Best Thing on the Worst Day

 via Library of Congress

It was a busy night.

That is saying a lot.

All of our Monday nights are busy these days, but this was bad even by our standards. We had our fastest night shift ER doc working and extra staff, but still the patient's kept pouring in all night long.

We had sick patients too.

It was so bad that we woke up the morning shift doc and brought him in at 4 am because the department and the waiting room were full and the night shift doc was still ten charts behind.

That wasn't the only thing that made it unusual.

It was that rare night in the Emergency Department when all my patients:

1) Have a good reason to be in the ED.
2) Actually appreciated my help.

A night like that can carry you for six months -- it usually has to since it is about as common as hen's teeth these days.

With the onset of the Affordable Care Act,  Emergency Departments have seen huge increases in patient volume. Many more people have access to health insurance under Obamacare, but there has not been a huge increase in primary care providers to see them.

Yet it is not just people with new access to insurance. A 2013 studies found that only about one third of the people who come to the emergency room require immediate attention and 70 percent at that time had private health insurance.

The emergency rooms are filled around the country with non-emergent conditions and unrealistic expectations. We don't dole out narcotics like candy. We don't solve mystery conditions that you've been to every specialist to see. We give toddlers with fevers over the counter medications that parents could have given at home. We get sent patients from clinics because they can't get a same day appointment -- or don't want to wait until morning. People call ambulances because they don't have gas money and don't want to pay for a taxi.

The least sick, it seems, are the most rude and impatient. It is tempting to be rude right back, but that's what they want. They want to start a fight, to get into a tug of war. Something to tell their friends and post on social media. The only way to win that sort of power struggle is to not engage, to not pick up the rope.

Moreover, these days nurses live in fear of the dreaded "Patient Satisfaction Survey." Federal insurers want to pay hospital based on patient satisfaction -- but it is a rigged game. It assumes the patient is a customer in a restaurant, but it is the doctor that places the order. Patient advocacy is the nurse's primary motivator, but sometimes what is best for a patient is not what the patient wants or expects -- because they aren't the medical experts and they don't always want what is best for their own well being.

When our surveys dropped a few years ago, our corporation ran us through a bunch of training to teach us how to be better service workers rather than professionals.

Unfortunately the first day of these classes they explained the methodology of the survey.  Satisfaction with care was rated on 1-10, but everything below an 8 was scored as a "0." The results were not randomized, sample sizes and response errors were big problems.  We were rigged to fail. Why? I suspect is has something to do with the fact that the companies that do these surveys also profit from the consultants and seminars and education products sold to hospital systems that panic at less than perfect scores.

So we are taught how to be kind and patient with people exhibiting behavior that would get them kicked out of the lowest dive bar in town.

This night was different.

My patients were sick. I had a brain damaged man having increased seizures because of a change in his medications. I had a cancer patient on chemotherapy with a fever -- he and his wife were kind and jolly despite a terminal diagnosis. He kept making jokes as I accessed his port and drew blood cultures.

"I'm terminal," he said. "What else is there left to do with my time, but laugh as much as possible?"

Late in the night I helped with a trauma patient. An elderly lady had fallen down a flight of stairs. She was on Warfarin and had a head bleed, broken ribs and hemo-pneumo that required a chest tube. She was deteriorating. We moved her to a trauma bay to get her chest tube in and possibly intubated for the flight to Portland.

The room was filled with nurses and techs -- so often when you have a sick patient, the staff appears when you need it most.

So I lingered to cover the other rooms and found myself standing with the woman's husband in the hall. I brought him a chair, which he leaned on, but did not want to sit.

This is nursing sometimes, standing with a family member while they come to realize how this night will never leave their memory.

The doctor came out -- and behind them, I saw the Lifeflight crew shouldering their bags and walking away. Our doc had got a call back from the receiving hospital. He was told by the neurologist that the prognosis was so poor that it was not worth risking a helicopter flight.

The doctor returned to the room to put in the chest tube and I stood with the husband as he started to cry. I just stayed there, stayed present with him and we talked.

He had bad nights before. He was a World War II veteran. He had been wounded twice and saw the war end while he was in Austria. The first time he had been wounded, he pulled the shrapnel out himself and kept going. He explained that if he was medivac'd out, he would have lost contact with this unit.

"Those were the guys you were fighting for," he said. "Those were the people who had your back. You didn't want to leave them. They're your family."

While nothing like combat, his story made me think of how the whole department pulled together when there was a disaster or trauma, or critically ill patient that needed extra hands, extra help.

In the room, three nurses and two techs helped the doctor secure the chest tube which quickly drained the blood from the woman's chest and allowed her lung to re-inflate.  The radiology tech stood by with the portable chest x-ray, respiratory therapists were at bedside.

All that staff in that one room meant that somewhere a call light wasn't being answered as quickly as would otherwise have been the case. Someone was waiting for a warm blanket. Other less acute patients were still waiting to be seen. Our critical care of this one patient would probably reduce our patient satisfaction surveys.

Most nights I'm the charge nurse, directing traffic and solving problems and rarely doing hands-on care. I love my one or two nights a month where I get to take care of patients. It reminds me why I got into this business in the first place.

When I first got into medicine -- as a volunteer EMT -- someone told me that I'd have the opportunity to be the best thing on the worst day of someone's life.

Being present doesn't have a billing code. Standing with a family member at a horrible moment during a tragic night might not move the needle on a patient satisfaction survey.

Yet sometimes, that's what nursing is.

-30-

Further Reading:
The Problem with Satisfied Patients
Seven Things You May Not Know About Press Ganney Statistics
Emergency Room Visits Continue to Climb
The Ten Types of ER Patients
The Yelp-ing of Emergency Rooms

The Increased Use of the ICU

We are using our ICU's more often than we have in the past, according to a new study. As published in the Academy of Emergency Medicine, George Washington University researchers found a 50 percent increase in Intensive Care Unit admissions between 2002 and 2009. 

As the patient's get older, we are utilizing intensive care more often. The group with the largest jump in ICU admission was those over the age of 85 years. That isn't likely to surprise, given the aging population in the United States.

Yet, the recent study that highlights an increase in hospice admissions only after intensive  and expensive ICU care in the last few days of life highlights the fact that we are still aggressively treating patients in the last chapter of their lives. That Journal of the American Medical Association study appeared with an editorial calling for an end to aggressive hospitalization in end of life care by increasing planning and communication between patients, families and doctors prior those final days. 

The article also notes that patient's also spent up to 5 hours in the Emergency Department waiting to get into the ICU. 

 "Studies have shown that the longer ICU patients stay in the emergency department, the more likely they are to die in the hospital," Pines said. "Better coordination between the emergency department and ICU staff might help speed transfers and prevent complications caused by long emergency department waits," he said.

Ummmmm ... I don't think it is interdepartmental coordination and ED wait time that is increasing these critically ill patient's mortality rate. Might have something to do with the fact that they are sick. 

Patient's are often stabilized the ED prior to transfer to the unit. Often times our ICU won't even take the patient until they are stable for transfer, have all their drips hanging and they have a tube in every orifice. Moreover, with increased admissions, there are increased demands on staffing the ICU. We retain core staffing in the Emergency Department even when our census is low because our patient population in the Emergency Department can change in a heartbeat. Many times we've seen the ER go from empty to full in just a matter of minutes. 

ICU's however, often call off staff when their population is low. Therefore, we are often waiting for a nurse to come in to take our patient. That doesn't mean that there couldn't be better coordination between the Emergency Department and the ICU. Those two departments attract very different personality types.

However, I doubt that lack of coordination between the ICU and the ED that is the primary reason for the increased mortality of patient's needing intensive care in the last years of their life. It may have more to do with the need for better communication between providers and patients and families before those days arrive. 

Washington Drops Plan to Deny Payment for Unnecessary ED Visits

Washington State Health Care Authority has dropped it's plan to deny medicaid payments for Emergency Room visits deemed "unnecessary," after intervention from the state legislature.  


The plan was a looming problem for Emergency Departments in the state. The "frequent flyers" who use the ED the most would no longer be compensated. That would have been insult to injury: the not-sick patients would have also been the ones that getting uncompensated treatment. A small number of these patients amass dozens to hundreds of ED visits every year -- mostly for things that did not require an ED visit. 


The plan was misguided because the law says everyone has a right to treatment in the Emergency Department. We can't turn anyone away without evaluation by a provider. Moreover, we have little control over the poor decision making or our customers.  This plan would have punished the hospitals for the public's overuse of the ED. Sure the patient would have been stuck with the bill, but hospitals would have had little expectation of payment. 


The new rules were supposed to go into effect April 1, but that was put on hold until an alternate plan passed through legislation. The new guidelines require hospitals to adopt seven best practices to help reduce frequent ED visits. (Listed Here, clipped from Washington ENA's newsletter.)

• All hospitals will have an electronic health care information system in place to share information on patient visits, case management plans, & flagged warnings.
• Hospitals must have literature in the department to discuss alternative care options.
• Hospitals must identify specific personnel as contact links to the HCA to receive & share information on patients requiring coordination (PRC), care plans, etc.
• ED providers must be in-serviced on "Patients Requiring Coordination" which is currently a list of about 5,000 HCA patients flagged as "over users" of Emergency services.
• ED's utilize the WA State Guidelines for Narcotic prescriptions for non-cancer chronic pain.
• ED Providers must document having signed onto the WA Prescription Monitoring Program to review all narcotic prescriptions written in the state for a patient.
• All hospitals must have a system to compile case management statistics to track success & compliance with the "to be determined" tracking points for quality improvement.

Better education and intervention with frequent users may help. Better access to primary care and better communication and patient education would help even more. 


Of course, it is not just the poor and uninsured using the ED for unnecessary care. Studies have shown that people with insurance have also increased their use of the Emergency Room.


"So, the real question is: Why is everybody, insured and uninsured, coming to the E.R. in droves?" wrote  Zachary Meisel and Jesse Pines in Slate Magazine. "The answer is about economics. The ways in which health information is shared and incentives aligned, for both patients and doctors, are driving the uninsured and insured alike to line up in the E.R. for medical care."


Often, when I am treating people, I find that they saw their primary care provider that day, and just didn't like the answer they got, or having to wait for test results. Even with longer wait times, the ED is like a fast food restaurant compared with making dinner at home -- quick, no reservations, minimal effort involved. 

Nurse advice lines after hours all seem to tell people to go to the ED to avoid the lawsuit that would follow if someone really sick was told to wait until morning. Communication and Education of patients are not compensated under the current system of care, but they could help avoid millions of dollars of ED charges.


Less than half of Emergency Department visits are for emergencies, according to a 2003 HSC study. A CDC study puts then non-emergent level at closer to 12 percent - it all depends on how you define emergency. As more insured and uninsured people use the ED for basic health care, waiting times get longer, and consequently the perception of quality decreases.  Guess what? Medicaid compensation is now going to be tied to patient satisfaction surveys.  

For more information on the proposed new guidelines, check out the following websites:

Washington ACEP

Washington State Hospital Association

Washington State Medical Association

Washington State Health Care Authority

Here's some links to studies on ED use:
CDC National Health Statistics Report 
Health System Change Report from 2003
Slate: The Allure of the One Stop Shop
Slate: Are Most Emergency Room Visits Really Unnecessary?
Ten Most Common Reasons for an ER Visit

CHARGE!

Well, Sunday was a big day. It was my 43rd birthday, and also my first night as Designated Charge Nurse. Of course, I've been a relief charge nurse for a couple years now, and I've basically been doing the job full time -- as relief -- since the last DCN stepped down.

Despite my experience, relief charge nurse expectations are lower. Your job is to keep the ship from hitting icebergs until the captain sobers up. I tried not to intervene in management or personnel problems unless things threatened to descend to physical violence (it happens).

The last DCN stepped down because it was not a rewarding experience. Emergency room nursing is brutal, fast and filled with moments of instant gratification. People come in sick and most of the time make them better or keep them from dying. That's cool.

Being charge on the other hand is a lot like herding cats -- only some of the cats are drunk, high on meth, vomiting, incontinent of bowel and bladder -- and that's just the nurses. Seriously, you spend a lot of time in a logistical nightmare of managing limited resources. You have to smooth over conflicts, break rules, make rules and otherwise be the calm adult amid the chaos.

The night we found out our fearless charge was stepping down, about 10 people came to me and asked if I was going to apply. Now there are three reasons that 10 people ask you to do a job:

1. Because they think you are the best person for the job
2. Because they think you can do the job and at least not screw it up worse than other people and ...
3. Because they think you are the only person stupid enough to do a job that no sane person wants.

Regardless, I was the only person who applied -- as far as I could tell. I still had to go through the interview process, where I impressed even myself with my managerial gobblygook. 

The hardest part for me is staying in the chair when I want to be jumping in a caring for patients. Or, as one unit secretary put it ..." you need to fly the plane, not get up and serve drinks."

I think I'm  a pretty good nurse, but being a good nurse does not make one a good charge nurse. It is a completely different job and I may be a perfect example of the Peter Principle which states  "in a hierarchy every employee tends to rise to his level of incompetence." Good engineers get promoted to become lousy managers, for example. 

Every job I've had, I've quickly been foist into the roll of being in charge. So, maybe I'm a lousy nurse but I'll be a good charge nurse. If I start feeling confident, I'll remind myself of the Dunning-Kruger Effect -- which posits that the most incompetent people don't know their are incompetent. Per Wikipedia:

"Actual competence may weaken self-confidence, as competent individuals may falsely assume that others have an equivalent understanding. As Kruger and Dunning conclude, "the miscalibration of the incompetent stems from an error about the self, whereas the miscalibration of the highly competent stems from an error about others"

So how did my first night go? Well, Sunday night was fine, but Saturday was crazy with a full department all night long and the staff stretched thin. At one point we had three ICU level patients in the department and two conscious sedations at the same time. I got my lunch at 4:30 AM, but everybody got their lunch and I didn't have to mandatory anyone. 

I also felt incompetent, which thanks to Dunning-Kruger, I'll take as a good thing.

Droperidol Rides Again!

Droperidol / Inapsine is back in the Emergency Room. Is it safe?

When I was a new nurse in the Emergency Room of a little coastal hospital, I learned to use a medication called  Droperidol - a powerful antipsychotic and antiemetic medication.

One shot was often enough to bring clarity and calm to an out of control behavioral health patient in just a few minutes. The paramedics carried it and often would dose in the field prior to patient arrival. It was a wonderful drug.

Switch to a bigger hospital a few years ago.  Mention of the name Droperidol instantly elicited the response of "black box." Indeed, the new hospital had had a sentinel event with the medication and many of the nurses that remembered the medication were still spooked by it. The patient coded - and the code did not got well.

This week however, droperidol was back in the pyxsis and back on the jump kits of our local paramedics -- and quickly was back in use in the ED.

The nursing staff was divided by the drugs reintroduction. Some remembering it fondly while others insisted that every pysch patient MUST be on a cardiac monitor and get 12 lead EKGs before adminstration -- of course, if you can get a psych patient to sit still for a EKG, you don't need droperidol.

This medication was also widely known as an effective antiemetic and was widely used post-op before it received it's black box. With an ongoing nationwide shortage of compazine, droperidol is being offered as an alternative to compazine in the treatment of migraine headaches and intractable vomiting. The doses are much lower for these applications than for acute psychosis.

What is the history of this medication? What are the risks?

Droperidol was discovered back in 1961. A powerful D2 anatagonist, with some seritonin  and histamine effect, small doses ( < 1 mg IV ) effective prevented post-op nausea and vomiting. Larger IM doses (5 - 10 MG) were used for acute psychotic patients. (details here)

In 2001, the FDA issued a an expanded black box warning and it was controversial. While, the medication already carried a warning for the potential of sudden cardiac death in doses greater than 25 mg in psychotic patients, the new warning expanded to include even small doses. The medication was essentialy pulled by the manufacturer soon after.

According to the Wikipedia entry:

"In 2001, the FDA changed the labeling requirements for droperidol injection, to include a so-called "Black Box Warning", citing concerns ofQT prolongation and torsades de pointes. The evidence for this is disputed, with 9 reported cases of torsades in 30 years and all of those having received doses in excess of 5 mg. QT prolongation is a dose-related effect,^[4] and it appears that droperidol is not a significant risk in low doses.

Writing in the July 2004 edition of the journal Anethesia and Analgesia, Duke University's  Tong Gan wrote about his experience on an FDA review panel for the medication. (full text)

I represented the Society of Ambulatory Anesthesia (SAMBA) membership and presented during the open public hearing session, to express the view that FDA’s “black box” warning is unwarranted for the antiemetic doses of droperidol, and that the warning has effectively removed one of the most efficacious drugs for the management of PONV for our patients. I presented evidence that droperidol is a cost-effective antiemetic and its safety profile when used in antiemetic doses is excellent. We have previously reported the 10 cases in the FDA database in which serious cardiovascular events were possibly related to the administration of droperidol at doses of 1.25 mg or less. Review of these case reports shows that there are many confounding factors that make it impossible to establish the precise cause of the adverse cardiac events. Many concomitant drugs with the potential of causing QTc prolongation were administered around the time of droperidol (3). Of note, since droperidol was approved in 1970, there has not been a single case report in a peer-reviewed journal where droperidol in doses used for the management of PONV has been associated with QTc prolongation, arrhythmias, or cardiac arrest (1).

Gan goes on to explain that there were millions of this medication in use, yet only a handful of clearly documented events supporting the black box warning. Yet the black box effectively wiped out the medication's use.

Close to 10 million vials of droperidol were sold in 2001 before the “black box” warning, and it was estimated that its use was reduced by 90% following the warning. It was recognized that there is a significant lack of data for the small doses of droperidol causing QT prolongation.

The problem is, lot's of widely used medications also cause QT prolongation -- many of which were often used in the same environment as droperidol. (Here is a full list and here is a good discussion )

For example propofol and Reglan are often used in surgery. How do you sort out which drug is causing the change in repolarization?

Indeed, when our ED nurses received our fact sheet on the reintroduction of droperidol this week, we were surprised at some of the commonly used medications that are also associated with long QT. Tons of medications that we used all the time without cardiac monitoring have a QT association. You don't automatically reach for the cardiac monitor every time give a patient Avelox, Azithromycin or Albuterol do you?

Moreover, the medication that replaced droperidol as the IM choice for "rapid tranquillisation" psychotic patients is Haldol. Haldol is the same class of medication, and in 2007 it too got the same warning from the FDA about QT.  Until droperidol reappeared this week, we used Haldol combined with Ativan.

Yet, even without these confounding medications, it is not all that easy to precisely measure QT changes in a way that allows researchers to determine a cause and effect with certainty  Moreover, Gan wrote: "QT interval is only a surrogate measure for Torsade de Pointe, which is what concerns clinicians." 

If you aren't familiar with Torsade's -- consult your ACLS manual - it will be under lethal ventricular tachycardia.