December 20, 2022 — My colleague and friend Karen Hunter, an informatics nurse and director at CommonSpirit Health, America’s second-largest non-profit healthcare chain, spoke with me about how her work was hugely impacted by a recent cyber attack. (Becker describes it here and here.) Their computers were immobilized. 620,000 patient records were stolen. For Karen on the front lines it was a nightmare.

Even on a normal day, the job of the informatics nurse is challenging. Typical activities include implementing and troubleshooting data systems, and supporting the clinicians who use them. They round and do check-ins, fine-tuning clinical workflows. New employees are onboarded and trained. EHR governance policies are considered and applied. Workflow changes especially during Covid are designed and deployed. Regulatory changes drive documentation changes which must be supported by data systems. When service lines are added (e.g. Karen’s organization recently added a new line of neurology offerings) these, too, must be supported. New systems builds are tested and rolled out. The job is complex and demanding.

But this was no normal day. When IT realized their systems — ten EHRs, payroll, and others — had been attacked, they took them off line to protect them and assess the damage. Meanwhile, of course, patients continued to need care. Informatics nurses functioned as runners, creating on paper the documentation needed in the various areas of clinical practice. A big one, CPOE (computerized provider order entry) — the essential step that initiates most clinical procedures — was disabled. It, too, was reproduced on paper.

The recovery process was supported by all the vendors. The FBI was summoned. Manual methods were substituted according to outage protocols that had been proactively designed to keep the hospitals running when the computers go down. Recovery was accomplished as quickly as possible. But those protocols were designed for outages of hours. It took four weeks.

During that time, charting and billing limped along on paper. When the systems came back to life, under the existing protocols, the data backlog would be entered and caught up. But after four weeks, that no longer made sense. It would have had unpredictable effects. Data must be entered in a specific sequence. For example, the revenue cycle was disrupted. Every bill starts with an order (CPOE). Later, results — for example, from lab tests — are entered. What if a lab test result was entered before the order was entered? It would be kicked out as an error. No bill would be issued.

Not only billing was disrupted; so were workflows. The labels on the test tubes had to be handwritten; barcode stickers weren’t printed when the systems were down. Sometimes RNs couldn’t read them. Neither could the machines. Quality assurance processes — usually automated — were disabled. Background processes such as confirming correct handling of chronic conditions like diabetes were also disrupted. So was patient identification. Ordinarily, tracking of patients as they move through the system (e.g. from ED to ICU) is done in sequence. This was no longer possible as each department entered its own data from the weeks of paper records and thus the systems received it out of order, defying the logic built into the software.

And it got worse. Average length of stay (LOS) is four days. How many patients cycled through during the four weeks the systems were down? Many! Was all the data collected and entered so that processing could proceed? Unlikely.

Near to my heart as a med/surg nurse is medication administration. The normal procedure relies on barcodes — we scan the med and the patient’s wristband. If there’s an error (remember the “five rights”? right patient, med, dose, time, and route), we’re warned. We nurses haven’t done it without the computer confirmation in more than a decade. We’ve forgotten how. It’s frightening. The potential for errors is suddenly like it was in the bad old days. To protect their licenses (remember Radonda?) some nurses stayed home, magnifying the difficulty.

Heroic effort by many eventually brought the systems back to life. It was painful but much was learned. Future attacks are inevitable but they will be better withstood.

Go cyber-savvy informatics nurses!

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Time management is one of the hardest parts of the job of the nurse. There is always more to do, and never enough time. Setting priorities, not losing sight of the big picture, multi-tasking (especially while juggling interruptions), and delegating are essential skills, subtle and complex, acquired only with years of experience. Here are some of the issues I’ve confronted in my own practice. Can you handle it all? Of course! You’re a nurse! Time management is what we do. But nobody says it’s easy.

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Falling is, of course, a serious health risk and one often assessed by nurses. A popular tool for this purpose is the Morse Fall Scale. It is one of many such tools offered by NurseAssess.

To use the tool, click the radio buttons and then Calculate. The degree of risk is then displayed.

A helpful web site that describes fall risk factors and hazards, and prevention strategies, is Sixty and Me. Recommended reading.

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November 24, 2021 —
With great sadness we acknowledge the passing of a giant of nursing informatics. Dr. Virginia Saba was a true visionary. “…Researcher, developer, and matriarch of the Clinical Care Classification system” (In Memoriam: Dr. Virginia Saba).

She invented CCC, the best of the coding schemes for nursing data.
I have met her, discussed this, and blogged about it and about her and again here. Here is her autograph.

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October 21, 2021 — Ageism in health care? Is that a thing? You better believe it! And none of us is getting younger.

Here is the story: a panel of experts moderated by my friend Judy Graham of Kaiser Health News, Confronting Ageism in Health Care: A Conversation for Patients, Caregivers and Clinicians.

It presents statistics and issues as well as several personal stories that make the facts and figures real. It’s an hour and a half and well worth it especially if, like me, you are old, or caring for someone who is. Or planning to be old some day.

How does health care fail us oldsters?

• We are often not involved in decisions.
• It is assumed that we are incompetent or cognitively compromised.
• We are often not heard and often not treated as fully human.
• We are omitted from clinical trials though new drugs and procedures are given to us anyway.
• Most medical education does not require training in geriatrics.
• It is often assumed that infirmity and pain are inevitable as we age and thus do not warrant attention.
• Another common assumption is that eventual relegation to institutions such as SNFs is inevitable.
• “Old people consume a disproportionate share of health care dollars.” But do we complain that children consume a disproportionate share of education dollars?

These are some of the negative results and claims of ageism and ageists in health care.

Judy’s panel talks about what ageism is and what we can do about it. On both sides of the stethoscope, this is a crucial issue.

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No, not the disease, the assessment. Now NurseAssess users can screen their patients for Covid-19 and capture their findings in the app.

The data you enter into this app screen are encoded as ICD-10-CM assessments and uploaded to your EHR when you click “Save”.

Useful and timely!

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A kinder view (The Atlantic, Sept. 2020, “How the Virus Won”) ascribes this idiotic behavior to complacency. “Vaccines eradicated smallpox and polio, and brought measles, diphtheria, and rubella to heel…  These achievements brought complacency.” In fact, I have known people of my parents’ generation crippled by polio.  Suffering and death brought by uncontrolled disease was ended by science not many generations ago. Have we already forgotten?

The evidence is indisputable. Covid death rates are inversely proportional to vaccination rates. Less vax, more death. Simple numbers. Science deniers are not “hesitant”.  They are fools. 

To my amazement, there are even some nurses among them.  “45% of Nursing Home Staff Still Unvaccinated Against COVID-19“.

We are taught — above all — to practice safely.  Do no harm.  Would these nurses infect their patients?  They should be suspended from the workplace until they’re vaccinated or the virus subsides. Especially in nursing homes!  Why do these Typhoid Marys still have licenses?

Go vaccinated nurses!

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Are you a nurse?  Of course you are;  otherwise you wouldn’t be reading this.

Do you use computers in your work?  Of course you do;  we all do, especially for the electronic medical record.

Do you design build, implement, train or support users of those systems?  Aha, maybe not;  this is a nursing specialty still in its infancy.  If you do do this, you’re a nursing informaticist.  You’re one of us.

And you should be a member of the American Nursing Informatics Association.  If you live in the Bay Area, you should also be in our local chapter, BANIA.

Why?  Many benefits, especially professional networking.  But what does that mean?

• Looking for a job or a gig?  It’s who you know.
• Solving hard problems? Discuss project strategies with others tackling similar issues.
• Share experience and wisdom.
• Keep on top of the hot issues of the day.
• See what others are working on;  you may soon work on those things, too.
• Hobnob with the movers and shakers in our industry.
• Attend conferences and see the cutting edge.

Another benefit is free/cheap CEUs (continuing education units):

• In California, to maintain our RN licenses, we are required to get at least 30 hours every two years.
• Attendance at conferences, workshops, and webinars often yield CEUs and are offered by ANIA and BANIA.

Go informatics nurses!

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We are proud to announce a valuable addition to the widely-used LOINC clinical terminology standard. This addition is the LACE scale. It identifies patients who are at risk for readmission or death within thirty days of discharge.

This is of great import to hospitals in deciding whether and when it is safe and appropriate to discharge a patient. Readmission or death of a patient within thirty days of discharge is considered an “adverse event” and can result in a financial penalty to the hospital from Medicare as a provision of the Affordable Care Act. For the sakes of both the hospital and the patient, premature discharges are to be avoided.

LACE Explained

The acronym stands for the four factors that are considered in making this determination:

    “L”: the length of stay of the admission

    “A”: the acuity of the admission (emergency or elective)

    “C”: co-morbidities (the Charlson Co-Morbidity Index)

    “E”: the number of Emergency Department visits within the last 6 months

This tool is widely used by hospitals as part of the process of deciding when to discharge patients. We describe it in detail here.

In order to capture the result of the LACE assessment in an electronic health record (EHR), a clinical coding scheme is required.  The two most popular for this purpose are Snomed and LOINC. We at Nurse Tech use LOINC for communicating with EHRs, enabling them to receive and store our nurse users’ assessments that now include LACE.

As a result of our submission to LOINC’s review process and with the permission of Dr. Carl Van Walraven, LACE’s author, LACE is now part (and, we claim, a valuable part) of an important electronic clinical terminology.

Thank you LOINC, Dr. Van Walraven, and Nurse Tech. And go nurses!

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A perennially hot topic in nursing is staffing ratios: for how many patients does a nurse care at one time? It is well-proven that keeping these low saves lives. California alone in the nation legislated nurse staffing ratios with Assembly Bill AB394 in 1999.

Of course, several factors must be considered: the acuity of the patients’ conditions and the type of nursing unit. For example, the level of care required in an ICU is higher than in a med/surg unit, so the staffing ratio for ICUs is 2:1 whereas for med/surg it’s 5:1. And, of course, when there is a pandemic everything is impacted.

Classic Struggle

Alas, as highlighted in National Nurse, the quarterly publication of National Nurses United, the Covid pandemic is driving us in the other direction. It is the classic struggle between payroll costs and quality of care.

“The California Department of Public Health (CDPH) handed hospitals a gift: permission to violate the State’s RN-to-patient safe staffing law. Under ‘expedited waivers’, hospitals can, upon mere submission of the form, increase the workload in intensive care units to 1:3, in step-down to 1:4, in ERs and telemetry to 1:6, and in medical-surgical to 1:7.”

With the pandemic, both patient admissions and acuities have risen. Nonetheless, some hospitals have actually laid off some nursing staff. As a result we are, NNU says, “…overworked and exhausted.” Is the culprit the pandemic or the opportunism of hospital management?

There are two sides to every story but I can say for certain that even in normal times, as a med-surg nurse I was at the limit of what I could do to deliver top-quality care for five patients. Today, with the added burdens of sicker patients and PPE, seven would stretch me beyond the breaking point. Something’s got to give… Let it not be our patients’ health and lives.

Who’s to blame? No one; we just serve different constituencies. Nurses serve patients; hospital management serves patients, too, but also shareholders.

Good News

Recent news is good: on Feb. 1, the California department of Public Health (CDPH) reversed itself on waivers of safe staffing ratios. That is, it no longer permits hospitals to increase nurse staffing ratios. We can resume delivering top-quality care — that’s why we are nurses!

Go nurses!

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