Are hospitals deadlier in July?

Published

Read this in CNN and I was wondering if any experienced nurses here, especially those that work in teaching hospitals, have seen this in their work place

Are hospitals deadlier in July? - CNN.com

oh my goodness yes!

In the past week I have had:

A patient with a heart rate of 20 with the newbies not wanting to pace or medicate because "she still looks pink" - albiet, non-responsive.

Its not that clearcut. I've been called to patients with HRs in the 20s before, only to find out later that the monitor was malfunctioning. I wouldnt break out the pacer immediately, I'd wait for a double check on the equipment first before doing so. Now, if the MD knew for sure that the HR in the 20s was legit, then yes they should have done something about it.

A patient with a co2 of 70, a resp rate of 60 and an pao2 of 55, minimally responsive - who the newbie didnt want to call anyone to intubate.

How far off is this from the patient's baseline? I've seen PCO2s in the 100s before in chronic retainers who we didnt do anything about. Did the MD just refuse to intubate and instead try BiPAP instead or some other resp support? I dont know that doing a stat intubation is the first thing that comes to mind with all patients with the blood gas you listed. Depends on the circumstances.

A NSTEMI admission who was not ordered *any* medications. When paged for the orders and advised that she was still having chest pain - an order appears in the computer for tylenol. TYLENOL. and a resulting argument on what needed to be done for this patient and that tylenol was not the appropriate medication for a person experiencing chest pain who is having an MI.

Was this REALLY an NSTEMI or just suspected? Elevated troponins by themselves dont necessarily mean NSTEMI, they are somewhat vague in terms of diagnostic criteria. I've seen patients with troponins in the hundreds before with chest pain that we didnt treat all of them as NSTEMIs.

An intern who tried to invent an "albumin replacement scale" for a low albumin level on the lab work, as if it was a K or Mag protocol and would not listen to us when we said that its really not how you go about that...

I disagree, I've worked on units before that had albumin replacement protocol prn orders in place. As long as the dose is correct, its a reasonable thing to do in some circumstances.

Arguments on why pushing someone who just starting vent weaning today, to go all day and all night, without an ABG checks and a high respiratory rate is not an OK way to vent wean someone and that you are inducing respiratory distress in an already sick patient.

I agree, the stipulations made above seem unreasonable to me.

Arguments on why if a patient was made NPO on admission because you were expecting the patient to be intubated, then 2 days later, the patient was made a DNR/DNI - keeping that patient NPO for several more days is silly. Your rationale is you don't want anything in the stomach in case you have to intubate, but you aren't going to intubate... sssooo...... you have a starving, crying patient who is dying and would just like some pudding.

I agree, but I think this is not something that deserves a page at 0300 if this issue came up on the night shift. They can wait till the next morning when the attending comes around to change the diet order.

..... I could go on and on. and this is only 8 days into the month. You get a spattering of people - you get the new ones that are super friendly, out going, excited to help out and willing to take suggestions and you get the others that do not want to listen to you at all, then get mad when you follow up the chain of command and go over their head to get things done. The lesson? - Never get sick in July, and if you do - you better hope you have a good nurse to back you up!!!

I agree, with the caveat that if all the RNs suddenly changed on July 1st and you had a bunch of new grads on the same day that you would have very similar problems and the death rate would go way up.

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Specializes in cardiac, ICU, education.
Take it easy on the new docs, lets not pretend that this problem is unique to MDs.

Very well said. Let us stop attacking all those that we work with. New nurses are just as likely to have problems, and those without a preceptor in their first year will have a 50% chance of leaving within the first year because of a host of "newbie problems."

Journal of Continuing Education in Nursing (J CONTIN EDUC NURS), 2010 Apr; 41(4): 163-71 (13 ref)

Journal of Nursing Education, 2010 Apr; 49 (4): 198-206

And my fellow nurses, please let us stop referring to CNN as a reliable source of medical/nursing research. They take the research, interpret on their own or only use parts of it to make the point they want to make to increase ratings. It ain't a story unless there is drama.

For real research, go to the researchers: The Journal of Trauma did a study regarding residents. It stated that there were increased errors but not increased mortality. Not only do new residents start in July, but new nurses in June and all new pharmacists, PT, OT, and every other May/June graduate in the health sciences. Put them all in one big pot within a 2 month period and you are headed for more errors.

Journal of Trauma (J TRAUMA), 2010 Jan; 68(1): 19-22

Abstract:

BACKGROUND: The "July Phenomenon" refers to the propensity for increased errors to occur with new housestaff, as they assume new responsibilities at the beginning of the academic year. The purpose of this study was to examine the impact of the new residents presenting in July at a high volume Level I Academic Trauma Center. CONCLUSIONS: At an academic Level I trauma center, admission at the beginning of the academic year was associated with an increased risk of errors resulting in preventable and potentially preventable complications; however, these errors did not impact mortality. Specific errors associated with this increased rate of preventable complications warrant further investigation.[/b]

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Specializes in PACU, CARDIAC ICU, TRAUMA, SICU, LTC.
I worked with a LOVELY intern the other night who knew what she didn't know, wasn't afraid to ask for help, and thanked me at the end of the shift for my patience and for teaching her something.

If only all new residents could have such humility.

You've got that right!!

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Specializes in PACU, CARDIAC ICU, TRAUMA, SICU, LTC.

When I worked in SICU and PACU, I always took the first two weeks of July off for summer vacation. Need I say why??

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Specializes in CCU, SICU, CVSICU, Precepting & Teaching.

never get sick, have an accident or schedule elective surgery in july. teaching hospitals are scary places with all the bright, shiny new doctors running around trying to prove how wonderful they are. most of them shape up into pretty good doctors sooner or later -- if they listen to the experienced rn. one of our medical directors once brought a group of newbies on a tour of the icu and said, "if the experienced icu nurse asks you 'are you sure you really want to do that, doctor?' you really don't want to do that. stop whatever fool thing you're about to do and listen to the nurse. if you don't listen to the icu nurses, they'll go up the ladder and call your resident, your fellow, your attending or me. you really don't want to be explaining to me why you didn't listen to the experienced icu nurse."

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I take it easy on them. I remember what it was like to be new. In addition to simply trying to do your job, you have no idea where everything is, and all the obnoxious, nit-picky policies and procedures you have to follow. It's scary.

Doesn't mean I don't get annoyed every now and again...

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I agree with Fibblet. It's not their fault that all the interns are new on the same day. Many of them are scared out of their minds at this new responsibility. Some handle that fear well, others not so well. Just think back to the last few new nurses you worked with - some were great and wanted to learn, others were know-it-alls you just couldn't reason with.

I'm not denying it's frustrating. I'm not denying that I haven't reacted in a way I shouldn't have at times, but they're young, they're new, they have no clue what is going on except for the book learning and little bits of rotations they've done.

One classic line I pulled on a very obnoxious intern, who turned out to be a very, very nice guy but just so unsure of himself in the beginning: "Don't **** off the nurses by talking to us like that. *We* know where everything is, *you* don't. You need us. Please and thank you go a long, long way."

I do wish though, that they would teach all new interns that when a nurse says, "are you sure you want to do that?", it's code for "Hang on a second and think about this - ask for help if you aren't sure." Life would be a lot easier for everyone, I think.

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Specializes in Med/Surg, Ortho, ASC.

"I do think there should be a different system so that all the new MDs dont just hit the wards at the same time. Let some of them start in July, some in August, some in September, etc and gradually rotate them in throughout the year."

What an outstanding, sensible idea! Unfortunately, it probably makes too much sense for healthcare administration to wrap their minds around...

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Specializes in multispecialty ICU, SICU including CV.
Very well said. Let us stop attacking all those that we work with. New nurses are just as likely to have problems, and those without a preceptor in their first year will have a 50% chance of leaving within the first year because of a host of "newbie problems."

Journal of Continuing Education in Nursing (J CONTIN EDUC NURS), 2010 Apr; 41(4): 163-71 (13 ref)

Journal of Nursing Education, 2010 Apr; 49 (4): 198-206

And my fellow nurses, please let us stop referring to CNN as a reliable source of medical/nursing research. They take the research, interpret on their own or only use parts of it to make the point they want to make to increase ratings. It ain't a story unless there is drama.

For real research, go to the researchers: The Journal of Trauma did a study regarding residents. It stated that there were increased errors but not increased mortality. Not only do new residents start in July, but new nurses in June and all new pharmacists, PT, OT, and every other May/June graduate in the health sciences. Put them all in one big pot within a 2 month period and you are headed for more errors.

Journal of Trauma (J TRAUMA), 2010 Jan; 68(1): 19-22

Abstract:

BACKGROUND: The "July Phenomenon" refers to the propensity for increased errors to occur with new housestaff, as they assume new responsibilities at the beginning of the academic year. The purpose of this study was to examine the impact of the new residents presenting in July at a high volume Level I Academic Trauma Center. CONCLUSIONS: At an academic Level I trauma center, admission at the beginning of the academic year was associated with an increased risk of errors resulting in preventable and potentially preventable complications; however, these errors did not impact mortality. Specific errors associated with this increased rate of preventable complications warrant further investigation.[/b]

If you had actually read the CNN article, you would have known they had linked the research, and if you had read the thread, you would have known that I mentioned this yesterday.

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Specializes in cardiac, ICU, education.
If you had actually read the CNN article, you would have known they had linked the research, and if you had read the thread, you would have known that I mentioned this yesterday.

Wow. You assumed a lot in your short statement. I did read the whole article. And it says a lot more than CNN revealed. The actual research done by a sociologist (??) said that there are additional reasons why there are an increase in mistakes other than new residents. But, making my point, CNN rushed to a story without reviewing all the literature that would define a professional reporter's work. They never mention how kids have a significant increase in deaths in summer because of car accidents, self-inflicted accidents, etc.

The article I put up contends such claims and says that mistakes may be up but mortality is not different. And sorry, we can't just blame the docs, it falls on us too.

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Specializes in Med/Surg.

I take the first two weeks off for vacation...which by the way I am enjoying throughly:yeah:

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Specializes in multispecialty ICU, SICU including CV.
Wow. You assumed a lot in your short statement. I did read the whole article. And it says a lot more than CNN revealed. The actual research done by a sociologist (??) said that there are additional reasons why there are an increase in mistakes other than new residents. But, making my point, CNN rushed to a story without reviewing all the literature that would define a professional reporter's work. They never mention how kids have a significant increase in deaths in summer because of car accidents, self-inflicted accidents, etc.

The article I put up contends such claims and says that mistakes may be up but mortality is not different. And sorry, we can't just blame the docs, it falls on us too.

I'm not sure exactly what you are saying here. CNN isn't a "professional reporter"? It has always been my impression that CNN is as reliable a news source as you can get as far as what is out there. How do you know they "rushed" to a story (the article they linked had been available since 2009?) And how do you know that CNN didn't do a lit review and came across the article you posted? To me, in some ways, it sounds like it backs up CNNs position if it says that mistakes are up in July as well.

The general public does not review medical or scientific research for accuracy or truths. I think it was wise for CNN to make the public aware of the fact that teaching hospitals can be dangerous places in July.

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