Nurses' Papers on Tuberculosis Part 2

The city is divided into twenty-two districts, each nurse being responsible for the care of all tuberculous patients in her district. The number of patients cared for by each nurse is from 100 to 180. A very small percentage of bedside care is given; far advanced patients as a rule are sent to hospitals.

Boston tuberculosis nurses do not wear uniforms. They are paid $900 a year, with no increase for length of service or efficiency.

BUFFALO

The purpose of the Buffalo a.s.sociation for the Relief and Control of Tuberculosis has been to stimulate progress in fighting tuberculosis. It very modestly shares with the city officials and with private charities the credit for the work accomplished. All it claims for itself is that it has been able, and will continue, to "point the way." How thoroughly it has succeeded in this may be seen by the progress made since 1909 when the Buffalo a.s.sociation made its first appeal for funds. At that time Buffalo had:

(1) A dispensary maintained by the Buffalo Charity Organization Society.

(2) The Erie County Hospital for advanced cases.

(3) A day camp, with a capacity of thirty patients, supported by a group of women.

(4) One visiting nurse supplied by the District Nursing a.s.sociation.

The present facilities are:

(1) A dispensary, open every day and one evening a week, with a nose and throat clinic, and a dental clinic with a paid dentist in attendance.

(2) The J. N. Adam Memorial Hospital for early cases, capacity 125, supported by the city.

(3) The Munic.i.p.al Hospital for the care of advanced cases, supported by the city.

(4) The Erie County Hospital, as before.

(5) Tuberculosis Division of the Department of Health with two tuberculosis inspectors and six visiting tuberculosis nurses.

(6) An Open Air Camp, with a capacity of from seventy to one hundred patients, with a special department for children. Patients are kept day and night. The camp has three resident trained nurses and one interne, and is visited daily by the a.s.sociation's paid medical director.

(7) Two open air schools, with another promised.

(8) A City Hospital Commission, with a plan for the erection of a pavilion for 500 advanced cases as the first of a general hospital scheme.

(9) Teachers soon to be appointed for the education of tuberculous children.

(10) The trades unions organized to promote the campaign among their own members in a unique organization.

(11) The whole community alert to the menace of tuberculosis, willing to shoulder the community burden and to a.s.sume the community responsibility.

The Dispensary is now operated by the a.s.sociation for the Relief and Control of Tuberculosis, and the nurses are supplied by the Health Department. The nursing staff consists of a supervising nurse and six field nurses, the latter receiving $720 per year. They wear no uniform.

They give a limited amount of bedside care, some member of the family being taught to properly care for the patient, if he cannot be sent to a hospital. Recently an additional nurse was engaged by the a.s.sociation to follow up cases on whom no diagnosis has been made and who have not returned to the dispensary for re-examination. Since the Dispensary was opened in 1909, there have been over one thousand such cases. Many of these had suspicious signs when examined, but there has. .h.i.therto been no means of keeping in touch with them, as the nurses have been obliged to confine their attention to positive cases. One of the chief difficulties of the Buffalo campaign, as elsewhere, has been the fact that more than half of the cases have probably already infected others. This latest movement of the a.s.sociation should antic.i.p.ate this condition to a certain extent, and is one more means by which it is "blazing the trail" toward its goal,--"No uncared for tuberculosis in Buffalo in 1915."

PHILADELPHIA AND PENNSYLVANIA

In the General Appropriations Act of 1907 the Legislature of Pennsylvania granted to the State Department of Health, in addition to its regular budget, the sum of $400,000, "to establish and maintain, in such places in the State as may be deemed necessary, dispensaries for the free treatment of indigent persons affected with tuberculosis, for the study of social and occupational conditions that predispose to its development, and for continuing research experiments for the establishment of possible immunity and cure of said disease."

Immediately after securing the above appropriation, the State Department of Health began to establish dispensaries throughout the state, one or more in each county. The staff of each dispensary consists of a chief, who is also county medical inspector, and a corps of a.s.sistant physicians and visiting nurses. There is a supervising nurse with one a.s.sistant at Harrisburg, who oversee and inspect the work of the staff nurses.

The number of nurses in the dispensaries throughout the state varies from a nurse shared by another organization or a practical nurse giving part time, to from four to seven nurses in one dispensary. There are now more than 115 State Department Tuberculosis Dispensaries in Pennsylvania, Philadelphia having three.

An idea of the general plan of the work may be gained from a description given of the State Department Dispensary No. 21, located in Philadelphia, by Dr. Francine:

"There are at present five nurses employed at Dispensary No. 21, two of whom give their whole time to following up the return cases from the State Sanatoria. As soon as the case is discharged from the sanatorium, that information, with other data regarding the condition on discharge, etc., is sent to us at once. At the end of a stated period, if that case has not been returned, the nurse looks it up, and gets it to come in.

The nurses make out detailed reports on all cases discharged from the sanatoria, at periods of six months, whether our own patients or not. These will be and are valuable for statistical data. Practically all the data for reports as to subsequent results in cases discharged from the sanatoria, which have appeared in this country at least, have been made up from information gleaned by writing the discharged patient and having him fill out his own report. It does not tax the imagination unduly to conclude which is the more accurate, the answers to questioning by a trained worker (we have selected for this work the two nurses who have been with us longest) who in addition takes the temperature, pulse, etc., herself, and usually succeeds in getting the patient back to the dispensary for at least one re-examination; or such answers as a patient may see fit to make to a printed questionnaire.

For the purpose of regular dispensary and inspection work, the dispensary limits itself to receiving patients from certain districts of the city, though as a state inst.i.tution it is impossible for the dispensary to refuse any case, no matter where they live, if they insist upon treatment. Usually by a little persuasion, however, we can get the patients to go to the dispensary in their district, co-operating in this way with the Phipps Inst.i.tute of the University of Pennsylvania, the Gray's Ferry State Dispensary, the Kensington Tuberculosis Dispensary and the Frankford State Dispensary. The section of the city from which we draw our cases is divided, for purposes of inspection and Social Service Work, into three districts with a nurse a.s.signed to each, and this gives each of our nurses, roughly speaking, about seventy-five patients per month to take care of.

These patients must be visited regularly every two weeks, which gives the nurse at least one hundred and fifty visits a month to pay, not including the visits to new cases.

Every new case which is admitted to the dispensary must be visited within one week of the day of admission. The nurses come in from their visiting work and report daily at 12:30 o'clock, for one hour in the dispensary office, and new cases, according to the district in which they live, are a.s.signed to the nurse having charge of that district. The advantage of having a nurse report daily to the dispensary at a time when all the doctors are there, lies in the fact that the doctor has thus the opportunity of talking over with the nurse the new cases which she is to visit and of making any suggestions which he has gleaned from the history and examination of the patient. It is thus possible for the nurses to visit the new cases in the afternoon of the same day. The advantage of this close co-operation between doctor and nurse must be at once apparent.

Further, each nurse is required to report to every physician one morning a month, with the histories in hand of all the patients of that particular doctor which are on her list. This is valuable, because in no other way can the doctor get so thorough an understanding of the home conditions and social problems of a given patient as by talking the situation over directly and personally with the nurse in charge."

A similar plan is in operation at the other two State Department Clinics in Philadelphia.

The best known tuberculosis dispensary in Philadelphia, conducted by a private organization, is the dispensary connected with the Henry Phipps Inst.i.tute. This dispensary during the eleven years of its existence has contributed greatly to the standardization of tuberculosis dispensary work, not only in Philadelphia, but throughout the entire country.

Connected with a scientifically conducted hospital for advanced cases, with its laboratories and other improved medical facilities, the Dispensary of the Henry Phipps Inst.i.tute occupies a high place among the similar inst.i.tutions of this country. The nursing staff of the Henry Phipps Dispensary consists of three visiting tuberculosis nurses, aided by two additional nurses (both colored) a.s.signed by other organizations to work on the Phipps Dispensary staff, one by the Whittier Centre, and the other by the Pennsylvania Society for the Prevention of Tuberculosis. Some of the important features of the work of this dispensary in its relation to nurses are as follows:

(1) An efficient training school for tuberculosis nurses, affording the opportunity of hospital and dispensary training.

(2) A course of lectures on tuberculosis given to the nursing profession at large.

(3) Intensive home work among tuberculous families.

Visiting tuberculosis work in Philadelphia is also done in connection with the Presbyterian Hospital Tuberculosis Clinic, St. Stevens Church Tuberculosis Clinic, and by the Visiting Nurse Society of Philadelphia.

PITTSBURGH

The Tuberculosis League Hospital of Pittsburgh was opened in 1907 for incipient and advanced cases, with a capacity of eighty beds. The League conducts at present a night camp, an open air school, a farm colony, a post-graduate course for nurses and tuberculosis clinics for medical students at its dispensary. There is also a post-graduate course in tuberculosis for nurses. The course requires eight months and nurses receive during that time $25 a month. Only registered nurses are accepted.

The training is along the following lines: nursing advanced cases in hospital, open air school work, sanatorium care of early cases, service in dental, nose and throat clinics, and in the dispensary for ambulant cases, district nursing, service in baby clinics, educational work, and laboratory work. Patients discharged from the hospital, families of patients in the hospital, and cases reporting at various tuberculosis dispensaries, are given complete follow-up care by the nurses taking the course, thus giving them excellent training in public health work, especially that phase of public health nursing dealing with tuberculosis.

At present there are nine nurses taking the course. The Dispensary of the Tuberculosis League employs six nurses.

Pittsburgh has also a State Department of Health Tuberculosis Clinic, with ten nurses, each caring for from 90 to 100 patients per month. These nurses give a small percentage of bedside care and are not in uniform, except when on duty in the dispensary. They are paid $70 per month. The plan of work is similar to that of the Philadelphia State Dispensary.

The Department of Public Health of Pittsburgh employs four visiting nurses, who investigate home conditions and instruct patients reported to the department who are not under the close supervision of a private physician, the State Department Clinic, or the Tuberculosis League Clinic.

The nurses are able to correlate, in a way, the work of the two dispensaries by a.s.signing patients to the clinic in the district in which they live. They receive $75 per month and are not in uniform.

Pittsburgh, then, has in all twenty visiting tuberculosis nurses, under three separate and distinct organizations.

CLEVELAND

In Cleveland, as in nearly every other city, the work of organizing the fight against tuberculosis was accomplished by private organizations, the Anti-Tuberculosis League and the Visiting Nurse a.s.sociation. For a number of years the Health Department confined itself to keeping a card catalogue of reported cases. In 1910 sufficient funds were voted by the City Council to enable the establishment of a separate Bureau of Tuberculosis, whose duty should be the development of munic.i.p.al tuberculosis work. This Bureau has taken over and gradually developed five dispensaries, with a staff of twenty-four visiting tuberculosis nurses, and paid physicians, besides the director and office force. The work in Cleveland is centralized in its Health Department.

General dispensaries are required to refer all cases of tuberculosis to the tuberculosis dispensaries, and physicians are required to report all cases to the Health Department. On report cards and sputum blanks is the statement: "All cases of tuberculosis reported to the department will be visited by a nurse from this department unless otherwise requested by the physician." With very few exceptions the physicians are glad to have a nurse call, and every effort is made to co-operate with the physicians in handling the case.

The city is divided into five districts, with a dispensary located in each district. Patients are treated only at the dispensary serving the district in which they live. "This plan prevents cases wandering from one clinic to another and enables the nursing force to do more intensive work in each district."