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Way Past Time of Death C Diff! Get Out of Here!

January 21, 2010

As a nurse I was caught by the National Public Radio article concerning a highly contagious "BUG" that all nurses are aware of and have the nose for calling it as they see(smell) it! Clostridium Difficile by any other name still makes cold chills run up and down all nurses’ backs. Everyone starts thinking back to a month ago...three months...even six months worth of the patients they had contact with, touched, cleaned, collected specimens...and the list goes on.

C Diff, as it most commonly named, is an intestinal bacteria that everyone carries within them at all times. Yes, it is true, you have this bug from the time of birth...your birth, not the bug' birth...at any rate it is caused usually by a patient whose immune system has been decimated to the point that anything can cause them to get sick, wiping out all the "GOOD" bacteria from their intestinal tract. When the smoke clears and your immunosuppressed patient starts to look a bit better that is when you, as nurses, as patients, as family members all of us have to become the most vigilant of all!! That is when the handwashing must REALLY begin!

Never mind the gels, the foams, and that cute little purse hand sanitizers in your pocket...ever cultured your pocket? Ever cleaned the cute little bottle?  Ever notice housekeeping cleaning the containers stuck to the walls where you pump the stuff into your hands?

No. I didn’t think so either...So what does that leave us with...uh...let me think (mental image of know it all teach tapping her finger against her temple and eyebrows going really wide)


"I've got it! We should wash our hands with soap and water! It is the only thing left to do!"

Smart aleck....

So, once identified and of course no one is responsible...then what? The patient has to receive another antibiotic that is worse than all the other antibiotics they received to get rid of whatever infection they had while they were immunosuppressed!

Whew! How is that for a doosey of a run on sentence?

That antibiotic is called Flagyl...given in several forms but for C Diff it is most effectively given intravenously. It attacks the clostridium in the intestine of your patient. Remember the number one side effect of any antibiotic in any form? That is correct.
Gastric Distress.

Great. You have a patient with diarrhea and no, you do not need to confirm how many loose stools during your shift and why is that? Right, because you are in there every hour in your PPE...

That is as GRPHIC A PICTURE AS THIS OLE NURSE IS GOING TO PAINT FOR ALL OF YOU NON NURSING TYPES OUT THERE!
YOU'RE WELCOME.

All of this scary 'the world as we know it' stuff and the point is? Exactly. The whole point that NPR skirted around is the fact that all of our antibacterial and all of our sanitizers has only done one thing, that is to make the BUGS smarter, and they are LAUGHING at us!

The Best way to prevent the spread of ANY infection is...

What?
 I can't heaaaaaarrrrrrr YOOOOOOUUUUUUU!!!!!!!!

Thank you and Good Night!
barbara bethard

Would You Report Yourself for Making a Drug Related Mistake

June 27, 2011

As a registered nurse since 1976, the headline today was more than tragic, it was frightening. Human’s are and always will be prone to mistakes. It is impossible to believe that even if you are a physician, a nurse, or any part of the healthcare team, that mistakes will somehow be magically eradicated. The best way to prevent drug errors is by following the ten rules of mediation administration. Then, if in doubt, always have another peer double check your work.  Those ten rules of medication administration include the following: Right medication, Right Manner and Route, Right Patient, Right Time, Right Dosage, Right Documentation, Right Assessment, Right Evaluation, Right Education, Right of the Patient to Refuse the Medication.

 Easily said. Not as easily followed, especially in high risk units such as ICU (Intensive Care Unit) or NICU (Neonatal Intensive Care Unit).

The drug error that occurred on September 14, 2010 to an eight-month-old infant was a matter of drug miscalculation. The drug was Calcium Chloride, an essential electrolyte of the heart and may have been given to help the infant’s heart pump more effectively. However, if too much is given, it can cause irregular heartbeat, rapid heartbeat, or coma.

Although the article does not state what steps were taken to reverse the error of calcium chloride it may be that the physician and other healthcare workers would have used Magnesium Sulfate to try and counter the effects of the drug error made with calcium chloride. Magnesium Sulfate is listed as the antidote for calcium chloride.  It was not stated in the news account that the drug error was the actual cause of the infant’s demise five days after the error occurred.

Of more importance are the events that happened right after the drug error occurred. The registered nurse who made the error was Kimberly Hiatt and this drug error was the first one in her career of 25 years. As another point of importance is that Ms. Hiatt had received a 4 out of 5-point evaluation just two weeks prior to this drug miscalculation. Immediately upon administering the wrong amount of calcium chloride, Ms. Hiatt called out “Oh my God, I’ve given too much calcium!”  This is the reaction of an ethical person and a prudent nurse.  Ms. Hiatt took responsibility for her actions and set into motion all attempts to correct the situation.

What did the administrator and Director of Nursing do to correct the problem and prevent it from occurring again? They escorted MS. Hiatt RN out of the hospital, placed her on administrative leave and terminated her two weeks after the error. Seven months later, Ms. Hiatt hanged herself in her home.

If you were a new or a seasoned registered nurse what would your instincts be if YOU were to make a drug error?
barbara bethard

http://www.msnbc.msn.com/id/43529641/ns/health-health_care/t/nurses-suicide-highlights-twin-tragedies-medical-errors/?GT1=43001

The ABC’s of Heart Medication

The differences between ace inhibitors, beta-blockers, calcium channel blockers and the functions of each.

Heart disease is the number one cause of death in the United States.  Heart Disease does give your body some warning, in fact, high blood pressure is also known as first stage heart disease. Once this diagnosis is given, you need to consider how to improve your heart and overall health. Your physician, or the nurse, will encourage you to change your diet and exercise but it is up to you to find and put into action everything necessary for your health. The top suggestions from the physician may include, stop smoking (if you smoke) stop drinking alcohol (if you drink) start walking consistently but slowly until you can walk at a brisk pace for up to forty-five minutes three to four times a week. Other suggestions may include stopping adding salt to food, stopping eating fried foods, baking or broiling meat and only eating red meat three to four times a month. The most important part is to take your medication as the physician ordered and see the physician regularly. Your physician may or may not have you seen by a cardiologist, depending upon the severity of the heart disease.

Sometimes physicians start slow and add one medication at a time for heart patients. This is usual if the person has only high blood pressure or if there are no other signs of heart disease. However, if the person has had heart disease a long time without improvement or if the person has had an episode of angina (chest pain) or a myocardial infarction (heart attack) the physician may order up to three different heart medications. Using an ace inhibitor, beta-blocker and a calcium channel blocker has been recommended by the American heart Association for over a decade. Sometimes the person cannot tolerate all three, their blood pressure and or their heart rate will drop dangerously.

Ace inhibitors

This heart medication is called an angiotensin-converting enzyme and goes by the acronym of ACE inhibitor. This drug stops (inhibits) the angiotensin-converting enzyme from entering the heart. Once in the heart this enzyme releases a hormone that causes the vessels of the heart to constrict. Once the ace inhibitor is in the system the vessels of the heart relax and open, which lowers the blood pressure and relaxes the heart muscle. An easy way to know which medications are ace inhibitors is to remember if the name of the drug ends in “pril” it is most likely an ace inhibitor. Some drugs I this class include Lisinopril, captopril, benazapril and ramipril.

Beta Blockers

This class of drugs also works by blocking a hormone (epinephrine) which lowers the blood pressure. Beta-blockers are also known as beta-adrenergic blocking agents.  Beta-blockers cause the heart rate to slow considerably and the rate of the heart beat also drops. This must be carefully monitored when the person is taking a beta-blocker for the first time. The easiest way to know if a drug is a beta-blocker is to look at the suffix. If the name of the drug ends in “lol” it is more than likely to be a beta-blocker. Some examples of a beta-blocker medication include Propranolol, Metoprolol, Atenolol and Acebutalol.

Calcium Channel Blockers

This heart drug does exactly what it says; it blocks calcium from entering the heart. This drug will relieve angina, lower blood pressure and heart rate, relaxes, and widens the walls of the cardiovascular vessels. Calcium channel blockers are made to be either short or long acting. The easy way to know if the heart drug is a calcium channel blocker is to look at the suffix. If the drug ends in “pine” it is likely a calcium channel blocker. A few examples of these drugs are Amlodipine, Nifedipine, Felodipine and Nicardipine.

In summary, persons with heart disease include even persons diagnosed with high blood pressure (Hypertension.) Persons with heart disease need to change their lifestyle altogether in order to live a fuller, better quality of life. Knowing how your heart medications affect your heart gives a well-rounded view and if there are untoward effects, you will be better informed when you see you physician. Remember to look at the suffix of the name of the medication for a clue as to which class of drug it belongs. If the drug ends in “lol” it is probably a beta-blocker, “pine” make it a calcium channel blocker and “pril’ means it is an ace inhibitor.
barbara bethard

Need To Know More About Medicare and Home Health Care?

Home health agencies have their deadlines of 2014 rushing at them. If the agency has not been putting all the requirements into place as they were due, that deadline will be chaotic and difficult. This deadline of January 1, 2014 was set in 1999 when Medicare changed all the rules and regulations concerning Home health Care. These changes began January 1, 2000 and cms.gov has them all laid out on their website, under home health care. Every agency at that time had the opportunity to change.  Everyone at that time was given the tools not only to follow Medicare guidelines for their patients, improve the patient’s health and well-being but also to raise the bar on all their home health staff.

It is true that change is never easy; it is doubly true that it is difficult to get everyone in the agency to want the desire to change as well as want to continue that change, to set their own bar of expectations and education higher than they ever had previously. If the agency management did not start in 1999 getting their staff excited about Medicare guidelines, then as the decade continued it would have become even harder to set the changes into motion. If the agency has not embraced the changes by now, then it is unlikely to change at all b this time. At that point, one must wonder at the motives of the agency and its management. The more suspicious of people may well be expecting those types of agencies to be waiting for January of 2013 to use that last year acquiring a buyer for their agency, thus cutting their loses, running with whatever profits they have already set aside.

Navigating the cms.gov website is not difficult but can seem a daunting task when first trying to tackle it. An easier way is to add “The Federal Register” to your list of favorites. This is an online publication that does nothing except keep everyone abreast of all the deadlines and or proposal and or so called ‘new’ changes. Again, it must be emphasized that while many say, “Medicare is always changing the rules and it is hard to keep up with them” this is not exactly true. There have been proposals to the Medicare guidelines and these have subsequently been put into effect or not, depending on the legislation in the District of Columbia.

For example, there have been two changes to the Medicare guidelines starting in January of 2011 and another to affect home health agencies effective January of 2012. The one that was set into motion January of 2011 was a 3.75% decrease for PPS (Prospective Payment System) that Medicare has been paying to all agencies since January of 2000. First, the explanation of PPS is necessary in order to grasp the monetary aspect of this decrease. Home Health Agencies nationwide used to be able to bill Medicare for every visit they did on every Medicare patient.  One of the first changes that occurred was in the way every patient was assessed. This assessment was and still is very similar to the MDS (Minimum Data Set) started in 1989 for all nursing homes. Both are similar to the way hospitals have determined the DRG’s (Diagnosis Related Groups) by which Medicare determines their payment.

In 2010 Medicare began monitoring HHA across the country to see if they had set into place the actions necessary for face-to-face encounters whose deadline was April 1, 2011. Again, it needs to be emphasized that this is not a “new” change to HHA. They were fully informed years in advance. Still, the percentages of compliant HHA were very low. In the summer of 2010 Medicare announced and 3.35% decrease in the PPS monies to be allotted to HHA’s beginning January 2011. The reason for this decrease was also succinctly laid out for the HHA to understand. If they were not compliant with all changes begun a decade ago my Medicare, they would be penalized.

In the year 2011, Medicare continued to monitor HHA across the country and what was found should make every nurse, therapist and manager hang their heads in shame. Medicare found that an increase of upcoding and a decrease in viable documentation that proved they improved the patients overall care and well-being existed! Upcoding means making the patient's diagnosis worse than what it really is. In other words, lying in order to obtain more money for every sixty-day episode. The worst, to this RN’s mind, s not proving on paper that the patient was better when they were discharged! What are we in their homes for; if not to help them get better?

Therefore, on July 12, 2011 Medicare announced its proposal of another decrease in PPS monies. The initial decrease was 4.75% however, this has now come down to 3.79% and it becomes effective January of 2012.

These decreases to the amount of monies that every Home Health Agency could be making if only they were following Medicare guidelines can make one think two things.

1) These types of HHA’s never took Medicare seriously in 1999, much less in 2011.

2)  These HHA’s will be the first to either sell or go bankrupt prior to January of 2014 and run with whatever profit they have managed to glean over what will be at that time thirteen years.

The ones most damaged by these types of agencies, of course patients and their families, staff of the agencies. However, it is the management that should be held totally responsible, as they had the prior knowledge from the start, unless they have been living without the benefit of technology today.

The staff should also shoulder some responsibility for all of them know that “ignorance is no excuse” and they should have had the desire to learn as much as possible about their chosen healthcare field. However, there have also been many staff, from nurse to therapist, who are aware of Medicare guidelines for home health and who may even have had the benefit of working for an agency where it was proven that using Medicare guidelines not only works but is profitable! When these staff try to speak up, many are ostracized, harassed, even fired it may be due to the agency not wanting to shoulder the expense, time or the stress of improving the patients outcome at the eleventh hour.

Hopefully, in 2013, it will be an even greater change in home health agencies than in 1999. Hopefully this time it will not be the small agencies that suffer. Hopefully, this time Medicare will take care of the agencies that have not been compliant with Medicare guidelines for over a decade. Medicare has more of an advantage now, more ability to see what is going on in home health now and the state boards of nursing as well as CHAPS and or JCAHO have been following along much better than previously.
barbara bethard

How will you use your professional and educational experiences to enhance and promote learning in your classroom

Professional experience: As a young woman this RN set her career goals as a nurse midwife. His RN started at the University of Alabama in Birmingham as a student nurse in September of 1971. This RN worked exclusively for the next 5 years rotating through only the OB-GYN floors. At that time, as today, UAB was the best teaching institution in the Southeast and this RN gained tremendous confidence and love of this field of nursing. For the next two years this RN worked as 11-7 RN in High Risk L&D on night shift.

Educational Experiences: Working in all these areas of OB-GYN allowed this RN to learn not only L&D but scrub RN for all Caesarian cases, then  had to instruct her LPN how to scrub and this RN had to learn how to circulate. This RN learned how to give nitrous gas for light sedation in the delivery room, how to monitor all pregnancies which were all high risk, how to handle precipitous deliveries, of which there were twenty-six, among a multitude of other manual skills. However, it was there that both the art of triage and of critical thinking became of greatest importance and best asset to this RN career.

This RN aspires to use not only the hands on knowledge gained as a new nurse specific to OB-GYN/Maternal Child Nursing but also knowledge gained from all of this RN 35 years of nursing. This RN’s professional and educational experience is not of one type of nursing but of many and this RN wants to show by example to nursing students all that this RN has to offer.  Then, by showing through the example of this RN’s professional and personal life, how a service oriented profession can not only provide a meaningful career but will hopefully inspire student nurses to become passionate about the art of nursing. One cannot passion for the art of nursing. One can only inspire others to become passionate about their nursing craft.

Philosophy of Teaching Statement

By the very definition of philosophy, a teaching statement must continually evolve. The instructor must continually be on the path of education at all times, learning as much, no, learning more than the very students in whom she hopes to instill knowledge! The very definition of philosophy has several underlying sub-definitions such as basic instruction, underlying principle, schools of thought, viewpoint of different beliefs. Due to the rapid increases in technology and medicine today the nursing instructor must continually reassess the concepts and theories of nursing in order to prepare students to pass the NCLEX but also to nurture them in continuing their own education once they have earned the initials for registered nurse after their name!
barbara bethard

Home Health Instruction and Documentation for Nurses

Home health is based on the model of the nursing process.

1)      What is the problem? 

2)      Define exactly what the problem is (this is the nursing diagnosis.)

3)      Formulate a plan to correct the problem.

4)      Implement and document on the plan.

5)       Evaluate the plan.

6)      Start all over again.

It is not nursing based; this is the patients care plan. All of the nursing care must be aimed at the patient. That is why nurses ask the patients “What are your goals for your home health care? What do you want to see happen in the next two months?” Al of the patients goals get set into field 22 of the OASIS (Outcome and Assessment Information Set) and in field 21 the nurse must put how, when, where, what those goals are going to be met. Every instruction or procedure must have a specific, realistic, amount (in percentage) and timely (in days, weeks or months) goal.

I realize you knew all that already, that was just a refresher.

Now, with instruction, comes a big responsibility. If you are very lucky, you will be the only nurse n that patient’s home. That is a nice fantasy isn’t it. In the real world, try as we might, patients may see several different nurses. This is true and guess what? Not all nurses instruct in the same way. Now, how do you become the nurse that everyone comes to for the CORRECT answer?

Home Health nurses must know their medical surgical nursing without fumbling through a handbook or looking it up on their point of care laptop or reading it off a sheet of paper. Moreover, all home health nurses worth their salt will instruct. It is one of the standards that Medicare expects from all home health nurses. How do you learn all those disease processes? Time, watching, reading, asking questions, studying, and knowing your patients so well that when they so much as breathe differently your ears will perk up! Another thing that does not hurt is something nurses did before laptops. They bought note cards and wrote the disease process on one side and on the other side, they numbered one through four.

1)      Definition of disease process

2)      Signs and symptoms to report to the skilled nurse and or the physician

3)      Methods or ways to manage the disease process

4)      Complications to report if all the above is not followed.

Not difficult at all and it works. Very old fashioned you say? Well, maybe so, but like I said, it does work. What will NOT work is not instructing at all then writing that you taught on something. Eventually someone will ask you to prove what you taught. Best hope it is only your supervisor and not a state surveyor or worse, a Medicare surveyor!

Which brings us to the last point of instruction and that is the documentation. Many times the disease process is just too lengthy to go through all for things that need to be covered. That is all right. It is better, actually, to break it up into chunks and make sure at the start of every visit that you ask the patient to repeat what they recall from the previous visit. This is your progress towards goals and you need to be documenting it specifically as well. Besides, it looks so good during a supervisor visit or a survey visit when you tell your patient “OK its homework time! Can you tell me something you learned from my last visit?” now you have your progress towards goals documented and all the check boxes done and you document on the negative findings. Then you document the specific skill. Many times, instruction is going to be your only skill I dreaded these types of hoe health episodes. It is these charts that will be scrutinized along with your most complicated patients. Why? Because every note must stand-alone. Every patient must have proof, indisputable written proof, hopefully with quotes and examples and percentages from and about the patient that what you as a nurse did improved that patients health and well-being.  Not to forget, even with a complicated wound or intravenous meds or TPN (Total Parental Nutrition) you must still instruct on the top three disease processes on the Oasis!

Also, do not forget that in 2012, Medicare will decrease the PPS (Prospective Payment System) and the second reason Medicare is doing this is why? Because from a survey of many home health agencies across the country it could not be proven that, the patients had improved under the care and instruction of the home health agencies. That means us. That means as nurses we did not act responsibly or as a prudent nurse should act. Embarrassing, is it not.

If you have point of care, you may have all your disease processes plugged in and all you have to is cut and paste for your documentation.

How nice,

Will it teach you med-surg nursing? Will it instruct your patient on what they need to know to improve their health? Will it pass muster if someone asks you a specific question that is not on your point of care? Not your boss; I am talking about your patient. After all, you can only say, “I will get right back to you with that on my next visit” so many times.

In summary what do we, as home health nurses, need to do in order to improve the care and health of our patients?

1)      Learn Medical surgical disease process, definitions, signs and symptoms, methods to manage and complications that can result.

2)      Repeat this information to our patients in as many visits as it takes.

3)      Ask our patients on every visit to repeat what they learned the previous visit back to us.

4)      Document in our nurses notes exactly what the patient was able to recall. This information goes under progress towards goals.

5)      Document your skill.

6)      Document your instruction.
barbara bethard

One Would Think a Biosafety Laboratory Would Be Free of Deficiencies

After 2001, the president and the government issued the National Homeland Security Act and with it came grants in the millions of dollars for BSL 4 Laboratories. There are hundreds of BSL 3 labs in the United States but as of 2001 there were only three BSL 4 Labs. Scientists all over the nation began vying for a coveted grant in order to build a new BSL 4 Lab. Today, in 2011, there are an additional three BSL 4 Laboratories. These new labs are in Hamilton, Montana, University of Texas in Galveston, Texas and the Boston Medical Center in Boston, Massachusetts. When these labs were brand new an article in "The Scientist Magazine" reported on its state of the art equipment and how self contained they were, how safe it is and the near zero possibility of a break due to the protective seals and security.

In 2004, the federal government began a survey of labs that received federally funded money. It was called "The Sunshine Project" and included over 400 members, who formed the IBC (Institutional Biosafety Committee), and the results of their surveys were not reassuring. Scientists may feel certain that dangerous organisms such as Ebola are not going to leave the facility; however, there was not enough proof that quality assurance methods were being performed inside the laboratories! Dangerous experiments were conducted without proper safety measures in place, no reviews of work that was being performed, no direct supervision on experiments, no periodic inspections of facilities to assure all equipment had remained in good working order.

The results of "The Sunshine Project" are well documented and each lab is handling their own list of measures that must be maintained for everyone's safety. The NIH has written and posted a safety fact sheet which gives specific instructions on different types of PPE (Protective Personal Equipment) and sharps handling for a BSL 2 Lab but there do not appear any standarized protocols across the board for each type of BSL Lab. Furthermore, on further scrutiny of the protocols for BSL lab but particularly BSL 3 and 4, there appear to be areas that could be improved upon.

First, because there are so many gifted minds working in the same building, it could become difficult for someone to attempt to supervise safety issues. Especially if that person is not another scientist. On the other hand, it may well take an outsider who knows only safety in the Healthcare setting to handle safety issues inside a BSL Lab. The right person may be able to encourage the scientists to develop good safety habits. Even the ones in charge of BSL 4 Labs agreed that training and then supervision of personnel needs to be improved as the language in the training manuals is too ambiguous.

The manual uses words such as "should" "must" or "need to" when speaking of specific training for work inside a BSL 4 Lab but that is not specific. Language such as this opens the way for a wide range of intreptation and with that, the risk for an error or a dangerous event escalates. Dr James W. Le Duc from Homeland Security wrote about the need to standarize the language in all training manuals for each type of BSL across the nation in "The Scientist magazine" in 2008. The safety fact sheet for a BSL 2 Lab mentioned in the above paragraph was dated 2009.
Even with a safety plan in place and all the instruction, training and records done; will that make these high-risk labs safe? Absolutely not, but it may make them safer for all employees. By instituting guidelines and holding all employees accountable, the risk of a dangerous, potentially fatal mistake is sharply reduced.

barbara bethard
References:
http://www.drs.illinois.edu/bss/factsheets/bsl2.aspx?tbID=fs
http://www.semp.us/publications/biot_reader.php?BiotID=555
http://classic.the-scientist.com/article/display/14403/
http://www.sunshine-project.org/biodefense/bb.html#11
http://en.wikipedia.org/wiki/BSL-3#Biosafety_level_3

Nursing Information For All

My name is Barbara Bethard. I am an RN with experience in Home Health, geriatrics, med-surg nursing
This is my second blog site for nursing information. The first part of this same blog can be found on weebly and that website address is http://www.weebly.com/weebly/main.php which contains pages of useful information on disease process, definition,signs to report, methods to manage and complications that can occur.

I also have another blog called About Barbara Bethard which will continue the nursing informtion as well as bits of interesting but little known nuggets of information. After all, we all need a break now and then.

I hope you will join me as all things nursing are discussed, brought to light and hopefully enjoyed!
barbara bethard

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