Transitional care: part of care coordination across time and settings, specifically for patient populations at high risk for poor and costly outcomes as they cross health care settings.
There is the ideal (smooth, patient and family-centric) transitional care and then there is reality.
Case in point is my elderly father with congestive heart failure—the diagnosis associated with the highest Medicare health care costs. My father has been in four different health care settings over the past six weeks. These include an inpatientacute care hospital, a skilled nursing care/rehab facility, home nursing care, and as of today, home hospice. I have worked as a nurse in three out of four of the specific health care systems he has moved through. I know something about how they work—the key people to contact—the questions to ask—the code words to use to get things done. In spite of all that—plus flying cross-country to do much of this care coordination in person—it has been more than just difficult. As my father says, “There’s been a mix-up everywhere I go—it’s as if none of them communicate with each other.” Indeed, it shouldn’t be this hard. I keep wondering: how do people with fewer resources do this?
The metaphor for ‘good enough’ healthcare transitions that has occurred to me are those orange safety cones lined up re-directing traffic. Knowing the more ideal freshly paved road of smooth health care transitions is a ways off in the future, all I’ve yearned for are orange safety cones. I did finally see one bright orange safety cone today. It came in the form of a wonderfully compassionate male hospice nurse who spent over an hour patiently and respectfully talking to my father about quality of life–about what matters most to him and how hospice can help support him to pursue those things. Finally! Sanity and clear, direct communication from someone in the health care system. I thanked this nurse and asked him how long he’d been in nursing–14 years–and what he did before nursing–he owned/operated a bar. There are many paths to becoming a really great nurse.
In the Preface of Notes on Nursing, Florence Nightingale wrote, “…every woman is a nurse.” That men were—or could be—nurses was not within Nightingale’s Victorian worldview. Men were doctors (husbands) and women were nurses (wives and mothers). A re-read of her book revealed to me one place in which she hints at the fact that men could be useful as nurses. It comes mid-way through her chapter “Noise”:
“A man is now a more handy and far less objectionable being in a sick room than a woman. Compelled by her dress, every woman now either shuffles or waddles—only a man can cross the floor of a sick-room without shaking it!”
She goes on to condemn the wearing of rustling silk and crinoline and the creaking of stays and shoes. Presumably she advocated simple (and quiet) cotton dresses for nurses.
As I wrote in my previous blog post “More than a few more men needed in nursing” (12-15-10), nursing continues to be the least gender balanced of any of the health professions. The traditionally male-dominated medical profession has achieved almost perfect gender balance. The other traditionally female-dominated profession of social work now has at least 20% men, while nursing continues to have a paltry 7% men in the workforce.
Until this week I considered myself an enlightened female nurse on the issue of gender diversity in nursing. But then I started looking at the required readings—especially the ones from nursing textbooks—that I had assigned for my community health course. I realized how un-gender neutral they are. All of the contemporary community/public health nurses who are quoted or included in photographs in the chapters are female. An otherwise well-written chapter on the history of public health nursing in the U.S. only mentions female nurses and uses terms like “our sister nurses” and “our foremothers.” Where are our brother nurses and our forefathers?
Important facts I learned this week from reading up on the topic of men in nursing include:
Men in nursing have a long and venerable history that is not acknowledged or taught very well in nursing schools. The history includes monastic orders dating back to the fourth and fifth centuries.
In the U.S. beginning after the Civil War men were actively shut out of nursing. For instance, the U.S. Army Nurse Corps banned men until 1955. When men were allowed to be nurses they were mainly confined to psychiatric nursing, which was considered dangerous and undesirable work for female nurses.
The commonly held perception (and resentment) among female nurses that men in nursing disproportionately get promoted and hold higher-paying administrative positions over their female counterparts does have merit. Economists call this phenomenon the “glass elevator,” and it applies to men in all female-dominated occupations (pink-collar jobs). However, within nursing this could also be partially explained by the fact that most men enter nursing at an older age and after time in another career versus their female counterparts. (see NYT ” More Men Enter Fields Dominated by Women” by Dewan and Gebeloff/5-20-12 and “More Men Trading Overalls for Nursing Scrubs” by Vigeland/3-21-12).
The Institute of Medicine’s Future of Nursing report specifically identifies improvement in gender diversity as a necessity for nursing. Running a profession on only half of the population (gender-wise) is unwise and untenable.
My conclusion: Nursing needs the best and the brightest no matter what their chromosomal make-up happens to be. We need more men in nursing. We need better nursing textbooks….
Theresa Brown, RN has a new NYT monthly opinion piece column called “Bedside.” In a recent e-mail, Theresa describes her column as, “…a nurse’s eye view on ways to make health care better and more humane.” In her debut piece “Money or Your Life” (6-23-12/print version 6-24-12 in Sunday Week in Review section), she argues for the Affordable Care Act (ACA) based on her work as a hospital-based oncology nurse. She describes working with an uninsured male patient with leukemia who asked her about death panels, hoping they existed. It seemed he wanted to be put out of his misery, while avoiding bankrupting his family. Ms. Brown then does a good job of describing some of the complexities of–and the argument for–the individual mandate component of the ACA. This, of course, is a key element of the ACA, and one before the US Supreme Court as to its constitutionality. Their decision is due out this week.
Congratulations Theresa Brown! And thanks NYT editors for recognizing and including a nursing perspective on the continuing health care debate in our country.
Since this is a blog, and since Theresa Brown asked for feedback on her new column, I offer a few reflections. The name “Bedside,” as in bedside nursing, implies direct patient care in an inpatient hospital setting. As such, it is descriptive of the type of nursing Theresa Brown is involved with. But bedside nursing is a term often used as code for “real nursing,” as if community/public health, home health, school and occupational health, and nursing home nurses are somehow not real nurses. The name “Bedside” also perpetuates the notion that nurses spend the most time with patients of any health care team member, and are, therefore, in the best position to advocate for patient’s needs. This belief undermines patient care and safety by working against good health care team communication. It is a paternalistic (maternalistic?) belief that undermines the patient autonomy and agency central to patient-centered care. The belief is also not supported by facts.
Recent studies indicate that hospital-based nurses consistently (and significantly) overestimate the amount of time they spend on direct patient care. Whereas many nurses ‘guesstimate’ they spend over half their time during a given shift on direct patient care, national studies (sophisticated versions of time/motion studies) indicate that hospital nurses spend just 15% of their time in direct patient care. (see RWJ study by Hendrich, et al, “A 36-hospital time and motion study: how do medical-surgical nurses spend their time?” The Permanente Journal, Summer 2008) The largest percentage of their time was spent on charting and other administrative tasks. And a recent study found that physician hospitalists also spent 15% of their time in direct patient care (“Hospitalist time useage and cyclicality: opportunities to improve efficiency” Kim, et al. Journal of Hospital Medicine, July/Aug 2010). So nurses’ time-honored claim to spending the most time at a patient’s bedside is no longer true.
The Truth About Nursing had a post yesterday, “Amanda Trujillo: Fired for Educating A Patient?” Briefly, it is reported that in April 2011 the hospital administration where Ms. Trujillo was employed filed a complaint against her with the Arizona Board of Nursing (BON) and also fired her. The firing and BON complaint were allegedly for Ms. Trujillo referring her patient with end-stage liver disease to have a hospice consult—when the patient’s surgeon had already scheduled the patient for a liver transplant. As stated in the Truth About Nursing post, the Arizona BON was scheduled to decide on the case at its meeting at the end of March, but there are no public reports of their decision.
What I find most interesting about this case is the level of social media presence about the issue, and much of it directly from Ms. Trujillo. Unless there is someone posing as her, she appears to weigh in with details about her case on high profile forums such as KevinMD (see guest post by a semi-anonymous ‘J. Doe’, RN. “Why Physicians Should Care About Amanda Trujillo” date unstated). Ms. Trujillo set up an online legal defense fund to help defray the costs of retaining a personal lawyer to assist with her case with the Arizona BON. A psychiatric nurse who goes by the name Mother Jones and blogs under Nurse Ratched’s Place, has a link to the NurseUp! nursing advocacy website that reports having raised $1,700 in additional support for Amanda Trujillo. Mother Jones speculates in April 25th blog post that the case is headed to the court system, and that this is why there is no public information on the Arizona BON decision. There have been numerous letter-writing campaigns to the Arizona BON and the Arizona Nurses Association, as well as to various state officials and even to the ANA. There were allegations of close ties between the Arizona BON and the hospital which filed a complaint against Ms. Trujillo. There have even been calls to boycott the Arizona tourism industry in protest of the Arizona BON in the their handling of the case of Amanda Trujillo. Maybe boycotting Arizona’s hospitals would have made more sense?
I continue to be dismayed by the lack of understanding by nurses (and the general public) of just how corrupt and inefficient our state-level health professions regulatory system is. It will be interesting to see if higher profile cases such as Amanda Trujillo help bring much needed reform to this system. (see my previous post “Not Just Culture” 11-19-11 for more information on the health professions regulatory system and its relation to nursing and public health.).
Nurse and NYT’s Well Blog contributor Theresa Brown has a NYT Op-ed piece today entitled “Hospitals Aren’t Hotels,” in which she states “…the growing focus on measuring ‘patient satisfaction’ as a way to judge the quality of a hospital’s care is worrisomely off the mark.” She points to the patient satisfaction section of The Centers for Medicare and Medicaid’s Hospital Compare website, where consumers can look up individual hospital quality of care information. Based on Medicare patient data and hospital reporting mechanisms, Hospital Compare includes process and outcome of medical care measures, use of medical imaging, patient safety measures, Medicare payment/volume, as well as a 10-item survey of patient’s hospital experiences.
It is instructive to note that patient satisfaction is only one of six categories of quality of care data on Hospital Compare from which consumers can make more informed medical care decisions. Obviously it is only useful for planned procedures and hospitalizations, since patients having a heart attack aren’t likely to stop and look up Hospital Compare data on their iPads. I used Hospital Compare several years ago when my sister asked my advice as to Seattle-area hospital choices for her planned abdominal hernia repair. At the time, Swedish Hospital had the highest volumes and best patient outcomes (including patient safety) for this surgical procedure, so my sister then picked a surgeon from their list. She had a decent hospital experience. Today for grins I pretended I needed to have laparoscopic gallbladder removal (I don’t) and ‘shopped’ for Seattle-area hospitals based on this specific procedure. Of the three geographically closest hospitals—Group Health Central, Northwest, and University of Washington Medical Center (UWMC), Group Health came out the clear winner overall for quality of care measures that are most meaningful to me: patient safety (UWMC is worse than national average for hospital acquired conditions such as infections and things besides vital organs left in after surgery—and for the ominous sounding “accidental cuts and tears from medical treatment”), having medications explained to me before they are given, nurses and doctors who communicate with patients well, and the area around patient rooms being quiet at night.
It can be and is argued that patient satisfaction with care is not a valid measure of outcome of medical care. I know from teaching that I can make my students happy and get high ‘student satisfaction’ with teaching scores, and still not have done my job of actually teaching them anything of importance. In her NYT Op-ed piece today, Ms. Brown uses an example of an elderly cancer patient who was told by the hospital oncologist that he was basically too old to qualify for treatment and was sent home. He may have not scored that hospital very high on his Medicare hospital survey, since he didn’t get what he wanted. Ms. Brown links to a recent study by Joshua Fenton at UC Davis showing that higher patient satisfaction scores with individual doctors was linked with greater use of hospital services (higher medical cost) and increased mortality. To me that’s a no-brainer and points to the danger of overuse of health care—more health care is not better health care, and health care can be dangerous to your health.
US doctors have been fighting consumer ratings of individual doctors. (see Ron Lieber’s “The Web is awash in reviews, but not for doctors. Here’s why.” NYT, 3-9-12) The developer of the online RateMyProfessors.com site created RateMDs.com. RateMDs.com now includes ratings of close to 1.4 million physicians in the US and Canada. The founder of RateMDs.com gets at least one lawsuit threat a week from physicians who don’t like what’s been posted about them. A physician reputation management service, Medical Justice, set up a system whereby physicians had patients sign a “no web posting opinions of the doctor” agreement in exchange for enhanced patient privacy protections. That’s almost like a restaurant owner asking you to sign an agreement not to post a review on Yelp in exchange for not putting flies in your soup. The Medical Justice system collapsed after a complaint was filed with the Federal Trade Commission.
Insurance companies and health plans collect consumer ratings and medical outcomes data for individual doctors and other providers, but they don’t make these data available to consumers. With the Affordable Care Act/health care reform, starting January 1, 2013, Medicare will be required to provide consumers more information on doctors as well as on hospitals. (As of this writing, they have a “Physician Compare” site, but it only allows searches to find physicians who accept Medicare.) I disagree with Theresa Brown on this issue. I think that patient satisfaction as one aspect of judging the quality of hospital or other medical care is essential for improving our health care system. It is an essential component of patient-centered care.
Isn’t it ironic that giving patients access to their own medical charts is considered a radical idea? So radical in fact that the Robert Wood Johnson Foundation—that pioneering, cutting edge organization—is funding research on the feasibility and effectiveness of giving patients access to their own medical records. A one-year pilot project called “OpenNotes” was conducted at three hospitals: Harborview Medical Center in Seattle, Beth Israel Deaconess Medical Center in Boston, and the Geisinger Health system in Pennsylvania. Results from the baseline survey data were reported in the Annals of Internal Medicine (12-20-11). Not surprisingly, patients were overwhelmingly (>90%) supportive of the idea of having access to their doctor’s medical notes, saying it would help them remember important health information. In contrast, the majority of the 173 doctors completing baseline surveys expressed reservations over the OpenNote idea. The doctor’s concerns included: 1) worrying/confusing patients with medical chart information, 2) doctors would be less candid in what they charted about patients, 3) it would take up more of their time in having to answer patient questions raised by access to their charts, 4) it could increase the number of lawsuits, and, 5) personal medical information could end up on Facebook. The yearlong pilot has ended and OpenNote researchers are now analyzing data to see how patients and doctors who participated in the project felt about it. They are also evaluating how often patients accessed their medical charts, how often they shared them with family/other providers, and how often they corrected errors the doctors had made in the charts.
As Carol Ostrom points out in her recent article on the OpenNote project, doctors may need to change some of their charting habits in terms of labeling patients. (“Patients eager to see doctor’s notes; physicians, not so much” Seattle Times, 12-25-11). She includes calling patients SOBs and charting on their BS (bowel signs). I’m not sure I’ve ever read a medical chart where someone called a patient a SOB, but I last worked in a clinic that had ‘slovenly’ as a standard term in a menu for describing patients. My colleagues and I had a debate, with some saying slovenly was a perfectly acceptable term for patients—similar to unkempt or disheveled. I maintained it was much more insulting because it implied a slur on moral character as well as physical appearance. And then there’s the still used FLK (funny looking kid) in pediatrics, used for describing a baby or toddler ‘just doesn’t look quite right and might have a genetic or other disorder but who hasn’t been diagnosed yet.’ Supposedly some pediatricians have been known to use FLP (funny looking parent) in children’s charts—I suppose by way of saying the FLK is genetic in a FLF (funny looking family) sort of way. I don’t think these terms would go over well in OpenNote.
Recently, I was in a hospitalelevator when three hospital employees walked up to it separately, all deeply concentrating on their smartphones. Their smartphones collided, and they looked up dazedly, sheepishly apologizing as they stepped on to the elevator. Then all three resumed communing with their smartphones. From where I stood I could see that at least two of them were not doing patient or work-related activities on their phones. I considered this research and not elevator eavesdropping.
By now everyone has heard of the dangers of cell phone and texting distraction while driving, although state laws banning or limiting cell phone use while driving seem to be scoff laws. Being a true Seattleite, I bike to work on our lovely Burke-Gilman bike trail. This used to be almost idyllic but now I have to watch for bikers on their phones, weaving as if they’re drunk. I am not a complete curmudgeonly Luddite: I own an iPhone, but I don’t use it while riding my bike, driving, or walking onto a hospital elevator.
A recent NYT article on distracted doctoring and distracted nursing highlights the extent of hospital personnel using smartphones, computers and other electronic devices for things other than work, including when they are doing patient care—even when they are doing surgery. (“As Doctors Use More Devices, Potential for Distraction Grows” by Mike Richtel, 12-14-11). A neurosurgeon reportedly was talking on his cellphone (using a wireless headset) during a surgery that got botched, leaving the patient partially paralyzed. An OR nurse in Portland was reprimanded for surfing an OR computer for airfares while she was covering a spinal surgery. And then for the truly frightening, over half of 439 technicians surveyed admitted to texting while monitoring heart bypass machines.
When my father was in the hospital last year, I noticed that his nurses spent much more time on the mobile computer stations outside of his room than they did in direct patient care. He had some terrific nurses, and they told me that they hated how much time they had to spend in checking and entering patient data in the computers. The legitimate use of technology in health care is all in the name of patient safety. But at what cost does it come in terms of the human interaction necessary as the core of all healing?