Patients will teach us how to be compassionate

I have reported below on Dr. Epstein's remarks about the place of compassion in medical care. (I provided the video excerpt because seeing it said is inspirational.) Who can doubt the worth of doctors like the two Dr. Epstein's as they consciously practiced this form of care delivery with their patients? We are so fortunate to have people like them.

But compassion has to show up in the actual physical delivery of care as well. We need to be ever alert that the day-to-day actions we take in the hospital can inadvertently send a signal that we don't care. Even when we have the best of intentions.

Here is an example of a lapse. The bad news is that it occurred. The good news is that our staff immediately responded when it was pointed out.

Here was my initial email to a couple of senior level clinical and administrative leaders:

I'd like you please to look into this and apply a Lean approach to the problem. The instant case was my friend Mary [name changed], but she says she has experienced it before and has seen other chemotherapy patients go through the same problem.

She is a chemotherapy patient who comes in for periodic CAT scans. The chemotherapy affects the blood vessels and makes it difficult to insert an IV for the contrast agent. The techs are not trained to insert these difficult IVs. They try several times, causing pain and swelling of these cancer patients, and then finally the special IV team is called. When Mary has asked for the special IV team to be called at the outset, she is told that there is no way to coordinate those teams with the CAT scan outpatients.

That, to me, is an unacceptable answer. These patients come in on a known schedule. They have a known problem. We do not respect that problem sufficiently to avoid the discomfort and pain that comes from multiple attempts to place the needle.

I saw Mary's arm after her appointment. Much of the lower portion of her arm was discolored and swelled up and painful to her. That is no way to treat a patient with metastatic cancer. We have to do better. Please keep me up to date as you resolve the issue.

In just a few days, I received the following response.

An update on the venous access situation. The working group consisting of the individuals listed below has met. Amy G. is investigating the best way to create a flag in BIDMC systems for those patients who are "difficult sticks", with the accompanying ability to unflag (many patients change vein status as their health conditions change). Once the flag system is functional, clinicians will be trained on how to generate flags for these patients in the system. Amy is also investigating how to provide an electronic dashboard to the Venous Access nurses, so that they know every morning where and when flagged patients have appointments during the day so as to be available when needed. Currently there is a white board/paper/phone based system which doesn't enable proactivity.

As these capabilities come on line, Barbara C. will work on scheduling her team for on-time availability, Donna H.will train Radiology schedulers on the new process to follow when scheduling flagged patients, and training will be deployed to insure that the nurses know how and when to flag and de-flag appropriate patients. No doubt there will be additional actions required as these changes are implemented.

While these improvements are underway, heme onc and radiology will continue their current process for managing patients with difficult veins:
1) When any patient requests the special IV team to insert an IV, the Venous Access Team is called. No one else attempts to insert the IV.
2) Some "frequent flyer" patients are known by the nurses and techs to be difficult sticks and special assistance from the Radiology nurse or Venous Access Team is initiated. The tech will call for Radiology nurse or IV nurse assistance as needed. Right now they can't be flagged ahead of time, so there can be a wait for nurse assistance.
2) For patients who do not make a special request, and for whom there is a reasonable expectation that insertion will be successful, the radiology tech will attempt to insert an IV once. If it is unsuccessful, the tech will determine whether an IV nurse is needed or whether a second attempt is likely to be successful (most insertions are successful by the second attempt). If the 2nd attempt is unsuccessful, the tech will call for either a Radiology nurse who has advanced skills in difficult sticks or for an IV nurse to insert the IV.

I think you will agree that these are good responses, and our folks deserve credit for their quick action. But, thanks to the training I have received from people like IHI's Maureen Bisognano and Jim Conway and e-Patient Dave, I then proposed one additional step:

One more thought on this, which is excellent work.

Why not convene a small focus group of such patients and go through the suggested new process with them to see if they like it or have other suggestions? Wouldn't that be consistent with our attempt to be more patient centered and engage patients in our decision-making?

You see, compassionate care does not occur solely because there are well-intentioned clinicians. It has to result from thoughtfully designed work flows that avoid harm to patients -- work flows that are not dependent on patients' self-advocacy when they are in vulnerable settings.

To do it right, though, compassionate care has to be designed with the help of the very patients we serve.

Try as we might, there is no way to for us to see things through their eyes. We have to welcome them to be there to help guide us.