I'm @SafetyNurse. Fly me?

Over the past decade, healthcare has borrowed a number of engineering strategies widely used in commercial aviation to improve safety. Barriers, redundancies, and opportunities to uncover errors inadvertently set in motion are increasingly used to help prevent patients from "going off the runaway."

In the aftermath of the US Airways flight that safely landed a planeload of people in the Hudson River earlier this year, a pilot's words about the investment the flight deck has in safety stuck with me. "We're first up and last down on every flight." His words resonate because they so clearly align with a jet's nose-up take-off and wheels-down landing, an image indelibly etched in my mind after flying hundreds of thousands of miles.

We don't have reinforcers like that built into healthcare. But there are signs that the stakes are going up for leadership engagement in patient safety. Last week, The Joint Commission issued a sentinel event alert describing safety-sensitive beliefs and actions required of leaders--many that challenge healthcare's historic "Just Do It" approach to safety.

The Joint Commission's bulletin stresses the importance of matching what leaders say is valued with what's visible to front line professionals during routine and high-stakes junctures of care, particularly in the aftermath of high-profile error. Once again, we'll be borrowing from aviation.

So here's a nod to modeling transparency, an essential element of a culture of safety. I'm @SafetyNurse. Fly me!

First responder at 35,000 feet: The value of a good book

A few years back, I took a flight to Philadelphia to interview for the Safe Medication Management fellowship at the Institute for Safe Medication Practices. I was using the travel time to skim through "Medication Errors" (2nd edition), a book written by people I would meet the next day. Seated in an aisle seat, I had the iPod going full tilt, a distraction that both blocked airplane sounds and helped settle the butterflies in my stomach.

I may have been aware of some peripheral commotion but didn't really pay attention until a flight attendant, who had apparently noticed the title of the large textbook on my tray table, tapped me and asked, "Are you a medical professional? There's a gentleman on the plane who thinks he may be having a stroke. Are you willing to help him?"

I'm a perinatal nurse. Placentas. Labor. Birth. High-stakes vascular events in my clinical world are nearly always preceded by the diagnosis "pre-eclampsia," something a male simply cannot get. "Sure," I said, struggling to put on my shoes. "Stroke, stroke," I thought as I lumbered toward the designated seat. I think I should say something like, "What makes you think you are having a stroke, sir? Does something feel numb? Are you having trouble moving?"

When I reached the gentleman, however, talking was out of the question. He was cold, clammy, unresponsive, with a thready, bradycardic pulse. Where I live, people call this condition, "fixin' to die."

The flight attendants, working from a checklist, had notified the captain and sought help from medical personnel amongst the passengers. Communication with medical experts on the ground were being facilitated (loudly, with assessments and observations called from one flight attendant, stationed near our passenger-turned-patient, to another flight attendant, stationed at the now-open cock-pit door).

We apply oxygen by tight face mask. The first responders are three: me, an ex-Army corpsman, and someone who declines to be identified, although he is able to get oxygen flowing. (Something that's useful to know if you're a first responder while in flight: they don't drop the oxygen from the over-seat compartments. That's for emergencies that impact the oxygenation of everyone on the plane. Your team will be given a portable oxygen tank, and it may be helpful to remember "lefty-loosey, right-tighty" once you locate the on-off valve.)

"I have an AED, ma'am, I have an AED," the flight attendant repeated, rather persistently, pushing the box in my direction. Still feeling a pulse, but he's grayer, and the pulse rate is lowering. "Think, think," I thought. (The image of defibrillating a large man, mid-cabin just couldn't take hold in my mind. All I could picture was the impossibility of saying, "I'm clear, you're clear, we're all clear," when 5 rows of passengers are sitting in the metal chairs this man is going to touch if we lay him out here.)

Meanwhile, there's more flight attendant-to-cockpit communication (okay, yelling) as preparations for flight diversion are considered in light of the passenger's grave condition. "Does he have any medical conditions? Heart disease, diabetes,....." came the question as the flight attendant moved down the checklist. His traveling companion looks up, gasps, and says, "He has diabetes." Sweeter words had never been heard. This was something a perinatal nurse could do something with.

"Sugar," I said to the flight attendant. "Bring me sugar from your cart." The gentleman was unresponsive but the table sugar, which I applied (er, jammed) rather unceremoniously under his tongue and moistened with a few drops of water made him come around right quick. (Something else that's helpful to know if you're a mid-flight first responder is that flight attendants have a checklist and their efforts work in tandem with any assistance you can offer. The checklist helped to get useful facts, like this gentleman's diabetes, uncovered rapidly. This information would have been used by the medical professionals on the ground if I hadn't been able to put the pieces together and initiate corrective action. The take-away lesson? Help may not be as far away as it initially feels at 35,000 feet.)

It turned out that the passenger was a relatively new diabetic, and the day of traveling had put him off of his normal eating routine (although he had remembered to take his medications that morning). We continued on to Philly, with the gentleman refusing the EMS care that met him at the gate. I waved to him at the baggage claim area, and told his companions that he really should seek follow-up care immediately, something I very much doubt he did.

At my interview at ISMP the next day, I was asked if I had had a good flight. Of course, I told the story about the book and the in-flight interventions, at which point one of the staff members said to Mike Cohen, ISMP's president, now my mentor and friend, "See Mike, the book saved another life." Probably true. (I learned a great deal of life-saving information when I actually read the book, and I highly endorse it, both for its intended purpose and any adjunct benefit it affords the traveling public.)

May you always have a good book and fly the friendly skies!

Materials in this post first appeared on my Medscape blog, "On Your Meds: Straight Talk about Medication Safety" in April 2009.

Blog carnivals & car dating

I'm always on the lookout for stories, research, and information that says something about where we are in the quest to attain the IOM's "Big 6." (That would be healthcare that's safe, effective, timely, efficient, patient-centered, and equitable). This makes me something of a cheap date since pretty much everything about healthcare worth reading is going to take on at least one of these things.

So I screen a bit harder on the second date, looking for ideas and experiences that I find authentic and those that push me to reflect on these issues in a deeper way. Blog carnivals provide the "Readers Digest" version of what bloggers have written over the past week or so. Sometimes carnival hosts ask for posts on a particular topic, others just ask authors submit their favorites. I've found blog carnivals are a good place to go on a second date.

Here are two that published this week: Grand Rounds and Patients for a Moment. If you go, you'll find front line clinicians and patients telling stories about how the rubber meets the road in healthcare. They're authentic and, if you're like me, you'll probably find some that push you to think more about what, and why, you believe what you do about healthcare reform.

Happy 21st Birthday, Margaret!

Twenty-one years ago today, my husband and I drove 50 miles from our midtown Atlanta home so that I could give birth to our first child in a rural hospital's birthing center. The decision to drive past 5 or 6 well-regarded hospitals, all with maternity units larger and more sophisticated than the one we selected, wasn't difficult. (But it was a little dicey when the first stage of my labor progressed so rapidly that I had to put my feet on the dashboard and use "B-98.5 FM" as a focal point while en route.)

In 1988, the Cesarean Section rate in metro Atlanta hovered around 35%. I was an intrapartum nurse, who had dutifully pushed more than my fair share of laboring patients to the OR due to presumed fetal jeopardy, only to watch--delighted and perplexed--when the vast majority of infants came out screaming: pink, flexed, and oxygenated. I was certain there were better ways to have a baby.

When I gave birth, I was a healthy, young woman at 41 weeks gestation, the far end of a planned and uneventful pregnancy. Back then, nurse-midwives offered a better approach to caring for women like me, and I believe they still do.

I wasn't morally opposed to surgical birth: I just didn't want to give birth that way unless it was necessary. So I shopped for care, using indicators I understood, like C-Section rates, episiotomy rates, and the number of infants still breastfeeding at 3 months. (If you have a C-Section in a facility where only 15% of the infants are welcomed that way, you probably need one.)

Although my daughter seemingly could not wait to arrive, labor slowed as we reached the hospital, a lull that's pretty typical when laboring mammals are disrupted. And it took a long time, quite a long time to finish transition and birth my 8lb 3oz baby, who had chosen to position her hand alongside of her face for the journey.

In the late '80's laboring women were allotted about 2 hours to get their first baby pushed into the world. And I can remember feeling worried as I approached that mark. It was around that time, however, that my nurse-midwife--who had delivered 3 other babies early that morning--settled herself in, assessed the situation, and began providing very specific directions: "Pull back this way, now push." "Try this." "Push again: harder!"

Eventually, I was but a push away from having a baby. Or so it seemed to everyone in attendance. (While I was in labor, I was nicer than I usually am and, after 3 hours of pushing, I had become something of a sympathetic patient to the nurses on the unit. So, in addition to my nurse-midwife, primary nurse, and husband, I had a gaggle of interested L&D staff members offering support.) But still, I could not push that baby out. "Push harder, one more push, and the baby will be here!"

The voices became louder with each contraction, and I remember thinking, "How in the world did I wind up with precisely the kind of mad, directive, cheering crowd we had driven past all of those other hospitals to avoid?" But, as my grandmother had opined, giving birth was a lot like shitting a ham. There was, literally, no room to worry about anything else.

That's when my midwife, Margaret, did the most amazing thing: She told everyone in the room to be quiet. Then she tapped my leg, kind of brusquely and said, "Look at me." So I stopped doing whatever I had been doing that hadn't resulted in birth. The contractions abated. I looked at her.

"Why won't you push your baby out?"

There was a very long pause. "Oh, Margaret," I said, "I'm really afraid to be a mother." And I cried.

The quiet in the room turned to silence. I could sense the staff shifting and felt their gazes move toward the ceiling. By the time I delivered my firstborn, I had probably witnessed upwards of 500 births myself. And I knew that this was not an everyday announcement. A stuck baby and "being stuck" were infrequently differentiated in the world of traditional obstetrics I had come from. And I had never witnessed an intervention like the one I had just received.

But Margaret knew what she was doing.

She took her time responding. And when she did, I remember her saying something like this: "You are young and healthy. You've worked hard to get this baby here, and it's ready to come out. And your life is going to change when it does. There are no guarantees in this world, but I think you'll be able to handle whatever changes come along. And I think it's time to let this baby go."

With the next contraction, there was no holding back. Moments later, my husband and I were welcoming our own baby: pink, flexed, and screaming. We named her Margaret Claire.

I've thought of Margaret's words many times over the years. And they're with me again tonight as I once again prepare to leave my daughter in a college town 800 miles from my home. You'll be able to handle whatever changes come along. It's time to let the baby go.

See you at Thanksgiving, Mags!

Happy Meals in healthcare: Not the Top Chef edition

Measuring quality and safety in healthcare is a process currently in the "Happy Meal" stage of development.

Packages like The Joint Commission's "Core Measures" target a small number of high-frequency, reasonably well understood disease processes, then measure how well people treated in hospitals receive standard, evidenced-based interventions. At their best, core measures mean people with conditions like congestive heart failure and community acquired pneumonia receive the care most likely needed to treat their condition and reduce the risk of complications whether they're in Denver, CO or Dahlonega, GA. Kind of like a #2 Value Meal is the same burger, fries, and Coke everywhere you go.

The Joint Commission's National Patient Safety Goals (NPSG) are another set of menu items. These measures identify error-prone places in systems used to deliver care, then specify practices individuals, teams, and organizations should take to minimize the risk of harm-causing errors. Many emerging norms, like "read back and verify" (used when high-stakes information is transmitted verbally) and fall prevention programs, are driven by NPSGs.

Accreditation bodies use performance on these standards when evaluating an organization's quality. So do payors (including Medicare, Medicaid, and a host of private insurers) with reimbursement schedules increasingly tied to performance. Consumers are seeing evidence of them, too. As I travel around the country, I notice remarkably similar billboards announcing awards received by local hospitals for their performance in highly visible measures of care.

This is a huge step forward in defining expected outcomes and making the processes used to achieve them more transparent. (It's worth remembering that until the IOM report To Err is Human was published 10 years ago, the possibility that patients were harmed as a result of seeking care was not discussed, let alone quantified or seen as the threat to public health that it is.)

I've been a registered nurse for nearly 25 years. And before that, a waitress. So I can tell you from experience that a boxed lunch is not the worst thing that can come of a kitchen.

Current measures and methods for measuring quality are imperfect. They're stymied by a host of confounding variables, but the science of measuring what's good, bad, and ugly in healthcare will mature. Being able to see what's on the menu is a good first step, but Happy Meals aren't satisfying and they're not enough to sustain us over time.

Change of Shift: A check up with your nurses

Change of Shift is up over at Emergiblog. A new blog, The Nursing Student Chronicles, caught my eye. How the next generation of healthcare providers harnesses the power of social media may say a lot about what providing and receiving healthcare will look like in the future.

I just can't picture a 22 year old--who, thanks to Guitar Hero, can play the riffs in "Dream On" better than Joe Perry--entering multiple passwords, then clicking on 8 screens to release a box of Depends from a med-surg supply room.

And you should definitely check out the student's post if you're worried that the next generation doesn't bring full hearts and the ability to see the big picture. Rock on!

Happy Meals do not strategy make

Last Monday I lamented the mid-August start of school in Georgia. What I really meant to say was, beware of Happy Meals.

Not that there's anything inherently wrong with standardizing, simplifying, and packaging so that it's easy to get a hold of stuff. "Happy Meals" happen when efficiencies used to deliver predictable results in a reliable fashion are applied to food. And it's certainly nice to give toys to children.

But, as I used to tell my children, the prize associated with a meal is supposed to be food. It makes the gnawing feeling in your stomach called "hunger" go away. That is your present.

As childhood obesity takes stage as a significant public health concern, Happy Meals are being called out. We're beginning to question whether reliable access to high-fat, low nutritional value food is a good thing.

People like me, who fed Happy Meals to our kids once in awhile, probably recognized that these meals weren't served from the table of bountiful harvest. But the short term benefit of a quick meal and minimal clean-up exceeded any longer-term consequences we were reasonably able to anticipate. Who among us knew that so many kids were eating so much junk so frequently? Who would have guessed that Type 2 diabetes would become a childhood illness? Who could have known that the burgeoning weight of American kids would render pediatric drug dosing reference guides, based on growth tables from a previous generation, obsolete?

This is why strategy must be separated from the processes used to make it through the day: we plan meals better when we're not hungry. Strategic planning is about coming to the table, not to eat, but to think about what should be served up and how the pantry should be stocked.

Coming next: Part 2, Happy Meals in healthcare.