Thursday, June 1, 2017

Sepsis – So Deadly, So Under Recognized


I work with a US-based group, Sepsis Alliance (SA). It’s a patient advocacy group with a mission to raise sepsis awareness and save lives. While it’s an American organization, the situation in the US parallels that of Canada when it comes to sepsis recognition and management. According to a report issued by Stats Canada in 2011, one in every 18 deaths in Canada is due to sepsis—one out of every 18. In the US, it kills over a quarter of a million people every year. That is a lot of deaths. Why is this happening?

Sepsis isn’t always preventable, this is true, but early detection and treatment often prevents it from progressing to severe sepsis and septic shock. A couple of years ago, I saw how effective a sepsis protocol can be. A family member who had a stroke was diagnosed with endocarditis while in the ICU. He showed the classic signs of sepsis onset and the staff was all over it, preventing more complications. Research has shown that for every hour patients with severe sepsis aren’t treated, their chance of survival drops by 8%. Like stroke and myocardial infarctions, there is a “golden hour,” during which immediate treatment can mean the difference between life and death.

I’ve learned a lot about sepsis and its impact over the past seven years, working with SA. One of my tasks is to respond to emails from people who want to share their stories of sepsis, hoping to spread the word to spare someone else the same pain. The stories, which are published on the site, are heartbreaking: parents who lost children, children who lost parents or siblings, survivors who live with life-changing effects caused by sepsis. So many of these victims may not have been in that situation if they or someone else had recognized the signs and symptoms of the condition.

Jim O’Brien, MD, former medical director of SA, often says that we could—right now—cut the sepsis death rate in half even without new technology, new tests, or new medications, simply with early recognition and immediate treatment with antibiotics and fluids. But there lies the rub –sepsis has to be recognized in time for successful treatment. People need to know about it and how to recognize it.

According to annual surveys commissioned by SA, most people have never heard the word “sepsis,” and many of those who have, don’t know what it means. The medical community is partly responsible for this. We talk about people dying of complications of pneumonia, of urinary tract infections, or meningitis. But that’s not that they died of; they died from sepsis. If someone has cancer, develops an infection and dies, it’s not the cancer that killed, them, it’s sepsis. But we don’t say that.

In three months it will be September, Sepsis Awareness Month. Let's find ways to spread awareness, to educate people about this often fatal illness that no one knows about. If you'd like to learn how, SA has developed tool kits for the public, professionals, and the media: Sepsis Awareness Month.



Wednesday, April 12, 2017

Whistle Blower Nurse Fined by Her Own Professional Body

I have two questions for you:

If you see something wrong and this something is hurting or having a negative impact on people, is it not your duty to speak out about it?

Does it matter what your profession is if you do call it out?

The answer to the first question should be - in my opinion - yes, it is your duty. The answer to the second question seems to be a bit more complicated if you are a nurse and you live in Saskatchewan, Canada.

I remember reading about Carolyn Strom last year and I didn't think too much about the story because I figured that the story didn't have legs and that everything would work out. I was wrong.

Two years ago, Carolyn, an RN, wrote a post on her Facebook page about the quality of care her grandfather received in a long-term care facility, particularly at the end of his life when he was in palliative care. She criticized the care, but according to reports, she also offered solutions - being a nurse herself, she understood the issues associated with caring for patients in a long-term care environment. However, her professional body, the Saskatchewan Registered Nurses Association, charged her with professional misconduct and Carolyn was fined $26,000.

What is worrisome about this is that Carolyn was not acting as a nurse at the time, she was acting as a private citizen who was concerned about the lack of quality care not just for her grandfather, but other patients at this facility and similar ones. She was expressing her frustration and disappointment as anyone might. Except, she has an RN behind her name, which apparently means she's not allowed to express those thoughts.

According to the Globe and Mail, this is what Carolyn wrote:

“My grandfather spent a week in palliative care before he died and after hearing about his and my family’s experience there, it is evident that not everyone is ‘up to speed’ on how to approach end of life care or how to help maintain an aging senior’s dignity. 
“I challenge the people involved in decision making with that facility to please get all your staff a refresher on this topic and more. Don’t get me wrong, ‘some’ people have provided excellent care so I thank you so very much for your efforts, but to those who made Grandpa’s last years less than desirable, please do better next time.”
So, Carolyn was charge by the body's disciplinary committee with five breaches:

1- Not respecting patient confidentiality
2- Failure to follow proper channels in making a complaint
3- Making comments that have a negative impact on the reputation of staff and a facility
4- Failure to first obtain all the facts
5- Using her status of registered nurse for personal purposes

Here are my arguments:

1- When it is your family member, patient confidentiality doesn't work here. When my mother was dying last year, I could have written about it all I wanted as long as she had never expressly forbidden it. (This charge was dropped).

2- Should Carolyn have written a letter to the facility or gone higher? Yes, she should have. However, she could have done so and still posted on social media as a private citizen. Many of us have stories of letters of complaint we've written that were never addressed.

3- So, does this mean we can't bash United Airlines for the horrible video of a man being forcibly removed from his seat a few days ago? Because it would have a bad reputation on the staff and organization?

4- Can anyone ever obtain all the facts?

5- We all use our background, education, and "status" for personal purposes. It's who we are. Does this mean that I can never comment on anything health or medical related - because I'm a nurse? Why is her call out of her grandfather's care any different than a sibling who isn't a nurse might have been?

So, what is the message here? If you're a nurse and you see bad care, shut up. Don't tell anyone. Don't vent on social media. Don't criticize. If you do, you're guilty of professional misconduct.


You can read more about her story here on the CBC website.

And there is a GoFundMe page raising money to help Carolyn pay those ridiculous fines, if you feel so inclined to help her.

Tuesday, February 28, 2017

Your Failure to Plan Doesn’t Constitute an Emergency On My Part: Mandatory Overtime

 When we think of mandatory – or forced – overtime, our minds might go back to the day before labor unions, when people in factories were steadily working hour after hour, day after day, in unsafe and unpleasant conditions. But mandatory overtime is not a thing of the past for some nurses in Canada. It’s a reality.
No one argues that units must be staffed – there must be a certain number of nurses to maintain a safe level of patient care. But what happens when there is no staff to cover the next shift?
At first, supervisors usually ask for volunteers who would like to work overtime. But what does the hospital do when no nurse steps forward? If they can’t call for outside help (private agencies), their only option may be to pressure nurses into working another shift or, to bluntly tell nurses that they must stay. This is mandatory overtime, although they may not use those words.
While the administrators are solving their staffing problems, they are causing a whole host of problems for their nurses who need or want to go home – they may have daycare issues, classes to attend, senior relatives to care for, important appointments to keep, or they may need to get some much needed sleep.
If nurses refuse to work overtime, they may be threatened with “abandoning their patients.” However, according to the Canadian Federation of Nurses in their position statement on mandatory overtime, this is not true. The union says, ”It is important [to know] that refusing duty to care is not [to be] confused with client abandonment, which occurs when a nurse leaves before the end of a scheduled shift, or being unavailable during a scheduled shift for a period of time that compromises patient/resident/client care.” So, by saying that you can’t/won’t work an extra shift, you cannot be told you are abandoning your patients. But that is on paper. Our conscience may say otherwise.
Research has shown that tired workers make more mistakes. Tired workers have more accidents going home. They are unhappier overall, and their health may suffer over the long-term. In fact, a 2015 review study, published in the Lancet, looked at people who consistently worked more than the usual 40-hour workweek. The researchers found several studies that concluded that these workers are at a higher risk of stroke.
This problem must be addressed, particularly as patients who are in the hospital are sicker than they ever were before. They need more eyes on them, more procedures done with them, and more split second decisions made. Their nurses must be on the ball and refreshed, not tired and frustrated because they are at work against their will.
The union’s position paper goes on to say, “With the exception of disaster situations, or emergency circumstances (where the Code of Ethics outlines the duty to provide care), nurses unions feel that there are no circumstances whereby employers should mandate employees to work overtime. Mismanagement of human resources and chronic unfilled vacancies do not constitute emergency conditions or grounds for ordering mandatory overtime. Additionally, the right to refuse duty to care may also be applied during an emergency situation when ability to provide safe care is compromised by unreasonable expectations, lack of resources or ongoing threats to personal well-being.”
In other words, your failure to plan ahead of time doesn’t constitute an emergency on my part.

What do you think hospitals should do if there is no one available when a nurse’s shift is over?

Friday, February 24, 2017

Do You Take Your New Prescriptions Right Away?

I came across an interesting, but not unsurprising press release this morning. It seems that a study done in Spain found that over 15% of patients who received a new prescription did not get it filled. The study, which was published in the British Journal of Clinical Pharmacology, found that initial medication non-adherence, or non-compliance, was 17.6%.

The most common medication prescriptions not filled were for a certain type of pain reliever (22.6%) and the least common was for ACE inhibitors, usually used to manage high blood pressure, hypertension (7.4%).

Understanding why someone doesn't fill or take a new prescription is important and it can have a substantial impact on a person's health. Do they not fill the prescription because they don't agree with the diagnosis? Can they not afford the medication? Do they plan to do so later but then get too busy or forget? Did someone talk them out of it?

The researchers did find that the patients who were most likely not to fill their prescriptions were:

  • Younger adults, 
  • Americans (the study was done in Spain), 
  • Having a psychological or psychiatric disorder, 
  • Having a pain disorder, or
  • Receiving treatment by a substitute/resident GP in a teaching center.


"We are especially concerned about the high rates of initial medication non-adherence in chronic treatments such as insulins, statins, or antidepressants and suspect that it is also related to an increase in costs, so we are designing an intervention targeting high risk patients," said Dr. Maria Rubio-Valera, senior author of the British Journal of Clinical Pharmacology study.

So what can we do to about this? Patients must take control of the conversation, no matter how hard
it might be. Patients need to ask their doctors why they are prescribing medications. If they don't understand the responses, the patients need to push for clarity. And if the patients feel they won't or don't want to take their medications, they have to relay this to their doctors so alternative treatments can be discussed. It's not a good idea to let the doctor believe you are going to be compliant if you don't plan on it.

And how can healthcare professionals help? Nurses, for example, are often in a good position to question why patients aren't taking their medications and to explain why the medications are necessary. Many times patients will tell nurses things that they would never discuss with their doctor. And doctors need to be aware, or more aware, of why their patients may be reluctant to fill that prescription. Taking a few minutes to explain why it's important and to actually ask if there are any concerns regarding the medication, the treatment overall, or even the cost, could make a big difference.