4.26.2010

Nursing homes are interesting, after all.

BRIDGEPORT, Conn. (AP) The former chief executive of a Connecticut nursing home has been sentenced to a year in prison for using money intended for the homes to buy real estate.
Raymond Termini, former CEO of Haven Health, was sentenced Tuesday to 12 months and a day in prison and a $6,000 fine. Prosecutors say he also has to forfeit $500,000.


Wow. Nursing homes can be pretty exciting places, huh?

The intrigue. The politics! The ever-present human drama unfolding. The unending labor, whether laboring for breath or laboring for pay.

Fortunately, the inevitable chaos of a busy nursing unit is finally starting to make sense to me. Something that can be controlled, or at least surfed.

It's a lot to keep track of at once. I can't go to sleep right after a shift, because there's too much to process. Even now, I've just worked a 12 hour shift that lasted about 14 hours, and I'm still fighting the urge to call back and add some random piece of info I suddenly thought might be useful.

At times like this I have to remind myself that we work in shifts for a reason. The next shift coming on can handle whatever happens next.

The main bottleneck seems to come down to how information is stored and retrieved. It sounds like such a ludicrous problem to have, to spend hours producing or reproducing minuscule amounts of data. Let's call it 8-64 bits per second. Copying down intake and output into multiple redundant binders, writing terse nursing notes, signing your initials hundreds of times. Let's say between the actual writing and checking the things you're writing from and to, I'm going to guess a bits-per-second rate of 8 to 64 (a bit is a 1 or a 0, and 8 bits make up one letter like "Y" or "s" or "." ).

Verbal report sounds like it contains about 16 thousand bits-per-second worth of info.

My internet connection is somewhere around 6.76 million bits-per-second.

I suppose the bandwidth isn't as important as how the data is related to itself and it's owners. Oh, how I yearn for a relational database! A touch of SQL or even Access.

No matter how faithfully and reproducibly information is stored and retrieved, however, the human element is most important. The right way to calm down an anxious co-worker or resident isn't always easily explained or reproduced.

The things that can't be easily explained, however, we still manage to communicate. We are, after all, Nurses.

and we work in shifts.

4.17.2010

Informatics of Nursing Education

Instead of raising your hand to ask a lecturer a question, why not press a button?

Why not put a screen on that button so it tells you how many people pressed their buttons first? Say you had only four people sharing one of these buttons. Two people might press the button one after another, then two numbers would be displayed. Add a second button to cancel the most recent button-press. Put microphones in all the buttons so everyone can be heard.

That would have been a nice lecture to have.


The anachronism that is Paper Charting continues to gnaw at me. The more I understand what's going on around me in a paper charting environment, the clearer it is to me that huge swaths of our time is being wasted in fools' errands. The worst part about it, to me, is that the charting isn't even fulfilling it's purpose. Conveying information. The charting of most healthcare institutions I've seen is more concerned with how to get reimbursements than conveying information in a useful and meaningful way.

I daydream, sometimes, about what an electronic charting tool for CNAs, LPNs and RNs in a skilled nursing facility might look like on a spiffy linux based tablet like the german-engineered wepad.

Nurses seem to be a pretty technophobic bunch, but many of them deftly use facebook, for example.

User Interface Design seems like a wholly foreign concept to the developers of most of the information technology I've seen in educational and healthcare institutions. Menus made up of laundry lists of nonsense and irrational depth, unintuitive layouts, it's like they aren't trying. Your fancy multi-million dollar computerized charting system is worthless if it's unintuitive and frustrating. More frustrating than, say, a piece of paper and a pen.

I struggle on with paper charting, since I'm not too optimistic that whatever electronic charting tool I'm handed will fail to infuriate me.

We have a computer at our desk, that's the thing that kills me the most. A computer none of us use. It's not that great, but even a low-end computer from a few years ago is light-years beyond what the old room-sized punch-card computers could do.

I'm not trying to crack the atom here, this is really simple.

For each person:
-What went into them?
-What came out of them?
-How are they feeling?
-What can they do?
-What did you do for them?

The CNA interface could just be icons. Tasks can be organized and presented for quick reference, signed by the person that completed them. Punch in that 120ml glass of water on the spot, no need to remember or "guestimate" what percentage of their meal so-and-so ate. Just tap it in while you're there. Signing off on when different types of care are performed also provides valuable information to anyone interested in bowl-and-bladder issues, sleep&rest, etc.

The floor nurse's view contains all the CNA info along with med-administration and treatment info. Instead of a huge 3-ring binder of flip-cards to initial, why not just a list of what needs to be done, and when it needs to be done by? Add to it a feed of the CNA's activities and the floor nurse knows right away if someone's been using the bathroom more often than usual or is suddenly incontinent when they weren't before. While they're at it, they can add the 120ml of water THEY gave the resident along with their meds. Info goes to the same place. Most importantly, maybe, current orders regarding activity and precaution are presented uniformly, universally, and changes are instantaneous. Better still, recent labs, consult reports and therapy progress notes could be referred to at any time. Medication orders would update automatically, without errors in transcription or comprehension.

The nursing supervisor would have all of the same info as the first two views, but with expanded options for managing workflow and staff scheduling, as well as a running list of all issues everyone in the unit is currently having, and what kind of help people need. Let's say someone gets tied up in an emergency, and hasn't gotten around to getting someone's blood-sugar or giving them their IV antibiotic. If there's already crap going on, who has time to run around looking for help?

There's an easier way, and we could probably put it together from scrap parts cheaper than our pulse oximeter.

This issue may be central to the future of the nursing profession. If we can't organize ourselves well enough to train new nurses quickly enough, more and more of the functions of the nursing profession will be ceded to unlicensed technicians with specialized functions.

I say specialization is for insects!

4.12.2010

The Killing Spree that Wasn't

A Dutch nurse given life for murdering seven people in a killing spree that never happened will hear about her appeal on Wednesday.

Moral of the story: Don't multiply your p-values.

The statistical analysis is a rather interesting read, even though the math's a little over my head. Basically, a Dutch nurse got convicted for killing patients just because a lot of deaths happened while they were working. From the paper:

4 Appendix: extended discussion of hetero-
geneity
4.1 Preliminary remarks
The null-hypothesis tested by the court statistician H. El ers in the case of Lucia de
Berk is supposed to mean that incidents on a ward, and shifts of a particular nurse,
are independent of one another. In the minds of lawyers or medical specialists, as in
that of the man in the street, independence means: lack of causality. Causality can
be \measured" by performing the thought experiment: suppose that Lucia worked
on a particular shift, and that an incident occurred: would the same incident have
happened if Lucia had been magically exchanged for another nurse? The idea in
this thought experiment is that \everything else that might be relevant is kept
the same", so that we compare strictly comparable situations: with and without
Lucia, everything else being unaltered. In a randomized double-blind clinical trial
we do keep everything relevant the same, by randomization. In observational
studies we are unable to do this, so instead we are forced to take explicit account
of anything which could be relevant, in one way or another, if we want to conclude
causality. This requires prior knowledge concerning the mechanisms underlying
the phenomenon under study.
4.2 Are nurses interchangeable?
According to many medical specialists we have spoken to, nurses are indeed com-
pletely interchangeable with respect to the occurrence of medical emergencies
among their patients: nurses merely carry out the instructions given to them
by the medical sta , and they do this according to standard practices of proper
care, so it can make no di erence at all to replace one nurse by another. However
according to nursing sta we have consulted, this is not the case at all. Di erent
nurses have di erent styles and di erent personalities, and this can and does have
a medical impact on the state of their patients. Especially regarding care of the
dying, it is folk knowledge that terminally ill persons tend to die preferentially
on the shifts of those nurses with whom they feel more comfortable. (This might
apply to the Red Cross Hospital, where Lucia worked on two adjacent wards for
terminally ill aged patients). As far as we know there has been no statistical
research on this phenomenon.
4.3 De nition of incidents
There is another respect in which nurses can have an impact on \incidents". In
the Lucia case, incidents were never formally de ned. However, if medical doctors
were expressly called to the bed of the patient by nursing staff , then that soon
quali ed as an incident, especially if Lucia was somehow involved. Who decides if
the doctors should be alerted? The nurses on duty, themselves, of course. It seems
that several of Lucia's incidents were created by herself in situations where she was
uneasy about the patient who appeared to be developing some new and, to her,
alarming symptoms. The nurse who keeps a closer eye on her patients, and who is
less prepared to take risks, will generate in this way incidents on her shift, which
otherwise might be postponed to the next shift or even fail to materialise at all.
According to medical specialists, nurses do not have a choice in such situations:
they have been trained to make the right decision and every nurse in the same
situation will make the same decision. According to nurses however, this is just
not true. Nurses do have to make their own decisions and though they should
always be able to justify their choices, this does not mean that every individual
will make the same choice in the same circumstances.


Wow, statistics is some heavy stuff, huh? Almost makes me excited to study it again in grad school (almost).

Even the Dutch state prosecution now accepts Lucia should be acquitted and there was no evidence of any unnatural deaths, though her convictions for stealing two books from the hospital library – a charge she denies – will be upheld. Now living with her partner while awaiting judgment, Lucia is penniless, denied benefits, and paralysed down one side following a stroke she had in 2006 in the week she was told her conviction would be upheld.


All because of a math error.

You might remember the Cat who predicted deaths in an RI nursing home. I haven't heard anyone seriously suggest the cat was killing the patients.


Work last week was full of action and excitement! It was one of the busiest weeks I'd seen in a while, and I was filling in for the day-shift supervisor. It was the kind of challenge I enjoy, lots of things to do and keep track of. Around 30 elders to keep track of, with two hip-height racks of charts to manage. MD appointments, changes in condition, changes in skin, changes in wounds, sudden changes of vertical status (if we're unlucky), charts to audit, phone-tag with various MDs, labs pouring off the fax machine, face-time with family members, staff issues to work out..there's no time to be bored! Thankfully the staff I work with are all great. Those of us that are left have been through a lot with each-other and I always look forward to seeing them, even the ones I don't always agree with.

Even better, the student nurses were there for two days out of the week. Having them around has been lots of fun and has given me plenty of opportunities to reflect on my own practice as a Nurse. It's also loads of fun having extra people around to help me look stuff up and collect samples, as well as ambulating and transferring people. The sheer logistics involved in moving what seems like a small number of bodies around can get pretty intense.

I had so much fun last week that the prospect of taking this next week off is daunting. I probably should have planned a trip or something, but I couldn't think of anywhere to go.

In my idleness I've been pondering my options for grad-school. The more I work in an environment without electronic charting the more interested I am in Nursing Informatics, especially considering the extremely small number of RNs who currently hold that degree. I've been prototyping in my head what I would want an electronic charting tool for a nursing home to look like, tablet PCs with icon interfaces to add I/Os, vitals and med administration, different views for CNAs, Floor nurses and nursing supervisors, integrated inventory management, etc. I think I may save that for post-grad, though, I'm more interested in bedside nursing at the moment.

I'm browsing through the list of masters degrees in nursing offered at University of Phoenix. Strangely enough they've reversed which courses appear on the Masters of Health Care Administration and Masters of Science in Nursing pages, but I figured it out after clicking around a little bit. The graduate degree I was looking for wasn't in the list (Clinical Nurse Leadership), but Nursing Informatics is. Also, staggeringly, a dual MSN/MBA program. The also have Family Nurse Practitioner up there, but I'm not sure I like the idea of working in a doctor's office. The fluorescent lighting gets to me. Anyway, I sent off a request for some info, We'll see where it leads.

It would be nice to take classes with names like "creating change in institutions" and "Management of pediatric and adolescent populations" for a change.