"You Is Smart, You Is Kind, You Is Important"

I was watching "The Help" a couple of days ago with my daughter.  The movie has so many strong depictions of love and acceptance in a complex world that has a lot of barriers.  There were racial, sex, age, class and socioeconomic barriers depicted throughout the movie, most of which my daughter at the age of ten just couldn't understand.  At first I really didn't think about the relationship the movie could have to the field of nursing, but then it dawned on me that there are still many barriers in nursing today that do apply.

I started to think about the way Hilly and her friends treated the other characters, Celia, Skeeter, Minny, Aibileen, Mae Mobley and even Missus Walters.  The harshness of their comments and their deliberate actions all while looking the poised part.  This is how some new nurses are treated when they enter the profession, there is that same bitterness and the "eating of their young" that is unfortunately exhibited.  That ugly way the characters treated "the help" was handed down generationally, it was ignorance then and it continues to be today.

The help, like new nurses were not empowered, they were pushed down, talked down to, treated as second class citizens, talked about and threatened.

For me one of the most emotion and important scenes of the movie occurs when Abilieen and May Mobley are alone in the nursery when May Mobley repeats back the valuable words her "real momma", Abilieen, tells her, "You is smart, you is kind, you is important".

I believe that new nurses need that same reinforcement, guidance, reassurance and love.

While there are many change agents in the story, the collaboration between Skeeter and the help, standing up together brining light to the treatment these women endured is encouraging.  With so many nurses entering and leaving the workforce there is a changing tide and attitude.  Now is the time to remind our peers that: "You is smart, you is kind, you is important".

Health or Poverty? Hospital Brass, Congress, and Lobbyists Are Killing Health Care!

Time Magazine featured a gripping and informative article by Steven Brill called "Bitter Pill, Why Medical Bills are Killing Us", that every health care consumer and nurse should read, .  The article was the longest in the history of Time, and in my opinion a nauseating look into how health care policy and pricing guts Americans.

Mr. Brill explains how nonprofit hospitals and for profit hospitals are price gouging patients on everything from a $7 alcohol wipe to $400 per hour nursing care (not 1:1 ratios either).  His article is supported by patients' stories and their medical bills.

He delves into the way that Medicare is able to contain some of the costs of care, such as pricing for CTs which have no price regulation nor consistency hospital to hospital, charging upwards of $6,000, where Medicare has been able to negotiate a charge of $500.  As for other insurance companies they have their own negotiating numbers, which are discounted from the hospitals' chargemaster.  Brill explains that each hospital has a charge master which is a listing of what each item costs, and that the patients are billed and sometimes over billed for these items. The chargemaster also prices lab tests and other diagnostic tests.  When Brill asks hospital higher ups about the charge master they responded as though it wasn't a concrete or important component of pricing, but again and again he provides evidence that everyday patients are charged enormous amounts of money for inexpensive items.

Medicare is the largest insurer in the U.S. and holds a good amount of leverage, but it is not absolute leverage.  While cost savings have been negotiated with hospitals for tests and services, congress has banned Medicare's ability to negotiate with big pharma over drug costs and the cost for durable medical equipment.

Congress has very little reason to do the right thing for their constituents when lobbyists out number the members of congress and spend millions of dollars to get them reelected.  According to Brill in 2012 the American Hospital Association spent $1,859,041 on lobbyists while other healthcare lobbyist have spent $5.36 billion since 1998.  Brill points out the during the same time lobbyists for defense spent $1.53 million and the petrol industry courted Washington with $1.3 billion.

While health care reform has come to the aid of some, the fundamental broken parts of health care are still very much intact, an internal anaconda, squeezing the wellness out of health care from inside the hospitals themselves.  If we are to take health care reform seriously we need to have a fair market value system. People generally don't choose to go to emergency rooms, they often have no choice, its like a hostage situation.  Do you want to live, then you take what you are given and hope the ransom isn't too high, or you leave without care and possibly die.

http://www.time.com/time/covers/0,16641,20130304,00.html

http://nursingrantsandraves.blogspot.com/2013/02/dont-choke-nurse.html

Don't Choke the Nurse

Hospital ER's have become the dumping grounds for drunks.  Unfortunately ERs also act as the holding place for mentally ill patents waiting for a disposition (either being admitted to a psych facility or discharged home).  Often our intoxicated patients have underlying mental health issues which can make a bad situation worse.

A few months ago a known "drunk" with a psych history got dropped off at our ER by an ambulance squad. He was assigned a stretcher.

A few minutes later he got up and headed over to another patient's bed and started yelling and threatening to kill him because the other patient was the guy who tried to steal his wallet at a bar (the patient wasn't even at a bar earlier).

I managed to calm him down and divert him away from the other patient.

A few minutes later the drunk got up again.  He began walking towards another patient bed, where a patient with a traumatic brain injury started screaming and flaying about. Seeing what was about to happen and the crazed look in the drunks eyes, a male nurse and myself positioned ourselves so that he could not attack the other patient.

I calmly talked to the drunk patient attempting to redirect him, but it wasn't working.  My co-worker, a male nurse also attempted to talk him down with no avail.  In the blink of an eye the drunk man lunged at my co-worker enclosing his hands around his throat.  Two visitors, myself, and a lab tech attempted to free this drunk psychotic man's hands from the nurses throat, my co worker was being choked.  Two other people came to the assistance.  The lab tech pulled the man's elbows back, myself and another nurse tried to pry his fingers off, while visitors secured his legs from kicking.  Our secretary called security, paging them nearly 10 times with no response, she finally had to call the local police.  We finally got the nurse free from the choke hold.  I ordered for someone to get the leather restraints and bring a stretcher closer.

We wrestled the man onto the stretcher.  From the look in his eyes there was no remorse.  He continued to fight as we moved him to a private room.  He attempted to bite, spit, punch and head butt the staff. Security looked stunned.  As I began drawing up Ativan I told security to put the restraints on him, they continued to just stand there looking at me.  "Put on the damn restraints" I ordered again.

Just as they began doing their job a very tall intimidating police officer entered the room.  The patient immediately knew that the game was over.  Security looked at the officer, but they were working at a snails pace. The police office looked at the security guys saying, "any day now".

The patient remained  in the ER overnight until he was sober.  While the charge nurse filled out an incident report the nurse who was choked did not press charges.  The incident was not debriefed, nor did the head of security ever meet with the staff that was involved.

While one nurse was choked, luckily in view of others who could come to his aid, another nurse was punched int her face.

I wish that my friend who was choked had pressed charges.  My profession for some reason just lets this stuff go.  Being assaulted is not part of the job description but we have adopted it as such.

Perhaps we should have let the patient go, let him attack the other patient.  If that should have happened then there would have likely been a lawsuit, and possibly a change.

As if rubbing salt in the wounds, a few weeks later, I was talking to some of the security guards about the incident.  One of them responded, "I don't get paid enough to get hurt", as he was looking at his Facebook page on the hospital's computer.

Safety in the workplace is an issue for everybody.  It doesn't matter how much money you earn.  I work in two ERs one in the inner city, and one in the suburbs.  I can assure you that I am far safer in the one in the inner city.  Our security there is top notch.

Nobody wants to go to work and get hurt, just as nobody wants to go to work and see someone getting attacked.

When Is Enough, Enough? Compassionate Care

In the past 18 years I have witnessed more people dying than I could ever recall.  The sound of the last wet breaths, the modeling of their skin, the cloudiness of their eyes.  When people are terminal, dying, they have "that look".  It is the look that I know as a nurse, but sometimes my patients' families don't understand.  Many time the family of the dying is holding out hope, and they are paralyzed, unable to make a decision on when enough treatment is enough and when compassionate care should begin.

A few years ago after my father's chemotherapy failed, actually it was is body that failed the chemotherapy, his oncologist came into his hospital room.  My mother and I were sitting in the plastic chairs to the side of his bed.  My father, weak, but alert, laid in bed as his doctor told him chemo was no longer an option, his weak heart couldn't handle it.  The doctor's eyes hardly met mine.  She danced around the subject of what the next step was.  But I knew the next step, it was hospice, and it would be soon.

When the doctor left the room my parents were left with the impression that my dad should return to the rehab facility.  When I left my dad that evening at the hospital I kissed him goodbye and I knew that he would have a long night of trying to sort out what he was told.

The next morning I spoke with my mother.  She had said she was going to look at rehabs.  But I already knew that the man who couldn't stand, go to the toilet, the man with lung, bone, kidney and brain cancer was not going to thrive in rehab.  He was miserable there before and now he had nothing to work for, his oncologist told him the cancer had won.

About a week later my dad was still in the hospital.  He was just waiting.  Waiting for the end.  

Originally my mom thought he could do hospice at home, but the set up of the home really wasn't going to be easy.  Fortunately the reality began to set in, and she visited a few hospices, eventually finding one, that when she walked in she knew he would like it, and he didn't have much time.  By the time she found a peaceful place for him his AICD had been turned off per his wishes.  His lung had collapsed.  He was slipping away.  

My father arrived in hospice on a Wednesday evening and died that Friday.  

Sometimes doctors don't like having "that" conversation with the patient or their families, and I find it selfish.  When there is little to no hope and someone is struggling it is unfair to hold information from them.  When they are drowning in their own fluids and their terminal disease had taken the life from their body patients deserve the respect of knowing how ill they are, so that they may plan the way they would like to be cared for.  

Striving for Five-- Buying Into Hourly Rounding

Customer Service!  Striving for five!  That's what its all about!

I don't know about you but I cringe just about every time we get to that part of the staff meeting and my departments' Press Ganey scores come to light.  It's even more fun when you look at the hospitals' websites and see the stats, those darn rehab nurses always beat us.  But I'm in the ER, and it's not easy to please people who are laying on stretchers, sometimes with no privacy in hallways, waiting for hours and having limited food choices- stale turkey or stale cheese sandwich.  

I've had some extra time to read a few books and professional journals lately.  I see pictures of smiling nurses and their happy patients, with happy captions, but does this reflect what is happening in the hospitals? There's has nursing research articles about how hourly rounding reduces call bell usage and reduces falls.  In theory this is a wonderful thing, but it's not a sure fire way to bump Press Ganey, is it?  

A recent article that appeared in the Journal of Emergency Nursing's January 2013 issue, written by two ER nurse managers supports hourly rounding.  Their article showed a statistical analysis of how their facility's Press Ganey scores dramatically increased.  It was reassuring.  In addition to hourly rounding the Emergency Room employees also had to buy into the concept that  they would meet specific goals that were directly related to the Press Ganey patient survey.  

The approach the authors reported is not unlike other emergency rooms.  AIDET was a key focus in addition to hourly rounds that included: "the 4 P's- personal issues, pain, position, and problems". 

So how did they get folks to buy in?  I know we have the same standards at the hospitals I work at, but it just doesn't seem to be uniform.  Rounding is generally left to the nurses, and when those nurses are busy and staffing is, well, short, hourly rounding sometimes takes a back seat. 

So how much of an increase did this particular hospital have?  The Press Ganey scores were at 57% prior to hourly rounding and increased sharply.  The authors also reported increased job satisfaction.  

The hospital was able to get the buy in from its staff and more importantly maintain it.  One of the ways they did that was through reward systems.  They utilized movie tickets, gift cards and employee recognition to keep their teams motivated.  In addition to the buy in from the employees side, the patient discharge paperwork also included a signed thank you note from the staff that cared for him.  According to Sharron Kelly, coauthor of the article, she stated that her department had not increased staffing levels, during that time.  She further clarified that the hourly rounding was a joint effort by physicians, techs and nurses.  

For more information please refer to the article "Improving the ED Experience with Service Excellence Focused on Team work and Accountability" by Sharon Kelly and Lou Faraone which was featured in the January 2013 issue of the Journal of Emergency Nursing.  

Little Hearts Big Love-- CCHD and CHD

February is a busy month of celebrations for matters of the heart.  Over the past few years heart health and wearing red has been in vogue for supporting the cause.  But who are we bringing awareness to exactly?

When you see CHD you might think coronary heart disease, but there is another CHD out there.  Congenital Heart Deformity  and Critical Congenital Heart Deformity which affects approximately 1 out of 120 infants. While some infants are diagnosed prenatally others may not show signs or symptoms until they are discharged home.

New Jersey has taken the lead in helping identify CHD by mandating a simple procedure that is non invasive and part of routine vital signs.  While most nurses wouldn't consider a pulse ox as being so groundbreaking, considering that we seem to use almost without thought.

Is that enough to diagnose CCHD and CHD?   No, it's not, but it is a start!

While some CHD can be suspected related to lowered pulse ox values, it is not the case for all forms of CHD.

Commonly associated CHD linked to low pulse ox include:

• Hypoplastic left heart syndrome

• Pulmonary atresia

• Tetralogy of Fallot

• Total anomalous pulmonary venous return

• Transposition of the great arteries

• Tricuspid atresia

• Truncus arteriosus

It is recommended that the pulse ox be done 24 hours or later, because newborns bodies will often show signs and symptoms several hours or days after birth. For optimal results it is important that the infant now be crying or moving during the reading.  The probe should be placed on the right hand or either of the feet.  
A positive screening includes one of the following

1. SaO2 measurement <90 percent
2. SaO2 measurement <95 percent in both upper and lower extremities on three measurements, each separated by one hour
3. SaO2 difference >3 percent between the upper and lower extremities

http://www.uptodate.com/contents/congenital-heart-disease-chd-in-the-newborn-presentation-and-screening-for-critical-chd#H270523895

While nursing is about medicine it is also about the families of these infants and children who are born with these serious and life threatening conditions.  Below is a link to some amazing stories that truly touch the heart.  http://www.chop.edu/service/cardiac-center/patient-stories/

Insurance and Addiction- Not What the Doctor Ordered

Having worked in the Emergency Room in a few facilities over the years I have seen the heartbreak in the eyes of the family or loved ones of addicts when they come to the ER in hopes of detox or rehab.  Unfortunately addiction recovery is not something that ERs do, and less and less hospitals have specialized units for this kind of medicine.  

http://www.nj.com/news/index.ssf/2013/02/new_jersey_heroin_insurance_tr.html#incart_river_default

Sadly when a person is triaged and they say that they want to "kick", stop using, whatever addictive substance they have been abusing and dependent on we can't always offer them help.  Sometimes the patient has been down this road before and they know that the only way they are going to get away from the substance is to say.."I'm suicidal". But what happens when the ER they go to doesn't have an addictive treatment center or unit?  

Unfortunately the person is generally medically cleared, they are seen by a mental health screener (social worker from a crisis unit) and then a psych doc and if that patient doesn't have a plan for hurting themselves, they are often given a list of treatment facilities and discharged.  If the person is truly an addict and they walked into a facility seeking treatment, then that was a major step.  Perhaps they really wanted to change their lives.  But then there is the discharge and the piece of paper.  There is no hand holding or someone to help them navigate the insurance red tape.  They are on their own.  If the person is lucky maybe they hit rock bottom and still have a family or support system intact, but there are the others who have nobody.  No support.  They have that piece of paper.  Perhaps no cell phone, no home, no address.  They might be withdrawing and this isn't what they expected recovery would look like.  Maybe it was easier just using. 

Addiction and mental illness are not luxuries like Botox and boob jobs!  It's time that we start treating the whole patient, addictions included. 

Nursing Rants and Raves: Saturday's Stupidity Snipits

Nursing Rants and Raves: Saturday's Stupidity Snipits: Saturdays are almost always good for the intoxicated members of society to stop off and visit the local ER.  Now sometimes there is a trauma...

Times Up

I've been recovering from shoulder surgery, no thanks to a 90 something year-old who was obviously opposed to the foley I inserted.  I had four months of pre-op physical therapy, a misdiagnosis of "I don't think it's anything" from the Worker's Comp ortho, even though an MRI result stated otherwise.  Well lucky for me I had a great therapist who was persistent.  It's been two months since surgery, and about 3 weeks since PT stated.  Things are painfully progressing.  

     

Normally PT appointments are scheduled for only 30 minute sessions, but my therapist always does an hour, knowing that my time to be back to full duty is very limited.  After a slew of exercises and stretching she starts the painful stretching again, which sucks, but it is helping me get better range. Mid stretch another therapist walks over and says, "Are you still working on that shoulder?  It's been a while." She returns a few minutes later and says, "I've already seen like three patients."  

And here lies the problem with healthcare today, we are time slotted into recovery.  We are not working towards progress of the patient we are more concerned about how many people we can put through the door.  

Maybe I should have explained to her that I only have 23 more days until my 12 weeks of medical leave are up and if I'm not 100%, I loose my job.  Yes, you can be terminated after being injured by a patient while at work if you go over your 12 week FMLA time and are not back to ship shape.  

EMS- Don't Shoot the Messenger

     I truly believe that nursing is a profession.  While I may don scrubs and clogs, I don't consider myself any less a professional than a lawyer, physician or scientist.  While nursing has made great strides and advancements in the past thirty years, with more nurses obtaining advance degrees and increased nurse based research, I still find myself cringing at the way some of my co-workers treat others, especially those who provide pre hospital care.

    EMTs and paramedics are not glorified taxi services.  They provide vital pre hospital care and they should be treated as professionals, but as I've heard from several paramedics that is not the case.  They complain, and rightfully so, that they often have a hard time getting a nurse to take report or are met by a nurse who rolls their eyes and throws them a major attitude for bringing in a patient.  

    I frankly appreciate the work these men and women do.  I'm not a fan of cold weather and adverse conditions, these medical professionals are performing intubations and codes without a respiratory therapists, good lighting and controlled environments.  These highly trained professionals are providing a great service to communities and the hospitals they are transporting their patients to.  I for one would prefer an already intubated patient verse an unstable airway rolling into one of my ER beds any day.  So why do EMTPs get so much flack? And why doesn't it stop? 

   In the customer service world that we live in where patient satisfaction has become a method by which hospitals are reimbursed shouldn't we be looking at this issue a bit closer and with more scrutiny?  

  As an ER nurse I get the frustration of being overwhelmed by more patients than you have beds for and when you are delivered an unexpected patient it can be stressful.  Is this really a problem caused by EMS?  It's not. Instead of getting upset with the medics, give them the attention they and your patient deserve and proactively work with your co-workers to identify ways to improve the situation.  

   If you feel like you are always being dumped on chances are you are not the only one.  Talk with your colleagues and identify patient safety issues that exist.  If you are chronically short staffed and it is directly impacting patient safety you owe it to your patients and yourself to document and report incidents.

  In some facilities nursing has a negative codependent relationship with the leadership of the hospital.  The nurses forego lunch breaks on twelve hour shifts because adequate staffing has not been established, yet the nurses, the largest employee group in the hospital have not joined forces with their fellow nurses to stand up for their workers' rights.  Nurses get frustrated, burned out, overwhelmed and patient care suffers.  Often times nurses will say "management knows but they don't do anything about it."  Well if that is true and you have notified management did you do it as a whole, or were there a minority of nurses complaining? 

  While it is easier at times to advocate for your patients than it is for yourself, patient care should not suffer because the nurses have grown indifferent.  EMT units bringing in business/clients/patients should not be shunned because we are having internal administrative issues that have not been proactively dealt with.  It's not an EMS problem it's a bad attitude problem that needs to be readjusted!