Sunday, January 31, 2010

A Patient’s Perspective: The Real Cost of Lack of Organization in Hospitals

I remember the hospitalization well. Dear Son had just been put on the ventilator and we were only on day 3 of the hospitalization. After a while, you get to know the routine. Not only is it hard when your child is in the ICU, but after you have done it a few times, you know what to look for in terms of whether or not your child is really improving or not. I have little sayings that I’ve coined over the years to describe the way things are going, such as:

  • “More people, bigger problem.” Back in 2006 when Local Hospital missed the MRSA pneumonia and I arranged for Dear Son’s transfer to Big Academic Medical Center (BAMC), he came to them in septic shock and acute respiratory distress syndrome. I had called BAMC on a Friday night to try to get someone to help me since Dear Son was ailing so bad. When he was admitted, they worked on him for fourteen hours straight in the ICU-the entire room was filled with doctors and people the entire time trying to get him stabilized.
  • “When the vent settings are increasing, things are bad, settings going down, things are heading in the right direction.”

  • “When you start to die, things go haywire.” This means that when you see they can’t control your blood pressure or your blood levels (potassium, etc.) and your skin starts turning gray, things aren’t going well. Of course your extremities are cold too since the blood flow is centered on your main organs.
  • “More frequent anything means you are in deep doo.” For example, if they are doing blood gasses more frequently, you aren’t stable. Chest pt and nebulizer treatments, same thing. Basically, anything that’s done every two hours or so, means you are in trouble.
  • “If the IV pole with the IV meds the patient is on, resembles a condo tower, meaning there aren’t any more places on it to place the pump, you are really messed up.”

It’s easy to get depressed when all of this is going on. Often times, I worry that Dear Son won’t make it or I wonder how many more times I can put him through this. Of course, when they make it, you are glad they made it but when you are going through it and watching them suffer, it’s not very easy and you question what you should do.

This past November, the hospitalization was especially grueling. Dear Son was a week away from his Make a Wish trip and we couldn’t go. He got the swine flu only after we couldn’t get the vaccine from BAMC, even though we set up the appointment weeks earlier. He was fighting for his life again, just six months after we were in the ICU in May from a hospital error (he nearly died when they used heavy sedation vs. general anesthesia to replace his VNS-the sedation suppressed his respiratory system, he got a mucous plug and his lung collapsed). Due to infection control procedures with the swine flu, I wasn’t able to leave the room. I soon developed the swine flu as well. That, coupled with trying to go home, bring all of my food down (they didn’t offer a parent meal), go grocery shopping while your kid's in the ICU and you are sick, plus lack of a hot meal in the hospital (with infection control you weren’t allowed to use the microwave or go anywhere in the hospital unless you agreed to wear gloves, mask and hospital gown 24/7 in the room with my son) made for a very long stay. But one of the most depressing parts of the hospital stay was the state of the hospital room. It was a mess.

I don’t think people realize how depressing it can be when everyone who enters the room brings in their supplies and just leaves them all over the room. Because I couldn’t leave the room, I watched each employee as they came in the room. Everyone would come in the room, dump the supplies on the counter in the room, do their task, throw 75% of it away, leaving the rest on the bed or the floor, and then leave the room. Due to infection control, they had to use a disposable supply to listen to Dear Son’s lungs. Each nurse put it in a different spot so each nurse spent time every day looking for it prior to doing his vitals. Even the same nurse couldn’t locate it when after she just did vitals the time prior. When they had to do an IV, they might look and see if they had the supplies, otherwise, they’d bring in a ton of supplies, use what they need, toss them on the counter in no particular order and leave. The amount of time wasted looking for supplies and money wasted on supplies was staggering. But it’s not just the nurses who don’t put things away, it’s the respiratory people too. I watched each one and over the course of a few days, even when Dear Son had nebulizer treatments every two hours, not “one” employee bothered to toss away the little plastic container that the albuterol came in, in the trash. Not one! All of them left it on the bed, on the tray table or in the room. If you don’t think this is a big deal, then think about this for a minute. If you aren’t in healthcare and are let’s say, in the business world, can you imagine for a minute going into a client’s place of business and leaving your trash on their desk, say a water bottle? What would the client think if you left an empty water bottle on the CEO’s desk before you left, or a Kleenex? Do you think he would want to do business with you or your firm? Do you think he would think you were “unprofessional” if you did that? Would you leave your trash on a conference table? Probably not. Only in healthcare will you find employees who think nothing of leaving trash with the client (patient). Probably because most healthcare workers don’t think of patients as clients.

The biggest drain on me was the state of the room. I knew with his vent settings increasing, we weren’t going home any time soon. I remember telling my mother that I would “never get out of here”. It was so depressing. I wondered if my Dear Son would live. And I couldn’t help but be depressed by the state of the room. I wonder if the staff ever stops to think about how their actions affect the patient’s mood or even how their messiness affects everything. Lack of putting things away in a patient’s room or a lack of order sends these messages:

  • A messy room generally indicates that you don’t care about something. If you like your job because of the patients, do your actions of not putting things away, reflect that?
  • How do you feel when you are in a messy room-whether it’s at home, a friend’s house or anywhere? Does it make you feel good and bring you up or does it bring you down?
  • Due to Infection Control procedures, whatever comes into a patient’s room can not be brought back to the supply room, so the patient is charged for these items. Do you think it’s fair to overinflate a patient’s bill due to your lack of organization? Would you like your hospital bill like this?
  • Many people disdain waste today and are into recycling and being green. Do you think your actions are “green” when you bring in excess supplies only for them to be tossed? Do you thing that’s being “green”?
  • What impression do you give your patient’s when you leave trash in the room or when you can’t locate simple items in the room because you misplace them. Do you think that gives the patient or caregiver the impression that this is a “magnet hospital” or that you are a “top 100” hospital?

  • This is a hospital tablescape I created with the plastic plates I brought from home, the flowers Dear Son received for his birthday. I created this because I was happy that Dear Son was extubated the night before I hoped he was getting better. To see more of my tablescapes, click here.

  • If you were critically ill and recovering, let’s say in your own bedroom to help give you a picture, would you feel better if the room was a disaster (mess) or would you feel better if it were clean? Would you feel better if someone brought you a fresh glass of water or would you think it’s o.k. if every time you needed something that people brought it to you but left the old glasses, old water, trash, etc. in your room?

On or around ten days of the hospitalization, I had enough. While I certainly pick up after myself, I decided to get the place organized. Remember, I was deathly sick myself with the swine flu and an ear infection, but I needed to do something since I was so depressed. I called the nurse and asked for six empty bathing bins (these are the pink bins that hospital have with bath supplies in them) and attached labels to them. I put changing supplies in one, feeding supplies in another one, monitoring supplies (anything from electrodes for pulse oxygen to heart rate leads, thermometers and so forth) in another, etc. until it was all done. I organized their needles, syringes and flushes the best I could since I didn’t have anyone to ask about all of the tasks they used these for. I made everything as nice as I could. I decided that I may not be able to change their habits, but I would ask them to throw their trash out when they were done with a task, assuming they didn’t.

A funny thing happened when I organized the room. The nurses stopped when they came in the room. They attempted to put things in the right order. They saved time when they did their tasks because they could find things. They commented on how nice it was. When the respiratory people came in, if they tried to leave without throwing out their trash, I simply asked them nicely to throw it out and mentioned matter of factly that I have to live here all day and I’d like to keep the room clean. If they didn’t then I would pick it up and throw it out myself.

Granted, I am a professional organizer so I notice these things but I don’t think that I am being overly picky when I want a patient’s room to be clean and neat. (I should also tell you that I’ve worked in the corporate side of healthcare for many years and oversaw operations as well so I tend to look at how people do things in order to save time or money.) I don’t think any of us want to spend time in a hospital that isn’t clean or is very messy. Given a choice, you always think the hospitals that aren’t clean or are very messy don’t give good care.

After we got out of the ICU, we went down to the main pediatric floor. I did the same thing and used the pink bins. I’ve done this for some time now but I guess it’s never been as bad as it was in the ICU this time. I remember people now by how they leave the room. There is one little old lady that draws Dear Son’s blood. She leaves a mess every time tossing only 75% of her trash and leaves bloodied cotton balls and band aid trash on the bed, every time. I know which cleaning people will always clean the floors and which ones skip over that task. I know which nurses put their tools away when they are done and which ones aren’t organized.

And finally, I should mention this before someone brings it up. I do realize that nurses are very task oriented and that they are very busy and don’t have time to “organize” a room. I am not expecting that. What I do expect is that a healthcare worker do what the rest of us do: put things away when we are done and take care when bringing supplies into a room.

In the end, I came to a few conclusions:

  • The best nurses were the best managers of their time and had good organizational skills.
  • The worst nurses were poor time managers and had the poorest organizational skills. While I am careful when I say this, it was easy to see the examples. For example, the ICU night nurse, who had only Dear Son to manage, waited until 6 a.m. when we were changing him and wanted to give him a bath. Both radiology (chest x-ray) and respiratory were outside the room waiting to do their tasks when she wanted to start a bath. And yes, she sat at the pc outside the room all night looking bored.

  • 90% of the nurses never made a list of supplies that were needed for the room prior to fetching them. A list would have saved them time from running back to the supply room again and give them "more time" in their day. This was especially problematic when they would attempt a procedure with another nurse, find out they don't have the supplies, start the procedure and send the nurse running back to get more only to find when she returned that the other nurse forgot to mention one of the supplies they need. From an operations standpoint, I might suggest hospitals create a standard supply list for each procedure, then when nurses are rushed, they get what they need without having to think about it.
  • When given a list of supplies that I needed, only about 70% brought back the items on the list. Some of them forgot they had a list or forgot to read it. I know this because they told me even though I didn’t ask. Keep in mind that in the ICU at this hospital, the nurses only have one or two patients max so often Dear Son is their “only” patient, unlike the pediatric floors.

So the next time you spend time in a hospital or if you are a healthcare worker, ask these questions:

  • Am I picking up my trash and putting things away when I am done?
  • Am I padding the patient’s bill by bringing in excess supplies?
  • Am I being “green” when I overstock a patient’s room with excess supplies because I didn’t think about what is needed?
  • Am I upholding the hospital’s image of a “top 100” hospital or “magnet status” when I do these things?
  • Would I feel good in this hospital if my room were left in this condition?

Keep in mind, we are all busy at our jobs today and that is no excuse to leave our trash and not be organized. There are a lot of people that would be happy to have a job.

Photo of Dear Son's hospital bed (with his Tendercare headboard) at home.

And the next time you are in the hospital, take a look around. What can you do to help keep things neat and organized and make it easier for everyone? After all, doesn't everyone feel good sleeping on clean sheets in a nice clean room?

Note: Dear Son is eighteen years old and suffers from a progressive neurological disease. In addition, he has intractable seizures, dystonia and is severely retarded due to a random mutation of the ARX gene. He was hospitalized in November 2009 for 26 days, 24 of which were in the ICU at a Big Academic Medical Center, for the swine flu and a viral pneumonia.


Anonymous said...

you raise several excellent points in this post, not only from a patient's perspective, but that of a former healthcare employee and professional organizer.

I suggest you send this article in to the BAMC's internal newsletter department to print in their employee newsletter.I'm sure they would benefit from this.

Sending hugs...

June Cleaver said...

I've been a long time reader of your blog, and check in just about every day but this is actually my first comment.

First I'd like to say, I hope DS is doing well today. I wait anxiously every night as your blog loads and hope for good news.

I found todays post interesting because it touched on a subject I had to deal with personally. When I was pregnant I spent an extended amount of time in the hospital on very strict bedrest (nearly 6 weeks). While I was technically healthy, I couldn't get out of bed except for quick potty breaks and a shower every other day. My room looked messy but, in fact, was the way I needed it to be so I could reach things like drinks, food, magazines and books, etc. Nothing irked me more than when a nurse would come on shift and come in my room and start to "tidy up". I understand she may have been trying to be helpful but it was very frustrating to realize she had moved something I needed/wanted to somewhere I couldn't reach because it was neater. Then I didn't want to call a nurse in just to hand me a book because I know nurses are busy and aren't there to be my maid.

Now, the trash thing, yeah, the kind of botehered me. I don't recall having a nurse leave any trash on the bed but occasionally on the counter.

I just thought it was interesting, the different perspecitves on nurses keeping the room clean. While I can understand why it bothered you, and it absolutely would bother me too if it was my child, I wasnt' so bothered when I was the one in the hospital.

Carrie said...

I have never had this experience in a hospital before, and I find it appalling. I wonder if the nurses feel it will take more time to clean up than it will, or if they are thinking, "this is the cleaner's job, not mine". I have never had a nurse not clean up after her/himself when I or my child have been in the hospital. And honestly, it doesn't take long. When I worked in EMS, if the patient wasn't emergent (most weren't) we spent 20 seconds scooping up wrappers and gloves, etc. before we left. No one wants to come home after a long night in the ER waiting room to a pile of trash. Besides, leaving stuff around with blood, etc, is a biohazard. I do hope you make the hospital aware of this issue, as well as the organizational one.

Anne said...

You may have a calling here being a professional organizer and having had such intense hospital experiences. Seriously, just this article alone is incredibly eye opening for a hospital administration willing to change.
When Dustin was little I remember an issue for him being in the hospital was the noise level.
THe constant over head announcements on the av system, the rolling carts outside, the loud talking among staff outside his room.
This last year I noticed changes in the noise issue: Staff using cell phones,no over head pagers, more architectual design elements that considered noise reduction, etc. IT must have taken conscious thought that noise levels harm healing in order for these kinds of changes to take place. IT will take conscious thought re: clutter and the stress it creates in order for hospitals to take on that issue also.
COntinuing to pray for your DS. Anne

Canucker said...

DM, you have hit on a huge pet peeve of mine.

I don't know how many times when Joe was in hospital, a nurse/blood team/resp therapist would come in, work on Joe and, instead of throwing the garbage in the waste bin right beside his bed, would just drop the garbage on the floor.

Every day, there would be a collection of alcohol swabs, kleenex, paper wrapping - even empty formula containers - on the floor around his bed.

Worse, a couple of times I found syringe caps/needle covers UNDERNEATH Joe in the bed. Yes, he'd end up laying on the darn things. You can imagine how uncomfortable that would be, not to mention the risk of skin breakdown.

This also happened when my mom was in hospital, so is likely a common practice at most hospitals.

I also remember one time, at a very large city teaching hospital, there being blood droplets on the floor in the bathroom. One of the patients who shared the room with Joe mentioned it to me, saying that he was curious how long it would take for it to be cleaned up. Cleaning staff would come in and out with mops, but those blood droplets were on the floor for 10 days before someone actually cleaned them up.

It is no wonder that there are so many hospital borne infections, if this is the way the rooms are kept clean.

Off my soapbox now!


Christina said...

Very interesting to read your post as a PICU RN Dream Mom! I have definitely seen what you describe- and I probably I have been guilty of some of it. I love to organize though so when I was working I always tried to keep my patient's rooms as organized and picked up as possible. (A lot of times however, parents were the ones who then messed everything up- not everyone has your perspective on this issue ;) The trash thing always bothered me too- I never understood why anyone would leave trash by the bedside.
Although there is no excuse for what you experienced, I think there were a couple factors that made things worse. First of all, the isolation status, as you note, makes everything so difficult. It's not cost effective, but it is time effective for me to grab a pile of things I might need before I gown up and go into the room. Obviously once those things are in the room, they can't come out, and they pile up, but there is nothing worse than having a child suddenly decannulate their trach or something similar and there not being tubing or tape or another relevant supply right by the bed. So most nurses operate on the "well i'd rather be safe than sorry". Also a lot of procedures in health care don't have a definitive list of supplies. One nurse may swear by a certain type of cannula for inserting IVs and another may never use that one. And you don't know sometimes ahead of time what size supply a patient will need until you are halfway into the procedure- so you grab several sizes when you are preparing for the procedure. So a list of supplies would not help in every situation, although I agree that it could help cut down on waste.

And then there are the kits they have for intubation, LPs, etc- they tend to have random other supplies in the kit that don't get used for that procedure but linger in the room- no one really wants to throw them away but no one uses them either. So it all piles up.

And I agree that some nurses seem to not use their time wisely- but sometimes there are other factors. I know for myself working nights that I did not give baths to my bigger patients until I had the help of other nurse to help turn and position- and sometimes I couldn't get this until 6am. Two patients in the ICU can be an incredibly heavy load, depending on how much support and help you get from your charge nurse and other staff. Also I frequently had a running list of about 15-20 things to keep track of in my head (and on my paper- the sheet that nurses call their "brain")- esp when things were busy- between med doses, docs calling, scheduling xrays, etc,etc and to be honest I know that I forgot a parent's request for something many, many times- I would always try to apologize and remedy it as soon as possible- it would just tend to slip in the "triage" of my mind.

It however sounds as if the ICU you were in has some big flaws that are being reflected in the small details.

And no hospital I have ever worked in had a very good cleaning system. Housekeepers are usually always overworked, not well trained and not particularly thorough.

I agree with the previous poster that you should sent this to BAMC! I think you should also look into advising on design of hospital rooms- I find that even the new ones I have worked in are poorly designed- I was always tripping on cords and trying to extricate IV polls, etc, etc. I don't think they ever consult nurses or parents about the design features. It always appears that there is no thought about the interface between the room itself and the medical equipment that will be used in the room.

Catherine said...

I agree with those who have suggested that you send your article to BAMC.

I did not see anywhere near this degree of mess and disorganization or waste of supplies at any of the many hospital room I visited this year. Though no one organized or did much cleaning up of my MIL's personal space, they certainly did not add to the disarray. I would organize her space when I visited.

I did notice quite a bit of inefficiency in time used. I thought the nurses and aids should know the daily schedules as I learned them in a few days and not let so many conflicts occur. I would see nurses have hours of time free and then decide to do some activity like a bath when it would conflict with something else. This would occur even when the conflict should have been obvious.

I called the floor and later the nursing home every single morning at 6AM to ask them to awaken MIL and have her use the toilet. Otherwise, she would awaken right around 7AM which is shift change time, and would wet her bed since the two shifts were too busy comparing notes and starting/ending their shifts. Not one hospital or rehabilitation center could consistently take care of her at 6AM. If I did not call, it did not happen.

Anonymous said...

I hope you and your son are doing okay.

What are the cost figures on waste like you've described? How much of the health care cost issues would disappear if there wasn't so much waste?

I was hospitalized for 2 weeks once. My room didn't get cleaned until my mom arrived.

Dream Mom said...

Thanks, everyone.

June-Thanks for commenting. As bloggers, we love comments and I appreciate you taking the time to do that. I do understand what you mean-Dear Son was in a rehab facility one time and his former classmate was in the other room, she had to have things close as well since they didn't have much staff to help her. She was recovering from her fifth hip surgery at 15 years old.

Anne-The noise issue was big too. Dear Son had one of those beds to prevent bed sores so the noise of the bed, the noise of the vent, the noise of the leg pressure cuffs he had on plus the normal noise of the hospital was a lot at times. Not being able to open the door with infection control made those noises seem louder hence more stressful.

Christina-Your point is well taken on nurses liking different supplies. I should mention that we had a staggering number of supplies that no one was using-say 20 or so of different types of syringes (I know because I sorted them) and all kinds of stuff. I also try to make it pretty easy for the nurses-I talk to them at the beginning of the shift and tell them that I give all home meds, do the diaper changes and I pretty much know what is scheduled and when so it's not as intense as other patients, but yes, it is still the ICU and I do realize how busy they can be!

Canucker-I've found syringes under DS as well. I appreciate your comments as I know you have had similar length of stays with Joe.

Everyone-Thanks for all of the great comments. One thing that made this hospitalization more challenging as well was how long it was-26 days. When you are in for the long haul, even minor issues get larger because around the fifth day or so your patience gets a little shorter as you repeat things and answer the same questions for the 1000th time, lol! I think a lot of the messes could be minimized too if people layed a cloth or something down and then set their tools or supplies on it...versus setting everything near the patient and in the bed and then hoping for the best at the end that they got everything.

Anon-I'd love to do a cost analysis at the end of the supplies that are left in the room. I understand people bringing in more items that are needed at times but there were so many blatant ones of bringing in massive amounts of supplies that weren't used or would never be used. Also, I should mention that at the end of the stay they let the patient take home any supplies that aren't used (because we've been billed for them) however the quantities of stuff that is left is so large, it wouldn't fit if I did want to take it home or there is just so much that I'd never ever use it all.

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