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JOHNS HOPKINS HOSPITAL & THE CENTER FOR INNOVATION IN QUALITY PATIENT CARE: Petitioner Appeals for Urgent Patient Safety Action
May 24, 2006

Focus:Health
Action Request:Petition
Location:United States
PLEASE SIGN THE PETITION; GO TO:  http://www.thepetitionsite.com/takeaction/938995258
How Long is Too Long for a Vital Member of the Sterile OR Team to Remain Continuously Scrubbed into Surgery Without a Break?        
         Although the general public might not understand that medical professionals, including the Surgeon, must leave the OR briefly during a lengthy Surgery, most conscientious practitioners realize that this is a normal safety measure necessary to combat fatigue. I am still trying to get a consensus of feedback, from those who must routinely face this dilemma in the OR, as to what time frame is universally accepted as the maximum period that any member of the sterile team should ever be expected to safely function while scrubbed into Surgery without a break?  

         Protocol refinements are urgently needed to prevent OR personnel being left stranded in Surgery for dangerously long periods without any relief.  In signing this Petition, please join me in my quest to convince Johns Hopkins Hospital and the Center for Innovation in Quality Patient Care that this important patient safety priority requires their most immediate action.

         I am now enrolled in the National Institute of First Assists, “NIFA,” training program to become a First Surgical Assistant, but even as a Surgical Technologist, performing the “Scrub” role, I had to concentrate on anticipating the Surgeons needs during a case.  After how long would you consider that Scrub role jeopardized by fatigue to the point where I might have lost concentration and focus on the operation? Is 6hours of metilulous attention to the demands of a Surgeon and maintaining the sterile field still within the bounds of safe patient care?  But, after 8hours of continuous duty standing in Surgery has this demanding OR task become a torturous and dangerously unacceptable ordeal? 

         Can we really afford to take such risks and blithely talk of the increased incidence of medical errors as if these issues were completely unrelated?

         While a Surgeon can, and should, demand that the person assisting them in Surgery is relieved briefly during a lengthy case, Nurses and Surgical Technicians fall under the control of OR Management.  This leaves them vulnerable to the vagaries of inappropriate OR coverage as determined by the Hospital. As a consequence of Hospital “downsizing” to cut costs, "redundancy of personnel" has been severely limited. This has reached the point where during the off-shifts, especially at night and on weekends, there are no free staff to break people out of Surgery for even a quick run to the bathroom!  

         At an inner city Level One Trauma Center these off-peak time periods are covered by a minimal compliment of essential, highly experienced medical staff, who must frequently deal with critical trauma cases, emergency returns to the OR and major Transplant Surgery.  This was my regular OR shift assignment at my former Hospital for the last 2years of my 5year tenure. With just one Nurse and two OR Techs on duty after 11:30 PM on a Saturday night, this challenging shift already required knowledgeable, highly adaptable and versatile staff. However, inhumane levels of endurance plus the ability to tolerate severe deprivation should not represent an essential component of any normal job assignment!  
                                     
         The real question is, can critical OR personnel fully maintain concentration during complex cases under such radical extremes as 12hours continuously scrubbed into Surgery?  The current lack of redundancy among Nursing personnel is harmfully impacting ICU’s and other critical care units of many US Hospitals, but the physical limitations are severest in the OR. To determine if a similar problem exists in NHS Hospitals in the UK should the British also now consider reviewing their "Operating Theatre" regulations and protocols?
  
         Calling in call team people just to provide OR relief breaks is considered an unnecessary expense, despite the fact that there is a clearly established link between staff fatigue and medical errors.  The sterile team scrubbed into Surgery must remain trapped without food or water until they are relieved which, after 8hours, represents an unacceptable deprivation strain on the body. For those who are unaware, no food or beverage is allowed into an OR, although it's extremely difficult to consume anything during Surgery, totally "hands free” while wearing a surgical mask! The inability to urinate when necessary is very unhealthy too and may predispose repeatedly abandoned staff to a UTI or other significant medical problem.

         To simply “break scrub” and leave the OR without handing over to an assigned relief Scrub and completing the necessary “counts” is considered "patient abandonment."    However, there are currently no real safeguards within the existing US employment laws or OCHA standards to insure that critical Hospital workers, including those in the OR, are not left for hours of continuous, and dangerous, practice without a break.   Under employment laws in most US States:
“breaks are at the discretion of the employer.”  

         I was left stranded at the field without relief for 8, 10 and on the worst occasion 12 hours straight during a Liver Transplant case while my patient was on bypass!    I regularly covered all their irrefutably least desirable off-shifts in the OR of a busy downtown Hospital famous for its active transplant program. We saw more penetrating Trauma than any other facility in Baltimore, a city with a homicide rate that averaged well over 300 a year.

         These unsafe abandonment situations impacted my ability to concentrate as my blood sugar plummeted.   Each time I reported becoming sick, dizzy and faint, to the point of nearly passing out. My Nurse Manager wanted me evaluated for a “sugar problem,” and I was asked, “who needs to eat at night anyway?”  When I dared to complain that my condition in response to this hardship presented a danger to my Surgical patients I was targeted for removal, forced to take unpaid leave and then fired. 

         Incidents where any member of the OR team is forced to remain on task for that long should be documented in an “Incident Report,” as an extreme of this magnitude presents an unacceptable, and in most cases unnecessary,  danger to the patient.  How many normal human beings are expected to go for 12 hours without water, food or urination? The Geneva Convention strictly prohibits such inhumane treatment of working POWs!  Why is this acceptable for critical Hospital staff?  

         I offered this mandatory Incident Report requirement suggestion to my former Hospital via their Compliance Line, only to be ignored as a terminated and vilified unreliable informant. I then presented the same information a suggested remedy to the Maryland Board of Nursing only to face a similar incomprehensible rejection. Healthcare facilities know all too well that the most effective way to deal with legitimate patient safety concerns and negligent under-staffing complaints like this to just: “shoot the messenger!” 

         Compliance Lines were established in the late 1990s to allow employees to report negligence, fraud and abuse without any fear of retaliation. But, have these Hospital appointed Compliance officers now become another valuable layer of defense from rigid external scrutiny?  No current legislation exists to fully protect Healthcare Whistleblowers. Clearly Hospital Compliance Lines cannot always be trusted with rigorous, impartial, internal investigations when their own facility comes under fire. Knowing there is no potential possibility of independent oversight why should they bother to investigate?

         The campaign of silencing a dissenter goes on long after they have been ousted in disgrace.  I contacted JACHO and several other Accreditation Agencies besides the Maryland Board of Nursing, but my dire warnings were easily discredited by my untimely, deliberatly conspicious, removal from my job.  

         A minor protocol change must be enacted immediately to prevent future incidents like this from becoming even more commonplace exposing OR patients to potential harm through preventable negligent under-staffing.  Despite the still unproven transgressions that supposedly put my own professional credibility into question, I cannot understand why so many US Government agencies have remained so complacent in adamantly refusing to review this under-staffing situation rationally and in the best interests of public safety.

         There is a lot of talk about medical errors right now, but far less mention of the current toxic work environment that is increasingly encouraging mistakes.  This situation is getting steadily worse.   While “At Will” employment laws silence those who dare to speak out, mandated overtime and lack of a humane break policy condones driving Hospital staff until they drop. 

         Is it such a big shock that fatal or debilitating medical errors and “sentinel events” are on the increase?   Is it any wonder that a sponge or an instrument is inadvertently left inside the patient when the Scrub is almost comatose after a stressful 12hour ordeal in Surgery?  All the rigorous cross checks and elaborate safeguards are completely irrelevant if the Hospital staff are trying to function while they are so severely fatigued, hypovolemic or hypoglycemic that they are at the point of either falling asleep or passing out.  Even a genuinely delinquent OR Tech. could attest to this painfully obvious fact.  

         When will the Nursing Boards and the various Patient Safety Advocacy Groups in the US finally address this very real problem and insist on proper protective legislation?  There have been advances recently with limiting the Residents working hours and trying to stop mandated overtime for Nurses.  But, much more emphasis must be placed on eliminating unnecessary fatigue among all of our Medical staff.  

         Unit Managers must be held responsible for providing adequate personnel to cover all of their shifts, including a safe redundancy of staff to relieve OR teams during Surgery and in other critical areas.    
If a Manager’s failure to provide relief was documented on a routine basis this shameful practice would no longer be an acceptable form of staffing coverage!   Such incidents would become the rare exception, confined as they should be, to genuine emergency situations where there is absolutely no other alternative. 

“No one is more important than the patient unconscious on the OR table.”      
         This was the statement that I gave to Hospital Lawyers at an Arbitration Hearing to determine my reinstatement.  For this well respected Maryland Hospital the “Nursing Shortage” was a very convenient excuse to justify unconscionable Managerial abuse that seriously endangered my patient in the OR. They claimed that the ER was busy and I had not asked for a break! The ER is an unrelated clinical area and just try begging for relief on a phone you cannot even touch!   Doctors, Nurses, Technicians and other Medical personnel face severe discipline when mistakes occur, but why isn’t an abusive Manager, implementing a negligent Hospital policy that condones drastic staffing cut backs ever recognized as the real culprit?  

         In some cases misguided administration policies even offer financial bonuses to further encourage self-serving Managers to implement grossly inadequate staff coverage: greed works!  Then, after clear indications demonstrate that deliberate under-staffing is continually putting patients at serious risk, they fail to hold repeatedly abusive Managers accountable as they drive dedicated staff until they drop.  

         This dangerous Managerial policy is focused purely on drastically reducing vital staffing costs to save money at the expense of creating a safe patient care environment that saves lives.  We must put proper safeguards in place to curb this negligent profiteering strategy before more Surgical patients are put at unnecessary risk of serious harm.  Medical staff in other clinical care areas deserve equally humane treatment and consideration of their basic needs so that they can focus all of their valuable attention on providing safe patient care.

         Additionally, when any Healthcare employee is courageous enough to come forward and expose a pattern of ongoing negligent under-staffing practices, or other significant dangers to patient safety, they must be protected from retaliatory Managerial misconduct that threatens their job.   If a Hospital’s internal Compliance Hot Line fails in their crucial self-policing obligation by refusing to investigate negligence or provide protection from retaliation they must be held fully accountable for this refusal to cooperate.

         Whistleblowers should not face the third degree from our US Government Agencies who are all too easily fobbed off with fictitious excuses implying that an informant might be just some “disgruntled former employee intent on revenge.”   In reality, few will risk jail time to “seek revenge” by making sworn statements under oath to a States Attorney! 

         The primary duty of accreditation agencies is to protect public safety.  They cannot therefore, afford to ignore information or evidence based on self-serving opinions: all complaints and allegations must be taken seriously.   No medical institution, no matter how iconic, prestigious, or powerful should be immune from rigorous scrutiny, as this lack of oversight simply encourages bending of the rules, ignoring regulations and cost-cutting that is harmful to safe patient care.  

         Relentlessly abusive Managers are a remarkably valuable tool in generating increased revenue by facilitating staff downsizing without obvious layoffs. I call this the spineless approach to cost-cutting, but it makes our Hospital working environment extremely dangerous for the patients.  The current so called, “Nursing crisis” has come about through a deliberate and calculated policy of dangerous downsizing to target Nursing staff, but particularly the most experienced Nurses who are higher paid.  Minimally trained assistive personnel are plugging the gaps, working under the direction of overwhelmed new Nurse Graduates who are being forced to take on responsibility they are ill-prepared to face. 

         The creation of a toxic work environment is driving Nurses to leave their chosen profession in droves.  When these Nurses are powerless to change under-staffing, and then powerless to report negligent practices, the only way to refuse to participate or condone the dangerous policy of keep taking unnecessary risks with patient care is to leave: hence the Exodus.  

The US does not have a “Nursing Shortage” it has a “Nursing Exodus!”  

         The US healthcare industry is still consistently expecting all of our medical professionals to take bigger risks by making do with unsafe staffing practices. This vital patient safety issue desperately needs to be addressed immediately.

         Please join me in appealing to Johns Hopkins and the Center for Innovation in Quality Patient Care for their help.   The Dean/CEO of Johns Hopkins, Dr. Edward D. Miller, may be contacted at: (410)955-3180 or via e-mail: emiller@jhmi.edu and the Medical Director for the Center for Innovation in Quality Patient Care, Dr. Peter J. Pronovost may be contacted at: (410)955-8032 or ppronovo@jhmi.edu  (These are all publicly available contacts.)  In addition please draw their attention to this important issue by signing the Petition and posting your comments on this subject directly into the Petition itself.

TO ACCESS THE PETITION DIRECTLY FOR SIGNING AND COMMENTARY; GO TO:  http://www.thepetitionsite.com/takeaction/938995258

.        The author is still struggling to overcome the severe damage that wrongful termination as a Whistleblower has inflicted on her professional reputation.  She has recently returned from Tsunami ravaged Aceh Province, Indonesia where she worked as an unpaid NGO Medical Volunteer in Surgery at Cut Nyak Dhien Hospital in Meulaboh. Above, and on the Petition itself Kim is pictured wearing a flimsy ER cover gown over her scrubs in Surgery at this minimally equipped disaster zone Hospital. She is pictured with Indonesian Medical Volunteers, Dr Adityo, and Tre an NGO translator, calling home from  PACTEC at the UN Compound in Meulaboh in her recent Care2Share explanatory letter of appeal.  
To Access this, GO TO. http://www.care2.com/c2c/share/detail/91853 
         This conscientious and dedicated Medical professional is now urgently calling for your help in the hopes that her Petition will at last precipitate meaningful debate on important issue like Under-staffing, Compliance and Whistleblower protections for all US Healthcare employees; eventually becoming a catalyst for new legislation of vital regulatory safeguards.  While this will be gratifying, just to make a tangible difference, personal vindication might remove the remaining barriers that still prevent her from reestablishing a worthwhile career as an NGO Medical Volunteer overseas. The author is also in the process of writing a book called: “ICONIC IMMUNITY,” detailing her experiences and the lessons learned.   Please feel free to e-mail your comments to her at:               
Kim L. Sanders-Fisher    -  MedicIntegrity@Care2.com   
Visibility: Everyone
Posted: Wednesday May 24, 2006, 4:50 am
Tags: human rights medical safety nursing exodus nurses healthcare workers patient employee protections safeguards working-hours [add/edit tags]

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Heidi T. (353) 		Friday June 16, 2006, 10:52 am
My first thought before reading the entire post is that during complicated surgeries doctors may not actually be able to leave for any amount of time. There is also the issue of objects being left behind, like gauze and tools, that can cause many complications and even death. I think rotating doctors during surgery for doctors to wash may seem like a good idea, but usually there is a shortage or staff... I will read on!

Heidi T. (353) 		Friday June 16, 2006, 11:11 am
I sent this to you as an IM but decided to post it: Excellent petition Kim. I will pass it on and sign.

I agree with your petition. No one can safely work without breaks, water, food, or bathrooms breaks! I have a problem with interstitial cystisis so I totally empathize with you!

Oprah featured a show on surgical errors, where items were left behind in the body and infection followed. Very scary!

How do you think the OR compares to the past, say 40 years ago? Were there enough staff members then? Were people able to take breaks? Did they feel the same fatigue and make errors as well?

I have noticed a huge trend in people unable to perform tasks that previous generations appeared to be able to cope with. I know that our generations have a lot more to cope with, our lives are not so simple, they are complex and very demanding socially and technologically.

Heidi T. (353) 		Friday June 16, 2006, 11:15 am
I sent this to you as an IM but decided to post it: Excellent petition Kim. I will pass it on and sign.

I agree with your petition. No one can safely work without breaks, water, food, or bathrooms breaks! I have a problem with interstitial cystisis so I totally empathize with you!

Oprah featured a show on surgical errors, where items were left behind in the body and infection followed. Very scary!

How do you think the OR compares to the past, say 40 years ago? Were there enough staff members then? Were people able to take breaks? Did they feel the same fatigue and make errors as well?

I have noticed a huge trend in people unable to perform tasks that previous generations appeared to be able to cope with. I know that our generations have a lot more to cope with, our lives are not so simple, they are complex and very demanding socially and technologically.

Heidi T. (353) 		Friday June 16, 2006, 11:29 am
I sent this to you as an IM but decided to post it: Excellent petition Kim. I will pass it on and sign.

I agree with your petition. No one can safely work without breaks, water, food, or bathrooms breaks! I have a problem with interstitial cystisis so I totally empathize with you!

Oprah featured a show on surgical errors, where items were left behind in the body and infection followed. Very scary!

How do you think the OR compares to the past, say 40 years ago? Were there enough staff members then? Were people able to take breaks? Did they feel the same fatigue and make errors as well?

I have noticed a huge trend in people unable to perform tasks that previous generations appeared to be able to cope with. I know that our generations have a lot more to cope with, our lives are not so simple, they are complex and very demanding socially and technologically.

Heidi T. (353) 		Friday June 16, 2006, 11:39 am
I completely agree that it is the end result- Doctors, Nurses, Technicians and other Medical personnel face severe discipline when mistakes occur- that is always focused on instead of the root cause of the 'mistakes'. It always seems to go this way for every situation! The issue then becomes something else, about personel accountability instead of personel working conditions. This only breeds contempt and anger in personel- and this is what will hurt the patients the most in the end! The medical system will created staff who no longer care about their patients because their own wellbeing is being jeapordized and exploited. Personel must be treated well in order to have good results!

Heidi T. (353) 		Friday June 16, 2006, 11:40 am
I completely agree that it is the end result- Doctors, Nurses, Technicians and other Medical personnel face severe discipline when mistakes occur- that is always focused on instead of the root cause of the 'mistakes'. It always seems to go this way for every situation! The issue then becomes something else, about personel accountability instead of personel working conditions. This only breeds contempt and anger in personel- and this is what will hurt the patients the most in the end! The medical system will created staff who no longer care about their patients because their own wellbeing is being jeapordized and exploited. Personel must be treated well in order to have good results!

Heidi T. (353) 		Friday June 16, 2006, 11:44 am
I completely agree that it is the end result- Doctors, Nurses, Technicians and other Medical personnel face severe discipline when mistakes occur- that is always focused on instead of the root cause of the 'mistakes'. It always seems to go this way for every situation! The issue then becomes something else, about personel accountability instead of personel working conditions. This only breeds contempt and anger in personel- and this is what will hurt the patients the most in the end! The medical system will created staff who no longer care about their patients because their own wellbeing is being jeapordized and exploited. Personel must be treated well in order to have good results!

Heidi T. (353) 		Friday June 16, 2006, 11:46 am
I completely agree that it is the end result- Doctors, Nurses, Technicians and other Medical personnel face severe discipline when mistakes occur- that is always focused on instead of the root cause of the 'mistakes'. It always seems to go this way for every situation! The issue then becomes something else, about personel accountability instead of personel working conditions. This only breeds contempt and anger in personel- and this is what will hurt the patients the most in the end! The medical system will created staff who no longer care about their patients because their own wellbeing is being jeapordized and exploited. Personel must be treated well in order to have good results!

Heidi T. (353) 		Friday June 16, 2006, 11:50 am
I completely agree that it is the end result- Doctors, Nurses, Technicians and other Medical personnel face severe discipline when mistakes occur- that is always focused on instead of the root cause of the 'mistakes'. It always seems to go this way for every situation! The issue then becomes something else, about personel accountability instead of personel working conditions. This only breeds contempt and anger in personel- and this is what will hurt the patients the most in the end! The medical system will created staff who no longer care about their patients because their own wellbeing is being jeapordized and exploited. Personel must be treated well in order to have good results!

Heidi T. (353) 		Friday June 16, 2006, 11:54 am
I completely agree that it is the end result- Doctors, Nurses, Technicians and other Medical personnel face severe discipline when mistakes occur- that is always focused on instead of the root cause of the 'mistakes'. It always seems to go this way for every situation! The issue then becomes something else, about personel accountability instead of personel working conditions. This only breeds contempt and anger in personel- and this is what will hurt the patients the most in the end! The medical system will created staff who no longer care about their patients because their own wellbeing is being jeapordized and exploited. Personel must be treated well in order to have good results!

Heidi T. (353) 		Friday June 16, 2006, 11:59 am
I completely agree that it is the end result- Doctors, Nurses, Technicians and other Medical personnel face severe discipline when mistakes occur- that is always focused on instead of the root cause of the 'mistakes'. It always seems to go this way for every situation! The issue then becomes something else, about personel accountability instead of personel working conditions. This only breeds contempt and anger in personel- and this is what will hurt the patients the most in the end! The medical system will created staff who no longer care about their patients because their own wellbeing is being jeapordized and exploited. Personel must be treated well in order to have good results!

Heidi T. (353) 		Friday June 16, 2006, 12:02 pm
I completely agree that it is the end result- Doctors, Nurses, Technicians and other Medical personnel face severe discipline when mistakes occur- that is always focused on instead of the root cause of the 'mistakes'. It always seems to go this way for every situation! The issue then becomes something else, about personel accountability instead of personel working conditions. This only breeds contempt and anger in personel- and this is what will hurt the patients the most in the end! The medical system will created staff who no longer care about their patients because their own wellbeing is being jeapordized and exploited. Personel must be treated well in order to have good results!

Heidi T. (353) 		Tuesday June 20, 2006, 1:49 pm
Kim, please delete all the triple posting in your share! It seems that my other messages were not posted. How bizarre!

Luisa S. (135) 		Monday July 31, 2006, 2:12 pm
I signed and a lot of my friends did as well. We have forwarded it also.

Lisa T. (31) 		Tuesday August 1, 2006, 9:27 am
But what if a doctor leaves for too long? And the patient suffers that way? What if the anesthesiologist up and leaves during the surgery?My question is not how long can they go without a break but also how long of a break is too long?

Lisa

Marna Rautenbach (28) 		Wednesday August 2, 2006, 11:42 pm
Hi there it looks that every were in the world there is this acridetation system that just does not work there is always a shortige of nurses, then when other nurses from the agensies is booked they don`t even know how to do the work, talking about RN that don`t know how ti give medication, puting the ball back into the hands of the permanent staff to work more hours than they can cope with. You have all my sympthy and I hope the situation changes soon but I am not to hopefull but something drastic has to be done.I have signed your petition although I live in a nother country I think merdical staff from botten to top is staring the same criseses in the face.

Hannah Sanders (9) 		Thursday August 24, 2006, 3:55 am
dear Kim, I agonize w/ u however, I also am close friends with several drs. 3 of which r surgen, 1 gen., 1 sports, 1 reconstructive. The latter and I have had long talks over dinners, we lived together about her surgeries and one of my questions was about food and bathroom needs, she assured me they took breaks. Now she worked in San Francisco at a small private hospital. Now I will have to go to my RN Sis, and Friend who I a Nurse Practioner both in the baby delivery line ask how their lives are. Yours sounds gasely. h.s.

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Kim Sanders-Fisher
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