2:01 p.m. Bedside manners. Spotlessly white-coated, Frank Boehm and four medical students crowd around a bed and stare down at the small redheaded woman under the covers. "How does this make you feel?" asks Boehm, a professor of obstetrics and gynecology in Vanderbilt's medical school. "Trapped," peeps 31-year-old Allison McGuire, who has had a C-section. Boehm sits on the edge of her bed, puts his hand on hers, and repeats the question. More comfortable, she says. "We have such high tech, we need high touch," he tells the students. "When you're leading rounds someday, you can do this." Third-year medical students at Vanderbilt go on rounds with Boehm for an hourlong microcourse in bedside manners, created two years ago because the students sought guidance on how to behave in patient rooms. Boehm coaches students through scenarios with the consent of patients like McGuire. Treat her room as if it were her home, says Boehm. Convey respect. Don't be afraid to show emotion.
2:33 p.m. Keeping up with patients. Assistant chief medical officer Jim Jirjis taps out an E-mail on his laptop to a diabetic patient seen earlier in the day. Alerted by his computer that the man's labs are ready, the internist congratulates him for controlling his blood sugar but points out that his cholesterol is high. Jirjis has already called up a list of cholesterol-lowering statin drugs covered by the patient's medical insurance plan. Several have a lower copay than the statin that the man had previously taken. Would he be interested? The patient later messages back that he would, and Jirjis zips off an electronic prescription to his pharmacy. The patient can look over his lab results, too, by logging into his MyHealth@Vandy Web account.
The homegrown system is widely used by Vanderbilt's nurses, doctors, and patients, handling some 38,000 messages a week. Physicians can quickly order tests (grouped for certain diseases so that one click will order all of the necessary tests), store notes from other clinicians in patients' electronic medical records, and set follow-up alerts if a patient hasn't checked a message in a certain number of days.
Day 3
9:56 a.m. Quick discharge. Lisa Hardy, 45-year-old owner of a bar and grill in Lebanon, about 30 miles east of Nashville, had a 4-centimeter tumor removed from the right frontal lobe of her brain 18 hours ago. Now she wants to know if she can go boating Saturday. "It would be better to wait until next weekend," advises nurse practitioner Susie Dengler. Surgeon Reid Thompson had estimated a two- or three-night post-op stay, but Hardy has his go-ahead to head home this afternoon. She has had none of the complications that can occur after a craniotomy—seizure, stroke, inability to speak, bleeding in the brain—and her pain is under control. "The first thing she said to me was, 'I want to go home today,' " says Thompson, director of the Vanderbilt Brain Tumor Center. Wanting to leave suggests an uneventful recuperation, he says. Among U.S. academic medical centers, Vanderbilt patients have among the shortest average length of stay following a craniotomy, according to data from the University HealthSystem Consortium, a group of academic medical centers. Thompson says it is because of careful and coordinated work by the anesthesia, nursing, and surgical teams and steps taken to "be gentle to the brain," his mantra.
1:03 p.m. Monitoring a risky drug. With a few mouse clicks, clinical pharmacist Dan Johnson evaluates all 50 to 60 inpatients taking Coumadin, a blood thinner. Too high a dose can instigate a fatal bleed, and each patient's proper dose can fluctuate daily. Morning blood tests identify patients whose dose needs adjustment. Johnson can arrange the display on his screen by dose amounts, specific lab values, trends, or even by patients overdue for their blood test. Coumadin patients used to be monitored by calling up individual electronic medical records, which for a complex patient could take 30 minutes. But the biggest challenge was finding them, because no system efficiently identified the Coumadin patients for pharmacists. Since the tool became available in January, about 3.3 percent of patients on average are "out of therapeutic range" in a given week, down from 6.8 percent.
