1: Hospital Routine
Patient and Family Experience
Avoiding Possible harms
The Hospital Routine
Being in the hospital is very difficult. As a patient, a lot of things are done to you at inconvenient times and it can feel very much like you have no control. There are, however, some routines in the hospital that are predictable. Knowing these routines can help you feel a little less frustrated or confused.
Knowing who everyone is and what they are doing to help you is important. Taking care of patients takes an entire team of people working together. For each patient, there is at least one doctor. Often there are several doctors---one doctor for the patient’s main problem and other doctors to help or “consult." For example, if you had a surgery, you might have a surgeon but another doctor may help manage your heart or your diabetes. If you are at a teaching hospital, or university hospital, you will also be seen by doctors that are still learning the skills of their specialty. These are called resident physicians or intern physicians.
Doctors are only a small part of the healthcare team. Every patient also has a nurse who helps to take care of the patient. The nurses make sure each patient gets the correct medicines, helps patients with questions and concerns, and helps patients if the patient gets sicker. Many nurses also have assistances, called nursing assistants. Nursing assistants help nurses to take vital signs and help nurses bathe patients.
Healthcare teams may have many members. Respiratory therapists help with breathing machines, oxygen, and breathing treatments. Nutritionists help make certain patients are getting enough nutrition and pharmacists review medicines ordered by doctors to make sure they do not interact, the doses are correct and that the medicines are made properly (in particular IV medications). Phlebotomists are trained to help the doctors and nurses get the blood that is needed for tests. Social workers, or specially trained nurses help patients and their families with organizing care in the hospital (organizing family meetings, etc) and with planning for discharge. Physical therapists and occupational therapists help patients with strength and movement.
There are also several very important people that help to make your stay more comfortable---environmental service people help with cleaning and maintaining your room, food service personnel help make certain you get the kind of food your doctor ordered, and unit personnel help with managing the phones and running the operations of all the healthcare team members.
The morning routine starts early in the hospital. Because doctors need a patient’s blood tests to decide what to do during the day, blood tests are often taken very early in the morning. In addition to blood tests, a patient’s vital signs (blood pressure, temperature, oxygen saturation, heart rate and weight) are also taken early in the morning by the nurse or nurse assistant.
The doctors check on patients in the morning to see how they are doing. Doctors call this “rounds.” Many doctors round with the whole healthcare team—the residents, the nurse, the pharmacist, etc. Depending on what else the doctor has to do that day, rounds can happen very early in the morning.
During rounds, doctors often decide on additional tests. These tests will be ordered in the morning and the patient will go to the tests at various points during the day. When the test happens is often beyond the control of the nurses and doctors. Patients who are sicker or whose tests were ordered earlier may get the test before you. If a patients test is abnormal, it may take longer for their test to be done, and this means you may have to wait longer before getting your test. Because of this, the doctors and nurses often cannot tell you when the test will happen. This is also frustrating—it makes it hard for you to plan your day.
In the late morning and into the afternoon, new members of the team may come by to see you. These new members of the team have been asked by your doctors to give them advice about specific problems. These doctors are called consultants. Even though you have already told the doctors who have taken care of you about your medical history, the consultants may ask you to repeat this information or they may ask you questions that your other doctors have not asked you. It can be frustrating to keep repeating your story, but it is important because the consultant doctors are often thinking about different problems than the doctors who admitted you to the hospital. In asking you your history again, the doctors may find answers to questions that the consultant need to make recommendations about additional tests or procedures that you need. For example, if you have had surgery in the hospital and your kidneys stop working right after your surgery, the surgeons may ask a doctor who knows a lot about kidneys to come see you.
In the afternoon, some doctors will round again on their patients. These rounds are often shorter and involve fewer people from the healthcare team.
Around dinner time, the doctors will start to leave to go home. At night, there are fewer doctors in the hospital taking care of patients. The doctors who leave will tell the doctors who are staying about you. If you get sicker during the night or need something when your doctor isn’t in the hospital, the nurses can call the doctor who is in the hospital at night. This doctor can order additional tests and medicines and if necessary, call your doctor at home.
Nighttime can be a very difficult time for patients. Visitors have gone home. There are fewer people in the hospital. Many patients cannot sleep, or are awaken at night for tests, medicines or vital signs. Often, the lights are on, even if it is nighttime. Patients can become confused about whether or not it is nighttime. Often, because there are fewer people around and less distractions, patients have more pain at night. Trying to minimize interruptions and sleep less during the day.
Patient and Family Experience
Being sick and in the hospital is really hard for most patients and for their families. Your doctors and the hospital routine say what you will be doing, when and how. Often you do not know when tests will happen or when your doctors and nurses will be in your room to check on you, discuss test results and answer your questions. This loss of control can be frustrating and scary.
Many patients who are in the hospital have had surgery or will have tests or procedures that may be painful. (The Chapter on Pain has a lot of information about what to do for pain.)
In addition to feeling a loss of control and pain, patients and their families can have a lot of fear and anxiety. (The Chapter on Feelings has more information)
As you lay in bed or wait in the waiting room, many questions will come in your mind. Some of these questions are related to your health, but other questions may be spiritual, financial or social---can I pay for my hospital stay or my medicines when I leave? Can I go back to work, and if so, when? Often it seems the doctors and nurses don’t have time to talk about these questions. Or, your doctors and nurses may not share the same cultural, religious or ethnic values. Hospitals have social workers, resource managers and chaplains who can help you with some of these questions. If your doctors or nurses do not ask you, you can certainly ask if you can speak to one of these people.
Some patients, particularly patients who have been very sick and had a life and death experience, have a difficult time with feelings after they leave the hospital. Patients may be frustrated that they are weak and cannot do as much. They may be frustrated that they can’t be the primary money-maker or primary child-care provider. Some patients have nightmares about being in the hospital. And some people, even their families, struggle with depression and anxiety after a serious illness. It is important to know you are not alone. This is also very normal---it is helpful to know it happens to a lot of other patients and families and it is good to talk about it with your doctors or a therapist.
Some things can happen as a consequence of being in the hospital. It is important to know what these things are so that you can look out for them. Your doctors and nurses will also be looking for these things and doing everything they can to keep them from happening.
Infections: People who are in the hospital can develop serious infections. This happens because most people in the hospital have IVs that go through the skin and into the veins or have incisions in the skin. The breaks in the skin make it easy for bacteria to get into the body and to cause infections. The bacteria that live in the hospital are used to antibiotics and these bacteria may be resistant to the usual antibiotics. To prevent infections, doctors and nurses will look at the IVs everyday, change the dressings on the IVs and wounds. The most important thing that can be done to prevent infections is to make sure that everyone wash their hands before and after touching the patient, everytime. It is okay for you to ask the doctors and nurses to wash their hands before touching you or your family members.
Pneumonia: People in the hospital often have problems eating or coughing. Some patients are in a coma and some are on breathing machines. People with these problems, particularly those on breathing machines and those that cannot cough properly, are at risk from catching pneumonia in the hospital. This is called hospital acquired pneumonia. Doctors will try to keep pneumonia from developing in patients by trying to keep the head of the bed elevated if a patient has a feeding tube or is on a ventilator. Some patients (usually patients who have had surgery) will be given small machines that teach them to take deep breaths, to try to keep the lungs from collapsing.
Blood Clots: Patients who are in the hospital and who are not moving can develop blood clots in their lungs that can break off and go to the lungs. To try to prevent blood clots, doctors will either put patients on blood thinners (an injection in the stomach or things) or the doctors will put wraps on the legs that squeeze the legs several times an hour. Many patients who will be in the hospital more than a day will either be on blood thinners or have special leg stockings to prevent clot.. However, if the patient is up and walking around, these preventing blood thinners or special leg stocking may be stopped.
Problem with Medications: Some patients can develop reactions to the medications that are given---allergic reactions that could not predicted. These are called adverse drug events. When an unexpected reaction happens from a medication, the doctors and nurses will record these events and enter an allergy in the patient’s medical chart to prevent that medicine, or any other like it, from being given to the patient.
Because there are so many patients in the hospital and because each patient is on so many medications, it is possible for a patient to get a medicine that was meant for another patient. To prevent these errors, some hospitals have bar-coded medicines and patients and use the bar codes to make sure the right medicine is being given to the right patient. In other hospitals, the nurses will verify the name on the medicine and the name on the patient. It is okay for the patient and the patient’s family to ask what medicine is being given, and why, to help make sure the right medicine is being given to the patient.