Saturday, May 30, 2009

Nurses make a (HUGE) difference

First of all, let me say, nurses rock. They work long hard hours, do indescribably important work, encounter the least pleasant aspects of the human condition, and are critical to the well-being of patients.

A lot of research is being done about the value of nurses, brought to the fore recently during the current nursing shortage. There is quantitative proof that fewer fully qualified nurses (i.e. R.N. vs L.P.N) per patient in the hospital (nurse to patient ratio) leads to poorer care and more bad outcomes. This is why I put in my previous blog the importance of having a low (ideally 1:4 or less) nurse to patient ratio on the hospital floor.

Below is an excerpt from the New England Public Policy Center and the Massachusetts Health Policy Forum Research and Reality (google "conreport051.pdf"):

The implications of nurses' working environments on patient safety can be quite serious indeed. Two-thirds of the respondents in a 2003 survey of MNA members believed that insufficient nursing care led to serious medical complications, many of which resulted in patient deaths. Nearly 90 percent of the nurses surveyed felt that they were being forced to care for too many patients...

For example, Jack Needleman, associate professor at UCLA, argued that "given the variety of studies, the robustness, the plausible clinical pathways that have been used to explain these results, [they] go beyond association to causality." Needleman's own research...estimates that switching a nurse's load from the level of the bottom quarter to that of the top quarter of hospitals nationally, a reduction of roughly one patient per nurse - lowers the risk of adverse outcomes such as shock and infection and decreases hospital length of stay by between 3% and 12%.

Thursday, May 28, 2009

How to choose a hospital PART 2

I have some additions and clarifications to my previous post.

To the above tips I add:

7) Find out which hospital closest to you has 24 hour cardiac catheterization capabilities. If you have a heart attack, you do not want to go to a hospital that is going to have to transfer you for this critical life-saving procedure. Time is muscle!

8) Pick a hospital with a pre-code team. What is a pre-code team? Usually when a patient "codes" i.e. heart stops or stops breathing, or both, a "code blue" is called where all available physicians who are part of the responding code team converge on the patient, with nurses, and respiratory therapists as part of the team (in many hospitals this is simply the ER doc running like a mad-man or mad-woman to the code). A pre-code team assess patients that are getting sicker BEFORE they code. And prevents them from coding in the first place. Not many hospitals have this. I would select one that does.


When asking if a there are hospitalists, you need to specify, "Do you have hospitalist in-hospital at night?" (some hospitalists take call from home - odd, I know, but that's why you need to specify).

While academic centers have residents taking care of you at night, you might be wary, but compared to not having anyone there at night, it is preferable. Though I would ideally want a hospital with intensivists (ICU specialists that are there 24 hours) and a pre-code team. And second to that would be having hospitalists overnight. An Academic center would be my third choice. In certain situations, academic centers may be superior - especially for unusual diseases, transplants, and state-of-the-art medical care.

I would like to thank minako for her suggestion for #7 above. An obvious omission on my part, I'm sure it will not be the last. I welcome your comments and suggestions.

Monday, May 25, 2009

How to choose a hospital

How do you choose a hospital?

This is a hard question for most people as the “Quality guidelines” are very subjective. But we have choices in which ER to visit or which hospital to have scheduled surgery. If you call 911 you can INSIST on your choice hospital.

Do some research and call an administrator of the hospital in your area. Ask them these questions:

1)What is the nurse to patient ratio in the ER and on the floor? Obviously the lower the better. Want to catch a sneaky administrator in a lie? Then call the actual ER/Floor and ask one of the Nurses there what the ratio is THAT DAY.

2)Who takes care of me at night? Meaning the doctor. YOUR doctor will be asleep. But someone is going to be managing your care if you have problems overnight. Many hospitals, even “good ones,” even some transplant hospitals, have NO ONE in the hospital overnight except the ER doc and (sometimes) the OB for Labor and Delivery. And the ER docs only come in the event of cardiac arrest. 

THE BEST hospitals have ICU Intensivists (Doctors who specialize in ICU care) on 24 hours a day, and Hospitalists (Doctors who only admit and manage patients in the hospital). While it is nice to have your own doctor, who knows you, to take care of you in the hospital, they don’t do you much good if they are home sleeping when you get sicker.

3)What is your nosocomial infection rate? In other words, how many people who enter the hospital get an infection FROM the hospital. In some hospital ICUs it can be as high as 90%. You don’t want to be at that hospital.

4)Choose a children’s hospital for your kids.
5)If you have a Neurosurgical Issue, go to a hospital with a dedicated Neurosurgical ICU.
6)Go to a Level 1 Trauma Center for your major trauma (Bad Car Accidents, Stabbings, Shootings, Falls from a height). This is usually your local County Hospital or University Hospital. If the ambulance Paramedic tells you they are “Diverting” you to a trauma center NEVER insist on your “favorite hospital.” It could be a fatal decision.