Book Review-Better: A Surgeon’s Notes on Performance

I’m sometimes a hard guy to impress. Sometimes, I strive for excellence and look for ways to get better, and I forget to appreciate that good is good enough. Maybe that is why I appreciated Better: A Surgeon’s Notes on Performance so much. It certainly doesn’t hurt that I’d previously read and reviewed Atul Gawande’s Checklist Manifesto and Being Mortal. However, in the end, I think what I recognize in Gawande is that passion for making things better, because better is possible.

Medical Advances

From the dawn of medicine until relatively recently, doctors largely did their patients more harm than good. Techniques like bloodletting weakened patients when they needed their strength the most. Sometimes, even when advances were possible to move medicine forward, they were resisted. Ignac Semmelweis discovered the basis for germ theory in 1847 and the need to wash hands after working on cadavers or before helping mothers deliver their babies. Today, it’s positively obvious, but back then, it was unique and different.

There are numerous accounts for why Semmelweis was so ineffective at convincing his peers that germs existed, and that handwashing was sufficient to stop (or at least hinder) their spread. Most of them involve what are described as “personality defects.” Gawande reports that Semmelweis refused to defend or support his germ theory and instead resorted to personal attacks – which didn’t win him friends. (See Mastering Logical Fallacies for some of the techniques that may have made it difficult to take Semmelweis seriously.)

Handwashing and Antibiotic Resistance

Over 150 years after Semmelweis’ discovery, we still struggle to wash our hands effectively. Depending upon whose numbers you want to believe, handwashing compliance in acute care settings (mostly hospitals) is somewhere between 20% globally and between 50-80% in the United States. And we’ve tried everything to get those rates up. We’ve put alcohol stations at every door. The WHO has spent countless millions on campaigns like the “The 5 Moments” to teach providers when to wash their hands, and we’ve barely moved the needle. More importantly, we’ve not managed to improve patient outcomes – not one iota.

The consequences are terrifying. We’ve become so reliant on antibiotics that when antibiotic resistant strains of bacteria emerge, we’re caught flat-footed. In 1988, a Vancomycin-resistant enterococci (VRE) strain infested a renal dialysis unit in England, and by 1997, 23 percent of ICU patients were infected. Vancomycin is a go-to drug for infections, and when VRE adapted, we didn’t know what to do. In healthcare, we assume our antibiotics will save us – but when the bacteria adapt, we don’t know what to do. SARS (severe acute respiratory syndrome) was primarily spread through healthcare workers.

We fail to realize that the scary things that we must combat today aren’t fixable by an antibiotic. Take MRSA (Methicillin-resistant Staphylococcus aureus). Methicillin is another go-to drug that a bacterium found a way to resist. What’s scarier is that the newer strains – the ones that haven’t made the news yet – are resistant to not just one of our antibiotics but multiple of our wonder drugs.

When It Doesn’t Work

Medicine has changed war. Medicine has dramatically reduced the death toll in war. It’s reduced the mortality of both mother and child during childbirth. It’s made conditions that would have been fatal into outpatient surgery, yet it’s not enough. “The paradox at the heart of medical care is that it works so well, and yet never well enough,” writes Gawande.

It’s hard to have conversations in a group of people and not have someone tell a story of a loved one who died of a health issue. Too many of these stories involve complications that happened as a part of the medical care itself, whether it was an infection they didn’t have when they came in, a medical error, or just something that wasn’t an expected outcome.

As much as we have made progress, we’ve not been able to deliver the best care consistently.

It’s a Business

While it’s nostalgic to think of the doctor who serves a community, accepting livestock and services in trade for the healing he can offer, that’s not the world of today. Healthcare is a business – a big business (as is pointed out by Mistreated). As a business, doctors need to do what is necessary to keep the business going, and that may mean they stop helping people when doing so means you can’t afford to be in business.

The reality is that the skill of a surgeon in the operating suite has almost nothing to do with how much money they’ll make. Their ability to make a business run will drive their revenue and their professional survival as a doctor.

Follow the Rules and Innovate

It’s a double bind. On the one hand, we know there’s not enough application of the best practices that have been demonstrated through research. On the other hand, there’s no way to innovate if we don’t break some of the rules – in a controlled way – to see if we can make things better. This is the central concern at the heart of making medicine better.

On the one hand, we want doctors who read the latest journals and follow all the latest advice. On the other hand, we’ve seen research be reversed as new information is gained – and that information is only gained when we stray from the rules.

Clearly, the difference is that, in the one case, doctors fall upon the norms of their groups and just do what they’ve always been doing, even when there is research saying it’s ineffective or there are better approaches. It’s just too hard to override your experience. You’ve done sometimes hundreds of these procedures with only a few complications. Why should you have to learn something new? How many injuries would it really save? We don’t believe the research; we believe our personal experience.

So, we have to encourage consistency and simultaneously find ways to carefully try new ideas to see if we can get even better.

The Ego and the Average

At the end of the day, being better is about elevating yourself above the average. The only way to know if you’re making progress is to measure your performance, and that comes with a great risk. You may discover, much to your dismay, that you are only average, despite your striving and struggle. Despite the trials and the conquests, your performance is only average. While this may be, on the surface, bad news, it does at least let you know where you are. If you want to become better – as a surgeon or just in life – perhaps you should read Better.

Book Review-Mistreated: Why We Think We’re Getting Good Health Care—and Why We’re Usually Wrong

It’s no secret that the American healthcare system is broken. While there have been great advances in healthcare that saves lives and improves the quality of lives for so many people, it is still broken. The problem is that we can’t take a step back and fix it because it’s still saving lives every day. Mistreated: Why We Think We’re Getting Good Health Care—and Why We’re Usually Wrong walks through the details of our healthcare system from blind spots and misperception to motivations that are out of alignment with what’s best for the public.

Confronting the Truth

It’s a convenient belief that we have the best healthcare system in the world. It’s convenient, because it fits the facts that we have the most expensive healthcare system in the world. More expensive means better, right? It’s convenient to believe we have the best healthcare system in the world, because we send our loved ones to get healed here, and we want the best for them. We ourselves get our care here, and why wouldn’t we want the best?

The problem is, while it’s convenient to think we have the best healthcare system in the world, that’s far from true. We have “the highest infant mortality rate, the lowest life expectancy, and most preventable deaths per capita” of the modern world. While we spend the most on healthcare, our results are far from the top of the pack. Instead, our system invites waste, greed, and poor outcomes, all the while believing the care we receive is good. At some level, we know that this is lunacy, but it’s a convenient thought that keeps us from confronting the truth. Seventy-six percent of people describe the quality of their care as good or excellent. This statistically can’t be true.

Affordable Care Act

The Affordable Care Act (ACA) is the most sweeping set of healthcare reform that has been done in decades. While focused on making it easier for every American to have access to healthcare, it was able to address some other issues as well. No longer would people be denied insurance because of a preexisting condition. Preventative care was made nearly or completely without cost to the consumer.

While this was important legislation, it didn’t strike at the heart of the structural problems healthcare faces. We pay for services instead of paying for health. We’ve not been able – yet – to transform the relationship to one where the consumer only pays for results. This change can make all the difference.

Unnecessary Surgery

If pain is the symptom, surgery rarely has better outcomes than alternative treatments. Yet we perform surgery to repair a torn meniscus and place stents in people’s arteries at great cost with little or no actual health benefit. The results are in – and they say we shouldn’t do them. Like dozens of other treatments that are ineffective, we still do them because it’s standard practice or because they’re marketed aggressively.

Opioids

There’s a bit of news now about how opioid manufacturers, particularly Purdue Pharmaceuticals, engaged in aggressive marketing of Oxycontin, which had a high potential for abuse but which the company routinely led physicians to believe was safe. Dreamland covers this aspect of our healthcare woes in detail. The short version is that we began treating pain as a vital sign, and physicians began getting more directly measured by their intentionality about treating pain. In most cases, this meant prescribing them a pill.

Pharmaceutical companies learned that, when marketed to them directly, consumers would ask their doctors for the medication. Often, they’d get what they ask for. Doctors are reluctant to deny their patients the medications they’re asking for – even when it’s not effective. Consider the over-prescription of antibiotics. A patient doesn’t feel well, and they make the decision to go to the doctor. They expect the physician will do something to make them better. They expect they’ll get a pill that will make them better. The physician, tired of explaining that an antibiotic won’t help, prescribes it anyway, knowing it won’t make them better. In the next week, the patient feels better and attributes their wellness to the drug – instead of to the virus running its course.

We see this desire of the public to just get a pill and fix it show up in every aspect of healthcare, including mental health, where it’s easier to take an anti-depressant than to deal with the underlying problem. (See Warning: Psychiatry Can Be Hazardous to Your Mental Health for more.)

Generalists and Specialists

The frequency with which you deal with a problem makes a big difference in your outcomes. The truth of the matter is that in medicine – like many other disciplines – you can’t get good at something if you’re never given enough time to practice and learn. Intuitively, it makes sense. If you do one gall bladder surgery a month, you’re not going to be as skilled at it as someone who does 100 a month. However, in most cases, the market doesn’t allow physicians to become hyper-specialized into a single kind of surgical procedure. Even our specialists cover a wide range of procedures and patient problems – too wide to drive the kind of volume in the procedure that would make them truly good at their craft.

What tends to happen is that a generalist treats a few patients a month and gets, at best, middling results from them. Even the specialist can’t afford to be hyper-specialized, because all the generalists are taking the cases they need to stay fully busy and get very good at what they do.

That’s not to say that generalists, like your primary care physician, are bad or not needed. It is believed (based on successes in other nations) that the best solution to the healthcare performance problem in America is to get primary care physicians better at preventative medicine – true health care – instead of trying to triage and route patients who are truly sick.

There’s a very old saying that “a stitch in time saves nine.” Meaning if we catch things early – like before they start – it takes very little to maintain or repair the situation. The later we catch a problem, the more challenging the recovery becomes – but that’s what we reward in our current system. Specialists (such as they are) are paid roughly three times what primary care physicians are paid. We undervalue the preventative measures that can have the greatest impact, and we elevate the heroic, last-minute attempts to help someone survive.

Undervalued

There’s a real soft spot in my heart for the understanding that we undervalue simple interventions that save lives and instead invest our money into technological marvels that have little or no real impact on outcomes. Another big marketing tool that healthcare systems are using is robotic surgery. Again, it makes sense. Doctors’ hands can be shaky, but robotic hands are not. However, the efficacy for robotic surgery isn’t any better than regular surgery – oh, and it takes longer. However, organizations are spending millions of dollars on these robotic surgery devices, which sit idle most of the time. Physicians want to have them but don’t see any need to make their jobs harder without better outcomes.

The soft spot for me comes because of our IV dressing patent. It’s simple. It’s straightforward. And we’re still trying to get the market to accept a change that may impact materials cost by $1 and may substantially reduce healthcare-associated infections (HAIs). It’s not sexy, but it seems to work. That may be why it’s not being used. Because, in the upside-down system of American healthcare, if it doesn’t seem like it’s cool, then it’s not worth doing.

Dr. Pearl shares his appreciation for information technologies and the ability for these simple technologies to improve outcomes.

Diabetes Advantage Program

It seems like a lifetime ago to me now. The study was being done in 1999, and the journal article was about the program titled “A Systematic Approach to Risk Stratification and Intervention Within a Managed Care Environment Improves Diabetes Outcomes and Patient Satisfaction” in Diabetes Care (Volume 24, Number 6, June 2001). The short version is we took patients with diabetes who were being treated by primary care providers, and we gave the primary care providers suggestions for the actions they should take to help their patient better manage the disease. We basically made it easy for the physicians to do the right thing.

The recommendations would print out to add another oral medication, the nurse would write a more specific recommendation in based on the physician and the specific drugs the patient was on, and the physician would sign the orders. The physicians quickly learned to trust the system (and the nurse). They realized the system was giving their patients the benefits of the best research on the disease without them having to study it.

The net result was about a 1-point drop in HbA1c values in 12 months. To put that in perspective, back then, the threshold for having diabetes was 6, and the threshold for uncontrolled diabetes was 8. (These values have been adjusted a bit in more recent standards.) So, a 1-point drop in HbA1c values was a substantial change. Most of that change is attributable to the system “reminding” physicians to do what the research suggested was best.

In short, helping caregivers with information technology works – and we’ve known it works for decades now.

Environment of Care

We tend to overestimate our rational rider and underestimate how much of what we do is shaped by the environments that we are in. Kurt Lewin proposed that human behavior is a function of both person and environment. You can’t predict what a person will do without understanding both. More recently, we’ve seen how people can be made to do awful things to other people with relatively little encouragement. The Nazi extermination of Jews was unfathomable. However, as both Albert Bandura (in Moral Disengagement) and Philip Zimbardo (in The Lucifer Effect) explain, it’s relatively easy to disengage our morality and cause people to behave in ways that don’t make rational sense. They both point to the work of Stanley Milgram after World War II, in which subjects were thought to be giving progressively higher voltage shocks to another subject in the next room. Most continued to give shocks that they perceived to be potentially fatal with little more enticement than knowing it was for the experiment.

It’s surprising how little factors can cause us to take different behaviors. Nudge uses numerous examples of how changing the easy or default answer changes the way people eat and save. When you look at the body of literature around change, you’ll find that, much of the time, making change work is about a few well-placed interventions. (See Switch, Redirect, Change or Die, Change Anything, Made to Stick for examples.)

These same factors hold true whether we’re talking about something truly evil or we’re simply talking about practices that aren’t effective. Once the group establishes a social norm, it’s hard for new people to adjust the norm, even when the new target has better demonstrated outcomes. In short, the team becomes fixed in their perspective and don’t accept the valuable input from the outside. (See Diffusion of Innovations and Hackman’s Collaborative Intelligence for more on the receptiveness of a group or team to outside influence.)

Sometimes, the best examples of what to do are sitting right under our noses. The Washington Post Magazine arranged for internationally-acclaimed virtuoso Joshua Bell to play his violin at a subway stop for spare change. The man who played for presidents and sold out concert halls earned a little more than $32 in his time at the subway station. The expectation that he was simply a street player led nearly everyone to treat him as one. The environment we’re in really does dictate how people respond to us.

Healthcare Is a Team Sport

In America, we’re enamored with the idea of a lone hero charging across the western plains to conquer a new land. The wagon trains of families banding together to face the hostile wilderness just doesn’t sell as well. We want to believe the surgeon has better outcomes while ignoring the impact of the hospital, the nurses, and even the janitors. In healthcare, janitors are called environmental services (EVS) workers. The painful fact is that most EVS workers clean somewhere between 30-50% of the things they’re supposed to clean between patients.

There’s a growing body of research that shows pathogens are being passed from one patient to the next because of improper or incomplete cleaning. Moving the needle from 50% to 80% of the objects cleaned can have a reduction in HAIs of about 20%. To put that in perspective, that’s more than one infection saved per EVS worker per year.

Nursing, too, has been shown to have a critical role in the outcomes for the patient. “Better” nursing care is associated with better outcomes. Subtle things like the degree of burnout nurses experience has an impact on the patient outcomes.

Everywhere we look, there is evidence that it’s more than the gifted surgeon that makes the difference in the outcomes. Now more than ever, healthcare is a team sport – and one that is sure to continue. The silent member of the team – but the one that is always present – is the patient.

Patient Non-compliance

One frustrating aspect of healthcare is that frequently the patient is non-compliant with the protocols they’ve been given by the healthcare staff. Whether that’s failing to take medications or it’s not doing the prescribed exercises, getting the patient to behave in their best interests is often a frustratingly difficult challenge. To be fair, most of the challenges here are ones that educational folks have learned to address but healthcare hasn’t picked up on.

Healthcare workers aren’t careful about educating patients and asking questions for which the correct answer is no. By default, humans will answer yes if we don’t understand. So, asking questions that have no as answers can help ensure the patient understands. (See Incognito, Predictably Irrational, and The Hidden Brain for more.) For instance, instead of asking “Do you understand that you should take this with a meal?” you might ask “So, do you believe you should you take this on an empty stomach?” Healthcare workers suffer from the curse of knowledge, which means they fail to explain in a way that patients can understand. (See The Art of Explanation for more.)

What’s more, healthcare workers haven’t been taught to give patients productivity aids to help make them more successful. (See Job Aids and Performance Support for more.) The handouts they give patients are largely unintelligible even by healthcare workers, and they aren’t inviting to someone who’s unfamiliar with healthcare and what’s happening to them. Beyond the paper they’re given, they’re rarely pointed towards tools that can help them be more compliant – like an application for their smart phone that will remind them when it’s time to take medications.

If we’re going to make healthcare better, we’ve got a long way to go. We’ve got to address the motivators that cause people to take advantage of others. We’ve got to move towards higher specialization and more preventative medicine. And we need to get everyone on the team – including the patient – so we can prevent more people from being Mistreated.

Book Review-Relationship-Based Care: A Model for Transforming Practice

Healthcare isn’t sausage-making. In sausage-making, “what’s in there” doesn’t matter. It’s simply that it tastes good. In fact, most people don’t want to know about the sausage-making process. However, in healthcare, we’re talking about people, and the process matters. That’s the heart of Relationship-Based Care: A Model for Transforming Practice – an understanding that the process of delivering care is important and the best way to do that is by recognizing the importance of relationships.

Three Directions

In the healthcare system, there are three primary kinds of relationships that a provider can have. First, there’s the obvious relationship to the patient – and their family. The second relationship is with the colleagues. Healthcare is a “team sport.” No provider can work alone. Finally, there’s the relationship to one’s self.

It may seem that a relationship to self is an odd thing to add; however, the truth is that the lack of self-care and self-awareness on the part of providers leads to burnout – and poorer outcomes for the patient. (See ExtinguishBurnout.com for more on burnout causes and resolutions.) The truth is that the relationship to self is the relationship from which the other relationships initiate.

Connecting to the Mission

Every day, care providers face new patients. They present with the same kinds of conditions and the same acuity as the day before and the day before that. There are variations to be sure, but the patients keep coming. It seems like the provider isn’t having an impact. The same patient comes back with the same problem, because they didn’t heed the provider’s advice.

It can be frustrating and demoralizing to realize that you can’t save everyone – that you can’t help everyone. As each day becomes more and more of a grind, it’s possible to lose your way – and wonder why you’re pushing yourself if you’re not seeing any results. That’s when it’s important to reconnect with the mission of the organization and to our personal mission.

Simon Sinek in Start with Why explains that connecting to why we’re doing something has a powerful effect on our productivity and our ability to continue in the face of adversity. In some cases, we know why we’re doing something – our personal and organizational missions – but we’re lost, because we don’t feel like we’re accomplishing the mission. Instead, we feel as if we’re engulfed in chaos, and we’re just trying to survive.

The Healing Power of Relationships

We think we’ve got the world figured out. We believe that our technology and techniques save lives – and to some extent, that’s true. Our technology does save lives, but there’s more to it than that. Aristotle knew that there was more than one way to know the truth. There’s the science – episteme – but there’s also the art – techne. The truth is that our technology and techniques are only part of the solution. (See Theory U for more about different kinds of knowing.)

In Being Mortal, Atul Gawande recounts research that assisted living facilities with patients who were given something to care for – a plant or an animal – lived longer than those who didn’t have something to care for. Our connection to other living things is a powerful tool for health.

Florence Nightingale knew this. She believed that the role of the nurse was to help patients attain the best possible condition, so nature could act, and self-healing could occur. The icon of nursing didn’t believe it was the nurse’s role to heal but rather to create the conditions for healing to occur, and those conditions seem to be found in caring, compassionate relationships.

Transforming an Environment of Care

Jayne Felgen developed a model, I2E2, for transforming the environment of care. The model is four concepts:

  • Inspiration – How do you connect people with the things that inspire them – in other words, their mission?
  • Infrastructure – The set of practices, systems, and processes that make the inspirational vision achievable.
  • Education – The promotion of competence, confidence, and personal commitment through providing the knowledge and skills necessary to do the job.
  • Evidence – Gut feel isn’t enough. In today’s healthcare world, it’s necessary to know for sure that the work being done is making a real difference.

The model encourages the tools that we know lead to change, including creating the initial pull to drive the change forward, supporting the individual both at a systemic and educational level to help them understand they can be successful, and providing continuing support in the form of demonstratable results. (See Diffusion of Innovations for more about motivating people to change.)

The Five Cs (Conditions)

In every organization, there are barriers to change. In fact, organizations, by their very nature, are resistant to change. The network of policies and procedures are designed to form a network that provides strength around unnecessary change. However, there are conditions that make it more likely that change can occur. They are:

  • Clarity – When people know what’s happening at a deep level – both to them and to the organization at large – they can move forward with less fear. (See The Fearless Organization about the role of fear in organizations and Trust=>Vulnerability=>Intimacy, Revisited for more on the role of safety.)
  • Competency – The more people feel competent, the more willing they are to step forward into the change. (See The Psychology of Hope for how waypower impacts a person’s ability to maintain hope.)
  • Confidence – The feeling that someone knows what is being asked of them and has the skills to execute on that leads to confidence – or courage – to move forward. (See Find Your Courage for more.)
  • Collaboration – Collaboration is the ability to work together towards a common goal. That’s essential if you want to transform an organization, because in all but the smallest of organizations, there are multiple people involved whom you need to work with. (See Collaborative Intelligence for a very detailed investigation in how to make collaboration work.)
  • Commitment – Being “bought in” to a goal is critical to its success. Commitment carries the change beyond just doing it if it’s easy, and instead moves it to the world of grit, where there’s a burning desire inside the person who is willing to face adversity to accomplish the goal. (See Grit for more.)

Though the 5 Cs aren’t a rich model for organizational change, it does provide a good framework for some of the basics.

Person not Diagnosis

Diabetes in room 3. Stroke in room 4. Breathing trouble in room 5. It’s a quick way of communicating, but it’s not a respectful way. In healthcare, we’ve got HIPAA to consider, but we can’t use that as a shield for our thoughts and words. Everyone has a story. Everyone is a real person – and they’re much more than a diagnosis.

When we dehumanize people, as referring to them by their diagnosis tends to do, we make it easier to unconsciously treat them poorly. Stanley Milgram demonstrated that, given light environmental controls and encouragement, most people are willing to administer what they believe are life-threatening shocks to others – if they’re not in the same room. (See The Lucifer Effect and Moral Disengagement for more on Milgram’s experiments and the topic of dehumanization in general.) Though we don’t want to admit it, the more we fail to think and communicate about patients as real people with real fears, hopes, and aspirations, the easier we make it to discount them – and that’s the opposite of being in a relationship with them.

Leadership as Being in a Relationship

Joseph Rost laid out in Leadership for the Twenty-First Century how he believed all leadership is done in relationships – non-coercive relationships – and how everyone is a leader. Rather than believing there are two classes of people (separating people into us vs. them), Rost believed that all of us are in relationships with others and are capable of leading. The common thread is that the relationship is accomplished for a meaningful, mutual purpose. In healthcare, the well-being of the patient is a meaningful, mutual purpose.

Sometimes in leading recovery, the patient will lead, and other times, the nurse will lead. Sometimes, in healthcare organizations, the manager will be leading, and other times the nurse will be leading. Leading is, according to Rost, centrally focused on the ability to be in a relationship.

Most nurses recognize that their relationship with their patients, the ability to be with them at their times of such great vulnerability and need, is a sacred and privileged trust. This puts them in the position to lead the patient to better health – as non-coercively as possible.

Organizational Models

Relationship-Based Care spends a great deal of time investigating structural models of organization and approaches to how to deliver the best care. From the historically highly authoritative to the more collaborative approaches, the walk-through shows the progression from a very power-based approach to one that is more collaborative and focused on mutual relationships.

The concerns are addressed about how organizations can maintain consistency of delivery when the delivery is done in a more collaborative and relationship-driven way. The fact of the matter is providing professionals with more autonomy provides for better outcomes – when that autonomy works inside of a well-defined framework.

I’m reminded of Chris Lowney’s work, Heroic Leadership, and how the Jesuits learned which things couldn’t be adapted to fit a culture they were working with – and which could. This clarity about the things that were and weren’t negotiable made it possible to operate effectively in very different environments.

Reflection

Relationship-Based Care recommends reflection – and that’s important both at an individual level and at a level of process improvement. When we do institutional reflection like after-action reviews (see Lost Knowledge), more commonly seen as root cause analysis, systemic cause analysis, or morbidity and mortality meetings, we create the opportunity to learn from our mistakes and not repeat them.

Perhaps it’s worth some reflection to see if you are providing the best Relationship-Based Care.

The Impact of Clinical Nurse Specialist

In a world where health care is focused on improved outcomes and safety the Clinical Nurse Specialist (CNS) is a light in the darkness. The role of the CNS is frequently one of the least understood of all advanced practice registered nurses (APRN). APRNs include nurse practitioners, nurse anesthetist, nurse midwifes and CNS. Of the approximately 350,000 APRN in the United States the CNS population in the United States is numbered at nearly 72,000.

The CNS specialist brings together three separate spheres: the patient, nursing, and the healthcare system. They practice within these spheres to create the best opportunities for patients to have optimal outcomes and for nurses to be supported to be able to provide the level of care they desire to give by working with systems to find better ways to support process that provide the best outcomes.

This week is national CNS week. I am proud and humbled to be among the amazing CNS’ that improve healthcare every day; not only for the patients but for everyone involved in their care.

Happy CNS week!

#NACNS #ANA

Cinco de Mayo aka World Hand Hygiene Day

Happy Cinco de Mayo! May your hands be washed well frequently and help prevent the spread of infection. I know this is not the typical toast to go with the annual Margarita splurging day that celebrates the Mexican army’s victory over the French army at the Battle of Puebla is 1862. I promise the intent of my toast is pure and full of hope for your good health.

The 5th of May is not only Cinco de Mayo it is also World Hand Hygiene Day. It is possible that World Hand Hygiene Day may never be as eagerly or widely celebrated as the Cinco de Mayo. It is likely that the simple act of cleaning your hands at the appropriate times will save more lives and prevent more infections than any other action we can take. The battle against pathogens and the development of antibiotic resistant bacteria is literally in our hands.

When we look at the data it is apparent that there is reason to celebrate World Hand Hygiene Day and take a stand to stop the spread of infection.

Let’s look at a bit of data related to hand hygiene:

  • A large percentage of foodborne diseases are spread by hands that were not cleansed well
  • Handwashing can reduce the risk of respiratory infections by 16%
  • Up to 80% of common infections are spread by hands
  • 10% of people do not wash their hands at all after going to the toilet
  • Only 1 in 20 people wash their hands appropriately after going to the toilet
  • In the United States, some healthcare providers clean their hands less than 50% of the times they should
    • These healthcare providers may need to clean their hands 100 times per 12-hour shift
  • According to UNICEF, one in every four childhood deaths, approximately 1.4 million globally, result from diarrhea and pneumonia. Handwashing with soap and water could reduce the death rates from these diseases up to 65% (Sam Stevens, Clean the World Foundation).

Effective hand hygiene takes less than 20 seconds and is truly an action that saves lives and changes the world. We spend millions of dollars looking for ways to keep humans safe from infection. The first line of defense is found in appropriate hand hygiene. Doing the right thing takes a small time commitment combined with the awareness of when it is important to perform hand hygiene.

There are very specific times when washing your hands is imperative:

  • After going to the toilet
  • Before eating or preparing food
  • Before and after taking care of someone who is ill
  • Before and after treating a cut or injury
  • After changing diapers
  • After blowing your nose, coughing, or sneezing
  • After touching animals, their food or waste
  • After touching garbage

There are five simple steps to washing your hands:

  1. Wet your hands
  2. Lather your hands with soap
  3. Scrub your hands for at least 20 seconds
  4. Rinse your hands
  5. Dry your hands

If soap and water is not available, you can use an alcohol-based hand sanitizer to clean your hands. It is important to remember that alcohol-based hand sanitizers are not as effective if your hands are visibly dirty or greasy. When using alcohol-based hand sanitizer be sure to follow these steps:

  1. Apply the product
  2. Rub your hands together
  3. Rub the product all over your hands and fingers until they are dry

Researchers in London estimate that if everyone routinely washed their hands, a million deaths a year could be prevented. Think about that, if it was your loved one that was still alive because we all washed our hands. We can’t live forever, but we shouldn’t die because someone didn’t wash their hands. Each time you wash your hands you could be saving a life, what could be more important than that. May you wash your hands well and frequently and have a very healthy Cinco de Mayo.

#HandHygiene #HealthForAll

Patent Issued: Dressing with Moisture Indicator

It was over four years ago on a trip to visit our son that we started a journey to create a way to help protect patients from developing life-threatening blood stream infections. The journey has been long, but today is the day that the US Patent and Trademark office issues our patent for a dressing with moisture indicator. We wanted to take this opportunity to explain why this is so desperately needed and why it works.

The Healthcare Associated Infection Problem

Central line-associated blood stream infections (CLABSI) are a special class of healthcare-associated infections (HAIs) and one that is particularly life threatening, because it can lead to sepsis. Each year in the US, roughly 100,000 people die of HAIs. That’s comparable to a commercial airliner crashing every single day, killing everyone on board. There has been a great deal of energy focused on reducing this problem, but still too many people are admitted to hospitals, have a central line inserted, and get sicker because of CLABSI or some other HAI. Some of those that develop a CLABSI die from this preventable infection.

The Story

It was 1:30 AM, and we were driving through western Pennsylvania when Terri exclaimed, because a young patient had developed a CLABSI and by the bacteria and the notes in the chart, she knew what happened. The patient had vomited on their central line’s dressing, and the parents, trying to be helpful, wiped it off. The problem is the moisture and the bacteria that naturally occur in the stomach were now on the dressing. Bacteria need two things to be able to replicate. They need food, and they need mobility. There’s food for bacteria nearly everywhere. The moisture from the stomach and from the washcloth made it easy for the bacteria to get to food and replicate.

Eventually, the bacteria penetrated the dressing, and the IV led them straight to the blood stream, where they could spread out and infect everywhere in the body.

The Dressing’s Role

IVs are used to deliver fluids and medicines to patients. Central lines are inserted into major blood vessels, so that greater volumes, multiple medications, and nutrition can be quickly infused without the complications of peripheral IVs. This is great when you need to be able to diffuse medicine quickly, but it makes them particularly vulnerable to bacteria getting the benefit of the same distribution. The IV dressing is designed to protect the insertion site of the IV from becoming contaminated with bacteria and serving as a direct pathway to the circulatory system.

Dressings, however, must be semipermeable. That is, they need to let the natural moisture emitted by our skin as small amounts of sweat escape to prevent reservoirs of liquid from forming under the dressing. This semipermeable nature means that it’s possible for external contaminants to make it through. The dressing creates a protective barrier but not an absolute one.

As a result, the CDC (and everyone else) says that dressings should be clean, dry, and intact. Cleanliness is an easy visual observation. While the exact standard for what constitutes clean and dirty can be argued, it’s easy to assess the degree of cleanliness by observation. Assessing whether the dressing is intact is slightly more invasive, as it requires that the nurse or provider lift the IV to see whether there are gaps between the dressing and the skin. However, dryness presents a particular challenge.

Assessing Dry

On the surface, assessing dryness – or wetness – of a dressing should be easy: just touch it. Except nurses and providers – for everyone’s protection – should always wear gloves when touching a patient’s dressing. You can’t tell if something is wet through gloves. It’s possible to assess cold-wetness, because it will feel colder; but because the fluids will be at body temperature, it’s very difficult to determine if a dressing is wet through gloves.

Because dryness is so hard to do, it’s not always done well. In truth, it’s not assessed as often as it should be based on research and healthcare system standards. This is the fundamental problem we solved. We found a way to make dressings tell you visually when moisture is present. The result is assessing dryness is as easy as assessing whether the dressing is clean.

Information Overload

We contributed a chapter to the American Nurses Association book Information Overload. It explains what nurses already know: they’re overloaded. They’re expected to document hundreds of observations per hour, and, for each observation, they may have to make multiple assessments – as is the case for dressings. There’s simply no time to do all that must be done to provide good care for their patients and properly document what is happening.

We recognized that, if we couldn’t make the assessment easy, we’d have no chance of changing behavior and helping nurses change dressings appropriately.

Antimicrobials

The industry has been moving down a path of using antimicrobials to combat infections. The idea is that, if you use something like chlorhexidine gluconate (CHG) in a dressing, you’ll kill the bacteria and eliminate the need to change the dressing. CHG-based dressings are better than non-CHG-based dressings for those patients that can tolerate it well; however, it creates a secondary set of issues. We have a limited number of chemicals (and metals) that we know to have antimicrobial properties. As a result, we use them frequently when timely cleaning isn’t practical or even possible.

Research indicates that some microbes are becoming resistant to the antimicrobial properties. In short, the antimicrobials are gradually becoming ineffective as the microbes adapt. At some point, we’ll overuse CHG and the other antimicrobials, and they’ll become completely ineffective. We see this already with multi-drug resistant organisms (MDROs) like Methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacteriaceae (CRE). We’ve killed the susceptible versions of the bacteria and the resulting bacteria replicates free of competition from its variants.

It’s not a question of if strategies using CHG will become ineffective – it’s a question of when. No one can predict when CHG will stop being sufficiently effective to continue its use, but the day is coming.

Unstoppable Humans

The good news is that humans are unstoppable. We’ve done amazing things as a species. This is particularly true when we make it easy to do the right thing. Evolutionary scientists have studied and modeled what has given us the power to be the dominant life form on the planet. Some of this has to do with our capacity to work together, but equally important is our capacity to adapt and to adopt behaviors that help us to protect ourselves and our communities. Caring for patients will never be easy, no matter how much we try to make it so. Having a dressing that signifies the need to be changed due to moisture helps make patient care easier. Making appropriate care easier improves the care we are able to provide and the outcomes for patients everywhere.

Conflict Resolution and Infection Prevention

Conflict is a natural part of life. We learn to resolve conflict so that we can be a part of the human condition that is designed to be social – so that we can be in relationship with others despite the conflict. In the emotionally-laden environment of healthcare, conflict consumes significant time and energy for the IP. In this brief conversation, we’ll explain the foundations of conflict resolution. Effective conflict resolution and communication skills can transform organizational culture and leadership and improve efficiency, reduce preventable errors and adverse events, and improve staff and patient satisfaction.

Rob and I are presenting Conflict Resolution for the Infection Preventionist: Improving Collaboration and Patient Outcomes at the national APIC convention in Minneapolis on Tuesday, June 13th. APIC is always an exciting conference to present at and attend. As infection preventionist there are so many opportunities to improve patient outcomes. The magic comes when you can improve patient outcomes and not add burden to the rest of the healthcare team. This transformation requires compromise to find ways to deliver the level of care that creates the best outcomes for patients in a sustainable and time effective manner.

Together we can eliminate healthcare associated infections.

Happy National EMS Week!

This week has been set aside to show our appreciation for all EMS providers who step into a problem with knowledge, compassion, and respect for those they care for.

Many years ago, I started my journey in healthcare as an emergency medical technician (EMT). It was not long before I entered nursing school with the goal of becoming an emergency room nurse. Some 35 years later, I still have a soft spot in my heart for EMS and emergency room nurses.

Our eldest son is a paramedic. I hear his stories and recognize the impact he has on the people he cares for. He provides care in the unexpected, emergent world we all hope to never experience. When we do experience it, the event is a potentially life-changing moment. Having someone willing to step in and provide the care you require is life giving.

When we teach about therapeutic boundaries, we discuss the care continuum of empathy, compassion, and altruism. Empathy is the ability to understand what someone is feeling. This is an important skill but is not enough to provide the level of care we require in healthcare. Compassion is a step further: it is an understanding of how someone feels and a strong desire to alleviate their suffering. At the far end of the continuum is altruism. The willingness to help another at a risk to oneself. We tell most healthcare providers that compassion is the place where you want to operate from; altruism is a step too far for most of us. For those who are part of the EMS team, it is normal to operate from altruism. The risk is calculated: the team has prepared and trained to limit their risk, but each rescue has a risk that is willingly accepted to provide for those in need.

Even though we only celebrate EMS week once a year, we are all thankful for every EMS provider and offer you our thanks and prayers.

Nurse’s Week Gift

Some of the nurses were talking about how nice it was that many restaurants had Nurse’s Week specials. It is wonderful to have people acknowledge the special work we do as nurses and to celebrate this with us each year.

This year, I want to offer all nurses a different gift. Each of us became a nurse for different reasons, and our practices differ dramatically. One commonality I see among nurses is the gift of compassion, not just the “I want to take care of you” style of compassion. It is the “by the book” definition of compassion I see over and over again. According to Merriam-Webster, compassion is defined as the sympathetic consciousness of others’ distress together with a desire to alleviate it. This depth of compassion is seen in nurses around the world every day. This compassion is what gives nurses that sense of accomplishment at the end of a hard day, knowing that they made a difference in someone’s life. To be able to truly alleviate someone else’s pain and distress is an incredible gift. If I had to guess, compassion is the basis that makes nurses the most trusted of professions.

While it is normal to see nurses show compassion to their patients every day, it is rare to see these same nurses be compassionate with themselves. Too frequently, we think that taking time for ourselves or doing something just for ourselves is selfish or unnecessary and should not be valued. Nurses in general, myself included, are not steeped in the tradition that it is necessary to care for yourself.

Rick and Forrest Hanson (authors of Resilient: How to Grow an Unshakable Core of Calm, Strength, and Happiness) tell us that compassion for yourself is fundamental. By being more compassionate with ourselves, we learn to recognize our own distress and work to alleviate it. This self-compassion feeds our souls; it helps us to find and keep the joy that life has in store for us. In the end, self-compassion gives us the strength to be compassionate to others. Being compassionate with ourselves not only helps us to be more compassionate towards other, it can help reduce compassion fatigue.

We are starting to see more encouragement for nurses to care for themselves. The ANA’s Healthy Nurse, Healthy Nation encourages nurses to take better care of themselves and be good role models for society. The first step in caring for ourselves is to develop self-compassion.

This Nurse’s Week, I ask you to be compassionate with yourself. If you can’t see a way to do this for yourself, do it for your patients, family, and friends. As we experience self-compassion, we will be better prepared to encourage one another; the ripples of compassion will grow to include not only ourselves and our patients, but also our families, friends, and co-workers.

Happy Nurse’s Week to an amazing group of people, I am honored to be a nurse with you.

Washing Hands

Cinco de Mayo

Cinco de Mayo; what does this date make you think about? Many people will think about their favorite Mexican food or beverage. History tells us that May 5th is set aside to commemorate the Mexican Army’s unlikely victory over the French Empire at the Battle of Puebla on May 5, 1062. Cinco de Mayo is not Mexican Independence Day as many believe.

Cinco de Mayo has special significance this year: May 5th is World Hand Hygiene Day! The World Health Organization (WHO) has declared May 5th as World Hand Hygiene Day to encourage patients and family members to join healthcare professionals in the practice of appropriate hand hygiene. According to the WHO, hundreds of millions of patients are affected by healthcare-associated infections (HAIs) every year. More than half of these infections could be prevented if caregivers properly cleaned their hands at key moments in patient care. Everyone has a role in encouraging each other to clean their hands.

Imagine an entire day across the globe to celebrate and remember the importance of hand hygiene. If only we were celebrating the incredible job that we as a species do at effective and timely hand hygiene. Recent data shows that on average, healthcare providers clean their hands less than half the times that they should. Alas, it appears that it is our failure to clean our hands that leads to this observation of World Hand Hygiene Day.

Too often, we only consider the importance of healthcare workers cleaning their hands at the appropriate time to prevent the spread of HAIs. The Joint Commission has stated that hand hygiene is the most important intervention for preventing HAIs. We know one out of every twenty hospitalized patients has an HAI; appropriate hand washing is the solution we somehow cannot succeed at. Hand washing in healthcare is a life-saving activity, but it is not the only place that hand washing is crucial. All of us need to clean our hands at the appropriate times, not only to protect ourselves but to protect our loved ones and society as well.

If you work in healthcare, you know there are five moments (according to the WHO) that you need to wash your hands:

  • Before patient contact
  • Before aseptic tasks
  • After body fluid exposure risk
  • After patient contact
  • After contact with patient surroundings

If you are a patient or have a loved one in the hospital or other healthcare facility, there are key times for you to wash your hands as well. These moments are not as widely broadcast but are essential in the prevention of HAIs. The CDC list patient/family hand hygiene moments as:

  • After using the restroom (use soap and water)
  • Before eating (use soap and water)
  • After touching bedrails, bedside tables, remote controls, or phone
  • Before touching your eyes, nose, or mouth
  • After touching doorknobs
  • After blowing your nose or sneezing
  • Before and after changing bandages

Hand washing, also known as hand hygiene, has two separate methods. First, washing your hands with soap and water; second is the use of an alcohol-based hand sanitizer. If the hand sanitizer contains at least 60% alcohol, alcohol-based hand sanitizers are more effective and less drying to your hands than using soap and water. This is true except after using the bathroom, times when your hands are visibly soiled, or when caring for a patient with C. difficile. At these times, soap and water is the best option because the C. difficile spores are not removed by alcohol-based hand sanitizers.

When completing hand hygiene with soap and water or alcohol-based hand sanitizers, be sure to clean your fingertips, thumbs and between your fingers. Hand sanitizer should be used in a quantity to keep your hands wet for 20 seconds. Hand washing should include take at least 20 seconds as well, with 15 seconds spent rubbing hands together.

Whether you are a healthcare provider or a healthcare consumer, you can impact HAIs through appropriate hand washing. It is time to wash out HAIs and improve all our lives.

Happy World Handwashing Day!!!!