Editor’s Diary

91

A vascular surgeon friend from the Midwest recently stopped by my office here in Southern California. His visit gave me a chance to compare our hospitals.

Like many private practitioners, I work at several community hospitals. My primary hospital has 250 beds with 85%–90% occupancy. My visitor’s main hospital, by contrast, is a magnificent nearly brand-spanking-new university hospital, which treats a mix of community patients and tertiary referrals, as well as esoterica that seldom come my way.

I asked him many questions about his hospital, but I was especially curious about the following: When he went on the wards, was it easy to find a place to sit and write his notes, or were all of the chairs taken by nurses writing their notes, as occurs in the community hospitals in which I practice?



Dr. Andros

Subjects like this can be difficult to raise, lest you be seen as one of the reminiscing old guard. But as soon as I asked, I realized that I had misspoken. The nurses at his hospital, no doubt, entered their notes into an equally brand-spanking-new EMR system, and he, or his house officer, presumably did likewise. But my colleague astonished me by saying that not only were places to sit in short supply, but also that access to the computers was extremely limited.

At my own hospital, the computer “shortage” has been addressed lately with an army of WOWs – workstations on wheels – but their appearance, so often the case with technology, has unintended consequences. Moreover, their advent has exacerbated a longstanding problem. Over the past several years I have found it increasingly difficult to pry a nurse away from the nursing station to make rounds with me; the WOWS (even when the WOW is positioned outside the patient’s door) have only made it worse.

I remind the nurses that there could be no better time to discuss the patient than when we are shoulder-to-shoulder at the bedside, but their reluctance remains in the “unmodified behavior” category. More often than not, the minute I leave the floor the nurse reads my (handwritten) orders and pages me to discuss exactly what it was that I wanted for the patient. I have given up explaining that the post-visit telephone page would have been entirely avoidable if we had seen the patient together. I took scant reassurance when my colleague confirmed that nurses’ attachment to their computers and their resistance to making rounds were, to his knowledge, common phenomena. Why is it that we all appear so purposeful and engaged in important work when we lean earnestly toward our computer screens and type?

It is assumed that having fewer patients to care for may free up nurses to spend more time with those patients – and with doctors – but I confess I am dubious. In 2004, California passed a law mandating a reduction in the patient/nurse ratio from 6 to 5. Then-Governor Schwarzenegger attempted to return the ratio to 6 to control costs but his action was overturned in the courts. Indeed, in the past few years, the gulf between doctors and nurses seems to have widened, and I doubt that adding more nurses to the ranks will enhance those interactions.

Personally, I see more food trays uneaten, and fewer patients being ambulated (“That’s physical therapy’s job”) than ever before. Assuming that an increase in the number of nurses will improve the quantity and quality of nursing care and reduce adverse events, the current limitations on health care spending make it unlikely that such an increase will ever occur.

Some experts have estimated the there will be a shortage of 800,000 nurses by 2020. The chronic lack of money puts that number beyond our reach. However, if I were given the power to make it happen, I would make a request.

Let all the new nurses, if possible, be drawn somehow from the ranks of the unemployed. There are many able, and in fact overqualified people, who are unemployed but could be made “patient-ready” in 18 months. Let’s identify those who might be interested in a nursing career and re-train them for these rewarding jobs.

Despite the advent of the paperless chart, I still troop regularly to the Medical Records Room to “do my charts” and lately I have taken to reviewing the nursing portion of the chart. This section is impressive not only for the sheer multitude of individual nursing entries but also for their stunningly meager clinical relevance.

It is as if the chart were being compiled to assuage a vague but menacing Leviathan. Most of the nursing entries are not part of the paper record. But when I bring up the electronic portion, I find that it is composed of preselected pull-down menus, vast notations of vital signs, lab work-ups, and a jaw-dropping array of additional computer-dictated form-filling.

For example, if hourly urine outputs are ordered, the computer complicates and bloats what is otherwise a straightforward, patient-centered exercise. That is, rather than simply note the output and vitals on a chart, the nurse checks the output, retreats to the computer, logs in, finds the patient’s file, scrolls through screen after screen, and finally plugs in the data.

With so many data to enter, is it any wonder that ICU nurses appear to spend more time serving the computers than the patients? Could this proliferation of nursing entries all be the result of the fine print in “the regulations”?

Nowadays, many aortic procedures, such as open aneurysm repair and aorto-bifemoral bypass, have ceded their role to endovascular therapy. As a result, aortic procedures are vanishing from the skill sets of many vascular surgeons, especially the younger ones.

Similarly, electronic dropdowns and radio buttons appear to be supplanting – or at the very least, diverting – the concrete nursing skills required to care for these patients. We protest that that open and endotherapy are complementary, but it cannot be so unless the infrastructure to provide care for both treatment paradigms remains viable and intact.

Today’s nurses seem to spend so much time making sure the computer has what it needs that I fear for those of the patients. Indeed, the loss of hands-on nursing skills may be an unintended consequence of the endotherapy revolution.

Would people laugh if I started carrying a folding chair on rounds?

Dr. Andros is the medical editor of Vascular Specialist.

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