Nursing Notes

September 7, 2011

Disruptive behavior, negligence, endangered patients, and millions of dollars

Centers for Medicare and Medicaid Services (Me...

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Here’s an article from the Patient Safety Monitor that makes my skin crawl.  Patient safety and well-being are tantamount to nurses.  Have we, as nurses, given up the role of patient advocate?  This article cites several recent court decisions against medical facilities for failed patient safety observances.  Where were the nurses in this?

Staffing is always the core problem in these types of problems.  Hospitals expect nurses to do more and more and more without giving the proper staff to accomplish this goal.  As long as hospitals continue to get away with short-staffing, they will because they are a business.  The bottom line is profit, even in non-profit facilities.

Think about it like this:  is it less expensive to pay a fine every so often that does not amount to the cost of maintaining proper staff to patient ratios?  Why pay every day for more staff, at a cost that is very high, when you can pay much less in fines and then only if you get caught.

I know that I do not speak for the majority of the nursing profession.  I can only speak for myself, based on my own experiences in hospitals.  I love nursing.  I love being a nurse.  I don’t love the way hospitals staff.

Please read this article and leave me a comment, won’t you?  When you visit the site, look around because you will find many interesting articles about nursing and hospitals there.  Be sure to leave them a comment on this post while you are there.

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August had been filled with a number of different patient safety rulings and findings that show poor patient safety can be costly in many different ways.

Let’s start with Boston, where two old cases have been settled.

First, parents of a newborn who died at Beth Israel Deaconess Medical Center in Boston seven years ago were awarded $7 million by the Suffolk County Superior Court after a physician and nurse practitioner were found negligent in their care. The parents claimed they did not react quickly enough to the infant’s deteriorating condition. The premature infant developed necrotizing entercolitis, something caregivers should have been watching for as it is common in infants delivered prematurely.

The parents alleged they came to visit their daughter and found her discolored and unresponsive, and said staff took more than an hour to respond.

In another recent decision, the U.S. Court of Appeals upheld a lower court verdict against Brigham and Women’s Hospital involving alleged disruptive behavior exhibited by Arthur Day, MD, the former head of neurosurgery. Sagun Tuli, MD, claims the hospital retaliated against her for complaining about her work environment.

The court ruled that Tuli was defamed and that her career was affected.

Now, on to Dallas.

It was recently reported that in March, 2010, Parkland Medical Memorial Hospital in Dallas, TX, informed 73 female patients that instruments that were not properly sterilized had been used on them, putting them and any sexual partners at risk of infections.

Following that incident, the Centers for Medicare & Medicaid Services (CMS) investigated the hospital in July, 2011. The investigation led to the finding that the hospital created an “immediate and serious threat to patient health and safety.” The report found that ED patients in severe pain were given maps of the hospital to find the appropriate place for treatment and children sent home without screenings.

Meanwhile, in a separate investigation, Parkland Memorial Hospital, along with the University of Texas Southwestern Medical Center, agreed to pay $1.4 million after a four-year Medicare billing fraud investigation revealed that resident surgeons were not properly supervised and also failed to comply with informed consent requirements.

Another Dallas hospital, Methodist Dallas Medical Center, was also recently cited for 10 violations by CMS, some which include failing to screen and stabilize emergency department (ED) patients and understaffing the ED.

Do these more recent findings indicate that CMS is getting tougher? Would similar findings be found elsewhere, if investigated? Is this the sign of the times of healthcare reform? What do you think? Share thoughts below.

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July 15, 2011

New Study Adds to Evidence—California’s RN-Patient Ratios Law Improves Nursing, Patient Care

NEW YORK, NY - JUNE 22:  Members of the nurses...

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Here is a press release from the nurse’s union, National Nurses United about the effect of California’s nurse-to-patient ratio has had on the number on nurses in California as well as the effect on patient outcomes.  This is an interesting press release, and yes, maybe it is self-serving, but I had just read another article on newswire about this exact same thing which I will post in a few days.

Let me know what your thoughts and feelings are about mandated ratios, won’t you.  I’d love to start a conversation here with all of you about the pros and cons of such a national law.

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Health Affairs study on achievements of California safe staffing law

Another major study has reinforced a growing body of evidence that California’s landmark law requiring minimum, specific nurse-to-patient staffing ratios enhances registered nurse staffing and the quality of patient care.

The latest study, conducted by eminent University of Pennsylvania and Arizona State University researchers, appears in the July 2011 issue of Health Affairs.

Titled, “Contradicting Fears, California’s Nurse-To-Patient Mandate Did Not Reduce The Skill Level Of The Nursing Workforce In Hospitals,” the report <http://content.healthaffairs.org/content/30/7/1299.abstract>  refutes worries promoted by healthcare industry opponents of the 1999 California law that hospitals might respond by disproportionately hiring lower-skill licensed vocational nurses.

In fact, following implementation of the law in 2004, the results have gone in exactly the opposite direction, the study concludes. California hospitals have added registered nurses, dramatically increasing patient access to professional RN care, a factor long associated with positive patient outcomes in a broad range of care barometers.

“This study brings home once again what California nurses could readily tell you. The safe staffing law has improved the quality of care in California hospitals, ensured that RNs have more time to spend with patients, respond to patient care incidents, and reduced the nursing shortage by keeping experienced, professional RNs where they belong, at the bedside,” said Deborah Burger, RN, a co-president of National Nurses United and the California Nurses Association.

CNA, an affiliate of NNU, the largest union and professional association of RNs in the U.S., sponsored the California law and fought off efforts by the hospital industry and former Gov. Arnold Schwarzenegger to roll back the law.

Overall, the authors write, “we found that the staffing mandate resulted in roughly an additional half-hour of nursing per adjusted patient day beyond what would have been expected in the absence of the policy.”

The study directly compared California hospitals to institutions in New York, Texas, Florida, and Pennsylvania – the five states with the most hospitals. While many states nationally saw increases in nurse staffing the past decade, in the period following implementation of the law, California readily surpassed the national average, and California had  five times as many registered nursing care hours as New York hospitals and twice as many as Texas hospitals.

Authors of the new study include Matthew McHugh and Douglas Sloane of the University of Pennsylvania’s Center for Health Outcomes and Policy Research in Philadelphia, UPenn nursing professor and well known RN researcher Linda Aiken, and Lesly Kelly, RN assistant professor at Arizona State University in Phoenix.

Aiken in particular is one of the nation’s foremost RN researchers and just last year led a study comparing California hospitals to facilities in Pennsylvania and New Jersey which documented that New Jersey hospitals would have 14 percent fewer patient deaths and Pennsylvania 11 percent fewer deaths if they matched California’s 1:5 ratios in surgical units.

In the new study, McHugh, Aiken, and the others note that the intent of the California Legislature in passing the CNA/NNU-backed law was to “improve quality of care and patient safety, and to retain nurses in employment in hospitals. Another primary goal of the law was to avoid high patient-to-nurse ratios, especially for registered nurses.”

Poor ratios, they note, are widely associated with “a number of negative patient outcomes, such as higher surgical mortality and higher complication rates due to errors” as well as to “job dissatisfaction and burnout” that drive nurses away from the patient bedside.

“The California law has clearly met all the goals, a major reason why safe RN ratios is considered the gold standard by direct care RNs across the nation,” says Burger.

Nurses throughout the U.S. continue to campaign for similar state and federal legislation, usually against the opposition of hospital corporate lobbyists.

NNU is sponsoring federal legislation, S 992, the National Nursing Shortage Reform and Patient Advocacy Act, in the Senate, and a companion House bill, HR 2187.

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May 13, 2011

Happy Nurses Appreciation Week!

Filed under: Nursing — Shirley @ 4:38 pm
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April 9, 2011

Prevent Readmissions With Discharge Planning

With The Joint Commission looking at “revolving door” admissions, it is time for everyone to get on board and start working to prevent readmissions.  Being readmitted benefits no one.  The patient feels like their health has become unmanageable and they are frightened.  The family becomes convinced that they cannot handle the needs of the patient safely.  The hospital, once a safe haven, becomes a scary place.

We have to work “better” not harder at discharge planning.  We need to be looking at the patients’ needs and desires as much as possible.  Just getting patients out of the hospital is no longer acceptable.

The article below is long, but well worth your time.  Only part of it is below, so please do click over to finish reading.  This is from one of my favorite sites, Health Leaders Media, where you will find many other great articles dealing with various issues in today’s nursing.

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Rebecca Hendren, for HealthLeaders Media , April 5, 2011

 

Discharge planning is a process that should begin as soon as patients are admitted to the hospital. In a perfect world, healthcare team members, patients, and families communicate and work together to move patients quickly and safely to home or the next level of care.

In reality, discharge planning can be fractious. Older adult patients and their families face many choices about where to go and often disagree on the best course of care. Communication among caregivers can be far from ideal and communication between patients and families can be fraught with disagreements.

As hospitals battle readmission rates, more attention is being paid to discharge planning. Lori Popejoy, Phd, APRN, GCNS-BC, assistant professor in the Sinclair School of Nursing at the University of Missouri, has been studying the discharge planning process around older adults and recommends hospitals pay more attention to the decision-making process with these patients.

Popejoy, who has years of experience with care of the older adult before entering academia, recently published a study, “Complexity of Family Caregiving and Discharge Planning,” in the Journal of Family Nursing. I spoke to her about the problems nurses face as they work with older adults and their families, the challenges faced by healthcare providers as they discharge older adults from the hospital, and the healthcare transitions faced by elderly people and their families following hospitalizations.

Popejoy says that our understanding of discharge planning and how patients make decisions is quite simplistic. We usually think about conversations between physicians and their patients or between physicians and families. In reality, dozens of people are involved in any decision. So she examined interactions between healthcare team members, including nurses and social workers, and older adult patients and their families. She wanted to understand how these diverse stakeholders come together to make a single decision about leaving the hospital and where they are going to go. She wanted to understand how much participation in decisions patients and families want the healthcare team to have and what actually happens as decisions unfold.

 

“Every participant comes to the situation with their own values, their own beliefs, and what they want to get out of it,” says Popejoy. “What stands out for nurses or social workers is their overall concern for patient safety. Their input into the decision making process is to find the most reasonable choice and the safest choice.”

For older patients, most just want to go home. Some recognized they were too weak and were willing to go somewhere else, but for them, it was to be a short-term stay where they could get stronger and then ultimately go home.

For families, safety is important, but also the issue of ‘I want my parent to be able to live the life they want to live,’ says Popejoy. “For a spouse, it’s a whole different ball game—they just want their spouse to go home with them.”

Within child-parent relationships, some want their parents to live with them; others recognize that their lives are too complicated to handle a parent at home who is functionally unable to care for themselves. Some can handle a short-term stay, but not one for the long term.

Popejoy says that hospitals need to figure out who the key players are who can influence decisions. “Listen to older adults and find out what they want, but also listen to the family and what they can do,” she says.

She cautions decision makers are often not available during Monday to Friday business hours. Although most organizations know this, it can be difficult to get good information across the week, not just during traditional work days. Discharge planning and communication may have to be done via conference calls or during off hours.

Another important thing that leaves healthcare teams in difficult positions is the idea of autonomy.

 

“In the United States, we value autonomy and your independence above all…[read more]

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February 7, 2011

Caring for the Chart or the Patient?

Filed under: Nursing — Shirley @ 12:59 pm
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Here is another wonderful article by Theresa Brown in the NY Times.  I really recommend any article she writes, as I believe she is uniquely able to articulate the thoughts and feelings of the staff nurse so that the non-nursing population can see the problem and can feel the stress that nurses work with.

This article points out the ridiculous need to chart “everything” for all the differing agencies that oversee healthcare today.  Charting now seems to take up the majority of each nurse’s shift.  Patient care seems to have been neglected, or worse, lost to this pile of needless paperwork.

I like her idea of a camera that follows the nurse around so she can concentrate on what she does best–patient care.  Maybe there is a nugget of a solution in this idea.  We need someone, somewhere to address this issue so that we nurses can get back to our patients and away from the charts.

Please do visit this site and read more articles by this nurse.  You will not be wasting your time and you will definitely get a feel for nursing today.

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February 2, 2011, 2:17 pmTheresa Brown

<!– — Updated: 4:35 pm –>

By THERESA BROWN, R.N.

At a recent medical conference in Miami, I sat spellbound as Dr. Stephen Ferrara, a commander in the Navy, delivered a keynote address describing his work in a mobile hospital in Afghanistan.

Dr. Ferrara is an interventional radiologist, a doctor who uses medical images — CT scans, ultrasounds and the like — to treat abscesses, biopsy hard-to-reach masses, check blood flow and cauterize bleeds. He first went to Afghanistan as a medic, then made a place for himself in the operating room, where he placed micro-stents to restore blood flow to damaged tissue, checked perfusion to save legs that would otherwise be amputated and embolized wounds to stop blast victims from bleeding to death.

It’s undeniably grim work, but done with a driving sense of urgency and very few administrative distractions. It may sound odd and naïve to say this, but watching the presentation, with its slides of horrific wounds, I was surprised to find myself feeling envy. He and his team members were free to attend to the area of greatest need: the patient. They were focused on care to a degree that I am rarely able to experience in my own work in the hospital.

Hospital nurses are required to do paperwork, or “chart,” throughout each shift. We do a full assessment of each patient at the start of a shift, and chart that on electronic flow sheets packed with a dizzying array of drop-down menus. If we have time, we document discussions with doctors, when a patient left the floor and when she came back and how we responded to an abnormal vital sign.

The mantra we all learn in nursing school is, “If it isn’t charted, it isn’t done,” an impossible rule to satisfy. Since what could be charted is infinite, I begin each shift feeling that I have already failed in my documentation.

In addition to charting the events of the day, there are required pieces of documentation that address the concern of one health care agency or another. In 2005, the Joint Commission for the Accreditation of Healthcare Organizations put “falls” on their national patient safety list, so our charting now has to exactingly detail our commitment to fall prevention. The Centers for Medicare and Medicaid Services will not reimburse the cost of treating bedsores that develop during a hospital stay, so a new drop-down menu charts whether a patient is at risk and whether they have pressure ulcers already.

The requirements come fast and furious and often have a flavor-of-the-month feeling. One large insurance company was concerned about a specific type of hospital-acquired infection, so for a while every patient had to be tested for that drug-resistant bacteria. We’re now done testing for that infection but get scolded for not consistently testing for another one.

Certain kinds of lab results get called in to the floor nurse, and we’re supposed to report them to the nurse practitioner or physician who is following the patient. Then we have to chart when the lab called us and when we delivered the message.

All medications must, of course, be charted. Intravenous drugs include a huge drop-down menu for noting the location of each patient’s IV line, a step we need to take every time we give the medication, even though the access location does not change that often. And every time we give a pain medication, we have to scroll through multiple drop-down menus to chart the level and severity of the patient’s pain, where it hurts, how sedated they are and how they describe the feeling of pain.

One accrediting agency is focused on education, so there’s also a separate menu for noting that a nurse provided patient education. Another menu charts more long-term care concerns, an important issue for the board of health.

I have joked that the hospital should install video cameras to record everything that nurses do. Having a permanent record of my actions would mean that all the time I spend charting could be time spent on patients instead.

Because that’s my real concern: the effect on patients of incessant record-keeping. Each of these individual initiatives has merit and is worthwhile, but together they become a mishmash of confusing and oppressive paperwork.

I had a patient recently whose cancer had recurred and spread. I had bought a button in the hospital gift shop that reads “Cancer Sucks” and was wearing it that day at work. She really liked it, but I knew it wouldn’t be easy for her to get to the gift shop to buy one. So later that evening I visited her room and gave her mine.

“You earned this pin,” I told her. Then I saw her eyes light up with recognition. Someone — her nurse — understood what she was going through.

The care we give our cancer patients is obviously much different from what we do for soldiers who’ve had their legs blown off by an I.E.D., but the threat to life and limb is no less real. I have no drop-down menu for charting “Empathized with patient over fear of metastatic disease and death.” And yet, that’s exactly what the patient needed.

“If it isn’t charted, it isn’t done,” we hear. But as the paperwork demands proliferate, my worry is that if it can’t be charted, it won’t be done.

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November 20, 2010

Texting improves medication adherence, patient health

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Here is an article that shows the way new technology can be integrated into plans of care to obtain positive outcomes.  With smart phones taking front stage, it was only a matter of time before the medical field discovered that these devices could be used to improve adherence and patient health outcomes.  This article is from FierceMobileHealthCare, which is a source I find useful and informative.  Please visit the site to see other really good articles.

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Text messages containing both medication reminders and information about a specific skin condition helped greatly improve adherence to treatment regimens, self-care behaviors and quality of life while also lessening disease severity, according to a newly published scientific article in the journal Dermatology Research and Practice.

“It is not surprising that text messaging helped patients stick with their treatment plan and take their medication as prescribed,” Dr.  Joseph C. Kvedar, director of the Center for Connected Health at Partners HealthCare System in Boston, says in a press release. “However, we went a step further by including educational information which, we believe, can lead to critical improvements in self-care behavior that were observed in this study.”

The Center for Connected Health says this is the first study to combine medication reminders with educational information in text messages.

Researchers at Massachusetts General Hospital examined 25 adolescents and adults with a form of eczema called atopic dermatosis, and then sent the patients daily text messages for six weeks, reminding them to continue their prescribed treatment or offering information about the condition. Though at the outset, 92 percent of participants reported occasionally forgetting to take their medication–with nearly as many saying they would stop treatment when symptoms improved–by the end of the study, 68 percent reported an improvement in the number of self-care measures they performed.

After the six weeks, 76 percent of patients had seen an improvement in their skin condition and 72 percent said their quality of life was better. About 90 percent found the text messages helpful, and 84 percent would want to continue receiving the texts.

“Text messaging is a cost-effective way to deliver short, concise information to patients over a longer period of time, and because it is automated, requires no extra effort from the provider,” Kvedar says. “Our study also indicates that patients are willing and ready to integrate technology, such as text messaging, into their care. It can also help to improve communication between patients and providers.”

Read more: Texting improves medication adherence, patient health – FierceMobileHealthcare http://www.fiercemobilehealthcare.com/story/texting-improves-medication-adherence-patient-health/2010-09-28#ixzz15TeSZJbm

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October 15, 2010

Hospital launches new telemedicine program for stroke and child trauma Neurologists and child trauma experts can now view patients at suburban Seton Hospitals through a webcam.

HELP Telemedicine clinic 1
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Here’s an article in the Austin American Statesman that shows the benefit of developing technology for better patient outcomes.  At Seton Hospitals here in Austin and the surrounding areas, this one technological change is saving lives.

Telehealth is a trend that will not only continue but will expand as the need for services outgrows the available service providers in any given area.  Hospitals that cannot or will not expand their use of technology will not be able to compete with those who do.

Won’t you tell me how your hospital is meeting this challenge?

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By Claire Osborn
AMERICAN-STATESMAN STAFF
Friday, September 04, 2009

ROUND ROCK — A woman lying in a hospital bed at Seton Medical Center Williamson in Round Rock on Thursday was listening to a series of questions Thursday from an Austin doctor on a 27-inch LCD television monitor.

“Can you open your eyes please and face the camera?” said Dr. Darryl Camp, medical director of neurology for the Seton Brain and Spine Institute in Austin.

“Elevate your right leg and then elevate your left leg. Can you say your name?” Camp said.

He was demonstrating new technology that will allow doctors at Seton hospitals in Round Rock, Burnet and Kyle to more quickly consult with neurologists in Austin about stroke patients and pediatric trauma patients.

The $250,000 program, based at Dell Children’s Medical Center in Austin, starts this week.

Instead of having to describe symptoms over the phone to neurologists, physicians can wheel their patients in front of a television monitor with a camera that allows a specialist to see the patients.

The program also allows the Austin neurologists to read CT scans on their laptops. Seton hospitals have handled 1,200 stroke cases in the past year and hope to double that number with the new technology, Camp said.

Time is precious when a person suffers a stroke because brain cells can die by the minute, Camp said. He is one of seven stroke specialists who will participate in the program.

Neurologists can advise doctors whether clot-busting drugs are needed immediately or whether a patient should simply be observed, said Dr. Brian Aldred, medical director for the emergency department at Seton Medical Center Williamson.

Neurologists can also catch subtleties in a CT scan that other physicians might miss, he said.

Children with traumatic injuries will also benefit from telemedicine, said Dr. Pat Crocker, emergency department medical director for Dell Children’s Medical Center of Central Texas.

A neurologist in Austin might need to tell a doctor in another county whether a child who comes into a hospital with a chest injury and a collapsed lung needs to be intubated before being transferred to Dell Children’s Medical Center of Central Texas, Crocker said.

Fifty-four pediatric specialists from Dell Children’s will participate in the child trauma part of the telemedicine program, said Emily Schmitz, a spokeswoman for the Seton Brain and Spine Institute.

The five Seton facilities that will be using the technology include University Medical Center Brackenridge, Dell Children’s, Seton Highland Lakes Hospital and Seton Medical Center Hays, which is scheduled to open in October in Kyle.

cosborn@statesman.com; 445-3871

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October 13, 2010

How do so many journalists miss it?

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This article originally appeared in The Washington Post, but I found it on one of my favorite websites, The Truth About Nursing.  This article is stunning in that a nurse was able to use common sense and experience to help a patient after numerous specialists were stumped.  I wondered, after reading the article, if any of these physicians ever really looked at the patient or asked him any questions about his life and locale.

I simply saw the picture and knew he had Lyme’s Disease, but I live in an area where ticks and deer are plentiful.  Maybe, in the defense of the doctors, they had never been in an area where either of these two organisms are found and therefore knew nothing about them.

Please read the entire article and leave them a comment if you feel like it.  There are many wonderful articles and stories to be read on that site.  I hope you enjoy.

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bulls-eye rashSeptember 27, 2010 —  Today The Washington Post published a lengthy entry in its “Medical Mysteries” series headlined “Nurse solves mysterious ailment that puzzled orthopedists, oncologist.” Sandra G. Boodman’s piece describes a local man who spent more than a year consulting various specialist physicians, enduring “two unnecessary knee surgeries and dozens of physical therapy sessions, as well as acupuncture and other useless and sometimes painful treatments that cost thousands of dollars,” before “a nurse” at an infectious disease specialist’s office suggested that he might have Lyme disease. He did. You might think, then, that the article would be a tribute to nursing expertise, but instead the central fact of the story is overwhelmed by disrespect for nursing. It’s not just that the piece repeatedly dismisses what the nurse did by calling it “simple” and “obvious,” “a basic query by a nurse, not the acumen of five specialists.” No, the most striking thing is that in this 1,300 word story describing all the erroneous thinking of the “specialists,” the nurse who actually solved the problem is never named, quoted, or further described. It’s true that none of the specialists are named or quoted directly either, which certainly protects them from embarrassment. And it seems that the approach of these pieces is to rely mainly on the patient’s account; perhaps this patient never actually met the nurse, though he says he “remains grateful” to the nurse. But the piece does name and quote an infectious-disease expert the patient consulted after the diagnosis, so it might have done more with the nurse, even if could not give the nurse’s real name. The net effect of what we do have here is to suggest that the nurse solved the problem by being so simple and limited, with a mind uncluttered by real expertise. Needless to say, there is no suggestion that maybe the nurse solved the problem because of her own expertise, or the nature of nursing, including the profession’s holistic and flexible approach, which is no less “expert” for being broad. The piece pokes fun at the specialist physicians, but it still reinforces the idea that they are the main source of health knowledge–the same idea that seems to have gotten this patient in so much trouble.

This is the story of John Gordon, the 54-year-old president of a commercial real estate firm. Gordon thinks he might have been better off “had his office not been located in a Montgomery County high-rise that also houses many medical offices,” which made it convenient for him to see all the specialists there. Gordon, “whose father and father-in-law were doctors,” says he did not ask enough questions, and was “too good a patient,” which must mean accepting whatever physicians say–hardly surprising for a person with that background. The result, apparently, was “two unnecessary knee surgeries and dozens of physical therapy sessions, as well as acupuncture and other useless and sometimes painful treatments that cost thousands of dollars.” This part of the article hints that we should not be so trusting of specialist physicians. But then we get this:

In the end, it was a basic query by a nurse, not the acumen of five specialists, that led to the correct diagnosis of a common malady. “If you don’t ask simple questions, you screw up,” Gordon said. “I see that in my business all the time.”

The piece traces the history of Gordon’s problem, which appeared in 2007, when he first noticed that his knee was swollen. He consulted an orthopedist, who recommended physical therapy. That did not help. The orthopedist drained the knee and gave Gordon cortisone shots. That did not help for long. An MRI showed no torn ligaments or cartilage, so the orthopedist recommended exploratory surgery. A surgeon operated, “told Gordon he had a partially torn meniscus, a common injury involving cartilage,” and then “repaired the cartilage.” That did not help.  Gordon consulted a physiatrist, who specializes in rehabilitation and pain management. This physician considered whether it might be an infection, but assumed that had been ruled out, and suggested acupuncture. That did not help. Gordon got a second MRI, and his orthopedist suggested surgery for “pigmented villonodular synovitis, which causes an overgrowth of tissue for no apparent reason.” Gordon switched orthopedists but had the surgery. It did not help. The surgeon suggested that the abnormal tissue in the knee pointed to cancer, and referred Gordon to an orthopedic oncologist and an infectious-disease specialist. But the tissue biopsy was negative.

The infectious-disease specialist confidently suggested that Gordon had contracted “valley fever,” a serious fungal infection, from a recent trip to the Southwest. Gordon took “the maximum dose of a potent antifungal drug” for two weeks. It did not help, but it did make Gordon “feel weak and very nauseated.” The infectious disease specialist was stumped, though that did not stop him from prescribing an antibiotic.

But a week later, in June 2008, the doctor called back. Gordon said he reported that during a staff meeting at which his case was being discussed, a nurse asked whether Gordon had ever been tested for Lyme disease.

nurse-physician discussionGordon said he had not, and that “no one had mentioned it.” We’re actually impressed that the physician admitted that this was the nurse’s idea. Physicians often receive credit for life-saving nursing ideas and observations, whether because physicians present the ideas to patients as their own, patients assume they must have been the physician’s idea, or nurses hide their own role. Of course, it’s also impressive that this specialist’s office had meetings in which a nurse’s professional opinion was considered. Physicians routinely leave nurses out of discussions of diagnosis and treatment, even though nurses’ input can mean the difference between life and death. Nurses must often use complicated social dances to have their views considered. Naturally, the Post article explores none of this, though it certainly would be worth discussion in a major newspaper.

In any case, the infectious-disease physician faxed an “order” for the test, which was positive. The disease was responsible for Gordon’s knee problems. The piece gives some basic information about Lyme disease, which is “a bacterial infection caused by a deer tick bite.” Lyme arthritis is “sometimes permanent.” Gordon was “stunned,” and wondered how this could have been “missed by so many specialists.”

For some answers, the piece turns to “Adriana Marques, an infectious-disease expert at the National Institute of Allergy and Infectious Diseases who is studying the natural course of Lyme…[read the rest of this article]

October 8, 2010

Linking Medical Errors, Nurses’ 12-Hour Shifts

As a 12 hour shift worker myself, I read this with concern.  I love working three days and being off 4 days.  It may be the only way I can stay working as a nurse until I retire.  However, that said, I have to agree that those last 4 hours of the shift are usually a nightmare and occur at a time when I am exhausted.  So, there is something to be said for the reduction of shift hours.  I like the idea of 4 hour shifts, but don’t see how they could work.

Please read this article and let me know what you think, won’t you?  This article is from HealthLeadersMedia and I hope you read the entire article which include many interesting comments on the original site.

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Rebecca Hendren, for HealthLeaders Media, October 5, 2010

It’s well known that caregiver fatigue is a huge cause of medical errors, whether the caregiver involved is a new resident coming off a marathon week or an overworked nurse pulling back-to-back shifts.

A few months ago, the Accreditation Council for Graduate Medical Education placed new restrictions on the hours residents can work and the supervision they receive. This follows years of research into new physicians’ training and the effect long hours and tiredness play in performance and contribute to poor quality care. A 2004 study found that first-year residents working all night were responsible for more than half of preventable adverse events.

Nurses don’t have the same extraordinarily-long work requirements as residents—and they clearly perform very different tasks—but like residents, they work long shifts and suffer from fatigue. Studies have linked nurse fatigue with medical errors, poor quality care, stress, and burnout.There are many reasons for nurse fatigue, but one stands out as pretty easy to fix: shift length. It’s no wonder that nurses are fatigued when 12-hour shifts are the norm. Despite the fact the Institute of Medicine has recommended limiting use of 12-hour shifts, it’s standard practice throughout the profession. Nurses routinely work back-to-back-to-back 12-hour shifts.

At the recent Nursing Management Congress in Grapevine, TX, held September 23-25, I attended a presentation by Cole Edmonson, CNO/vice president of patient care services at Texas Health Presbyterian Hospital in Dallas. Edmonson noted that research is helping us understand the dangers nurse fatigue presents to patients and to nurses themselves. He called 12-hours shifts a dead idea whose time has passed and suggested they may cause more problems than they solve. He asked attendees whether it is time to declare the end of 12-hour shifts.

I can’t imagine working a 12-hour day as a nurse. Nursing is a professional job, requiring college education and high-level thinking. But it’s also manual labor. Nurses are on their feet all day, running everywhere, lifting patients, changing dressings, inserting IVs, and all the other direct patient care responsibilities.

It’s no wonder that nurses are fatigued. Shifts include mountains of paperwork, difficult patients and families, and hundreds of tasks. Somewhere in all this nurses make time to connect with their patients, expressing compassion and empathy. Let’s not forget that 12-hour shifts also frequently run into overtime, when the nightmare shift means they have to stay late to complete their charting.

Over the next few years, more studies will be published that show the danger of nurse fatigue. What if hospitals preempted the public outcry and started reducing 12-hour shifts now? Let’s focus on shifts that are best for patients, nurses, and hospitals alike. This means ending rigidity and allowing greater flexibility.

Senior leadership can embrace creative staffing and scheduling options that increase satisfaction for nurses and improve efficiency. For example: <…click here to continue…>

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October 6, 2010

Hospital bed transfers put thousands of patients at risk of infection

Here is an article I found on Nursing Times that comes from across the ocean.  It seems that our sisters over in the British Isles struggle with many, if not all, of the same issues we struggle with daily.  This particular article caught my attention because it seems that JCAHO or TJC, whichever you are familiar with, is always looking for a new issue to deal with and I think this should be one.

At my facility, patients are moved from one unit to another, from one floor to another, etc. with little concern for what is best for the patient.  I have always felt that we should look at the needs of the patient and place them in the correct unit from the very first minute.  This article is talking about infection control issues in medical hospitals, but in a psych hospital there are many other issues involved as well.  Mixing depressed people with actively psychotic people or bringing active detoxing patients into a unit with 30 or more patients should be contraindicated.  When we transfer patients to the correct units, staff are tied up, patient belongings get lost or left behind, and the patient experiences increased anxiety about the unknown on a new unit.  This cannot be good customer service and I know is detrimental to good patient care.

It was interesting to see that other nurses are also having these worries.  I also worry about the infection control issue of moving my patients around.  In today’s hospital settings, you have to be concerned about this.

Anyway, I hope you enjoy the article.  Won’t you leave me a comment to tell me what you think?

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Hundreds of thousands of hospital patients are being moved from one hospital ward to another with no clinical justification and risking the spread of infection, evidence collected by Nursing Times suggests.

The bed moves often happen because wards are too full and so patients are admitted into inappropriate wards and then moved.  If you are transferring patients lots of times you are moving bugs around the hospital

Patient transfers between wards are a well known cause of infection outbreaks as they reduce the ability of hospitals to contain infections. The transfers can also result in a disruption in patient care as notes are misplaced and observations missed.

Despite the risks only a small number of hospitals monitor their non-clinical patient transfers.

Nursing Times has analysed the data from those hospitals. It suggests that nationally there are around 1.3 million patient bed moves made each year for non-clinical reasons.

The figures suggest nearly one in 10 hospital patients could be affected, although a proportion of patients will have been moved more than once during their hospital stay so the precise number affected is not clear.

Eighty-eight trusts responded to a Nursing Times freedom of information request asking for data about patient transfers. Among the 42 that collected information about the number of patients being transferred from one ward to another, monthly transfers ranged from 9 per cent of inpatients in one trust to 88 per cent in another.

It is impossible to compare the trusts and judge which have the biggest problem as they measure performance in different ways.

Only six trusts were able to distinguish between transfers that were clinically justified – such as when a patient needed to be moved to a lower dependency unit or a different specialty – and those that were not.

Their rates ranged from 0.4 per cent of inpatients transferred without clinical justification at Frimley Park Hospital Foundation Trust to 15 per cent at Imperial College Healthcare Trust in London.

At Southampton for example, an average 5,922 patients were admitted each month between July 2008 and July 2010, and there were 703 non-clinically justified transfers – 12 per cent of admissions.

At Taunton and Somerset Foundation Trust, another which collects detailed information, there were an average of 6,301 inpatients a month and 735 non-clinical transfers in the same period -11.7 per cent of admissions.

Across the six trusts the average monthly rate of non-clinical transfers was 8.8 per cent of total inpatients.

Scaled up across the 13.6 million hospital admissions in England last year, the data suggests there are around 1.3 million clinically unjustified patient transfers each year.

Royal College of Nursing emergency care adviser Alan Dobson told Nursing Times hospitals were struggling to admit patients to the appropriate ward as the bed occupancy rate in hospitals was higher than ever, meaning fewer beds were left vacant to cope with surges in demand.

Mr Dobson said: “Bed occupancy should be about 85 per cent to enable good patient care. Most hospitals are running at about 95 per cent and sometimes it is at over 100 per cent.

“Patients are often moved around the hospital for non-clinical reasons and it’s unacceptable. If you are transferring patients lots of times you are moving bugs around the hospital.”

Frimley Park Hospital Foundation Trust nursing director Mary Dunne said the trust had changed its arrangement of wards to reduce non-clinical transfers.

She told Nursing Times that senior nurses frequently intervened to prevent patients being moved several times.

She said: “We began looking at it as a patient safety issue, but being moved can also be upsetting. Patients like to get to know their team, and just as they are settling they can be moved to another new team.”

However, she said increasing beds and staff would not help because more patients would be admitted to fill them, rather than the flexibility used to reduce transfers. She said: “The more beds you open the more beds are filled. We should be looking to supporting patients back into their own homes.”

Earlier this year a Nursing Times investigation revealed that patients were regularly being placed in areas not designed for care – including wards that were already full, store rooms and mop cupboards – because appropriate wards were full.

The National Audit Office’s report on hospital infection in 2000 highlighted transfers as a risk factor. Accommodating patients in the wrong area – away from the team that is meant to be caring for them – also means they get less attention and are less likely to get the treatment they need, and more likely to deteriorate.

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