Sunday, October 21, 2007

"Credentialed" to Check Poo


In their infinite collectivist wisdom, a committee composed of paper-nurses and paper-doctors decided to do away with the old standby poo-checking card used for decades without accidental death or decaptitation, and get a fancy-schmancy super poo-checking-can't miss tubette that will not be fooled by, say, goat's blood in someone's ass or something.

Seriously, we do, occasionally, check stool for blood with the whole finger-in-the-bottom thing and it used to be a quick and dirty (pun intended) little exercise that no one liked but would tell us immediately if someone had blood in their stool and then we could fashion our treatment based on the knowledge that somewhere in the patient's GI tract was a bleeding "something".

Much to my surprise the other day I got the old 'letter in the box' on official hospital stationery. During one of my busy shifts I had needed a stool check for blood and had taken the super fancy can't miss tubette into the room and got some poo and mixed it up in the fluid and the test was positive and I wrote it in the chart as such. It didn't change my management of the patient while they were in the ER.

The letter was signed by one of our super power-through-paper folks and it kindly informed me that I was not 'credentialed' to run the poo-check test. Gotta go take a 6 hour course now on finger-angle, lube application, tubette maintenance, and proper form filling-outedness. Call me if anyone gets sick.


  1. 6 hours!? Wow, assholes must have really evolved.

  2. My prior facility required training and credentialing to use the cards. And if you hadn't been credentialed, then you had to bring the card to an LVN who then interpreted it for you!


  3. make mine trauma said...
    6 hours!? Wow, assholes must have really evolved.

    Yeah, most of them made it to management.

  4. About a year ago, we had to take a color blind test (for red/green color blindness) in order to be "credentialed" to read a stool guaiac. I asked the nurse with high heels and a clipboard the following two questions:
    1. Since the stool guaiac is BLUE, what good does it do to test me for red/green blindness? and:
    2. Since I've been reading these at bedside for almost 20 years, what is the rate of colorblindness development in previously non-colorblind people (since red/green blindness is genetic)? I guess this would be presbychromia.
    Of course, the answers to my questions weren't covered in her 3 hour JCAHO/CLIA "How to Piss off a Doctor" seminar...where she obviously gained great knowledge.
    Anyway, once I demonstrated that I could tell red from green, I was allowed to read the blue test again.
    BUT....we can't leave them at the bedside anymore, oh no. We have them in a notebook and each card has to be signed out with lot number and patient name, then the lot number and expiration of the developer must be recorded. The "control" drops must be placed on the card at that time and whether the card passes or fails must be recorded before I go to make a finger puppet of the patient and dig some dookie for this complex test. Then, the results from the patient have to be recorded in the book.
    Funny, the first day, a whole stack of cards and a bottle of developer disappeared! This sent the high-heeled, clipboard carrying, can't start and IV nurse into a tailspin!!
    I don't have any idea where the supplies went!
    But if you need some let me know since it somehow found it's way to my pocket!

  5. Y'all always make me laugh when you talk about ways to annoy the admin types.
    Sic 'em.

  6. at the hospital i was at this summer, they would let the nurses use the guaiac cards, but only a DOCTOR could put the drops in the boxes. They would keep the cards in the nurses cart by the bedside, but the small bucket of drops was kept on the doctor's desk!

  7. I work on the administrative side of a medical center at this time..and I have to say credentialing has become a frillin joke. Physicians that have been doing procedures for years now all the sudden have to apply for privileges to do every little thing. it's all a bunch of worthless paperwork that doesn't show skill at anything.

  8. Because part of my job involves being the medical director of the hospital laboratory (for which I am paid... wait for it... ZERO) I am asked to ENFORCE this crap. The sad thing is, everyone realizes what a fucking waste all of this is, but organizations like CAP, ACoS etc.. make up these inane 'checklists' that an inspector will come and go over in about 4 hours to 'certify' an entire hospital program. The bullshit forms will be scrutinized: expiration dates, written proof of competency and training and re-training (yes, he can stick his finger in someone's ass and see blue), documentation of appropriate use of 'control' material etc. etc. etc..... If all these are not in order, herr inspektor does NOT put down that check-mark, and guess what... NOW, instead of jumping through a hoop, you have to jump through a hoop backwards, sit up and beg, catch a frisbee in your mouth, and demonstate the ability to avoid eating your own feces.
    This clusterfuck mentality is what we are going to get more and more of as our business becomes more socialized and 'controlled' by gov't.

    oh yeah, dealing with the shithead administrators on these issues, I've dropped a passive-aggresive approach for a simply obnoxious-aggresive stance: demand tons of money and staffing for everything; berate administators constantly that they don't give a shit about patients during meetings and in hallways (best in front of random passers-by); whenever something pisses you off, even if unrelated to anything administrative, barge into the CEO's office unannounced and tell him what a crap hospital he runs; never ever let any administrative issue, no matter how minor, drop - bring it up every single time you see a hospital exec., reminding him why this proves he doesn't care about patients. Administrators by nature are spineless douchebags and will cower in fear when you get near them - I know this is all very immature and probably ineffective - but it sure is fun.

  9. My 3 year old was sitting next to me when the picture popped up, and he said "remember when you painted with my poop?" I have had to collect poop, "paint" with it on the card, and also have done the mix it up in a tube stuff for both of my sons. I would gladly have someone tell me I am not qualified to do this...I had no idea in the job description of "mom" there were so many gross things coming for me.

    My son's colonoscopy is Wednesday, so tomorrow will involve lots of poop for him I am sure. Luckily I don't have to paint with it again.

  10. Leave it to The Brains to think of a test that takes more time away from treating patients. Amazing. With this target-rich environment, it's no wonder I write medical fiction. What's scary is that the only fictional elements are my characters.

  11. Creditialing for stool quiacs. I have to admit I love it. Where else in the world can the doctor say that he has a Creditial in bloody assholes. Not even the Brit's have the corner on that one.

  12. This is just unbeliev-ably 'ass'inine (sorry couldn't resist that). I realized you guys exist and blog to make people like me HAPPY in our jobs wherein we have not (yet) been subjected to such stupidity. However, our turn is likely coming.

    Regrettably there's no way to remediate these administrators other than a good dose of BAD PRESS (anyone know John Stossel's email?)--this would be a great story on the 5 o'clock news; or the threat of a major hospital philanthropist to pull his donation.

  13. Yeah you should add that to your list of credentials for sure....on your badge...

  14. Patients would be impressed if I added the initials C.D.C. after M.D. since I'm a credentialed dookie checker!

    You might enjoy this story: as I said...since guaiac cards and developer are no longer in the drawer at every bedside (the efficient patient care model), somehow the KY goo has disappeared too. Last week, I needed to perform a stool guaiac test, so I grabbed my illegal card and developer, but I couldn't find any gel. I asked the RN, but it was apparently in the store room so the RN sent a tech to find it. As I was waiting, I noticed a patient meal tray along with a packet of Ranch dressing next to a bland looking salad.
    Being one for making dramatic points, I just proclaimed that I'd do the test with the Ranch since nobody could find any KY! I have no idea how that might have affected the test, but they sure found the KY quickly when I headed towards the patient's room with the dressing in hand (I wouldn't have really done it)!

    Another issue in the same category is urine dips. I get so pissed at having to wait an hour for the lab to give me a simple urine dip that I bought my own strips. I found them for about $25 on the internet and I keep them in my locker. When I'm looking for a positive blood dip or a positive leuk est dip, they save about an hour. I still send the urine to the lab for an "official" reading, but it lets me treat and evaluate the patient much more quickly.

    I gave up on UCG tests. I just send them to the lab and wait.

    I understand and appreciate Etotheipi's position, but I have to do my own thing to get things rolling quikly. I appreciate the controls on important stuff like my chem tests and cbc's, but it's gotten crazy. I hope it's a jcaho/clia issue and not a billing issue.

  15. Is this a confessional booth?

    Forgive me father for I have sinned.

    I recently guaiac'd someone's stool without a certification course, exam, nor wall plaque co-signed by the President of the United States and, amazingly, it was positive.

    Forgive me, father, for I did this and it led to rapid FFP infusion to reverse the critically high INR and blood to correct the Hgb of 4 all within a few minutes of the patient's arrival.

    I did not confirm that the guaiac cards had been properly inspected by the Chief Guaiac Card inspector and signed-off on the guaiac clipboard for effectiveness and accuracy prior to saving my patient's life.

    I'm sorry.

  16. I'm sorry you guys have to go through this inane BS just to do your jobs which is actually to treat/help the patients. Gee!

    All this credentialing so it looks good on paper...didn't years of medical training count for anything? Have you not proven your skills/intellect by getting your degrees/licenses and any ongoing education?

    And what about the the trees?

  17. SeaSpray said...
    "didn't years of medical training count for anything? Have you not proven your skills/intellect by getting your degrees/licenses and any ongoing education?"

    Answer is: NO (but good question)

    They are trying to measure "quality care". Since that's a nebulous measure, they are trying to create surrogate markers that they CAN measure. So these ridiculous credentialing issues and "core measures" are used put a number to something that administratively and governmentally somehow equals "quality".
    I had rather go to Nurse K's hospital where her finger is in my ass and the FFP is flowing quickly....that's quality in my book. But if a clinical decision was based on a stool guaiac test performed by someone who is not credentialed to rub poo on a coffee filter, drop some developer onto it, and see if it turns blue.....that's poor quality in administrative eyes.
    See the logic?

    1. I don't understand the relationship between quality care and the poop test. Are you saying a more sophisticated poop test represents higher quality of care or getting "credentialed" means the patient is supposedly receiving better care?

      I am curious what doctors think about how or if quality care should be measured.

  18. If it is THAT simple, once I learned how to(and get over)putting my finger in someone's poo basin or whatever... rectum to retrieve said sample...would I being of reasonable intelligence, yet without a medical degree probably be able to follow the instructions? Just overkill!

    The "raison d'etre" for these quality control people and upper administration seems to be to create/implement these new policies with what seems that they don't have a clue about real life in the trenches. Everything can look good on paper but how many hoops to jump through and at what cost (on all fronts)to comply?

    Have you all ever considered that maybe they DO know EXACTLY what they are doing and they are just DIABOLICAL?? ;)

    Your explanation is appreciated ER doc85. I'm sure there are good things that have been implemented over time and then there are things like THIS. Don't they consult with the actual medical staff actually working in the middle of it all?

  19. In answer to my last question...I am guessing not very much.

  20. erdoc85 you know why it takes the lab an hour to give you results to a simple urine dip? It's because we're recording lot numbers and expiration dates, dates reagents were opened, QC results and the action we took if the QC didn't work the first time, analyzer problems on the "analyzer problem log", sample irregularities on the "sample problem log", documenting calling critical results in the computer (after rechecking them if it's the first one on this patient, or if it doesn't agree with the patient's diagnosis) with "Critical result phoned to and read back by nurse k (must document first AND last name AND make sure you're talking to a "licensed caregiver")/ED on 10/25/07 at 1630 by me".
    Nothing is "simple" in the laboratory. Just ask etotheipi.
    I agree with you that all the documentation sucks ass, but you wouldn't believe how fast I'd get a nastygram if I fail to document something I did.

  21. sue,
    please do not misunderstand. we are not mad at you guys. we understand you labor under all the same restrictions we do. the evil bit of all this governmental and committee oversight is that it gets those of us directly involved in patient care fighting with each other when, instead, we should be fighting 'the man'. so, be it resolved, from this day forward i'm all about stickin' it to the man.

  22. Sue: being a good lab tech is a TOUGH JOB... made more difficult by all the bullshit. These are the evils you will simply get more and more of as Press Ganey types, administrators and gov't regulators stick their beaks into our business.

    These are the 'quality measures' that everone is so ga-ga about... obviously, systems to assure accurate results and reporting are necessary, but when 'the man' tries to own this process, we are all fucked.

    I'm on board with 911 about stickin it to the man - and I'm only being slightly sarcastic about being nakedly aggressive toward administrators. It's really the only thing they respond to.

  23. etotheipi: I do believe that most of the quality assurance measures in the lab, and that most med techs tend to be incredibly anal are good things. But yeah, there's some overkill- in particular, the manual cell count controls that make me waste time proving every single day that I still know what WBCs and RBCs look like in body fluid. OMFG! It infuriates me every time I have to do it.