not provided at all, such as wound checks or assessment of patient’s condition. A hurried question, such as “What is your Pain Score from 1 to 10”, does takes some mental effort on the patient’s part, when they are sedated or preoccupied with other issue, such as vomiting or shortness of breath. Simple traditional questions “Can I help you?”, “ Is anything bothering you?”, or “Are you in pain” would benefit the patient much more than having the nurse fill out the mandatory boxes on the computer screen. The patients often have other conditions beside pain that is more bothersome to them.
When still working clinically, obtaining any meaningful information to follow-up on an admitted patient would require wading through multiple pages of irrelevant screens. I once asked our most competent hospitalist how she survived this incomprehensible record. She replied that she generally did not look at the nurses computer notes, but just asked the nurse about the patients condition. Here is a wide open door for miscommunication and error—the night nurse gives report to the day nurse, who gives a summary to the treating physician.
Another ED visit on my part for a complication of a medicine produced multiple pages of electronically produced Discharge Instructions, that had some semblance to the presenting complaint, but otherwise were incorrect and actually dangerous. Here again we were treating the computer program and the need to click some box, rather than the patient. Three lines of relevant instructions would have been much more beneficial (which I often did in my practice). Being a physician I looked at these instructions, and knew to ignore them, but here was an error.
I summary I agree with Dr Nezda, but want to state that the main issue may not be the measures, but rather physician and nursing ability to individualize patient care and time to actually care for them. The Hospital Acquired Conditions with reduction of catheter acquired infections measure may never have been necessary if catheters had been placed only on those who truly needed them and not for staffing convenience. This of course means adequate staff to respond to call bells and bathroom needs, and to be on the floor and in rooms rather than in front of computer screens. This applies to physicians also, where they seem to be looking at the computer screen and holding the mouse, rather than looking at the patient and examining them. I felt like I was becoming a mouse veterinarian.
When I started practice many years ago, ED Nurses’ notes were 3-4 lines and a worrisome item would be circled in red. Here I knew right away what concerned the Nurse. Discharge instructions were also about 3-4 lines, unfortunately usually illegible. We do not have to go back to that minimalist level, and typing does helps legibility. However important information is now buried in multiple screens and lost in the usually irrelevant screens of domestic abuse, suicide risk, diet assessment, etc. The information could be on one screen, taking a brief time to fill out and relevant to the patient and his/her condition, not what a computer programmer sitting at a desk has contrived. Granted there are beneficial regulatory measures and helpful protocols. However applying them to entire populations—i.e. instituting a sepsis alert for any minor infectious illnesses, or a stroke protocol for every neurological complaint or the myocardial infarction protocol for every chest complaint is unnecessary. Granted such a case may be missed, but would be rare with even a brief, but proper HX and PX. In addition, such a fixation on a specific diagnosis that is being aggressively monitored by external agencies leads to missing other actual conditions, in turn harming the patient. The cost issue is a whole other area of discussion. From a human and patient perspective, he/she would also feel like being treated as a person not just as a cog in some hospital ritual. Usually the patient does not understand what is happening, and such comments as “We always do this” “We have to do this” do not help.
I have focused here mainly on Nursing, and I do not want to criticize the Nursing staff that in my experience from both sides are all working hard, but subject to many external non-patient care constraints. They should be allowed to again focus on patient care.
In summary, let us go back to treating patients.
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