Public Hospitals
Funded by federal, state or local govt. (John Dempsey Hospital a.k.a UConn Health Center)
Community
Privately owned (don't really exist anymore)
For profit
Focus is on financial gain not necessarily service
Federal
Don't serve general public (e.a. VA)
Outpatient Care
Services that do not require an overnight stay; Hospitals in Ed or outpatient clinic; ambulatory care
4 categories of ambulatory care
Wellness - primary care physician
Diagnosis - x-ray, mri's, bloodwork
Treatment - same day surgeries, chemo, dialysis
Rehabilitation = OT (Occupational Therapy) or PT (Physical Therapy)
Medicare and Hospital Reimbursement
Medicare Part A covers hospital stays and related costs for 65 and older; does not pay for cost of care due to errors (ex. catheter associated urinary tract infections [CAUTI], ventilator associated pneumonia [VAP], bloodstream infections [BSI]), 38.4 billion is uncompesated hospital care expenses in 2017 across 5256 hospitals (American Hospital Association)
Respite Care
For the caregiver
Hospice
Palliative care for those where there is no curative treatment
Palliative Care
Comfort
Difference between Palliative and Hospice
Not all palliative care is hospice, but hospice is always palliative
Industrial Revolution
Younger people moved to city, childless but wealthy = paid for health, no children and no wealth = fended for themselves, local government helped with almshouses, poorhouses, poor farms, country infirmaries, asylums
Disability Requiring Care
Mobility, eyesight, hearing, cognition, self-care; 20% of all adults; 1/3 of all adults aged 65+
Long-Term Care Settings
Skilled nursing facilities, assisted living facilities, senior centers, continuing care retirement communities, respite care, hospice care
Skilled nursing facilities
Licensed Facility, provides general nursing care; custodial care and medical services; licensed nurse present; regulated by state, HHS, CMS
Assisted Living Facilities
Residential Care Communities, assistance with ADLs, less intensive, allows for some independence, majority of residents are "oldest of old"
Continuing Care Communities
Retirement Complex, wide range of services, social activities + home maintenance, may provide assisted living and/or skilled nursing, most expensive
Lowest # of Nursing and Social Work FTEs
Adult Day Service Centers
Highest # of Nursing and Social Work FTEs
Skilled Nursing Facilities
Nursing Aides
CNS, home healthcare aides, and home care or personal care workers, aka "direct care workers"; duties = feeding, bathing, dressing, moving patients, changing linens; high school education, some additional training; backbone of formal LTC system, most influence over client's type of care and quality of life, most difficult jobs to fill
Private Long-Term Care Insurance
High premiums (not feasible for current or near-future needs ), must estimate when insurance will be needed, must estimate how long insurance will be needed, LTC insurance claims climbed by $2 billion (2015-2018)
Elder Abuse
1 in 10 experience abuse (60+); physical, emotional, neglect, abandonment, sexual, financial, fraud; most victims are women, most abusers are family; caregivers and stress-one of the causes
More key Trends in LTC
Aging of baby boomers, emphasis on personal choice, emphasis on quality improvement, technological innovation, new treatments for dementia, home care rather than institutional care
6 Aims (IOM Report 2001)
Safe (avoid injuries), effective (scientific based care), patient centered, timely, efficient (avoid waste), equitable
IOM 10 Rules (Values) of Redesigns (top 5)
Customized based on patient needs and values
Patient in control of own care
Evidence based decision making
Anticipate rather than react to patient needs
Cooperation among clinicians
3rd Leading Cause of Death in US
Medical Errors
Failure of planned action to work or selection of an incorrect action examples
Adverse Drug Events
Misdiagnosis
Surgical Injuries
Falls
Pressure Sores
Infections
Model for Improvement Questions
What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?
Registered Nurses Scope of Practice
Who - Registered Nurses (RN) and Advanced Practice Registered Nurses (APRN)
What - Protect, promote, and optimized health and abilities, prevent illness and injury, facilitate healing, alleviate suffering
Where - Patient needs to care
When - When there is a need for our knowledge, compassion, and expertise
Why - To achieve the most positive patient outcomes in keeping with nursing's social contract and obligation to society
Most Common Practice Settings for Registered Nurses
Highest - Hospitals (60%) Lowest - Education (3%)
Most Common Degree For Nurses to Obtain
BSN (Baccalaureate Degree - Nursing)
Least Common Degree for Nurses to Obtain
Doctoral Degree - Nursing (any)
Decreasing Degree for Nurses to Obtain
Associate and Diploma Degrees
Increasing Degree for Nursing to Obtain
Masters Degree
LPN
-Licensed Practical Nurse -Fastest track to become a nurse - 1 year -Can find classes at local hospitals or community colleges -Eligible to receive license after completing state registered exam National Council Licensure Examination for Practical Nurses (NCLEX-PN)
RN
-Associate’s Degree in Nursing (ADN) -Registered Nurse -Completed in about 2 years -Blends liberal art classes w clinical nursing classes -Higher pay and more responsibility -Transition to the business side of healthcare -Have to take National Council Licensure Examination for Registered Nurses (NCLEX-RN)
APRN
Masters or Doctorate
Different types
Nurse Practitioner, Nurse-Anesthetist, Nurse - Midwife, Clinical Nurse Specialist-Doctorate = Highest Degree
Physicians Assistant (PA)
Advanced Practice Provider (APP)
Any Bachelor’s Degree (Must complete prerequisites) -No formal clinical (Must complete between 1000-4000 hours of direct patient healthcare experience -ex. EMS, CNA, Scribe) -Immediately move to PA Master's Program -Complete Master’s of: Physician Assistant Studies,Health Science,Medical Science -Trained as Generalists (Can work in any clinical setting under Physician supervision) -Will have to pass P.A.N.C.E. Exam (Physician Assistant National Certifying Exam) -Obtain H&Ps -Order/Interpret Diagnostics -Rx Meds/Therapies -Perform Bedside Procedures -Consult Specialists As Needed -Work in all specialties (Outpatient offices,Impatient Hospitalists, ICU,Emergency Department,Hospice,Surgery [More likely to scrub into surgery]) -Must work under direction and supervision of a physician -Degree of supervision will vary based on State -Discussing complicated case -Co-signing on controlled RXs -Co-signing on documentation -National Average Salary - 107k
Nurse Practitioner/ Advanced Practice Registered Nurse (NP/APRN)
-Advanced Practice Provider (APP) -Bachelor of Science in Nursing (BSN)-800 - 1000 Clinical Hours - Learning to be a Bedside Nurse -Take NCLEX-RN -Work as a nurse for 1-20+ years -Complete Master of Science in Nursing (MSN) -Trained in specific patient population -Will have to pass either AANP or ANCC (Nurse Practitioner Certification in Specific Specialties) -Obtain H&Ps -Order/Interpret Diagnostics -Rx Meds/Therapies -Perform Bedside Procedures -Consult Specialists As Needed -Work in all specialties (Outpatient offices,Impatient Hospitalists, ICU,Emergency Department,Hospice,Surgery) -Full Practice Authority in 23 states and counting -No required supervision or collaboration by a physician -If working in a FPA state - have a collaborative agreement (Outlines collaborative practice protocols, documentation oversight, and prescriptive authority [depending on state legislature],Occasional chart reviews,Access for consultation) -More Autonomy (especially in an FPA State) -National Average Salary -$117k
What is the P.A.N.C.E. Exam for PAs?
Physician Assistant National Certifying Exam
Jane Brown is a 5 yo female who has a history of sleep apnea. She was referred to your hospital for a tonsillectomy and adenoidectomy (T&A). Jane went in for surgery this morning. You, the nurse, are receiving Jane postop.
Pt sitting in wheelchair (fall risk) which is not locked
Mom brought in snack to make her feel better! Put candy etc in pt’s hands
Baby sister in Jane’s arms and pulling on O2 tubing
Pulse ox is on ground and wire tangled in wheel of chair
Pt pulled IV out
Jane didn’t like the tube in her nose so she put cannula in her mought
Nasal cannula not connected to O2 and lying on floor
Pt bracelet with wrong name and DOB
Dirty/bloody gauze hanging out of pt’s mouth and on chest by her sister
Toys scattered across ground/fall risk
Noelle Escobar is a 34 yo patient who delivered vaginally 3 hours ago. She had been in the hospital for 7 days on bedrest due to preeclampsia. She experienced a Stage 2 postpartum hemorrhage and is therefore on bedrest with a foley catheter and is NPO. She reports maternal exhaustion and is bonding with her baby (Baby Girl Escobar). She is anxiously awaiting a call from the father of the baby.
NPO, but holding McDonalds soda and empty McDonalds fries in baby crib.
Bracelet says Nancy Escobar
Babies bracelet says Labore Baby (wrong ID)
Cell phone cable attached to IV pole
IV out of date
Holding baby in bed with no side rails
Scissors in bassinett
Urine on bedside table
Foley on ground
ASA allergy – bottle of ASA on bedside table, open
Johnathon Wu is receiving a blood transfusion and care for his foot wounds
Blood tubing hanging on floor
IV tubing expired label
ASA Allergy with ASA on table
Urine on table
Phone and cord draped across patient
Bugs in bed
Gown in trash
Henry Williams, is inpatient for uncontrolled diabetes
ID band incorrect patient
Left restraint tied to “side rails”
Lantus needle and vial on table
Candy on table (he is diabetic
D5W hanging
PCN infusing (allergy to PCN)
IV labels are expired
Catheter