Proactive not Reactive

[AbigailJo]

Hi all,

I’m currently working at a teaching hospital in NYC that is very good but slightly disorganized when it comes to workflow. I am trying to brainstorm how it could be improved. From my perspective, the residents are very overwhelmed and completely unsupervised on nights. When they admit patients there are usually no “standing orders.” It’s very much thrown together. Simply a diagnosis, diet order, some home meds, and a handful of things specific to the patient like oxygen. This leaves the nurse with no choice but to call the resident each time the patient requests something. “The patient has a headache, could we get an order for Tylenol” etc.

How does your hospital handle this issue? Do you also have to call each time you need something? Or do you have a system in place to prevent this? It seems extremely inefficient for both the doctor and the nurse to constantly have to page back and forth for simple things that could be anticipated.

Thanks in advance!

[Cowboyardee]

I can think of two basic solutions. They are not mutually exclusive.

One is to make sure that you have experienced nurses present in rounds with a list of concerns and anticipated complications so that the attending physician can address and order as many of these likely eventualities as possible all at once. The downside is that you need your staff to be seasoned enough to anticipate and advocate for their own patients, and many settings rely too heavily on new grads and experience too much turn over for this to be realistic. Its what I do in critical care to try to have the plan of care set up appropriately for night shift, where there are fewer physicians and less experienced staff; it's also more or less what the day time charge nurse used to do in morning rounds for all of our patients back when I worked in med surg.

The other (or additional) option is to have your hospital include more of these kinds of standing orders into large bundles of pre-selected order sets that your physicians can activate based on the patient's diagnosis and then modify based on the patient in question. The downsides of this are that it can lead to the occasional inappropriate order, and also that nursing staff typically have zero input into order sets and the computer system in general. Maybe drop a hint into the right ear and things will happen, but often you're just yelling into the wind.

You can also always try to bundle your questions for thw residents and try to fix up your order sets before they go to sleep or get busy. But that often doesn't work since your nurses all need to have solid anticipation and medical knowledge, and even if your nurses do, residents tend to be a little gun-shy over night.

[AbigailJo]

Awesome suggestions! Thanks so much for your thoughtful insight!