With complete credit for authorship to John J. Skreenock, HEM as published in the August, 2011 issue of "HEALTH FACILITIES MANGEMENT"
Designing space for the high-tech patient room
By John J. Skreenock, HEM
When planning for new patient rooms, today's health facility professionals have quite the challenge. They must ensure that the room design will provide effective, state-of-the-art technology when the space is initially occupied and adapt to future technologies.
This is easier said than done. Depending on the size of the project and funding, it may be years before the space is actually constructed and ready for occupancy. Working closely with a knowledgeable medical-equipment planner will increase the probability that the design will last well into the future.
Three types of rooms
Most hospitals have three general types of patient rooms, depending on the acuity level of the patient: intensive care unit (ICU) rooms, step-down or intermediate care rooms, and acute care rooms.
ICU rooms are grouped together in a unit to take advantage of the nursing skills required to care for these patients. These nursing units are called medical ICUs, surgical ICUs, cardiovascular ICUs and cardiac ICUs, to name a few.
Each type of patient room must accommodate an extensive array of specialized medical equipment required to care for the clinical needs of the specific patient population. Consideration also must be given to the safe and efficient use of fixed and movable medical equipment brought in to care for the patient. They also must accommodate nursing staff and the cardiac resuscitation team, if they are needed. Consequently, these rooms need to be designed to allow safe, easy access to all sides of the patient.
Once the types of equipment that could be used in the room and the location and position of the patient are known, the room layout can begin.
Room organization
A major consideration for an ICU room is getting the utilities to all the movable and portable equipment brought in and out of the room during a patient's stay. The ceiling, wall and floor space are usually at a premium in these rooms and the anticipated use of specific medical equipment will dictate the location of both the fixed and mobile medical equipment.
Types of utilities and outlets that typically need to be available in the room range from electrical and emergency power receptacles for equipment (e.g., ventilators, hemodialysis units and physiologic monitors); to low-voltage connections for various devices (e.g., television, information technology data lines for bedside physiologic monitors, electronic medical records and alarm monitoring); and medical gases (e.g., oxygen and medical air and vacuum outlets).
There are several methods of getting the utilities near the patient. Fixed floor-to-ceiling columns and movable ceiling- or wall-mounted booms have been gaining popularity over a standard prefabricated headwall or mounting the utilities directly on the walls adjacent to the patient bed. The columns provide better organization of the devices, better accessibility for staff and reduced wire and tube clutter, and fewer tripping hazards.
The columns and booms also allow for some bed movement to take advantage of window vistas, which have been attributed to patient well-being. However, window views may not always be an option due to existing external obstructions. One innovative hospital solved that dilemma by planning to install windowlike frames to display real-time camera views from several locations on the hospital roof.
If a fixed column or boom is used, space on the ceiling needs to be evaluated for proper layout, ceiling support structure and lighting requirements. Some ICU rooms may be equipped with one or two special procedural lights mounted in the ceiling above the patient for procedures that could be performed in the room in an emergency. Procedure lights sometimes are specified for ICU rooms. One model enables lights to be directed to the specific site using a wand- or wall-mounted panel.
Another consideration competing for ceiling space is the patient lift. Patient lifts can be mounted to the ceiling, installed as freestanding structures, or attached to a boom. The Facility Guidelines Institute's 2010 Guidelines for Design and Construction of Health Care Facilities identifies the need to conduct a patient handling and movement assessment and to address this during the construction process, which could have major implications for room design.
If there is a possibility of installing ceiling-mounted lifts in the future it is prudent to plan for them in the early design stages to prevent clashes with structures above the ceiling or to add structural support while the room is being planned.
Nursing staff need good visibility to the patient from the hallway. This is accomplished by using a significant amount of glass. However, sometimes privacy is needed for the patient and switchable or so-called "smart" glass is used in some units to accommodate the dual needs of privacy and observation.
With the touch of a switch, the glass changes from transparent to opaque, blocking light and providing privacy and security. This high-tech glass eliminates the need for blinds or curtains that may present an infection control risk and pose a cleaning challenge for environmental services. These glass panels are relatively expensive compared with that of standard glass, however.
Equipment needs
This is Modular Services Company's equipment solution for neonatal intensive care operations. The design team must ensure that the room is future-proofed for all of the equipment that may be fixed or wheeled into the room. It needs to consider the possible uses of the room when it is completed as well as how the room may be used in the future.
Ultimately, the type of critical care unit and patient determines which technologies are needed in the room. Most ICU rooms include ventilators; physiologic monitors mounted on a wall, boom or column; IV poles that are movable or mounted to a column or boom that can accommodate multiple IV pumps; and patient-controlled analgesia pumps. All of these may require multiple emergency-power receptacles.
Many of these devices will be integrated with the hospital electronic records through wireless connections. This integration requires that the information technology (IT) group be intimately involved with the planning of the room design and antenna placement.
Some facilities monitor ICU patients from a remote site, often called the electronic ICU or command center. For remote-monitored rooms, a pan-tilt-zoom (PTZ) camera, microphone and speakers — either ceiling- or wall-mounted — are needed to enable the remote site to communicate with the patient or nursing staff and observe patient and vital equipment displays and settings.
There is also a telepresence robot on the market that can be maneuvered into the room to gather the same type of information. This type of device requires a clear floor path through the room without wires, tubes or cables on the floor.
Intelligent patient beds are another new component in high-tech patient rooms. They not only require electrical power, but also a low-voltage data jack to connect to the hospital infrastructure for nurse-call and bed-exit alarms to monitor for fall risks. They also require connections for electronic medical records.
The flow of patient care within the room needs to be planned carefully to accommodate wireless workstations on wheels (WOWs), which typically are used for patient charting and confirmation of medication delivery. While they do not require an electrical receptacle or data jack, they take up space and need to be considered in the room layout. The typical footprint for the WOW is approximately 26 inches wide by 28 inches deep; however, newer tablet devices eventually may supersede WOWs for charting patient care.
As more and more new technology is introduced for patient care, the design team faces new challenges in providing the required utilities and adequate footprint. For example, ICU patients too ill to be moved for imaging studies need space in their rooms to accommodate mobile imaging devices like a mobile C-arm radiography or fluoroscopy unit.
The type of patient receiving care will dictate the equipment and utility requirements for the room. Here are some examples of typical ICU room equipment that have relatively large footprints and their utility requirements:
Hemodialysis equipment using continuous renal replacement therapy requires a hot and cold mixed water supply, drain and emergency power.
Ventilators require emergency electrical power, a medical air connection and a data connection for alarm management.
Hypo/hyperthermia units require electrical power.
Intra-aortic balloon pumps used in the cardiovascular ICU require emergency electrical power.
Video endoscopy carts or bronchoscopy carts require electrical power.
C-arms require electrical power.
Space also is required to ensure quick patient access by the resuscitation team with their resuscitation cart or crash cart.
Other types of ICU rooms may require very different equipment needs. For example, specialized orthopedic beds in a trauma ICU that provides for traction are usually larger and have bars that extend toward the ceiling. These require clear space above the bed to accommodate the bars. Likewise, neurologic intensive care areas may call for specialized monitoring equipment that require data jacks as well as a ceiling- or wall-mounted PTZ camera and microphone and speakers.
Point-of-care technology may have an impact on additional requirements for the design of the room as blood gas monitoring and portable ultrasound are becoming more prevalent. The key is using the medical-equipment planner to provide those glimpses into the technologies of the future of patient care and to raise the awareness of potential implications of the design on future needs.
Decisions must be made about making the investment to provide for the necessary flexibility, or at least addressing the potential impact, and designing the room to be able to add future equipment or technologies.
Beyond the ICU
Critical care areas aren't the only sections of hospitals with high-tech patient rooms. Step-down rooms and acute care rooms have their share of technologies requiring planning and installation considerations.
Step-down rooms are associated with the ICUs and have a reduced complement of equipment needs depending on the type of step-down unit. These rooms may be monitored via a telemetry transmitter that sends a patient's heart trace signals and maybe pulse oximetry to a central monitor that is being watched by a trained monitor technician. A step-down room also has a lesser requirement for both the regular and emergency electrical power systems and the number of oxygen, medical air and vacuum outlets. The design may have to accommodate fixed-ceiling patient lifts.
The acute care room has an even smaller complement of medical equipment and, consequently, less infrastructure. Some health care facilities are designing step-down and acute care rooms to be more like hotel rooms, conveying a less clinical and more comforting experience for both patients and their visiting family and friends.
Many hospitals also treat critically ill infants and children. Neonatal and pediatric ICUs have highly specialized equipment and unique room design requirements.
More of these rooms are being designed as private rooms to provide better control over the sensory environment for the neonate. Alarm management from the equipment in the room requires data jacks. Lines of site that are lost due to privacy and communication challenges need to be addressed with technology because of hard walls. Equipment to care for the neonate can be mounted on the wall or suspended from the ceiling on a boom. Utilities like regular and emergency electrical power are needed in sufficient quantity. Additionally, medical air, oxygen and vacuum are required, as are data jacks for connection to the central monitoring and the hospital information systems.
Planning for future
While considering the equipment now used in each type of room, hospital designers and facility managers must work in conjunction with clinicians to consider the potential use of the room in the future.
It is generally easier and less expensive to include additional space, electrical and data outlets, and utilities while in the design and construction phase of a project, rather than waiting until the spaces are occupied with patients and then deciding an upgrade is needed.
John J. Skreenock, HEM, is senior associate for the Applied Solutions Group at ECRI Institute, Plymouth Meeting, Pa. He can be reached at jskreenock@ecri.org.
Sidebar - Flexible rooms provide savings
A medium-sized hospital planned to renovate a couple of its acute- care nursing floors and convert all of the semiprivate rooms to private rooms, creating a new intensive care unit (ICU) step-down space.
While initial plans called for the rooms to be used for step-down patients, the longer range plan was to convert these spaces to ICU rooms when needed. For a step-down room, telemetry monitoring is sufficient. However, for future use as an ICU setting, centrally monitored, wall-mounted physiologic monitors or other high-technology equipment would be required.
With that in mind, the design had to be modified. The hospital decided to plan the rooms with increased infrastructure to handle the future conversion. Increased gas and vacuum capacity for additional outlets and additional electrical power and data jacks allowed for future upgrades.
These design changes now allow the high-technology equipment that is routinely deployed in the ICU to be used in these rooms in the future. The cost for such infrastructure at such an early stage is a fraction of the cost required in the future to convert the rooms.
However, cost is only one factor that would be considered for future conversion. If the hospital had not increased the infrastructure during the original renovation, a future conversion would have faced major complications, including the potential loss of revenue while the rooms were being renovated extensively, disruption to patient care and department operations, complex infection-control issues and a longer time to complete the conversion.
With all of these considerations, the conversion for ICU patients may never have happened.
Sidebar - Prepping for mass patient surges
When hospitals need extra space for unplanned patients in mass numbers, such as during or after a flu epidemic or a disaster with mass casualties, some facilities provide a flexible solution for allowing the census in a particular nursing department to flex up in times of need and then flex back down when the need subsides.
A portion of the acute care private rooms are designed with the ability to accommodate two patients in the same room, essentially creating a semiprivate room. This flexibility is provided by having the room designed with built-in infrastructure, such as utilities to accommodate two beds.
The design requires two headwall arrangements, each with enough gas and vacuum outlets; regular and emergency power; data jacks for plugging in equipment that communicates with the hospital's information systems; and separate lighting controls for each bed. Movable equipment required for patient care, like beds and IV pumps on poles, can be wheeled in when needed.
The second bed can be set up similar to the first but may not need all the amenities, because it only would be used for a short duration. Flexibility designed into the rooms allows for an unexpected short uptick in the hospital census.
The surge plan then will call for fixed medical equipment as well as additional mobile medical equipment to provide patient care. The mobile equipment may be relocated from another area of the facility, from storage or requisitioned from local rental firms.
This article first appeared in the August 2011 issue of HFM magazine.
Friday, August 26, 2011
Sunday, August 14, 2011
Friday, June 24, 2011
Violence In Hospitals
With complete credit to author Whitney L.J. Howell
This article first appeared in the January 2011 issue of H&HN magazine.
Security issues
Violence in Hospitals
By Whitney L.J. Howell
With attacks against staff and patients on the rise, administrators rethink security policies
Shortly after 12:30 a.m. on Sept. 3, Darrell Garner walked into Baton Rouge (La.) General Medical Center with a gun. He entered the room where his teenage stepson was a patient and argued with his estranged wife, allegedly shooting her in the arm and shooting her boyfriend in the arm and head. Local police responded quickly, but Garner apparently left while doctors and nurses treated the victims. (Ten days later, the suspect turned himself in to local police where he remains in custody.) Authorities put the facility on lockdown, and for hours, most employees got either erroneous information or none at all.
"At that time, we had no way to alert people to what had really occurred," says Edgardo Tenreiro, Baton Rouge General's executive vice president and chief operating officer. "We also hadn't yet thought about having a command center outside the hospital, so when I arrived at 1 a.m., I spent valuable time driving around our campus, trying to find the center location."
After a three-hour sweep of the facility, the SWAT team gave the all-clear and the medical center returned to normal operations.
Hospital administrators recognized that their security policies needed an upgrade. For one thing, Code White—the emergency code Baton Rouge General uses to announce violent patients—was not only inaccurate, but in this case, with a gunman involved, it also could have put at risk employees who responded to assist colleagues. The following Monday, leaders instituted Code Silver to alert staff to the presence of an active shooter.
"With the Code Silver, we're able to tell everyone to get out of harm's way—close patient doors, close doors to the unit, and barricade themselves behind desks," Tenreiro says. "In these situations, we don't want any hospital employee trying to control the individual, and we want to keep others from walking into affected areas."
Traditionally, the public perceives hospitals as places of healing—environments that are antithetical to violence. But recent data reveal a different reality. Shootings at Baton Rouge General, Danbury (Conn.) Hospital, and Johns Hopkins Hospital in Baltimore this year have prompted the health care community to re-examine security policies and procedures.
According to the Joint Commission Sentinel Event Database, 256 assaults, homicides and rapes have occurred in hospitals since 1995. The June Sentinel Event Alert showed a marked spike in activity in the last three years—since 2007, 110 violent incidents have occurred. Joint Commission officials, however, believe hospital violence is significantly underreported.
"Hospital administration makes the decision whether to report incidents, and people don't like to report violence more than they have to," says Russell Colling, a health care security consultant who serves as an adviser to the Sentinel Event Alert. "Many incidents go unreported because they don't fall into the hospital's definition of 'violence,' but others are omitted because officials don't want them to reflect negatively on the hospital's image."
The 2010 International Association for Healthcare Security and Safety crime and safety survey of 212 hospitals found that hospital crime of all kinds is rising. There were 660 aggravated assaults and 2,720 simple assaults in 2009.
Changes in the ways patients and police use hospitals place the facilities at greater risk for violent activity. A 2004 Occupational Safety & Health Administration report for health care providers on preventing workplace violence identified three substantial risks to patient and employee safety: an increased number of mental health patients using hospitals for follow-up care because so many psychiatric facilities have closed or lost beds; a rise in police use of hospitals to hold aggressive and intoxicated individuals; and 24-hour public access to hospitals.
However, neither The Joint Commission nor the OSHA guidelines include a mandate to enact any changes in security.
Not all hospital units or employees are at equal risk, however. Heavy traffic, high stress levels and the types of cases that come in make emergency departments most susceptible to violence. Intensive care units are also vulnerable, Colling says, because of elevated stress levels among patients and their loved ones.
Nurses Bear Brunt
Overall, nurses are the most frequent targets of violence because they have the most direct patient contact. A 2009 study from The Journal of Nursing Administration found that in the past three years, 50 percent of ED nurses experienced some type of physical violence, from shoving, hitting, kicking to being spit upon, and 70 percent experienced verbal abuse. In addition to patient volume and stress levels, the study points to long wait times, a lack of privacy, and anger from patients and family members as contributing factors.
Nurses are not automatically inclined to report abuse, says Diane Gurney, R.N., president of the Emergency Nurses Association. "As nurses, we feel a responsibility to assist patients who need our help, and being involved in these violent incidents has generally been accepted as part of the job," Gurney says. "But this part of the health care and nursing culture must change."
The first step to reduce hospital violence is conducting a risk assessment, says Donna Gates, a nursing professor at the University of Cincinnati. Gates works with the federal government to identify strategies for reducing the number of violent acts in health care environments. As part of an assessment, The Joint Commission recommends hospitals review crime rate records and statistics for the area around the facility and survey employees about their perceptions of risk. All disciplines must be included to identify all areas that need more security.
"Nurses and doctors tell us they want to know what to do when, they want to know what the specific guidelines are, and they want to know when to call security," Gates says. "We have to use their input to move toward a culture of safety."
This type of plan is important because it gathers top-down support throughout the hospital, says Joe Bellino, IAHSS president. By bringing together security personnel, chief nursing officers, ED managers, chief operating officers and local police, hospitals can draft and implement zero-tolerance policies that encourage all staff to report actual and perceived threats.
Data from the Emergency Nurses Association shows that hospitals with zero-tolerance policies are 50 percent less likely than hospitals without one to experience a violent incident.
Hospitals can train their employees based on the results of the risk assessment, Bellino says. Depending on the facility's experience with violent events, employees may require extensive training or they may simply need a refresher course on recognizing initial violent signs or on physical techniques to restrain patients safely. Bellino also suggests allocating funds to have an ED nurse or security officer trained to be a certified safety instructor. He or she then can customize the security information for a specific hospital.
Training employees to de-escalate a potentially violent situation is a hospital's first line of defense, Colling says. Active listening and giving patients and their visitors space can help hospitals sidestep many problems. He suggests all staff uniformly enforce such policies as the number of visitors allowed per patient at any given time to avoid prompting anger or frustration. Hospitals also should reduce the number of access points through which the public can enter.
From Police to Panic Buttons
Bellino says local law enforcement agencies should be involved in planning. "I recommend that all hospitals sit down with their local police to discuss protocols and determine the processes to respond to violence in the hospital, as well as what works best for all involved," he says. "It's optimal to invite law enforcement to the training opportunities for your employees so they know how you respond to these situations, and they learn the layout of your facility."
Sandra Schneider, M.D., president of the American College of Emergency Physicians, says doctors and nurses should become comfortable with requesting a security presence with threatening patients before violence occurs. "It's proactive, if you have a violent patient, to arrive with security and to have the officer with you the entire time," says Schneider. "But make sure the officer knows where his or her resources are and that he or she is adequately trained to quickly subdue a dangerous person."
Hospitals also can use discreet tactics to identify volatile patients and alert staff to take precautions, she says, such as color-coding charts or supplying potentially violent patients with different colored socks. ACEP supports installing panic buttons in case of emergencies.
Technology is an effective tool to prevent violence or counteract an event should it occur. Jane Lipscomb, R.N., a professor at the University of Maryland School of Nursing and an expert in workplace violence prevention, says an architect with safety experience can analyze which hospital units need additional security. The IAHSS also recommended closed-circuit television monitoring of high-risk units, metal detectors at ED entrances and electronic access controls.
The OSHA guidelines endorsed giving staff who work with volatile patients hand-held alarms that can be activated in an emergency and installing shatterproof glass in reception, triage and admitting areas.
The confusion associated with having an active shooter on hospital grounds taught Baton Rouge General two valuable lessons, COO Tenreiro says. Hospitals should establish the location for a command center outside the hospital and ensure all personnel involved in managing a crisis know the location. In addition, hospital officials need a listing of all pertinent land line and cell phone numbers, and the command center should offer Internet access to allow administrators to use such social media sites as Facebook and Twitter to communicate messages to staff inside the facility.
"Most importantly, in a situation like ours where we had an armed person in the building, you must accept that you aren't in control. The cops take over immediately," Tenreiro says. "We served as support resources only."
After a patient shot a nurse at Danbury Hospital, now Western Connecticut Healthcare, in March, OSHA cited the hospital for violence-prevention deficiencies. The hospital has implemented new strategies to better protect staff and patients, says John Lucas, director of security, including a policy posted on the hospital's Intranet home page that outlines responsibilities for the CEO on down. The hospital hired six additional security officers, bringing the total to 34, and placed some of them in the ED that serves both medical and psychiatric patients. Visitors must register at the information desk when entering the hospital and must wear visitor passes.
If a patient begins to exhibit unruly behavior, providers at the bedside may request a security consultation to determine whether the patient poses a threat. If officers identify danger, a patient will undergo a safety assessment—a detailed search of personal effects for any weapons or dangerous items. For patient behavior beyond what hospital security can control, the ED attending physician can request a call to the police by asking for a consultation with "Dr. Blueman."
"In the three months after we implemented the new safety protocols, we've seen a 75 percent drop in reported incidents," Lucas says. "Nine out of 10 conflicts are resolved at the bedside through discussion."
Whitney L.J. Howell is a freelance writer in Durham, N.C.
Facts About Violence
A nationwide survey of emergency nurses between May 2009 and February 2010 found that in hospitals:
97.1% of physical violence was perpetrated by patients and their relatives.
80.6% of physical violence occurred in patients' rooms; 23.2% in corridors, hallways, stairs and elevators; and 14.7% at nurses' stations.
38.2% of physical violence against emergency nurses occurred while they were triaging patients, 33.8% while restraining or subduing patients, and 30.9% while they were performing invasive procedures.
15% of male nurses reported having been victims of physical violence compared with 10.3% of female nurses.
13.4% of violent acts occurred in large urban areas compared with 8.3% in rural areas.
Source: The Emergency Nurses Association's Emergency Department Violence Surveillance Study, 2010
This article first appeared in the January 2011 issue of H&HN magazine.
This article first appeared in the January 2011 issue of H&HN magazine.
Security issues
Violence in Hospitals
By Whitney L.J. Howell
With attacks against staff and patients on the rise, administrators rethink security policies
Shortly after 12:30 a.m. on Sept. 3, Darrell Garner walked into Baton Rouge (La.) General Medical Center with a gun. He entered the room where his teenage stepson was a patient and argued with his estranged wife, allegedly shooting her in the arm and shooting her boyfriend in the arm and head. Local police responded quickly, but Garner apparently left while doctors and nurses treated the victims. (Ten days later, the suspect turned himself in to local police where he remains in custody.) Authorities put the facility on lockdown, and for hours, most employees got either erroneous information or none at all.
"At that time, we had no way to alert people to what had really occurred," says Edgardo Tenreiro, Baton Rouge General's executive vice president and chief operating officer. "We also hadn't yet thought about having a command center outside the hospital, so when I arrived at 1 a.m., I spent valuable time driving around our campus, trying to find the center location."
After a three-hour sweep of the facility, the SWAT team gave the all-clear and the medical center returned to normal operations.
Hospital administrators recognized that their security policies needed an upgrade. For one thing, Code White—the emergency code Baton Rouge General uses to announce violent patients—was not only inaccurate, but in this case, with a gunman involved, it also could have put at risk employees who responded to assist colleagues. The following Monday, leaders instituted Code Silver to alert staff to the presence of an active shooter.
"With the Code Silver, we're able to tell everyone to get out of harm's way—close patient doors, close doors to the unit, and barricade themselves behind desks," Tenreiro says. "In these situations, we don't want any hospital employee trying to control the individual, and we want to keep others from walking into affected areas."
Traditionally, the public perceives hospitals as places of healing—environments that are antithetical to violence. But recent data reveal a different reality. Shootings at Baton Rouge General, Danbury (Conn.) Hospital, and Johns Hopkins Hospital in Baltimore this year have prompted the health care community to re-examine security policies and procedures.
According to the Joint Commission Sentinel Event Database, 256 assaults, homicides and rapes have occurred in hospitals since 1995. The June Sentinel Event Alert showed a marked spike in activity in the last three years—since 2007, 110 violent incidents have occurred. Joint Commission officials, however, believe hospital violence is significantly underreported.
"Hospital administration makes the decision whether to report incidents, and people don't like to report violence more than they have to," says Russell Colling, a health care security consultant who serves as an adviser to the Sentinel Event Alert. "Many incidents go unreported because they don't fall into the hospital's definition of 'violence,' but others are omitted because officials don't want them to reflect negatively on the hospital's image."
The 2010 International Association for Healthcare Security and Safety crime and safety survey of 212 hospitals found that hospital crime of all kinds is rising. There were 660 aggravated assaults and 2,720 simple assaults in 2009.
Changes in the ways patients and police use hospitals place the facilities at greater risk for violent activity. A 2004 Occupational Safety & Health Administration report for health care providers on preventing workplace violence identified three substantial risks to patient and employee safety: an increased number of mental health patients using hospitals for follow-up care because so many psychiatric facilities have closed or lost beds; a rise in police use of hospitals to hold aggressive and intoxicated individuals; and 24-hour public access to hospitals.
However, neither The Joint Commission nor the OSHA guidelines include a mandate to enact any changes in security.
Not all hospital units or employees are at equal risk, however. Heavy traffic, high stress levels and the types of cases that come in make emergency departments most susceptible to violence. Intensive care units are also vulnerable, Colling says, because of elevated stress levels among patients and their loved ones.
Nurses Bear Brunt
Overall, nurses are the most frequent targets of violence because they have the most direct patient contact. A 2009 study from The Journal of Nursing Administration found that in the past three years, 50 percent of ED nurses experienced some type of physical violence, from shoving, hitting, kicking to being spit upon, and 70 percent experienced verbal abuse. In addition to patient volume and stress levels, the study points to long wait times, a lack of privacy, and anger from patients and family members as contributing factors.
Nurses are not automatically inclined to report abuse, says Diane Gurney, R.N., president of the Emergency Nurses Association. "As nurses, we feel a responsibility to assist patients who need our help, and being involved in these violent incidents has generally been accepted as part of the job," Gurney says. "But this part of the health care and nursing culture must change."
The first step to reduce hospital violence is conducting a risk assessment, says Donna Gates, a nursing professor at the University of Cincinnati. Gates works with the federal government to identify strategies for reducing the number of violent acts in health care environments. As part of an assessment, The Joint Commission recommends hospitals review crime rate records and statistics for the area around the facility and survey employees about their perceptions of risk. All disciplines must be included to identify all areas that need more security.
"Nurses and doctors tell us they want to know what to do when, they want to know what the specific guidelines are, and they want to know when to call security," Gates says. "We have to use their input to move toward a culture of safety."
This type of plan is important because it gathers top-down support throughout the hospital, says Joe Bellino, IAHSS president. By bringing together security personnel, chief nursing officers, ED managers, chief operating officers and local police, hospitals can draft and implement zero-tolerance policies that encourage all staff to report actual and perceived threats.
Data from the Emergency Nurses Association shows that hospitals with zero-tolerance policies are 50 percent less likely than hospitals without one to experience a violent incident.
Hospitals can train their employees based on the results of the risk assessment, Bellino says. Depending on the facility's experience with violent events, employees may require extensive training or they may simply need a refresher course on recognizing initial violent signs or on physical techniques to restrain patients safely. Bellino also suggests allocating funds to have an ED nurse or security officer trained to be a certified safety instructor. He or she then can customize the security information for a specific hospital.
Training employees to de-escalate a potentially violent situation is a hospital's first line of defense, Colling says. Active listening and giving patients and their visitors space can help hospitals sidestep many problems. He suggests all staff uniformly enforce such policies as the number of visitors allowed per patient at any given time to avoid prompting anger or frustration. Hospitals also should reduce the number of access points through which the public can enter.
From Police to Panic Buttons
Bellino says local law enforcement agencies should be involved in planning. "I recommend that all hospitals sit down with their local police to discuss protocols and determine the processes to respond to violence in the hospital, as well as what works best for all involved," he says. "It's optimal to invite law enforcement to the training opportunities for your employees so they know how you respond to these situations, and they learn the layout of your facility."
Sandra Schneider, M.D., president of the American College of Emergency Physicians, says doctors and nurses should become comfortable with requesting a security presence with threatening patients before violence occurs. "It's proactive, if you have a violent patient, to arrive with security and to have the officer with you the entire time," says Schneider. "But make sure the officer knows where his or her resources are and that he or she is adequately trained to quickly subdue a dangerous person."
Hospitals also can use discreet tactics to identify volatile patients and alert staff to take precautions, she says, such as color-coding charts or supplying potentially violent patients with different colored socks. ACEP supports installing panic buttons in case of emergencies.
Technology is an effective tool to prevent violence or counteract an event should it occur. Jane Lipscomb, R.N., a professor at the University of Maryland School of Nursing and an expert in workplace violence prevention, says an architect with safety experience can analyze which hospital units need additional security. The IAHSS also recommended closed-circuit television monitoring of high-risk units, metal detectors at ED entrances and electronic access controls.
The OSHA guidelines endorsed giving staff who work with volatile patients hand-held alarms that can be activated in an emergency and installing shatterproof glass in reception, triage and admitting areas.
The confusion associated with having an active shooter on hospital grounds taught Baton Rouge General two valuable lessons, COO Tenreiro says. Hospitals should establish the location for a command center outside the hospital and ensure all personnel involved in managing a crisis know the location. In addition, hospital officials need a listing of all pertinent land line and cell phone numbers, and the command center should offer Internet access to allow administrators to use such social media sites as Facebook and Twitter to communicate messages to staff inside the facility.
"Most importantly, in a situation like ours where we had an armed person in the building, you must accept that you aren't in control. The cops take over immediately," Tenreiro says. "We served as support resources only."
After a patient shot a nurse at Danbury Hospital, now Western Connecticut Healthcare, in March, OSHA cited the hospital for violence-prevention deficiencies. The hospital has implemented new strategies to better protect staff and patients, says John Lucas, director of security, including a policy posted on the hospital's Intranet home page that outlines responsibilities for the CEO on down. The hospital hired six additional security officers, bringing the total to 34, and placed some of them in the ED that serves both medical and psychiatric patients. Visitors must register at the information desk when entering the hospital and must wear visitor passes.
If a patient begins to exhibit unruly behavior, providers at the bedside may request a security consultation to determine whether the patient poses a threat. If officers identify danger, a patient will undergo a safety assessment—a detailed search of personal effects for any weapons or dangerous items. For patient behavior beyond what hospital security can control, the ED attending physician can request a call to the police by asking for a consultation with "Dr. Blueman."
"In the three months after we implemented the new safety protocols, we've seen a 75 percent drop in reported incidents," Lucas says. "Nine out of 10 conflicts are resolved at the bedside through discussion."
Whitney L.J. Howell is a freelance writer in Durham, N.C.
Facts About Violence
A nationwide survey of emergency nurses between May 2009 and February 2010 found that in hospitals:
97.1% of physical violence was perpetrated by patients and their relatives.
80.6% of physical violence occurred in patients' rooms; 23.2% in corridors, hallways, stairs and elevators; and 14.7% at nurses' stations.
38.2% of physical violence against emergency nurses occurred while they were triaging patients, 33.8% while restraining or subduing patients, and 30.9% while they were performing invasive procedures.
15% of male nurses reported having been victims of physical violence compared with 10.3% of female nurses.
13.4% of violent acts occurred in large urban areas compared with 8.3% in rural areas.
Source: The Emergency Nurses Association's Emergency Department Violence Surveillance Study, 2010
This article first appeared in the January 2011 issue of H&HN magazine.
Wednesday, June 22, 2011
U. of Illinois at Springfield Offers New ‘Massive Open Online Course’
U. of Illinois at Springfield Offers New ‘Massive Open Online Course’
June 21, 2011, 6:52 pm from: CHRONICLE OF HIGHER EDUCATION
By Marc Parry
What happens when you invite the whole world to join an online class?
As The Chronicle reported last year, a growing number of educators are giving that idea a try by offering free “massive open online courses,” or MOOC’s, to anyone who wants to learn. Today, that experimental idea gained some more traction in mainstream higher education. The University of Illinois at Springfield announced a new not-for-credit MOOC devoted to examining the state of online education and where e-learning is heading. Nearly 500 people from two dozen countries have registered so far, with 1,000 expected to sign up by the time the course begins next Monday.
These courses are part of a small but expanding push toward “open teaching.” Universities such as the Massachusetts Institute of Technology have offered free educational materials online for years, but the new breed of open teachers—at the University of Florida, Brigham Young University, and the University of Regina, among other places—is now giving away the learning experience, too.
The idea for the Springfield course grew out of a presentation called “The Open Future of Higher Education” delivered at a conference this spring by Ray Schroeder, director of Springfield’s Center for Online Learning, Research, and Service.
“The discussions there led me to more deeply consider the path of online learning in this era of a ‘higher education bubble,’” Mr. Schroeder said, referring to PayPal co-founder Peter Thiel’s recent claim that college is comparable to previously overvalued markets in technology and housing. Another influence was the concept of an “Open Educational Resources University,” which, as Mr. Schroeder explains it, involves students learning from freely available materials and then seeking certification of their knowledge from traditional universities.
“I found that many others also were taking stock and questioning where we are headed,” Mr. Schroeder added.
Various online-learning leaders are participating in Mr. Schroeder’s course, which runs through August 19. Not enough MOOC for you? Stay tuned. Starting in September, another group will organize what the MOOC pioneer George Siemens calls the “Mother of all MOOCs.”
In a blog post Monday, Mr. Siemens welcomed the growing interest from traditional universities. And he countered the more skeptical take offered by another open-education leader, David Wiley, who wrote recently that “MOOCs and their like are not the answer to higher-education’s problems.”
“I don’t think I’m overstating it when I say that we are at a similar point to open online learning that we experienced with the growth of the LMS (learning-management system) in the late 90s,” Mr. Siemens wrote. “While some have argued that MOOCs are limited in their appeal—mainly for professional development and highly prepared individuals—I believe MOOCs will continue to be easier to develop and deliver as the growing number of institutions develop pedagogies … and new technologies to run the events.”
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June 21, 2011, 6:52 pm from: CHRONICLE OF HIGHER EDUCATION
By Marc Parry
What happens when you invite the whole world to join an online class?
As The Chronicle reported last year, a growing number of educators are giving that idea a try by offering free “massive open online courses,” or MOOC’s, to anyone who wants to learn. Today, that experimental idea gained some more traction in mainstream higher education. The University of Illinois at Springfield announced a new not-for-credit MOOC devoted to examining the state of online education and where e-learning is heading. Nearly 500 people from two dozen countries have registered so far, with 1,000 expected to sign up by the time the course begins next Monday.
These courses are part of a small but expanding push toward “open teaching.” Universities such as the Massachusetts Institute of Technology have offered free educational materials online for years, but the new breed of open teachers—at the University of Florida, Brigham Young University, and the University of Regina, among other places—is now giving away the learning experience, too.
The idea for the Springfield course grew out of a presentation called “The Open Future of Higher Education” delivered at a conference this spring by Ray Schroeder, director of Springfield’s Center for Online Learning, Research, and Service.
“The discussions there led me to more deeply consider the path of online learning in this era of a ‘higher education bubble,’” Mr. Schroeder said, referring to PayPal co-founder Peter Thiel’s recent claim that college is comparable to previously overvalued markets in technology and housing. Another influence was the concept of an “Open Educational Resources University,” which, as Mr. Schroeder explains it, involves students learning from freely available materials and then seeking certification of their knowledge from traditional universities.
“I found that many others also were taking stock and questioning where we are headed,” Mr. Schroeder added.
Various online-learning leaders are participating in Mr. Schroeder’s course, which runs through August 19. Not enough MOOC for you? Stay tuned. Starting in September, another group will organize what the MOOC pioneer George Siemens calls the “Mother of all MOOCs.”
In a blog post Monday, Mr. Siemens welcomed the growing interest from traditional universities. And he countered the more skeptical take offered by another open-education leader, David Wiley, who wrote recently that “MOOCs and their like are not the answer to higher-education’s problems.”
“I don’t think I’m overstating it when I say that we are at a similar point to open online learning that we experienced with the growth of the LMS (learning-management system) in the late 90s,” Mr. Siemens wrote. “While some have argued that MOOCs are limited in their appeal—mainly for professional development and highly prepared individuals—I believe MOOCs will continue to be easier to develop and deliver as the growing number of institutions develop pedagogies … and new technologies to run the events.”
This entry was posted in Distance Education. Bookmark the permalink.
Saturday, June 11, 2011
Disaster Warnings
HHS releases toolkit of public health emergency text messages
The Department of Health and Human Services yesterday released atoolkit of prepared cell phone text messages that state and local emergency managers can distribute through their emergency notification systems in a disaster. Many communities have text alert systems for emergency notification. The toolkit currently features text messages relevant to hurricanes, floods and earthquakes, which emergency responders can use as is or tailor based on specific local needs. The messages complement public service announcements for radio and television available through the Centers for Disease Control and Prevention. State and local agencies register to use the toolkit by providing contact information to HHS, so they can receive alerts and updates as the content expands to include health tips for additional types of disasters. Agencies can register by e-mailing publichealthemergency@hhs.gov. Community residents should contact their local emergency management agency to learn whether text message alerts are available in their community and to register if available.
The Department of Health and Human Services yesterday released a
Friday, June 10, 2011
"THE POST-AMERICAN WORLD" by Fareed Zakaria NEW BOOK ANNOUNCEMENT
The Post-American World
Fareed Zakaria (Author)
The New York Times bestseller, revised and expanded with a new afterword: the essential update of Fareed Zakaria's international bestseller about America and its shifting position in world affairs.
Fareed Zakaria's international bestseller The Post-American World pointed to the "rise of the rest"-the growth of countries like China, India, Brazil, and others-as the great story of our time, the story that will undoubtedly shape the future of global power. Since its publication, the trends he identified have proceeded faster than anyone could have anticipated. The 2008 financial crisis turned the world upside down, stalling the United States and other advanced economies. Meanwhile emerging markets have surged ahead, coupling their economic growth with pride, nationalism, and a determination to shape their own future.
In this new edition, Zakaria makes sense of this rapidly changing landscape. With his customary lucidity, insight, and imagination, he draws on lessons from the two great power shifts of the past 500 years-the rise of the Western world and the rise of the United States-to tell us what we can expect from the third shift, the "rise of the rest." The great challenge for Britain was economic decline. The challenge for America now is political decline, for as others have grown in importance, the central role of the United States, especially in the ascendant emerging markets, has already begun to shrink. As Zakaria eloquently argues, Washington needs to begin a serious transformation of its global strategy, moving from its traditional role of dominating hegemon to that of a more pragmatic, honest broker. It must seek to share power, create coalitions, build legitimacy, and define the global agenda-all formidable tasks.
None of this will be easy for the greatest power the world has ever known-the only power that for so long has really mattered. America stands at a crossroads: In a new global era where the United States no longer dominates the worldwide economy, orchestrates geopolitics, or overwhelms cultures, can the nation continue to thrive?
Book Details
Norton Books
* Hardcover
* May 2011
* ISBN 978-0-393-08180-0
* 6.5 × 9.6 in / 336 pages
*
* Territory Rights: Worldwide including Canada, but excluding the British Commonwealth.
Endorsements & Reviews
“Starred Review. Zakaria updates his best-selling earlier vision of world economics and politics, which foresaw the decline of American dominance but reassured us that with that decline came the rise of the rest of the world.” — Booklist
“This is a relentlessly intelligent book that eschews simple-minded projections from crisis to collapse.” — Joseph Joffe, The New York Times Book Review
“Zakaria . . . may have more intellectual range and insights than any other public thinker in the West.” — Boston Sunday Globe
“A provocative and often shrewd take that opens a big picture window on the closing of the first American century and the advent of a new world.” — Michiko Kakutani, The New York Times
“Fareed Zakaria is one of the most thoughtful foreign policy analysts of our day and his new book . . . is a must read for anyone interested in globalization—or the Presidential election.” — Bruce Nussbaum, BusinessWeek
“A far-reaching analysis.” — Slate
“Compelling.” — Thomas Friedman, author of The World is Flat
Fareed Zakaria (Author)
The New York Times bestseller, revised and expanded with a new afterword: the essential update of Fareed Zakaria's international bestseller about America and its shifting position in world affairs.
Fareed Zakaria's international bestseller The Post-American World pointed to the "rise of the rest"-the growth of countries like China, India, Brazil, and others-as the great story of our time, the story that will undoubtedly shape the future of global power. Since its publication, the trends he identified have proceeded faster than anyone could have anticipated. The 2008 financial crisis turned the world upside down, stalling the United States and other advanced economies. Meanwhile emerging markets have surged ahead, coupling their economic growth with pride, nationalism, and a determination to shape their own future.
In this new edition, Zakaria makes sense of this rapidly changing landscape. With his customary lucidity, insight, and imagination, he draws on lessons from the two great power shifts of the past 500 years-the rise of the Western world and the rise of the United States-to tell us what we can expect from the third shift, the "rise of the rest." The great challenge for Britain was economic decline. The challenge for America now is political decline, for as others have grown in importance, the central role of the United States, especially in the ascendant emerging markets, has already begun to shrink. As Zakaria eloquently argues, Washington needs to begin a serious transformation of its global strategy, moving from its traditional role of dominating hegemon to that of a more pragmatic, honest broker. It must seek to share power, create coalitions, build legitimacy, and define the global agenda-all formidable tasks.
None of this will be easy for the greatest power the world has ever known-the only power that for so long has really mattered. America stands at a crossroads: In a new global era where the United States no longer dominates the worldwide economy, orchestrates geopolitics, or overwhelms cultures, can the nation continue to thrive?
Book Details
Norton Books
* Hardcover
* May 2011
* ISBN 978-0-393-08180-0
* 6.5 × 9.6 in / 336 pages
*
* Territory Rights: Worldwide including Canada, but excluding the British Commonwealth.
Endorsements & Reviews
“Starred Review. Zakaria updates his best-selling earlier vision of world economics and politics, which foresaw the decline of American dominance but reassured us that with that decline came the rise of the rest of the world.” — Booklist
“This is a relentlessly intelligent book that eschews simple-minded projections from crisis to collapse.” — Joseph Joffe, The New York Times Book Review
“Zakaria . . . may have more intellectual range and insights than any other public thinker in the West.” — Boston Sunday Globe
“A provocative and often shrewd take that opens a big picture window on the closing of the first American century and the advent of a new world.” — Michiko Kakutani, The New York Times
“Fareed Zakaria is one of the most thoughtful foreign policy analysts of our day and his new book . . . is a must read for anyone interested in globalization—or the Presidential election.” — Bruce Nussbaum, BusinessWeek
“A far-reaching analysis.” — Slate
“Compelling.” — Thomas Friedman, author of The World is Flat
Thursday, June 2, 2011
Multicultural Differences in Healthcare Delivery ... A Quality Issue!
Several of my doctoral students have indicated an interest in focusing research on multicultural differences in health care delivery. I would like to bring to their attention the following article with complete credit to authors; H. Awo Osei=Anto and Cynthia Hedges Greising. The article appeared in the online H&HN magazine, May 2011. hhnonline@healthforum.com
R. E. Hoye
Quality
Using Patient Data to Provide Equitable Care
By H. Awo Osei-Anto and Cynthia Hedges Greising
Most hospitals and health care systems collect patient race, ethnicity and primary language data, but using the data to provide equitable patient-centered care is a challenge for many. Providing equitable care—one of the six Institute of Medicine's Six Aims—is a priority as racial and socioeconomic inequity persists in health care. Leading hospitals are moving beyond data collection to analyzing and using the data to develop targeted interventions for improving care for underserved populations.
According to the 2010 National Healthcare Disparities Report released by the Agency for Healthcare Research and Quality, racial and ethnic minorities continue to receive a lower quality of care, as measured by performance on core quality measures. The 2009 NHDR notes three major implementation strategies to accelerate reduction of health care disparities:
Train health care personnel to deliver culturally and linguistically competent care for diverse populations
Raise awareness of disparities using research and data
Form partnerships to identify and test solutions
Heywood Hospital, a 134-bed, nonprofit facility in Gardner, Mass., is one example of a hospital that has focused on training staff to deliver culturally and linguistically competent care, using data to raise awareness of diversity and potential disparities in care, and using a multidisciplinary team to lead improvement.
Though its geographic area seems to lack diversity, Heywood actively collects and uses racial, ethnic, linquistic and religious data and preferences of its patients. This process has revealed pockets of socioeconomic and minority groups who can benefit from specialized services. In 1999, the hospital established a multicultural task force with representation from executive management, information services, telecommunications, nutrition, plumbing services, mental health, social work and food service. Before 1999, Heywood only provided interpreter services for American Sign Language. In 2002, the hospital developed a program that offers video relay for deaf and hard-of-hearing populations, a phone interpreter and in-house interpretation.
Providing multicultural services has had a tremendous impact, including increasing the number of minority patients and attracting diverse staff and volunteers. Before establishing its in-house interpreter program, Heywood had 56 hospital encounters with deaf or hard-of-hearing patients. Last year, the hospital serviced 1,422 encounters with patients having limited English proficiency, including deaf and hard-of-hearing patients. Once Heywood started providing Spanish interpretation, it received more demand for the service. The hospital now provides interpreter services for Vietnamese, the third most frequently used language by its patients.
Heywood mandates cultural competency training for new hires, and trains staff annually on cultural competency issues. April is diversity month at Heywood, and the hospital educates staff on specific topics impacting various patient populations. The local community respects the hospital and looks to Heywood as a resource for cultural competency issues.
Challenges and opportunities remain at Heywood, including the need for more resources to fund equity efforts and to train staff to provide optimal customer service to all patients. Moving to the next step after identifying trends in patient race, ethnicity and primary language data will involve translating materials into patients' preferred languages, providing specific services for patients, and going out into the community to connect with community leaders and provide education.
For other case studies about hospitals working to provide equitable, patient-centered care, visit the Hospitals in Pursuit of Excellence website at www.hpoe.org and download the report Improving Health Equity Through Data Collection AND Use: A Guide for Hospital Leaders.
H. Awo Osei-Anto is a researcher and Cynthia Hedges Greising is a communications specialist, both at the Health Research & Educational Trust. Visit Hospitals in Pursuit of Excellence at www.hpoe.org to explore these and other topics.
This article first appeared in the May 2011 issue of H&HN magazine.
R. E. Hoye
Quality
Using Patient Data to Provide Equitable Care
By H. Awo Osei-Anto and Cynthia Hedges Greising
Most hospitals and health care systems collect patient race, ethnicity and primary language data, but using the data to provide equitable patient-centered care is a challenge for many. Providing equitable care—one of the six Institute of Medicine's Six Aims—is a priority as racial and socioeconomic inequity persists in health care. Leading hospitals are moving beyond data collection to analyzing and using the data to develop targeted interventions for improving care for underserved populations.
According to the 2010 National Healthcare Disparities Report released by the Agency for Healthcare Research and Quality, racial and ethnic minorities continue to receive a lower quality of care, as measured by performance on core quality measures. The 2009 NHDR notes three major implementation strategies to accelerate reduction of health care disparities:
Train health care personnel to deliver culturally and linguistically competent care for diverse populations
Raise awareness of disparities using research and data
Form partnerships to identify and test solutions
Heywood Hospital, a 134-bed, nonprofit facility in Gardner, Mass., is one example of a hospital that has focused on training staff to deliver culturally and linguistically competent care, using data to raise awareness of diversity and potential disparities in care, and using a multidisciplinary team to lead improvement.
Though its geographic area seems to lack diversity, Heywood actively collects and uses racial, ethnic, linquistic and religious data and preferences of its patients. This process has revealed pockets of socioeconomic and minority groups who can benefit from specialized services. In 1999, the hospital established a multicultural task force with representation from executive management, information services, telecommunications, nutrition, plumbing services, mental health, social work and food service. Before 1999, Heywood only provided interpreter services for American Sign Language. In 2002, the hospital developed a program that offers video relay for deaf and hard-of-hearing populations, a phone interpreter and in-house interpretation.
Providing multicultural services has had a tremendous impact, including increasing the number of minority patients and attracting diverse staff and volunteers. Before establishing its in-house interpreter program, Heywood had 56 hospital encounters with deaf or hard-of-hearing patients. Last year, the hospital serviced 1,422 encounters with patients having limited English proficiency, including deaf and hard-of-hearing patients. Once Heywood started providing Spanish interpretation, it received more demand for the service. The hospital now provides interpreter services for Vietnamese, the third most frequently used language by its patients.
Heywood mandates cultural competency training for new hires, and trains staff annually on cultural competency issues. April is diversity month at Heywood, and the hospital educates staff on specific topics impacting various patient populations. The local community respects the hospital and looks to Heywood as a resource for cultural competency issues.
Challenges and opportunities remain at Heywood, including the need for more resources to fund equity efforts and to train staff to provide optimal customer service to all patients. Moving to the next step after identifying trends in patient race, ethnicity and primary language data will involve translating materials into patients' preferred languages, providing specific services for patients, and going out into the community to connect with community leaders and provide education.
For other case studies about hospitals working to provide equitable, patient-centered care, visit the Hospitals in Pursuit of Excellence website at www.hpoe.org and download the report Improving Health Equity Through Data Collection AND Use: A Guide for Hospital Leaders.
H. Awo Osei-Anto is a researcher and Cynthia Hedges Greising is a communications specialist, both at the Health Research & Educational Trust. Visit Hospitals in Pursuit of Excellence at www.hpoe.org to explore these and other topics.
This article first appeared in the May 2011 issue of H&HN magazine.
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