Running a hospital: The message you hope never to send

As with many stimulating blog postings, the comments are as interesting as the post itself. Kudos to Paul Levy for doing his best to handle this differently than is the norm in health care - that’s an important role for a CEO who wants to change health care for the better.

I’m particularly drawn to the comment(s) by Ray Poses, MD about doing a “5 Why’s” type exercise to see what is happening upstream (why are teams being pulled in so many different directions regularly) that causes protocols to be slipped.

I also think there’s an opportunity for BIDMC to bring in patients and families to own the solution together. What would care be like if there was a family member in the operating room during surgical prep (Medical College of Georgia does this)? Or if the family had access to the patient’s electronic medical record in real time while in the hospital? Preventing this for another patient may be less about “what” to do in the operating room, but “how” teams (that include patients and families) are involved in the design of the system.

Given the work BIDMC has been doing to be transparent and involve more, rather than less, people in designing and improving their care system, it seems that they’ll do their best for their patients this time, too.

I am in Besthesda, MD, attending the Institute’s intensive training seminar. The quote above is from Roslyn Marshall, RN, Nurse Manager for the Neurosciences Unit at Medical College of Georgia, who placed a sign with the words in the title near the place where nurses used to do their shift changes. They now do shift changes at the patient bedside. The other quote I liked was from Terry Griffin, who said:

No one more than parents wants to make sure their baby’s care is error free

In reference to including parents in hospital rounds and nursing rounds. I also learned to not call “Carts on Wheels” “COWs” - “WOWs” (”Workstation on Wheels”) is better.

This article is very interesting to me, because I seem to be living the statistic:

In the air, health emergencies rise quietly - USATODAY.com

I have been on several flights in the last 2 years with medical emergencies on them. On the last one, there were so many doctors on the flight, that the flight attendants actually turned people away from assisting. On two I have been on, I was the only physician on the flight, but not the only allied health professional (nurses are as important as physicians in these situations).

I’m glad this is being reported on, because I think that this issue should be recognized and there are some opportunities for us to do some things:

1. Establish helpful guides for patients deciding whether to fly or not. For example, a person recently discharged from a hospital with a new medication regimen may be at risk on a transcontinental flight
2. Establish helpful guides for airline personnel for working with in-flight physicians and nurses. This includes seeking out the right expertise, and maybe a 30 second coaching session on procedures like using the air to ground radio and what is available and not available on board (and there’s usually a medical kit with a lot of useful things on board).
3. A guideline about intervening on a flight plan. One thing that was confusing for me in the times I assisted surrounded landing a plane in an emergency - this is the kind of thing I don’t want anyone to be guessing about. If a patient is critically ill, there should be an option to order a plane down to get help, and maybe scripting that goes with this. What’s possible though - how long does it take to land a plane and is it better to continue on and bring medics on board? Sometimes, it’s the humane thing to do to get help quicker.
4. A guideline for medical providers to prepare documentation and work with flight crew to maximize their talents in an emergency. Maybe an introduction as to who has medical experience and what they can do (perhaps as part of the 30 second orientation I spoke of).
5. Maybe, a guideline for patients and providers. In an in the air emergency, people encounter very intense moments and form something of a bond. I think it is therapeutic in some cases for the provider to connect with the patient/family after the incident is over, or with the patient’s regular provider in some cases. I did this with one family and it was really special.

I also have to make a broader societal call for our profession to engage in making medication reconciliation a norm in all parts of care, and in involving patients in their care by giving them access to all of their medical information (as I did in this blog post about a medical emergency I attended to on the ground). Informing and empowering patients throughout the process of care prevents a devastating outcome in these situations. None of us wants a family member in distress in a situation where they do not have accurate information about their health care regimen that they can either tell someone or have written down from their physician.

An in-air medical emergency is both an intense time and a time when people come together to do the best they can to help another person. I am a big fan of creating a process where everyone can maximize their talent and minimize their anxiety during a life or death situation.

If anyone else has attended on an emergency or seen one in the air, let me know your thoughts. Comments are open.

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These were the words I heard overhead while I was having dinner with a friend recently. Within minutes I was ushered into a back room and encountered a true medical emergency, with confused and concerned bystanders. They ultimately showed excellent judgement by activating the emergency medical system and reaching out for help locally in the interim.

I have answered several public calls for a physician in the past few years, and each situation makes my heart sink out of compassion for both the unwilling patient and the people around them, who want to do whatever they can to help.

As it so happens, my friend found me as I was pondering the situation. He asked, “Ted, how would a patient having their medical records accessible to them on the Internet make a difference here?”

I didn’t have well formed answer then, but I do now. It could have made a big difference, and not because we would bring up a web browser and start surfing.

A physician who practices with the knowledge that their patient is a partner and will see everything they do is more likely to produce records that are (a) accurate (b) involve the patient in treatment planning (c) at the patient’s health literacy level (d) involve family members in assisting in ongoing care needs. Patients can carry accurate diagnosis and medical lists and learn more about how treatment impacts their daily living.

So it’s not about the web site, it’s about the way we respect patients when we involve them and their families in care. When I think about the types of very powerful compounds we prescribe patients and the amount of information we give them (in one study, only 62% of prescriptions were fully explained to patients, 26% of the time even the name of the drug was not told to patients), it is possible to think about how many of our friends or family could be in a situation like this against their will. Prepared, knowledgeable, patients may be less likely to have emergencies in the first place. I know for certain that this was the cause of one of the emergencies I responded to about a year ago. No one leaves their home in the morning hoping to ride in an ambulance later in the day.

As my friend and I parted for the night, it seemed that the story had a happy ending as the patient received the help they needed and life went on in the environment we were in. But just like the physician in “A Fortunate Man,” even if everything turned out just fine, I would still be sad.

Each time this happens I can’t help asking the question, “Why did this happen? And why didn’t the health system prevent it?” When I think about the answers, I become just a little bit more restless to change things.