DiversityNursing Blog

Despite “measurable progress” in the three years since the release of the Institute of Medicine’s landmark report on the future of nursing, more work remains “to fully realize the potential of qualified nurses to improve health and provide care to people who need it.”

That assessment is part of a commentary by Harvey V. Fineberg, MD, PhD, president of the IOM, and Risa Lavizzo-Mourey, MD, MBA, president and CEO of the Robert Wood Johnson Foundation, on the aftermath of the report.

“The Future of Nursing: Leading Change, Advancing Health” was released Oct. 5, 2010, by the IOM with the support of RWJF. It provided a blueprint for transforming the nursing profession to “respond effectively to rapidly changing healthcare settings and an evolving healthcare system,” according to a report brief.

The key recommendations: allow nurses to practice to the full scope of their education and training, provide opportunities for nurses to serve as healthcare leaders and increase the proportion of nurses with a BSN to 80% by 2020. Following the report, RWJF and AARP formed the Campaign for Action to implement the report’s recommendations at the state level. 

Regarding scope of practice for advanced practice registered nurses, Fineberg and Lavizzo-Mourey wrote that 43 state action coalitions have prioritized initiatives to remove scope-of-practice regulations that prevent APRNs from delivering care to the full extent of their education and training. Iowa, Kentucky, Maryland , Nevada, North Dakota, Oregon and Rhode Island have removed barriers to APRN practice and care, and 15 states introduced bills this year to remove physician supervision requirements that can hinder APRN care.

Regarding education and training, the proportion of employed nurses with a BSN or higher degree was 49% in 2010 and 50% in 2011. “Progress is likely to accelerate in the years to come,” Fineberg and Lavizzo-Mourey wrote, “because between 2011 and 2012 along there was a 22.2% increase in enrollment in RN-to-BSN programs and a 3.5% increase in enrollment in entry-level BSN programs.” The authors also noted a recent increase in the number of students enrolled in nursing doctorate programs. Of the 51 action coalitions, 48 have worked to enable seamless academic progression in nursing.

The authors noted that the influence of the campaign has paid off with a $200 million Medicare initiative to support the training of APRNs at hospital systems in Arizona, Illinois, North Carolina, Pennsylvania and Texas.

Regarding nurse leadership, Fineberg and Lavizzo-Mourey wrote, the “Campaign for Action has tapped established and emerging nurse leaders across the nation and is working to provide them with opportunities for networking, skills development and mentoring. A key strategy is to advocate for more nurses to serve on hospital boards.” 

Full commentary: http://bit.ly/176XyZs

Campaign for Action: http://www.rwjf.org/en/topics/rwjf-topic-areas/nursing/action-coalitions.html

“Future of Nursing” report: www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

Graduate Nurse Education Demonstration: http://innovation.cms.gov/initiatives/gne/. 

Source: Nurse.com

By Debra Wood, RN

To achieve the national goal of improved health outcomes, many researchers and health advocates agree that patients must assume a greater role in managing their health

care. But how can facilities and health systems accomplish this kind of patient engagement? The answer may rest with nurses and nurse leaders, who have long overseen patient education about how to care for chronic conditions and make lifestyle changes to improve health.

“Promoting patient education has always been a part of our nursing role and obligation to the
patient,” said Debi Sampsel, DNP, MSN, BA, RN, chief officer of innovation and entrepreneurship at the University of Cincinnati’s College of Nursing in Ohio. “It has been a long-standing practice that nurses involve the patient across the life span in their own care.”

Sampsel finds nurses strive to and take great pride in promoting healthy lifestyles. And research has demonstrated that active, engaged individuals have far better health outcomes. The University of Cincinnati includes health promotion in the nursing curriculum and gives students an opportunity gain patient-engagement experience while working with the homeless and elementary and secondary school age youth.

“What’s new is old,” added Patrick R. Coonan, EdD, RN, NEA-BC, FACHE, dean and professor at the College of Nursing and Public Health at Adelphi University in Garden City, N.Y. “I went to nursing school 35, 40 years ago and what did they teach but to be the patient advocate, to teach the patient. But we got away from that in the last few decades.”

Coonan pointed out that today’s consumers and patients, particularly baby boomers, are better informed. They often turn to the Internet for facts, but he called it a nursing professional’s obligation to verify whether the online information is accurate. Boomers are not going to settle for a paternalistic “Just take this pill” without knowing why and how it will benefit them. And that often falls to the nurse.”

“We have to get away from the patient-doctor or patient–nurse relationship that is almost like a parent–child relationship, in existence for many years, to a more informed and empowered [consumer] who will take responsibility for their health,” said Rosemary Glavan, RN, MPA, CCM, senior vice president of clinical operations at AMC Health, a telehealth provider based in New York. “Baby boomers have been go-getters and always wanted to be in charge. They want to be empowered.”

Advocating with a personal connection

“As patient advocates, nurses and nurse leaders play a key role in promoting patient engagement,” said Cynthia M. Friis, MEd, BSN, RN-BC, associate association executive for SmithBucklin’s healthcare and scientific industry practice in Chicago. “Nurses are privileged with having the opportunity to spend more time with the patients to assess, plan, implement and then help clarify the plan of care with the patient and his/her family or caregivers. Nurse leaders are key in helping to ensure this role is realized. Nurses can do their jobs better with the full support of our nurse leaders.”

Nurses ask questions, she added, and draw patients into thoughtful discussions about their care, helping them move forward when they feel overwhelmed and understand how to best care for themselves.

Establishing principles of engagement

Patewood Memorial Hospital in Greenville, S.C., participated in a national study by the Agency for Healthcare Research and Quality (AHRQ) and in the development of theGuide to Patient and Family Engagement in Hospital Quality and Safety.

Recommendations in the AHRQ guide include:

• Working with patients as advisors;
• Communicating effectively; 
• Giving bedside shift reports, where nurses do not talk with each other but involve the patient and family members he or she wants to participate; and 
• Engaging patients in transitions to home.

The hospital has experienced improvements to its HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey since implementing the program.

“The patients and families are much happier,” said Kerrie Roberson, MBA, MSN, RN-BC, CMS, nurse educator at Patewood. “Patient engagement is a partnership with the patient and families, and they trust you more when they see you are open about their care.”

Nurses at Patewood are leading discussions about patient engagement across the Greenville Health System and have begun sharing their experiences with others.

Other nurses gathered to develop Guiding Principles for Patient Engagement, released last year by the Nursing Alliance for Quality Care (NAQC), which was supported by the Robert Wood Johnson Foundation.

Principles in the NAQC guide include:

• Having a dynamic partnership with patients and their families; 
• Respecting boundaries; 
• Maintaining confidentiality; 
• Adhering to responsibilities and accountabilities; 
• Recognizing patients able to engage; 
• Appreciating patient rights; 
• Sharing information and decision making; and 
• Advocating for the patient.

“Patient-centered care and engaging patients is very important to improving quality outcomes, which includes reducing cost and better health of populations in the community, but also reductions in disparities of care,” said Maureen Dailey, PhD, RN, CWOCN, senior policy fellow for nursing practice and policy at the American Nurses Association (ANA), a member organization of the NAQC. “The patient is at the center of the team and must assume accountability for self-care and part of the outcome. But that evolution has yet to take place.”

Nurses must instill confidence and competence in patients’ self-care, Dailey explained. And patients need nurses to provide knowledge, support and symptom management.

“Nurses hold a central role in patient engagement,” Dailey concluded.

Combing nursing skills with technology

Along with the personal touch, many nurses are finding technology can assist with their patient-engagement efforts.

“As the responsibility of nursing advances to one of building and sustaining patient activation and the role of nursing moves to be more consultative across care settings, technology will play a vital role for both the nurse and the patient,” said Karen Drenkard, PhD, RN, NEA-BC, FAAN.

Drenkard, who has served as executive director of the American Nurses Credentialing Center (ANCC) and past director of the ANCC Magnet Recognition Program, will join GetWellNetwork in January as chief clinical/nursing officer, where she will lead the development of a nursing model of patient engagement. Her responsibilities will include studying and designing new ways to assess and improve patient activation through clinical practice and technology solutions across all care settings.

“Nursing can use interactive patient care technology to proactively engage the patient and shift the responsibility for completing certain care interventions,” said Drenkard, explaining patients can document daily signs and symptoms. Care providers use the network to send reminders about taking medications or the need for follow-up visits to their physician when data and input from the patient indicates the need to do so.

By Melissa Assink, RN, BSN

I was in med/surg for 13 years before moving to hospice, where I have been privileged to work for almost 24 years. At age 5, I was telling people I wanted to be a nurse. I believe it was a vocational passion that God placed in my heart those many years ago. 

A recent loss in my personal life, followed by a visit from a former patient, brought my passion into even clearer focus. 

I had received a phone call from my brother, telling me that moments before our father had suffered a massive heart attack and died. Even though he had been in declining health in recent years, the news felt like it hit me completely out of left field. 

The day of Dad’s memorial service arrived. While the presence of those in attendance was a comfort, it was also overwhelming to greet the many people who joined us to celebrate his life. Some we had not seen for many years, and it seemed they all had stories to share about him. 

One of the first people to approach me after the service was a man who appeared to be maybe 85. He had white hair, was hunched over and used a walker. He came up to me and stood there, staring at me, as if willing me to remember who he was. I drew a blank and asked, "How do I know you?"

His response was amazing: "You were my nurse 30 years ago, when I was in the hospital for five days to have my gall bladder taken out." He said it very matter-of-factly, as though I should remember him out of probably thousands of patients I have cared for over the years. 

Rather flabbergasted, I asked, "Did you know my dad?" He indicated he did not, that he had simply seen the obituary in the paper and wanted to come to the service as a tribute to me, his former nurse.

My mind raced. This dear man had connected me with Dad by recognizing me as a listed survivor in his obituary. It meant that he had to remember my first name and my maiden name from a brief hospital stay more than 30 years ago. 

I wanted to sit down and talk with him about his memories, but he promptly turned, walked out the door and was gone as suddenly as he had appeared. It seemed as if he knew he had accomplished his mission. I was engulfed with people wanting my attention, and it became impossible to follow him.

I have been reflecting on this former patient and his sudden reappearance in my life for several months. It was almost like he was an angel of sorts, sent to remind me how we, as nurses, touch the lives of people in our care at every turn. We sometimes are in good moods, sometimes not so good. We can become distracted by computerized charting, time management and policy and procedure manuals. 

It is easy to sometimes forget that we care for people when they are most vulnerable, sharing in their joys and sorrows in a way we might not always appreciate. We might forget their names by the next day, often as a coping mechanism, allowing us to go forth and care for the next person. We neglect to recognize they often do not forget us so easily. 

This former patient reminded me that we should never take any interaction for granted. We need to be caring and supportive, treating each of our patients with the respect and honor we’d like to experience if we were in their shoes. Our personal issues and circumstances are not important to them. They are watching us at every turn, looking for the light of our knowledge and support to see them through. A hug, a smile, a kind word, a moment of laughter or a shared tear — these are easy to give, but never forgotten. 

I pray I will always remember the responsibility I have to provide love, care and perhaps a moment of joy to the patients and families I interact with every time I put on my name badge. After all, we never know when a white-haired angel with a walker who received our care will cross our path and help us remember why we became nurses in the first place. 

Melissa Assink, RN, BSN, works for Providence Hospice and Home Care of Snohomish County in Everett, Wash. 

Source: Nurse.com

by Mark Downey

One of the questions that I frequently ask my students is, “Do you need to care to be a great nurse?” It’s always interesting to read the expressions on their faces and imagine what they must be thinking, because for the majority of my students it is the wanting to be a nurse and all that it entails that is a motivating factor in studying for their nursing degree.

From “Is he trying to trick me?” to “My teacher is an idiot!”, I can see the cogs and wheels ticking over in their brains. More often than not, I don’t give them an opportunity to answer. Instead, I tell them, “You don’t have to care about people to be a nurse. I consider myself an excellent nurse, but I’m not paid to care”.

Reactions to this vary. The two most common being dumbstruck, tongue tied and not knowing quite what to say or alternatively the hairs on the back of the neck bristle and I am challenged (often quite vigorously). Rarely, if ever, does anyone agree with me.

Let me explain with an example. If you’re a patient in an Accident and Emergency Room or perhaps lying unconscious in an Intensive care bed or on an operating table, is it really going to matter if the nurse gives two hoots about caring for you? Of course not! What is important is that the nurse is clinically competent and understands your health requirements so that every opportunity is afforded in generating a positive health outcome.

A steam train driver doesn’t have to care about his train to drive it, but he does need to understand how it works. As long as the gauges stay within the safe zones and coal is regularly fed to help generate steam to drive the engine, it doesn’t matter if he cares about the train or not. In fact, regardless of his care factor, the end result will never vary as long as he is good at his job. To be a good and great nurse is to know how to do your job right. I know everyone will agree.

Isn’t a nurse just like the train driver? Health outcomes will always be the same regardless of how much caring the nurse gives. It all boils down to the nurse trainings and the skills they have developed and how they are implemented. Nothing more, nothing less. A Cardiac Nurse needs to know about your heart, how it works, what the ECG squiggles mean and what the drugs that have been prescribed for you are going to do, but they don’t need to know your hearts desires or what’s in your heart. Isn’t that the job of the Chaplain?

Another important point is not to confuse advocating for the patient with caring. Advocacy is mandatory if the nurse’s training and experience lead them to believe that an alternative option may deliver a better health outcome for the patient. But really you don’t have to care to advocate as it’s just part of being a good nurse.

My argument is further proven when you consider the nursing process. Although it comes in many forms and guises, it is essentially:

• Assess the situation.
   
• Planning a course of action.
   
• Implement that action plan.
   
• Review the effectiveness of the plan and when necessary returning to step 1 and repeating. 

Nowhere, I repeat, nowhere, in any of the literature I have read, have I ever seen or mentioned that caring was required as part of the nursing process.

So do nurses care about their patients? Of course they do! Don’t be a goose! For the vast majority it’s an integral part of what makes them who they are. Nurses are looking after people, not machines. So, do I care for the people that I look after? I do and with a passion, but I don’t have to and, if couldn’t care for people, I couldn’t do my job.

Earlier on in this post I made the comment “I consider myself to be a great nurse, but I’m not paid to care.” This, I hold, as an absolute truth. When I am nursing, I am not paid to care.  You cannot pay me to care. I will not accept money to care! I choose to care because I want to care and you get that for free.

Source: NurseTogether

By: Marsha Van Hecke

People pursue careers in nursing for many reasons: they want to help people, they’re natural caregivers or they want to do some good in the world. The 31 nurses of Hospice of the Carolina Foothills add another reason: It’s truly a ministry.

“Hospice is a calling,” Christina Hughes, RN said, “I knew several years ago that this is what I wanted to do, but watching my father pass that prompted me to make the change.”

Previously, Hughes worked in a skilled nursing facility.

Hospice nurses perform all the tasks you’d expect of nurses in a hospital, clinic or nursing home setting. They draw blood, administer and monitor medications, assess patients’ conditions, review charts, consult with doctors, complete paperwork, and attend staff meetings, among many other typical responsibilities. There’s an added dimension to working as a nurse at hospice.

“Hospice work is more of a team effort, patient and family oriented, putting the patients first always,” says Marla Searcy, RN and Homecare clinical manager in North Carolina.

“And,” adds Monica Pierce, LPN, “we do a lot of education with the families, teaching them how to take care of their loved ones.”

Linda Travers, RN agrees. “HCF allows nurses time to listen to patient feelings and concerns. Teaching family caregivers about disease process, symptom management. Providing comfort and support.”

“Working for Hospice, you are able to spend more time with patients and families,” adds Joanie McDade, RN.

“Having the opportunity to build a relationship with some of the patients here is a gift no other job allows you to have,” says Barry Lowman, RN. “But then when they pass you have a piece of you go with them.”

Developing those close bonds with patients and families is not only an important part of the job, but it’s also one of the most enjoyable. And certain patients find a permanent place in the nurses’ hearts.

“I had one patient who served in Japan for 14 months as a medic. When he saw me, he asked if I was Asian. I told him that my mother was Okinawan and my father American. He began speaking Japanese to me. All throughout his journey of dementia, he continued to speak Japanese to me. There were times he couldn’t remember his wife’s name, but he remembered those few Japanese words,” says Hughes.

Homecare RN, Jennifer Greene tells how a simple gesture of gratitude left a lasting impression on her.

“I was taking care of a patient at the Hospice House and when I would give her any personal care, she would say, ‘Thank you, Mama.’ She would say that to me whenever I took care of her, until she passed.”

Hospice House RN Ashley Crissone fondly remembers the woman with whom she played piano duets.

When Crissy Simpson, RN and Homecare clinical manager in South Carolina, first started at hospice, she found herself facing a potentially difficult situation.

“I was sent to see a patient that lived in a rural community. I was told that he was a very challenging patient, not because of his terminal illness, but because he may not be accepting of my race,” she says, “I went to visit him. He wasn’t rude, but asked a lot of questions to see if I was qualified to take care of him.”

After a few visits, the patient became comfortable with her, and Simpson would give him a big hug right before she left. If she got stuck in traffic and arrived a few minutes late, he would tell her he had been worried about her.

“Every visit he would be sitting in his recliner, facing the door, waiting for me to come, with his beautiful blue eyes,” she says.

As the patient began to decline in health, he asked his wife to buy Simpson a gift, a coffee mug that read, “Thank God for Daughters.”

“From that day, he called me his black daughter and he was my white daddy,” Simpson says, “Some people may be offended by that, but I know I meant a lot to him, and so did he to me.”

On the night he passed away, Simpson sang to him the old gospel song, “I’m Going to Take a Trip,” which she also sang at his funeral.

Just as Simpson goes above and beyond her job duties by singing to patients, other nurses contribute their talents and time outside of work. Jennifer Greene makes jewelry, donating necklaces and bracelets to patients, and Christina Hughes attends special events held at the facilities where she serves.

“One facility had ‘Cowboy Day,’ and the HCF social worker and I dressed up, and attended on our day off. The social worker even brought two of her horses for the patients to see,” says Hughes.

Every nurse has had a special person who inspired him or her to pursue the role of caregiver in life. For some it was another nurse who nurtured and mentored them, or a hospice nurse who ministered to one of their relatives. For others, a special family member encouraged them to follow their hearts. In RN Crystal Mitchell’s case, it was both. Her favorite aunt is a nurse and from a very young age, she would visit her at work in the hospital. Now, it seems, Mitchell is paying it forward.

“I’ve known since I was four I’ve wanted to be a nurse from watching her with her patients,” Mitchell says of her aunt. “I have had a similar role to a family friend who is like a little sister, and she is now a pediatric oncology nurse. I never knew I was the reason she wanted to be a nurse until later. How jaw-dropping it was to find out how much my work had influenced her by God’s grace.”

While working for hospice brings nurses many jovial moments, they also deal with the sobering reality of death every day. For that reason, many people hold them in high regard and wonder how they handle such a job.

RN case manager, Kim Griffey shares how people react when she tells them where she works.

“They always say that it takes a certain person to do your job, that they couldn’t do it. I always reply, ‘It’s very rewarding.’”

When asked what is the most important characteristic or skill needed to be a hospice nurse, one word comes up repeatedly.

Lowman and Travers and Pam Essman, RN, come right to the point.

“Compassion,” they say.

“The most important characteristic you need to be successful in hospice is compassion. It’s not always the physical symptoms that you’re relieving, but also the patient’s and family’s psychological pain,” says Simpson.

When hospice nurses go to work every day, they’re not simply going to a job. They’re going to touch someone’s life. They hold patients’ hands, celebrate patients’ birthdays, play games, share stories, help patients create their life stories to leave for their families, offer comfort, a smile, a laugh, and, in some cases, a song.

“I have had so many patients say they look forward to the hospice nurse’s visit. What greater reward in life can we have than to put a little sunshine in someone’s day, maybe their last day,” Searcy says.

Source: Tyron Daily Bulletin

BOSTON (AP) — The screams and cries of bloody marathon bombing victims still haunt the
nurses who treated them one week ago. They did their jobs as they were trained to do, putting their own fears in a box during their 12-hour shifts so they could better comfort their patients.

Only now are these nurses beginning to come to grips with what they endured — and are still enduring as they continue to care for survivors. They are angry, sad and tired.  A few confess they would have trouble caring for the surviving suspect, 19-year-old Dzhokhar Tsarnaev, if he were at their hospital and they were assigned his room.

And they are thankful. They tick off the list of their hospital colleagues for praise: from the security officers who guarded the doors to the ER crews who mopped up trails of blood. The doctors and — especially — the other nurses.

Nurses from Massachusetts General Hospital, which treated 22 of the 187 victims the first day, candidly recounted their experiences in interviews with The Associated Press. Here are their memories:

THEY WERE SCREAMING

Megann Prevatt, ER nurse: "These patients were terrified. They were screaming. They were crying ... We had to fight back our own fears, hold their hands as we were wrapping their legs, hold their hands while we were putting IVs in and starting blood on them, just try to reassure them: 'We don't know what happened, but you're here. You're safe with us.' ... I didn't know if there were going to be more bombs exploding. I didn't know how many patients we'd be getting. All these thoughts are racing through your mind."

SHRAPNEL, NAILS

Adam Barrett, ICU nurse, shared the patient bedside with investigators searching for clues that might break the case. "It was kind of hard to hear somebody say, 'Don't wash that wound. You might wash evidence away.'" Barrett cleaned shrapnel and nails from the wounds of some victims, side by side with law enforcement investigators who wanted to examine wounds for blast patterns. The investigator's request took him aback at first. "I wasn't stopping to think, 'What could be in this wound that could give him a lead?'"

THEIR FACES, THEIR SMILES

Jean Acquadra, ICU nurse, keeps herself going by thinking of her patients' progress. "The strength is seeing their faces, their smiles, knowing they're getting better. They may have lost a limb, but they're ready to go on with their lives. They want to live. I don't know how they have the strength, but that's my reward: Knowing they're getting better."

She is angry and doesn't think she could take care of Tsarnaev, who is a patient at another hospital, Beth Israel Deaconess Medical Center: "I don't have any words for him."

THE NEED FOR JUSTICE

Christie Majocha, ICU nurse: "Even going home, I didn't get away from it," Majocha said. She is a resident of Watertown, the community paralyzed Friday by the search for the surviving suspect. She helped save the lives of maimed bombing victims on Monday. By week's end, she saw the terror come to her own neighborhood. The manhunt, she felt, was a search for justice, and was being carried out directly for the good of her patients.

"I knew these faces (of the victims). I knew what their families looked like. I saw their tears," she said. "I know those families who are so desperate to see this end."

On Friday night, she joined the throngs cheering the police officers and FBI agents, celebrating late into the night even though she had to return to the hospital at 7 a.m. the next day.

Source: Times Union

By Karen Cheung-Larivee

A series of simple phone calls from a nurse can reduce readmissions and cut $1,225 in costs per patient, according to a study in this month's Health Affairs.

Researchers from the University of Wisconsin School of Medicine and Public Health looked at more than 600 patients enrolled in the Coordinated Transitional Care (C-TraC), a low-resource Madison (Wis.) VA program that uses registered nurses for quality transitional care, according to the C-TraC website.

Patients discharged from the William S. Middleton Memorial Veterans Hospital and considered high risk received weekly phone calls from a nurse case manager for four weeks or until the patient transitioned to a primary care provider, according to last week's research announcement. High-risk patients had dementia, were over 65 years old and living alone or had a previous hospitalization in the past year.

In an open-ended discussion, the nurse talks about medication adherence--most often the biggest issue--symptoms and other follow-up.

The program has been popular with almost full patient participation, according to lead investigator Amy Kind, assistant professor of medicine (geriatrics) at the UW School of Medicine and Public Health.

"Patients don't mind a phone call," Kind said. "Our role is not to complicate the process but to more seamlessly bridge the patient's journey from the hospital to the home and to primary care," she added.

Such nurse-led contact has saved the hospital nearly three-quarters of a million dollars ($741,125) in healthcare costs over 18 months, according to the program.

Patients in the program had 11 percent fewer 30-day readmissions at 23 percent, compared to 34 percent of the those not enrolled.

Because the nurses don't spend a lot of time traveling, they can therefore reach out to more patients by phone, Kind noted. Most of the patients live in remote areas where a home visit is easily accessible.

"Simple, protocol-driven, telephone-based programs like C-TraC may be able to reach larger patient populations, including patients living a greater distance from hospitals and could be used in a wider variety of care settings than traditional in-home transitional care programs can," study authors wrote.

Researchers said resource-strained hospitals, such as safety nets, that can't afford home visits can implement similar telephone protocols. However, they also recognized that the VA is unique from other hospitals in that the VA has a single electronic health record system, shared among all VA-affiliated inpatient and outpatient providers.

By ANEMONA HARTOCOLLIS and NINA BERNSTEIN

Published: November 1, 2012

Officials rushed to move the most critically ill patients closer to an emergency generator. After midnight, doctors heard shouts in the hallway. The basement fuel pumps had stopped working, and medical residents, nurses and administrators formed a bucket brigade to ferry fuel up 13 flights to the main backup generators.

By Tuesday, the elevator shafts at Bellevue, the country’s oldest public hospital, had flooded, so all 32 elevators stopped working. There was limited compressed air to run ventilators, so oxygen tanks were placed next to the beds of patients who needed them. Water faucets went dry, food ran low, and buckets of water had to be carried up to flush toilets.

Some doctors began urging evacuations, and on Tuesday, at least two dozen ambulances lined up around the block to pick up many of the 725 patients housed there. People carried babies down flights of stairs. The National Guard was called in to help. On Thursday afternoon, the last two patients were waiting to be taken out.

The evacuation went quickly only because Bellevue had planned for such a possibility before Hurricane Irene hit last year, several doctors said. But the city, which had evacuated two nearby hospitals before that storm, decided not to clear out Bellevue. In the wake of Hurricane Sandy, the consequences of bad calls, bad luck and equipment failures cascaded through the region’s health care system, as sleep-deprived health care workers and patients were confronted by a new kind of disarray.

A patient recovering from a triple bypass operation at Bellevue walked down 10 flights of stairs to a waiting ambulance, one of the dozens provided through the Federal Emergency Management Agency to speed patients across the metropolitan region.

Mount Sinai Medical Center, already dealing with the 2 a.m. arrival of a dozen psychiatric patients who spoke only Chinese, was struggling to identify the relatives of brain-injured traffic victims from Bellevue who arrived three hours later with only rudimentary medical records.

Maimonides Medical Center in Brooklyn was straining to meet a rising need for emergency dialysis for hundreds of people shut out of storm-crippled private dialysis centers. Patients who would normally get three hours of dialysis were getting only two, to ensure the maximum number of people received at least a minimal amount of care.

“The catastrophe is growing by the minute,” said Eileen Tynion, a Maimonides spokeswoman. “Here we thought we’d reached a quiet point after the storm.”

Every hospital maintains an elaborate disaster plan, but after Hurricane Sandy, the fact that many health care facilities are in low-lying areas proved to be something of an Achilles’ heel. Bellevue became the third hospital in the city to evacuate after the storm’s landfall, after NYU Langone Medical Center, just north of Bellevue, and Coney Island Hospital, another public hospital.

New York Downtown Hospital, the only hospital south of 14th Street in Manhattan, and the Veterans Affairs Hospital, just below Bellevue, had evacuated before the storm.

Hospital executives were reluctant to criticize their colleagues or city officials. But the sequence of events left them with many questions.

“All hospitals are required to do disaster planning and disaster drills,” Pamela Brier, the chief executive of Maimonides, noted. “All hospitals are required as a condition of being accredited, to have generators, backup generators.”

City health department and emergency officials have been particularly fervent about citywide disaster drills, she added, but “as prepared as we think we are we’ve never had a mock disaster drill where we carried patients downstairs. I’m shocked that we didn’t do that. Now we’re going to.”

The city’s health commissioner, Dr. Thomas Farley, defended the decision not to require evacuations of Bellevue, Coney Island and NYU Langone hospitals before the storm, which he said had been made in consultation with the state health commissioner, Dr. Nirav Shah.

Dr. Farley said they based the decision on their experience with Hurricane Irene, when they ordered the evacuation of hundreds of patients from six hospitals, including NYU Langone, and a psychiatric center, as well as of thousands of residents of nursing and adult homes.

“We saw there was definitely risks to patients from evacuations,” Dr. Farley said.

He added that, “As the storm got worse on Sunday, we did recognize that there would be some risk to health care facilities, so we took some steps to make sure that they were aware of that.”

But he said he considered the decision to wait a success overall: “There was no loss of life as a result of those evacuations.”

He said the city was still assessing what to do differently next time. “We certainly are seeing many more severe weather events in this city than we’ve seen in the past, that does mean we have to rethink the vulnerability of our health care facilities,” Dr. Farley said.

A major concern for hospitals is that traditionally, generators, fuel tanks and fuel pumps have been located in their basements. Both NYU Langone and Bellevue had actually shored up their defenses after Hurricane Irene, according to executives of both hospitals. Among other changes, both built flood-resistant housings for their fuel pumps.

But some circuitry, as well as tanks and pumps, remain on low floors, making backup systems vulnerable. The equipment is enormously heavy, so putting them on higher floors would require a great deal of reconstruction and possibly changes in building codes, said Dr. Steven J. Corwin, the chief executive officer of NewYork-Presbyterian Hospital, which has been taking on extra patients and bringing in extra staff.

Another serious issue is how long a hospital should expect to rely on a generator if the power fails.

“Heretofore, it was felt that generator power would be for a self-limited time, not more than a day — two, three at the outside,” Dr. Corwin said. “Now we’re looking at events where it could be a week.”

Alan Aviles, president of the Health and Hospitals Corporation, which runs the city’s public hospitals, said that all signs pointed against a storm emergency. “Up until an hour before the storm made landfall, the National Hurricane Center was saying that there was only a 5 percent probability of a storm surge over 11 feet in the area that would impact Coney Island, and they weren’t even showing a 5 percent probability on the East River,” Mr. Aviles said.

When the main power went off about 9 p.m. Monday, doctors and nurses were initially told not to worry, because the backup generators were working fine, people there at the time said. But by about 10 p.m., the basement was completely flooded, the pumps were flooded, and doctors were warned that they could lose backup power very shortly.

Critical-care doctors and nurses immediately began moving their patients to the area served by a lower-floor generator. Everyone moved quickly to disconnect patients from respiratory machines and then reconnect them.

A Bellevue doctor said midlevel administrators began begging their bosses to evacuate the hospital Monday night, when water could be heard pouring through the elevators, “like Niagara running through the hospital.”

“The phones didn’t work,” he said, speaking on the condition of anonymity for fear of being fired. “We lost all communication between floors. We were in the dark all night. No water to wash hands — I mean, we’re doctors!”

When the evacuation began, patients were bundled into red and orange sleds and dragged down as many as 13 or 15 flights of stairs. “If they were ventilated, someone was dragging them with a bag” of hand-pumped oxygen, one doctor said. “It was a herculean effort.”

Despite the power problems, Bellevue was able to print out some medical records or get summaries from doctors to send with patients. But landlines and cellphones were affected, and doctors and nurses said they wished some other form of communication, like walkie-talkies, had been available.

It was not until Wednesday, Mr. Aviles said, that everyone realized the situation was beyond repair and the final decision to evacuate everyone was made. “It was at that point that it was clear that it was just not tenable to keep patients for a longer term in the hospital,” he said. “We know that all these patients were successfully transferred to safety and are doing well, and I think that’s what’s important.”

By PAM BELLUCK

Published: October 8, 2012

“I thought I was going to see a regular doctor,” she said, but instead she saw “this giant screen.”

Suddenly, two doctors appeared on the video screen: dermatologists in Boston. A nurse in the room with Ms. Cohen held a magnifying camera to her face, and suggested she close her eyes.

Why? she wondered — then understood. The camera transmitted images of her face on screen, so the doctors could eyeball every bump and crater. “Oh my God, I thought I was going to cry,” Ms. Cohen recalled. “Even if you’ve never seen that pimple before, it’s there.”

That, she realized, was the point. Technology, like these cameras and screens, is making it affordable and effective for doctors to examine patients without actually being there.

More hospitals and medical practices are adopting these techniques, finding they save money and for some patients work as well as flesh-and-blood visits.

“There has been a shift in the belief that telemedicine can only be used for rural areas to a belief that it can be used anywhere,” said Dr. Peter Yellowlees, director of the health informatics program at the University of California, Davis, and a board member of the American Telemedicine Association. “Before, you had to make do with poor quality, or buy a very expensive system. Now, you can buy a $100 webcam and do high-quality videoconferencing.”

The technology is especially being embraced in professions like ophthalmology, psychiatry and dermatology, which face shortages of physicians. At Kaiser Permanente, dermatologists “sit in a suite in San Francisco” and tele-treat patients throughout Northern California, Dr. Yellowlees said. “It’s much more efficient than having 20 hospitals, each with a dermatologist.”

On Nantucket, an island 30 miles from the nearest spit of mainland, “telemedicine just makes a lot of sense,” said Dr. Margot Hartmann, chief executive officer of Nantucket Cottage Hospital. “It allows us to meet the mission of the hospital better because we’re offering more locally,” and saves patients the cost and time of flying or ferrying off-island, then driving to Cape Cod or Boston hospitals.

The island may be small, but it has strikingly diverse medical needs. Its year-round population of about 10,000 balloons to 50,000 in the summer. And while it is famous for wealthy visitors, its year-rounders are much less affluent. They include immigrants from many countries, and range from businesspeople to scallopers.

Nantucket has all the ailments one would find anywhere, plus some exacerbated by island life: skin cancer, tick diseases, water accidents.

“Most people are within an hour of some major hospital,” said Joanne Bushong, the hospital’s outpatient clinical coordinator. Not Nantucket. “We’re not practicing rural medicine; we’re practicing island medicine.”

Nantucket’s hospital has a handful of year-round doctors. While mainland specialists do visit, fog or storms can keep them from getting there. And specialists cost money. The hospital, millions in the red in recent years and now needing $60 million to replace its outmoded 1957 building, must pay for the specialists’ travel and lodging.

Telemedicine, done by doctors at Massachusetts General Hospital, saves some of those costs, and generates revenue because it means more tests are done on Nantucket. “If someone was going off-island to see a dermatologist, they would probably have their labs and X-rays done where that dermatologist was,” Dr. Hartmann said.

Instead, tele-dermatology saves nearly $29,000 a year because two dermatologists now visit only four times a year, but appear on screen six times a month and see 1,100 patients a year. Previously, dermatologists visited monthly, and always had “100 people on the waiting list,” Ms. Bushong said.

Nantucket also uses tele-radiology, having Boston radiologists, some specializing in certain body areas, read X-rays and scans. It has used tele-pediatrics twice, for a child in a car accident and one in diabetic crisis. Tele-stroke uses video neurologists to quickly determine if a patient’s stroke type warrants a clot-busting drug, tPA, or if tPA could harm the patient.

Tele-endocrinology, for thyroid problems and diabetes, is starting. And Nantucket hopes to have video sessions for autistic children “so parents would not have to take kids with autism off-island, since it’s hard to travel with them and it upsets them,” Ms. Bushong said.

Dr. Hartmann envisions tele-rheumatology and tele-psychiatry, among other teles. Instead of screens in one exam room and the emergency room, “I would love to see every room telemedicine-capable,” she said.

But there are limitations, nationally and on Nantucket. Dr. Yellowlees said interstate telemedicine was hindered by rules requiring that doctors be licensed in the state where patients are treated.

Insurance coverage varies, with Medicare and some policies covering telemedicine services only in rural areas. “If you’re in a city, Medicare will only reimburse if you’re in the same room as the doctor,” Dr. Yellowlees said.

And some telemedicine is not cost-saving or accepted by doctors on the receiving end. Memorial Hermann Hospital-Texas Medical Center in Houston ended a tele-I.C.U. program in which intensive care specialists monitored and assisted intensive care units at five other hospitals. It was expensive and not demonstrably better, and some doctors and nurses disliked being watched from afar, said Dr. Eric J. Thomas, associate dean for health care quality at University of Texas Medical School at Houston.

On Nantucket, Dr. Timothy J. Lepore, 67, a surgeon and the hospital’s medical director, sees value in some long-distance doctoring, but has some concerns. He especially prefers having a radiologist on-site because he believes that conferring in person helps prevent mistaken readings and gets quicker results.

Dr. Lepore said that one tele-radiologist misread a chest X-ray, missing that the patient had pulmonary edema, fluid in the lungs. And when Dr. Lepore injured a hamstring while running, a tele-radiologist said an M.R.I. showed Dr. Lepore had pulmonary edema of the hip, which was bizarre and impossible. His actual diagnosis: a torn hamstring.

Occasionally, Dr. Lepore said, “it just goes completely off the trolley.”

Dr. Efren Flores, a radiologist who divides time between Boston and Nantucket, said he has learned to heed Dr. Lepore’s insistence on fast, accurate tele-radiology readings because on Nantucket it is important to determine if patients can be treated there or must be flown to Boston.

Many patients appreciate that telemedicine saves them trips off-island, but not everyone likes it.

“There are some people who just flatly refuse, and I see them in person,” said Dr. Peter Schalock, one of the two Mass General dermatologists who treat Nantucketers remotely. He said he has had to get used to diagnosing without feeling a patient’s skin, relying on the nurse, Ms. Bushong, for that. “Somebody with 100 strange-looking moles, I can probably do in 10 or 15 minutes myself, when it might take half an hour with the camera. Definitely people with more interesting moles, I like to see myself.”

Still, “we’re pretty good at picking up what looks funky, to use a technical term,” Dr. Schalock said. “I really feel like we’re providing essentially the same quality care.”

So, in August Dr. Schalock remotely diagnosed eczema in Aaron Balazs, 35, but saw him in person in September and increased his medication dosage and switched him from a cream to pills.

Mr. Balazs, stationed on Nantucket with the Coast Guard, was not expecting video doctoring, and said initially “it was sort of awkward.” But he concluded “it’s definitely beneficial for both parties.”

By the time Ms. Cohen had her second session in August, this time with Dr. Schalock, she said, “I feel like it’s the same thing” as an in-person visit. She had accepted the mega-magnifying camera by then.

“It kind of freaks out some people,” Dr. Schalock said. “They say, ‘Oh my God, I should have shaved my legs!’ I’m not looking at the hair. I’m looking at the mole.”