Would Like Input - CABG - page 2

Can't stop thinking about my pre-op CABG... Any input would be greatly appreciated! My patient was admitted for recurrent CHF exacerbation, mostly having SOB that would come and go. So she was... Read More

  1. Visit  leslie :-D profile page
    0
    actually, it's the anesthesiologist that pretty much decides if pt is candidate for surgery.
    i am wondering where this pt is with her lung ca, as she very well may be candidate for hospice...
    and certainly not major surgery.

    it's too bad, as it 'sounds' like yet, another futile and invasive intervention for this person.
    may she soon find comfort and peace.

    leslie
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  3. Visit  MomRN0913 profile page
    3
    Quote from leslie :-D
    actually, it's the anesthesiologist that pretty much decides if pt is candidate for surgery.
    i am wondering where this pt is with her lung ca, as she very well may be candidate for hospice...
    and certainly not major surgery.

    it's too bad, as it 'sounds' like yet, another futile and invasive intervention for this person.
    may she soon find comfort and peace.

    leslie
    When my grandfather was in the hospital, they tried to unsuccessfully endoscopic ally peg him and couldn't. They anted to do it surgically under general anesthesia . My dad was his health care proxy . My grandfather lived quite a full active life and would not want to spend his life on a vent with a peg. My dad asked me to help make the decision. He put me on the phone with the nestesiologist and I asked " wi his CHF and pleural effusions, will he come off the vent? He said, most likely not. So, to get trached to get pegged was not a quality of life for an 86 yo like my grandfather. I told my dad not to do it, and to make him DNR. The next morning he passed in his sleep, peacefully.
    GrnTea, Esme12, and leslie :-D like this.
  4. Visit  leslie :-D profile page
    2
    Quote from MomRN0913
    When my grandfather was in the hospital, they tried to unsuccessfully endoscopic ally peg him and couldn't. They anted to do it surgically under general anesthesia . My dad was his health care proxy . My grandfather lived quite a full active life and would not want to spend his life on a vent with a peg. My dad asked me to help make the decision. He put me on the phone with the nestesiologist and I asked " wi his CHF and pleural effusions, will he come off the vent? He said, most likely not. So, to get trached to get pegged was not a quality of life for an 86 yo like my grandfather. I told my dad not to do it, and to make him DNR. The next morning he passed in his sleep, peacefully.
    God bless you, momrn.
    very wise and compassionate decision on your part.

    leslie
    GrnTea and Esme12 like this.
  5. Visit  Esme12 profile page
    1
    Quote from NickiJules
    Can't stop thinking about my pre-op CABG... Any input would be greatly appreciated!

    My patient was admitted for recurrent CHF exacerbation, mostly having SOB that would come and go. So she was admitted, had positive cardiac cath, and scheduled for open heart the next a.m.

    Last I knew, she was still intubated, over 2 weeks post op.

    Her Hx included lung ca and R lower lobectomy. Im the one who completed her pre op orders. CXR showed possible small pleural effusion. For some reason, it did not occur to me until later that day that PFTs were not ordered for her.

    I don't know if they routinely check PFTs pre op at this facility but does anyone know if this could have made a difference in decision to operate? I cant remember the extent of occlusion per her cath. Also, what are the chances of recovery for someone intubated this long?

    Thanks!
    There is a learning exclusion to HIPAA. How else do people learn.

    Now..your patient. Recurrent CHF...there are many thing that determine CABG and post op outcome.

    My questions/thoughts would include...what what the ECHO...what was the ejection fraction? How may prior MI's had this patient had? What co-morbidities were present? She is behind the 8ball due to the lobectomy and lung CA....the surgeon's I had worked with would do PFT's and baseline abg's pre-op for guidance post op.

    Her mortality depends if she experienced any complications during the surgery like another MI, a stroke, damage to the phrenic nerve.....that will affect her mortality.

    Just because someone is still intubated 2 weeks op isn't necessarily a sign that they will not leave the hospital it is significant that she has suffered complications that will prolong and complicate her stay.
    NickiJules likes this.
  6. Visit  Laurie52 profile page
    0
    Quote from Esme12

    There is a learning exclusion to HIPAA. How else do people learn.

    Now..your patient. Recurrent CHF...there are many thing that determine CABG and post op outcome.

    My questions/thoughts would include...what what the ECHO...what was the ejection fraction? How may prior MI's had this patient had? What co-morbidities were present? She is behind the 8ball due to the lobectomy and lung CA....the surgeon's I had worked with would do PFT's and baseline abg's pre-op for guidance post op.

    Her mortality depends if she experienced any complications during the surgery like another MI, a stroke, damage to the phrenic nerve.....that will affect her mortality.

    Just because someone is still intubated 2 weeks op isn't necessarily a sign that they will not leave the hospital it is significant that she has suffered complications that will prolong and complicate her stay.
    The only learning exclusion I can think of is when aggregate used . I don't know of ant health care organization that lets health care workers look at charts of patients you are no longer carrying for. If I'm wrong could you please direct me to what that exclusion is called? Tganks
  7. Visit  NickiJules profile page
    0
    Thanks everyone for the helpful responses! I'm happy to learn she has hope for recovery-unfortunately, it will be a difficult one, if she does improve. If/when she returns to our floor, I will get to see her but will not be checking her chart anymore, certainly!

    Regarding HIPAA, I don't see the harm in checking the chart (for purposes of learning or just simply out of concern) but if it's a violation, I'm sure it is for a good reason.

    Anyway, thanks again everyone for your input.
  8. Visit  psu_213 profile page
    0
    Quote from Esme12
    There is a learning exclusion to HIPAA. How else do people learn.
    Unfortunately nurses look at their patients charts "just to see what happened to them" and not necessarily as a learning experience.
  9. Visit  sandyfeet profile page
    0
    Quote from psu_213

    Unfortunately nurses look at their patients charts "just to see what happened to them" and not necessarily as a learning experience.
    How could this be proven if a nurse was brought into question? I am genuinely curious because I have looked up patients the next day--recently to see if my patient who was stroking out got TPA after I finished my shift. I was looking at his labs and the MAR. This was a violation?
  10. Visit  Kunzieo profile page
    0
    But the OP IS learning from this. She would like to know what went "wrong" in this case and could it have been prevented?

    HIPAA (ahem) allows for PHI disclosure under the following circumstances:

    1. Treatment. Healthcare providers may share information about a patient for continuity of care.

    2. Payment. Any insurance/3rd party payer has the right to pt info so they can determine how much they will pay, charge for copays, determine what and what not was a covered service.

    3. Routine Healthcare Operations. This one is more vague, but one thing that does specifically fall under this heading is EDUCATION. Hence, the OP's situation. She is EDUCATING herself about how things could have gone differently in this situation. We've all had patients that ended up doing better or worse than expected. Instead of shrugging our shoulders and wondering, why not educate ourselves? We had case studies in school; each of our patients has the possibility of becoming a personal case study. As Esme so wonderfully put it- How else would we learn?
  11. Visit  GrnTea profile page
    2
    Quote from Kunzieo
    But the OP IS learning from this. She would like to know what went "wrong" in this case and could it have been prevented?

    HIPAA (ahem) allows for PHI disclosure under the following circumstances:

    1. Treatment. Healthcare providers may share information about a patient for continuity of care.

    2. Payment. Any insurance/3rd party payer has the right to pt info so they can determine how much they will pay, charge for copays, determine what and what not was a covered service.

    3. Routine Healthcare Operations. This one is more vague, but one thing that does specifically fall under this heading is EDUCATION. Hence, the OP's situation. She is EDUCATING herself about how things could have gone differently in this situation. We've all had patients that ended up doing better or worse than expected. Instead of shrugging our shoulders and wondering, why not educate ourselves? We had case studies in school; each of our patients has the possibility of becoming a personal case study. As Esme so wonderfully put it- How else would we learn?
    Education for purposes of this discussion does not, alas, include self-directed and self-managed learning or recreational scholarship. It means participation in a bona fide educational program. Even if the OP were a student when she had this patient on the med/surg floor, she has no business peeking into the record when the patient is elsewhere; she can look at it again when the patient returns to her med/surg floor IF the patient is assigned to her then.

    Regardless of your opinion, if this is an electronic record, her electronic fingerprints are already all over it, showing date and time of her access. If the IT department and the RM department feel munificent they might not decide to whup her butt over it. If a state or national surveyor finds those fingerprints, they may not be so kind.
    psu_213 and Ashley, PICU RN like this.
  12. Visit  samadams8 profile page
    1
    Quote from leslie :-D
    actually, it's the anesthesiologist that pretty much decides if pt is candidate for surgery.
    i am wondering where this pt is with her lung ca, as she very well may be candidate for hospice...
    and certainly not major surgery.

    it's too bad, as it 'sounds' like yet, another futile and invasive intervention for this person.
    may she soon find comfort and peace.

    leslie
    Wondering the same thing Leslie.
    tewdles likes this.
  13. Visit  samadams8 profile page
    0
    Quote from psu_213
    Unfortunately nurses look at their patients charts "just to see what happened to them" and not necessarily as a learning experience.
    Looking at outcomes is part of learning.

    Again, some degree of the use of HIPAA is just reactionary. I'm not gonna wrestle anyone over though--I just think it a sad think that people can't learn. In the days before HIPAA, my colleagues, other doctors, and I learned a ton about patients through following them throughout their course in the hosptial--and through their previous records. I can't tell you the name of the person I learned X and Y over clnically speaking, but I do know that information helped us grow--and we have no idea who the people were to this day. For one thing, it's just too many patients & years, and B., there was a point where the holistic aspect of care was able to take a back seat while we looked at, well, the medical and pathological aspects of what transpired with them. Of course when they were in our direct care we employed both knowledge and a holistic approach. But there comes a time when you have to look at information and data objectively and scientifically in order to learn.

    Anyone that is just snooping so they can go back and tell someone, "Well you know what happened to Mrs. Z in ICU bed 3, . . .blah, blah, blah, isn't about learning or being professional.
  14. Visit  psu_213 profile page
    0
    Quote from sandyfeet
    How could this be proven if a nurse was brought into question? I am genuinely curious because I have looked up patients the next day--recently to see if my patient who was stroking out got TPA after I finished my shift. I was looking at his labs and the MAR. This was a violation?
    To be honest with you, I'm not sure where the burden of proof lies. Do you have to prove that you were looking at the chart as a learning opportunity? Or, does the hospital, regulatory organizations, etc. have to prove that you were just 'snooping'?

    Our hospital is certified by TJC as a stroke center. When they come for our recertification, they comb through the charts of every pt that got TPA. The EHR will specifically name who opened the chart and when. When they look closely, I'm don't want my name on that chart hours or days after I was done caring for the pt. If I want to learn from what happened, I can go through the proper channels (our department education, the stroke APN for the hospital, etc.) to get access to the chart. It is not a wise decision to decide for me to go on my own to peruse a chart and call it a learning experience.


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