Stories about: hospital care

In the ICU, nurse experience and education can mean life or death

Morning rounds on the pediatric cardiac ICU.
Morning rounds on the pediatric cardiac intensive care unit.

Registered nurses (RNs) remain the largest group of health care providers and typically account for the greatest share of most U.S. hospitals’ operating budgets, about 60 percent. In adult hospitals, research has shown a consistently positive effect of increasing percentages of nurses with baccalaureate educations, and linked increased RN staffing and healthy work environments with improved patient outcomes.

However, this assessment has not been conducted in children’s hospitals—until now.

In a study in the Journal of Nursing Administration, nursing leaders from 38 free-standing children’s hospitals explored which nursing and organizational characteristics influence mortality for children undergoing congenital heart surgery.

The study, involving 20,407 pediatric patients and 3,413 pediatric critical care nurses, was led by Patricia Hickey, PhD, MBA, RN, from the Heart Center at Boston Children’s Hospital.

In pediatrics, congenital heart disease is the most common birth defect requiring surgical intervention for survival. Due to their critical care needs, these patients consume a disproportionate share of U.S. hospital resources.

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I-PASS this patient to you: Can standardizing “handoffs” make care safer?

(Kenny Louie/Flickr)

National data suggest that up to 70 percent of sentinel events—the most serious errors in hospitals—stem at least in part from miscommunications. Communication problems are especially apt to occur during hospital shift changes, when a patient’s care is transferred to incoming doctors and nurses—known in health care as the “handoff.”

More than a year ago, a team led by Amy Starmer, MD, MPH, of the Division of General Pediatrics at Boston Children’s Hospital, developed and began testing a bundle of interventions to ensure that the hospital’s residents were thoroughly and accurately briefed on each patient’s medical history, status and treatment plan in a standardized way.

Through measures such as communications training, a mnemonic to help residents remember key information to pass on and a computerized handoff tool that integrated with the patient’s electronic medical record, they managed to move the needle: Medical errors fell by 40 percent—from 32 percent of admissions at baseline to 19 percent of admissions three months after the program started.

But that wasn’t all.

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Hospital rounds: How’s the doctor-patient communication system?

(Andreas Gohr/Flickr)

When patients are sick enough to require hospitalization, medical decisions often involve nontrivial tradeoffs between risks and benefits. They require discussions with patients and families from a variety of cultures and backgrounds. And sometimes these discussions break down.

Patient-clinician communication is increasingly recognized as an integral part of clinician competency. Indeed, family-centered rounding, increasingly practiced at Children’s Hospital Boston, is a critical step in this direction. Fully adopting this practice surely will enhance communication quality.

Yet, I suspect we’re still missing cues from patients and families, signs that our alliances with them are not sound. We can’t be maximally perceptive all of the time. It is busy, we are tired, we want to teach, we want to be efficient, and we want to get to the noon conference to learn to be better doctors.

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