More Nonsense
When I first started working at this emergency department several years ago, one page did it all. The triage nurse would write the patient's chief complaint, a basic past medical history, the initial vital signs, the current medications, and the allergies. All on one fourth of a page.
Below that there were several lines for physicians to order medications, and at the bottom there was an area to order laboratory tests and radiology studies.
Over time, various changes to this effective document have been proposed by meddling management types, certainly with the best of intentions but unfortunately lacking the benefit of reason. For a few months we had a little red stamper the triage nurse had to stamp on this sheet and check off yes/no boxes relating to TB warning signs. Fever? Night sweats? Weight loss? I'm not sure who authorized the discontinuation of that initiative, but probably someone finally realized that we just don't have enough TB cases where I work to justify such an aggressive screening program during triage.
Now we have a little box in the corner for the triage nurses to check documenting that they have asked the patient "if anyone has threatened them." Yes/No. I'm not sure what we do with that answer, but the box remains. Sometimes checked, sometimes not.
A witty nurse manager decided one day that our nurses were no longer going to take vital signs in triage. I swear to God this is true. Well, you might be thinking, the techs can take vitals too, that might be a way to save some time. But nobody was going to take them, according to this plan. The vital signs would be taken after the patient was brought back to a room. The very second I heard this I told the triage nurses working with me that I didn't really care if they did anything else BUT take vital signs, but they sure as hell weren't going to omit them while I was working. Of course they all agreed with me, and I never heard anything else about it again.
The latest revelation is that the physicians medication orders are no longer allowed to be written in the space provided for that purpose. There is a gray box covering the area which says "do not write orders in this space." We have another separate page to write our medication orders now.
The medication allergy section has been grayed out too. The triage nurses have been told not to write the patient's allergies on the triage note. Do they write that important information on the page where we order medications? Of course not. There is a totally separate page for allergies to medications. And another page to write down the patient's current medications. And about 10 more pages of other administrative crap that serves to camouflage those pages so that we can't find them when we need them.
Shock the monkey!
Below that there were several lines for physicians to order medications, and at the bottom there was an area to order laboratory tests and radiology studies.
Over time, various changes to this effective document have been proposed by meddling management types, certainly with the best of intentions but unfortunately lacking the benefit of reason. For a few months we had a little red stamper the triage nurse had to stamp on this sheet and check off yes/no boxes relating to TB warning signs. Fever? Night sweats? Weight loss? I'm not sure who authorized the discontinuation of that initiative, but probably someone finally realized that we just don't have enough TB cases where I work to justify such an aggressive screening program during triage.
Now we have a little box in the corner for the triage nurses to check documenting that they have asked the patient "if anyone has threatened them." Yes/No. I'm not sure what we do with that answer, but the box remains. Sometimes checked, sometimes not.
A witty nurse manager decided one day that our nurses were no longer going to take vital signs in triage. I swear to God this is true. Well, you might be thinking, the techs can take vitals too, that might be a way to save some time. But nobody was going to take them, according to this plan. The vital signs would be taken after the patient was brought back to a room. The very second I heard this I told the triage nurses working with me that I didn't really care if they did anything else BUT take vital signs, but they sure as hell weren't going to omit them while I was working. Of course they all agreed with me, and I never heard anything else about it again.
The latest revelation is that the physicians medication orders are no longer allowed to be written in the space provided for that purpose. There is a gray box covering the area which says "do not write orders in this space." We have another separate page to write our medication orders now.
The medication allergy section has been grayed out too. The triage nurses have been told not to write the patient's allergies on the triage note. Do they write that important information on the page where we order medications? Of course not. There is a totally separate page for allergies to medications. And another page to write down the patient's current medications. And about 10 more pages of other administrative crap that serves to camouflage those pages so that we can't find them when we need them.
Shock the monkey!
posted by scalpel at 6:04 AM
10 Comments:
Frustration duly noted. We went to a similar system in one of the EDs in which I work. At least on our physician record we still have a space for allergies so that it's easy to check them while ordering meds. I've heard it's due to a JCAHO initiative to have a consolidated drug list so the pt can have a copy upon discharge, and less excited I could not be. I guess it's just another paper to mess with while trying to see a patient and record the H and P. Almost makes me want to go to an EMR sooner...almost.
Yup, they mentioned JCAHO as part of the reason for the changes.
How do we vote them out of existence?
At least you get to write down an order on the chart and put it in the rack for it to be taken off. Every time I see a patient these days, I have to go back over to the computer station, pull down the menus and type in all the freggin' orders, labs, xrays, meds, IVF, sutures, lac tray, splints, all of it. Slows things down considerably. This, of course, all in the interests of capturing charges and supposedly cuts down on medical errors.
Whereas I used to be able to grab a bunch of charts when the ED is extremely busy and the rack is loaded, to see 10 or so patients within an hour, I can't do that anymore. So triage and the lobby gets backed up even more and the waiting time is now worse than ever. The only time I ever use my pen these days is to sign my name on the charts and write prescriptions for patients when they are discharged. And even that is soon to be superfluous because we're signing charts electronically now, too. And they're setting up electronic Rx as well. I'm not really an old dinosaur who is computer inept. I just wish that I can beat some common sense into the administrators of this hospital to stop all these nonsense and stop wasting money. Switching to an entirely electronic system may help to eliminate medical errors on the inpatient units but in the ED its implementation is really impractical and slows us down tremendously. When a critical patient rolls in, I can't do a damn thing until their electronic medical record is generated. Verbal orders goes out the door because without a medical record/ID, no xrays, no CT, no FAST, no labs, no meds, no nothing....DAMN IT, WHAT A BUNCH OF MORONS.
Charity Doc,
Techonological improvements happen in gradual steps. We're trying to work toward a system where physicans can eventually perform all of what you described on a portable palm-pilot. Before we get there, we need to figure out how to make innovations based on trial and error.
The present inconvenience to you and your patients is a price we pay for a better tomorrow.
We're going to an EMR soon too. I think the plan is to make the current system so intolerable that the annoyances of the EMR will seem minor by comparison.
Excuse me, but when did taking vital signs become optional in triage? I know a lot of people don’t view me as “a real nurse” because I work in psych, but I thought vitals were, you know, IMPORTANT!
Love the little monkey man. I was hoping to see a picture of you in your black scrubs. Oh well, maybe one day we'll get a look at you.
our paper forms were definitely unweildly but then we went to EMR that crashes frequently, slows down our processes meaning that doctors that used to be able to see 25 or 30 patients in 8 hours now barely manage 20. Our LWOB rate is thru the roof (greater than 7%) and nurses which used to be able to manage 4 or 5 patients can barely take care of 3. Ain't technology great. On top of that, JCAHO - in an effort to justify their existence - comes up with more and more burdensome regulations that seem to require more and more forms to prove that we are following their dictates. I see a resemblance to the story the Emperor's new clothes. When are we going to stand up and get rid of this bloated, ridiculous governmental agency?
Tim,
During your "trial and error" period.
Do you take liability when an MI that waited 2 hours in the waiting room, or a patient with a life threatening condition decides not to wait any longer because the current docs were slowed down with forms, papers, log-ins, procedures that slow treatment down?
Do you reimburse the doctors for lost revenue because they now see fewer patients per hour?
Do you answer the customer service complaints for slower service and face time while "the doctor worked on the computer"?
We now need three different sheets of paper to administer one medication. This is in the name of "conforming to JACHO", whether this makes sense or not. Whether it's patient safe or not.
The paper makers are winning, and it's at the expense of the patients and their caregivers.
GruntDoc
Chucky,
Your point is well taken. All these new regulations make you feel like fighting with your hands tied.
That is why field experience is crucial to administrators who want to implement change. Furthermore, economic understanding, business management skills, and the ability to serve as the conduit between medical and non-medical professionals are also important skills to have.
If one can't forsee the logistial challenge in "computer log-in" problems and the amount of strife that "extra forms" create, then that person is ill-qualified to be a good administrator, in my opinion.
The next time that "Chief of ___" position comes up, don't let someone get promoted simply because he/she has been there for a long time. Likewise, don't let an MBA or an MPH run your hospital simply because he/she has the degree; we have to make sure that they know what it's actually like to practice medicine.
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