Month: December 2013

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Consult-Liaison Education Lessons Medicine Systems

Have You Thanked Your Nurse Today?

As I noted earlier, hospitals permit around-the-clock observation of patients. If you don’t need around-the-clock monitoring, you don’t need to be in the hospital.[1. “But what about ‘social admits’?” you may cry. “They don’t need to be in the hospital, but we admit them anyway.” True. “Social admits” reflect the intersections of social policy, politics, health, economics, and the lack of resources. That topic is beyond the scope of this post.]

Who is doing this around-the-clock monitoring? Nurses.

Therefore, whether you are a patient or a physician, one of the best things you can do is get on the good side of the nurses.

If you are a patient, a nurse watches over you and your care. Nurses make sure that you won’t fall. They make sure they give the right dose of the right medication in the right route to the right person at the right time (which can be easier said than done). Nurses provide education about medicines, tests, and health conditions. They make sure you know what day it is, where you are, and who you are. (Also easier said than done.) They monitor your progress and try to ensure that your health only improves. Nurses can also page the doctor for you or your family. They can find out when you are scheduled to go through a procedure. They can find out what you are waiting for. Nurses advocate for you.

Sometimes it may seem like they’re not “doing” anything. They are. They’re keeping an eye on what is happening with your health.

If you are a physician, you must already recognize the value of nurses. (If you are a medical student or resident and have fantasies that, one day, you will be “running the show”, don’t be a fool: There is no way you could do your work in the hospital without the help of nurses.) Nurses serve as our eyes and ears. They tell us information about patients that patients themselves cannot or will not tell us. They do triage with us when we have multiple patients who are not doing well simultaneously. They tell us if someone is starting to look a lot worse… or a lot better.

While it is true that nurses provide around-the-clock observation of patients in hospitals, it is also true that nurses provide around-the-clock monitoring of doctors in hospitals.

Nurses know when doctors typically meet with patients. They know which doctors are more likely to spend time with patients and answer questions. They know which doctors work in collaboration with nurses and which ones treat them like second-class citizens. They know which doctors return pages promptly. Nurses quickly learn how to alter their approaches with various doctors to get work done.

This is yet another reason why, as a patient, you want to get on the good side of nurses. Nurses manage doctors. Skilled nurses will know how to work with different doctors to help you get what you want (e.g., answers to your questions, a meeting with your family, better pain control).

(Patients, you should also know that nurses also manage you. Nurses tell doctors which patients yell at nurses, which family members are berating them, which patients are trying hard to follow recommendations, and which family members left cookies and treats for them.)

Physicians, thank your nurses for helping you do your job better. Positive reinforcement and good manners go a long way. The more you acknowledge the skills and efforts of your nurses, the more they will want to work with you and make your job easier.

Patients, thank your nurses for watching over you. Nurses play an essential role in your care in the hospital. Be kind to them. The more you acknowledge the skills and efforts of your nurses, the more they will want to work with you to get you back to health as soon as possible.

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Consult-Liaison Education Medicine Observations Reflection

The Patience of Patients.

When I was a resident one of my attendings said, “You know why patients are called ‘patients’? It’s because they have a lot of patience. For us.”

Patients in hospitals do a lot of waiting. They wait for physicians. They wait for nurses. They wait to use the bathroom. They wait to undergo procedures. They wait for their IVs to stop beeping. They wait for the person next door to stop vomiting up what sounds like all of their internal organs. They wait for the person down the hall to stop screaming. They wait to eat. (Doctors: Reverse those NPO orders as soon as you can! Food is at the base of Maslow’s hierarchy of needs! Food is more important than safety and security of health!) They wait for the nursing assistants to finish taking their blood pressures so they can sleep. They wait for the unit clerk to answer the phone so a nurse can help them get out of bed without the bed alarms screeching throughout the unit.

They wait to feel better. They wait for good news.

No one has any idea how much patients wait in the hospital until you become a patient in the hospital.

Sometimes it’s not even clear what patients are waiting for. Hospital staff arrive and they have no idea why they are there:

  • “Hi, I’m the physical therapist.”
  • “Hi, I’m here to take you down for an ultrasound.”
  • “Hi, I’m the dietician.”
  • “Hi, I’m the consulting psychiatrist.”[1. Hospitalists: If you call a psychiatry consult for your patient, tell your patient. Most people, with or without psychiatric issues, do not appreciate an unexpected visit from a psychiatrist. “I’m not crazy! Get out of my room! No one asked you to come here!”]

Because of the nature of acute care in hospitals, rarely do things run on a consistent, predictable schedule. This lack of punctuality is not intentional; things change. Hospital staff triage patients all the time and, unfortunately, patients and patient care are shuffled around in order of acuity.

Thus, if you’re in a hospital and someone tells you that So-and-So will see you at 2pm, don’t believe it. Yes, So-and-So might actually see you at 2pm, but it takes extraordinary planetary alignment for that to happen. So-and-So might show up at noon… or at 4:30pm.

Yes, doctors wait, too. The waiting doctors do, though, is informed by the knowledge they have about why they’re waiting. Doctors wait for patients to come out of the bathroom. They wait for patients to go for a study or imaging test. They wait for family members to arrive to get more history. They wait for the pathology or study results to clarify diagnosis and treatment. They wait for information that affects what happens next.

Patients often wait without knowing what will happen next.

If you work in a hospital, remember that most patients have an extraordinary amount of patience, given the circumstances. Yes, there is a minuscule minority who have the frustration tolerance and impulse control of toddlers, but that is not a common means of coping in adults. (Physicians tend to call psychiatry when this happens. This is not a common consult.)

Do what you can to orient patients to what is going on. Give them approximate times for your visits and if you are running late, send a message to them to let them know. (Technology could help here: What if we could send text messages to patients through the television? or if the text message could become a voice message on their in-room telephones?) If patients are not around when you come by to see them, leave a note to let them know that you’ll try again later. (Technology could help with this, too.) Tell them why you don’t want them to eat after midnight. Tell them why you want them to work with physical therapy. Tell them the purpose of the bed alarm.

Help them understand what they are waiting for. Don’t take their patience for granted.

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Consult-Liaison Education Medicine Reading

DSM-5: Delirium.

This post is the most recent addition to my DSM-5 e-mail list. I include it here only because I apparently have a fondness for delirium; it was one of my favorite teaching topics when working with medical students. If you’d like to read my other DSM-5 summaries, let me know.

(724 words = 5 min read)

How rarely, particularly outside of hospital settings, do we remember to think of delirium!

DSM-5 lists five criteria for delirium:

A. There is a disturbance in attention and awareness.

Because people who are delirious have problems with focus and sustaining attention, this means you might find yourself asking the same questions over and over. The delirious patient may end up providing the same answer over and over, even though you’re asking a different question.

Furthermore, if patients have severe inattention, they might not be able to have a conversation with you at all.

B. Delirium develops over a short period of time, typically hours to days. There is a change in baseline attention and awareness. It fluctuates throughout the day.

Attention and awareness often worsen at night (sometimes referred to as “sundowning“).

C. There is also another disturbance in cognition, such as in memory, orientation, language, and perception.

Delirious patients might think that a pair of socks is an opossum (illusion), the nurse is trying to sell his blood (misinterpretation/delusion), or that he can hear the conversations that are happening in the cafeteria (hallucinations/delusions).

D. The disturbances in (A.) and (C.) are not better explained by another pre-existing, established, or evolving neurocognitive disorder. (Having a neurocognitive disorder, however, increases the risk of the development of delirium.)

You also can’t diagnose delirium is someone is comatose. Essential to the diagnosis of delirium is that the patient can respond to “verbal stimulation”.

E. There must also be evidence that the delirium is due to a direct physiological consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or is due to multiple etiologies.

This means that delirium always has a cause. Your job is to find that cause (or work with someone who can help you find that cause).

There are many specifiers for delirium (which clarify the cause):

(1) substance intoxication delirium
(2) substance withdrawal delirium
(3) medication-induced delirium
(4) delirium due to another medical condition
(5) delirium due to multiple etiologies
(6) acute
(7) persistent (how terrible!)
(8) hyperactive (more frequently recognized, because these are the people who are shouting that they are on a boat and think that the IVs are snakes)
(9) hypoactive (this is often missed because these are the people who seem to be the most “compliant” patients ever)
(10) mixed level of activity

DSM-5 spends a fair amount of time discussing the recording procedures. If you are a consult-liaison psychiatrist, you should look those over.

DSM-5 states that, in hospital settings, delirium usually lasts about one week. Some symptoms, though, persist even after individuals are discharged from the hospital.

Delirium is considered a “great imitator” amongst psychiatrists. People who are delirious can look psychotic, depressed, manic, anxious, or a combination of all four. Delirium also messes with sleep-wake cycles and may manifest more at night because there is less environmental stimulation present.

DSM-5 provides some prevalence numbers:
(1) people in the community: 1-2% (that number ideally should be 0%)
(2) hospitalized people: 6% to 56% (this is not a comforting range)
(3) people who just had surgery: 15% to 53%
(4) people in ICUs: 70% to 87%
(5) people in nursing homes: 60% (yikes!)
(6) people who are at “end of life”: 83%

Thankfully, the majority of people with delirium experience a full recovery, though delirium is a harbinger of death: About 40% of people who are diagnosed with delirium in the hospital are dead within a year. Delirium also increases the likelihood of “institutional placement” and “functional decline”.

In addition to neurocognitive disorders, other risks for delirium include extremes of age, drug use, polypharmacy, a history of falls, and functional impairment.

Delirium is a clinical diagnosis (there is no test for it), though EEGs might show “generalized slowing”.

I have never thought about the differential for delirium, as that is what I always consider first (but that may be due to my past work as a consult-liaison psychiatrist). DSM-5 includes psychotic disorders, acute stress disorder, malingering, factitious disorder, and other neurocognitive disorders in the differential for delirium. Rarely, though, do those conditions have the “waxing and waning” in level of consciousness and attention that is seen in delirium.

I’ll resume sending [DSM-5] posts out after January 1st. May you all recall fond memories from 2013. May 2014 bring you good health, mirth, and ongoing learning.

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Consult-Liaison Medicine Observations Policy Systems

Ever Seen a Hospital Orientation?

Perhaps more important than the actual “rules” of hospitals is how these “rules” are communicated to patients.

Medical students spend two years training in a hospital before they work as physicians. It often took me over a week on a specific service (e.g., surgery) to understand its routines and rhythms. While it is true that patients and hospital staff have different roles in the hospital, how can we expect patients to understand their roles upon admission?

Those of you who work in hospitals might be thinking, “But patients don’t have roles in the hospital. They’re there to receive care.” Of course patients have roles in the hospital. When patients deviate from the roles you think they should play, that’s when you start calling them “difficult” and then consult psychiatry.

In general, hospitals have not honed their skills in orienting patients to their roles in the hospital. Rarely does anyone tell you what to do or what to expect when you go to the hospital. This orientation may happen on an individual level (thank you, nurses!), but it is an uncommon institutional practice.

Consider all the places you visit that are not “yours”, though you might be labelled the “customer”. How about fast food joints? They often have signs that tell you where you order your food and where to pick it up. The cash registers tell you where you pay. Shallow corrals tell you where to line up. Those are small details, but they help define your role and shape your behaviors while you are in the fast food restaurant.

Hospitals would do well to adopt the practices of airlines. Have you been on an airplane? Remember how you paid attention to the safety announcements before your first flight? The flight attendants tell you how your seatbelt works, point out the exits to you, tell you about the flotation device that is disguised as a seat cushion, and how to work the oxygen masks that will appear if the cabin pressure drops. It only takes a few minutes. And, in case you want to review the information on your own, they include all of that information “on the card in the seat back pocket in front of you“. Have you ever looked at that card? There are few words on it: It aims to be universally understood.

Why not include a small booklet—comic book?—in each hospital room that provides similar orientation?

Consider hotels. Not only do hotels have written material in each room about hotel operations, but some of them also have a television channel dedicated to hotel features and operations!

Most hospital rooms have a television bolted to the ceiling or to the wall. Why not develop a “hospital channel” that offers similar information about hospital operations and features?

A skim through Google shows me that some children’s hospitals (in Cincinnati and Chapel Hill) have created YouTube videos that offer hospital orientation to kids. Why do we not do the same for adults?

When I have worked in hospitals, I often felt like there wasn’t enough time for me to do everything I needed and wanted to do. When I sat in my mother’s hospital room, I was surprised with how much waiting we did. That time could be used to teach patients and their family members what to expect during the hospitalization, like when the doctors typically round (and what “rounding” even means) or what to do when the IV starts to beep.

If you work as a hospital CEO or at a similar paygrade, I encourage you to work on easy-to-understand materials that orient patients to their roles in the hospital. Realize that patients want their hospital stays to go smoothly. They want to know what to expect. The vast majority of patients don’t want to “bother” hospital staff. They want to help hospital staff so that the medical staff can help them. Patients don’t want to stay at the hospital longer than they have to.

Understand that hospital orientation is like building rapport on an organizational level. Data shows that effective communication between physicians and patients leads to better patient health outcomes. If the outcomes are better on an individual level, why couldn’t outcomes improve on an institutional level?

Categories
Education Medicine Nonfiction Observations Systems

Who Works at a Hospital?

Who works at a hospital? (Again, just indulge me for now.)

Doctors. If you’re a patient at a teaching hospital, this includes medical students (people in school to become doctors), interns and residents (people who have earned the title of “doctor”, but who are still learning their craft), and attendings (people who have completed their formal training as physicians). If you’re not at a teaching hospital, it’s less likely you’ll see medical students and other trainees (the army of white coats tromping through the hallways). Instead, you’ll see lone attending physicians.

Nurses. Nurses play vital roles in patient care; without them, hospitals simply would not work. Nurses arguably spend the most time with patients. They monitor and observe patients around the clock. As a result, they’re often the first to realize that something has changed and thus have the responsibility to do something about it.

There are different kinds of nurses, such as registered nurses, licensed practical nurses, and certified nursing assistants. Their roles differ in terms of their training, skill sets, and responsibilities, but they all serve to observe and monitor patients and their conditions.

Therapists. Not the talky kind. There are respiratory therapists, speech therapists, physical therapists, and occupational therapists. They focus on skills and function: How can we help this patient walk? How can we help this patient talk with less difficulty? How can we retrain the muscles in this patient’s hand so he can write again?

Technicians. Radiology technicians, pharmacy technicians, surgical technicians, electroencephalogram technicians, patient care technicians… the list is long. They assist other professionals in the hospital in their duties and may have more contact with patients that the professionals themselves.

Consider an ultrasound technician. A physician may order the ultrasound, but it is the technician who will explain to the patient what an ultrasound is and perform the procedure. A radiologist will interpret the results.

A special note about patient care technicians (PCTs): These individuals often spend the most time with patients and are often a treasure trove of data for nurses and physicians. If you are a physician working in a hospital, make a point of talking with the PCTs. They’re the ones who will know if the patient slept, went to a procedure, has a change in mental status, etc.

Janitorial staff. These individuals have one of the most important jobs in the hospital: They help with hospital-wide infection control. They help prevent people from getting more sick. If you work in a hospital, thank a janitor today for what they do.

Clerical staff. This includes the clerks who serve as receptionists for the hospital units (not an easy job: imagine juggling phone calls from patients, managing the anxiety of family members of patients, paging physicians multiple times because they don’t call back…), hospital operators, all the people working in medical records, and the staff who work with the hospital administrators. Hospitals generate a lot of data. Someone has to help manage and organize all that data.

Information technology staff. Electronic health records now hold patient information. The networks fails. The mouse doesn’t work. There aren’t enough terminals. Someone can’t remember their password. The radiology images aren’t showing up. The orders didn’t go through. The IT department gets a lot of pressure to get it all right.

Food services staff. There are all the people who cook hospital meals, transport and deliver the meals to each patient, and wash the leftover dishes. These people also prepare the food in the hospital cafeteria, which feeds the rest of us who are well enough to get it on our own.

People want to eat and they want to eat food that tastes good. In the hospital it is hard to please all of the people all of the time.

Environmental services staff. These are the plumbers, electricians, HVAC experts, etc. who make sure that the electricity stays on, that there are backup generators available, that the water temperatures are satisfactory, that the ambient temperatures are within a certain range, that the windows seal tight, etc. If the building doesn’t “work”, then the hospital doesn’t work.

Pharmacy staff. I don’t know how many thousands of medications are available, but the pharmacy takes care of all of them. Whether they are amazing antibiotics that will drip through an IV or cartons of chicken soup (yes, doctors can order chicken soup), the pharmacy takes all of those orders and fills them. They ensure that medications are available in every single hospital unit and prepare medications for patients to take with them when they leave the hospital. And they have to make sure that they fill the right drug at the right dose at the right time for the right person.

There are many more people who work in hospitals; I do not omit them willfully. We often take for granted all the people who make a hospital work.

If you are a patient (or someone visiting a patient) in a hospital, I encourage you to thank all the people who have helped you. Hospital staff appreciate hearing that and want to know that their actions made a difference.

If you work in a hospital (especially physicians), I encourage you to thank your colleagues, particularly those who have a completely different job from yours. They are doing something to help you do your work. Let them know that you appreciate it.

Next time: The “rules” of the hospital.