An almost childlike sense of wonder requires that I point you and anyone you care about to a recent blog post by the Happy Hospitalist. For those of you who may not keep track of such things, a hospitalist is a relatively new type of doctor who does nothing except care for patients while they are in the hospital. Once a patient is discharged from the hospital, his care reverts back to his or her usual array of primary care and specialty doctors.
One of the great problems faced by many patients in the hospital is disorientation and confusion. This is especially true in the intensive care unit or “ICU”, where extreme disorientation is given the name of “ICU psychosis”. Hospital-associated disorientation/confusion has a number of causes, but main one is the loss of many of the normal, familiar cues that we have as to where we are in space and time. Many hospital rooms do not have windows, or may have windows whose drapes are perpetually closed. People are working and lights are often on all the time, especially in the intensive care setting. One is surrounded by strangers, and in an unfamiliar world. It can be extremely difficult to keep track of time or even tell day from night. People who lose touch with familiar things like friends, family, place and time don’t tend to do well. They can become agitated, depressed and even violent. Most doctors and nurses who work in hospitals are well aware of this.
I’ll let the Happy Hospitalist take it from here:
“ I took this picture of this giant three armed hospital clock stuck to the wall of my patient’s room. I was kind of taken back by the monstrosity of it all. This thing is huge.
Happy: What the heck is that thing?
Nurse: It’s something we started a few weeks ago.
Happy: It’s a three armed clock.
Nurse: I know.
A Three-Armed Hospital Clock
.Happy: You’re going to make my confused patients really confused.
Nurse: I know.
Happy: I don’t get it. What’s the point of hanging a pediatric looking three armed clock in the rooms of elderly patients with dementia? You’re just going to agitate them and think they are looking a three armed clocks.
Nurse: I know.
Happy: What do all the arms mean?
Nurse: The move arm is to remind us and the patient that it’s time to move. The pain arm is to let the patient know when their next pain pill is due. And the toilet arm is to remind us to ask the patient if they need to use the restroom to prevent incontinence.
Happy: You do this on all your patients?
Nurse: Yes. At least when I remember to move the arms.
So let me get this straight. Between all the ridiculous computerized documentation requirements, hourly rounds, medication administration, answering call lights, communicating with other doctors, nurses, lab people, and taking lunch break, we are now asking our nurses to remember to change the arrows on a three armed pediatric clock that will cause demented patients to question everything about their existence?”
There is more good stuff in the post, but this is the important part for our discussion here.
Pop quiz: Before the dialog told you what the clock was for and what the arms mean, did you have the slightest idea of what you were looking at, or were you slightly disoriented and taken aback by the clock in the picture? Be honest. Did you think that perhaps one of the arms was for hours, one for minutes and the third for God-knows-what-else? Now, even looking at the picture and with perfect vision (which most elderly patients in hospitals certainly don’t have), can you figure out what each of the arms is supposed to represent?
One thing that the Happy Hospitalist’s post did not mention was whether all of the hospital rooms also have a real clock in them that would allow patients to tell the actual time. If not, inserting a three-handed clock is not only strange, but almost cruel. What good would it do to know what time the next pain medication could be given if you don’t know what time it is now?
The reason I’m going to so much trouble to reiterate the content of Happy’s post is not to boost his blog circulation or get off easy on creating my own content (although there is nothing wrong with either of those things). Instead it’s to illustrate just how easy it is for well-meaning people to think up and promulgate clinical practices that use up valuable time and resources for little or no clinical benefit. Take another look at the clock in the picture. What do you want to bet that one of those costs at least $5-$10 each? Of course, each patient will need his own since their medication and movement schedules will all be different. If we have a 500 bed hospital, that’s an initial investment of roughly $3,750.
Now let’s account for the nurse’s time. (S)he’ll probably need to check the patient’s records each and every time that the clock is to be set to make sure that she’s positioning the three hands correctly. It’s hard to remember exactly which patient is on which movement, bathroom and medication schedule – especially if the patient’s schedule were to be changed or disrupted for common reasons like being away for tests, having more or less pain than usual or getting some much-needed sleep. Let’s assume that checking with the record and the patient for accuracy takes just three minutes each time, and that the clock has to be reset an average of three times per patient per day. (Of course, it might need to be set even more often if, for example, patients were to get their medications every four hours.) Finally, let’s assume that actually changing the hands on the clock takes just twenty seconds three times each day for a total of one minute. That’s a grand total of time devoted to clock changing of ten minutes per patient per day.
If our hospital is full, we’ve now added 10 minutes x 500 patients = 5,000 minutes of nursing per day to the process of caring for patients, or a little over 83 hours. According to this website, the average registered nurse (RN) earns between $46,427 and $66,397 per year, or roughly $22.32 and $31.92 per hour. Let’s use the bottom end of the scale to allow for the fact that some of the nurses in hospitals will be lower-paid licensed practical nurses (LPNs) or other non-RNs. Multiplying 83 hours by $22.32 per hour = $1,852.56 per day in additional expense that has been added as a result of adding three-handed clocks to each patient room. That adds up to $676,184 per year, plus the initial cost of the clocks = the equivalent of fifteen full-time nurses each and every year! Of course, if the three-handed clocks do end up confusing and disoriented patients, they’ll also need more nursing care. That’s not included in our calculations but what the heck, we’ll give Happy’s mutant clocks the benefit of the doubt.
We’re getting there, but aren’t done yet. Let’s say that we went ahead and installed three-handed clocks nationwide. The Federal government mandates things like this – or even worse uses of valuable medical resources – all of the time. What would that mean?
Well, in 2006 there roughly 950,000 hospital beds in the United States. If clocks were required for all of them, we’d have to multiply the impact that we’ve already calculated by a factor of 1,900. That comes to an extra time and labor expense of roughly $1.3 billion in additional healthcare expense every year. At an average premium cost of $13,000 per family that’s enough to insure about 100,000 families, or about 400,000 individual Americans. => Note that we’ll also need to find and train an additional 28,500 nurses to handle the extra workload.
This sort of thing is exactly how the Road to Hellth comes to be paved with good intentions as well as evil ones. Somebody somewhere thought that the clocks would help. “Hey”, they thought. “it’ll remind nurses and comfort patients. Quality of care will be enhanced.” But did they think about the downstream costs and consequences before pulling the trigger? Probably not. Instead, this “great new thing” simply got slathered on top of everything that every provider everywhere already has to do with too little time and dwindling amounts of money. This sort of thing is exactly why we find ourselves in a multi-trillion dollar financial hole. It may seem like a trivial amount of money is involved compared to the $2.5 trillion we spend on healthcare each year, but the little things tend to add up add up.
As Senator Everett Dirksen supposedly once said, ” A billion here, a billion there, and pretty soon you’re talking real money.”
Now we’re going to go out on a limb and make some predictions. If the Happy Hospitalist or someone working at his hospital would like to verify or invalidate these we’d appreciate the feedback. We bet that:
- Whoever came up with the idea for the three-handed clocks (THCs for short), thought that it was a good idea because it would help patients get the care that they needed in a more timely fashion. Absolutely no harm or extra cost was intended. .
- The person who thought of this idea was an administrator. They might even be a doctor or nurse, but they’re an administrative doctor or nurse. Specifically, they themselves would never, ever, be responsible for actually keeping the clocks up to date.
- Absolutely no cost-benefit analysis was done prior to the installation of the three-handed clocks, aside from determining that the purchase price seemed minimal relative to the cost of running the hospital. Furthermore, no cost-benefit analysis has been done since the clocks were installed, and they have become a permanent part of the hospital’s new cost structure. Furthermore, no study of their clinical effectiveness was ever planned.
- Few, if any, clinical care doctors or nurses were actually consulted before implementing the idea and making it mandatory for all patients and nurses on the applicable wards.
- No new nurses or other personnel were actually hired to keep the clocks up to date and showing the right times. Instead, this new administrative overhead was simply added to the burden of existing personnel, thus crowding out actual patient care services. Instead of having the time to actually exercise, medicate or take patient to the bathroom, nurses now spend those valuable minutes changing the hands on clocks. Or they ignore the clocks altogether – thus ensuring that no patient ever really does know the correct time to exercise, go to the bathroom or receive their next pain medication.
- The invasion of the THCs was part of a “quality care” initiative. Ironically it is having an negative impact on care overall, as more and more patients become confused and disoriented by three-handed clocks.
Happy, how are we doing? Are we right?
And for our readers, we’d like to make one more prediction. If you don’t currently have three-handed clocks in your local hospital, it’s only a matter of time before they start showing up. How much time? Try this. Take your own three-handed clock and place it in front of you. Now pick a hand, any hand…
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