Who’s who in the hospital?

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Having a loved one in hospital is one of the most stressful experiences a caregiver can have. It’s often fraught with fear, confusion, frustration and disappointment—but it can also be a productive learning experience that enhances a senior’s life. What makes the difference?

Successful hospital experiences have common factors:

  • Comprehension—of who does what in the hospital universe.
  • Confidence—to ask questions of the “experts.”
  • Continuity—despite changing units, staff and routines.
  • Communication—effectively requesting, receiving and understanding information.
  • Cooperation—how to work as a team member.

To illustrate these concepts, let’s follow a patient on his journey and look at different scenarios in the hospital experience.*

Roy Gilbert, 80, is divorced and was living alone in his suburban bungalow. He managed fairly well with frequent calls from his daughter, Sheila, who lives 90 minutes away, and a helpful next-door neighbour. Climbing the stairs from the laundry room one day, Roy slipped on a stair, pitched forward on his face and rolled face-first down the stairs, landing at his back door. Two days later his neighbour noticed the newspapers on the porch, tried her back-door key and immediately discovered an unconscious Roy. The neighbour called 911, then Roy’s daughter, and his adventure began.

Scenario one

Dad was alone in his house when he fell. When the neighbour found him, he was rushed to the hospital.

In the emergency department, Roy was seen by a geriatric emergency management (GEM) nurse.

The GEM nurse spent extra time with Roy until he was stabilized. When his daughter, Sheila, arrived, the GEM nurse explained that a diagnosis of cerebral stroke had been made and immediate surgery was scheduled to repair the blood vessels and reduce the bleeding. She explained that tests would be done later to determine the extent of brain damage, and that after surgery Roy would be moved to the intensive care unit (ICU) for observation. Since at this point Roy was barely conscious and unable to speak, Sheila was very anxious to learn as much as possible from the nurse. She was greatly reassured by her comprehension of the upcoming process.

Roy’s surgery was successful and he was moved to the ICUwhile his recovery was monitored. Sheila maintained watch in the waiting room until the charge nurse in the unit advised her to go home for a rest and change of clothes—Roy would be there for 12–24 hours, and then moved to a step-down unit on another floor.

After a few days of keeping in touch by phone, Sheila went to Roy’s room to find he had been moved to a medical unit—that must be a good sign! She found him in a chair, hooked up to tubes but conscious. He recognized her and tried to wave, but was unable to move his right arm. Roy seemed unable to speak, merely grunting. Sheila unpacked his clothes and went hunting for some answers.

Scenario two

I stood at the nurse’s station for 15 minutes and no one even looked up from their computer screens. How can I find out what’s happening with Dad’s care?

Finally, someone did give Sheila some attention and asked her to return to Roy’s room where someone would come to see her. A young woman eventually arrived, name-tagged “Julie, personal support worker.”When asked if she was “the nurse,” Julie replied no, but that the licensed practical nurse (LPN) would be in soon and the registered nurse (RN) would be giving him a shot later.

Susan, the LPN, arrived with a number of pills and a blood pressure monitor. “We’re very glad you’re here—I’ll send the patient care manager in to see you.” The patient care manager, who is usually an RN, is responsible for all aspects of planning, organizing and directing the delivery of patient care services within hospital care units. She assesses all incoming patients for their requirements from the care team, which includes nurses, physiotherapists, occupational therapists (OTs), speech pathologists, psychologists, dieticians, recreation therapists and social workers. These team members interview new patients to identify goals, which are then assigned a tentative achievement date. These goals may seem deceptively simple—”sit alone on edge of bed for one minute”—but they are challenging and meaningful to the patient. The team meets weekly to discuss progress, share information and make any adjustments. After their initial meeting, Sheila quickly realized that the patient care manager was going to be her number-one ally in obtaining information about her dad.

Over the next few days, Roy began to meet his care team.

Karem, an OT, worked to adapt activities to meet Roy’s changed abilities.

Yip, the physiotherapist, found that Roy was very depressed about his condition, especially the weakness in his limbs. Yip responded that more therapy isn’t necessarily better and can actually be counterproductive. This was a difficult concept for “go-for-the-burn” people such as Roy and Sheila to grasp. Sheila also learned to discuss any questions or criticisms with the therapist in private, not during a therapy session or in front of Roy.

Leslie, the speech-language pathologist, knew the most devastating effect of the stroke was undoubtedly Roy’s inability to speak, termed “aphasia.” Tests showed that Roy was clearly able to hear, understand and act on information, but was unable to recall or even form words.

Leslie enlisted Sheila’s involvement to develop a story-board of Roy’s life—his early years, homes, professional life, hobbies, favourite sport teams—which could help break the ice when meeting new people. Leslie also worked hard with speech-development techniques, identifying problem sounds and coaching Roy in vocal production to try and reinstate his power of speech.

Scenario three

Things are all moving so quickly. Dad said he met with a dietician—he doesn’t need to lose weight!—and now we have to meet with a “discharge planner” too.

Next up was Sara, the dietician. No, Roy didn’t need to lose weight and wasn’t on a diet! Sara’s concerns were around enticing Roy to eat enough calories to maintain his strength while eating a pureed and minced diet due to the choking risk. As a meat and potatoes guy, Roy picked at his food and refused the milkshake-like supplements.

Roy was understandably despondent about the turn his life had taken. Deprived of his hobbies of fitness, meeting pals at sports bars, drinking and eating, what was left for him? How could he face the future being unable to speak? Where would he live next, what would it be like and could he afford it? His days were filled with anxious thoughts when the geriatric social worker made a visit.

After two weeks in the medical ward, Roy was visited by another social worker, who introduced herself as the discharge planner. Yes, it was time to leave—but what was the next step?

Moving on

The discharge planner explained that the options were a rehab hospital, to be followed by a placement in a nursing home or retirement home, or the complex continuing care unit of the hospital.

Patients in complex continuing care may be charged a “co-payment” if the patient requires such care and is more or less a permanent resident in the hospital. This includes some “alternative level of care” patients in regular acute beds who are awaiting placement in a chronic care hospital/bed or long-term care facility. The current co-payments are around $55 per day in Ontario. (Rates are established by the provincial ministry of health.)

Sheila discussed the alternatives with Roy and got the best understanding she could of his wishes. Being in complex continuing care would resolve the issue of where Roy would live, the level of care he would receive and the fixed costs he would pay. But Sheila argued that rehabilitation would give Roy every chance to continue the intensive therapies he had worked so hard to adopt. However, it also left a question mark as to where he would live and what it would cost.

Sheila worked hard to communicate her concerns, and to have the confidence to challenge the care team and get the answers she wanted Roy to have. At the weekly team meeting, the care team reviewed Sheila’s request and agreed to recommend that Roy be admitted to a rehabilitation hospital for two months.

The discharge planner’s next task was to recommend nursing homes, retirement homes and community services for Sheila to research in preparation for Roy’s discharge from the rehabilitation centre. The options were many and confusing, and it took communication and cooperation for them to agree on suitable plans for Roy’s next phase of life.

Did Roy enjoy his hospital stay? It was certainly not something he would have chosen. But has his current situation improved as a result? Definitely—the goals, sense of purpose and discipline instilled by the therapy regime, as well as the medical interventions, have certainly benefited his health and well-being. He is now more prepared to choose his next home, wherever that may be.

*Editor’s note: These scenarios have been simplified for demonstration purposes and to introduce the care team. They are not intended to provide medical advice.

Glossary

A geriatric emergency management nurse, provides specialized frailty-focused nursing services in emergency departments. Seniors represent as many as 30% of the patients seen in emergency departments, more than any other age group. Illness complexity, hospital admission rates, lengths of stay and risk of functional decline are all high for seniors. Indeed, emergency department visits are often sentinel events for seniors, threatening loss of independence, health and well-being. By providing specialized frailty-friendly services, decline and loss of independence can often be prevented or postponed.

An intensive care unit, critical care unit, intensive therapy/treatment unit or high dependency unit is a specialized department in a hospital that provides intensive care medicine. A geriatric intensive care unit is a special type of unit dedicated to the management of critically ill elderly patients. The goal of this unit is to restore physiologic stability, prevent complications, maintain comfort and safety, and preserve pre-illness functional ability and quality of life in older adults.

A step-down unit is a hospital nursing unit that provides care intermediate between that of an intensive care unit and a normally staffed in-patient division, such as a medical unit.

A personal support worker is trained “care aide.” The personal support worker may observe and report clinical and treatment information, assist with range-of-motion exercises and other rehabilitative measures, take and record blood pressure, temperature, pulse, respiration, bodyweight and height, assist with ambulating and mobilization, and help with personal hygiene.

Licensed practical nurses and registered practical nurses are regulated healthcare professionals who work in partnership with other members of the healthcare team to provide nursing services to individuals, families and groups of all ages. Licensed practical nursesassess, plan, implement and evaluate care for clients throughout the life cycle and through palliative stages. They do not administer intravenous medicines or give injections or narcotics. They can take basic vitals, give routine medicines and provide basic care.

A registered nurse is a nurse who has graduated from a nursing program at a university or college and passed a national licensing exam. Aregistered nursecan administer intravenous medicines, give injections including narcotics and perform admission assessments. These nurses will often assume an administrative role regarding staff management, compliance and reporting.

Occupational therapy treatments that develop, recover or maintain clients’ activities of daily living. The therapist helps clients not only to improve their basic motor functions and reasoning abilities, but also to compensate for permanent loss of function.

A physiotherapist or physical therapist provides physical rehabilitation and pain relief. A physiotherapist assesses a patient’s physical abilities and needs, and develops an individualized treatment plan including therapeutic exercise, manipulations, massage and education.

Speech-language pathologists have expertise in assessing and intervening for typical disorders of communication and swallowing, such as prevention, counselling, treatment, consultation, management, rehabilitation and education.

A dietitian is a healthcare professional who focuses on proper food and nutrition to promote good health. The goals of dietitians are to provide medical nutritional intervention to address medical issues involving dietary intake.

Social workers help people function in their environments, deal with their relationships, and solve personal and family problems. Geriatric social workers try to improve the quality of life for senior citizens and help alleviate some of the negative aspects of aging.

Physical medicine and rehabilitation, physiatry or rehabilitation medicine is a branch of medicine that aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities. The objective of rehabilitation is to transition a patient from an illness to recovery, with physical, emotional, social and spiritual components. The process is initiated in the rehabilitation hospital and continues after the patient is discharged back to the community.

Complex continuing care or chronic care units provide continuing, medically complex and specialized services in hospitals for patients with long-term illnesses or disabilities requiring skilled, technology-based care that is not available at home or in long-term care facilities. These units provide patients with room, board and other necessities, in addition to medical care.

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About Pat Irwin

Pat M. Irwin, BA, CSA, is president of ElderCareCanada and has recently been certified as an eldercare mediator.

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