A West Texas jury quickly acquitted a nurse who had been charged with a felony after alerting the state medical board that a doctor at her hospital was practicing unsafe medicine. After a four-day trial, a state court jury found that the nurse, Anne Mitchell, was not guilty of the third-degree felony charge of "misuse of official information." Conviction could have carried a prison sentence of up to 10 years and a fine of up to $10,000.
Boston-based Tufts Medical Center says it has found a way to trim the high cost of nursing while improving care, but the plan prompted a protest by nurses who say it is an example of the intense cost-cutting pressure on hospitals statewide. Tufts administrators said they will save up to $3 million annually by increasing the number of patients assigned to each nurse, which will allow the hospital to hire fewer nurses. But they added that they want to improve care and working conditions for nurses by bringing on 35 technicians to free up nurses from unskilled jobs, the Boston Globe reports.
When Kathleen Mikos, RN, MSN, CNO and vice president of patient care, came to Ingalls Memorial Hospital in Harvey, IL, she couldn't shake the sense of déjà vu when she found that patient handoffs took an hour to 90 minutes to complete.
At her previous hospital, Mikos had dealt with a similar issue—performing patient handoffs took longer than it should have. The lengthy amount of time became an issue with incremental overtime and also got in the way of patient care.
"I was concerned because during a period of an hour, where so many nurses are tied up, who is taking care of the patients?" says Mikos.
Drawing on her past experience, in May 2008 Mikos began to develop a new, efficient method for patient handoffs that allowed for more patient-nurse interaction and reduced nurse overtime at Ingalls.
The old and the new
For years, nurses nationwide have used different methods for handling handoff reports. One technology was the use of taped records. This caused problems because if an interruption occurred while the nurse was reporting, the nurse had to make a note on the recorder where the tape left off, causing confusion later on.
There were also instances when the tape recorder broke or someone had recorded over a report, causing the nurses to take more time to rerecord each patient report.
More recently, nurse-to-nurse interaction between shifts is how patient handoffs are handled. As the nightshift is coming on and the day shift is leaving, and vice versa, the nurses discuss each patient and how the shift went.
Although effective, this process takes a lot of time, and many nurses go into overtime.
"Between shifts, I can have up to 20 nurses tied up," says Mikos. "Having that many nurses tied up, trying to get reports, cuts into the patient care."
Much of the delay occurred because not all nurses shared the same patients. Mikos turned to The White Stone Group, Inc., for a technological solution to facilitate a new handoff process. This company provides healthcare organizations with software to help improve the management of healthcare communication events.
Having had experience with The White Stone Group in the past, Mikos was confident in setting up OptiVox, a voice technology program for handoffs, and made the program accessible to all staff members through any telephone in the hospital system.
Other similar programs that facilitate the patient handoff process include the PatientKeeper Sign-Out technology and Vocera's communication systems. Physicians use the PatientKeeper program as a continuity of care tool and enter patient care details that the next shift's physician will need. Vocera's wireless devices enable instant communication among staff members.
Voice technology OptiVox
OptiVox is a computer-based voice platform technology that is built into the phone system, says Mikos. Nurses can dial into OptiVox and record their patient reports or listen to the patient reports from any phone in the health system.
Nurses coming off a shift and needing to report on their patients dial in an individual access code, pull up each patient's medical record number, and begin recording a report on that patient.
In addition to using OptiVox to record their reports, the nurses are also encouraged to use the SBAR format. The SBAR technique helps guide communication between staff members on a patient's condition.
To identify each patient in the system, Ingalls uses the patient's medical record number to prevent confusion, says Mikos.
"You are always up against potential patient safety issues, and some patients may have the same name or date of birth, but medical record numbers are always going to be unique," says Mikos.
When nurses arrive to start their shifts, they can access the reports from the previous shift the same way nurses record them. Using any phone in the health system, the nurse dials in with an individual access code and uses his or her patients' medical record number in order to listen to the reports.
"To receive reports on five or six patients should take about 15-20 minutes of shift report time," says Mikos.
Now, with extra time, the nurse can find the previous shift nurse to clear up any unanswered questions and visit his or her patients for brief assessments and introductions.
"Here at Ingalls, we believe there is a need for face-to-face, or bedside rounding," says Mikos. "After the nurses [listen to the] handoff report, they should immediately go out to their patients, introduce themselves, and have a brief discussion on how the previous shift went."
Advantages for the entire hospital
OptiVox received a positive reaction from patients, nurses, and the management team, says Mikos.
For the nurses, there are features in OptiVox that help make recording and listening to the reports easier and more convenient than listening to a normal tape recording.
The program gives the nurses the option to slow down or speed up a recording if the nurse who recorded the report is a fast or slow talker.
In addition, OptiVox provides the capability for nurses to go back to where they left off if they were interrupted while recording any reports.
The program also allows managers and nurse leaders to leave a broadcast message there for all staff members to hear.
"Typically, if there is something of importance that I need to get out, I can have that message presented for as many shifts and days as I believe necessary to penetrate my staff," says Mikos.
OptiVox is also beneficial to the nursing students that come through the Ingalls health system, says Mikos. The program allows the students to listen to reports and helps them become more acclimated to real-life situations, says Mikos.
Another benefit of this technology is that the records can be kept for any length of time, depending on how long the organization wants.
"We hold on to the records for two weeks," says Mikos.
By keeping the records for this length of time, Ingalls ensures that in the event of a near miss or an error, the report is on file and can be listened to again.
Involvement with other departments
The OptiVox technology is also beneficial when it comes to patient throughput and alerting an area of the hospital to expect a patient from the ED, says Mikos.
Prior to implementing the technology, ED nurses had difficulty reaching nurses on other floors and units.
"We tried all sorts of things, from bringing the patient up to a certain floor to attempting to keep calling back and forth," says Mikos.
Now, with OptiVox, when a nurse needs to transfer a patient from the ED to another unit, he or she simply voices the report into OptiVox and the system automatically sends a voice message to a designated unit telephone number. That patient's report is then available for the receiving nurse.
The ED nurse also includes his or her name and telephone number in the event the receiving nurse has any questions.
"This has really taken away the bottlenecks that were created when giving reports," says Mikos. "This gives us a precise process to user report and helps expedite the patients out."
Savings and positive thoughts
One of Mikos' goals when implementing the new technology was decreasing incremental overtime. "With the new process, we saw a great reduction in overtime," she says. "And the savings helped pay for the technology."
However, Mikos warns that there has to be a strong message sent from the leadership team about incremental overtime and backing the system.
"There are some nurses that aren't so in tune with us managing incremental overtime," says Mikos. "You have to monitor the time and send a message so no one resorts back to the old ways of recording incremental overtime."
Overall, Ingalls staff members have been pleased with the new handoff process, and even the unit secretaries noted how much the noise level decreased, Mikos says.
Once, the halls were filled with nurses chattering, trying to catch up on reports. Now, the halls are noticeably more quiet because nurse-to-nurse communication for handoff reports has been replaced by telephones and computers, says Mikos. "The healing environment has improved tremendously."
Anne Mitchell, a Texas nurse, is being indicted and threatened with 10 years in prison for informing state regulators that a doctor at her rural hospital was practicing bad medicine. Mitchell is scheduled to stand trial in state court for "misuse of official information," a third-degree felony in Texas. The prosecutor said he would show that Mitchell had a history of making "inflammatory" statements about Rolando G. Arafiles Jr., MD, and intended to damage his reputation when she reported him last April to the Texas Medical Board, which licenses and disciplines doctors.
Typically when infection preventionists (IP) evaluate bloodstream infection rates, their initial thoughts turn to central line compliance. Rarely is there much attention given to the use of multichamber bags versus compounded bags for parenteral nutrition.
But a study that was presented at the Infectious Diseases Society of America's (IDSA) 47th annual meeting October 29–November 1 found that the way in which parenteral nutrition is delivered could affect bloodstream infections among high-risk patients.
Authors of the study focused their research specifically on the oncology unit because patients in that unit are already susceptible to infections, says Robin Turpin, PhD, senior director of health economics in IV nutrition at Baxter Healthcare Corporation in Deerfield, IL.
"In this particular analysis, we were interested in looking at the oncology population because they were high risk," Turpin says. "They already have a compromised immune system, so we had thought they might be at a higher risk [for bloodstream infections]."
By evaluating data among 19,540 patients, Turpin and her colleagues found that patients who were given compounded bags were more likely to have major or extreme illness severity, more days of parenteral nutrition, more days in the ICU, and a longer overall hospital length of stay. After adjusting baseline differences, the study concluded that the adjusted probability for bloodstream infections was 19% higher for compounded bags compared to multichamber bags.
"It has been fairly well documented in literature that parenteral nutrition is a risk factor for bloodstream infections, but we were curious as to, in general, if different types of preparation may have a higher risk versus another," Turpin says. "Because compounding parenteral nutrition is a very different process than a multichamber bag, we were curious."
Compounding is more popular
Compounding parenteral nutrition is a process in which a pharmacist takes the amino acids, dextrose, and perhaps lipids, depending on the physician's prescription, and literally mixes the nutrients in the pharmacy under aseptic conditions. Multichamber bags are dual-chamber bags with premixed solution that can be mixed by rolling the chambers together. Additional vitamins and micronutrients can be added if needed.
For whatever reason, the compounding process has become a standard of practice in the United States, says Turpin. The IDSA study found that more than 18,000 of the 19,540 patients were given compounded parenteral nutrition. Other countries, such as France, favor multichamber bags.
"I don't think there is necessarily clinical evidence for that," Turpin says. "In the U.S., there is just a lot of compounding."
Developing a standardized process
The reason multichamber bags may lead to fewer bloodstream infections is because they involve a much more uniform process. Compounded bags provide a much larger window for human error by breaking a sterile barrier.
"A multichamber bag is really a standardized parenteral nutrition [process], and we believe, and sometimes you see thought leaders that publish this, probably a good number of patients can really be serviced with a standard parenteral nutrition," Turpin says. "Some [patients] certainly would need some customized, which is where compounding is ideal. In other words, there are some patients for which compounding is ideal, then there is a large group of patients where a multichamber bag is great too."
Unlike some infection prevention checklists or processes, there is no cut-and-dry determination for when each approach produces the most favorable results. Because this was a retrospective study, the final numbers produced very limited evidence. Turpin says Baxter does have some prospective studies in the works that may provide much more consistency across all units and populations.
"But it's not just a prospective study within the hospital, we also have a study looking at home care patients as well," Turpin says. "It's looking at various patient populations. [We will know more] assuming we find similar results."
Raising questions
This study is not intended to be the final recommendation for parenteral nutrition use across all hospital units, Turpin says. Although authors of the study had a vast amount of variables and data to work with, they still only focused on the oncology unit, and there are likely many more factors yet to be determined.
Rather, it's a chance for IPs to look at the process that is used at their hospital and consider whether an alternative solution might help in particular instances.
"I think for infection control practitioners, what they love about this is really just raising the issue," Turpin says. "It's providing some more information for people to understand a little bit more about these issues, raise the issue, and say, 'Wait a minute, let's look a little bit more carefully.' "
The study was well received by IDSA meeting attendees. "I think people seemed to be very, very interested in the bloodstream infection issue, and I think people hadn't considered the whole parenteral nutrition piece of it before," Turpin says.
This article was adapted from one that originally appeared in the January 2010 issue ofBriefings on Infection Control, an HCPro publication.
Florida Gov. Charlie Crist has paved the way for nurses from outside Florida to fill in for colleagues in Miami who want to go to Haiti in the wake of the catastrophic earthquake.
Crist signed an executive order that allows out-of-state nurses to be licensed to work in Florida for the next 90 days. About 200 nurses from Miami-based Jackson Memorial Hospital have signed up to go to the island, hospital officials said.