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!