Nursing Notes

June 13, 2011

Inglis: Efficiency can make health care better and cheaper

Kathleen Sebelius

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Here is an article that ran in our Austin Statesman and was contributed by Toni Ingles, RN.  She is a very funny lady that I have emailed back and forth before and I am proud to list her among my associates and friends.  The article is about the visit of Health and Human Services Secretary Kathleen Sebelius to the Seton Hospitals to see the innovation and changes made by nurses that impact the bottom line.

While this article lacks the humor I have come to associate with Toni’s work, it is still right on target which is also her trademark.  I am proud to be a Seton nurse and I would like to share here some of our successes.

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Toni Inglis, Regular Contributor

Published: 7:14 p.m. Tuesday, May 10, 2011

There’s a little history leading up to Health and Human Services Secretary Kathleen Sebelius’ visit to Austin last week. It began in 1999, the year that health care across America woke up.

Sebelius’ visit coincided with the 12th anniversary of a report by the Institute of Medicine that upward of 100,000 people die in any given year from medical errors in hospitals. As if the 1999 data weren’t bad enough, a prestigious study published last month indicated that the number might be 10 times that much, with one-third of patients incurring illness or injury while in the hospital.

The Centers for Medicare & Medicaid Services’ stark, dark data show that the agency spent $4.4 billion in 2009 on care for patients harmed in hospitals and another $26 billion on patients who were readmitted within 30 days.

Enter the Patient Protection and Affordable Care Act. Its cumbersome name denotes what it is intended to do — protect patients, hold providers accountable and make health care affordable. The law intentionally left the job of cutting costs to the professional clinicians in the field.

The first year focused on insurance company reform. The second year zeroes in on clinical practice. That’s where the talents of President Barack Obama’s pick to head CMS, Dr. Donald Berwick, come in.

Berwick founded the Institute for Healthcare Improvement and over two decades enlisted thousands of hospitals worldwide to test and identify best practices for patient safety and to ensure their broadest possible adoption.

Sebelius has visited several sites that adopted Berwick’s model. She visited a hospital in Seattle for preventing patient falls and bed sores and a community in Ohio for preventing infection in children.

She visited ICUs in Michigan that used a simple checklist famously chronicled in “The Checklist Manifesto” written by a cancer surgeon at Johns Hopkins, Atul Gawande. Given the enormous potential for human error in such complex care, adopting a checklist including the simplest things like hand washing and donning sterile gloves, turned out to be enormously effective. In the first year, the Michigan hospitals reduced infections by two-thirds, saving 1,500 lives.

Sebelius came to Austin to learn about the Seton Family of Hospitals’ successes in patient safety. She learned of the nurse-led initiative that virtually eliminated bed sores, ranking Seton first internationally. She learned how major reductions in infections were achieved. She learned how University Medical Center Brackenridge achieves the national standard of restoring circulation in 90 minutes after an acute heart attack — 100 percent of the time.

The biggest draw for Sebelius, however, was to see how Seton dropped its birth injury rate to zero. Partnering with IHI, Seton nurses and doctors developed a bundling of best practices for obstetricians: no elective induced births before 39 weeks gestation and limited use of the drug oxytocin to shorten labor and of vacuum extraction of the baby.

Of interest to Sebelius was the saving in government spending by preventing birth trauma. In 2003, when the safety initiative began, Seton billed Medicaid $500,000. In 2009, Medicaid was not billed at all.

During her visit, Sebelius introduced Partnership for Patients, an initiative begun last month with Berwick’s design. The $1 billion government investment targets hospitals to help them learn about and implement proven methods to improve care. The partnership is expected to avoid millions of unnecessary medical injuries and complications and thousands of deaths. It is also expected to reduce Medicare costs by $50 billion over the next decade.

Her visit also coincided with the release of a federal rule to take effect in 2013. It will reward better-performing hospitals with commensurately higher incentive payments. Government will reverse economic incentives from quantity to quality of care.

Berwick, a recess appointment, might not be long for public office. He has been a target of political criticism and is not expected to win Senate confirmation to remain in his seat past 2011. Hopefully, his legacy of innovation for patient safety will continue. Through public office, his model to change the way health care is delivered represents the government’s first serious attempt to address patient safety.

Given the number of deaths, health care needs to view itself as an industry just as complex and high-risk as the airline and nuclear energy industries — both of which use checklists.

If corporations producing commodities like TVs, microwaves and cars can make better products and save money by eliminating waste and increasing efficiency, so can health care. Most Americans can afford a TV, but no uninsured American can afford health care.

Inglis is a neonatal intensive care nurse at the Seton Family of Hospitals and editor of ‘Seton Nursing News.’

 

 

 

 

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June 7, 2011

Public Health Nursing, Anyone?

Filed under: Nursing — Shirley @ 2:16 pm
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Image representing YouTube as depicted in Crun...

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Have you ever thought about becoming a Public health nurse?  I never had even given it a single moment.  Then I had a friend email me about going to Alaska to do public health nursing and I had to see what it was all about.

I found this video on YouTube and thought it would be interesting for other nurses to see, so will post it here.  I’m too far along in my career to consider this, but for you younger nurses, this looks like real nursing at its best!

Please watch the video and leave me a comment on your thoughts about this type of nursing, won’t you?

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June 1, 2011

How protocols are taking the decisions away from nurses

Illustration of Florence Nightingale

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Here’s a wonderful article I found on Kevin MD‘s blog that is written by SaraBethRN.  As I read this article, I found myself shaking my head in agreement.  I felt like my own thoughts were printed right there in the article.  I immediately emailed her for permission to reprint here.  I hope you enjoy this article as much as I did.

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by Sarah Beth Cowherd, RN

If you have been at your nursing job for a while, you’ve probably almost forgotten.

Forgotten what it was like to come in to the healthcare system you now work for and realize there are hundreds of new protocols for you to learn and adhere by as a nurse. After years of routine, you now go about your day as if you actually have some choice in the way you give care.

At one point you probably did. I was not around during this age of nursing. The age when we had autonomy. Freedom to practice. Freedom to be innovative.

Today, I am somewhat saddened by the current state of the nursing profession. Don’t get me wrong: I love what I do. I am so thankful for the opportunities set before me.

But whatever happened to “nursing judgment.” Or “nursing decision.”

I can’t tell you how much recently I’ve heard the phrase, “It is hospital policy that…” “You can’t do that, it is protocol that…”

I understand the need for protocols. They help us in the case that something goes wrong and the hospital gets sued. Did the nurse adhere to the protocol? If not, they will be subject to disciplinary action and take the fall. If something goes wrong and there is no protocol, the hospital can say in its defense: “There is now a protocol in place.”

Maybe a less cynical need for protocols: promote and regulate evidenced-based practice among nurses. Evidenced-based practice was developed for a reason: it brings good outcomes and protects the patients.

Even so, to me it seems we are being protocoled to extinction.

When nursing sprang up, before it was considered a profession, nurses had to make due with what they had. They were forced to be innovative. I heard this once in a seminar on preventing pressure ulcers: the reason we turn patients “every two hours” is not from a scientific experiment that proved people won’t get bed sores if they are turned this often. It was from the very roots of nursing itself. When nurses were (how do I put this nicely?) prostitutes and drunks. They would walk down the room and turn all the patients to one side. Then they would sit and have a drink. When they were done with this, about 2 hours later, they would get up and turn everyone the other way. And repeat.

Even today you will read some “protocols” that require nurses to document turning patients every 2 hours. Some recent studies have shown that slightly repositioning (and not completely turning) patients every hour or even every 30 minutes has had better outcomes.

Now if I used this method of preventing pressure ulcers and did not “turn” my patients every two hours, I would be breaking protocol. I would also be forced to “lie” in my repositioning documentation.

This is just one example. I surely don’t mean to argue we should have no protocols in place.

My point is that at times, the red-tape forces nurses into a corner. We may not be creative for fear of disciplinary action.

One more story: While working night shift with a coworker and friend of mine, we had a patient with dementia that kept complaining that air was drifting on her. She was hallucinating. My friend decided to make a tent. A tent of blankets around her bed. The nurse used the IV pump, the bedside light (turned off, of corse), and the sides of the bed. (Keep in mind, this patient was not ambulatory, nor did she have the strength to sit up or attempt to leave the bed.) This was so she felt safe. She felt as though there was no air blowing at her anymore. She finally got some rest for the first time in her hospital stay.

At 6am, my coworker made a point of going into the room to take down the “tent.” Management was coming in. “I’m not trying to get fired.”

Get fired? For making use of what she had? For helping the patient sleep without sedatives? For being innovative and realistic?

We may not be extinct, but we sure are endangered species.

Sarah Beth Cowherd is a nurse who blogs at SaraBethRN.com.

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