Thursday, September 25, 2008

A Review of Our Hospital Experience

Review of Hospital Systems through the Lens of One Family’s Experience

Here are some of the items Kearney and I noted in our review of our trip through hospital-land, in addition to yesterday’s suggestion for double-sided staff ID tags. Out of the 60 people for whom we kept records over our journey, we submitted by-name commendations for 24 of them. That’s a pretty impressive record, in and of itself. We had only one truly bad experience with a medical staff member across that whole time. It was short and we figured out what we needed to know from the next really wonderful person.

New Family Rule. We have a new family rule that no member of our family will ever be left alone in the hospital for even one minute if we can avoid it. There were several times when the family was so tired and I was sufficiently stable or getting ready to sleep that the most prudent course seemed to be for them to go home to rest. This turned out to be a mistake often enough that we stopped the practice, even though it added to the exhaustion load. This is because of the size of the system and the sheer number of individuals and interactions that occur. No matter how alert, the patient simply cannot absorb or retain all the information that passes by or really cope with events alone. We lost information or took recovery setbacks every time I was left alone.

Checking In for Surgery/Surgical Waiting Room. Carle’s system for surgical check-in that let the family stay around until I was wheeled off to the operating room was good for all of us. The staff were helpful and attuned to our needs as well as their own tasks; it was humane and well-organized. The surgical waiting room with the surgery liaison nurse is a superlative system and reduced tremendously the stress of the whole experience for those waiting. It’s well set up, well run, and the quality of the nurse performing the liaison duty on September 10 was of the very highest caliber. The calls from surgical nurse—whom we’d all met in the surgical preparation suite—every hour or so were also very helpful and appreciated. The information provided supported Michael and Kearney’s periodic posts on the progress of the surgery. Boffo.

A Superlative Shift Change Procedure. As the nurses among you commented, shift changes were ragged and the problems that occurred were most likely then. Another reason to have family there the whole while. We saw one superlative hand-off on the surgical floor, when Ruth and Linda came to the room together. Ruth introduced Linda to us, and then she read from her notes about my status, my meds, the care, the problems I was having and what she was watching. She reported in front of us and then asked us if we had any questions for Linda. Linda made eye contact with each of us and told us how long she’d be around. It didn’t take long, it was incredibly reassuring and we felt completely in the loop about all that was going on. Impressive. Plus, a human being checked in with us during what were otherwise totally dead periods.

Oddities; Further Improvements Needed; Suggestions.

Orientation Needed. Overall, the level of care was very high. At the same time, it would be hard to call any of the system patient-centered. This is a very large, complex system and it marches to its own rhythms and mandates. The difference between the nurse-centered environment of the ICU and the other-centered surgical floor was striking. All primary contacts in the ICU were with nurses. As we moved to the surgical floor, the tone changed and there wasn’t much explanation or orientation. Even a short explanation to family and patient would have helped, especially about the hierarchy of care roles. The role of the health care technicians could have been explained to benefit. They were great, adding real gentleness and humanity to the stay and they took the time to make daily human contact. Still, knowing who/what their role was would have been helpful.

Learning Style Questions. Many staff members asked about best learning style before they started to share information: “do you get information better by listening or reading?” was a common question. This was yet more evidence of extensive and reasonably effective staff training. Not all of them knew what to do with the response once they had asked, but the question was asked quite often and the effort to systematize this was clear. Kudos for effort.

Discharge Instructions. The written discharge instructions are a nice touch. Being handed a written sheet and then going over it is a great plan. (More evidence of attention to learning styles.) It’s a good start but the template needs improvement. Not having a coordinated medication plan, for example, is goony. We’re educated, comfortable with technical terminology (Kearney is a grad student doing research on cancer cells) and we were still unsure for days when we were at home that we were handling it properly. This was far more complicated for us than it should have been.

The form begins with a nice concise statement of its purpose, and lists the medical professionals responsible for the instructions. It has date and time and my clinic numbers, etc. Then come the following headings, each followed by inset information:
STOP taking these medications
CONTINUE taking these medications
CONTINUE these medications, which have CHANGED
START taking these medications
There is not a single unified plan for taking medications going forward. Once we got home, the interaction of these four sections caused us tremendous confusion and we went over and over and over them to make sure we’d gotten everything straight. For the first few days, we weren’t ever confident that we had it right. If we had this much trouble, we’re thinking some more improvement is surely possible. There isn’t some program out there for entering how often different meds need to be taken than can produce one or two sample schedules that would work and could be adapted?

Even worse is the phrasing of the instructions for one of the key medications, the steroids:

“Take 1 Tab by mouth 3 times daily. Take 4 mg tid for 3 days then 4 mg bid for 3 days then 4 mg q day for 3 days then d/c.”

We could and did look this up to puzzle it through (Latin and abbreviations) but at least in the discharge instructions, regular old people-talk would have been nice…

Marketing Call on Monday. Monday morning, after a late Saturday-afternoon discharge, we received a marketing survey call asking about hospital experiences. As this call came in well before we had any follow-up appointments scheduled and before we’d had any contact with any medical staff on any matter since leaving the hospital, it was a dissonant moment. We were still shaky on the medication schedule and were still in a period of flux and uncertainty. This call would have been better delayed a day or two.

General Staff Attitudes. As a general rule, the staff we encountered seemed fulfilled and content in their jobs. At least one health tech is being supported to get a nursing degree and a number of people talked about being given schedules that varied from the norm in order to accommodate their own life needs. We visited with a lot of staff members, and most were quite positive. The frustrations we did hear about were generally focused on making things better not complaints or gripes. That’s unusual in a large organization and worth noting.
Stars for effort. The white board with information in the hospital rooms with the names of the people on duty, orders (regular diet, use the breathing exercise device every hour), room phone number, etc. is a great idea. When I arrived on the surgical floor, the first and second shift (nurses and health techs) both kept it updated and it was most useful. After that, it was used only sporadically. It would have been nice to see that kept up the whole time.

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