Overcoming Perceptions in the Emergency Department

I work as a Clinical Nurse Specialist in a community hospital emergency department. My most recent challenge has been ensuring we correct documentation problems on moderate sedation performed in the emergency department that were found as part of our annual Joint Commission self-survey.

Only one out of four procedures were documented thoroughly and accurately. Do I think we are taking short-cuts and harming patients? No. What I do think we're not doing isdue diligence in documenting the work we do and, if something bad were to happen, we have no way of proving before a jury that the work was performed to standard.

The problem is, the ER nurses don't see it that way and I am stymied in how to change this perception. Their first complaint was that the GI docs bring their patients down to do procedures at the end of their clinic day. "These aren't emergencies!" the nurses cry. They don't understand that these patients may not be emergencies, but these cases are urgent in that they drive the next diagnostic decision for that patient. They also don't understand budget constraints.

"If they keep their nurses past their standard working hours, they incur overtime which affects their budget. If there is somewhere else in the hospital that these procedures can be done without incurring overtime, doesn't it make sense to do the procedure there?" That just turned the conversation into complaints about how the ER nurses are dumped on and the hospital takes advantage of them.

I tried the approach that the nurse who is administering the sedation needs to "know" the patient and the best means of doing this was through documentation of the pre-sedation exam. "That's the physician's role," they asserted.

"You're right. It IS the physician's role," I agreed, "and there is nothing that says you can't ask the questions and review the patient's answers with the physician, especially if he or she is busy setting  up. If the physician has completed the pre-sedation paperwork, there is nothing that says you can't review it and tell the physician, 'Hey, you missed a spot over here.'" I am so frustrated that they can't see this is a teamwork and patient safety issue.

I spoke with my ED nurse manager and she doesn't know how to change this. This moderate sedation problem is just the tip of the iceberg in this department. It's like watching toddlers---everyone LOOKS like they're functioning as a team, but they're not. It's all parallel play: the techs are doing their own thing, the nurses are doing their own thing, and the physicians are doing their own thing. In the meantime, patients spend much more time in the ED than they need to, the physicians are not meeting benchmarks, and the nurses station looks like the Cantina in Star Wars.

The unfortunate thing is, I think I know how to fix this, but I only have the consultant role in this department. I've asked about the operationalized efficiency of an emergency department that sees patients within 30 minutes and I've been shut down. I've enquired about starting hourly rounding, bedside shift report, and bedside triage when census is low and I encounter extreme resistance from everyone, including the director.

The Business of Being Born

Celebrity actress/host Ricki Lake's new movie, "The Business of Being Born" points out that some of the most traditional practices of contemporary obstetrics have everything to do with the convenience of the physician, but can actually make delivery more difficult for the mother.

The Next Inconvenient Truth?

"Birth is miraculous, a natural process. But birth is also big business and this movie will change your mind about everything you think you know about it," said Sabrina McIntyre, a Fairfax County mom and former flight attendant who delivered one daughter by Cesarean section (c-section) and another at home by midwife.

To most people, the idea of giving birth outside of a hospital seems foolish and even dangerous: why would any parent limit their newborn's access to technology in the event of an emergency? Why would any couple put their child's life in the hands of a midwife instead of an obstetrician? "When my friend Ricki (Lake) approached me about making this film, I admitted to her that I was afraid to even witness a woman giving birth, let alone film one," said Abby Epstein, the Emmy-winning director of "The Business of Being Born." "I discovered that the business of being born is another infuriating way medical traditions and institutions -- hospitals and insurance companies -- actually discourage choice," said Epstein.

"The point here," observed Dr. Marsden Wagner, former Director of Women's and Children's Health, World Health Organization, "is there's not a good history in obstetric practice of careful study of the long term effects of all these interventions. This is why; if you really want a humanized birth, the best thing to do is get the hell out of the hospital."

A Movement Underway?

Arlington-based midwife, Tammi McKinley, said her practice has "boomed" with the number of women questioning high-tech birth. "Women are really starting to understand that all those gadgets don't always mean a safer birth, and women are looking to replace high-tech birth with high-touch birth," said McKinley, who delivered one child by c-section and her second at home by midwife.

Statistically, the use of c-section, a major surgery, is being widely employed, more as a measure of convenience for both doctor and patient instead of a last resort in the event of an emergency. Dr. Michael Brodman, Chief OB/GYN at New York's Mount Sinai Hospital, cites a study that reveals the peak hours for c-section procedures are 4:00pm and 10:00pm. Brodman interprets the data from the perspective of the hospital-based physician:

"It's obvious," he says, "that four in the afternoon is 'It's late in the day, I don't know what's going on here, I want to get out of here and the ten o'clock at night is, 'I don't want to be up all night.'"

FAST FACTS:
-- In America, midwives attend less than 8% of all births and less than 1% of those that occur outside a hospital. At the same time, the US has the second worst newborn death rate in the developed world. Lake and Epstein ask, "Why do less than 8% of Americans take advantage of the benefits of midwifery, which is statistically safer and cheaper than physician-attended birth?"

-- The five countries with the lowest infant mortality rates in the March of Dimes report -- Japan, Singapore, Sweden, Finland and Norway -- midwives were used as their main source of care for 70 percent of the birthing mothers.

-- C-section is the most commonly performed surgery in the US, at a cost of $14 billion per year. Cesarean-delivery rates are now at an all time high in the United States, standing at 1.2 million, or 29.1 percent of live births in 2004. The increase represents a 40 percent increase in the past 10 years.

-- In one 1999 survey, 82% of physicians said they performed a C-section to avoid a negligence claim.

Jennifer Block, author of "Pushed: The Painful Truth About Childbirth and Modern Maternity Care," writes, "Too many Caesareans are literally medical overkill. Yet some US hospitals are now delivering half of all babies surgically. Across the nation, one in four low-risk first-time mothers will give birth via Caesarean, and if they have more children, 95 percent will be born by repeat surgery. In many cases, women have no choice in the matter. Though vaginal birth after Caesarean is a low-risk event, hundreds of institutions have banned it, and many doctors will no longer attend it because of malpractice liability."

She adds, "We've become dangerously cavalier...the Caesarean rate should be a major public health concern."

Natural Solutions to a "Medical" Problem
Midwives are definitely a viable solution; however, many find it difficult to assist with birthing because of the impossibility of obtaining malpractice insurance. Peggy Vincent, a midwife in California, writes candidly about her life as a midwife and the barriers she encountered with regulations and insurance in her book, "Baby Catcher: Chronicles of a Modern Midwife."

I am still bitter about my birthing experiences at San Diego Naval Medical Center. As an active duty sailor, I was not permitted to have a midwife assist with my labors nor was I permitted to have a homebirth. Consequently, I got the physician only on-call when I went labor and that resulted in a an emergency room physician (not even someone doing their residency) catching my baby for only the second time in his life. I suffered a fourth degree laceration (extending through the rectal mucosa to expose the lumen of the rectum) with an infant that weighed only 5 pounds, 13 ounces. At least, I didn't have a Caesarean, although they threatened me with that.

Addendum
ABC News published a story on unassisted home births. You can view the story and comments here:
DIY Deliveries: More Women Go It Alone

Here's an additional resource on the history of childbirth. As someone who studied medical sociology, this book should add depth to the rise of the American Medical Association:
http://www.mcfarlandpub.com/book-2.php?id=978-0-7864-3362-9

Medical Mistakes Happen

This newspaper in Wisconsin details some of the medical mistakes healthcare providers make. Here is another link to a web site for journalists covering healthcare: http://www.healthjournalism.org/

I regularly receive the ISMP newsletter (offers free CEUs twice a year!) and have been amazed at some of the errors RNs have made. As nurses, we are instructed to use the "6 rights" of medication administration:

1. Right patient



2. Right medication



3. Right dose



4. Right route



5. Right time



6. Right indication

However, using these 6 rights does not guarantee patient safety. Critical thinking skills are essential and even then they can fail the best nurse, especially in Hour 10 or 11 of a 12-hour shift on the third day of a string of 12-hour shifts.

Patients must take responsibility and ask questions about the medications that are being administered to them. I frequently encounter patients who have no idea what medications they are taking or what they're used for.

Here is a link to an online medication form that patients can use to fill out and carry with them at all times. The Institute for Healthcare Improvement (IHI) provides extensive information from hospitals nationwide who have implemented safer healthcare delivery practices. The site requires free registration to access information and I have found it to be a wonderful resource.

As an RN, I tell my patients they should always ask who the person is who is administering the medication (are they an RN? a CNA? a crazed patient from room 210 who is offering you his stashed medicines?). Patients should also ask what the medication is, the dosage, and what the medication is used for. The RN should also instruct the patient on the common side effects and what the patient should do if he or she experiences one of them. However, this would happen consistently in the ideal world and that's not where we live.