paid leave doc

Policy Memorandum

To: Paulina Flores, Director of Cardiac Services
From: Ronda A. Malabe-Stagias
Subject: Patient Safety during Transfers from the Emergency Room
Date: September 17, 2015

The new policy regarding patient admissions from the emergency room to the in-patient units in under an hour is a great concept in theory but in practice it has caused a tremendous amount of confusion and unsafe situations. The new mandate requires the emergency room nurses to give an oral history at bedside and only report advance life support equipment (ventilators, arterial lines) prior to transfer.
A large majority of the patients that are being admitted to the Coronary Care Unit (CCU) are being transferred with virtually no information given to the physicians in charge or the staff nurses. In fact, the CCU Fellow has frequently been bypassed by the admitting department and quite often has no idea what is going on with the patients that are brought up to the unit. Under the new policy the physicians have been relegated to the tasks of asking the nurses why the patients are on the unit and are examining them on the stretchers before the nurse has a chance to attach them to the cardiac monitors. As per the National Safety Goals set by Joint Commission (2009) improper patient handoff was cited in 80% of adverse patient outcomes analyzed. (Schmit, 2013).

While bedside reporting between the nurses has been helpful, we have had numerous incidents in the CCU that resulted in missed information and patient deterioration during transit from the emergency room . A registered nurse should not be responsible for getting and receiving patient information simultaneously and then having to attach a critically ill patient to life-support equipment. The most recent incident triggered a fight between the staff of the Coronary Care Unit Nurses and the Emergency Room Nurses. The incident involved a patient who was transferred up from the ER in a third degree heart block. The patient was confused and hemodynamically unstable. The admitting nurse in the Coronary Care Unit was not given a report so she had to set up for an emergent trans-venous pacemaker and connect the patient to life support simultaneously with the CCU doctors at bedside. The nurse from the Emergency Room stood at bedside and requested to give report and was told to wait because the patient required acute care. The emergency room nurse then called her manager and stated that the CCU nurse is refusing to take report. The Emergency Room Nurse Manager then came to the CCU in the middle of pacemaker insertion was promptly told to stop speaking during the procedure which only caused her to escalate this situation to the directors of nursing.

On several occasions there was an obvious difference in the information reported and the actual patient presentation. There have been a number of incidents where patients were admitted to the Coronary Care Unit (CCU) that had vitals that were incompatible with life. There have been CCU admissions that arrived blue or ashen and have died within hours of arrival. As a direct result of these events, the nursing staff of the critical care units have begun to question the abilities and motives surrounding the rapid transfers of patient’s out of the emergency room. As you know, there have been hostile exchanges between the nursing staff of the coronary care unit and the emergency room. The resultant meetings with the nurse managers of both departments did not change the hostile dynamics that are ongoing.

I am proposing to organize a collaborative care counsel between the staff nurses from the emergency room and the intensive care units so that we can explore the current patient handoff system and find solutions that work for both arenas. In addition to the nursing staff participation it is imperative that the attending physicians from both the intensive care units and the emergency room be present at the initial meetings of the counsel so that we may discuss the physician’s role in during admissions. I have researched this topic and found some interesting material to bring to the table.

There are small interventions that can be done to ensure a seamless patient transfer that does not result in patient harm or hostile exchanges between nursing staff. Prior to any transfers being performed there is crucial need for communication either in writing or verbal between the staff that are transitioning the patient care (McFetridge, Gillespie, Goode, & Melby 2007). For instance, a written policy that no patient transfer can be performed until the Critical Care Fellow receives handoff from the emergency room. This one intervention alone would prevent the unnecessary confusion depicted in the aforementioned examples and also give the staff nurses in the critical care areas a chance to assign the patient to a specific nurse. Furthermore, early physician involvement with a brief handoff to the critical unit would assist the nurse in determining as to whether there will be any specialized equipment or procedure involved in the plan of care.

The use of a charge nurse/admitting nurse would alleviate problems that develop once the patient arrives to the critical care unit by providing an extra resource to help the staff nurse who has this patient assignment. A charge nurse/admitted will provide immediate nursing care and can take report from the emergency room nurse. Quite often the nurses on the intensive care units are involved in emergent situations and the patients coming from the emergency room are part of that equation. When the managers are off the unit there may not be a staff nurse available to take report. The unit is staffed according to patient census but there are instances where the critical care nurses are tending to other physical ill patients. There are numerous complaints from the emergency room that there is no one available to take a patient report. The critical arenas have responded by stating that they cannot take a patient report during a crisis.
One last option would entail the nurse who is assigned to take the patient on the critical care unit go the emergency room and take report at bedside. The critical care nurse could then assist the emergency room nurse with the transfer. This intervention would enhance collaborative care and foster good working relationships between both departments. This intervention would mean a small wait time but the benefits would address a multitude of problems. A team nursing approach to patient care is not a new concept and has been used in various medical arenas across the country. For instance, Centegra health system has an algorithm that requires the bedside nurses to go the emergency room from the critical care unit and take report using a standardized assessment tool format that exactly the same as the one we use in Lenox Hill Hospital. The SBAR tool, which stands for Situation, Assessment, Background, and Recommendations, has proven to be very useful in the transfer of the critical ill from the emergency room. As a result of this intervention, there was a 75% decrease in reported cases of patient deterioration during transfer from the emergency to intensive care (Schmit, 2013).

The use of the standardized interaction handoff sheet should be (SBAR) should be available in a ready to use in paper format on the intensive care units. This intervention would fall in synch with the 2009 recommendations made by the Joint Commission as a national safety goal for standardization or bedside handoff (Joint Commission, 2009).
The information I choose to highlight in this memorandum are just suggestions. I am confident that nurses from the critical care units and emergency room can come together and find intelligent resolutions to these challenging situations.
Thank you in advance for your continued support and consideration.

References
Joint Commission. (2009). National patient safety goals: Patient handoff. Retrieved from http://www.jointcommission.org/toc.aspx
McFetridge, B., Gillespie, M., Goode, D., & Melby, V. (2007). An exploration of the handover process of critically ill patients between nursing staff from the emergency department and the intensive care unit. Nursing in Critical Care, 12(6), 261-269. doi:10.1111/j.1478-5153.2007.00244.x
Schmit, C. (2013). Emergency department nurses reporting at the bedside to intensive care nurses. Retrieved from http://www.nursinglibrary.org/vhl/handle/10755/306616

The writings of Aristotle have to be taken in the context of the time that they were written.  It is almost common sense that a leader should possess the characteristics of “phronesis”.  The problem is that Aristotle was probably referring to an emperor. The character of phronesis is something that has to be developed overtime and can never really be tested until that person is in a position to rule.  When I vote I strive to pick the candidate that I believe has the wisdom and insight to make the right decisions. A system had to be developed to make sure the leader does not become the absolute ruler, which is why we no longer have the aristocracy in decision making positions. One can even say that the new candidates for president come from old dynasties that are heavily connected in Washington which resemble ancient Greece.  It is also clear that Aristotle understood the necessities of separating the different branches of government and gives the rationale for his theories in his writings.  Aristotle speaks of having absolute knowledge of finances, goods, and the ability to import and export material.  The military branch of decision making would have to include an extensive knowledge of history, allies, borders and what actions other nations took to prevail or simply live in peace.  Aristotle speaks of having expert knowledge of the law and legislation (ancient lawyer) and maintaining a balance that is neither excessive nor too relaxed that would eventually cause rebellion.  All these systems have to be in place in order to create an environment so that people may pursue happiness.  Happiness is the goal of a just society according to Aristotle.

The expert knowledge required by a leader or leaders is reiterated thousands of years later by Walter Lippman who believed that people make judgments based on pictures in their mind and not the actual facts.  This is a practical point that causes misjudgments and bad decisions to be made on a daily bases.  I see it on a very small level at work.  I have also succumbed to the images in my mind of old situations and made bad decisions.  I think drawing conclusions, however right or wrong, is necessary unless you plan to research every topic you come in contact with.  A separate fact finding branch of the government should not be developed because it could never really address every issue without making any errors.  It would simply not be possible.  Exactly, who is going to manage the fact finders themselves and double check their facts.  What I find disturbing is that Walter Lippman suggests that the fact finders determine what should be stated in the media.  Lippman suggests that censorship of nonsense be imposed which would directly infringe on the freedom of free speech.    I do believe that the average person does need to be well informed and needs accurate information. However, it takes internal motivation and not simply controlling the media.

James Madison understood basic human nature and developed a practical paradigm to address the inevitable factiousness that would eventually develop amongst different groups of people. It is the essence of factiousness itself that will cause the eventual checks of the laws to be upheld. As a result, the majority cannot have absolute power of a minority.  This is definitely not always the case in terms of majority control but it does prevent insurrection.  This was realism at its best.  James Madison took corrective action and implemented system checks and balances to prevent absolute group domination.  As discussed in class, only white property owning men were allowed to vote during the time that the Federalist papers were drafted.

Finally, John Dewey took a philosophical stance stating that democracy is the people themselves living side by side with different opinions, from different racial backgrounds, and different religions demonstrating tolerance. The belief of human potential and goodwill to strive and create environments to foster human development is the essence of democracy according to Dewey. John Dewey speaks of a democratic faith, which is a beautiful concept. A total belief in equality and the ability to develop any gifts you have without being shut out or held down by another group of people. This is the goal that democracy strives to achieve but often fails. Unfortunately, John Dewey never lived to see this utopia exist even here in the United States because when he died in 1952 there was still segregation of the African American citizens.

The process of deliberation depicted in this film was extremely difficult.  The characters in this film verbalized many of their biases against class, race, and age.  The irony was that it was these very negative comments that propelled some of the jurors to reconsider the evidence. The first once was Jack Klugman (Juror #5) who responded to reference of “slum kids” with a sense of shame and thoughtfulness.  Juror #5 then changed his vote to not guilty because of the availability of the “unique knife” and the way the crime was said to have been carried out.  When the immigrant Juror #11, responded to the notion of a hung jury and proclaimed the importance of civic duty, he was met with an angry rant from juror #3 who makes negative comments about immigrants.  Juror #10 then proceeds to give a racist speech “these people don’t need a reason to kill someone” and was promptly told to shut up by the stockbroker (Juror #4).  Finally, the elderly Juror #9 made the most compelling arguments for the defendant by punching holes in the testimony of the two witnesses. This fell in stark contrast to the comments made by juror number #3 who states that ” the witness, who was also an elderly gentlemen, didn’t know what he was talking about because of his age”.  The comments made by Juror #3 had the opposite effect that the one intended and his statement was met with incredulous stares from the other jurors. Furthermore, Juror #3 was assaulted by his own son who walked out of his life.  This probably explains why Juror #3 was the last to be swayed and was in tears as he voted innocent.

I loved the fact these characters had to overcome their own biases to come to a decision that was fair.  Based on the evidence and the statements there was significant reasonable doubt.

I believe that all people have some form of bias that effects their decisions and may cause people to predetermine outcomes before considering the facts.