seen from the other side of the bed- what's the best way to communicate this?

[rach_nc_03]

I've been thinking about posting here for weeks, trying to figure out how to handle this situation. I don't want anyone to think I'm asking for legal advice, because I'm not- I really want to find the best way to communicate what I believe could be a problem that needs to be addressed hospital-wide. I'm just not sure, and I want to see what you all think. (This is REALLY long, so I apologize- I tend to be a wee bit verbose.)

I had hip surgery last month at a well-respected private teaching hospital by a nationally respected specialty surgeon. He has patients from all over the country, and does many surgeries each day. Personally, I don't see how he gets through as many as he does, but somehow, he does it.

I had general and epidural anesthesia. When i was in pre-op, the place was jam-packed, and all the ORs were behind schedule. It was pandemonium, and the nurses were understandably stressed and rushed. Somehow, I got into the OR only 20 minutes later than scheduled. My epidural had to be re-done at least one time because I still had sensation in my operative leg. I'm well aware of the problems with epidurals, so I knew going in that it might not work correctly. But I've seen that happen with patients, and the POC is always adjusted to compensate for it.

I woke up in the PACU with excruciating pain in the hip and leg on my operative side. I looked around, and there was only one other patient in the room. I kept begging for someone to give me some pain meds, but the only person who ever responded was the anesthesiologist, who tried increasing my epidural meds. That didn't work- my other leg was completely numb, but I never got any relief from pain.

There were two nurses there, and both were at the computers, charting. I could hear them complaining about my surgeon, and how he'd scheduled too many surgeries that day, which made their day horrible. I'm sure it did! I also heard report being called in on me to the floor. Still, neither nurse would come address my pain issues. Two hours later, a transporter took me up to the floor, while I was begging for meds- I was in 10/10 pain and shaking like a leaf.

When I got to my room, it was 20 minutes until shift change. The day nurse came in, asked why I was crying- and I told her I was in 10/10 pain and had been given nothing in the PACU for my pain. She told me where my call button was, how to turn on the TV, said the night nurse would be in soon, and left. An hour and a half later, my husband tracked down my night nurse and insisted someone see me. She walked in, asked what was going on, and came back with some morphine (clearly marked on my chart as an allergy).

Anyway, it took 36 hours, a pain management team, a super CRNA who actually took the time to listen to me and get the right people involved (he'd only come by to remove my epidural catheter) and my surgeon offering to put me in a coma so they could get my pain level below a 10. Within the next 12 hours, my PCA was taken away because I wasn't maxing out the demand dose (I had no steady dose)....I was still delirious from pain, and could barely bring myself to reach the button to press it. Eventually, the surgeon had my PRN meds changed to scheduled doses, and after an extra two days in the hospital to get my pain low enough to pass the required PT eval, I was sent home. Total of six nights in the hospital instead of the regular 4.

I know we can't address the legal issues here, and I'm still on the fence about how- and if- I want to address them, anyway. I'm more worried about the fact that the majority of the nursing staff (except for one wonderful, but overworked charge nurse) really never addressed my pain independently. I'd spoken with someone else who had the same procedure with the same surgeon at the same hospital six months ago (talked to him before my surgery), and he'd reported an experience very similar to mine. He was very opioid tolerant before admission, so I assumed that was the root of his problems- but I was not (i'd only been taking 10mg of vicodin/day, PRN, for the 3 weeks prior to surgery).

there were other problems with my care- my skin wasn't assessed until 4 days post-op when I already had 3 pressure ulcers, and I wasn't repositioned for 48 hours after surgery; a pain management NP found out I had a massive rash on my back and buttocks when she helped me up for PT; a CNA kicked me while changing my bed (I was in the bedside chair), then told me I needed to move over (she refused to scoot the bed over instead); I had excoriated skin in my perineal area from never getting peri-care....lots of other things, but again, I consider these things to be due to understaffing and/or shortcomings of individual staff members. So I'm not interested in addressing those problems here (though I'm still angry about them).

My main concern here is that I believe, based on my experience and that of my friend, nursing staff is not adequately addressing pain management. To me, this is a knowledge and training problem. I'm back home recovering, progressing well now, and I'm not worried about *me*....I'll be fine. But hundreds (maybe thousands) of patients will go through that hospital each year, and the majority will be in far worse shape than me when they go in!

I'm trying to figure out *who* I should communicate my concerns to. I talked with nurse at my surgeon's office, and she said I should write a letter to the hospital president. But I kinda think that's not going to help- I don't want to just complain about the care i received- I want to let someone know that this seems like a systemic problem. Someone who can actually assess the pain management protocols for the nursing staff, and take steps to improve it.

I realize it's possible that my friend and I both had bad experiences with specific nurses, and that our experiences may not be representative an overall nursing problem. But I feel compelled to bring it to the attention of someone who can really address it.

I've thought of writing to the DON for the hospital, or perhaps to the Nursing Manager for the ortho unit (this is a specialty wing; it's only for advanced procedures, not general ortho surgeries, which are done in the main hospital).

What I *don't* want to happen:

1. the problem isn't addressed at all; or

2. the specific nurses involved are given a slap on the wrist, while faulty processes and/or training issues aren't looked at.

Am I being unreasonable? Am I somehow crossing a line between rach the RN and rach the patient? I'm a huge pain management advocate, and I think it's one of the biggest shortcomings in hospital care. I really don't know.

And, again, I'm not talking about legal issues or actions. I may or may not address such issues separately after talking to the state BON. I just worry that this may be a problem that exists beyond my personal experiences.

Am I completely out of line? Crazy? My friends and family don't understand- all they see and remember is my pain, and that's all that matters to them. But rach the nurse keeps nagging me about this!

Any thoughts?

[muffie, RN]

i wish you a speedy recovery

what a rotten experience

[VivaLasViejas, ASN, RN]

I am so sorry you went through this.

What you experienced is completely unacceptable. As a nurse yourself, you are in a unique position to help make things better for the next surgical patient, and you can do this by sending letters to the surgery department manager, the director of nursing services, the surgical floor manager, and the hospital administrator. Describe your experience as objectively and professionally as possible; the fact that your stay exceeded the 'normal' expected LOS by two days is also something your insurance company may be interested in investigating.

Of course, we can't offer any legal or medical advice here, but you may want to consider using another hospital the next time you need surgery, because the problems you faced during your stay are indeed systemic, and the institution probably needs a big overhaul from the top down. I wish you all the best, and again, I'm sorry for what you went through. I've been a hospital nurse, and I don't care HOW busy things get, it is inexcusable to ignore a patient in pain!!!

[ukstudent]

I am not really sure about this advice, but JACHO is very big on pain issues. They also have the power to get institutional changes pushed through. A call to them may get the changes you are wanting.

[TazziRN, RN]

Most definitely inform JCAHO!!

If it were me I would contact anyone and everyone who might need to know, in a CC fashion so that each person knows that others have been informed: patient relations, director of nursing, chief of medical staff (the doctor should have taken steps to insure the care was improved), the hospital administrator.

The pain management issue is the core here, but the poor skin care needs to be brought up also. I am so sorry you had to go through this.

[Jolie, BSN]

I'm terribly sorry for your experience, and thank you from the bottom of my heart for making a sincere effort to intervene on the behalf of future patients!

I would suggest a "blanket" approach, sending letters to anyone and everyone who is in a position to effect the change you rightly seek: your surgeon, the chief of orthopedic surgery, chief of anesthesia, chief of pain management, VP for nursing, nurse manager of the unit, nurse educator for orthopedics, patient advocate (if the hospital has one), risk management, your state board of health (or the agency that licenses hospitals in your state), JCAHO, etc.

Please also send a letter acknowledging the excellent care provided by the CRNA who finally addressed your needs.

Take good care of yourself, and Godspeed!

[Daytonite, BSN, RN]

Address a letter with your concerns to the Chief of Surgical Services of the Hospital as well as the Chief of the Medical Staff or the Medical Staff Services Coordinator of the Hospital. You might even send a copy of the same letter to the Chief Medical Executive Officer. This should, at least, spur them to place your case in line for a medical peer review. I'm not sure that the Medical Staff Office staff keep letters of complaints by patients against doctors in doctor's files for consideration for when those doctors are up for their regular credentialing as part of their renewal of privileges, but it should be made known to them by way of writing letters to these folks I've mentioned above. Contrary to what most people think, the actions and poor performances of physicians is tracked by the medical staff offices in hospitals and mandated by both JCAHO and Medicare.

If you do file any kind of lawsuit, it will automatically be reported to a couple of different databases, the National Practitioner Data Bank included, that track this information. This will get reported to the hospital when the doctor comes before the governing board for regular renewal of his privileges to practice there. Just like most of us have to have a criminal background check for licensure and for jobs, doctors also must submit to a similar check of these databases for lawsuit filings and settlements against them at least every two years to keep their staff privileges at acute hospitals. Element of Performance #15 under Standard MS (Medical Staff) 4.20 of the CAMH (JCAHO Accreditation Manual for Hospitals) states: "The hospital queries the National Practitioner Data Bank (NPDB) at the time of initial medical staff appointments to membership and initial granting of clinical privileges, and at the time of expanding privileges or requesting to add new privileges, as well as at least every two years thereafter for information on physicians, dentists, and other health care practitioners granted clinical privileges."

I am sorry for the suffering you endured. I had a flare reaction to an epidural that was given for back pain and had similar reactions of ignoring from both the staff and the physician. It's very frustrating when something like this happens. It makes one a better practitioner in that we tend to really listen to what patients are telling us. I am always amazed at how so many nurses are able to just "turn off" the pleas of a patient when they have no clue what to do to help them. Some nurses, huh?

[Liddle Noodnik]

Am I completely out of line? Crazy? My friends and family don't understand- all they see and remember is my pain, and that's all that matters to them. But rach the nurse keeps nagging me about this!

Any thoughts?

At the hospital where I was there is a patient advocate, maybe if you call social services they can get you the name/number. If not, your local dept of health and human services should be able to put you in touch with an ombudsman program - (or try an online search on "Ombudsman [your state]") - it isn't just for nursing homes and etc.

I am thrilled you aren't going to let this go - it is inexcuseable.

[NRSKarenRN, BSN, RN]

So sorry you went through this ordeal... It would have taken 5 minutes to have given you meds at onset severe pain upon floor transfer that would have prevented this cascade of events....lesson for all the nurses/students reading this thread.

My main concern here is that I believe, based on my experience and that of my friend, nursing staff is not adequately addressing pain management. To me, this is a knowledge and training problem.

You've laid out your concerns here well. I would use that as a basis for your letter to hospital personal stating you are filing a quality care grievance with desire to have situation addressed "to improve patient pain management and care on this unit" for future patients. Look at the hospital pamphlet given to you re who to address concerns and names of hosptial admin staff or consult hosptial website for names. Request a copy of your chart so you have personal names that can jog your memory if you want to address specific persons care.

Address and send return receipt requested to:

a. Unit Manager

b. Operating Surgeon

c. Anesthesiology Department Chair

with cc to

c. Quality Improvement Director

d. Chief Nursing Officer

e. Family doctor

I had similar situation with anesthesia personal not listening to me nor following standards of care for difficult to intubate patient 2 yrs ago.. My nice polite letter outlined my concerns included professional standards website links that showed how my care deviated from standards. Follow-up call from Administrator and Anesthesia co-chair were made to me along with written response. At follow-up visit surgeon said my letter was truly making a difference and issues were lenghtly discussed and addressed.

Letters regarding legitimate complaint sent to facilites are part of QI... JCAHO reviews to see that follow-up done/corrective action taken.

My DH too couldn't understand the situation and why I was so upset upon telling him events.... The professional in me kept saying: this situation could have been prevented if only they had listened to me.

Now that you've vented here, copy and paste to word document and get that letter writing process started!

Please PM me if need to vent further. Hope you are fully recovered soon.

[Nursonegreat]

Everything that happened was shameful and neglectful. please take the time to write/call all who has been said in above posts. if every pt who was treated like this complained, perhaps nurses would get better nurse/pt ratios and other benefits to keep all the good nurses from leaving and leaving behind bitter, overworked, shortstaffed nurses. i bet this happens a lot more than just once....and people dont know who to complain to....and most certainly NOT to defend those nurses and staff...but they did not just come out of school like that...i bet they act/treat pts like that because of the workload,hrs, u name it, cause i have seen it happen. i would actually be a little worried if i had to go to the hospital from all that i know that goes on. something MUST be done...

and where i worked there was this reknowned surgeon...and he did like 15-16 knee replacements a day...rather he had a team of like 10 people who did almost all the work...he did about 15-30 minutes per case and all the other time was from his "team" so im sure that is how your surgeon comes off on doing so many surgeries a day. best of luck and im sorry u had so much pain for so long...as i am a big time pain control backer. and if u do decide to seek legal action, wish u the best...as i think neglect is abuse!!

[Jolie, BSN]

I would also consider contacting your insurance company and letting them know of the uniformly unsatisfactory care you received. It may impact on their decision whether or not to contract with this facility in the future.

Again, best wishes to you. I sincerely hope that you ultimately experience the outcome you desire in terms of healing, mobility, function and pain control.

[Jo Dirt]

There is nothing more despicable to me than to roll your eyes (or whatever those loser nurses were doing) when someone says they are in pain. When I had surgery I remember waking up and the post-op room was very crowded and busy and a nurse said, "here is some morphine to help with your pain" and pushed the meds through the side of the heplock. I was too out of it to call her attention to it but thankfully she soon realized what she had done and fixed it, even though she was so busy. I am forever grateful to her for that.

My experience on the med-surg floor was not as good. I realize they are overworked there too but when I started vomiting I got scared and called the nurse. Someone answered the call button but no one ever came. I guess it would have been all the same had I choked to death on my own vomit. The next person I saw was over an hour later with the lunch tray.

I don't see it getting any better. It's probably less expensive to keep settling out of court than it is to hire adequate staff to care for patients.