By Ctd 2005, via Flickr

I’ve begun volunteering at a local free clinic. While it’s been rewarding and satisfying, it’s also been fraught with challenges I didn’t expect; I’ve only worked in an ICU, and the assessment skills specific to critical care don’t translate smoothly to the clinic setting. I’m out of my professional comfort zone, and I feel so inexperienced.

Here’s what I’m used to: By the time a patient is admitted to the ICU, they’ve already been “worked up” in the emergency room. Physicians have been assigned and a preliminary diagnosis is in place. The patients are connected to equipment that displays their vital data continuously, on monitors I can see from almost anywhere, and alarms are triggered by any alterations. I’ve got easy access to radiology reports and films, laboratory values, and microbiology reports. The nursing physical assessment is thorough and paramount; I know what I’m looking for, what I’m listening and feeling for, what certain smells indicate, and I trust my instincts. I’m accustomed to not only the forced intimacy that comes with the in-depth physical assessments of critical care, but the technology and data that supplement my assessments, as well.

At the clinic my nursing role is quite different. I sit at a desk. I am to determine the reason for each patient’s visit and take their vital signs. I ask how they’ve been and what’s changed since their last visit.

One gentleman, when I ask what medications he takes at home, fishes in his pocket and drops pills wrapped in toilet paper on the desk that separates us. I sit across from him, considering how to proceed, itching to take his hand and slide my fingers along his wrist to feel the pulse of his radial artery. I wonder about his breath sounds, what his feet look like, whether I’d be able start an IV on him, and what I’m missing. There are no same-day diagnostic reports to refer to and no dictated medical histories. All I have is the snapshot capture of his vital signs and what he wants me to know.

I’m used to knowing my patients from the inside, out. Here in the clinic, I hardly even touch anyone. I feel blind.

These are the challenges I’ve found: to create a picture of my patient with limited information and subtle clues;  to listen to what someone tells me, hear what they don’t say, and know what to ask; and finally, to not lose my vision because I miss my familiar tools, but instead find a different way to see.

By Shawn Kennedy,

When I had a recent medical emergency, I went to the local community hospital near my home in northern New Jersey. I had been there before for outpatient testing or to the ER with a child and found the care attentive and efficient and the staff friendly and professional. Besides, it was a Magnet-designated hospital, so I was confident that I’d receive good care.

The ancillary staff was wonderful, but I found myself disappointed with the nurses on the acute med/surg unit where I was located. There was no rounding that I was aware of, and they seemed to only show up when it was time to administer meds. Only a few nurses introduced themselves, and only two nurses over three days really engaged me in any conversation. Nurses seemed to respond to call lights only for those patients to whom they were assigned. The unit clerk who promptly answered the call light intercom would say, “I’ll let your nurse know and she’ll be in soon”—when I asked for pain medication, she told me “your nurse is giving report; I’ll let her know when she’s finished.” I waited uncomfortably for more than half an hour.

There were whiteboards, but often the information—especially regarding the date and the name of the nurse—was unchanged from day to day and no longer accurate. (This was annoying, in that they kept asking me what date it was and I kept getting it wrong!)

The worst, though, was the noise level at night. I’ve worked nights, and I know it’s easy to forget to keep conversations hushed. But this unit was a good example of those that are as “noisy as chainsaws” (see our recent post on this). I was two doors down from the nurses’ station and I could hear every conversation, people singing holiday carols, detailed discussions of patients (forget HIPAA!). Requests that they reduce the noise made no difference. One night, I learned every detail about one nurse’s vacation plans while she and a colleague spoke in normal, conversational tones, occasionally laughing, while providing care to the elderly woman in the bed next to me at 2:30 am.

When I asked if they could speak a bit more quietly, one of the nurses angrily pulled back the curtain and told me that I had to understand that they needed to take care of the woman and would be done shortly. She then resumed talking about her vacation. I barely slept at all the three days I was there. It was exhausting, and I was happy to get home.

A few days later, I was admitted to a large teaching medical center in Manhattan, where I stayed for 10 days. The contrast was startling. The ICU nurses were incredibly attentive and supportive; they made me and my family feel that I was safe and in excellent hands. On the med/surg unit, the nurse manager introduced herself when I arrived. My assigned nurse for each shift would introduce herself and ask me if I needed anything; she came by frequently, even if only to poke her head in the room and say, “Everything OK?” Nursing assistants likewise introduced themselves and would inquire if I needed anything.

Yes, one or two nurses seemed to wish they were elsewhere, but by and large, the nurses at this hospital were engaged and patient focused. I saw and felt the presence of nurses at all times, and it made me feel safe. And blessedly, noise levels were low. This facility, while not designated a Magnet hospital, clearly held their nurses to a high standard of practice comparable to Magnet principles. (This is why we must be careful in comparing outcomes from “Magnet” versus “non-Magnet” facilities.)

Perhaps the unit I was on in the local community hospital had a poor nurse manager and didn’t hold staff accountable to a high standard of care. I wonder if the nurse manager there ever made rounds to see how patients were faring, or asked patients if they knew who their nurses were. I never saw him or her.

I want to be clear that I support the Magnet program, but appraisers—and nurse executives and managers at Magnet-designated facilities—must be vigilant in assuring that their organizations do not become complacent once they have achieved Magnet designation. Otherwise, it will have no meaning.

From its earliest beginnings, nursing has embraced a holistic view of health. What we eat, the environments in which we work and live, our social relationships—all these influence health. Yet, as nurses, many of us shy away from looking at the big picture; instead we narrow our focus, addressing only the immediate problems of this patient, this family. It’s true that many patients treated in hospitals or outpatient clinics are there only for a short time. But how will such patients and their families fare in the long run if they lack access to public transportation to get to their follow-up appointments? How can patients recover from illness when they must choose between paying the mortgage and filling prescriptions?

That’s an excerpt from “Voices Rising,” the editorial in the January issue of AJN by Shawn Kennedy, editor-in-chief. We hope you’ll take a moment to read the whole thing and give it some thought.

Also in the January issue, you’ll find plenty of reading suggestions in the AJN 2011 Book of the Year Awards; a CE on the causes, diagnosis, and management of hypothermia; and a great deal more, including a feature, “Cardiac Catheterization Through the Radial Artery,” that advocates the use of the transradial artery rather than the femoral artery for cardiac catheterization in certain situations.—JM, senior editor

By ArtsieApsie, via Flickr

Fierce Healthcare reports this week on the latest findings about hospital room noise: ”hospital rooms can be as noisy as chainsaws, according to a new study [subscription required] published this week in the Archives of Internal Medicine….The average noise level in patient rooms was close to 50 decibels….The noise disruptions mostly come from staff conversation, roommates, alarms, intercoms and pagers….Loud hospital rooms are associated with clinically significant sleep loss among patients and even may hinder recovery.”

So, nurses (and patients, MDs, others): can anything be done about this? Does your hospital do anything? Take our poll, and also of course feel free to leave a comment on this post.—JM, senior editor

Take Our Poll

I read with interest the article “Central Venous Pressure Monitoring: Where’s the Evidence?” (purchase required for nonsubscribers) in the January issue of AJN. It’s part of a series called Critical Analysis, Critical Care, which will appraise the evidence regarding common critical care practices. So much of what we do in nursing is not based on evidence but on how we have always done things in practice—or on research that was not credible.

This article looks at the evidence supporting the use of central venous pressure (CVP) monitoring alone to guide treatment decisions for patients. According to the article, a 2008 systematic review by Marik and colleagues concluded that CVP is not an accurate indicator of intravascular volume, nor is it an accurate predictor of fluid responsiveness (whether a patient will respond to a fluid bolus with an increase in stroke volume). The authors of the AJN article critically appraised the evidence and determined the following:

• The relationship between intravascular volume and CVP is a weak relationship and clinicians should not use CVP to estimate a patient’s intravascular volume.
• The absolute CVP value or a change in CVP should not be used to predict a change in the stroke volume or cardiac index.
• There is not an absolute CVP value that can be used to determine what the next step of treatment should be, be it a fluid bolus or the use of a vasoactive medication.

In brief, the evidence tells us that we can’t base treatment decisions on just one hemodynamic indice. The clinician needs to look at the entire hemodynamic picture, including, for example, heart rate, blood pressure, mean arterial pressure, and urine output, when determining the best treatment option for the patient.

References
Kupchik, N. & Bridges, E., 2012. Central venous pressure monitoring: what’s the evidence? American Journal of Nursing. 112 (1).

Marik, P. et al. 2008. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 134(1).

Diabetes everywhere. There’s an entire Health Affairs issue devoted to the topic of “Confronting the Growing Diabetes Crisis.” It looks at many interrelated issues, such as the personal financial burden of having diabetes over the course of a lifetime, whether it’s best to put scarce health care resources into focusing on prevention or treatment, models for community-based lifestyle programs for those with type 2 diabetes, the positive effects of the Affordable Care Act on giving those with diabetes access to affordable health insurance and crucial care, genetic factors related to type 2 diabetes, and a great deal more. Inevitably, many of the articles focus on type 2 diabetes, which is so closely linked to America’s obesity epidemic.

by Jorge Barrios, via Wikimedia

Joint studies. The New York Times reported this week on a large government study showing that, whatever one believes about marijuana’s psychological effects or the efficacy of its various medical uses, long-term marijuana smoking—at least one joint per day, every day of the year—does not impair lung function or contribute to the development of COPD. Will this change anyone’s mind about whether this drug is evil, a panacea for all ills, or somewhere in between? Probably not.

Unreported harm. The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services issued a report last week stating that only 14% of medical errors and other events that harm Medicare patients were reported by hospital employees. The report calls for improving reporting systems and the creation of a list of ”potentially reportable events.” According to the New York Times story on the topic, adverse events that have gone unreported include ”medication errors, severe bedsores, infections that patients acquire in hospitals, delirium resulting from overuse of painkillers and excessive bleeding linked to improper use of blood thinners.”

Which leads us (or does it?) into nursing blogs. Many of the ones in our blogroll have been pretty silent in the past few months, or longer, and it’s not clear why. Some bloggers are taking a break, some have burned out or decided to use their time for other things (like going back to school), some have simply decided to spend more time on Facebook or sharing their thoughts by ’microblogging’ on Twitter (or are simply playing lots of Words With Friends on their smartphones). There are almost certainly many interesting new nursing blogs we don’t yet know about that are taking their places. If you know about them, please let us know. We need to take some time and do some digging. And we plan on doing a serious revision of the blogroll in the next few weeks.—JM, senior editor  

It happened back in 1976, but I still remember the sound of the distant ambulance. Why was I lying in the grass and the weeds? Hadn’t I been in the car, driving home from the Visiting Nurse Association along the country road?

So begins the January Reflections essay, “Nurses Know.” By Lois Gerber, it’s one patient’s vivid story of the many crucial roles that nurses played in her care—and it’s free, so have a look and let us know what you think. For those of you who write or who think you have a strong story to tell about nurses, nursing, or some aspect of health care, Reflections submission guidelines can be found here.—JM, senior editor/blog editor

Photo by Jasleen Kaur, via Flickr

Advances in health technology can save patients’ lives, but can also cause harm, as the recent Ecri Institute report, Top 10 Technology Hazards for 2012, reminds us. Here’s a snapshot of the hazards nurses should be focusing on, and some suggestions they give on how to prevent them.

1. Alarm hazards
The risk: With nurses being constantly bombarded by bells, it’s easy to see how alarm fatigue can set in, leading to desensitization, nurses being unable to distinguish the urgency level of alarms, and improper alarm adjusting.

Some suggestions: According to the report, a facility should look at the big picture, examining the entire alarm environment when setting up an alarm-management system. Alarm notification and response protocols should be developed to ensure that each alarm will be recognized, that the appropriate caregiver will be notified, and that the alarm will be promptly addressed. Policies should also be established to control alarm silencing, modification, and disabling.

2. Radiation exposure
The risk: High levels of radiation used during radiation therapy can cause serious harm if errors occur, including damage to normal tissue and organs. And despite radiation levels being lower in diagnostic settings, the increasing number of patients undergoing diagnostic radiography may reveal more risks in the future.

Some suggestions: The report suggests that adequate staffing levels may be a place to start. For radiation therapy, standard checklists should be developed for each step of patient treatment, and standard patient treatment procedures should be documented and followed. For CT scanning, radiation doses used should be as low as reasonably achievable while maintaining acceptable image quality.

3. Medication errors using infusion pumps
The risk: Mistakes such as mistyping data or entering it into the wrong field can have major adverse effects, including death. The use of “smart” pumps has helped, but preventable errors—such as misprogramming—can still occur.

Some suggestions: The report suggests hospitals should develop appropriate drug libraries for clinical areas that use infusion pumps, with standardized concentrations of drugs and solutions. Facilities should also get “buy-in” from staff members who will be using the system before and during purchasing of the system. Infusion pump technology safeguards should be emphasized, and noncompliance with safety systems should be addressed immediately. For more on smart pumps, read the CE feature “Increasing the Use of ‘Smart’ Pump Drug Libraries by Nurses: A Continuous Quality Improvement Project,” in AJN’s January issue (link pending in next day).

4. Needlestick and other sharps injuries
The risk: Exposure to bloodborne pathogens such as hepatitis B virus, hepatitis C virus, and HIV.

Some suggestions: Facilities are recommended to assess injuries and current practices to determine where and when these injuries occur most often. Using the data, an action plan should be developed and implemented. Some aspects of the plan could be ensuring adequate training of personnel and obtaining supplier support for in-service training on the use of protective devices.

5. Enteral feeding misconnections
The risk: Misconnection incidents can result in nutrients intended for the GI tract to end up elsewhere—potentially resulting in death by embolus or sepsis.

Some suggestions: The report suggests using enteral pumps for enteral feeding whenever possible. It also warns against using a standard Luer syringe for oral medications or enteral feedings and against modifying or adapting IV or feeding devices. Feeding tubes and connectors could be color-coded and labelled. Lines should also be traced from end to end when making an initial connection and any time there is a reconnection. Look for our upcoming February CE feature, “Bedside Assessment of Enteral Tube Placement: Aligning Practice with Evidence,” for more.

Other hazards that topped this year’s list include cross-contamination from flexible endoscopes, inattention to change management for medical device connectivity, surgical fires, anesthesia hazards due to incomplete pre-use inspection, and poor usability of home-use medical devices. Click here to request a copy of the full report.—Amy M. Collins, associate editor

by patchy patch, via flickr

I first met Ella (name and some details have been changed) when she was my patient in the intensive care unit. She’d been riding in a car she wasn’t supposed to be riding in, heading to a party she wasn’t supposed to be going to, high on drugs and not wearing a seatbelt when she was involved in a high-speed crash that left her with broken bones and internal injuries. She was in the ICU for more than a month.

Her situation wasn’t that remarkable. Ella could easily represent a common category of ICU admissions—the young adult who is often described by her parents as a “good girl,” yet who lives wildly, fearless and flip, taking risks as if consequences will never apply. I feel particularly protective of these patients, mostly because I relate to them, on some level. I remember the sense of invincibility that came with youth, and when I’m caring for these girls I often marvel at consequences I avoided in my own life. I shake my head at my younger self, alternating between feeling extraordinarily blessed and very lucky. I’m not sure the risks I’ve taken in life compare—but still, I had no concept of the fragility of life. I certainly didn’t comprehend its worth.

I cared for Ella often and became fond of her. I felt like I knew her, even though she was usually sedated. I fussed over her, when I had the time. “Don’t do drugs,” I whispered in her ear as I washed her hair. “Wear your seat belt. Stay away from bad guys!” And also, “You survive this, you can do anything!”

She slowly got better and was moved to the step-down floor. A few weeks later I ran into her mom in the cafeteria. She told me Ella was doing great, that she was walking with physical therapy and talking. She encouraged me to come and visit her, and so I did.

Ella was on the phone when I stopped by, casually capping her tracheostomy tube with her thumb to keep up her end of an animated conversation. She glanced over at me distractedly as I chatted with her mom. When she finished her call, her mom introduced us. Although Ella was polite, she said she didn’t really remember me; I just seemed vaguely familiar. And it occurred to me, while standing there, that I didn’t really know her, either—just her physiology. Which made meeting her this time feel sort of awkward, at least to me.

I told her she looked great, wished her well, and made a quick exit. Her progress was impressive, yet I found myself feeling removed and a tiny bit deflated. I suppose I expected that I would see in her some sense of relief in escaping a tight brush with mortality, some zest born of second chances and redemption—and although I don’t know what I’d thought such reverence would look like, she appeared, and acted, unaffected. She just looked normal.

But I hope she knows, somewhere inside, how amazing she is. I hope she believes she can do great things in life. I hope she heard me, even if she doesn’t remember me.

Photo by James Russo, via Flickr

Less Is Sometimes More
A hopeful trend that’s gained some serious momentum this year—and may be connected to both the recession and some provisions of the Affordable Care Act—is that we’re beginning to question whether we really need quite so many tests and drugs. By ‘we’ I mean researchers, some journalists, some nurses and physicians, and of course patients. The answers aren’t always clear, and there’s plenty of room for disagreement on many such issues, but at least we’re asking the right questions more often, rather than retreating in fear and simply hurling around the word “rationing”:

Who really benefits from prostate and breast cancer screening and who is more likely to be harmed, and why? When are you too young or too old to be likely to benefit from a certain type of screening? When does aggressive care at the end of life cease to make sense? Are we confusing a risk factor with a disease, an association with causation, relative risk with absolute risk?

Does that drug you see relentlessly marketed in advertisements during breaks in the network news actually help you? Which physicians are being paid as consultants in support of various drugs, tests, or treatments, and does this compromise their objectivity? And so on. The latest example of this kind of analysis I’ve stumbled across can be found here: “Disease Creep: How We’re Fooled Into Using More Medicine Than We Need.”

The Many Faces of Nursing
So, that’s one good sign as the year heads toward its close. Another is that nurses are making their voices heard and finding new roles and new ways to use their knowledge and skills as our system begins to slowly transform itself. And they are also blogging and sharing ideas on Twitter, organizing in support of safe staffing and fair wages, getting elected to Congress and assuming major leadership positions in health care organizations, providing essential primary care as nurse practitioners, spearheading quality improvement initiatives, learning new technologies, volunteering in disaster zones, doing exciting new research, providing crucial and compassionate bedside care, advocating for patients, and much more.

This blog will probably be pretty quiet until the New Year. Be well.—JM, AJN senior editor/blog editor