Process is important — it helps large and complicated objectives like transferring a patient out of the ED, performing ACLS stay on task and not disintegrate with the spontaneity of human error. There is already so much standardization throughout the regular workings of a hospital that one tends to take it for granted. From prescribing IV antibiotics that get checked by pharmacists then confirmed with nurses and reconfirmed by their charge to the admission process where one ED physician contacts the admitting physician who then gets in touch with the resident, etc. I think about this now because like most things, processes have the tendency to be taken for granted or worse broken.
Why do processes get broken throughout the day? I admit that a strict adherence to algorithmic thinking is likely not the answer but balancing fidelity and the ability to stray when needed is likely the cornerstone of any successful hospital system. As a third year resident now having witnessed and been part of many processes over the past few years I’ve decided to list the common ones that seem to be privy to being broken more than others.
Always a complicated process involving putting in labs, diagnostic tests, code statuses, and involving specialists when needed. Usually there is some form on communication between the ED physician and the admitting team. There is room for error over here because of the transition of responsibility that is occurring i.e from the ED to the primary team. The same could be said of the transition occurring between the ED nurses and floor nurses. It is here in the ED where orders may be delayed including antibiotics, fluids and also communicating valuable information.
- Communication is key between ED and primary teams
- If orders need to be done in the ED, follow up on them and communicate with the nurses.
- Make sure patients have everything they need (antbiotics, fluids) since there may be a delay getting them up to the floors
Another complicated process is that of moving patients from point A to point B. This can during escalation of care such as upgrading to ICU status or vice versa, a downgrade. Often times standing orders such as lab draws, medications, and protocols need to be adjusted for where ever the patient is heading. Of utmost importance is making sure the plan is communicating from where they are coming to where they are going and making sure everyone is on the same page.
- I go through all the orders of each patient to make sure there aren’t some that can be strippped away. For example on EPIC if someone is transferring from the ICU to the floors there may be old sedation/ventilator orders such as mouth washes and precedex drips that need to be discontinued.
Some medications that are titratable can be written in the EMR through a protocol, such as IV insulin for DKA patients or heparin drips for ACS patients. RNs dutifully follows these protocols and if there is any deviation that is desired the physician has to make sure it is communicated in a clear way since it will go against what RNs and pharmacists have learned to expect. A great example are patients on heparin drips who had them turned off for a short periods of time for one reason or another and then placed on them again — boluses usually are not required but on some order sets they are automatically reentered. If the physician does not clarify then the order will be followed exactly.
The process of administering medications has sometimes frustrating me — especially when STAT orders need to be administered from the point of care but they are held up because of multiple checkpoints. I have to remind myself this is for the sake of safety but perhaps this is on example where processess that are adhered to without room for flexibility can backfire.
- Once again communication between providers is essential for patient safety
Finally the act of getting patients out of the hospital requires multiple moving pieces. From a physician’s perspective making sure they leave on appropriate therapies and have follow ups is vital to the continuity of care. As a resident I’ve worked in a few hospitals and personally, places where there is a strict process i.e medications are overlooked from pharmacy and RNs are expected to call follow ups seems to me to be the safest. It is in this setting where lapses can be caught earlier on since more individuals are participating.
- If multiple caregivers are involved in discharge make sure they each understand their responsibility.
- Listen to everyones perspectives and expertise since each patient is multifaceted and will benefit from care aimed at different levels (dieticians, case managers, physical therapists, etc.)