Monday, March 23, 2015

Don't Let Curiosity Destroy Good Care

Curiosity Killed the Business

Could you imagine a medical professional saying to a person with HIV/AIDS, “You scare me so I would rather not treat you”? What about telling a person with disabilities that they are a “bother” and take up too much time?

You wouldn’t think that it could happen, but even if such things are not said out loud, only thought about, the care and treatment of the patient is compromised.

I recently gave a presentation about the work PULSE of NY does with community groups and vulnerable populations. I finished with a brief discussion about patient safety and my work with a variety of populations — one being patients who are transgender. As I was walking away, a man stopped me and wanted to have a private conversation. “What do we call these people?” he asked me. I stopped to think about this question and the words he used: “these people.” I know that if I were transgender, the hair would stand up on my neck. Instead I sat down with him, gave him my biggest smile and said, “I’m so glad you asked. I just wish you had asked earlier so everyone could hear the answer.”

I asked who he was, because earlier when I was with senior leadership I got the impression there wasn’t much interest in this topic, but now he was asking a very basic question. He was calling them “people,” and although it seemed a bit cold, his intentions were good.  It seems he was the head of the transportation team in this large community hospital and he explained that he conveys plenty of people who are transgender — people whose names don’t match their looks. He was grateful for my response and was taking notes. I was grateful that he cared enough to ask. But would he ask someone who is transgender?

Years ago when teaching a gathering of senior leadership in a small hospital about working with people with various physical disabilities, a nurse in charge said, “They take up so much time.” As an advocate for this community I had to catch my breath. I thanked her for her comments. “Now,” I said to the group, “what can be done to fix this?”

When we don’t acknowledge the hidden feelings, the stigmas or our fears of the unknown, it puts a burden on the people entrusted with the job of caring for people they don’t know enough about.

Not all patients are ideal patients. Some have many questions, some come to the hospital after a bad experience. Some patients will take extra time for a variety of reasons. This often can’t be helped. Allowing staff to explore their feelings about unwed mothers, people addicted to or dependent on pain medications, people with disabilities or people who are transgender is important to making a fully rounded medical team. Some medical professionals will say, “I really don’t care: a person is a person.” Wouldn’t it be great if they all did?

Monday, March 16, 2015

True Story in the Emergency Room

The Emergency Room Dilemma

As I walked into the emergency room to visit a patient, I saw the halls filled with equipment and beds.  No matter where I walked there was staff rushing by me – no smile, no eye contact, no one was aware that I was even there.  As I went down the pathway to see the patient I was there to visit, each tiny cubicle that had room for a bed and a chair, was divided in half for 2 beds.  The nurse standing next to the bed, talking to a patient couldn’t do so without her back pressing up past the curtain and into the next patient’s space.  How dirty is that curtain I thought to myself, to have it handled by visitors, staff’s clothing brushing up against it and so close to the bed, the patients are touching it. When I saw a man about 3 feet from the curtain, lying on his side continually coughing, I was sure that the curtains were full of germs.
My first thought was that if animals were caged like this there would be a public outcry.  How is this acceptable?
A patient on a gurney was only feet away from the patient I was visiting.  One of about 5 beds lined up at a wall because there were no cubicle’s left.  I heard the doctor asking the patient questions about her drug use and recent surgery.  For sure I would not be having an honest conversation with my doctor if I knew my business was for everyone to hear.  When I turned around, the doctor was pressing on her belly.  An exam usually done in private.
The sink was behind the patients head blocked by the bed and an IV stand so no one could wash their hands. 
I knew someone who worked there who invited me to see a nurse in charge.  “She really is concerned” he said and took me back to meet her.  I had the opportunity to listen and learned that there are just no beds and physically no room.  She explained; we have to move patients out faster and safely but if patients come, they need to be treated.  I knew she was right.  She said that there is on-going conversations about moving patients out more timely, getting more staff but “it takes time”. 
A complaint to the state would cause additional delays in care.  Resources would be used talking to state surveyors.  A call to the Joint Commission would also cause additional stress and further slow-down of care.  They know what’s wrong and don’t need to be told.  They need resources to fix the problem.
At a recent emergency room visit, cubicles were so tight the
patients bed took up the entire space .  The sink is hidden
here behind the patient's bed, blocked by equipment
I want to help – not blame. How do we all help ensure safe care for these patient’s.  The building is only so big.  Every bed is full.  Staff is being hired and trained to move patients out faster.  Would the hospital CEO be treated as these patients are treated?  Would the family of the CEO use these beds?   There are numerous opportunities for errors here.  Staff morale must be low.  I can’t imagine any medical professional would come into this business to work in these conditions.  A supermarket would never be run like this.  A gas station, post office, hotel or restaurant would never be this crowded or chaotic.  What are the answers?  Before an injury or death from staff working too hard, too long and being rushed we need to stop this craziness.   Any ideas?

Sunday, March 8, 2015

Patient Safety Awareness Week - Some History

The History of Patient Safety - Patient Safety Awareness Week March 8-15, 2015
Some say patient safety started in the late 1800’s with Dr. Ignaz Philipp Semmelweis who was a Hungarian physician now known as an early pioneer of antiseptic procedures.   He was born July 1, 1818 in Hungary and lived until 1865 where he died in Austria.
Seimmelweis was best known for his discovery that the incidence of puerperal fever, also known as childbed fever, an infection following childbirth, could be reduced by use of hand washing standards in obstetrical clinics. 
Puerperal fever was common in mid-19th-century hospitals and often fatal, with mortality at 10%–35%.
During a research on the autopsy of his friend who died because of a fatal dissection wound, Semmelweis noticed symptoms similar to those of childbed fever. This observation prompted him to connect cadaveric contamination with puerperal fever. Soon after he declared that medical students carried infectious substances on their hands from dissected cadavers to the laboring mothers. This also provided the logical explanation for a lower death rate in the second clinic, operated by midwives because they were not involved with autopsies or surgery.
Seimmelweis introduced chlorinated lime solutions for interns who had performed autopsies and this reduced the incidence of death of mothers following childbirth.
His discovery was not supported by his colleagues. At a conference of German physicians his ideas were rejected.  The years of controversy gradually undermined his spirit.   
The stories surrounding his being institutionalized are controversial.  From suffering a breakdown because he had no fight left or that he was showing early signs of dementia.  The stories surrounding his death are also questionable.  He was beaten by staff until he died or he died from an infection.  Either way, there is no question that infection caused many deaths in the 1800’s and it does so now.  There is also no question that 150 years later, hand washing in the healthcare setting can reduce infection rates – but it’s still not done enough. 
Today there are over 90,000 deaths from hospital acquired infection with a cost to the economy of $10 billion.

Wednesday, February 18, 2015

The Talk on Joan Rivers Lawsuit

Joan Rivers and The Talk
I watched the show The Talk. It opened with the story of Joan Rivers death and a lawsuit her daughter Melissa is bringing against the doctors and facility where the procedure was performed that ultimately killed her.  

A host asked “If you were Melissa, would you be suing?” gives us the impression that everyone who has lost a family member sues.  They don’t and they often can’t.  Not every medical negligence case gets the media attention that Joan Rivers received helping to move it along.  

Sharon Osbourne tells the cheering audience that to make sure this never happens again she would not rest until they all lost their license and she had a “whole chunk of money”. 

Unfortunately,  Ms. Osbourne is leading people to believe that a big chunk of money is what will improve medical care in this country.  It won’t.  When the lawsuit is done and everyone is paid (and attorneys have every right to be paid for their services) what will the change be?  These doctors can go get a license in another state and though this exact behavior may not be the problem, these behaviors can happen again. 

Saturday, January 31, 2015

Making Meatloaf

Can You Really Repeat Back Everything?

During a recent classroom of nurses I was instructing, one of them asked if she is the patient's advocate shouldn't she be able to explain to the patient what the doctor said if the patient doesn't understand?

I gave her the "Meatloaf" lesson I have been working with for years.   "Who here has a wonderful meatloaf recipe" I asked the group.  One hand shot up, so I then asked who wants to go with me for dinner and have meatloaf?  Another hand went up.

I set the stage that the two of us were going to dinner to have meatloaf at Jayne's house and it was so wonderful, I asked Jayne to share the recipe with us.  I would love to make that meatloaf!  Jayne gave us the recipe.  "I use some pork and beef and an egg some seasoning and mix it all together and bake it".

I then asked the other nurses if they can repeat it.  She, nor the rest of the class could get the recipe exactly as it was shared, nor could they remember everything that was said.

So the answer is "no".  If the patient or their helping family member doesn't understand the treating clinicians instructions, diagnosis or information, the advocate is responsible for having the clinician explain it again until the patient understands it.  Too much information can be lost in the explanation.

The teach back method also is important for the same reason.  If the person receiving the meatloaf recipe writes it down, or repeats back what she heard, Jayne can verify that she has the information correct.  If Jayne just asked if we understood, it's too easy to just say "yes" and when we get home, we forgot what the actual recipe is.

Medical errors happen too often because of miscommunication.  An important part of patient safety is understanding each other.  Patients should never feel embarrassed or intimidated when  not understanding what is said, its also hard to remember a meatloaf recipe.