Hospital Organization-Nursing

After working at two different major hospitals in the United States, I've seen a few things that should be applied to any health system to improve efficiency. Here's a few of them:

1. In all stockrooms have all the shelves labeled with a code and a list somewhere in the room saying what is on each shelf. This makes it so much easier to grab supplies that are not used all that often, you can just use the list to see exactly where it is and get back to work. This is even more essential in hospitals that have nurses float to different units, because every unit inevitably organizes their stockrooms differently.

2. Place commonly used supplies, such as caps for IVs, in the patient's room. This reduces the need for staff to walk back and forth to the supply room every few minutes when they need to complete a task, saving a considerable amount of time. Most units in both hospitals I worked at have a storage unit in the patient's room with several drawers filled with everything from blue pads to biohazard bags to gauze. This makes it much easier to get through a shift without feeling like you ran a marathon.

3. Simplify the computer system as much as possible-add functionality to existing programs rather than adding new programs. One hospital I've worked at does a great job with this-everything is available from just two programs-Careweb and Carelink-from lab results to physician orders to medication charting. For nursing purposes, Carelink alone is sufficient to discharge almost every task for the whole day. A new program is being added, Centricity, that allows nurses to chart on patients electronically instead of on paper. However, it is easy to use so it's not a big deal.

In comparison, the other hospital I worked at was a bit of a mess. You had to open Q-reads to look at X-rays, use two different programs for charting, and a fourth program, synthesis, to access all of the information from these various programs. The medication system was confusing as well-there were three different ways to view the medications for each patient, each way organizing them completely differently. In short, it was a bit of a clusterfuck and in many cases staff did not know how to perform the tasks that were not done on a daily basis, necessitating questions to colleagues.

In planning a computer system for a hospital, try and limit the number of programs needed for staff to perform their duties as much as possible, it will make everything more efficient and probably improve patient safety. Even better, do a test run where you have staff use the system to take care of imaginary patients so you can find stumbling blocks before a gigantic investment is made.

4. Keep commonly used educational materials on each unit. When all of the educational pamphlets are easily available for staff to grab and explain to patients it makes it a lot easier to provide patient education. If a patient came back with an Ivor-Lewis esophagectomy-all the pamphlets needed were on hand-one describing the surgery, one describing pain control, one describing how to control constipation caused by narcotic medications, etc.

In comparison, when patient educational materials have to be accessed through the online system and manually printed off it's much less likely that these necessary materials will get to the patients early in their stay. Instead, they will be thrown at the patient when they are being discharged in a big lump. This means that the patient will be less likely to understand their discharge instructions, and thus more likely to face complications from not properly following clinician directions.

5. Pain Teams-basically this is a multidisciplinary team with a M.D., nurse, and other staff who specialize in assessing patient's for pain and make recommendations about the medication regimen that they should be on to control their pain. They also assess epidurals, PCAs, and other devices that may be in use on the patient. Although obviously the general service and regular nurses should also be assessing all of these devices, the pain team is extremely helpful because they have more experience with pain and provide good recommendations to control it. Good pain control contributes to better patient outcomes so it's important to achieve.

6. Bedside Report. At the end of every shift, nurses are responsible for giving a status report on each patient they have to the nurse coming on. This allows for any problems such as changes in vital signs or an upcoming test to be described to the next nurse so they know what they need to do on their shift. This report is usually given at the nurse's station or some other private area.

Instead, this should be done at the patient's bedside. Sometimes the patient may have some information that the nurse coming off shift does not have, such as if a doctor came in while the nurse wasn't around or if a problem they're experiencing is getting worse. Additionally, physically seeing the patient helps bring about continuity in care. The nurse can note what is going on with the patient, such as IV infusions running and how the patient actually appears, which is frequently important to know for the purposes of comparison if they worsen later in the day. The patient also knows who is taking over for their last nurse, helping to reduce confusion.

There are a few systems in place at each institution that I have more reservations about, but may still be a good idea to consider for other hospitals.

1. IV teams-basically these are nurses who go around the hospital and do nothing but put in peripheral IVs, PICC lines, and other types of intravenous access devices. The advantage to this system is that you have very experienced nurses putting in your IVs, limiting complications and pain to patients from incompetent IV insertion techniques.

The disadvantage is that it makes the rest of the nursing staff basically unable to insert a regular IV-they've maybe done it in school once or twice or while working at a different facility that did not have an IV team. If an emergency arises where a patient needs IV access and there is not time to wait for the IV team, the regular nursing staff may be unable to gain access. At Saint Mary's, I don't believe that the equipment for starting IVs was even available on the floor, it was all with the IV teams.

2. Catheter teams-Similar to IV teams, these are urology techs who place all of the foley catheters and do all of the straight caths in a hospital. Once again, this leaves a lot of nurses with only a theoretical knowledge of how to insert a catheter, as the urology team ends up doing it for almost all patients. The advantage is that these guys do nothing but insert catheters so they know what they're doing, possibly reducing the incidence of UTIs from cath placement. Additionally, there is a female and male cath team, which may make many patients more comfortable. As catheter placement is a less frequent and less urgent occurrence than many other procedures, you don't need that many techs to cover the whole hospital either.

Any hospital should think about all of these methods and consider whether they are appropriate for their institution. They potentially can save a lot of staff time and improve patient outcomes, thereby improving staff and patient satisfaction.

To Write Love on Her Arms

Today I went to an event for suicide prevention. I didn't know that topic was going to be involved at all, I thought it was just a free concert. However, nothing adds more fun to a night than an open conversation about depression and suicide.

The whole thing was sponsored by The Buried Life, a MTV show that travels around helping people with various things they want to do. In this case, the woman who they were helping was a cutter, a person who relieves their stress and anxiety by using various implements to cut their skin open. What she wanted was to help support To Write Love on Her Arms, a non-profit that provides assistance to people struggling with depression and other issues.

A large part of why people with depression struggle so much is that it isn't acceptable to talk about. People will go on for hours talking about their surgeries, heart problems, diabetes, and other physical problems, but when mental health issues come on to the stage everyone becomes uncomfortable and quiet. I'm not sure what the best way is to deal with this. Everyone has their own struggles and hurdles to get through, but it's extremely hard to get people to ask for help. Maybe if it was more acceptable to talk about depression there wouldn't be such a huge market for antidepressants-if people got help and talked through their problems earlier then maybe full major depressive disorders would be less likely to occur.

However, this is much easier said than done. It just seems like there is still a huge stigma against admitting you have any sort of mental health problem. At the hospital you get referred to as a psych patient and most of the nursing staff would prefer not to deal with you. I'm sure it closes a lot of doors for employment purposes too, no one wants to hire someone with an extensive psychiatric history. That would need to change as well for people to feel comfortable with admitting they need help.

Anis Mojgani, a national poetry champion came and and gave two inspiring poems. They were the sort of thing I usually snort at, that everyone faces their own challenges and yet all have something unique to offer to the world. Somehow, I didn't end up feeling that way today. I thought about it and he has a point. I'm a fairly boring person in most respects, yet I have worked for Gamereplays.org as a discussion moderator, senior discussion moderator, moderation administrator, and editor. During that time I had several articles published on the site. When I was in high school I got another article published on a now defunct website about how to win FFA games in Warcraft 3. I did a lot of things for the first time this summer in Rochester. I went tubing down a river and I can't even swim. I did chest tube and PICC line site care. A patient said that I looked like I enjoyed my job. I actually believed Anis a bit when he said that his poems came from the people he meets, not from himself.