Most Ridiculous Hospital Policies

[DoctwoB]

While I'm still pretty new at this, I've seen that every hospital I've rotated at has had some pretty ridiculous policies/procedures in place. Some are just annoying, some are actually bad for patient care. What are some of the worst that you've seen?

I'll start: One hospitals ED had a policy where if a patient was being admitted, the ED physician would stop taking care of them after 4 hours in the ED. Meaning you'd get called for a patient that you were going to admit, and even if they hadn't left the ED yet they became your responsibility at some point in time. Meanwhile the nurses in the ED wouldn't know this or call you if anything went wrong. I'm betting it was supposed to improve ER turnover, but in reality led to situations where patients would sit in the ED when no beds were available and no-one would take charge of their care.

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[vhawk]

So you've seen them and admitted them, but you still expect the ED to keep taking care of them all day until a bed is available? At my hospitals you are basically responsible for them the second you see them, whether they are being admitted or discharged. Only exception is if you see them and refer them back to the care of the ED for further workup, but that requires specific communication.

 

[DoctwoB]

So you've seen them and admitted them, but you still expect the ED to keep taking care of them all day until a bed is available? At my hospitals you are basically responsible for them the second you see them, whether they are being admitted or discharged. Only exception is if you see them and refer them back to the care of the ED for further workup, but that requires specific communication.

Its from the time of the phone call. You could get a call at noon, be in the OR until 2, and have a gap of two hours where the ED has basically signed off but you haven't even seen him/her.

 

[Pir8DeacDoc]

That's what junior residents are for. A patient with a potential surgical problem isn't seen for 4 hours? Bad idea. I'm not terribly old school but the junior resident will get their turn to operate at some point, but it might be later in residency. There is no excuse to leave a patient hanging out in the ED with a surgical problem and have the ED physicians who are triage specialists/primary care physicians manage that pt.

 

[rongeur]

So you've seen them and admitted them, but you still expect the ED to keep taking care of them all day until a bed is available? At my hospitals you are basically responsible for them the second you see them, whether they are being admitted or discharged. Only exception is if you see them and refer them back to the care of the ED for further workup, but that requires specific communication.

You must work in some weird hospitals. So when you call neurosurgery for a head trauma the moment you see a neurosurgeon bed-adjacent you give the guy next to you a high five and sign off?

There is certainly some room for debate over the role of ED docs for a patient who is "boarding" in the ED for a bit. I've never heard of any service automatically relieving the ER of responsibility prior to an "Admit to:" order being placed, nor can I imagine it being common.

 

[Winged Scapula]

Its from the time of the phone call. You could get a call at noon, be in the OR until 2, and have a gap of two hours where the ED has basically signed off but you haven't even seen him/her.

That sounds dangerous.

As others have noted, I'm surprised you don't have a residency policy where surgical consults get seen within "x" amount of time; ours was 30 minutes regardless of whether the consult resident was scrubbed in or not, or a trauma was going on. Someone either scrubs out or calls the backup resident or even attending to see the patient. To allow hours go by after a consult is placed without seeing the patient puts you at risk of liability and potentially harsh the patient. That plus this lunatic idea that the ED has "signed off" the patient but no one is managing them is outrageous. Maybe your ED is reliable in telling you that someone can wait to be seen until you're out of the OR, but I'd be skeptical.

 

[DermViser]

That sounds dangerous.

As others have noted, I'm surprised you don't have a residency policy where surgical consults get seen within "x" amount of time; ours was 30 minutes regardless of whether the consult resident was scrubbed in or not, or a trauma was going on. Someone either scrubs out or calls the backup resident or even attending to see the patient. To allow hours go by after a consult is placed without seeing the patient puts you at risk of liability and potentially harsh the patient. That plus this lunatic idea that the ED has "signed off" the patient but no one is managing them is outrageous. Maybe your ED is reliable in telling you that someone can wait to be seen until you're out of the OR, but I'd be skeptical.

Absolutely ridiculous.

 

[Winged Scapula]

Absolutely ridiculous.

What? It's generally a good policy to see surgical patients ASAP.

 

[DermViser]

What? It's generally a good policy to see surgical patients ASAP.

Assuming they're actually surgical patients and not just being turfed off to you by the EM resident.

 

[ram006]

Assuming they're actually surgical patients and not just being turfed off to you by the EM resident.

Our EM docs/residents are actually pretty good at identifying sick patients that need immediate attention and not so sick patients that can be seen when things slow down. The 30 minute rule doesn't actually end up being much of an issue.

I can only think of one EM doc at the VA who is notorious for halfassing his job, calling surgery about everything, demanding the patient be seen within 30 minutes and refusing to continue to participate in the patients care(apparently there is some "policy" that requires us to coordinate consults). It's too much effort to argue with him and I now I actually kind of enjoy poking him with a stick.

PA's on the other hand... You'd be surprised how often they page and have no idea why they're calling or what the relevent surgical question is. I usually just bypass them and go ask the attending. I find that most of the time there is an actual surgical issue that was lost on the PA.

 

[ram006]

We have one ED PA who is notorious for calling a surgical consult for "classic" cases (e.g. "Hey, I've got this guy down here with a classic story for cholecystitis"). Every time they call, they've done no workup beyond H&P - no labs or imaging. And in my personal case series with this PA they are like 0/10 in "classic" stories ending up being the correct diagnosis.

Haha. Funny how some things are universal.

"Ya I got this guy--classic case of acute appendicitis. Two to three week history of dull, achey right lower quadrant pain that got worse this AM. Hasn't had a bowel movement in like a week in a half. Should I get some labs and start Zosyn?"

 

[ThoracicGuy]

Haha. Funny how some things are universal.

"Ya I got this guy--classic case of acute appendicitis. Two to three week history of dull, achey right lower quadrant pain that got worse this AM. Hasn't had a bowel movement in like a week in a half. Should I get some labs and start Zosyn?"

Or the classic VA consult I got once that had a concern for appendicitis... I went and talked with the patient and looked at his belly. I saw a scar in the RLQ and asked what that was. He replied that it was his appy scar. Classic.

 

[balaguru]

Stump appendicitis can happen if the prior appendectomy was inadequate.

 

[vhawk]

You must work in some weird hospitals. So when you call neurosurgery for a head trauma the moment you see a neurosurgeon bed-adjacent you give the guy next to you a high five and sign off?

There is certainly some room for debate over the role of ED docs for a patient who is "boarding" in the ED for a bit. I've never heard of any service automatically relieving the ER of responsibility prior to an "Admit to:" order being placed, nor can I imagine it being common.

I dont, because I dont work in the ED. And I doubt anyone thinks that about neurosurgery, since at my hospital neurosurgery almost never admits, and I'd bet thats how it is elsewhere.

But if you replace general surgeon in your example, then yes, that is exactly how it works.

 

[vhawk]

If we are consulted and decide to admit them, they are ours the moment we put the order in. The ED nurses will get the inpatient orders and carry them out. But if we don't admit them ourselves - it's up to the ED what they want to do with them, admit to another service or discharge them. It's not like a hot potato where once we've touched the patient they are our problem. We still have the discretion to say yay/nay and they are the ED's patient until we decide what to do with them.

This is sort of what I was talking about with "referring them back to the ED" but I guess we are slightly more the ED's bitches than you are, since its the default that we are either admitting them or finding some dispo for them. I'd say 90% at least of ED consults we become instantly responsible the second we see them, and then we either admit, discharge, or work out dispo ourselves. The other 10% we refer them back to the ED physician to figure out the next step, but like I said that requires specific communication on our part.

I think thats pretty similar to what you are saying, we are just a little more subservient to the ED. I'd prefer it your way.

 

[DermViser]

I've had probably a half dozen r/o appy consults in patients with no appendix. It's really hard to resist writing some serious snark in the chart when that happens

Yup, they definitely crack down on that type of stuff esp. between specialty consult services.

 

[bambi]

We have a policy that NG tubes have to be at least 5cm into the stomach. If you have to X-ray a tube and it is only 4.5cm in the radiographer will call you and demand that you drop whatever you are doing and immediately go down to X-ray and advance the tube and if you don't do it within 30 minutes the radiographer will remove it. So, in my specialty at least this will lead to many, many patients having an unnecessary uncomfortable procedure for the sake of maybe a cm. When I first encountered this issue I looked it up, a lot, and found no evidence for this 5cm cutoff, yes it shouldn't be just barely in but 5cm was plucked from thin air. Most tubes that are never x rayed probably aren't in 5cm and the radiographers follow this rule only when they feel like it but when the junior doctors try to fight it, pointing out that there is no evidence for it, it's unpleasant for patients and will usually take the only doctor off a ward full of actually pretty unwell patients we are the problem. Management don't seem to care if a patient dies on the ward because the doctor has been forced to leave due to this ridiculous policy, we have to follow it because it came from someone more senior who is very nice and it took a long time to do. Great reasons! Most places this isn't even a doctors job, certainly not at my level which makes it even more annoying!

 

[DarknightX]

There was a policy at a private hospital that we rotated at that if the ED consulted you, the patient then became your responsbility, even if the patient didn't have a surgical issue. So if you got consulted for abdominal pain and it was an OB/GYN problem, you had to call OB yourself and explain the consult. If the patient had something like biliary colic and could go home, YOU had to do the discharge. It was basically like a game of hot potato with the ED. As you can imagine, this lead to a lot of unnecessary and ridiculous ED consults.

It eventually ended after the residents started flat out refusing to see surgical consults and our PD threatning to pull us off the rotation.

 

[Arcan57]

Assuming they're actually surgical patients and not just being turfed off to you by the EM resident.

If you don't trust what the person on the other end of the phone is saying, shouldn't that that make you more concerned about the patient?

 

[DermViser]

If you don't trust what the person on the other end of the phone is saying, shouldn't that that make you more concerned about the patient?

Yes, but we can't be the saviors of the world. If the EM resident/physician doesn't know what he's doing, then how is that the admitting resident/attending's problem?

 

[DermViser]

There was a policy at a private hospital that we rotated at that if the ED consulted you, the patient then became your responsbility, even if the patient didn't have a surgical issue. So if you got consulted for abdominal pain and it was an OB/GYN problem, you had to call OB yourself and explain the consult. If the patient had something like biliary colic and could go home, YOU had to do the discharge. It was basically like a game of hot potato with the ED. As you can imagine, this lead to a lot of unnecessary and ridiculous ED consults.

It eventually ended after the residents started flat out refusing to see surgical consults and our PD threatning to pull us off the rotation.

Surprised that even happened.

 

[balaguru]

Sounds like somebody once had their lungs fed.

We have a policy that NG tubes have to be at least 5cm into the stomach. If you have to X-ray a tube and it is only 4.5cm in the radiographer will call you and demand that you drop whatever you are doing and immediately go down to X-ray and advance the tube and if you don't do it within 30 minutes the radiographer will remove it. So, in my specialty at least this will lead to many, many patients having an unnecessary uncomfortable procedure for the sake of maybe a cm. When I first encountered this issue I looked it up, a lot, and found no evidence for this 5cm cutoff, yes it shouldn't be just barely in but 5cm was plucked from thin air. Most tubes that are never x rayed probably aren't in 5cm and the radiographers follow this rule only when they feel like it but when the junior doctors try to fight it, pointing out that there is no evidence for it, it's unpleasant for patients and will usually take the only doctor off a ward full of actually pretty unwell patients we are the problem. Management don't seem to care if a patient dies on the ward because the doctor has been forced to leave due to this ridiculous policy, we have to follow it because it came from someone more senior who is very nice and it took a long time to do. Great reasons! Most places this isn't even a doctors job, certainly not at my level which makes it even more annoying!

 

[DarknightX]

Surprised that even happened.

Why? It was ridiculous. We got called to see almost every single patient in the ED, surgical or not. We spent more time doing paperwork and the attendings at the site didn't care, since they could bill for all the consults we were seeing. It was only once we bumped it up to our program director and our chair about what was happening that any change occurred.

 

[DermViser]

Why? It was ridiculous. We got called to see almost every single patient in the ED, surgical or not. We spent more time doing paperwork and the attendings at the site didn't care, since they could bill for all the consults we were seeing. It was only once we bumped it up to our program director and our chair about what was happening that any change occurred.

It's bc usually Program Directors defer to hospital CEOs.

 

[bambi]

Sounds like somebody once had their lungs fed.

Apparently they did but it wasn't because the tube was only in 4.5cm instead of 5!

 

[DarknightX]

It's bc usually Program Directors defer to hospital CEOs.

Not when they don't work for them. Like I mentioned above, it was a private hospital that we rotated at, not our home institution. Sorry if it wasn't clear.

 

[DermViser]

Not when they don't work for them. Like I mentioned above, it was a private hospital that we rotated at, not our home institution. Sorry if it wasn't clear.

Ah, ok. Makes much more sense then.

 

[balaguru]

Our hospital enacted some crazy policies after a tube feeding of the lungs episode, but nothing that extreme.

We finally succeeded in getting them to accept that intraoperatively placed NGTs where we palpate them in the stomach don't need an abdominal film postop to verify...

Other classical events that spawn comically bad policies include retained surgical instruments and patients declared dead who aren't actually dead.

 

[vhawk]

Other classical events that spawn comically bad policies include retained surgical instruments and patients declared dead who aren't actually dead.

OR fires, wrong site surgery...

 

[vhawk]

Yes, but we can't be the saviors of the world. If the EM resident/physician doesn't know what he's doing, then how is that the admitting resident/attending's problem?

Best interest of the patient I guess. Same as when you get called for a patient transfer from some outside hospital and they have no idea wtf they are talking about, and the patient definitely doesnt need transfer.

 

[vhawk]

There was a policy at a private hospital that we rotated at that if the ED consulted you, the patient then became your responsbility, even if the patient didn't have a surgical issue. So if you got consulted for abdominal pain and it was an OB/GYN problem, you had to call OB yourself and explain the consult. If the patient had something like biliary colic and could go home, YOU had to do the discharge. It was basically like a game of hot potato with the ED. As you can imagine, this lead to a lot of unnecessary and ridiculous ED consults.

It eventually ended after the residents started flat out refusing to see surgical consults and our PD threatning to pull us off the rotation.

This is basically my home institution. Didnt used to be so bad but a few years ago an intern sent home a "biliary colic" who had elevated LFTs who really had choledocholithiasis who then came back in 2 days later septic as **** from cholangitis. So now any call from the ED must be seen in person by the senior resident on call, and we discharge them.

 

[DermViser]

I know according to SDN a program director who cares about education is rarer than a unicorn...but they do exist

I'm talking about clinical responsibility. When the work needs to be done, then it needs to be done. That being said, the scenario above is a moot point, bc the hospital was an outside private hospital where residents rotated - and having residents was a luxury for them. The PD was not employed by that hospital.

 

[Arcan57]

Yes, but we can't be the saviors of the world. If the EM resident/physician doesn't know what he's doing, then how is that the admitting resident/attending's problem?

Because of EMTALA. Like Vhawk mentions, once the patient is aimed at you (which I have some appreciation of having worked at the hub of a multistate hospital system that required all patients come through the ED and be seen by an EP prior to going to the floor) you have to deal with them. For every 3-4 BS patients that the OSHs sent, one billed as "stable" patient would be something horrible like completely untreated septic shock or "cellulitis" that was really nec fasc. Sadly, the referring doctor being an idiot doesn't mean the patient isn't sick.

 

[Winged Scapula]

It's bc usually Program Directors defer to hospital CEOs.

Ours didn't.

He would back us up in our disagreements with other services as long as we were advocating for the patient.

 

[DermViser]

Ours didn't.

He would back us up in our disagreements with other services as long as we were advocating for the patient.

DarknightX's scenario (I believe) wasn't a clash with another service but with a different rotation site (that was a private hospital not part of the academic med center). But I think also Surgery PDs tend to also be very different when it comes to sticking up for their residents vs. IM PDs, who are usually more conciliatory, when it comes to dealing with Emergency Medicine. Hence why IM residents become the so-called "dumping ground" for the hospital.

 

[Dissected]

We have a policy that if you break the door frame you have to 'foam in' (use the hand cleanser) and 'foam out' when you leave. One of our residents got written up for putting one foot in the room to look at a patient's vital signs and not foaming in/out. Our employer stated last year that we could be considered for termination if it happens three times. I'm all for hand sanitation, but we take it to a pretty extreme level.

 

[mimelim]

Our rule is call back consult within 15 minutes of page (otherwise it rolls to attending on call). Consults are seen within 30 minutes unless the requesting physician specifically says, okay to see later in the day. All ED consults are <30 minutes. But, then again we have a decent relationship with our ED. They still pull the, "your patient is sitting in the waiting room, will you come see them?" every once in a while, but they don't dump on us (since we don't accept ED patients onto our service).

 

[DoctwoB]

We have a policy that if you break the door frame you have to 'foam in' (use the hand cleanser) and 'foam out' when you leave. One of our residents got written up for putting one foot in the room to look at a patient's vital signs and not foaming in/out. Our employer stated last year that we could be considered for termination if it happens three times. I'm all for hand sanitation, but we take it to a pretty extreme level.

We have a similar policy regarding patients on contact precautions and gowning/gloving up. Even if you aren't going to touch the patient or anything in the room, if you pass through the door you'll be written up. It leads to a lot of awkward rounds with 1 or 2 gowned people in the room and group of people watching from the doorway.

Nevermind that the ID doctors behind the policy recommended gowns/gloves only if physical contact was occurring.

 

[CBG23]

At one hospital, you are only suppossed to get a pair of scrubs during a set couple of hours in the morning. After those hours_ it's taboo to request a pair of scrubs and you will get a lot of dirty looks despite the fact that there are many still available. Seems like an absurd policy to me.

 

[Winged Scapula]

At one hospital, you are only suppossed to get a pair of scrubs during a set couple of hours in the morning. After those hours_ it's taboo to request a pair of scrubs and you will get a lot of dirty looks despite the fact that there are many still available. Seems like an absurd policy to me.

So if you have bodily fluids all over them you're just supposed to wait until the next morning to get a new set?

 

[DermViser]

We have a policy that if you break the door frame you have to 'foam in' (use the hand cleanser) and 'foam out' when you leave. One of our residents got written up for putting one foot in the room to look at a patient's vital signs and not foaming in/out. Our employer stated last year that we could be considered for termination if it happens three times. I'm all for hand sanitation, but we take it to a pretty extreme level.

You can blame this guy: http://community.the-hospitalist.or...ng-patient-safety-compliance-by-remote-video/

Handwashing monitoring by hospitals is catching on.

 

[Over9000]

It's been pretty well established that caregivers are very bad at predicting when physical contact will occur. Something like 40% of the time they go into the room with the mindset of not touching anything they end up touching the patient anyways. That's why a lot of hospitals adopt a universal gown/glove policy for entering the rooms.

I at least understand the rationale behind those policies, even if they are sometimes taken to draconian extremes.

I vaguely recall some data that said that patients on contact precautions receive worse care because of the hassle of gowning and gloving up to go in there. How true is that?

 

[Dr.LeoSpaceman]

I vaguely recall some data that said that patients on contact precautions receive worse care because of the hassle of gowning and gloving up to go in there. How true is that?

This review would suggest that is the case.

Conclusion
Although CP are recommended by the Centers for Disease Control and Prevention as an intervention to control spread of MDROs, our review of the literature demonstrates that this approach has unintended consequences that are potentially deleterious to the patient. Measures to ameliorate these deleterious consequences of CP are urgently needed.

 

[meister]

Contact precautions for MRSA were eliminated at a former hospital of mine for that very reason.

 

[Over9000]

Contact precautions for MRSA were eliminated at a former hospital of mine for that very reason.

This is a good step. MRSA contact precautions are in my opinion detrimental to patient care. The research states above concurs.

What I am curious about is how the MRSA contact precaution policies started.

 

[TallScrubs]

Ever have a circulator destroy your world for not taking a patient's legs out of lithotomy without EXACT watch-time synchronization because 'it's hospital policy'