Formal vs. Informal Care Process: MRI

We touched on systems that we deal with in our daily lives outside of work. Now let’s look at an example of a formal vs. informal system in the hospital setting. (Reminder: the challenges that we face in healthcare are universal, and the purpose of this forum is not to separate out one institution from the next nor is it to finger point at individuals or departments. There will only be two references to hospitals, the larger hospital (>500 beds) as LGR, and the smaller hospital (<500>)).

Formal System: LGR provides anesthesia coverage for challenging MRI cases. This includes patients with severe anxiety and claustrophobia as well as patients with severe pain or co-morbidities that require extra attention. The formal system is set up as follows:

1. Anesthesia provides MRI coverage one morning per week on Thursdays.
2. The requesting service books the MRI case in advance with Radiology and with Surgical Scheduling so that the patient is officially on the anesthesia schedule
3. The outpatients are seen in the pre-admission test center on a day preceding their scheduled MRI; inpatients are evaluated the night before by the on-call anesthesia team.
4. The patients arrives at MRI about 30 minutes before the scan with complete paperwork
5. The anesthesiologist assigned to MRI reviews the chart, checks the anesthesia equipment set up by the anesthesia tech, and off they go.
6. The MRI cases are completed by 11:30AM and the anesthesiologist then proceeds to interventional radiology to provide similar afternoon anesthesia services.

Here is a description from the vantage point of the anesthesiologist of the system as it actually plays out at LGR. It’ not quite the same!

Informal System:
0730: There is construction going on in one of the MRI bays at LGR – it’s very noisy from the use of Jack Hammers; everyone is yelling to be heard.
0730: The patient arrives, upon chart review it is determined that there is no laboratory data. The MRI scan requires the use of contrast, which requires a baseline creatinine level to be drawn. There is no record of any recent laboratory work in the computer (looking in two IT systems: inpatient and outpatient); the patient had been seen in the pre-admission clinic 2 days earlier and blood had been drawn only for a coagulation profile (PT/PTT/INR). This lab is not necessary for this study.
0740: The patient is approached by the nurse and the radiology tech about the lab issue. The patient informs them that he presented a form with the necessary lab data when he presented to pre-admit clinic. No such sheet in the chart. The patient is now angry that LGR could lose this information. He now will have to have labs sent before we can do the study. He wants to talk with his referring neurosurgeon in person.
0750: The resident and attending anesthesiologist meet with the patient, acknowledge his frustration and suggest that to save him an additional needle stick that they can draw the blood sample through the iv. They also review his history and come up with an anesthetic plan to keep him comfortable during the study.
0810: The nurse contacts one of physician assistants to personally transport the blood sample from the MRI area to the lab after it is drawn. She arrives, apologizes to the patient and informs him that she will go to pre-admit clinic to find out what the problem was with the lab process. The patient says that he would love to go with her and give them a piece of his mind!
0820: The patient is taken out of the waiting area to the MRI patient prep area and placed on a stretcher. The resident starts the iv and draws a blood sample for the PA to take to the lab as arranged.
0830: PA goes to the lab – even though the sample is labeled “super stat” the result will take about an hour to obtain.
0908: The second MRI case is an inpatient scheduled for 0930. The tech asks the attending anesthesiologist (attending) whether she should delay the transport of this patient from the floor to MRI prep given the delay. She informs him that transport is usually arranged the night before for scheduled inpatients. He suggests that they hold off on sending for this patient until 10AM – given the unpredictable nature of transit time this will provide plenty of leeway so that this second patient has arrived by the time they’re ready; transport usually takes at least 30 minutes.
0910: The tech calls transport and is informed that the patient had never been scheduled with them (had they been on time with the first patient this second patient would not have arrived!). The tech asks that the patient be sent for at 10AM. She then calls the patient’s floor to inform the nurse that the patient will be coming down at 10AM.
0914: The attending receives a text page from Angiography to please call. He speaks with the nurse-in-charge, who inquires whether they will be able to start their scheduled case with anesthesia at 1130 as booked. The attending informs him of this unlikelihood given the delay. Fortunately, their schedule is flexible and he asks that they call him when they begin the second case so that he can send for the Angio patient.
0928: The nurse looks online for the necessary lab result for the first patient and it is still not entered. She calls the lab for the result and after a minute of waiting is informed of the lab value: It’s a go.
0930: The patient is taken into the MRI scanner, monitors are placed and sedation is given.
0942: The patient requires more sedation than expected, so while the resident remains with the patient the attending goes to the OR pharmacy to retrieve additional medications (OR pharmacy is at the other end of the building).
0943: The attending encounters an outpatient who is lost and requests assistance in finding the nuclear medicine clinic. He has a sense of where it is but given the poor signage, he offers to take the patient there himself. The clinic is halfway back to MRI. The patient is very thankful.
0945: The attending heads back to the pharmacy. Along the way three elderly family members stop to ask him who the third member of the Three Stooges is: Mo, Curley and? Without hesitation he answers “Larry” – he knows this data cold! They all have a good laugh.
1000: The MRI scan finally begins. The patient is well sedated, however, the pulse oximeter that they rely on to measure the patient’s oxygenation malfunctions repeatedly, resulting in continued scan interruptions, going into the scanner, pulling the patient out of the tube, readjusting the pulse oximeter, sliding the patient back in the scanner, leaving the room. Finally they get an intermittent signal by securing the pulse oximeter to the patient’s finger with a piece of tape.
1001: The second patient arrives to MRI – apparently they sent for the patient immediately disregarding the call requesting a 10AM pick up. This patient will now spend at least an hour on the stretcher waiting for her scan.
1013: The attending goes out to see the second MRI patient. Although the case had been scheduled the day before and should have been seen by the anesthesia call team, there is no pre-procedural assessment, no consent. The nurse informs him that she has the necessary paperwork for him to complete this but that she cannot stamp them up with the patient identification because the patient’s black ID card did not come down with the patient’s chart. She has called the floor and asked them to send it down.
1015: He reviews the chart in the meantime and begin to fill in the pertinent information
1028: The black ID card is hand delivered to him by one of the radiology patient care assistants
1104: The first case is complete, They’re 1.5 hours delayed. The patient will be recovered in Day Surgery and this recovery area requires discharge orders to be completed by the service performing the surgery or procedure. Radiology has never incorporated this requirement into their care process, so the attending asks the nurse to page the neuroradiology fellow to please go to day surgery to complete the paperwork. The patient informs them that he and his wife have traveled by train to get into the city and that they have to catch the outbound train at 12PM. Given that the scan was supposed to be completed at 0900, he thought that they’d have plenty of time. He tells us he’s leaving in 30 minutes whether we like it or not.
1109: I sign out the patient to the recovery room nurse and we realize that the patient’s chart has been left behind in MRI. I offer to go get it.
1141: Next patient in the room for MRI. Pulse oximeter continues to malfunction in the same way, adding approximately 25 minutes of additional time to the study.
1304: Patient taken out of the scanner. In the meantime the attending is down in Angio getting the patient ready for the procedure there. The resident pages him to inform him that the recovery room is full and that they will be on hold in MRI with this second patient if she has to recover there as originally planned. He inquires whether they might bypass the recovery room given that the patient has already met discharge criteria (alertness etc.). Fortunately they are out of the main OR and can exercise this work around option. The attending calls the resident back and inform him that this would be fine.

Think about the impact this informal system has on:
1. Levels of patient and care provider frustration
2. Efficiency and scheduling
3. Safety
4. Cost
5. Other?

This informal process has been in place for years and is so routine that it has become invisible!! Nobody thinks twice about this process – it’s just the way it is. Until we see it, dig into the core causes, and take a frontline system-based approach to correcting the issues, nothing changes; it’s the heroics of the people at the front who keep things running to the best of their abilities.