Building a new hosptial...bedside charting...meds in the rooms?

[NRSKarenRN, BSN, RN]

I did per diem at a local hospital that had meds. supplies and bedside charts and LOVED it once I was adjusted to the approach.

I would ask designers to give you names of hospitals in your area so you can see this system in practice---get a committee together and visit several units before you give up on idea.

[deespoohbear]

Originally posted by CANRN

At the hospital I work at, we have our charts, meds, linens, syringes, IV tubing, tape, alcohol swabs, etc all in a cabinet just inside the room, a sink etc is also right there with a stool and a desk. We can chart, in the room but out of site of the patient, get our meds, etc and it's great! They call them "nurse servers" they are stocked daily by our unit hostess. Blank physician orders, nurses notes, and other chart items and the entire chart are kept in this locked area. Sure saves on the feet! I love it.

So what do you do when a physician calls in and wants lab or xray reports? Do you have to run to each room then and get the chart? What about ancillary departments that need access to the chart such as social services, therapy, resp, etc? Then what? I can't imagine how it can save time that way. It seems like I would be locking and unlocking constantly....

[Dr. Kate, BSN, RN]

I've experienced this done two slightly different ways. One was original design, the other retrofit. The first worked better than the second.

Original design: narrow hallway, 20 bed unit in 5-4 bed "pods" two rooms on each side of the hall. Each room had its own med drawer with breadboard for writing, the cabinets held general suppies for both rooms bandaids, cups, alcohol, PPE, etc.), a charting desk with phone for each two rooms, computers for each pod. This worked well except the med drawers were almost never locked and didn't have double locks. Keys would get lost and there were seldom enough sets for each nurse to have their own. It also increases the amount of stock supplies that need to be available to each unit. The charagble item cart was at the end of the hallway. There was no central nurses station. If utilized for the type of nursing it was designed for--primary with each nurse having 4 patients--it was a great system. Because the meds were almost but not quite in the Pt's room, the nurse could prepare meds in relative peace, have a med book available, and easy access to the chart (kept in a drawer of the charting desk.) The system breaks down when a nurse has more than 4 patients, or a group of patients not in the pod. Because of the med security issues, they have gone to a central med cart for all patient meds.

The retrofit moved meds and nonrefrigerated IVs into locked cabinets in the patient room. These were two bed rooms, but one cabinet (med errors waiting to happen.) There never were keys available for each nurse so you had to go looking for someone with a key whenever you wanted to give anything. Cabinets got left open for obvious reasons. It took getting used to but was eventually workable, if not ideal. The charts were not kept near the patient rooms so if you had a question you had to go back to the desk, find the chart, check what you needed to know, go back to the room, etc. Very cumbersome. There were security issues.

The biggest problem with both systems related to missing meds. If missing meds are a chronic problem and you have to create a slip for each one or even each patient, immense amounts of time can be spent fussing with that paperwork. It's bad enough if you are doing it from a cart where you can check for all the meds for all your patients at one time and send missing slips to the pharmacy in a large group (know what one of the issues is where I work?)

My concern with the proposed system is that it does not lend itself easily to the new medication systems and other technological tools that are coming onto the market. You

You don't mention whether or not there will be a central nurse's station; where the charts will be kept; where physicians will access their patient's information, if they will be using the computers, etc.

If you look at hospitals you can tell what kind of nursing care delivery system (team, primary, functional) they were designed to support. They work well for that one system, for any other they end up jerryrigged and cumbersome. Currently working nurses really need to be consulted on these things. Pity they don't seem to be.

[deespoohbear]

Originally posted by NRSKarenRN

I would ask designers to give you names of hospitals in your area so you can see this system in practice---get a committee together and visit several units before you give up on idea.

Great idea Karen. I just e-mailed my manager and asked her about arranging something like that. I think that is only fair.....at least give us a chance to see what we are looking at....Thanks...

[deespoohbear]

This is the funny part. Our manager is all gung ho about bedside charting. She said just our nurse's notes and flow sheets will be kept in the room, the rest of the chart will be kept at "mini" nurses' stations...in the halls. Believe it or not, some of the docs actually do look at the nurses' notes....Supposedly we will still have paper charts (does that make sense? to build a multi-million dollar facility, but not go to computer charting? ) I am not sure what kind of nursing we do, I guess it would be called primary nursing. We usually have 6-8 patients per nurse on days (8--10 on some nights) and each nurse has her own CNA usually who does the baths, bed changes, pass water, ambulate, etc....The nurse is responsible for assessing the pt, reporting pertinent labs, med pass, starting IV's et so on. We do have ancillary departments such at resp, and lab does all draws except for central lines....

I mentioned to our manager about having a chair or stool for us to sit on when we are charting, but that also fell on deaf ears....

[CANRN, MSN, RN]

Originally posted by deespoohbear

So what do you do when a physician calls in and wants lab or xray reports? Do you have to run to each room then and get the chart? What about ancillary departments that need access to the chart such as social services, therapy, resp, etc? Then what? I can't imagine how it can save time that way. It seems like I would be locking and unlocking constantly....

Our unit secretary has access to all the reports on the computer. If a doctor calls and wants it, he gets it from her, and the reports are taken to the charts and clipped to the front by the unit secretary first thing every morning before docs make rounds and if the doc comes in, writes an order and just leaves it in the chart, he gets written up. He must take the order to the desk! Imagine that!!!!

If the doctor calls and needs to speak with the nurse caring for his patient, our secretary pages us (we carry beepers) and tells us who is on the phone and what they want, we can either take the call right there, or walk to the patient's room and take the call from the phones in the rooms near the nurse server's. These are not the patient's phones, they have their own.

[CANRN, MSN, RN]

OH, ancillary services knows where the charts are, they can get them for themselves. Everyone knows the system, and they are aware of privacy policies, etc so they lock and unlock themselves. Only the nurse has keys to the locked meds.

[MrsK1223]

I did clinicals in nursing school in an inpatient cancer center where they had this small section before you enter the actual room(the bathroom, then the bed area)It had a desk with a stool and locked cabinets with commonly used resources ( ex, drug books.) The chart and mar was there. We did our assessments and treatments and could shut their door if they wanted to rest and I could sit at the desk/counter next to the room and do my charting and preparing medications or tx's. I really liked it as a student. It helped me to concentrate on my charting and on that one patient, but you still could hear and be aware of the rest of your patients. I never had a problem getting my meds out in time and it was very organized unlike the med/surg units I've been on where I spend more time running back and forth to a cart. Each room had this little desk space with cabinets and each cabinet was stocked with things specific to the patient and other necessary items that you never know when you might need them. We could go and sit with the patients and chart too. Their rooms were really nice...they had all cherry furniture except the hospital bed...looked like a really nice bedroom...wall paper and pictures, flower arrangements too.

[legsmalone, RN]

I too have been at a hospital with this type of setup, meds in room with chart racks that lock outside each room. It was nice, but my only issue was the chart racks. I amrather tall (6'1") and my back was always killing me after charting because of the height level these racks were at, I had to kinda lean over. Otherwise, it wasn't a bad setup, but I think I prefer the traditional charts at the nurses station, meds in carts like I work with now.

[Flynurse]

As a student nurse I had the opportunity to work with something as you are describing. They were called Nurse Servers. However, they were just outside of the room. They actually looked like a cabinent set in your kitchen: Top cabinent, a counter 2'x2', a drawer, then another cabinent below that. All doors and drawers were locked for patient confidentiallity. The MAR, Pain sheet, diabetic sheet, Assesment Flow Sheet, Care plans, were on a clipboard for the nurse's easy access. The patient's chart was also locked in the Nurse server, so the doctor could access it immediately after seeing the patient (Believe it or not the physicians made less mistakes when this was in place). It was the most wonderful thing I have ever come in contact with in my Nursing career. Almost anything specific to that patient was within reach, immediately! What could be better than that? The nurses station was the core of the unit so that if you wanted to sneak the clipboard/chart to a place to sit you easily could, while watching for someone else who might be looking for that chart.

I could go on and on. I wish all hospitals were equiped with these Nurse Servers! The really are a God send!

[cactus wren]

Well, Deespoohbear...I think that you can relax...If the new hospital construction goes as well as most...it will be 3-4 years before it`s even almost done....and I know of one small hospital that took 5.............

[deespoohbear]

Originally posted by cactus wren

Well, Deespoohbear...I think that you can relax...If the new hospital construction goes as well as most...it will be 3-4 years before it`s even almost done....and I know of one small hospital that took 5.............

I think the target date is July 2005.....to open....so we will see...

I guess I wouldn't be totally opposed to the nurse servers IF they were done the correct way...but what the managers speak in theory and what really happens are two different things. I guess I mean, if they are going to do this, I want them to do it correctly and not half-azzed the thing. Our hospital administration is notorious for only doing things halfway....