Observing care at Maimonides

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New MSc Global Health Policy blogger Sandra writes:

Over the New Year period I embarked on a great adventure doing a three-week nursing observational period at the famous Maimonides Medical Center in Brooklyn, NY. Part of my afternoons I spent at their very well-equipped Degenshein Memorial Library to study for my elective modules and work on the proposal for my MSc project report, but more than six hours a day I was following nurse managers, clinical nurse specialists, registered nurses, nurse practitioners and nurse preceptors (trainers) while I penned down noteworthy observations and made the best out of this learning experience.

Sandra's nurse tags

The first thing the Maimonides Department of Nursing Education requested me to do before I got to the U.S. was to ensure they brought in a nurse whose medical file was in order. This included a physical examination, immunity status testing, an influenza vaccination and even a tuberculin skin test. To my big surprise the latter was negative even if over the last decade I had spent considerable time in MDR wards, TB centers and even prisons as a Stop TB ambassador for the high burden countries of Eastern Europe and Central Asia!

Sign about nurses

patient detail notice

Sign warning that patient details should not be discussed in public areas

I choose to be mainly in the Oncology Department and the Cancer Center as my LSHTM project report topic is opioid pain relief in palliative care and I have experience as a palliative care nurse in Tbilisi, Georgia.

Use of controlled substances is well organized at Maimonides, partly thanks to well-targeted efforts to fight diversion and misuse in New York where drug users could go opioid-shopping from one hospital’s ER to the other without getting detected. Inside the hospital, use of opioids is all computerized and a drug disposal machine allows nurses to take only the analgesic for their patients and in the quantities and timeframe prescribed. If a vial has a higher dose, then a second person needs to be called into the drug storage room and witness how the nurse disposes of the excessive quantity in the sink.  As I learnt from the Pharmacy Department, concerns have been raised from an environmental health point of view about hospitals’ disposal of opioids residues in sinks and as we speak alternatives are being considered (e.g. drug absorption devices).

Of course I had heard of ‘meds’, ‘vials’, ‘feeds’ and ‘labs’ but during the so-called daily interdisciplinary round -to which an oncologist or medical doctor, a few residents, attending physicians, nurses, the nurse manager, case manager and firm director usually attend, my head started spinning of unusual abbreviations and it took me a few days to get used to their use:

  • I got the family to agree to DNI and DNR (do not intubate, do not resuscitate)
  • He is NPO so we need a PEG (nil per os/nothing passes orally, percutaneous endoscopic gastrostomic tube)
  • She is waiting on her PCA (patient-controlled analgesia pump)
  • Before DC, I will KVO her for the 24/7 (discharge, keep vein open, 24 hours home-care)

IMG_0314Concerning discharge, I was impressed by the ‘deconditioning’ option by which patients, before going home get the chance to gain strength and get physiotherapy for an in-patient period of 2 to 4 weeks.

Next to oncological (and non-oncological) patient care daily meetings there are also less frequent pain management-specific and bio-psychosocial rounds . At one such round staff learned to take the edge of emotions (your own and the patient’s) when called in the middle of the night…

What caught my attention within the wards was the very practical information chart hanging opposite each patient’s bedside, stating in big and clear letters the name of the nurse on duty, the goal of the day, the medications, the temperature (in Fahrenheit obviously) and next to the chart a cardboard clock with red hands that could be turned to indicate the last time that the patient had been turned in his or her bed.

The issue of pain is naturally one of the main concerns on the floor where I observed. Untreated pain makes hospital stays longer and more expensive. In a way pain can be considered as the fifth vital sign. We distinguish chronic and acute pain, the last being brief and subsiding and the first being persistent. The goal in pain management is relief for acute pain and prevention for chronic pain. There are three levels of pain medication: basal rate (automatic release), patient-control (PCA pump) and clinical dose according to need.

It is a challenge to measure pain levels in patients with dementia or low conscience levels. A pain specialist told me to be attentive to grimacing, moaning and dyspnea.

Nursing is a very well respected and remunerated occupation in the USA. Nurses work either day or night shifts, 13 days a month,  a little over 11 hours a day, get paid every week/2 weeks, receive 150% pay for overtime, get 25 days off and 3 paid conference days per year. Six weeks ahead they choose their working days for one month.

I am extremely impressed by the workload of the nurses and find them to be thorough, fast yet not hasty, and very compassionate indeed. The discussions I had with my American colleagues caring for oncological patients showed a deep and very updated knowledge and a genuine dedication and commitment. The nurse managers I have met are definitely the jewels to the crown, shining in efficiency and display of humanity and knowing exactly what kind of passionate and professional female and male staff they need to fit in their teams.

On the last day of my observational period the ‘Joint Commission’ was around. This very thoroughly proceeding audit team is visiting all floors and tries to identify areas for improvement. Management nor floor staff knows beforehand when exactly the Commission is coming until they get there at 8 am.  All staff get really busy (if they can be even more busy than usual) and make sure everything is fine and clear with dates on IV tags, refrigerator stock, premeds for wound care, pressure ulcers, narcotic books and even dust on top shelves! After almost a week, the Commission then suggests corrective action with dates of accomplishment and leaves for the next ‘client’ (as hospitals request this service themselves).

Sandra E. Roelofs (1968), Dutch born, BA in French and German languages (1991), married a Georgian lawyer who became politician in his home-country and served as President of Georgia between 2004-2013. As a first lady, Sandra was very much involved in charity and public health, especially policy-making and advocacy for infectious diseases and mother and child health care but also got trained as a medical nurse and worked in palliative care and a Tbilisi hospital’s delivery room. She returned back to academic life in 2012 as a distance learning student of MSc Global Health Policy at LSHTM and hopes to finish this year.

This is her first post for the University of London International Programmes student blog, but she has previously written for the LSHTM student blog.

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