Twelve California hospitals received the latest fines for putting patients in "immediate jeopardy" of harm or death, including three that failed to remove sponges or towels from surgical patients, one where a psych tech repeatedly slapped an unconscious patient in the face in the belief he was "faking it," and another where staff failed to properly use restraints, resulting in a patient's critical fall. Poor training of medication use resulted in a heparin overdose that caused a brain hemorrhage in a patient at a sixth facility while at a seventh hospital, managers failed to properly staff the intensive care unit, and a patient whose condition was quickly deteriorating was not adequately treated. Some of the hospitals have been fined three times, and some for repeating similar violations.
Like other Americans, a growing number of physicians are using smartphones—mobile phones that combine online access to information with PDA functionality. In fact, a recent report noted that physicians who use smartphones increased by 64% over the past year. Smartphone users are constantly on the lookout for new applications that can make their lives easier and more enjoyable. Physicians are also finding that they are a way that can help their practice and patients. This article highlighted some of the hottest apps for physicians.
In hopes of getting healthcare reform back on track, President Barack Obama spoke to a joint session of Congress about a comprehensive health reform bill in September. The 45-minute speech was Obama's first in-depth national speech about healthcare reform after spending months on the sidelines as Congress worked on multiple reform proposals. So, after finally hearing directly from the president, what did health leaders think? Nine health leaders gave their thoughts.
With the annual Medicare price tag for physician radiology services more than doubling between 2000 and 2006, the federal government looked to cutting payments for advanced imaging as a way to help pay for healthcare reform. Federal lawmakers looked at two major ways to lower what Medicare pays imaging providers. Radiology groups opposed both strategies, but acknowledged that the high increases in federal payments have made them a target.
Few topics can get physicians worked up like generational differences in practice styles. It's easy to fall back on dichotomic caricatures with this topic: Older physicians are hard-working professionals who think younger doctors aren't productive or committed enough to medicine and patients, and younger doctors are tech-savvy life balancers who view older doctors as burned-out luddites. Although they are overblown stereotypes, there are grains of truth in both of those perceptions. But the deeper reality is far more complex. The characteristics that define each generation of providers overlap and constantly evolve, so that the two are beginning to resemble each other more than they think.
One of the hottest topics in healthcare in 2009 was: How will health reform affect my business? In a July article, we looked at the possible winners and losers in healthcare reform. The almost certain winners predicted were: primary care physicians, health information technology, and comparative effectiveness. Possible winners: nurses, rural healthcare, and pharma. Possible losers: health plans, specialty physicians, and pharma. Almost certain losers: imaging, biologics, physician-owned specialty hospitals, durable medical equipment, home health agencies and providers of home healthcare, and skilled nursing homes.
While the healthcare debate kept health leaders' attention in 2009, many were not aware of a Centers for Medicare and Medicaid Services plan to eliminate a series of five-digit CPT codes that specialist physicians, such as cardiologists, oncologists, and surgeons, use to bill for medical or surgical consults. This November article highlighted the issue and potential ramifications if the change became part of Medicare's physician pay schedule. Specialty providers said the change would have dire consequences for care far into the future, especially for rural communities where specialty doctors are in heavy demand.
Alegent Health CEO Wayne Sensor's resignation was big news in the hospital world in 2009. In the time leading up to Sensor's resignation, medical staff at two of Alegent's largest hospitals took votes of no confidence against Sensor, who is considered a healthcare pioneer—from the drive to make healthcare prices transparent to the consumer to building a staff of employed physicians at the health system. Senior leadership editor Philip Betbeze highlighted the Sensor situation and questioned Alegent's board's decision to accept his resignation based on the physician employment question. He wondered if the move would put Alegent on the wrong side of history and questioned whether Alegent's board strategy will end up penny wise—and pound foolish.
There are various ways pain can be measured by hospital staff members, depending on the organization.
At Altru Health System (AHS) in Grand Forks, ND, the patient receives a comprehensive initial pain assessment upon admission. Then every shift thereafter, an ongoing pain assessment is completed.
To ensure that pain assessment and reassessment were happening in patient documents, AHS conducted monthly chart audits.
The data—collected from these monthly chart audits for the Joint Commission Provision of Care standards—revealed low compliance with the need for timely documentation of pain reassessment.
The Pain Management Committee at AHS began revisions of the pain assessment policy after recommendations for policy revisions from Patricia Pejakovich, RN, BSN, MPA, CPHQ, CSHA, senior consultant with The Greeley Company, a division of HCPro Inc., in Marblehead, MA, and Janelle Holth, RN BSN, AHS' regulatory compliance coordinator.
Reassessment for time and policy
Chart audit data indicated that the reassessment for inpatients was occurring, but not documented within the timelines written in the pain assessment policy.
"For example, if a nurse gave a patient medication through an IV, which is supposed to be reassessed within a half hour, it was not happening within that timeframe," says Holth.
AHS has electronic medical records, so even though the nurse was able to reassess the pain timely and document before the end of their shift, the reassessments were not making it back into the records within the required time.
The location of the computers was another complication added to the documentation of pain reassessment within the timelines.
The computers are located in the hallways and not at the bedside, which adds steps to the flow of work processes.
With discussion and clarification of the requirements, the timeliness for reassessment was removed from the policy. This allowed the nursing staff to focus on pain management for the patient, without interrupting the care for the patient.
The nursing staff was also able to reference the time pain was reassessed within their documentation before the end of their shift.
Beneficial options for nursing staff
Now with timelines not a part of the pain reassessment, AHS added other options and opportunities for nurses to document each reassessment they completed.
There are three options available for nurses to choose from when they document pain reassessment:
A medication tab located under the comments section in the electronic record
The nurses' notes under the shift-to-shift summary note in the electronic record
A flow sheet so all medications and times are available to see immediately (this is used more commonly used on the oncology floor)
"The most common method used for pain reassessment is the comments section within the medication tab located in the electronic record," says Holth.
Health system standardization
Once the revision of the pain assessment policy was complete, Nancy Joyner, clinical nurse specialist and co-chair of the pain management committee at AHS, began working on a tool for pain assessment that would be standardized and consistent throughout AHS.
One thing that stood out to Joyner was the fact that there was no non-verbal pain scale.
“With only a verbal pain scale available, nurses did not have a tool to use for the cognitively impaired patient," says Jodi Savat, RN, BSN, OCN.
When dealing with patients who were unable to express how much pain they felt, many nurses were taking an educated guess by using visual cues.
Through research and the assistance of Pejakovich, Joyner developed a comprehensive pain assessment tool. Joyner, Holth, and Pejakovich felt non-verbal pain scales using behavioral and physical signs were most appropriate for AHS.
The tool that seemed the best fit for adults was the Non Verbal Behavioral Pain Scale for Cognitively Impaired Patients. This scale uses a nursing report, not a self-report, and is reflected as such in the nursing notes.
"The nurse looks at the behaviors and vital sign cues and correlates them with a number on the non-verbal scale," says Savat.
"At first it was difficult to decide if the visual and vital sign cues were due to pain or something physiological going on," says Doreen Lindsey, RN, BSN, supervisor of patient care, ICU/CCU.
All the pain assessments are included in a poster that AHS has placed throughout the health system. This makes it easily accessible to any staff nurse, at any point, because the age of patients varies depending on department.
When it comes to quality and medicine, we're often comfortable discussing many subjects, such as the latest technologies, the newest journal findings, recent legislation, or even revised payment strategies. However, if we move the subject to the human aspect—examining patient spiritual needs—the comfort zone seems to shrink.
We may have our own set of personal beliefs, but sometimes addressing a patient's spiritual needs as part of his or her care may appear out of place or inappropriate. However, two new studies find that recognizing that spirituality may be an important part of providing quality care.
In the first study, researchers at Dana Farber Cancer Institute in Boston found support of terminally ill cancer patients' spiritual needs by medical teams was associated with greater quality of life—even during the last remaining days.
Recent research has shown that religion and spirituality many times are prime sources of comfort and support for patients confronting advanced disease, according to the study's senior author, Tracy Balboni, MD, MPH, a radiation oncologist at Dana Farber.
"Our findings indicate that patients whose spiritual needs are supported by their medical team—including doctors, nurses and chaplains—have better quality of life near death and receive less aggressive medical care at the end of life," she said.
The study, which appears on the current online version of the Journal of Clinical Oncology, involved 343 incurable cancer patients at hospital and cancer centers nationwide. Participants were interviewed about how they coped with their illnesses, the degree to which their spiritual needs were met by medical teams, and their preferences regarding end of life treatment. Each patient's course of care were tracked during the remainder of his or her life.
Patients whose spiritual needs were supported by the medical team were likely to move to hospice care at the end of life, the researchers noted. Also, spiritual support among those patients who relied on their religious beliefs to cope with their illnesses reduced their risks of receiving aggressive medical treatments at the end of their lives.
Support of patients' spiritual needs by the medical team also was associated with better patient well being toward the end of life: scores averaged 28% higher among those receiving spiritual support.
In a separate study from Rice University, Houston, and Brandeis University, Waltham, MA, it was found that while more physicians say religion and spirituality help some patients and their families cope with serious illness, it was often the families and patients—not the physicians—who raised the issue of prayer.
This study, which appears in the current issue of Southern Medical Journal, suggests that medical education could be enhanced by courses that address the topic of prayer—but which go beyond just praying.
"We know that prayer in physician patient interactions is attracting more attention," said coauthor Wendy Cadge, a sociologist at Brandeis University. "Most research in this area focuses on whether physicians and patients think prayer is relevant. But, in this study, we wanted to find out when and how prayer comes up in the clinic, and how physicians respond."
The study found that pediatricians usually respond to requests for prayer in one of four ways:
They participate in the prayers.
They accommodate the prayers, but don't participate.
They reframe the prayers.
They direct the families and patients to religious and spiritual resources, such as hospital chaplains.
A few physicians did join in prayers with families and/or participated in religious rituals, such as baptism or being at the bedside. Others said they accommodated prayers, but didn't actively participate in them.
Another group of pediatricians reframed the prayer requests in ways they thought were more realistic and appropriate, Cadge said. The fourth group of physicians responded to requests for prayer by referring patients and families to other resources, such as the family's religious leaders or hospital chaplains.
Overall, the study showed that the situations that lead to requests and physicians' behaviors in response are far more complex "than simply praying or not praying," said Cadge.
In the long run, both these studies seem to show that while responding to spirituality seems to be a personal issue, there may be more there in adding it to the arsenal of providing quality care—and maybe we shouldn't be so shy to talk about it.
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