The importance of senior rehab - the distance between knowledge and action can be a killer…

Senior Rehab is essential in helping those who have suffered a set-back, get back on their feet – often literally.

Maybe it’s part of the human condition that we can know so much and yet act so little.

Nowhere was that more apparent than in a hospital family meeting that I attended yesterday.  The Client, age 88 years, was present with her three children and the social worker. Prior to her hospitalization she had lived independently. In the three weeks she had been in hospital since her heart attack she had barely been out of bed.

This is a huge issue.

Colleen S. Campbell, Geriatric Evaluation & Management Director at the Geriatric Research Education and Clinical Center outlined many of the issues  in her paper; Deconditioning: the consequence of bed rest. 

Deconditioning (disuse) can lead to:

• Muscle weakness and Atrophy.
• A 3% loss in muscle mass within thigh muscles within 7 days
• 3 – 5 weeks of total inactivity can lead to a staggering 50% decrease in muscle strength.
• Disuse Osteoporosis can result from a lack of weight bearing, gravity and muscle activity.
• Within 24 hours of bed rest there is an increase in the resting heart rate of 4 – 15 beats per minute. And a 5% decrease in blood volume. An Increase in Orthostatic hypotension can result.
• Immobility can result in atrophy of the heart muscle
• Seniors who are left in bed are more likely to suffer from Pressure ulcers, decreased appetite, and constipation.
• Psychologically immobility can result in depression, loss of motivation and a feeling of helplessness.
• Increase in Anxiety, fear, and neurosis
• Decreased concentration and impaired judgement
• A life threatening Pneumonia can result from the decrease in all pulmonary function parameters.

In short, seniors who become deconditioned because they have been left to languish in bed are more likely to suffer a loss of independence because of their inability to function.

Now back to our meeting….

The social worker explained that the physiotherapist was stretched very thin (no pun intended) and would not likely be in a position to offer much.

Somehow she didn’t appear to be mortified by this.

The family understood that an application had been made to a rehabilitation setting so that this once semi-independent senior could receive senior rehab and return to her home with assistance.

The social worker corrected this impression by stating that the Social Worker who had originally been assigned was no longer on the case. She added that as the new social worker, she was unaware whether the application had been completed or not. (She then felt it was important to inform us that she worked only part time, did not know this Client at all, and that these things were known to move very slowly….no kidding!)

There was no acknowledgement about the negative impact on the Client, no suggestion as to how things could be moved along any faster or how to improve the outcome of the Client’s hospital stay.

There was also an observation that the Client was not eating or drinking well while in hospital. On more than one occasion she was dizzy, tired and weak (see Deconditioning, above).

Those who had seen the hospital meals felt that the poor quality of the meal was partially to blame. Everyone agreed that this might be an issue – no one suggested how to deal with it. (Family could bring in food, meal choices might include sandwiches or other foods that are more agreeable to the Client’s palate, contact the dietitian, allow client have a meal in the cafeteria each day…something-do something!)

Everyone knows that a prolonged hospital stay with these kinds of conditions is not in the best interest of the Client. Everyone agreed that if the Client did not start moving soon, she might permanently lose the ability to do so.  (Essentially use, it or lose it).

And to top it all off,  there seemed to be an error or miscalculation in the application for rehab itself. The application had been made for aggressive rehabilitation, not the slow stream rehabilitation more suited to the Client’s age and frailty. (The wait for aggressive rehabilitation is longer - the social worker said it could be months!).

We insisted that the social worker check the status of the client application for senior rehab while we waited. She returned and told us that all she needed to do now was touch a button to set the slow stream application process in motion - push the button, push the button!

What if the client had not had the benefit of an experience Registered Nurse advocating for her at that meeting?  Would the button have ever been pushed? Why is a previously independent senior left to languish in a bed? Why is there not more urgency to the whole process?

We absolutely know that a person has to eat, drink and move around in order to improve in their general condition. We absolutely know that a lack of nutrition, hydration and movement are debilitating to anyone – never mind a frail senior.

And yet, the lack of action that we saw with this client appears to be more the norm than the exception.

What you can do:

Remember inaction is a decision (today we are not going to do range of motion exercises with Mrs Smith) – In the hospital setting, a person’s condition can  get better or it can get worse. You can make a difference. Decide to act and ask others to act.

Be informed, know what is going on and why, ask questions. Don’t be shy. If the answers you get don’t seem to make sense, ask someone else.

Oh and did I mention, ACT!

Discharge Prescriptions need to be reviewed

When a Client is discharged from hospital, we always review their discharge prescriptions and compare that list to the medications that they were taking before being hospitalized. Sometimes during the course of a person's hospitalization their medication regimen is changed. Sometimes however, there are oversights, errors or as in this case, Printer problems.

So many times one problem compounds another and the end result is a dangerous mess of mixed up medications that goes unnoticed until a person becomes unwell or experiences a crisis.


Here is a story from our Practice today:

Today we were organizing a client's medications.There were multiple vials of medications strewn throughout the apartment. Some were years old. The client had a dangerous habit of pouring medications from one vial to another vial. The printed directions on the medication vials were not necessarily the most recent instructions and some dosages had, in fact, changed. The client confided to us that she has difficulty opening the vials. We introduced a medication dossette.

Although this client had a recent history of low hemoglobin and she had iron tablets at home by order of her family doctor, the discharge note from the hospital did not mention anemia as one of her pre-existing conditions. Nor did it mention the iron therapy or any follow up that might be required by a person with anemia.  We called the Nurse Practitioner at the hospital who revealed that the client had had a transfusion while in hospital, related to low hemoglobin but that they had been unaware of any history of iron therapy.

An oversight.

This particular client also has diabetes. She is newly diagnosed and is insulin dependent. She has been directed to take her blood sugar readings four times daily and adjust her insulin dose based on the reading. She does not have a chart to reference. She is unsure of what foods she should eat in order to maintain good blood sugar control. She is uncertain as to what she would do if her blood sugar reading was low. She lives alone and is frail.

Another oversight?

The Client received a referral to a dietitian but the period of time between her discharge from hospital and the appointment for the dietitian is 5 months....

During our home assessment we found, candies, white bread and other items that would not normally be found on a diabetic diet. The client's family said that visitors are bringing all kinds of foods to the house when they visit...

Finally, in reviewing the medication  in the discharge note we found a discrepancy.The family doctor ordered a medication to be taken three times daily.  The hospital discharge prescription noted that it was only to be taken once per day. We could not see any reason for the discrepancy.Once again we called the Nurse Practioner to help clarify the prescription. In assisting us, she discovered that the medication dosage should have been one tablet, three times a day and that it was due to a Printer error that the order had been cut off (instead of reading that the meds should be taken with breakfast, with lunch and with dinner, it read only that the drugs should be taken with breakefast. The rest of the message was not included.)

True story.  One of many.

Please check your discharge prescriptions. Ask questions if there seems to be a discrepancy.

Printer problems, errors and oversights happen.

Nurse, there are Giraffes in my room....

We recently had a Client, young by our standards, only 79 years old. She underwent hip replacement surgery.  The surgery, by all accounts was a great success, but the Client was reportedly suffering a post operative delirium.

The medical staff predicted she would recover, but they could not say how long it would take.  The Client's daughter contacted me and told me her mother was reporting giraffes in her room. Also,  the Client telephoned her friend at 5am wondering if her dinner would be there soon.

We decided to head to the bedside to investigate further.

When I walked into the room and greeted the Client she recognized me, did not seem to be in distress and reportedly did not have any pain.

What I noticed next was a poster of a giraffe, hanging on the wall, directly in front of the Client. The Client was correct...there were giraffes in her room.

Next I noticed the clock on the wall. It was too far away to be read by a patient in the bed (who did not have her glasses with her in hospital, I might add...) There was not a lot of contrast betwen the colour of the face and the colour of the hands on this particular clock and even if it could be read by the patient, did not have an am/pm indicator.

It was Fall. And for those of you who are early birds, like me, you know that at 5am it's dark outside- it's also dark at 5pm.

So if you were in an unfamiliar setting, waking up to the stare of giraffes, the darkness of evening and possibly hungry for something to eat - you might call your friend at 5am and tell her "there are giraffes in my room and I'm hungry for dinner".

The Patient left hospital shortly thereafter and did well with some follow up physiotherapy at home.

Scary new trend

We've been interviewing again.  As a result we've been meeting Registered Nurses who are practicing in a variety of settings.  A scary trend is emerging: the inexperienced float pool Nurse.

I have met a number of newly graduated Nurses who have positions in the "float pools" of large multi-service acute care hospitals. Being a member of the float pool entails being available and prepared to work  at the last minute on any floor, any shift, within the hospital, where there is a staffing gap. 

To their credit, these new graduates, happy to have a job, are jumping in with both feet.  They answer calls for last minute staffing needs, are being placed in a variety of work environments, they are being required to perform unfamiliar tasks, with unknown colleagues on almost every one of their working days.

And in the event that you think that this is only occurring in Clinic settings or other predictable and somewhat stable environments, think again. The Nurses that I meet are being assigned to critical care units, to the emergency room and as one Nurse told me recently...it's nice to get some experience with a chest tube-that's something I've never done before!!! (I don't know about you, but if I had the need for a chest tube, I'd like to be at least the second person the Nurse had seen with such an appliance.)

These Nurses are being asked to work with patients who have complex care needs. They are being asked to administer medications that they have never administered before. And they are being asked to handle equipment and procedures that are new to them. These newer Nurses are not being sent in to these busy environments to be mentored by a more experienced and knowledgeable colleague. They are expected to function as a fully qualified and experienced member of the health care team.

They are understandably nervous; about being unfamiliar with a procedure and harming a patient; about being unfamiliar with a procedure and having to ask for assistance and then being seen as not able to handle their responsibilities; about whether or not they will be called for enough work to cover their bills; about what they will encounter the next time they answer the last minute call for work....

Patients don't benefit under this kind of work arrangement. Nurses don't benefit either.

Patients deserve quality care. And quality care is delivered through the work of experienced practitioners and by newer practitioners who are mentored by expert colleagues.

Where is the Professionalism in Nursing?

We’re hiring, again.

And it is an exciting time. It means that our company is growing and that our concept of quality home health care for seniors is an important and necessary one.

But interviewing for the Registered Nurse Case Manager role is incredibly challenging.

It is a time that I reminded how difficult it is to be faced with the task of meeting nurses who are just not, well….professional.

It’s very discouraging and frankly very difficult for me to understand.

Right from the start, things often do not go very well and probably 90% of the Registered Nurse applicants could be dismissed before ever sitting down for the interview.

Nurses, let me give you a piece of advice: showing up for an interview wearing a baggy polyester scoop neck shirt and a flowery skirt with flip-flops will not put you first in line for a professional nursing position of any kind. Definitely not one with Eldercare Home Health.

Here are a few pointers on how to score a good first impression.

Get Dressed:  Overdo it on the first interview. Look like you own the position you are applying for. Don’t make it a stretch for the interviewer to imagine you in the role.

Demonstrate Good Attitude: During your interview, don’t talk about all of the failings of the places you’ve worked, unless you are going to follow it up with how you worked diligently to turn things around. Identifying and complaining about poor practices only shows that you have the critical assessment skills to recognize problems but not the commitment or strength of character to intervene and do something about it.

Definitely doesn’t work for us.

Be On Time Or Early: Show up on time - even if it means arriving early, walking the neighborhood, cooling your heels with a newspaper and a coffee at the local coffee shop. Almost nothing makes me angrier than people who do not show up on time for an appointment.  It shows poor planning and a blatant disregard and disrespect for other people’s time. It is my practice to refuse to interview candidates who are late – and that is true for those applying for any role in the company.

And we don’t give them a second chance either.

The Business Relationship Is About Business: Many applicants address me very casually – like we’re neighbors or chums something – I may also be educated as a Nurse but I’m not your new best friend.  I’m the President of an established company and your potential new boss.

Do your Homework: Some Nurses arrive without having done their homework. Most in fact. They haven’t bothered to research the position offered or the company doing the offering. Haven’t visited the website or looked at competitors in the industry. Some applicants simply ignore the details of the job description and state rather annoyingly that they feel they can easily handle the job responsibilities, despite not ever having had any experience doing anything remotely similar.

The Company Does Not Exist To Make Your Life Easier: Don’t talk about winding down from the demanding pace of your current position in order to now enjoy a more leisurely pace. Don’t talk about your social life, troubles with your home life, break-ups, family responsibilities, personal setbacks or other personal details that have had an impact on your past job performance or career choices.

It’s gotten to the point that I truly dread the process of recruiting Registered Nurses and I wonder if the universities and colleges offering Nursing education shouldn’t also offer classes in “Being a Professional Nurse”.

This kind of professional grooming for Nurses might go a long way in bringing Nurses and Nursing knowledge to the political decision making table and helping Canada make good health care decisions for its population.  Nurses have long lamented that in many health care settings, they are not considered equal partners with other health care professionals. If Nurses want to stand shoulder to shoulder with other decision makers, then Nurses have got to present themselves as professionals.

A Professional Presents Herself In The Most Positive Light: Research the position offered. Demonstrate that you know something about the company and the industry. Dress as though you already practice in that setting. Be on time. Use business etiquette when addressing other professionals. Begin and end with a firm handshake. Make eye contact. Be positive.

If these behaviours are all second nature to you and if you are a Registered Nurse with at least five years of experience and enhanced education focused on the care of people over 70 years old, please email me (and remember to include a proper cover letter and resume).

We’ve got a very rewarding position and an exciting career opportunity waiting for you.

This is part 1 of a series on Professionalism in Nursing. My next piece will address Professionalism in the workplace. Stay tuned!

Lisa Wiseman RN BScN GNC(C)
President
Eldercare Home Health Inc
www.EldercareHomeHealth.com

Parkinson Society Spring/Summer Speaker series - Love, Intimacy & Parkinson’s

The Parkinson Society Central & Northern Ontario branch did a wonderful job hosting the event featuring speaker Gila Bronner, Director, Sex Therapy Service, Sexual Medicine Center, Dept. of Urology; Sheba Medical Center, Tel-Hashomer, ISRAEL.

Gila spoke about issues relating to intimacy, sex, and emphasized the importance of personal time - time where the person with Parkinson's and their caregiver have an opportunity to be apart - either by themselves or with others, but without the other present.

Gila answered a range of audience questions including a discussion about the difficulty in distinguishing between aging related issues and Parkinson's issues. She talked about problem solving and emphasized the need for open communication and frankness.

Eldercare Home Health is pleased to be the sponsor of the summer series and we look forward to the July and August events:

1. July 25, 2012—Financial Planning &Disability Tax Credits: What you need to know
2. August 22, 2012—Medication & Parkinson’s: Greta Mah; pharmacist and facilitator of the Living Well with Parkinson’s program at North York General Hospital

We hope to see you there!

All sessions are free but advanced registration is required.
Call Naseem Jamal: 1 800 565-3000 ext. 337
or e-mail: naseem.jamal@parkinson.ca

Parkinson Society Spring/Summer Speaker series...

The Parkinson Society Central & Northern Ontario branch presents its Spring/Summer Speaker series.

• 1. May 9, 2012—Love, Intimacy & Parkinson’s: Gila Bronner; Director, Sex Therapy Service, Sexual Medicine Center, Dept. of Urology; Sheba Medical Center, Tel-Hashomer, ISRAEL
• 2. July 25, 2012—Financial Planning & Disability Tax Credits: What you need to know
• 3. August 22, 2012—Medication & Parkinson’s: Greta Mah; pharmacist and facilitator of the Living Well with Parkinson’s program at North York General Hospital

Sessions are from 7PM to 9PM at the Parkinson Society Conference Center 305 - 4211 Yonge St., Toronto.

Eldercare Home Health is happy to be the Official Sponsor of all 3 Parkinson Society Central & Northern Ontario branch Spring/Summer Speaker events.

All sessions are free but advanced registration is required.

Call Naseem Jamal 1 800 565-3000 ext. 337
or e-mail: naseem.jamal@parkinson.ca

Health Council of Canada report on CCAC hours and our experience...

The Globe and Mail published an article yesterday highlighting the findings of a report by the Health Council of Canada. John G. Abbott, chief executive officer of the Health Council of Canada is quoted as saying that “The vast majority of cases are getting 14 hours, maybe 15 and 20 hours,”

We commented on the Globe and Mail site as follows:

It’s important that the public have a realistic expectation for the amount of home healthcare support that they likely will be able to access through the CCAC.

While it’s true that some seniors, living at home, are receiving daily care funded by CCAC, the vast majority of seniors requiring care are not receiving anywhere near the 14-20 hours stated.

We’ve been providing care to seniors in the throughout the GTA since 1995. I’m not sure where Mr. Abbot found his numbers, but in our experience, in the GTA, seniors in the community are generally able to access only 2 to 4 hours of care per week through their Community Care Access Center (CCAC), not the 14 to 20 reported by the Health Council of Canada. Those who are assessed as needing palliative care may be eligible for additional  hours of support.

When families commit personal resources, either their own time or purchased care hours, to support seniors at home, the health care system and the community at large, benefit. We already know this to be true through the studies that have been done related to the Veterans’ Home Health Care benefit program. Other positive side effects for the individuals involved are fewer visits to hospital and better quality of life for the senior.

Read the Globe and Mail article http://www.theglobeandmail.com/life/health/new-health/health-news/home-care-support-for-elderly-fails-caregivers-report-finds/article2403241/

Read our comment and give us a "thumbs up" here: http://www.theglobeandmail.com/life/health/new-health/health-news/home-care-support-for-elderly-fails-caregivers-report-finds/article2403241/comments/

Lisa Wiseman BScN., RN.
President, Eldercare Home Health Inc.

Client Feedback

We receive a lot of positive client feedback about the quality of care provided by our caregivers. This note arrived today and was so lovely, I thought I would share it:

Dear Ms Wiseman:

"We are so grateful for the care that Jean gives our mother. We welcome her each week and are at ease knowing that she is so well taken care of.

Jean is always cheerful and warm.  She is intelligent and shows genuine concern not only for the welfare of our mother, but makes sure that I and my siblings are well informed and also cared for.

I give her the highest commendations.  She is truly a gem."

We appreciate the hard work and effort of our caregiving staff. Our clients and their families do too. Working with positive and caring people makes for a wonderful work environment.

(And by the way, if you know a Registered Nurse with a specialty in Geriatrics who is bright, skilled, social and funny, let them know.....we're hiring!!)

Lisa

Request for advice-removing rings safely from mom's swollen fingers

I often get asked for advice from families who are caring for seniors.  As you might imagine, the questions cover a wide range of topics. Thought I would share this set of messages in hopes that anyone else facing this dilemma might get some bright ideas...(also, I think it's one of those problems no one talks about!)
__________________________________________________________________________________

From: Joan
Sent: December-29-11 5:42 PM
To: Lisa Wiseman
Subject: Removing rings from a Nursing Home Resident with Alzheimer's Disease

Good afternoon:
My mother is a resident in a Nursing Home. The staff are concerned that her wedding ring band & engagement ring are cutting off her circulation, as her fingers are very swollen, and have suggested the family get the rings cut off. My mother has Alzheimer's Disease, and is not able to travel out of the residence. Her hands are also very contractured, and it is painful for her to open her fingers.

I have seen online suggestions to remove a ring using a lubricant, ice, and/or dental floss. I don't know if any of those would work, under the circumstances.

Do you have any suggestions on how we can remove the rings with the least amount of distress to my mother? Do you know who to contact regarding a ring-cutting service?  I have sent emails to a local Jewellery store, the hospital and fire department.  We would like to get Mom's rings resized and returned to her.

I look forward to hearing from you. Thank you.

---

From: Wiseman@eldercarehomehealth.com
To: Joan
Date: Fri, 30 Dec 2011 12:16
Subject: RE: Removing rings from a Nursing Home Resident with Alzheimer's Disease

Hello Joan,

We recently had a client in a very similar predicament.  We tried some of the interventions that you’ve listed, but they were not successful.

In the end, our Registered Nurse purchased a small wire cutter with a flat tip, from Home Depot. She cut the ring off without incident.  (You could then have the ring repaired and re-sized by a jeweller.)

I hope this has been helpful. 

  

Lisa

_____________________________________________________________________________________

Good afternoon, Lisa:

Thank you for your reply. I thought you might want to know how it was resolved.

On Friday, Dec 31/11, the Nursing home called 911, and Paramedics arrived at the Nursing home, but did not have the tools to remove the rings.  They escorted my Mom by non-emergency ambulance to a local hospital emergency department, where her 2 rings were cut off. Mom was then returned to the Nursing home, again by ambulance, within an hour. The rings were quite damaged, but our family will pick them up and hopefully be able to get them repaired and resized and returned to my Mom.

Again, thank you for your interest in our situation.

Sincerely,
Joan