PATIENT SAFETY PART II

MHS TICKLERS THAT KEEP TICKING

HEALTH CARE THOUGHT OF THE DAY

Hospital beds were full so the patient spent 24 hours in post anesthesia recovery room and was moved in the middle of the night to a room
OOB in chair eating
Discharged (with grade 3 pressure sore occurring this hospital stay)to subacute rehabilitation for intense therapy
At a therapy session he felt weak and was cold and clammy. His niece had to insist he go to hospital
Emergency room diagnosed as pulmonary embolism(PE) and grade 5 pressure sore
Placed on Heparin therapy for the PE and the pressure ulcer was treated with vacuum-assisted wound closure (VAC), total parental nutrition (TPN) for a nutrition supplement and he was put in a clinitron bed
The family noticed he was not turned or OOB in 6 hours. They asked the RN caring for him why he had not gotten up. She said, "I will check his activity level!!!" She returned and said "he has an OOB order but Physical Therapy is off for the weekend."
Surgical procedure to debride the ulcer was completed. Because the VAC was put on the patient in the operating room he went into shock in the first 24 hours due to a bleeder post operative( Note:He was on heparin therapy for PE)
He received blood transfusions
Physician told the patient he would make a 100% recovery, but needed to go back to subacute rehabilitation for about a month. The patient refused so the family researched Long Term Acute Care (LTAC) and suggested it. The family asked ( actually demanded) for a family conference which the patient wanted to participant in.
The patient, nieces and nephews attended the patient conference which was held at the bedside. Attending were nutrition therapy,risk management, case management, a nurse manager, physician, social worker, wound specialists( who had not seen the wound recently because the patient had students doing the dressing). The patient was saying they caused his problems with poor care ( they agreed) and he wanted no more done. He was a Do-not- resuscitate (DNR), and wanted aggressive treatment stopped. The physician requested one to two more weeks and the patient was transferred to LTAC. The LTAC team was great but the patient went downhill. Family requested a transfer to hospice to satisfy the patient's wishes. The LTAC physician said give them two more days.
Patient was moved to hospice two days later and died a few hours later
Case Study II
This case study is from a different hospital. Case Study II was a 84 year old, male, widower, with three daughters. He had a surgical blanket inserted around an abdominal aortic aneurysm. The surgery was completed in a well renowned teaching hospital,and he spent a short stay in a Cardiac Rehabilitation Center. He did very well and per his physician no longer was a walking time bomb. Actually he survived the surgery better than a 50 year old. About a week after being discharged home he complained of pain and swelling in his arm.
Highlights of Clinical Course
Treated as an outpatient but as the complication progressed he was re-admitted to the hospital and it was determined he had a nosocomial post surgical staphylococcus infection.
Treated with strong antibiotics and discharged to homecare.
Suffered diarrhea from the antibiotics and developed pressure ulcers
Requested Hospice but physician did not think he was a candidate
Could not eat or drink
Re-admitted to the hospital and he wanted treatment stopped
There was an order written for hospice and before the evaluation could be completed he died with out the support of hospice
The healthcare facilities servicing both of these cases had excellent reputations, some were awarded Magnet status by American Nurses Association and some posted Service Excellence Commitments. The basics were missing in all and we would love to hear from you as to how you would provide care differently. WE NEED TO FIX THIS TREND.
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Eye Popping Statistics
According to the Center for Disease Control (CDC) nosocomial infections affect approximately 2 million patients annually in acute care facilities in the United States. (Institute of Medicine. To Err is Human. 2000 p. 268.) Prescripition for Success:HAND WASHINGThe cost for acute care nosocomial infections is approximately $3.5 billion per year(Institute of Medicine. To Err is Human. 2000 p. 268.) Prescription for Success:HAND WASHING
Successful Outcome: Newark, New Jersey Beth Israel Medical Center recently was highlighted on the television evening news as having reduced nosocomial infections by 50% by changing practice and washing hands. Kudos to Newark Beth Israel!!!!!
Magnetic Health Care Strategies, LLC

Labor Day, September and October, Fall: What does it mean to you? A new season of the year? New clothes and colors? Leaves changing? Summer temperatures reaching 100 plus ending? Back to routine of school? Assessing goals for the year? Beginning of the second financial quarter or yikes end of the third financial quarter and time for the annual goals review. Whatever it is for you each season is a time of reflection. This issue will reflect on Phase II Patient Safety.