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Tuesday, February 07, 2012

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Bill Peckham

We can wish the world was different but with lives on the line shouldn't we see the world as it is ?

Peter Laird, MD

Bill, unfortunately that is the double edged sword we face. We give up loss of privacy in so many areas of our lives already that placing ongoing video surveillance seems too intrusive to me, but as you state it is the way the world is. I prefer individual responsibility coupled with freedom. I washed my hands so much I always had to deal with dry and cracking skin on my hands.

Sadly, professional integrity has suffered and will likely continue to suffer. I believe the hand hygiene issue is only a symptom of deeper underlying deficiencies of care. I am shocked that only 6.5% of health care professionals washed their hands in this study prior to the feedback portion. The ghost of Dr. Ignaz Semmelweis I am sure is turning over in his grave. The tragic loss of life due to nosocomial infections is incalculable. Simple soap and water is our most important "high tech" solution to infections. It is also the most ignored.

http://en.wikipedia.org/wiki/Ignaz_Semmelweis

Roberta Mikles BA RN

Once again I state the following related to the most basic infection prevention practices in dialysis units.
(1) There is a lack of effective unit-level supervision
(2) There is a lack of adequate and thorough education/training/preceptorship programs
(3) Staff do not fully understand the extent of patient negative consequences in order to implement correct practices
(4) Many staff, including some regional individuals have informed me that the training is not detailed enough
(5) There are no consequences for patient negative outcomes as a result of staff not implementing correct practices.
AND, what is even more concerning is
(6) Since dialysis certification (mandatory) in California, there are not significant changes in the types of deficiencies cited in infection control. Hence, nothing has really changed with delivery of care since the initiation of mandatory diaysis technician certification.
And, I might add, some RNs in units are not even aware of correct infection control practices. One RN recently contacted me stating her training was very limited, new to dialysis arena. She was placed on the floor and when she asked for more direction/training she was terminated. When CMS tells us that handwashing and glove changing are the most frequently cited deficiencies, one must ask 'what type of training and supervision is taking place in the unit?' ...
Roberta Mikles
Dialysis Patient Safety Advocate
www.qualitysafepatientcare.com

Bill Peckham

I don't see it is a double edged sword Peter, as employees there is no expectation of privacy.

I believe the only expectation that matters is the patient's expectation that they won't be harmed. Perhaps if the effect of surveillance was slight we could credit the privacy issue but given the impact of surveillance on patient health the privacy issue pales to insignifigance.

Peter Laird, MD

Bill, I guess we will have to add this to a list of things that we will agree to disagree upon. My perspective is you get much better care from a professional motivated internally to do the right things. That attitude carries over into so many other areas not observable. I believe that is the driving force behind the work of men like Dr. Scribner for instance.

To place an industry that should know better already under Big Brother surveillance speaks to me of larger issues than whether they wash their hands all the time. It points to a group of people who realistically just don't care about the patient before them. I believe my post on Suffering Silently in Dialysis is just one such symptom that goes hand in hand with the lack of care to even wash their hands. Failure of hand washing in the end and an actual complete disregard with only 6.5% adherence says loudly to me, they just don't care.

No amount of Big Brother technology will ever make up for that I just don't care attitude so prevalent today.

Peter Laird, MD

Bill, I would add that the surveillance of the employees lead also to a huge invasion of privacy of the patients as well. After all, they often use the same sinks to wash their hands. It is not only the employee who is under surveillance. In fact, everyone that comes into the room is under surveillance. Yes, it is an invasion of privacy, but that seems to be the way this world is headed. Sadly, it won't restore the lack of caring that is at the heart of this problem.

Peter Laird, MD

Bill, one more issue, the surveillance wasn't effective by itself anyway. Even with the cameras going and the healthcare workers aware it was on, only 6.5% washed their hands. It was only the behavioral modification portion of the study that changed the outcome. I found that very interesting.

I worked with autistic kids before going to medical school. When I was special education teacher for that institute, all of the class rooms had two way mirrors. You never knew if you were being watched by administrators or even parents and other observers. It was an interesting life in a fish bowl. On occasion, we would be corrected on ways to do things in a different manner. It kept us on our toes. I was frankly surprised that the camera by itself had so little effect. I don't know why that would be true.

Bill Peckham

I would be in favor of anything that would increase patient hand/access washing. The privacy issue seems academic in the face of the reality of two infections per year.

Peter Laird, MD

Once again, I don't entirely disagree, but this is just a symptom of a profession losing its way. I worked with my mother at the age of 19 as an orderly. She was a charge nurse RN that routinelyl questioned doctors and almost always was correct as an advocate for the patients. I can remember seeing doctors personally apologize to her for tyrades over issues that actually saved their buts as well as the patient.

I learned that lesson well when I became a doctor myself. I can't count the number of times something a patient said or a nurse changed my entire outlook of what I had thought I was going to do for a particular patient. I was one of the few doctors that spent the time to read nurses notes. I did it for two reasons, first of all, in any malpractice suit for adverse events, you are held responsible for everything in the chart. Secondly, the nurses often documented important information on patient symptoms or responses to medications that was important to know.

I wish I would have had a third source to go to at times, but that is the nature of medicine dealing with uncertainty day in and day out. Medicine truly is your best guess more often than doctors wish to admit.

For those that will not adhere to professional standards, their reward is more oversight and supervision. Proverbs sums it up well:

Proverbs 22:29 Seest thou a man diligent in his business? he shall stand before kings; he shall not stand before mean men.

Bill Peckham

I think that is nostalgia Peter. Infection rates were as bad when you were a kid as they are today. Patients (and staff, and family) do not wash their hands. It is insane but that's what we face.

I applaud the action taken by North Shore Hospital. It is regrettable that it has come to this but human nature is a bitch. No one ever washes their friggen hands and something has to be done. Too bad if docs don't like to be supervised, they are frequent offenders.

Peter Laird, MD

It may be nostalgia, but it was a way of life with me as doctor and even more so as a patient today. As you note, I would resent that sort of intrusion into my life especially since I was not an offender. Unfortunately, doctors cell phones are the most contaminated item in hospitals. Yes, the mean man is coming and the health profession deserves every mean man that will supervise their every action.

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