Umm, yes. That and Facebook, Twitter, SMS, email, MP3s, high-fructose corn syrup and video games.
It’s so easy to fool spell check too. Example: I was board with my roll at work. Sure, it’s all spelled correctly, but the usage is definitely not. My first degree involved a ton of reading and writing, banging out 10 page essays was child’s play, so I have an eye for errors and I see it all the time. One job I worked at in nursing school had a typing portion where we were read a paragraph and had to type it without spell check. We were then graded on how many mistakes we made, which played into the company’s decision to hire us. From what I heard later on, it wasn’t pretty.
It’s not just with kids/teens, but it happens in the work place. Even in our new EMR, there was a spelling mistake, using “course” instead of “coarse” for describing breath sounds. Reliance upon technology makes us complacent, thinking that the red squiggly line will fix our writing errors, is like relying just upon the EKG to determine a patients’ diagnosis.
Being able to speak well and successfully convey ideas in a written format is essential to survive in our society. As nurses we have to translate what we see/feel/hear into words and phrases to ensure others coming after us can understand what it was we were encountering. Sometimes it works, “bibasilar coarse crackles heard”, others “rumbling sound heard” it doesn’t. That’s why it’s important. Having new nurses, or folks right out of school with the inability to do this beyond, “LOL” or “OMG, ur so rite! ” becomes a concern, even moreso when you realize that even modern EMRs don’t come equipped with spell check…
I’ve come to the conclusion that the people in charge of things like regulations and billing are some of the biggest morons in our industry. Worse though, is that they just don’t get it. They are so far removed from the bedside that they have no clue that adding an extra check box in itself spawns that many more things to click and chart under and then you multiply that by the number of patients you have and the number of times you have to do it. The single click quickly spirals into more than just one click. That and the rules so often do not reflect the true nature of what we do.
Today while going over charge capture methodology for our Epic transition, one of the billing people said the following, “My clinical experienced is pretty limited, so let me see if I understand this correctly…” So what’s wrong with that you ask? She’s in charge of auditing charts for billing/regulatory compliance. One would think that some degree of clinical expertise/understanding would be required to accurately understand the charts.
And the folks making the BIG rules, CMS, is suffering from such a case of rectal-crainio inversion it’s not even funny. A perfect example we went over today was blood transfusion. Simple right? Drop a charge every time you enter a unit of blood into the computer. But no, that would be too easy. For CMS (and thusly everyone else) beleives that you should only get paid per instance. In other words, per MD order, not number of units. So if the order is for 1 or 6 units, we get the same thing, even though we do the exact same amount of nursing care for each unit. Every time we have to double verify, take vitals, stay with the patient for the first 15…each time. So if it is 6 units, you’re doing the same work 6 times, but really only getting reimbursed for the first. Makes sense to me!
I still believe that every billing person, CMS regulator, TJC auditor and anyone who writes rules and regulations be required to spend at least a week a year, if not more in the trenches. No cushy units, but units where they would have to work and be subject to the rules they have enacted. Then they might not be so regulation happy.
Normally I’m loathe to have anything to do with Fox News, but this particular headline caught my eye. And it’s complete bullshit.
The recession apparently has solved a problem in the healthcare industry, at least temporarily. A study out of Vanderbilt University shows that a decade-long nursing shortage has nearly disappeared in the past year. Researchers found that more nurses are delaying retirement or coming out of retirement because of demolished 401K’s and partners who have lost their job.
No, not totally.
Well, at least partially this is the case. But usually the determinant of a shortage is am overabundance of open positions. This means there are jobs that need to be filled, hence not enough nurses (or whatever) are filling those positions. The problem here is this: NO ONE IS HIRING. Maybe I shouldn’t yell, but I am talking about Fox News…
OK, there are pockets of hope where folks are getting hired, but there are none in my city. We have no, read that zero, positions open for nursing staff at my facility. And it’s a story being told around our city, and across the country (some places worse than others). The nursing shortage has been solved by the institutions not creating a shortage by having open positions. Added to nurses staying put longer and voila’, no more shortage.
It’s going to suck when the economy does turn around and the boomers will finally retire. It’s not going to be pretty.
The hue and cry throughout the land over health care reform usually ends with the same admonition: read the bill.
Sorry. Not going to happen. Much like any other carefully crafted piece of legislation, this vaunted bill carries a ton of bureaucratic legalese that makes as much sense as Ancient Latin. For example:
(a) Medicare-
(1) IN GENERAL- Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended
(A) in subsection (s)(2)—
(i) by striking `and’ at the end of subparagraph (DD);
(ii) by adding `and’ at the end of subparagraph (EE); and
(iii) by adding at the end the following new subparagraph:`(FF) advance care planning consultation (as defined in subsection (hhh)(1));’; and (B) by adding at the end the following new subsection: h/t Junkfood Science
Yes folks, this how it is written, full of additions, striking, subparagraphs, subsections and enough misdirection and confusion to employ a cadre of lawyers full-time for the next millennium (maybe that’s the point…). My point being this: it does no good to read something if it makes no sense.
I know that I’m probably oversimplifying things, but again, a quote:
(hhh)(1) Subject to paragraphs (3) and (4), theterm `advance care planning consultation’ means a consultation between the individual and a practitioner described in paragraph(2) regarding advance care planning, if, subject to paragraph (3), the individual involved has not had such a consultation within the last 5 years. Such consultation shall include the following:
`(A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to./p>
`(B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses./p>
`(C) An explanation by the practitioner of the role and responsibilities of a health care proxy./p> (JFS again)
Sure, this is a little clearer, unless defined by paragraph 2, subsection 2, which refers to chart 23a for those referred to in subparagraph 2, section 3. Those in subparagraph 3, section 2a, please use chart 84-4b.
Sorry, got carried away for a second. The pundits wonder why our representatives don’t read bills (remember, no one really read the Patriot Act either as it was full of the same crap, and there wasn’t “enough time” to do so.) It’s simple, this is why. Understanding biochemistry is easier than reading Congressional legislation. It’s no longer as simple as “I’m Just A Bill” of Schoolhouse Rock fame. The concept is the same, but the ideas contained therein are a little more complex.
The argument goes that to encompass such a wide swath of American life, it needs to be complex. But it is the very complexity that makes it unwieldy and administratively top-heavy. Like the tax code, this too will spawn, or at least encourage the cottage industry of interpretation due to the mostly vague nature of the act itself. We can’t have our decisions made by committee or by the elite, especially when it comes to our health. That is something between a doc and his patient. If the doctor is not the Primary Provider, see Section 21a, paragraph 5, subsection 4. But I think you get my point.
I have no answer to this problem. Wish I did. I don’t think socialized medicine is the answer, nor do I think our current system has any life left in it. We obviously can’t continue on the same path we’re on. And yes, there is going to be some pretty bitter pills to swallow in the coming months and years. But I know one thing: I don’t want the government running my health care.
Perhaps this is one Happy quote I do totally agree with:
He said I was treating her like baby and told me not to come back.
Which is fine. Except that attitude is a major part of the problem. Perhaps adults who act like babies, adults fully incapable of making grown up decisions (like showing some initiative in their own disease management); Maybe they should be treated like children.
I don’t know what to do for someone who chooses not to help themselves. Free will is a powerful thing. But it works both ways. All I can do is make sure we do everything within our power to remove the barriers to patient’s care. And hope they make the right decisions for themselves and their family.
It’s funny we were just talking about patient responsibility this week at work and how that should play into the reforms slated to take place in health care. I’m of the nature that says, “You can do whatever you want. BUT. You must be willing to take responsibility for your actions.” And that is the problem with so many of our gomers. They refuse to take care of themselves and end up back in our halls time and time again.
Take for example the twin renal patients who by all accounts have used up their money from the MNB (I didn’t know that was possible to do, so that assumption may be wrong). They spend months at a time in-house, then get discharged. And when they get sick again, because they live 200+ miles away, they get Lifeflighted back to our hospital – because that is where their docs practice and they refuse to live closer.
Or the young (under 50) gentleman who is already in ESRD due to uncontrolled diabetes. Last A1C was something like 14. As he’s sitting with a CBG (actually serum glucose beacuse the meter just read “HIGH”) of 520mg/dl, says, “So can I have 2 bowls of Cheerios to go with the sandwich I have in my bag?” And these are just a few of our frequent flyers.
So many are just the same. They decide that they don’t want to take their meds, or won’t go to the pharmacy to pick them up, or decide that 3 times a week dialysis cramps their busy social schedule too much and only go twice, think that movie theater popcorn and Wendy’s is an essential part of a low-salt diet or think nothing of just stopping their Lasix one day out of the blue. They come in all saying, “I don’t know what happened! I was doing everything I should!” And we spend hours trying in vain to (re)educate them, hoping that they will not bounce back once we turn them loose.
Part of me says, “Fuck ‘em. They’re not willing to take an active role in their health care, they shouldn’t get any more than the barest of minimums.” Research has shown that the management of chronic diseases is the one that saps the most money out of our health care and while the specter of paying for outcomes instead of fee-for-service may be a valuable tool to prod docs (and nurses!) into more productive engagements with their patients, this too is a two-way street. All the teaching, even if done in the most agreed upon, for sure to work approach, most interdisciplinary method possible will never work if the recipient of said information is not willing to put it to work and practice the concepts we teach. Maybe those that refuse to do this should be excluded, be given a certain amount of chances, document the refusals, then at a certain point, begin to withhold all but the most basic of care.
The other part says that maybe if we keep doing what we’re doing, it will sooner or later sink in and the habits will start to change. Plant a seed and all that crap. The problem there is we cannot continue the status quo. Something will break and it isn’t going to be the patients.
And as for our ideas about reforming health care, we all conceded one point: the paradigm of health care must change but that entails a societal shift in values. More prevention, less end-of-life heroics with the understanding that death is a part of life and the reduction (some argue by any means) of non-compliance with medical therapy. It sounds harsh, but we are reaping what we’ve sown. The American Entitlement attitude has led us to this point and it will only be by changing that attitude will we be able to fix the probelm we’re in. And if that means treating adults like children when they are acting that way, so be it.
“Now, in the unfortunate circumstance where you might become sick, you will need to develop symptoms that follow a few simple rules. Do not, under any circumstances, develop symptoms that fall outside federal protocols developed based on comparative effectiveness research data. If you do, your doctors will face pay cuts, litigation, limited resources due to lack of funding for cost-ineffective technologies, and the scourge of discharge planners. Does the term “leper colony” mean anything to you?”
“The IRS believes that some percentage of the costs incurred by employees using company-provided wireless devices should count as a “fringe benefit” and thus be subject to taxation. Since workers inevitably end up taking personal calls or emails, the thinking goes, it’s only fair that they pay for the privilege. What’s next? Maybe a per-cup tax on office coffee, or targeting furtive visits to ESPN or Hulu on the office PC? As one wag put it on the Journal’s Web site, “It’s like charging for the use of the company washroom.”
I understand the need to have taxes to support the myriad programs of our government, but this is ridiculous. And the thing that stings, is that it is happening from top to bottom. It’s one thing if your federal taxes get jacked, but now many states, counties and cities are finding new and creative ways to wring every last penny out of you. Fees for awnings, inspections and permits are all going up in my fine city. If there is a way to slap a fee on it, our lovely city leaders have figured it out. Not to mention the colossal waste of money that the new soccer stadium will turn out to be. How is it that a city who’s roads are so behind in repairs intends to spend millions on a new soccer stadium, that may or may not bring in any new revenue to the city?
And so like our friends in Washington, who think that our use of office resources needs to be classified as a “fringe benefit”, it will not be long until the local folks try to figure out a way to do that as well. Or in other words, “If it moves, tax it.”
Too cool. Glad we’ve moved beyond this, kind of. What passed for medicine in the 19th century really seemd to be more like butchery and until the realization of germ theory and infection control, odds were pretty grim. Not to mention lack of anesthesia!
For the most part my floor has been a cohesive team. There was a sense of togetherness and mutual support that was very comforting. You knew, based on who was on, if someone had your back when the shit hit the fan. While there were a few times where that was suspect, for the most part you knew you had support. Usually there was someone around to ask questions of, if nothing more, bounce and idea at, just to see if you were thinking correctly or if you were way off base. It was a family of sorts, dysfunctional at times, but a family.
We underwent a split this last summer, with some core staff on each new unit and the rest of us floating between the two units based on census and need. Because of this, there began to be fissures in the feeling of security. While you knew for the most part that if really needed, there was someone to back you, but that feeling of family seemed to be fading. Attitudes emerged which further added to the division. On the less acute unit, an influx of new grads made that feeling of being alone even worse. Not only did you have your issues, but if you were a “seasoned” nurse, you inherited their issues as well. There have been nights where it was me and one other seasoned nurse and the other 4 or 5 were new grads. And it wasn’t an issue of them being bad nurses, but it was the lack of experience, that acquired knowledge and comfort zone that comes with working with the kinds of folks we do for them to be self-sufficient. Many nights I felt like the Oracle at Delphi, answering questions non-stop thru the night.
That sense of team was pretty loose. We all worked together, but it wasn’t as tight as it may have been before. In the last month however our manager decided to make a permanent staff split. The floaters would be gone and each unit would have a set core staff. There might be a little floating, if needed, but the staff would be set. We knew it was coming, it was only a matter of time. It had to happen to allow a set staff to develop that necessary bond of a team. If you constantly have different people flitting in and out, getting to know your fellows, their strengths and weaknesses was difficult. But when you start working with the same folks night after night those imperceptible bonds begin to emerge.
A new energy has begun to settle onto the unit. That mild sense of uneasiness and doubt is beginning to fade as the staff are slowly getting to know each other. It’s nothing that you can point your finger at, but a general sense of a team starting to emerge. When things start to go south people are stepping in to ask if the nurse needs help, offering to do what is needed. When we have an admit dropping into our laps at 0705, they get 2 nurses working to get them settled in, without the admitting nurse asking. When I was trying to admit a patient at 0430, the busiest time for me as a charge nurse, one jumped in to finish a long and complex medication reconciliation, despite my protestations. It’s starting to gel and form into a cohesive group of professionals. Sure I get asked questions non-stop, but it becoming more of a “Am I thinking about this correctly?” more than the “Uh…what do I need to do now?”
And I know I’m not crazy, others see it too. Several of us went out for breakfast the other morning a we all commented on this fact, that it’s starting to feel like a team. I wish I had a company card so I could have expensed the breakfast to the unit under “team building”, but alas that doen’t happen. But becoming a team is.
Wanderer is a Charge Nurse on a busy telemetry unit somewhere in metro Portland. He reads, he writes, he cooks and is a passionate bicycle commuter. Any patient account has been scrubbed to best of his ability. As the saying goes, if you think it's about you, it ain't.
” becomes a concern, even moreso when you realize that even modern EMRs don’t come equipped with spell check…
