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The New Observation Unit
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Old 05-04-2018, 09:53 PM
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jedimaster91 jedimaster91 is offline
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Default The New Observation Unit

My place of employ has recently opened a chest pain observation unit to try to get emergency patients cardiac testing the same day instead of transferring them to other locations. My location is mostly an outpatient testing center in a semi-rural area, but does have an ER. As such, our resources for the really big stuff is somewhat limited.

And let me tell you what a cluster-fark this thing has been from the get-go.

-The clinical staff wasn't brought into any of the planning meetings until things were well underway. I'd gotten a few general questions from my immediate supervisor, but really they were questions Google could have answered. The first conference call I was asked to sit in on spent 45 minutes discussing what to do with patients who had positive stress tests (meaning likelihood of a heart attack was pretty high). Apparently there are at least a dozen different ways to say "It depends on how stable or unstable they are and what resources and openings we have at other locations." That's 45 minutes of my life I'll never get back.

-The next meeting I went to spent the entire time going back and forth on how to classify these patients in the computer system. "Observation" status is different from "Emergency Department" or "Inpatient" status and they're not really outpatients either. Yes, it does matter for coding and reimbursement purposes. And the ER here can only keep patients up to 23 hours. After that they have to either be discharged or admitted/transferred. But the software the nurses use doesn't have an "observation" category, or it does but it doesn't show on the tracker, or something. IT wasn't anywhere near ready and we were about a month out from the initial launch date. It later got pushed back. Twice.

-After that snoozefest someone finally asked the techs what we needed. Hilariously enough all this was going down while the regular tech was on maternity leave. But she's an Air Head on a good day so Boss Lady wanted me handling this anyway. So we discussed patient prep and the fact we need a cardiologist or a nurse practitioner to supervise stress tests. Ok, the later will have to be coordinated with the office manager for the cardiology group. We'll call her Waffle for reasons that will become apparent later. Now because we're mainly an outpatient facility, cardiology isn't staffed 24/7 like the ER and XR/CT, nor are we on call (and we'd like to keep it that way, thankuverymuch). So then the issue became how to let us know we had a chest pain patient if we'd already left for the day. Initially, the ER was going to text us, but that got shot down because that would technically put us on call. There's still no real answer. I think Air Head calls the ER on her way in just in case we need to order radiotracers. I petitioned to have a standing set the pharmacy would send us every day, but I got overruled "due to cost."

-Let's talk about Waffle. Oh, Waffle, you make my job so much harder than it needs to be. She is supposed to send out a weekly schedule of who is coming to supervise stress. It's rarely on time and often incorrect. She is also supposed to tell the docs/nurses when there is an obs patient they need to come out for. Either she forgets to tell them when we do have a patient, or still sends them out when we don't. And it's still a tossup whether the person who actually comes is the person on the schedule. There has been some talk about switching up the days we do only cardiac studies since Waffle said she couldn't send anyone out on Thursday afternoons for afternoon outpatients. But we had a late obs patient this week on Thursday and she didn't have a problem sending the nurse back. So.....why is one ok, but not the other? This isn't the first issue she's changed her answer on either.

-Not directly related, but there is some feuding going on between the cardiologists. It's gotten to the point where the one who sends us most of our patients (let's call him Dad1) refuses to let anyone read his exams except for Dad2. And the other side of the conflict, Husband and Wife, are looking for any dirt they can throw. I have no idea what happened that started this, but it's spilling over to the techs now. We're getting caught in the middle and it's awkward. Personally, I don't have any issues with Husband and Wife (though Husband is kind of an odd duck, but at least he's nice to us), but I've worked with Dad1 and Dad2 longer. So if push comes to shove, I'm siding with Dad1 and Dad2.
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  #2  
Old 05-05-2018, 10:52 AM
Mental_Mouse Mental_Mouse is offline
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So, let's see if I've got all the points here:
* They want to be able to lay hands on cardio staff 24/7, without actually paying for on-call staff, let alone continuous staffing.
* And radiotracers available, without actually keeping them in stock.
* Meanwhile, the computer systems are so closely bound to your current work that they won't allow you to hold a patient for observation, and nobody bothered to check with IT about this.
* And meanwhile, the cardio office has a office manager who can't seem to keep track of her staff or the patients, and also doctors who are ratcheting up to war with each other.

Dare I wonder how much the patients will be paying for getting diagnostic work via the ER? (See also these Vox articles about ER costs.)
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Old 05-05-2018, 02:21 PM
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jedimaster91 jedimaster91 is offline
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Pretty much, yeah.

Due to licensure and regulations, we can't stock the radiotracers ourselves; they have to come from a central pharmacy (thanks USP797). The tracers are technically pharmaceuticals so they fall under those regulations, but the radioactive component puts them under our scope of practice to be able make them ourselves. Some outlying areas have been able to get around it by arguing scope of practice and showing they can comply with USP797.

And no cardiologist is going to come supervise a stress test in the middle of the night. They'd laugh at you for even suggesting it. Personally I wouldn't mind if they put us on call just to be able to let us know, hey you have a patient for tomorrow and not have to actually come in for anything but they're not going to do that.
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