Nursing

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Hospitals are places of recuperation, and sleep is essential to recuperation. But hospitals can be very, very noisy places. Patients have criticized the clatter for years, but the alerts emitted by all of the various alarms, whistles and buzzers have typically been deemed by hospital administrators to be more important overall.

That attitude has been changing though with a greater focus on patients, new policies linking hospital reimbursement to patient satisfaction, and more research on the effects of a noisy hospital environment.

In this article in the New York Times, Pauline W. Chen, M.D., says that patients endure a level of noise that “borders occasionally on deafening.” A recent study found that average noise levels in a hospital room way outstripped the recommended 30 decibels (slightly louder than a whisper) that is recommended by the World Health Organization. Meanwhile, peak noise levels were sometimes as loud as a chain saw! The more noise, the more of a negative impact on patients’ sleep. And the less sleep, the worse the health outcomes.

Some noises were found to be more disruptive than others. While all loud noise was problematic, the electronic alarms from monitors and the ringing from telephones were most likely to wake up a patient. And each time patients were awakened, their heart rates jumped.

“There is a threat perceived in those noises,” said Orfeu M. Buxton, lead author of the study and an assistant professor in the division of sleep medicine at Harvard Medical School, “and hospitalized patients are probably in a high state of ‘threat vigilance.’ ”

Manufacturers of monitoring and medication infusion devices have not turned a deaf ear to the problem. The industry has begun sponsoring and conducting research on the amount of noise generated by medical devices, and several groups have begun working on creating more patient- and sleep-friendly products. Some companies, for example, have tapped into the increasing use of wireless technology in hospitals, designing monitors, pumps and nursing call systems that do not buzz or beep right at the patient’s bedside, but rather channel the alarms only to the doctor or nurse responsible.

While these early wireless efforts are promising, many companies and hospitals remain reluctant to switch over completely to the newer designs, and industry standards for device alarms are changing slowly, if at all. “The holy grail is that a pump would never sound its alarm while near a patient,” said Tim Vanderveen, vice president of the Center for Safety and Clinical Excellence at Carefusion, a medical technology company that produces infusion pumps and other health care devices. “But what would happen if a hospital’s wireless system went down?”

The most challenging obstacle in the quest for quiet, however, appears to be not the machines but rather the approach to patient care in most American hospitals. Doctors, nurses and other members of the hospital staff often wake patients up in the middle of the night or during afternoon naps to assess a non-urgent blood pressure or temperature, draw blood or administer medications that could safely be delayed by a couple of hours.

“Everyone in the hospital tends to do things at their own convenience instead of working together as a team to figure out what might be best for the patient,” said Susan B. Frampton, president of Planetree, a nonprofit organization that works with health care providers and organizations to deliver more patient-centered care. “We forget what it is like to be a patient in this alien environment, at the mercy of people and their machines and agendas.”

To change this culture, some health care systems have initiated hospitalwide campaigns, with names like “Shhh” (Silent Hospitals Help Healing), “Hush” (Help Us Support Healing) or simply “Too Loud,” that institute mandatory quiet times, designate noise reduction teams to encourage compliance and use sound meters in the shape of traffic lights or human ears that turn green when the noise level is acceptable, yellow when it increases, and red when it goes above the acceptable range.

With the support of Planetree, one hospital system, the Department of Veterans Affairs New Jersey Health Care System, has gone beyond minimizing noise and actively elicits suggestions from patients on how the hospital can help them sleep better. When admitted to the hospital, all patients are asked about their sleep patterns, then given a laminated “sleep menu” card from which they can choose a variety of sleep aids, like light-blocking masks, sound machines, warmed blankets and aromatherapy. The patients’ sleep preferences are then posted in their rooms to alert staff members, and a nurse assesses their sleep experience each day.

While it is still too early to know whether any of these initiatives will prove successful, it is now clear that patient complaints about noise and lack of sleep are critical to quality of care. “Sleep is such a powerful source of resilience,” Dr. Buxton said. “Its absence results in a degradation of that resilience.”

“We need to change how we view noise and sleep,” he added. “We need to begin grouping sleep with all the other things we do to make patients better.”

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Uncompensated health care is a major issue for hospitals, with an estimated $39.3 billion of care going uncompensated in 2010. The size of this financial burden has forced hospitals to use more creative debt collections, such as asking for payment at time of service versus asking solely for insurance information.

Hospital debt has lead to the development of companies like Accretive Health. Accretive Health states on it’s website, “Accretive Health increases access to care by bringing increased discipline to the revenue cycle.” Non-profit health care organizations would all agree that a positive revenue cycle allows them to fulfill their missions. But how they collect “bad debt” has become the challenge and the legal question.

For many, the hospital is seen as a “sanctuary to treat the sick and infirm” as stated in a report by Minnesota’s Attorney General, Lori Swanson. Swanson has been working to push the issue of debt collection in health care to the forefront, forcing us to wonder what can and should hospitals be doing to address bad debt with the hope of remaining financially stable. It’s important to keep the doors open, but how to best do this?

An ill patient who is asked about payment before care is given may understand or hear the question, “how would you like to pay for your care today” very differently then a patient asked the question after care is provided. And a patient who is able to hand the hospital staff member a health insurance card is likely to have a different level of stress then one who does not have this option.

Nurses, who do not routinely have knowledge of patients’ insurance coverage or ability to pay, need to be aware of the practices being used by their employers to decrease bad debt. As the first health care professional the patient is likely to encounter after completing registration or checking in, nurses are in a key position to reassure patients that the quality of the care they will receive is not based on their ability to pay.

The nurse does this by showing the patient respect and dignity; answering questions about cost and billing honestly; and seeking help from any internal resources available in the organization, such as Social Services, a financial counselor, or a pharmacist. The nurse can also act as a patient advocate in relationship to treatment plans. The selection of a less-expensive dressing or stoma pouch versus selecting the clinic or hospital standard could mean dollar savings for a patient, with no decrease in quality.

Nursing as a profession has the responsibility to understand both sides of the bad debt issue. Advocating for patients to receive quality care regardless of ability to pay is important. However, nurses will fail patients if this is their only involvement. Nurses also can be active in quality improvement and resource projects directed at reducing cost and length of stay for patients. These are the actions that will provide our national health care with sustainable choices by addressing the cost of health care for all patients.

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In this article on Canada.com, a professor of nursing named Laurie Gottleib examines the role that nurses have in educating doctors.

She points to the combination of theoretical and practical knowledge that nurses possess, as well as their tendency to be much more accessible than senior doctors. Nurses frequently point out the warning signs of a patient’s deterioration to medical interns and residents, correct their misinterpretations of signs and symptoms, suggest diagnoses, and anticipate when and how to intervene. In this recent post about the “July Effect,” for example, a nurse recounts how she had to convince a new young doctor that his patient was in dire need of more pain medication.

Gottleib says that physicians are often grateful for this sort of guidance, yet nurses are not usually given credit for their role in doctors’ education.

Knowledgeable nurses protect the system in countless ways, not least by ensuring that physicians have the most up-to-date and salient information about their patients so they can make medical judgments and take appropriate action.

They are people who have committed themselves to nursing as a career and have selected workplaces that value nursing. Experience working in one place or with one group of patients is required to develop expertise and intuitive know-how – a key to reading the signs correctly and predicting which patients are in trouble.

Two decades of research have exposed the deleterious effects of devaluing and undermining nurses and nursing. The cost has been high in terms of nurse burnout and patient morbidity and mortality.

Research has also revealed the conditions needed to retain professional nurses. When nurses are recognized and respected for their expertise and given status, resources and opportunities to function autonomously within their scope of practice, they stay in the profession. The most intriguing finding in this research is that the most consistent predictor of nurse satisfaction and good personal health (i.e. a low burnout rate) is positive professional relationships with doctors. When doctors partner with nurses and there is clear communication between them, patients’ needs are met.

Within the McGill university and hospital network these lessons have been heeded. For example, there has been ongoing dialogue within McGill’s Faculty of Medicine and School of Nursing about how to improve inter-professional education. (This discussion extends to physical and occupational therapists and speech therapists.) At the Jewish General Hospital, nurse-physician partnership is the organization’s managerial structure in all matters of patient care.

These are important beginning steps for restoring the health-care system and a healthy nursing workforce. We are still recovering from the effects of the recent past, when Quebec’s nursing operations were dismantled and the nursing workforce was left not adequately prepared for today’s health-care challenges.

In the next decade we need to continue to build a workforce of front-line nurses who are well educated, knowledgeable, skilled, compassionate and committed to nursing as a career. Quebec nurses took this step themselves when they voted at this year’s meeting of the Ordre des infirmières et infirmiers du Québec to make university education a basic requirement for entry into the profession.

Employers need to continue to create workplaces where nurses are given support to practise to the full extent of their training, and where physician-nurse partnership is the governance structure. Physicians need to treat nurses as respected and valued partners, not as subordinates. Nurses need to embrace these new opportunities and become accountable for their practice. And governments need to dedicate resources to support innovative nursing roles that complement those of doctors and other health professionals to meet the complex needs of patients and their families.

When this happens, the health-care system will be transformed and quality, safe patient-and family-focused care will follow.

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The Supreme Court has upheld almost all of the Affordable Care Act, a fact applauded by many nurses. It’s a complicated law, though, and many people are not completely sure what’s in it.

NPR solicited questions from their audience online and on air and received many questions, and then went ahead and answered those health care questions in this article.

Many of the questions have a short answer and a long answer — which is part of why there is so much confusion. For example, when someone asked about whether the penalty for not having health insurance affects people at all income levels, or whether low-income people will be spared, a simple yes or no answer doesn’t quite suffice. Basically, if you can’t afford insurance, you don’t have to buy it. That means (using 2010 numbers) $9,350/ year for an individual, or $18,700 for a married couple.

What if you make more than that, but you still are struggling financially? ($19,000 a year still doesn’t go very far.) Under the ACA, you can’t pay more than 8% of your household’s income for health insurance, after whatever help you might qualify for from your employer or government subsidies.

Some other questions and answers:

Q: I understand that businesses above a certain size have to provide a health care insurance option, but do they have to pay for it? Does the law require a certain contribution from the employer, or can the employer make the employees just pay, say, 99 percent of the premiums?

A: This is where the law seems a little bit tricky. It doesn’t stipulate how much of the premiums employers have to pay, but it does say that overall, employers with more than 50 workers have to provide a plan that covers 60 percent of the covered expenses for a typical population. And that plan can’t cost more than 9.5 percent of family income.

Q: How does the law affect Medicare recipients? I heard it cuts billions of dollars from the program. Does it have other effects?

A: Let’s take these one at a time. Yes, the law does reduce Medicare spending by roughly $500 billion less than it would have been without the law. That’s over 10 years, by the way, and Medicare will cost a little under $500 billion this year. But none of that comes out of benefits guaranteed under the law.

The biggest single chunk comes from reducing what had been overpayments to private HMOs and other health plans that serve about 20 percent of Medicare patients.

The next biggest chunk comes from hospitals and other providers of health care that hope to get that money back because more people will have insurance.

As to other changes to Medicare, there are actually some new benefits. The doughnut hole, that gap in coverage for prescription drugs, is being gradually closed. And Medicare patients are now getting new preventive screenings, like mammograms, without having to pay a deductible.

Q: My son lives overseas, where he is covered by the national health insurance plan. As an American citizen, would he be required to pay the fee for not being covered under an American plan?

A: No, only residents of the U.S. and its territories are subject to the insurance requirements.

Q: I am a veteran getting my medical care from Veterans Affairs. Am I correct that this counts as having insurance, when it comes to the requirement that everyone be covered or pay a penalty?

A: Yes, the VA counts. So does TRICARE and other military health plans. In fact, just about all government health care program, including Medicare and Medicaid, count as well. That’s why the Urban Institute estimates that come 2014, only about 7 million people out of the U.S. population of well over 300 million will have to either purchase insurance or be subject to paying the penalty.

Q: If my current insurance policy does not meet the minimum requirements in the Affordable Care Act, and my insurer must raise the standards of my policy, can my insurer raise the premiums I pay?

A: In a word, yes. That was part of the goal of the law, not just to get people without insurance to have it, but to get people with what was considered substandard insurance up to par. This is controversial, and it’s the part that leads to claims that the government is interfering in the private insurance market, which in this case it is. But it’s in the law because Congress heard about lots and lots and lots of cases where people who had insurance nevertheless ended up bankrupt because the insurance didn’t cover what they thought it did. So will this make healthy people who have to spend more unhappy? Yes. But will it protect people better when they do get sick? Yes, it will do that, too. And will the arguments about it continue? Yes, undoubtedly.