[ler_]

I'm a nurse and I find the 7th point on the post especially relevant. I will add a disclaimer that I never worked in the ICU so I can't speak for what happens in that type of unit.

There is a serious issue with the flow of information in healthcare, (or at least in the U.S, I never worked elsewhere to know if it's any different). But If you find something during your shift which will be important to know later on, it will certainly be lost as soon as you are off for a few days, or even as soon as a new nurse comes on. To think of a somewhat crude example, if you find out that it is much easier to obtain a blood sample from the veins on the left arm of a patients vs the right, many nurses will still stick the right arm countless times hoping to get something.

And you can leave a chart note about things like that or speak about it during report, but for the most part few people will think "hm, I wonder what everybody else had to deal with." They are probably too busy handling a thousand different things happening all at once. And, even if that is not the case, from what I observed it's simply not part of how things are done. And very often patients will get (justifiably) angry, saying "I've been complaining of x thing for days!" or some version of that. I think it would be much better for both patients and healthcare staff alike if there was a greater emphasis placed on focusing on the series of successes and failures that happen over the course of someone's care, not just seeing it as a single shift or a single problem happening in some isolated point in time.

[watersb]

> I think it would be much better for both patients and healthcare staff alike if there was a greater emphasis placed on focusing on the series of successes and failures that happen over the course of someone's care, not just seeing it as a single shift or a single problem happening in some isolated point in time.

I once had a week as a patient at the Mayo Clinic in Scottsdale AZ. There were many remarkable aspects of care there versus the impossible mess out here in the other world.

But the single most significant aspect of care at Mayo Clinic is that the doctors and nurses and techs get to read your chart before seeing you.

That's it. You write something in the chart, it doesn't get tossed. It might not get parsed completely, but the essential info is there. And the staff does not get penalized for reading it.

(The other big reveal for me at Mayo was the sheer scale and throughput of the system. Healthcare at Mayo did not cost more than healthcare in my small town. It. Cost. The. Same.

It took six months to get in, I had a week, then it was someone else's turn. I presume that the high paying "celebrity" customers can get seen more regularly. So it's not perfect. But holy cow I wish it were easier for healthcare professionals to do their job.)

[nradov]

In general for US healthcare providers there is little relationship between price and quality. They have to meet certain quality standards in order to operate at all, but outsides few limited areas they don't get paid more for delivering higher quality care. So quality (or lack thereof) tends to come down to organizational culture and management.

[Aeolun]

For someone that hasn’t heard of they Mayo Clinic other than through webite articles describing medical conditions, are they that desired/high-quality?

[throwaway892238]

This is similar to problems that would often happen in car manufacturing. The person assembling the car the standard way finds a problem, but the problem doesn't get addressed, or information isn't disseminated correctly, so the cars go out with problems. Toyota developed a methodology whereby such problems are addressed immediately and fixes were disseminated immediately, and would not send a car out otherwise. That kind of obsessive attention to detail and "crazy" focus on quality is what made them the top automaker. But most businesses are led by management that refuse to believe that being slow or focusing on quality first will result in more profits. And none of their lower-level workers are trained on how to spot and fix quality issues, nor are they told to care.

Hospital systems are the same way. Moronic, scared management that is fine with these kinds of problems as long as the dough keeps coming in, ignorant of the fact that more dough would roll in (in addition to better health outcomes, which of course is not their first priority) if they would just focus on quality.

[retconn]

This is my favourite ever episode of This American Life, about NUMMI, the shop floor level and individually fraternal miracle that was created by workers at Toyota and GM in a CA GM plant, until management shut them down:

https://www.thisamericanlife.org/561/nummi-2015

[ler_]

Very cool point. In my ideal world a whole nursing unit or facility would be a self-correcting operation. There are problems that a nurse on the floor can fix but it takes up time. If those problems were prevented to begin with, it would be much easier. I would like a system where the nurse notices a problem and simply sends it up to a manager / supervisor who 1) finds a way to handle the immediate problem and 2) always writes up and enforces a new guideline to prevent it from happening again.

Good managers probably already do this, but healthcare has a very short supply of such people. It would be great if this type of improvement were the standard across the board. Let's say, for example, that you have latex and non-latex foley catheters mixed in the same bin in a supply closet. Your patients with latex allergies have gotten a latex catheter put in more than once and it now becomes a problem. Well, someone notices the issue, sends it up to someone above and now there is a new guideline to place the different catheters at least 3 feet apart, or something to that effect. It almost sounds silly, but people would be surprised how many of these mistakes happen over and over again due to equally silly reasons / lack of basic prevention.

[Aeolun]

> Moronic, scared management that is fine with these kinds of problems as long as the dough keeps coming in

That sounds like it’s the same in any sector? Especially IT.

[giantg2]

Not lost, but I've had a lot of trouble with information being captured incorrectly.

Things like date are pretty commonly messed up. I've also had doctors and nurses put their own, incorrect, interpretation on information I've given them when they repeat it to others. When I say "my child wasn't eating and drinking normally and had half of what they normally do throughout the day", it's incorrect to say "the patient didn't eat or drink all day". That's the type of shit that can look really bad if it's recorded and looked at later. But it's like nobody cares if they record things correctly.

I've also had trouble with people not doing anything with important information. Like maybe you should slow down on the morphine and oxy if the patient is answering fewer basic questions correctly than when they came out of surgery. But it's OK if they can't tell you their own birth date - just give them more and later order a CT ro check for a stroke. Sorry guys, but it should be pretty obvious you're putting them into a opium stupor...

[civilized]

I've noticed recently that there are people out there who simply can't accurately listen to others and repeat back what they say. It's not about being stressed for time, the skill is just not there. You say ABC, they write CBD, and they have no idea it's not the same thing.

[nradov]

OpenNotes can help a little with this, but only if the patient or one of their caregivers has the time and ability to do a detailed review of every chart note.

https://www.opennotes.org/

[gundmc]

This comes up every once in a while when discussing the crazy 24+ hour shifts that doctors in residency are often assigned. One argument in favor of keeping the hours is that continuity of care is by far the factor most strongly correlated with good patient outcomes. So the argument goes that a change in caregiver is more detrimental to the patient than continued care from one doctor even if that doctor is sleep deprived.

I am not knowledgeable or qualified enough to weigh in on this, but it's something I've heard cited by multiple friends in the field.

[haldujai]

As a physician, shift length is honestly a red herring.

As much as I hated doing 24-28 hour shifts on inpatient services, continuity of care does matter and errors do occur in handover.

You have to keep in mind that medicine between 12am and 6am is what we call “keep people alive.” 6am to 12pm after an overnight is for handover.

You’re not trying to diagnose a new illness overnight or make changes in management, your job is to deal with acute overnight concerns only. Furthermore, you’re supported by services such as RACE (an in hospital emergency response team) so you’re not dealing with critically ill patients alone. If you’re on a surgical service and need to go to the OR, staff/fellow + senior residents come in to help.

Acute care services where you’re seeing new/undifferentiated patients and need to be on your game, such as ER and radiology, tend to limit shifts to 8-12 hours.

[20after4]

Thanks for sharing!

Even outside the medical field, it seems like most humans are pretty bad about both writing down and consulting notes. Even worse for the notes written by another human. We really aren't particularly good at transferring knowledge / experience and it takes a lot of effort to do a good job of it, so most people don't even make much of an effort.

This really seems like a problem that still needs a lot more attention, especially in critical places like hospitals and really any long term crisis response situation where there is important knowledge gained over time with a (poorly handled) hand-off to successors.

I had some exposure to formalized incident management[1] at a previous job. There, I learned a few formalities and practices that seemed valuable, especially assigning a single coordinator to be responsible for continuity of information and coordination between many independent actors over a long period. The coordinator role had explicit hand off to their successor where the stated purpose was to transfer important working knowledge and prevent the kind of problems you (and the article) describe.

1. https://en.wikipedia.org/wiki/Incident_management

[ler_]

I liked the way you framed this as something universal. Is there any field where one can quickly reference knowledge from your peers to just as quickly solve a problem in practice? Maybe it's asking too much. Though I suppose it wouldn't be necessary to get everyone on board with such an idea if you have that single coordinator who everyone knows as the reference point. Although, if you think about it, even then that person would have to be available 24/7, which isn't feasible.

With patient documentation specifically, what I would really love to have is a simple search mechanism for patient notes. This still wouldn’t solve the problem of getting everyone to capture the right information. But assuming the information is there, and I'm having a real hard time sticking that right arm, I would love to be able to search for "arm", "blood draw," "stick" and see what pops up. I hope it's not something I missed entirely, but I have never used an EMR with such a feature.

[mncharity]

> a single coordinator to be responsible for continuity of information and coordination

Years ago I saw a talk by a VA (US veteran's health care) thoracic surgeon, who was trying to entice tech folk to address the following problem. A surgeon is both team manager and skilled technician. When heads down in the technician role, the management role suffers for lack of attention. Especially severely at the VA, which did randomized staffing of operating teams, so you don't get the "group mind" and practiced gap filling of team which stays together. So surgeons would say "do X", and being distracted, not notice the order was dropped, and then proceed assuming X had happened, with regrettable results. The VA surgeon envisioned a voice system which noted the request, waited, and then whispered a nudge in someone's ear "did we do X?".

[heavyset_go]

I think this is a symptom of hospitals being understaffed, whether that's from a deliberate lack of hiring or an actual labor shortage. I feel like many of the problems in this aspect of healthcare could be solved if doctors, nurses, etc weren't run ragged with insanely long shifts and expected to care for a ton of patients.

[throwaway2037]

I don't know how to respond to your post. I'll try: Money. Skilled people cost money, a lot of money. I disagree with both of these: <<deliberate lack of hiring or an actual labor shortage>> They are making do with the amount of money that is available. It would be wiser to focus on why healthcare is so expensive in the United States compared to other highly advanced countries -- France, Germany, Netherlands, Finland, Japan, etc.

[civilized]

I wonder if part of the issue is having to remember a bunch of random things about a bunch of different people so that you can apply the information at the relevant time. E.g. the left arm is easier to find a vein, but this information is only useful for 30 seconds a day during a blood draw, so it's hard for people to remember or even retrieve (how much notes do you have to read through to find this info?)

If the info were somehow magically there when needed, it would be used, right?

[Aeolun]

Like, google glasses but for ICU workers?

[jillesvangurp]

I have great respect for what people like you do. I've lived all over Europe and a have some first hand experience with care in different countries. Universally, nurses are heroes and it's just a very hard and often thankless job. Not to mention under paid in many places. But there's a big difference in what I would label as institutional stupidity between different countries. Some countries feature a lot of mismanaged health care facilities where things are bureaucratic, slow, etc. For example, Germany is hopeless on this front. Being in the health care system here means an endless sequence of forms that need to be filled in with the exact same data points over and over again and over worked nurses dealing with all that crap on top of their normal job. It's beyond stupid. Nobody shares any data. And it's inefficient and dangerous for patients because no doctor or nurse can possibly have the full picture.

My home country the Netherlands is very different. My father had a stroke quite recently and spent some time in a very modern hospital where they are applying some of the latest insights for patient care. So, he was obviously hooked up to lots of equipment and intensely monitored. However, this hospital has separate rooms for all patients. Reason: it's best for the patients and helps them recover more quickly. Basically, more privacy for the patients and less restless nights. There are no TVs in these rooms. Instead patients are issued ipads with entertainment options and access to various things like indicating dietary preferences. Nurses carry ipads as well. Everything is digital. There are no paper charts in sight anywhere.

The rooms were modern, clean, and clearly optimized for making patient handling easy and straightforward. What struck me was the attention to detail and level of pragmatism in this. For example, my father's room had wall mounted hangers for folding chairs. These are for visitors. And when they are folded they are not in the way. The room had a whiteboard and a locked cabinet for medication and supplies. The doors are sliding. So, it's easy to move things in and out. Like beds, wheel chairs, equipment, trolleys. Etc. And so on. Just a really well designed and thought through design and architecture. Well managed and efficient.

BTW. This is not a private hospital: my country has a mandatory private insurance system: they can't reject people, people must be insured, and they can switch insurer. So, insurers mainly compete on quality care. Miserable patients and inefficient hospitals are bad for business and they are working to fix any issues there with hospitals. Which is why everyone, rich or poor, gets the same quality treatment in this hospital. It's way better than the private insurance I pay for in Germany. Way cheaper too. My German insurance is about 5x the price. I've been in a hospital here a few times and they can learn a thing or two about efficiency there.

[Aeolun]

The only bad thing about Dutch healthcare is that, if you are not acutely in need, it can take months to get a spot.

[tbihl]

That makes sense. When I worked shiftwork (8 hr days), you'd get good info from the people before you, but not about the people before them (after you), so you'd often have the same problem in that rhythm. But we would stay on shift for months on end, and obviously that helped with all the knowledge walking away all the time.