ED Staffing Ratios Affect Performance?

More and more information is coming out that we are putting patient at risk for adverse effects in the hospital by under staffing and overworking. This sounds like it is a no-brainer, but a study was done this year that looked at how staffing of nurses in the emergency room actually affects metrics. We all feel anecdotally that if we had a lower case load, we would perform better in our nursing duties. We feel that our charting is getting in the way of our patient care! Is that really true though?

Within a one year period about 100,000 patients were seen and their length of stays were averaged in relation to nursing hours. Overall, it was found that length of stay while in the ED greatly decreased with more staff in the emergency room. This consideration should be further explored and implemented if it means better patient outcomes and turnaround time for the ER.

This is so vital because the ED is the gate to the rest of the hospital. Unless you are a direct admit bringing your wheelbarrow of home meds for us to process while we try and get you admitted like any other patient. We love that they act as a buffer for us, but they can only do so much with limited staff. Patient use of the emergency department as a source of primary care has significantly increased as people struggle to afford health services. This influx could greatly overload the health system if not properly addressed. ER administration needs to look at the causes in delays of care and mitigate them as much as possible to help provide smooth and efficient service. There are many factors affecting emergency room times ranging from the socioeconomics of the area to nurse staffing.

One effective way that facilities can improve patient outcomes, staff satisfaction, patient satisfaction, and benchmarks is decrease nursing and patient ratios. It would be interesting to see if there are any studies on decreased patient ratios on inpatient populations length of stay.

If there is another area you would like us to look at or a topic your itching to hear about, let us know! As always, please continue to monitor.

Western J Emerg Med. 2018;19(3):496-500. © 2018 Western Journal of Emergency Medicine

My Dressing Is Smarter Than Me!

Wound care practices are changing almost daily. How often have you gone into your patient's room to find wound care has placed another dressing you have no idea how to use properly?

Does it need to be absorbent? Have antibiotics? Is silver okay? Would you like a side of compression with that?

It can start to get a little ridiculous. To help make things simple, there are smart bandages in development. The article states it will include various layers for temperature, moisture, and infection monitoring; management of antibiotics if needed; among other components. There are so many great implications for this technology; particularly for those very complicated wounds that have multiple dressing changes that have to be adjusted almost every other day to respond to how the wound is healing. Given that the nurse may not always know what is going on with the dressing, let alone have a spare thirty to sixty minutes to dedicate to wound care, it seems a "no brainer" to have this kind of technology available.

It does raise some concerns of cost, patient perception, proper monitoring of wound healing.

The dressing components are supposedly inexpensive and some of the parts could be reusable. This is not just a question of cost for the patient or clinic, but the environment. Many of the individual wrappings of medical supplies and instruments are simply tossed and cannot be recycled due to their make up of impermeable materials and very nature of their construction. Would these materials have a cost on the environment? Many patients and clinicians are trying to be conscientious of environmental burden and may be adverse to a multi-layer dressing that will assuredly go to a landfill or other means of disposal that would impact the environment.

It is reassuring that some of the parts, specifically the electronic monitors would be reusable on other dressings to be placed.

The dressing has "wireless electronics to monitor sensor data and control drug release". While this is great, wounds still need a trained eye to evaluate the wound bed itself as nothing can replace the trained clinician assessing their patient. Plus, will it being wireless, the patient perception may be that no one is doing anything for them regarding their wound. For some interactions of patient care, how the patient perceives something can make or break your care interaction. If we are remote monitoring our patients' wounds with no orders to disturb the dressing, will be still be allowed or expected to check the wound bed for proper granulation or sloughing?

What do you think about an electrical smart dressing? Please comment and continue to monitor...

Smart Bandage Can Detect Infection, Deliver Targeted Treatment - Medscape - Jul 16, 2018.

Should We Not Use Certain Medical Terminology

An article was posted by MedScape about some words that need to be removed from medical language and we wanted to discuss it will you all! Personally, we have noticed a shift in how we talk to and about our patients regarding their medical conditions. Now, using the right words can be a struggle on a good day, especially taking your patient's native language, education level, and other factors into account. Some things have begun to fall out of fashion, so to speak. We think this is due to a shift in our understanding of disease process, changes in insurance reimbursement, and social factors. We're going to break down this discussion by each of these categories. Then we'll talk about some specific conditions.

Better Understanding
Medicine is constantly changing! Tomorrow there could be a dozen new drugs on the market for various ailments. Our understanding must grow and be flexible. This flexibility includes our use of various terms with our patients. We must be consistent with our choice of words and considerate of their implications. The next two examples are some reasons for those implications.

Changes in Insurance
We have found at our own facility that physicians are often discouraged from coding their patient as CHF patients and when asked a few of them have said they and the hospital are not reimbursed fully if at all if the patient comes back within 30 days of discharge. If left poorly treated, CHF'ers will come back to the hospital within that time. So, they code the discharge in such a way as to not indicate heart failure for coding purposes. The physicians we have spoken to agree that this is unfair to the patient and the clinical staff. It isn't quite dishonest, but it doesn't truly paint the picture of the patient's stay with us.

Social Factors
It is no secret that the use of certain words can affect how your patient will behave or perceive a diagnosis or plan of care. All you have to do is mention the big "C" word to see your patient start to bristle. HIV/AIDS is another condition that will bring forward all these preconceived notions for your patient.

Do you think there are other reasons we should watch out language with patients and their families?

Heart Failure
This is perhaps the word that has the biggest misconception for clinicians and patients. The word failure sounds so final and disruptive, which it can be. It also describes a whole set of conditions and etiologies that just are not adequately covered by the word "heart failure". Do you mean right-sided or left-sided heart failure? Your patient may have family or friends who have been diagnosed with this and they have an idea of what their heart failure was, but it doesn't adequately describe their own condition.

"Heart dysfunction" and "cardiac insufficiency" have been tossed around as better words to be using in this situation. If you do continue to use the term "heart failure" it is advised that you explain to your patient what their specific condition means for them.

The article presented "intensify" in terms of treatment as a word that needs to be softened so as not to alarm the patient. We have not heard that particular term used when educating patients, but it could be a little aggressive for the patient and family to hear.

Mid-Level Provider
This term is just starting to come up more often. With the shortage of MD's to handle the local patient loads, many nurse practitioners and physicians' assistants are coming on the scene to save the day. This term could downplay the role that ARNPs and PAs have in the healthcare team. One NP in the article stated she felt "belittled" by the term and it doesn't reflect the scope of practice that she is providing to the public. Many individuals are not only seeing "mid-level providers" for their primary care service. Should we not just call them primary care provider or do we really need that distinction?

This may leave some people confused to have this term on the list! When we use diabetic in a phrase we often say, "245 is a diabetic and their sugars have been in the 150's and is scheduled to go to surgery later today." This phrase reduces the person to their condition. While we often get in the habit of remembering our patients by their conditions, we must make an effort to make them feel like people first. It would be more correct to say, "Mr. Smith in 245 has diabetes and will be going to surgery today. His blood sugar was 153 this morning and was covered with R." This pulls the focus to the patient as a person who has diabetes while the other reduces him to just a diabetic.

This is definitely offensive to a patient or family member if you tell them this! If you feel a patient is not following the treatment plan, you must address it in their plan of care. There could be any number of reasons they don't take their medication or go to their appointment. Have a discussion with your patient to find out the reason. Don't just dismiss them as noncompliant and tell them to do better.

What other words do you think should be included in this list of possibly abrasive or offensive words in the healthcare setting?

Join us next week for another post and as always - continue to monitor...

Banish These Five Terms From Medicine? - Medscape - Sep 26, 2018.

Don't Be Silly, Check Your Titty!

Happy Wednesday!

It has been a busy week coming back from vacation and getting back in the swing of things! It is so hard to return and have to try and remember your passwords or even basic nursing skills sometimes. We also got back just in time to get ready for Hurricane Michael! Send well wishes to our friends and families who are in the storm's path. Be safe everyone and stay in shelter if you can. We hope our co-workers who are sticking out the storm at hospitals and clinics are safe and don't have too many patients trying to brave the elements to come see you.

Anyway, lets get on with the post for this week! It is Breast Cancer Awareness Month! In honor of breast cancer awareness, we felt it was important to discuss this topic. We have all known someone that has battled breast cancer. While there isn’t a cure yet, that doesn’t mean we can lose hope. As healthcare professionals our duty is to educate our patients.

Breast cancer awareness infographic

These are so pretty staggering numbers that help to put breast cancer in perspective. It can be anyone you know who is at risk for breast cancer and we need to be proactive. Early detection can save lives so we must promote regular monthly self examinations. During the exam, if something feels different, it is in that individual’s best interest to seek medical attention to rule out cancer. Take a look at this self-examination diagram. This should not take you long, but it will be time well spent. Many clinicians recommend doing this exam in the shower when the skin is moist and lumps can be felt a little easier. It is also a private space where you can take some time to perform this examination.

Perform these four steps to complete a breast examination. This includes feeling each breast with three fingers in a circular fashion from the inside to the outside of each breast; feeling for any thickening or lumps. Look at each breast and assess for symmetry and any visual changes to the shape of the breast. Then raise each arm and look for lumps under the arms; these could be swollen lymph notes that can help identify tumor growths. Finally, squeeze the nipple of each breast and make note of any discharge from the nipple. Notify your primary care provider immediately if you have any changes.
Breast Self-Examination

Perform these four steps to complete a breast examination. This includes feeling each breast with three fingers in a circular fashion from the inside to the outside of each breast; feeling for any thickening or lumps. Look at each breast and assess for symmetry and any visual changes to the shape of the breast. Then raise each arm and look for lumps under the arms; these could be swollen lymph notes that can help identify tumor growths. Finally, squeeze the nipple of each breast and make note of any discharge from the nipple. They should notify their primary care provider immediately if they have any changes. Their physician may request they get a mammogram along with some blood work at that point. 

When you are caring for someone who has been recently diagnosed, they are more than likely scared and we have to be there for them. If they are going to have a mastectomy, they may not be able to have their IV sticks, blood drawn, or blood pressure checked on the side of the surgery related to any possible lymph node removal during the procedure. If their treatment plan is chemo or radiation, discuss neutropenic precautions and the potential side effects of the treatments such as hair loss, weight loss, nausea and/or vomiting. 

If there’s one thing you can take away from this is just be there for the patient or client. This is also true for the family as well. We have gotten much better in healthcare to think of the patient not just as one individual, but also the family as a unit.

When offering comfort they may just need someone to hold their hand, give them a hug, be their cheerleader, or just them a word of encouragement to keep fighting. There is a reason those who have been through cancer diagnoses are called survivors and we need to respect that. A positive attitude goes a long way. We’ve all heard the phrase “mind over matter” and kind words can have a great impact. 

There’s an abundance of resources readily available. For more information, click on the link visit Mayo Clinic's page discussing breast cancer awareness. Point your patient in the direction of good resources if your facility does not have a specific handout for them. Be mindful that some clients may not have computer access, so be prepared to print some information out for them.

If you would like to donate to American Cancer Society, click on the link.

Be on the lookout for breast cancer walks in your local town! Not only are they fun, but your time and money goes to a great cause!

Please continue to monitor your family, friends, patients, and of course yourself...

*Disclaimer: ADPIE is not sponsored by Mayo Clinic, or the American Cancer society. All links and graphics are the property of their respective owners.* 

We've been readmitted!

Happy October, ADPIE Followers!

As you may have noticed, we have been MIA and that’s because...
we were on VACAY!

Finding time for ourselves and loved ones can be tricky in our field, so trips like these are much needed. You may be thinking it is irresponsible of us to be taking time away, but its essential. As healthcare professionals, we always put the patients’ needs ahead of our own, so on our days off we’ve got to take the time to do something that replenishes that font of caring we pour from. Having meaningful and mindful time away from work will reduce the likelihood of burn out and ensure that your patients experience you at your best!

Coming back to work won’t be easy after the adventures of the past couple weeks. Between the two of us, be have breathed in the Hawaiian air and screamed our faces off in Orlando. #rollercoasters

We are both back, energized, and ready to take on whatever comes our way! By setting aside time to relax and encounter new things you invigorate yourself. This makes a huge difference in how you care for you patients. The connections we make with your patients is enriched by the stories we tell one another. We can't tell you how many times a patient has kept us in a room with a story they are tell. We should be checking on our other patients too, but Pops is just so precious! The exchanges are made better when we can relate with them on some level. The experiences you share at work can only come from going out into the world to learn and enjoy.

The ocean waves and seemingly unsafe rides have made us incontinent, but we are back! Ready to do what we do best! ...Prevent decubitus and other medical stuff!

So, take time for yourself and CONTINUE TO MONITOR...

What's My Day Like Nursing?

This post may contain affiliate links and advertising. We make a small commission if you make any purchases through any of these links, at...