Visiting Hours Are NOT Over: Innovative Patient/Family Council Hospitals in Massachusetts

In my role as President of the Consumer Health Quality Council, I had the privilege of participating in a training session for Massachusetts hospitals yesterday on starting their patient/family advisory councils. These speakers mentioned specific improvements in partnering with patients that their councils have already inspired:

Susan Shaw of Children’s Hospital of Boston described many changes, e.g., the welcoming patient guide, the redesign of Family Sleep Space, and "Executive Family Walk Rounds," among others.

Karen Conley described how South Shore Hospital has greatly extended its visiting hours, focusing on the Emergency Department, Intensive Care Units (ICUs) and PACU. In the past, every evening the loudspeaker would intone, "Visiting Hours Are Now Over," forcing family members to leave their ill, scared, and vulnerable loved ones at their moment of greatest need. After this announcement was eliminated, the number of formal grievances fell by 94% from one year to the next! South Shore Hospital began using family-initiated rapid response teams in June (I hope to report more on this soon) and has several other very exciting ideas in development from its council.

At my visit a few weeks ago to the pediatric family advisory council of Dana Farber Cancer Institute, Maureen Connor's team mentioned that parents had asked for and received a washer and dryer on the kids' floor so that the parents themselves could help keep their kids' bedding and clothes clean.

BRAVO TO THESE PIONEERING HOSPITALS! It's worth noting that none of these ideas costs hospitals much, if any, money, and yet mean a lot to patients and their families. I hope patients will tell their primary care providers and friends about these practices, so more patients get their care at those patient-friendly hospitals.

At the Consumer Health Quality Council of Health Care for All, we're asking Massachusetts hospitals to send us their plans as they complete them by the end of the month, so we can learn about and publicize more of the innovative ways that hospitals are becoming more patient-friendly.

Advice to patient advocates: Steer your clients to hospitals with productive and imaginative Patient/Family Advisory Councils.

Read our Council's testimony on the new Chapter 305 law that mandates these patient/family advisory councils. Thanks to Paula Griswold and Effie Brickman of the Massachusetts Coalition for the Prevention of Medical Errors, and Tracy Gay of the Betsy Lehman Center, for organizing the series of conference calls as training sessions. Thanks to Marlene Fondrick of the Institute for Family-Centered Care for sharing IFFC's knowledge and resources in the calls. Thanks for the legwork by Linda Burgess, Nicola Truppin, Deb Wachenheim, and Alec Ziss of the Consumer Health Quality Council's work group on Patient/Family Advisory Councils.

For all of them on this Jewish New Year, may they be written in the Book of Life.

Intervening before there’s drama: Rapid Response Teams

"A trigger [for a rapid response team] is not about excitement and drama; it's about intervening before there's drama," said Jeanne Quinn, a senior nurse on a unit for post-surgery and trauma patients. Minutes earlier, Judy Wagoner, a 29-year-old nurse with 2.5 years experience, had activated a trigger when her patient's blood pressure plunged to 56.

As the senior nurse on the floor, Jeanne responded and helped Judy gradually raise Carol Emerson's pressure back into the 100s. The team ordered an electrocardiogram to rule out underlying heart problems and a blood transfusion, and kept the patient an extra night. About 80% of the nurses on the floor have less than two years of experience, while Jeanne has 15.

No one knows for sure if early intervention helped Carol, who was in the hospital so surgeons could repair broken bones in her left arm, avoid cardiac arrest. And Judy said she would have asked for Jeanne's help even before the new rules.

But doctors believe the key to reducing patient mortality is to intervene at the first sign of trouble, before the patient "[cardiac] arrests," an emergency where the heart or lungs — or both— shut down.

Dr. Michael Howell, an intensive care specialist, hopes the Rapid Response team will prevent delays like one he described a few years ago to the Beth Israel Deaconess board of directors: Doctors admitted an elderly man to the hospital for gastric bleeding. When his systolic blood pressure dipped into the 80s, his nurse and an intern gave him intravenous fluids to push it back up to normal range. His pressure climbed back into normal range. Over the next eight hours, his blood pressure kept falling, and they kept pumping in fluids. Low blood pressure is generally not life threatening until it dips into the 70s or 60s. But they failed to recognize that the subtler decline masked a more serious underlying problem: massive stomach bleeding. The next morning, a senior doctor did, and transferred the patient to the ICU, which has the staffing expertise and equipment to intervene more rapidly. But it was too late.

"I don't know that we would have saved him," Dr. Howell said. "But it's absolutely possible."

Advice to family members of hospitalized patients: Find out how the hospital activates a rapid response team.

Read about Massachusetts legislation enabling family members to activate rapid response methods in hospitals.

Thanks to Liz Kowalczyk for the source story in the Boston Globe of Nov. 27, 2005.

He'd sailed through heart surgery: Failure to rescue

Six-year-old Christian Padilla of Fort Wayne, Indiana had sailed through a successful heart surgery to correct a birth defect in 2005, only to die days later from the preventable complications that characterize a failure to rescue case.

"The nurse didn't recognize his symptoms as something of concern," said the boy's father, Jim Padilla, 38, an assistant professor at a local university. "She described him in her medical notes as 'acting fidgety.'"

In reality, Christian was unconscious and suffering seizures as a result of the brain swelling that killed him, said his father, who received a $1.25 million combined settlement from the Indiana Patient's Compensation Fund and the hospital, according to the Indiana Department of Insurance.

It's not clear whether a drug reaction or another problem caused the swelling, said Padilla, who was at his son's side, frantic, throughout the ordeal.

"We got to the point where I had asked multiple times: 'Should he be sleeping so long?'" he said. "Over and over, I was told this was normal.'"

Such a failure to make a diagnosis in time, or to provide treatment in time, is called "failure to rescue."

The nurse's failure to notice Christian's subtle but increasing symptoms of distress is a key element of this measure of how well hospitals respond to unexpected complications — or don't, said Dr. Samantha Collier, chief medical officer for HealthGrades. "As an example, somebody comes in for an elective surgery like a knee replacement and turns up with vague symptoms, like shortness of breath, and the next thing you know, somebody dies," explained Dr. Collier. "It's obvious that if you go in for a knee surgery, you shouldn't die."

The term "failure to rescue" refers to cases where caregivers fail to notice or respond when a patient is dying of preventable complications in a hospital. Between 2004 and 2006, failure to rescue claimed more than 188,000 lives, amounting to about 128 deaths for every 1,000 patients at risk of complications, according to a report from HealthGrades, a health care ratings organization. That's more than any other measure found in the 2008 report, and indeed in five consecutive annual reports by Health Grade.

Advice to family members of a hospitalized relative: Insist that a Rapid Response Team help your relative if you see them declining rapidly in the hospital.

Thanks to JoNel Aleccia for the source story in MSNBC, and thanks to Helen Haskell.