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Why Don’t Hospitalized Elderly Patients Walk? | Guest Blog

I'll tell you why. Medical staff are too busy documenting unnecessary garbage in the electronic medical record. But don't worry, the unresponsive comatose patient was documented to having received smoking cessation counseling.

Forty-three minutes—that’s the median length of time a hospitalized elderly patient spends standing or walking daily, reports a New York Times story. Not only that, the paper from which the 43 minutes number came also noted that the elderly spend 83% of their hospitalization time lying in bed.

This was a study on the activity of elderly patients who spent about 6 hours per day on their feet before they were admitted. Failure to walk around in the hospital had significant negative effects on the activity levels of patients for as long as 2 years after discharge from the hospital.

That brings up the question: Why didn’t they walk more?

According to the Times, “Even when physicians recognize the hazards of immobility and write orders that include ambulation, overworked staff can’t always find the time.”

Ah, the real question is: Why can’t they find the time?

I’ll tell you why. They are too busy documenting unnecessary garbage in the electronic medical record (EMR).

Here’s an example of what I am referring too. This was tweeted on June 2, 2013:

“@Apathetic_Cynic: Check da box @docgrumpy: Intubated, GCS of 3 x 2 weeks. Today someone documented counseling pt to quit smoking”

If you don’t speak Twitter, here’s the translation:

A doctor who calls himself Apathetic Cynic retweeted what a another doctor (docgrumpy) wrote, which said that a comatose patient who was completely unresponsive for 2 weeks in an ICU was documented as having received smoking cessation counseling.

Of course, the patient could not possibly have understood such counseling; it likely never happened. But the box in the EMR was properly checked, and so all is right with the bean counters.

A paper from the Journal of General Internal Medicine found that interns spent 12% of their time with patients. That’s 8 minutes per hour. “Computer use occupied 40% of interns’ time,” much of it spent documenting.

Ask any nurse, and he will tell you that the EMR demands ever-increasing amounts of documentation such that the documentation itself is now the endpoint. One hospital I am familiar with has a 7-page nursing assessment section that must be completed for any admitted patient.

Here are the sections that need to be filled out:

Cognition, verbalization, hearing, vision, educational barriers, pain assessment, restraint information, health history, advance directive, alcohol and drug use history, smoking history, diabetes mellitus, discharge planning (self-management of health, latex allergy screening, nutrition assessment, room service appropriate, urinary elimination habits, bowel elimination habits, activities of daily living/mobility, fall risk assessment, legal contact information, living situation and primary caregiver, abuse, opt-out/visitor restriction, suicide assessment, psycho-social concerns, spiritual needs, allergies, vital signs, height/weight, respiratory, cardiovascular, peripheral vascular, venous access, tubes and drains, neuromuscular, skin-Braden scale, skin assessment, skin co-morbidities, HEENT, gastrointestinal.

How long do you suppose that takes? There is a fair amount of redundancy too. For example, nutritional assessment will be done by the nutritionist. A complete history and physical should be done by the physician (or maybe not, because she has a lot of documenting to do too). Discharge planning is done by case managers and social workers. Contact information is obtained by the admitting office.

And guess what? A number of these nursing assessments must be documented every shift.

Now do you wonder why the staff doesn’t have time to get  the patients up and walking?

Note: This is Part 1 of a 2-part series on this topic.

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 900 page views per day, and he has over 6,000 followers on Twitter.

  • Great article I am looking forward to part 2. Please keep me updated!

  • Anesthesia Doc says:

    I’ve found electronic anesthesia records to be a problem, too. I don’t use any now, but I have in the past. The one I used required me to step away and turn my back to the patient to chart. No more mask cases – I can’t hold a mask and work a computer. Things I can scribble in seconds took much longer to document, as I had to go into menus and check boxes, type in a bunch of crap, and so on. The vitals recorded automatically, but that didn’t make up for the sheer volume of garbage that had to be documented.

    Long cases were OK; I could get the patient stabilized, and go play with the computer. Short cases? Forget it.

    When the focus is on the documentation instead of the patient, our priorities are upside down.

    • SkepticalScalpel says:

      Interesting problems that I had not thought of. What you describe is even worse than what I wrote about. What is the solution? I doubt you will be able to go back to paper.

  • Ellen Lerner says:

    Good Article. Question is, what can anything be done about this. I know that my husband complains how much time it takes him as a radiologist to log in and log out of his computer at work every day. He’ll sit down and the phone rings, for example, and he is automatically logged out. It takes him several minutes to log on again, and then Bingo he is interrupted again and the whole process is repeated. It all adds up. Docs don’t have time to come up and speak with him about patients like they used to. Now he has to spend time learning some new computer system that he doesn’t want to spend time doing. He feels like he is just getting to old for all this computer stuff and that it takes away from the real purpose of the art of medicine, taking care of the patient and using experience and knowledge, not computers, to manage patient care.

  • exhausted from documentation says:

    Is there a way to hold the People who sell the EMR responsible for selling systems that do not improve patient care. The software can be written in a way to avoid numerous clicks and redundancy. Why have they been allowed to sell us junk that makes physicians feel overwhelmed and in the end does not improve pt care.

    • SkepticalScalpel says:

      Exhausted, That’s a good question. I don’t know why we can’t hold off paying them until they give us something we really like. Unfortunately, the bean counters like all the clicks because it helps them count the beans and they don’t have to do the clicking. Therefore, the hospital administrators OK the EMR and then tell the docs and nurses to make it work.

  • cathy jones says:

    My 97 yo mom admitted to southside refional petg. Va for 5 days walked when she went in 2 months ago was not abulated or walked around and now cannot walk! She has had pt too. Too much time went by. Cj

    • SkepticalScalpel says:

      Anyone who is kept in bed for two months will have trouble walking. A 97 y o woman kept in bed that long has no chance of ever walking again. Very sad.

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