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?

[bethin]

I wouldn't write a letter, I'd demand to speak to the president, chief of surgery, etc. Would the board meetings be an avenue to explore? I know (at least where I work) that they're closed to employees but I'm not sure about the public.

It doesn't sound like you just had a bad day with nurses but six bad days. For a nurse to come in after you complained about the pain and only showed you the call light, tv, etc is despicable. It may be toward the end of her shift, but her duties and responsibilities don't end until she clocks out.

Please don't let this go. I'm sure you aren't or won't be the only pt with a bad experience. Wait, this was beyond bad. I wouldn't be suprised if you don't come out with some kind of emotional trauma from this. I'd be scared to have surgery again after an experience like that.

[rach_nc_03]

I am SO grateful to all of you for responding! Your suggestions about who to contact are extremely helpful- it's wonderful to have access to the wealth of experience and information the members of this board possess. Above all, the fact that you agree I *should* move forward with this bolsters my confidence immensely. I no longer feel like I'm going through this experience in a vacuum. Thank you!!

I put in a request for all of my medical records when I went for my follow-up appointment two weeks ago. I remember a few names from my stay, but only a few; I want to make sure that, at a minimum, I have dates and times straight in my head- I'd hate for something to be dismissed out-of-hand because I'm wrong about the date when something took place. (And I *really* want the name of my hero CRNA so his management can be informed of the difference he made in my care. I cannot thank him enough.)

I got the operative report when I was there for my follow-up, and interestingly, it states that my surgeon was present for, and participated in, the entire case. Hard to believe, huh?

While I was there, a couple of people from Patient Relations came by, unaware of the situation at hand (this was before the Pain Management people were called in). I know that they left business cards, and they're somewhere in the house (which has been in disarray since I got home- half of it taken over by my crutches, walker, wheelchair, bedside commode, etc.). They will most certainly be on the list of people receiving my letter. To my knowledge, they were not directly involved in getting the ball rolling to correct the problems at hand. I know that they dropped by once a couple of days later, while I was sleeping, and asked my friend (who was making sure I kept breathing, as I was VERY heavily medicated by this point) if things were ok; he told them that PM had be consulted, and they left in a hurry.

Does anyone know if Patient Relations staff actually charts in the patient records? I know that the staff member who calls them for a consult is responsible for doing so, but they (PR) told me they were on the floor visiting another patient and just 'dropped by' to see how I was doing.

On the topic of my insurance company- I actually work for my insurance provider, which contracts with the various PPOs throughout the US. The account manager for my PPO works on my floor, so I'll be able to get through to the appropriate people within the PPO who handle contracts with specific hospitals. I'm grateful that this information will be fairly easy to get- one less battle to fight.

Another good thing- we have two different companies we use for outsourcing our UR and case management. They actually called on my discharge day to ask if I wanted to transfer to a SNF instead of going home; they've been in the loop throughout the process. They were concerned that I wouldn't have enough support at home (my husband couldn't take off any more shifts, as he'd called off a couple of times during the height of the pain problems). Ready access to them (and their documentation of events) could be invaluable as this goes forward.

I mentioned that my recovery is now progressing, and I'm certain I'll be fine. I do want to point out to everyone reading this thread that my inadequate inpatient care continued to affect me after I went home. I'm behind the power curve in terms of physical therapy, and it's taking longer to reduce my pain meds. Because of this, I'm going to be out of work for longer than anticipated- I am too weak, and still too heavily medicated, to drive. I have been depressed, and I have trouble sleeping (depression and pain are both contributing factors, I think). My pressure ulcers are still not completely healed (not to mention the excoriated perineal areas- I'm like a baby with persistent diaper rash ), and I've had TWO bouts of cellulitis in my incision (complete with multiple, night-long ER visits). Was the cellulitis a direct result of the quality of care I received in the hospital? Maybe. I'm certain it was indirectly related, at least.

I remember all the times I got end-of-shift admissions, and how annoyed I was. And the times patients asked for pain meds ten minutes before I was due to clock out at the end of a long, hard day. I also think about the young, otherwise healthy patients I've had- patients I wouldn't have thought were at risk for pressure ulcers. Or those irate family members I encounter at the beginning of a shift- after the previous nurse had dropped the ball on pain management. (My husband was definitely at the end of his rope, and I'm sure he didn't exactly endear himself to some of the nursing staff.)

Like everyone else, I was taught to give the best care possible, and not ignore these issues. But I certainly never thought about the fact that *one* instance of ignoring a request for pain meds could set off a chain of events like this. We all know how easy it is to let it slide just a little- to ask the oncoming nurse to give meds to that end-of-shift admission, for example. I know, though, that if the tables get turned one day and I'm the nurse in this scenario, I'm going to remember what I went through.

Thank you all for supporting me through this. I'll keep you informed as to what happens.

Rach

[Simplepleasures]

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.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?

OH Daytonite, despite our differences, I have to say this is a JEWELL of an answer!!

[GatorRN]

Rach, I'm sooo sorry to hear about your ordeal. I've thought about you often the last few weeks, wondering how your surgery went. It's just awful that you recieved such treatment, or should I say mistreatment. I'm so dissapointed to learn that your experience was so horrific. There is absolutely no excuse for such incompetence.

As many know, I am also a huge advocate for adequate pain management. We, as nurses, do our patients a grave disservice by allowing them to suffer needlessly, when we have the means to relieve their pain. I've said it before, and I'll say it again, I think every nurse should be required to take an extra class on pain management. Not everyone is "drug seeking" many have genuine, legitimate pain issues that most certainly should be addressed, particularly immediately post op, as in you case.

I had a very bad experience after a hip replacement last year at a very reputable teaching hospital, with a world renowned surgeon. My surgeon has other surgeons from around the world come to observe/learn his particular minimally invasive technique. I, like you, had post op pain issues, skin breakdown,lack of basic nursing care, and post op complications. In addition, I woke up during my surgery! I think these teaching hospitals just get so big, have so many staff and patients that they loose sight of the basics. A sad situation indeed.

There is no excuse what so ever for that nurse to have passed you off to the next shift. I don't care if it was 20 mins or 5 mins to change of shift, she should have done whatever she needed to do to get you some degree of pain relief. And the nerve of the CNA to tell you to move instead of moving the bed to do what she needed to do...unbelievable. Basics people basics.

I don't think your being unreasonable at all. I agree with everybody else, you definately need to get on a letter writing campaign. I would not only address your pain management issues, but also your lack of basic nursing care. I would write a letter to each and every person you can think of that might actually pay heed and make the necessary changes so nobody else has to go throught what you went through.

Again, I"m soo sorry your experience was so horrific. I am glad to hear that your finally on the road to recovery. I hope that your rehab from this point forward goes smoothly and that you have no further complication. I've been where your at, feel free to PM me if you need to vent or for whatever reason. Keep us posted. Take care.

[donormom]

I am so sorry for your experience. I am 110% behind you on following up on this and not just "letting it go". Despite the fact that JCAHO considers pain the fifth vital sign, it often goes without treatment.

In our PACU they are very good about medicating before moving the pt to the wing. But our ER doesn't seem to even try to understand pain (esp. chronic pain) unless you are having a major MI or trauma!

Good luck and let us know how it goes.

Karen

[UM Review RN, ASN, RN]

After I had a surgery in a different hospital than I work in, my IV blew and my PCA was disconnected. A couple of the night shift nurses attempted to place a new IV, but were not successful. I could understand in my case why they thought I was ok, because I kept nodding off to sleep through the night, and basically, I wasn't having any pain then.

But after 8 hours without pain meds, it began to be an issue. I tried every non-medication pain control method I could think of, but could barely keep it together as everyone kinda blew it off.

Finally a spasm of pain gripped me so hard that all I could do was....

scream.

I got medicated within 3 minutes and if I'd known that was the way to get results, I probably would've done it sooner, without the least twinge of shame.

I'm very glad you're pursuing this, rach. Had I been in your position, I also would have. Best wishes for a speedy recovery, and please keep us updated.:icon_hug: