Caregiver Gift Idea

Looking for a gift idea for a caregiver? One of the more thoughtful gifts I received in recent years was a nice, lightweight 'anti-gravity' recliner.

These light, durable chairs are perfect for sitting bedside for long periods of time. If you have someone in a care facility, you will find that these chairs encourage lengthy visits. They can be tucked away easily when not in use. Any brand is fine, and prices vary greatly, but the higher quality ones really do last longer and are easier to use.

Just watch the weight.  There are heavier versions of these chair that are well made and good for home use, but they are really too heavy to be transported easily. Also, if the chair is to be used in a hospital or similar institutional setting, made sure it is well labeled.

The Caregiver's Notebook

Imagine this.  A well credentialed caregiver shows up at a new client and is briefed at length by the previous caregiver, who is leaving. This new caregiver listens to everything without making any notes at all on this complex case. She is there, her first day, without the thought of keeping a notebook!  

I actually recommend keeping two books.

One, a professional diary of client vital signs, medications, exercise, therapy, and other relevant information. The data included should be specific to that client's condition. Notes should be professional and factual. So often, caregiver diaries are either irregular and disorganized, or interesting to read but not particularly useful. This notebook is for professional use, and should be treated as confidential for the client. In keeping it, though, we should consider that if there is an emergency of some kind, we would want to be able to retrace everything that might be relevant for the attending physicians.

Secondly, a condensed notebook to bring to routine doctors' appointments. Ask the client's doctors what they would like to see in this book, and remember that they will want to scan it easily from the previous appointment for pertinent data. They won't want a lot of commentary. Some specialists have their own format that they like to see used.

Don't forget. Update the notebooks on a regular daily schedule, while the day's activities are still fresh.

Expiration Dates

When taking on any new home care case, don't forget to check expiration dates on all food as well as, of course, medicine.  This point was also mentioned briefly in the earlier Disaster Preparedness post, however the discovery of some very old cans of food in an elderly client's cupboards suggest that this is worth highlighting.

Nursing Home Selection Notes

There are certainly plenty of guides and checklists published on the internet and elsewhere for selecting a nursing home. Medicare has an on-line pamphlet, and also a checklist.  Here are some of my own notes:

1. As I have suggested previously, check out the government websites of nursing homes, and specifically the '5 Star ranking' score of the ones you are considering. As you narrow down your choices you may want to look into the factors behind the rankings.  As an example, I see my son's employer received only a mediocre ranking. That nursing home received 5 stars for "Quality Measures" and 1 star for staffing levels, factors that didn't surprise Martin. Remember also that the rankings are averages of only selected measurements, during certain times.  Critics of the ranking complain that things like patient satisfaction surveys are ignored.  In any case, you won't want a place that puts more effort into 'passing the test' than in improving overall quality.

2. Have a look at the short list of USNews 'Honor Roll' nursing homes. Also, watch for other articles and news reports that identify other noteworthy facilities, like Miami Jewish Health Systems and Hebrew Home of Riverdale.  Be aware that the Honor Roll list is based on the government 5-star ranking mentioned above.  These are nursing homes that scored a "5" in all three categories measured, and the list has the same drawbacks as the ranking itself.  Even if you don't select one of these nursing homes, just visiting them probably gives you a good reference for comparison.

3. See what the CNA's who are actually providing hands-on care are saying, in their own forums. While they won't name employer names, you can get an idea of their issues and frustrations. Try to get an idea if the concerns you read about on-line, like inadequate coverage and unrealistic expectations, might be concerns in the places you visit.

4. Before visiting any home, take just a little time to learn some of the tell-tale signs of quality care. Also, remember to trust your nose. You won't always find bad news. In one nursing home I visited, for example, the cleanliness standards and disciplines were so impressive that I had immediate respect for the staff. In another fancier place I was dissappointed.

5. Check out Elder Abuse Attorney websites, and avoid any nursing home owned by companies with frequent problems in their other facilities. You may have to do some research, because ownership is sometimes not clear. One national operator of 200 homes, many of which have been cited by elder attorneys and the AARP, operates under many different local names.

6. While this is not a critical factor in itself, you might check to see if the nursing home is for-profit or non-profit. Although individual institutions vary, staff salaries are typically higher in non-profits.  In the past, most 'honor roll' facilities were non-profit, though that may be changing.

7.  As with any care provider, check references.  Besides families, professional care managers can be a help.  Also, many states have ombudsmen that look into complaints about nursing homes.  For example, Florida has regional ombudsmen who take consumer complaints.  While they usually get involved after there is a problem, it may be worthwhile to check with them during the selection process. 

Once you or your loved ones make your selection, consider having your own private CNA, RN, or care manager visit. Ideally, it should be someone who will not only give personal care and attention on a regular basis, but will be thorough and able to identify possible problems, signs of infection or developing sores for example, as well as observe general conditions and care. Even with regular visits by family members, you will want to verify that all is really well.

CNA Continuing Education

As we know, CNA's have continuing education (CE) requirements similar to those of other licensed professionals.

Self-employed CNA's sometimes have challenges in meeting this requirement, but they also have some interesting opportunities. No need to be bored.

For example, there are professional conferences. Here in South Florida, the annual Alzheimer's conference provides that kind of opportunity. The conference lectures are the types of things that you would certainly want to attend anyway. Attendees can meet recognized leaders in their subjects, and get updated on the latest research and developments. As a bonus, licensed providers can get CE credit for attending.

For those who just can't get away from their client commitments, professional organizations can help. In Florida, for example, there's the Florida Association of Professional Caregivers. They provide coursework for home study at a reasonable cost. Just complete the course materials at your convenience and mail them in for grading and credit. Sometimes these organizations also have no-cost lectures for credit.

Why shouldn't meeting CE requirements be really interesting?

PHI - The Caregiver Advocates

Professional caregivers should be aware that at least one non-profit organization is working on their behalf - the Paraprofessional Healthcare Institute, or PHI, which is supported by private foundations.

Their motto:
- Improving the quality of eldercare and disability services by improving the jobs of direct-care workers.

Some program titles:
- Quality Care through Quality Jobs, and
- Health Care for Health Care Workers

Clever titles. (There's more, including reference on their site to a conference:"Being a Woman is Not a Pre-Existing Condition").

More important, though, is that during this national healthcare debate they are trying to make sure that care workers are not overlooked. PHI points out that two out of every five professional caregivers do not have health insurance. We all know there are no easy solutions, but at least PHI seems to be reminding everyone of an important problem.

Men With Hammers

A famous writer supposedly said, "to a man with a hammer, everything looks like a nail."

That saying may be appropriate in the elder care field. The challenge for clients and their families is to understand the best course of action or treatment, instead of just the best efforts of a specialized provider.

Sometimes the best care for the client involves several different approaches or disciplines. Perhaps it includes a combination of appropriate therapies, medicines, and counseling. Some providers may have good short-term solutions, but not have the tools or experience needed to achieve long-term improvement. Be cautious when the solution offered for a difficult condition or situation is simply more hammering, meaning increased dosages - of prescriptions, sessions, care providers, and the like.

Sometimes it's helpful to step back and re-evaluate. For those too close to a situation, or too emotionally involved, there are geriatric care professionals who will help clients and their families consider alternatives. Even within that group, though, you have to be careful that the professional is not also selling hammers on the side.

An example of a geriatric care manager might be the professional who left the kind comment on my Disaster Preparedness post. In selecting a manager, you would want to go through the same level of screening and reference-checking that you would with any other provider. For those with big budgets, there are the high-end concierge services. What one of my clients found was that they can work wonders with major medical issues, but their service and knowledge in a particular geographic area was not as strong as the best local providers.

In researching care managers, the National Association of Geriatric Care Managers might be a good place to start.

CNA Report Card

So often, impressions of caregiver performance are subjective. As with any medical provider, a home caregiver's bedside manner is important. Just as with others providing treatment and care, however, we must not forget that actual, measured results do count.

As a caregiver, you should be aware of whether the client has improved or not under your care, even if the change has been gradual. This is not something you get from impressions, but from your actual daily records.

If you have been keeping a good record you will have the information you need. Key measurements depend on the client. These might be progress in vent weaning, weaning from certain medications, limb flexibility, body mass index, blood pressure, blood sugar, or any other specifically relevant measurement.

While clients and their families may not be attuned to this, the physicians and other professional providers will be. Ask them how the client, and you, are doing. Make sure you understand what they see as the important measurements of progress. Don't hesitate to have them evaluate your results.

As you go along, use the measurements that the physician and other medical providers are reviewing to grade your own performance.

Stretching your LTC claim dollars

I sometimes work for clients who have Long Term Care insurance policies. Often, these policies have dollar limits to payouts, rather than specific time limits.

One of my clients, a couple, did some research into this, and found that their policy covered care by state-licensed individuals - meaning CNA's like myself.

Many other LTC policies, including those offered through the AARP, also have that same provision that covers the direct use of licensed CNA's.

For reimbursement, the client simply submitted a claim form indicating my license number. The insurance company paid the couple directly, and from that payment they then paid me our negotiated rate. That rate was lower than they would have paid through an agency or other corporate provider.

They would not be able to do this with unlicensed caregivers, but since CNA pay rates are usually the same as those paid to unlicensed providers, and considerably less than rates paid to corporate providers of these services, there was an opportunity for them to greatly stretch coverage.

I would add some points:

1. Clients should use legitimately licensed, self-employed caregivers to prevent 'employer liability' issues.

2. Clients should check that the CNA they use has her own malpractice insurance policy.

3. Follow the normal safe-guards that would apply to any home care agency or individual, including reference checks.

4. Whether considering licensed caregivers, agencies, nursing homes, or assisted living facilities, clients should educate themselves as to signs of quality care.

By checking into their actual LTC policies, clients may find simple ways to stretch their benefit dollars.

Saw Horses and Quality of Care

The Wisconsin technical colleges have a series of 80 training videos online (Lessons 1 - 80) that can be useful for caregivers. The series is geared towards training aides in hospitals and the like, but the techniques and precautions apply to home care as well.

These are classroom-type lessons, so the style might be a bit tedious for casual viewers. Even so, the lessons are organized well, and you can pick your subjects.

Several of them can be especially informative for those who have loved ones in care facilities. So often, I am discouraged by the actual practices in nursing homes or even hospitals that seem wonderful to the casual observer. They remind me of a friendly, personable mechanic who shouldn't be touching your car.

I'm not alone in this. A recent Consumer Report magazine issue includes a survey of patients in hospitals, and of nurses in those same hospitals. The survey highlighted the differences between what patients were concerned about - with the care level, facility, and all - compared to what their nurses thought they should have been concerned about. The nurses considered the lack of coordination among the providers (communication) and deficiencies in hand-washing discipline to be the two most significant things that the patients should have been worried about. Very few of the patients picked up on these, especially the hand-washing.

All this leads to a seemingly simple video topic - Lesson 22 Bed Making. If you watch the video, at least the first half, you can't help but notice the emphasis on sanitary practices necessary for even this ordinary task. Next time you are in a hospital or long term care facility, observe the bed making. Watch the details. This is one, just one, small indication of the quality of care and attention to safe practices in the facility.

I'm impressed when I see tasks like this being done to proper standards. You should be, too. If you see that the staff attends to every detail, as these lessons will explain, compliment them and their supervisor. If you see short-cuts, however, be concerned. Friendly faces (at least in your presence) don't make up for lack of good practices.

Again, the Bed Making procedures are just an example. All the procedures laid out are important, of course. A carpenter friend once said that his boss had job applicants make a quick set of saw horses in the interview. The boss could tell all he needed to know from that. Bed making is something like that. Watch the video, and you'll see what I mean.

Hiring Privately

By engaging a private caregiver, you can often get a highly qualified professional at affordable rates. With the latest developments in licensing, insurance, and on-line resources, you might consider using a licensed CNA.

When considering a CNA, ask for the caregiver's license number, and check it out with your state's Department of Health, either on-line or by phone.

Licensing. Exams for CNA's have become standardized across many states. State licensing also includes law enforcement checks, with FBI checks as appropriate. Many states maintain easily accessible databases of licensees. License holders also have continuing education (CE) requirements.

Insurance. Professional liability insurance is now available for individual caregivers. Check that the person you engage has a professional liability policy. If your favorite caregiver doesn't have a policy, you might suggest that she obtain one.

Self-employed contractor. Much has been made about the risks of being an 'employer.' To stay clear of problems, use a licensed professional who offers services to the public as an independent contractor. Quoting the IRS: "the general rule is that an individual is an independent contractor if (the person for whom the services are performed) has the right to control or direct only the result of the work, and not what will be done and how it will be done or method of accomplishing the result." Use a licensed professional who has the necessary training and experience to do the job.

Internet resources. Most states have on-line databases of licensed professionals, which provide the licensee's status. For those who want a more current background check than provided by the state licensing board, there are numerous on-line services. These typically charge nominal search fees.

Spot-checking. One of my clients' families had a motion-sensor video security system installed in the foyer. If desired, comings and goings could be monitored, spot-checked, or even communicated by email. The added advantage of that system was that, combined with cell-phones, it could be an entertaining form of communication. Of course this is only appropriate if used with discretion.

Affiliations. If you are planning to use a CNA extensively, check that she has back-up resources available. Many independent CNA's have good networks, including caregivers with prior hospital or other institutional experience. Some private caregivers have close affiliations with RN's. This can be especially helpful in complex cases. As a further back-up, you could also research some local agencies for possible short-term coverage needs.

Long Term Care insurance eligibility. Licensed caregivers are eligible providers under many LTC policies (including the AARP-affiliated provider). Check with your agent or refer to your policy. Since the policy may have dollar limits, you may be able to get more 'bang for your buck' hiring directly.

Financial & Quality advantage. By engaging a caregiver directly you can sometimes get professionals of caliber that you might not have access to through an agency, and at significantly lower cost.

The result. For short-term needs, or in transitional situations, using an agency may make more sense. For longer-term situations, the key relationship is between the actual caregiver and the care recipient. With the developments in licensing, the availability of professional insurance, and advanced technologies, private hiring can be a rewarding alternative.

Finding that "Throat to Choke"

A recent post by an elder care adviser: "Important point:With an agency- you have someone with money to sue if need be!"

Seconded by the franchise owner(?) of a new home health care agency: "you have an agency to sue when you hire an agency (I call it a "throat to choke")".

In case we don't get the point, they are both saying you had better arrange for your home health care worker through an agency, and not deal directly with the caregiver. After all, throttling is banned in most places, and suing for money only works if there is some to be found. And home care agencies have insurance policies. Therefore, their logic goes,....

Well, good news! Your caregiver can, and increasingly does, have a professional liability policy.

These policies are easy to obtain and affordable for the caregiver. With this insurance, you can still directly engage your caregiver, and have the peace of mind of being able to legally throttle her some day, if you choose. And actually get paid when you do the deed.

So, make sure she has a liability policy. From one provider's site:

The policy is specially designed for home healthcare providers, giving you protection from lawsuits arising out of any mistake, real or perceived, during your care as a home healthcare provider. Here are just a few of the benefits:

• Professional malpractice insurance that protects and defends
• 24 Hour a day coverage - 365 days a year
• Up to $1 million per incident/ $6 million maximum policy period
• Policy travels with you no matter where you work

Agencies, Nurse Registries, Companions

Florida has three kinds of licensed or registered home care companies.
- Nurse Registries (recruiters)
- Home companions (sitters and non-health)
- Home care agencies

Only the last group is technically a home care agency, but all compete for mostly the same clients. Clients are often unaware of the distinctions and most of us, myself included, usually refer to any of the three groups as agencies despite the actual differences.

Online search:
When considering a Florida "agency" you should check out their licensing status on the FloridaHealthFinder.gov search site. Using the drop-down menu, select Home Health Agency, Nurse Registry, or Homeaker and Companion Service. Unfortunately, the categories must be searched separately. If you don't see your "agency" listed in one, try the others.

The differences:
Registries generally are not eligible for Medicare-covered work, and neither are home companion companies. Agencies may be eligible Medicare requirements if they meet certain licensing requirements.

Placement through a home companion service means the caregiver should not be providing the actual personal care, such as bathing. Adding to the confusion, local offices of national franchise chains like Comfort Keepers may qualify as home care agencies in many states, but not necessarily in Florida, where the local branch might only qualify as a companion service.

Nurse registries do not actually hire the nurse or CNA. They arrange for the professionals registered with them to work for clients on a contract basis. Hospitals, especially those in areas with skilled nurse shortages, often use registries to fill specialized or temporary needs. I register with nurse registries, and have found that the assignments that some have access to can be interesting.

Registries, and any agencies that place caregivers like myself on a contract basis, are not paying any portion of social security or withholding taxes. Contract caregivers report and pay taxes themselves, just as any other contractor would (despite the articles we read that imply otherwise), and often have their own liability coverage.

In Florida, licensed CNA's are 'eligible providers' under Long Term Care policies, whether they are hired directly or placed through agencies or registries.

DNR's

DNR, "do not resuscitate". As some politicians have put it, this subject is above my pay grade. Or is it?

As aides or family members, we are advocates for the client, and for the best care possible. I am naturally suspicious of DNR's because I don't want an excuse for anything but the best safety measures and care.

The argument for DNR's is frequently that they may be appropriate where the act of resuscitation is likely to be painful or unreasonably traumatic for what will be a poor outcome anyway. For example, a terminally ill patient might want to pass away peacefully rather than have his last experience be a powerful and painful shock in a hopeless attempt at revival. Subsequent 'quality of life' issues are sometimes mentioned as reasons, too.

But actual end of life situations are often complicated. For example, if a client or family member on a respirator and with a weak heart is suddenly suffocating, you would want fast action to enable breathing. However, it might not be appropriate to try to shock his heart into beating again if it came to that. DNR instructions should be specific and appropriate. If you are considering one, be very careful and very specific. Don't let a DNR be an 'out' for anyone responsible for care.

From a CNA/HHA point of view, and for that matter, for anyone but the physician, a DNR instruction should make no difference in the level of care. Actually, that's not quite correct. Caregivers should be more vigilant than ever when there is a DNR instruction, because a DNR could very well mean that the caregiver is the last line of a client's (or loved one's) defense for their life.

Low-Cal Monkeys Age Slowly

A study now in the headlines indicates that monkeys who consume fewer calories over their lifetime live longer. The study has been underway for 20 years, and will continue through their life-span.

The low-cal monkeys in the study consumed 30% fewer calories daily, but researchers made sure that their vitamin intake was comparable to the big eaters.

"Sixty-three percent of the calorie-restricted animals are still alive compared to only 45% of their free-feeding counterparts. For age-related deaths caused by illnesses such as cardiovascular disease and cancer, the voracious eaters died at three times the rate of restricted monkeys" and "monkeys that eat nearly a third less food than normal monkeys age more slowly."

The key point mentioned in the findings that is not always highlighted by the newspapers reporting this story is that consistently lower consumption of calories over a life-time actually slows the aging process. At least for monkeys....but it seems to confirm our suspicions.

CNA? or HHA?

Certified Nursing Assistant or Home Health Aide? Which is more appropriate? It depends.

When I worked in home care in a different state, I was trained and certified as a Home Health Aide. Since I was not 'assisting nurses' but rather providing private care, a CNA designation seemed less relevant.

Florida, where I live, recognizes that there are HHA's in the workforce, but it does not test or license them. Florida only requires that some appropriate but unregulated training be given, by agencies themselves, for HHA's that they place.

CNA licensing, however, includes coursework and hands-on training that generally includes an internship in a nursing home, a law enforcement background check, and a state licensing exam. The exam includes both a written section plus a hands-on test of patient care activities. There are also annual continuing education and training requirements. For those applicants that don't have a long enough residency in Florida, the background check also includes an FBI check.

Florida also provides useful information about each currently licensed CNA on its Department of Health website, including expiration date of the license and whether there are any disciplinary actions against the CNA. If you are hiring a CNA, ask for their license number and check them out through the website. Those in other states should see if their state has a similar online database of CNA's, and if not, phone the state licensing board with the inquiry, instead.

Since CNA license holders can work as HHA's in Florida, but not the other way around, it is helpful for caregivers to maintain a CNA license. It's useful because interested employers can quickly and easily check on us and be assured that we have been trained, tested, and have undergone the background check.

Nursing Home "Honor Roll"

US News & World Report's honor roll of nursing homes.

Arkansas: St. Mary's Regional

California: Golden LivingCenter-Fresno / Rady Children's Convalescent

Connecticut Grove Manor / Matulaitis / Lourdes

Delaware Cokesbury Village / Jeanne Jugan

Florida Brooksville Healthcare

Illinois Memorial Convalescent / Selfhelp Home of Chicago / Prairieview Nursing

Kansas Wichita County / Grisell Memorial / Dooley

Kentucky Home of the Innocents

Louisiana Lane Regional

Maine Oceanview / Charles A. Dean Memorial

Maryland Crawford / Althea / Woodland

Massachusetts Bethany / Hannah B.G. Shaw / Seven Hills Pediatric

Michigan Marywood

Missouri Lutheran at Breeze Park

Montana Wibaux County

Nevada Nevada State Veterans

New Jersey Broadway House / Holy Name Friary

New Mexico New Mexico State Veterans

New York Our Lady of Hope / Mapplethorpe Residential / Jeanne Jugan

North Carolina Mayview Convalescent

Pennsylvania South Mountain Restoration

Texas Rambling Oaks Courtyard

Vermont Wake Robin-Linden

Virginia Central Virginia Training / King's Grant Retirement / Snyder

The ranking appears to rely mostly on the government's 5-star rating system.

Dress Code developments

Will patients now mistake their doctors for dentists?
Will dentists defend their trademark?

Since my posting on the subject of CNA / HHA Dress Codes, I discovered a new favorite website by two physicians specializing in infection research and control, Controversies in Hospital Infection Prevention.

There was a recent post that referred to a Cleveland newspaper article. The article pictured some hospital workers in scrubs, shopping at an outdoor farmer's market.

The "Controversies" site includes several postings regarding a "white coat" controversy among doctors. In some countries, doctors are giving up their white coats, and going with just short sleeve scrubs. In the US, that may take some updated thinking.

From the "Controversies" site, another post,

"Dan Markley presented results of a survey of doctors that showed that roughly one-third wash their white coats weekly, another third every other week, and the remaining third wash their coats monthly or even less often. Dawn Butler presented her work showing that in the laboratory organisms inoculated onto white coats can indeed be transferred from the coat to skin with little effort.

"Over a year ago, I adopted the “bare below the elbows” approach when I work in the inpatient setting. It has made me cognizant of several things: how often the skin of my forearms touches patients in the course of care, how visibly dirty many lab coats are, and how much easier it is for me to wash my hands without worrying about getting the cuffs of my shirt or coat wet."

The Bare Elbows post on that site has more information (also, take notice of the pictures).

Trust Your Nose

If it doesn't smell right, it probably isn't.

Facilities

When visiting care facilities, including acute care hospitals, nursing homes, rehab units and even assisted living homes, trust your sense of smell as you check out conditions. A sanitary place will smell sanitary. Odors won't be covered up with cleaning sprays.

You will find that even within one facility, the odors in wings can vary. At one highly respected rehab center in the Midwest, one wing didn't pass the the smell test, while the rest of the building was ok. If you come across anything like that, have your client moved to an area that is acceptable. Aside from the sanitation aspects, if the odors bother you, why subject your client to them?

Bathing

After your client has been bathed, he or she should smell fresh. If you detect any sour smell or anything less than fresh, see that the job is done over again, properly.

Infections

Infections will often cause odors, and you should be familiar with those and attuned to them. I once detected a foot sore on a patient in an acute care hospital by its odor. The patient's foot had been wedged at the bottom of the bed. He had no feeling at all in his legs and was unaware of the developing sore. Meanwhile, the staff assigned to him had missed the warning signs.

If you discover a sore, what do you do? If a doctor isn't available right away, arrange for a Wound Care Nurse to treat the wound immediately.

Never Say Never

A study by Vanderbilt's Buerhaus and others on nursing employment:

"The recession may temporarily end an 11-year-long nursing shortage in many areas of the country.....the increase of hospital employment of nearly 250,000 RNs in such a short period of time (2007-2008) is stunning.” said Buerhaus.

"...the study found that the recession had induced older nurses to delay retirement and others to re-enter the workforce....... between 2001 and 2008, 77 percent of the increase in total registered nurse employment was accounted for by registered nurses over the age of 50"

Hand washing

Please excuse me if I seem upset about this.

We've all see the headlines like "Inadequate hospital hand hygiene is spreading MRSA."

CNA's in most states are even tested on hand washing. Hospitals are increasing enforcement of the procedures. Is it working? Or do we still see situations where the staff wash their hands when they enter the room, put on the latex gloves, then go about their duties in the room touching one patient, then the next? When they leave, they throw out the gloves, then do the same in the next room? At least the staff is protected from MRSA, right?

We won't win friends when we point this out. I certainly don't make many. But we need to speak up.

Too many of our clients have contracted MRSA and other infections unnecessarily.

Bedsores - Prevention Summary

There are a number of things that can be done for prevention of sores:

• Help the person shift frequently, at least every couple of hours.

• If the person can't move at all, consider getting a bed that can shift teir position automatically.

• Be careful of pressure on bony areas, like the heel or lower spine. Pay special attention to those areas.

• For people who can't move their feet, I always try to place a sheepskin pad under their heels. The elbows can also be protected by pads.

• If the bed tilts up, put padding or a roll pillow at the foot of the bed so that feet don't get wedged against a hard surface. Be careful of sliding.

• Be careful not to allow friction burns from sliding on the bed. This can happen accidentally when tilting the bed up, when changing the linen, or when sliding the person off or on the bed.

• Bathe daily, and more frequently as needed, using appropriate products.

• Don't allow the skin to get too dry. After bathing or cleaning, use a good moisturizing lotion all over. Thoroughly massage the lotion into the skin.

• Keep bedding clean and dry, and be careful of wet or damp linen or bedding.

• If using a wheelchair, be careful of prolonged contact with hard surfaces. Use high quality pads.

Bedsore prevention - lotions

I recommend using the best cleansers and lotions you can get. These are often only available at medical supply stores or from online medical suppliers, and are usually expensive. I believe in being frugal, but this is one area where you don't want to save pennies.

Even if your client or loved one is in a long-term care facility, you will still want to look into this. There is a good chance that even acute care hospitals might not be using high quality products. Find out what is being used, and if necessary, bring in samples of your favorites. Be prepared to ask your client's physician directly for prescriptions for the most appropriate products, and then make sure the care facility actually gets them. If a lotion is prescribed for your client, you will want to be sure it is kept aside for his or her use and not put with the general supplies.

You may have to insist, but it's worth it. Of course these only work if used daily, and properly.

Bathing should be performed at least daily, with additional follow-up bathing as necessary. Prosducts for rinse-less bathing are available at some pharmacies and most medical supply stores. After the bath, lotion should be applied, and thoroughly massaged into the skin so there is no residue. You should be checking for the possible development of sores while doing this.

NIH's Wound (bedsore) Treatment Chart

This chart from the NIH's website is just a reminder that the treatment of bedsores is not "do it yourself." Wound care is complex, and important.

See your physician or Wound Care Nurse.

When Bedsores are Discovered

First, I should say that my experience is with prevention, and you should discuss any treatment with a doctor.

Second, wound care is complex. The proper treatment, including ointments and cleaning materials, will depend on whether the sore is infected or not and whether it is wet or dry. Get expert medical treatment.

Bedsores are serious.

Bedsores are very serious, especially if they develop into open wounds. They don't heal easily, and can get worse quickly if not treated carefully and expertly. Bedsores are also commonly referred to pressure ulcers or pressure sores. If you look up the bedsore topic online, these terms are used more commonly on the medical sites.

Bedsores are classified by stage, one through four. Stage 1 is before it breaks the skin surface, while at Stage 4 it is an open wound all the way to the bone or tendon.

Don't look at these if you get upset easily, but there are pictures of the sores on the internet, including in Wikipedia under the bedsore definition.

Identification.

Hopefully you will be able to identify the existence of a sore early in Stage 1, before it breaks the skin. At Stage 1 the area will look red or purple under the skin surface. If you touch it, it won't temporarily turn white, like a spot that is red from routine pressure would.

The areas that are susceptible and should be checked are those where the bone is close to the skin surface and subject to pressure, such as the hips, lower spine (tailbone), heels, elbows, etc. These ares should be checked frequently, especially the tailbone area and heels.

At the very least, the skin should be fully examined at least daily, during the daily bathing. After the cleaning, you should be applying moisturizing lotion to the skin. As you apply the lotion to the entire body, check thoroughly for anything that could look like a developing sore. If you see a stage 1 sore, don't massage it, as this may cause further damage to the area under the skin. Also, you can sometimes identify that there is a sore from odor, so be sure to investigate to any foul smell.

Treatment.

If a bedsore is discovered, get professional medical treatment. At a very least, if these are discovered in a rehab or nursing facility, have them treated by a "Wound Care Nurse". Wound Care is a nursing specialty. Ask to speak with that nurse about the prescription for treatment. If the facility does not have a wound care nurse on staff, they should be able to arrange for one.

Make sure the prescribed treatment is followed. The dressing should always be dry, and should be changed according to schedule. My experience is that this often does not happen as you would think it might. In rehab facilities or acute care hospitals, there may be 15 patients assigned to each CNA and there might be only a few RN's on duty, so scheduled dressing changes can easily get overlooked.

I try to talk to the client's doctor about possibly prescribing specific cleansers and ointments, rather than have the staff rely on whatever is on hand at the facility.

Monitor carefully.

I might Trust, but I also Verify, so I'll sometimes mark or date a bandage so I can be sure that it is being changed. More frequent changing is much better than a skipped changing. Also, even if it has just been changed minutes before, if the dressing gets wet or contaminated at all, make sure the wound is treated and changed all over again. Wounds in the tailbone area or hip can easily get contaminated. Don't compromise if the wound gets contaminated. Be sure that it is cleaned and bandaged all over again if this happens, no matter how many times this may need to be done.

If the sore is being treated in a rehab facility, find out when the wound care nurse is scheduled for a follow-up so you can get the progress. By doing that you will also know that there actually is a follow-up.

Elder abuse?

Some patient advocate groups you find online consider any bedsore to be an indication of abuse. That may be a severe view.

My own opinion is that these sores are preventable. They afflict people who can't care for themselves, when the attention they require is not provided. These sores are painful. They come about when a person is left in one position so long that discomfort gradually builds up to the point that it is painful.

Bedsore prevention - high-end beds

In my earlier post Bedsore Prevention Part 1, I mentioned the importance of a good bed, and I used Hill-Rom as an example. The main reason beds like these are so helpful for preventing bedsores is that they can be set to gently roll your patient from side to side at regular intervals. The timing, speed, and amount of the roll can be preset, and can be set to be more gentle than you could do it yourself.

You can reposition the patient yourself, of course, but it is difficult to monitor that consistently around the clock, and you might need a second person to help. These beds can do the shifting so gradually that it won't wake or disturb the patient.

Some models of these beds also can have a percussion setting. For someone with respiratory problems, this acts like a regular pat on the back to help loosen any accumulation in the lungs. Some also have temperature controls to prevent sweat buildup, since sweating increases the chances of skin problems.

As I said before, these beds are expensive and the full featured models are not even available for home. The mattresses and controls, which are still expensive, are available for home use.
It is frustrating that you can't usually get these beds under most insurance unless unless there already is a sore.

Even the better nursing facilities won't have these, so you need to ask the physician if this would be appropriate. I was surprised that at a better known nursing facility in South Florida, the staff wasn't familiar with beds like these and needed to be trained to use the one we had them get.

More than the beds, the important point is proper positioning. You can still get that with your existing bed by using wedge pillows, which are available at medical supply stores. You just have to be attentive and reposition regularly.

Trust but Verify

This is a delicate subject.

How often have heard that the staff in a particular rehab or long-term care facility is caring and loving, and that everything is so nice and clean? Everyone smiles and hugs, and the linen and gowns are fresh. These are good signs.

It's wonderful to find a place like that, especially if it also provides genuine rehabilitation services. I've found that you need to actually check under the covers, though, before you get too carried away by good impressions.

Few family members will want to actually check on the work that's being performed. Much too often, supervisors don't thoroughly check, either. Creases in the skin can hide small problems that soon become big ones.

If you don't feel comfortable performing the inspection yourself, find or hire someone who will. It will be a great service to your loved ones. The sores and discomfort that so often result are completely avoidable. Also, if the staff knows that you may verify, the full level of care is likely to improve.

Bedsore prevention - intro to beds

The best cure for bedsores is prevention. Preventing sores takes a great deal of effort, but it is always worth it. There is one piece of equipment that can help.

For clients who can't move themselves in the bed, make sure that when they are hospitalized or in long-term care they have a prescription for the best possible bed. Often that's a Hill-Rom bed or similar brand.

Hill-Rom beds are expensive though. Unless there are pre-existing bedsores, which there shouldn't be, it may be difficult to get reimbursement. It is still worth it to try, and your client may find it worthwhile anyway.

You can't buy the entire Hill-Rom bed for home, but you can get the mattress and control unit that can go on certain home bed frames. It doesn't look like much, but it can make a tremendous difference in your client's comfort and well-being.

CDC on Nursing Homes & CNA's

The CDC recently published The National Nursing Home Survey: 2004. The report was based on a sample of approximately 1,500 nursing homes, out of the 17,000 nationwide. The CDC's previous report was for 1999. A new survey of CNA's was added.

Nursing homes:

• In 2004 there were 1.5 million nursing home residents, 136,000 fewer than in 1999.
• Overall, nursing homes occupancy rates were 86%.
• 62% of the homes were for-profit, 30% non-profit, and the rest government/other.
  
• 88% of homes were certified for Medicare and Medicaid, up from 82% in 1999.
• 55% of the homes were owned by chains.
• Nursing homes employed 939,000 in care jobs, of which 600,800 were CNA's.

Residents:

• 45% of residents were age 85 or older.
• The Midwest had the most nursing home residents, as a percent of population, followed by the Northeast, then South. The West had by far the fewest.
  
• 71% of Nursing home residents were female.
• Most residents had more than one payment source. At admittance 42% paid some or all of their care privately, but as of the survey 66% were then paying some or all of their costs.
• 23% were originally admitted for circulatory problems, 16% for mental disorders, and 16% for nervous system disorders.
• 11% of residents had pressure ulcers, 76% of those were stage 2 (open sore) or worse.
• 42% of patients with stage 3 or 4 sores had been in acute care hospitals prior to admittance.
• 56% of residents had DNR directives

CNA's:

• Nursing home pay for CNA's was about $10 per hour
• Non-profit homes paid $0.70 per hour more than for-profits, and government-run homes paid $1 per hour more, on average.
  
• 54% were enrolled in employer health plans (46% at for-profits, and 63% at non-profits).
• 16% did not have any health care insurance.
• 36% had family incomes below $20,000 per year
  
• 92% were female, half were married
• 54% had 6 or more years experience
  
• 43% said that they did not have enough time to adequately assist residents (51% in the Northeast)
• 40% reported being dissatisfied with pay.
• 20% were dissatisfied with workplace morale
• More felt they were respected by residents than by resident family or supervisors
• 32% said supervisors did not discipline or remove poor performers
• 30% had problems with co-workers
• 45% said they may leave their facility within a year, poor pay being biggest factor

283 of the homes selected for the nursing home survey "refused to participate" according to the report. Of the 769 homes (employers) selected for the CNA survey, 665 had their CNA's participate.

Acute Care Hospitals, "The Good"

As a follow-up to the previous posts discussing Bad and Ugly acute care hospitals, it might be helpful to mention one of the Good.

A client of mine had the good fortune to be admitted to RML, outside Chicago.

RML is "primarily focused on treating and weaning patients dependent on mechanical ventilators, and today is the largest single ventilator weaning hospital in the nation. Our scope expanded several years ago with the addition of our Wound Management and Medically Complex programs."

On their web-site, they include statistics for infections, sores, nurse coverage, and patient satisfaction.

(Though nobody is perfect. RML was the hospital I had in mind when I recommended trusting your nose in scouting out specific wings within even good facilities.)

"The Bad and the Ugly"

Even more from the owners of the the Bad and the Ugly.

Update: And yet even more! (different facility name, but owned by the same national chain of for-profit nursing homes)

Nursing Homes - Dregs list

"Special Focus Facilities" , judged by the US Department of Health and Human Services to be the very worst 1% of nursing homes.

Acute Care Hospitals, revisited

A malpractice attorney's Nursing Homes Abuse Blog recently posted a YouTube video, which I provided a link to, below. The video is from a client of the attorney, regarding his experience with an acute care hospital in California.

In my earlier post titled Acute Care Hospital notes I shared a few of my notes from an acute care hospital in Massachusetts. Both the Massachusetts hospital, and the California hospital in the video, are owned by the same for-profit corporation! This same company owns over 80 acute care hospitals nationwide, and also 200 nursing homes. They were also cited in a warning on AARP's website in January 2009.

The attitudes described in the California video were very familiar to me. That company's management approach, tactics, and procedures are obviously the same, on the opposite coasts.

Being "just a CNA", I'll leave the naming of names to the Nursing Homes Abuse blog. The YouTube video is for reference. I can't promise that the video link will remain valid.

Geriatric Care Hospitals - Top 10

US News & World Report's Top 10 Geriatric Care Hospitals:
Ronald Reagan UCLA Medical Center, Los Angeles
Johns Hopkins Hospital, Baltimore
Mount Sinai Medical Center, New York
Massachusetts General Hospital, Boston
Duke University Medical Center, Durham, N.C.
Mayo Clinic, Rochester, Minn.
Yale-New Haven Hospital, New Haven, Conn.
UPMC-University of Pittsburgh Medical Center
University of California, San Francisco Medical Center
Cleveland Clinic
Ratings were based on reputation (32.5%), mortality index (32.5%), safety (5%), and technology, nurse staffing and other factors (30%).

Healthcare Statistics. And More Statistics!

Here is a link to a USA MAP of Health Care information by State

Nursing home short-stay residents having pressure sores

• Best (10%-12% rates) Minnesota, Iowa, Nebraska, North Dakota, South Dakota
• Worst (19%-21.4% rates) California, New Jersey, New York, Nevada

Nursing home long-stay residents that are physically restrained

• Best (under 2% rate)Delaware, Nebraska, New Hampshire, Iowa, Kansas, Wisconson
• Worst (over 9% rate) Arkansas, California, Louisiana, Oklahoma

The site also has graphics, including these two for Florida that rate Florida home health care providers as better than the national average, and Florida nursing homes as worse.

Nursing Home Restraints

Here is a link to a previously recorded webinar presentation by Advancing Excellence in America's Nursing Homes. The original audience for this was nursing home administrators. 800 were on the original call. However, if you have anyone in a nursing home, or if you work in one, I would at least recommend this.

Towards the end they have some remarks from an administrator for a home that used to have more than a 20% resident restraint rate.

WEBINAR - NURSING HOME RESTRAINTS

The webinar discussion also refers to powerpoint slides, also available in pdf, but the discussion itself is the worthwhile even without the slides.

Nursing Home Rating System

Here is a link to the governtment ratings of individual nursing homes: HHS.gov (http://www.medicare.gov/NHCompare/Include/DataSection/Questions/ProximitySearch.asp)

They rate each of more than 10,000 nursing homes on a scale of one-star to five-stars, based on inspections and various measurements.

Much Above Avg.
Above Avg.
Average
Below Avg.
Much Below Avg.

If you click the nursing home name, and then select there categories, there are some comments. Here is an example, for a place with a "One Star" rating:

"Inspectors determined that the nursing home failed to:

• Keep each resident's personal and medical records private and confidential.
• Provide services to meet the needs and preferences of each resident.
• Quickly give a resident's personal money to the heads of his or her estate after the resident's death.
• Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help.
• Store, cook, and give out food in a safe and clean way."

Some critics of the ratings wonder if nursing homes will now focus on the factors that will raise ratings, rather than improve overall quality of care. Still, one would think that publicizing and ranking the results of inspections, percentage of patients with sores, etc. is a good thing.

What are the CNA's saying?

If the home care effort seems discouraging, read what the nursing home CNA's are saying among themselves. Well at least some of them. : Link to Indeed Forum>Jobs>Nursing Assistant

The link lists responses to the question: "What is considered a normal Patient:CNA Ratio? I work 24 patients myself"

Some of the responses:

"My unit, when 1 CNA is working, is 35 residents spread between 3 halls; 44 between 4 halls when 2 CNAs are working."

"I went in and was told I would have to care for all the patients on one side of the hall by myself and another CNA would do the other side. This left us with 23 patients each. We had to feed breakfast, do showers, make beds and pass water and than get them ready for lunch. Do rounds and change the patients who needed changed, put some back to bed for a nap and chart everything. We also had to do vital signs. I went home exhausted."

"I am a CNA and also 17, and I have 29 patients at night and they are all on the hospice hall."

"We have 2 CNA'S To work 35 people i feel that the patients are not getting taken care of at all."

For those providing home care, take comfort in knowing your loved one is fortunate to be with you.

Roll pillows as foot bolsters

These pillows make good bolsters for the feet. Not under the ankle, but between the client's foot and the bed's footboard. The foot should be propped up to a normal position, at close to a right angle. Not straight out and unsupported for lengths of time.

You also need those pillows when using Craftmatic or hospital type beds, because the client may slide down when you don't realize it. You don't want their feet wedged against anything hard at the foot of the bed.

Home care supply shelf

Home supplies for a severely impaired vent patient.

As with any craft, the right tools (and supplies) make a difference.

In this case the objective was to provide home care that was at least equivalent to the capabilities of an acute care hospital.

Disaster Preparedness for Diabetics

We don't want to wait until a natural disaster is at our doorstep to think about getting ourselves prepared. Here in Florida hurricanes are a worry, but almost every part of the country has its own natural disaster threats.

As caregivers we have special concerns and responsibilities, especially when we are caring for those with special needs. Diabetics are an example.

There are many articles and checklists available online these days. Here is a link to a helpful example of a checklist for diabetics. In Florida, aside from having a secure residence not vulnerable to flooding, we have to assume that we could be without power for a week or longer, and that we might not have access to medicine, food, or other supplies.

We need to have an ample supply of medications, including the insulin, and be aware of the visual signs for the particular type (either clear or cloudy, not sticking to sides of bottle, etc.). For food, we need a variety of appropriate, sugar-free foods with long expiration dates, that don't require cooking. Crackers, canned tuna and such, peanut butter, canned fruits in very light or no syrup, and of course plenty of water.

When checking supplies on hand it's easy to forget about expiration dates, so this is a good time to make sure that we aren't relying on last year's stockpile.

Of course, there are the usuals, including flashlights, extra batteries and all. Better to think about getting food and other supplies ahead of time rather than waiting for that first storm advisory.

Air conditioning ducts

Air conditioning and heating ducts are easy to overlook.

When you are establishing a clean, safe environment for your clients, these should be professionally cleaned.

You might be surpised at the accumulation.

Kindle, the book reader

Many of us have way too many bills to ever worry about buying something like Amazon's Kindle.

However, if your loved one enjoyed reading books, newspapers, or magazines and now has difficulty, it may be something to consider. A friend explained some of the benefits of this year's Kindle II.

The print size can be adjusted to large print. You can have it read out loud to you, and even adjust the speed that it reads. Newspapers and magazines download automatically as they are published.

Some people don't like the voice reader, so judge for yourself.

Maybe it won't replace books on tape CD's, but it certainly sounds more stimulating than daytime television!

Natural alternatives

We all know that honey has many health benefits. I always use honey in tea instead of sugar.

A physician speaking at a recent conference here described the benefits of honey as a skin lotion. He pointed out that honey never needs refrigeration, and for a reason. It is antibacterial.

So we can include honey to our list of topical lotions.

There are numerous websites addressing this subject, and studies describing the differences between medical grade and grocery store honey. For wound care treatment, there is a website that describes application procedures in more detail.

Safety Tip - EMS and Fire Department

If your client is confined to a wheel chair, or even just uses a walker, see your local Fire Department and EMS, and let them know. The emergency workers will appreciate it, and they may stop by and introduce themselves to your client.

This is especially important if your client lives in a condo or apartment. If there is a fire or other need to evacuate, they will know to check and will make a special effort to make sure your client is safe.

Air Ambulance

I have traveled twice on trips by air ambulance. One was a lengthy trip that required a short refueling stop along the way.

Small Lear jets were used, and along with the pilot and co-pilot there was an RN and a respiratory therapist. These very competent people were arranged by the air carrier as part of the flight.

The jets looked like private aircraft from the outside, but inside were stripped out, with no luxuries, and set up like an ambulance. Instead of being as heavily equipped as an ambulance, though, to save weight they only carried the equipment necessary for the particular client. There was a small bench seat out of the way in back for a passenger besides the client. Only one small suitcase was permitted, and other luggage had to be shipped separately. The planes were colder inside than I expected.

Travel to and from the airports was by ambulance, also arranged by the charter company. Everything tightly coordinated so there were no delays. These flights are expensive, and are priced by the hour of flight time. When you need safe long-distance transportation, they do the job.

The trips were booked through charter agents suggested by the hospital counselors, but the actual jets used for the flights were owned by Kalitta, which also provided the crew and staff.

Dress warmly and travel light.

Concierge Advocate Service

Here we are talking about the concierge medical service companies that have been featured in magazines and newspapers.

These are not the concierge physicians or practices. These are not "Dr. Hank." These are high-end service companies that provide advice and open doors for their clients, but do not provide actual medical care.

When you have a special need they will pull whatever strings that need to be pulled. They get the client into the best clinic without waiting, or an appointment with the best specialist.

Fees range from a few thousand dollars a year to tens of thousands, depending on the service plan. Are they worth the price?

I provided care for an elderly gentleman who was enrolled, by his family, in one of the more prominent concierge care services. I asked one of the family members for comments.

"There were some things that the service did exceptionally well, and other areas where the provider fell a little short. The value of the service was almost entirely in the abilities of a few senior people. This particular service had an exceptional medical director, and a few highly capable liaisons to that person. The support staff beyond that, and the local representatives, really did not add much value.

"Their strong point, and the reason for having them, was that with just a well-placed phone call or two from the medical director they could move a mountain. They were able to gain entry (or more accurately, 'force' entry) to a world-class diagnostic clinic to which we otherwise would not have access. They also arranged for a senior-level medical director to make house calls.

"Their weak points were in "blocking and tackling" functions: identifying a high-quality rehabilitation clinic; personal follow-up on the member's status and care; and communication. That level of activity was delegated to staff that did not have the experience or influence to get the results one might expect. Perhaps more disturbingly, the staff did not have the same standard for 'quality care' that the likely subscriber for this service might normally expect.

"There was no doubt that the top few people were recognized professionals, but beyond that it was hit-or-miss. Additionally, subscribers should be aware that the level of service will likely vary by geographic region. Outside the Mid-Atlantic states the service suffered.

"I would still recommend that company's base-level service, however, and use it sparingly - just to make those few important calls."

To sleep, perchance...

It's no news that as we age, many of us have increased difficulty getting a good night's sleep. As we head toward the century mark (knock on wood) it can be a real problem. Our 'circadian rhythm' starts to out of whack. For those with Alzheimer's, sleep rhythms have been described as 'chaotic.'

Research groups at both Rensselaer Polytechnic and Case Western think that they may be able to help get the rhythms back closer to where they should be.... by using blue light. They have been testing the use of blue light indoors, in the community rooms of local nursing homes and in VA hospitals, with favorable results.

One 100-year-old participant commented that she didn't know if her sleep improved, but she liked the blue bulbs so much that she got some for her own lamps, explaining "it's a beautiful light."

New Agencies

I came across this posting on a national home health care agency's web site, in the company's "franchise opportunities"section.

Yolanda: " ....I am currently unemployed. I am an automotive management professional..... I have an entreprenurial spirit, very passionate and motivated to work hard. But now, I want to build a future for myself and my family that I can grow, nurture and build a retirment from. I have always wanted a business of my own and I agree that the elderly population is growing and a nursing home is not always the answer. I have grown up in a home where my grandmother lived with us to the end and also my great aunt. We believe in great home care where the elderly can be around family. I am very interested in this line of business because I lived my teenage years with a bedridden grandmother. It can be done!

Franchiser : "Yolanda, you sound like many of our [Home Care Agency] franchisees. In fact, we have a new franchisee here in our training class right now that was laid off from her job at Ford recently..."

And this, from a different national agency (their use of bold letters, not mine):

Our Franchisees
With our hiring practices, support, and training, it is not required for our franchisees to have a medical background, just the drive to succeed. Our company’s mantra is “Failure is Not an Option.” Join our franchise team to start reaping the benefits of an unlimited revenue stream.

""unlimited revenue stream"?

When considering agencies, look for the quality and experience of management. You will want to rely on people that have had actual experience in the best facilities. Medical facilities.

HBO Alzheimer's Project series, On-Line

HBO's series of shows about Alzheimer's is available for on-line viewing. The five-part series is on the Alzheimer's Association web page:
http://www.alz.org/news_and_events_16202.asp

And also on HBO's website:
http://www.hbo.com/alzheimers/the-films.html

The shows include:
"The Memory Loss Tapes" (85 minutes)
"Grandpa, Do You Know Who I Am? With Maria Shriver" (30 minutes)
"Momentum in Science, Part 1" (55 minutes)
"Caregivers" (48 minutes)
"Momentum in Science, Part 2" (70 minutes)

Cell phone (infection) transmission poblems

Infection transmission. Not lost calls.
From the 'Anaesthesia Journal of Great Britain and Ireland' in 2007:

"Following hand disinfection, 40 anaesthetists working in the operating room (OR) were asked to use their personal in-hospital mobile phone for a short phone call.

"After use of the cell phone, bacterial contamination of the physicians' hands was found in 38/40 physicians (4/40 with human pathogen bacteria)....

"The benefit of using mobile phones in the OR should be weighed against the risk for unperceived contamination. The use of mobile phones may have more serious hygiene consequences, because, unlike fixed phones, mobile phones are often used in the OR close to the patient."

A different study released this year tested the cell phones of doctors and nurses in a hospital setting and found that about 95% of the phones were contaminated. Only 10% surveyed responded that they regularly clean their phones. Caregivers might also want to take note.

Acute Care Hospital notes

A few years ago I had a private client who was in an acute care hospital. The client could not speak for himself or press his own call button.

The family was not fully satisfied with the level of care in the facility, based on their observations during visits.

This hospital was one of 80 across the country owned by the same for-profit corporation. They also own 200 nursing homes.

Looking back at the notebook entries from that experience:

One of the aides came in with a pair of gloves on, took another patient's pressure, then came to attend to my client. I asked her if she would change her gloves, but she said it wasn’t necessary. She used the same gloves for all three patients in the room, and left with them on.

Client’s foot was squeezed on the wedge and I called for the nurse. Client was already recovering from a previous foot injury caused by a similar situation, and I asked that he be more carefully checked. The nearby aide said “no one is coming in here to watch him every minute so you all better get someone to do it.”

Pressed call button for cleaning.Two aides started cleaning my client roughly with a wet towel, one holding him and the other scrubbing. I asked them to let me do, more gently, and they became indignant and questioned my qualifications and training.

One of the aides was cleaning patients, placing the [waste] in a single bag and dragged it from room to room, adding to it as she went.

Cleaned and bathed my client, placed the trash by the door and pressed the call button. No one came to get the bags for four hours.

Someone identifying herself as an IV nurse came in, saying she wanted to put a line into my client. I have always considered this a sterile procedure. She was in regular street clothes, including a dirty sweater however she did wear gloves. There was no cover on the wire she was carrying, and she didn’t close the door or draw the screen.

Client's belongings were moved into a closet that already contained a previous patient’s clothes.

Pressed call light for cleaning. After a half-hour, an aide came in and cleaned him. Afterwards, he was still dirty, so I cleaned the rest from him. She watched and said “you can dig it out, I am not digging it out.” She placed the soiled wipes on the floor, and then transferred them to the trash, leaving two spots of residue on the floor.

Finally we were able to move my client was moved to a different facility. Are these experiences unusual?

Not according to newspaper accounts describing another one of this same company's acute care hospitals, in another state.

Also, in January 2009, AARP Bulletin published a notice regarding one of their nursing homes, in even another state:

A [ ] nursing home has received a Type A citation, the most serious citation the state can give, for alleged abuse and neglect, and the federal government has said it will terminate its Medicare and Medicaid funding.

Trust but Verify. That doesn't mean you can't Trust any acute care facility or nursing home. But you should always Verify. This is one company that needs a lot more verification than others.

Scotland's fight against MRSA

"Scotland launches zero tolerance policy on handwashing to fight MRSA and C. diff"

"NHS nurses and other staff in Scotland who fail to wash their hands will be targeted in a move designed to stamp out hospital infections like MRSA and C. diff.

"The ‘zero tolerance policy’ announced by the Scottish Government means that the public will be able to check superbug infection rates and levels of hand cleanliness for each hospital on a website to be established by the end of the month.

"The ‘zero tolerance’ approach has been set out by the Scottish Government’s chief nursing officer, Paul Martin, in a letter to all health board chief executives and suggests possible disciplinary action if hospitals or individual staff are found to be below recommended standards."

MRSA

My apologies for the graphic picture.

"Most MRSA infections occur in hospitals or other health care settings, such as nursing homes and dialysis centers."
http://www.mayoclinic.com/health/mrsa/DS00735

This upsets me because it is entirely avoidable. It spreads so easily when proper standards are not maintained that some facilities seem to accept MRSA as a fact of life.

Unfortunately, this also means that many seniors are not getting the physical contact that they need. You will notice that many caregivers only touch patients when they are wearing gloves. And then, too often, they touch others while still wearing the gloves.

What they really need to do is simply wash their hands using proper techniques.

CDC on Handwashing

The following is a presentation prepared by the CDC:

WHY IS HAND HYGIENE IMPORTANT?

• Infections are a serious problem in healthcare facilities.
• Every year, an estimated 2 million patients get a hospital-related infection. 90,000 die from their infection.

DO YOU USE HAND HYGIENE WHEN YOU SHOULD?

• Healthcare personnel practice hand hygiene about half the time they should.
• Immediately before touching a patient, performing an invasive procedure, or manipulating an invasive device
• Immediately after touching a patient, contaminated items or surfaces, or removing gloves
• After removing gloves
• After touching items or surfaces in the immediate patient care environment, even if you didn't touch the patient while you were there

BUT I DIDN'T TOUCH THE PATIENT. WHY SHOULD I PRACTICE HAND HYGIENE?

• Bacteria can survive for DAYS on patient care equipment and other surfaces.
• Surfaces in the patientcare environment – includingbed rails, IV pumps, andeven computer keyboards – are often contaminatedwith bacteria.
• It’s important to practice hand hygiene after you leave the room, even if you only touched patient care equipment or other surfaces.

HOW DO I PRACTICE HAND HYGIENE CORRECTLY?

• Apply to palm of one hand (the amount used depends on specific hand rub product).
• Rub hands together, covering all surfaces, focusing in particular on the fingertips and fingernails, until dry.
• Use enough rub to require at least 15 seconds to dry.

HANDWASHING

• Wet hands with water. Apply soap.
• Rub hands together for at least 15 seconds, covering all surfaces, focusing on fingertips and fingernails.
• Rinse under running water and dry with disposable towel.
• Use the towel to turn off the faucet.

The University of Florida has been testing a device they developed that monitors the thoroughness of handwashing:

Northwestern Memorial, Chicago

If you happen to go to Northwestern Memorial in Chicago as a visitor or with your client, I recommend asking for a tour. Many of the features are very interesting, but easy to miss.

For example, in all the patient areas, even in the corridors, the ceiling lights are placed so that a patient will never be looking directly into them. They said that the lobby and check-in area were designed to be like a first-class hotel, but in some ways they are more low key and relaxing. The beds are efficient for moving patients. There is a medical library for visiting families, with computers, and books organized by medical category. Even the corridor layouts are interesting.

It is worth asking the administration for a tour if you are in Chicago.

Five Star Griffin Hospital & Planetree

Fortune magazine has featured Griffin Hospital near New Haven, CT, as one of the “100 Best Companies to Work For” and other publications have listed it as a "Five Star Hospital."

160 bed, non-profit Griffin has become such a model for other institutions that it has a side business charging health-care executives from other hospitals thousands of dollars for “benchmarking” tours. It is a community family hospital (not a geriatric specialist). Although it says it has always paid slightly below-market wages, it has had a long waiting list of applicants to work there, even during nursing shortages.

Several years ago, Griffin acquired control of, and now runs, the Planetree Alliance, which is the "original" patient-centered hospital model. From the Griffin website:

".... if patients have access to information regarding their illness and hospitalization, they can become active participants in their own health..... allowing patients to read their own charts.....satellite resource centers located on each unit for those who wish to learn more.....

".... there are no “restricted zones.” The traditional nurse station is replaced with an open workplace that anyone can use - patients and families alike..... full kitchens, patient and family lounges are on each unit..... a music lounge where patients and their families can enjoy the talents of the various musicians who staff the daily Arts and Entertainment Program.

"The Planetree model also incorporates complementary therapies, such as therapeutic touch, meditation, massage, acupuncture and therapy dog visitation. Each week, dogs of all shapes and sizes come to Griffin to cheer patients and their families. These dogs are certified through a Therapy Dog Group.

"Griffin's aromatherapy program uses atomizers of fresh and calming essences as well as the smell of freshly baked goods on the patient floors from volunteers in our Volunteer Baking program.

"In 2000 a Healing Garden was designed by one of our physicians.....healing plants include lavender, Bee Balm, St. John's Wort and many more along with colorful day lillies and small shrubs.

"Our satellite resource centers are equipped with state-of-the-art computers boasting high-speed Internet connections so patients who are on our floors can stay connected to their families, jobs or friends."

People Centered Care

Catchy new business phrases come and go.

These days, every hospital claims to be people centered or patient centered. Google the phrases, in quotes, and you'll get the idea. Is this the latest fad, or a trend? (More on that in a future post)

Some interesting notes, though, from one report:

"One reason that people-centered health care has been slow to take hold in many hospitals is the underlying reality:

"The customer, at least in the sense of the person who pays the bills, is usually not the patient. Employers, insurers, and governments (in the form of national health services, or in the U.S. through Medicare and Medicaid) are collectively known in the business as “payers.”

"Physicians are also important customers. Everything a hospital sells, from an aspirin to the use of an operating room for a heart bypass, is ordered not by the patient or the payer but by the physician. And it is the physician, traditionally, who decides which hospital to send a patient to."

Range of Motion Exercise

Don't forget to ask the doctor or physical therapist for the "range of motion" exercises that they prescribe for your client. Take your client through the routines, and keep to the schedule that the professional recommends.

Some home health care agencies prohibit "massage therapy" by aides, as part of their general policy. While there are reasons for having that type of policy, you should not let that get in the way of proper care.

If your client is diabetic, don't forget the foot, finger and other localized massages necessary for proper circulation.

The link below is to a University of Washington website that has quite a few range of motion videos.

Univ of Washington - Range of Motion exercises

Remember, when it comes to flexibility, there's always room for improvement

Foot massage?

When is the last time your client had a really good foot massage? They will appreciate regular massage.

I learned from the Art Riggs instructional DVD's, but there are also free foot massage instruction videos available online.

Foot Massage Techniques for the Elderly -- powered by ExpertVillage.com

Dress Code

If you are working for a hospital, the dress code is fairly simple. It's whatever you're told.

With private care, there is certainly more flexibility. Some agencies try to set some standards, but that doesn't necessarily work.

My private clients often don't want people to think that they need a caregiver, though, and definitely don't want to be seen in public with one. I can't pass myself off as a visiting niece or bodyguard, though, so even if they are in a wheel chair the safe choice is to look like I might be the personal trainer taking them over to the club.

Neatly pressed khaki slacks and a fitted short-sleeve blouse are usually safe choices.

First name basis?

A useful guideline for addressing elderly clients is to assume that:
1. they were professionals or business owners before retirement, and
2. you were working for them back then.

Besides, workplaces were more formal years ago, and your client may have been quite accustomed to "Mr." or "Mrs."

Some service providers say that they always ask in advance for permission to use first names. Clients will almost always say it's ok, of course, out of politeness. Better to wait until the client suggests it first, if he or she cares to.

We usually give physicians that courtesy. Why not clients? Is there any doubt that they outrank the rest of us?