Be a Patient Advocate
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By TMFRoZany
March 27, 2007

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A Life Changing Event and Patient Advocacy
We all have life changing events, it happens to everyone during life's journey in the form of marriage, birth of a child, overcoming some great trial like divorce, changing jobs, loss of a loved one - be it through death or separation, and a diagnosis of cancer.

Sitting in the doctor' office hearing a doctor say to my husband, "You have cancer of the bladder, talk to my nurse to get you scheduled for surgery," brings new dimensions to your life. Even though one knows it is a treatable disease in many cases, it changes quickly the priorities in a life. But that is just the backdrop to what I hope may benefit anyone or a family member in our Inside Value community facing a hospitalization experience.

A nursing colleague, Donna J. Middaugh, PhD, RN, has written an editorial entitled, "Take someone with you," in which she explains how important it is to ask a trusted friend or loved one to be with you during a hospitalization. Let me digress.

Health and Safety of Patients Standards
The Joint Commission, formerly Joint Commission on Accreditation of Healthcare Organizations, is the nation's predominant standards-setting and accrediting body in health care. In fact, no medical school can have an affiliation to a teaching hospital without that accrediting agency approval of the hospital. The Joint Commission standards are intended to ensure that patients have a safe environment of care and is voluntary self-care regulation agency.

To the point! The Joint Commission, together with the Centers for Medicare and Medicaid Services (CMS), launched a national campaign in 2002 on Speak Up: Help Prevent Errors in Your Care. This initiative urges patients to take a role in preventing health care errors by becoming active, involved and informed participants on the health care team.

This means a loved one may need an advocate at times to "...stay with you, even overnight, when you are hospitalized. You will be able to rest more comfortably and your advocate can help to make sure you get the right medications and treatments.".

Does the Joint Commission know something that John Q. Public may not be aware of about healthcare in institutions? You bet they do, as they review standards of care (Quality Care reports and more) in institution after institution. Originally, the "Joint Commission" surveyed and accredited only hospitals. Today Joint Commission accreditation can include critical access hospitals, pathology and clinical laboratory services, home health agencies, behavioral health care services, long-term care facilities, ambulatory care centers, health care networks and managed care. The Joint Commission conducts a voluntary survey program. Institutions must request and pay for a survey.

And what fusses the Joint Commission is no different than what fusses us about analyzing corporate behavior. Findings are not always what we would like it to find. However, the Joint Commission has power; they can deny accreditation which then disallows Medicare/Medicaid reimbursement (cuts out all Medicare admissions) and medical school affiliation. Healthcare accrediting agencies recognize first hand how caregivers are human, mistakes are made, and this time it is about a human life.

Self Concept
This takes me to examination of my self-concept and my loved one's hospitalization. Forty years practice in the nursing profession and a few less years as a wife, somewhat blends the two identities with beliefs and ideas. Nursing and nurturing attributes of wife or mother thrive together when it comes to family.

I pretty well know the Standards of Care for patients, but this is not just any patient, this time it is my husband. I also know the frailties of human judgment. As a former hospital Nursing Care Giver, Nursing Administrator, and Nursing Educator, I know the problems of hospital's short staffing, medication errors (number one error in hospitals), mixing up orders, to mention a few.

A most difficult attribute in Nursing, or any profession, is moving from a novice to expert. The beginner nurse has to have years of experience to walk into a room, take a look at a patient, and know intuitively that danger might be lurking that requires preventative action. That is what encompasses clinical competence, experience. Only the novice nurse gets a 'co-pilot' so to speak during an orientation period.

The Dreyfus model posits that in the acquisition and development of a skill, a person passes through five levels of proficiency: novice, advanced beginner, competent, proficient, and expert. This is a progression from rule-based problem-solving to a different approach based on matching against past experiences. These decision behaviors exist for people who are teachers, programmers, investment analysts, engineers, pilots, CEOs, surgeons, etc; expertise is a learned skill.

"Turns out that we shouldn't be frustrated, the Dreyfus model explains it plain and clear: experts don't follow rules, because they don't think in rules, they have so much experience and the context is so important for them, that every situation is special, and it deserves to be analyzed. Professionals can't always explain to us why a particular move is good in a particular situation not because they are mean, but because there may be so many particular details and aspects in that situation that are not handled analytically by the professional, but intuitively, based on many years of experience."

Warren Buffett and Charlie Munger fit here along with other financial gurus with expertise, to include our own Philip Durell.

Let me share an experience in an operating room with a surgeon who was well into the domain of expert. It's about 2 a.m. CST in Omaha, NE. ". . . . .every situation is special, and it deserves to be analyzed," meant that he wanted to call another expert surgeon in New York as to what he had found and consult on how to proceed to give this man on the operating table the best of life possible. Yes, the situation was special and deserved to be analyzed by two experts.

Patient advocate role
So there I was, sitting at the bedside of my loved one for hours on end, nurse or wife? I can tell you quickly whether it was nurse or wife. Upon my arrival one morning, the sequential pneumatic intermittent compression system (venous compression leggings that balloon and release to prevent Deep Vein Thrombosis, one of the leading causes of death in hospitals today) was laying on the floor and not wrapped around his legs. Yikes, laying on the floor, a very unsanitary place. Hey, this is scary stuff if you follow it to a logical conclusion, potential infection and potential thrombosis.

When the oxygen hose and cannula was left hanging on the oxygen outlet by a respiratory therapist and not in my hubby's nose, when I had to call out to him to breath because his respirations were too few (sedation?), you can damn well be assured the nurse in me came forward.

Where is the pulse oximeter (a medical device that indirectly measures the amount of oxygen in a patient's blood)? Why are his respirations this shallow? This has gone on too long.

None of this looks right to me I tell his nurse. OK, Morphine and B&O Suppositories can depress respirations, he still doesn't look right, some beginnings of labored breathing going on here.

She calls the surgeon, a lung scan is ordered that finds a blood clot in the lung, a pulmonary embolus that is a known risk for this kind of surgery. Intravenous blood thinners started, pulse oximeter attached, respiratory treatments around the clock, pulmonologist on deck that is in the hospital 24/7.

I still have to remind him to breath . . .'wake up, take a breath.' God, I am getting so tired. More coffee. Finally, he is breathing adequately as determined by the pulse oximeter. His stay was extended by five days as he got his blood thinned with antithrombotic therapy (dissolve/resolve blood clot), medicine intravenous Heparin to oral Coumadin.

All is well that ends well, he is home now and mending slowly. The moral of the story, take an advocate with you to the hospital. How absolutely reassuring for me to find the best nurses on the night shift (12 hour shifts) that allowed me peace of mind to go home for some rest, the night shift is so frequently left shorted and sometimes lesser experienced nurses get assigned there. How comforting to have the same nurses for more than one day at a time on the day shift with competent assessment skills once out of that dark passage.

All nurses carried cell phones; their numbers were on the board hung on the wall to call them. Yes, there is the old fashioned call light; a call may go to central call place, that then dials a nurse.

Fine for the cell phones but when it is dark, you can't see the board for numbers, night nurse Jennie brings a flashlight. Jennie also does a head to toe assessment at the nurse expertise skill level and returns on schedule. A majority of the hospitalization was positive with quality care.

Note that I didn't mention the food that arrived daily by truck, transported from one central dietary department serving some five hospitals. What was ordered and what was received wasn't necessarily the same. The coffee was good and the provision of 'extras' to me was above reproach and much appreciated and to be commended.

There was no such thing as 'visiting hours', just come and go as desired.

You take charge, or your Advocate
The Speak Up Initiatives reminds you that:
"Everyone has a role in making health care safe -- physicians, health care executives, nurses and technicians. Health care organizations across the country are working to make health care safety a priority. You, as the patient, can also play a vital role in making your care safe by becoming an active, involved and informed member of your health care team." "....After all, research shows that patients who take part in decisions about their health care are more likely to have better outcomes." (2007).

So true, but if you or your loved one is temporarily incapacitated for whatever reason, I offer this personal story as a wake up call. Only the very, very sickest go to Intensive Care. Get a patient advocate in that patient room, trusted friend or family member to "...stay with you, even overnight, when you are hospitalized. You will be able to rest more comfortably and your advocate can help to make sure you get the right medications and treatments."

I would like to be able to say Intensive Care (Surgical, Cardiac, Medical Units) can be excluded from needing a patient advocate. Most of them only allow you in ten minutes on the hour. Needing a patient advocate depends on geographically where you are and the extent of the nursing shortage. The rent-a-nurse programs staff many ICUs on weekends where there are critical shortages of qualified nurses.

Unfortunately, nursing salaries are not competitive with many other fields, and a major problem is that there is a lack of qualified nursing faculty whose salaries are even lower considering investment in education. Hours of work (rotation and weekends) and an aging boomer population adds to the crunch for hospital nurses. Many more career options exist that do not offer the overwhelming workload and hours found in hospital nursing.
"Nursing shortage: How it may affect you."

The American Association of Colleges of Nursing estimates that more than 1-million nurses will be needed by the year 2014. The health-care industry has bemoaned the nursing shortage for more than a decade. Laws of supply and demand would seem to apply. The demand for nurses should drive wages up, and more people would train to fill those higher-paying jobs. It is not happening even as wages eek slowly upward. The average salary of a registered nurse in Oakland, Calif., is $80,270 per year, according to a 2007 Minority Nurse magazine article (California nurses are unionized in many places). The median expected salary for a Staff Nurse - RN in the United States is $58,575 (

Workload is one factor, convenience of support systems another, the Illinois legislature is discussing a bill that would specify nurse, patient ratios in a hospital. More paperwork, sicker patients, quicker turnover time, make a very stressful atmosphere.

That is just another dance that was tried in California that will not resolve needing a patient advocate with you or your loved one while at critical stages of recovery in a hospital. And that is my strongly biased opinion supported by the Joint Commission. A hospitalization can be a life changing event in and of itself, depending on the outcome.

Registered nurses strive to minimize dangers by providing the greatest care possible, after all the doctor is in that room about five minutes out of twenty-four hours. He relies on that bedside nurse to be update
him as necessary. With the nurses very best efforts, errors and mistakes can happen. So a patient advocate can serve as a second opinion.

Modern technology is great, it just can't tell a patient that he needs to wake up and take a deep breath even with all the bells and whistles on that bedside machine that does beep when the oxygen saturation is too low. A nurse can't stand there all the time in this instance, it takes a patient advocate.

There was not one nurse who was intimidated by me, the wife with nursing experience. In fact, one nurse even thanked me for sharing some guidance with her.

Ro, a very tired and retired nurse, now returning to the nurturing wifely duties

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