Wednesday, May 11, 2016

Nursing, and the Crocodile of Time

Every day patients present to the Emergency Department for care:

They come in ambulances, they come in vans, and they come in crawling, drunken, and puking in pans.
They come with strokes, overdoses, injuries and pain.
They fall and get fractures from ladders, and many other things that really don’t matter.
They demand the best, the most, the quickest, for free - and yet, when needed, they can’t even pee.
They injure themselves in so many ways; too many to count as there are not enough days.
It is sad really, the condition of people - so grand a species, that finds everything so lethal.
They will not stop coming, these humans with brains, they just need immediate relief of all of their pains.
So in the end, there really is nothing to do; drugs, seatbelts, gravity and rape, learn they will not, these humans with brains; as we will patch them up good, send them back where they stood, and wait for their return, for it is our livelihood.

An ED is a stressful place, quite different than any other work environment, outside of, perhaps, active duty military, paramedics, and police. We, the nurses, are stretched to accomplish all manner of tasks, in the quickest way, without an error, with the least amount of cost, with the most skill, capturing all of the data, with the fewest steps, and with an overwhelmingly cheery demeanor – all day, all night, all year long.

Every second counts, but not only for patient care, speed of service delivery, electronic chart manipulation, management benchmarks and facility goals – but for time itself. Seconds add up to minutes, and minutes to hours. It is the basis of all science. And so, every second lost to a missed step, a mishandled medication, a broken printer, another trip with a patient to the bathroom, is time compounded. Add to all of the thousands of tasks performed in each 12-hour shift, another 2.8-second chart entry, another software screen to navigate, another step in any process. Without taking away precious seconds from another task, this will all end up lengthening the day.

The Massachusetts Institute of Technology (MIT) produced a wonderful study of why traffic comes to a complete stop on the freeway for no apparent reason. The results show that if any one vehicle even taps the brakes for a half second, producing just a quick glow of the brake lights and a drop in speed of an infinitesimal amount, that this action is carried on behind that vehicle - each one driver lengthening the reaction until, one mile away, you are at a standstill. Apply this to any task in a busy ED, such as a printer that won’t function. Such a delay (the glow of a brake light) means you have to re-print a document by altering the print options, checking for a signal, checking the paper supply, changing the default location, etc. Eventually you will walk to another room, or location, and try this same procedure with a different terminal, and a different printer. This simple, yet overlooked delay, has prolonged the medication administration for another patient by 2.4 minutes. On the surface this time seems short, yet compounded with hundreds of others – you are sitting in your stalled car, in gridlock, listening to death metal pouring out of a nearby Pinto.

In addition to the thousands of tiny delays, is the fact that no one person is responsible for eliminating or repairing these delays. This magical fix-it person is actually – you. Yes, the nurse who is actively engaged in the time delay is also the one responsible for finding a solution for the problem. A repair can be something like signing into a ‘work order’ software program and navigating through various fields for hardware repair, resetting all of the default printer preferences – or, worse yet, a time consuming telephone call to some outsourced IT call center, to someone who has no investment in your situation, and is not concerned about the passage of time in any way.

A recent study from Michigan State University in East Lansing, shows that on average, an interruption in a task of only 2.8 seconds leads to a 15 minute delay in completing that task. Think of how many times you have walked toward a patient room, only to be diverted by a call light from another room, or the time you go to the electronic medication dispenser, forget the patients name, and then have to go find a computer, log in, and search. Compound all of these by 100 for a 12-hour shift, and it is no wonder that the length of stay (LOS) is creeping up again. As the complexity of a system grows, so does the potential for delays. And with people only employed to add to the complexity, and not to streamline it, there is no end in sight for the difficulties.

Concerning the hospital LOS, it was decreasing ten years ago, and everyone was quite proud. But as the population has grown and aged, rampant drug use has increased, care has become intolerably expensive, and the computer systems that bind it all together have become more fractured – the length of stay has risen.

Antoine de Saint-Exupery wrote, “A designer knows he has achieved perfection not when there is nothing left to add, but when there is nothing left to take away”. Any experienced computer programmer in the medical profession has this same St. Exupery ability; to create a streamlined user-friendly platform that is modern, and simple, and attains the goals set forth by the care. Think Amazon and Google – two of the worlds most user-friendly and lucrative businesses on earth. They are simple to navigate, never go down for upgrades, and are super efficient. If only charting an intubation in the EMR was as simple as buying a vibrator on Amazon. Oh the glory!

However, by a series of unfortunate events, we the Emergency Department nurses (as well as the floor nursing staff) have been burdened with an Electronic Medical Record (EMR) that is nothing more than ten thousand loose parts flying in formation. I can stream live color video from Saturn on my iPhone, and yet our $390 million dollar EMR cannot spellcheck or convert pounds to kilograms, doesn’t know that penicillin is a drug or an apple is a food. Every day within the EMR there is a tweak, or a change, or a malfunction, or a discovery, all adding tiny little bits of time to the day, all reverse-engineered at the sacrifice of timely patient care.
So, with time being finite, and the fact that patient severity and volumes have increased - and with a limited corporate budget, choke holds on staffing, and with the phrase ‘multi-tasking’ becoming the invisible phrase between each line of a mission statement –all of these measurable factors are pushing quality to its edge.

A study published in The Lancet in 2014 found that an increase in a nurse’s workload by one patient increased the likelihood of a patient in that hospital dying by 7 percent. Staffing ratios also appear to reduce the rate of readmissions, many of which are preventable and constitute a significant cost for hospitals. The Affordable Care Act (ACA) sets penalties for hospitals with high rates of readmissions. In one 2013 study researchers at the University of Pennsylvania School of Nursing examined data from hospitals across the U.S. and found that those with higher staffing ratios had 25 percent lower odds of being penalized under the ACA for excessive readmissions than ones with lower staffing ratios but otherwise similar conditions.

Staffing ratios for the Emergency Department are generally viewed upon as blasphemy by management. It tastes like freezer-burned brussel sprouts to the well-educated palates of higher offices, and it also affects corporate earnings and creates shareholder distain. So, even though the evidence supports staffing ratios, it is not likely to occur anytime soon. So, with an ever-increasing population of very ill humans, computerized charting that bludgeons to death even the most digital savant, and an employing host incapable of understanding the trials of its workers – the future is bleak my friend.

Time is what is killing the nursing profession - or, to be precise, the lack of time.

We have a nurse in our Emergency department, and I will call her Grace. Every department has one - a true to life, dyed in the wool, for real nurse. She holds patients hands, believes their crazy stories, looks into their eyes, hugs them and cries with them, even spends her own money on them. She walks them out to their car, she thinks about them at night, she…cares. There is nothing in the electronic record that reflects her care – nothing. There is no check box for ‘care’, or ‘concern’, or ‘love’. But, she is measured on the same scale as the rest of the staff: 500 data points per trauma patient, LOS is too long, time to pain meds is unacceptable, CMS benchmarks are insufficient, medication scanning is sub-par, etc. Grace decided to use her time for patient care instead of bowing before the graven idols of statistical data – and she will be punished for it. However, is this the nurse you want taking care of your daughter or mother - or would you prefer the nurse that excels in haste.

So how does good direct patient care look to the billers and codes of a profitable organization? The more boxes checked, lines filled in, tabs completed, tasks timed, and redundant research based data entered (all timed to organizational and national benchmarks of speed) – the greater the patient bill, the greater the reimbursement, the greater the ability to pay staff and procure new technology. How does one code for Grace’s level care - you can’t. Nursing has its flaws, but intelligence is not one of them. We all know that taking care of the EMR, even with all of its defects, is better for the bottom line than actual bedside care. The EMR makes money – bedside care does not.

A recent 3-year longitudinal study shows, “that nurses spend about 37% of their time with patients. Work patterns were increasingly fragmented with rapid changes between tasks of short length. Interruptions were modest but their substantial over-representation among medication tasks raises potential safety concerns. There was no evidence of an increase in team-based, multi-disciplinary care. Over time nurses spent significantly less time talking with colleagues and more time alone.” -Westbrook, Open Access.

Additionally, a new study, published in April of 2016 by Johns Hopkins, is claiming that complications from medical errors in hospitals are now the third leading cause of death behind heart disease and cancer. This is a bold statement, and yet it describes the environment where, being over tasked and understaffed, it is almost anticipated. Various entities that hold great stakes in these findings – particularly, the insurance companies, the government, and pharmaceutical lobbyists - will dissect this study with vigor, most likely adding new forms to the already fragmented EMR, adding steps for giving medications, perhaps even an official “time out” with a co-worker as witness, before even a Tylenol can be given. Again – time.

Many new nurses are overwhelmed at the ability to capture time, divide it, and dole it out in safe increments, especially in an active almost battlefield style atmosphere. Multi-tasking is a term that is pushed down the gullets of bedside nurses by all of administration. It is a clich├ęd term, loosely expressing the ‘apparent human ability to perform more than one task, or activity, over a short period of time. Multitasking, however, can result in time wasted due to human context switching and apparently causing more errors due to insufficient attention. I for one do not want my orthopedic surgeon multi-tasking.

This relentless battle for time could be pushing nurses into new directions; instead of hand-to-hand combat with tasks and time, why not join a new legion - where time and direct patient care have been replaced by the ability to create time itself. In 2015, the burgeoning field of nurse informatics now has an average salary of just over $100,000. These are seasoned nurses who have either ‘been there, done that’, or are fresh out of school, intent on good money without the direct exposure to the various illnesses and maladies of humans. Lets face it – informatics is where the money is right now, not bedside nursing. These jobs, however, are as scarce as Bigfoot sightings. But as technology slowly consumes almost all of a nurse’s time, there will be many more openings in the informatics galaxy.

We, as nurses, have twelve hours to produce as much profit as we can for the institution. We, as nurses, all know where our paychecks and retirement plans come from, and we understand the inner workings of the healthcare system and all of its governmental tentacles. We are the data entry specialists. We have 720 chaotic minutes to produce 10-20 complete medical records, documenting up to 250 items per patient encounter, in real time, with good outcomes. We are not measured in care, but in speed. We are not measured in interactions and conversations, but in volume of data points.  We are only measured by the electronic medial record. “If it wasn’t charted – it wasn’t done” is the maxim we live by. Medical care is a huge business – huge! The amount we spend on health care every year has grown from $75 billion in 1980 to nearly $500 billion today. If this rate continues, by the year 2020, we will be spending 40 cents of every dollar we make on health care.

So, there you have it. A finite amount of time for patient care, defined by economics and computer programmers - with an infinite range of potential challenges, defined by human nature and chaos. Emergency care could be described as a fractal -an expanding wave of symmetrical duties; a spiral of events in time, always compounding, never ending. Just like the ticking crocodile in Peter Pan, time is following us all.

The only real solution is to manage, as best we can, the time we are given - and hope for reasonable, noble changes from above. Changes such as; single task, simplify, create practical patient ratios, eliminate redundancy, hire adequate staff, hire the correct staff, streamline documentation, employ shift based problem solvers, use new technology only if it is beneficial, base care on quality not quantity, compensate experience, take pride in effort, talk with each other, and always do the right thing – the first time.

Monday, February 8, 2016

Seeing is Not Always Believing


So, there are a few things you should know about what you see in real life, about what you see on the monitor at home, and what you think you see on the monitor at home. Because all of this “seeing” is going to result in a print – a colorful, accurate, sharp, paper print – that you can hold in your hands, frame, and quite possibly – sell.

Pingora Spire, Wind River Range - Wyoming
 You are standing on boulder in the middle of a lake, with the tripod so low that only a yoga instructor could comfortably look through the viewfinder. Backing up is impossible, and lying down is even more so. Your fingers are stupid with cold, and the whole time you are thinking, why is there so much metal on a camera? The scene before you is fantastic, and the golden hour of dawn is slipping past quickly – clouds moving around, sections of rock glowing pink and then falling again into silhouette. You work quickly to compose the shot, stand up and groan, and then start pushing the shutter release – each 15-second exposure seeming like an eternity.

At this very moment you relax, it’s all up to the camera and the lens now - you are the only witness to this crazy colorful landscape. For a few minutes you watch and memorize the scene, the colors, the shadows – it is beautiful. This is what we work for.

Once back home you scroll through the dull raw images, looking for that one that pops out, the one that reminds you most of what it was like standing there on that boulder, freezing. Eventually one image stands above the rest, and it is moved into a raw processor, and then transferred into Photoshop for fine-tuning.

Of course, your monitor is already calibrated, your image is captured and presented in the correct color space, you have a dark grey background on your desktop, you are sitting alone in a darkened room, and there is no ambient light to alter the work. Simple enough, right? It is like the total opposite of where you were for those 15-second exposures.

You adjust the overall white balance, attend to the green hues in the shadows with some selective color balance, draw down the glaring whites, make sure the shadows are not too deep so that they don’t appear black on a physical print, concentrate on the sharpness, look for dust spots on the sensor, erase the errant purple tent in the background. All of these processes take some time, sometimes hours – and the longer it takes, the more you are being fooled.

I know that once I get involved with an exciting image I just can’t stop until I think it is at a finished state. So, an hour and a half go by and I save the file as a finalized .TIF and compliment myself on the finished image. I drink a toast on a job well done and then do some stuff that doesn’t involve sitting in a chair, in the dark.
Wind River Range - Wyoming

However, when I open the file the next day or, God forbid, look at the image that I hastily posted on my Facebook business site – it looks horrible! The colors are all weird, there is a blue cast that I can’t explain, the oranges are pale – what the hell happened?

Eye fatigue my friend, or more accurately – color fatigue. I am sure there is a scientific ophthalmological term for this, but color fatigue seems perfect to me. It’s like all the cones in your eyeballs just get tired or lazy, “Yea, that’s green, whatever” or, “Orange? Oh this nasty yellow is good enough for now.” You have 7 million color cones in the very center of your eyes’ retina, and its hard to image all of them just falling asleep at the wheel when you are using them the most – but they do.

Each little cone has to transfer a chemical reaction into an electrical impulse and then send it on to your brain. Each one of these impulses takes a little bit of energy, and then the cone has to ‘recharge’, for a lack of better term. We trichromates (red, green, and blue cones) weren’t meant to sit and stare at the emissive display of a computer screen for hours. Instead, we were designed to spot the lime colored edible leaf, to avoid the vivid red tree frog, and to watch out for anything with spots hiding in the grass. I believe that by staring at an image for too long reduces or alters the colors that we see. And the longer you stare – the more you are being fooled.

So, what have I learned? Never post an image to the public for at least one day. Open the image the next day, in the same darkened environment, and look at it again with some fresh cones. Nine times out of ten you will be wondering what the hell you were smoking when you did the post-processing the day before. Better yet, what I now do is take a break while editing. So, about every 15 – 30 minutes, I just walk away. Go get coffee, check for the mail, figure out why that sound of rushing water is coming out of the kitchen. Just get away from the display for a little while.

When you come back from the break you also get a fresh sense of your composition, the center of focus, and the color. It’s like proofing print images – tweaking them until the output color is just right.

Wind River Range - Wyoming

It seems like there are always elements that can alter the way your print appears, many of which are out of your control; the color temperature of lighting, the print paper, the surrounding wall color, the refraction of glass, the yellowing of the human lens and cornea. However, at least now you are aware of color fatigue, and know when to - just walk away.

Wind River Range - Wyoming