Physical Condition of Hospitals

When was the last time you spent time in a hospital ward looking closely at the physical condition of the building?

Did you notice the chipping paint? The peeling wallpaper? The cracks in the floors? The stained ceiling tiles? The upholstery that was worn thin and so stained it can't be cleaned anymore? The blinds that are missing slats and won't open or close? The curtains that are worn and stained? The bed linens that are stained? The clutter of equipment in the hallways and rooms?

I notice these things every time I step into the hospital ward I work on. I do my best to make sure stained linen is changed before my patient ever goes near the bed. That stained curtains are taken down and replaced. But it is impossible to hide the deterioration of everything else.

The patients who are admitted to hospital are acutely ill or requiring some immediate intervention. Mothers are arriving to deliver their babies. The physical environment should be one of impeccable cleaniless and condition. Yet Canadian hospitals are often falling far short of this standard under the guise of fiscal restraint. Even if the money would be spent to restore the units, there isn't any place to physically put patients while the work is done.

Can a hospital defend its infection rate and care when it can't provide patients with an environment that promotes health and healing?

Canadians give clear message on health care

As early as July 2008, Leger Marketing did a study which showed 70% of Canadians believe prescription medications are prescribed more often than necessary. The same study showed one third of Canadians do not believe the Canadian health care system meets their needs.

The lack of confidence in health care to meet their needs is a powerful commentary on the current state of healthcare in Canada. Recent changes to some provincial health care systems will result in even less ability for Canadians to access the care they need, when they need it.

Patients who enter a system when they are already doubting their care may be more likely to seek compensation for negligent care. Adding to this atompshere is the lack of trust simmering between front line staff and management. Internal strife directly impacts patient care-- and the patients know it.

A legal nurse consultant assists attorneys faced with these claims primarily through careful analysis of the choronology and the care records to determine if the facts translate into merit. This "weeding out" process helps reduce costs while also establishing a base for claims which move forward.

Changes to Care for Moms with Breech Pregnancies

The standard of care in Canadian hospitals since 2000 has been to deliver all breech babies by caesarean section. This method of delivery was based on solid research which showed the risks for potential harmful outcomes to the baby were too high for vaginal delivery. The Society for Obstetricians and Gynegologists of Canada has recently announced that this standard care will be reversed.

It is a basic premise of mechanics. The largest part of a fetus is the head-- and breech babies have their heads delivered last. There is always a risk that the head will prove too large for the mother's pelvis which results in fetal death and dismemberment as well as major injury to the mother during attempts to save the baby.

The other harsh reality is that delivery with best outcomes for mom and baby requires genuine finesse and loads of experience-- neither of which is easily found in our latest generation of obstetricians. They haven't seen or done enough breech deliveries to be good at it.

As a labour and delivery nurse in her third decade of experience, I have seen the time where breech pregnancies were delivered without a c-section. I have also seen babies severely compromised in the process when the obstetrician is not skilled enough to do it.

Two issues present themselves in the world of medical liability:

1. Will mothers be completely informed and truly understand the risks their babies face? If a delivery goes very wrong during this period of attempting to reduce the c-section rate by any means possible, can the defence argue against years of evidence that planned c-section delivery is best for the baby's safety?

2. Thousands of women were not given the choice in the type of delivery. Does this mean they have grounds to question that lack of options should obstetricians return to vaginal delivery of term breech pregnancies?

Breech deliveries are high risk, even in the operating room babies can have a traumatic delivery, cases presenting themselves over the next few years will require specialized expertise to determine if every possible factor was considered before the method of delivery was determined.

Defective Implanted Defibrillator Leads

A common procedure for people with irregular or unusual heart rhythms often receive defibrillators implanted into their chest to provide a necessary shock to maintain a healthy heart rhythm whenever necessary. It was a big, and unwelcome, surprise when the manufacturer, Medtronic, announced last year that their Sprint Fidelis leads were malfunctioning at rates that were higher than other leads. These defective leads were pulled from the implant market but cannot be changed or removed without a real risk of harm to the patient. Numbers vary depending on the source, but in the range of 87.9% to 94.3% of the leads are still in place in patients.

In May of 2009, the Heart Rhythm Society, an American cardiac physicians’ group representing MDs who implant and extract defibrillators and their associated leads, issued policy statements calling for hospitals to better police the experience and training of the surgeons who extract defibrillator leads. This is especially important given the risk to the patient to remove or change these defective leads. HRS also issued a statement calling for companies that produce the leads to do be more accountable in the tracking the performance of their devices once they’re on the market.

A legal nurse consultant can provide information for a case where there may be a suspicion of a malfunctioning cardiac defibrillator, its leads or an injury that occurred while the leads were being removed. One of the questions that must be answered is the experience of the doctor who connected or extracted the leads. While the new guidelines have yet to be determined in Canada, the training and experience of the physician may be relevant to the injury. Legal nurse consultants for the defence may be able to raise the level of experience as an avenue of defence of the doctor. Legal nurse consultants for the plaintiff will question the lack of experience of the physician as evidence of negligence.

The incidence of medical device failure is a serious one. And is definitely the type of case requiring the expertise of a legal nurse consultant.

Economy and healthcare changes bring business to lawyers

This week saw glimmers of recovery in the Canadian economy. Mortgage rates, always tied to the bond market, have started to rise and this is a sign that the slump is beginning to come to an end.

However, the healthcare industry is not going to follow that trend. Layoffs and budget cuts have begun in major hospitals at a time of increasing patient loads. Nursing shortages that were the focus of news articles as recently as two weeks ago are suddenly announced "over" by politicians seeking to justify radical changes to the voting public. Clinical educators are slated for layoffs as well which directly impacts the continuing education for nurses and other professionals.

This has been good news for nursing and other health professional recruitment firms from other countries; they have begun actively seeking to recruit our experienced, well-educated registered nurses and they are succeeding. Offers are for positions with great wages and benefits in prime locations.

How does all this bring business to lawyers?

Patient care is coming under direct duress in the current work environment and this leads to mistakes.

Management is being shifted so that managers are in charge of units in which they have no clinical experience. Management of units is being consolidated under the supervision of one manager.

Education and training programs are being cut so staff will not maintain their skill levels at current standards. New staff, already coming in without the background of a registered nurse, will not receive a consistent orientation program so their care may not reflect policies and procedures.

Hiring freezes mean no replacements for maternity leaves of up to one year, no replacements for the retiring nurses, no replacements for nurses injured on the job and no coverage for absent staff. Nurses already have the highest absentee rate in Canada and this will only increase as staff become more overworked and stressed.

Less staff on the floor means current standard nurse-patient ratios will come under pressure to change. Areas where levels of care now dictate 1:1 nursing for the optimum patient outcome may see nurses caring for 2 or 3 patients and important information on the patient's condition will be missed or delayed in being seen resulting in compromised outcomes. Even layoffs in the clerical sector impacts patient care when nobody is at the desk to answer calls from the rooms while the nurses are busy with patient care in other areas of the unit.

There are implications for the mental health of all hospital staff during this period. Rumours and awareness of the impact of these changes have created an environment of high stress, lack of concentration and decreasing commitment to an employer who cuts jobs. Stressed hospital staff simply cannot perform at optimum levels.

Legal nurse consultants have the experience of hospital nursing to know the implications for patients and families during times of high stress and staff cutbacks. They can tell the legal team what to look for to see if the employer is at fault for the care that was or was not received during a hospital stay. Legal nurse consultants can pick up the subtle wording of other nurses that provides clues about the unit activity that affected your client. They can also give advice on questions for interviews that will demonstrate the environment during the event and its impact on your client.

Legal cases involving hospitals in Canada will see an increase as acuity, activity and populations rise while staff and budget levels decrease. Are you ready with your full legal team that will best represent your client?

What happens when entire health care portfolios are gone?

Recent administrative changes to Alberta Health Services are bringing changes to the organization. Within the Calgary area, for example, Women’s Health Services no longer exist. And the word is that this may be slated to happen province-wide.

The immediate effects are seen in the absence of top level management positions to advocate for health care services geared toward women’s health care. At a time of record numbers of maternity cases, maternity units in dire need of renovation and updating and increasing demand for gynecology services, there is no leadership with a specific interest in this specialty. There has also been a hiring freeze placed on nursing staff and support staff in these areas despite clear indications that there are understaffing issues and pending retirements.

What does this mean for medical liability attorneys? It means there are going to be cases emerging as a direct result of insufficient resources to provide the standard of care expected in Canadian hospitals. The staff will not available to maintain the current standard of nurse-patient ratios. Less qualified and experienced staff will be hired as a cost-cutting bridging measure which puts patients at risk. The equipment necessary to monitor patients for their safety and best outcome will either not be available or will be outdated and not meet current standards. The physical environment of the hospital patient will deteriorate—even to the point of being dangerous from an infectious disease standpoint with such things as cracks in the floors under delivery beds and beds unable to be cleaned to acceptable standards because they are need of replacement after years of use and breakdowns.

Nurses are aware of the shortfalls of working within a hospital environment during times of economic downturns while patient populations and acuity rise. Having that experience and perspective will assist you in evaluating and building your next case involving women’s health gone wrong.

Nurses are active in risk management

I am about to begin an interesting new task on the busy obstetrical unit at the hospital. My task will be to audit medical charts of patients recently cared for within the unit-- and they need a nurse to do it.

I am excited by this opportunity because it is another demonstration of the important role nurses play within the medical industry. This is not a blame game. The risk management team for the health authority recognizes that nurses are uniquely qualified to evaluate the documentation of patient care. Not only do audits check to see if policies and procedures are being followed but also if a complete course of care can be tracked for, in this case, multiple patients under one system (mother and baby or babies).

We all learn from doing and sometimes a gentle reminder of what was missed or a congratulatory note of a task well done may lead to improved documentation that assists the legal team in a case up to twenty years down the road. On that note, what were the charting practices ten or twenty years ago? Is your team prepared to deal with "exception charting" or "SOAP" charting that were common directives then?

A legal nurse consultant cannot be a recent graduate of a school of nursing because policies, procedures, knowledge, equipment and, yes, even charting were not the same even five years ago. This is a specialty area of nursing where experience is the rule not the exception and it is an exciting opportunity for these senior nurses to use their background in a whole new way!

What role could a nurse have in a law firm?

Canadian nurses have discovered a new area of specialty-- legal nurse consulting. It can be the best of both worlds for an experienced RN. She can use her established knowledge and skills in a whole new way. She can explore employment options outside of shiftwork. She can remain an important member of a professional team that can make a difference.

Here is how a nurse works within the team:

*Strategizes with the legal professional for successful resolutions between parties involved in health care-related litigation or other medical-legal or health care-legal matters;
*Educate attorneys and/or others involved in the legal process regarding the healthcare facts and issues of a case or claim;
*Research and integrate healthcare and nursing literature as it relates to the healthcare facts and issues of a case or a claim:
*Review, summarize, and analyze medical records and other pertinent healthcare and legal documents and comparing and correlating them to the allegations;
*Assess issues of damages and causation relative to liability within the legal process;
*Identify, locate, evaluate, and confer with expert witnesses;
*Interview witnesses and parties pertinent to the healthcare issues in collaboration with legal professionals;
*Draft legal documents in medically related cases under the supervision of an attorney;
*Develop collaborative case strategies with those practicing within the legal system;
*Provide support during discovery, depositions, trial, and other legal proceedings;
*Support the process of adjudication of legal claims.

Source: AALNC

Critical Flaw Costs Lawyer Thousands

A critical flaw was discovered by a defending attorney after the plaintiff’s attorney had spent thousands of dollars bringing the case to discovery.

a. 25 yr old woman in third pregnancy with one living child; first pregnancy had a compromised outcome
b. Premature rupture of membranes at 34 weeks of pregnancy; stabilized and transferred to antepartum unit to wait for pregnancy to reach 36 weeks, a common practice at this time
c. Sudden onset of bleeding and pain at 35 ½ weeks; fetal monitoring shows fetal distress; to OR and baby delivered within 8 minutes of primary nurse entering patient’s room
d. Mother had significant blood loss but fully recovered; baby needed extensive resuscitation but died two days later
e. Claim was made against the primary physician, admitting physician, and primary care nurse. Basis of the claim was that the patient’s call for help was not answered for twenty minutes by primary care nurse. This was substantiated by the patient’s husband watching the clock on the wall of the room.

Two vital errors were made by the plaintiff’s attorney that could have been identified by a legal nurse consultant:

1. He did not ask the primary care nurse what her patient load was at the time of the incident. There had been layoffs on the unit at this time. The incident also occurred during a time of night when nurses commonly take a one hour break and patient loads can be heavy. On this night, the primary care nurse was caring for six triage patients, an early labour patient and two antepartum patients which she had told the nurse in charge was too heavy for patient safety. However, the primary care nurse was never obliged to give him this information during discovery.

2. He did not confirm the actual presence of a clock on the wall of the patient’s room for her husband to time the response time. This unfamiliarity with hospital layout and the custom of clocks on the walls of rooms in other parts of the maternity unit cost the plaintiff their claim against the primary care nurse and wasted the attorney’s resources in preparing the case as well as three hours in discovery with the primary care nurse.

Another Diet Pill Recall Alert

According to a May 1, 2009 news release by attorneys at Morgan & Morgan, the Food & Drug Administration (FDA) issued a warning to consumers to immediately stop using Hydroxycut products. Hydroxycut products, dietary supplements manufactured by Iovate Health Sciences, Inc., have been linked to serious liver injuries and at least one death. The products were sold in Canada as well.

This recent example in the product liability field is within the expertise of the legal nurse consultant as part of the legal team. Legal nurse consultants are not hired to know the law but rather to understand the injury, what caused it, its extent and how it could have been prevented. Once the free legal consultation has been completed, the legal nurse consultant can piece together vital pieces of information to assist the attorneys in evaluating the merit of each case.

Nurses have specialized knowledge and resources to assess the risks and benefits of a product, whether it was regulated and for what particular use, identify common off label uses of a product, explore the history of the product and the side effects that have been reported as well as personal patient histories which might have affected the outcome with this product. Then they can assist in the preparation of cases for legal teams faced with a large scale recall within the healthcare-related industry.

What is a legal nurse consultant?

The legal nurse consultant is a licensed registered nurse who performs a critical
analysis of healthcare facts and issues and their outcomes for the legal profession,
healthcare profession, and others, as appropriate. With a strong educational and
experiential background, the legal nurse consultant is qualified to assess adherence to standards of healthcare practice as it applies to the nursing and healthcare professions.
There is a diversity of practice settings and services performed by legal nurse
consultants nationwide.

The legal nurse consultant practices the art and science of this nursing
specialty in a variety of settings, including law firms, government offices, insurance
companies, hospital risk management departments, and as self-employed practitioners.
The legal nurse consultant is a liaison between the legal and healthcare communities and
provides consultation and education to legal, healthcare, and appropriate other
professionals in areas such as personal injury, product liability, medical malpractice,
workers’ compensation, toxic torts, risk management, medical professional licensure
investigation, and criminal law.