McCleary MRSA Prevention

Sending warm vibes from Florida….still standing up for Patient Safety.  Nurses, in the right numbers, keep patients safe.  Stand strong.
I am at the Institute of Healthcare Improvement National Forum in Florida. IHI is considered to be very progressive and effective with patient safety measures including Central line and other bundles. It is my understanding that EMMC uses the IHI CLABSI prevention bundle.
 Presenters came from all over the country and world to tell us about their effective approaches to very serious quality issues, medical errors and infections.   Amazing strides have been made in Patient Safety.  Many are touting their own facilities progress,  because so many have them have gone a full year without ONE SINGLE CLABSI!!   Others are reducing their HAI rates with effective and extensive IC programs including MRSA screening and Isolation and other HAI prevention methods.  Early detection Sepsis bundles are being used and are working in hospitals nationwide.  Sepsis is being detected earlier and more lives are being saved because the bundle use starts in the ER with early screening. The “bundle” includes  blood Lactate and Blood cultures…always done together.  They have pins that say “Got Lactate?” and the tubes for those two  blood tests are “bundled” together.  Simple strategies that make the bundle easy to use with consistency.  This is amazing news…encouraging news.  I am thrilled…

These innovative and powerful approaches require a cultural change within facilities.  Safety must become the priority….the number one priority from the Board of Directors, to the CEO, to the CNO, to the COO, to middle management, to the physicians, pharmacists, Quality and IC departments and on down the line……YEP, all the way to the bedside nurse (I think you should be at the HEAD Of the line)   There is no “quality” without “safety”

Every single new, innovative, effective approach for safety and infection prevention  requires hands on, eyes on and ears on the PATIENTS and on the process. Every new bundle requires monitoring and nurses do that.  Safety approaches (bundles and infection prevention measures) require time….mostly direct bedside nursing care time.  Every patient deserves the safest best care every time. 
The chaos and fire snuffing caused by insufficient staffing is not acceptable…it never has been and never will be. 
Stand strong for your patients. Keep them safe.  And when you get past this grueling negotiation process and time allows,  promote and get yourselves onto patient safety committees to further your agenda for Patient Safety.
I wore my heart shaped MSNA pin stating that “Patients are my Special Interest” and I got tons of comments on it…people wanting to know where I got it.  You can all be sure I told them…in detail…where I got it and about your fight for Safer Patient Care.
My body is in FL but my heart is with the MSNA nurses…….

The study results released today by the Office of the Inspector General of the DHHS about Medicare patients is very disturbing.  ONE IN SEVEN medicare hospital inpatients suffered harm because of medical error/or infection.  This is huge. It is unacceptable and it is a big secret from most unsuspecting patients being admitted to the hospital.  Although half of our States have mandated reporting for medical error, not even all of those accurately report medical errors/hospital acquired infections.

How do we change this?  First of all we make them report it.  Mandatory public reporting of medical error and hospital acquired infections is a must.  Without transparency and accountability, there will be no change.   Mistakes and deadly infections will continue to be swept under that dirty rug and paltry investments in prevention will continue.  Second, we support improved staffing at our local facilities.  Safe staffing equals safer patients.  Third, we pressure our legislators to support any and all Safe Patient legislation, including prevention legislation,reporting legislation, patients rights legislation and informed consent legislation.

At the  recent Consumers Union Safe Project summit,  ad campaigns to educate people who are entering the hospital were discussed.  Having blind trust in our hospitals and doctors and other caregivers is a very naive way to conduct one’s self when hospitalized.  Educate yourself about your condition and help others who cannot do that for themselves. Ask if the surgery/treatment/medications are necessary and if there are alternatives.  Get second opinions.  Check out your Doctor’s history and experience.  Ask for your hospitals record on medical error and infections.  Finally take a patient advocate with you.  If you will be impaired physically and/or mentally because of your surgery or medical condition, ask a trusted loved one or friend to be your advocate. Don’t sign your consent for treatment or surgical procedure until you are perfectly clear on all the risks, including infections. Carry a journal for yourself or your advocate to use to document who visited you in the hospital and for what reason, list your medications, etc.  And make sure all of your caregivers, and visitors are washing their hands before touching you.

Don’t count on your hospital to do it all for you….as much as you would like that.  Take a stand for yourself or your loved one. Be prepared and educated.  You will be safer because of it.

http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf

Last week, I attended my first CU Safe Patient Project Summit.  Besides the incredible CU staff, about 30 grassroots activists and patient advocates from all over the US attended.  There were the “old timers” and some new faces too.  In that group is the most incredible pool of experiences and knowledge I have ever known.  Our knowledge and wisdom is not really anything we have sought out. This is not a club that people clamor to be part of.  Each of us has had a tragedy in our lives, a loss, a horror that hurts every time we talk about it.  Either we have lost a loved one or some have suffered themselves because of medical error or hospital acquired infection.  Amongst us are mothers, fathers, sisters, brothers, daughters and sons,  of people who have died or become severely disabled because of  a failure in our healthcare system.  We have a beautiful member who is still suffering and who will this month, have her first day in 4 years without a hole in her gut from flesh eating infection contracted in a hospital.  We have another who was rendered blind during surgery.  These are unspeakable tragedies, and yet we all share this common thread.  We talk to each other about our pain and loss, we cry, and then we haul out the BIG GUNS.

Each of us have done incredible things in our own states and communities to make a difference for others.  None of us want these horrible things to happen to anyone else in our families or our communities.  So, we have taken it upon ourselves to stop the horror.  We have taken on our State hospital and medical associations, our hospitals, our legislators, and others in power to change the broken system that has killed or maimed us or our loves ones.  We don’t know the word “failure”.  It is not an option because it means more will suffer. The healthcare system has already failed, so it’s nothing we will accept.

These meetings are heartbreaking, enlightening, validating. stimulating, educational, and most of all necessary.  We compare notes, share successes, and strategize for future work.  We compile our work and our personal “best practices” and take them home to help us succeed in our next steps toward healthcare safety improvements.

CU gets it.  They know exactly what they are doing by bringing us all together.  Our work, as individuals and as a union will get noticed.  We, with the help of CU, are moving or busting up the big  boulders in our way. We are a movement that will not be ignored or stopped.

Thank you CU for drawing me into this movement.

This is the Bangor Daily news story about a very brave and determined woman.  She felt that a grave injustice was done to her when she sought care at EMMC in 2007.  She had abdominal cramping and was 16 weeks pregnant.  Her hometown hospital has no OB/GYN service or doctor.  So she travelled the 70 miles to EMMC for care.  They examined her, determined that her baby was dead and sent her home.  Please read the three stories that the BDN wrote regarding this womans case. 

It is my opinion that this brave woman may have made a statement to Maine and US hospitals that even if they have a policy that protects THEM if they discharge a miscarrying woman, it isn’t the right thing to do.  I believe she may have set a precident with her determination to reveal the injustice done to her.

http://www.bangordailynews.com/story/bdn/Jury-deliberates-Morin-miscarriage-case,156701

http://www.bangordailynews.com/story/Statewide/Woman-ends-testimony-in-stillborn-fetus-case-in-Bangor-court,156563

http://new.bangordailynews.com/2010/10/19/news/bangor/woman-sues-emmc-over-stillbirth-at-home/

I was surprised to read that the Vinal Haven,  Maine  MRSA outbreak continues.  It was declared by the previous Maine Public Health director that the outbreak was controlled last fall.

When I spoke to one of the Island’s MRSA victims, he told me that it had spread into at least one young family last fall.  He also stated that in his opinion that the outbreak originated in the mainland hospital rather than on lobster boats.  It then spread amoungst the lobster men on lobster boats.  I cannot confirm this, but since 85% of MRSA is Health care associated, I do not doubt him.

Aggressive MRSA education for the public and for Health care providers is necessary.  Also, aggressive screening, isolation and other preventative measures in our hospitals and all health care settings are necessary if we are ever going beat this horrible infection.

http://www.bangordailynews.com/story/Midcoast/MRSA-infections-persist-on-Vinalhaven,155268

On September 28, 2010, my colleague Lori Nurbonne had her first official Board of Directors meeting for the NHPV.  This is Lori’s new non profit organization.  Her goals are ambitious and excellent.  She hopes to help patients of NH hospital become safer and infection free.  She will do this by advocating for them, collecting their stories, proposing legislation for patient safety and working with her board, her family and friends, victims and with the Consumers Union to promote higher quality, safer care for all NH residents. 

Her quest was started after her own mother died of avoidable medical errors and infections.  Unfortunately, this has happened to most of us who do the same kind of work.  Our loved ones have suffered and sometimes died because the hospital they were in failed to diagnose, treat, or prevent error or infection.

Lori is an intellegent, inquisitive, savvy advocate.  She will undoubtedly accomplish everything she sets out to do.  I am proud to be on her Board and I wish her the best of luck in her endeavors.

In this photo are Lori Nurbonne and her husband and board member Bob Nurbonne.

When I read my invitation to the recent (September 23 and 24) US Department of Health and Human Services meeting regarding HAI prevention , it stated this was a meeting of “experts” to discuss progress in reducing Hospital Acquired Infections.   Websters online dictionary definition of expert  is “ one with the special skill or knowledge representing mastery of a particular subject “.  I seriously wondered if I would be out of my element at this meeting.

Other experts there were doctors from Medical schools, hospitals, and the CDC, epidemiologists, hospital representatives of all professions,, nurses, respiratory therapists, representatives from CMS (Centers for Medicare/Medicaid, SHEA, APIC and so many others.  How did I fit in?

The Consumers Union Safe Patient Project invited me as part of their ‘team’.   Each of us in our group of 12 (out of 160 DHHS event attendees) has a personal experience with Hospital acquired infection or medical error.  We have all taken on the task of making improvements and reducing risk to medical consumers in our own States and/or country.  We sat at tables with all of the experts at the event and most of us had equal opportunity to speak our minds.  WE ARE EXPERTS!  I soon realized this.  Not only are we experts, we are a group of well prepared, educated, aware and in touch advocates for all Medical Consumers.  All of us have stayed by the bedside of a loved one while they suffered because of HAI or medical error, and some of us saw them die of HAI.   One of our members had an infection herself and is still suffering the long term disability, pain, surgeries and loss caused by it.  We saw the underbelly of the hospitals.  We witnessed inadequate infection precautions and isolation.  We saw our loved ones go from being  independent to becoming totally dependent upon the care the hospital provided, inadequate or not.  We watched the rapid decline of our loved ones’ health status and felt the helplessness and eventually hopelessness of the situation.  We saw how caregivers avoided eye contact and conversations because of their guilt, shame and sometimes ignorance.  We saw lack of disclosure of the full facts about the infections and descrimination against our loved ones because of the infection the hospital gave them.  Above all, we saw the real raw suffering and we suffered too.

 Not all of what we had to say was welcomed in these meetings, but every bit of it needs to be said, repeatedly if necessary.   In the talk of data, numerators and denominators, data mining, process measures, prevention, technical and physical science, improvement or lack of improvement, remaining goals and work, cost, barriers to success, standardization of recommendations, etc etc etc, the suffering because of HAIs is almost never brought up. Also, the urgency of the problem in very rarely mentioned.

 My CU colleagues and I bring the talks back to the PATIENTS and VICTIMS during these discussions.  We make them remember our loved ones and ourselves, and the suffering and grief HAIs have brought to us.  We all do it with intelligence, compassion, and eloquence.  We are EXPERTS about what HAIs do to trusting vulnerable patients and we will continue to remind the other experts about why they do their work.

Zero HAIs is the only goal to set for these horrible infections.  And 100% compliance on preventative bundles, handwashing and other preventative measures is the only level of compliance we will accept. 

Thanks again to the CU for bringing me into this Union of Experts.

http://hc4.me/quality

This is the new webpage for Maine Peoples Alliance where Mainers can tell about their healthcare experiences.  My story about my father, who died of hospital acquired MRSA pneumonia is the lead story for this new blog webpage.  Please visit and comment.  Hopefully, this opportunity for Mainers to tell their Healthcare stories will shed light on the problem of medical error and hospital infections in Maine.

Thank you.

A local guest editor, Dr Eric Steele, Bangor, ME, writes about transparency regarding Medical Errors in today’s Bangor Daily news.  This link tells the story of an unfortunate man who lost his life in a small Maine Hospital because of a huge overdose of Epinephrine.  Dr Steele, while recognizing the tragedy of the mans death, also applauds the hospital because they accepted the responsibility of this error ,made changes to correct the problem and apologized to the family.

If only this same thing could be done for the thousands of people who die each hear from Hospital Acquired Infections.  Many things are being done, but the most important one for MRSA is not being done as practice in the State of Maine.  Active Detection and Isolation is a proven method of prevention for MRSA.  Mandatory public reporting as also been successful in making hospitals accountable and transparent about these infections, and yet the Maine Hospital Association and Epidemiologists and other representatives from all Maine hopsitals have rejected and fought both of these measures.

I hope that Dr Steele is as serious about HAIs as he is about other Medical Errors. 

http://www.bangordailynews.com/detail/147267.html?comment_result=posted#comments-post

I was recently invited to attend the first ever Conversation between the CDC and the Consumers Union.   I have affiliated myself with the CU and other powerful selfless MRSA prevention advocates during the past few years.  There isn’t much that these activists don’t know about the fight for better MRSA Prevention.

Under our new administration, and the leadership of Secretary Kathleen Sebelius, the CDC is becoming more consumer friendly.   The conversation we had two days ago was held between us (activists with the CU) and many high officials at the CDC who specialize in HAI prevention including MRSA prevention.   I was humbled by their expertise, but at the same time I was not intimidated by it.  20 years ago, I would never have expected that I …….an employee health nurse in my local medical center, who used the CDC recommendations as my bible and the Federal Registar as my mandates,  would ever be sitting where I was,  expressing my frustrations at the snail’s pace of enacting ADI for all US hospitals.

Active detection and Isolation has most recently been proven effective in our over 150 VA hospitals nationwide.  The Study was revealed at the HICPAC meeting, which I unfortunately missed most of.  The Study revealed incredible reductions of hospital acquired MRSA after using ADI in a 2 year study.  The study was a collaborative between the CDC and the VA.  Over 200 other studies prove that ADI works to stop MRSA.

All of us were asked at the end of an enlightening and exciting meeting what our feelings were about the meeting.   I told them about calling the CDC once in 1992 when I was an Employee Health Nurse at Eastern Maine Medical Center.  My project during that period of time in the early 90s was to do 2 stage TB tests on every EMMC employee.  It amounted to between 4000 and 5000 PPD or TB tests.  There was some discussion and disagreement on what exactly a positive TB test looked and felt like, so I called the CDC experts.  I remembered how daunting and intimidating that call was for me.  Never in my wildest dreams did I expect to be sitting in a conference room, having a “conversation” with top ranking CDC physicians and others,  and confidently and repeatedly expressing my personal and profession opinion on MRSA control.  The experience was humbling  and I was honored to be part of this meeting.  And, I was very grateful to be included by the CU.

I hope to return to the CDC.  I have all of my newly found passion, my research and my heartfelt sympathy and sorrow for victims and survivors of victims of MRSA.  I am not a top scientist at the CDC, but I am an expert on the human suffering that comes with deadly MRSA.  I watched what it did to my father and I have listened to the numerous stories of others or their loved ones.  This is an epidemic that must be stopped.  It is not going away, unless we take a strong stand and push it away.  It was wonderful to hear the CDC officials saying that ELIMINATION is their goal.

  There is also fear amongst nurses and other health care workers that if they are ever diagnosed as being MRSA colonized, they will lose their jobs.  This is not right or fair and needs to be addressed.   No nurse should accept the constant inadequacies of their hospitals resulting in unprotected exposures to MRSA.  Without ADI, delayed detection of colonization and infection will continue, exposures will be commonplace and outbreaks will not stop.

My sincerest thanks to the CDC for opening up this conversation, and I hope to return there soon. 

There is so much more to add to our new “Conversation”.