You are nearing the end of your 4th consecutive 12-hour shift (more like 13-14 by the time documentation is done) in the ICU. You don’t usually work more than 3 consecutive days, but due to staff shortages and the recent uptick in COVID call-ins, you agreed to help your colleagues. Mr. Smith’s family has just left after saying final goodbyes since he passed from heart failure, and you need to prep the body. Room 2 just had his entire med list changed by the intensivist (again), and the new COVID patient (what was her name?) in room 6 has alarms on the ventilator going off. Room 2 and Mr. Smith can wait—time to gown up and resolve the alarm issues on….Judy!…that’s her name!—same as your wife’s best friend, hence why her name and age stood out when you received the report 20 minutes ago.
After donning a gown, gloves and a new mask, you push the door open and enter the isolation room. Within seconds you realize the problem, 02 sats are at 63%, and she appears tachypneic and struggling to breathe. That’s when you realize the vent tubing is disconnected. A quick read of the other monitors and Judy, this 35-year-old new mother of twins is crashing….FAST. You get the tubing reconnected and push the code button for the rapid response team. You are on your own until the team arrives. A million things are running through your mind as you initiate the Code protocol. As you prep a syringe, you can’t help but think “don’t let her die.”
Three days later, during a deposition, lawyers are asking you questions about the ventilator tubing. Your initial documentation didn’t indicate validation of connections, so they want to know, did you confirm the patient was connected to the ventilator or was her breathing spontaneous when you admitted her? Patient Judy remains in a medically induced coma with possible anoxic brain injury, and it seems you are being blamed. For the first time in your career, you are seriously questioning why you stay in the nursing field.
I spent nearly a decade as a travel nurse, (a profession that saw a surge during COVID-19) and I truly loved what I was doing. Every three months I was off to a new facility, sometimes a new state and always a new documentation system. Some systems were better than others, but all had a learning curve, and by the end of my patient care career, I was burning out. I’ve seen the above work scenario, save the deposition, play out at almost every site I went to. Understaffed, long work hours without breaks, higher patient acuity, and disparate software systems; it sometimes felt like an uphill battle to care for the patient, the families and the systems all at once, and it seemed the systems were designed for anything but clinical documentation.
The need for accurate and timely documentation is not only intended to ensure patient care communication, but to also protect the author should negative outcomes occur. I left bedside nursing to find a way to improve that documentation for clinicians, so they spend more time caring for their patients and families, and less time worrying about the systems they must use to provide that care.
Software systems have enormous capabilities to aid the clinician to complete timely, accurate and concise documentation. Picis uses a combination of EVENTS (canned text), PROTOCOLS (order sets based on best practices/policies/procedures), MACROS (combined events for common tasks) and ASSESSMENT ITEMS to ensure concise documentation is completed in a timely manner. REMOTE VIEW allows documentation to occur away from the bedside when necessary (or when prudent to decrease exposure time to contagious patients).
Software may not prevent the above scenario, but a system that is well designed and configured to meet the needs of the clinician will allow them to quickly document the care they’ve provided, giving them more time to take care of patients. By improving the processes necessary for the provision of patient care, clinician satisfaction may improve, and lessen clinician burnout.
About the Author
Rob Aldrich, Team Lead, Professional Services
Robert has been a Registered Nurse for over 25 years. His experiences in patient care range from rural hospitals in Alberta, to heart/lung transplant patients in Texas, to Transplant/Trauma services at Johns Hopkins Hospital in Baltimore. Travel nursing allowed him to build a wealth of knowledge across several different documentation systems and to work with various clinical champions across the country. Transitioning to software informatics allowed Rob to provide training and product improvements to clinicians that were increasingly spending more time documenting, and less time caring for their patient. His goal is to ensure the products in the clinicians’ hands will improve their experiences with the patient, rather than impede their patient care while providing data that can be used to individualize patient care.
In his spare time, he sells real estate in the Arizona Market, coaches his son’s hockey team and enjoys camping and traveling with his wife and two children whenever time allows.