Monthly Archives: June 2017

Reflection 2: Editing Reports and Application Packages

Never tell a new parent that their child is ugly.

Apparently this maxim also applies to writers and their new writing pieces. It shouldn’t, but it does.

My recent experience in editing was not an enjoyable one. It got me thinking about the futility of putting in good effort after bad. At what point does any attempt at editing become fruitless and starting again becomes the better option? How bad does a piece of writing have to be for the editor to be able to say that it’s irredeemably bad? The law of diminishing returns states that sooner or later the point of no return appears and a decision has to be made. We eventually replace a machine when the maintenance costs are too high to justify the output that we get from that machine. We eventually tear down a home when we can’t renovate it to function in a desired fashion or when the cost of renovation is prohibitively high. We eventually stop CPR or any other treatment when the costs of the treatment outweigh the effectiveness of the treatment, or if the side effects do not justify the rationale for the treatment. In the time-strapped professional world, simply restarting from scratch is sometimes more resource-efficient than wading through a poorly written document in an attempt to salvage the time and effort already invested. My thought is that the decision to fish or cut bait happens sooner rather than later, and should be applied to the writing and editing process as well.

My experience also got me wondering about respect. Much is made of the necessity of being respectful when editing documents. Criticism has to be constructive and positive whenever possible. I agree with this. Editors should not get to be deliberately or gratuitously mean.

But what if the writer does not show a similar respect to the editor? What if the writer presents a draft riddled with bafflegab and gobbledygook, expecting the editor to produce an acceptable document from it?

I think most people have had the experience of not putting in sufficient effort into a task and trying to get away with it. They also have had the experience of having to deal with the consequences and results of half-hearted work. In this environment, deadlines loom, writers get blockage, bosses’ expectations of work output rise unrealistically, and any other number of things can happen in order to make a writer want to “just finish the blessed thing and get it off my plate!”. I get it. Life happens. However, I don’t think that writing a substandard document is justifiable.

The following aspects of any document at the university level or professional level are, as far as I can tell, non-negotiable:

The document must be free from spelling and punctuation errors.
The document must have a clear audience and statement of purpose.
The editor should not have to hunt for the thesis statement.
The editor should be able to see a logical progression throughout the document.

I’m going to say this again: THIS SHOULD BE NON-NEGOTIABLE.

Editing a document is one thing. Having to rewrite an entire document because the original writer didn’t (or couldn’t) create a cohesive thesis statement, back up the argument with appropriate material, and come to a logical conclusion using standard writing conventions is something else entirely. The editor’s time is completely wasted in the latter case because the writer did not do their job. Furthermore, putting the onus on the editor to clean up a messy piece of writing shows a distinct lack of respect for the editor. Respect has to be a two-way street and must be present in all aspects of the writing and editing process.

Rant over. Moving on…

301 OP Reflection 2

Report Progress Report

PROGRESS REPORT

To: Dr. Erika Paterson, UBC Department of English

From: Owen Picton

Date: 23 June 2017

Subject: Progress Report on Feasibility of Adding Physician Extenders to the St. Paul`s Hospital Emergency Department (SPHED) Fast Track Staff

Project Overview

For my formal report, I am investigating the feasibility of physician extenders (non-physician experts) to the St. Paul’s Hospital Emergency Department Fast Track staff in order to provide consistent, effective, and maximally efficient care to more patients who are assigned to the Fast Track area of the Emergency Department.

Tasks Completed

Reviewed the scope of practice of many health care professionals (HCPs) and chose the HCPs who would be most appropriate to support the staff members currently working in the SPHED.
Completed introductory literature search for instances where physician extenders are used in medical practices.
Arranged interview with the St Paul’s Hospital Emergency Department Operations Leader.
Developed questions for the staff survey and the patient survey.
Sketched out the typical Fast Track patient care trajectory.
Investigated the method of obtaining information from the BC Ministry of Health.

Tasks In Progress

Investigating what general information about the SPHED requires clearance under the Freedom of Information and Protection of Privacy Act (FOIPPA) and which can be obtained without such clearance.
Ensuring survey questions pass UBC ethical clearance.

Tasks to be Completed

Administer survey to St. Paul’s Hospital staff and patients.
Collate information gathered from surveys and examine trends in the data.
Obtain FOIPPA-governed data and analyze it.
Interview the St. Paul’s Hospital Emergency Department Operations Leader, the St Paul’s Hospital Physician Leader, and
Analyze cost of hiring, training, and retaining physician extenders vs. nurses and physicians.

Completion Date: The first draft of this document is due to be completed on 10 July 2017.

The report is currently behind schedule. However, once the FIPPA-protected information is obtained, the time should be able to be made up with no changes to the completion date needed.

Complications

Obtaining data about patients and data from patients in a public hospital setting is an intricate, time-consuming process. St. Paul’s Hospital has a very strict policy regarding patient involvement in surveys due to privacy concerns.
The staff is undergoing “investigation fatigue”—fatigue from the sheer increase in the amount of work each has to complete as well as the sheer number of different investigations into streamlining care and the number of trial initiatives that have been implemented and abandoned. Although they welcome any assistance in doing their jobs that they can get, they have been Six-Sigma’ed and LEANed to death already.
The issues of scopes of practice and job descriptions are very apparent and prevalent. While some staff members welcome the idea of additional help, they also see the addition of non-nursing or non-medical staff to the department roster as a threat to their employment. They are very aware that changes to their job descriptions have the possibility of negatively affecting their ability to take on overtime shifts or even maintain their lines. They are willing to help in theory, but their willingness to potentially handicap their own efforts to get ahead puts the value of their help in question.

301 OP Progress Report

Report Proposal Memo

MEMORANDUM

To: Alison Jordan, Operations Leader, St Paul’s Hospital Emergency Department

From: Owen Picton, Unit Coordinator, St. Paul’s Hospital Emergency Department

Date: 07June 2017

Subject: Proposal for Report

Dear Ms. Jordan:

As you are aware, the St. Paul’s Hospital senior management team has requested that each unit propose a unique and innovative strategy to increase its ability to provide exceptional care to its patients. I have attached a proposal for a solution that I believe will satisfy the request to this memo. I have chosen to focus on the Fast Track area of the department.

Included in this proposal:

An overview of the challenge facing the department
A plan to meet the challenge
A method of information gathering

Please let me know if you require more information. I look forward to hearing from you.

Sincerely,

Owen Picton

CC: Dr. Erika Paterson, ENGL 301 Professor

Attach.

301 OP Report Proposal Memo –Feasibility of Adding Physician Extenders

Report Proposal — Feasibility of Adding Physician Extenders To The St Paul’s Hospital Fast Track Staff

Introduction

Use of the St. Paul’s Hospital Emergency Department (SPHED) has increased exponentially over the past five years, and has increased even further in recent months due to the opioid crisis and a burgeoning population of people within the hospital catchment area who have acute health care needs. Processes and strategies to streamline care at every point in the emergency room experience while maintaining and exceeding the standards of care mandated by the British Columbia Ministry of Health (MOH) are devised and implemented on a regular basis. However, efforts in this regard have been restricted by the constraints placed on the department in terms of physical space, standards of care, and resource availability (including technology and staff), and the ability to afford each.

The budget is often the most obvious restriction in implementing new ideas. The SPHED receives a set amount of money from the MOH for operating expenses each year, and an additional portion of the SPHED funding comes from meeting certain benchmark times. The department can earn additional operating funds based on the length of each patient stay – either between admission and discharge from the SPHED or between admission to the SPHED and successful admission and transfer to an inpatient unit. Routinely meeting these benchmarks provides funding for additional staff positions and additional patient programs. Conversely, the loss of that funding results in the loss of programs and the loss of staff positions. That in turn results in patients receiving poorer care.

One section of the SPHED that consistently gets overlooked is the Fast Track area, where the needs of patients with relatively minor medical concerns are treated. Current staffing strategies dictate that both physicians and nurses who are assigned to this particular area leave Fast Track patients to attend to patients in other areas in times of surge – when the medical staff in an area caring for more acutely ill patients otherwise cannot provide appropriate care within the times set out by the Canadian Triage Acuity Scale (CTAS). Increasing the time that patients spend in the SPHED often costs the department in funds because more patient stays may not be eligible for the additional funding offered by the MOH. More importantly, the increase in wait times.will result in negative consequences on the staff, the services provided, and ultimately the patient.

Statement of Problem

The relative lack of acuity of concerns voiced by patients in the SPHED Fast Track area as opposed to other areas of the department leaves patients vulnerable to variation in the quality and the efficiency of the care received during their SPHED visit. This variation in care has the potential to do the following:

influence the ability of the department to finance itself
jeopardize the existence of care programs offered by the SPHED and the staffing levels,
contribute to poor patient outcome.

Proposed Solution

One solution that will provide more consistent optimal care to more patients who are triaged to the Fast Track area of the SPHED in a cost-effective manner is to hire dedicated physician extenders – paramedical professionals who have slightly different skill sets than either physicians and registered nurses and whose presence can allow the nurses and physicians to care for more and more acutely ill patients. The physician extenders would perform less urgent tasks within their scope of practice that require more time to complete, freeing up physicians and nurses to perform the more acute or emergent tasks and acts that are restricted to them. This step will allow more efficient, yet still appropriate, treatment of patients throughout the department.

Scope

This report will address the following questions:

Mapping the SPHED Fast Track patient trajectory – where are the current roadblocks to maximally efficient care?
Who would be the physician extenders – which health care providers would be best suited for the role?
What would the physician extenders do, and how will the physician extender role affect other roles within the department and, ultimately, timely completion of patient treatment?
How quickly could the physician extenders be implemented, and what would the process look like?
Cost analysis – how much would the physician extenders cost, and where would the money come from?
What would the foreseeable benefits and pitfalls of hiring physician extenders be?

Methods

My primary data sources will be from within the stakeholders themselves:

SPHED physicians
SPHED nurses
Other SPHED staff members
SPHED patients
Paul’s Hospital staff members from other departments

Information would be gathered from interviews and questionnaires.

I will also be analyzing data collected by the department as part of the ongoing funding agreements with the BCMOH, and will be drawing on my own experiences as an SPHED employee.

Secondary data sources would include the results of a literature search to investigate instances where other emergency departments have employed physician extenders and the successes and failures of doing so. Another secondary source would be interviews with health care professionals who have worked in other emergency departments as physician extenders.

My qualifications

I have worked at St. Paul’s Hospital for ten years, nine of them in the SPHED, as a nursing unit coordinator. I am intimately acquainted with patient flow within the department and between the SPHED and other units of the hospital, as well as with the various initiatives taken to expedite patients through the system while attending to their medical needs appropriately.

I also have been a certified athletic therapist for fourteen years and a registered orthopaedic technologist for five years. My education and experience in these non-nursing and non-medicine health care fields give me insight that is different from the viewpoints of the more traditional hospital researchers, which is more often based in the disciplines of medicine (physicians) and nursing.

Conclusion

Obtaining stable funding levels for the SPHED and providing effective and streamlined care to patients using the SPHED are two aspects that are critical for the hospital to meet the needs of the patients it serves. The use of physician extenders to fill gaps in care caused by fluctuations in patient acuity in other parts of the SPHED would be one way to do this. By answering the questions that I have posed in this proposal, I can determine the most cost-effective and appropriate way to give patients the excellent and expedited care that they deserve.

301 OP Report Proposal

Revised Definition of “PICC Line”

DEFINITIONS OF “PICC LINE”

Audience: Healthcare executives– educated individuals but not necessarily individuals trained in a health care discipline.

Parenthetical Definition

PICC line (peripherally-inserted central catheter)

Sentence Definition

Extended Definition

A PICC line (peripherally-inserted central catheter) is a long, flexible tube inserted into a patient for a medium to long time period, either to introduce fluids directly into the circulatory system or remove fluids from it. The circulatory system is most frequently accessed from a vein in the front of the top of the elbow, running to the point in the chest where blood enters the heart; however, a PICC line can be used to access the circulatory system through veins in the lower leg as well. Figure 1 demonstrates what a PICC line looks like when it is inserted into the upper body, and Figure 2 depicts what a PICC line actually looks like.

Figure 1: A representation of how a PICC line sits in the upper body.

Figure 2: A PICC line.

Components of a PICC Line

A PICC line consists of the following parts: the Luer lock, the lumen, the clamp, the hub, the body, and the tip– as shown in Figure 3. The Luer lock is a standardized point of attachment between the tube and either the container holding the medication to be infused or the syringe for blood collection that is specifically designed to minimize fluid leakage. The lumen is a one-way valve that prevents fluid from backing up and encourages flow in the right direction. Some PICC lines only have one lumen, but more often multiple-lumen catheters are inserted to provide alternate routes of use if one route is unusable. The clamp provides a manual physical barrier between the Luer lock (and the environment outside the body) and the inside of the body. The hub is where the lumens converge into one common tube to enter the body. It helps to stabilize the catheter, preventing any movement of the apparatus in or out of the patient. The catheter body is the actual conduit that allows the fluid to transfer into the patient, and the tip is the interface between the catheter and the circulatory system inside the patient.

Figure 3: Components of a PICC line. A double-lumen PICC line is shown.

Uses and Indications for PICC Lines

The most common uses for PICC lines are:

delivering medications, such as antibiotics and anti-cancer agents, directly into the bloodstream on a regular basis over weeks to months.
feeding patients in situations where the traditional ways of introducing nutrients into the body are either inadequate for meeting the patient’s nutritional needs or impossible to use.
drawing blood samples from patients whose veins make obtaining samples through other methods difficult.
measuring and monitoring the pressure within the veins.

PICC lines are particularly useful for patients who do not have many viable veins in which to insert peripheral intravenous lines, and for patients who require medications that may be harmful to the veins in higher concentrations. They are also suitable for patients who do not need a permanent interface between the circulatory system and the environment outside the body, but who need secure, consistent, and hygienic access to the bloodstream for more than a few days.

When inserted correctly and with proper technique, and when well looked after, PICC lines are more cost effective and have fewer negative side effects for patients in terms of subsequent infection. PICC lines can be inserted at the bedside with minimal manpower and equipment when compared to the requirements of inserting central lines and ports, saving operating room costs as well as the cost of specialised surgical teams and equipment. Introducing the catheter away from vital organs gives the vital organs a buffer from invading bacteria and viruses. Medications can be given more safely through a PICC line than through other methods of intravenous administration. Because the blood flow is faster and the blood pressure is higher by the heart than in the peripheral veins, the fluid coming into the body is diluted more quickly as it enters the blood. As a result, fewer side effects associated with higher concentrations of medications have been noted when using a PICC line as opposed to a more traditional peripheral intravenous infusion.

Contraindications for PICC Lines

A PICC line is not suitable for every patient, and a PICC line insertion, like any other invasive medical procedure, carries with it some risk. Examples of these risks include a chance of blood clots, air bubbles, or pieces of the catheter being dislodged during insertion, and a chance of bacteria being introduced into the body as a result of the procedure. Other issues that may arise from the use of a PICC line include the skin around the entry point becoming damaged or the vein itself rupturing if the tube has pressure put on it or moves in any direction once the insertion is complete. Improper or inadequate care and maintenance of the PICC dressing may result in the insertion site getting infected and infection spreading rapidly throughout the body. Another set of problems may occur as a result of the catheter becoming blocked. If the catheter is blocked by things like naturally occurring glues, such as fibrin, or medications that have crystallized out of solution, the contents will not enter the body as quickly as expected (and be of less therapeutic value) and the catheter itself may rupture if the internal pressure becomes high enough.

Pre-existing conditions also play a role in whether a PICC line is inserted. For example, patients with chronic kidney disease often are not considered for PICC lines because in the event that they need to use a machine rather than a kidney to clean their blood, their choices for sites to attach to the machine may be limited if they have had PICC lines inserted in the past. Similarly, patients with abnormalities in their ECG (heart rhythm tracing) may not get a PICC line because PICC lines may cause abnormal rhythms to worsen.

For most otherwise-healthy and mostly-healthy people, a PICC line is a relatively safe and effective vehicle to move fluid in or out of the body. It saves veins, it delivers medications and food safely, it allows removal of blood samples for testing, and it does so in a cost-effective manner – a real boon to medicine and health care.

Works Cited

Argane J. “IV Essentials: Picking Up on PICC Lines”. Nursing Made Incredibly Easy 12 (1): 2014. Web: Accessed 30 May 2017.

Bowe-Geddes LA, Nichols HA. “An Overview of Peripherally Inserted Catheters.” Topics in Advanced Practice Nursing eJournal. 5(3): WebMD, LLC, 2005. Web: Accessed 30 May 2017

Earhart A. “Central lines: Recognizing, preventing, and troubleshooting complications.” American Nurse Today 8(13): 2013. Web: Accessed 30 May 2017.

301 Owen Picton Definitions PICC Line

Reflection 1: On the Writing and Editing Process

I miss my red pen. My blue one, too.

Back in the day, when my mother taught secondary school English, one of my duties when I went home for university holidays was to go through piles of papers and mark all the spelling and grammar mistakes I could find. Because my mother was a stickler for grammar and spelling, and the other English teachers were not, I often made a student paper bleed red with strokes from my pen. I could not let a single spelling mistake or grammar faux-pas slip by. It became a point of pride. (And there is where my grammar-Nazi-ism began.)

I think it’s safe to say that I’ve done a fair bit of editing. I have not edited very much 2017-style, though. The two processes feel very different because “2017-style” entails editing and writing for collaboration and not correction. During the writing and editing of this assignment, I eschewed the technology I knew well and put my first draft on Microsoft Word rather than on a piece of paper in my own handwriting, I have to admit that writing and editing on a computer screen is not nearly as gratifying as writing and editing on paper. I miss the tactile sensation of putting pen to paper.

The experience also has proven to me that errors in spelling, grammar, and syntax escape me more easily when I use a keyboard rather than pen and paper, Especially during the writing of the definitions, I found completing a sentence difficult without re-jigging it in my head. Most annoyingly, I would sometimes fix the sentence before it was actually on screen — which meant that from time to time my original thought got lost. At least when it was on paper, I had a record of my thought process that didn’t get destroyed by a few backspace-key strokes.

I had a similar experience when proof-reading and editing online. I’d read, correct and then re-read – only to find that I’d missed something that I would normally catch. After three tries, I broke down and printed a copy. The editing process went much smoother when I used technology I fully understood.

I was reminded of the importance of proper syntax and grammar, the frustration of looking to say what I mean and mean what I say, and the feeling of satisfaction when I place just the right word in just the right context in just the right position in a sentence.

While writing the application letters and going through the team selection process, I came to appreciate the importance of a good application package. Deciding whether to hire or pass on a candidate based solely on the strength of a letter and a page or two of advertising is daunting, and choosing the exact words to convey an image that resonates with the reader is vital to persuading the reader to do what the writer wants.

Editing and proofreading the definitions was an interesting experience for me. What I found most difficult was making suggestions without totally rewriting the paragraph and consequently taking the writer’s voice away from the product.

On a side note, at the risk of (further) sounding like a grumpy old man, the speed of requests and responses is blowing my mind a little bit. It feels like a big request to expect a thoughtful and insightful critique at my home from someone within forty-eight hours from the time I send it to them from my home. In my mind, it takes a day just to organize a place to meet and exchange information, unless the situation is unbelievably dire!

The speed at which documents can travel these days seems to bring with it the expectation that replies should be coming faster and faster. A balance must be struck between the speed and the quality of the reply. I have found that giving a bit of time between writing a document and editing and sending it to be very useful. The break between writing and editing gives me a bit of perspective and allows me to find better words and phrases to clarify points I am trying to make. (However… missing a deadline to give myself that perspective, no matter how inadvertent, is disrespectful and unacceptable. I truly believe this, and I apologise profusely and sincerely to the poor person whom I made wait for feedback.)

301 Reflection 1 — Writing and Editing Process