Category Archives: Clinical care
This is part of the March 2014 issue of Sharing Nursing’s Knowledge.
It took Arnold S. Relman, MD, one of the nation’s foremost medical thinkers, nine decades and a full-blown medical catastrophe to fully appreciate the value of nurses, according to an essay he penned in the Feb. 6 edition of the New York Review of Books.
Relman, 90, a doctor, a professor emeritus at Harvard Medical School, and a former editor of the New England Journal of Medicine, learned this lesson the hard way: as a patient. Last summer, Relman fell down the stairs and suffered life-threatening injuries—and discovered the critical role nurses play in health and health care during his lengthy recovery.
He shared his late-in-life epiphany in his recent essay: “I had never before understood how much good nursing care contributes to patients’ safety and comfort, especially when they are very sick or disabled,” he wrote. “This is a lesson all physicians and hospital administrators should learn. When nursing is not optimal, patient care is never good.”
Relman’s remarks spawned a surprise reaction from Lawrence K. Altman, MD, who begged the following question in a post on the New York Times Well Blog: “How is it that a leading medical professor like Dr. Relman—who has taught hundreds of young doctors at Boston University, the University of Pennsylvania (where he was chairman of the department of medicine) and Harvard—might not have known about the value of modern-day Florence Nightingales?”
What do you think? Do medical educators and scholars fully appreciate the contributions nurses make? Register and leave a comment.
Nicole Lurie, MD, MSPH, is the assistant secretary for preparedness and response at the U.S. Department of Health and Human Services (HHS), and Kacey Wulff, MPH, is special assistant to the assistant secretary, at HHS. An alumna of the Robert Wood Johnson Foundation Clinical Scholars program, Lurie is the co-author of “The U.S. Emergency Care System: Meeting Everyday Acute Care Needs While Being Ready for Disasters,” published in the December 2013 issue of Health Affairs, which focused on the future of emergency medicine. This is part of a series of posts featuring RWJF Scholars who authored articles in the issue.
As we approach the Affordable Care Act’s March 31 enrollment deadline, data is starting to emerge about how these reforms are making care more accessible, cost less, and, ultimately, Americans healthier. As these reforms take effect, and make our day-to-day health care system stronger, they also result in strengthening communities across the country to become more resilient and disaster-ready.
The gaps that inspired and propelled health reform like untreated chronic conditions and mental illness, and health disparities plague our health care system every single day. During a crisis, like a hurricane, earthquake, or attack, these issues can become magnified. As a result, the ability for individuals and communities to prepare, respond, and recover successfully is intrinsically linked to the strength of the underlying health care system.
The Affordable Care Act expands mental health and substance use disorder benefits and federal parity protections for 60 million Americans. As a result, many Americans who previously have not had coverage for mental health care will have greater access to this and other important aspects of health care. This will help to make the tools that support recovery from injuries sustained during disasters, whether illness, injury, or trauma, more accessible.
This boost in preparedness is important for responding to disasters big and small: the biggest indicator of how a person or community will fare during a disaster is how they were doing before the crisis struck. While health insurance doesn’t guarantee that you will be healthier, it does make health much more likely.
This is part of the January 2014 issue of Sharing Nursing’s Knowledge.
Hush!!! Testing nurse-designed noise-reduction strategies for hospital wards
A common complaint of hospital patients is that just when their bodies need it the most, they can't get a good night's sleep because of noise and interruptions. A new initiative of three nurses at Beth Israel Deaconess Medical Center in Boston takes direct aim at the problem.
In response to patient satisfaction surveys that highlighted the problem of nighttime noise, Gina Murphy, BSN, RN, Anissa Bernardo, LCSW, and Joanne Dalton, PhD, RN, studied existing literature on the topic, developed a program they call Quiet at Night, and tested it on a 44-bed medical-surgical unit. The program includes a number of strategies for reducing noise, including closing doors at night when medically appropriate, supplying earplugs to patients, keeping patients by themselves in semi-private rooms when the census permits, using mini-flashlights when performing overnight checks to avoid turning on the lights, performing change-of-shift conversations in the break room rather than in hallways or at the nurses' station, providing headphones to patients who need the television on at night, and using beep-free keypads on doors. In addition, after 9 p.m., they implemented a number of “quiet hours” practices, including dimming lights, turning pagers to vibrate, avoiding overhead pages and hallway conversations, and more.
After implementing the strategies, the trio compared before and after surveys. In the three survey periods before the program, 43 to 47 percent of patients reported that their rooms were “always” quiet at night. After the program was in place, that jumped to 60 percent, which is the goal the nurses had set.
Zane Gates, MD, is a Robert Wood Johnson Foundation (RWJF) Community Health Leader and medical director of Altoona Regional Partnering for Health Services in Altoona, Pennsylvania. Gates and Patrick Reilly, president of Impact Health Solutions, founded the Empower3 Center for Health program, which is the model for a new health care law in Pennsylvania.
The Commonwealth of Pennsylvania has recently adopted a law to fund community-based clinics that can demonstrate real impact to the community with regard to increased access, reduced costs, lower emergency room (ER) visits, and improved behavioral health outcomes for the low-income working uninsured. It is modeled on community-based clinics featuring a unique structure that I created along with Patrick Reilly, an insurance consultant from western New York:— Empower3 Center for Health program.
The model we created features an “insurance-less” office concept that allows patients to come in as frequently as needed without worrying about being billed or having any balances to pay. The program has no co-pays, deductibles or balance billing when the patients use the participating community hospital that partners with the program. Since there is no billing at the point of service, there is more face time with the medical professionals to spend creating a true relationship that focuses on care and provides dignity to the patients seeking quality medical care. The office is open five days a week to provide access to patients as needed.
First-year surgical interns are getting less experience performing or assisting with surgeries as a result of the 16-hour workday cap enacted in July 2011 by the Accreditation Council for Graduate Medical Education, according to a study in JAMA Surgery.
In a review of 10 West Coast general surgery residency programs, researchers found 2011-2012 interns recorded a 25.8 percent decrease in total operative cases as compared with the preceding four years before the cap was enacted. There was also a 31.8 percent decrease in cases performed primary by the interns, under faculty supervision, and a 46.3 percent decrease in cases in which the interns assisted a faculty member.
“The decline in operative case volume in our present study is in some respects surprising given that the new duty-hour changes did not mandate a reduction in an overall 80-hour work week for interns,” the researchers write. “Thus, interns were presumably working the same number of total hours.” The program directors surveyed in the study reported that their predominant solution to the 16-hour rule was to expand the “night-float” system, meaning interns are increasingly working overnight when there are fewer intern-level, elective surgeries taking place.
This is part of the June 2013 issue of Sharing Nursing's Knowledge.
Summer’s here, and so is murder and mayhem—at least in the pages of a trio of newly released books about nurses.
In Death Without Cause: A Health Care Mystery, a young critical care nurse explores a series of unexplained deaths at the hospital where she works. Written by Pamela Klauer Triolo, PhD, RN, FAAN, the book was released in May to coincide with National Nurses Week.
Another nurse-centered mystery also hit the shelves in May. Bone Pit, featuring lead character Gina Mazzio, a registered nurse (RN), was written by RN Bette Golden Lamb and J.J. Lamb. It follows Sin & Bone and Bone Dry, the first two books in the series.
In the nonfiction department, investigative journalist Charles Graeber tells the haunting story of hospital nurse Charles Cullen. The Good Nurse: A True Story of Medicine, Madness, and Murder documents Cullen’s crimes against patients and the health care system’s failure to prevent them.
Also in the non-fiction department is a new collection of essays about nursing called I Wasn’t Strong Like This When I Started Out: True Stories of Becoming a Nurse. Edited by Lee Gutkind, the book will be featured in the July edition of Sharing Nursing’s Knowledge.
Other new titles—also published in 2013—take an academic approach to hot nursing topics.
Hospital units designed specifically for the care of older patients could save as much as $6 billion a year, a study from the University of California at San Francisco (UCSF) finds. In a randomized controlled trial, patients in “acute care for elders units” had shorter hospital stays and incurred lower hospital costs than patients in traditional inpatient hospital settings. At the same time, patients’ functional abilities were maintained, and hospital readmission rates did not increase.
The Acute Care for Elders program (ACE) relies on a specially trained interdisciplinary team, which can include geriatricians, advanced practice nurses, social workers, pharmacists, and physical therapists. The team assesses patients daily, and nurses are given an increased level of independence and accountability.
“Part of what ACE does is improve communication and decrease work. And that’s a strategy that’s generally popular with lots of folks involved,” Seth Landefeld, MD, senior author and chief of the UCSF Division of Geriatrics, said. “What we found was that ACE decreased miscommunication and it decreased the number of pages nurses had to make to doctors. Having people work together actually saved people time and reduced work down the line.”
The study was published in the June 2012 issue of Health Affairs.
Human Capital News Roundup: Screening for prostate cancer, organ donation, bariatric surgery, and more.
Around the country, print, broadcast and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) scholars, fellows and grantees. Some recent examples:
In an op-ed in the New York Times, Andrea L. Campbell, PhD, writes about how health care reform could benefit her sister-in-law, now a quadriplegic after a car accident. “As a scholar of social policy at [the Massachusetts Institute of Technology], I teach students how the system works,” she writes. “Now I am learning, in real time.” Campbell is an alumna and a member of the National Advisory Committee of the Robert Wood Johnson Foundation (RWJF) Scholars in Health Policy Research program, and the recipient of an RWJF Investigator Award in Health Policy Research. The Washington Post Wonk Blog and Esquire’s Politics Blog also picked up on Campbell’s story.
Medical News Today is among the outlets to report on a study led by an alumnus of the RWJF Clinical Scholars program, Danil V. Makarov, MD, MHS (a 2008-2010 U.S. Department of Veterans Affairs Clinical Scholar). A large share of patients diagnosed with prostate cancer are sent for unnecessary imaging, the researchers found, which could compromise the care they receive, delaying their ultimate treatment, and could also run up the costs associated with diagnosing and treating their cancers. Read more about the study.
Susan Bakewell-Sachs, PhD, RN, PNP-BC, program director of the New Jersey Nursing Initiative (NJNI), spoke to The Record (Hackensack, N.J.) about a report in the New England Journal of Medicine that finds the country’s nursing shortage may have temporarily eased. She also discussed nursing education in New Jersey. “What I tell students is they should be thinking of a career trajectory that includes an education projection path,” she said. “Anyone who has other people’s lives in their hands must be a lifelong learner.” NJNI is a program of RWJF and the New Jersey Chamber of Commerce Foundation.
Oregon Public Broadcasting reports on the success of an RWJF initiative—Transforming Care at the Bedside—in the state. The program encourages nurses and other frontline workers to suggest and implement ideas to make their hospitals safer. A recent survey by the Oregon Association of Hospitals and Health Systems found that over the last 10 months, there was a "10-percent increase in better access to supplies and equipment among staff; a 12-percent improvement in communication on the wards; and a 16-percent increase in nurses who say their ideas seem to count."
By Jason Karlawish, MD, professor of medicine and medical ethics at the University of Pennsylvania, and recipient of a Robert Wood Johnson Foundation Investigator Award in Health Policy Research
Just one year after President Obama signed the National Alzheimer’s Project Act into law, the U.S. is beginning to talk about Alzheimer’s disease. With input from 23 federal departments and agencies, the Department of Health and Human Services has issued the nation’s first National Alzheimer’s Plan, and the President’s budget proposes to increase funding for Alzheimer’s research and care by at least $156 million.
Alzheimer’s disease is now a national problem that we will tackle guided by a plan with five goals. Goal #1 is ambitious—to prevent and treat Alzheimer’s by 2025. The other goals are far reaching. They include detailed proposals to change the delivery of health care for patients and families, evaluate new models of care and housing for people with Alzheimer’s, and to provide services for their caregivers’ health and well-being.
Health care reform is hotly contested, and may even be repealed, but so far, this disease specific expansion of federal interventions and spending has largely escaped the recurrent and bitter partisan disputes over the role of the federal government in solving the nation’s health care problems, and the size of the federal budget and its deficit.
Alzheimer’s may, like other diseases of aging, largely remain free of partisanship at least in part because America is aging. Studies show that the chief risk factor for developing Alzheimer’s is something we can little change: our age. Demography is destiny, and as the number of Americans over 65 steadily grows, so too will the number of Americans with Alzheimer’s.
National action is needed, but as the U.S. is about to dive into tackling the Alzheimer’s problem, it is worth considering a fundamental guide of ethics. Before you decide what to do about something, you have to know what it is, otherwise, your plan may fail. Alzheimer’s disease is called the most common cause of dementia. But what we talk about when we talk about Alzheimer’s disease is changing. How might this changing language impact the success or failure of our national plan?
By Jason Karlawish, M.D., professor of medicine and medical ethics at the University of Pennsylvania, and recipient of a Robert Wood Johnson Foundation Investigator Award in Health Policy Research (2008).
Pat Summitt’s announcement that, at the age of 59, she has been diagnosed with dementia caused by Alzheimer’s disease is sad news. Her plan to continue working as the head coach of the eight-time NCAA Division I national championship University of Tennessee Lady Vols basketball team is a shot heard round an aging world.
A person diagnosed with dementia still working? The idea seems bizarre, and yet a big-money college athletic program does not run its coaching staff like a small town volunteer basketball program. The University’s decision to retain her as a coach is an opportunity for society to engage in a vigorous debate about how we will live with cognitive impairment as well as with other impairments associated with chronic diseases common to older adults.
Summitt’s exact story is unusual. Alzheimer’s disease is rare before the 7th decade of life. But the theme of her story is common, and, in the coming decades, it will be even more common.