Haydel Consulting Services LLC

Looking at the tropical weather map this morning, it occurs to me that our friends on the North East coast may be experiencing some very unpleasant weather over the weekend. Because we have experience in hurricanes, I am going to list the things that I think are most important to weather the storm and I encourage all my Gulf Coast and Florida Readers to contribute anything that may help our friends that are visited by Earl over the weekend.

• Follow your emergency preparedness plan. I am assuming that all states require one. If you have never been involved in mass evacuations, you will learn that the plan is more than a regulatory exercise.
• Medicines. Medicines. Medicines. Patients need a complete, accurate list of medications. After Katrina, it was a nightmare trying to determine what displaced people took. When asked, patients will say they take a white pill for sugar or the purple pill. Yay Nexium for that marketing campaign.
• Medicines again. If possible, ensure that your patients have a two week supply of medications. Often the state will allow Medicaid patients to pick up medications early when a hurricane landfall is expectected.
• BACK UP YOUR DATA. TWICE.
• Keep track of patients. It is wonderful when a patient is going to weather the storm at a family member’s house. But after the storm, you need to locate your patients and will require contact information to get in touch with them.
• Contact the electric company to let them know the address of any patients who are dependent upon electricity for oxygen, IV pumps, etc.
• Call your state OASIS coordinator to determine how to deal with patients who go to hospitals for shelter. Otherwise, your hospitalization rate can skyrocket.

I am sure there is so much more. I am counting on all my Gulf Coast and Florida readers to add to the list.

Finally, if your agency is off the path of the storm in an area that is likely to receive evacuees, remember that natural disasters are NOT marketing events. If you are called upon to see a patient who has been temporarily evacuated, call the original agency and visit them under contractual arrangement. This will mean less paperwork for an agency overwhelmed by a storm and will clean up your karma.

Having experience with hurricanes, I am praying that our friends on the northeast coast are spared. If they are not, let’s do everything we can to help them.

I am not a fan of Clinical Pathways. Let’s get that out of the way. The pathways I have seen offer arbitrary steps to achieve a goal that may or may not be appropriate for a patient in an arbitrary sequence that is in no way related to the individual disease process of the patient and do not take into consideration comorbidities of the patient.

But a serious, almost pathological aversion to Clinical Pathways doesn’t mean that we can’t improve upon disease state management.

In traditionally offered, academic exercises, we identified a patient with a specific disease process and followed a recipe for care. Thus clinical pathways were born. Disease Management is a little different. When I mention disease management, I assume that a patient has one or more illnesses that has been studied sufficiently to determine best practices. And those best practices, whether they are written for MD’s or nurses should be a part of our practice.

Diabetics should have a Hemoglobin A1c, feet inspections, dilated eye exams, etc. at determined time points. So, if I ask you to tell me when the last time your diabetic patient had a dilated eye exam, could you tell me? If I read your arthritic patients chart, would I find anything other than pain medicine for pain relief? What about your CHF patient? Are you certain that all of your CHF patients are on an ACE Inhibitor? If the MD did not order PT/INR’s for your Coumadin patient, are you certain they are having lab drawn at the MD’s office?

Yes, these are medical interventions. But coordination of care means coordinating care with other providers. Furthermore, this attention to detail will likely appeal to physicians and other referral sources. If I were referring a diabetic patient to your agency, I would want the one who keeps up with everything whether they did it or simply provided reminders to other health care providers.

In fact, a short fax could be generated to the MD upon admission stating that their patient has been identified as having a high risk of complications related to (name your disease) and you are interested in incorporating certain information in the clinical record. And then ask for it. Date of last eye exam, last A1C, weight range, last lab, etc.

Anything not provided by the physician can be arranged by the agency. And if the physician is not interested in playing along with you, it might just be time to find other referral sources.

So ask yourself if you want to improve care to your patient. An overlooked foot inspection or PT/INR is caught and complications are avoided. That gives me a warm feeling inside. It also protects the MD because they have outcomes that are measured for certain disease processes as well. That gives him or her warm feeling a possibly more cash at the end of the year. It distinguishes you from one of the agencies where nurses go in, grab some vitals and teach the same thing 82 visits in a row notifying the MD only when the patient is really bad.

And you get more business. How’s that?

I have spent a good deal of time this past weekend managing pain – my own dental pain. It is a full time job. I had to plan my meals to be just the right temperature, take just the right combination of pain meds at exactly the right times, avoid ice cream, sleep when I could, etc. It was an exhausting weekend. But today, my pain will be fixed.

What does this have to do with home health, hospice, etc? I was reminded first hand that there is more to managing pain than just teaching the patient to take their medications as ordered. And that is what I see the majority of the time. A patient complains of pain and a nurse teaches the patient to take meds as ordered.

It takes creativity and insight to manage pain. Patients who are not healthcare professionals need our help to do this. Pain management cannot be accomplished without individualizing care plans for patients.

Taking medications as instructed is always important regardless of the med. But just as we do not expect diabetes to be managed by medications alone, we should not expect pain from arthritis, disc problems, etc. to be managed by medications alone. Terminal patients with retractable pain obviously need large doses of narcotics to cope with pain but a good nurse can balance the side effects of narcotics with the patient and family needs to spend quality time together.

Since beginning this blog post, I have spent some quality time with my dentist. My pain has been drilled away. So many of our patients have pain that is not solved by a 30 minute procedure. If ever we as nurses can be of value to our patients it is in the mitigation and management of pain. I challenge you to be as creative and effective as possible in pain management. It takes time and imagination but it is worth it – especially to our patients.

Some suggestions I have learned from my clients:

1. If a patient is afraid to take pain pills because they will be hooked, ask the MD if a non-narcotic may help. If so, refer to the medicines as anti-inflammatory meds instead of pain pills.
2. Teach the aide to call the patient before visits and teach the patient to take pain meds before the aide arrives to make bathing, etc. more comfortable.
3. Pain meds often contribute to falls in the elderly. Teach the patient to eat, void and be in a position to relax prior to taking narcotic pain meds.
4. For pain moderate pain, try NSAIDS during the day and stronger pain meds at night. This allows the patient to get rest and participate in household activities during the day.
5. Fear exacerbates pain. Whenever possible, reassure the patient that their pain is not a sign of a worsening or new illness and that it can be treated.
6. Physical and occupational therapy can teach the patient how to function safely while minimizing pain.
7. Be very careful of pain medications containing Tylenol. Many over the counter pain relievers, allergy meds and prescription pain meds all contain Tylenol. It is easy for an elderly patient to get too much Tylenol when on multiple medications.
8. Non pharmaceutical pain relief measure may be beneficial by themselves or in conjunction with pharmaceutical measures. Consider meditation, breathing and relaxation exercises, yoga, music therapy, distraction through books and movies, etc. to assist in pain relief measures.
9. Remember that any rating of seven and greater on a 1 – 10 pain scale is considered to be severe pain and should be addressed.

    

Any additional suggestions that you wish to share with readers would be greatly appreciated. As always, you can email me or leave a post below.