A middle aged woman had an appendectomy in outpatient surgery. Her postoperative vomiting and pain were controlled before she left the same day surgery area. She called the same day surgery nurse later in the day complaining of increasing pain and vomiting. Although the patient also complained of weakness and significant fatigue, the nurse apparently made the assumption that these symptoms were related to her surgery earlier that day and discounted the significance of the complaints. She advised the patient to “wait and see”. The patient had, in fact, ruptured her appendiceal stump and was leaking fecal material into her peritoneum. The patient later died of peritonitis and other complications related to her surgery.
The nurse had a decision support tool that included the words “weakness” and “fatigue” as red flags, but she failed to utilize it appropriately. This case is an example of the nurse jumping to a conclusion about the cause of the patient’s complaints and failing to err on the side of caution. The patient was at high risk because she had surgery that day, and was getting sicker at home. Although pain and vomiting are frequent complaints following abdominal surgery, the telephone triage nurse must “look outside the box” in order to identify unanticipated complications.
Lessons for Attorneys: Institutional Liability
How does an employer contribute to this kind of outcome?
1. Failure to provide adequate staffing for handling phone calls. A poorly staffed same day surgery unit may overtax the critical thinking skills of a nurse, setting him or her up to fail.
2. Initial phone call handled by unqualified people. In many settings, clerical people answer the call, collect the initial information about the nature of the call and then send it to the appropriate person. This relies on the untrained person to identify high risk patients.
3. Failure to provide specialized training. Nurses who take calls from patients should be educated to recognize the potential significance of patient complaints and to provide the appropriate referral. Same day surgery nurses must be aware of the potential postoperative complications and direct the caller appropriately.
4. Failure to provide policies and procedures. Decision support tools should be provided, reviewed, and approved by medical, nursing, and administrative personnel. Nurses should be taught how to use them, but also be free to use clinical judgment and critical thinking.
Case contributed by Carol Rutenberg MNSc, RNC and described in Rutenberg, C, Greenberg, M., Councell, T. and Evans, A., (2011). Telephone triage: A primer for lawyers and LNCs, in Patricia Iyer, Barbara Levin, Kathleen Ashton and Victoria Powell (Eds.), Nursing Malpractice, Fourth Edition, Tucson, AZ: Lawyers and Judges Publishing Company. Carol also described this in a teleseminar: Review of Current Litigation Relative to the Practice of Telephone Triage – How to Anticipate and Avoid Mistakes that Result in bad Outcomes.
Patricia Iyer MSN RN LNCC is president of Med League.
A two-year-old was seen by his pediatrician and diagnosed with tonsillitis. He became sicker throughout the day. The mother called later that day complaining that she was “concerned about his breathing”. A multitasking office nurse returned the call an hour later. She advised the mother that the office was closing and that she could take her son to the urgent care center or emergency department if he got worse. The initial documentation was scant and even the full page late entry failed to reflect an adequate assessment or any evidence of the nurse performing critical thinking. The mom and dad thought the child was better as his breathing became calmer. The child died later that night related to respiratory difficulties. The physician knew nothing about the phone call.
The nurse made multiple clinical errors in this situation including:
• failure to perform an adequate assessment,
• failure to utilize critical thinking,
• failure to err on the side of caution and
• failure to create adequate documentation of the call.
Additionally, the situation was further complicated by the organizational failure to develop and implement policies regarding the practice of telephone triage (sorting through problems over the phone), including failure to provide decision support tools and failure to provide specially trained staff to provide this service. It is also likely that the fact that the nurse was multitasked contributed significantly to the nurse’s poor performance.
Lessons for Attorneys
1. Receptionists should not be making decisions and giving advice to patients calling in with complex concerns. A registered nurse should handle this call.
2. Some offices are staffed by licensed practical nurses, but this level of nurse, who has less education than a registered nurse, is not equipped to gather information and make decisions about complex problems over the phone.
3. Office nurses who are expected to handle varied responsibilities are at risk for missing important information during a phone call from a patient. During discovery in a case involving an office nurse, determine what else the nurse was expected to do that day. Some offices use nurses who are dedicated to answering patient calls.
4. Nurses may have decision support tools that guide them through the process of gathering information and developing a decision on whether the patient should be seen in the office or referred for emergency care. There is a risk that the nurse who relies on the decision support tool will not apply independent judgment by considering other factors, like the distance from the office, the time of day, and the patient’s characteristics and condition. The standard of care requires the nurse to use critical thinking skills. On the other hand, the nurse who ignores the available decision support tools may miss important details.
5. Although patients are frequently right about what is wrong, they have limited knowledge about the possible reasons for the symptoms. Nurses are expected to use clinical judgment and not rely on the patient’s self-diagnosis.
6. Nurses must refrain from stereotyping the patient. They may think, for example, that a woman is too young to be having a heart attack, or a patient who frequently calls the office is needlessly trying to get attention.
7. There is increased awareness in the healthcare world about the risks associated with fatigue and haste. The nurse may be feeling pressured by calls backing up, but must spend the time needed to gather the data and form a plan of care that is warranted by the patient’s complaints.
8. Nurses are educated to follow, “If in doubt, send them out (of the home to the office).” They must err on the side of caution and consider the worst case scenario. “The worst headache of my life” could be an impending stroke. “Indigestion” could be an impending heart attack. Nurses are no educated to make medical diagnoses or prescribe medications. They are educated to collect data and obtain help for the patient.
Case contributed by Carol Rutenberg MNSc, RNC and described in Rutenberg, C, Greenberg, M., Councell, T. and Evans, A., (2011). Telephone triage: A primer for lawyers and LNCs, in Patricia Iyer, Barbara Levin, Kathleen Ashton and Victoria Powell (Eds.), Nursing Malpractice, Fourth Edition, Tucson, AZ: Lawyers and Judges Publishing Company. Carol also described this in a teleseminar: Review of Current Litigation Relative to the Practice of Telephone Triage – How to Anticipate and Avoid Mistakes that Result in bad Outcomes.
The story of Amanda Trujillo is a horrifying one. Briefly, she is a single mom who fought to get off welfare and fulfilled her dream of becoming a nurse. Not only did she become a nurse, she earned a masters degree in nursing. One night while working at Banner Health in Arizona, she took care of a patient who was being asked to undergo a liver transplant. In talking to the patient, Amanda learned that the patient did not fully understand what was going to occur. Amanda educated the patient. She explained the option of hospice instead. The patient decided against the transplant. Then the physician came in, had a well- witnessed tantrum at the hospital when he found out his patient had decided against surgery, and Amanda was fired by the hospital. Her case came up for review by the Arizona Board of Nursing. The summary of her case written by the attorney representing her is below. Amanda has been devastated in terms of her career and her finances. She is back on welfare, her dream of being a nurse shattered.
Read more about the details of what happened here, including Amanda’s description of the events.
Amanda Trujillo was guilty of doing what nurses are trained to do – to be a patient advocate. We are required according to our ethical codes to speak up on behalf of patients. The physician was obligated to explain the risks and benefits and alternatives of the surgery. Somewhere along the way this process got derailed, and the patient was left not understanding the impact of what she was facing. Shame on the doctor for not seeing his patient as a person instead of a case, and shame on Banner Health for bowing to the pressure to terminate Amanda for doing her job. Shame on everyone for labeling Amanda as being in need of a psychiatric evaluation.
I have been reviewing medical and nursing malpractice cases as a legal nurse consultant for 23 years. I am a past president of the American Association of Legal Nurse Consultants. When nurses do NOT speak up to question doctor’s orders, to advocate for their patients, to report changes in condition because they are intimidated, BAD outcomes can result. All of us are patients; all of us need advocates to help us make decisions. Amanda fulfilled that role. The nightmare that has descended on her head is horrifying.
Here is my letter to the Arizona Board of Nursing
Arizona State Board of Nursing
4747 North 7th Street, Suite 200
Phoenix, AZ 85014-3655
602-771-7800 Phone
602-771-7888 Fax
arizona@azbn.gov Email
http://www.azbn.gov/Default.aspx
To whom it may concern,
In the case of Amanda Trujillo, RN, as I understand the details of her case, she was doing her job. She was upholding her obligation to be a patient advocate. I have been a legal nurse consultant for 23 years, a past president of the American Association of Legal Nurse Consultants, and editor of Nursing Malpractice, Fourth Edition, 2011, published by Lawyers and Judges Publishing Company. I have seen cases in which patients have been injured by incompetent physicians.
Amanda’s case needs to be looked at in the bigger issue of patient care. Yes, she educated her patient to help her decide on the best option for her. But what happens to other Arizona nurses who need to educate their patients if that education results in incurring the wrath of a physician? When the nurse is silenced, afraid to speak up, afraid to advocate for the patient, some very bad results can occur. Your disciplinary action against Amanda would send a message to nurses that they should not speak up. Your failure to support her would undermine the very necessary safety net that nurses provide.
Ten years ago, five years ago, the Arizona Board of Nursing could have taken action against Amanda with very little notice from the world outside your borders. Now, through social media, you have a spotlight on your actions. We watched the case of the nurses in Texas and rallied behind them. You can’t hide. Do the right thing and drop the complaint against Amanda. Allow her to resume her life.
Best regards,
Patricia Iyer MSN RN LNCC
Past president of AALNC
Read more about Amanda below and at this link: http://www.nursefriendly.com/amanda/
BEFORE THE Arizona STATE BOARD OF NURSING
In the Matter of Registered Nurse License No. RN137552 issued to:
Amanda Trujillo,
Respondent. )
RN/LPN INVESTIGATIVE QUESTIONNAIRE
DESCRIPTION OF EVENTS
(Nurse Practice Consultant, Ann Schettler)
Respondent Amanda Trujillo, by and through undersigned counsel, submits this Description of Events in response to a complaint filed against her in (date omitted) with the Arizona State Board of Nursing (“Board”) by (“facility”).
Description of Relevant Events
The allegations contained in the complaint arise from events that occurred on (omitted), when Ms. Trujillo was caring for a patient with end stage liver disease in the (unit at facility). Ms. Trujillo had been a registered nurse with (facility) for approximately six months prior to the date of the alleged conduct and she normally worked the night shift from 7 a.m. to 7 p.m.
After assessing and communicating with the patient, Ms. Trujillo’s evaluation led her to believe that the patient did not fully understand what she had consented to when (pt) agreed to go forward with an intensive transplant evaluation scheduled to begin at (facility) the following day. Based on her nursing assessment, Ms. Trujillo gathered patient education materials and spoke with the patient regarding the transplant evaluation, the waiting period and the commitment needed in following a lifelong self-care regimen. After their discussion, the patient expressed a desire to learn more about hospice care because (pt) was uncertain she was willing to take the necessary steps to maintain a successful organ transplant. Thus, the patient inquired into whether (pt) could speak with a hospice representative. Ms. Trujillo then placed an “order” for a case management consult with a hospice representative. Ms. Trujillo did not believe that requesting a case management consult was a medical order requiring physician permission; she believed the consultation was for educational purposes in order to give the patient a broad understanding of her options.
As a result of the additional information given by Ms. Trujillo, the patient determined (pt) did not want to go through with the liver transplant evaluation or resulting transplant procedure. When the doctor treating the patient found out about the patient’s wishes to forgo the evaluation he was unhappy that the patient had changed (pts) mind and determined that the education given by Ms. Trujillo was the underlying cause of the patient’s change of heart. He accused her of going beyond her scope of practice by entering a physician order without permission (“ordering” the case management consultation). As a result of the accusation, Ms. Trujillo was placed on administrative leave by her nursing director, and was eventually terminated by (facility).
Ms. Trujillo believes she was well within her scope of practice to assess the patient’s understanding of (pts) plan of care. She was not acting outside her scope of practice by educating the patient (deferring all questions outside of her scope to the medical team), once she determined the patient had a gross misunderstanding of what (pt) had agreed to participate in. Ms. Trujillo believed that the case management “order” she placed on the patient’s behalf was not a medical order that needed physician permission. Each step of the treatment provided by Ms. Trujillo to the patient will be analyzed below.
Patient Assessment
It is standard practice for Ms. Trujillo to ensure her patients understand their medications, plan of care and treatments. While fully reviewing the patient’s medical record Ms. Trujillo read a progress note entered by the patient’s primary care physician from earlier in the day that noted a “transplant evaluation is the only viable option outside of Hospice.” Utilizing the standard nursing process of patient assessment (assessment, diagnosis, planning, intervention, evaluation), Ms. Trujillo asked the patient a number of open-ended questions regarding (pts) hospital stay, medications, liver disease, procedures, etc. Ms. Trujillo asked the patient if (pt) had received any information or teaching regarding the proposed transplant evaluation. The patient, to Ms. Trujillo’s surprise, responded that (pt) did not understand (pts) disease, plan of care or what a transplant evaluation entailed. The patient asked Ms. Trujillo if she could provide some information regarding the disease and any less invasive choices that would allow (pt) to go home and be with (pts) family. Based on this request Ms. Trujillo determined the patient had a knowledge deficit regarding (pts) disease and the choice to receive palliative care.
Patient Education
Having assessed the knowledge deficit related to the patient’s routine medications, disease process, associated tests and procedures, the plan of care for transplant evaluation and palliative care options, Ms. Trujillo proceeded to print out patient educational material from facility’s website that addressed those areas. Additionally, she printed out education materials from facility’s transplant website pertaining to what to expect during a transplant evaluation and what to expect after a transplant. Ms. Trujillo also provided materials related to hospice care per the patient’s request. Ms. Trujillo, concerned about the patient’s lack of understanding of (pts) treatment regimen and the option for comfort care, discussed her education of the patient with her clinical manager, (omitted), who readily supported Ms. Trujillo’s plan of care and interventions.
Ms. Trujillo and the patient reviewed the materials over the course of the night. After a full review of the materials the patient stated, “Had I known everything I would have to go through and the commitment I would have to make, I would not have agreed to the transplant evaluation.” The patient inquired into whether there was anything else (pt) could do besides enduring more tests, procedures or surgeries. Ms. Trujillo then explained hospice care services and the differences between symptom relief care and end of life care. The patient expressed serious concern that (pt) would not be able to commit to an extensive aftercare regimen following the transplant by stating “at this stage in (pts) life (pt) just wanted to be around family.” The patient requested to visit with a representative from hospice in order to ask some questions and gain additional information that would assist (pt) in making a more informed decision regarding (pts) course of care.
Ms. Trujillo placed a note in the chart pertaining to the assessment of knowledge deficit, the specific education provided and the palliative care discussion, in addition to, the patient’s request to see a case manager from hospice. She used the SBAR (Situation, Background, Assessment and Recommendation) format of report required in (facility) policy when she handed off care of the patient to the dayshift nurse, alerting the nurse that the patient requested more information prior to being transferred to another facility for a transplant evaluation. She also alerted the dayshift nurse that there was a nursing note in the record for the doctor to read that detailed what occurred over the course of Ms. Trujillo’s shift with the patient.
Case Management Consult
As a relatively new nurse to (facility), Ms. Trujillo self-educated in order to work within facility’s policies and procedures. She found no specific policy or procedure regarding end of life care that prohibited her from obtaining case management consultations for her patients. She also could not find any policy or procedure that gave a formal definition of a “physician order” or what nurses could order and what they could not. In fact, Ms. Trujillo had ordered hospice consultations for her patients on numerous occasions prior to this incident without any objections from other physicians or (facility) administration. She entered the “order” with a note stating, “per patient request, patient wants to visit with hospice representative for more information.” In fact, the computer system in place at (facility) allows her to click a box that further specifies “Nurse Ordered,” which she did on this occasion.
The only reason Ms. Trujillo’s actions turned into allegations of unprofessional conduct is because the primary care physician on this case, The Dr. initiated an angry public display when he found out that the patient had changed (pts) mind regarding the transplant. Ms. Trujillo was surprised when the nursing director, went so far as to tell Ms. Trujillo that the physician was angered because she had, “messed up all of the work they had done, and that the doctors were nowhere near going down the hospice route.”
Conclusion
This was not a medical order. This was a nurse trying to help a patient become better informed about a life changing procedure and (pts) right to choose what direction (pts) care would go. Ms. Trujillo’s actions were well within her scope of practice and she conscientiously kept her line of teaching within the boundaries of her scope of practice by taking care to utilize the proper channels to obtain patient teaching materials and advising the patient to ask the doctors about more complex questions she was unable to answer as a registered nurse.
The patient had the absolute right to self-determination regarding her course of treatment, as illuminated in Senate Bill S. 1052, the Bipartisan Patient Protection Act, after receiving additional information regarding her disease. Ms. Trujillo, working within her scope of practice and the nurse’s code of ethics, honored and protected that right when she abided by the patient’s requests to the best of her ability.
Accommodating a patient’s request for a consultation with a hospice case manager does not require a physician’s order. No medication was requested, no equipment was needed, and no procedures were required. A patient simply wanted to speak with an expert regarding her options for comfort care and end of life care, so that (pt) could make the best decision about (pts) future.
It is standard knowledge that the Cerner electronic health records system in place at (facility) contains a box that states, “Nurse Ordered.” Why would this box exist if nurses were never allowed to “order” anything? The Complainant contends that Ms. Trujillo overstepped her scope of practice by ordering the consult; however, it is standard practice of the hospital to allow nurses the freedom to do the exact thing alleged in the Complaint.
Ms. Trujillo was allowed to order case management consults on numerous occasions prior to this and was never told by the hospital that this practice was not allowed or outside the scope of her practice. It is apparent that the hospital is simply trying to appease and placate an angry physician by filing this Complaint against Ms. Trujillo.
She looks forward to discussing this matter with the Board, if necessary, and hopes to conclude this matter expediently.
SUBMITTED: July 11, 2011
ROBERT CHELLE LAW
By: ______________________
Robert Chelle
Attorney for Amanda Trujillo
****Amanda Trujillo’s response to this post:
Amanda Trujillo: Patricia i have seen your name before all this, like I’m supposed to know you for some reason—thank you for your wonderful support–having a veteran nurse such as yourself behind today’s nurses is an incredible gift
Nursing homes: brace yourself. The baby boomers will be flooding nursing home in the not that distant future. Although there are about 1.5 million Americans in nursing homes now, the number will dramatically increase as the baby boomer population begins to need care. It is anticipated that as many as half of all Americans who are now sixty-five years old or older will be admitted to a nursing home at least once in their lifetimes. By 2030, one in five will be elderly. By 2040, the number of nursing home patients will have reached an unprecedented six million. (1)
And watch this video. If you litigate nursing home cases, you have built in job security.
(1) Elder Mistreatment: Abuse, Neglect And Exploitation In An Aging America, 2003, Washington DC National Research Council Panel to Review Risk and Prevalence of Elder Abuse and Neglect
The plaintiff’s nursing home expert is asserting that the nursing home resident died as a result of poor medical or nursing care. A geriatrician is the best expert to evaluate the complicated interplay of chronic and acute illnesses. The long term care medical record presents details of the resident’s illnesses and conditions. A legal nurse consultant is an effective professional to summarize the details of medical problems documented in acute care, physician office records and nursing home charts.
Two nursing home defense attorneys (Ami DeMarco, Esq. of Chicago and Eugene Giotto Esq. of Pittsburgh) presented a program in Miami last year, in which Pat Iyer participated as a panelist. Here is what they did to present medical information to the jury. They created a number of effective exhibits.
1. They created an exhibit with a picture of the nursing home resident, now deceased, with her photo centered on the exhibit. On the left side of her photo, in a column running from the top of the page to the bottom of the page, they listed all of her medical conditions. The problems fit into the categories of heart, lungs, kidneys and other conditions. On the right side of the page, they listed all of her 16 medications.
2. On the second exhibit, they presented her death certificate and highlighted the causes of death in a yellow box. In this case, they were congestive heart failure, ischemic cardiomyopathy and end stage renal disease.
3. On the third exhibit, they grayed out all portions of the death certificate except for the causes of death. The causes of death were enlarged. Under the enlarged section, they transcribed the causes of death into typewritten words.
4. The final exhibit showed the medical conditions which were detailed in the left side column of exhibit 1, as described above. The attorneys took the sections of the death certificate and the transcription boxes and placed them on the right side of the exhibit. Using black arrows, they pointed from the causes of death to the left column.
A charge of tampering with medical records was one of the factors in this case. The treatment records showed the resident was discharged from the facility on 10/2/08. Yet the nursing home staff documented care (turning and positioning, application of ointment) as being given until 10/11/08, the day of her death. In an effort to rebut charges of inaccurate charting, the defense attacked the causation of death.
Pat Iyer is President of Med League, which supplies nursing experts for Nursing Malpractice cases.
Did policies to reduce medical residents’ fatigue compromise quality of training? Is learning more important than risks of fatigue-induced medical errors? The debate raged as we approached a deadline of July 2011, which limited residents’ working hours to no more than 16. A doctor told me that limiting hours for residents did not prepare them for the “real” world after training was over. I would hate to be harmed, or see a person I loved harmed, by a well meaning but sleep-deprived resident.
Patient safety has long been a critical concern for hospitals, in particular for those training new doctors. Since 1984, when the death of 24-year-old Libby Zion at a New York hospital was attributed to an overtired medical resident, training programs have faced restrictions on the length of work shifts for the least-experienced medical doctors. Last year, the ACGME, which oversees residency programs, issued the most restrictive guidelines to date: Residents should serve no longer than 16-hour shifts in the hospital.
“Our results showed that the duty-hour limitations may not be a quick fix to an important problem,” says Mayo Clinic internist and co-author Darcy Reed, M.D., M.P.H. (http://www.mayoclinic.org/bio/12376205.html).
The survey sent to directors of residency programs around the country found that many were concerned that the duty-hour limitations to be implemented by July 2011 would impinge on physician education. Of the nearly 500 respondents from the fields of surgery, internal medicine and pediatrics, 87 percent of program directors felt that the shortened shifts would interrupt the interactions between residents and hospitalized patients. “Many survey respondents expressed concern that the limits will decrease the continuity of care. As residents face more hand off of responsibilities within a 24-hour period, they have less opportunity to see and learn how patients’ care progresses,” Dr. Reed says.
You don’t hear much now about the possible compromise to residents’ learning. Hospitals have adjusted to the new limits by hiring more nurse practitioners and hospitalists to provide coverage.
According to a December 2011 Joint Commission Sentinel Event Alert, the impact of fatigued residents and physicians has been the focus of many studies. Here is what we know;
Residents who work traditional schedules with recurrent 24-hour shifts:
Make 36 percent more serious preventable adverse events than individuals who work no more than 16 consecutive hours
Make five times as many serious diagnostic errors
Have twice as many on the job attentional failures at night
Experience 61% more needlestick and other sharp injuries after their 20th consecutive hour of work
Experience at 1.5 to 2 standard deviation deterioration in performance relative to baseline rested performance on both clinical and non-clinical tasks
Report making 300 % more fatigue related preventable adverse events that led to a patient’s death.
The Joint Commission made several recommendations directing healthcare organizations to assess the risks of fatigue-related injuries and to take steps to create a safer culture. These directives will be increasingly important for medical malpractice attorneys as they investigate the factors that led to an injury of a patient. We know residents have to learn; that is part of the training. We know that learning medicine is challenging. But we don’t have to make them learn and function crippled by sleep deprivation.
Pressure relief mattresses
Pressure relief mattresses treat the risk of pressure sores, but also create another risk: death. Selecting the correct mattress for pressure relief should take into account these factors in MATTRESS:
Microclimate and moisture
Activity levels
Tissue tolerance
Total body weight
Repositioning needs
Edema
Shear and friction
Symptom management
Bed entrapment
When considering support surfaces in bed, healthcare providers must consider the risk of entrapment. Health Canada and the FDA have released documents defining the seven zones of entrapment and guidance measurements:
1. Within the bed rail
2. Under the rail
3. Between the rail and the mattress
4. Under the rail at rail ends
5. Between split bed rails
6. Between end of rail and side edge of head or foot board
7. Between head or foot board and mattress end.
Prescription of a therapeutic support surface, whether an overlay or mattress replacement, may impact several of these zones (e.g. zone 2, 3, and 7). A standard measuring device is available to check to see if the new support surface increases the risk of entrapment by allowing spaces greater than those outlined in the guideline. The risk of entrapment may also be greater with support surfaces with large air bladders (these are usually found on low air loss, alternating, or rotating surfaces). These surfaces tend to collapse the further the individual moves to the edge of the surface, even when a perimeter border is present within the mattress.
Entrapment risk: Liability
When an entrapment risk has been identified, bed rails should only be used with extreme caution, and be based on the needs of the individual patient. Some patients find the half bed rail at the head section helpful for repositioning. Another approach for people at high risk is to use an adjustable bed with a very low deck height and a floor mat. This approach allows the bed to be raised during care, to a comfortable height for care providers, but allows the bed to be low enough to help prevent injury if the person falls out of bed. Foam wedges and other devices are also available to help reduce the risk of entrapment.
The standard of care will focus on correct selection of the mattress based on identification of risk, and monitoring the patient.
Dr. Diane Krasner
Modified with permission from Kestral Woundsource Devices White Paper, coauthored by Dr. Diane Krasner, November 2011
Get in on the shifting thinking about pressure sores by learning from one of the experts in the field. Dr. Krasner explores these and other controversies in an all new multimedia course that will take place on February 27 and March 5. Set aside the day of February 27 to join us for an interactive course, and complete the course the evening of March 5. Reserve your spot today. Can’t join us on either date? Get the on demand recordings for Pressure Sore Case Analysis and Reports here.
When you register for the course, you will receive 10 articles loaded with essential information about pressure ulcers, the opportunity to participate in the course and receive the transcripts, plus a substantial discount off two programs: Take the Terror of out Testifying and Negative Pressure Wound Therapy. Receive an individualized optional critique of your report. Sign up for Pressure Sore Case Analysis and Reports here.
Hospitals in which nurses work long hours have higher rates of patients deaths from pneumonia and acute myocardial infarction, according to a study.
Fatigue harms patients
Researchers at the University of Maryland School of Nursing and Johns Hopkins School of Medicine conducted a study of nurses’ work schedules, staffing and patient outcomes as part of ongoing research funded by the National Council of State Boards of Nursing.
In the study — “Nurses’ Work Schedule Characteristics, Nurse Staffing, and Patient Mortality,” which appears in the January/February issue of Nursing Research — the authors examined patient outcomes and staffing information from 71 acute care hospitals in Illinois and North Carolina. They compared the data with survey responses of 633 randomly selected nurses who worked at the hospitals.
Long work hours and lack of time off were the components most frequently linked to patient mortality. Co-author Alison Trinkoff, RN, ScD, MPH, FAAN, professor at the Maryland School of Nursing, said nurses need time off to rest and recuperate for their own health and to ensure a high level of performance on the job. Read more.
Comments: Fatigued, distracted, and exhausted nurses are working 12 hour shifts or longer. Some are working these hours by choice because it provides more days off. Some have no choice since 12 hour shifts are the only possible staffing pattern. And patients are paying the price. What may be good for an organization, in terms of staffing, may not be good for nurses. Ultimately patient safety depends on clear thinking, critically thinking, and clear communicating nurses. Fatigue from being on one’s feet for 12 hours interferes with these abilities. One study from 2004 showed that nurses who work shifts of 12.5 hours or longer are three times more likely to make an error in patient care. Here it is 6 years later and we still have 12 hour shifts.
In December 2011, The Joint Commission published a Sentinel Event Alert about healthcare worker fatigue and patient safety. This is the impact of fatigue:
lapses in attention and inability to stay focused
impaired communication
memory lapses
irritability
confusion
compromised problem solving
slowed or faulty information processing and judgment
diminished reaction time
reduced motivation
indifference and loss of empathy
It is time we look at the evidence and rethink long, intense, and exhausting shifts. When a poor outcome occurs, medical malpractice attorneys should be asking for the staff records of the nursing unit, and delve into how many shift sin a row and how many hours in a row the nurses were working. With the publication of the Sentinel Event Alert, pressure increases on hospitals to address the fatigue-related risks.
Pressure ulcer product selection
Current wound care expertise encompasses numerous dressing-related skills including:
• Treating the cause of the wound and addressing patient centered concerns to set the stage for local wound care
• Properly assessing the wound and identifying the dressing requirements
• Selecting dressings based on their form and function for an individual wound’s needs
• Meeting setting-specific requirements for dressing change frequency and maintenance
• Addressing formulary or healthcare system availability as well as reimbursement requirements
Wound care product selection today must be as sophisticated and as evidence-based as possible. Wound dressing product selection process is based on three principles:
Pressure ulcer products: the olden days
Many wound care clinicians remember the “good old days” when wound dressing product selection simply involved choosing between a handful of products that were essentially variations on the same theme. There was gauze, impregnated gauze and filled gauze pads. In the earlier 20th century, clinicians added antimicrobial solutions, creams and ointments (like Dakin’s solution developed during World War I and silver sulfadiazine developed in the 1960’s) and the wound care formulary was limited and simplistic.
Fast forward to the 21st century and wound care clinicians are confronted with a totally different situation: hundreds of products, scientific rationale for moist interactive dressings and an emerging evidence-base for product selection. Selecting appropriate wound dressing products and supportive care to maximize healing and patient outcomes is a complex process. Dressing and local wound care options based on science and best practices must be filtered by clinical experience and must be consistent with patient preferences, care- giver requirements and setting/access issues. Additionally, effective dressing selection and local wound care planning involve the perspectives of the entire interprofessional team.
Knowing the performance parameters of dressing categories/ individual products and matching these attributes to an individual’s wound can optimize the healing process. But dressings are only one piece of the puzzle. Dressings alone will not promote wound healing, unless the underlying cause(s) for the wound are also addressed (e.g. treatment of the wound cause, blood supply, nutrition, patient centered concerns, local wound care etc.). As the wound changes, the plan of care must change and dressing products may have to be changed.
• Optimizes the local wound healing environment
• Reduces local pain and suffering
• Improves activities of daily living and quality of life
Inappropriate presure ulcer dressing selection can:
• Cause the wound status to deteriorate (e.g. wound margin maceration, increased
risk of superficial critical colonization or deep infection, skin stripping).
• Increase local pressure or pain especially at dressing change (dressing removal
and cleansing).
• Increase costs with the need for frequent dressing changes or the selection
of an inappropriate advanced or active dressing.
National and international wound care guidelines and best practice documents mean that there is no longer a local standard of care. No matter where nurses and doctors practice, they will be held to national/international standards of wound care practice. Some experts have argued that the selection of the wrong dressing is just as problematic as the administration of the wrong drug and the clinician would be just as liable in a court of law. If dressings can be shown to delay the healing process (e.g. wet-to-dry gauze dressings in a wound that requires moist wound healing, pain from inappropriate adhesives, failure to treat critical colonization that can lead to deep infection), their use might be deemed negligent by a jury in a court case.
Modified with permission from Dr. Diane Krasner, coauthor of Wound Dressing Product Selection, 2010
Dr. Diane Krasner
Dr. Diane Krasner provides an analysis of the liability associated with pressure sore development and treatment in a new multimedia course that will take place on February 27 and March 5, 2012. Set aside the day of February 27 to join us for an interactive course, and complete the course the evening of March 5. Reserve your spot today. Can’t join us on either date? Get the on demand recordings of Pressure Sore Case Analysis and Reports here.
When you register for the course, you will receive the full article quoted from here, plus 9 additional articles, the opportunity to participate in the course and receive the transcripts, plus a substantial discount off two programs: Take the Terror of out Testifying and Negative Pressure Wound Therapy. Receive an optional individualized critique of your report. Sign up for Pressure Sore Case Analysis and Reports here.
Early bird pricing ends on February 13.
A middle aged woman had an appendectomy in outpatient surgery. Her postoperative vomiting and pain were controlled before she left the same day surgery area. She called the same day surgery nurse later in the day complaining of increasing pain and vomiting. Although the patient also complained of weakness and significant fatigue, the nurse apparently made the assumption that these symptoms were related to her surgery earlier that day and discounted the significance of the complaints. She advised the patient to “wait and see”. The patient had, in fact, ruptured her appendiceal stump and was leaking fecal material into her peritoneum. The patient later died of peritonitis and other complications related to her surgery.
