Category Archives: Nursing

Behind Oklahoma’s nation-leading access-to-care problems

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

In February, the New England Journal of Medicine ranked Oklahoma as the worst when it came to access to medical care. With help from a California Endowment Health Journalism Fellowship, Tulsa World reporter Shannon Muchmore sifted through reams of data to emerge with a three-part series helping readers better understand the state’s unique health care delivery challenges.

Fans of data analysis and numbers will want to dive straight into the first installment. According to Muchmore, 66 of Oklahoma’s 77 counties contain “Health Professional Shortage Areas, which means “they don’t meet the national standard of one physician for every 3,500 people.” And those doctor-patient ratios aren’t improving.

The state is facing a severe shortage of doctors as the population ages. Adding to that, as many as 180,000 people are poised to receive insurance when provisions of federal health-care reform kick in 2 1/2 years from now.

What’s behind that shortage? Muchmore enumerates the key drivers.

Medical schools are not increasing their class sizes, residency slots are hard to come by, and doctors are choosing to locate in other states.

The last two factors go hand-in-hand, as doctors often practice where they have their residencies. Without a connection, they have little reason to locate in a rural area.

The state is not well-positioned to handle a further deterioration in its health-care system. Oklahoma consistently ranks among the worst states for obesity, diabetes, smoking, heart disease and overall health. It has the least improvement in the country in age-adjusted death rate since 1990.

In the second installment, she examines the link between disparities in access to medical care and disparities in life expectancy and other indicators throughout the state, with a special focus on Oklahoma’s most rural counties.

In the final piece, Muchmore looks at the future of health care provision in Oklahoma and the key role that physician extenders, such as nurse practitioners and physician assistants, are poised to play.

Keep an eye on the AHCJ website for an upcoming “How I did it” article from Muchmore in which she shares how she did the reporting on this project.

Navigators work to keep patients from falling through cracks

Pia Christensen

About Pia Christensen

Pia Christensen (@AHCJ_Pia) is the managing editor/online services for AHCJ. She manages the content and development of healthjournalism.org, coordinates AHCJ's social media efforts and edits and manages production of association guides, programs and newsletters.

Patient navigators – “like the air traffic controllers in health care” – captured the attention of Pamela Fayerman of the Vancouver Sun.

Fayerman explains that patient navigators are specially trained health care providers who help patients get access to care and services they need, serve as liaisons between patients and doctors and generally ensure patients don’t fall through the cracks of a complex health care system.

Fayerman’s five-day, multiplatform series on patient navigators was published last week and is a comprehensive look at this relatively new practice being applied to Canadian patients. She explores the roots of patient navigation in Harlem and goes on to document the evolution in Canada over the past decade.

In a story about one patient, Fayerman shows how the role of a navigator in getting efficient treatment, follow up and having a point of contact got the patient into the hospital for triple bypass surgery before she had a heart attack and sustained damage to her heart.

Other stories look at how navigators bring a culturally sensitive approach to treating members of the aboriginal community, as well as the unwillingness of Canadians to pay out of pocket for navigators, but:

In the U.S., where people are used to paying for health care, navigators are becoming more and more common – in both insured and non-insured settings and at for-profit and non-profit hospitals.

Fayerman, who used a $20,000 grant from the Canadian Institutes of Health Research, visited five provinces and 12 cities over eight months, interviewing nurse and other navigators, their patients and health system leaders. She explains why the series is important and how patients can be their own navigators.

Members’ investigations prompt bills in Wash.

Pia Christensen

About Pia Christensen

Pia Christensen (@AHCJ_Pia) is the managing editor/online services for AHCJ. She manages the content and development of healthjournalism.org, coordinates AHCJ's social media efforts and edits and manages production of association guides, programs and newsletters.

Three health-related bills moving through the Washington legislature came about as a result of articles reported by AHCJ members at The Seattle Times and InvestigateWest.

One bill is part of a “proposed overhaul of laws on long-term care of elderly adults” that was prompted by “Seniors for Sale,” a series by Seattle Times reporter and AHCJ member Mike Berens that detailed problems in the state’s adult family homes.

Another bill, unanimously approved by the state senate, will push a state agency to create standards on how to handle chemotherapy drugs. It was prompted by reporting from AHCJ member Carol Smith of InvestigateWest, a nonprofit journalism organization, that revealed that nurses who handle those drugs are exposed to health problems.

A related bill, intended to identify potential links between occupational exposures and cancer outcomes, also was unanimously approved by the senate. It would “require that a cancer patient’s occupation be reported to the registry, and that if the patient is retired, the patient’s primary occupation before retirement be reported,” InvestigateWest reports.

Alarm fatigue hurts patient care, overwhelms nurses

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

In the wake of several high-profile incidents, The Boston Globe‘s Liz Kowalczyk has assembled a thorough investigation of alarm fatigue in hospitals. Alarm fatigue, for the record, is the idea that the huge arsenal of patient monitors in any given hospital floor are going off so often that nurses become slower in their responses to the alarms. For example, in one 15-bed unit at Johns Hopkins, staff found that, on average, one critical alarm went off every 90 seconds throughout the day.

With the help of ECRI, Kowalczyk has managed to attach some numbers to the issue.

The Globe enlisted the ECRI Institute, a nonprofit health care research and consulting organization based in Pennsylvania, to help it analyze the Food and Drug Administration’s database of adverse events involving medical devices. The institute listed monitor alarms as the number-one health technology hazard for 2009. Its review found 216 deaths nationwide from 2005 to the middle of 2010 in which problems with monitor alarms occurred.

But ECRI, based on its work with hospitals, believes that the health care industry underreports these cases and that the number of deaths is far higher. It found 13 more cases in its own database, which it compiles from incident investigations on behalf of hospital clients and from its own voluntary reporting system.

Kowalczyk also looks at potential solutions to the problem and how some institutions are trying to make changes to eliminate alarm fatigue, including cutting back on unnecessary monitors and having monitor warnings appear on nurses’ pagers or cell phones.

To back up the numbers, Kowalcyzk got some telling quotes from frustrated nurses.

“Yes, this is real, and, yes, it’s getting worse,’’ said Carol Conley, chief nursing officer for Southcoast Health System, which includes Tobey Hospital. “We want to keep our patients safe and take advantage of all the technology. The unintended consequence is that we have a very over-stimulated environment.’’

“Everyone who walks in the door gets a monitor,’’ said Lisa Sawtelle, a nurse at Boston Medical Center. “We have 17 [types of] alarms that can go off at any time. They all have different pitches and different sounds. You hear alarms all the time. It becomes . . . background.’’

Kowalcyzk’s investigation points out that, while alarms do tend to go off when there’s a real problem, it appears that they do so at the expense of also going off when there isn’t.

Monitors can be so sensitive that alarms go off when patients sit up, turn over, or cough. Some studies have found more than 85 percent of alarms are false, meaning that the patient is not in any danger. Over time this can make nurses less and less likely to respond urgently to the sound.

For more specifics on device design issues, see the final subheading, titled “Looking for solutions.”

For a one year, the Joint Commission made routine alarm testing and training part of their accreditation requirements, but dropped the stipulation in 2004 when it felt the problem had been solved.

Other parts of the series:

NPR explores the right to at-home care for disabled patients

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

When it comes to summarizing the NPR news investigation “Home or Nursing Home,” you really can’t do much better than its tagline: “America’s empty promise to give the elderly and disabled a choice.”

The package is anchored by Joseph Shapiro’s wonderfully written profile of the family of a young woman who lives at home, despite the need for 24-hour intensive care. She’s 20, and Illinois Medicaid will stop covering her care as soon as she hits 21. Why?

It’s expensive to care for Olivia at home: nurses cost about $220,000 a year. Still, that’s less than half the cost of what the state counts as the alternative — having her live in a hospital. The Welters figure they’ve saved the state millions of dollars by keeping her at home.

But when she turns 21, the state changes how it measures cost. For an adult, the state says the alternative is no longer a hospital — it’s a less expensive nursing home.

At 21, Olivia and thousands like her around the country enter an uncomfortable gray area rife with lawsuits, acts of government and supreme court decisions. In fact, families like hers have lately been suing states – and winning. Shapiro explains how.

In 1999, the U.S. Supreme Court ruled, in Olmstead v. L.C., that under the ADA, people with disabilities often have the right to live in the community rather than in institutions. Since then, other federal laws and policies have said that states have an obligation to provide more home-based care. The new health reform law is filled with incentives for the states to spend more.

But federal law is contradictory. An older federal law, the 1965 law that created Medicaid and Medicare, says states have an obligation to provide nursing home care. Home care programs are still optional.

Also not to be missed: Shapiro’s profile of a patient advocate that doubles as a seamless history of how the system reached this point. A timeline and interactive graphic round out the package.