Reference no: EM133268812
It Has To Be Easier to Do the Right Thing
Background
Recently enacted work restrictions for medical residents now dictate that they: 1) cannot work more than 80 hours per week; 2) work no more than 30 hours at a stretch; 3) have at least 10 hours off between the end of one shift and the start of the next; and 4) have at least one day off per week.
Their work hours have decreased, but the workload expectations haven't. The third year senior residents supervise the interns and medical students. It is typical for the third year resident to be responsible for 12 patients, with the intern taking the lead on 6 of them, and each medical student taking 3 patients. In addition to seeing patients, residents and interns are also responsible for making sure all paperwork is completed - medical records, forms, etc. The implementation of the EMR hasn't decreased documentation time. Many state the EMR implementation has increased documentation time by almost an additional hour per day.
The attending physician is responsible for supervising the residents and interns. This is made more challenging than desired because patients are spread across multiple wards. It is not unusual to have patients across six wards, which makes it hard to have a "team." The attending is generally the one who knows how to get things done in the hospital and how to coordinate work - who to call to get needed tests done, the specialists that should be contacted, etc. The attending must also complete medical record documentation on each patient (thus, both residents and attendings must chart on each patient), as well as be present for every procedure done to the patient if they wish to bill for their time. Residents are hesitant to call attendings when they have questions.
A Day in the Life of Gina R.
At 7am, Gina R. arrives on the main Med/Surg ward of the hospital for another day. She is a third year (senior) resident who will graduate in less than six months. As she walks in she looks at the white board that lists the patients on her team and their locations.
Gina waits for her intern to arrive, as well as the night float resident. This resident was on-call last night, and admitted the General Medicine patients. While she waits she pulls up the vital signs on the computer for some of her sicker patients.
Once the night float arrives, she learns that she has a new admission who just got to the floor. Gina dispatches the intern to see that patient and begins to see the others. Today she has patients only on four wards instead of the usual six, which is better than usual.
At 9am she and the rest of the team meet with her attending physician. They discuss the patients and see two of them together, including the new admission. This patient is new to Gina as well. The team is interrupted six times by nurses with questions about other patients. At 9:45am the intern is sent to interdisciplinary discharge rounds. This is the daily round for patients on the main Med/Surg ward only, so not all patients are discussed. The intern returns 15 minutes later to rounds.
The attending gives a 10-minute talk on anemia from 10:20-10:30, at which time the team goes to morning report until 11:15. This is a teaching lecture given 4 days a week by the Medicine Chief Residents. Both Gina and the intern are paged throughout the lecture.
At 11:20am they get back to the wards. The intern works on a discharge by filling out the paperwork and calling to set up follow-up appointments. Gina gets paged to finish the Med Rec form on the new admission. She is also told that the patient needs to have the Community - Acquired Pneumonia Order Set in place, since that is their admitting diagnosis. Gina does not know where this order set is placed, since she has only been on this ward twice before, and the last time was over a year ago. In addition, order sets are in a slightly different place and order on each ward. The HUC directs her to the order sets. Gina recopies the order for this patient's record.
At noon Gina grabs some food from the cafeteria and goes to lecture, which is from 12-1 most days. After being paged for the 4th time during the lecture, she leaves. Gina then notices that morning labs have not been drawn on a patient. She calls the lab, who says that their policy is to not draw on a patient with a port without flush orders. Nobody had called the nurse, HUC, or medicine team about this issue. Gina goes to the ward, writes the flush orders, and asks the HUC to call the lab back. The lab says they will collect them at 2:30 pm, during their afternoon lab draw.
When called about a transfer out of the ICU, Gina heads down. She writes a new order set (these must be re-written from scratch on transfer by hospital policy). Her intern has clinic off-site this afternoon so cannot help out. She is paged approximately every 8 minutes throughout the afternoon. Although she has a text pager, text pages are rarely sent in place of call-back numbers.
At 4pm she notices that a patient has not gone to have an ultrasound that was ordered. She asks the HUC about it, who does not know what happened. Gina pages the radiology resident, who says that the test must be approved since one was just done 2 weeks ago. After discussing the indication, the resident says the test will be done tomorrow.
By 5pm, she is trying to think about potential discharges for tomorrow. She cannot get a hold of the 3 other social workers for the patients on other wards, so she makes a note to do this tomorrow. The labs on the patient who had the delay come back, showing a low blood count. She writes orders for a transfusion, and goes to the ward to get consent from the patient.
The newly admitted patient from that morning has outside records that are needed, Gina asks the HUC where the medical records forms are. After getting this, she has the patient sign the form and faxes it to the other hospital's medical records department.
At 6pm Gina sets down to dictate the discharge summary for a patient who left 2 days ago. She cannot find the chart, and asks the HUC to request it from medical records.
At 7pm Gina signs out and goes home for the night. She wonders where her time is to think and reflect as a learner.
- She has been interrupted at least 30 times while either learning or trying to make complex decisions today.
- She has had no breaks of any kind, other than to run to the bathroom once.
- Gina has spent over 30 minutes in the pure act of walking between wards.
- She spent only 10 minutes speaking to other health professionals about the plan of care (other than when answering pages).
- Gina spent 55 minutes filling out forms or re-copying orders (not including writing orders).
- She spent only 110 minutes at the bedside of patients.
Questions:
- What are your redesign ideas?
- How would you develop and implement your redesign ideas?
- How would you test whether your ideas really would be a better way?
- How would you describe your new resident system?
- What would the flowchart of your resident system look like?
- Which of the activities in the case reflect the impact of legislation, JCAHO, medical standards, tradition, or other factors?