20 05, 2015

What is going on with hand hygiene compliance and healthcare-associated infections?

By | May 20th, 2015|Real Stories|6 Comments

Real Stories from the Streets of Healthcare!

 Martine Ehrenclou, MA, and Beth Boynton, RN, MS

With patients and healthcare professionals all too often on opposite sides of the table, our goal is to bridge that gap. As a patient/patient advocate and registered nurse, Real Stories From the Streets of Healthcare is our way of discussing real stories and issues that involve patients and families, nurses, other healthcare professionals, and the healthcare environment itself.  We plan to look behind the closed door, break down walls of silence, and tackle thorny issues to increase understanding of the complex healthcare problems we all face.  See our welcome page for  more information about our blog duets here.


Blog Duet # 3:  What is going on with hand hygiene compliance and healthcare-associated infections?

Beth

Hand hygiene seems like a simple thing.  It is well documented that following protocols decreases the incidence of healthcare-associated infections (which can be debilitating or life-threatening) and the spread of bacteria that are resistant to antibiotics. In preparing for this duet I did a little research looking for the latest statistics and recommendations about hand hygiene.  There is a lot available online and much of it requires sifting through sophisticated scientific data.  The CDC progress report  indicates significan reductions in many infections with an increase in catheter associated urinary tract infections. There’s even a ~200 page document by the Joint Commission called, “Measuring Hand Hygiene Adherence:  Overcoming the Challenges”!   I even found conflicting or at least confusing  information on CDC recommendations re: alcohol-based handrub versus soap and water handscrub.

Now, I’m not against science or data, please know this.  But as a busy nurse I only want to know what I need to know and I want the infection control people to distill out the essential information and make it available.  In my opinion, we have what we need to know:

  • Research supports association between nurse staffing and healthcare associated infections (HAIs).  http://bit.ly/1A0AiAW

  • Hand Hygiene in hospitals is less than 50 %  (OUCH!) http://1.usa.gov/1A0ALTB

Let’s make sure there is enough staff (try putting a catheter in an obese patient without help or when you are rushing) and focus on behavior and the underlying communication and interpersonal skills that contribute to positive relationships and cultures.  Ironically, even solving the staffing dilemma requires effective communication that ensures nurses (and others) are able to set limits, delegate, and exchange constructive feedback as an ongoing dynamic that is going on all the time.   This is the kind of work that will ensure practitioners remind each other to wash hands and create the psychological safety that will help patients feel comfortable doing the same.

Martine

When I first read your post, I started doing some research with your thoughts in mind. I found studies and articles that support what you wrote. A Medscape article gave this example: a nurse is taking care of a sick patient in the NICU and the baby has an infection. Another emergency arises with another baby and the nurse has to rush to care for that baby and in the process doesn’t have time to wash her/his hands or because of the demands of the emergency.

I also understand about understaffing and time pressures. Ever since I interviewed over a couple hundred nurses for my books, I gained a lot of empathy for nurses and their struggles.  I heard first-hand what they are up against. Which is why in both of my books I tried to instill empathy for nurses and appreciation for the jobs they do. Patients need loved ones to act as their advocates when hospitalized because of the patient safety risks. It’s unfortunate that we have to enlist loved ones in the first place. Some nurses and physicians I interviewed said, “Never be a patient in the hospital alone. Always have a family member with you.” Hospital administrations need to do something.

But I keep bumping up against the commitment to the patient. The safety of the patient is the most important right? People are terrified of hospitals and for good reason. I’ve written about hand washing quite a bit because of the 1.7 million hospital-acquired infections a year in hospitals http://www.ahrq.gov/research/findings/factsheets/errors-safety/haiflyer/index.html and the 99,000 people who die from those infections annually. Hand washing is such a simple act to prevent the spread of infections and it is the most effective. Washing one’s hands for 20 seconds in warm, soapy water does the job.

If we undergo a major surgery or life threatening event, we are treated in hospitals by clinicians who are supposed to help not harm us. The number of preventable HAIs and resulting patient deaths is just unacceptable. Those kind of odds would not work in any other business. But in healthcare it’s tolerated. Patients go to hospitals anyway because we have to. And if loved ones are available, we enlist them to act as our advocates during our hospital stays to help prevent HAIs, to prevent medication mistakes and other medical errors. We have no choice but to count on nurses and physicians to help us recover and heal. If patients truly are the #1 priority in hospitals, then something needs to be done to reduce the number of HAIs and deaths because of them.

As patients we are the customers. Through our health insurance, we pay the bills. In what other service industry would this kind of hazard be tolerated regardless of the internal pressures employees suffer with? Not to minimize what you describe as those pressures  are real, reported in studies, and they affect the morale of clinicians and then translate to patient care. But the argument that hand washing simply takes too much time (patient emergencies aside) is like saying we are too tired and stressed from a bad marriage to take care of our kids properly.

Beth

I hear you, Martine.  I really do.  And as a consumer or patient I agree that washing hands is a simple procedure that makes a big difference and should be done.  I know HAIs are a big problem and am a strong proponent of the work you are doing to encourage patients to remind healthcare professionals to wash hands and have an advocate with them as much as possible.   Staying as healthy as possible and avoiding hospitals is also wise, although I understand most people who are in the hospital are there because they have to be.

As a nurse, I want to scream, “Give me the resources and I’ll provide safer care.  Make sure that soap, towels, gloves, and alcohol-based sanititizers are easily and consistently accessible, make sure I have enough help to do ALL of the tasks I have to do according to the protocols of my organization, and create products that protect my skin.”  Proper handwashing, rinsing, and drying takes  closer to 1 min (the washing part is 20 sec).  I only pick at this issue because in a chronically understaffed hospital, I guarantee that if I do it right for one patient, I will have to cut corners someplace else.  (In the CDC slide-show they note 56 min out of an 8 hour shift for one nurse based on 1 min/wash and 7 times/hour [I’m sure it is more in some situation e.g. long-term care] ).  I can’t tell you how many times I had to go get paper towel or soap or that someone had hung a cloth towel on the back of the bathroom door in my last job.  It didn’t matter that I practically begged for more nurse assistant staff.  I also guarantee that if I have to go looking for soap or towels that this 1 minute can easily become 5 or more.  This is eternally frustrating in an environment that relentlessly calling upon us to do more than humanly possible.

A friend of mine told me once that she would want a nurse to be a martyr because she felt that nurse would turn over every stone to help her spouse.  She challenged me to consider the same if it were my son in the hospital.  As a mother, yes I want every stone unturned, but as a nurse, I want every stone unturned for all my patients and be healthy and have a long rewarding career and I can’t do that in many places in the current system.  So, when you ask whether patient safety is most important, I answer with ‘Yes, of course it is and making that a reality requires attention to staffing.’

A nurse researcher whom I admire,  Patricia Ebright, PhD, CNS, RN, FAAN shared this quote for the youtube:  Interruption Awareness:  A Nursing Minute for Patient Safety, “A commitment to understanding and appreciating the complexity of RN work is needed to guide the more substantive and sustained improvements required to achieve patient safety and quality”.

Having said all of that, I want to add that my text book which is due out late this summer, “Successful Nurse Communication: Safe Care, Healthy Workplaces, & Rewarding Careers” will contribute to a stronger voice within the nursing profession. As such, I believe it will help with HAIs and many other issues.  I am passionate about patient safety and I so respect your work in that direction.

So what else can we do now?  Maybe we could start a campaign where consumers could get an inside glimpse of the work of nurses called ‘Walk a mile (or 10) in my shoes’. We’d have to make it safe for HIPAA and make sure the nurse and hospital want to give an honest view, but maybe worth talking about.  What are your thoughts?

Martine

I’m not convinced it is our place as patients to get in between you and your employers. We do our best to be our own advocates, to enlist loved ones to help us, but the bottom line is that patients need to be taken care of. We pay the bills to those who treat us for very serious and often life-threatening conditions if we are hospitalized. We need those hospitals. It might feel threatening to patients to speak up on your behalf, just as it is scary for patients to even ask physicians questions because of the fear that care will be compromised. I don’t believe that patients will take that risk. This is really an issue between hospital staff and administration.

It is not a big part of my work to educate patients and families on how to speak up to nurses and doctors to request hand washing. I wrote one post on that because a study was published which reported that most nurses and physicians do not welcome requests from patients/families to wash their hands. It’s uncomfortable for us to make requests for hand washing. We don’t want to have to do it. I certainly don’t.

Patient safety has to come first. From what you describe, hospitals and their employees are on opposite sides of the fence about this issue. I hear your frustration about not having what you need to implement patient safety standards. It’s a sorry situation and the hospital administration should be paying attention and giving their employees what they need to do the job they aspire to. I hear that and agree that something must be done. However, it feels like a boundary violation to ask the patients who are in dire need or might be at some point, to protest or intervene in this conflict.

Maybe there is another way to approach your superiors since past approaches have not worked. I don’t believe it is the patient’s place to get an inside view of what you go through to help you solve what is a work/insider problem. Perhaps your administrators should be enlisted to walk in nurses’ shoes. Maybe that should be a requirement before they take on the job. Maybe you and your colleagues could join together and present the problems and offer solutions. Maybe nurses’ unions could play a more important part in this problem.

Beth

I’d like to be clear that I’m not suggesting that patients, who I agree are dependent and vulnerable, should walk in our shoes.  I distinguish patients from consumers and perhaps there is or should be a better term.   Change agents need to understand the systems they are trying to change.  I wonder if Patient Advocacy programs educate about the complexity of the work.  Do you know?

Also, I  have ‘screamed’ many times with rare success (once) and more often messages to be quiet e.g.  “If you don’t like it here, there’s the door” or  “You need to manage your time better”.

I think your idea would work for administrators/leaders who are willing to listen and learn. Many are not and that is part of the underlying problem.

This is a frustrating place to end a blog duet.  A place of tension and conflict.  And yet, we put it out there to invite input from others, consider each other’s perspective,  and generate more topics to discuss.

Martine

Having completed and graduated from a patient advocacy program at UCLA, I did not hear much about nurses’ struggles. Perhaps that should be part of the curriculum since professional patient advocates who work in hospitals will be working with the nursing staff. But how that would manifest, I don’t know. Patient advocates who work in hospitals work for the hospital and their allegiance is to their employer. Independent patient advocates work for the patient. It sounds like nurses who work in hospitals need their own advocates or a team of advocates.

I did not understand that administrators/leaders don’t listen and simply blame nurses. Now I think I understand better why you are looking elsewhere for intervention. I still don’t believe that patients should be a part of it, but maybe there is another way to go. It would seem that the people with more power could be helpful. Perhaps hospital board members and investors could be informed about this pressing and ever-present problem and the reasons behind it. Perhaps if they were approached with detailed information about what you have described, how those internal problems affect the success and reputation of the hospital, how they affect patient safety and ultimately patient satisfaction (scores.) Perhaps then they would be amenable to your solutions and be willing to get involved.

Maybe you and other nurses are in unions. I don’t know if they are effective with a problem like this or not.

Beth

I think that we are uncovering some of the real dysfunction in our system and although it is frustrating to not have clear solutions for the seemingly simple problem of hand hygiene, I am inspired by your willingness to get closer to the truth of core issues.

I would be very grateful if we can hold on to discussion of unions and consumers’ role or patients’ role (and terminology) in evolving our healthcare system for future duets.  You raise a key point about power and yet even that is complicated because it raises questions in my mind about the power that consumers have and what happens when people in power refuse to listen?

I do think we could take an action step regarding your idea about patient advocacy programs and awareness of the struggles of (your term) or the complexity of (my term)  nurses’ work.  I propose that we draft a letter that WE can send to program leaders using hand hygiene as a persistent problem, asking for feedback about what is and isn’t in the program and maybe offering to develop a seminar or course.  I don’t know exactly what this would look like, but suspect it would be a valuable process for us.  If you agree, let’s work on that while waiting to see what other thoughts readers have about the hand hygiene issue!

29 04, 2015

Will Cameras in the OR Improve Patient Safety?

By | April 29th, 2015|Real Stories|8 Comments

Real Stories from the Streets of Healthcare!

 Beth Boynton, RN, MS and Martine Ehrenclou, MA  

With patients and healthcare professionals all too often on opposite sides of the table, our goal is to bridge that gap. As a patient/patient advocate and registered nurse, Real Stories From the Streets of Healthcare is our way of discussing real stories and issues that involve patients and families, nurses, other healthcare professionals, and the healthcare environment itself.  We plan to look behind the closed door, break down walls of silence, and tackle thorny issues to increase understanding of the complex healthcare problems we all face.  See our welcome page for  more information about our blog duets here.

Below is our second duet.

Beth

The incidence of surgically related sentinel events, (or patient safety events) tracked by the Joint Commission is consistently high and there are three types that are in the top ten list of those most frequently reviewed;

  • wrong-patient, wrong-site, wrong-procedure
  • unintended retention of foreign body
  • Op/post-op complication

This has been true since the Joint Commission began tracking data in 2014.

So when I received a request to sign a petition to mandate cameras in the OR I felt compelled to look at it closely. I also felt torn.

On one hand putting cameras in OR seems like it might make the OR team more accountable for doing things properly and making sure they have the right patient, maintain sterile technique, and do not leave any foreign objects behind.  A level of accountability that cameras might indeed positively impact.

My hesitancy comes from worries about what the underlying problems are.  I worry that the underlying human dynamics going on are a primary problem and that we should do the work required to ensure that the team and organizational culture are safe, just, and respectful and that the surgeons and OR nurses and techs are practicing effective communication first.  If we put cameras in an operating room where there is bullying and blaming, what will cameras do?  They may stop overt mistakes, but those dynamics will not go away and are likely to surface in other creative (or destructive ways).  Maybe staff turnover would increase, (there is a steep learning curve for OR nurses) or last minute cancellations of surgery would become a frequent problem leading to delays in treatment and added stress, or there would be more documentation errors leading to loss of revenue, or maybe a patient’s surgical procedure would end up on Facebook.  I’m just guessing, but my sense of human nature is that if we don’t build healthy relationships, the negativity will ripple out somewhere.  Plus, I can’t imagine wanting to work in an environment of such close supervision unless there is a positive team dynamic.

This blogpost provides a little more info about the dynamics in the OR and some interesting similarities between the US and UK.

I think fixing the underlying problems and THEN putting cameras in the OR along with policies and protocols for ensuring privacy and being clear about use of recordings, i.e. to monitor standard operating procedures are followed and perhaps teaching.

What are your thoughts?

Martine

I too feel torn about putting cameras in the OR. For one, I don’t like the idea of cameras everywhere. Entire cities in the U.S. have video surveillance in effort to catch terrorists, to prevent vandalism at parks and other locations, catch drivers who run through red lights, and more. There seems to be a big push for the police to wear body cams. According to a report by the Department of Justice, “both officers and civilians acted in a more positive manner when they were aware that a camera was present.”  Today’s Los Angeles Times reported that the Los Angeles Police Commission approved body cameras for the LAPD.

As you pointed out, the number of sentinel events related to surgery is very high. For those who don’t know, a sentinel event results in a patient’s death, permanent harm or severe temporary harm and intervention to sustain life. You gave good reasons to support cameras in the OR in effort to make the surgical team more accountable. That just might make patients safer.

I think of the Dallas, TX, anesthesiologist who was supposed to be minding the patient during surgery but instead was texting and reading on his iPad. The patient died. It would seem that cameras in the OR would halt this type of behavior.

However, I also believe that cameras in the OR would only initially stop preventable medical errors. As we’ve witnessed on reality TV shows, the camera is soon forgotten.

You bring up some very valid concerns about real, underlying behavioral problems among surgical staff and how a camera in the OR might affect how those behaviors play out if the issues aren’t addressed. As you suggested, bullying and blaming might just surface in other insidious ways outside of the OR. I agree with you that a camera won’t build healthy working relationships if the root cause isn’t taken care of. In fact, I could see further destructive problems arising as a result of cameras in the OR.

You also brought up the frightening risk of patients’ surgeries being posted on Facebook. If it hasn’t happened already, surely it would.

However, I believe that patient safety must come first. As much as I don’t like the idea of cameras in the OR, I wonder if they wouldn’t force healthcare professionals to pay more attention to which part of the body is operated on, to the count of sponges after surgery to make sure none are left inside the patient’s body, to an instrument used in the surgical process to make sure it is accounted for and not accidentally left beneath the sutures.

I keep going back to the same idea—if there had been a video camera in the the surgical suite where Joan Rivers lay asleep on the operating table, would her doctor still have taken a Selfie with her while she was lying there completely unaware? Probably not.

Wholeheartedly, I agree with you that the underlying problems need to be fixed. But I wonder how long that will take. I wonder how long patients and their families can wait.

Beth

Excellent and provocative points, Martine.  The idea that a surgeon would take a ‘selfie’ with Joan Rivers lying there vulnerable is so disturbing.  And bizarre if you consider the idea that it is a camera that would (or at least, might) have prevented him from honoring a boundary that he was using a camera to break! Where was his sense of professionalism and respect for the patient and their therapeutic relationship?  And how would his inappropriate thinking and behavior manifested if he didn’t take the picture?  What need was he trying to meet?

Thank you for the Department of Justice report and your comments.  I find the ‘cameras everywhere’ to be a disturbing phenomenon.  Is this is a symptom of a world that is spinning out of control?  It raises so many questions about individual accountability, leadership, and privacy.  ‘We’ seem desperate to control things rather than creating platforms from which they can emerge healthily.  Maybe we need to do both in the world we are currently living in.

I am clear that I need to be assured that effective efforts to address interpersonal dynamics, organizational culture, and professional boundaries are in place and ongoing in order to advocate for cameras in the OR.  And I’m not talking about putting up signs that say “Professionals must behave respectfully”, or “ABC Hospital Maintains a Zero Tolerance for Bullying” but rather experiential learning techniques that develop people skills  and emotionally mature behavior such as Crew Resource Management, TeamSTEPPS, and Medical Improv while creating safe and just cultures that support healthy dynamics and collaborative.  These take time and effort, but aren’t impossible and there are many opportunities to be doing this all along the course of doctors and nurses’ education and careers.  IF we are willing to make it a priority.

Patients do deserve the best we have to offer and shouldn’t have to wait.

Martine

I understand where you are coming from about the importance of addressing the underlying problems. I agree that intensive learning techniques should be put in place. But perhaps both video cameras (temporarily) and learning techniques can be implemented at the same time. Cameras could be installed in operating rooms while mandatory classes/lectures for CEUs are offered by hospitals to teach members of the surgical staff about workplace bullying and its effects. Perhaps these classes/lectures could outline exactly what bullying and disrespectful behavior is, complete with live/videoed case examples about how it affects the surgical team as a whole as well as its members. It would also be important to illustrate how resentment from workplace stress trickles down to patients in the form of compromised quality and patient safety.
After disrespectful behaviors are fully understood by the surgical staff, then live or videoed case studies could be shown to teach healthy ways to deal with anger, frustration, and resentment. Effective and respectful communication strategies could be taught and each healthcare staff attendee could be asked to engage in “teach back” with the instructors or with one another about what they had learned. Perhaps after some learning had taken place, all healthcare providers could be asked to analyze different case studies to ID bullying and disrespectful behaviors and ID which behaviors are in fact appropriate and effective in reaching the goal.
Perhaps you and I could create courses like this with videoed case studies, a mini-text, tests, and either put them on ourselves or market them to hospital administrators that shows clearly how they will increase their bottom line. That’s the only way they’d go for it.
What do you think?
Beth
I think that is an excellent idea, Martine and would love to consider how we might do this.  I think healthcare professionals and hospitals might welcome some real-to-life videos that convey healthy vs. toxic behaviors.
What do readers think about cameras in the OR?
24 03, 2015

Time For an End-of-Life Conversation?

By | March 24th, 2015|Real Stories|0 Comments

Real Stories From the Streets of Healthcare!

With Beth Boynton, RN, MS and Martine Ehrenclou, MA

With patients and healthcare professionals all too often on opposite sides of the table, our goal is to bridge that gap. As a registered nurse and patient/patient advocate, Real Stories From the Streets of Healthcare is our way of discussing stories and issues that involve patients and families, nurses, other healthcare professionals, and the healthcare environment itself.  We plan to look behind the closed door, break down walls of silence, and tackle thorny issues to increase understanding of the complex healthcare problems we all face. See our welcome page for more information about our blog duet here

Time For an End-of-Life Conversation? 

Martine

Why is it so hard for patients/their families and medical providers to talk about end-of-life issues? Maybe we have created living wills, healthcare directives, & durable power of attorney for healthcare but too many people do not have a clear view of what it means to say, “I want everything done.”

If a patient has a life threatening illness and is on full life support with no hope for recovery, why do we keep putting the patient through aggressive medical treatment? All too often this causes the patient pain and suffering.

I went through this with my mother, my godmother and more recently with my uncle, see KevinMD article here. Each of them suffered miserably on full life support, with aggressive medical treatment, and the end of their lives was spent in a hospital room hooked up to machines. It was heart wrenching to witness.

What is this aggressive medical treatment about at end-of-life?

Beth

As a nurse, I’ve seen this kind of suffering too, don’t like being part of a process that prolongs it, and believe we can and should do a much better job. I also know that identifying what is ‘too much’ is tricky and varies among individuals.  Fears about death, challenging family dynamics, and some measure of uncertainty contribute to a perfect storm that leads us to treat.  

Your story about your uncle is heart wrenching and I think the docs, nurses, and administrators involved had many opportunities to be more responsive to him, his friend, and you on his behalf.  And that it is sad that they didn’t.

I think you are hitting on one integral problem, i.e. that people don’t understand what it means to say, “I want everything done” or “I don’t want to be hooked up to machines”.   This is complicated by unclear and even changing desires by patients, constantly evolving treatments and technology, limitations that healthcare professionals have in holding space for difficult conversations about death, and perhaps an overall lack of understanding or comfort with dying in our society.  The ‘truth’ is, we can help with alleviating pain and respiratory distress, but there is much we don’t know.  Maybe this involves a shift in our roles as healthcare professionals that we haven’t quite figured out.  Hospice practitioners have a better grasp of this I think.  It is a more supportive and less directive role than much of the work we do.  But people often resist hospice.  It is scary to hear and scary for some of us to suggest. 

Also, I think money is part of this picture.  We know that a lot of healthcare dollars are spent during this phase of life and this may be a disincentive, (consciously, subconsciously, or unconsciously) for facilities to let death take its course. 

I think seasoned docs and nurses may be more comfortable with clinical and interpersonal dynamics going on during death and more able to not intervene or be more thoughtful about responding.  Some professionals, and this is part of our training, are more geared to intervene.  React.  Treat.

I’ve seen Living Wills work well and not work well.  The portable ones of late make sense and do help with communication.  I also know that time can be an issue.  Do we have enough time and staff including continuity of staff to have the kinds of conversations that would help.  Listen.  Be with.

Sadly, on an understaffed unit, sending a patient from Med-Surg to ICU or from LTC to the ED may allow a nurse to take better care of others. We don’t consciously discuss this, but I suspect it is a factor at times.

I worked in long-term care for several years recently and wondered many times why we would initiate emergency treatment i.e. send someone to the ED as opposed to hospice.  These intersections, i.e. when someone is showing signs of septicemia or pneumonia are a somewhat predictable course towards death and is a time when tough, honest, compassionate conversation should take place between physician (NP, PA, RN) and patient/family.  If we made this one concept a priority, I think we could shift things considerably.  Perhaps we could ask questions about how this might unfold in the clinical setting and consider what training and staffing issues are raised.

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