Tag: Nursing

The Nurse Practitioner … Er, We Mean Doctor Is In

Nov 17, 2014• 7

By HANS DUVEFELT, MD

A rash could be leukemia or idiopathic thrombocytopenic purpura. A sore throat could be glossopharyngeal neuralgia or a retropharyngeal abscess. A blocked ear could be Ramsay-Hunt syndrome, a self-limited serous otitis or sudden sensorineural hearing loss with an abysmal prognosis if not treated immediately with high doses of steroids. A headache or sinus pain could be cancer, and a cough could be a pulmonary embolus or heart failure.

Treating the Well:

In my early career in Sweden, well child visits were done in nurse-led clinics, some of them only open on certain days, with a local doctor in attendance. Parents carried the children’s records with them, containing growth charts, immunization records and so on.

These nurses had great expertise in differentiating normal from abnormal appearance of children, and would direct the attending physician’s attention to children with abnormal metrics, appearance or behavior.

With this arrangement, the physician time requirement was reduced, and limited to evaluating children attending the clinics who needed special attention. Physicians also performed specific examinations at certain ages, such as checking for hip clicks. These clinics freed up the local pediatricians to evaluate more sick children.

Well-baby visits are now the bread and butter of American pediatricians and family practitioners, and with the ever expanding mandates of politically determined items that must be covered in order for doctors to get paid for their services, we sometimes have trouble accommodating illness care demands.

Angry Nurses Tell of Ebola Patient’s arrival at Texas Hospital

Oct 15, 2014• 125

By THCBist

A group of nurses at Texas Health Presbyterian has come forward with a very different picture of what happened when Liberian Ebola patient Thomas Duncan arrived at the hospital with Ebola-like symptoms on September 28th. If true, the allegations are certainly unsettling.

In an unusual move, the nurses spoke anonymously to the media, conducting a blind conference call in which none of the participants were identified.

After arriving at the emergency room with a high fever and other symptoms of the disease , the nurses said the patient was kept in a public area, despite the fact that he and a relative informed staff that he had been instructed to go to the hospital after contacting the Centers for Disease Control in Atlanta to report a possible case of Ebola.

Ceci Connolly: Will Technology Replace Doctors?

Sep 26, 2014• 35

Ceci Connolly

It’s a provocative question, but it’s also the wrong one.

The question ought to be: When will healthcare fully embrace technology and all it has to offer?

It’s widely known that the $2.8 trillion US health system has significant waste and errors – between 25% and 30% of our health dollars go to services that do not improve health. Technology has the ability to put a big dent in that through standardization, real-time insights, convenient gadgets and complex data analysis the human brain simply cannot perform.

Consider some of the early innovators. There’s the heart monitor in the phone. The wristbands that count steps. And then there’s Oto, the cellphone attachment that snaps an image of the inner ear sparing frazzled parents one more trip to the doctor’s office for yet another infection.

The Org Chart of the Damned

Sep 26, 2014• 1

THCBist

HAT TIP: Mr. Nosta

Doctors and Nurses in a Twit about Technology Destroying Healthcare

Jun 3, 2014• 10

By Bill Crounse, MD

Every workday morning I spend 30 minutes or so reviewing my Twitter feed.

By following a select group of top healthcare news observers and thought leaders, I find that Twitter works pretty well as a filter for the news events and topics that matter most to me. Over the past couple of days, I’ve been alerted to some articles about nurses and doctors who are, shall we say, quite frustrated with electronic medical records and what they perceive as a decline in the physician-patient relationship.

One of the articles that caught my attention was about a nurses’ union, National Nurses United, that has launched a national campaign to draw attention to what they say is “an unchecked proliferation of unproven medical technology and a sharp erosion of care standards” in today’s hospitals.

Of course, their agenda and real concern seems quite transparent. It is not so much about technology itself as it is a decline in the number of Registered Nurses directly involved in caring for patients at the bedside.

The nurses’ union campaign seems to resonate with another article I came across last week about the lost art of the physical exam. That article from Kaiser Health News and the Washington Post extols some very legitimate concerns about doctors who rely too much on lab tests and medical imaging to arrive at a diagnosis instead of talking to, touching, and examining the patient.

Vendor Management Systems and the Commoditization of Physicians and Nurses

May 29, 2014• 3

By Val Jones, MD

In a policy environment where quality measures and patient satisfaction ratings are becoming the basis for reimbursement rates, one wonders how VMS software is getting traction. Perhaps desperate times call for desperate measures, and the challenge of filling employment gaps is driving interest in impersonal digital match services? Rural hospitals are desperate to recruit quality candidates, and with a severe physician shortage looming, warm bodies are becoming an acceptable solution to staffing needs.

As distasteful as the thought of computer-matching physicians to hospitals may be, the real problems of VMS systems only become apparent with experience. After discussing user experience with several hospital system employees and reading various blogs and online debates here’s what I discovered:

1. Garbage In, Garbage Out. The people who input physician data (including their certifications, medical malpractice histories, and licensing data) have no incentive to insure accuracy of information. Head hunter agencies are paid when the physicians/nurses they enter into the database are matched to a hospital.

To make sure that their providers get first dibs, they may leave out information, misrepresent availability, and in extreme cases, even falsify certification statuses. These errors are often caught during the hospital credentialing process, which results in many hours of wasted time on the part of internal credentialing personnel, and delays in filling the position. In other cases, the errors are not caught during credentialing and legal problems ensue when impaired providers are hired accidentally.

Higher Workloads and Fewer Nurses? Not a Recipe for Patient Protection and Affordable Care.

May 8, 2014• 10

By Mark Graban

In further celebration of Nurses Week, it’s worth discussing this TIME article about the “Killer Burden on Nurses” under the Affordable Care Act.

The point I’m raising and highlighting here is not meant to be political or partisan, but really one about nursing workloads, management decisions, and what’s right for patients.

We’ve seen recently that American healthcare spending is UP about 10%(the biggest increase in spending since 1980) – mainly due to newly insured patients getting care. The point is to get people care and treatment, but maybe the law should have been called the “More People Getting Healthcare Act?” That’s a noble goal.

From the TIME article, an opinion piece written by a nurse from California:

“… I worry that the switch may compromise the quality of the care our patients receive.”

The nurse talks about patients who are sicker due to not getting good healthcare previously. These patients require more attention and more nursing time.

In any workplace, the staffing levels should be set based on the total workload. Using “number of patients” is not a good basis, since the acuity of patients (and the resulting workloads) aren’t equal. Not every patient is the same.

Hospitals, due to other industries, do a really poor job of “industrial engineering” work that would establish the right staffing levels based on workloads.

Why Nurse Practitioners Will Not Solve the Primary Care Crisis

Sep 4, 2013• 11

By Nicole Fisher

In coming years the US could see growing shortages in the availability of primary care physicians (PCPs). With the number of individuals seeking care increasing and the current medical system continuing to incentivize physicians to specialize, the number of available PCPs will decline proportional to the population. To fill that gap, Ezra Klein and others have asserted that expanded scope of practice will allow nurse practitioners (NPs) to serve as viable substitutes for primary care shortages.

While NPs serve a vital role in the system and meet need, the argument that they are a 1:1 substitute for PCPs (but for the greedy doctors and pesky regulations holding them back) is singular and shortsighted. The argument also fails to address broader policies that influence both NP and PCP behaviors. Policies that unjustifiably lead to the unequal distribution of caregivers, location or expertise, inherently parlay into unequal care for patients. Sadly, a broader scope than “freeing nurse practitioners” is necessary to meet primary care needs, as NPs are complements, not substitutes. Policy must address the need for more primary care and assist to realign the system to meet our country’s basic care and equality through redistribution.

Primary care is the foundation of the evolving health care system, with equal access the intended goal of the ACA. Along the way to meeting future demand for primary care, NPs can be increasingly utilized to meet the needs of Americans and improve the health of the nation. And let it be known I am a strong proponent and supporter of nurse practitioners and all non-physician providers and coordinators. However, the argument that most NPs practice in primary care and will fill the primary care gap, estimated at about 66 million Americans, is inaccurate. It isn’t a 1:1 substitute, especially given that models of the solo practitioner are vanishing in lieu of complementary and team-based care.

The US, unlike many western countries, does not actively regulate the number, type, or geographic distribution of its health workforce, deferring to market forces instead. Those market forces, however, are paired with a payment system whose incentives favor high volume, high return services rather than health or outcomes. These incentives are reflected in where hospitals steer funding for training, and in the outputs of that training.

Throughout the US there are geographic pockets that fail to attract medical professionals of all kinds, creating true primary care deserts. These deserts occur in part due to the unequal distribution of practitioners in the health care system, with our medical schools and salary opportunities producing low numbers of generalists across the board. We have even continued to see shortages in nurses throughout the US.

An “F” for Quality

Aug 27, 2013• 13

By Ken Covinsky, MD

Huge numbers of older persons transition from hospitals to the nursing home. Often, an older hospitalized patient needs skilled nursing care before they are ready to return home. In other cases, a nursing home patient who needed hospitalization is returning to the nursing home. Older patients and their families certainly hope that great communication between the hospital and nursing home would assure a seamless transition in care.

But a rather stunning study in the Journal of the American Geriatrics Society suggests the quality of communication between the hospital and the nursing home is horrendous. The study was led by researchers from the University of Wisconsin, including nurse researcher, Dr. Barbara King and Geriatrician Dr. Amy Kind.

The authors conducted interviews and focus groups with 27 front line nurses in skilled nursing facilities. These nurses noted that very difficult transitions were the norm. Sadly, when asked to give the details of a good transition, none of the nurses were able to think of an example.

Most of the nurses felt that they were left clueless about what happened to the their patient in the hospital. They lacked essential details about their patient’s clinical status. The problem was not the lack of paper work that accompanied the patient. In fact, nurses often received reams of paper work, often over 80 pages. The problem is that the paper work was generally full of meaningless gibberish such as surgical flow sheets that told little about what was actually going on.

Often the transfer information had errors, conflicted with what the facility was told before the transfer, and lacked accurate information about medications.

#MomInHospital

Aug 17, 2013• 10

By Bob Wachter, MD

A few weeks ago, a middle-aged man decided to tweet about his mother’s illness from her bedside. The tweets went viral and became the subject of a national conversation. The man, of course, was NPR anchorman Scott Simon, and his reflections about his mother’s illness and ultimate death are poignant, insightful, and well worth your time.

Those same days, and unaware of Simon’s real-time reports, I also found myself caring for my hospitalized mother, and I made the same decision – to tweet from the bedside. (As with Simon’s mom, mine didn’t quite understand what Twitter is, but trusted her son that this was a good thing to do.) Being with my mother during a four-day inpatient stay offered a window into how things actually work at my own hospital, where I’ve practiced for three decades, and into the worlds of hospital care and patient safety, my professional passions. In this blog, I’ll take advantage of the absence of a 140-character limit to explore some of the lessons I learned.

First a little background. My mother is a delightful 77-year-old woman who lives with my 83-year-old father in Boca Raton, Florida. She has been generally healthy through her life. Two years ago, a lung nodule being followed on serial CT scans was diagnosed as cancer, and she underwent a right lower lobectomy, which left her mildly short of breath but with a reasonably good prognosis. In her left lower lung is another small nodule; it too is now is being followed with serial scans. While that remaining nodule may yet prove cancerous, it does not light up on PET scan nor has it grown in a year. So we’re continuing to track it, with crossed fingers.

Unfortunately, after a challenging recovery from her lung surgery, about a year ago Mom developed a small bowel obstruction (SBO). For those of you who aren’t clinical, this is one of life’s most painful events: the bowel, blocked, begins to swell as its contents back up, eventually leading to intractable nausea and vomiting, and excruciating pain. Bowel obstruction is rare in a “virgin” abdomen – the vast majority of cases result from scar tissue (“adhesions”) that formed after prior surgery. In my mother’s case, of course, we worried that the SBO was a result of metastatic lung cancer, but the investigation showed only scar tissue, probably from a hysterectomy done decades earlier.