Prescriptions for better health care and health: empowering patients, increasing health education and collaboration

By Melissa Patrick
University of Kentucky School of Journalism and Telecommunications

The importance of empowering patients, increasing health education and collaboration were a few of the topics discussed at the Health Watch USA 2013 Conference in Lexington Nov. 1.

"Patients must be empowered with knowledge" was the primary message of Dr. Joycelyn Elders, professor emeritus of pediatric endocrinology at the University of Arkansas School of Medical Science and former surgeon general under President Clinton.

“You can’t keep ignorant people healthy,” Elders said. “We must educate our patients or we will continue to have major problems.”

Elders called for doctors to fight for comprehensive health education, everyone must be involved – the schools, the Internet, social media – and said that as a country we need to embrace comprehensive health education instead of being afraid that all discussions will lead to sex.

Patients have a responsibility to ask questions about their health care, Elders said, and if people are better educated in health care they will have a better idea of what to ask.

Karen Meyers, who works with catastrophic-injury victims and health-care providers, shared the story about her elderly mother who was critically injured during a fall; the doctor said she was terminal. Meyer persuaded the physicians to try to save her critically injured mother eight years ago, and that spurred her passion for the importance of patient and family-centered care. She attributes her mom’s recovery to doctors who listened to her and excellent nursing care.

 “Patient and family centered care,” Meyers said, “is based in dignity, respect, information sharing, participation and collaboration. We must teach doctors collaboration and that the patient and family are part of the team. We are not a threat. We are not ignorant. We should not be dismissed.”

Meyers went on to say that “The home care agency of the future is the patient, the family and the support systems. We have to have a support system that works and we have to include them.”

Elders also talked about collaboration between physicians. She said they need to provide integrated, comprehensive and transparent care because when a patient is seen on the same day by a team of specialist, they receive better care and experience better outcomes.

Martha Deed, a retired psychologist and a member of the Consumers Union Safe Patient Project's patient safety advocates network, was a seasoned patient advocate for her daughter, Millie Niss. who had Behcet's disease, a chronic disorder of the blood vessels.  Millie was hospitalized with a severe case of swine flu in 2009, coding within one hour of arrival at the hospital, and died less than a month later.

While in the hospital, Deed and Niss documented everything.  They voiced their concerns, followed the proper channels of communication, documented faulty medical equipment, found inaccuracies in nursing and doctor reports and requested test.  Despite this high level of advocacy, Millie died.

Millie's autopsy revealed a missed diagnosis that might have saved her if it had been discovered and treated, Deed said. She has since applied her research skill to investigate both the specific medical as well as hospital culture/system causes of her daughter's death. Her goal is to prevent future premature deaths in the hospital. "Patients and families very much need to be listened to," Deed said.

Elders offered advice on how to be an empowered, health literate patient:
• Take a trusted person with you when you go to the doctor
• Ask questions, write them down before you go to the doctor
• Bring all of your medications with you to each doctor visit
• Ask the doctor to write down suggested actions and medications
• Let your doctor know if you have vision and/or hearing problems
• Ask your doctor about the results of your test and what they mean

“Our health care system is presently physician centered, but patients need to be involved,” Elders said. “The largest health care work force that we are going to have is our own patients. We need to push for education.”

Health Watch USA, based in Somerset, was founded by Dr. Kevin Kavanagh to promote health care transparency and patient advocacy, says its website.

Speakers at conference discuss impacts and possible solutions for deadly mistakes and near misses in hospitals

By Melissa Patrick
Kentucky Health News

Medical mistakes made in hospitals cause 98,000 deaths per year. Or four times that many?

That is the widely accepted number based on a 1999 Institute of Medicine report, but a study published in the Journal of Patient Safety says that as many as 210,000 to 440,000 Americans die each year in the hospital because of a preventable harm, Marshall Allen of ProPublica reports on NPR. But the current culture in health care does not support the reporting of mistakes or near misses, said speakers at the Health Watch USA 2013 Conference on Nov. 1 in Lexington.

Keith Widmeier, training officer for the Wayne County Emergency Medical Service, talked about the importance of reporting medical errors: "How are we supposed to fix things if we don't address the near misses?" he asked. "We must look at patterns and address them, learn from the data. Reliable data helps promote systemic change. The current system creates a system of not reporting."

Helen Haskell, president of the grassroots patient-safety organization Mothers Against Medical Error, said there are many contributing factors to this culture, and suggested that there is much to be learned from patient stories.

She told story after tragic story of young patients who had died because of medical error, including the story of her son, Lewis Blackman.

Lewis was a healthy 15-year-old who developed severe upper abdominal pain while on a non-steroidal anti-inflammatory drug and a narcotic following an elective surgery. Nurses and residents failed to act upon increasing signs of instability, including 24 hours with no urine output and four hours with no blood pressure. Haskell asked repeatedly for an attending physician. Four days after the operation, her son died. The autopsy showed a giant duodenal ulcer and 2.8 liters of blood and gastric secretions in the peritoneal cavity. He had been bleeding internally.

It is the responsibility of our health care system to become more transparent, listen to people's stories and put systems in place to decrease the chance of medical errors, Haskell said. Health care must improve in the areas that errors most commonly occur, she said, such as true informed consent, unnecessary surgeries, medication and diagnostic error, failure to rescue, and communication errors.

To decrease medical errors, Haskell suggested that the system use technology as the driver of improvement, providing continuous feedback between everyone involved in the care of a patient and involve the community and government.

Nurse burnout and job dissatisfaction also lead to medical error in hospitals.

"We cannot expect high quality health care with burnout," said Jeannie Cimiotte, a Ph.D., RN and associate professor at the Rutgers University College of Nursing and executive director of the New Jersey Collaborating Center for Nursing.
Cimiotte cited a Pennsylvania study that found the implications of increases in nurse workload are burnout and job dissatisfaction, missing important changes in patient conditions and failing to report important patient information at shift change. She said the study also found high nurse burnout appears to be a possible explanation for the association between nurse staffing and infection, jeopardizing patient safety resulting in hospital-acquired conditions and poor health care outcomes.

A culture of change and transparency has been implemented and is working at the Department of Veterans Affairs hospitals in Lexington since 1987, said Dr. Steve Kraman, who was chief of staff and chairman of the Risk Management Committee of the hospitals from 1986 to 2003. They not only require the reporting of medical errors and near misses, but provide full disclosure to patients who have been injured because of accidents or medical negligence, and offer fair compensation for injuries, Kraman said.

The VA has used this model since 1987 and has had "encouragingly moderate liability payments," said Kraman. In 2010, the University of Michigan reported remarkable decreases in suits, costs, trials and time to resolution. They also linked the openness of such a program with patient safety benefits due to reduced need for secrecy surrounding errors. The University of Illinois reports no increase in either number or suits or payouts since participating in this model of care, according to Kraman.

Kraman asked the participants: Is full accountability and transparency the way we should do health care? The answer was a resounding yes.

"This is a decision based on how we behave in society.  We should behave in a stand-up manner," Kraman said.

Health Watch USA, based in Somerset, was founded by Dr. Kevin Kavanagh to promote health care transparency and patient advocacy, says its website.

Congressman visits Telehealth Primary Care Clinic in Campton

U.S. Rep. Andy Barr

U.S. Rep. Andy Barr, a freshman Republican from the Sixth District, recently visited the Telehealth Primary Care Clinic in Campton. The clinic, one of two in Kentucky funded by federal telehealth grants, opened in August 2012, and "provides access to primary and specialty care for the community through network established by KentuckyOne Health, the largest health system in the Commonwealth," reports KyForward.

Shelley Neal of KentuckyOne told KyForward, “We established these clinics to make quality health care accessible to the communities in and surrounding Powell and Wolfe counties. If we are to be successful in our mission to create a healthier Kentucky, we must continue to implement new technologies and services to reach our state’s medically underserved communities.”

The clinics minimize "the need to travel to see a specialist therefore reducing the costs of care," KyForward writes. The newest addition is a social worker, who serves both clinics. Through the first six months of this year the social worker "helped 185 patients complete financial assistance paperwork to obtain drug assistance for 1,804 medication orders." During that same span, the clinic saw 1,417 patients from 34 counties. The clinics, which have specialists in cardiology and pulmonology, plan to add specialists in urology, obstetrics and gynecology, endocrinology, neurology and psychiatry. (Read more)

School boards across Ky. realign school-nurse programs, squeezed by budget cuts and Medicaid payment issues

School districts in Kentucky have long relied on county health departments for school nurses, but state budget cuts and problems with Medicaid reimbursements have squeezed the health agencies, and they in turn have put the squeeze on the schools for more money and other measures.

Despite some concerns, the Russell County Schools board voted to approve a contract with the Lake Cumberland District Health Department to provide school nursing services. Corbin Independent Schools did not continue its normal contract with the Whitley County Health Department for these services, and has employed its own nurses this year instead. Fayette County Schools will coordinate a hybrid, scaled-back program with the Lexington-Fayette County Health Department, rather than relying solely on the department for services.

The Russell County board had tabled its contract with the Lake Cumberland department last month due to concerns about a lack of provisions allowing for reimbursement if the nurse ever had to take time off, reports John Thompson of The Times Journal in Russell Springs. Superintendent Michael Ford said the health department was unwilling at this time to accept such provisions, but that it has not been a problem in the past.

Ford also said the district would get the same services if it hired its own school nurse. So, in the face of concerns from many members, the board voted last week to continue providing school-nurse services through the department, Thompson reports.

On the other hand, Corbin is hiring its own nurses. Its health-department contract ended in May because the department went months without receiving Medicaid reimbursements for school-nursing services, and the department had no financial resources to continue them, reports Jeff Noble of The Times Tribune.

Citing cuts in federal funding, Fayette County Schools has scaled back its school-nurse program. The joint program between the school system and the local health department will go from having 30 registered nurses for school services to operating with 13 registered nurses and 14 licensed practical nurses, reports Jim Warren of the Lexington Herald-Leader.

Fayette Superintendent Tom Shelton said last week that the plan is to supplement the nurses with other health care providers or additional help from the department; school personnel will also help by administering some medication.

This is a temporary solution to meet school nursing needs to give the schools time to develop a permanent solution, Shelton told Warren. Shelton said he wants to develop a completely new model for providing nursing services after next year.

LaRue County High School collaborates with university and nursing home to offer nurse-aide training course

Fifteen students at LaRue County High School have signed up for a new nurse's aide class offered in coordination with Campbellsville University and a local nursing home through which students will earn a nurse certification. The class is being subsidized by the county school district.

The school board agreed on June 17 to pay $300 per student.  Although students accepted into the program will be expected to cover the remaining $200 of the course fee, grants are available to help them, and upon completion of the course, students will receive a certificate stating that they have completed some medical training, says Denise Skaggs, instructional supervisor for the school system.

"The course is titled as an SRNA (State Registered Nurse Aide) program; where students will learn skills involving senior personal care, mobility assistance, checking vitals (i.e. heart rate, blood pressure etc.) and minor medical equipment use and care," says Rebecca Roscoe of the LaRue County Herald-News.

Classes will be coordinated by Campbellsville University and held at the Brockman Center in Hodgenville and at the Sunrise Manor nursing home, where the course's required 16 clinical hours will take place, reports Roscoe. The hands-on clinical experience will be a great benefit, Skaggs said.

The idea for the course came from a survey in which 45 students expressed interest in a nursing program due to their interest in pursuing a medical career, Roscoe reports. Administrators talked to Taylor County school officials, who have implemented a similar program, to gain insight about launching their own program.  Thirty students applied and 15 students have been accepted by a review committee.

“I’m glad to see us offer something specific for our students that will help them achieve success in their future career,” Skaggs told Roscoe. “I think the program is a great addition because it speaks to our community … and now that we know the services that are available for us we want to take advantage of programs offered to benefit and increase our students success.” The program serves as a model for other public high schools to do the same.

Frontier Nursing University in Hyden helps bring better family health care to rural America with distance learning

Midwives and nurse practitioners who recently graduated from Frontier Nursing University in Hyden address the unique challenges of rural areas, including shortages of health care providers, by bringing local health care to rural communities across the country. FNU was featured in a recent report from the Robert Wood Johnson Foundation.

FNU, a graduate program that offers distance education to nurses with an interest in nurse-midwifery and family nurse practitioner and women’s health specialties, aims to build a pipeline of highly educated nurses serving in rural or underserved areas, reports RWJF, one of its funders.  Many scholars and grantees sponsored by RWJF go on to spearhead projects to improve access to high quality nursing care in remote areas, the foundation says.

“We’re trying to introduce primary care providers into rural areas in such a way that they can provide high quality care and preventive services too,” says Suzan Ulrich, associate dean of midwifery and women’s health at FNU and an RWJF executive nurse fellow.

Demand for health care is rising nationwide because of an aging population that is living longer, but sicker, with multiple chronic conditions. The need for health care providers will intensify next year, when millions of new patients will become eligible for health insurance under the health-reform law.

Rural parts of the country face unique challenges and shortages of health providers, including nurses, can be particularly acute in rural areas, said Alan Morgan, CEO of the National Rural Health Association. These nurses and other providers have less access to education programs, which tend to be located in more densely populated areas. Programs that offer advanced degrees, from the baccalaureate to the doctorate, can be especially difficult to access for students living in rural areas, according to RWJF.

Identifying and educating nurses from rural areas is a key goal of FNU, which offers distance education programs that enable students to remain in their home communities and a “bridge” program that allows nurses with associate’s degrees to move more easily into master’s and doctorate programs. “These students really love where they live,” Ulrich said. “If we can educate them to stay within their communities, then those communities are going to have a provider who’s going to be there a long time." (Read more)

School nurses start getting scarcer, due to Medicaid problems

By Molly Burchett
Kentucky Health News

Students in many Kentucky counties will find it harder to see a school nurse due to changes in the state Medicaid program and lack of payment from managed-care companies.

Takirah Sleet, 7, and school nurse Michelle Marra looked at Takirah's
lunch tray to calculate her insulin dosage at Lansdowne Elementary
in Lexington. (Lexington Herald-Leader photo by Pablo Alcala)

In Crittenden County schools, budget woes have forced the Pennyrile District Health Department to request additional money from the school district to keep its school health clinics fully-staffed and open, reports Jason Travis of The Crittenden Press. Allison Beshear, director of the health department, told Travis one reason from the budget crunch is a lack of payment from Kentucky Spirit, which owes the health department $266,000.

Without additional money from the school district, Beshear says, the health department cannot maintain the current level of service at school clinics through the end of the school year.  Proposals have been made to offer services to the district that entail reducing clerical staff without reducing the number of nurses; but in order to do so, trained school staff would have to handle daily medication distribution and help to answer the phones for the clinic.

"Kentucky Spirit has filed two appeals with the Cabinet of Health Services and the Finance Cabinet in which it claims to not be financially responsible for healthcare given in school clinics," reports Drew Adams of WKMS-FM in Murray reports in a story about similar problems in Hopkins County.

Other school districts facing similar problems include those of Bell, Clark and Pike counties. Eleven school health clinics in Bell County could be shut down by the end of this school year, reports WBIR-TV of Knoxville. In Clark County, a lawsuit between the state and Kentucky Spirit has put a halt to reimbursement for health services provided in county schools, reports Rachel Gilliam of The Winchester Sun.

Last month, the Pike County Board of Health filed a lawsuit against Kentucky Spirit because the managed-care firm has stopped reimbursing the Board of Health for school-nurse programs, reports Jordan Vilines of WYMT-TV in Hazard. The money has to be reimbursed in order to provide school nurses.

“I think having someone in the school to ensure that our children are healthy is imperative for the quality of life of our kids, especially in a very rural area," Pike Judge-Executive Wayne T. Rutherford told Vilines.  He said that without reimbursement, school nurses could lose their jobs, which would leave hundreds of kids without immediate medical care.

Kentucky Health News is an independent service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Health Kentucky.

More hospital-acquired infections are reported in patients cared for nurses who are overworked, study finds

Getty Images stock photo.

Overworked nurses dealing with heavy patient loads are associated with increases in hospital-acquired infections, say researchers with the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.

"For each 10 percent jump in the proportion of nurses who logged high levels of burnout, there was roughly one additional catheter-associated urinary tract infection per 1,000 patients and almost two extra surgical site infections per 1,000," reports JoNel Aleccia for NBC News.

Researchers conducted a survey with 7,000 registered nurses at 161 Pennsylvania hospitals and matched that data with hospital infection rates and characteristics of hospitals nationwide. The study found more than a third of nurses said they feel high levels of burnout. They cared for an average of 5.7 patients each, and "when even one patient was added to that load, the result was an additional 1,351 infections within the hospital population studied," Aleccia reports.

The study, published in the American Journal of Infection Control, also found cutting down on burnout not only reduces infections but saves money. Cutting it by 30 percent decreased urinary tract infections by 4,000 and surgical site infections by more than 2,200, resulting in a savings of between $28 million and $69 million each year, researchers found.

When it comes to nurse-to-patient ratios, no one seems to be tracking the averages, Aleccia reports. They can range from one nurse for every one or two patients in intensive care units or a one-to-five ratio, as mandated in surgical units in California. (Read more)

School nurses in Fayette cut as public-health dollars shrink

Takirah Sleet, 7, and school nurse Michelle Marra assess her
lunch to manage Takirah's diabetes. (H-L photo by Pablo Alcala)

As public health and education dollars shrink, school nurses are caught in the middle. The Lexington-Fayette County Health Department is among those scaling back its school-nurse program due to cuts, even as "more students with greater medical needs are appearing in classrooms," reports Mary Meehan for the Lexington Herald-Leader.

The cuts and the need present a difficult scenario: "In order to be educated, a student has to be healthy. How do you make that happen?" asked Mary Burch, president of the Kentucky School Nurse Association.

Schools nurses are not mandated in Kentucky, and the way school districts address the issue varies widely. Some districts use a nurse consultant to train school staff. The National Association of School Nurses recommends one school nurse for every 750 students. With 40,000 students, Fayette County falls short of meeting that level of care. The Fayette County school board helps to increase funding to keep nurses in place. About $600,000 would need to be reallocated. (Read more)