HEALTH CARE ETHICS

: HEALTH CARE ETHICS

p The project involves the following skills acquired in your previous courses

- assessment of healthcare organizations

-planning a project to address a healthcare organization problem

1 . Assess an institution at the unit , department or division level for management related needs

2 . Identify a health care management situation or problem to address (HEALTH CARE ETHICS SITUTATION- IN HOSPITAL /CLINIC

3 . Conduct literary search of the identified problem (HEALTH CARE ETHICS ISSUE

4 . Identify and discuss the administrative /managerial , legal , ethical financial implications of the problem

(HEALTHCARE ETHICS ISSUE

6 . Develop a plan to implement the proposed project (TO FIX THE ISSUE

7 . Identify and discuss the potential for success of the proposed plan and the obstacles or pitfalls that may prevent success of the proposed plan

8 . Discuss solutions to the obstacles or pitfalls to success of the proposed plan

9 . Submit a final written project

Structure of Final

The final will have the following subheadings

(1 ) Introduction (background and context of the problem /concern

(2 ) Objective : The objective of this is to-------

(3 ) Methodology : How did you perform the literature search ? Mention databases and other major sources , as well as the search strategies (including search engines , and key words /phrases ) used

(4 ) Findings : Synthesize the major issues , themes and supporting information from the literature

(5 ) Plan outline : Based on the information gathered from the literature outline the plan addressing the problem

(6 ) Conclusions

(7 ) References : Note that all references must be properly cited in the body of the . Identify at least 15 references and there should be at least 3 peer-reviewed journal articles among them . Additionally , most of your resources should have been published in the last 5 years

Introduction

The Trauma Care Center X in Miami is one of the biggest emergency medical care units in the US and the World . It is a part of the Hospital Y and functions as a mini-hospital within the premises of the hospital (University of Miami , 2007 . Thousands of people use this facility every year . It works in collaboration with the Department of Surgery , University of Miami . The Center has received a Level 1 Certification from reputed accreditation organizations , and remains to be one of the few with such certifications in the region . More than 3600 patients get admitted every year , out which about 1000 are from weapon injuries and the remaining for road-traffic accidents (University of Miami , 2007 . The trauma care center was founded in the year 1992 Many medical teams from other countries have visited the organization to study the set up . The facility is located in a four-storey building and occupies about 160000 square foot area . The trauma care center provides world-class facilities without much concern for finance . The funds are usually provided by the public health trust . Several emergency services such as resuscitation , emergency surgery , diagnostic and medical treatment , intensive care , rehabilitation , CT and MRI scans , recovery services , etc , are provided at the trauma care center (University of Miami , 2007 . The center is open 24 hours a day , seven days a week The trauma care network of Miami uses emergency mobile services to locate the position of the person needing immediate medical care Paramedics stabilize the patient and bring them to the trauma care center . The paramedics inform the surgical team of the condition of the patient . The surgical team gets ready to provide care to the patient on arrival . Ambulances and helicopters are utilized to transfer the patient to the trauma care center . The trauma care center provides training and research facilities to paramedic and other support personnel . The trauma care center employs surgeons , physicians , nurses anaesthiologists , radiologists , burn care specialists , orthopedic surgeons , neurosurgeons , cardiac and thoracic surgeons , oral and maxillofacial surgeons , hand surgeons , pediatric surgeons intensive-care specialists , radiographic technicians , support staff , etc (University of Miami , 2007

The trauma care center receives funds from the University , insurance reimbursements , patient collections , the associated hospital and the public health trust . The public health trust was founded in the year 1973 (JHS , 2007 . Citizens are the members of the trust who form policies that ensure the organization works towards fulfilling the needs of the community . The trust performs planning between the organization hospital , community and the university . In the year 2003 , major changes were made to the structure , number and responsibilities of the public trust . The center also executes several projects in collaboration with the Department of Transportation , Trauma Research Centers and Burn Research Centers (JHS , 2007 . This Organization also provides funds for these projects . More than 300 patients visit the trauma care center every day for medical help (JHS , 2007

The first floor of the center houses resuscitation facilities , Imaging rooms , and recovery rooms . The Second floor houses the intensive care units , and a computerized trauma research center . The third floor houses and inpatient facility and the fourth floor contain an inpatient rehabilitation unit . More than 150 beds are present in the hospital (JHS , 2007

One of the major problems the trauma care center is facing is regarding excessive patients . There has been a sudden increase in the need for emergency treatment in Miami . The physicians and other healthcare staff seem to be insufficient to handle the excessive number of patients . Due to this , the quality of care provided seem to decrease , the chances of error are even greater and often it is very tough for the physician to interact with the patient or their families and seek consent for treatment

Objectives :-

The objectives of this project are to :-

To improve the facilities (such as emergency care , intensive care emergency surgery , CT , MRI and other diagnostic imaging , inpatient neurosurgery , rehabilitations , etc

To provide highly specialized and life-saving care to local population in time of need

To create an environment in the center conducive for training and research of various healthcare personnel related to radiology , nursing paramedics and other support staff

To reduce the delay caused when providing care for the patients

To bring about a solution for any insufficiency in the healthcare personnel

To ensure that greater interaction exists between the healthcare professionals and the patients or the relatives

Bringing about conditions conducive to the development of an ideal physician-patient relationship (JHS , 2007

One of the gravest problems faced in the Organization was the delay in providing care for the patients . The first one hour is considered to be the golden hour , during which it is necessary to provide care to ensure that the outcome of emergency treatment is good . Provision of medical help within the first one hour is considered to be one of the most preventable causes of death in trauma patients (University of Miami 2007 . Hence , at any cost it is essential that the patients are given attention . However , it is very difficult for the staff to provide immediate attention to the patients . Often patients in the inpatient and the intensive care division are so high that specialists are unable to attend to the patients urgently brought in . Besides , specialists are also unable to attend to the calls from the paramedics in providing assistance . Frequently , the relatives , family and friends face a lot of distress waiting frantically for their loved ones to receive care (Benatar , 2001

Sometimes , problems associated with excessive patients , may lead to medical errors , as the specialists are unable to spend enough time understanding the problem the individual is facing and strategizing the treatment . The need for surgery or utilization of certain drugs was wrongly estimated , leading to complications later . As the doctor-patient relationship and interactions were minimal , the trust and the confidence in the physician were almost absent (Benatar , 2001

Usually , informed consent is superficial due to the time issue that frequently develops in intensive-care settings . In fact , the gap between informed consent in theory and that in practice is huge . Many individuals are subjected to medical , surgical and diagnostic procedures without the consent of the relatives (Yoh , 2003

Methodology

No . Criteria Report

1 : Health Care Ethics Issue in a Healthcare Organization

2 . Databases searched : Entrez Pubmed , Cochrane , Google Scholar , and BMJ .3 . MeSH Terms Used : Not A MeSH Term 6 . Text words used (with truncation : Healthcare Ethical Issues Problems , Healthcare Ethics , Ethical Issues Healthcare

Google Scholar : healthcare organization , ethical issues , emergency care

7 . Limits Utilized : Abstracts , English , Human , 7 years publications

8 . Search Strategy with Boolean (OR ,AND ,NOT ) Healthcare Ethics ' AND Issues AND organization Problems OR Issues And Healthcare Organization ' AND Ethics Ethical Issues ' AND Healthcare AND Organization

Further Refined Using the Word Emergency , Intensive-Care (but not very appropriate articles

9 . Outcome : 322 Articles , including 106 Reviews in Pubmed

9330 Recent Articles in Google Scholar

Refined : 8 Articles (Emergency 13 Articles (Intensive-Care

10 . Was the Research Question Answered through the searched results Yes , To a Reasonable Extent The search was conducted on several internet search engines included Entrez Pubmed , Cochrane and Google Scholar . of the terms in the existed in MeSH database . The Boolean operators AND OR was utilized frequently while conducting the Pubmed Searches . The limits were set to the last 7 year publications (2000-2007 . The Results of the Searches included 322 articles out of which 206 were reviews . The search strategy was further refined , using the words Emergency ' or Intensive-care ' with the Boolean operator AND 8 and 13 articles were obtained respectively

Findings

There may be several ethical problems in the common practice . A problem which is frequently observed is that ethics has developed only recently following transformation of healthcare into business . This has lead to devaluation of the healthcare professionals . Ethicists have tried to reduce commercialization of medical practice , but this has not been possible . The healthcare professionals should increasing link healthcare with human rights (Benatar , 2001

According to surveys conducted by several governmental organizations at present the shortage in healthcare workers is not so severe However , with an increase in the population , these problems are going to have a disastrous effect in healthcare . By the year 2012 , the US would be experiencing a shortage of about 2012 nurses , and a greater proportion in the other support staff (such as radio-technicians surgical assistants , etc . Many people feel that the effect of the shortage in the staff is going to be even more severe in the future due to faster than normal aging of the present healthcare workers . The percentage of nursing staff above the age of 40 was 44 in the year 1980 , which had become 67 in the year 2000 . About 36 of nurses in some states are close to the retirement age . In the year 2005 , about 11 positions were vacant in the nursing and support staff sector Several other problems have resulted in the shortage of clinical staff including different utilization patterns , management problems , etc Besides nursing , there is likely to be a shortage in physicians . The US is going to experience a shortage of about 200000 physicians (or 20 within the next ten years . The much needed facilities including intensive care are more likely to suffer because in these fields the professionals are needed much more (Pearson , 2006

Usually Americans turn to the emergency department whenever they suffer from any illness . This is because the public perceives that the emergency department would be the only place where they would receive immediate attention . Besides , several patients without health insurance are more likely to go to the trauma care center for care rather than to other places where they are more likely to pay for treatment . Insured patients on the other hand are more likely to visit the emergency care department when a general physician is unavailable . During management of a disaster , the intensive care unit plays a critical role , and the already existing problems arising from shortage of staff becomes even more severe . The number of people visiting the trauma unit has increased by over 10 million , within the last ten years . However , the number of organizations or facilities that provide intensive care has not increased , nor has the number of staff members in some of these facilities . During the 1993 to 2003 period , the number of emergency units in the US fell by about 425 . Hence , there has been an overcrowding at this facility which has directly affected with the provision of quality services . An associated rise in other inpatient departments in the hospital has resulted in difficulties in transferring patients from the emergency department . Hence , it becomes even more difficult to admit newer patients . Often patients are held in the emergency department for more than 48 hours . Unreasonably holding the patients in the emergency department can result in serious problems during recovery . Some patients may find it difficult to express privacy and to receive individual attention in the emergency unit (Giffin Et al 2006

Overcrowding has lead to another problem . Often , the ambulances that bring in patients with acute problems are refused treatment and are diverted to other hospitals . This problem occurs about half a million times annually . The occurrence of such cases was even higher in patients requiring immediate cardiac care . More than half of all the hospitals in cities diverted such patients to other facilities Diversion can result in serious problems , because the time during the first one hour of the event is lost . The process of shifting can also result in unnecessary delay in transferring other aptietns that need emergency ambulances . The already overcrowded situation in the emergency department makes it even more difficult to handle to handle disasters or situations in which the influx of patients temporarily rises . Many hospitals in the US do not have much resources management (Giffin Et al , 2006

In the trauma care center , children are often admitted for emergency treatment of injuries or for pediatric medical conditions . Emergency management of a child calls for a completely different approach compared to adults . The physiology of the child is completely different from that of the adult , and frequently drug doses , techniques utilized and equipment required , has to be altered . Less than 10 of all hospitals in the US are completely compliant in handling pediatric emergencies Some hospitals have a shortage of pediatric surgeons . Sometimes specialists belonging to corresponding adult fields are used in handling pediatric emergencies (Giffin Et al , 2006

In another study conducted in Toronto Canada , the reasons for admitting the patients to intensive care units were determined . The study showed that in most cases , patients suffering from acute conditions were admitted to the intensive care unit either on request of the physician or the families of the patient . Physicians felt the need to admit the patient to the emergency care unit because they perceived the outcome of the condition may otherwise be uncertain or due to legal implications They felt that in case of fatal outcomes , they would be questioned for the reason for not admitting the patient to the emergency department (Palda , 2005

Often the hospitals tend to spend less on the emergency care unit . It should be remembered that the emergency care unit is the vital wing of a hospital , and several complicated issues such as end-of-life care passive euthanasia , complicated decision-making , etc , are dealt with in the intensive care unit . Often the patient expectations may not be a prime consideration in the emergency care unit . However , this is the most important issue and a greater amount of interactions should exist between the patient and the family to ensure that a physician-patient relationship exists under all conditions (Koh Et al , 2003

Plan Outline

SWOT Analysis

Strengths

Clear objectives of the organization

Huge infrastructure and resources

Adequately trained staff

Unity between the staff members

Funding and resources are obtained adequately

Support staff available

Activities of the trauma center well planned

Adequate ambulance facilites available

Staff training facilites available

Weaknesses

Time limitation present

Staff poorly trained in disaster management and ethical issues

Not much communication between management and operational staff due to time constraint

Staff members frequently changing jobs

Opportunities

Space for expansion of the trauma care center exists

New staff can be acquired

The need for emergency services by the community is increasing

Funding from the public health thrust is increasing every year

Threats

Cost of providing intensive care is increasing

Newer trauma care centers around this one are coming up

The people have very high expectations following treatment in the trauma care center

Increasing medico-legal accountability

Increasing importance given to informed consent

Resources Action

Personnel Recruited in position Recruited not posted Not recruited appropriately

Logistics Supplied in time Supplied late Not supplied

Infrastructure Sufficient Insufficient but achievable Insufficient and not achievable

Ambulances Sufficient Insufficient Unavailable

Other supplies Obtained and supplied Supplied late Not obtained

Funds Allocated /Received in time Received late Awaited

Training Available Likely to be available Not available Sl . No . Problem Impact Extent Ease in resolution

1 Insufficient manpower High Severe

Some amount of difficulty

2 Insufficient interaction to the patient Moderate Severe Some amount of difficulty

3 Inadequate feedback to the staff members regarding work performance Moderate Moderate Easy

4 Inadequate monitoring and evaluation Moderate Moderate Easy

5 Performance and implementation problems Moderate Moderate Some amount of difficulty

6 Shortage of Infrastructure

High

Severe

Some amount of difficulty

Problems

Medium to high impact

but low extent Require attention

easy to resolve Remaining problem

needs more attention Inadequate monitoring and evaluation

Inadequate feedback to the staff members regarding work performance Performance and implementation problems Shortage of Infrastructure

Insufficient interaction to the patient

Insufficient manpower

Action

Low Priority Action to be taken Requires an action plan Strategic Choices

Sl . no . Option Viability Funds Problems Desired outcome

1 . Increasing Human Resources Yes High Shortage of Human Resources in the Job Market Efficiency and Effectiveness in performing the job

2 . Building new infrastructure Yes High Time constraints and difficulty in getting permission from the trust Adequate space for expansion

3 . Monitoring and Evaluation techniques . Yes Moderate Implementation devices may be costly Regular monitoring and evaluation of the work to maintain ethical standards

4 . More interactions and time spent with the patients or relatives especially in explaining the treatment needed (after getting in more human resources and training the staff adequately ) Yes Moderate Problems in recruitment and training the staff members Absence of ethical problems due to inadequate informed consent Action Plan

Adequate Human Resources should be acquired within the next 6 months The funds have to be released by the Trust

The trauma care center needs further expansion to house newer facilities . This needs to be done within the next 2 years and the funds have to be released by the Trust

Adequate monitoring and evaluation devices to examine the ethical standards in care are required . Monitoring and evaluation instruments should be designed and set up appropriately within the next 6 months once the new staff members are appointed

Greater amount of interactions between the healthcare professionals and the patients or their relatives to ensure that ethical standards are being maintained . This should be initiated immediately

Conclusion

An improvement in the building infrastructure and the human resources of the trauma care center would definitely help in reducing the overcrowding problem . If there are facilities to house a greater number of patients delays in treatment would reduce , and the quality of care would increase . Besides , several devices should exist to help the patient understand the need for certain medical , therapeutic and diagnostic interventions (Giffin , 2006

References

Benatar , S . R . Et al (2001 . Clinical ethics revisited : responses BMC Medical Ethics , 2 (2 . HYPERLINK "http /www .biomedcentral .com /1472-6939 /2 /2 http /www .biomedcentral .com /1472-6939 /2 /2

Breslin , J . M . Et al (2005 . Top 10 Healthcare Ethics Challenges Facing the Public : Views of Toronto Biostastician ' BMC Medical Ethics 6 (5 , 1-8

Giffin , R . B . Et al (2006 . The Future of Emergency Care in the United States Health System . Retrieved February 17 , 2007 , from National Academy of Sciences Web site : HYPERLINK "http /www .iom .edu /Object /Master /35 /014 /Emergency 20Care .pdf http /www .iom .edu /Object /Master /35 /014 /Emergency 20Care .pdf

Jackson Health System (2007 . History . Retrieved February 17 , 2007 , from JHS Web site : HYPERLINK "http /www .jhsmiami .org /body .cfm ?id 9227 http /www .jhsmiami .org /body .cfm ?id 9227

Jackson Health System (2007 . Mission Statement . Retrieved February 17 2007 , from JHS Web site : HYPERLINK "http /www .jhsmiami .org /body .cfm ?id 143 http /www .jhsmiami .org /body .cfm ?id 143

Jackson Health System (2007 . Public Health Trust . Retrieved February 17 , 2007 , from JHS Web site : HYPERLINK "http /www .jhsmiami .org /body .cfm ?id 45 http /www .jhsmiami .org /body .cfm ?id 45

Jackson Health System (2007 . Purpose of the Public Health Trust Retrieved February 17 , 2007 , from JHS Web site : HYPERLINK "http /www .jhsmiami .org /body .cfm ?id 1142 http /www .jhsmiami .org /body .cfm ?id 1142

Jackson Health System (2007 . Ryder Trauma Center at Jackson Memorial Hospital . Retrieved February 17 , 2007 , from JHS Web site : HYPERLINK "http /www .jhsmiami .org /body .cfm ?id 8419 http /www .jhsmiami .org /body .cfm ?id 8419

Koh , Y . Et al (2003 . Ethical Issues identified in Intensive Care Units of a University Hospital ' Eubios Ethics . HYPERLINK "http /eubios .info /ABC4 /abc4108 .htm http /eubios .info /ABC4 /abc4108 .htm

Palda , V . A . Et al (2005 "Futile care : do we provide it ? Why ? A semistructured , Canada-wide survey of intensive care unit doctors and nurses ' J Crit Care , 20 (3 , 207-213 . HYPERLINK "http /www .ncbi .nlm .nih .gov /entrez /query .fcgi ?db pubmed cmd Retrieve do pt AbstractPlus list_uids query_hl 10 itool pubmed_docsum http /www .ncbi .nlm .nih .gov /entrez /query .fcgi ?db pubmed cmd Retrieve dop t AbstractPlus list_uids query_hl 10 itool pubmed_docsum

Pearson , J (May 22 , 2006 . Help Wanted : Health-Care Worker Shortage Looms ' Tulsa World , 37 (3 . HYPERLINK "http /www .okcareertech .org /expressions /2006 /fall06 /headlines /healthcar e .htm http /www .okcareertech .org /expressions /2006 /fall06 /headlines /healthcare .htm

University of Miami - Division of Trauma and Surgical Critical Care Services (2007 . Emergency Care Overview . Retrieved February 17 , 2007 from Univeristy of Miami Web site : HYPERLINK "http /surgery .med .miami .edu /trauma /division_overview .asp http /surgery .med .miami .edu /trauma /division_overview .asp

University of Miami - Division of Trauma and Surgical Critical Care Services (2007 . Faculty . Retrieved February 17 , 2007 , from Univeristy of Miami Web site : HYPERLINK "http /surgery .med .miami .edu /trauma /faculty_a .asp http /surgery .med .miami .edu /trauma /faculty_a .asp

University of Miami - Division of Trauma and Surgical Critical Care Services (2007 . Services . Retrieved February 17 , 2007 , from Univeristy of Miami Web site

HYPERLINK "http /surgery .med .miami .edu /trauma /expertise .asp http /surgery .med .miami .edu /trauma /expertise .asp

University of Miami - Division of Trauma and Surgical Critical Care Services (2007 . Welcome . Retrieved February 17 , 2007 , from Univeristy of Miami Web site : HYPERLINK "http /surgery .med .miami .edu /trauma /index .asp http /surgery .med .miami .edu /trauma /index .asp

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