i witnessed inpatient hospital care through a new lens this weekend. my dad was hospitalized with cellulitis in his foot that wasn't responding to oral antibiotics. the infection required topical anti-fungals as well as high dosages of iv vancomycin -- a medication we've become all to familiar with as one of the only heavy hitting antibiotics for mrsa.
i want to acknowledge right off the bat that veteran patients and their families present unique challenges for in-house hospital staff. depending on the hospital culture and policies, we can either be an enormous asset for the delivery of optimal care or an enormous annoyance to the staff. in my experience at my current hospital, i really believe that my active participation in my care is highly valued by my medical team -- as i think it should be. however, i strongly suspect this isn't always the case and my suspicion was verified by an interaction with one of my dad's nurses this weekend.
i'll replay the series of events. to give you the necessary background, my dad got his first infusion of vanco at 5:45 pm.
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nurse enters the room to take my dad's vitals.
nurse: your next infusion is at 5 am.
dad: is there any way to slowly start pushing that infusion time later? i'd like to get on a more reasonable schedule in case i go home on ivs. ideally, i'd like my infusions at around 7 am/7 pm.
n: no, your vanco is at 5 am. we can't infuse at 7 am.
d: yes, i know you can't infuse at 7 am. i'm just wondering if we can push the vanco infusions back by intervals of 15 minutes or so since i know vanco has a 1 hour leeway. ideally i'd like to be on a 7 am/7 pm schedule by the time i leave in case i am discharged on home ivs.
n: your vanco was at 5 pm tonight and it is written for 5 am tomorrow morning. i can't change your order.
d: i'm pretty sure the vanco infused later than 5 pm tonight, which is good because we can keep pushing that infusion time back little-by-little. there's no reason for me to have to wake up to do vanco if it only infuses every 12 hours. all i'm asking is if we can push back the morning infusion within the accepted leeway time so i don't have to keep waking up at 5 am.
n: your vanco definitely infused at 5 pm tonight, which means it is at 5 am tomorrow.
the nurse walks to check the medication log.
the nurse walks to check the medication log.
n: yes, see, it says here that you did vanco at 5:45 pm.
d: right, it was given at 5:45 pm not 5 pm and i'd like to do the morning dose at 6 or 6:15 am to keep pushing the time back.
n: it was given at 5:45 pm, which is within the 1 hour leeway time for vanco. the order is written for 5 am/5 pm. we have to follow the order.
d: i completely understand and i agree that it was fine to give it at 5:45 pm. all i am asking is to keep gradually moving my infusions later so that the morning dose is at a more reasonable time. it seems ridiculous for a medication that only infuses every 12 hours to be at 5 am/5 pm. i really don't see why that should present a problem.
n: if you want to change your schedule, the doctor has to change the entire order.
my dad starts to get slightly exasperated.
d: well there's no reason it has to be at 5 am/5 pm. as long as we stay within the allowed leeway time, it should be fine to push back the infusion times. if you need to call a doctor to change the order, then call the doctor.
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it was at this point that i interjected. i will admit that my tone was probably a bit too aggressive, my exasperation was too evident and it wasn't really my place since my dad was fully capable of advocating for himself. however, the veteran patient, logical person and bioethics graduate student in me was screaming out in frustration.
his request was totally reasonable, he was polite and respectful and she wasn't citing any legitimate reasons why she couldn't comply or at least try to comply. she said no because hospital systems all too often are rigid, top-down and unwelcoming to patient involvement in medical care. the nurse was clearly asserting that it wasn't my dad's place to speak up or ask questions about his care, thereby denying his role as a part of the health care team.
his request was totally reasonable, he was polite and respectful and she wasn't citing any legitimate reasons why she couldn't comply or at least try to comply. she said no because hospital systems all too often are rigid, top-down and unwelcoming to patient involvement in medical care. the nurse was clearly asserting that it wasn't my dad's place to speak up or ask questions about his care, thereby denying his role as a part of the health care team.
tiffany christensen, patient advocate, public speaker and author of the iconic "sick girl speaks!" blog and book, suggested in a recent blog post that the key to improving quality and safety in hospitals may be actively engaging patients in the effort. until now, efforts to increase patient safety have mostly centered around health care providers, who in reality are only half of the equation. her idea is absolutely brilliant; it's application is a lot more complicated. after all, for patients to effectively partner in the movement to improve quality and safety in hospitals, health care providers have to truly want their participation. unfortunately, i don't think that is often the case in hospitals today. the incident with my dad this weekend confirmed my concern.
in my experience, patients too often become adversaries in the eyes of health care providers as soon as they chime in or question the status quo -- even when they are asking reasonable questions in respectful ways. my dad happens to be a super smart guy with advanced degrees including a doctorate. he has 25+ years of professional experience, a good head on his shoulders and, i'd argue, an ability to advocate for himself better than most. i truly believe that if he wasn't surrounded by the rest of my family at that moment, my smart, accomplished, self-confident father would have backed down to the nurse -- and frankly, that not only saddens me, but it terrifies me too as a testament to the bullying and quieting nature of hospital practices.
the campaign to engage patients in their medical care must originate at the top and trickle down to every provider in the hospital, from administrators and department chiefs to housekeeping and transport services. it requires seismic culture and operations shifts because, sadly, it is a far cry from how many hospitals function today. that said, it is absolutely worth the effort. elevating patients to equal partners on the health care team may be a brilliant way to improve hospital quality and safety and to increase patient accountability, but it is also the only way to provide truly ethical and respectful medical care -- and in the end, everyone benefits from that.
in my experience, patients too often become adversaries in the eyes of health care providers as soon as they chime in or question the status quo -- even when they are asking reasonable questions in respectful ways. my dad happens to be a super smart guy with advanced degrees including a doctorate. he has 25+ years of professional experience, a good head on his shoulders and, i'd argue, an ability to advocate for himself better than most. i truly believe that if he wasn't surrounded by the rest of my family at that moment, my smart, accomplished, self-confident father would have backed down to the nurse -- and frankly, that not only saddens me, but it terrifies me too as a testament to the bullying and quieting nature of hospital practices.
the campaign to engage patients in their medical care must originate at the top and trickle down to every provider in the hospital, from administrators and department chiefs to housekeeping and transport services. it requires seismic culture and operations shifts because, sadly, it is a far cry from how many hospitals function today. that said, it is absolutely worth the effort. elevating patients to equal partners on the health care team may be a brilliant way to improve hospital quality and safety and to increase patient accountability, but it is also the only way to provide truly ethical and respectful medical care -- and in the end, everyone benefits from that.
Great points (and post!), Emily. I would argue also that many nurses feel their hands are tied; they understand and would *personally* like to comply with our requests, but are so tightly bound by protocol and afraid of its consequences that they feel there is nothing they can do.
ReplyDeleteI heard a story on NPR the other day that touched on this, and a caller (nurse) said that when the upper-level management changed, and empowered they staff with an attitude of "you are the CEO of your patient rooms/floor/etc", both patient and employee satisfaction skyrocketed.
I have a ton more to say on this (and still owe Tiffany my response) so I'll try to post about it this week, but interesting topic. Glad you were there to interject for your sick, tired, exasperated dad :o)