731 Nurses Reveal What to Watch Out for in the Hospital

Consumer Reports Health.org
August 2009

You might already worry that hospitals aren't as safe or sanitary as they should be, but nurses say you don't know the half of it. That is the startling conclusion of our first side-by-side surveys of hospital conditions from two very different perspectives: those of nurses and patients.

In the surveys, conducted by the Consumer Reports National Research Center, we heard from subscribers who told us about their own or a loved one's most recent hospital stay, and nurses reported on their most recent week at work.


- Step 1: Do Your Homework
- Step 2: Plan for a Smooth Admission
- Step 3: Avoid Chaotic Care
- Step 4: Stay Vigilant for Problems
- Step 5: Plan Ahead for Discharge
- Wash up, Doc
- Whom to call
- Check up on your hospital

Their responses show that hospitals look very different depending on your vantage point. About 4 percent of patients told us they saw problems with hospital cleanliness, compared with 28 percent of nurses. Thirteen percent of patients said that their care wasn't coordinated properly, but 38 percent of nurses said that was a problem. Five percent of patients, but 26 percent of nurses, said hospital staff sometimes did not wash their hands.

In spring 2009, we surveyed a national sample of 731 nurses who cared directly for patients in emergency rooms, critical-care units, operating rooms, and other areas of the hospital. For the patient's viewpoint, in spring 2008, more than 13,540 readers told us about their own or a family member's hospital stay during the previous year.

We also collected suggestions from dozens of interviews with hospital officials, doctors, registered nurses, social workers, dietitians, and hospital pharmacists -- and patients who were willing to share their experiences with us.

Here's their combined wisdom on how to get through a hospital stay safely and with minimal confusion, from the initial choice of where to go all the way through to your discharge.

Step 1: Do Your Homework

Fifty-nine percent of patients in our survey did not enter the hospital through the emergency room, so they might have had a choice of which hospital to go to. But 65 percent simply went to the hospital their physician recommended or was affiliated with. Forty percent chose a hospital for its location, and 28 percent because it was in their health plan's network.

(Respondents were asked for their top three reasons.)

Only 11 percent chose the hospital for its record in treating their condition, and only 2 percent on the basis of the hospital's ratings in books or magazines or online. That's unfortunate, because hospital quality differs, and there's limited but growing public information about it, but you have to find it and make proper use of it. (We've listed some online sources of hospital information in Check up on your hospital.)

If you, like 99 percent of our respondents, have health insurance (our readers are not representative of the U.S. population and are exceptionally well insured), start by getting an up-to-date list of the hospitals, physicians, and specialists in your plan's network. And if you're going to have surgery, don't forget the anesthesiologists. Be sure to understand and observe your plan's coverage rules, especially any preauthorization requirements.

If you or a family member has a chronic medical condition that can lead to frequent hospitalization, such as heart disease or respiratory problems, you might benefit from research even more than people headed for elective surgery. Nonsurgical patients we surveyed, though generally positive about their experiences, were less so than surgical patients. They had more trouble getting the attention of doctors and nurses and more difficulty getting pain treatment and the information they needed about medications and diagnostic tests.

Patients who need highly specialized or technologically difficult treatments, such as surgery for esophageal cancer, a pediatric heart condition, or a brain aneurysm, should make a special effort to locate a hospital and surgeon with extensive and regular experience in that specific surgery. Research has shown that a key to a good outcome in those difficult cases is the experience of the surgeon and hospital. If you can't find what you need from the public resources we've provided, call doctors or hospitals directly and ask how often they do a specific procedure or take care of patients with your condition.

Another important piece of information that's often difficult to get: the ratio of nurses to patients. In our survey, patients who reported that the staff was responsive to their needs and who were satisfied with their overall nursing care were more satisfied overall with their hospital stay.

Other research has linked higher nurse-staffing levels with greater patient satisfaction scores and lower complication and mortality rates. "They can attend to patients' needs more quickly, respond to issues like pain management, and can probably do a better job of giving discharge instructions, all the things that go into having a more satisfied patient," says Ashish Jha, M.D., associate professor of health policy and management at the Harvard School of Public Health.

To find out the nurse-patient ratio of the hospitals you're considering, call the hospitals and ask, says Cheryl Peterson, R.N., director of nursing practice and policy for the American Nurses Association. Peterson says the association does not advocate any particular ratio, but adds, "If I was going into a medical-surgical unit and I had a nurse with more than five patients, I'd get a little worried." That could happen to you. In our survey, 31 percent of nurses reported that in an average hour on a shift they provided direct care for six or more patients.

- Check your health plan for its rules on hospitalization.
- Research hospitals online.
- Ask about a surgeon's experience with unusual or complex treatments.
- Ask about nurse-patient ratios.

Step 2: Plan for a Smooth Admission

Errors in medication are a leading cause of preventable injury to hospital patients in this country, and research suggests that mix-ups are especially likely during "care transitions," when patients are admitted, are transferred from one ward to another, or are discharged from the hospital.

But it is estimated that less than 2 percent of hospitals in the U.S. have comprehensive electronic records systems that make patient information readily available anywhere in the hospital. That means that you'll have to be your own record keeper. Rita Kobert, 51, of Fredericksburg, Va., who has a seizure disorder, learned that lesson long ago. "If I fall from a seizure or something and have to go to the hospital, I already have a printout of medications, past surgeries, things like that," she says. "If you smack your head, you're out of it for a little while sometimes."

Everyone should follow Kobert's example. Keep an up-to-date list of your current medications and dosages, including over-the-counter drugs and dietary supplements, in your handbag or wallet at all times. (Include your emergency contact information and your primary-care provider's.) Nurses in our survey said that's one of the most important things you can do to help ensure better hospital care.

If you have a chronic condition or a significant medical history, take a written summary with you, including dates of significant events, treatments, and tests, so you can fill out forms accurately.

Patients with a limited command of English should call ahead to make sure the hospital has doctors or staff who speak their language or interpreters and translated documents.

If your admission is planned, pack a small bag of personal items, including some family pictures to comfort you, and books, magazines, and a portable music player with headphones to help pass the time. Check with the hospital about cell phones and laptop computers. They're usually OK except in or near intensive-care units, where they might interfere with sensitive equipment. Ask whether there's a secure place to keep them when you're away from your room.

For safety reasons, hospitals prefer to supply all medications, says Bona Benjamin, director of medication-use quality improvement at the American Society of Health-System Pharmacists. If you're concerned that your particular medicines might be unavailable, call the hospital in advance and ask to speak with its pharmacist. If you're being hospitalized by someone other than your primary-care doctor, remember to let him or her know that you're going to the hospital. And when you get there, be sure to fill out forms authorizing the hospital to send records of your stay to your primary-care doctor. Make sure you have an "advance directive" (available at www.caringinfo.org) that gives your preferences for care in the event you are ill with no prospect of recovery and unable to express your wishes.

You might be surprised to discover that you've never met the doctor who will actually take care of you in the hospital. A new breed of physician known as a hospitalist, a specialist trained specifically to practice in-hospital medicine, might be in charge of your care. "It's likely that over half of Medicare fee-for-service patients in the U.S. are cared for by hospitalists," says Mark V. Williams, M.D., professor and chief of the division of hospital medicine at Northwestern University Feinberg School of Medicine. Although off-site doctors might come to check on patients only once a day, hospitalists are available around the clock.

Lingering trust issues remain. An editorial in the April 2009 issue of the Journal of Hospital Medicine said hospitalists are often portrayed as doctors who work "for the hospital and not the patient, an employee focused on efficiency and rapid discharge rather than continuous medical care." To allay any concerns, feel free to ask the hospitalist to consult with your regular doctor before you agree to have particular tests or procedures and to keep the lines of communication open.

If you, like 41 percent of our respondents, enter the hospital through the emergency room, expect a more difficult experience all around. ER patients and families were far less satisfied than non-ER patients with every measure of staff attentiveness, including pain control, nurses' responsiveness, having their questions answered promptly, and getting explanations of medications and tests.

Waiting time is the top cause of patient dissatisfaction, says Howard Blumstein, M.D., medical director of the emergency department at Wake Forest University Baptist Medical Center and a vice president of the American Academy of Emergency Medicine. "The longer we make you wait, the more dissatisfied you will be."

If you have a chronic condition that lands you in the hospital occasionally, try to avoid going through the ER. But don't hesitate to call 911 if you have a true medical emergency, such as severe physical trauma, difficulty breathing, sudden chest pain, serious loss of blood, a possible broken bone, a sudden inability to use one of your limbs, a loss of vision, unexplained seizures or convulsions, or a severe headache.

Summing up

- Take a list of medications and a brief health history to the hospital.
- Speak with the hospital pharmacist about special medications.
- Keep your regular doctor in the loop.
- Understand the hospitalist's role.
- Avoid the ER except for genuine medical emergencies.

Step 3: Avoid Chaotic Care

When Jim Costigan, 69, of Edison, N.J., was hospitalized in December 2008, two doctors ordered separate tests, each of which required fasting, he said. But they didn't coordinate their schedules. "I don't mind fasting for a procedure," Costigan said. "But when I wind up not eating for 72 hours, that's when it gets out of hand."

Disjointed care is seen as a problem by both patients and nurses, our surveys showed. Thirteen percent of patients and family members who monitored care told us they had problems with care coordination. Thirty-eight percent of the nurses, who have a more complete picture of what's going on in hospitals, said they saw problems in the coordination of care, such as unnecessary or duplicate tests or treatments.

Disjointed care usually stems from having multiple doctors involved in your case, which can lead to confusion and miscommunication—such as when the two doctors inadvertently condemned Costigan to three straight days of hunger pangs. A March 2007 study in the New England Journal of Medicine estimated that the typical fee-for-service Medicare beneficiary sees seven doctors each year—two primary-care physicians and five specialists—from four practices.

Uncoordinated care can also be dangerous when it puts patients at increased risk of infections and medical errors that can occur when different doctors independently prescribe drugs or order tests.

Whether your hospital stay is planned or unplanned, do your best to take along a knowledgeable family member or friend to run interference for you when you are too sick or too sedated to advocate for yourself. This person can monitor your care, ask about treatment options, and speak up for you if you can't. Most nurses in our survey also said it would help if patients or their relatives or friends kept a written log of tests, treatments, drugs, changes in condition, the names of hospital caregivers, and notes of doctors' visits.

If your admitting doctor or hospitalist isn't doing a good enough job of coordinating your care, you have some options. Fifty-two percent of nurses in our survey agreed that patients should work closely with a patient advocate, social worker, or case manager to coordinate care.

But patients usually have to ask for such help, and only 9 percent of patients and 17 percent of their relatives (12 percent overall) in our survey did so. They might not have known they can summon those allies simply by using their bedside phone

Use the call button for urgent requests, such as alerting a nurse if the patient's condition deteriorates suddenly or pain is inadequately controlled. But be aware that 34 percent of nurses in our survey said they had to take longer than 5 minutes to respond at least once in their most recent work week because of inadequate time or not enough staff or other resources.

That's not surprising, considering that American Hospital Association statistics show a shortage of registered nurses, nursing assistants, licensed practical nurses, and pharmacists. "If you don't have enough RNs on the unit, we're not going to be able to pay as much attention" or be as responsive to call buttons and requests to treat pain, says Cheryl Peterson of the American Nurses Association.

So when calling for a nurse it's important for patients and family members to articulate what's wrong. Specify whether you're short of breath, in pain, or just want more ice water, so whoever answers the request knows whether to send a nurse, an aide, or an orderly.

And if there's something you need or think you might need, let the nurses know about it an hour before they change shifts, says Laura Pike, a registered nurse in San Diego. "Sometimes patients can feel almost abandoned during change of shift," she says.

And be nice. In our survey, just 33 percent of nurses strongly agreed that patients respect nurses' contribution to their care; 78 percent said patients and relatives might find that being respectful to hospital staff would "help very much" in getting better hospital care.

"In a hospital, you definitely catch more flies with honey than you do with vinegar," says Howard Abramovitz, 51, of Brooklyn, whose mother was recently hospitalized. "You assert your rights when you have to, but if you don't need to, make nice with everybody because hopefully they'll make nice with you, too."

Summing up

- Have a friend or relative with you as much as possible during your stay.
- Keep a bedside log of tests, treatments, and consultations.
- Identify a single individual to coordinate your care, whether a physician, hospital social worker, case manager, or patient advocate.
- When using the call button, be specific about your needs.
- Be respectful to the staff, but don't hesitate to ask to speak to a nursing supervisor if you feel your needs aren't being met.

Step 4: Stay Vigilant for Problems

Just because a hospital looks clean and well run doesn't mean it is. It's estimated that more than 100,000 patients die needlessly every year in U.S. hospitals and health-care facilities, infected because of the staff's sloppy compliance with cleanliness policies or injured because simple safety checklists were not followed. In our patient survey, 7 percent said an infection developed during or within a month of their hospital stay. Of those, 41 percent said the infection extended their hospital stay; the median was six days.

Little progress has been made implementing key measures to protect patients. That's why patients and watchful family members and friends must do what they can to guard against preventable errors.

For instance, our surveyed nurses confirmed serious problems in hygiene. Twenty-six percent reported observing hand-washing lapses.

"It seems like a simple little thing, but doctors and nurses pick up a lot of nasty germs and then transmit them to other patients," Blumstein, of Wake Forest, says. "By far the best way of preventing that is to wash your hands. But it's easy to forget. So you might want to pay attention to whether or not the doctor or nurses wash their hands or use that alcohol-based hand-sanitizer stuff."

Mistakes don't stop at hand-washing lapses. Eleven percent of surveyed nurses said that in their most recent work week, they observed "incorrectly administered medication or dosage," and 9 percent said doctors had prescribed the wrong medicine or dosage. (We didn't ask whether the nurses intervened.)

Patients should take steps to protect themselves. Forty-six percent of nurses said it would help very much if patients checked the medications being administered to them during their stay. But only 28 percent of the patients and 35 percent of the family members (31 percent overall) in our survey said that they did so.

Patients we interviewed said it sometimes took a lot of persistence to get answers. "You really have to be your own patient advocate," says Duane Rayford, 50, of Desert Hot Springs, Calif. He's on kidney dialysis, he says, and has been in and out of three hospitals since October 2008. "We had to constantly ask questions like, 'What about this?' 'What happens if this happens?' 'Is there another way to do this?' 'What else can we do?' " Rayford says. Eventually he got the information that he needed.

Summing up

- Make sure caregivers wash their hands.
- Check medications and doses before you take them.
- Be insistent if you're unhappy with your care or don't understand something.

Step 5: Plan Ahead for Discharge

Your caregivers say it's time for you to leave the hospital. That's great, but it's no time to let down your guard. You're actually approaching one of the most dangerous times of your hospital stay.

Research suggests that patients who don't understand their discharge plans or how to manage their drug regimen are at increased risk of developing a drug interaction or some other problem that lands them right back in the hospital. Eleven percent of the patients in our survey were in the hospital because of a complication from a previous hospitalization or surgery. Of those patients, 19 percent said they had contracted an infection from their previous hospital stay.

Our analysis of government patient surveys found that patients gave most hospitals low ratings for discharge instructions. (In our own survey, which was not a representative sample of all patients, the vast majority of respondents said they felt adequately informed about the medications and other care they'd need after discharge and had a contact for any questions or problems.)

One way to head off problems, our nurse respondents said, is to ask the hospital's patient advocate, social worker, or case manager to help review your discharge plans. One key step is called "medication reconciliation," which consists of comparing the medications you took in the hospital with the ones you were previously taking at home to make sure you leave with the medication regimen you need, no more, no less. If you don't see medication reconciliation in your discharge plan, insist that it be provided.

Another critical step: Before you leave the hospital, schedule an appointment with your primary-care doctor within a week after your discharge. Double-check to make sure your doctor receives copies of your hospitalization records and discharge plan. In fact, it's a good idea to take copies to your appointment, just in case. Patients should get follow-up care to "make sure that they're remaining stable and that there aren't any interactions with medications and so forth," says Williams of Northwestern University.

A surprising number of people neglect that step, according to a study, co-written by Williams, which found that almost 20 percent of nearly 12 million Medicare patients discharged from the hospital were readmitted within a month. In half of the nonsurgical cases, researchers found no bill for a follow-up visit to a physician's office, suggesting that inadequate post-discharge care might have contributed to the return hospital trip, according to the study, published in the April 2, 2009, issue of the New England Journal of Medicine.

What if the hospital wants to send you home before you feel ready? Ten percent of the patients we surveyed said they ran into that problem. Of that group, 54 percent requested a postponement and 42 percent of those were allowed to stay longer.

Summing up

- Make sure you understand plans for your discharge.
- If you're not satisfied, ask for help from your hospital's patient advocate, social worker, or case manager.
- Insist on a medication reconciliation between home and hospital drugs.
- See your primary-care physician within a week of your discharge and arrange for him or her to get copies of your hospital records.