It’s hard to explain what we do. And so maybe, it’s hard for others to sympathize with our situations. I mean, physicians, mid-levels, and nurses in emergency departments are tied to computers in often cramped work-spaces, even as they are required to be at the bedside almost constantly for the latest emergency or (in other cases) the latest bit of pseudo-emergency drama.
If you haven’t worked there, or haven’t for a long time, it could be that this lack of understanding is what leads hospital administrations to do one of the stupidest things imaginable. What is that thing? Banning food and drink from our work-spaces.
Now, this isn’t the case in my current job. But it is the case in all too many facilities. I talk to people. I hear things. And it’s usually justified with some unholy combination of infection control, Joint Commission and public health clap-trap, coalesced and refined, then circulated as a cruel policy.
When it’s enacted, clinical staff have their water bottles taken
away. Nobody is allowed to eat where they work. Dedicated, compassionate
staff members grow tired and dehydrated and hungry. (Maybe it’s a good
thing. They often don’t have time to urinate anyway, and water just
makes that happen more often.)
Mind you, the water bottles are sometimes kept in a nearby room, or on a nearby shelf. It’s an act of kindness, I guess. And the food? Well, all you have to do is take your break and go to the cafeteria or to the break room, right?
Those who come up with these rules don’t understand that a scheduled break is a great idea … that never happens. It’s an emergency department. It isn’t (technically) a production line; however, we try to impose time restrictions and through-put metrics. It isn’t “raw material in/product out.”
It’s “sick, suffering, dying, crazy human being in” and if all goes well, “somewhat better (at least no worse) human being evaluated, stabilized, saved, calmed, admitted, transferred, and sometimes pronounced dead” out of the other end of the line.
Those Herculean efforts can take anywhere from, oh, 20 minutes to 12 hours. During which time, it’s pretty hard to leave the critical patient in the understaffed department, with the “five minute to doctor” guarantee and the limitless capacity for new tragedy rolling through the door.
That setting makes it remarkably hard for breaks or even meals to happen at all.
As such, it’s nothing short of cruel and unusual for anyone to say to the staff of a modern emergency department, “you can’t have food or drink” — especially when it’s typically uttered by people who have food and drink in their offices and at their desks. People who have lunch meetings with nice meals or who have time to walk to the cafeteria or drive off-campus. And who feel so very good about protecting the staff from their deadly water bottles.
The argument, of course, is that the clinical staff work in a “patient care area.” Even when they aren’t at the bedside but are, for instance, behind a glass wall at a desk. If this is the case, then one could argue that the entire hospital (including administrative suites) is a “patient care area.”
They are afraid we’ll catch something. That it’s unsafe for us to eat or drink where we work. Of course, this is while we positively roll around in MRSA and breathe in the fine particulate sputum of septic pneumonia patients. This is while staff clean up infectious diarrhea and wear the same scrubs all day.
This is after we intubate poor immigrants who may well have tuberculosis and start central lines on HIV patients. This is after we wrestle with meth-addicts who have hepatitis C. And this concern for our “safety” occurs in places where physical security, actual security against potential violent attack, is a geriatric joke which is often tabled until the next budget cycle.
And as for our patients? Our food and drink are no danger to them. They and their families fill the exam rooms with the aroma of fried chicken, fries, and burgers, eaten at the bedside (often by the patient with abdominal pain). Their infants drag pacifiers across floors that would make an infectious disease specialist wake from bacterial nightmares in a sweat-soaked panic. In short, our food or drink are no threat to them and no threat to us.
But the absence of food and drink? That’s a problem. Because the ED is an endless maelstrom of uncontrollable events and tragedies, of things beyond our control for which we are responsible. It is a place of physical, emotional, and spiritual exhaustion where we rise to the challenge and manage (against the odds) to do so much remarkable good by virtue of our knowledge, our training, our courage, and our compassion.
In the midst of all that, a bottle of water, a cup of coffee, a glass of Diet Coke, a Styrofoam cup of iced tea is an oasis in the desert. And that sandwich, slice of pizza, cupcake, or salad is the fuel that helps make it happen.
More than that, food and drink are among the few pleasures we have time for each shift. They serve as bridges to the end of the day, small reminders of normalcy in a place where so little is normal.
Doubtless, one day someone will take away our music so that it doesn’t hurt our ears, or offend our patients. We’ll fight that battle when it comes.
But until then, depriving staff of food and drink proximate to where they work is of no health value and strikes me as just one more way of exerting control over the people actually engaged in the hard, grinding work of saving lives.
On November 21, the US House of Representatives passed the Workplace Violence (WPV) Prevention for Health Care and Social Services Act of 2019 (the bill now moves to the Senate). Strongly supported by the Emergency Nurses Association, the bill now moves to the Senate for consideration.
In the U.S., the prevalence of workplace violence (WPV) in the healthcare industry is four times higher than in other private industries. According to surveys by the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA), some 70 percent of emergency department (ED) nurses have been hit or kicked while at work. Because of ease of public access, crowding, long wait times, presence of weapons, and other factors, the emergency department is a highly vulnerable area, especially where triage occurs.
ED Health Providers Literally on the “Front Lines” for WPV
The shocking statistics on WPV in emergency departments are behind ACEP and ENA’s campaign, “No Silence on ED Violence.” This joint effort aims to educate, empower and protect doctors and nurses working in emergency departments. By raising awareness of the serious WPV dangers emergency health providers face every day, and promoting action among stakeholders and policymakers, the campaign seeks to ensure a violence-free workplace for emergency nurses and physicians.
Acts of workplace violence (WPV) can cause physical and/or
psychological harm to emergency nurses. WPV can lead to job dissatisfaction,
emotional exhaustion, burnout, secondary trauma stress, PTSD, absenteeism, and
intentions to leave the job or nursing profession, all of which have potential
impacts on patient care.
Workplace Violence Affects Majority of ED Doctors and Nurses
ACEP President William Jaquis, MD, FACEP, said, “If you asked the majority of our nurses and our physicians, they have all been impacted directly by violence—as have I. It goes everywhere from verbal violence, which happens frequently, to physical violence. Ultimately, we hope that in sharing our stories we will gain insight and share resources on how to prevent future harm to our medical teams and our patients.”
The “No Silence on ED Violence” website includes a variety of workplace violence resources for emergency healthcare providers, including guidelines for safety in and around the Emergency Department, and lists of warning signs indicative of potential violent events.
Inspired by the Raise Your Hand movement—which first encouraged emergency nurses in 2018 to share their workplace violence experiences — ACEP and ENA have collaborated on this effort to minimize the frequency of attacks, protect emergency department professionals and build a new level of awareness about this crisis.
Some Tips on Staying Safe
To increase program effectiveness, it is recommended that a workplace violence prevention program include education and training; formal incident reporting procedures; and administrative, environmental and consumer risk assessment, physical design, and security components to address all types of WPV.
Trust your feelings if you feel uncomfortable
around a patient.
Don’t isolate yourself.
Have security around.
Call security when you first become aware of a
Maintain safe distance.
Keep an open path for potential exit.
Present a calm, caring attitude.
Don’t match the threats.
Don’t give orders.
Acknowledge the person’s feelings.
Avoid any behavior that may be interpreted as
Limit eye contact.
Further, if you do become a victim of workplace violence, report it! Underreporting is a documented barrier to effective identification and mitigation of workplace violence. Although many nurses do report WPV incidents using both informal (e.g., telling a supervisor or colleague) and formal channels, the latter is only likely when an injury is sustained. Organizational commitment including workplace policies such as zero tolerance and the role of nursing leadership for establishing a just culture that discourages bullying and retaliation—is essential to mitigating all types and forms of WPV in emergency nursing and other healthcare environments.
Passed in the House, Now Advocate for the Bill With Your Senator
Among other features, the “Advocacy” page on StopEDViolence.org focuses on S. 851, the Workplace Violence Prevention for Health Care and Social Service Workers Act. Resources include an easy form for writing your Senator to support the act. In its current form, S.851 will require health care and social service employers to develop and implement comprehensive workplace violence prevention plans. These plans must include procedures to identify and respond to the common risks that make health care settings so vulnerable to WPV incidents. In addition, the bill is designed to help ensure that employees are appropriately trained in mitigating dangerous situations. For examples of action taken in State legislatures, see this PDF.
This is the first time nursing contract negotiations are being
held since 2016, when Allina hospital nurses went on strike for health
insurance benefits. These current negotiations have been in talks, with
contracts set to expire May 31. But it appears that no deal will be happening
by then, and the MNA is planning to strike again.
Workers compensation claims increased by nearly 40 percent
between 2013 and 2014, up to 70 percent, and have remained at 65 percent or
higher since then. These numbers reported by the Minnesota Department of Labor
and Industry only count the most severe cases reported, including those where
nurses missed three or more days of work due to injury.
Talks for nurse protection have been gaining speed since a
2014 incident, where a patient attacked and injured four nurses with a metal
bar. Minnesota passed a law in 2015, making hospital staff training on
de-escalating and preventing violence mandatory.
Another nurse, Michelle Smith, is back to work in surgical recovery but still going through recovery from a concussion she got roughly two years ago. She similarly is pushing for more support in negotiations to prevent these incidents from happening.
In-hospital patients with delirium are vulnerable during the early posthospitalization period
In-hospital delirium is a predictor of readmission, emergency department visits, and discharge to a location other than home, recent research shows.
The development of delirium in the hospital setting impacts about 12.5% of general medical admissions and as many as 81% of intensive care unit patients. Earlier research has shown delirium among hospitalized patients is predictive of prolonged hospital length stay, lengthened mechanical ventilation, and mortality.
The recent research in the Journal of Hospital Medicine featured data collected from more than 700 delirious patients and nearly 8,000 non-delirious patients. The researchers found delirious patients had increased odds for 30-day readmissions, ED visits, and discharge to postacute care facilities.
The Journal of Hospital Medicine research builds on earlier studies about in-hospital delirium, the lead author of the research said. “Prior studies have shown that delirium is associated with functional decline at discharge, so these patients may be particularly vulnerable in the days and weeks following hospital discharge. Our work helps to confirm this as we show that patients who become delirious in the hospital are far more likely to be readmitted within 30 days of discharge, compared with patients who do not develop delirium,” said Sara LaHue, MD, a resident physician in the Department of Neurology, School of Medicine, University of California San Francisco.
The new research indicates that hospital-based interventions should be targeted at delirious patients to reduce readmissions, she said. “Hospital-based interventions that reduce the development of delirium may then reduce the complications of delirium, such as readmission.”
Reducing delirium-associated postacute care service utilization
To avoid hospital readmissions linked to delirium, clinicians should focus on preventing patients from becoming delirious in the hospital.
One team member who is often overlooked is the caregiver at home, she said. “Educating caregivers about delirium risk factors can be very helpful — he or she can bring glasses or hearing aids from home, engage the patient in meaningful conversation to help with orientation, and encourage regulation of sleep-wake cycles. If a patient does become delirious, the caregiver can continue to help with these interventions.”
Caregivers at home are an essential component of postacute care, LaHue said. “We know that delirium is associated with functional decline at discharge, so coordinating safe discharge plans with the caregiver, especially to identify [the] need for resources — physical therapy, occupational therapy, home health, and nursing — can potentially help reduce post-discharge complications.”
Follow-up care is another crucial factor, she said. “Ensuring expedited follow-up with a primary care provider, who can assess for any additional needs, is also important.”
Ballad Health, a healthcare system serving parts of Tennessee, Virginia, North Carolina, and Kentucky, recently committed $10 million to ensuring their nurses receive well-deserved raises. As the Kingsport Times News reported, this investment will be directly put toward wages for acute care registered nurses, long-term care licensed practicing nurses, and scrub techs, among other roles for direct inpatient care and behavioral health.
Alan Levine, Executive Chairman, President and CEO of Ballad
Health, shared this announcement during National Nurses Week in an email to
Ballad Health team members, noting that this increase will be helping thousands
The pay increases will go into effect on June 23 for
existing team members. This investment will also affect starting hourly rates
for new hires.
“Our nurses and those who work with them in the provision of direct patient care are heroes,” Levine added. “Each of us does important work, and that, no doubt, is an important fact. Our amazing nurses would be the first to say they could not do their work without all the people who make a hospital or health care facility operate. And that is part of the humility that makes them great servants. However, it is also true that in an environment where we face a significant national shortage of these critical health care providers, a shortage so significant that the productivity of our nurses and direct bedside caregivers is as high as it has ever been, it is important we appropriately recognize the sacrifice that is being made.”
Fewer nurses on staff linked to increases in length of stay
Ask a nurse and they will tell you that staffing levels matter. Now a study in the Western Journal of Emergency Medicine supports that popular opinion, providing further evidence to make the case for nursing’s role in achieving healthcare outcomes and metrics.
“Our study provides additional data that may help providers further engage hospital administration to supply adequate nurse staffing that allows EDs [emergency departments] to better achieve performance goals and improve the patient experience,” the researchers wrote. “This analysis is a pivotal step in identifying and ensuring appropriate nurse staffing to optimize ED quality metrics.”
In the retrospective observational review of the electronic health record database from a high-volume, urban public hospital, researchers compared nursing hours per day with door-to-discharge length of stay, door-to-admission length of stay (LOS), and the percentage of patients who left without being seen.
From January to December 2015, more than 100,000 patients were seen in the ED at an average of 290 visits each day. During this time, the ED had an average of 465 nursing hours worked per day.
The researchers found that regardless of daily patient volume, occupancy, and ED admission rates, days in the lowest quartile of nursing hours experienced a 28-minute increase per patient door-to-discharge LOS when compared with the highest quartile of nursing hours.
However, door-to-admit LOS showed no significant change across quartiles.
There was an increase of nine patients per day that left without being seen by a provider from the lowest to highest quartile of nursing hours.
The authors concluded that lower staffing rates contribute to a statistically significant increase in wait time for patients, which then impacts how many patients receive treatment each day.
In addition to the clear patient safety and patient satisfaction issues around failing to receive timely treatment, the decrease in patients seen can also impact throughput metrics and decrease the overall revenue of facilities.