case 2 - 448

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HCA 448 Case 2 for 10/04/2018

Recently, a patient was transferred to a cardiac intensive care unit (CICU) at Methodist Hospital.

Methodist is a 250-bed hospital, which is one of five hospitals in the University Health System.

The patient was a retired 72-year-old man, who recently (i.e., 25 days ago) had a mild heart

attack and was treated and released from a sister hospital, which is in the same system as

Methodist Hospital. An otherwise health individual, Mr. Charlie Johnson (a husband, father of 4,

and grandfather of 12) is in now need or lots of medication and a battery of tests. To the nurses

on shift, it appears that the entire Johnson family is in patient’s room watching the clinical staff

treated Mr. Johnson. The family overhears everything and they want to know what is being done

to (and for) their loved one. In addition, they want to know the meaning behind the various beeps

coming from the many machines attached to Mr. Johnson.

Over the past 10 years, the latest U.S. News and World report has ranked Methodist Hospital as

one of the Best Hospitals for Cardiology & Heart Surgery. However, it is important to note that

over the past few years, the unit has dropped in the rankings.

Katherine Ross RN, the patient care director of the CICU, which has 14 beds, has held this post

for two years. (See Figure) The unit has a $20 million budget. Ms. Ross has worked at Methodist

Hospital for 16 years. She spends 50 percent of her time on patient safety, 25 percent on staffing

and recruitment, and 20 percent with nurses in relation to their satisfaction with the work and

with families relative to their satisfaction with care. Ten percent of Ms. Ross’s time is spent on

administrative duties. According to Ms. Ross, “I like is working with exceptional nurses who are

very smart and do what it takes with limited resources. However, we don’t always feel

empowered, despite the existence of shared governance, a structure I help to coordinate.”

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Relationship with Nurses on the Unit:

Nurses on the unit work a three day a week, 12 hours a shift. Ms. Ross says, “we did an

employee opinion survey that went to all employees on the unit, 50 people in all, but only 13

responded. Some of them weren’t sure who their supervisor was. The employees aren’t happy

but our patients are happy.” She adds that “my name is on the unit, not the medical director’s. If

anything goes wrong with the unit, they blame it on nursing. Yet I’m brushed off by people

whom I have to deal with outside of the unit. For example, we have a problem with machines

that analyze blood gases. I spoke with the people there about the technology. This was four

weeks ago. It’s a patient safety issue. I sent them e-mails. I need the work to get done, the staff

don’t feel empowered if I’m not empowered. This goes for other departments as well. For

example, respiratory therapy starts using a new ventilator without informing us. We have never

seen this machine nor have we been trained on it. They don’t phone or e-mail. So I make the

decision that we’re not going to use the machine. With surgeons, when I tell them to wash their

hands, they roll their eyes. It takes tremendous energy to deal with this.”

Megan Smith, RN, age 25, is a clinical nurse in the CICU where she has worked for six months;

she has been at the hospital for nine months. Ms. Smith spends 40 percent of her time dealing

with patients (turning, suctioning, and changing dressings); 30 percent talking with physicians

(negotiating plans of care and medication plans); 20 percent on medication administration and

conversations with the pharmacy; and 10 percent on miscellaneous activities. She has worked on

the day shift for only three weeks now but was also on days for three months during orientation.

Ms. Smith says she is challenged to get the core services she needs. If she has to give a 2:00 PM

medication, she would like the medication by 1:00 PM but she gets it by 4:00 PM, even if she

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calls. Ms. Smith stated that she finds it difficult to discuss complex difficult cardiovascular terms

and process to patients’ families. She states that it is very hard to explain what happened and

what is going to happen. Ms. Smith stated that when she needs additional medical expertise, it is

hard to find the cardiac surgery consultant when she needs them and doesn’t have their pager

number. Ms. Smith’s main satisfaction comes from working with her patients.

Ms. Smith comments that Ms. Ross is “good about getting stuff if you ask her. She deals with a

lot. Ms. Ross goes around and talks with families, provides continuity, helps out when we’re

short. Lately she’s not been so stressed out and is more accessible. When we were short, Ms.

Ross and the unit secretary admits patients, helps with codes, and patient deaths. Ms. Ross gets

respect from the nurses, but she doesn’t trust us enough. For example she asks us why we were

sick and to bring a doctor’s note. Ms. Ross is spread thin. There is no assistant director, so the

unit secretary helps her. Ross took the job having had no management experience.

Relationships with Families:

Ms. Ross says, “I’m clear with them in orienting families to the unit, to how we do our job. We

treat families with respect. Families watch me, and mentoring of nurses is important. Ms. Smith

agrees that the unit generally does a good job supporting families. She says, “families are kind

and happy. There is a problem with turnover of doctors and residents, who aren’t here two days

in a row. The plan of care can get lost with the attending physicians, when they change every

week. Families get stressed out and are often far from home. I listen to them and ask, ‘do you

have any questions? ‘What do you want to see done?’ and ‘do you have any questions for the

doctors?’ I ask them if they want to participate in rounds. Sometimes we just listen. When

families can’t come in they can call me every two hours as we have an in-house phone that

accepts outside calls.

A survey of families in a California hospital about their experiences and their suggestions for

improving the quality of end-of-life care found that:

• Parents want to be involved in the decision-making process

• Isolated incidents are extremely painful (e.g., poor communication, feeling dismissed)

• Delivery of difficult news is an issue – families found it important that a familiar person deliver this news (one caregiver in charge)

• A language barrier is an issue – families felt isolated and under-informed

• Bereavement follow-up is helpful and appreciated

• Pain management is an issue – families describe anguish witnessing their loved one in pain.

• Families’ interactions with staff are as important as medical aspects of treatment

Ms. Ross and Ms. Smith feel that families are a very important part of what they do, that the unit

has special structures and processes to involve families, and that what they are doing is generally

working. But they lack concrete ways of measuring unit performance in this regard.

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Relationship with Social Work:

Ms. Ross says, “There is a social worker who deals with complex heart cases. However, the

service is fragmented and I have difficulty getting her to come to the unit. I will go to her

director or my director if I have to. I understand she has other responsibilities, but she need to

come to rounds, to deal with issues around getting nurses for home care. Of course, social

workers can’t wave a magic wand.”

Maria Montez, the unit social worker, has worked in the CICU for ten years. She spends 75

percent of her time on the floors with families. She works from 9:30 a.m. to 5:30 p.m. five days a

week. There is limited social work coverage at other hours. The kinds of issues Ms. Montez

deals with are: requests for a visiting nurse; medications and associated education; ordering

oxygen; ordering a special intervention team at home if there is a need to assess; and physical,

occupational, and speech therapy. If a patient is dying, she discusses with nursing what they can

do together when crises arises.

Ms. Montez says she has a good relationship with Ms. Ross, and that she orients with new nurses

to social work. Ms. Montez respects the work that nurses do. ”We’re invited to each other’s

rounds. The work is so intense, there are so many patients. We’ve reached a level understanding;

if there’s a problem it’s not personal, it’s what we’re all going through.

We discuss each of the 37 patients in the three CICUs once a week at an interdisciplinary

conference. Montez concludes that if I could advise the hospital administrator, I would tell him

or her to take care of your nurses.”

Last month, Katherine, Megan, and Maria had lunch in the cafeteria. They discussed what

“taking care of your nurses” really means from a hospital point of view. A summary of

highlights of their discussion follows:

Ms. Ross: I don’t know, why should taking care of nurses be any different from taking care of

any of the clinicians who are working under stress in the hospital? Oh, I’m sure the

hospital administrators would say we pay the nurses enough. I think the hospital should

do more to reward the patient care directors. None of us got into this business to do

management, and they aren’t really giving the tools to do what needs to get done for our

patients.

Ms. Montez: Staff is doing all we can for the patients and families, and we’re providing good

care. I think things are fine as they if we could be sure that we won’t be short staffed, and

if other departments would respond better to our requests to help our patients.

Ms. Smith: But Maria, don’t you agree that sometimes nurses get stressed out and that this isn’t

good for those nurses, the other nurses, the patients, the families, or the hospital? How do

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you determine what’s “stressed out”? Well, it automatically flows form the number of

patients, the complexity of the treatments, and the numbers of the staff and support staff.

Families can tell you when the nurses are no longer providing the services at the level or

quality they were providing before.

Ms. Ross: I wonder what more I can do as a manager to deal with this problem. I think our

regular nursing staff has a pretty good deal here, if you want to work with these patients.

And we’re provided generally with the support to take good care of these patients and

families. Nurses work three days on and four days off. Four days off is a lot of time to

recover from stress, I believe that after a number of months working in the unit, our

nurses should work with patients who are less acutely ill. But I’m not sure everybody

wants to do that.

Recently, the vice president of patient care services has been talking about the importance of

continuity of care and is investigating the concept of patient navigation. However, Ms. Ross, Ms.

Montez and the rest of the cardiology unit are not sure of the need for this position.