Patient Safety – It’s what we do!

by Tina Hilmas, RN, BSN, Project Manager, Center for Patient Safety

Patient Safety Awareness Week is coming up March 12-18 and I’m always excited during this time of the year. You see, patient safety seems so simple yet is so complex and I could literally spend hours talking about it. But what I’d really like to do is intrigue you into becoming as excited about patient safety and patient safety culture as I am. The analogy that comes to mind for me is that of an onion. When you peel away the layers of an onion, you are left with the heart of the onion, or rather the core. The same is true with patient safety. As you begin to peel away the actions of an organization and look underneath at the rationales for those actions, you find the underlying beliefs of an organization, the foundation, the culture regarding Patient Safety and that is where a journey of patient safety must begin.

As a nurse, it seems like patient safety should be ingrained into our daily actions. After all, aren’t nurses supposed to promote, advocate for and protect the rights, health and safety of our patients? But can we honestly say that we have always, in every situation, put the safety of the patient first? How about that day where you were being called for one start of care after another? Or that day when you’d been on call, received multiple calls throughout the night, and began seeing patients the next day with little to no sleep? Were your first thoughts truly of patient safety or more on just how you could keep your head above water with all the visits you needed to complete? More importantly, does your organization have built in safety guards to help protect the safety of your patients?  Does your organization promote a strong patient safety culture?

You see, patient safety is more than just the National Patient Safety Goals (NSPG) of the year. Patient safety is a combination of technical change and adaptive change and it never stops. It’s not something that is “achieved” rather it is an aspect of your organization’s culture and therefore ongoing. Culture, as it pertains to an organization, is defined as a way of thinking, behaving, or working. Safety culture can be defined as the following:

“The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management.” (Health and Safety Commission Advisory Committee on the Safety of Nuclear Installations, 1993; adapted by AHRQ)

So to break it up, the technical change aspect is focused on those NPSG’s – developing processes and policies for fall prevention, medication education and identification of the patient. The adaptive component of culture is the leadership component, the systems component and looking deeply at human factors engineering. Some nurses have called this the “touchy-feely” part of nursing because it deals not only with processes, but also the on-going evaluation of the organization’s behavior, from leadership all the way down to the home health aide, in regards to a specific item, the heart of the onion – patient safety culture.

So where do we begin this journey? Evaluate your organization’s culture, not just employee engagement, to actually look at how the employees within your organization feel about the organization’s commitment to safety. Look at your processes and what happens when a mistake is made. Is there an investigation or Root Cause Analysis of the event including not just the outcome of the mistake, but review of the system, including policies, and contributing factors? Is there a tendency to discipline or maybe terminate the employee responsible for the mistake with the reason being, if you eliminate the person responsible then the problem is solved? Do the employees in your organization feel comfortable admitting to near mistakes, mistakes that resulted in no harm, or pointing out unsafe conditions? If so, keep up the awesome job! If not, ask why? Is it because of the culture? Does everyone just keep their head down and try to sweep mistakes that didn’t result in harm under the rug? Surveys, such as the Survey on Patient Safety, can help leaders visualize where their organization is on the culture scale. It also allows for identifying a starting point for change.

When trying to change there are multiple frameworks that can be reviewed because change is hard and threatening. In organizations that have success in promoting a strong patient safety culture, there is one factor in common, it all starts with leadership. The leaders have to show that patient safety is a priority and part of the mission of their organization. The leaders should engage with their personnel on a daily basis and they should incorporate patient safety as part of their daily routine. Patient safety will only become a priority when it is incorporated and embedded into everyone’s daily routines.

But in focusing on patient safety, leaders shouldn’t lose sight of their most valuable asset – their employees. Employees need to feel supported and invested in by their leaders. This is where leaders and organizations should ensure they have a strong Employee Assistance Program, but maybe should also look into other supportive programs such as Second Victims. This program trains the staff on how to support a fellow employee who may have been involved in an adverse event. In home care and hospice, this is something that could help not just if an adverse event occurs, but also if a long-term patient expires. Even if it was expected in hospice and home care, relationships develop between the health care team and the patient; a Second Victims Program can help to provide the support needed to those involved in the care of a long-term patient who passes.

So hopefully, I’ve helped you to see why I’m so passionate about Patient Safety.  It isn’t just the technical or the top layer of the onion, but the whole onion, the heart and core that I enjoy dealing with to make certain it is strong, healthy and sweet.

Don’t Miss HHQI’s Next Underserved Populations (UP) Network Webinar

Patient Safety: All in a Day’s Work! – Thursday, April 20, 2017,  2:00 p.m. ET

Ready to learn more about patient safety? Join Ms. Tina Hilmas, RN, BSN and the HHQI team for the next Underserved Populations (UP) Network webinar. During this webinar, you will learn how to begin preparing a Quality Assurance & Performance Improvement (QAPI) plan related to patient safety that will be required by all home health agencies. This will be a 2-hour interactive event that will include work on a QAPI plan. Register Here

About Our Guest Blogger – Tina Hilmas, RN, BSN

Ms. Hilmas has spent more than 20 years in the nursing profession both within hospital walls and outside in the home care arena. Her current work includes collaborating on quality improvement projects that include incorporating a strong patient safety culture. She also reviews patient safety events reported to the Center to analyze for trends and causal factors to assist organizations with changing their culture and improving patient safety.

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The Super Bowl of Super Foods

by Lacy Davidson, MS, RDN, LD, CDE, RYT, Nourish Appalachia

2-3-17_lacy-davidsonGearing up for the big game? I have to admit, at the very moment I’m writing this I have absolutely no idea which teams are even playing in Sunday’s game. I know my brothers would be so proud! At any rate, Super Bowl Sunday has ALWAYS been a part of my life. There have been many years when the big game fell on my birthday, or often times my birthday party was held on the same day. What a great way to kill two birds with one stone, mom!

Recently, a patient asked me what sorts of foods and snacks I might be serving up this year on Super Bowl Sunday. Being a Registered Dietitian Nutritionist, I get these questions quite often, WHICH I LOVE!

You can also submit questions for me to answer by going here and select ‘get started’.

As a child, and nearly every adult year I recall, the foods that are most synonymous with Super Bowl Sunday, besides the birthday cake and ice cream, are chili and nachos with cheese.

As I have grown more health conscience over the years and am aware of the relationship between food and health, the recipes for these ‘holiday’ staples have evolved. For many years, the chili was vegan (err, I was a broke college student and beans were cheap – heart healthy, too). While other years it may have been made with ground turkey, grass-fed beef or my personal favorite, venison!

Soup-er Bowl 2017 will in some ways most closely resemble the way I first noshed on this warm and spicy dish, however this year the menu will be dressed up with a few super food add-ins to tickle the taste buds and stoke the metabolic fire.

Here’s the recipe for this delicious chili dish if you’d like to try your hand.

chili-peppersINGREDIENTS:

  • 2 tablespoons olive oil
  • 1 ½ pounds ground venison (deer meat)
  • 1 ½ cups finely chopped onions
  • 1 ½ cups finely chopped celery and carrot
  • 1 ½ tablespoons finely minced garlic cloves
  • 1 cup red wine (and an ounce or so for the chef to enjoy all the commercials)
  • 2 tablespoons ground cumin
  • 2 tablespoons chili powder (we add a pinch of dried habanero or jalapeno, from the garden for a little more heat)
  • 1 tablespoon cinnamon (yes, cinnamon)
  • 2 bay leaves
  • 2 cups frozen corn kernels from the summer harvest
  • 1 cup roasted green peppers, peeled, seeded & chopped into medium dice
  • 1 cup roasted red peppers, peeled, seeded & chopped into medium dice
  • 1- 2 quarts organic canned tomatoes
  • 1 small can organic tomato paste
  • 1 ½- 3 cups dried beans (I prefer a blend of kidney, pinto, and black – soaked and drained at least 36 hours – the key to not blowing everyone away at halftime if you know what I mean!)
  • 2 tablespoons coco powder
  • ½ cup left over coffee
  • 2 tablespoons maple syrup
  • Salt and pepper

PREPARATION:

Serves 12

Total Prep and Cooking Time: 45 minutes

  • Drizzle a bit of olive oil in a large stockpot (I love using my cast iron kettle), add the onions and garlic and cook until the onions are soft, about 4 minutes.
  • Then add the meat to the pot and cook until it’s no longer pink and it starts to brown, about 5 minutes.
  • Add the wine to the pot, bring to a boil, and reduce it by about half.
  • Put in the cumin, chili powder, cinnamon, and bay leaves and cook until aromatic, about 30 seconds.
  • Add the corn, peppers, tomatoes, and beans.
  • Bring to a boil and then reduce to a simmer.
  • Put in the Super Bowl MVP and antioxidant rich cocoa powder, coffee and the WV maple syrup. Continue to simmer for a few minutes, to gently combine all of the flavors.
  • Season to taste with a dash of salt and grind of pepper.

SOME ADDITIONAL NOTES:

Meat is optional. Although some wouldn’t call it ‘chili’ if it doesn’t have meat, it will have nearly the same flavor and will satisfy vegetarian guests if omitted. The emphasis on veggies is what makes this rendition so incredibly heart healthy (a little secret my boyfriend doesn’t need to necessarily know to enjoy).

I’ve made this dish many times with the ancient grain, quinoa. Loaded with fiber from the complex carbohydrates while providing nearly the same texture and protein content as the ground meat, it has always gone over well with a crowd.

In my opinion, where you can really take this dish up a notch in both presentation and nutritional status is to have a bar of fresh toppings for the chili like cilantro, limes, sour cream from grass fed dairy cows, coconut cream for the lactose intolerant, heart healthy avocados and diced green onions to add a contrast of color and to entice your guests.

nachosAs for the nachos, I’m not crazy about cheese these days (certainly not the fake cheese spreads, dips, slices, and whizzes out there) and neither is my belly. Some of these cheeses lack nutrients and include questionable ingredients that can make their way into ‘processed cheese products’. This year, I’ll be serving up a rendition on this Epicurious concoction and will be making a few recipe tweaks of my own.

It’s important to ensure that toppings on the nachos are local and organic ingredients (when possible) and that the chips are a variety of non-GMO corn tortillas so that they’re not a total empty calorie bomb. My personal favorite brand of chips is Shagbark Seed & Mill which I can pick up at our local food market.

Having tried it a couple of times, always changing the recipe slightly, I will certainly give this Butternut-Queso a go as well. Beyond that I’m sure I’ll whip up another batch of Cauliflower Buffalo Bites as I have in years past. I’ll probably also serve nutrient dense versions of classic staples like:

  • Spinach Artichoke Dip – double up on the spinach and artichoke and swap the weird ingredients you might spy in the store-bought stuff for real ones.
  • Homemade Ranch Dressing – use a real mayo that’s loaded with herbs like dill and garlic with a base of simply eggs and oil for dunking various veggies.
  • WV Smoked Trout Dip – thanks to a recent fishing adventure, this dip will most likely make an appearance and it will be topped with a few hot jalapeno peppers that we canned from the summer’s harvest.
  • Beverages will abound, but a sparkling water with seasonal grapefruit and mint from the indoor herb garden will certainly be showcased. Vodka or gin may be added at guest’s discretion. I’m not policing but would be remiss if I didn’t mention that a heart healthy serving of alcohol is one 5 oz. glass of wine, a 12 oz. mug of beer, or a 1 oz. jigger of hard liquor per day for women and no more than two for men.
  • Hot Toddy’s using white pine and freshly bottled maple syrup will also be an option for guests, and maybe a knob of Kentucky’s finest bourbon will even make a halftime appearance!

I’m also curious to know:

  1. Who’s playing?
  2. What do you plan to serve?
  3. What are your tricks for pleasing your guests while keeping your dishes penalty-free?

Party on!

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HHQI’s New Easy-to-Use Online Resource Library is Now LIVE

by Misty Kevech, HHQI RN Project Coordinator

happynewyearSince this is the first blog for 2017, the Home Health Quality Improvement National Campaign (HHQI) would like to wish you a Happy New Year! We hope that this is a successful year related to your quality improvement efforts. To assist with those efforts, HHQI has some exciting news. Our new comprehensive online resource library will help you find evidence-based tools and resources quicker and ensure that you haven’t overlooked valuable resources.

It’s the perfect time to make our resources easier to search because of many new, upcoming, and continuing Centers for Medicare & Medicaid Services (CMS) quality improvement initiatives.

  • OASIS-C2 became effective 01/01/2017
  • Home Health Conditions of Participation (CoP) final rule will take effect 07/13/2017
    • Main focus of the CoP changes revolves around developing a Quality Assurance & Performance Improvement (QAPI) program with specific Performance Improvement Projects (PIPs) that create and sustain improvement.
  • Home Health Compare Star Reporting
    • Quality of patient care
    • Patient experience of care
  • Home Health Value-Based Purchasing Model
    • 9 states (AZ, FL, IA, MA, MD, NC, NE, TE, & WA)
  • IMPACT Act for Post-Acute Care Providers
    • Providers include Long-Term Care Hospitals (LTCHs), Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs), and Inpatient Rehabilitation Facilities (IRFs)

All of these home health initiatives support the CMS Quality Strategy for:

  • Better Care: Improve the overall quality of care by making health care more person-centered, reliable, accessible, and safe.
  • Smarter Spending: Reduce the cost of quality health care for individuals, families, employers, government, and communities.
  • Healthier People, Healthier Communities: Improve the health of Americans by supporting proven interventions to address behavioral, social, and environmental determinants of health, and deliver higher-quality care.

So where do you start? 

educationcircleicon-croppedHHQI should be your first place to look. We search for evidenced-base practices and then compile supportive resources for implementation of the practice. All HHQI materials are free and are in the public domain (no copyright issues). HHQI encourages you to customize the resources to best meet your organization’s needs, including adding your agency’s logo to them.

This month is HHQI’s 10-year anniversary, and we have amassed nearly 1,000 resources on our website. The great majority of these resources live on HHQI’s Best Practice Intervention Package (BPIP) pages but there are also non-BPIP resources located elsewhere on www.HomeHealthQuality.org and on our Data Access and HHQI University websites. It has become very cumbersome to search and narrow down a list of relevant resources that might assist you with one of your quality improvement projects. So for the last year, HHQI has been very busy developing a new comprehensive resource library to serve as the “one-stop shop” for the industry’s best free resources, and we are so excited to tell you… it’s live! Check it out now at www.HomeHealthQuality.org/Resource-Library.

The new resource library uses filters to help you narrow your search and find relevant resources faster without visiting multiple webpages or websites. You can pick one or any combination of filters to assist you in the search. You can filter resources by:

  • Best Practice Intervention Package (BPIP)
  • Topic
    • Diabetes, hospitalizations, self-management, quality improvement, etc.
  • Material Type
    • BPIPs, informative resources, interactive tools, webinars, courses, etc.
  • Audience
    • Aide, Leadership, Nurse, Patient, Social Worker, and Therapist
  • Language
    • English, Spanish, Chinese, Polish, Russian, and Vietnamese

So here’s an example of how to use the filters. Your agency is going to work on improving your diabetes disease management program. You are interested in finding diabetes evidence-based practices.

  • Select the BPIP filter for the Disease Management: Diabetes BPIP. All the current guidelines will be included in the BPIP as well as links to many tools and resources related to diabetes to assist with education and implementation.

Next, maybe you want to further limit your search to clinician education resources.

  • Use the Audience filter to specify clinician type, such as
  • Then browse through the results OR refine your search further with the Material Type and/or Language

The best way to try out the new comprehensive resource library is to play around. Think of something you might want to look for and select some filters. A tutorial will be posted soon on the new Resources page. Remember to always feel free to email us at HHQI@qualityinsights.org with any questions or if you need assistance.

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Fall: Not Just a Season on Your Calendar

What OhioHealth is Doing to Prevent Falls and Educate Our Patients on Home Safety

 12-13-16_ohiohealthby Jean Howard P.T., M.S., WCC, Manager of Clinical Services, OhioHealth Home Health

Leading experts from around the country are calling falls in the home an epidemic, and for good reason. We know the goal in home care is to provide a way to give the patient the best care possible at home and to keep them out of the hospital. In the comfort and sanctity of their own home they feel better about everyday life; a familiar place, with familiar people, and familiar surroundings. But after an injury or illness, sometimes having the old familiar items they have had around them for years, even decades, now presents a big challenge for safety. Some of the biggest challenges for a home health worker is trying to make sure that the patient has what they want, and need, while making sure that those things don’t present a safety issue that could land them back in the hospital.

12-13-16_accidents-imageThere is some good news: Falls are not just a way of life, they aren’t happening just because someone is getting older, and we can help!

OhioHealth Home Care is a large multi-hospital based service line with home health locations in central Ohio, which includes Marion, Mansfield and Athens. We have over 300 field clinicians serving nineteen counties working hard every single day to improve the safety of our often frail or vulnerable citizens in their homes. Being such a big organization presents distinct advantages and challenges when it comes to fall education and prevention.

First, let’s discuss the challenges. How can we get our message across to so many of our associates and ensure we have a universal message and education plan? This year we worked hard to make sure every person that spends time inside of a patient’s home had what they needed.

We distributed approximately 2,500 discipline specific patient education/teaching sheets on preventing falls and community falls resources. The teaching sheets were all customized and discipline specific for Nursing, Speech Therapy, Occupational Therapy, Physical Therapy, Social Workers and our Home Health Aides to use and distribute to their patients.

12-13-16_falls-image

In addition, and thanks to the generous support of donations through the OhioHealth Foundation, we will be distributing 1,000 nightlights to our homebound patients that may be at risk for falling due to night time visual impairments and no lighting.

Our goal is simple, keep people in their homes safely for as long as possible. The goal might be simple but the execution on a daily basis is anything but simple. There are big challenges when you go into someone’s home. First, every set up is different. We are a guest in people’s homes so finding a way to change someone’s home for their own good is not easy. You don’t want to come off as the safety police. What we try to do at OhioHealth Home Care is to earn that trust and help them understand and believe in what we are saying. We know when it comes to safety and fall prevention that we are the experts, with teams and individuals who have been doing this for years. And the great thing about our industry is that it has become much more sophisticated, with monitoring and tools available. But nothing gets around that personal connection. It is built with an understanding that we are part of their team now. This allows our great men and women to really shine, and show why they are so special.

caneOne of the many things we have really focused on this year is the education component. We know that for a patient at home that balance is key. We started asking ourselves within OhioHealth Home Care, “What are we doing for intervention?” We know that we are the efficiency experts inside the home and can teach family members how to be there and help, but what about screening our patients for mobility so they know expectations and limitations. Because of that, OhioHealth Home Care started agency-wide screening for PTs and OTs to get an overall look at evidence based standardized plans for intervention.

We believe that home care works best when each discipline is working with the same play book. At OhioHealth, we sent out talking and teaching sheets for social workers, speech therapists, with their own focus and talking points to prevent falls. These color-coded sheets show everyone has a role, and some roles are similar, some are different. It is a concept, a plan that we will carry throughout the year.

I believe that gaining buy-in is key to making changes and implementing things we know will work. No matter if you are a smaller operation or a group as big as OhioHealth, you can never communicate enough. With your staff, your patient, or their family, sometimes it is that communication that will avoid a fall which could ultimately save a life. Falling into a false sense of security, taking something for granted, and/or not taking that extra step can be all the difference. OhioHealth Home Care is always trying to get better with the patient as our focus. Do we have it all figured out? No, and we never will. But nothing will stop our leaders and front line workers from trying to get better and be safer in the homes of our patients.

12-13-16_best-way-to-treat-falls

 

Posted in Education, Guest Posts, Home Health, Home Health Care Provider Ratings, Quick Tips | Tagged , , , , , , , , | Leave a comment

Immunization and Heart Disease

National Influenza Vaccination Week is December 4-10, 2016

by Lilliam R. Gomez, RN-BC, BSN, CPHQ, and Laurel E. Martin, RN, BSHCA, COS-C, First Choice Home Health, Inc., Boynton Beach, FL

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The leadership and quality teams at First Choice Home Health, Inc. utilize evidence-based practices to improve disease management and ultimately our quality indicators including immunization rates. We are always updating our disease management programs to continue to improve the health and welfare of the patient populations. The Centers for Disease Control and Prevention (CDC) indicates that patients with heart disease are at a higher risk for serious complications from influenza (CDC, 2016) and/or pneumonia (CDC, 2016). Therefore we have integrated immunization into our pneumonia and heart failure disease management programs.

Data drives quality improvement! The immunization data reports from the Home Health Quality Improvement National Campaign (HHQI), CASPER and Home Health Compare are reviewed regularly for trending and progress towards improvement. We review our organization’s CASPER data reports, including tally reports, and utilize spreadsheets and graphs to disseminate the findings to all personnel at monthly staff meetings. In addition, all data is posted in key areas of the organization. The quality team reviews the ongoing CDC listserv for updates, current state influenza status, and the Morbidity and Mortality Weekly Report (MMWR).

Our quality team utilizes national resources from the CDC, HHQI, Joint Commission, CHAP and ACHC. Clinicians screen and educate all patients with heart failure about influenza and pneumoccocal immunizations. Specific patient education materials are available with the pneumonia and heart failure disease management programs. We provide regular clinician education and offer patient immunization and infection control pamphlets and resources at our monthly staff meetings. The Nursing Track from the HHQI Immunization & Infection Prevention Best Practice Intervention Package (BPIP) is provided to all nurses as part of their clinical education materials.

First Choice Home Health also works on improving staff influenza vaccination rates. The monthly staff meeting’s attendance form includes a checkbox to indicate if any staff member has had their influenza vaccination. There is a follow-up process to validate immunization or a declination of vaccination form. This process is also included in the orientation of all new staff.

Our agency is also participating in HHQI’s Home Health Cardiovascular Data Registry (HHCDR) which aligns with reducing risk of cardiovascular events. We are collecting data on:

  • Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic
  • Hypertension: Controlling High Blood Pressure
  • Tobacco Use: Screening and Cessation

We are very proud to have achieved HHQI’s Cardio Milestone 4 and are currently working toward Milestone 5. Currently, only one other home health agency in the country has completed the fifth milestone.

Our efforts to improve immunizations for patients and staff have affected our publicly reported rates on Home Health Compare. First Choice Home Health, Inc. currently has a 4-star Quality of Patient Care Star Rating which includes influenza immunization rates and a 5-star Patient Surveys Star Rating. We are also in one of the nine states implementing the Home Health Value-Based Purchasing (HHVBP) model which includes both influenza rates for patients and for home health care personnel. We feel the leadership’s support for quality improvement including immunizations and the quality foundation we have created aligns us well for the first year of HHVBP.

Consistency is another key to our success. We stay focused on our quality work, integrate it into daily practice, and monitor our performance by conducting chart audits monthly and reviewing our data and progress at monthly staff meetings. We also see the value of keeping our cardiovascular patients current with their immunizations to improve their lives.

Leadership commitment and teamwork is a must, and First Choice has both!

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Posted in Adult Immunizations, Cardiovascular Health, Guest Posts, National Health Observance | Tagged , , , , , | Leave a comment

What Being a Home Health Aide Means to Me

By Mary Leitner, Home Health Aide, T.O.N.E. Home Health Services, Inc., Detroit, MI

11-13-16_tone-logoA home health aide is someone with a clear understanding of the plan of care for the patient, as well as sympathy and empathy. This consists of communicating with each team member, such as the RN, PT, OT and LMSW, to insure the plan of care comes together for the good of the patient.
Patients often have a tendency to be a little closer to their aides then the rest of the team. They tend to communicate some key issues without knowing it. For example, I had a diabetic patient whose glucose levels would spike, and no one on the team could figure out why. The patient would take his insulin on time every day and the caregiver cooked well balanced meals. But through normal conversation with the patient, I found out that his son worked at a bakery and would bring goodies home every other night – which would cause the spike in glucose levels. I spoke to the nurse, who then spoke with the caregiver and doctor. The insulin was adjusted for evening dose and all was well.

While caring for the patient is my most important role, there are times when just listening to other family members can be helpful. Sometimes the family member or caregiver may be the only person taking care of the patient. As a home health aide, you may be the only outside person the caregiver sees all week. In this case, being a listener can go a long way.

taking-bp-homeI had a patient with a daughter and a son who were her caregivers. Sometimes a family member is so close to the patient that they overlook what they are saying. For example, the son did all the leg work (taking the patient to appointments, grocery shopping, and running errands). The daughter made the appointments, cleaned the house, and cooked the meals. The patient felt she was being heard. When the daughter would make a doctor’s appointment the mother (patient) would say, “I’m tired of getting stuck in my arm. Look at it, my arm is black and blue.” The daughter heard, “I’m tired of going to the doctor because they are not helping me.” I suggested to the daughter and son to check with the doctor to see if the injections could be given in another area besides the arm for now. I also encouraged them to maybe take her to her favorite restaurant, just to give her something positive to look forward to. Going on a car ride around the area before her appointment might also brighten her day.

Being a home health aide, you always have to remember to work efficiently to get everything done that you need to get done, in addition to getting everything done that the patient wants and needs. Three ways to work efficiently is to distribute, prioritize, and simplify tasks. Also, be realistic. You may not be able to get everything done, even if you plan carefully. Reassess your schedule during the day. Don’t be afraid to change your plan. It is better to accomplish the highest priority tasks and let others go unfinished than to do everything half way. The key to success is to be flexible.

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Be a Quitter! Take Part in the 2016 Great American Smokeout

by Nervana Elkhadragy, PharmD, and Karen S. Hudmon, DrPH, MS, RPh, Professor of Public Health Pharmacy, Purdue University College of Pharmacy

smoking_stopWith the 2016 Great American Smokeout just around the corner (November 17), there is no better time to start planning an attempt to quit smoking! The Smokeout challenges smokers to quit for a full 24 hours, with the hope that this day will be the first of many, many more without tobacco.

Individuals who are interested in quitting often ask, “What’s the best way to quit?” Fortunately, there are countless research studies that collectively inform our knowledge base and provide effective strategies for quitting. However, there is one big problem: Most individuals attempt to quit on their own…without help…and this is the LEAST effective approach to quitting.

Here we describe how to treat tobacco dependence as two parts – specifically, we discuss the importance of: (1) treating the nicotine dependence and (b) receiving professional counseling to address the behavior of smoking. We also suggest different resources for quitters as well as for health care professionals who want to help their patients.

PART 1: Nicotine Dependence

First a few words on nicotine, which is the addictive component in tobacco. Nicotine is not the harmful part of tobacco, but it’s the reason why quitters feel anxious and irritable when they’ve gone too long without a cigarette. Fortunately, there are seven different medications that can make individuals more comfortable by helping to alleviate withdrawal. Three of these are sold without a prescription (nicotine patch, gum, and lozenge), and four require a prescription (nicotine inhaler, nicotine nasal spray, bupropion SR, and varenicline). With so many options, which is best? It depends. All of these options are effective, and several can be used in combination. Below, we list some factors to be considered – with a key factor being the individual’s ability to adhere to the recommended dosing regimen. Cessation medications must be taken according to a fixed schedule to “prevent” withdrawal symptoms, rather than to “treat” them after they occur.

Nonprescription Medications

  • Nicotine gum and lozenge: The nicotine gum and lozenges are available in 2 mg (if you smoke your first cigarette > 30 minutes after waking) and 4 mg (if you smoke < 30 minutes after waking). These products can serve as an oral substitute for tobacco, and they can be titrated to adjust for withdrawal symptoms throughout the day. The challenge, however, is that gum and the lozenge are short-acting formulations and must be dosed every 1-2 hours while awake, with a minimum of nine 9 doses a day initially for the first 4 to 6 weeks. If an individual is not able to adhere to this rigorous dosing schedule, then the gum and lozenge should be ruled out as an option (unless combined with the nicotine patch – more on this later). The gum is more viscous than normal chewing gum and therefore is not recommended for persons with significant dental work or with jaw disorders. Proper chewing technique, as described on the box, is necessary to ensure appropriate release of the nicotine from the gum.
  • Nicotine transdermal patch: The nicotine patch is available in 7 mg, 14 mg, and 21 mg, and the initial strength is based on the number of cigarettes smoked per day. The most important benefit of the patch is its ease of use – it’s a long-acting formulation that is applied only once daily and therefore is ideal for individuals who are unable or unlikely to be able to take the minimum of 9 doses a day initially that is required for the short-acting NRT formulations. The patch can be combined with a short-acting NRT product, such as the gum, lozenge, inhaler, or nasal spray. The patch delivers consistent nicotine levels over 24 hours and the short-acting products are then used as a supplement for situational cravings. The patch is not recommended for persons with dermatologic conditions because nicotine and the patch adhesives can be irritating to the skin.

Prescription Medications

  • Bupropion SR (Zyban) and Varenicline (Chantix): Bupropion SR and varenicline are both tablets that are taken by mouth twice a day (after an initial few days of titrating the dosage upward). Bupropion use requires a discussion with a healthcare provider about potential contraindications and warnings, and both medications require a discussion about monitoring for potential neuropsychiatric symptoms. Bupropion use can lead to increased seizure risk in certain individuals.
  • Nicotine inhaler and nasal spray: The nicotine inhaler is designed to release nicotine as a vapor into the mouth (not the lungs) where it is absorbed across the buccal mucosa, and the nasal spray is absorbed across the lining of the nasal passages. These are both are effective when used as prescribed but are short-acting and therefore require frequent dosing throughout the day. Individuals with chronic nasal disorders should avoid use of the nasal spray, and individuals with any type of bronchospastic disease or airways disorder should consider other options.

Combination Therapy: There is abundant evidence to suggest that combination therapy (using two or more cessation medications) outperforms monotherapy (use of one medication alone), and it should be recommended with confidence for most patients who are quitting smoking. This approach, which is likely new to many tobacco users, typically involves the nicotine patch plus one of the short-acting NRT medications. Another option is to combine the nicotine patch with bupropion SR. Combination therapy should be a regimen of choice for anyone who: (a) has a high level of dependence, e.g., smoking a pack or more of cigarettes a day, or (b) has tried to quit before using one medication but suffered significant withdrawal symptoms (despite appropriate dosing of their medication) that led to relapse.

In general, all of these medications work well – when taken as directed – but the tips provided above will help patients decide which approach is best for them. Whether you are a patient talking with a healthcare professional, or a clinician trying to help a patient, be sure to discuss how many cigarettes are smoked daily, how soon after waking the first cigarette of the day is smoked, and whether it will be possible to stick to a frequent dosing schedule (e.g., 9 or more times a day).

PART 2: Changing Behavior

smokingEqually important, if not more important than using cessation medication(s), is the need to focus on changing smoking-related behaviors. Several strategies have been shown to enhance the rate of quitting and prolong abstinence. A strategy that can help is to consider the “5 R’s”:

Relevance: Think about reasons why quitting is important for you or might be important for your family – it could be that you have children and do not want to expose them to second hand smoke, that you want to be a good role model, or that you want to live to see your grandchildren.

Risk: Identify the potential negative consequences of smoking on your health – these could include difficulty with breathing, increased risk of cancers, reduced ability to conceive, or reduced heart function.

Rewards: Identify the potential benefits of quitting – examples range from improved health, ability to exercise or be more active, or reduced skin wrinkles.

Roadblocks: Write down what’s keeping you from quitting and what coping strategies you can use to overcome those barriers. Be honest and explicit when thinking about those roadblocks, it could be fear of failure, or concern about weight gain.

Repetition: Continue to reassess and revisit your 5 R’s, determine new coping methods, and repeat interventions.

In addition to thinking about the 5 R’s, consider accessing one or more of the variety of available services, such as individualized tobacco cessation counseling sessions via the Tobacco Quitline (call 1-800-QUIT NOW), local group programs, or web-based programs such as www.quitnet.com. In general, the more help you get, the better the odds are of quitting for good. But that’s not enough – remember, when you sign up for those sessions, make sure you do the “homework” assigned to you during the program. Moreover, when enrolled in a program, be sure to learn effective coping strategies for withdrawal symptoms; those who have effective coping methods have better results.

Whether you have no previous experience with quitting tobacco, or you’ve had numerous quit attempts, having the right tools, knowledge, and support is important for long-term success! There has never been a time when resources that provide individualized support and reliable information was so widespread and accessible. Why not make the most of it?

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And for the history buffs, a little background on the Great American Smokeout… it was started by Fred Mayer, a pharmacist in Marin County California, back in 1977.Fred is widely regarded as the “Father of Public Health Pharmacy,” not only for his initiation of the Great American Smokeout, but also for his work in promoting safety caps on prescription vials, working with the Drug Enforcement Agency for Medication Take Back Day programs, and reducing unplanned pregnancies and sexually transmitted diseases and infections by promoting condom awareness campaigns, advocating for sex education in schools, and working in tandem with Planned Parenthood and PTAs in school districts.

ADDITIONAL RESOURCES

For healthcare providers:

For individuals who want to quit:

  • 1-800-QUIT NOW – tobacco cessation quitline for individualized counseling
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