"When you get those rare moments of clarity, those flashes when the universe makes sense, you try desperately to hold on to them. They are the life boats for the darker times, when the vastness of it all, the incomprehensible nature of life is completely illusive. So the question becomes, or should have been all a long... What would you do if you knew you only had one day, or one week, or one month to live. What life boat would you grab on to? What secret would you tell? What band would you see? What person would you declare your love to? What wish would you fulfill? What exotic locale would you fly to for coffee? What book would you write?"

Wednesday, May 22, 2013

Patient Freedom

Hey everyone!

This post stems from something that's been brewing in my mind for quite some time in my nursing experience. It is an unrealistic fantasy, but still one I'd like to talk about. Enjoy!

When patients are admitted to the hospital, a lot of things happen. They go to the ER, their problem either gets resolved or it needs further treatment or observation and they get admitted to a floor. When I receive patients, they only have a couple of orders to start out. These being medication orders and nursing task orders. When a patient then gets settled and is being taken care of by day 2-3 ish, these orders are probably bound to change a little based on the patient plan of care. Now, lets say a patient gets a headache- a normal headache that is completely unrelated to the problem admitted with, but instead related to the high amounts of stress from missing work and being away from family and stuck in hospital? So this patient with the headache asks me for a Tylenol. Simple request, right? Something the patient would naturally do if at home with a headache.

Well, I as the nurse, take this request. But if your doctor wasn't nice enough to order you Tylenol as a pain management preventive to begin with, I have to call the doctor for an order for Tylenol. Don't get me wrong, I don't mind doing this at all. But then when he finally calls back, it may be up to 10 minutes already. Then lets say he says yes, he orders it, it goes down to pharmacy and they can take up to 30 minutes for it to be profiled in your orders and in my medication dispense machine. So you as the patient have a headache that's bad enough for you to have reached out for help from me, and it may take me up to 40 minutes, 20 if you're lucky. Maybe up to 3 hours if something else- like CPR or something- takes precedence- if you're unlucky. For a Tylenol.

Don't you think this severely restricts patients freedom? Patient's involvement in their own plan of care? How do you think patients feel when treated like a 5 year old asking for something they can easily buy over the counter and take at home, without a doctors order?

So here's what I propose. What if we gave patients that meet a certain criteria a packet of OTC medications that they can take at their own will in the hospital? Some things included in these packs would possibly include: Tylenol, Motrin, Colace (stool softener), Benadryl, just for starters.

I realize that this idea comes with a lot of complications and responsibilities.  First off, only certain patients would qualify for having the privilege of having this pack. Some qualifications to start might include being in complete stable mental health, no drug abuse history or impulse decision making, and patient must have no dementia-short term or long term, and patient must be 18 or older. Those are just some qualifications I can think of on the top of my head. Also, there are some health qualifications. For example, someone admitted with liver cirrhosis or alcohol abuse shouldn't exactly be taking Tylenol. Or someone receiving a lot of Percocet or additional high strength relief NSAID therapy, shouldn't have access to their own reach of Tylenol or Motrin.

Next complication is cost. It would be very expensive to give each patient a pack, and to replace the supplies and stock of medications in the pack. But would it equal out in the high amount of patient satisfaction? In the press ganey scores? If you remember from my last post, happy patients make happy scores, which makes a lot more insurance reimbursement to hospitals.  Plus, giving a patient freedom to lose Tylenol and restocking that has got to be less expensive than constantly giving patients the most powerful narcotics such as Morphine and Dilaudid, right? I know that there will always be that patient population that purposely seeks out those types of narcotics, but for the patients that have minimal amounts of pain that could lead into a more serious amount of pain in the future, maybe having bedside OTC painkillers to start out with might help prevent that pain from exceeding too much in the future, therefore saving having to give the patient an expensive narcotic.

Take the following scenario as an interesting example:

A patient of mine not too long ago was in her 60's. She was admitted with kidney failure and was having a lot of back/kidney pain as a result of a recent stent placed. When I initially assessed her, I asked if she was having pain. She said no, but she was having pain earlier that day. I told her that if that pain crept back, to let me know and I could give her something to help with that. She said OK. Now, the way my hospital is designed is that we can sit in between two patient rooms and chart if we so desire. It's supposed to help with keeping an eye on our patients, but I see it as a peaceful escape from the nurses station sometimes.  So it just so happened that I was charting outside this patients room, the one with the kidney pain. It was a couple of hours after my initial assessment, and I overheard the patient talking with her daughter, small talk mostly. The patient must have repositioned herself and winced in pain, because the daughter asked "are you having pain, mom?" The patient must have nodded and the daughter said "Well you gotta tell the nurse, mom", in response the patient said "No I hate to bother those girls, they are busy."

Now I could write a book about that statement right there. I hate it when patients think they can't call because we are too busy. And all it takes is one time, one nurse to really have been too busy with something else - to make the patient feel that way. Other patients think we are too busy because they hear stories from family members or friends that work in healthcare. Others just genuinely don't want to rely on other people and don't like calling for something they need.

So in these examples, these patients could take their bedside pack and take something like Tylenol or Motrin. A lot of times, its enough to do the trick- especially with the elderly.

Something else to worry about in terms of cost is waste. How would healthcare handle leftover medications in these packs that the patient didn't use? For infection control reasons, anything that enters a patients room cannot be used again in another patients room. So we would have to throw good OTC medications away at the end of the patients stay. However this could be reduced with a couple measures: We perhaps can only give these packs to patients that have been declared inpatient status, those that are more likely to be there for longer than 2 days- rather than those on observation status (supposed to leave before 24 hours). Also, we would only stock about 2 doses of each OTC medication in each pack.  Also, analytical studies can be done to see which medications patients are using or not using the most in these packs, and we can adjust what we offer.

Another complication is how do we keep track of how much the patient has taken? Easy. Like I said earlier, these packs would be given to patients in sound mind, and would receive an education sheet on these packs AND drug information about all medications in the pack. They would sign a sheet on admission, upon receiving this pack- that they acknowledge the responsibilities of the pack and respect it.  They would be given a sheet that would be at bedside, for them to log what medication they took, and what time/date. Now either nurses can collect these sheets at the end of each shift, or every 24 hours (like midnight), depending on what system works best. Now the nurse can log into the computer what the patient has taken at this point, or can log when the patient needs more supplies.

Consider the following example:

The patient has 2 doses of Tylenol in her pack, amongst other OTC meds. She uses her 2 doses of Tylenol within the recommended time frame, every 4-6 hours. Now she needs more doses replenished in her pack. The nurse at this point would look at her log and make sure the patient would not exceed the safe amount of Tylenol per day, and replenish the pack- at the same time completing medication documenting in the computer.

It would be very hard for a patient to lie that they took less than what they said, because missing medication packets would be in the pack. If at any point the nurse feels the patient is using the pack irresponsibly or if the patient outwardly breaks the commitment signed upon admission, the nurse can take it away. Of course this creates confrontation between the nurse and the patient, confrontation that a lot of nurses would feel uncomfortable with. But its the same thing as confronting a patient about hiding cigarettes or unsafe medications or street drugs in their possession in the hospital. We've all been there and it sucks  to have to be the bad guy and take it away.

The way I see it is, patients are going to take whatever they want when they go home, regardless of the doctors firm instruction. There aren't cameras watching them at home, and patients are free to make their own choices upon their own judgment. So maybe if we watch them, watch what they are most inclined to do, we can better predict what they will do at home.

I know its a long stretch, and will probably never be adopted as a practice in the hospital. But I do think it would be nice. Maybe in futuristic hospitals. Although we have potential for our hospitals to be even stricter in the future, at the rate we're going now. So thanks for listening to my inventive rambling! Anybody in healthcare have any thoughts? Pros or Cons to this idea? I'd love to hear some other viewpoints!

Anyway, with much love,



1 comment:

Andrew Malpaso said...

Great article with some great questions. As long as the patients are screened as you mentioned, it makes a lot of sense. I look forward to future posts. Let me know if Discount Cardiology can be of assistance...