DiversityNursing Blog

By PATTY WIGHT

Some of us are lucky enough to stumble into a job that we love. That was the case for Gabrielle Nuki. The 16-year-old had never heard of standardized patients until her advisor at school told her she should check it out.

"I was kind of shocked, and I was kind of like, 'Oh, is there actually something like this in the world?' "

Since Nuki wants to be a doctor, the chance to earn $15 to $20 an hour training medical students as a pretend patient was kind of a dream come true. Every six weeks or so, Nuki comes to Maine Medical Center in her home town of Portland, Maine, slips on a johnny, sits in an exam room and takes on a new persona.

Third-year medical student Allie Tetreault knows Nuki by her fictional patient name, Emma. A lot of teens avoid the doctor, so it's important for Tetreault to learn how to make them feel comfortable.

"What kinds of things do you like to do outside of school?" Tetreault asks.

"Um, I play soccer, so preseason is coming up soon."

Nuki preps weeks ahead of time for her patient roles. She memorizes a case history of family details, lifestyle habits and the tone she should present. "I've had one case where I was concerned about being pregnant. That was kind of like the most harsh one, I guess."

As Emma, Nuki's playing just a shy, healthy teen.

"How did school finish up for you this year?" Tetreault asks.

"Um, it was good. Yeah, school's been good. Um, yeah."

Emma's an easy role, Nuki says, but she ups the shyness factor because it poses a classic challenge to the medical student: how to get a teen to open up?

"Each case kind of has what's on paper, but then you can come in and kind of add another level," Nuki says. "Depending on how complex it is, you can add your own twist to it."

After asking Emma about her personal history, Tetreault moves on to the physical exam and listens as Emma takes deep breaths.

Tetreault gives Emma a clean bill of health and the practice appointment is over. But the most important part of Gabrielle Nuki's job is about to begin.

The 16-year old now has to evaluate the adult professional. She's smooth and tactful after lots of training on how to deliver feedback. Nuki tells Tetreault she did a good job making her feel comfortable.

"I also liked how you mentioned confidentiality, because for my age group, that's important to touch on," Nuki says. "And I think that maybe you could have had a couple more times where you asked me if I had any questions, but other than that I think you did a really great job."

It's communication skills versus acting skills that really qualify someone to be a standardized patient, says Dr. Pat Patterson, the director of pediatric training at Maine Medical Center.

"A lot of patients want to please their physician," Patterson says. "It's not easy for a patient to say 'That didn't feel right', or 'The way you asked that made me feel bad.' "

Gabrielle Nuki says working with medical students and being forthright about their performance has given her more confidence. In the future, she hopes to take on more complex roles — maybe someone with depression.

But she knows no matter what kind of patient she portrays, this job will prepare her well for when she reverses roles and one day becomes a doctor.

Source: http://www.npr.org

By Bill Toland

Pharmacy errors, hard-to-find clinical alerts, “farcical” training, and potentially life-threatening design flaws: Reading through the U.S. Food and Drug Administration’s catalog of electronic medical records malfunctions could be hazardous to your mental health.

If not yours, than that of the physicians and nurses who must work with the records systems, and who are reporting their experiences to the FDA’s adverse event database, otherwise known as MAUDE (the Manufacturer and User Facility Device Experience).

Most of the events submitted to the database involve misfiring medical equipment — broken aerosol compressors, faulty defibrillators — but as electronic records and computerized physician-order entry systems take hold at hospitals and clinics across the country, complaints about those systems are on the rise.  

For decades, electronic patient records systems have been heralded as a potential game-changer for the health care industry, leading to improved patient health outcomes, fewer duplicate tests and, eventually, savings for the health care industry.

While most clinicians and academics still believe the promise is there, the systems are coming under increased scrutiny from doctors, nurses and some on Capitol Hill who say the technology is poorly regulated, often unproven and occasionally unreliable. 

As such, the health records systems haven’t yet lived up the promise that was made when the Obama administration won passage its 2009 stimulus bill, which included $25.8 billion for health IT investments and incentive payments.

“Like with any new technology, there’s going to be unintended consequences,” said William M. Marella, director of Patient Safety Reporting Programs for the suburban Philadelphia Emergency Care Research Institute. He’s also director of the state’s Patient Safety Reporting System, which tracks adverse events and near-misses in Pennsylvania.

“In the long run, [electronic health records] will make us safer than we were” using paper records, Mr. Marella said. “But in the short term, we’ve got a lot of [implementation] issues that need to be addressed before [electronic health records] meet their promise.” 

Last month, the nation’s largest union of registered nurses sent a letter to the FDA asking for broader and more stringent oversight of electronic records systems and of computerized physician-order entry systems, which allow clinicians to log treatment instructions for patients.

The National Nurses United, as part of its broader campaign highlighting the potential dangers of “unproven medical technology,” says FDA officials should test electronic medical records as rigorously as they might a new drug or an artificial hip implant.

“I don’t think that opinion is an outlier opinion,” Mr. Marella said. “Lots of clinicians are unhappy with the way these systems work, and are unhappy with the documentation burden we put on them.”

The nurses union also wants the U.S. Centers for Medicare and Medicaid Services to suspend its “meaningful use” program, which requires providers to start installing electronic medical records systems at the risk losing Medicare funding, “unless and until we have unbiased, robust research showing that [electronic health records] can and do, in fact, improve patient health and save lives.”

To date, since 2011, that CMS program has issued nearly $24 billion to hospitals and physicians clinics seeking to upgrade their electronic records systems and make the transition away from paper records.

Tracking the errors

The letter submitted by the nurses union to the FDA was part of the commentary related to the federal government’s proposed overhaul of its framework for regulating health IT. That draft proposal was published in April, a joint effort of the FDA, the U.S. Department of Health and Human Services, the Federal Communications Commission and the Office of the National Coordinator for Health IT.

Others offered their own responses. The College of Healthcare Information Management Executives and the Association of Medical Directors of Information Systems, in joint comments to the FDA, said that the government needs a retooled electronic health records certification program in order to “identify clear standards and require strict adherence to those standards.”

The report itself noted that “a nationwide health information technology infrastructure can offer tremendous benefits to the American public, including the prevention of medical errors, improved efficiency and health care quality, [and] reduced costs. … However, if health IT is not designed, developed, implemented, maintained, or used properly, it can pose risks to patients.” 

Patient risk was a concern when, last summer, UnitedHealth Group Inc. recalled software that was used in hospital emergency rooms in more than 20 states “because of an error that caused doctor’s notes about patient prescriptions to drop out of their files,” according to Bloomberg News. There were no reports of patient harm, a UnitedHealth spokesman said, but the glitch illustrates the potential pitfalls for digital health records.

The MAUDE system, which accepts voluntary and anonymous incident reports from practitioners, and Mr. Marella’s own reporting have turned up plenty of other glitches. Some involve human error, others involve software and interoperability malfunctions, and many are simply design flaws, such as this example from a 2012 Pennsylvania Patient Safety Authority report:

Patient with documented allergy to penicillin received ampicillin and went into shock, possibly due to anaphylaxis. Allergy written on some order sheets [but] never linked to pharmacy drug dictionary.

And this one, from MAUDE: 

Potassium chloride was prescribed twice per day as treatment for hypokalemia. The lab testing revealed a [bad] jump in the potassium level, but the result came to the EHR without alert or warning, and the nurses continued to give the patient potassium anyway [because] the nurse did not know that the potassium level was high. ... Though this patient did not die, others have from this type of defect.

Or this one, from 2013: 

Patient’s medication list and other active orders did not appear on the doctor’s order section on the CPOE system, rendering it impossible for the doctor to confirm, alter, and reconcile the medication list. ... For obvious reasons, this defect in the CPOE is potentially life threatening when the doctor(s) do not have access to the current medication list.

And from April: 

A patient [was] at risk for respiratory arrest due to a narrowing in the trachea. There is no place on the EHR to list such a life-threatening condition that would be visible to each and every care team member who opened the EHR for this patient. ...  Care was delayed due to the above mentioned reasons, [and] the patient sustained a complete respiratory arrest that led to a cardiac arrest and anoxic brain injury.

Human factors 

While examples of electronic health records problems can be retrieved via various state and federal databases, many in the medical field say tracking the issues in a more comprehensive way will lead to better systems. Mandatory reporting would help, too, since only a fraction of adverse events related to electronic health records are actually reported to the FDA or state authorities. 

But health IT vendors are against mandatory reporting, or any other system that would run afoul of the confidentiality clauses that are built into contracts with hospitals and clinics. Public, mandatory confessions of errors might also discourage such reporting, since the clinician who admits the error could be punished by his or her employer. 

“We have felt that reporting by both providers and vendors should be voluntary. That is most consistent with the notion of a learning environment,” said Mark Segal, the chairman of the Electronic Health Records Association, told The Boston Globe.

Clinicians, too, are also wary about striking the right balance. “FDA oversight and regulation could slow innovation,” particularly if electronic health records and related systems are indeed scrutinized like other medical devices, according to a letter to the FDA from American Medical Association CEO James Madara. 

And they have the FDA on their side. The agency does not intend to require the reporting of electronic health records-related adverse events, and does not intend to vet electronic health records in the same way that it reviews drugs and other medical devices.

But when push comes to shove, though, regulators should err on the side of safety, said Dean Kross, a cardiologist in private practice at the Allegheny Health Network and a longtime critic of electronic health record companies and the side effects of health IT adoption. 

“The vendors have not been held accountable for the devices they are manufacturing,” he said. There is negligible pre-installation vetting, or post-market surveillance, for “safety, usability and efficacy,” he said.

And regulators should keep a watchful eye on human usability.

“Ninety percent of [complaints] have got something to do with faulty user-device interaction,” said Robert A. North, chief scientist at Human Centered Strategies, a Colorado company that studies and seeks to reduce risk and error in medical device design. “It’s not that something that is breaking or freezing. ... it’s nothing to do with the electronic circuit board. It’s the human circuit board.”

While Mr. Marella is aware of the design shortcomings of electronic health records, he’s still a believer that the systems can, and are, improving patient and population health.

He points to the example of a Pennsylvania hospital that noticed some its patients were overdosing on narcotic painkillers while in the hospital, and had to be given reversal agents to mitigate the overdose symptoms. When clinicians dug into the electronic records, they saw that the overdoses were happening primarily among people being given painkillers for the first time.

“So they decided that the default dose was actually too high” for first-time opioid recipients, and adjusted the first-time dosage going forward, Mr. Marella said. Identifying a hospital-wide problem, and addressing it quickly, probably couldn’t have happened without electronic health records.

“We really have to do a lot more work in what we call human factors,” so that the systems are intuitive, he said. “We’re quite a long ways from there.”

Source: www.nationalnursesunited.org

Source: www.rntobsnonlineprogram.com

By Associated Press

WASHINGTON (AP) — Federal health regulators have approved a first-of-a-kind set of robotic leg braces that can help some disabled people walk again.

By Danielle Dellorto, Miriam Falco, and Jen Christensen

The Ebola epidemic isn't getting any better in Africa.

The World Health Organization reports there have been 759 cases, including 467 deaths in Guinea, Sierra Leone and Liberia since the outbreak began in March, according to a statement the organization released on Tuesday.

The World Health Organization has said "drastic action is needed" to stop the deadly outbreak in West Africa. It has sent teams of experts to help locals deal with the epidemic. WHO will meet this week to discuss how to contain it.

Relief workers on the ground said the epidemic has hit unprecedented proportions.

"The epidemic is out of control," said Dr. Bart Janssens, director of operations for Doctors Without Borders.

Complicating matters, the countries hit hardest by the epidemic have major medical infrastructure challenges. There is also a real sense of mistrust toward health workers from communities. In Sierra Leone and Guinea, WHO has said that community members have thrown stones at health care workers trying to investigate the outbreak.

In April, CNN Chief Medical Correspondent Dr. Sanjay Gupta traveled to Conakry, Guinea, to report on what was being done to treat patients and contain the outbreak.

"It took only moments to feel the impact of what was happening here," Gupta wrote after landing in Conakry. "There is a lot we know about Ebola, and it scares us almost as much as what we don't know."

Ebola outbreaks usually are confined to remote areas, making the disease easier to contain. But this outbreak is different; patients have been identified in 60 locations in Guinea, Sierra Leone and Liberia.

Officials believe the wide footprint of this outbreak is partly because of the proximity between the jungle where the virus was first identified and cities such as Conakry. The capital in Guinea has a population of 2 million and an international airport.

People are traveling without realizing they're carrying the deadly virus. It can take between two and 21 days after exposure for someone to feel sick.

Ebola is a violent killer. The symptoms, at first, mimic the flu: headache, fever, fatigue. What comes next sounds like something out of a horror movie: significant diarrhea and vomiting, while the virus shuts off the blood's ability to clot.

As a result, patients often suffer internal and external hemorrhaging. Many die in an average of 10 days.

Doctors Without Borders, also known as Médecins Sans Frontières, has been working to fight the epidemic since March. The group has sent more than 300 staff members and 40 tons of equipment and supplies to the region to help fight the epidemic.

Still, the group warns, it's not enough.

"Despite the human resources and equipment deployed by MSF in the three affected countries, we are no longer able to send teams to the new outbreak sites."

The good news is that Ebola isn't as easily spread as one may think. A patient isn't contagious -- meaning they can't spread the virus to other people -- until they are already showing symptoms.

Serious protective measures

Inside the isolation treatment areas in Conakry, doctors focus on keeping the patients hydrated with IV drips and other liquid nutrients. Health officials have urged residents to seek treatment at the first sign of flu-like symptoms.

There is no cure or vaccine to treat Ebola, but MSF has shown it doesn't have to be a death sentence if it's treated early. Ebola typically kills 90% of patients. This outbreak, the death rate has dropped to roughly 60%.

The outbreak will be considered contained after 42 days -- twice the incubation period -- with no new Ebola cases.

Source: cnn.com

By MICHELLE ANDREWS

School nurses today do a lot more than bandage skinned knees. They administer vaccines and medications, help diabetic students monitor their blood sugar, and prepare teachers to handle a student's seizure or asthma attack, among many other things.

And though school nurses see many students regularly, they don't always have the most up-to-date information about the students' health. School nurses must get permission from parents to communicate with a child's doctor. Once the doctor gives them a care plan for the child, they generally rely on the doctor and/or parents for updates and changes.

"When things change, we don't always get told in a timely manner," says Nina Fekaris, a school nurse in the Beaverton, Ore., school district. "It works, but it takes a lot of coordination."

At the same time, school-based health care is unfamiliar territory to many medical professionals, who operate in a health care universe largely separate from school clinics and other community-based medical services.

In Delaware, "lots of nurses expressed that they had difficulty communicating with providers" at Nemours Health System, which serves children around the state, according to Claudia Kane, program manager of the Student Health Collaboration at Nemours.

In 2011, Nemours got together with the Delaware School Nurses Association and the state Department of Education to develop a program that, with parental approval, gives school nurses read-only access to the electronic health records of more than 1,500 students who have complex medical conditions or special needs. That includes conditions such as diabetes, asthma, attention deficit hyperactivity disorder, seizure disorders or gastrointestinal problems.

Beth Mattey, a school nurse in Wilmington, says that now that she has access to the Nemours system, she can check the recent lab test results of a student who has diabetes. "It's helpful for me to monitor his [blood sugar levels] and work with him to make sure he's in better control," says Mattey, who is president-elect of the National Association of School Nurses.

When a student put a staple through his finger, Mattey was able to check to make sure he went to the doctor and got treatment. "Checking with him directly involves calling him out of class," she says.

Eventually, school nurses will be able to put information into the Nemours electronic records system as well, says Kane.

In the meantime, Nemours doctors, some of whom were initially skeptical about allowing school nurses access to health system medical records, are warming up to the arrangement. Kane says it encourages communication between physicians and school nurses, and eases the burden of routine tasks because Nemours doctors no longer have to fax over care plans or instructions to the school nurse every few months for students who are part of the program.

The Nemours Student Health Collaboration project is operating in all Delaware public school districts as well as half of charter schools and about one-third of private schools. Kane says Nemours plans to extend the program to school-based health centers next.

Source: npr.org

Do you think they should have access to medical records?

By KATE MURPHY

PITTSBURGH — Trauma patients arriving at an emergency room here after sustaining a gunshot or knife wound may find themselves enrolled in a startling medical experiment.

Surgeons will drain their blood and replace it with freezing saltwater. Without heartbeat and brain activity, the patients will be clinically dead.

And then the surgeons will try to save their lives.

Researchers at the University of Pittsburgh Medical Center have begun a clinical trial that pushes the boundaries of conventional surgery — and, some say, medical ethics.

By inducing hypothermia and slowing metabolism in dying patients, doctors hope to buy valuable time in which to mend the victims’ wounds.

But scientists have never tried anything like this in humans, and the unconscious patients will not be able to consent to the procedure. Indeed, the medical center has been providing free bracelets to be worn by skittish citizens here who do not want to participate should they somehow wind up in the E.R.

“This is ‘Star Wars’ stuff,” said Dr. Thomas M. Scalea, a trauma specialist at the University of Maryland. “If you told people we would be doing this a few years ago, they’d tell you to stop smoking whatever you’re smoking, because you’ve clearly lost your mind.”

At normal body temperatures, surgeons have less than five minutes to restore blood flow before brain damage occurs. CreditUniversity of Pittsburgh Medical Center

Submerged in a frozen lake or stowed away in the wheel well of a jumbo jet at 38,000 feet, people can survive for hours with little or no oxygen if their bodies are kept cold. In the 1960s, surgeons in Siberia began putting babies in snow banks before heart surgery to improve their chances of survival.

Patients are routinely cooled before surgical procedures that involve stopping the heart. But so-called therapeutic hypothermia has never been tried in patients in which a penetrative wound has already occurred, and until now doctors have never tried to replace a patient’s blood entirely with cold saltwater.

In their trial, funded by the Department of Defense, doctors at the University of Pittsburgh Medical Center will be performing the procedure only on patients who arrive at the E.R. with “catastrophic penetrating trauma” and who have lost so much blood that they have gone into cardiac arrest.

At normal body temperatures, surgeons typically have less than five minutes to restore blood flow before brain damage occurs.

“In these situations, less than one in 10 survive,” said Dr. Samuel A. Tisherman, the lead researcher of the study. “We want to give people better odds.”

Dr. Tisherman and his team will insert a tube called a cannula into the patient’s aorta, flushing the circulatory system with a cold saline solution until body temperature falls to 50 degrees Fahrenheit. As the patient enters a sort of suspended animation, without vital signs, the surgeons will have perhaps one hour to repair the injuries before brain damage occurs.

After the operation, the team will use a heart-lung bypass machine with a heat exchanger to return blood to the patient. The blood will warm the body gradually, which should circumvent injuries that can happen when tissue is suddenly subjected to oxygen after a period of deprivation.

Dr. Tisherman and his colleagues plan to try the technique on 10 subjects, then review the data, consider changes in their approach, and enroll another 10. For every patient who has the operation, there will be a control subject for comparison.

The experiment officially began in April and the surgeons predict they will see about one qualifying patient a month.

It may take a couple of years to complete the study. Citing the preliminary nature of the research, Dr. Tisherman declined to say whether he and his colleagues had already operated on a patient.

Each time they do, they will be stepping into a scientific void. Ethicists say it’s reasonable to presume most people would want to undergo the experimental procedure when the alternative is almost certain death. But no one can be sure of the outcome.

“If this works, what they’ve done is suspended people when they are dead and then brought them back to life,” said Dr. Arthur L. Caplan, a medical ethicist at New York University. “There’s a grave risk that they won’t bring the person back to cognitive life but in a vegetative state.”

But researchers at a number of institutions say they have perfected the technique, known as Emergency Preservation and Resuscitation, or E.P.R., in experimental surgeries on hundreds of dogs and pigs over the last decade.

As many as 90 percent of the animals have survived in recent studies, most without discernible cognitive impairment — after the procedure, the dogs and pigs remembered old tricks and were able to learn new ones.

“From a scientific standpoint, we now know the nuts and bolts and that it works,” said Dr. Hasan B. Alam, chief of general surgery at the University of Michigan Medical Center, who has helped perfect the technique in pigs.

“It’s a little unsettling if you think of all the what ifs, but it’s the same every time you push into new frontiers,” he added. “You have to look at risk and balance it against benefits.”

Trauma accounts for more years of life lost than cancer and heart disease combined, and it is the leading cause of death in people up to age 44, according to the Centers for Disease Control and Prevention. Surgeons are eager for new techniques that would help better the odds in emergency situations. Black males are disproportionately victims of homicide, especially gun violence, and most of the patients likely to fit the study criteria in Pittsburgh are African-American males, according to officials at the medical center.

In order to obtain an exemption to federal informed consent rules, the hospital held two town hall meetings on the university campus, placed advertisements on buses, and made sure the news got in newspapers catering to minority readers.

Officials posted information about the study on a website,acutecareresearch.org, and conducted a phone survey in the neighborhoods most at risk for “involuntary enrollment” in the trial. Still, a taxi driver, grocery clerk and security guard — all African-American men approached at random — said they had never heard of the trial, though they work within a couple of miles of the hospital.

They also did not object. “I don’t have a problem with it, if it saves lives,” said Charles Miller, a 52-year-old security guard.

Just 14 people have so far requested “No E.P.R.” bracelets, according to the medical center.

Nearly a half-dozen trauma hospitals may join the trial and begin testing the hypothermia procedure on dying patients, including the University of Maryland Medical Center in Baltimore.

Dr. Scalea, who will head the effort there, said he hoped to receive final regulatory approval by the end of the year.

He recalled a recent stabbing victim who died on his operating table.

“He might have lived if we could have cooled him down,” Dr. Scalea said.

Source: nytimes.com

By AGATA BLASZCZAK-BOXE

Do men and women feel pain differently? A new study finds an unexpected gender divide.

Researchers found that men tend to report feeling more pain after major surgeries than women, whereas women tend to report experiencing more pain after minor surgical procedures than men.

In the study, researchers found that men were 27 percent more likely to report higher pain ratings after a major surgery such as a knee replacement, while women were 34 percent more likely to report experiencing more pain after procedures that the researchers labeled as minor, such as biopsies. (The researchers differentiated between "major" and "minor" procedures depending on the intensity of pain that people typically expect to feel after a particular procedure.)

To conduct the study, the researchers interviewed 10,200 patients from the University Hospitals of the Ruhr University of Bochum, Germany, following an operation, over more than four years. About 42 percent of the patients were male and 58 percent were female.

Initially, the study authors didn't find significant differences between the genders in people's overall experience of postoperative pain. However, that changed when the researchers distinguished between different kinds of surgeries.

The researchers are not sure where these differences stem from; however, they speculate that a lot may depend on the kind of surgery a person is undergoing. For instance, procedures such as cancer-related biopsies or an abortion may take a particularly serious emotional toll on women, and therefore exacerbate their individual perceptions of pain.

"It could be anxiety," study author Dr. Andreas Sandner-Kiesling of Medical University of Graz, Austria, told CBS News.

"This is a very interesting study," Dr. M. Fahad Khan, an assistant professor in the Department of Anesthesiology at NYU Langone Medical Center, told CBS News. "Ten thousand patients in any type of study is a huge number, and it is really great to see studies on that number of patients because it can limit a lot of the bias that some studies have."

Khan noted he found it interesting that in women, even smaller procedures "can be fraught with the development of pain problems after the procedure," which many people may not expect when they go to the hospital for a simple biopsy, he said.

Sandner-Kiesling said he did not think the findings should change the way men and women are treated for pain. "Clinically, there is no relevance," he said.

According to certain popular cultural stereotypes, women are often considered to be tougher about dealing with pain than men, but is this really the case?

"Anecdotally, people will say that women have a higher threshold for pain and they are more tolerant to pain, just because of their life experience. And perhaps, emotionally, maybe they are stronger than men," Khan said. "However, medically, in my experience, we haven't really noticed much of a difference with regard to men and women in the development of problems with dealing with severe and chronic pain."

The new study is presented at this year's Euroanaesthesia meeting in Stockholm.

Source:cbsnews.com