"When you get those rare moments of clarity, those flashes when the universe makes sense, you try desperately to hold on to them. They are the life boats for the darker times, when the vastness of it all, the incomprehensible nature of life is completely illusive. So the question becomes, or should have been all a long... What would you do if you knew you only had one day, or one week, or one month to live. What life boat would you grab on to? What secret would you tell? What band would you see? What person would you declare your love to? What wish would you fulfill? What exotic locale would you fly to for coffee? What book would you write?"
Wednesday, May 22, 2013
This post stems from something that's been brewing in my mind for quite some time in my nursing experience. It is an unrealistic fantasy, but still one I'd like to talk about. Enjoy!
When patients are admitted to the hospital, a lot of things happen. They go to the ER, their problem either gets resolved or it needs further treatment or observation and they get admitted to a floor. When I receive patients, they only have a couple of orders to start out. These being medication orders and nursing task orders. When a patient then gets settled and is being taken care of by day 2-3 ish, these orders are probably bound to change a little based on the patient plan of care. Now, lets say a patient gets a headache- a normal headache that is completely unrelated to the problem admitted with, but instead related to the high amounts of stress from missing work and being away from family and stuck in hospital? So this patient with the headache asks me for a Tylenol. Simple request, right? Something the patient would naturally do if at home with a headache.
Well, I as the nurse, take this request. But if your doctor wasn't nice enough to order you Tylenol as a pain management preventive to begin with, I have to call the doctor for an order for Tylenol. Don't get me wrong, I don't mind doing this at all. But then when he finally calls back, it may be up to 10 minutes already. Then lets say he says yes, he orders it, it goes down to pharmacy and they can take up to 30 minutes for it to be profiled in your orders and in my medication dispense machine. So you as the patient have a headache that's bad enough for you to have reached out for help from me, and it may take me up to 40 minutes, 20 if you're lucky. Maybe up to 3 hours if something else- like CPR or something- takes precedence- if you're unlucky. For a Tylenol.
Don't you think this severely restricts patients freedom? Patient's involvement in their own plan of care? How do you think patients feel when treated like a 5 year old asking for something they can easily buy over the counter and take at home, without a doctors order?
So here's what I propose. What if we gave patients that meet a certain criteria a packet of OTC medications that they can take at their own will in the hospital? Some things included in these packs would possibly include: Tylenol, Motrin, Colace (stool softener), Benadryl, just for starters.
I realize that this idea comes with a lot of complications and responsibilities. First off, only certain patients would qualify for having the privilege of having this pack. Some qualifications to start might include being in complete stable mental health, no drug abuse history or impulse decision making, and patient must have no dementia-short term or long term, and patient must be 18 or older. Those are just some qualifications I can think of on the top of my head. Also, there are some health qualifications. For example, someone admitted with liver cirrhosis or alcohol abuse shouldn't exactly be taking Tylenol. Or someone receiving a lot of Percocet or additional high strength relief NSAID therapy, shouldn't have access to their own reach of Tylenol or Motrin.
Next complication is cost. It would be very expensive to give each patient a pack, and to replace the supplies and stock of medications in the pack. But would it equal out in the high amount of patient satisfaction? In the press ganey scores? If you remember from my last post, happy patients make happy scores, which makes a lot more insurance reimbursement to hospitals. Plus, giving a patient freedom to lose Tylenol and restocking that has got to be less expensive than constantly giving patients the most powerful narcotics such as Morphine and Dilaudid, right? I know that there will always be that patient population that purposely seeks out those types of narcotics, but for the patients that have minimal amounts of pain that could lead into a more serious amount of pain in the future, maybe having bedside OTC painkillers to start out with might help prevent that pain from exceeding too much in the future, therefore saving having to give the patient an expensive narcotic.
Take the following scenario as an interesting example:
A patient of mine not too long ago was in her 60's. She was admitted with kidney failure and was having a lot of back/kidney pain as a result of a recent stent placed. When I initially assessed her, I asked if she was having pain. She said no, but she was having pain earlier that day. I told her that if that pain crept back, to let me know and I could give her something to help with that. She said OK. Now, the way my hospital is designed is that we can sit in between two patient rooms and chart if we so desire. It's supposed to help with keeping an eye on our patients, but I see it as a peaceful escape from the nurses station sometimes. So it just so happened that I was charting outside this patients room, the one with the kidney pain. It was a couple of hours after my initial assessment, and I overheard the patient talking with her daughter, small talk mostly. The patient must have repositioned herself and winced in pain, because the daughter asked "are you having pain, mom?" The patient must have nodded and the daughter said "Well you gotta tell the nurse, mom", in response the patient said "No I hate to bother those girls, they are busy."
Now I could write a book about that statement right there. I hate it when patients think they can't call because we are too busy. And all it takes is one time, one nurse to really have been too busy with something else - to make the patient feel that way. Other patients think we are too busy because they hear stories from family members or friends that work in healthcare. Others just genuinely don't want to rely on other people and don't like calling for something they need.
So in these examples, these patients could take their bedside pack and take something like Tylenol or Motrin. A lot of times, its enough to do the trick- especially with the elderly.
Something else to worry about in terms of cost is waste. How would healthcare handle leftover medications in these packs that the patient didn't use? For infection control reasons, anything that enters a patients room cannot be used again in another patients room. So we would have to throw good OTC medications away at the end of the patients stay. However this could be reduced with a couple measures: We perhaps can only give these packs to patients that have been declared inpatient status, those that are more likely to be there for longer than 2 days- rather than those on observation status (supposed to leave before 24 hours). Also, we would only stock about 2 doses of each OTC medication in each pack. Also, analytical studies can be done to see which medications patients are using or not using the most in these packs, and we can adjust what we offer.
Another complication is how do we keep track of how much the patient has taken? Easy. Like I said earlier, these packs would be given to patients in sound mind, and would receive an education sheet on these packs AND drug information about all medications in the pack. They would sign a sheet on admission, upon receiving this pack- that they acknowledge the responsibilities of the pack and respect it. They would be given a sheet that would be at bedside, for them to log what medication they took, and what time/date. Now either nurses can collect these sheets at the end of each shift, or every 24 hours (like midnight), depending on what system works best. Now the nurse can log into the computer what the patient has taken at this point, or can log when the patient needs more supplies.
Consider the following example:
The patient has 2 doses of Tylenol in her pack, amongst other OTC meds. She uses her 2 doses of Tylenol within the recommended time frame, every 4-6 hours. Now she needs more doses replenished in her pack. The nurse at this point would look at her log and make sure the patient would not exceed the safe amount of Tylenol per day, and replenish the pack- at the same time completing medication documenting in the computer.
It would be very hard for a patient to lie that they took less than what they said, because missing medication packets would be in the pack. If at any point the nurse feels the patient is using the pack irresponsibly or if the patient outwardly breaks the commitment signed upon admission, the nurse can take it away. Of course this creates confrontation between the nurse and the patient, confrontation that a lot of nurses would feel uncomfortable with. But its the same thing as confronting a patient about hiding cigarettes or unsafe medications or street drugs in their possession in the hospital. We've all been there and it sucks to have to be the bad guy and take it away.
The way I see it is, patients are going to take whatever they want when they go home, regardless of the doctors firm instruction. There aren't cameras watching them at home, and patients are free to make their own choices upon their own judgment. So maybe if we watch them, watch what they are most inclined to do, we can better predict what they will do at home.
I know its a long stretch, and will probably never be adopted as a practice in the hospital. But I do think it would be nice. Maybe in futuristic hospitals. Although we have potential for our hospitals to be even stricter in the future, at the rate we're going now. So thanks for listening to my inventive rambling! Anybody in healthcare have any thoughts? Pros or Cons to this idea? I'd love to hear some other viewpoints!
Anyway, with much love,
Wednesday, May 8, 2013
Anyway, todays post is a nursing post, a somewhat controversial one and I even debated awhile even posting it at all. But, here goes...
So I worked Friday through Sunday this past weekend. What started as a slow-ish weekend quickly turned extremely busy (who woulda thought for early May? Weird.) Anyway, Saturday night I thought I had a pretty easy assignment. Most of my patients were in their 50's, the easiest and very nicest age range group in my opinion. This is not to say that they don't have potential to be very sick because by all means- any patient in any age group has potential to be critically sick. But it just so happened that that night my patients were very nice and had what I thought to be easy diagnoses to take care of.
Now, when it comes to customer service in the hospital- patient satisfaction means everything. It's how hospitals get reimbursed from huge insurance companies. It's how we get more patients. You've all heard the term, one patients good experience- they tell one person but if they have a bad experience they tell ten. When something good happens to a patient in the hospital, it makes them smile. But they still feel yucky. They just want to feel better and go home. They *might* go home and remember that they had a good nurse, but probably won't remember your name. But, they may tell other people that your hospital has "good nurses". But all it takes is one bad experience mixed with one grumpy or really sick patient to create a chaotic mess of unhappiness. Suddenly that patient feels wronged, that what has been done to them is unjust- even if all it was was that they had to wait 40 minutes for you to remember to bring a soda back they asked for. What they don't know is that when you leave their room, maybe you had to suddenly help a coworker in a dire situation, or another one of your own patients needed you, or whatever! Patients don't think about that. Realistically, patients do know that they obviously aren't the only patient there on your floor. They know that. But they don't like to think about it.
Think about how you would feel or have felt if you were a patient. You are bored. You're thirsty and all you want is a coke. You ask the aide to bring you some when she comes in for vitals- and she says yes but then keeps going along with vitals and when she's done she forgets. Thirty minutes go by and you ring your call bell and the nurse comes in- you ask her. She says no problem but then gets pulled into another patients room and forgets about your soda. The nurse doesn't even realize how big of an issue to you this is because in our eyes, the nurses, its just a soda in the whole scheme of things. We are worried about your vitals, your health condition, our other patients, etc. But to the patient, they just want the friggen soda and they feel that as if everyone is forgetting about them. Next they go home and tell ten people that your hospital has horrible customer service, even if you provide the best healthcare.
On that note, I always try and do my best possible job when it comes to customer service. I always knock when I enter patient rooms. I always address them properly and then remember how they like to be addressed after that. I smile with them, I listen to everything they have to say and I don't belittle them. I do my best to remember if they asked for something and I get it as soon as I can. I always tell them what shift I'm working and what time they will be under my care until. Before I leave at the end of my shift I make sure to explain that I will be leaving in approximately a half hour and then your next nurse will be in shortly after so that patients know. Patients tend to not like when their nurse just disappears and a new nurse takes over, or when a nurse hasn't been in for over an hour because they were in report or seeing other patients. I always always do my best to explain everything to the patient, even if its just pushing a saline flush into the IV. To us its a simple saline flush, harmless- to them its a large syringe of something that is being pushed into their body.
So despite my best efforts to be attentive to all and provide the best customer service, sometimes its truly impossible. The more patients you have, the harder it gets to be as attentive to all as the patient wants you to be. Take the following story as an example.
I had a young patient, lets call him John Smith. He was in his 50's and his wife was as well, and was staying with him in the hospital, watching and listening to everything. John had just had a heart procedure done with us and was put on a very good blood thinner, now extremely necessary and important for his heart to function. However, John was prone to nosebleeds. In addition to the (very good) blood thinner and the dryness of our hospital, he came down with a nosebleed. When my nurse aide had told me that it had begun, I went in right away to check it out. I told him exactly what to do and told him I'd be back in ten minutes. At that exact same time an admission had just arrived under my care. Now, small blip- patients just admitted to the floor require a lot of customer service. They are scared, probably tired, hungry, they don't know whats going on, they need a lot of answers. They don't like rolling up to your floor on a stretcher and then being left there for 90 minutes before the first person comes in to see them. I always try to greet admissions within ten minutes of their arrival and do my whole admission shebang. So anyway, I told John I'd be back, and I went to go say Hi to my admission. I gave her the downlow on what was going on and completed a quick assessment. I told her the aide would be in soon and we should be able to get her to be able to sleep shortly, as it was 12:30 at night. So back I went to see John, and suddenly realized it wasn't just a nosebleed, it was a water fountain. I tried a couple more tricks and then quickly got my nursing supervisor.
To make a LONG story short, I was basically in that room from 12:30 to 7:00 am, with maybe a 45 minute break (in which I quickly went to the bathroom, got something to eat, and charted like my life depended on it). The nosebleed was so severe that it required my constant attention, constant manual pressure to the nose, and a STAT consult to the ENT MD team, twice.
Okay so point here- In this case, I was able to provide excellent customer service to John. Him and his wife even said at the end of it all, right as I was saying goodbye, how fantastic I was all night and how excellent this entire hospital has been so far. They were pleased, despite John being in a very uncomfortable clinical situation. However, I had a brand new admission that was probably wondering where I was after I gave her the down-low, and I had 4 other patients that needed me as well. One of those four patients began having chest pain while I was with John, and another was yelling that he couldn't breathe. Because it was necessary for me to stay with John, I had to delegate responsibility to handle these new problems to other nurses on the floor.
Now think about this for a second. While I was doing what I had to do and on my end was taking care of the patient by sending another nurse in- this is what the patient feels: Its 2am and you wake up with chest pain. You ring for your nurse who you've had for two nights now and knows your story- but in comes the aide. You tell her you have chest pain. She goes and gets me, who unbeknownst to her- sent in another nurse. Now one of my (very good) friends and coworkers handled the chest pain for me by attending to this patient by explaining that I was tied up in another room. But does the patient want to hear that some other patients problem is more important in my eyes than her chest pain? Probably not.
Maybe I over think things. In fact I know I do. But to me, its basic human connection. I've always been extremely aware of peoples emotions around me and I have the extraordinary ability to put myself in others shoes and see how they might be feeling, and then I have the decency to try and fix it. I try to make patients as happy as possible and in situations like that shift, those five other patients probably weren't very happy with me, but John was. So I made one patient happy and sacrificed five. But let's say I had left John to be on his own for his nosebleed- to provide his own manual pressure to his nose for six hours while I tended to five other patients. Sure- I would have made five happy and sacrificed one, but that one sacrifice would turn into a monstrous story if not even a lawsuit. So although I couldn't obey the law of attending to the greater good, I obeyed the law of excellent nursing. Although I may not have made my patients the happiest, I at least knew about their problems and made sure they were taken care of by at least someone. To me that's the best I could have done.
Well thank you for reading today, as always! I love you all,
Friday, May 3, 2013
Anyway, this topic sprouted into my mind a couple days ago. Let me give you a small back story. Lately, my boyfriend and I have come to the inevitable conclusion that its seriously time to lose weight. Neither of us are significantly overweight, but we're both at the point where it definitely couldn't hurt to lose, either. Those happy blissful first years of dating make for a lot of restaurant frequenting and alcohol, neither of which are good for you! :( So we decided to do this together, the whole diet and exercise thing.
Now I overall thought I ate pretty healthy to begin with. As some of you know, I decided about 6 years ago that I was never going to eat or support any fast food franchise ever again. By support I mean I refuse to even take my kids there and give the franchise money even if its not actually being eaten by me. Will that change when I have ten minutes to feed the kids en route from soccer to dance practice? I hope not! Time will tell, but I hope that I can stick true to my beliefs.
So being that I never eat fast food (except for Subway and Panera if you want to count them), I also never drink Soda, never eat Chocolate and don't typically indulge in a lot of sweets, I eat a LOT of fruit and a fair amount of veggies....My only understandable downfall is my love for restaurants and that I probably don't drink enough water. I also have a bad habit of eating late at night. Also, working night shift doesn't help at all. So based on all that, it didn't seem fair or right to me that I was still seemingly gaining weight at a rapid pace. So I had to put a stop to it before it got any harder to lose, and my boyfriend was on board. We thought about a couple programs, including Weight Watchers (a personal favorite of mine) or perhaps trying it on our own, or going to see a nutritionist, or a freelance dieting company, or one of those marketed weight loss pills/shakes or whatever.
But instead of spending money right away, we decided to do it on our own with the help of the program "my fitness pal". It's available online and via apps on a lot of phone carriers. Via phone, you can literally scan bar codes of what you are eating and it calculates everything for you. It's futuristic and awesomely awesome. It sets up a profile for you and makes goals and predicts progress for you based on how your day went. At the end of the day it even gives you pie charts of the breakdown of carbs, protein and fat you ate. It's pretty cool, and all for free. It focuses on calories mostly, but also tracks the remainder of nutrition for each product. Like Weight Watchers, It really teaches you what you were doing wrong and opens your eyes to how much you actually eat during the day and where you can cut back. Just from using the app for three days now I've realized a couple of my hinders to weight loss, some being: Starbucks Green tea frapps with soymilk/no whip (still unhealthy), Thai tea with bubbles, RITAS (I'm a ritaholic), my soy ice cream, and wineeeee. All of those said things I knew to not be extremely healthy per say but I didn't consider them to be *the* reason I wasn't losing weight. Now I treat myself to one of those said things when I have a couple calories to spare.
Anyway, the point of this post- what's wrong with this country?
The other night for dinner, my boyfriend and I picked Saladworks for dinner. For those of you unfamiliar with the franchise, its a lot like a Panera Bread- you can pick soups to eat, salads, sandwiches. What I found to be cool is you can create your own salad. My boyfriend got a Chicken Cesar premade salad, dressing on the side- And I made my own. I got romaine lettuce and added chick peas, carrots, egg whites, wheat noodles, croutons and lite raspberry vinaigrette dressing on the side, and it came with a whole wheat roll. For me, that's 509 calories. Not too bad for what I got (a lot) and the roll is to blame for a lot of that. My boyfriends was 441.
Now before I make my point here, lets think about a meal at McDonalds. Now I went to their dollar menu choices and picked out a theoretical/fake meal for my boyfriend and I.
Two McDouble Cheeseburgers, two medium fries and two sweet teas. This led to 1,840 calories, being 920 each.
So Saladworks: 950 calories for BOTH of us, cost me $19.58.
Mcdonalds: 1,840 calories, would cost me about $6.
I had to pause there for a second because it makes me so angry. So lets think about this. The country of America has a raging epidemic of obesity. We have ads everywhere to lose weight. Take this pill, drink this, eat this, join our program, be high school skinny again! Yet we have endless ads for fast food, too. So Okay lets say someone wants to lose weight but they are on a budget, like 89% of the country is. Lets face it the majority of us aren't swimming in cash. So someone wants to go lose weight so they think, oh hey! Saladworks! I like salad! It's healthy! I'll lose weight! But oh, how much? That's $20!? When I used to spend about $6 dollars on my dinner? I can't afford to lose weight! So they go back to McDonald's, spend less but also eat less matter, but eat more calories, gain more weight. See where I'm headed here? What incentive does the majority of America have to lose weight when it's obviously dramatically more expensive to lose weight. Joining Weight watchers alone will cost an individual about $52/month alone. People go to the fast food because its cheap, its fast and it tastes good. Places like Panera and Saladworks are dramatically more expensive and it takes longer. This.Is.Why.America.is.Overweight.
In an ideal utopian world, well- my utopia- people would have incentive to buy healthier things because its a lot less expensive. Popular fast food chains would become sky rocket prices-the dollar menu would cease to exist and "Value" meals would now cost $20. People on severe budgets would be drawn to healthier food because its cheaper. Think about it, we are digging ourselves a hole right into health care itself.
Someone on severe budget---> Eats fast food----> Becomes severely overweight----> A lot of health problems arise (diabetes, high cholesterol, high blood pressure, muscle/bone issues, etc)----->they don't go to the doctor because they don't have the money----->they wait and wait and those problems now become---->Strokes, heart attacks, knee replacements, gastric bypass, lifelong rehab, or even death.----they can't pay for that either.
Those second problems are so much more hard to take care of, not only on the demand to healthcare workers but to our economy! Treating someone for a FIRST heart attack that they can't pay for could cost the economy tens of thousands of dollars- and that's if its remotely uncomplicated!
It just gets me so angry. I am blessed enough to be able to afford the higher prices that come with losing weight. But a single mom with 3 kids trying to feed herself and her kids? Perhaps not so much. Yes I over exaggerated, yes I picked out dollar menu items as an example from McDonald's to make my point. Perhaps a more in depth meal at McDonald's would cost up to $15, but can you imagine how many calories that could be? Not only that, but my boyfriend and I were very full after our meal at Saladworks, and we felt great. If I ate $10 worth of food at McDonald's- Not only would I probably feel like complete crap, but it wouldn't be able to keep me full. I'd be craving more fat and sweets within an hour or two and then the cycle repeats.
Okay so I'm done now. I could probably talk for hours and hours about the Nutrition problems with our country, but I can't keep my audience forever. You're probably hungry by now. Just kidding. No I'm actually pretty hungry, I shall make myself some strawberries perhaps....yumm.
I'm sure some people won't agree with me, and that's totally cool- that's ALSO what America is all about- freedom of speech. Amen to that!
Wednesday, May 1, 2013
|Some of my bookshelf on the left with my CRAZY cat|
|my pathway, the beginning stages...|
|She loves to hide|
|the vet said she's weird because she likes her belly rubbed...|
|She thinks shes the queen of England.|
|the day she got home, when she was a weeee bitty kitten!|
|taken tonight, she loves me, 80% of the time|
|Sitting on "her" window|
|she sleeps a LOT|