Dora's Nursing

Sometimes nurses make a difference and today was one of those days. I have been taking care of M. for a few days, but I have taken care of him before on a previous admission for the same thing. I know this young man well and it pains me to see him destroy himself. M. is a 30 year old substance abuser especially alcohol but drugs also. He was admitted with severe DT’s having seizures. He is always a handful at first and then he turns into a little boy. He has a history of bipolar disease, and he is manipulative having surrounded himself with a host of characters just like himself, great fun but self destructive. His older sister has tried to help him but it’s been hard on them.

M. calls me ”the IRA” (the Irish Republican Army) because he says I don’t put up with his shit and he actully likes it. Today his sister became his POW; Power Of Attourney. He will go to a long term rehab. facility in a few days and MAYBE give himself a chance at living. Today nursing came through for this young man and forced his physicians to think past the acute phase of his illness because he needs long term care. He can’t do it alone. Now he has a real chance to survive and spend time with his 2 children, who he does love, but he doesn’t know anymore how to be anything other than a drunk and a bum.

Now he has no choice but to change, at least for the next 3 months. If down the road he falls off the wagon again, we will at least know we did all we could, we gave him the chance. I want him so bad to rise up and be the man I know he can be. Substance abuse is a terrible illness to save this one would be so awesome!

 

By Debra Wood, RN,
August 25, 2011 - During these tough economic times, some nurses have seen their ranks dwindle or remain flat while demand increases because their hospital or physician practice is trying to get by with fewer nurses. But at what cost? These situations can cause nurses to become stressed out and their patients, in some cases, may pay the ultimate price. Some recent deaths linked to understaffing have experts taking a fresh look at the best methods for cutting health care costs without cutting nurses.

“Knowledgeable persons understand that the way to reduce cost is by reducing waste, not by laying people off or reducing nurse-staffing ratios,” said David B. Nash, M.D., MBA, dean of the Jefferson School of Population Health at Thomas Jefferson University in Philadelphia.

Eliminating duplicative and unnecessary testing, excessive waiting times, duplicative steps, additional forms and other wasteful practices will reduce costs without compromising patient care, he said.

“The dilemma is it is easier to simply fire people than to reduce waste, and hospitals and others take the path of least resistance,” Nash said. “But we know from research from every industry since the Second World War that the best way to reduce cost is to reduce waste, hence [cutting nurses] is penny wise and pound foolish.”

In addition, he said, “If you fire nurses or reduce staffing, you run the risk of increased mortality and morbidity. There is good evidence, most especially that comes from research when institutions have suffered a nursing strike, that morbidity and mortality increases.”

“Nurses are the last protective barrier between patients and possible harm,” added Ramón Lavandero, RN, MA, MSN, CCRN, director of communications and strategic alliances at the American Association of Critical-Care Nurses (AACN). “Without the proper number of nurses, more patients could be harmed by inadvertent errors in complex hospital systems, and fewer would receive the high quality they expect and deserve.”

Karen Stutzer, RN, MSN, CCRN, APN-C, executive director of nursing practice and critical care services at Chilton Hospital in Pompton Plains, N.J., and a director on the AACN National Board of Directors, explained that monitoring a patient’s response to inpatient treatment and patient education are nursing responsibilities that can’t be delegated to others. With federal rules changing reimbursement for patients readmitted within 30 days, she added, nurses are important in ensuring patients and families have the information they need about medications and self-care.

“Cutting nursing positions will have an effect on a hospital’s bottom line — a negative one,” Stutzer said.

Karen Higgins, RN, a co-president of National Nurses United in Massachusetts, agreed, pointing out that adequate RN staffing can decrease infections and skin breakdowns, hospital-acquired problems increasingly not paid for by third-party payers.

“[Hospitals that cut nurses] are playing with human lives, and all of the research done over the last seven to eight years has stated when nurses have too many patients, bad outcomes occur, patients suffer and die, which is exactly what we are seeing,” Higgins said. “Limiting the number of patients nurses take care of is a huge cost savings to the hospital. It makes no sense that this is where they make the cut.”

In California, which has a nurse–patient staffing ratio law, quality of care has improved since that bill was enacted.

Patients can die

Recent events have provided additional evidence that poor staffing can lead to patient deaths. Records of inspections at Carlisle Regional Medical Center by the Pennsylvania Department of Health reveal serious staffing shortages, which may have contributed to the deaths of two emergency department patients.

A patient arriving in critical condition at Carlisle on June 5, 2011, at 3:17 p.m., was evaluated and scheduled for admission to the intensive care unit, following a CT scan. At 9:39 p.m., returning from the scan, the patient became unresponsive, resuscitation was attempted and the patient died. The state investigation found that employees had sent the patient to the scan without a nurse, because they did not have enough staff.

An employee told the state inspector, “Management was aware of the staffing situation throughout the hospital, and ED nurses were told that they must be more creative in their care.”

On June 22, 2011, at 11:14 in the morning, a cardiologist recommended transferring a patient with syncope and increasing chest pain to Harrisburg Hospital, with the intent of him receiving an aortic valve replacement. The transfer never happened and at 6:37 p.m., more than seven hours later, the patient died while waiting for an inpatient bed at Carlisle. An emergency department physician’s note from the next day stated that the patient had been admitted to Carlisle “but remained in the emergency room due to staffing issues.”

That day, patient-nurse ratios in the emergency department were 9:1, 6:1 and 7:1, and the intensive care unit was full.

The state inspector observed: “Based on a review of facility documentation and interviews with staff (EMP), it was determined the hospital emergency department did not have sufficient nurses to safely administer nursing care.” The health department concluded that the facility was not acting in “compliance with the requirements of the Pennsylvania Department of Health’s Rules and Regulations for Hospitals.”

John Kristel, CEO of Carlisle Regional Medical Center, issued a written statement, saying, “We closely and continuously monitor staffing levels on a continuous basis and are confident that we are providing an appropriate level of nurses on an ongoing basis to insure high-quality care for our patients. At this juncture we have no reason to believe that staffing levels had anything to do with the very regrettable deaths of two patients.”

Other findings by the inspector indicate staffing ratios on a medical-surgical floor of 7:1 and 8:1 and in the intensive care unit of 3:1.

“In many places, they are pushing nurses to take three [patients], and that is asking for a bad outcome,” said Higgins, a critical care nurse. “Missing anything, even the amount of urine put out in an hour can be crucial. I don’t have the luxury of missing anything. My assessment has to be the whole time.”

Safe staffing legislation

Legislators in several states, including Massachusetts and Pennsylvania, have introduced bills to mandate nurse-to-patient staffing ratios, but California remains the only state to adopt such statutes.

At the federal level, Sen. Barbara Boxer (D-Calif.) has introduced the National Nursing Shortage Reform and Patient Advocacy Act (S-992) to set the maximum number of patients assigned to each nurse, varying by the needs of the patient.

Proposed safe-staffing bills set minimum staffing. If patients require more care, they require lower ratios, explained Higgins, who co-chairs the Coalition to Protect Massachusetts Patients, an alliance of 125 healthcare, consumer and labor organizations promoting the Massachusetts safe staffing bill.

“When you see what is going on in Pennsylvania, you shake your head, because this is going on everywhere,” Higgins said. “It has to stop, and the only thing that will stop it is legislation. These hospitals that want to make money and everything is about the bottom line will not change their attitude unless they are forced to.”

mystrongmedicine:

The Perception Treadmill: Has Nursing’s Status Really Gone Anywhere? http://ping.fm/zS05V

“Nurses are the front line of care and last line of defense for every patient we encounter. We’ve worked hard to be recognized for what we are and what we do”. I like that…but the fact is we are the worker bees, it’s the physician that brings in the $$ from pharmaceutical companies and from patients coming to the hospital for THEM. They don’t come for the nurse (but they should hope they get a good one because it’s the nurse that will deliver most of their care). Nurses and PA’s you need to know, accept and be OK with this, no matter what kind of nurse you are all the way up to PHD. If it bothers you “GO TO MED SCHOOL”! Dora

theitunurse:

You still shit yourself when you realize that the figures on the monitor are real and not due to a mechanical fault. 

“Oh, 80% sp02?. Must be a faulty probe”

60 seconds later

….*pulls emergency buzzer*

YEP….if in doubt check it out!

23 AUGUST, 2011

“Dogs can be trained to identify the scent of lung cancer long before symptoms develop,” the Daily Mail has today reported. The newspaper said that “sniffer dogs can be relied upon to find the unique smell of the disease in seven out of 10 sufferers”.

The claim is based on a study that had trained four dogs to detect breath samples from people with lung cancer among those taken from healthy people and people with the lung condition COPD. The researchers determined that when three out of the four dogs agreed on which samples indicated lung cancer then this consensus could correctly detect a cancer sample 72% of the time. The dogs could also correctly rule out cancer in healthy samples 94% of the time.

However, the researchers point out that the dogs may have been detecting the medication used by the cancer patients rather than substances indicating the disease itself. This casts doubt on how well the technique might detect undiagnosed cancer. The accuracy of the test is unlikely to be the same in an unselected group from the general population. Therefore further testing will be needed.

As it stands, it is not possible to say whether dogs will be useful to sniff out early lung cancer in a sample outside of a research setting, such as a random selection from the general population or from high-risk groups. Although a novel idea, researchers must see whether cancer-specific compounds are actually released when a tumour is present, and assess the practicalities of using the technique outside of a research setting.

Where did the story come from?

The study was carried out by researchers from the Ambulante Pneumologie in Stuttgart, Germany, and Schillerhoede Hospital, Gerlingen, Germany. The study was funded using the authors’ own money. One of the credited authors declared a possible conflict of interest due to them owning the training kennel used in the research. The study was published in the peer-reviewed medical European Respiratory Journal.

The Daily Mail and BBC News did not highlight the potential confounders identified by the researchers, such as the fact that the dogs may have been detecting drugs used to treat cancer rather than the presence of cancer itself.

What kind of research was this?

This research tested the ability of trained sniffer dogs to distinguish between breath samples from volunteers with confirmed lung cancer, from healthy volunteers and from people with the lung condition chronic obstructive pulmonary disease (COPD).

The researchers were interested in testing the sensitivity and specificity of this canine test. The sensitivity is the proportion of samples from people with lung cancer that the dogs correctly identified as having the condition. The specificity is the proportion of samples from people without lung cancer that the dogs correctly identified as not having the condition, i.e. correctly ruling out the presence of lung cancer.

The researcher said attention is periodically drawn to the concept that dogs may be able to detect the presence of cancer due to their highly sensitive sense of smell. There is current speculation that tumours may release unidentified volatile chemicals that dogs but not humans can smell. While ‘electronic nose’ sensor devices have been developed to try and distinguish patterns of volatile chemicals (smells), these require people to refrain from eating or smoking before the test. The researchers say that, as yet, no volatile chemicals specific to lung cancer have been identified.

What did the research involve?

Between December 2009 and April 2010 the researchers collected breath samples from people from a hospital and medical practice in Germany. The samples were collected from people with lung cancer (60 people), people with COPD (50 people) and healthy people (110 people). No restrictions were made regarding smoking behaviour or food ingestion prior to sampling. All participants provided their medical history so that the risk of lung cancer, other cancers and COPD could be assessed. They excluded people who had suspected or confirmed cancers other than lung cancer, as well as those who had previously had surgery of the chest or airways.

The participants breathed into a glass tube that contained a fleece material to absorb the smells. In order to minimise their degradation, the samples were kept at room temperature in the dark until testing.

Four family dogs (two German shepherd dogs, one Australian shepherd dog and one labrador retriever - two male, two female) were trained by a professional dog trainer by using rewards to indicate which samples were from patients with lung cancer. The dog indicated the lung cancer sample by lying in front of the sample tube with its nose touching the tube. Each testtube containing a human breath sample was used only once to prevent the dogs’ actions from being influenced by memories of each person’s unique odour signatures. The dog training phase used breath samples from 60 healthy volunteers and 35 patients with lung cancer. Samples from people with COPD were not used in training.

Following training, three types of test were performed:

How well the dogs could identify a lung cancer sample placed alongside four healthy control samples. How well the dogs could identify a lung cancer sample placed alongside four COPD samples. How well the dogs could identify a lung cancer sample placed alongside four mixed samples from healthy controls and COPD patients. Among the samples from people with lung cancer, 36% were from people with early stages of the disease. The majority of samples were from people who had a type of lung cancer called ‘adenomatous non-small cell lung cancer’, although the samples were from a mixture of lung cancer types.

What were the basic results?

In the first test, where lung cancer samples were hidden among healthy samples, the researchers used 10 lung cancer samples and 40 healthy samples over 10 rounds of testing. In the second test, researchers tested 10 lung cancer samples and 40 COPD samples. In the third test, researchers used five lung cancer samples, 10 healthy samples and 10 COPD samples across five rounds of the test.

The four dogs had a “hit rate” (identifying the lung cancer sample) of between 68 and 84% across the three types of test. The researchers calculated the sensitivity and specificity using a “corporate decision approach”, i.e. where an agreement was made when at least three dogs gave the same result.

Across all of the tests the sensitivity was 0.72 (confidence interval [CI] 0.51 to 0.88), meaning that the dogs could correctly identify the presence of cancer in a lung cancer patient 72% of the time. The specificity was 0.94 (CI 0.87 to 0.98), meaning that the dogs could correctly rule out a cancer in a non-lung cancer sample 94% of the time.

The researchers found that lung cancer detection was independent from COPD and the presence of tobacco smoke and food odours. However, further analysis identified nine drugs as potential confounders. Three of these drugs have been administered to patients with lung cancer and may have biased the study.

How did the researchers interpret the results?

The researchers said that “it must be assumed that a robust and specific volatile organic compound [or pattern] is present in the breath of patients with lung cancer”. They say that in order to create suitable scent-based screening tool, additional research efforts are required to overcome current technical limitations of electronic sensor technologies.

Conclusion

This small study adds to previous small studies which have shown that dogs can be trained to distinguish between breath samples from cancer patients and healthy controls. The researchers point out that their work was not intended to suggest that dogs would be used for cancer diagnostics but rather to encourage further research into developing ‘electronic nose’ sensor devices and identifying volatile chemicals that may be associated with the presence of tumours.

This study has strengths in so much as it looked for confounders that could have been associated with the dog’s ability to detect the cancer sample. However, the researchers highlighted that they found that nine drugs were potential confounders. Three of these were used for lung cancer, casting doubts on whether the dogs were detecting tumour-specific volatile compounds or just detecting the drugs being used to treat the cancer.

The trial was also relatively small, so the accuracy of these sorts of scent-based tests (with dogs or with electronic noses) will need to be tested in a large, unselected community sample before it can be said that it would be useful for screening.

Overall, further research would be needed to see whether dogs would identify samples of the cancer drugs as “cancer samples” and whether dogs were able to detect cancer on the breath of people who had not yet started treatment. If the technique were to show that it could detect cancer rather than cancer medication, researchers would then have to assess a number of key considerations, such as what stage of cancer it could reliably detect, how the technique could be practically used and whether or not it actually improves upon current diagnosis techniques. In short, the idea is certainly novel and interesting, but its use would still need to deliver in practical and clinical terms before it could be adapted into technologies to be used in clinical practice.

mystrongmedicine:

Choking on Your Own Vomit « http://ow.ly/6a1Wt