PBS recently aired this four part series, which I just watched on their DVD of the same title. Overall I think it’s worth buying and watching and thinking about. Because this was my life’s working environment, I’d like to offer my observations and opinions about their presentation.
Part one was a real tear-jerker for me, both because it was about the death of a child and because of the dramatic portrayal of the story. I do not object to drama in a documentary – it’s a valid method of getting and keeping our attention, but we must be careful to not lose the facts in our emotional response. In this case, the fourth child of a well-to-do family apparently decided to take a bath on her own and scalded herself. She was taken to a medical center and ended up in their pediatric intensive care. She survived, and was discharged to a pediatric ward. There she developed severe dehydration, a well-known risk factor in burns, and her altered behavior caused her mother to repeatedly ask for help. The "nurse" said she was all right. She had a cardiac arrest and died.
The first time I read this story in an email from a friend, who had seen it on television, my immediate response was, the "nurse" was not paying attention to business. But let me back up and talk about hospitals for a minute. In intensive care the staff to patient ratio is about one to two, and usually the staff consists of highly specialized RNs. On a ward the staff to patient ratio might be one to ten or more, and the staff usually consists of RNs, LVNs, NAs (nurse assistants), and student nurses of widely varying education, experience, and competence. An ICU can be a busy place, especially in the morning, but there are plenty of eyes and ears, minds, and electronic monitors paying attention to patients, whereas on wards the pace can get so frantic and confused that nobody can keep track of patients. So who (what) was the "nurse" in this case? They don’t tell us.
The consequence of this tragedy was most unusual. The parents used the settlement money to establish a foundation in their daughter’s memory to fix the system, and the medical center decided to cooperate with the effort. The latter was unprecedented, to my knowledge, but here the documentary overlooks some long-standing standard procedures to celebrate supposedly new procedures. The "Rapid Response Team" that they advertise as new has been operational under different names in hospitals since the 1970s. It was called the "code team" everywhere that I worked. Quality Assurance departments were established soon after the Reagan Medicare Reform Act in 1985 and now consist of a small army of bureaucrats who review patient records to be sure that standard procedures are followed and that patient treatment conforms to doctors’ orders. An MD specialty emerged from this and now large hospitals employ full-time doctors who review records, see patients, and otherwise troubleshoot on the wards. That does not count the post-graduate residents in teaching hospitals who do a similar job. The documentary implies that these improvements came about as a result of this singular incident. I don’t think so. Is it enough? Again, I don’t think so, but I’ll get to that in a moment.
The next problem they undertake is infection control, which I have addressed before. They speak only of MRSA, and not the more dangerous VRSA, and they imply that hospitals are the victims, not the perpetrators, of the menace. These antibiotic resistant forms of everyday bacteria were born and raised in hospitals, and nowhere else, although now MRSA has escaped into the community. I thought the presentation was feeble at best, despite the fascinating evidence of the money wasted fighting and not preventing these infections. To get an idea of the magnitude of the problem, see the November, 2006, report from Pennsylvania: 19,154 infections costing $3.5 billion to treat in 2005.
Then they move on to medication errors. Here the blame is again pinned on the "nurse" without defining the word. Let’s follow the paperwork. First the doctor sees the patient, then the doctor writes orders for medications and treatments. Those orders go to a ward clerk, not an RN, who then transcribes them and sends them to the appropriate department, in this instance the pharmacy. There a pharmacy aide, not a pharmacist, records the order and often fills it, and sends the medication to the ward. Do you see the opportunity for error? Let’s say the ward clerk has thirty sets of orders to get through in time for a lunch date and there is an indecipherable squiggle after a medication order. Does that say PRN? (As needed.) Sure. But it doesn’t, it’s a squiggle. Error. Or the ward clerk misspells a word and the pharmacy aide makes a guess and sends the wrong drug. Bad error. (Our first rule in respiratory therapy was, read the original order yourself before you do anything.) Medication errors are usually caught by on-site QA review before anything bad happens, but not always. The documentary implies that the solution lies in computer technology where a doctor transmits orders directly from one computer to another. Maybe. I’m not so sure about that.
Part three is about the "epidemic" of diabetes in Los Angeles and elsewhere that threatens the economic existence of the health-care system. Multiple complications of diabetes result in escalating and costly ER visits. The solution described involves dedicated clinics and home-health nursing to monitor diabetics more closely and catch complications before they require a hospital visit. The problem is money. Medicaid and Medicare will not pay for prevention, but only for treatment. The documentary does not mention the cash-only clinics in LA which have successfully competed with the welfare clinics in poor neighborhoods. Nor does it mention the long-standing home-health nursing businesses, both public and private. These are serious omissions.
The final program returns to pediatric medicine. They feature some uncommon childhood birth defects and chronic diseases, which I thought was a strange choice. Here the family is invited to participate in building design and patient care. That’s a good idea, but it isn’t new. My first experience with a pediatric ward room designed for both the patient and the family was in 1969, and the family most definitely participated in patient care decisions there. While that is hardly the norm, the idea did not arise as the documentary implies.
My own solution of the non-financial clinical problems cited is simple and complex: Pay attention. If care-givers are not paying attention, bad things can happen. Simple, but there are moments in a hospital when paying attention is next to impossible. Change of shift is such a moment. When one shift is reporting off to the next, who is watching the patients? Meal breaks and rest breaks reduce staff, so nurse X who knows patient Y is gone; it takes years of experience to immediately assess an unknown patient. Stress levels can rise to the point where some staff literally blank out and can’t pay attention. How do we solve those problems? Better building design, parental involvement, new computer systems, and yet another layer of bureaucracy do not even address the problem.
Nor does PBS show the viewing audience the simplest infection control procedure, that is putting on and taking off gloves. Putting on gloves is simple, but taking off gloves is critical. Imagine that the glove is grossly contaminated with a visible substance, how do you get it off without getting it on yourself? Easy. Peel the glove off so it’s inside out. Then wash your hands. This is counter-intuitive to people who are not accustomed to it.
In summary, I think the documentary is valuable, both to acquire a grasp of the problems involved in US health-care systems, but more importantly to see which way the systems are moving. Decentralization is happening. Supplementing MDs with RNs is happening. Not in the documentary, cash-only systems are happening. Not in the documentary, foreign competition for big ticket surgery is happening.
Despite its flaws, I think that Remaking American Medicine is worth watching.