The Value of Discharge Instructions

The purposes of discharge instructions are:

• To provide time-specific follow-up with the appropriate family physician or specialist
• To  convey to the patient and/or family some knowledge of the probable disease or injury process
• To list prescriptions and treatments given
• To establish a layer of medical-legal protection for the practitioner 

At minimum, instructions need to be legible, and so are best computer generated and printed.

Unfortunately, however, unintended consequences of these efforts have evolved into a complex morass of endless paperwork.  As a result, the patient now receives a bundle of pages equivalent to a small textbook, containing more information than most people can realistically comprehend, including drug interactions, side effects, multiple contingency plans, and complex symptom sets to watch for.

The KISS (Keep It Simple Stupid) principle should predominate.  

Most importantly, the patient and family need to know that he/she should comeback, or be brought back, immediately if there is any deterioration or if new symptoms have developed. This bottom-line principle message needs be stated concisely in fourth grade level language, using large readable letters.

What to Do About PAIN in the ED?

The treatment of chronic pain has become a very complex and hot topic for providers. Little or no controversy exists about the treatment of acute pain; one just treats as necessary.  Acute exacerbation of chronic pain is also less clear.   

The goal is to treat patients humanely and appropriately without facilitating drug dependence and drug trafficking.

The pressures are complex and complicated. On the one hand, are those forces that make a physician more reluctant to prescribe pain medication, including:

1. States have created databases that keep, and make available online, records of all controlled medications prescribed, including the DEA number of the prescribing provider

2. Certain states, such as Florida, now require special licensure to treat non-cancer pain chronic pain.

3.Peer pressure from colleagues and support teams who feel everybody is a potential abuser. This puts certain patients with severe, painful conditions in the assumed category of “potential drug abuser”.

On the other hand, the real-time daily forces of clinical practice lead one to be less restrictive in administering pain medication. These include:

1.     CMS has made pain a de facto “vital sign” that must be addressed and documented.

2.     Patients request pain relief for a variety of complaints that are often very reasonable.

3.     Patient satisfaction scores like PRC and Press-Gainey emphasize pain relief. These scores affect contracts, RVU’s and levels of complaint to administrators. The #1 complaint in our ED is that the doctor was insensitive to pain relief and refused treatment.

What should one do? It is indeed a challenge to find a balanced, thoughtful approach trying to blend the various demands into a reasonable outcome. Our ED actually considered hiring its own pain specialist to deal with these endless problems.

Time----Time---Time

Time to click—Time to task—Time to everything

The modern tracking board has allowed the provider, the hospital consultants, administration to time multiple events in the ED.

The tracking board can be used to calculate

1.     Door-to- Provider

2.     Provider to Decision

3.     Decision to Admit

4.     Decision to Discharge.

5.     Door- to End of Event –LOS

6.     Last Lab to decision

7.     Last x-ray to decision

8.     ETC/ETC/ETC

Using Lean-Six Sigma techniques the ED efficiency can be improved dramatically. The only problem that “quality” is rarely brought into the mix. It is implied that “quality care” is fixed quotient without any variables that can be reproduced in the same time frame every time. After practicing more than 30 years, I am consistently surprised by certain events, results, and outcomes.

"Let the TRACK MEET begin”.

Doctor Aware” - The Integration of Nursing Notes and Physician Documentation

How does the provider keep track of the nursing notes with the use of purely electronic medical records?

         

Theoretically, in the “paper world” the provider would read all the nursing notes and then comment or appreciate the content. In reality, the provider rarely reads more than the initial triage assessment and nursing note. The rest of notes are kept with the nurse and usually completed long after the physician is finished with their documentation. Physicians who document after the fact on their own time, may or may not use or have access to the notes.

         

In the “Electronic World” the provider rarely has real-time access to the nursing notes with a single mouse click. They have to maneuver around the program to find the data (if it even there yet). Your computer program should have easy access of all data to all providers that have been granted access. This should be accomplished easily and without requiring the user to be a computer expert.

Additionally, how do healthcare providers know when the nursing notes are complete concerning the interaction with a specific provider? The notes can go on and on for “ED Boarders” when the initial provider is long gone. This is also true for discharged patients when the nursing notes are done long after the fact.

My favorite nursing notes are “Doctor aware” and “Doctor notified”. About what?????

The EMR we use attempts to solve some of these problems with simple interface like a “tab button” that allows quick access.

Take Me Out to the Ball Game

The role of the ED physician has dramatically evolved over the last 10 years. The perfect ED provider must be a combination of Dr. Marcus Welby from ABC’s 1970’s hit show, Dr. Leonard “Bones” McCoy from Star Trek, and the staff from the 90’s TV show ER.  Doctors are expected to be good-looking, decisive, charming, and always get it right in the end – all in less than 48 minutes (barring extra commercials.

This is obviously a difficult task for us mere mortals. The present model has the physician perform every role for every patient. Assigning a provider to the intake (formally known as triage) has started to break down the classic role.

To take this concept one step further ED staff members can be broken down to using a sports analogy –a baseball team.

• Starting pitcher—triage—get the ball rolling—start the evaluation ASAP
• Middle relief—fully evaluate the patient and develop treatment plan
• Long relief—on call to deal with massive volume shifts
• Closer—makes the final compact with patient, family, admitting physician, consultants in a very timely manner.
• Designated hitter—provides critical care to free up rest of staff
• Manager—medical director guiding flow and dispute resolution
• Broadcaster—public relations specialist in Press-Gainey and PRC scores
• Statistician—documents all the data for medical-legal, reimbursement, and time frames.
• Rest of Team—The key to success is the support staff - nursing, administration, trainers, secretarial staff, etc.

In conclusion—a single provider even with an all-world team members is hard pressed to perform all these tasks.

The Art of Medicine: Evidence-Based vs. Evidence-Enhanced

Medical care has evolved from using the individual practitioner’s training belief system, and own personal bias to using data, studies, and evidence to make appropriate decisions. This more scientific approach has yielded better results and more rational treatment programs.

However, in the mantra of “double-blind-controlled study," there is another side of medicine that needs to be addressed. This is the “Art of Medicine”.

Medical care not only includes scientific assessments and treatment protocols but also the human side. Patients come for the best scientific care but also for compassion, empathy, measured opinions, and guidance.

The Electronic Health Record (EHR) gives access to the data, but not the whole story.

By combining “evidence-based medicine” and the “art of medicine” you will achieve “evidence-enhanced medicine” giving the patient a holistic approach for which they are grateful. There is a reason other than scientific medical care that patients are nostalgic for their “own doctor."

Why Your EHR is "Creepy"

The definition of creep according to Wikipedia is the tendency of a solid material to slowly move or deform permanently under the influence of stresses.

           

The software you are dealing with is in a constant state of flux leading to multiple changes that may inadvertently lead to user dissatisfaction.

1.      Version “creep”—constant upgrading of the software with leads to potentially unwanted changes.

2.      “Creeping Elegance” ---- developers seeking the “HOLY GRAIL” of perfect software while detracting from its fundamental utility.

3.      Government “Creep”------ new rules every month that forces the software to make changes that may or may not be in the actual user’s interest.

4.      Payment “Creep”---“meaningful use” is a classic example of making programmatic changes to reimburse the client for their investment. Whether the purchaser recoups their investment remains to be seen.

5.      “Enterprise Creep”---- the institutions purchases an enterprise computer system (full hospital system) not designed for the particular end-user ( i.e. –no specific ED module). This may force a relatively satisfied user to reinvent the wheel.

The goal is to find an end-user friendly product that helps the provider rather than putting up a spider web of obstacles.