Welcome to the new year! Unlike last year when I had the day off, this time I was on call. Although I did not feel the transition from one year to the next (it was just another day), I managed to slip a “happy new year” greeting either at the beginning or end of my first conversations of the day. Some patients reacted with a pleasant response, but for most, it was another reminder that they were in the hospital during this festive time. Just as 2008 rapidly approached, a lot of patients were strongly negotiating to be discharged. I cannot blame them. I myself would much prefer to be at home, but the work must go on 24 hours a day, 365.5 days a year. MRSA (methicillin-resistant Staphylococcus aureus) does not keep a watch. And there is the deluge of trauma, intoxication, congestive heart failure, pancreatitis, reactive airway disease, etc. that roll in after a night of dietary (or drug) indiscretion. In any case, I love what I do and will gladly serve these needs. It was just another day, but it is now a new year. Happy new year!
Mr. Jones is a 65 year-old gentleman with a past medical history significant for hypertension (HTN), diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), and coronary artery disease (CAD), who presents from OSH with … who-knows-what?
OSH denotes an “outside hospital” from where a patient was transferred. These hospitals are generally smaller medical centers that do not have the advanced specialists, equipment, or support facilities to manage the evolving complexity of a patient’s disease. Consequently, they request from a higher-level care center (i.e., tertiary hospital, major academic institution) to have the patient transferred there. In rare instances where patients carry cryptic or immensely challenging clinical diagnoses, a tertiary center may even refer the patient to another hospital where supposed “world experts” of a particular field may practice.
A common complaint at tertiary centers receiving transferred patients is that they arrive with poor supporting documentation. That is, what had been done for the patient while at the other hospital? What happened whereby the patient now requires higher level care? Discharge summaries sometimes appear as if they were drafted on the fly; at other times, they are replaced by randomly copied chart notes or nothing altogether. In worse scenarios, patients may arrive with such dearth of information that the admitting physician is left dumbfounded about the real reasons for admission.
In response, a group of medicine residents from the University of Pennsylvania created the following video to critique–with gross exaggeration, of course–the infamous OSH.
The Department of Health in the UK published today new guidelines for hospital dress codes and laundering. The guidelines represent a compilation of expert opinion, scientific theory, and empiric research.
Among other recommendations, it is expected that health care personnel wear short-sleeved shirts and blouses. The sleeve cuffs presumably present a viable source for transmission of microorganisms. Interestingly, the report also recommends that white coats not be worn. I have several colleagues who would willingly give up the extra layer of fabric in a heartbeat. Oh wait, they already do. I, on the other hand, would prefer to wear the coat for personal protection and as a reservoir for my million-and-one accessories (e.g., stethoscope, pens, penlight, paperwork, PDA). The report suggests that “(w)here staff have direct patient contact, then suitable protection - for example, plastic aprons - should be worn.”
If the sleeve cuff is the principal reason for abandoning the white coat, then why not go for a short-sleeve coat? They are already standard issue in several countries. I realize this may become a fashion nightmare, but the compromise permits the pro-coats and anti-coats to live in harmony. Moreover, I can easily imagine disposable gowns mounting health care costs, particularly given the large number of caregivers and high frequency of entries into each patient’s room on any given day.
Another interesting–and probably nit-picky–recommendation is that health care workers wear soft-soled shoes, because they “reduce noise which can disturb patients’ rest”. Although the recommendation sounds good and benevolent in principle, I question its relevance in practice. Take a moment on a relatively quiet call night and listen intently to the sound from hard-soled Dansko® clogs. Unless the wearer is running to a code, the sounds these clogs emit are largely trivial. Moreover, compared to the competing sources of sound in a noisy hospital, heel clicks are practically insignificant.
Not to appear completely critical of the report, one recommendation I can fully support is the ban on ties. According to the report, it is “poor practice to wear neck-ties (other than bow-ties) in any care activity which involves patient contact”. The ties supposedly “perform no beneficial function … and have been shown to be colonized by pathogens”. Despite the professional appearance, I feel that ties are more a nuisance than a benefit. I doubt any hospital will suffer in public relations due to an absence of ties.
The report admits that there is no definitive evidence that uniforms pose a significant infection risk. It also falls short of calling all physicians to wear pajamas, er, scrubs. It emphasizes that professional dress is still important for the professionalism it communicates and the confidence it cultivates. There are other related recommendations, such as the use of clear name tags to identify the provider’s role. Naturally, tattoos and excessive jewelry are discouraged.
I will not delve into the report’s discussion of laundering, but here are a few tidbits: 1) 10-minute washes at 60 oC supposedly kills most microorganisms (10% of C. difficile spores may remain); and 2) MRSA can be removed at 30 oC with detergent.
The recommendations are scheduled to take effect in January 2008. Despite my seemingly critical review of the report, I largely support the changes. I think it is a valiant effort at further addressing infection control and implementing policies to hopefully stave off a MRSA catastrophe.
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My first–and hopefully, only–experience as a hospital patient occurred several years ago when I needed a minor surgical procedure performed. Although I would not want to repeat this experience, it was interesting to observe the delivery of medical care from the patient’s standpoint. It was pleasant to receive the attention and respect of the medical staff following my case. I also felt pampered by the ancillary services who did the cooking and cleaning. Regardless of how tempting it may have been to just move in, I was much more eager to leave.
The hospital can be a fairly inhospitable place. The most drug-resistant pathogens wander the halls. Noisy neighbors and their noisier visitors inevitably occupy every other room. Let us not forget the infiltrated IV lines that trigger endless alarms or the monotonous beeps of the telemetry monitors. There are the mass-production renal-cardiac-diabetic diets and bareback paper-thin cloths called “gowns”. As for the hospital odors that permeate throughout the premises? Unique. Then, there is the constant interruption by the army of medicine: phlebotomists, patient care assistants, nurses, nursing students, social workers, medical students, residents, fellows, and attending physicians.
Please don’t get me wrong. The goal of this post is not to lambaste the hospital system. As a cog in the American health care machine, I am endlessly devoted to the promotion and improvement of hospitals. I just continue to be amazed how some truly ill patients can endure their pain, discomfort, and the often unfriendly environment, yet exhibit enormous patience when I awaken them at some odd hour before dawn to do my pre-rounds. My hat goes off to them.
Note: I realize the image shows a building of the University of Michigan Health System. I have no affiliation with the institution and did not target them in this post. Any similarities between this post and a patient’s experience there may be more reflective of hospitals in general and not of the University of Michigan. I have no intention to denigrate any institution or anyone.
