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.  

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. 

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!