We like to think that healthcare in the US is on the cutting edge of medical practice. While we do a lot of pioneering in the development of drugs, devices and procedures, we can be slow to update our more mundane, day-to-day activities. These are some of the more egregious examples of things that should no longer be a regular part of American healthcare:
Charting on paper
Seriously, people – why is anyone still using paper charts in 2020? I trained during a period of mass transitions to electronic medical records, so I had the opportunity to work with paper and EMR systems simultaneously. Frankly, I don’t know how patient care happened in the days before computers. The paper chart is always somewhere else when you need it. Only one person can access it at a time. Then there’s the fact that doctors have a well-deserved reputation for bad handwriting, and they’re always in a hurry, so the already bad writing gets truncated, making it even harder to read. Many times during my training, I was left scratching my head while trying to decipher a hastily-scrawled sentence fragment that was supposed to tell me another physician’s plan of care. Of course, whenever you needed clarification, the other doctor was tied up in clinic or in the OR, so you just made your best guess at what the cipher meant and hoped you didn’t wreck someone else’s treatment plan.
Paper records are not just an inconvenience – they sabotage patient care. When you need to review old records, someone has to go fetch them from the warehouse, rather than just navigating to a different section of the electronic chart. Even if you procure the paper records in a timely fashion, you may not be able to glean any useful information from them once their already illegible morsels of information make it through the copier and fax machine. The same phenomenon creates countless opportunities for medication errors, should an ink smudge be mistaken for a decimal point or additional zero. Yes, EMRs have greatly accelerated “note bloat,” but at least I can clearly read what’s written in the plan once I find it among the pages of auto-generated garbage.
I’ll never understand the reminiscing I hear about the “good old days” of paper records. EMRs have room for improvement, but paper records interfere with patient care while driving up costs with the need to store, transport, sort, shred, fax and photocopy millions of pieces of paper on a routine basis – not to mention their environmental impact and the fact that CMS now penalizes healthcare entities for using paper records.
Contact precautions for MRSA and VRE
I address this in more detail in another post, but the bottom line is that gowns and gloves do not decrease transmission rates of these organisms. We’ve known it since at least 2013 when two large, multi-center studies were published on the topic. Implementing contact precautions also leads to patient harms like delays in care, feelings of depression and anxiety and adverse events stemming from reduced contact with healthcare workers. A sizable body of medical literature and real-world experience have now shown us that doing away with routine contact precautions for MRSA and VRE improves outcomes and lowers costs. Fear and habit seem to be the primary factors keeping those PPE carts out.
Routine MRSA nasal swabs
This is sort of an extension of the problem with contact precautions. If placing patients in isolation doesn’t affect MRSA transmission rates, then why are we bothering to screen people? In some contexts, screening could make sense. For example, a lot of literature on bacterial decolonization prior to surgical procedures focuses on eradication of Staph aureus – if a MRSA nasal swab is being used to decide who undergoes a decolonization procedure prior to surgery, it may provide helpful information. It can also be useful in determining which patients with pneumonia should get empiric MRSA coverage. Otherwise, in my experience, swabbing everyone for MRSA just because they’re in the hospital is a waste of time and money, not to mention an unnecessary source of anxiety for patients, families and staff.
Annual tuberculosis screening for staff
While it still makes sense to perform a one-time screen at initial hiring, the CDC now recommends against annual Tb testing for healthcare workers. Tb testing is expensive, and, if you’re using the traditional skin test (PPD), it’s also time-consuming and produces unreliable results. PPD testing has problems with incorrect interpretation, as well as false positives and false negatives, even when skin findings are interpreted correctly. Given our low Tb prevalence in the US, you’re likely to turn up some false positives, which then require additional testing and treatment. Even if all goes well and you get a true positive, it’s likely latent Tb, which isn’t transmissible.
Only those with active Tb (fever, night sweats, weight loss, persistent cough) pose a risk to public health, so the current recommendation is to either treat known cases of latent Tb to prevent progression to active disease or perform yearly symptom screens if latent Tb is left untreated. Additional Tb testing may be necessary in the setting of an outbreak or a specific exposure, but the historical approach to yearly testing is wasteful and does little for public health.
Putting carpet in patient care areas
We all know what ends up on the floor of a hospital, so I’d like to know – who ever thought it was a good idea to cover it with absorbent material? I don’t care how industrial-grade it is or what chemical protectants it’s been treated with – you will never get carpet as clean as a non-porous hard surface. Carpet becomes a breeding ground for bacteria and mold in short order, not to mention that it turns into an eyesore as it acquires stubborn stains and starts to fade and fray over time. I’m sure carpet was an attempt to introduce a bit of warmth to the whitewashed hospitals of yesteryear, but can we all agree that it’s time to move on to laminate? Faux wood, perhaps?
Placing patients in shared rooms
There are a lot of reasons why we moved away from the open ward in hospitals. Aside from making it nearly impossible to have a private conversation with a patient, you have multiple people putting their respiratory droplets into a shared space – something that should be of particular concern in the age of COVID. What about when your roommate suddenly develops C diff-associated diarrhea? Or gets diagnosed with a highly-resistant organism? (Candida auris comes to mind here, considering current events.) As a roommate to the affected patient, by the time you find out about it, you’ve already been exposed and possibly infected. Then there’s the increased potential for wrong-patient treatment mistakes – what if those two demented patients in the same room happen to switch beds overnight? I’ve certainly had patients who answered to the wrong name because there were demented and/or hard of hearing, so I don’t think that scenario is too outlandish.
I’m sure there are situations where shared rooms are still inevitable in a healthcare facility, but for the sake of patient privacy, safety and infection control, it’s time to move on from this approach whenever possible.
Giving everything intravenously
“If the gut works, use it” – it’s a mantra I heard multiple times through my training, and I still think it’s good advice. We tend to default to the IV route when ordering medications for patients in the hospital. Maybe it’s because we feel like we’re being more aggressive with treatment. Maybe we tend to assume that patients will be unwilling or unable to take oral medications when they’re acutely ill. Maybe it’s just a product of culture and habit. Whatever the reason, running everything you can through an IV is not a benign practice – it introduces a whole host of additional risks like DVT, bloodstream infection, thrombophlebitis, infiltration and falls (from patients being tethered to an IV pole). Then we have all the added costs of maintaining IV access and using IV medications: IV catheters, IV tubing, medication bags, syringes, IV pumps, sterile dressings, sterile gloves, sterile drapes, central line insertion kits, pharmacy time to mix and deliver doses, therapeutic monitoring…you get the idea.
IV therapy certainly has its place in the hospital, from delivering medications with no oral equivalent to bypassing the gut when it isn’t working or when patients are unable to swallow pills for any number of reasons. I just think we use a whole lot of IVs for the wrong reasons. Once more – if the gut works, use it. It’s safer for your patients and cheaper for the healthcare system.
We should never get complacent in medicine – the field changes too quickly. Staying even remotely abreast of the latest developments is an endless personal endeavor, and it’s all too easy to take our common practices for granted. When we get too comfortable with our healthcare habits, however, it’s generally bad for patients, clinicians and the bottom line. The “right” way of doing things today may very well have us asking “what were we thinking?” tomorrow.