Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name's Dr. Warrick Bishop and I would like to welcome you to my podcast station and of course to the Healthy Heart Network. Today's podcast I've called Wood for the Trees because sometimes I think we can miss the important bits for all the clutter and busyness going on and this podcast is going to be me ranting a little bit. I'm sure there'll be some nurses out there and some doctors out there who will resonate with this and perhaps understand where I'm coming from. I know the CEO of my hospital will think I'm grumpy, maybe lazy, maybe just have a bad attitude or maybe just being difficult. But today I'd really like to talk about what I've observed over the last two decades working. on the wards, on the wards of hospitals that is. What's become really apparent is that there's been more and more bureaucracy put upon the nursing staff and there's a knock-on effect to the medical staff. This bureaucracy or red tape is all driven by so-called best standards and supervisors who want to put in place protocols and pathways and make sure that we're following guidelines. There's a real emphasis brought to bear these days on what we call parameters. So for medical patients and cardiological patients like I deal with, those parameters are things like a patient's blood pressure. Or their pulse rate. Things that might indicate that that person could be an at-risk candidate at some stage in the future. So not a bad idea. The trouble is that I think some of those limits, some of those protocols, some of those guidelines are starting to become the primary objective of nursing. to make sure that those tick box systems are filled out appropriately as the priority to patient care. Now, I would be absolutely the first to recognise that checklists are crucial, in fact, critical in any domain where there is potential for error and that error could lead to... significant consequences in our game loss of life in other spheres for example airline pilots there is good data documenting that even for experienced airline pilots checklists are not only valuable they are irreplaceable so there's no question that we do need to step through structured guideline or structured approaches to individual patients to make sure we're not missing things that could be of consequence. I think what's become problematic is that we've lost sight of the fact that there's variants around, particularly in medicine, some of the issues that are difficult to pigeonhole. So let me just give you an example that comes to mind from this week. I had a number of patients in hospital. One of them was on a particular medication to slow their heart rate down, part of their management for angina. And I get a call from the ward late at night letting me know that this patient's pulse rate was 48 beats a minute and the designated limits are 50 beats a minute. So this person was two beats per minute under the designated limit. Now this was in a situation where the patient was well, warm, conversing, had eaten dinner, was watching television and felt absolutely fine. The point I'm trying to make here is that 50 becomes a rather arbitrary cutoff. And in fact, for this gentleman, was a cutoff that didn't make sense because he was medicated and that medication was going to change the way we'd evaluate his particular parameters or limits. Of course, that... approach that thought was lost unfortunately on the nurse who called me up who simply acted on the limit alone and unfortunately really represented a situation where I got a call for a perfectly well patient so that I could order that the patient's limits be set down to 35 such that if his heart rate went below 35, then they should give me a call. Have a think through that, perhaps. Have a think about how that really just doesn't make sense because the limit of 35 or 40 or 42 or even 50. becomes secondary to what's going on with the patient. This gentleman's heart rate could well have dropped to 40 beats a minute overnight while asleep, while on a monitor, and he may have been perfectly well. We know highly trained athletes, for example, have really slow heartbeats overnight. Does that mean we need to call or be ready to call an arrest team to come and assess them? I think common sense would dictate that that's not the case. So I had another episode this week, which was just bureaucracy on steroids, really. I'd had a patient in for two days. They'd been admitted through the accident emergency department. A sticker had been adhered to the front of the notes, the front of the medical chart, I should say. And for some reason, the wrong sticker had been adhered to the back of the Same medical chart. The front sticker had been used for identification of the patient. All the patient's drugs had been written on the drug chart. During the course of the admission, the patient had drugs administered from the drug chart. And at the time of discharge, I was requested to rewrite the entire drug chart. Because of the erroneous wrong sticker on the back of the chart. I put a new sticker over the wrong sticker and signed across it. And said old sticker in error, new sticker correct with my signature. And believe it or not, that was just not legal. And I'll say not legal in quotes. Only because I... have had such a long working relationship. And the highest respect for the nurse I was working with, did I actually sit down on a Saturday morning and rewrite that entire drug chart, which I might add was not going to be used because the patient was being discharged. I don't know about you. I don't know if you've been in a space for 20 odd years and you find the little niggly things just get under your skin. But I have to tell you that really got up my nose and struck me as completely Unnecessary and bureaucracy defining what we do, not common sense. The reason why I'm flagging this, and I hope there are nurses out there listening to this. I hope there are doctors out there listening to this. And I even hope my CEO is listening to this. The reason I'm flagging it is this bending the knee to bureaucratic documentation. creates stress in the wrong direction. It prioritizes the wrong aspect of what we're doing. It means we're not thinking about the patient, we're thinking about the paperwork. It takes a lot of time for the nurses to be dealing with these issues. For example, the heart rate two beats per minute below the current limits to call me up and track me down and then respond to it and document it all in the notes. the time taken to rewrite this drug chart, the stress it creates, creating a situation where nurses are demanding from doctors a requirement to do, you know, to tick every box, cross every T and dot every I in spite of those manoeuvres, those actions not necessarily impacting patient care. And if we think about that stress and the time used, then I really want you to think about the opportunity cost. Because in the last week, the opportunity cost, as far as I could see, meant that two of the patients I had in hospital missed drugs that should have been given completely. One patient had a mechanical mitral valve. This is a valve that requires anticoagulation so that it doesn't seize up. or throw off a thrombus, which could cause a stroke. This patient's blood thinning medication, his warfarin, was missed altogether. Another patient I had in hospital for chest pain had their anti-anginal medication or their anti-chest pain medication missed altogether. I would put to you that the nurses looking after those patients we're unfortunately prioritising the documentation of the patient, not the overall patient wellbeing. I actually find this really distressing. I think that this protocolisation, this tick box approach, this flowchart approach, this drive to fill out forms properly, it stops people thinking. And by stopping people thinking, we no longer understand how to prioritise the most important aspects of patient care. I don't want you to think of me as a whinging, whining, grumpy old man who's sick to death of doing work on the wards, but I am being worn down and I really do hope that the pendulum starts to swing the other way because things are just not good the way they're going. I hope you found this little insight, this rant interesting. If you have any queries or questions, or if you want to offer any feedback, please go to members at Dr. Warrick Bishop online and let us know your thoughts. If you've got any thoughts for any future podcasts, also same email address, drop us a note and let us go. Oh, let us go. Let us know. Again, I'd like to thank you so much for listening. As always, I wish you the very best of health and please don't die. From a heart attack, goodbye. You have been listening to another podcast from Dr Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
