Archive for category Health Care

Where does the Rot Start in Nursing Home Abuse?

This story has been bouncing around the Canadian media since last May. Camille Parent, the son of a nursing home resident, set up a hidden camera in his mother’s room for four days after she (the nursing home claimed) was assaulted by another patient. The results were appalling. Watch here:

The nursing home immediately fired the four staff members seen in the video; the contract of the director was not renewed. The police, however, have decided not to prosecute; the legal case for pressing assault charges, they said, is a lot narrower than what you or me would consider abusive.

That the standards in this nursing home are so abysmally lax is nearly beyond comprehension. Just after this particular facility opened about ten years ago, I accompanied a friend on a tour of the place. I remember thinking at the time, “If I ever need supportive care, this is where I want to go.” They had an exemplary care model, good staff/patient ratios, and a well-designed environment.

For me, it was interesting the reflex reaction of the director was to axe the employees involved, because as we all know, the best way to address issues in any health care institution is to fire employees.

Voilà! Problem fixed!

The problem with this hypothesis (i.e. the Rogue Employee Theory) is that four employees in four days with one patient displayed behaviours that were, um, sub-optimal.

No, sorry. You can’t just blame the employees, though they need to be accountable for their actions. The administration of the nursing home needs to take some (most?) of the responsibility for permitting an institutional culture where waving faeces-soiled wash cloths in patients’ faces, and canoodling in patients’ rooms is acceptable behaviour.

Let’s take a look at the Mission and Values statement of the nursing home:

Our Mission

St. Joseph’s at Fleming is a non-profit long term care health provider committed to excellence in the delivery of quality care and services to persons of all faiths. Continuing the legacy of the Sisters of St. Joseph of Peterborough, the Home takes pride in a model of care distinguished by compassion, dignity, respect and integrity.

Our Vision

Leader and valued partner in long term care through the use of innovation and best practices in living, learning and caring.

Our Core Values

Living
St. Joseph’s at Fleming is committed to creating a healthy living and working environment that:
[. . . ]

• Treats people with fairness and social justice

[. . . ]

Learning
St. Joseph’s at Fleming is committed to creating a unique learning environment for Residents, families, staff, volunteers and students that:

• Promotes innovation and best practices

[. . . ]

• Develops leadership and promotes teamwork

Caring
St. Joseph’s at Fleming is committed to providing exemplary physical, emotional and spiritual care to our Residents, their families, staff and volunteers. Our philosophy of care:

• Engenders trust, healing and wholeness 
• Integrates best practices and innovative solutions
• Promotes individuality as well as personal and spiritual growth 
• Is characterized by compassion, respect, dignity and the sanctity of life

All of which is very good, anodyne and even commonplace, and I am sure it looks very nice hanging in the front lobby. It’s pretty easy to point out where the nursing home and its employees betrayed its own mission and values, so obviously, it’s not enough. If I were the provincial investigator looking at this nursing home, my very first question would be, “How are your values exemplified in how you provide care?” In other words, how do you ensure institutional values — all those warm fuzzies listed above — align with the personal values of the staff? (Clearly, they didn’t in this case.) And also: what policies and procedures do you have in place that address abuse? What education do you give staff around patient abuse, or the issues that surround the care of cognitively impaired patients?  How do you evaluate the effectiveness of that education? How do those in leadership positions role model behaviour? What processes do you have in place to care for demented patients? How do front line staff participate in the development of such processes? How do you reward/celebrate excellence? And so on.

I’m guessing the answers to most of such questions would be “a little” or “not at all.”

So who should be held accountable?

The front line staff?

Yes.

The leaders, the managers and the administrators?

Yes. Probably more so.

So what do you think? Who is to blame? Staff or administration or both?

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11 Comments

Registered Nurses won’t make newspaper headlines, but your local sports pro will

Click to enbiggen

With Ontario’s Nursing Week approaching, May 7 – 13, posters for the Ontario Nurse’s Association (ONA, our union) campaign on supporting nurses the same way pro-athletes are have been put up around Acme Regional.

The conversation often arises among my colleagues about how a baseball player can make over 20 million dollars a year where 3 or 4 nurses’ lifetime salaries combined will never compare to that. I often feel bitter when I think of those in the business world who receive all sorts of financial and personal incentives for their work. People who go on all expense paid trips because they have sold the most insurance (selling you safety nets in case you fall, but you likely won’t, however you have to have it…) for example that year, meanwhile in that same year I may have resuscitated a child, held the hand of a dying man during his last breath and treated a father of 4 for a heart attack among caring for other incredible people. I received my same pay as always and more importantly, do not expect an incentive. I don’t feel bitter that I’m not getting a trip, I feel bitter that in this society, a pro-athlete or businessman is more supported than nurses. On the other side of the coin, it makes me wonder what sort of nursing culture would be bred if nurses were provided incentives for life saving measures or actions/treatment/education. And what treatments or care would be deemed “more important” than others, garnering a higher incentive? In the emergency department health teaching is imperative; to prevent illness and disease so one could argue that is as important as treating the patient having a stroke. If incentives in nursing existed would the wrong sort of people be attracted to the nursing profession? Some say it’s a calling, the art of the practice; only certain people can and will do the job and do it well have you. It would be worrisome to think that an individual would only want to save a life or teach parents about how to appropriately treat fevers if it meant they would get a financial bonus.

And yet, despite all of this, I still struggle with the fact that people who sell the most cars, buy the most stock in a company, etc… are seemingly more valued and appreciated then those that save lives, give people more time on earth and genuinely (most of us at least) care about humanity. I have a hard time finding the balance in it all. Emergency nursing is in the “business of life saving” is it not? With more and more facilities receiving incentives for improved and rapid physician to patient initial assessment times, where does appreciation for the nurses fall in to all of this?

(See also ONA’s website here and RNAO’s website for nursing week.)

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The Insanity of It All

Warning: my semi-annual politicalish post. When I read this, I admit I gawped:

$26,659: Our 2011 Medical Expenses

 Yes, you read that right. And we had insurance coverage for everyone last year, including daughter, 16, and my son who is 23 years old. Let me break it down for you:

    • Insurance Premiums……………..$14,179.04
    • Prescription Costs…………………$ 7,198.00*
    • Doctors Fees, etc…………………$ 2,068.49*
    • Eye care……………………………..$ 404.28*
    • Dental………………………………..$ 2,752.00**
    • Mileage……………………………….$ 300.00

* Costs in excess of insurance coverage.
** No insurance coverage.

Our medical costs in 2010 were $18,636. The principal reason why our medical expenses in 2011 increased by such a large amount was because our insurance premiums increased from roughly $7,000 in 2010 to over$14,000 in 2011.

This same crappy, expensive health insurance will likely be cancelled because my wife’s former employer has filed Chapter 11 bankruptcy and has filed a motion with the bankruptcy court to cancel all medical benefits for retirees and their families. My wife is classified as a retiree because she became disabled as the result of her pancreatic cancer, and the surgical chemotherapy and radiation treatments she received in 2006, and was unable to return to work. The story of her disability is described in detail at this link. Fortunately she is covered by Medicare, but we will lose even this crappy insurance coverage for myself, my daughter and my son.

I have a rare autoimmune disorder that unfortunately was not properly diagnosed until after the time had passed for me to file a disability claim with Social Security. Thus I am not eligible for disability benefits or Medicare. New York has a program for younger children that my daughter for which my daughter might qualify.

Because the insurance exchanges required under the Affordable Care Act will not go into effect until 2014, it is unlikely that my son and I can find insurance until then, assuming that the Supreme Court doesn’t find the ACA unconstitutional.

Basically one large every two weeks for medical expenses. Can any American defender of the status quo tell me why this isn’t completely insane and morally bankrupt? Or any Canadian admirers of U.S. health care — I know you are out there — tell me why the American system is superior in the fair and equitable provision of health care?

Just askin’.

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“What’s Wrong With Our Bodies, Anyway?”

Um, nothing. Just that runway models — and expectations — are getting skinnier. From Plus Model Magazine. On the left is a “straight-size” runway model, on the right, “plus” size model Katya Zharkova (size 12-14). A stunning contrast between the near-anorexic “norm” and healthy reality, wouldn’t you say?

According to the magazine:

-Twenty years ago the average fashion model weighed 8% less than the average woman. Today, she weighs 23% less.

- Ten years ago plus-size models averaged between size 12 and 18. Today the need for size diversity within the plus-size modeling industry continues to be questioned. The majority of plus-size models on agency boards are between a size 6 and 14, while the customers continue to express their dissatisfaction.

- Most runway models meet the Body Mass Index physical criteria for Anorexia.

- 50% of women wear a size 14 or larger, but most standard clothing outlets cater to sizes 14 or smaller.

More images here.

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A Nasty, Medically Unnecessary, Coercive Procedure

This is just grostesque:

A Republican supermajority has muscled two of the most restrictive anti-abortion bills in years through the Virginia House, despite bitter yet futile objections from Democrats, with one GOP delegate deriding most of the procedures as “matters of lifestyle convenience.”

You want to put what where?

[SNIP]

And the ultrasound legislation would constitute an unprecedented government mandate to insert vaginal ultrasonic probes into women as part of a state-ordered effort to dissuade them from terminating pregnancies, legislative opponents noted.

“We’re talking about inside a woman’s body,” Del. Charnielle Herring said in an emotional floor speech. “This is the first time, if we pass this bill, that we will be dictating a medical procedure to a physician.”

The conservative Family Foundation hailed the ultrasound measure as an “update” to the state’s existing informed consent laws “with the most advanced medical technology available.”

The Oklahoma legislature passed a similar law a couple of years ago. Full disclosure, in case you didn’t know it: I dislike abortion, but I’m strongly pro-choice. Even if you are strongly against abortion on moral or religious grounds, I would like to know how a medically unnecessary, coercive, invasive procedure can be ethically justified in order for a patient to receive health care? (I think we can safely dismiss the Family Foundation’s reasoning as spin.) And if the patient is a 13-year-old rape victim, how is this not despicable and evil?

Another question I would like to ask: if you’re a health care professional, would you excuse yourself from participating or facilitating in enforcing this law?

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Got Mine. Got Yours?

The flu shot, that is.

I got mine yesterday. And no, I did not get any flu-like symptoms. So get it over it, and go get the shot. Now. Especially if you’re a health care professional. What I wrote during the glory days of H1N1 two years ago still applies:

Finally, I won’t tell you to get the vaccine, because it’s professional, or that the hospital is making you anyway, or because it’s the right thing to do, or because you’re saving yourself the misery of having the flu for a week or two, though these are all more or less valid reasons. However, getting the shot will prevent you from being a complete tool when you pass the virus to someone compromised — maybe even one of your colleagues, a patient or even, God forbid, a loved one —  and end up killing them. I think this argument is nearly irrefutable.
So in summary: don’t be a tool. Get the shot.

Don’t make me nag you. Because you know I will.

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Smokers Have Other Problems Besides, Well, Smoking

If you work in the North, you’re familiar with the scene: patients in gowns, riding wheelchairs and trailing IV pumps scrambling over snow banks and icy walkways and braving frostbite-inducing winds to get off hospital property to have a smoke. I suppose for most of my readers, the image will induce a great big “Meh.” But a new article in the Canadian Medical Association Journal suggests otherwise, and that smokers who need to exit the hospital to smoke face special risks and little support in managing their addiction. Money quote:

Study findings affirm evidence that tobacco dependence treatment is inconsistently offered in hospitals and heath providers were uninformed about tobacco dependence treatment, despite availability of nicotine-replacement therapy at study sites. This treatment gap is perplexing, especially as within Canada there exists an evidence-based hospital tobacco dependence treatment program. Unintended patient safety consequences of smoke-free property necessitate effective tobacco dependence treatment during a stay in hospital simply as a risk-management action. Moreover, a health-promoting policy that causes patients to face diverse safety concerns (treatment disruption, infectious disease contact, exposure to adverse weather and possible violence) projects a contradictory health message.

Not helping, of course, are the usual (and sometimes, let it be said, judgemental) opinions of heath care professionals who view smokers adversely and see them as the authors of their own problems.* They tend to take the somewhat cavalier position that if smokers want to go outside for a cigarette, well, that’s their lookout. Elderly woman who falls on ice and fractures a hip while out for a puff? Hell, she brought it on herself by smoking! But is it actually humane to send sick people to the curb in the winter to tend to their addiction? Is it consistent with good nursing practice? And what about the liability and duty-to-care?

___________

*I will never forget the physician who told a young, pain-wracked lung cancer patient that she was responsible for her suffering, and that she should go home and “deal with it.” But some HCPs like to play the blame game in general and especially with patients with addictive behaviours.

 

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Sometimes Things Ain’t What They Seem

Niagara Health is taking a beat down lately. First it was an uncontrolled C. difficile outbreak, then a provincial administrator was appointed to deal with the outbreak, and now this:

When Doreen Wallace fell and broke her hip in the lobby of a Niagara Falls hospital, she figured at least she’d get help — and fast.
But that’s not what happened.
Instead, the 82-year-old Wallace — who was leaving with her son after visiting her dying husband at Greater Niagara General Hospital on Oct. 8 — was told by staff no one could help her until an ambulance was called.
To a hospital.
“It was horrible. It really was. Everybody who walked through the door stopped and stared at me,” said Wallace, who already had a broken arm from a previous fall. She ended up spending almost 30 minutes on the ground.
“I was inside the hospital. Why did they have to wait for an ambulance to come and pick me up?”
As she lay face down on a metal grate, her right arm slashed, a security guard called for help and two nurses from the emergency room came over. But Wallace’s son said they refused to help until paramedics arrived.
“I was floored,” said Mike Wallace. “We’re probably, maybe, like a 50-yard walk, literally, down to the emergency department.”

Almost predictably, Christie Blatchford weighed in, in the context of the stupid unthinking column I wrote about yesterday.

It’s an absolute given: With the great mass of Baby Boomers getting old, we too will weaken, grow frail and fall upon the mercies of the already badly faltering health care system. That system — what an amusing moniker that is for a bizarre and impenetrable collection of flourishing bureaucracies – does not change. It does not have the institutional equivalent of a “heart”; it does not learn from past mistakes; it does not respond to terrible plights; it does not bend.
There are already examples galore — just one the case of 82-year-old Doreen Wallace, who this month was leaving a Niagara Falls hospital where she was at her dying husband’s bedside, when she fell in the lobby and was left there, with what turned out to be a broken hip, face-down on the floor because 911 had to be called and an ambulance dispatched.
This had happened at this particular hospital several times before, where emerg staff seem to have a devil of a time treating anyone who doesn’t arrive by ambulance; it is contrary to hospital policy that it should happen; yet nothing seems to change.
I know what I’d do — fire the asses of anyone remotely involved in the decision that Ms. Wallace wouldn’t be seen unless she arrived the proper way. But that won’t happen.

Funny thing, this happens fairly often, and it’s a bit more complicated than you might think. Elderly hospital visitor falls down, goes boom. Someone says, “Let’s call those all-competent emerg nurses, they’ll know what to do,” ED nurse arrives, and the first thing she thinks about is c-spine protection as part of the ABCs. The point is, you just can’t simply move a patient who has fallen from standing height without protecting their neck. Especially elderly women, whose bones tend to break like eggshells. The result from moving a patient precipitously could be catastrophic if they have a cervical spine fracture. Patients in these situations need to be immobilized, which requires special training and equipment. (I’ve been trained how to immobilize necks, but that is by no mean true of all ED nurses. Or physicians, for that matter. In any case, I don’t do it often enough to be an “expert” practitioner by any means.)

Blatchford’s implication that hospital staff stood by callously and incompetently — her perennial complaint and modus operandi — is deeply unfair. If you don’t have trained staff or an available spinal board, the way give the best patient care is to call the paramedics, who are trained and have the equipment to offer c-spine protection. (In any case requiring spinal immobilization, I would defer to EMS without thinking twice.)

Or to put it another way, do you really want a porter (or whoever) scooping an elderly visitor into a stretcher and racing down the hallway to the ED for the sake of appearances (and drama, I might add) without knowing whether she has any c-spine trauma? The first rule of health care, after all, is to do no harm; on balance, it’s probably better to wait thirty minutes in relative discomfort (for the patient) for a paramedic with a spinal board, than face permanent paralysis or even death. The staff at Niagara Health probably made the best possible decision given the circumstances.

Granted, there’s the question of whether hospitals should provide the training and equipment so nurses can manage visitors who fall or otherwise injure themselves in public areas of the hospital. I would argue strongly yes. But I think that’s a separate discussion, involving prioritization and spending in an era where every health care nickel is being squeezed for the best possible value. Niagara Health could have done better, certainly, but not for reasons that Blatchford, or the rest of the media for that matter, imagines. Maybe she needs to, like, speak to an Emerg nurse or physician before rushing to conclusions.

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On Allegations of Patient Abuse at St. Joseph’s

This story concerning alleged abuse of a senior at St. Joseph’s Health Care Centre (and yes, I know “alleged” is a weasel word) has been making the rounds in the Toronto media, including some blaring front pages in the Toronto Sun:

Ron Meredith claims two burly security guards at a west-end hospital manhandled him, dragged him to an empty room and shackled him to a bed like an animal.
The frail 79-year-old alleges he lay there unattended at St. Joseph’s — forced to wear a diaper — for seven hours until he was discovered by cleaning staff.
His only crime, he claims, is that he was sitting in a chair waiting patiently to be discharged.
“What they did to me was unbelievable,” Meredith said Monday, still in shock and covered in bruises two days after his ordeal.

Woken up by a noisy patient in the next bed, Meredith got dressed, went for coffee, and believing his discharge was imiment, sat down by the nurses station to wait. Unfortunately, the situation escalated.

He claims two security guards, “big guys,” approached shortly before 7 a.m.
“They accused me of trying to escape and told me to go back to my room,” Meredith recalled.
The senior explained he was waiting to be discharged but the guards again ordered him back to his room.
“I told them I was already dressed and I didn’t feel it was necessary to go back.”
After a third warning, he says the situation turned ugly.
“All of a sudden they pounced on me,” Meredith claims.
Both guards allegedly pulled him out of the chair, pinned his arms behind his back in a painful position and dragged him down the hall to an empty room.
“They threw me on the bed and I hurt my back on one of the rails,” Meredith said, adding the guards then cuffed his wrists and ankles to the bed.
“They really did a job on me,” he said. “And when that diaper was put on me I knew I was in for a long haul.”

Ugh. Nasty story. The thing is, as an old RN, I can immediately see suggestions there is much more to this story than meets the eye. The bruises, for example, on this poor patient’s arms are clearly old and related to IV starts or blood draws; they are particularly common in patients taking anticoagulants, which I strongly suspect this patient is on. They weren’t caused, in any case, by undue restraint. Further, one wonders if this patient refused a reasonable request to return to his room and wait for discharge; the patient then became increasingly angry and frustrated, and matters escalated from there.

On the other hand, as an old RN, I can clearly (and distressingly) understand how this story is completely plausible. Poor (or no) communication from the nurses on the inpatient unit to the patient and family on the care plan. Overreaction and assumptions made on the part of the nursing  staff. Stereotyping of the elderly as always confused and/or demented. Overuse of restraints. Underlying view of nurses that patients must be under control at all times. (Hospitals aren’t prisons!) Et cetera.

The point  is that there isn’t enough information to make an informed judgement one way or another, accusations made by the media notwithstanding. The problem is when health care horror stories — a favourite Canadian meme — appear in the press, it’s always a one-sided conversation. When hospital spokespeople say they cannot discuss the issue because of patient confidentiality, they aren’t being obfuscatory. Hospital administrators aren’t perpetuating a cover-up  By law, hospitals absolutely cannot make public patient information. This is to protect patients themselves. I mean, do you want information about you bum boil perianal abscess publicized?

The interesting thing for me is that the story, and how it is being played out in the media, suggests the public has a fundamental lack of trust in hospitals/health care and their ability to address complaints, and especially serious complaints like this one. This is precisely because there is a legislatively mandated lack of transparency. It’s not like hospitals want to treat patients shabbily, or think unethically (and possibly illegally) restraining patients is best practice, or don’t approach patient complaints with the necessary due weight. From experience, I can verify hospitals take all sentinel events extremely seriously, because we are, after all, in the business of making people better. I have no doubt that multiple various administrators at St. Joe’s are addressing the issue as I write. In short, time is needed for the appropriate investigations to be made.

I have to think, whatever the outcome, that this whole business was fundamentally a nursing issue. It could have been avoided. Basic Nursing 101: Avoid power struggles.  The nurses should have just let Mr. Meredith sit in his chair. Maybe that’s the ultimate takeaway.

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Saving the World from Terrorist Breastfeeding Toddlers [UPDATED]

An Atlanta, Georgia suburb is fighting one of the most pressing causes of our era — children who breastfeed past twenty-four months. Because breastfeeding after the age of two will damage human society beyond repair:

On Monday night, Forest Park passed a public indecency ordinance to prevent public nudity. Previously, the city only had a public indecency ordinance that covered adult entertainment businesses.

 According to the law, no woman can breast feed anyone older than 2 years old in public. City manager John Parker called the law a proactive step.

 “It sets up a process whereby we can try to control nudity throughout the entire city,” Parker said.

There was, in response, a public nurse-in ridiculing of the notion of breastfeeding posing a clear and present danger to societal values, and a response to the nurse-in predictably filled with comments from various yobs and jackasses. What I’m not getting, though, is the conflation of breastfeeding (regardless of the age of the child) and public indecency. Or stigmatizing  a practice which is healthy and beneficial for both child and mother, and for 99.9999% of human history was the normal means of providing nutrition for infants and young children and continues to be for the vast majority of the world. Oh, but there’s this bit of enlightenment:

Do you think he — or the Forest Park City Council — knows what projection means?

UPDATE: I was gulled (blush), as Jenn points in the comments, by a hoax. “Citizens Against Breastfeeding,” portrayed in the Youtube clip, as snopes.com points out, is a prank. Such are the times when even an outrageously obvious hoax is believable — and yes, the point still stands.

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