A Tragedy Named Linton
What Agencies can do to lessen their chances of a catastrophic incident related to nurse mental health issues.
Posts tagged ‘Home Health Nursing’
Oct 11
It’s that Time Again
It seems like every week or so we are learning of a new way to get very sick and, well, die. It’s not always pleasant to read the news but, even in the wake of all these new viruses, there are some old ones that command respect.
The one that immediately comes to mind is the Flu. It is boring in comparison to Monkeypox and it doesn’t kill as many people as Covid but really, how important is it to you that your virus is interesting? Do you care how many other people are dying when you are on life support?
Last year, the flu wasn’t as much of a threat as it has been (and will be).. Everyone stayed home and wore masks. Smart people did not hang out in crowded places and N95s became available. Jeff Bezos and delivery companies made a ton of money but I don’t begrudge them considering the alternative would have been a higher risk of contracting Covid.
Compare last year’s isolation to this year. School’s are well populated judging by the long lines of traffic when school lets out. People are going out again to shop and eat and visit. The President has erroneously declared an end to the Covid Pandemic and the CDC has revoked its advice that people in healthcare facilities should wear masks. Please note that the CDC did not prohibit masks in healthcare facilities although the department of motor vehicles might take exception if you don’t remove your mask when you take a picture when you renew your license.
So the flu is a real threat this year. If you have never had a case of the flu, consider yourself lucky. Death is an attractive alternative when fevers reach 104 and every muscle in your body aches. Furthermore, the flu is contagious before symptoms appear. That means you can go out to several family homes and give them the gift of flu before you even know you have it.
When a nurse is out with the flu, it isn’t for a day or two. There are no badges of honor for going to work sick with the flu. All of the uninfected nurses have to pick up the slack (and overtime). And flu season peaks in winter when it already takes extra time to visit patients. Roads may be icy and the holidays and end of year tasks cause everyone to get behind.
And that’s what the flu is like for us. Imagine the patients!
In the 2019 – 2020 flu season, the last year for which data was collected, 38M people were sick with the flu resulting in 400,000 hospitalizations and 22,000 people died from the flu or flu related complications. The virus that causes the flu is quite adaptable and mutates often to get around immunity. Because of the ever changing nature of the influenza virus, the flu statistics vary each year.
The vaccine is mostly free but even if you pay out of pocket, it is cheap. If you are an agency that doesn’t pay for your employees to get flu shots, I want you to remember this when you’re writing those overtime checks. There is no charge to Medicare patients and that includes those receiving hospice care. Home Health and Hospice can bill Medicare although many agencies choose not to bill. You may also administer the flu vaccine to spouses and other Medicare recipients who live in the house. For billing purposes, there is no physician order needed. Get an order anyway.
With one exception, the flu vaccine is unable to cause the flu. The exception is the nasal inhaler vaccine which does contain minute quantities of the live virus so there is a similarly small chance that it could give the flu to the recipient. All other vaccines do not contain live virus particles. Because it takes a while for the vaccine to offer full protection, it is possible to get the flu in the week or so after the vaccine which is a good reason to get your flu shots early. And it is possible to contract the flu after being vaccinated but these cases do not cause as many hospitalizations and deaths.
Finally, the CDC has a boatload of resource materials that you can use as teaching guides or even wallpaper. Midway down the CDC Resource page are infographics and fact sheets. The CDC receives billions in funding. Make use of it. You don’t want to be known as the nurse or therapist who wasted billions of dollars and current CDC information will support any complaints about you or your agency.
If misery could be contained in buckets, each case of the flu would fill ten or so home depot buckets. Think about that and prevent some misery.
It seems like every week or so we are learning of a new way to get very sick and, well, die. It’s not always pleasant to read the news but, even in the wake of all these new viruses, there are some old ones that command respect.
The one that immediately comes to mind is the Flu. It is boring in comparison to Monkeypox and it doesn’t kill as many people as Covid but really, how important is it to you that your virus is interesting? Do you care how many other people are dying when you are on life support?
Last year, the flu wasn’t as much of a threat as it has been (and will be).. Everyone stayed home and wore masks. Smart people did not hang out in crowded places and N95s became available. Jeff Bezos and delivery companies made a ton of money but I don’t begrudge them considering the alternative would have been a higher risk of contracting Covid.
Compare last year’s isolation to this year. School’s are well populated judging by the long lines of traffic when school lets out. People are going out again to shop and eat and visit. The President has erroneously declared an end to the Covid Pandemic and the CDC has revoked its advice that people in healthcare facilities should wear masks. Please note that the CDC did not prohibit masks in healthcare facilities although the department of motor vehicles might take exception if you don’t remove your mask when you take a picture when you renew your license.
So the flu is a real threat this year. If you have never had a case of the flu, consider yourself lucky. Death is an attractive alternative when fevers reach 104 and every muscle in your body aches. Furthermore, the flu is contagious before symptoms appear. That means you can go out to several family homes and give them the gift of flu before you even know you have it.
When a nurse is out with the flu, it isn’t for a day or two. There are no badges of honor for going to work sick with the flu. All of the uninfected nurses have to pick up the slack (and overtime). And flu season peaks in winter when it already takes extra time to visit patients. Roads may be icy and the holidays and end of year tasks cause everyone to get behind.
And that’s what the flu is like for us. Imagine the patients!
In the 2019 – 2020 flu season, the last year for which data was collected, 38M people were sick with the flu. The flu caused 400,000 hospitalizations and 22,000 people died from the flu or flu related complications. The virus that causes the flu is quite adaptable and mutates often to get around immunity. Because of the ever changing nature of the influenza virus, the flu statistics vary each year.
The side effects of the vaccine are generally mild unless the recipient of the vaccine is allergic to eggs. For the majority of people any mild side effects can be treated with tylenol or ibuprofen. It is mostly free but even if you pay out of pocket, it is cheap. There is no charge to Medicare patients and that includes those receiving hospice care. Home Health can bill Medicare although many agencies choose not to bill. You may also administer the flu vaccine to spouses and other Medicare recipients who live in the house. For billing purposes, there is no physician order needed. Get an order anyway.
With one exception, the flu vaccine is unable to cause the flu. The exception is the nasal inhaler vaccine which does contain minute quantities of the live virus so there is a similarly small chance that it could give the flu to the recipient. Because it takes a while for the vaccine to offer full protection, it is possible to get the flu in the week or so after the vaccine which is a good reason to get your flu shots early. And it is possible to contract the flu after being vaccinated but these cases do not cause as many hospitalizations and deaths.
Finally, the CDC has a boatload of resource materials that you can use as teaching guides or even wallpaper. Midway down the CDC Resource page are infographics and fact sheets. The CDC receives billions in funding. Make use of it. It would be a shame to waste billions of dollars and current CDC information will support any complaints about you or your agency.
If misery could be contained in buckets, each case of the flu would fill ten or so home depot buckets. Think about that and prevent some misery.
It seems like every week or so we are learning of a new way to get very sick and, well, die. It’s not always pleasant to read the news but, even in the wake of all these new viruses, there are some old ones that command respect.
The one that immediately comes to mind is the Flu. It is boring in comparison to Monkeypox and it doesn’t kill as many people as Covid but really, how important is it to you that your virus is interesting? Do you care how many other people are dying when you are on life support?
Last year, the flu wasn’t as much of a threat as it has been (and will be).. Everyone stayed home and wore masks. Smart people did not hang out in crowded places and N95s became available. Jeff Bezos and delivery companies made a ton of money but I don’t begrudge them considering the alternative would have been a higher risk of contracting Covid.
Compare last year’s isolation to this year. School’s are well populated judging by the long lines of traffic when school lets out. People are going out again to shop and eat and visit. The President has erroneously declared an end to the Covid Pandemic and the CDC has revoked its advice that people in healthcare facilities should wear masks. Please note that the CDC did not prohibit masks in healthcare facilities although the department of motor vehicles might take exception if you don’t remove your mask when you take a picture when you renew your license.
So the flu is a real threat this year. If you have never had a case of the flu, consider yourself lucky. Death is an attractive alternative when fevers reach 104 and every muscle in your body aches. Furthermore, the flu is contagious before symptoms appear. That means you can go out to several family homes and give them the gift of flu before you even know you have it.
When a nurse is out with the flu, it isn’t for a day or two. There are no badges of honor for going to work sick with the flu. All of the uninfected nurses have to pick up the slack (and overtime). And flu season peaks in winter when it already takes extra time to visit patients. Roads may be icy and the holidays and end of year tasks cause everyone to get behind.
And that’s what the flu is like for us. Imagine the patients!
In the 2019 – 2020 flu season, the last year for which data was collected, 38M people were sick with the flu. The flu caused 400,000 hospitalizations and 22,000 people died from the flu or flu related complications. The virus that causes the flu is quite adaptable and mutates often to get around immunity. Because of the ever changing nature of the influenza virus, the flu statistics vary each year.
The side effects of the vaccine are generally mild unless the recipient of the vaccine is allergic to eggs. For the majority of people any mild side effects can be treated with tylenol or ibuprofen. It is mostly free but even if you pay out of pocket, it is cheap. There is no charge to Medicare patients and that includes those receiving hospice care. Home Health can bill Medicare although many agencies choose not to bill. You may also administer the flu vaccine to spouses and other Medicare recipients who live in the house. For billing purposes, there is no physician order needed. Get an order anyway.
With one exception, the flu vaccine is unable to cause the flu. The exception is the nasal inhaler vaccine which does contain minute quantities of the live virus so there is a similarly small chance that it could give the flu to the recipient. Because it takes a while for the vaccine to offer full protection, it is possible to get the flu in the week or so after the vaccine which is a good reason to get your flu shots early. And it is possible to contract the flu after being vaccinated but these cases do not cause as many hospitalizations and deaths.
Finally, the CDC has a boatload of resource materials that you can use as teaching guides or even wallpaper. Midway down the CDC Resource page are infographics and fact sheets. The CDC receives billions in funding. Make use of it. It would be a shame to waste billions of dollars and current CDC information will support any complaints about you or your agency.
If misery could be contained in buckets, each case of the flu would fill ten or so home depot buckets. Think about that and prevent some misery.
Jul 27
Mar 22
Apr 13
Care for the (whole) Person with Diabetes
A couple of months ago, I contacted Palmetto GBA about the LCD requiring agencies to obtain Hemoglobin A1C’s on diabetic patients every 90 to 120 days. Included were the ADA guidelines as well as a Medscape continuing education offering that spoke to the dangers of over-testing. Palmetto agreed to reconsider the current Local Coverage Determination and today, a response was received from Dr. Harry Feliciano MD, MPH – Senior Medical Director of Palmetto GBA.
It seems that Dr. Feliciano read the information I sent and additional research concerning the prevalence of hospitalizations related to hypoglycemia. He pointed out that the research I sent excluded diabetics who were on insulin and agreed that the current LCD should be updated.
As such, we can expect some changes in late April to be effective in early May regarding Palmetto’s policy regarding A1C’s. Based on information from Dr. Feliciano, I would expect to see:
Testing reduced to twice yearly for stable diabetic patients who have met their treatment goals.
Physicians may adjust treatment goals to lessen the risk of hypoglycemia.
Patients receiving insulin will continue to have quarterly A1C testing.
Patients who have their diabetic therapy changed or are not meeting treatment goals should have quarterly A1C’s monitored.
The purpose of requesting a reconsideration was to lessen the risk of denial for patients who are provided care by your agency. I am not going to insult you by reminding you that you still have to give appropriate care to patients with diabetes. You already do that, even when documentation is lacking. But is it enough? I ask because the incidence of diabetes keeps climbing and the costs are staggering – 245B per year. If you do the math, 245B is roughly equal to a whole lot of misery for millions of people. Maybe its time we up our game.
For very good reasons, the OASIS data set and Home Health compare put a premium on diabetic foot care but there is more to good diabetic care than looking at feet. The following is from the ADA guidelines regarding diabetes and older adults.
Recommendations[1]
- Consider the assessment of medical, functional, mental, and social geriatric domains for diabetes management in older adults to provide a framework to determine targets and therapeutic approaches. E
- Screening for geriatric syndromes may be appropriate in older adults experiencing limitations in their basic and instrumental activities of daily living, as they may affect diabetes self-management. E
- Older adults (>65 years of age) with diabetes should be considered a high priority population for depression screening and treatment. B
- Hypoglycemia should be avoided in older adults with diabetes. It should be screened for and managed by adjusting glycemic targets and pharmacological interventions. B
- Older adults who are functional and cognitively intact and have significant life expectancy may receive diabetes care with goals similar to those developed for younger adults. E
- Glycemic goals for some older adults might reasonably be relaxed, using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients. E
- Screening for diabetes complications should be individualized in older adults, but particular attention should be paid to complications that would lead to functional impairment. E
- Other cardiovascular risk factors should be treated in older adults with consideration of the time frame of benefit and the individual patient. Treatment of hypertension is indicated in virtually all older adults, and lipid-lowering and aspirin therapy may benefit those with life expectancy at least equal to the time frame of primary or secondary prevention trials. E
- When palliative care is needed in older adults with diabetes, strict blood pressure control may not be necessary, and withdrawal of therapy may be appropriate. Similarly, the intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may be appropriate. E
- Consider diabetes education for the staff of long-term care facilities to improve the management of older adults with diabetes. E
- Patients with diabetes residing in long-term care facilities need careful assessment to establish a glycemic goal and to make appropriate choices of glucose lowering agents based on their clinical and functional status. E
- Overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity are primary goals for diabetes management at the end of life. E
How many of you ensure that your patients have annual eye exams? How well and how often do you screen for depression? Do you run through the PH2 on the OASIS or do you stop and consider each answer carefully in both what is reported to you and what is revealed by other factors? When was the last time diabetic training for staff was offered at your agency? If you are visiting a hospice patient, have you adjusted the diabetic regime to provide for comfort as opposed to tight glucose control?
Clinical Record Review
Here are some of the things I see when reviewing records.
- A patient is taught to drink juice and have a snack when experiencing hypoglycemia. The same patient is dependent on a walker, has vision loss, moderate to severe pain and is occasionally confused. Documentation is absent any provisions made for a patient who cannot stroll to the fridge and pour some juice.
- A patient has a CBG barely over the reporting parameters and the nurse explains it by reporting the patient just ate and took insulin late. No MD notification. If you think that’s okay, look at the upper parameter. If it is 150, you might get a pass on patient care but it’s probably double that. More importantly, surveyors take exception to nurses not following orders.
- Teaching that complications of diabetes include heart disease, stroke and renal failure to a patient who is on dialysis and suffered a stroke in the post op period following bypass surgery.
- Patients are scolded when they are discovered eating something that will likely raise their blood sugar such as a donut or jam. Manners, please. These patients are our elders and they deserve respect. Nobody was ever embarrassed to the extent their A1C dropped to below 7.
- Generic teaching of medications that have very specific and unique side effects.
So maybe the greatest benefit of a relaxed LCD for diabetes is that we can focus our resources on overall better care. The lowered frequency of A1Cs only applies to stable diabetics with no changes to their treatment but these patients also need eye exams, assessment for depression and emergency teaching for hypoglycemia. Even if they have been a diabetic for ten years and have been stable for almost as long, make sure they know which medications might cause lactic acidosis and to notify the agency when their activity changes to prevent hypoglycemia. If you believe that the physician is overly optimistic about your patient’s diabetic goals based on your assessment of the patient in their home environment, respectfully bring it to their attention.
All of these interventions take very little time and can easily be included in care plans when the primary diagnosis is something else. If we don’t take advantage of ensuring that diabetes is addressed completely when it is not a crisis, the costs – both human and economic – to treat complications will be significantly higher.
To help you get started, her are some resources that may help in developing skills required to assess and treat diabetes. Please take the time to read one or two and if you find anything that helps your patient care, please share.
Resources for Diabetes
Lower Extremity Amputation Prevention (LEAP) program
Coping with Diabetes in Adults
Diabetic Retinopathy from National Eye Institute
[1] American Diabetes Association. Older adults. Sec. 10. In Standards of Medical Care in Diabetesd2016. Diabetes Care 2016;39(Suppl. 1):S81–S85
