In a way, it is amazing that they can do as good a job as they do. So in this sense they are the “best” of the Dickens’ idea. But when you see hospitals in operation, you realize they are far from what they should be. That is the “worst” of Dickens’ idea. So this column presents some of their deficiencies and what to do about these deficiencies. Some may seem minor, but the combination of these elements or even a seemingly minor element, when combined with that old perfect storm, can spell catastrophe.
Another way to make this point is Winston Churchill’s statement that democracy is the worst form of government except all the rest that have been tried. So again, the “worst” of Dickens idea is the corruption and injustice that permeate even the greatest of democracies. But despite all its deficiencies, only democracies in general and American democracy in particular have managed to unleash the great output of liberty, freedom and economic prosperity that makes other forms of government seem puny by comparison.
Perhaps the most direct way to make the point is by citing discussions of health care reform. The advocates of radical reform point to the deficiencies of our present health care system. But in the argument, those deficiencies are immaterial unless the new system would be an improvement. Advocates for radical reform are largely content to focus on deficiencies of the present system, as if they prove their case by that alone. But the real issue is whether the new system would be better, a minor detail to those eager to adopt a nationalized, socialized system of the kind that history shows fails.
So with all due respects and praise for the near impossible job our hospitals accomplish let me offer some ideas for their improvement.
CASCADE OF BASIC MISTAKES. Every time I visit a hospital I see a constant parade of basic mistakes such as failure to wash hands before patient contact, improper hand washing techniques, failure to properly swab and flush IV lines, ignorance in handling central IV lines, and mishandling of food utensils. For example, I’ve seen many nurses wash their hands with soap and water, and then turn the faucet off with their bare hands. This of course recontaminates their hands. It is elementary that you turn the faucet off with touching it with the paper towel or perhaps use your elbow. I’ve seen people from infectious disease departments make this mistake. What is so disheartening about these basic blunders is not only their high frequency of occurrence, but also that they not only endanger the life and health of all patients but also that they lead to the discerning patient losing all confidence in the hospital and its personnel. If they can’t get that right, what can they get right? It’s like having English professors who don’t know the alphabet. Incidentally, how many health care providers have you seen wiping the bell of their stethoscopes off with an alcohol swab before putting it on your chest?
I had a beautiful illustration of the problem in a recent encounter I had with a nurse while visiting a patient. She gave the impression she was trying to figure out how to administer a certain drug, so I said it was administered IV. She said, “I’ve been a nurse for 20 years and know how to give medicines.” Then when she started to administer the drug, she alcohol swabbed the injection site about two seconds instead of the recommended thirty. Needless to say we had an interesting conversation. Another nurse told me about her 28 years in that profession, and then proceeded to inject into an IV line without swabbing. When I noticed that, I said why didn’t you swab. She said, “I usually do. I forgot this time, so now I’ll do it again.” I said, “No, that won’t do any good.” So she demonstrated gross negligence by not swabbing, and gross stupidity by assuming she could undo the damage by swabbing and injecting again.
My solutions would be simple and obvious. More drilling on correct techniques and, more signs in hospital rooms, such as “Be sure anyone that touches a patient, first washes their hands…in the presence of the patient.”
One of the great improvements in hospital infection control came with the advent of the alcohol wash. Bottles of that hand-washing material are now sprinkled all over hospitals, making it much easier for both providers and visitors to wash their hands. I’ve seen more hand washing since the coming of alcohol wash than in any previous period.
FORGETTING REQUESTS. I find if you ask six members of a hospital staff for something you need, four times each, there’s about a 50 percent chance they’ll remember and act on your request. Don’t hold me to scientifically validate those hyperbolic statistics, but reality comes close to that.
I have the feeling they haven’t learned of the invention of writing. You’d think they’d carry a paper pad and take notes so they don’t have to rely on their memories, which are clearly less than perfect. And the ones making written notes seem to forget to read them.
NEGLECTING CRITICAL THERAPEUTIC MEASURES. I know nurses are busy. I know hospitals are often understaffed. Having said that, you can be flat on your back for a week, and no one will suggest you start walking. In some cases, the hospital creates a set-up that makes it almost impossible to walk. Take, for example, what I discovered in a heart critical care unit. Their heart monitors are not wireless, so the patients require a special unit to do the monitoring during a walk. What’s more, the nurses are busy and seldom have time to walk patients. That combination means you will rarely be walked. When someone complained, they were told few patients in a heart critical care unit are walking, so that apparently means none will walk. You could also go for a week in a hospital without eating, and there’s a good chance no one will notice or do anything about it. (In fact, there’s a famous study showing that a high percentage of hospital patients were in fact suffering from malnutrition.)
Don’t assume nurses and others will do what they should, so a little prompting and questioning is already in order. For example, if you are going to be in bed for a substantial period, ask about special steps to prevent blood clots forming in the legs. Some hospitals use stockings worn on the legs that keep contracting and relaxing to stimulate blood flow.
CONVENIENCE OF THE PATIENT BE DAMNED. In a hospital almost everything is done for the convenience of the doctor and other health care providers. Almost nothing is done for the convenience of the patient. Doctors pop in at any time, and there is rarely a clue as to when they will come or when they will return. This would give the patient a better chance of having his questions in order and being prepared for the visit. Still another example involves tests and procedures, which are often scheduled the same way, with little advance notice of even a rough time. What’s worse, the patient may not even know the test was ordered until someone arrives for the procedure. I know emergencies come up and all the rest, but they could still do a better job of informing the patients of scheduling.
INACTION ON SYSTEMIC COLLECTION OF COMPLAINTS. The good news is that if you complain in a hospital, everyone will listen to you. The bad news is that they rarely if ever do anything about it.
I’ve personally complained about safety concerns at hospitals, sometimes even documenting them for television reports, and, more often than not, nothing is done to bring about corrective action. For example, I once made a major issue with a hospital about unsanitary handling of ice in a cafeteria. After vigorous complaining, laced with some threats, the situation was corrected. On three subsequent occasions I found the same unsanitary ice handling, one in the same cafeteria of the hospital, another on a hospital floor, and on still another occasion in its emergency room.
I also remember a case when they had two blood pressure machines in a patient’s room. They had two because one was broken. No one bothered to remove or mark the broken one, so it was subject to continuing use. It seems no one wants to take responsibility and press for corrective action. Finally, I told a nurse about it and she turned in a request for repair. Action was taken almost immediately after that. But even then, no one seemed to know if the machines had actually been fixed, or was still in the process of repair.
Then when there is a problem, you may talk to a patient advocate, which I have found to be more public relations baloney than real advocates. I’ve encountered some nursing supervisors whose main talent seems to be throwing gasoline on the fire they are supposed to be putting out. Needless to say I’ve also accounted some of extraordinary effectiveness.
TREATING PATIENTS LIKE A PIECE OF MEAT. Doctors often write orders for drugs, for tests, and other procedures and don’t tell the patient, and the nurse often doesn’t bother to relay the message either.
I’ve been in hospital rooms visiting patients many times and a member of the house staff announces he’s there to take you for your X-ray. The patient often doesn’t know why the test was ordered or what doctor ordered it. In one case, the patient asked the transport person to find out who ordered the test. After checking, the transport person came back and said he was in the wrong room.
Probably the best example is the prescribing of drugs. Doctors routinely prescribe all kinds of drugs, without even telling the patient. This seems more like veterinary medicine, where the vet doesn’t talk to the dog or horse.
The remedy is obvious. But I’d add one other twist: Leave the patient’s chart in the patient’s room, giving him free access to it. That would mean the patient would know what is going on even if doctors and nurses don’t bother to explain things to him.
MAKING IT IMPOSSIBLE TO SLEEP AND EAT. Anyone who has ever been in a hospital for long, knows that they specialize in making it impossible to eat with lousy food and impossible to sleep with all the alarms, whistles, bells, and monitors.
I’d make two suggestions on food. Meals such as lunch and dinner should include some of the standards such as roast chicken, roast fish, and roast beef. I’ve seen many menus with three entrees I would have trouble eating.
I’d also suggest that they teach those who handle foods the basic of food sanitation. For example, I’ve seen nurses and food service people handle glasses and cups with their fingers over the rims and other such basic sanitation violations.
On the noise at night, I know certain alarms from monitors and other noise is unavoidable. But too much of the noise is avoidable and patients should be spared every buzz and squeak emitted from monitors. With technology of the 21st century the monitors should be able to deliver the signals to the nurse without blasting into the ear of the patient.
CONCLUSION. Years ago, I did a spoof on hospitals and health care for the great producer George Schlatter for his NBC program “Real People.” In the spoof, I said something like this: If you go to the hospital you better take along your own chef, body guard, lawyer and nurse. At the time, I thought I was just trying to be funny. Now, enriched by experience, I know I was being too conservative in terms of what you need to protect yourself in the hospital.
My mother used to say, “There’s no such thing as a good doctor, including my three sons.” She educated me on unnecessary surgery as a pre-teen, and on much of the rest of the health care delivery system. With all due respects to some great institutions of higher learning, I learned more from her than when I studied the subject at Harvard and the Wharton School of the University of Pennsylvania. So if you don’t like what you find above, blame her. And if you like it, I’ll give her full credit. And I’m sure if she would have been asked about hospitals, she would have said, “There’s no such thing as a good hospital.” Incidentally, all of the incidents related above involve supposedly top-of-the-line hospitals. I shudder to think about bottom-of-the-line hospitals.
Herb Denenberg is a former Pennsylvania Insurance Commissioner, professor at the Wharton School, and
Pennsylvania Public Utility Commissioner. He is a member of the Institute of Medicine of the National
Academy of Sciences and is a board member of the Center for Safe Medication Use. He is an adjunct
professor of insurance and information science and technology at Cabrini College. You can write Herb
at POB 7301,St. Davids, PA e-mail him at hdenenberg@aol.com or reach him at his two Web sites:
thedenrep_archive.org or denenbergsdump.org