Blog
From abysmal to mediocre: Encouraging hand hygiene
Here’s my latest article on McKnight’s Long-Term Care News:
From abysmal to mediocre: Encouraging hand hygiene
As a consultant in long-term care, I learned how to properly wash my hands by reading the hand hygiene poster hung above the sink at one of my first nursing homes.
I’ve gotten more diligent over the years (read: paranoid), making an effort to sanitize my hands as I move from room to room, but I wonder about those whose roles in long-term care don’t specifically emphasize infection control procedures.
While infection control is an integral part of training for most staff members, there are many other people in facilities — visitors, volunteers, vendors and residents, among others — who might not fully recognize the importance of hand washing to prevent the spread of infection.
In fact, a recent study suggests that even those who should know better don’t wash their hands as often as they should. Researchers found that doctors in a California hospital had a hand hygiene compliance rate of about 22% when they didn’t realize they were being observed and a rate of 57% when they recognized that the infection control staff was watching them.
The research paper is titled, “Hawthorne Effect in Hand Hygiene Compliance Rates,” referring to the change in behavior due to being observed. To me, however, the takeaway is that hand hygiene compliance rates range from being abysmal to mediocre. Clearly, this is an area that needs more attention.
A study presented at this month’s Association for Professionals in Infection Control and Epidemiology conference suggests a novel method of increasing hand-washing compliance.
Because prior research had found success in appealing to emotional motivators such as disgust in changing hand-washing behavior, investigators exposed subjects to unappealing photos of bacterial contamination. This visual exposure helped participants imagine the contamination on their own hands and increased their likelihood of hand washing by 11% to 46%.
We could call it the “Eww, Gross! Method.”
Other techniques suggested by infection control and other researchers to increase hand hygiene compliance are below:
• Publishing (in-house) rates of hand-washing observance for each unit to create a healthy sense of competition. The best team could be rewarded, perhaps with pizza or a special lotion to soothe frequently cleansed hands.
For the entire article, visit:
From abysmal to mediocre: Encouraging hand hygiene
Dr. El’s work mentioned on “Last Comforts” blog
I’m pleased to report a nice mention of my work on the blog of journalist Ellen Rand, author of Last Comforts: Notes from the Forefront of Late Life Care. Last Comforts, the book and the blog, focus on improving ways of managing late-life care.
Below is an excerpt of her blog post. The rest can be found here. Thanks, Ellen!
You’re In a Nursing Home. Now What?
I’m a big believer in the benefits of person-centered culture change in long-term care settings like nursing homes, where the aim is to focus more on the feeling of “home” than on “nursing.” According to the Eden Alternative , a nonprofit organization that promotes, supports and teaches about person-centered culture change, currently there are 190 skilled nursing facilities on its registry, 45 percent owned and operated by for-profit companies and 55 percent by nonprofit, county and government sponsors.
But these homes still represent a small fraction of the total number of skilled nursing facilities in the U.S. What if you, or someone you love, must make the transition to a nursing home now?
Fortunately, many excellent resources are available to guide you in making your choice. Deeply buried in Medicare’s Nursing Home Compare website, for example, is an excellent 56-page booklet called “Your Guide to Choosing a Nursing Home or Other Long-Term Care.” Fewer resources are available to guide you about how to live well once you’re there, however.
That’s where Eleanor Feldman Barbera, PhD, comes in. A seasoned nursing home psychologist, “Dr. El,” as she calls herself on her website and blog, says that her goal is “to make long-term care a place I’d want to live when it’s my turn.” She is called in to work with residents if they are causing trouble – e.g., arguing with staff members or other residents, or refusing to take medications, or participating in rehab, or are depressed.
Her approach is one of empathy, pragmatism and humor. Sometimes it’s a matter of residents adjusting to the reality of not being able to do everything for themselves, she pointed out.
For the rest of the article, visit: Last Comforts
Full code: Discussing advance directives
Here’s my latest article on McKnight’s Long-Term Care News:
Full code: Discussing advance directives
Assistance in creating a “good death” is a fundamental task of any organization working with elders and may be addressed by a number of team members singly or in combination. Since these discussions are often easier said than done, I thought it might be helpful to share some of my experiences since I, as a geropsychologist, regularly discuss dying with residents and their families.
It’s a more-than-timely topic. As I once wrote in my column, “Creating better deaths in long-term care,” end of life care has been the subject of increased media attention in recent years. The importance of a conversation or series of conversations about the resident’s wishes has been emphasized by organizations like The Conversation Project and writers such as Atul Gawande, M.D. in his bestselling book, “Being Mortal.”
Here’s some added perspective. Not too long ago, I was checking the medical orders in a long-term resident’s chart when I noticed that she was “full code.” Bernice was 92 years old with a history of chronic illnesses and a recent decline in functioning.
While many residents have advance directives that prohibit care in the event that breathing or the heart stops (such as a Do Not Resuscitate order), full code allows for all interventions needed to restore breathing or heart functioning, including chest compressions, a defibrillator and a breathing tube.
I thought of the distraught expressions on the faces of the nurses who had rushed to provide full code care to Jim, a frail elderly man who’d been a staff favorite during the course of his stay. The full code was at the insistence of his son, who couldn’t bear the thought of his dad’s passing. Jim’s ribs were cracked, the effort was unsuccessful and the nurses were devastated – at having to perform the procedure, not because Jim had died. It was obvious to everybody in the nursing home that Jim had been dying for months despite his son’s desire to forestall the inevitable.
Mindful of Jim’s painful demise, I raised the issue of advance directives with Bernice, asking her if she knew what “full code” meant and if she’d given any thought to how much medical treatment she wanted at the end of her life.
“What will be, will be,” she told me. “I don’t want to talk about it.” Her tone made it clear that persistence would be futile.
“There’s a lot more to it than that,” I replied, “but we don’t have to talk about it today.” I made a mental note to pursue the topic when she seemed less inclined to throw me out of her room.
For the entire article, visit:
Full code: Discussing advance directives
Depression – AND its treatments – are fall risks
Here’s my latest article on McKnight’s Long-Term Care News:
Depression – AND its treatments – are fall risks
Feeling “down” takes on a wicked double-meaning for some seniors. Even conscientious providers could be unaware of it, let alone know what to do about it.
As McKnight’s Staff Writer Emily Mongan points out in “Depression treatments may increase risk of falls in SNF residents, study shows,” a psychosocial treatment for depression increased the likelihood of resident falls. I spoke with Suzanne Meeks, Ph.D., first author of the study, to discuss the problem and the results of her research.
Meeks and her colleagues studied the impact of the Behavioral Activities Intervention (BE-ACTIV) on depressed nursing home residents. They determined that the risk of falls in the treatment group was six times that of the control group, a statistically significant number.
Meeks told me all treatments for depression, including medication and behavioral interventions, increase the chance of falls. When an individual is no longer depressed, he or she has more energy to stand and walk, thus creating more opportunities to fall. If depression has immobilized them for some time, deconditioning may exacerbate the problem.
Meeks points out that more than 81% of her research subjects in both treatment and control groups were receiving antidepressants, suggesting that the behavioral intervention activated the residents more than the medication.
It’s important to treat people for depression despite the increased risk for falls because, as Meeks states, “depression is a fall risk.” Other researchers have found that the risk of falls increases when an individual has more of the following risk factors: depressive symptoms, antidepressant use, high physiological fall risk, and poorer executive function. Any two of these risk factors increase the likelihood of a fall by 55%. Participants with three or four risk factors were 155% more likely to fall — 155%!
The BE-ACTIV intervention
The BE-ACTIV model was quite successful in reducing depression, Meeks and her colleagues found, as described in an earlier article about their work. Study subjects in the 10-week treatment group were encouraged and assisted to participate in pleasant activities such as regularly scheduled group programs, in-room crafts and self-care such as haircuts. Compared to the “treatment as usual” control group, BE-ACTIV was “superior … in moving residents to full remission from depression.”
For the entire article, visit:
Depression – AND its treatments – are fall risks
Creating a dialysis-friendly facility
Here’s my latest article on McKnight’s Long-Term Care News:
Creating a dialysis-friendly facility
Studies show there will be an increasing number of people on dialysis in the coming years. It’s likely many of them will be in long-term care.
There is much that can be done to improve the quality of life for these individuals and to showcase your facility as dialysis-friendly. Unfortunately, many providers are not doing all they can to help these people, or boost their own business operations, for that matter.
New diagnoses of end-stage renal disease (ESRD) in residents should prompt a team discussion with them and their families about wishes for end-of-life care (see Dialysis: Gauging its need, and how to reduce its stress). Some may prefer to avoid dialysis, but many of the newly diagnosed will choose to begin dialysis treatments. In addition, most facilities already have residents committed to the ongoing process of dialysis.
To understand how to best improve care, let’s consider what life is currently like for many hemodialysis patients in long-term care.
A week in the life …
Most people undergoing hemodialysis leave their LTC facility three days a week in order to receive treatments that last for about 3 ½ to 4 hours. In the case of James, for example, he is awakened at 6:30 a.m. to get ready for a 9 a.m. pickup for a 10 a.m. dialysis appointment. He spends the day dozing on and off in front of the television while hooked up to the dialysis machine. By 2 p.m., he’s disconnected from the machine and has a 2:30 p.m. pickup time that sometimes doesn’t happen until 3 p.m. He’s back at the facility by 4 p.m.
Not surprisingly, James and other residents are frequently fatigued on the days in between treatments, making it less likely they’re able to participate in rehab or in the life of the LTC community.
A typical dialysis patient has interacted for hours with an entirely different staff that generally has little contact with the facility care team. They’ve been on an ambulette dealing with various personalities in close quarters (and possibly in traffic or bad weather) and it’s likely that lunch was a renal diet sandwich eaten while being dialyzed.
Considered from a “patient experience” perspective, the bar is set pretty low and there’s a lot we can do to raise it.
For the entire article, visit:
Creating a dialysis-friendly facility
Dr. El tries on the Genworth aging suit
Here’s my latest article on McKnight’s Long-Term Care News:
Dr. El tries on the Genworth aging suit
I’d read about the Genworth R70i Aging Experience and when I discovered the exhibit was making a brief appearance near me at the Liberty Science Center in New Jersey, I headed over with my 9-year old assistant to see what it was all about.
The Aging Experience involves a high-tech suit designed to help younger people gain insight into the physical effects associated with aging. When I told residents I was going to age myself via the suit, reactions ranged from an incredulous, “Why in the world would you want to do that?!” to “Great! We can compare notes,” to, “Can they make a suit to make you feel twenty-five?”
My assistant and I arrived 15 minutes before the 11 a.m. demonstration so that I’d be dressed and ready. The Applied Minds staff, who partnered with Genworth on this project, took us into the back of a tech-filled room where they Velcroed various parts of the suit onto me, adding an extra 40 pounds strategically placed to mimic age-related weight gain.
This resulted in the constant thought throughout the half-hour presentation that it would be really nice to sit down.
The helmet included goggles and headphones, so that they could give me various disorders including glaucoma, macular degeneration, cataracts, age-related hearing loss, tinnitus and aphasia. I was finally able to see what one of my patients referred to when she said, “I have macular,” as if she was intimate enough with the condition to be on a first name basis.
After undergoing vision and hearing loss, I was faced with rheumatoid arthritis and hip problems that made walking on the treadmill a chore. Even without the additional physical challenges, trudging on the virtual beach was so difficult that I estimated a two-minute hike would be enough before it lost its pleasure – and I love walking on the beach.
The audience was able to observe my heart rate and perceptions on the screens behind me and then to try on goggles and headsets and experience the ailments themselves.
For the entire article, visit:
Dr. El tries on the Genworth aging suit
Help for hoarders, and those who care for them
Here’s my latest article on McKnight’s Long-Term Care News:
Help for hoarders, and those who care for them
It can be challenging for long-term care providers when residents amass large quantities of possessions. Facilities generally worry about hoarding when the amount of belongings prohibits the resident or staff members from safely moving about their room or apartment.
Other concerns include fire safety and the possibility of attracting vermin in spaces that are unable to be properly cleaned, as well as apprehension that a cluttered room will attract negative attention from state surveyors.
On the other hand, cleaning out a room against the will of a resident could be perceived as a violation of their right to “security of possessions.”
Facilities often feel stuck between the proverbial rock and a hard place.
Firsthand observations
Over the years, I’ve observed many different scenarios that arise when facility try to manage residents’ hoarding. Here’s a small sample:
• “The State is going to be here any minute,” the Director of Social Work told me, her voice rising a couple of octaves with panic, “We need you to tell Mrs. White that she’s got to get rid of all that junk.”
• Hoarder Number One, complaining bitterly about Hoarder Number Two: “Why are they telling me I need to throw away my things when she has even more stuff than I do? Her room is a mess! At least mine is organized. They just don’t bother her because she’s friends with the administrator.” (All accurate perceptions.)
• Comment from the maintenance guys to the hoarding resident after showing up at the door with cardboard boxes and a dolly: “We’re going to pack up your room for a few weeks until after the State visits, then we’ll bring it back.”
• Sitting with Ms. Rosario following an unannounced purge of her room while she was at dialysis: “How could they do this to me? I trusted them! That stuff was really important to me,” she said, referring to, among other things, an assortment of straws and every food tray slip she’d gotten since her arrival at the facility over a year ago.
What is hoarding?
For the entire article, visit:
Help for hoarders, and those who care for them
Are Families Ready For The Death And Dying Conversation?
Aging advocate Carol Marak interviewed a group of eldercare experts (including me) regarding their experiences discussing death and dying with elders and their families. Her Huffington Post piece on the topic, excerpted below, suggests that yes, families — and many healthcare providers — are ready to have these important and necessary conversations.
Are Families Ready for the Death and Dying Conversation?
Most people avoid the topics of aging and dying like the plague, don’t you agree? Erica Hollack, the author of “Live Well, Die Well,” doesn’t think so and argues the opposite. She attended a conference on end-of-life concerns and discovered that the 800 chairs set up for the workshop were not enough. The community came out in droves to hear the meaningful conversation in Spokane. So, as a whole, our culture may not be averse to talking about the end of life.
The Institute of Medicine (IOM) believes the time is right for a national dialogue to normalize the emotions on death and dying. They think that the social trends point toward a growing willingness to share stories about the end-of-life care and that it will help drive more family discussions. In the IOM consensus report, Dying in America, experts found that accessibility of medical and social services could improve a patient’s life at the end. But if people don’t discuss which medical care or social services they want or not, how will their wishes be known and carried out?
Since 70 percent of ill adults become unable to express their care preferences, the separation between what they want, and what they receive is significant and usually is the result of misinformation. Having end of life discussions can put a stop to the discrepancy. IOM believes we can do this through public education and engagement.
My family experienced several deaths over the years. However, one, in particular, sticks out. It was my brother-in-law’s. The medical and hospital staff followed his values, goals, and educated preferences. It made the process for everyone more relaxed and comfortable. The best of all, it created the sacred space for good-byes, forgiveness, and regrets. To this day, the family remains in awe of that unprecedented event.
There is power in stories. And by sharing them, it’s my hope to encourage meaningful dialogue between individuals and their families about beliefs, care, and choices. By sharing personal events and accounts, fear will dissipate. Death is a process to appreciate, and family members should spend the time reminiscing not deliberating over medical treatments.
The Institute of Medicine also recommends that service providers stimulate advance care planning between clients and medical teams so that the individuals can make informed choices based on one’s needs and to make them known. To unlock the narratives of death and dying so that others become more comfortable with the topic, I asked the Seniorcare.com Aging Council,
“Share one example of a family or person/client who experienced a higher quality of care as a result of having an open talk with loved ones?”
For the entire article, visit:
Are Families Ready for the Death and Dying Conversation?
Clone this woman. Steal this idea.
Here’s my latest article on McKnight’s Long-Term Care News:
Clone this woman. Steal this idea.
A few months ago, I was consulting at the Margaret Tietz Nursing and Rehabilitation Center in Jamaica, NY, when a remarkable woman named Trudy Schwarz walked down the hall. Her noteworthy qualities were obvious in several ways.
A diminutive woman, she nevertheless was pushing a sizable rolling metal cart filled with all manner of neatly arranged goods. This was despite being as old or older than many of the residents at the facility.
She exuded a calm, pleasant demeanor enhanced by her smile and her peach-colored lab coat as she purveyed merchandise from what I’ve previously termed an “independence cart,” an essential yet rare enterprise in long-term care.
“Trudy’s here!” exclaimed the resident I’d been speaking with, excusing herself for a moment to exchange a few dollars for a bottle of lotion. “She buys me the things I can’t get here. She’s a real lifesaver.”
It was a sentiment I heard echoed by many other residents over the next few months.
Overcoming systems failure
An “independence cart” is a small store on wheels that brings goods to residents. While many residents have personal needs allowances and therefore a small amount of money for purchases, it’s virtually impossible for many frail elderly to spend it due to a systems failure within long-term care communities.
Residents generally have no access to a store unless it’s one that visits their facility or they’re physically able to go off-campus with a family member or as part of a staffed excursion. Social workers are usually too inundated with other tasks to assist with online purchases and most residents don’t have access to a credit card, debit card or PayPal account necessary for web-based transactions anyway. Residents without family members to make purchases on their behalf are left to ask for help from staff members who sometimes assist them out of kindness — but against facility policy.
The psychological impact
For the entire article, visit:
Clone this woman. Steal this idea.
McKnight’s Online Expo, FREE, March 29th and 30th 2016
Once again, McKnight’s will host its annual online expo, which is a chance to attend a conference without leaving your desk. Register for the conference in advance, and then log in to hear the talks, visit the vendors, and chat with the reps and attendees.
This year’s topics are:
PAYMENT: MDS 3.0 Update: Get ready for more changes March 29, 10 am EST / 7 am PST
WOUND CARE: Deep-tissue injuries — Recognition, Strategies and Risk March 29, 11:30 am EST / 8:30 am PST
TECHNOLOGY: Trends and best practices March 29, 1 pm EST / 10 am PST
QUALITY: Engaging staff in reducing readmissions to improve quality March 30, 11:30 am EST / 8:30 am PST
CAPITAL: The state of capital availability March 30, 1 pm EST / 10 am PST