Monday, October 27, 2014

Communication in the hospital setting

Communication in the hospital is essential. Patients have several staff members taking care of them and staff has many different patients to take care of. Lack of communication can have serious repercussions. Most medical errors can be traced to lack of communication. Whiteboards serve as a very valuable way to facilitate communication.  I spent several years working the in the hospital, in both inpatient units and the emergency departments and hospital whiteboards have been important in every hospital setting I have ever worked in.
The inpatient unit is a busy place. Patients come and go quickly. Whiteboards are a central place where secretaries can locate a patient, figure out which nurse is caring for them and figure out what tests they have having done. Many people come to the unit looking for a specific patient and patient care whiteboards are a good way to find the information they need quickly. A lot of units also have another board with important phone numbers. This is very useful to the nurses who may need to reach a doctor in a hurry. Having all the important phone numbers right in front of them can be a huge help.
With a revolving door of staff members, patients often can’t keep their caregivers straight or remember their nurse’s name or even the date. Families may not be able to be present for rounds and may feel like they don’t know what is going on. In order to help these problems, each patient room has a whiteboard. These magnetic whiteboards are used to record information such as the date, room number and nurse caring for the patient. It is also a useful place to record information the patient needs reminding about such as walking three times per day or asking for help before getting up. Staff can also keep track of intake and output and family members can write down questions for the health care team.
I have also worked in the emergency department. The whiteboards in the ED are also used as a central point of communication. Staff gathers around the board for signout at shift change. The board is used to record the patient’s name, room number, diagnosis, doctor and nurse taking care of the patient. The ED staff can also record what needs to be done for the patient or what they are waiting for. It is a very important tool to keep everyone on the same page.
Whiteboards are also very important in the operating room. OR rooms turn over quickly and everyone needs to know what’s going on. The central OR board usually has the patient’s name, diagnosis, surgical procedure, surgeon and expected time of surgery. These whiteboards serve as a central communication point where everyone can know what is going on.
Electronic medical records can also be a helpful tool in improving communication between staff members. However, they do have limitations. The location of the computer may not be ideal or immediately available or some staff may not have access to the computer. It can be difficult to make changes to a program or worst case the computer system may go off-line at a critical time making it difficult to get information about the patient quickly in the case of emergency.  I worked in one emergency department who had gotten rid of the whiteboard when they started using an electronic medical record. One night the computer system went out and it became immediately apparent that no one had come up with a backup plan! The nurses didn't know who was in each room and had to go around the unit “checking” which patient was in each room. This was a case where a whiteboard would have prevented this from happening.  It serves as a good compliment to the EMR and is not sensitive to power outages!

Thursday, October 23, 2014

What happens after a heart transplant?

Recently I've been talking to a lot of transplant patients about how it is after transplant. I have heard a recurring theme that people in their lives thought they were all better when it took awhile to get back to normal. I want to share some of the things I have learned about how life is different after transplant. After I have my transplant I will have my own observations but for now here is what I have learned.

A body's natural reaction is to reject a foreign body. This includes a transplanted organ. In order to prevent this, a transplant patient must take immunosuppressant drugs for life. These drugs will weaken the immune system and prevent rejection.  Patients are monitored with biopsies to check for rejection. This is done weekly, then every two weeks then every month. Eventually they will be done less frequently. If there is evidence of rejection it is usually treated with medication. Rejection is not as scary as it sounds and is usually easily treated.

The immune system is weakened from the anti rejection drugs. Because of this there are precautions that the patient must take. They are encouraged to wash hands frequently and use masks when in crowded areas. A transplant patient is more likely to get sick, especially in the first year after transplant. There are different comfort levels around this. Some patients just go out and live their lives and try to be careful and there are others who are hypervigilant. Each patient is different and will find their own comfort level.

Food safety is important to a transplant patient. They must be very cautious when eating out. Buffets and shared food should be avoided. Meat must be throughly cooked and fruits and vegetables should be washed before eating. Most of the food safety guidelines are common sense that most people should follow but they are especially important when you have had a transplant.

The anti rejection drugs can have a lot of side effects. Everyone's tolerance is different and some have a very hard time with them. They can cause cancer and kidney damage. A lot of heart transplant patients go on to develop kidney failure.

Heart transplant patients are cured of their heart failure but have a new set of limitations. As long as they take their medications and stay on top of their care they can go onto live long healthy lives.

Wednesday, October 22, 2014

Advice for new nurses

Since I'm on the advice theme, I thought I would share some advice for new nurses. I remember the first few months as a new nurse. It was an overwhelming time. Here is some advice for those in their first year as a nurse.

1. Organize yourself.

Time management is key for a new nurse. Depending on the setting you are working in you may be expected to take care of multiple patients. Nurses often get pulled away from one thing to do another and it can be very frustrating and feel like you never get anything done. Find an organizational system and stick to it. If you are constantly falling behind, ask for help. Other nurses can help you figure out how to manage your time.

2. Learn as much as you can.

Everything is new at this point. Once you get out of school you will see just how much you didn't learn in school. Ask questions, try to understand what's going on with your patient. Don't think of your patient as a series of tasks. Take the time to understand the physiology of what's wrong with your patient.

3. Listen to your patients.

This goes along with not seeing your patient as a series of tasks. That person in the bed is a real person with real issues and real emotions. Take the time to stop and listen to them. Offer support when you can.

4. Take time for yourself.

It can be overwhelming to be in charge of another person's health. Try not to bring your work home with you. Remember you have a life too.

5. You will make mistakes

Learn from them. Don't beat yourself up. It happens to everyone.

Most of all, try to relax and enjoy your new role. 

Tuesday, October 21, 2014

Things I wish I knew when I was in nursing school

It's hard to believe I finished nursing school 18 years ago. (But I'm not old!) I became a nurse practitioner 5 years later. As I look back on my years, I think about things I wish I knew when I was in school.

Here's my list.

1. Most of the stuff you learn in school will be outdated in 5 years. 

Medicine is currently changing and it's important to keep up. Read journals, go to conferences, most of all just keep your eyes and ears open.

2. Nursing diagnoses and care plans are obsolete.

Alteration in respiration due to impaired gas exchange as manifested by dyspnea and tachypnea. Hmm.. maybe shortness of breath? I think the point of nursing diagnoses is to teach nurses to think for themselves but let's be realistic. What nurse in their right mind diagnoses their patient with alteration in comfort due to surgical incision as manifested by patient's complain of pain? If nurses want to be treated as equals on the health care team they should probably use the same language as the rest of the health care team.

3. Learn to think for yourself!!

I see this all the time. Nurse has taken care of many patients with the same diagnosis and is really good at how to take care of them. She listens to their lungs, she changes their dressings, she gives them pain medication. But then one patient has something unusual happen to them. Nurse can't possibly figure out what to do because she's used to "what she was taught" and defers to the doctor's orders. Nurses need to be able to look at the situation at hand and make a decision based on the data available, not just thinking generically that patients with the same diagnosis are all the same. It's easy to get into a rut. Think for yourself.

4. Learn from your patients.

I can't tell you how many patients stick out in my mind over the years because they taught me something. Listen to their stories, get to know them. You might see a patient with a particular problem and then 5 years later see another one. You will be more likely to recognize it because you have seen it before. File it in the back of your brain for next time.

5. Work together with your coworkers.

No one takes care of patients alone. Everyone has an important job- from the PCT who takes the blood pressure to the doctor who orders the meds to the nurse who gives the meds to the secretary who makes the chart to the person who cleans the floor. People in health care depend on each other. Treat everyone with respect. You are no more important than anyone else.

6. You don't know everything.

Nobody knows everything. Learn from the people around you. Ask questions.

What are some things you wish you knew?

Monday, October 20, 2014

A heart for Laura

Some of you who know me may know that I am currently waiting for a heart transplant. This site was created by my mother so I thought I would share it here.

A heart for Laura fundraiser

Thanks for any help you might be able to provide.

What is an VAD?

VAD stands for Ventricular Assist Device. It is an artificial heart pump that is used to treat end stage heart failure. It can be used as a bridge to heart transplant or as "destination" for patients who are not candidates for a heart transplant. In some cases it can also be used as a temporary measure while the heart recovers from injury.

There are several different types of VADs. This is a picture of the HeartWare VAD.

The VAD can be used to support either the left or the right side of the heart. There is also a device called a BiVAD which supports both sides. The most common use is to support the left ventricle.

The device is implanted during open heart surgery. The pump is attached to the left ventricle and the aorta which effectively takes the place of the pumping of the left ventricle. This allows the left ventricle to rest. After surgery the patient goes to the ICU and is closely monitored. Recovery time in the hospital can range from 10 days to 4-6 weeks. 

The bottom of the pump has a cord coming out called the driveline. It exits the body through an abdominal wound. 

The driveline must be carefully cared for because there is a high risk of infection. The dressing needs to be changed with strict sterile technique. The frequency of dressing changes depends on the person.

The driveline is connected to a small computer called a controller. The controller must be connected to two sources of power at all times. This can be batteries, wall power or a car charger. This is a picture of the controller and its batteries. The device pictured is also connected to a monitor which is used in the hospital to adjust the LVAD settings.

Patients with an LVAD can do activity as tolerated. They cannot take a bath or swim. The settings must be carefully monitored each day. The patient and a caregiver need to be trained in the use of the device and emergency procedures. 

LVADs have come a long way in the last several years. What was once experimental technology the size of a suitcase can now allow patients with heart failure to lead relatively normal lives.

Monday, June 30, 2014

What is a PICC line?

I am currently receiving IV medication at home while I wait for a heart transplant. It is being delivered via a special type of IV called a PICC line. 

PICC stands for peripherally inserted central catheter. It is an IV that is inserted in the hospital by a specially trained nurse. It differs from a regular IV because it is longer. The tip of the catheter ends at the entrance to the heart.

The major risks of having a PICC line is infection and clot. It is covered with a sterile dressing that is usually changed once per week. It's very important to be careful with the tubing and keep it very clean. If you have a PICC line, you will be instructed how to take care of it. 

Most PICC lines have 2 tubes, called lumens, at the end. One of them can be used to infuse medication and the other one can be used to draw blood. Drawing blood off the PICC line is a nice feature because it means you won't need to be stuck for lab draws. Usually a nurse will draw the blood off the line. You may need to make arrangements for the blood draws because most lab techs won't be able to use the line. 

The line will also need to be flushed at least once per day. This is a simple procedure that you will learn how to do. It is important to flush the line to prevent clotting. If you notice that the line isn't flushing as well then you need to call your provider. The line may need to be changed.

If you have a PICC line, it is important to watch for signs of infection. These can be fever, feeling poorly or redness around the insertion site of the PICC. If you notice these things it is very important to notify your health care provider because you will need prompt treatment. An untreated infection can make you very sick. 

PICCs can be a nice alternative to IVs and allow you to receive medication at home. With care, the lines can last a long time. Take good care of your PICC line and it will take care of you. :)

My PICC line