Posts Tagged ‘health care’

Working Conditions for Nurses Impact Patient Health

Tuesday, May 3rd, 2011

I suspect that anyone who has spent even as much as one day or night in a hospital knows just how critical the nursing staff is in the , health, care and comfort of a patient. A compassionate and personable nurse can put a patient at ease and help them feel better in ways that go beyond just medicine.

Recently, I wrote about how different schedules impact nurses’ lives and how they cope with shifting from day to night schedules. This week, I was drawn to write about nurses again after seeing an article on that spoke about a study done by the University of Maryland School of Nursing.

According to the article, the study determined that “[b]etter working conditions and better staffing of nurses can significantly improve the care of patients with serious conditions…” The study examined the psychological demands and work schedules of nurses:

…they measured high psychological demands by very fast work, lack of time to complete work, excessive required work, being slowed by delays from other workers, and frequent interruptions.

The data showed “…pneumonia deaths were significantly more likely in hospitals where nurses reported increased psychological demands and more adverse work schedules.” Equally troubling, “…patients were more likely to develop deep vein thrombosis after surgery in hospitals where nurses reported high psychological demands.” These were not the only areas in which the demands placed on nurses negatively impacted patient health.

The researchers calculated the association between job demands on nurses, both psychological and physical, and work schedule, against outcomes of patients with heart attacks, congestive heart failure, stroke, and surgeries that open a bone flap of the skull [craniotomy].

Also, they discovered that deaths from congestive heart failure were also significantly associated with long shifts and with nurses continuing to work while sick.

They found that deaths from heart attacks were associated with nurses frequently working with awkward postures and heavy weekly burdens.

Patients were more likely to experience postoperative hemorrhaging when their nurses were frequently interrupted.

And, where nurses reported a lack of time away from the job, patients were significantly more likely to develop respiratory failure and infections.

While difficult working conditions for nurses have a negative impact on patient health, the article reported that “[p]ositive aspects of the practice environment, such as peer and supervisor support, did not offset, or balance, the adverse impact of these demands.” Only, “[h]ospitals where nurses reported a focus on patient safety were less likely to have such complications or adverse patient outcomes [compared to] hospitals where patient safety was not a stated focus.”

What should be done with this information? To me, the critical lesson here is that work conditions for nurses dramatically influence patient outcomes. Attention must be paid to the conditions for nurses in terms of scheduling, interruptions, time off, and other work conditions. Do hospitals currently examine nurses’ psychological and physicals burdens as part of a comprehensive focus on patient safety? How as a patient do you chose a hospital – do you look only at the doctor’s qualifications or do you look also at other factors such as nursing at the hospital? Is it the duty of a hospital to provide working conditions for nurses that promote optimal patient safety?


Health Reform: What voice does the patient have in the debate?

Tuesday, April 26th, 2011

Recently, I came across an Op Ed entitled Health Reform Requires Listening to Doctors. The very title suggests that  physicians and the health care system in general don’t have much of a voice in the discussion of health care legislation.

The question struck me – can that really be true? If the medical profession and health care industry are crying “poor us,” as the Op Ed author would suggest, that’s rather disingenuous at best. It’s well-known in today’s world of American politics that one sure way to have a voice is to hire a lobbyist. According to the Center for Responsive Politicsover $1 billion was spent on lobbying related to health care in 2009 and 2010. Who were the big players and payers in the hiring of lobbyists?

CNN Money tells the tale of the tape:

[L]obbyists for 1,251 organizations disclosed that they worked on health care reform in 2009 and 2010, according to the center and an analysis by the Sunlight Foundation. The number of individual lobbyists who reported working on health related legislation last year hit 3,154 in 2010.

Big Pharma topped the list. The Pharmaceutical Research and Manufacturers of America spent $22 million and deployed an army of no fewer than 52 lobbyists, according to the center.

Blue Cross Blue Shield, which used 43 lobbyists, spent $21 million. The biotech company Amgen (AMGNFortune 500) employed 33 lobbyists and spent $10.2 million.

Yet another source,, reports the following:

A Center for Public Integrity analysis of Senate lobbying disclosure forms shows that more than 1,750 companies and organizations hired about 4,525 lobbyists — eight for each member of Congress — to influence health reform bills in 2009.

Among industries, 207 hospitals lined up to lobby, followed by 105 insurance companies and 85 manufacturing companies. Trade, advocacy, and professional organizations trumped them all with 745 registered groups that lobbied on health reform bills, illustrating the common Washington strategy of special interests banding together to pool money and increase their influence.

Seems like a whole lot of money was spent by the health care industry to have a voice.

This blog, however, is not intended to address issues relating to the Obama Health Care Reform (or as it is referred to in some circles as ObamaCare). I don’t claim to understand the in’s and out’s of that political football. I’ll leave that for the so-called pundits to address. What does strike me, however, is the travesty that recently played out in the setting of a threatened federal government shutdown.

Health Care Reform – the goal of the President’s Plan

What was the stated purpose and goals of the President’s health care reform? Look no further than the online posting by the White House for the answer:

Health reform makes health care more affordable, holds insurers more accountable, expands coverage to all Americans and makes our health system sustainable.

Sounds good in principle, right? Putting aside all the politics, rancor and ranting surrounding the debate over the specifics of health care reform, don’t you find it rather ironic that when recent budget cuts to avoid a government shutdown were the topic du jour, those who had very little, if any, voice were the people who desperately need can’t afford health care?

Recent Budget Cuts and Who Paid the Price

As I learned last week, when the back room deals were struck, those without a voice were the victims of political expediency.

As our own Jason Penn reported in his blog post, Budget Crisis Avoided, But What About the Babies? Can They Live With $504 Million Less in Funding?:

At the 11th hour, cuts were made, backroom deals were struck, and Washington spoke:  there will be $38 billion dollars trimmed from the federal budget.  On a positive note, federal agencies will remain operational until the end of September. Reason to cheer? Maybe. Before we break out the party hats and noise makers, let’s take a look at how healthcare fared.  The following areas are among those cut:

-         Special Supplemental Nutrition Program for Women, Infants and Children (WIC):  $504 million

-         Community Health Centers:  $600 million

-         Substance Abuse & Mental Health Services Administration:  $45 million

-         Infectious Disease prevention:  $277 million

Total:  $1.426 Billion.  Yes, billion, with a “B”!

Isn’t the answer of who does and who does not have a voice in the bigger picture of health care legislation and so-called fiscal reform self-evident. Who was there in the back rooms of our hallowed halls of Congress protecting those in need of good primary care programs? I suspect that when it’s crunch time, political expedience wins the day. Need cuts to keep a bloated beast alive and floundering? Snatch it from the ones who will be heard the least – the ones who don’t have the ability to spend over $500,000,000 a year for lobbyists so they can have their voice heard.

As Written in the Book of Isaiah the Prophet…

Apparently it’s just “politics as usual.” For all the rhetoric about making primary health care available to all Americans and improving and sustaining programs to deliver critical healthcare to those who need it the most, the voice crying in the wilderness was not loud enough. Maybe, as the Op Ed author claims, everything the medical profession and health care industry has to say is not being heard or at least being accepted. Nevertheless, they have a voice, which is more than can be said for those they claim they want to protect. How many of the enormous lobbying dollars did the medical community and health care industry spend to protect primary care programs from the budget-cutting ax? I suspect we all know the answer.


Image source: fromtheleft.wordpress


Specialization in Health Care and Its Impact on Patients – Who is Taking Responsibility for the Patient’s Care?

Tuesday, June 15th, 2010

Recently, I wrote a blog encouraging patients to ask more questions of their physicians. One of the comments in response to this blog raised an issue of particular interest to me – how does specialization in health care impact patients?

Specialization seems to be the name of the game for most physicians today.  For example, a century ago, there were surgeons. Now there are neurosurgeons, orthopedic surgeons, cardiac surgeons, colorectal surgeons, pediatric surgeons, eye surgeons, hand surgeons, dental surgeons, plastic surgeons, trauma surgeons, vascular surgeons, breast surgeons, transplant surgeons, cancer surgeons, just to name a few.  Yes, I know, I am beginning to sound like Bubba talking to Forest Gump about shrimp. Contrary to what Bubba may say, I am convinced that there are more medical specialties than there are shrimp recipes. That’s a good thing. A cancer patient should be able to go to an oncologist who has specialized training in cancer. The same is true of all patients who have a particular medical problem that would benefit by a specialist’s care. Simply put – would you want your vision problem being treated by a general internist? Specialization has real advantages.

On the other hand, what if you don’t know what specialist to go to because you really don’t know what your medical problem is? I suspect that for as many patients seeking treatment for a known medical problem, there are probably as many patients trying to just have their medical problem diagnosed. For patients in the latter category, encountering specialized physicians may not always be the best thing.

A situation we encounter in our practice way too often speaks to this issue. We have found that patients with underlying co-morbidities (e.g. lung problems, diabetes, etc.) present to hospitals with acute medical problems which may or may not be directly related to the reason they are admitted. The primary care physician is listed in the medical record as the primary attending physician (i.e. the one in “charge”) in many instances. That physician, ill-equipped to handle some of these complicating co-morbidities, brings in a host of sub-specialties (e.g. endocrinology, infectious disease, gastroenterology, etc.) to deal with this complicated patient. Should the patient also have a potential surgical issue, the internist, acting as the so-called “captain-of-the-ship” properly calls for a surgical consult as well. Depending on the rules, regulations and by-laws of any given hospital, these “consultants” may come and go on an “as-needed” basis leaving the ultimate diagnosis and treatment plan to the “attending” primary care physician. Their notes in the chart often read: “Thank you for permitting me to see your patient…(recommendations noted). Please call on me should the need arise.”

The clinical course of the patient many times gets further complicated when one or both of the following scenarios occurs: the primary care of the in-hospital patient is left to house-staff or resident staff and nursing and/or partners of the “attending” physician are called upon to “cover” for this patient whom they may never have met before.

What many times follows leads to disastrous consequences for the patient. Consultants come and see the patient and leave their thoughts and recommendations in “consult notes” for other members of the team to review and consider. At times, these consultants take no responsibility for the on-going care of the patient; they are just consultants giving their impressions from their sub-specialty perspective. They come and go at the behest of the attending physician, who brought in these consultants to help manage the patient’s overall care. Often, we have found, these consultants never even speak to one another. Their consult notes, if they are read at all, may well be in conflict with another specialist’s recommendations for care or diagnostic testing. This haphazard come-and-go scenario plays out for days if not weeks while the patient’s underlying presenting problem worsens. Yet we rarely find, albeit from our limited perspective, when we question these consultants and the attending physicians, that they have ever met or even spoken with one another to coordinate care and work-through the myriad issues each has identified as potential causes for the patient’s condition. What results more times than not – at least from what we see too often as lawyers – is a complete failure to come to a timely, meaningful diagnostic approach resulting in proper patient care. The pieces of the puzzle simply are never put together, they remain just that – unconnected pieces.

We as lawyers are then asked to deal with the unfortunate outcomes in such situations. When we question the physicians under oath (i.e. a deposition) we hear defenses that go like this: From the attending physician“I called in the right consultants and was relying on them to help me figure out what needed to be done.” From the consultants the following mantra: “I was just the consultant. I gave my recommendations. It was for the attending to make the ultimate decisions and to follow or not follow my recommendations as they saw fit.” The classic follow-up question to each is: “Did you ever talk to the attending (or consultants – when the attending is being questioned) and work-out a unified, comprehensive diagnostic work-up or treatment plan?” The response is usually – “Well no, but I reviewed all of the consultant’s reports and considered them.” What is often discovered is that tests that may have ruled-in or ruled-out a key component of a differential diagnosis may not have been done at all. Why? At times they are overlooked. At times one consultant’s recommendations are at odds with another consultant’s recommendations. A conference involving the attending and the consultants is the rare exception rather than the norm. Who suffers? – the patient!

Sure, we all recognize that reimbursement rates, especially in governmental third-party payor situations (e.g. Medicare and Medicaid) are abysmal. That is simply no excuse for these failures to communicate meaningfully. There is absolutely no doubt many physicians put the patient’s interests first and foremost and communicate with other members of the ‘team.’ This simply needs to occur universally; there is no justifiable reason for it not to occur in complicated medical treatment situations. If consultants are called-in, then consult with them. If a consultant makes a recommendation, then follow-up and determine if your recommendation has been followed and if not, why not.

As a patient, have you encountered this problem? As a physician, what has your experience been and what recommendations do your have when these clinical scenarios present themselves? Let us know.

Contributed to and edited by: Brian Nash

CHIP Grants: North Carolina's Perdue announces $9.3M grant for NC's children’s health care

Sunday, February 28th, 2010

A positive initiative indeed – North Carolina’s Governor, Bev Perdue, recently announced North Carolina’s receipt of a $9.3 million grant to improve the quality of health care delivered to children.   In an article in, it is reported that the North Carolina Department of Health and Human Services “was the lead applicant for this competitive grant and worked closely with a coalition of children’s health leaders in the state.”  According to the post, funding will be used to develop technology that tracks and measures quality of care for children.”

“This competitive grant is vital to ensuring that children in our state are healthy and ready to learn,” said Gov. Perdue. “This will help pediatric offices throughout the state make better use of technology so we can be sure that children, those with special needs in particular, are receiving the care they need.”

North Carolina is one of only ten lead states announced as part of the $100 million grant program under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA).

Talk about someone using federal tax dollars wisely!  It will be most interesting to see how this grant money is, in fact, utilized by states such as North Carolina.  We will try to keep you posted on the success of this project.

If we are reading this legislation correctly, it appears that applications for grant money remains open until (the currently posted ending date of) March 25, 2010.  Further information on the grant program and applications, eligibility and other key aspects of the program are available online at