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It’s that Time Again

Don’t be fooled by her beauty. The CDC shared this visual representation of the flu virus.

It seems like every week or so we are learning of a new way to get very sick and, well, die.  It’s not always pleasant to read the news but, even in the wake of all these new viruses, there are some old ones that command respect.

The one that immediately comes to mind is the Flu.  It is boring in comparison to Monkeypox and it doesn’t kill as many people as Covid but really, how important is it to you that your virus is interesting?  Do you care how many other people are dying when you are on life support?  

Last year, the flu wasn’t as much of a threat as it has been (and will be)..  Everyone stayed home and wore masks.  Smart people did not hang out in crowded places and N95s became available.  Jeff Bezos and delivery companies made a ton of money but I don’t begrudge them considering the alternative would have been a higher risk of contracting Covid.

Compare last year’s isolation to this year.  School’s are well populated judging by the long lines of traffic when school lets out.  People are going out again to shop and eat and visit.  The President has erroneously declared an end to the Covid Pandemic and the CDC has revoked its advice that people in healthcare facilities should wear masks.  Please note that the CDC did not prohibit masks in healthcare facilities although the department of motor vehicles might take exception if you don’t remove your mask when you take a picture when you renew your license.

So the flu is a real threat this year.  If you have never had a case of the flu, consider yourself lucky.  Death is an attractive alternative when fevers reach 104 and every muscle in your body aches.  Furthermore, the flu is contagious before symptoms appear.  That means you can go out to several family homes and give them the gift of flu before you even know you have it.  

When a nurse is out with the flu, it isn’t for a day or two.  There are no badges of honor for going to work sick with the flu.  All of the uninfected nurses have to pick up the slack (and overtime).  And flu season peaks in winter when it already takes extra time to visit patients.  Roads may be icy and the holidays and end of year tasks cause everyone to get behind.

And that’s what the flu is like for us.  Imagine the patients!

In the 2019 – 2020 flu season, the last year for which data was collected, 38M people were sick with the flu resulting in 400,000 hospitalizations and 22,000 people died from the flu or flu related complications.  The virus that causes the flu is quite adaptable and mutates often to get around immunity.  Because of the ever changing nature of the influenza virus, the flu statistics vary each year.  

The vaccine is mostly free but even if you pay out of pocket, it is cheap.  If you are an agency that doesn’t pay for your employees to get flu shots, I want you to remember this when you’re writing those overtime checks. There is no charge to Medicare patients and that includes those receiving hospice care.  Home Health and Hospice can bill Medicare although many agencies choose not to bill.  You may also administer the flu vaccine to spouses and other Medicare recipients who live in the house.  For billing purposes, there is no physician order needed.  Get an order anyway.  

With one exception, the flu vaccine is unable to cause the flu.  The exception is the nasal inhaler vaccine which does contain minute quantities of the live virus so there is a similarly small chance that it could give the flu to the recipient.  All other vaccines do not contain live virus particles. Because it takes a while for the vaccine to offer full protection, it is possible to get the flu in the week or so after the vaccine which is a good reason to get your flu shots early.  And it is possible to contract the flu after being vaccinated but these cases do not cause as many hospitalizations and deaths.

Finally, the CDC has a boatload of resource materials that you can use as teaching guides or even wallpaper.  Midway down the CDC Resource page are infographics and fact sheets.  The CDC receives billions in funding.  Make use of it. You don’t want to be known as the nurse or therapist who wasted billions of dollars and current CDC information will support any complaints about you or your agency.  

If misery could be contained in buckets, each case of the flu would fill ten or so home depot buckets.  Think about that and prevent some misery. 

It seems like every week or so we are learning of a new way to get very sick and, well, die.  It’s not always pleasant to read the news but, even in the wake of all these new viruses, there are some old ones that command respect.

The one that immediately comes to mind is the Flu.  It is boring in comparison to Monkeypox and it doesn’t kill as many people as Covid but really, how important is it to you that your virus is interesting?  Do you care how many other people are dying when you are on life support?  

Last year, the flu wasn’t as much of a threat as it has been (and will be)..  Everyone stayed home and wore masks.  Smart people did not hang out in crowded places and N95s became available.  Jeff Bezos and delivery companies made a ton of money but I don’t begrudge them considering the alternative would have been a higher risk of contracting Covid.

Compare last year’s isolation to this year.  School’s are well populated judging by the long lines of traffic when school lets out.  People are going out again to shop and eat and visit.  The President has erroneously declared an end to the Covid Pandemic and the CDC has revoked its advice that people in healthcare facilities should wear masks.  Please note that the CDC did not prohibit masks in healthcare facilities although the department of motor vehicles might take exception if you don’t remove your mask when you take a picture when you renew your license.

So the flu is a real threat this year.  If you have never had a case of the flu, consider yourself lucky.  Death is an attractive alternative when fevers reach 104 and every muscle in your body aches.  Furthermore, the flu is contagious before symptoms appear.  That means you can go out to several family homes and give them the gift of flu before you even know you have it.  

When a nurse is out with the flu, it isn’t for a day or two.  There are no badges of honor for going to work sick with the flu.  All of the uninfected nurses have to pick up the slack (and overtime).  And flu season peaks in winter when it already takes extra time to visit patients.  Roads may be icy and the holidays and end of year tasks cause everyone to get behind.


And that’s what the flu is like for us.  Imagine the patients!

In the 2019 – 2020 flu season, the last year for which data was collected, 38M people were sick with the flu.  The flu caused 400,000 hospitalizations and 22,000 people died from the flu or flu related complications.  The virus that causes the flu is quite adaptable and mutates often to get around immunity.  Because of the ever changing nature of the influenza virus, the flu statistics vary each year.  

The side effects of the vaccine are generally mild unless the recipient of the vaccine is allergic to eggs. For the majority of people any mild side effects can be treated with tylenol or ibuprofen.  It is mostly free but even if you pay out of pocket, it is cheap.  There is no charge to Medicare patients and that includes those receiving hospice care.  Home Health can bill Medicare although many agencies choose not to bill.  You may also administer the flu vaccine to spouses and other Medicare recipients who live in the house.  For billing purposes, there is no physician order needed.  Get an order anyway.  

With one exception, the flu vaccine is unable to cause the flu.  The exception is the nasal inhaler vaccine which does contain minute quantities of the live virus so there is a similarly small chance that it could give the flu to the recipient.  Because it takes a while for the vaccine to offer full protection, it is possible to get the flu in the week or so after the vaccine which is a good reason to get your flu shots early.  And it is possible to contract the flu after being vaccinated but these cases do not cause as many hospitalizations and deaths.

Finally, the CDC has a boatload of resource materials that you can use as teaching guides or even wallpaper.  Midway down the CDC Resource page are infographics and fact sheets.  The CDC receives billions in funding.  Make use of it. It would be a shame to waste billions of dollars and current CDC information will support any complaints about you or your agency.  

If misery could be contained in buckets, each case of the flu would fill ten or so home depot buckets.  Think about that and prevent some misery. 

It seems like every week or so we are learning of a new way to get very sick and, well, die.  It’s not always pleasant to read the news but, even in the wake of all these new viruses, there are some old ones that command respect.

The one that immediately comes to mind is the Flu.  It is boring in comparison to Monkeypox and it doesn’t kill as many people as Covid but really, how important is it to you that your virus is interesting?  Do you care how many other people are dying when you are on life support?  

Last year, the flu wasn’t as much of a threat as it has been (and will be)..  Everyone stayed home and wore masks.  Smart people did not hang out in crowded places and N95s became available.  Jeff Bezos and delivery companies made a ton of money but I don’t begrudge them considering the alternative would have been a higher risk of contracting Covid.

Compare last year’s isolation to this year.  School’s are well populated judging by the long lines of traffic when school lets out.  People are going out again to shop and eat and visit.  The President has erroneously declared an end to the Covid Pandemic and the CDC has revoked its advice that people in healthcare facilities should wear masks.  Please note that the CDC did not prohibit masks in healthcare facilities although the department of motor vehicles might take exception if you don’t remove your mask when you take a picture when you renew your license.

So the flu is a real threat this year.  If you have never had a case of the flu, consider yourself lucky.  Death is an attractive alternative when fevers reach 104 and every muscle in your body aches.  Furthermore, the flu is contagious before symptoms appear.  That means you can go out to several family homes and give them the gift of flu before you even know you have it.  

When a nurse is out with the flu, it isn’t for a day or two.  There are no badges of honor for going to work sick with the flu.  All of the uninfected nurses have to pick up the slack (and overtime).  And flu season peaks in winter when it already takes extra time to visit patients.  Roads may be icy and the holidays and end of year tasks cause everyone to get behind.


And that’s what the flu is like for us.  Imagine the patients!

In the 2019 – 2020 flu season, the last year for which data was collected, 38M people were sick with the flu.  The flu caused 400,000 hospitalizations and 22,000 people died from the flu or flu related complications.  The virus that causes the flu is quite adaptable and mutates often to get around immunity.  Because of the ever changing nature of the influenza virus, the flu statistics vary each year.  

The side effects of the vaccine are generally mild unless the recipient of the vaccine is allergic to eggs. For the majority of people any mild side effects can be treated with tylenol or ibuprofen.  It is mostly free but even if you pay out of pocket, it is cheap.  There is no charge to Medicare patients and that includes those receiving hospice care.  Home Health can bill Medicare although many agencies choose not to bill.  You may also administer the flu vaccine to spouses and other Medicare recipients who live in the house.  For billing purposes, there is no physician order needed.  Get an order anyway.  

With one exception, the flu vaccine is unable to cause the flu.  The exception is the nasal inhaler vaccine which does contain minute quantities of the live virus so there is a similarly small chance that it could give the flu to the recipient.  Because it takes a while for the vaccine to offer full protection, it is possible to get the flu in the week or so after the vaccine which is a good reason to get your flu shots early.  And it is possible to contract the flu after being vaccinated but these cases do not cause as many hospitalizations and deaths.

Finally, the CDC has a boatload of resource materials that you can use as teaching guides or even wallpaper.  Midway down the CDC Resource page are infographics and fact sheets.  The CDC receives billions in funding.  Make use of it. It would be a shame to waste billions of dollars and current CDC information will support any complaints about you or your agency.  

If misery could be contained in buckets, each case of the flu would fill ten or so home depot buckets.  Think about that and prevent some misery. 

Five Things 5 Days at Memorial gets Right

Seven of the eight episodes of 5 Days at Memorial have aired and thus far it stays true to Sheri Fink’s book of the same name. So far, the Apple TV series has gotten five things that may be relevant to us absolutely correct.  I recommend that you all watch the series or read the book and then talk about it in your next Emergency Preparedness table meeting.

  1. A strong leader from your organization must be chosen before a life threatening emergency occurs because regardless of what you have done, a strong leader will assume authority.  It would be in everyone’s best interest if you approved of the person. At Memorial, Anna Pou, an EMT assumed control for both Memorial and Life Care which was an LTAC leasing space from Memorial hospital. Do you really want a doctor you don’t  know or who has no affiliation with your agency running your show?  
  2. If you are fortunate to have ample warning of a natural disaster, encourage your patients to move.  Move them out of your service area if that’s what it takes.  Lose money if necessary.  For the sake of comparison, I had an LTAC client that leased space on the top floor of a building across the street from Memorial.  Prior to the storm, they moved patients to Baton Rouge. It was expensive and most inconvenient but everyone was safe.
  3. Communication sucks before, during and after a disaster.  There is no other way to state that in a ladylike or professional manner. As soon as there is an inkling of a possibility of a disaster on its way, the employees need to call the patients and families and find out where they might be should they evacuate.  Although this information is part of the admission process, things change.  For weeks after Katrina, we were getting emails from people looking for relatives and loved ones.
  4. Plans fail.  Katrina was likely a category two storm when it hit New Orleans down from Category 4 or 5 while it churned in the Gulf.  Everyone was fine the next day.  It was around mid morning when the first trickles of water from a breached levee started to flood the street.  A city prepared for a storm ended up suffering from some of the worst flooding in history.  The generators in place to maintain power were under water. Focus on keeping your patients foremost in your plan and don’t try to anticipate how a disaster will evolve.
  5. Even though plans fail, it is important to have one.  If you work for an agency or hospice provider, be available if there’s any way possible.  Know what the plan is and if you are knocked off course by an unforeseeable event, at least you will know where you should be and can work to get back on track.  

Many of you are wondering why I am stating the obvious.  It’s because many people don’t learn.  Last year, Hurricane Ida hit and one nursing home owner, Bob Dean, thought it would be a good idea to warehouse almost 800 people in a warehouse.  It flooded and the patients were moved to a dryer area.  Most patients were side by side on wet mattresses that were touching with no room for nurses to get through.  Eight people died as a direct result and more died in the following weeks.  It is impossible to care for 800 elderly patients in a dark warehouse with no electricity or running water. Bob Dean felt he was treated unfairly when his licenses were revoked.  When that was largely rejected by the public he went on to say that he suffered from temporary Dementia.  He thinks his licenses should be restored.  Maybe if he hadn’t been visiting friends in the cool dry climate of Connecticut and been out to the unsanitary (to be kind) warehouse, he would have a different opinion.

When we live through a once in a lifetime event, we tend to believe that it is just that – once in a lifetime.  These unimaginable events are exactly that – beyond the scope of our imaginations.  All we need to keep in mind is that bad things happen and our patients come first.

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The Scapegoat

I have spent the morning reading and re-reading the complaint survey related to the death of a patient who gave Vecuronium instead of Versed at Vanderbilt University hospital. Clearly the nurse made a costly mistake. She was prosecuted and convicted of two felonies.

The complaint survey was conducted almost a year after the death. Vanderbilt Hospital did not report the death so there was no reason for the surveyors to conduct a complaint survey.  The death is rumored to be reported by an anonymous tip. The irresponsibility demonstrated by Vanderbilt university in not reporting a patient death due to a medication error is a clear violation of minimum standards but don’t worry.  They have changed their policy. 

This tragic death occurred when the patient was sent for a PET scan. It is noted that the patient was received in radiology awake and alert but anxious.  That’s when the Versed was ordered.  Why pray tell, did the response to the state survey focus so intensely on the transport policy.  

Radanda Vaught gave what she believed to be Versed.  The radioactive dye had already been given and the patient was placed in a room while the dye dispersed throughout her system.  

The radiology techs acknowledged that video monitoring was in place but the cameras could not discern the movement of breathing in a patient.  Not wanting to sound callous, a patient who dies from Versed looks about the same as one who died from Vecuronium.  I can afford a Ring Doorbell and it would let me know if someone was breathing.  Can Vanderbilt University Hospital not afford a trip to Best Buy?  Even if they shelled out the cash for quality equipment, the best camera in the world is not a Registered Nurse. 

Something that was completely glossed over in all the chatter is the surveyor’s account of the interview with the radiology tech.  Please read carefully.  I have chosen to not summarize in case I am wrongly interpreting this.  

Because surveys are public information, names are substituted and frankly it can be confusing.  My assumption is the nurse who was referred to as the patient’s nurse was the one assigned the patient that morning and the nurses sent were the resource nurse (Vaught) and her preceptee.  Please read and let me know if you interpret it differently because it appears as though an ICU nurse told radiology that the patient did not require monitoring after the administration of Versed.

I don’t make this stuff up.  This is extracted from the Versed package insert in one of those ominous black boxes.

Intravenous midazolam should be used only in hospital or ambulatory care settings, including physicians’ and dental offices, that provide for continuous monitoring of respiratory and cardiac function, e.g, pulse oximetry. Immediate availability of resuscitative drugs and age- and size-appropriate equipment for bag/valve/mask ventilation and intubation, and personnel trained in their use and skilled in airway management should be assured.

So I have questions.  If the patient had her pulse oximetry monitored or a portable ekg, would an alarm have alerted staff to a problem before a transport tech happened to walk by and notice the patient was not breathing?  Monitors do not take the place of a nurse but they are better than nothing.

So, the fact that the wrong drug was given probably didn’t affect the outcome because if Versed was given according to evidence based practice standards, monitoring would have been in place and lots of alarms would have sounded and there would have been an ambu bag and someone qualified to intubate right there. 

Back to the transport policy which has been revised to include critical care patients.  As of November 27, 2018 all patients will be ‘transferred with the equipment and supplies, and staff appropriate to monitor and support the patient’s physiological needs’.  What on earth did the policy say before it was revised.

The Transport Policy also includes provisions that after arrival at the receiving department/unit, if a patient requires continuous monitoring, a clinical staff member is required to be available to receive handover of the patient pursuant to the Hospital’s CL SOP – Clinical Handover Communication.  Who might this clinical staff member be? I would hope a Registered Nurse experienced in conscious sedation would be the least qualified person allowed, assuming anesthesia wasn’t available.

Remember, the radiology department refused to give the Versed because no nurse was available to monitor the patient.  This change in policy doesn’t appear useful.

The argument against Ms. Vaught is that she fell short of accepted nursing standards.  There is no doubt in my mind.  There is also no doubt in my mind that Radonda Vaught, given the chance to practice again, will never make this or a similar mistake again.  

Vanderbilt University Medical Center, on the other hand, will continue to suffer the very bad outcomes of disinterested leadership concerned with image rather than patient care unless something has changed or will change.  

Don’t let this discourage you from reporting errors.  Ms. Vaught’s patient is not the only one who died from a med error.  Every day, med errors harm patients.  Home Health and hospice are not exceptions.  Let this be a reminder to reconcile your meds, be mindful and learn from your mistakes before they result in the death of a patient.

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