Elevate patient care—even on crazy daysTips to refine protocols, create checklists, prevent errors, improve patient care, and make clients happy November 13, 2018 By Phil Zeltzman, DVM, DACVS, CVJ, Fear Free CertifiedMost busy practices have days where (wo)manpower, or lack thereof, may limit the care provided. Regardless of your love of animals, it’s easy to miss the “little things” when you have trouble carving out a minute to use the restroom or eat lunch. Here is a list of 20 little things we tend to overlook. Focus on them to elevate patient care, even on the craziest day. Client communication 1) When you ask a client if her pet is on any medications, never take no for an answer. Clients may be stressed out, in a hurry, not fully present, and may forget. We have personally talked to many clients who didn’t consider aspirin to be a medication! Be persistent. Ask several different ways: “Anything over the counter?” “Any supplements?” “Any pain medication?” “Any aspirin?” Relying on what has been dispensed by your practice can be misleading at best. Drugs may have been provided by another practice (including an emergency clinic) or an online pharmacy. What’s worse—meds could have been dispensed three years ago, or for another pet in the family. 2) Nothing is more frustrating than needing to call a client who scribbled an illegible contact number on the sign-in sheet. Review the information with the owner and confirm the best number to call them. 3) Keep your promises. If you tell a client you will let them know when Kiki is waking up from anesthesia, do it. Even if you physically cannot call this client, ask a teammate to do it on your behalf. And then make sure it was actually done while you were busy. 4) After every touch point with a client, including phone calls, always document what was discussed. Here’s a silly example: You may be the only human being in the universe who knows that a patient ate or defecated. And that may be an absolutely critical piece of information in the eyes of the owner. If you don’t document it, the next team member who talks to that owner may sound ignorant or may give the wrong information, leading to unnecessary worry—or blame. 5) Always obtain permission for CPR or DNR. Yes, even for visits that seem straightforward. Case in point: A dog was presented for a broken nail. Oh, and he “just seems a little off.” A few minutes later, he collapsed in the treatment room. Turns out he had congestive heart failure. Patient treatments 6) In a busy practice, it can be really tough to give multiple medications to multiple patients simultaneously. Actually, it is physically impossible. One solution is to always treat patients in the same order. This way, patient A gets his treatments at 9 a.m. and 11 a.m., while patient B gets her treatments at 9:05 a.m. and 11:05 a.m. Another option is to “borrow” a technician to specifically help out during treatment times. 7) It is important to physically remove patients from their cage or run every few hours. They could be sitting or lying in urine or feces, which you may not realize until you move them and change the bedding. 8) In addition, any patient with mobility issues should be rotated every two to four hours. To avoid confusion, everybody should agree on a “code.” For example, note in the medical record which side is down. This will help the team keep track during the next treatment or whether the patient has started moving on his own. In addition, passive range of motion should be performed throughout the day. 9) Every practice has a “rhythm”—treatments are done every four, six, or eight hours. Yet some patients need treatments more often than that. This is especially true for patients coming out of surgery with low temperatures, pets with dyspnea, and those with cardiovascular issues. Some vitals should be checked every 30 minutes. It’s very easy to let an hour or two go by when you’re busy or swamped. A timer is your best friend for situations like these. IV catheters 10) When placing an IV catheter, please take an extra minute to shave all the way around the leg. And please use aseptic technique. And please don’t touch the hair (or the floor or the table) with the catheter. And please leave tabs on the tape for easier removal. An IV catheter must be placed and maintained aseptically. 11) When performing venipuncture, always document the exact location and any difficulties you may have had. This helps avoid confusion between a blood draw and petechiae, and concerns about values that may be falsely increased due to hemolysis. 12) Patients on IV fluids should have several values checked to make sure we are helping and not hurting them. Such values include albumin, electrolytes, and blood pressure. Remember, “first do no harm.” 13) Have you ever found a disconnected IV line that was delivering fluids to a towel or a cage floor? Ensuring IV fluids are running correctly should entail more than a quick walk-by to make sure no pump is beeping. A proper check should include: Pump status “Volume to be infused” verification Whether the IV line is physically connected to the patient or not Whether there is swelling above or below the IVC site Bandaging and untaping the IV catheter daily to check for phlebitis can extend its life. Recent data suggests a properly managed catheter can stay in longer than 72 hours with no risk to the patient. “Properly managed” is the key. 14) Wipe all IV ports and IV drug stoppers with alcohol. A recent study (Guillaumin, JVECC 2017) showed bacterial contamination of IV fluid bags with improper care. This could become a problem, especially in sick or immunocompromised patients. Take a few extra seconds and wipe every IV port and every bottle cap with alcohol before sticking a needle through it. More patient treatments 15) When rushed, it’s easy to miscalculate a dose, miss a decimal point, or misunderstand the requested amount. Have someone else double check medication doses to avoid deadly mistakes. Ego has no place in drug calculations. In addition, please label syringes. It’s easy to mix them up when you are about to give several injections via different routes (IV versus SQ versus IM). 16) Check expiration dates, especially with drugs that are rarely used. Make it a habit of checking the expiration date of a drug before administering or prescribing it. And by the way, please double check the name of the medications, as some brand names are stupidly similar (sorry, no names here). 17) Our patients also have a circadian rhythm. In 24-hour facilities, turn down the lights when you can. A little bit of rest and relaxation does wonders to help with recovery. 18) The purpose of anesthetic monitoring is not only to display pretty curves and colorful numbers. The person monitoring a patient should understand the data provided, and should know how to rectify a low MAP or a high CO2. Otherwise, you are doing your patient a disservice. At the very least, always notify your doctor when values are abnormal. Of course, this means you need to know what normal values are. 19) Use appeasing pheromones in exam rooms, in hospital areas, and on clothing. Even better, spray cat pheromones on one side of your clothes and dog pheromones on the other at the beginning of each shift. 20) Since the creation of the first veterinary practice, there has never been a recorded case of overcommunication. Keep an open dialogue with all team members. This can be in the form of morning huddles, afternoon rounds, regular staff meetings, and/or shared notes in paper or electronic records. Having everyone on the same page with both patient status and clinic protocols will avoid miscommunication, mistakes, and misunderstandings. This nonexhaustive list should be an opportunity to have a constructive dialogue in your practice. Use it to refine protocols, create checklists, prevent errors, improve patient care, and make clients happy. Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified is a board-certified veterinary surgeon and serial entrepreneur. His traveling surgery practice takes him all over Eastern Pennsylvania and Western New Jersey. Visit his websites at DrPhilZeltzman.com and VeterinariansInParadise.com. AJ Debiasse, a technician in Stroudsburg, Pa., contributed to this article.