ARTICLES

Posted August 24, 2018

Aspiration Pneumonia: Treat the Cause

“Meet my patient, his name is MM and he is 90years old and was walking 3 months ago. I know he looks like an inactive Elderly man lying on this stretcher but such a rapid decline in a short period of time is not normal, we need to help him, we need to find the cause of all of this.”

My name is Deedee and I am a Homecare nurse. My company was hired to look after MM in his home after his 3rd discharge from hospital. No significant medical history, MM did not have the main Geriatric Syndromes. When I met MM he was weak, not moving and fully dependent on others for care, bed bound most of the time.I knew something was not right about being in and out of hospital three times over the past 2 months.

“Aspiration Pneumonia” was the diagnosis in hospital. Swallowing difficulties during mealtime led to chest infection as food particles entered the lung field. During the first hospitalization the doctors inserted a G Tube (feeding tube into his stomach). Eating orally was no longer an option as per the swallowing assessment. The prolonged hospitalization (3 weeks) weakened his leg muscles beyond use. Sent home with a G Tube. “Aspiration Pneumonia” repeated twice more. IV antibiotics and sent home.

Getting to know the patient. On my first day, I was determined to “get to know the patient”. What was his previous work, what was his day to day program, what foods did he eat, what his sleeping pattern, was he a night sleeper or a day sleeper. Was he a talkative man or was he reserved. I gathered the information from his private carer, domestic staff, as well as daughters and son. Each member of the family provided valuable information that others did not know, and when pieced together it gave a more complete understanding and appreciation of my patient.

I learnt that three months ago, MM was walking around the house with the support of his private carer. MM was a successful business man, and spoke many languages, was very active. After probing deeper to his eating habits it was revealed that he had a history of indigestion, stomach was sensitive, acid reflux and burping was common.

When stomach contents enter into the lung field (aspirate) the chances of chest infection is high. Stomach contents are liquid, acidic, and for those individuals that are bed bound or have a history of reflux GERD, indigestion, and low gastric emptying, chronic constipation are higher risk for aspiration. As we age, the sensors for acid reflux diminish, leaving the airway exposed.

The inner coating of his mouth had signs of repeated acidic exposure. The back of the tongue (hidden and not easily accessible) was coated with a brown film even though he was not eating by mouth. Positioning in the bed was managed well, the feeding volume was controlled through residual volume checks, the medications to control acid and aid in emptying was administered as ordered.

The patient began to cough, and small amount of aspirate came out of his mouth. Another episode of regurgitation had caused MM heart rate to elevate, a fever broke, and his oxygen levels dropped. The family was informed, we need to move to the hospital.

We arrived at the Emergency Department via ambulance in stable condition with applied oxygen. MM cannot speak. I needed to tell his story. His family present alongside the patient, I became the patients voice. I need to get to the facts immediately. I need to summarize the facts in front of the family so that they could add information. As I looked at my patient, I saw a tired Elderly man lying on the stretcher wrapped in blue blankets with a beeping heart rate and completely different to the picture I had painted in my mind.

“Meet Mr MM, he is 90 years old and was walking 3 months ago. He has been in and out of hospital over the last 3 months. He is continuously regurgitating his feeds despite the proper positioning, and volume control. His vital signs have been stable throughout, he does not have any previous medical history, he is receiving all the prescribed medications, not constipated, no signs of infections to his G tube, skin condition is perfect. His family reports that he has a history of indigestion and you may wish to check your records if this was disclosed the first time around. Its worth noting that there were 3 different types of feeds trialed. I am his nurse, and I am speaking for my patient, I know he looks elderly to you, but he was an active man 3 months ago and such a rapid decline in a short period of time is concerning. We need to rule out the cause so that this does not repeat itself.”

LEADERS IN HOME NURSING, Enayati Home Nursing are committed to delivering safe patient care. Enayati nurses are ranked as one of the top nursing teams in the country through the adoption of Canadian Best Practice Guidelines. The RNAO Best Practice Guidelines and caregiving strategies for elders with Dementia, Delirium, and Depression.

Posted May 18, 2018

ELDERS ACQUIRE BED SORES IN ED

Hospitals Emergency departments can cause harm to Elderly seeking Emergency care. The environment is extremely noisy and understaffed and very tight spaced that distresses the already confused and anxious Elder. Elders render themselves incontinent due to the facilities and are subject to lying on hospital stretcher for at least 6 hours (and upwards to 6 days if there are no beds). Pressure injuries are one of the most common unsafe occurrences for elders in hospitals and they start in the ED.

According to Johns Hopkins Medicine, a sore can develop if blood supply is cut off for more than 2 to 3 hours. If there is pressure on the skin on one side, and bone on the other, the skin and underlying tissue may not receive an adequate blood supply. Sustained pressure can cut off circulation to vulnerable parts of the body. Without an adequate supply of blood, body tissues can die.

Anyone who stays in one place for a long time and who cannot change position without help is at risk of developing pressure sores. The risks are greater in the Geriatric patients who have thinner skin, and poor nutrition. Add some wet underpants and the poor skin does not have a fighting chance.

Families need to plea with Case Management to provide comfortable appropriate beds for Elders if medical investigation will take some time. Given the multiple secondary diagnosis with each Elder, ruling out and investigations will be longer than the average adult. This may require admissions to a Geriatric Medical Unit. Families will need to keep a family appointed caregiver alongside their elder to ensure that their position is turned hourly.

Emergency room nurses on average manages 15 patients at the same time. They do not have the time to provide more direct care for elders. Our poor Elders, non-communicative, vulnerable, frail and helpless require special attention. The Emergency Department requires a whole new design and consideration to cater towards the needs of the Geriatric patient.

Enayati Home Nursing can provide private duty nurses to attend to Elders in the hospital to provide assistance with toileting function, nutrition and skin pressure injury prevention. Enayati Home Nursing are committed to delivering safe patient care. Enayati nurses are ranked as one of the top nursing teams in the country through the adoption of Canadian Best Practice Guidelines.

Posted May 18, 2018

ELDERS FALLING ALERT

One in three Elders (age 65+) will experience a fall that can have a devastating physical and psychological impact resulting in disability, chronic pain, loss of independence, reduced quality of life, and even death.

The risk for falls can go as high as 85% in Elders that have 2 or more chronic conditions and who have previously fallen, taking multiple medications and using a form of walking assistant device, and or have a form of catheter.

Eight percent (8%) of fall-related hospitalizations ended in death. (Preventing Falls: From Evidence to Improvement in Canadian Health Care, Accreditation Canada, the Canadian Institute for Health Information (CIHI))

The most powerful predictor of a fall is a history of falling. In home care, individuals at risk of falling are identified on the basis of their history of falls. Individuals with a history of multiple falls are considered at high risk, while those with a single previous fall are considered at medium risk.

Falls are the main reason for all Elderly Hospitalization. So what are we doing about it?

Falls Prevention Strategy in the Elderly begins with awareness of the severity of the problem and steps to reduce the risk begins with a comprehensive Geriatrics Medical Assessment. Elders need to be checked by Geriatricians. All specialties including Orthopaedics, Cardiologist, Internal Medicine and Endocrinology will request for a Geriatrician assessment.

Medications management, removing unwanted catheters (catheters are not safe and pose high risk for infection).
Inactivity and or bed rest greater than 2 days related to flu, hospitalization can create severe loss of muscle mass in the body responsible for stability and balance. Muscle recovery in the elderly is not the same as for the younger adult.

Geriatric Physiotherapy conducted by Licensed Physiotherapist who are aware of the other medical needs of the patient and can work on building stability, balance and improve gait.

LEADERS IN HOME CARE, Enayati Home Healthcare is committed to ensure the development of its staff and the ongoing competency skill upgrades needed to keep up with best practice standards.” Enayati Home Physiotherapist are committed to delivering safe patient care. Contact Enayati Home Physiotherapist team for consultation. 055-352-0186

Posted May 5, 2018

Stroke Survivors and Autism?

Is it possible to re-wire the brain after a Stroke? A stroke sometime called “brain attack”, occurs when blood flow to the brain is interrupted. When a stroke occurs, brain cells begin to die because they stop getting oxygen and nutrients they need to function.

The affected areas of the brain stop working certain parts of our body system. “The mind is thinking to move the arm, but the brain does not move the arm.”
After a stroke, our brains cannot grow new cells to replace the ones that have been damaged, so your recovery depends on your brain’s ability to reorganise its undamaged cells and make up for what has been lost. This is called neuroplasticity.

Neuroplasticity enables people to recover from Stroke, Autism ADD and ADHD, learning disabilities and other brain deficits.

The ability of the brain to re-organize itself physically and functionally by repetitive training, the brain begins to formulate new pathways to send signals. The more something is practiced, the more connections are changed. Every time we repeat a thought or an emotion we reinforce a neural pathway.

Physiotherapy after stroke is critical to reinforce weakened connections and develop new ones. The sooner the recovery can begin, the better the outcome. Research has shown that the most effective types of physiotherapy are exercises and practising specific tasks that you aren’t able to do well. So if you are having difficulty keeping your balance when standing, you need to practise standing up a lot; if you have difficulty lifting your arm, you need to practise doing activities which make you lift your arm, and if you are having difficulty walking you need lots of walking practice.

Our Home Physiotherapy team will work on a one-to-one basis, particularly on the tasks and the movements you are just learning to do. Talk to your physiotherapist about what is suitable for you.
LEADERS IN HOME CARE, Enayati Home Healthcare is committed to ensure the development of its staff and the ongoing competency skill upgrades needed to keep up with best practice standards.” Enayati Home Physiotherapist are committed to delivering safe patient care.

Posted May 1, 2018

DEMENTIA DILEMMA FOR EXPATS

Dubai Expats are often separated thousands of kilometers from their aging parents and other family members. Stepping up to become a carer to distant parents with Dementia is a struggle as it involves a complete re-engineering of family roles and responsibilities and living arrangements.

“My father has dementia and I wish for him to come and live with me in Dubai”. An emotional and guilt-ridden decision that has significant consequences.

Relocating an elderly WITH dementia is hazardous as their cognitive impairment will not withstand changes to environments easily. The rate of cognitive decline can vary with the stage of Dementia.
Dementia is a slow progressive illness that can deteriorate rapidly when their comfort environment is altered in any form. Their environment may be “their room, their favorite chair, their favorite clothes, their familiar sounds, and familiar faces”. Dementia does not like new things very well.

“At home, my fathers highlight of the day is sitting by the large green window and greeting the postman.”

Its not about how much money you have to finance the relocation to Dubai. Its not about society/family pressure, being perceived as neglecting your parents in the home country (siblings place an enormous amount of guilt). The focus is about how to maintain the best quality of life for your parents during their remaining cognitive limited condition.

Families must explore methods to maintain and or recreate a similar environment that “the Elder calls home” Home is where THEY prefer to live. Try not to choose an environment that is convenient for you, choose the environment that they are familiar and feel comfortable and safe.

If all other options fail and you were to relocate a person with Dementia to Dubai, you will need to put in constant nursing supervision. The risk for confusion is high, which will precipitate a fall, and or decline in nutrition, and or constipation, and will lead to a medical Elderly Emergency called Delirium. Delirium will present itself as sudden onset of confusion. Any SUDDEN changes to the cognitive and or mental function is an Emergency. Cognition does not change rapidly unless it has been altered by a threat of illness and or stress.

LEADERS IN HOME NURSING, Enayati Home Nursing are committed to delivering safe patient care. Enayati nurses are ranked as one of the top nursing teams in the country through the adoption of Canadian Best Practice Guidelines. The RNAO Best Practice Guidelines and caregiving strategies for elders with Dementia, Delirium, and Depression.

Posted April 29, 2018

HOME TUBING- PEG tube TRACH tube, can Families Cope?

It is quite possible that non-complicated Tracheostomy and PEG care can be provided by families. When it comes to managing “care at home”, families go through an initial struggle in coping with the required interventions and or treatments.

The most common invasive clinical intervention that families have to deal with include PEG feeding (infusion of nutritional feeds through an artificial opening into the stomach, as the patient has lost the ability to swallow due to some neurological change), and Tracheostomy management (an artificial airway into the trachea that reduces the effort in breathing and clearing of the secretions (most commonly related to similar neurological conditions that affect the swallowing mechanism). Usually PEG and Tracheostomy in the Elder with Chronic Illness coincide. Both PEG sites and Tracheostomy are Stomas (an artificial opening).

It is quite possible that non-complicated Tracheostomy and PEG care can be provided by families. The competency can be reasonably achieved by a family member or appointed carer, having a willingness to learn. Family receiving training in hospitals often fall short of the required time and repetitions to achieve a level of competency. “I want to practice this in the house, not in the hospital”, say family appointed carers. “We don’t have all these equipment in the home. What will I do if I don’t have these supplies?”

“I have seen families ushered out of the hospital within 48 hours of a PEG insertion and asking the family to seek a homenursing service to manage.” Many families do not have the funds for weeks of Home Nursing. Its not the family that need the hands on training, it is their long standing reliable home helper. The home helper, carer, domestic staff, PDN, drivers all are part of the extended family here in the UAE.

Family/Carer TRAINING for PEG and Tracheostomy can be provided in your home by a Homenursing team. It is more than just managing the actions surrounding the Stoma, it is understanding the proper positioning, the flow rates, blockages, equipment failure, accidental pull out of the tubes and how to manage the common challenges. Hospitals discharge training is not sufficient as families are dealing with other anxieties and distractions.

Patient Safety begins with Safe Environment for knowledge transfer.

Enayati Home Healthcare has made significant investments in patient simulation training models that can be transported into the patient homes to provide Family/Carer training.

LEADERS IN HOME NURSING, Enayati Home Healthcare is committed to ensure the development of its staff and the ongoing competency skill upgrades needed to keep up with best practice standards. Enayati Home Nursing are committed to delivering safe patient care. Enayati nurses are ranked as one of the top nursing teams in the country through the adoption of Canadian Best Practice Guidelines.

Posted March 31, 2018

TRAIN LIKE PILOTS

Using the same technologies used to train airline pilots, simulation training provides a safe and effective platform to develop nursing skills. Enayati Home Healthcare announces the arrival of JUNO, Fidelity Nursing Training Technology by CAE, Montreal Canada.CAE Technologies have deployed simulation training devices to Emirates Airlines to provide real life training and competency skills assessment.

Our nurses are employed from various cities around the world with different nursing educational backgrounds, using different equipment, or lack of equipment. “As an example, NG is dominant over PEG feeding (a form of enteral feeding) in the Philippine due to the scarcity of technologies available for PEG insertion as well as the high cost of procedure. The nurses arrive in the UAE with very little exposure to PEG feeding. Using Patient Simulation training, we are able to apply the nurses knowledge of Enteral Feeding to NG as well as PEG and use the various technologies available here in the UAE.

Minimizing the variations in practice begins with implementation of an effective training program using guidelines developed by researchers and scientists and creating a learning space to practice those guidelines.
“We are delighted to be the first home to JUNO in the UAE. Enayati is committed to ensure the development of its staff and the ongoing competency skill upgrades needed to keep up with best practice standards.”

The home healthcare nurse has since transformed its role to deliver a wide scope of practice skills than in any other clinical setting. The home health nurses are developed to be responsive and to trouble shoot those issues that would otherwise require a trip to the Emergency Department. In the home environment, there are many scenarios that can play out as the variables related to the surroundings are constantly changing.

Patients are at home with various technologies such as Oxygen therapy, Mechanical Ventilators, Feeding Pumps, IV Infusion Therapy. Patient Simulation Mannikins such as JUNO provides an environment for nurses to practice various troubleshooting scenarios such as power supply interruption, blocked tubing, malfunction equipment, changes in vital sign parameters.

Enayati Home Nursing are committed to delivering safe patient care. Enayati nurses are ranked as one of the top nursing teams in the country through the adoption of Canadian Best Practice Guidelines.

Posted November 18, 2017

SWALLOWING DIFFICULTIES

Swallowing difficulties in the older adult if understood can prevent unnecessary hospitalization. The inability to swallow is called Dysphagia. Aspiration is when fluid or food particles enter into the lung field. Dysphagia and aspiration occur more often during the early stage of a stroke due to changes in the brain. Dysphagia can also develop during advanced stages of Parkinson’s Disease, Alzheimers and Brain Cancer, wherever there are changes to cognition. When there are changes to the brain, the common centers responsible for swallowing become impaired, which disrupts the swallowing network and debilitates the command center.

UNDERSTANDING HOW SWALLOWING WORKS

There are 3 types of swallowing.
1- subconscious swallowing (which occurs approximately once every minute);
2- reflexive swallowing (which is an airway-protective mechanism triggered by a sudden stimuli, such as the arrival of refluxate from the stomach or an inadvertent drop of food into the pharynx); a reflexive swallow activates only the sensorimotor area, commonly known as the gag reflux.
3- nutritional, or volitional, swallowing (which occurs when eating). When volition is involved, there is a swallowing network in the cerebral cortex that includes the insula, cingulate gyrus, prefrontal gyrus, somatosensory cortex, and precuneus regions. All of these areas are activated when a person takes a volitional, or nutritional, swallow.

SIGNS AND SYMPTOMS OF DYSPHAGIA

Any neurologic or muscular damage along the upper airway and upper digestive tract can cause dysphagia. Thus, central causes of dysphagia in stroke patients include damage to the cortex or brain stem, and peripheral causes include damage to the nerves or muscles involved in swallowing.
(a) A lack of cough in the stroke patient may signal the inability to sense a foreign substance entering the airway; a poor gag reflux, unable to perform reflexive swallowing. Coughing is good defense mechanism to clear the lung field of any aspiration.
(b) Cough after drinking fluid may signal weakness in taking an intended swallow (volitional), a lack of sensation at the back of the throat which arose from nerve damage.
(c) Weakness in Speech can be also be a sign of dysphagia as the musculature responsible for producing sounds are within the same proximity as those muscles needed to swallow.
(d) Excessive drooling from the mouth. Parkinson’s Disease produce less saliva, and the drooling is a sign of inability to do subconscious swallowing and may need to be prompted to swallow.
(e) Watch out for secondary signs such as weight loss, avoidance of certain foods, dehydration, and recurrent chest infection as secondary symptoms to a swallowing difficulties.

TESTING FOR DYSPHAGIA

All stroke patients should have a swallowing assessment prior to discharge from hospital. Technologies have advanced which allows camera to view the swallowing function and identify any deviation of food into the lung field. There are several pockets and areas where food can “park” due to nerve and muscle changes, and the use of such cameras can provide precise evaluation.

CORRECT POSITIONING

Upright sitting is advised during all meal times with shoulders back. The placement of the chin is often confused by families. While the shoulders are pressed back, the chin can be slight tilted to the chest to assist with swallowing. This facilitates positioning of the epiglottis, and narrows the entrance to the throat by the trachea or windpipe. Use this positioning the next time for individuals who experience difficulty swallowing pills and reduces the chance of choking and regurgitation.

We demonstrate with our nurses and our families the difference in drinking a sip of water with your chin slightly dipped to your chest, and with your chin elevate away from your chest. You will feel the difference.

For those patients who are respiratory compromised such as COPD and CHF, supplemental oxygen through nasal cannula during meal times may be required to provide sufficient oxygenation while the throat focuses on delivering the food to the stomach. The use of oxygen does require a physician evaluation and medical order.

HOME NURSING AND PHYSIOTHERAPY

Homecare is recommended for elders to improve muscle strength associated with swallowing. Speech Pathologist along with Physiotherapist use exercise focusing on strengthening the esophageal muscle and maintaining correct sitting position during meal time.
Home nurses from Accredited Organizations are trained to detect signs and symptoms related to dysphagia and practice proper positioning techniques to prevent aspiration.
Enayati Home Nursing is recognized by Accreditation Canada International for providing safe home nursing care. Our teams are trained in Patient Safety, Elderly Care, Parkinson’s disease, Dementia, Alzheimer Stroke/CVA .
For more information contact nursing@enayati.org

Posted November 18, 2017

GAIT CHANGES vs BRAIN CHANGES

If an older adult walks more slowly, take smaller steps, or look insecure as they approach a step or stairway, it should raise a red flag to seek medical attention. The manner in which we walk is called gait.
Researchers have discovered an association between slower and unstable gait in older adults and a higher risk of cognitive decline. Before an older adult shows symptoms of cognitive impairment, he or she may exhibit gait problems.

WALKING REQUIRES EXECUTIVE FUNCTION

The part of the brain affected in older adults is executive function, which is responsible for planning ahead. In order to walk correctly, you require the perfect integration of many areas between your brain and body and planning your next movement. As the executive function decreases it will decrease our ability to walk correctly.

COGNITIVE GAIT CONNECTION

Sometimes we have a hard time doing two tasks at the same time. For the elderly, remembering where they put that mobile phone while walking may predispose them to a fall. Distracted to find that phone, the brain loses its focus to process the movement of the muscles. Our brain is continuously working in overdrive trying to remember and that overcompensation will cause us to slow down, interrupt our gait and stability.
Research has recommended elderly playing with young children to improve motor cognition results with simple activities that include walking and another task such as beating a drum.

ALTERED SENSORY RELATED TO OTHER CONDITION

Don’t forget that Diabetes in the elderly can also impair sensation in the feet thereby further complicating gait patterns. The damage to the nerve endings associated with the presence of high blood sugars can reduce the elders ability to feel that step. Changes in gait may not always be related to cognitive impairment, other factors can also play a role.

GAIT ASSESSMENT

If an older patient already has experienced cognitive decline, physicians should perform a gait assessment. Common assessment tool include the Timed Up and Go test TUG. If a patient’s balance or walking is unstable, family members need to seek medical care to ensure that it’s safe for the patient to move around the home or determine the need for an aid such as a walker or cane. Introducing a walking aid without advice and teaching may cause misuse and further risk for fall.

HOME NURSING AND PHYSIOTHERAPY

Home physiotherapy is recommended for elders in their home environment to improve muscle strength, balance and coordination and build confidence in functioning within their environment.

Enayati Home Healthcare Center is recognized by Accreditation Canada International for providing safe home nursing and physiotherapy care. Enayati home care teams use the TUG, timed up and go assessment. Our teams are trained in Elderly Care, Parkinson’s disease, Dementia, Alzheimer Stroke/CVA . For more information contact nursing@enayati.org

Posted November 17, 2017

UTI SILENT DANGER AMONG THE ELDERLY

Among the Elderly, symptoms of a Urinary Tract Infection are often missing. Beware!

A UTI is an infection of the urinary tract, most commonly the bladder. For most people, the need to urinate frequently and/or urgently are two key symptoms of a UTI. A burning sensation when you go, and a change in color and odor are other common signs. Sometimes, a small amount of blood in the urine is visible. But in older adults, those symptoms are often missing. Instead, older adults may suffer from unexplained incontinence, vague fatigue or significant changes in their behavior and mental status.

ALL OF A SUDDEN CHANGES

Beware! A sudden change in behavior for an Elder is a medical emergency. Our patients in the home present different sign and symptoms. All of a sudden, the elder becomes confused, combative, agitated, cannot sleep, sees bugs crawling, and shadows on the wall. The behavioural changes are often dismissed by the family as “a sign of aging”, or “it’s the dementia”. We call this Delirium. Even if the Elder has a current diagnosis of Dementia, a sudden change in mental status is considered to be Delirium. And a main cause of that sudden change is usually a UTI. Medical attention is required to diagnose a UTI and look out for other probable causes such changes in sodium and potassium levels, elevated urea, thyroid levels, dehydration and constipation or even medication levels in the blood stream.

RECOVERY FROM UTI

Home nurses can help recently discharged patients and their families at home following hospitalization. Prescribed antibiotics can cause short term inconvenient side effects such as loose stool, upset stomach, loss of appetite, dizziness and weakness in walking. Recovering from a UTI is challenging for the elder and if not managed well can cause feeling of sadness related to their loss of independence.

HOME NURSING AND PHYSIOTHERAPY

For the once independent elder, coping with the sudden unexplained incontinence and change in mental status is a major setback. With proper care at home, functional independence can be restored. Home physiotherapy is most recommended for elders being treated for a UTI to build muscle strength, balance and coordination and restore confidence to functionally manage bowel and urinary continence.

Home nurses from Accredited Organizations are trained to detect sudden changes in mental status and behaviours and can help rehabilitate the elder back to his or her routine and regain function and restore mental health, once the underlying medical condition is addressed.

Enayati Home Nursing is recognized by Accreditation Canada International for providing safe home nursing care. Nursing strategies to manage Delirium, Dementia and Depression in the elderly are integral to Enayati training program. Our teams are trained in Elderly Care, Parkinson ’s disease, Dementia, Alzheimer Stroke/CVA.

Posted October 27, 2016

MEDICATION SAFETY IN HOMECARE

Medication errors in the home registers as the one of the highest risk to patient safety in the UAE. According to recent admission data to Enayati Home Healthcare, approximately 50% of hospital discharges contain some form of discrepancy as defined by the Institute of Safety Medication Practices, ISMP Canada.

INCOMPLETE INFORMATION

Often the ordering physician is unaware of treatments and medication regimens treated by other physicians. Discharge orders on the final day at hospitals are often left for the medical house officer on duty. Families will choose to ignore the team of doctors who have just treated a major stroke, and defer to their long standing Cardiologist of choice at another private hospital. We have seen patients being discharged home on a blood thinning agent while family is insisting to continue a previous prescribed anticoagulant (also blood thinning). The nursing team searches and tries to draw out the information delicately from all members of the care team.

INADEQUATE TIME

The hospital discharge in all facilities at many times is rushed. Families have been given a tentative discharge date and time but all is dependent on the results of the morning blood draw. The ward or unit doctor reviews the lab results with the primary Consultant to get the final discharge clearance instructions. Within a 2 hour time frame the family will need to vacate the room, attend to the billing department, and wait for the medications from the pharmacy. There is little time spent on reviewing the medications, and if so, retention would be poor due to anxiety related to going home.

MEDICATION RECONCILIATION AT THE HOSPITAL

Reconciliation of medications prior to discharge from hospital will allow the opportunity for clarification with the hospital team. Common errors include discrepancy with the physician order and the pharmacy issue instruction; the physician order and what the verbal instructions given by the nurse, omitted instructions for medications taken prior to hospitalization. If asked, the homecare nurses will insist to visit the hospital on discharge day as part of its admission process at no extra cost. Spending 1 hour in the hospital can save numerous of hours spent on seeking clarification after hours.

FAMILY UNDERSTANDING

It is important to ask the family “and why are you taking this medication for ?” as part of the medication reconciliation. Families have a rich and long health history of the patient. Their understanding of the medication will give insight to any existing gaps and or discrepancies which will require clarification. Sometimes all that is required is one phone call or visit to the doctor. The homecare nurse can gather the information and work to resolve discrepancies within the first 24 hours. Our homecare team will converse with the family drivers and cooks and other domestic staff that have a daily account of the medication routine. Remove the clock from the wall and ask the family cook to point to the time that the medication is normally given.

HOMECARE CHALLENGES

Medications at home is a high priority program for Enayati. Standardization of discharge medication procedures is urgently needed for all hospitals to follow to minimize variations in practice settings. Patients returning abroad from treatment bring a different medication regiment which families are insisting to follow. The reconciliation of these medications has proven to be difficult and a new challenge that falls outside the normal medication safety guidelines. Identifying for medication discrepancies include drug-drug interactions requires a systematic approach to program management.

Enayati Home Healthcare Center follows the Institute of Safety Medicine Practices ISMP Canada for medication safety. Being Accredited to Canadian Standards requires a diligent review of medications upon hospital discharges as well as on admission to the homecare service.

Posted October 27, 2016

CARE CONTINUITY vs BURNOUT

 

While families prefer to have the same nurse, recently surveyed homecare nurses prefer to look after multiple patients at any given time frame. Homecare agencies are often asked to provide a regular home nurse for their clients. We call this continuity of care, one of the quality performance indicators of a homecare agency. Nurses who manage multiple caseloads will have higher standards of practice because of their continued exposure to various clinical cases. Who benefits? The patient!

Homecare nurses in the United Arab Emirates commonly practice 12 hour shift nursing (commonly known as private duty nursing in Canada). They are committed and caring professionals that understand the importance of building a trusting therapeutic relationship with the patient and family. The bonds formed within the first 48 hours are important. The patient/family likes and routines are discovered as well as information about the patient’s life, previous occupation hobbies and interests. The nursing care plans are developed around the patient and their lifestyle within their environment. Patient centered care in its truest form.

MAINTAINING COMPETENCY NURSING SKILLS

Managing families expectations from the beginning is key as the most common request is “we don’t want a different nurse, we want the same nurse”. Caregiver burnout can happen even amongst the best of nurses. We call it fatigue of the same daily routine. Caring for the Dementia patient does require a different skill set than caring for someone with COPD or Stroke condition. The cardiorespiratory assessment and management skills are more developed in the latter and are those critical skills you want the nurse to have during period of crisis. To ensure that the nurse maintains a level of proficiency in the cardiovascular and respiratory management, exposure to those patients is ideal on a regular basis.

Health care research has proven that positive results is linked to volumes “The more you do, the better the outcome”.

Nurses in hospitals are exposed to different case mixes within the same shift and length of stay is less in hospitals than in the home. When we step away from the routine for a couple of days, we return fresh and bring a new approach or idea or sometimes we notice small subtle changes that would have gone unnoticed. I recall working on a Burn Unit which made it a policy to float the nurses to the medical wards once every 6 months so that we freshen up our skills in Diabetes and Cardiac care. It created a stronger Burn Unit that was able to respond to a wider range of thermally injured patients.

CONTINUITY OF CARE vs BURNOUT

Continuity of care no doubt is important in homecare. Communicate to the family from the onset the assignment of a team leader, and the relief nurses. Families beware of agencies that promise the same nurse every day. You don’t want a fatigued nurse caring for loved one. However do negotiate an appropriate level of care continuity.

Enayati Home Nursing tracks its continuity of care as one of its quality indicators in accordance with Canadian Homecare Accreditation Standards. Providing a variety of case mix will ensure competency of staff skills required to delivered comprehensive and responsive care. Nursing staff have the opportunity to work in Palliative Care, Wound Care, COPD, Dementia Parkinsons Disease and Stroke Care teams.

Posted October 21, 2016

HOMECARE PEG FEEDING

Aspiration risk is the same for all patients with or without a Nasogastric or Percutaneous Endoscopic Gastrostomy Tube (PEG or NG) when in a state of bedrest. Imagine yourself eating a full meal and lying down flat. In quick time you will feel your stomach contents rising and teasing your esophageal sphincter. Acid burning, and sometimes, regurgitation (GERD). For the immunocompromised, Elderly and or Stroke CVA patients who have weakened swallowing muscles, the risk of aspirate into the lungs is high.

GASTRIC EMPTYING TIME

Gastric emptying time is around 2 ½ hours for liquefied meals and 4 hours after a solid meal. Factors which alter gastric emptying include Medication e.g., prokinetic agents can increase gastric motility and help to empty the stomach (Cisapride, Phenergren). Other medications slow down the emptying as a side effect (e.g., narcotic analgesics, anticholinergics). Hyperglycemia also slows down gastric emptying. Stroke patients who commonly have diabetes need special attention and should be on aspiration risk watch when their Blood Sugars are high.

POSITIONING

For patients at home on long term feeding, we recommend a hospital bed to be used that can be elevated for patient safety during meal/feeding times. During any feeding, it is ideal that the patient is placed in a high fowler position, 45-90 degrees to assist in the breathing and digestion of food contents. After 30 minutes of meal time, the bed can be lowered to 30 degrees NOT LOWER. Turning to the right side after the meal will further aid in gastric emptying and minimizing aspiration risk.

Keeping the bed at 45 degrees for long periods can increase the risk of pressure sores and thus careful attention to turning and positioning and planning meal times is important. We advise families to plan ahead and create a schedule. Any activity that requires the patient to be flat in the bed be conducted BEFORE meals, such as bathing, shampooing and or changing of the sheets etc.

Most beds have a diagram on the frame below the mattress and you can see the 30 degree mark.

HOME NURSING

Home nurses can help recently discharged patients and their families at home maintain safe positioning whilst PEG feedings and NG. Home nurses from Accredited Organizations are trained to conduct medication reconciliation and are aware of the medications that can delay the gastric emptying. Enayati provides medical equipment and bed rentals are available for those families looking for a temporary solution while maintaining Safe Care.

Enayati Home Nursing is recognized by Accreditation Canada International for providing safe home nursing care.  Our teams are trained in Elderly Care, Parkinson’s disease, Dementia, Alzheimer Stroke/CVA.

Posted October 17, 2016

HOME NURSES OR FIREFIGHTERS

Apparently there exists a belief that nurses can work 24 hours straight for 5 days and still be responsive to provide care? How is that physically possible? When have nurses become firefighters?

Firefighters have a bed in the fire station and can close their eyes and sleep with no obligations until that SIREN goes off and slips into their boots and helmets and out to save lives within 2 minutes. They can be at work for 5 days continuously for 24 hours. During the day, they perform the routine activities and at night they have their guilt free sleep.

If a patient requires a home nurse at night, it usually means the patient is completely dependent on others for basic care. Home nurses at night are obligated to turn the patient every 2 hours to prevent bed sores, to suction and maintain an open airway for tracheostomy, to help prevent pneumonia and aspiration risk during continuous feeds, to monitor for signs of falling blood sugars at night for the complicated diabetic, to be awake and responsive to walk the patient to the toilet, to provide comfort and orientation to the confused patient with dementia, to look for non-verbal signs of pain and discomfort for those who are unable to talk.

Home nurses who shift every 12 hours are ready to be engaged in delivery of care and are prepared to respond to any crisis that may arise. This is how Enayati Home Nursing practices and delivers it nursing service.

Home nurses prefer to work 12 hour shifts and are starting to refuse and flee from 24 hour shifts. At a recent interview a candidate shared her experience of how she loved caring for her previous patient “I had to keep slapping my face to stay awake on the second day” She was unable to sleep during the day and night as the patient care required her to be attentive at all times.

Home Nursing Care is a specialized skilled professional, who have the confidence and protocol to provide nursing care in remote destination. They use their skills in communicating with their colleagues and Nursing Supervisors and tapping into the policies and procedures to guide their practice. Home Nursing is the future and only those strong and supported will be able to render a service that families can see positive outcomes.

We salute the firefighters and their standby commitment.

Enayati practices a 12 hour shift policy to ensure patient safety. For those patients that need 24 hour care, 2 nurses are rotated each 12 hours to ensure a smooth handover and transition.

Posted October 15, 2016

FROM ICU TO HOME

When callers begin the conversation “..my father has been in ICU for 3 weeks,..”; hundreds of images of patients flash before me. Having worked in an ICU, the dramatic changes in the elder’s physical health stemming from the critical care environment is far too familiar.

To the general public an ICU is a smart environment, everything is buzzing all around, the most expensive medical equipment for life saving, blood transfusion as well as a number of available doctors, and junior doctors. It looks like a little city within a hospital. It is often a closed unit, with restricted access only to immediate family at the specified visiting times. As the most vulnerable patients fight for their lives, the threat of infection is high and the road to recovery remains at the hand of their families.

I visit my patient “Baba”, grandfather 18 times. His blood pressure has been stabilized and within reasonable limits after battling a chest infection. Large framed man, with extreme muscle weakness. He has not moved in 3 weeks confined to the hospital bed. His muscles have depleted, leaving sagging fat and lose skin. We call this muscle atrophy. The rate of muscle atrophy is higher in the elderly than in the younger adult. Every day of bed-rest causes depletion of muscles with higher loss to the leg muscles, responsible for stabilization during walking. The road to recovery begins with retraining and rebuilding those muscles. Rebuilding muscle in the elderly is FOUR times lengthier than in normal adult. Baba needs time to be able to stand and walk alone.

Muscles all over the body have depleted, including those responsible for breathing and swallowing. The rib cage space has constrained in size due to lack of positioning and immobility of the shoulders and arms. The lungs trapped within the rib cage cannot expand to its full capacity, sticky and unopened with small trapped particles inside at the bases, which further increases risk for infection. It’s time to sit up and cough. Deep breath and cough. Cough Baba Cough. Gaha Baba Gaha !

Hospitalization causes many complications in the elderly, and the road to recovery must begin from day one. While an ICU is welcomed during lifesaving, the risks of prolonged unnecessary stay need to be minimized. Minimizing muscle atrophy as a result of bed confinement should be a priority for families who wish to see their loved one restore as much functional status as possible. Having extra help at the hospital during the working hours can maximize the retraining and recovery time available. Skilled nurses will serve the best help for families to aid in the recovery time. Focus on breathing and airway management, muscle recovery and conditioning, coagulation prevention, nutritional support.

Posted September 2, 2015

Be Cautious of Food and Medication Mixtures

Eating healthily and taking medications as prescribed are both very important. However, some medications shouldn’t be taken with certain foods; some mixtures make medication less effective, may cause physical discomfort, or may cause dangerous chemical interactions.
In order to minimize the risk of food-medication interactions, seniors should discuss any possible interactions with the prescribing doctor or pharmacist and read the labels on the medications to make sure that there are no recommendations which the doctor or pharmacist may have missed.

Following are some of the common food and medication combinations to avoid:

Kale and blood thinning drugs: Kale is full of vitamin K, which is good for the bones and the brain. However, kale also helps blood to clot, so aging parents who take blood thinners should limit their intake of kale and other vitamin K-rich foods, such as spinach and broccoli. Such foods don’t need to be avoided entirely, but they should be consumed in moderation.

Grapefruit juice and a range of medications: A great big glass of grapefruit juice has many health benefits. It can impact the intestines and may in turn allow many medications to more easily access the bloodstream – sometimes making such access too easy, leading to potential side effects. The list of medications that interact this way with grapefruit juice include many statins, calcium channel blockers, and immuno-suppressants Fiber-rich foods. Whole grains, fruits, and vegetables should definitely be a big part of aging parents’ diets.
However, fiber also increases the amount of time that it takes the stomach to get rid of food. It therefore impacts how much of some medicines (including antibiotics) get out of the stomach and into the blood – and can decrease the effectiveness of a dose. Consult with a doctor or nutritionist to learn how maintain both fiber intake and drug effectiveness.
Cheese and antidepressants. Many cheeses, such as parmesan, bleu cheese, cheddar, and mozzarella, contain an ingredient which negatively impacts many antidepressants.

Potassium and ACE inhibitors: Those taking ACE inhibitors should consume potassium-rich foods such as bananas, oranges, sweet potatoes, yogurt, and avocados with care. ACE inhibitors tend to increase the amount of potassium in the body; if potassium level gets too high, there is a risk of heart palpitations.

It’s important to note each individual reacts differently to every medication. Some aging parents may have no side effects from mixing, say a calcium channel blocker and grapefruit juice, while others may. However, it’s best to play it safe and avoid food-medication combinations that have the potential to cause issues.

Posted June 22, 2015

6 Things That Cause the Elderly to Fall (at home)!

Rather than being a secure nest for our seniors, homes are the number one place for elderly falls. Falls at home are the leading cause of death, injury and hospital admissions among the elderly population. Here we have identified 6 main reasons seniors fall at home so much more frequently than younger people:

1. Lack of physical activity: Failure to exercise regularly results in poor muscle tone, decreased bone mass, loss of balance, and reduced flexibility. Among all the reason, at Enayati home care we believe this is the most prominent but easily avoidable.

2. Impaired vision: Among the reasons, is a simple but usually overlooked cause related to age vision diseases, as well as not wearing glasses that are off the shelf and not particularly prescribed for them.

3. Medications: Sedatives, anti-depressants, and anti-psychotic drugs, plus taking multiple medications are all implicated in increasing risk of falling.

4. Diseases: Health conditions such as Parkinson’s disease, Alzheimer’s disease and arthritis cause weakness in the extremities, poor grip strength, balance disorders and cognitive impairment.

5. Surgeries: Hip replacements and other surgeries leave an elderly person weak, in pain and discomfort and less mobile than they were before the surgery.

6. Environmental hazards: One third of all falls in the elderly population involve hazards at home. Factors include: poor lighting, loose carpets and lack of safety equipment. When caring for elderly, we always make sure to keep their entire environment as secure as possible.

However, falls are not an inevitable part of growing older. Many falls can be prevented, by making the home safer and using products that help keep seniors more stable and less likely to fall, check our next blog to see how at Enayati home care we made fall prevention among elderly our mission and how we can prevent your beloved seniors from falling.

Posted June 21, 2015

Falling: Dangerous,but a preventable, threat:

From a flashlight to Tai Chi to homecare nurses, strategies that prevents from falling or reducing the aftermath of a fall.

Falling is a dangerous — and very expensive — problem. Its direct medical costs are in the thousand Dirhams yearly.

It’s well-known that the risk of falling and being hurt increases with age. About 20 percent of the elderly who have a major fall are likely to die within a year, according to national studies.

Falling injuries, including slips, trips, and falls among elderly are prevalent and serious — but more importantly they are preventable.

A lot of work on fall prevention is being done in the UAE,” said “Shiella”, program coordinator for injury prevention at the Enayati homecare. “It’s very important that we let the public know what’s available to help our seniors.” for this reason there will be a conference in October that covers falls preventions among other patient safety topics.

Among the activities that can reduce falls for elderly at home are:

Tai chi has been researched using randomized control trials,” Head said. “Studies have found tai chi can reduce falls by as much as 30 percent.”

Tai chi is an ancient Chinese martial art with low-stress training techniques beneficial for physical fitness and mental focus. In the past several decades, it has spread worldwide, and many programs, especially those geared to seniors, concentrate on exercise and health improvement rather than self-defense.

Shiella says a major problem with falls is “as we age, no one thinks a fall can happen to them.” And the surprise is what happens when they do fall: fractures, hospital bills and an increased chance that they will fall a second or third time, according to hospital reports.

Another way are Flashlights. Seniors may not want to wake a spouse during the night but need to get out of bed for one reason or another. A simple item like a handy flashlight can make a big difference.

Yet a private nurse at home can be excellent proactive activity. “Our plan was straightforward,” says Shiella, a registered nurse at your home that doesn’t just prevent elderly from risks of falling, but also assist in organized daily exercise and physiotherapy.

This group is just sitting down all day, which changes their muscle composition of the body rendering them non-responsive to balance themselves during any rapid action or reaction and they fall.

“Our geriatric management tool looks at how to address patients on a personal level,” Shiella said. “Vision, medications and the environment are all items to be considered in the assessment.”

“Nurses at home are there for care or possibly rehabilitation,” said Shiella and they make sure elderly participates in exercise that helps preserve their muscles and prevents falling.

Posted April 30, 2015

Technology meets Homecare in Dubai

Etisalat, the UAE’s leading Telecommunication Company and Enayati; signed a memorandum of understanding today for the pilot launch of an innovative patient home monitoring system. The system, developed and manufactured by British health Technology Company – Equivital, includes body worn sensors which measure multiple physiological parameters in real time.

The development of wearable and mobile healthcare technologies is reducing the burden of healthcare cost and frequent, inconvenient visits to the clinic, thereby enriching people’s quality of life. Etisalat’s nationwide 3G, 4G mobile and fibre-optic broadband networks are opening doors to many such innovative solutions in the field of e-health and mobile health, helping healthcare systems in the UAE evolve.

During the pilot, Enayati will be able to efficiently manage high volumes of variable, real time and retrospective data for its patients while they are in the comfort of their homes. We have positioned ourselves as a leader in homecare, with a focus on Patient Safety. Using the Equivital platform, including the body worn LifeMonitor sensor, Enayati’s nurses will be able to monitor changes in patient condition and alert Enayati’s clinical team and the most responsible physician instantly, therefore allowing for any adjustments in the care plan to occur with no delays. The new system will also provide family members with a dedicated portal to monitor the health status of their loved ones while they are away.

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