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 . 

Nothing By Mouth

Health Literacy 101

When I went to see the patient before her surgery she said "Don't get too close, I haven't brushed my teath."  I asked her why and she said "Because they said nothing by mouth".

Working Together for the Sake of the Patient

Homeless Not Helpless
The call came in that a patient who is hospitalized was getting discharged too soon.  He was still very weak, unable to walk and had no place to go.  His Medicaid payments, the caller explained was about to run out and he had no family to help him.  The caller was contacted by a family member of the patient.  Not knowing how to help, the caller called PULSE of NY.

My first reaction was ‘How could they?’  But I know, after all these years that there are always two sides to hear. In this case it will be three.  When I called the patient, I found out his family wasn’t supportive, he didn’t know which doctor was in charge since there were numerous problems and he was homeless.  Hospitalized for many weeks, with many problems, he couldn’t focus on what the professionals were telling him. 

I decided to pay a visit and invited the nurse into the patient’s room to talk in front of him about his concerns.  I noticed there was no nurses name on the patient’s white board and was careful to say to the nurse’s aide, “there is no name, can you tell me who the nurse is?”  I then asked the nurse to call the social worker in to see us.  The social worker tried to get us to leave the patient’s room (the patient had an infection and we were “gowned up”) but I suggested that we stay and talk in front of him.

He was homeless but the hospital would pay his cab fare the social worker said, to get him to a friend, family or a shelter.  He hadn’t yet called all his friends who might help as he led me to believe and if he needs rehab, the social worker explained that there are shelters now set up to take homeless people who need special services.

The patient, obviously in need of company and companionship was hesitant to let me go but I was confident that there was a system in place to care for him and the hospital staff knows about it and is willing to help.

Put Ice ON it

I Don't Get It

So I get my shot and I ask the doctor about any side effects.  She tells me it may swell and get red but ice and Motrin will help.  It is a bit uncomfortable so I begin sucking on ice cubes and tape a Motrin pill to the area that has swelled.  Just kidding!!!!!

But it’s really not a joke.  Many, many patients don’t get the doctor’s information correctly.  The way this was explained to me may have been confusing to someone who doesn’t know what to do with their directions, can’t read well or speak another language.  In all of our lives we often assume people know what we know.  That comes from using words that aren’t used by everyone or not encouraging someone to reflect back instructions or information.

As a patients advocate we need to be sure we are hearing exactly what the doctor or nurse is telling the patient to do.  Think of ways the information can be jumbled and assume the patient isn’t hearing it because it can get jumbled or they are distracted. 

If I were with an advocate when my doctor gave me instructions to just use ice and Motrin for pain, what are some of the things you could have said to help?

Doctor, can you explain exactly how much ice and how much Motrin?  Can you explain further what to do with the ice and Motrin?

Or

Doctor, how long should we use ice and Motrin or is there another medication we can use?

Ask the patient to explain what she will do.  “Ilene, what will you do with the ice and Motrin?” The response should be in front of the doctor so when I say I will suck on the ice, the doctor knows additional explanation is needed.

Thanks for reading!

One and Only

Safe Injections

I went to get a vaccination today and as the woman came into the room with a needle, wrapped in cellophane and a vial in her other hand,  I asked her, will you be reusing a syringe or the vial?

“This?” she asked as she held up a small glass container that looked about the size of a thimble.  “There is only one dose in here”.  She told me that some medications have more than one dose but in this case,  it is a single dose and then will be thrown out.  She asked me why I was asking.

Disposable Needle and Syringe

 “I just attended a program on safe injection and learned about one needle and one syringe.”  I told her I was curious if she ever heard of that.  She hadn’t, but showed me the whole needle and syringe gets thrown out after it’s used. She displayed the packaging  that she just opened to retrieve a new, unused needle and syringe.   I was grateful for this real time discussion on safe injections.  I could now say I practice what I preach.

I asked if she knew of others who may reuse the syringe or is it pretty standard to use disposables.  She said she didn’t know what others do but was confident that in this doctor's practice only disposable needles and syringes are used.  I felt reassured and just before she walked out the door she said “not only is it unsafe, but to not throw them away is gross”. And she was gone.  I barely felt her giving me the shot.

To learn more about the Safe Injection Campaign, read about it here:  One and Only

NPSF and Patient Safety

Patient Safety from the Top

Next week I will be at the board meeting for the National PatientSafety Foundation.  From there, the NPSF Congress which is a yearly event that attracts patient safety leadership from all throughout the country, and very often other countries.  The NPSF was the first group of almost all medical professionals and hospital administrators who thought the patient’s voice was important to patient’s safety - but also gave us a voice.

About eight survivors of bad medical outcomes like myself gathered in 1999 at an early conference of about 200 people.  They were mostly risk managers and others representing the medical field.  I heard first hand from doctors and hospital administrators who also experienced the loss of family and colleagues at the hands of medical professionals.  Many who were overworked, distracted, didn’t have the right tools or information to do the best for their patients.

I remember learning how it is the system that is at fault, usually not an individual and how systems in healthcare are not built to avoid injury.  Healthcare is often compared to the airline industry and if we looked at the airline industry we could improve. 

For one thing, it doesn’t matter what airline you use, Delta, United, Jet Blue, the safety policy, going into the plane is the same.  We are screened the same and we remove our shoes, belts and laptops.  If there is a problem at Delta, every airline changes policy and learn from the incident.  In hospitals, in most cases the problems are handled internally and repaired.  Flyers are shown safety video’s or are asked to read the safety handout before flying. In hospitals we are lucky to find safety literature in our admission packets when we get home from surgery.

The airlines interview the passengers.  Hospitals have been known to close the doors when patients have questions after a bad outcome.  The pilot dies if there is a crash, doctors don’t.

Since 1996, even before I went to my first patient safety conference I have been teaching the public about patient safety.  What we, as the patient need to know to participate in our care to stay safe.  In the past 15 years much has happened in healthcare and the patient and their families voice is being heard louder and more clearly.  We have a unique opportunity to continue growing on the popularity of patient’s voices.

To learn more about patient safety and how you can be involved vist www.pulseofny.org or call (516) -579-4711

Patient Discharge - What Did You Say?

Speaking Up for the Advocate

I was invited to be at the hospital before the patient went for surgery and was confident I would have time to stay following her surgery.  I knew her husband would be there so it was important that I didn’t try to “replace” him.

My role is to be sure he has his voice as the husband and primary caretaker for the patient when she comes home the same day she has surgery – probably too soon.  When I got there I saw that her body was marked, she had a warm blanket, she was getting antibiotics and they had the patient’s list of allergies and medications.  Everything seemed to be going fine.

I left with the husband, he went to have lunch.  I came back in a couple of hours.  The surgery was successful he told me and his wife was sleeping.  He got to see her following the surgery.  He had no questions.  I thought we waited long enough.  I suggested we go see her and we were greeted by the nurse while the patient  was groggy  in the hospital bed slowly coming to.

“I went over all the discharge information with the patient” the nurse told us.  I asked the husband if he knows the plan.  He shook his head.  “Since the patient slept through your instructions, I suggest you now tell her husband” I told the nurse.  She wasn’t happy but explained the plans to both of us.  It’s no wonder there are so many problems at discharge!