Monday, March 24, 2008

When SPIRIT helps patients

For those of you following my stories about BIDMC SPIRIT, you know that our main purpose in starting this process improvement program was to enhance the quality of the work environment for our staff, those involved in direct patient care as well as in other hospital functions. But we also believed there would be spill-over benefits in improving the quality of patient care -- in ways that are not necessarily related to specific programmatic areas like reducing central line infections or ventilator associated pneumonia.

Here are two recent examples along those lines. I am going to present the log reports in "hospital-speak", i.e., as written by the staff, so please accept my apologies if not all the terms are familiar to lay readers; but I think you will get the picture. I think you will also get a feel for how complex the patient care environment is in a large academic medical center.
The first case involves treatment of psychiatric patients entering the Emergency Department. There is a general shortage of psychiatric beds in Massachusetts -- having mainly to do with grossly inadequate reimbursement rates for these patients and also a failure of the state to properly care of patients who should be under its care -- and this shortage spills over in hospitals in the way described in this case. We can't solve those broader societal issues, so you will see how the staff cobbled together an appropriate solution to this particular issue. (Note, for example, how the materials on the "Expressive Cart" have to be carefully chosen so the patient cannot intentionally harm himself or herself.)

On March 5, an Emergency Department nurse called out a serious concern: that patients presenting to the Emergency Department (ED) for psychiatric evaluation are often held in the ED for a number of days while a bed search takes place. During that time, the patient is held in seclusion, without the benefit of therapeutic or diversional material.

On March 10, Michelle McCool, Director of Ambulatory and Emergency Operations; Karen Lottatore, ED Practice Manager; and Kathy Fanning, ED Nurse Manager, had a plan in place to purchase some activity materials by March 17, and to have a physician in Psychiatry approve them within five days. In the meantime, Michelle McCool updated the SPIRIT Problem Log, mentioning that long-term solutions are currently under discussion on a governmental level as well as on an internal, interdisciplinary level between the ED team and Psychiatry leadership.

On March 13, Michelle McCool and five others (Mary Anne Badaracco, MD, Chief of Psychiatry; Dyanna Domilici, MD, Psychiatry; Jonathan Florman, MD, HMFP Psychiatry; Tina Gosselin, RN, Psychiatry Nurse Manager; and Sandi Leitao, Administrative Director of Psychiatry) met to discuss improvements in the care of psychiatry patients with extended stays in the ED. They agreed on an extensive action plan that includes the following:

One crank hospital bed will be available to those patients uncomfortable on stretchers;
Michelle McCool will communicate with Central Processing on this.Patients will be offered items from an “Expressive Cart” which will include cordless radio head sets, non-toxic art supplies, books and other items.
After the acute evaluation is complete, if approved by Psychiatry, patients will be offered more comfortable clothing. (Michelle McCool to obtain a supply.)
A daily team meeting will occur, including Nursing and Psychiatry at a minimum. The team will develop a treatment plan which will be documented daily.
Consider other types of consults – possibly Nutrition, Physical Therapy and Occupational Therapy – for patients who have been in the ED for more than 24 hours.
Possible assignment of a case manager to patients requiring disposition. Marsha Maurer, RN, Vice President of Patient Care Services is considering this.

The second case is more typical of a large hospital. Capacity or staffing or continuity of care problems on one floor that require coordination with several other units to resolve.

Problem: At 8:30 a.m. a staff nurse (Lucy Miller, RN) on Farr 9 needed to page the medical house staff with a question about a patient admitted overnight from the Emergency Department (patient arrived on floor between 3:30 and 4:00 a.m.). The nurse paged the resident listed as covering, but that beeper was forwarded to another resident who stated he was not covering. That resident instructed the nurse to call another resident who also stated she was not covering. The nurse paged the attending physician of record who gave the nurse two additional options to page. At this point, John Ryan, RN, Nurse Manager on Farr 9, became involved and paged the Chief Medical Resident for help in determining coverage.In addition, coverage for the SIRS firm, which often covered medical patients on Farr 9, was not easily identifiable through the online paging system like other medical firms such as MERIT or Blumgart. The nurse had to get the SIRS on call resident information by calling page operator.

Person(s) Describing Problem: Lucy Miller, CN2, Farr 9, and John Ryan, RN, Nurse Manager, Farr 9.

Help Chain Contact: Jane Foley, RN, Director of Clinical Operations.

Root Cause: There were a higher number of medical admissions than usual overnight. The patient was assigned to a different medical firm (team of residents, interns, medical students and attending physicians) than the SIRS firm that usually covers Farr 9 patients. The POE order set did not indicate the correct firm coverage. Why? Until recently, Farr 9 had been primarily an inpatient surgical unit. In early February we moved several surgeons that had been admitting to Farr 9 to the east campus. This left available capacity on Farr 9. Additionally we had a couple of surgeons still operating on the west on vacation and high Emergency Department medical volume – thus Farr 9's population shifted to 40-50% medical service patients. Why? The overall increase in medical patients house wide and particularly on Farr 9 led to some coverage issues for the medical firms. Why? In order to safely spread medical firm coverage, patients on Farr 9 were getting assigned to teams other than the SIRS firm which usually covered F9 medical patients.

Solution After Investigation: The immediate issue was fixed and the correct team assignment was notified, but it took 30-45 minutes. On March 5, Jane Foley contacted Sandra Denekamp, Telecommunications, about adding SIRS on call to the online paging system. Completed.

Action Plan: Julius Yang, MD, Hospitalist, and Todd Pollack, MD, Chief Medical Resident, worked on solutions with Nurse Manager John Ryan, RN, to prevent issue from occurring again:

· Medical firms reassigned to support increased medical volume on Farr 9. (completed by Yang/Pollack)
· Farr 9 RN staff educated about medical staff coverage – virtual pager for Robinson/Kurland Firm; page #s posted on unit and staff educated on how to find medical call schedule on portal. (completed by J Ryan)· Medical house staff will up date POE order set to accurately reflect team coverage. (completed by Yang/Pollack)
· As a back up, if POE order set is not up-to-date, medical house staff will either evaluate patient if critical issue is occurring or locate correct coverage as opposed to giving RN another intern/resident to page. (completed by Yang/ Pollack)
· On call paging system updated to list SIRS firm by name. (completed by Sandra Denekamp)· Automated paging system (generates an automated page to medical admitting resident once bed assigned for patient admitted via ED) updated to reflect new admitting scheme – (completed by Yang/Pollack/Larry Nathanson, MD, Emergency Department)


Anonymous said...

As a student who will graduate from nursing school in May, I want to thank you for sharing your experiences (related and unrelated to health care) in this blog. Quite often, things I have read here have been directly applicable to what I was seeing in my program and in my clinical experiences. I've been inspired to try to change the institutions I'm involved with rather than just identifying the problems.

The SPIRIT process is just one more reason that BIDMC is my first choice as a new grad. I've recently applied to your Clinical Entry Nurse Residency Program, so I won't leave my name, but thank you again. And keep up the great work and thoughtful writing.

Anonymous said...

OK, but I'd take the second incident one step further - I would guess this issue is not strictly confined to Farr 9, despite their recent changes, so maybe the Chief Medical Resident should check other medical units, and maybe even the surgical units too, and record that somewhere in SPIRIT? Or is there a way for people on other units to review this stuff and say - hey, that would solve our problem too?
Also, who will follow up on Farr 9 in a month or two to make sure the new system is working on all shifts?

Oh, and the psych thing sounds horrible to a layman, but psychiatric emergency care is a MESS on a national level, people. Read it and weep - or call your congressman.
Keep it up, Paul!

nonlocal MD

Unknown said...

Thought I might share this website with you,
Looks to be an interesting place for patients to share experiences and such. I know a website like this might peak interest of you and some of your readers.

Gotta give credit to my college roommate who found it and put it on his website.

Anonymous said...

You made people lie on those hard ER beds for days? They are awful for hours, much less days!

Anonymous said...

Anon 10:56, if there is no pysch bed available, there is not much choice. I tried to explain that that is what makes this such a problem.

Anonymous said...

nonlocal, Sharing across the hospital is exacly the point, and I'm glad you raised it. The problem/solution log is available to all, plus there are others ways we get the word around.

And who will follow up? Everybody on the floor!

Anonymous said...

Check this out--re "boarding":;_ylt=Av4Jit4W6UM7TyLZj41Bes3VJRIF

Jerry said...

I work in the psych admissions department. I'd like everyone to know these people are not stuck in the ED due to lack of effort. there are times when we call more than thirty hospitals before finding a bed. If there are none available that shift the calls begin again on the next shift until tht pt is placed.