1:58 p.m. Efficient transfer. Listening in on physicians' phone conversations is part of Jan Powers's job in the cardiac access center. She and up to three other critical-care nurses take incoming calls from doctors who want to transfer their heart patients to Vanderbilt, connect them with a Heart Institute physician, and stay on the line to note the arrangements to be made for a room, tests, and perhaps surgery. "It sounds like a pretty large clot. We'll determine if he needs surgery or medication management," cardiac surgery chief Byrne tells a doctor 75 miles away who wants to send over an 81-year-old man who arrived in his emergency room short of breath the night before. Powers looks at the online "bed board" that shows the status of every bed in the hospital—full, empty, pending discharge—and enters a request for the incoming patient. She then sends out a page with his diagnosis, estimated arrival, and required tests to about 15 doctors and nurses in the cardiac surgery group. If the patient had needed surgery on arrival, Powers could have turned to look at a large screen that displays the real-time or schedule. Cardiac transfers were broken out from the general transfer center in 2004 after too many instances of physicians put on hold and dumped into voice mail. "Transferring doctors need to talk to a human," says Byrne.
Day 5
9:04 a.m. Ghost town. During the week, the 97-chair main lobby serves as a massive waiting room for families and friends. In grand southern tradition, they often set up with coolers, balloons, and meals for days on end. Saturdays are quiet; now only two or three families keep vigil. Seven operating room cases scroll down the "status board," a large LCD screen affixed to one wall; during the week, all 21 ors are in continual use. The board lists patients' first name and last initial and their status, such as "incision made" or "in recovery." Information is drawn from charting computers used by nurses in the ors, so it is right up to the minute.
10:22 a.m. The problem solver. Tamara Fulk walks briskly through the hallways on her way to a situation on the orthopedics floor that threatens to escalate. As one of five administrative coordinators, she constantly circulates through the massive center's two dozen inpatient units and some outpatient services such as the ER during her 12-hour shift, preventing and putting out fires of various kinds. The most clear-cut is to juggle beds when the hospital is crowded so that incoming patients don't have to be diverted to other hospitals. Other duties are less obvious. There has been a recent outbreak of gang violence in Nashville, and Fulk must keep injured members of rival gangs in completely separate parts of the hospital and conceal their identities.
Today, a recurring problem has surfaced. The girlfriend of a patient complaining of pain on the orthopedic floor was warned repeatedly to stop slipping him her prescription painkillers. She continued and became determinedly uncooperative. If he codes, she told a nurse, she'll do CPR. Fulk has already contacted the university's police force, and when she reaches the orthopedic surgery unit, the nursing staff says that two officers are meeting with the woman. The officers appear and report that when threatened with loss of visitation rights, the girlfriend agreed to lock the medications in her car. "That was a fairly common occurrence," says Fulk as she resumes her rounds. Visitors don't realize that even a seemingly benign dose of Tylenol could interfere with other medications. "Next thing you know," she says, "the patient is coding."
1:16 p.m. Tell us how we're doing. Two nurses in the emergency department's break room eat lunch beneath a bulletin board displaying performance data. Charts show how the team is doing on key patient safety tasks, including weekly errors made administering an EKG (such as improperly placing the leads on the chest) and the average time between ordering and administering antibiotics. But there is more than in-house data. Every patient not admitted to the hospital directly from the ED is called within 48 hours of the visit to solicit feedback. Some of the comments are posted on the wall. They don't reveal the names of their caregivers and generally are positive ("I was treated like a king" and "I have never been to a better ER"), but there is "They could've run more tests on me" and "I didn't see a nurse for an hour and my IV bag ran out." "The bad ones are painful, but we learn from them," says charge nurse Brenda Smith. That's a hospitalwide theme. "Complaining patients are nuggets of gold," says Gerald Hickson, director of Vanderbilt's Center for Patient and Professional Advocacy, which oversees efforts to promote patient safety and professional conduct. "We can't make it right if we don't know about it." But marketing studies suggest that complaints often go unvoiced, especially during a hospitalization. Patients clam up for fear that complaining will affect their care, says Hickson. "Every complaint you hear represents the 20, 30, 40 you don't." His 2008 goal is to surpass the roughly 2,500 anecdotal complaints that came in last year. "We want to reduce the number of people we make unhappy," says Hickson. The secret, he observes, is to hear from more of them.
