Who Knows What Really Happens?

Hey You,

Hey, you behind the big wooden desk.  Do you really know what goes on at the patient’s bedside?

When I arrived at the emergency room and visited with the billing department at 6:00 in the morning while the patient was brought into the emergency room, I was greeted by two women who were of another culture.  In between my conversation with one of them doing the billing, they spoke their native language to each other.  It probably would not have affected the patient’s care, but were I the patient, it surely would make me feel uneasy as this is my first impression.

A small community hospital, I was glad to be with a patient using a facility that I would probably use for myself.  Though they don’t have all the trauma needs as a much larger hospital just a short distance away, the fact that it is small, staff are known to be “nice” and this wasn’t a trauma case, I was confident all would go well.  No suspense, it did go well but what I witnessed anyway was still unsettling.

I was asked to sign that I received an admission packet, advanced directives and about 10 items on the list.  When I questioned that we received none of that, the woman handed me a Patient’s Rights manual and explained that everything else on the list is only for Medicare patients.  I wrote “not received / for Medicare only” and signed the bottom information of the form.  It was my impression that the woman handing me the forms to sign may have never read what I was signing.

When I arrived at the patient’s bedside, the nurse treating the patient  was using the light on her phone to check the patient’s throat.  When I commented on this she smiled as she threw her long hair back behind her shoulders and then ran her hands through her hair.

The area between patients was very close.  I can hear what was happening next to us but until the curtain was pulled back could not see.  I do know that next to us was a patient who was preparing to leave.  When she did leave, the curtain was fully pulled back.  The nurse pulled off all the bedding, lifted a nearby bin with her hand and placed the bedding in there.  She then threw over the bed the clean sheets, tied them in the back put a folded blanket on the bed and put equipment out -probably for an IV.  She straightened the bed table and walked away to escort a new patient to another bed, also close by. 

The bed was not washed, the rails were not wiped and the tray table was not cleaned.

I then watched as another nurse pulled bedding off another bed, discarded it and went behind the curtain with another patient.  A pattern I soon realized was quit disheartening.

Still in plain view I watched the nurse go about her duties, never to wash her hands.   I noticed that two sinks on our side of  the room, one right next to me, were dry.   In the short time I was there, they were never used.  As the new patient finished changing into a gown, the same nurse put on gloves, opened the wrapper for the IV and tied off the woman’s arm but before she started the IV she lifted off an IV obviously left from the last patient, opened a bin (I assume this was the garbage) using her foot and hand and dropped it in.  Same gloves, she went back pulled the curtain open and started the IV.

When my patient was ready to leave and was to get a shot, the nurse explained that it will hurt for the day and gave him a shot in the arm that he needed to work with.  She said “I hope you’re not right handed, I should have asked”. She giggled and walked away.

These may not be life threatening conditions.  This may even sound minor, silly or not worth discussing, but it only takes a small amount of germs to cause an infection.  It only takes a small amount of carelessness to start bigger problems and it takes one person to set an example for others.  When one, two or three people in an emergency department let their guard down, we are in for bigger problems.  I'm not sure that the people who are in the corporate offices, make the policies, write the checks and go to the patient safety conferences even know how to start watching for this breach of conduct.   I’m not sure I would feel safe there, and now I don’t know where I would go.

Kate Middleton's Privacy

Royal Privacy

 



King Edward VII's Hospital

Kate Middleton, Duchess of Cambridge becomes pregnant.  The complications from her pregnancy land her in King Edward VII Hospital in London where she is suffering from severe morning sickness.   DJ’s  Mel Greig and Michael Christian from an Australian radio show call the hospital pretending to be Queen Elizabeth and Prince Charles.  They ask the nurse who answers the phone, as a prank for the radio station, if they can speak to Kate. A nurse, Jacintha Saldanha patches them through.

 

Another nurse, who has not yet been identified picks up the call and offers information about Kate’s condition.  Not realizing this is a prank, this nurse tells the DJ’s detailed information about Kate Middleton’s condition, on tape for all the listeners to hear.

Three days later, after most of the world heard the phone call on the news, Jacintha Saldanha, a nurse at that hospital for four years, and the mother of two teens is found dead from an apparent suicide.

Could this have happened here, in the United States?  Aren’t we “protected” by HIPAA so this information would / should never get out?  What did this nurse who answered the phone, or the nurse who gave out the information but didn’t kill herself actually do wrong?

The hospital policy, as one article wrote “forbids employees to patch phone calls through to the ward”.  This is the only place Saldanha committed any wrong doing.  The nurse, who gave out the information to the DJ’s may have gone a bit overboard in the details, but there too committed no offense. 

The privacy we may expect as a patient in the hospital is our right to ask that information not be shared with family or friends. If that request is not made, there is no public policy in place that protects patients from having a family member get information from the doctor or nurse about our condition, were we the patient.  Healthcare workers usually do not freely give out personal information over the phone to callers to protect the patient’s privacy or because it can get to time consuming to share details with everyone who might call.  But, the HIPAA laws do not protect us from that conversation – although over and over again, medical professionals use HIPAA as the reason they won’t share information about a patient with family or friends.

The nurse who did give out the details may be reprimanded for not using better judgment and Saldanha may have broken the rule about passing on a phone call.  But the only tragedy here is that a woman (that I know nothing else about) took her own life instead of apologizing and now her children don’t have their mother.

I hope that this will be used as an opportunity for people to decide now who you want to have your information were you to be hospitalized.  Who will be your advocate or support person and have that conversation with them about your expectations were you to be suddenly incapacitated.   Were Kate Middleton to have a patient advocate at her bedside, or helping her husband, Prince William know their rights to privacy, there is always a chance the outcome may have been very different.

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Registration is now open for Long Island Family Centered Patient Advocacy Training, Registration

See the following links for more information about HIPAA:

LI Patient Safety Advisory Council Information

HIPAA: Everything You Want to Know about Patient Privacy but Are Afraid to Ask! US Department Health and Human Services For Consumers HIPAA Video 

PPAI 2nd Annual Conference

Professional Patient Advocate Institute

I just spent two days in Orlando at the second annual Professional Patient Advocate InstituteConference.  Day one consisted of a certificate program.  The training covered legal issues, hospital visits, billing and reimbursements, direct services, a business plan, marketing and family support.

You wouldn’t go to court without a lawyer someone said, so why enter the healthcare system without an advocate?

According to the PPAI, some facts to justify the need for a patient advocate; 52 million caregivers provide care to adults ages 18 and up with a disability or illness.   26% of employed adult children take care of a family member and the annual loss to American businesses due to caring for aging parents is $3 trillion.

Presently we are in the early stages of professional patient advocacy services.  This service is not regulated so we are in a unique position to begin preparing for what an advocate needs to do and how they could / should be helping a patient.  Whether it is billing or reimbursement, medication management or doctors visits, at the bedside in the hospital or understanding a care plan, patient advocates can play an important role in the future of healthcare. 

Many nurses are becoming advocates because the time spent at the bedside in nursing is diminishing and nursing no longer allows enough time for patient interaction.

The cost for an advocate can vary from a very high daily rate or a retainer to an hourly rate decided by predicting the needed services.

Another way to encourage advocacy is the way PULSE of NY teaches the family and friend of the patient.  This community based teaching is called Family Centered Patient Advocacy Services.  It focuses on the families need to participate.  This way, there is no charge and the people who know the patient best, want to help and be part of the support system are there for the patient with the needed tools learned at one of the half day workshops.

Day two at the conference focused on guest presenters starting with Trisha Torrey as the keynote.  Trisha started Every Patients Advocate a number of years ago following her own unfortunate experience using the healthcare system. 

Lisa Freeman, the PULSE ofNY contest winner attended her first contest with the professional scholarship of $500.00.  Lisa took a Family CenteredPatient Advocacy Training on February 7, 2012 which made her eligible to apply for the scholarship.

Consider becoming a family centered patient advocate and learn about patient safety.  The charge to take this program is minimal and the lessons will last a lifetime.

Register here for the January 12, 2013 training.  Family Centered Patient Advocate Training Registration.  

Hospital Ratings

Leapfrog Group Hospital Ratings

A recent report from the Leapfrog Group has rated hospitals across the country. The Leapfrog Group is an independent, national not-for-profit organization of employer purchasers of health care. The Leapfrog Group is a voluntary program aimed at mobilizing employer purchasing power to alert America’s health industry about health care safety, quality and customer value.

An A, B, C, D, or F score assigned to a hospital based on expert analysis of infections, injuries, and medical and medication errors that cause harm or death during a hospital stay—looked closely at how safe hospitals are for patients.

Locally, on Long Island, 5 hospitals scored an A and now have bragging rights to being the “safest” hospitals on Long Island, in New York and maybe in the country. 

One of these hospitals was reported by another group last spring as one of the worst hospitals in patient safety while at the same time winning an award for Excellence in Patient Safety from yet another group.

The CEO of a Midwestern hospital that scored low expressed reservations about how the Leapfrog Group compiles and validates the data it uses to compile scores.

A well known California hospital disputes their F score because they say one patient death in 2010 unfairly lowered its grade from a C to an F.

The senior vice president for a 101-year-old hospital, says he "patently disagrees" with his hospital's F grade, saying that's not reflected in current federally reported data.  "Much of what Leapfrog is using is three or four years old," he says, "and is based on some proprietary methodology, capriciously assigning adverse grades to someone."

Hospitals across the country scoring an A have a very different outlook. They boast to their commitment to patient’s safety, quality care and committed staff.

Years ago I went to a meeting and on the plane I read a magazine listing top hospitals.  I didn’t see a hospital that I knew was always winning awards.  When I saw a top administrator from this hospital, I mentioned that his hospital wasn’t listed.  He grabbed the magazine from my hands and sat in a corner reading it.  Upon his return just minutes later, he shared that this magazine is trash and their scoring doesn’t mean a thing.

Using these rating tools, whether it’s about your local hospital or physician, patient safety and quality care is a two way street and by being vigilant as patients or family members we can help control the outcomes.  Going into a hospital with an F rating might even keep you on guard and with good reason.  Ratings are a tool.  I know of too many people who were injured or died in “the best” hospitals.

What's the Plan?

Getting the Plan

He is a very, very large man.  He is not warm and fuzzy but instead outspoken and assertive.  He is disabled with the loss of one leg following a horrible accident almost ten years ago.

He was found in his home, during Hurricane Sandy in water neck high when his electronic wheelchair stopped working.  He yelled for his girlfriend to get to higher ground with their dog.  He waited there until he was rescued.  His rescuers brought him to a local hospital.  His girlfriend is still in a shelter with no place to go waiting for some help and direction.  Their beloved dog has been left to be cared for by others.

He met me, on this visit, in the lobby of the hospital in a new loaned electric wheelchair that he used to scoot around the hospital lobby.  While sitting and talking with him, he shared that his “good leg” was in a lot of pain but he wasn’t getting his pain medication.  When I looked down, I waited for him to remove his sock but soon realized it wasn’t a sock at all but his leg was turning dark purple or even black.

“What have they done for this” I asked him.  “Nothing” he told me.  He said he told someone about it two days ago but still no one has done anything about it.  I brought him in his wheelchair to the nurse’s station and asked for someone in charge.  The nurse told me she was in charge and would call the doctor to meet us in his room.

I asked the man who came in if he was the attending.  He told me he was a resident.  “What year” I asked.  “First year” he said.

I asked him to look at the patient’s leg and let him know what will be done about it. As the first year resident put his hand out to touch the elevated leg, I stopped him and said “please wash your hands before touching him”.  He complied and then took gloves and looked at the leg.  He said he didn’t know what the problem was.  I insisted he find out.  “Is there anyone who would know?  A vascular doctor, the attending, someone has to know before I leave what the plan is to treat this?”   The young man avoided eye contact with me but kept looking at the leg.  When the silence went on too long I asked him, “If this was your father, brother or child, would this be ok?”  I kept reminding him we need a plan of care but the resident tried to talk about the patients discharge and going to rehab.  He said this is where they would be able to treat this better.

I would not let him change the subject and told the resident that we are not discussing rehab right now, there is a problem right now that needs addressing and I can’t leave until I and the patient know the plan.

The resident said he would find someone with an answer and left.

He returned a few minutes later and explained that his leg needs to be elevated. “Now that’s a plan” I said.  I asked the patient if he understands that and asked what he will do?  “I can’t keep it up 24/7” he said.  The conversation was now between the doctor and patient.  The dark color was already fading.

Improve Diagnosis in Medicine.

Diagnostic Errors in Medicine; We’re talking about it now!

We now have something else to talk to patients about when it comes to medical errors.  Diagnostic errors.

I had the privilege this week to speak at Diagnostic Errors in Medicine (DEM) Conference at Johns Hopkins University, Baltimore.  There was a new group launched called Society to Improve Diagnosis in Medicine.  Their mission; We envision a world where diagnosis is accurate, timely, and efficient.

I took this from their website; “Diagnostic error, defined as wrong, missed or delayed medical diagnosis, occurs in 10-15% of cases, leading to immeasurable harm and billions in inappropriate medical costs. These errors are also the largest contributor to total medical malpractice payments”

So what can we learn from this?  The conference leaders brought in many different speakers who have experienced diagnostic errors as well as medical professionals willing to talk about them.  We learned from the patient’s perspective that the doctor isn’t always right.  For hundreds of years we have been asking the doctor what’s wrong and we expect the answer and the treatment to make us well again.  We are now learning (I have known this but now the docs have let the information out) that we should probably be asking the doctors his / her advise and then we make a sound judgment , after gathering all the facts on what needs to be done.  

I spoke about communication and how body language plays a big role in our sharing, or not sharing of information.  If we don’t feel comfortable sharing, we may forget to tell the doctor something to help with the diagnosis.  Do we understand the explanation about our treatment?  Maybe not.  It is not low literacy as someone insisted to me. It is poor communication, usually on the clinician’s part.

One researcher insisted that she can tell who patients are with low literacy because of how they struggle to put sentences together.  I suggested that many people with low literacy have a very sophisticated vocabulary and have used that as a tool to cover their lack of reading skills.

Many people have heard about a misdiagnosis.  It can be a stomach ache that was actually an enlarged appendix that burst, or a deadly ectopic pregnancy where the doctor tells the patient to take an antacid.  A patient who has a misdiagnosis that a painful infection is a rash or being told that there is (or isn’t) cancer when the tests, which went unread, or were misplaced were the basis for lack of communication.

Rory Staunton’s dad was there talking about his son’s misdiagnosis of an infection.  Rory was in deep pain following a scratch at gym during school.  At  a New York hospital they didn’t wait for the lab results to come back showing he was compromised and soon after Rory died from an undiagnosed infection that got into his blood stream.

It’s easy after the fact to say what the family should have done but we, the patient don’t always know that doctors make mistakes.  It’s up to each one of us to now know that.

The following morning after Mr. Straunton spoke about his son, he sat with me at breakfast and told me some of his real feelings that he has as a dad.  He used the words that I remembered using so well when my own son died years ago.  It wasn’t only that his son died that is so painful but Rory died because his parents trusted the doctors to care for their child.  That trust makes it much more painful.  Ciaran Staunton shared stories about how wonderful his son was.  How smart he was and caring he was about others.  Rory, like many advocates can change the world.  Sadly, he just won’t be here to see it.

Assessing the Pain

Pain Meds for You

I walked into the patient’s room and his adult children stood around his bed concerned about his pain after surgery.  He was still in a lot of pain days later, but told us he didn’t know what the nurses thought was a lot of pain when they asked him how he was feeling.  He just kept saying he was OK figuring that’s what they wanted to hear.

I asked the nurse about him getting medication.  I knew she was busy with other things but thought it was important that she knew he was not wanting to complain but was still hurting.  The nurse agreed and went about her work.  I waited a reasonable amount of time and when she didn’t come, I went back to her desk.  She was still at her desk doing paperwork.  I now asked her “when you assessed his pain on a scale of zero to ten, what number did he give you?”  The nurse looked at her papers, looked at me and jumped to her feet.  Obviously realizing that she, nor anyone else had properly or appropriately assessed his pain, within 3 minutes she was in his room asking about his pain and distributing his pain medication.

Should We Close Down a Hospital?

Close Down a Hospital For Unsafe Care; Is that the Answer?

I spoke at a large group of about 100 retired professionals this week. The topic was Patient Safety and I covered the usual falls, infections, literacy, surgery and medication safety. We touched on advanced directives, generic brand medications and communication. Following the presentation I was met with a flurry of compliments from people about how informative it was.

A woman came up to me and asked privately “how do we have a hospital closed down?” I asked her why, and she said it was a terrible hospital. She wasn’t giving me specifics but pressured her to think about her comment, “why would you want a hospital to close and not improve?”

I finally got her to tell me that they released someone from the hospital who was not ready to leave. Her anger and frustration was apparent and I suggested that we can meet with the hospital administration to share what she witnessed. 

It isn't unusual that in the helplessness of caring for someone we love and feeling that we are not being heard, a family member gets angry at the situation and takes it out on the entire establishment that they trusted. 

I have learned to recognize that when someone is treated poorly or there is an injury or death of a patient, their loved one's want to punish the place that caused them grief.  They don't see that in the next house there is a family who survived the care, and may be alive today because of that facility.  So, as a society, how do we improve on the "little" things that may have been an injury or caused a death to a patient before it becomes a tragedy?

If that women never acted on what she witnessed by reaching out to the hospital, and I can't because we haven't met to talk more about it, then there is a tragedy waiting to happen that can cost the life of a patient.  Closing the hospital may not be the answer but starting a conversation with that hospital might very well save a life.

 

Patient Safety or Mystery Shopper?

Patient Safety Observer

I have been called a “mystery shopper” of hospitals. I don't think that's what I do.   I like to be called in to the hospital to visit a patient by the family or the patient themselves.  I usually get the call because the patient doesn't know who is in charge of their care, aren't getting their needs met or feel that the care they are receiving is substandard.   That call gives me a reason to go into the hospital and see some of the problems that may cause unsafe care to a patient.  I don’t make the trip if it can be handled over the phone, but sometimes I just can’t get someone in administration to help and the bedside staff are just too busy.  In that case, I will go to the hospital.

When walking through the halls I will observe things like a cluttered hallway, overflowing garbage pails and empty hand sanitizer holders.  I will see if medication carts are unattended and listen for staff who are loud and un-attentive.  I will even look to see if there are any patient safety brochures or posters.  If you have read past posts you know that I will watch how the cleaning crew washes the bathrooms and if they touch items in the room with soiled gloves.

I don’t do this to get people in trouble.  Goodness knows the staff work hard, but if there is a discomfort to me about being in this facility, someone, with the power to make changes needs to know about it. 

The problem is the response I get when I write.  Some places answer immediately and ask for help and input.  Some leave the impression that I was seeing things and many others (most) hospitals don’t respond at all.

The letter sent out explains that it is for informational purposes only.  There is no official report going out to any of the places we are to file a complaint like the Department of Health or The Joint Commission or the news .  I am not looking for a pretty atmosphere but I do look at patient’s safety. Accessible   information, courtesy and comfort will bring a patient back in the future.  Early intervention is also safety.  A patient who feels chest pains but won’t go back to the hospital because it was dirty, they felt the people were rude or they didn’t feel welcome is, in fact a patient safety problem and should be addressed.

Personally, I don’t need to know how things are changed, or even if they are.  I’m pretty confident I will be back again to see for myself.

Designated............

The DMM
I jokingly asked my friend at her birthday party if she was able to drive home.  She looked at me with her droopy eyes and sleepy smile and said “sure, but you can drive if you want”.  Together, we had already planned that I was her designated driver and prearranged for a mutual friend to drive her car home.  At the time we made these plans, she was not drinking and she was thinking straight.  I have no doubt that if the plans were not previously made she wouldn’t want to “bother” me and may have insisted on driving.

A few days later I visited someone on pain killers for a shoulder injury.  His wife commented on how medicated he was and how he was not thinking straight.  I wondered how he might be when the time was to stop taking the pain pills.  Would he even bother stopping?  It was a chronic condition he had, after all.

I thought it would be a good idea if before he went on the pain medication, he and his wife made a decision that not unlike a designated driver, she would start to have some control over his pain medication or planning the pain management.  If the pain pills are working, and he feels in control, even if he isn’t, it is understandable why someone wouldn’t want to take the chance of being in pain all over again, unless of course there is a Designated Medication Manager in the home. 

The conversation may not be pleasant but at least it will not be a surprise when the DMM starts the conversation about getting off or reducing the amount of the pain killers a patient is taking .