Adult Acute and Intensive Care in Hospitals
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CHAPTER 6 Adult Acute and Intensive Care in Hospitals Richard R. Hurtig, Marci Lee Nilsen, Mary Beth Happ, and Sarah W. Blackstone Introduction ments in acute care hospitals diagnose and ini- tiate treatment of acute conditions caused by accidents and injuries, illness, and disease. Acute care hospitals have specialized staff and Many acute care hospitals function equipment to provide treatment to patients like freestanding municipalities because they who present with a broad range of acute and require large, complex infrastructures in chronic illnesses, injuries, and medical condi- order to (a) coordinate the delivery of medi- tions. They vary in size, but all provide care cal care, (b) house and feed patients and staff, on a continuous 24/7 basis. Larger, special- (c) implement medical protocols, (d) manage ized acute care hospitals are sometimes known resources, (e) monitor infection control and as tertiary hospitals. They employ a team of safety issues, (f) maintain administrative and health care professionals, administrators, and financial records, and (g) continually strive support workers and may specialize in trauma to establish and maintain relationships with and the diagnosis and treatment of complex consumers and providers, as well as with out- diseases and conditions. side organizations and agencies. Their funding Health care providers in local or regional comes from different sources, including the acute care hospitals conduct assessments, carry public sector, health organizations (for-profit out procedures, attend to patients and fam- or nonprofit), health insurance companies, ily members, and maintain hospital records patients and their families, and charities. and protocols. Most critically ill patients are Smaller community and rural hospi- housed in intensive care units (ICUs) where tals often provide critical health care access they receive continuous monitoring by critical to local residents and to those living in rural care nurses and a wide range of life-sustaining areas (American Hospital Association, 2013). treatments delivered by interprofessional teams Approximately 35% of hospitals in the United (Fairman, 1992). Less critically ill patients are States are considered rural hospitals. Large treated on “step-down” and general care units, hospitals (≥500 beds) make up only 5% of where the patient-nurse ratio is greater, and the all hospitals in the United States (Centers for intensity of care is reduced. Emergency depart- Disease Control and Prevention, 2011). 139 140 Patient-Provider Communication in ensuring that patients are not subjected to The following is an example of the size “avoidable” harm, establishing good lines of and complexity of a large academic communication between patients, health care medical center. The University of Iowa providers, and hospital staff is widely recog- Hospitals and Clinics (UIHC) in Iowa nized as essential. City, Iowa, is the only comprehensive Over the years the University of Iowa academic medical center in the state Hospitals and Clinics (UIHC), the UPMC– and a regional trauma center with a University of Pittsburgh Medical Center, large emergency department. In 2012, Boston’s Children’s Hospital, the Mayo the UIHC employed 1,548 physicians, Clinic, and others have taken proactive steps residents, and fellows, and 6,673 to address the communication needs of their nonphysician employees, including patients more systematically. 1,845 professional nurses. The emer- gency department had 59,889 patient visits, and there were 32,087 acute care The Importance of admissions. The UIHC has 711 staffed beds, with an average daily census of 544 Effective Patient-Provider patients and an average length of stay of Communication in Hospitals just over 6 days. It also has seven inten- sive care units with 157 beds (Neonatal Over the course of a day, hospitalized ICU, Pediatric ICU, Medical ICU, patients and family members may need to Cardiovascular ICU, Surgical & Neuro- interact with physicians, nurses, physical science ICU, Burn ICU, and Respiratory therapists, occupational therapists, speech- Services ICU). Patients are typically language pathologists, pharmacists, medical transferred from an ICU to step-down technicians, dietary staff, social workers, pas- units when their status improves, or, toral care providers, housekeeping staff, and conversely, transferred from other care volunteers. The nature of these interactions units to an ICU if their condition deteri- often differs dramatically from the kinds of orates or they require ventilator support. conversations that occur during a routine In 2012, UIHC provided 25,967 days of visit to a doctor’s office or outpatient clinic. ventilator care. For example, hospital-based communica- tions often take place between people who Researchers have repeatedly shown that have recently met or are meeting for the first effective patient-provider communication time, come from very different backgrounds, plays an important role in the medical out- and may be under significant stress and time comes of hospitalized patients, as well as in constraints. Topics discussed during medical measures of patient and caregiver satisfaction, encounters in hospitals often relate to assess- patient safety, quality of care, and utilization ing the patient’s condition, obtaining a health factors (Gallagher, Porter, Monuteaux, & history, reducing pain, administering medica- Stack, 2013; John-Baptiste et al., 2004; Kar- tions, describing and discussing symptoms, liner et al., 2012; Lindholm, Hargraves, Fer- and explaining procedures. These conversa- guson, & Reed, 2012; O’Halloran, Grohn, & tions, while routine to providers, are often Worrall, 2012; Rogers, Martin, & Rai, 2014). unfamiliar and perhaps confusing to patients Because hospitals are expected to be proactive and their families. Adult Acute and Intensive Care in Hospitals 141 In 2012, The Joint Commission, an and comprehended their complaints, symp- accrediting body for hospitals in the United toms, and concerns. Research suggests, how- States, formally recognized the critical nature ever, that this is often not the case, especially of effective communication in hospitals and when patients have disabilities that make it promulgated a set of standards that hospi- difficult for them to speak, write, understand, tals must meet. As shown in Table 6–1, The or remember what providers are saying. Also, Joint Commission Standard Advancing effec- an increasing number of patients do not speak tive communication, cultural competence, and or understand the same language of hospital patient- and family-centered care requires that providers. Patients may come from very dif- hospitals develop ways to identify and address ferent cultural and religious backgrounds, sex- patient communication needs, offer profes- ual orientations, and past experiences. Many sional language access services, deliver infor- patients have limited health literacy and may mation in a manner patients can understand, know little about hospital forms, procedures, provide access to a support person 24/7, and and policies. These patient groups often have collect information on their patients’ language difficulty following discharge instructions, a and communication needs (The Joint Com- major cause of unnecessary hospital readmis- mission, 2010). sions (Alberti & Nannini, 2013; Halverson A common misperception of patients, et al., 2014; Karliner et al., 2012; Lindholm family members, and providers is that com- et al., 2012; Regalbuto, Maurer, Chapel, Men- munication channels work effectively dur- dez, & Shaffer, 2014; Schell, 2014). Also, poor ing medical encounters. Health care team patient-provider communication is a major members may too often assume that patients contributing factor to adverse drug reactions have understood them, and patients tend to after discharge from a hospital (Forster, Murff, believe health care professionals have “heard” Peterson, Gandhi, & Bates, 2003). Table 6 –1. The Joint Commission Identifying and Addressing Patient Needs Standard PC.02.01.21 The hospital effectively communicates with patients when providing care, treatment, and services. This standard emphasizes the importance of effective communication between patients and services. Elements of Performance (PC.02.01.21) 1. The hospital identifies the patient’s oral and written communication needs, including the patient’s preferred language for discussing health care. Note: Examples of communication needs include the need for personal devices such as hearing aids or glasses, language interpreters, communication boards, and translated or plain language materials. 2. The hospital communicates with the patient during the provision of care, treatment, and services in a manner that meets the patient’s oral and written communication needs. continues Table 6 –1. continued Providing Professional Language Access Services and Providing Information in a Manner Patients Understand Standard RI.01.01.03 The hospital respects the patient’s right to receive information in a manner he or she understands. Elements of Performance (RI.01.01.03) 2. The hospital provides language interpreting and translation services. Note: Language interpreting options may include hospital-employed language interpreters, contract interpreting services, or trained bilingual staff. These may be provided in person or via telephone or video. The hospital determines which translated documents and languages are needed based on its patient population. 3. The hospital provides information to the patient