Policy Memorandum

To: Angela Adjetey, Nursing Director of Oncology Service Line. New york Presbyterian Hospital Weill/Cornell

From: Chinsia Francis-Hill

Re: Visitation Policy for Medical Oncology Unit

Date: 9/15/15

EXECUTIVE SUMMARY

The medical oncology/hematology unit is designed to meet the medical and emotional needs of oncology patients. It is concerned with diagnosis, chemotherapy administration, hospice and palliative care (New York Presbyterian Hospital, 2014). Being admitted on a medical oncology/hematology unit can be very challenging and depressing for patients, nurses, ancillary support staff and family members (American Cancer Society, 2014). At this current hospital, open visitation hours are well supported to meet psychological and emotional needs of all patients. According to Center of Medicare and Medicaid centers (CMS), every hospital should inform patients of their visitation rights (CMS, 2015). One of the main advantages of open visiting hours is that family members can be with the patient all the time in case of physical and emotional hardships (Pervan, Cohen, & Jaftha, 1995). The same advantage has been a limitation for patients and staff members. Hence, visitation hours can be tailored, due to infection control, treatments, social issues and end of life care (New York Presbyterian Hospital, 2015). But in recent times, there have been challenges that have become a burden for patients, staff members and visitors on the medical oncology unit. This is contributed by open visitation policy. Such challenges include fatigue due to the lack of sleep, interference with patient care and lack of privacy (Johnson et al., 2013). Therefore, visitation policy should be tailored according to unit base.

PROBLEM

Fatigue is one of the major side effects of receiving chemotherapy treatment and radiation (National Comprehensive Cancer Network, 2015). Not having adequate sleep and rest affects healing and may negatively affect patient quality of life (National Comprehensive Cancer Network, 2015). A recent study shows that 70% of ICU patients have sleep disturbance, which is the most traumatic aspects of their ICU stay. According to Matthews, sleep disturbance causes fatigue, which is mostly caused by the family members communicating and huddling in the hallway (Matthew, 2011). This issue affects Hospital Consumer Assessment of Healthcare Providers and System (HCAHPS) and eventually affects revenue.

Open Visitation hours are also problematic for patient care. Family members can exhibit potential interference in the medical care and their behavior may cause problems to staff members (Johnson et al., 2013). A recent survey was conducted which illustrates the negative impact of 24-hour visiting policy. The results show that “53.3% of the participants do not think that the open visiting policy consistently increases family satisfaction with patient’s care; 59.4% of ICU workers think that the open visiting policy impairs the organization of the patient’s care; 72.7% of participants believe that their work suffers more interruptions because of the open visiting policy” (Ramos et al, 2013). Families can cause delay or may prevent the completion of medication procedure and may verbally abuse staff members. Families may demand excessive staff time, which ultimately affects other patient’s care and may even cause disputes between families (Johnson, et al., 2013). Caregivers may reflect confusion because of the intense anxiety and overwhelming nature of their experience. Some families at the hospital have unrealistic expectations of nurses and ancillary support staff and sometimes may become violent (Berger et al., 2010).

Continuous and prolonged visiting hours affects patient privacy. Patients may also feel uncomfortable when visitors are around. As a result, patient may feel that their dignity is being loss (Hunter et al., 2010). On the oncology unit, visitors oftentimes consist of five or more family members. They sometimes share restroom and may try to seek medical information of the neighboring patient. Another issue associated with lack of privacy is that patient may not express their needs and may withhold critical information if they think someone could hear what they have to say. Hence, ultimately affect patient care (Hunter et al, 2010). At this current hospital, most rooms are semi-private and family members may camp out in patient’s room as well as sharing restroom. This behavior is unacceptable and has caused inappropriate behaviors on the oncology unit. It often leads to disturbance to other patients and sometimes cause disputes between family members on our current oncology unit.

POLICY OPTIONS

Complications due to open visitation hours for families ultimately have resulted in a need of new visiting policy for families of patients that are admitted on the medical oncology unit.

Visitors should not sleep in semi-private room

First of all, patient should only be allowed to sleep over only if there is a need for a night stay: The requesting patient’s family member or proxy must be referred to the Nurse Manager /Nurse administrator on call only if its urgent situations such as end of life, newly diagnose or first line of chemotherapy. All visitors must be instructed to stay in the patient’s lounge. However, due to space limitations  cots or foldout chairs should not be allowed in the visitors lounge as well.

Informed Knowledge: Clarification of visiting hours

Open visitations and sleeping over should be clarified and inform to patients and visitors at admission. Visiting hours for families should be flexible however, families should always follow directions in an appropriate manner. Family members should understand the difference between open visitations and sleeping over. The advantage of this clarification is to give patients sufficient time to take a rest, reduce noise level, meeting patient expectations and satisfaction (McAdam, 2013). A study was conducted on a visitation practice in a healthcare setting. The result shows that family members are more likely to be cooperative when information is given to them at admission (McAdam, 2013)

Two visitors rule

Thirdly, only two visitors are allowed to visit a patient in a semi-private room at the same time. At admission, it should be a policy for each patient to receive a booklet of visitation guidelines. This booklet will educate patients and family members of visitation rights and the rules associated with the hospital policy. It will also prepare family members to decide on what time will be appropriate to visit their love ones. Consistency is key. The same information should be communicated to visitors with no exception. 

Quiet Time

Quiet Time hours must be respected. If a patient and overnight visitor wish to converse during quiet time, they must go to the patient lounge. All cell phones should be turn off or be place on silent when visiting a patient in a semi-private room. All calls should be answered in the patient lounge and not in patient’s room or hallway.

Security Rounding

Security rounding should be implemented to identify disruptive behaviors. Visitors should check with security before entering the unit. Clarification of disruptive and unsafe behaviors should be communicated to visitors during this time.

Late visitation

The patient and the registered nurse taking care of the patient should do approval for late visitation. Patient and visitors should communicate in the patient lounge and not in patient’s room if family members want to visit patient at a late time.

As we move forward, there is a need to improve and individualized visiting policy for oncology patients. These suggestions will assist in achieving these goals and improve patient satisfaction. I thank you in advance for your time, ideas and support. I am looking forward to assist in a solution.

References

American Cancer Society. (2014). Emotional Impact of Cancer Diagnosis. Retrieved from http://www.cancer.org/treatment/treatmentsandsideeffects/emotionalsideeffects/copingwithcancerineverydaylife/a-message-of-hope-emotional-impact-of-cancer

Berger, A. M., Shuster, J. L., & Roenn, J. H. (2010). Principles and Practice of Palliative Care and

Supportive Oncology. United States: Wolters Kluwer Health.

Centers of Medicare and Medicaid Services. (2015). Hospital. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/Hospitals.html

Hunter, J., Goddard, C., Rothwell, M., Ketharaju, S., & Cooper, H. (2010). A survey of intensive care unit visiting policies in the United Kingdom. Journal Association of Anaesthetists of Great Britain and Ireland, 65(11).

Johnson, F. E., Maehara, Y., Browman, G. P., Margenthaler, J. A., Audisio, R. A., Thompson, J. F.,

et al. (2013). Patient Surveillance After Cancer Treatment. United States: Springer Science.

Matthews, E. (2011). Sleep Disturbances and Fatigue in Critically Ill Patients. AACN, 22(3), 204-224.

McAdam, J. (2013). Critcal Care. Open visitation policies and practices in US ICUs: Can we ever get there?, 17(4), 171.

National Comprehensive Cancer Network. (2015). Fatigue. Retrieved from http://www.nccn.org/patients/resources/life_with_cancer/managing_symptoms/fatigue.aspx

New York Presbyterian Hospital. (2014). Cancer. Retrieved from http://nyp.org/services/oncology/index.html

New york Presbyterian Hospital. (2015). Visiting Poilcy.

Pervan, V., Cohen, L. H., & Jaftha, T. (1995). Oncology for Health-Care Professionals. Capetown:

Ramos, F., Fumis, R., Azevedo, L., & Schettino, G. (2013). Ann Intensive Care. Perceptions of Open Visitation Policy by Intensive Care Unit Workers, 3(34).

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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

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