How Nurse & Nurse Assistant Staffing Impacts Quality & Safety: Part I-Bed Sores

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So often when working as an RN in a long term care facility I find myself feeling exasperated and discouraged about a gap between what my team tries to do and can do. Last night, after 12 hours of relentless stress, I came home exhausted and worried. I couldn’t sleep and at 4;30 am called the night supervisor to tell her I would not be able to work today. “It wouldn’t be safe”.  This gap between what we should do and can do in healthcare is felt by many of my colleagues and ultimately our patients. Yet, things are more complicated than meet the eye.

I believe that in the big picture of safer kinder care, there is room for long term meaningful change and this will happen as Patient Advocates and Nurses align in seeking it. This alignment requires open discussion and deeper understanding of what is involved in providing the safe patient care.  With that in mind, I want to share two insights that help shed light on the relationship between staffing and bedsores, aka pressure sores, aka decubitus ulcers.

Anyone who is unable to move around on their own accord is at risk for what we call “skin breakdown“.  Basically, there is too much pressure on one area and not enough blood flow.  The skin wears away, an ulcer forms and and becomes an open invitation to infection!  In all honesty, we may not be able to eliminate pressure ulcers, but we can minimize incidence and optimize treatment with two seemingly simple interventions; repositioning and optimal nutrition.

So what’s the big deal, how do these simple interventions get complicated in the real world?

Repositioning

  • Often requires two staff members to boost a patient up in bed and turn him/her.
  • The two staff members must be available at the same time in the same place.  This may mean waiting for someone to get back from their rest or lunch break or finish what they are doing for another patient.
  • If several patients on a unit require repositioning, then two staff have to be available at the same time every 2 hours for each of these patients.
  • The bed must be raised to height that prevents back injuries for staff, (and returned to lowest position afterwards to prevent patient injury).
  • If the staff start to reposition the patient, but s/he seems to be in pain, a nurse must be notified.
  • The nurse can assess the patient and provide PRN pain medication if ordered.  (PRN pain medication is often suggested by nurses, families etc and ordered by physicians and nurse practitioners to help minimize pain  There are all sorts of different medications and schedules that can be ordered).
  • If the nurse finds that the patient is suffering from pain she can go back to the med cart and follow the process for administering medication.  She may need to finish what she is doing for another patient, i.e.  administering medication, changing a dressing, reviewing a lab result or a multitude of other things.
  • If there is no PRN pain medication ordered then the nurse will have to contact the physician.  Once the physician orders medication or possibly other testing, the nurse must transcribe the order and actually obtain the medication.  This may be as simple as using a stock medication such as tylenol that is readily available or as complicated as getting a prescription for a controlled substance such as Morphine.  This can involve multiple phone calls to physician & pharmacy, faxes, documentation and reviewing the patient’s chart.  We may have to wait for call backs or be put on hold.
  • If the patient has been incontinent of feces or urine, then they must be cleaned first.  This will require getting towels, linen and bathing supplies.
  • If the supplies are available they may be obtained fairly quickly, but if not a phone call to laundry or trek to supply closet may be necessary.
  • Any of these steps may be interrupted by an alarm warning that an unsteady patient is getting out of bed, or an IV pump isn’t working, or a resident with dementia is trying to leave a locked ward.

Optimal Nutrition

  • Patients who are immobile often require feeding assistance and preparing them for a meal may often require repositioning.  Again, having enough staff available at the same time to boost a patient so they are sitting up in bed is part of preparing someone to eat.
  • Often healthy snacks such as nutritional milkshakes, juices,  or pudding are available from or provided by the dining/kitchen department.  Sometimes a patient will eat a vanilla one but not chocolate.  In this case a phonecall or trek to the kitchen may be necessary.
  • The patient may have food allergies, be on a special diet requiring their drink to be thickened in order to prevent choking or aspiration which can lead to pneumonia.  Nurses and nurses’ assistants must be attentive to each patient’s diet to ensure appropriate food and drink are provided.
  • The patient may have a poor appetite, poor fitting dentures, tooth or gum issues all of which will effect his/her interest in eating and each of these issues may require further nursing assessment, dietary consult, and communication with family, Speech Therapist and physician.
  • Some patients will eat, but very slowly.  The staff must make sure that patients have enough time to chew and swallow food.
  • Sometimes patients may be in the bathroom when their meal arrives and it will be cold and unappealing. Usually, a microwave is available.  A simple task to heat up food will be more involved if someone else is using the microwave and/or several patients require heating food at the same time.
  • A patient who is having problems w/ nausea and vomiting may be more likely to eat or drink if they receive medication prior to meals.  As in PRN pain medication above, this may involve nursing assessment, communication w/ the healthcare team, obtaining and administering medications and documentation.
  • Sometimes patients do better eating when they have specific kinds of eating utensils, cups and plates.  Assessment may involve Occupational Therapy Professionals, doctor’s orders, and availability of specialized plates, etc.
  • As with repositioning, any of these steps may be interrupted by an alarm warning that an unsteady patient is getting out of bed, or an IV pump isn’t working, or a resident with dementia is trying to leave a locked ward.

Having enough skilled nurse or nurse assistant’ hands available to facilitate repositioning and provide optimal nutrition will decrease waiting, help ensure supplies are available, minimize interruptions, and decrease a sense of “rushing” with all care. Outcomes will be better for patients and staff!

Learn more about what it is really like with this 12 min YouTube about interruptions:  watch?v=PGK9_CkhRNw

Patient advocates can offer to help w/ many of the above.  In addition, talk with a nurse or nursing assistant you know to learn more about the real world we practice in.  Nurses and assistants can share experiences, (without revealing any confidential information), with friends and families.

What do you think?

 

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