Sunday, 13 December 2009

The Slovenian model of care

Wake up and smell the coffee with Ronald Reagan circa 1981.

Correct me if I am wrong here  (really I mean that) but isn't this model of care pretty much everywhere except western Europe.

Currently, the residential homes in the UK are  little victorian townhouses with lots of steps. The staff is comprised of care assistants.  Once those patients deteriorate and age enough to the point that they are confused and /or cannot mobilise they get sent into hospital and wait 8 weeks for a bed in a nursing home.  The minute a patient becomes confused suddenly or mobility deteriorates they are sent into hospital. 

The nursing homes here are wee little old victorian townhouses with lots of steps.  They have RN's on duty 24/7 as well as care assistants.  But, they do not take patients on IV fluids of any kind, they cannot give IV antibiotics and if a patient needs a chest xray they get sent into hospital. Many of them will not cannot take peg feeds etc. 

Is it really any goddamn wonder why are acute medical hospital floors in the NHS are 75% nursing home patients who are very demanding but not acutely ill?  Their relatives expect them to be cleaned and fed and entertained constantly.  They don't seem to realise that the hospital is only staffed with just enough nurses to barely keep on top of all the IV meds for the 25% acutely ill.  The hospital is the worst place for any medically stable but dependent elderly person to be. Duh.

Are they really just figuring out now that this set up is bad and that they need to "modernise"?

They should have figured it out in '81.  No excuses.  The NHS should have planned for his and implemented something before Reagan was shot and anyone ever even heard of Madonna.  Here we are in 2009 and suddenly they wake up?  Fucktards.  And nurses are taking the heat for the elderly getting poor care? Christ.

I worked in a "long term care" facility- in lets say- Maryland many many (more than 10) years ago.  It was set up very similiar to what is described in this article.

Ground floor was physio, OT, patient entertainment, restaurant etc.

Floor One: residential care with 60 beds.

Floor Two: EMI with  60 beds

Floor Three: nursing home with 60 beds

Floor Four. 30 beds. Skilled nursing unit for patients needing IV antibiotics, blood, IV fluids, Peg feeds, complex pressure ulcer management etc.  This was to keep extreme geriatric patients out of the hospital unless absolutely necessary.  Hospitals are the worst place for medically stable but extremely geriatric dependent patients.  The hospital staff cannot cope with acute patients and nursing home patients at the same time.  They are not staffed too cope.

Floor four had another 30 beds.  This was ultra skilled nursing care: long term patients on ventilators etc.

The local area was full of such homes.  They were known as nursing homes.

Sometimes patients needed to get sent to hospital.  But 24 hours a day we had a respiratory therapist on staff at the facility.  The GP's and specialist doctor surgeries  who were responsible for the patients did daily rounds and always had one on phone duty to give the nurses any orders required  We had a guy with a mobile x-ray machine and we could get one done 24 hours a day.  We had a phlebotomist who came in to get the bloods that needed to be taken every morning.  We had our own pharmacy.

If a patient became confused we checked their temperature and dipped their urine...maybe got the doc to order a chest x-ray from our in house chest x- ray guy.  When elderly people become confused it is sometimes due to an infection.  We could start IV antibiotics and fluids right then and there if that is what the doctor wanted. Other problems like extreme bradycardia and ecg changes would warrant a call to 911 and transfer to the local hospital a&e.   It was the doctors decision. But we even treated DVT's at the facility. he gave IV heparin infusions.  The skilled unit also functioned as a stepdown, rehab area for hospitals to discharge elderly patients too.   If they couldn't care for themselves at home once they recovered they stayed with us and moved downstairs. We took patients who paid privately and medicare, medicaid patients as well as insurance patients.

When a residential home patient became unwell but did not require hospitalization they were moved to the skilled nursing floor.  If their cognitive or mobility issues continued to deteriorate, which is what happens to most elderly people whether or not the decline is accelerated by a disease process, then they moved onto the nursing home floor at this same facility.

The NHS may be looking at this model of care but I doubt they will want to fund it and staff it properly.

At work in the NHS we get many many phone calls from angry family members of our patients.  "The residential home won't take 99 year old granny back because she can't walk now AND IT IS ALL YOUR FAULT BECAUSE YOU LET HER LAY IN BED."  Umm. Granny had a massive stroke.  Anyway Granny will wait 6-8 weeks for a nursing home and develop a pressure ulcer and hospital acquired chest infection.  Much of the time we are not staffed in away that allows us to bathe and feed granny at any point without killing KILLING our acute patients. Sorry.  We (frontline staff) did not create this situation nor can we control it. We aren't the ones who want it to be this way.  We want a controllable workload so we can do basic care for our dependent patients as well as deal with all the other things getting thrown our way.

We get patients from residential homes who are sent in due to confusion, diagnosed with a urine infection, given oral trimethoprim and stay in the hospital for 6 weeks because the residential home "cannot cope".  Yeah it does take this long to sort out another place for them to go on discharge.

Elderly people will deteriorate cognitively and physically. A disease process that you or I would get over quickly will accelerate this decline in elderly patients and most of the time they will not get their former level of function back.  The nurses did not do this to your gran. 

The current system in place for dealing with our elderly patients is a total fail and it cannot function in the 21st century as the geriatric population explodes dramatically.  We may be keeping people alive more now but not always at a level where they can function independently. Don't blame the hospitals and for god's sake please don't blame that lone RN running between 15 acutely ill patients and trying to care for  multiple elderly and dependent patients between giving IV drugs etc.

The system is not set up in a way that they can manage the rapidly growing aging population. 

Look at the system.

Is it any wonder why our elderly community is suffering?  Who still believes that their suffering and lack of care is down to uncaring nurses who require dignity lectures? Some people just need to be slapped and then thrown off a fucking cliff you know.   If only these older out of touch nurses would focus on the real problems rather than indulging in the nursing profession's greatest pastime-eating their young. If only....
Personally, I would love to turf the acute patients and drug users out of my face and sit with and nurse sweet granny all day.  But you would never know it when I am at work and running past these poor elderly patients at 10 miles an hour, ignoring their cries because my pregnant heroin user just shot up in the day room and collapsed on the floor at the same time that some one else has started with a lethal GI bleed.

Am I wrong?  Am I way off base about nursing and residential homes in England? Am I wrong about the ones overseas?  Let me know.  One can still be provincial even if  she has lived all over the world. Seriously.


The Dobbing Doctor said...

I see what you mean. I worked in a residential home between finals and starting work and have started to see some changes for the positive. We (the care assistants) were being trained how to take temperatures, BP and urine dips, and being encouraged to give trimethoprim at home, instead of blocking a bay at GenericTown general. It was also integrated into floors for levels of dementia top, challenging behaviours on middle and sheltered living on the ground.

It was a very new purpose built home and I think it was a lot better than some I've seen. I still think it could be better at preventing acute admissions and community care. For example you can teach a patient to NG feed themselves, why not teach a care assistant to do it for an old person, to keep them in residential and not nursing care?

I find IV drug adminisitration is the reason for ~10% of the patients on my ward. The amount of times I write "Medically fit for discharge, awaiting social placement" in a patients notes is astounding. This then backs up medical assessment unit, which backs up A&E, which makes some hospital manager moan on our ward, and make us discharge some of the acutely ill patients who actually need our care. In fact sometimes they magically find rehab/intermediate/respite housing for social bed blockers when we have 50 patients waiting for a bed in MAU.

Cheers Nurse Anne for your tirades, keep fighting the power.

Nurse Anne said...

"The amount of times I write "Medically fit for discharge, awaiting social placement" in a patients notes is astounding."

Astounding is an understatement. We have patients with that written in their notes, and they are with us in hospital for weeks and months.

The thing is that if they want to do this right they need to staff these places with lots and lots of well trained staff and pay them well.

That's where they will fail. They cannot bear to admit that you need decent, well trained people who deserve to be treated like human beings to work in geriatrics.

The Dobbing Doctor said...

The acute medical ward is not the place for these people, and I can understand relatives frustrations when they don't see a doctor for a week because they're granny isn't actually ill. I really hope something gets done to help people out of hospital and support their needs in the community where they will most benefit.

I see too many patients catch pneumonia or C Diff, because they have sat in a hospital bed for 4 weeks without anything wrong.

p.s. I hope not to be a Gynae Consultant like that!

Nurse Anne said...

The public doesn't understand the difference between acutely ill and not acutely ill.

To them, a patient who cannot feed or care for themselves due to a 10 year old stroke is "really sick".

But in reality the mobile normally independent patient with deranged u+e's or screwed up ABG's is the one that is sick.

Anonymous said...

I wonder why the Slovenian model has been singled out? No mention is made of the systems in place in our nearer European neighbours such as France and Germany who must be facing the same problems as the UK in terms of having to cope with the health problems of an ageing population.

Anonymous said...

Hi, Anne
That sounds a lot like a facility my friend in Ohio works in. They do very complex care in a LTC. Mississippi is not up to speed either. Money is the reason. Many of these LTC's are privately owned and do not want the responsibility of trachs, ventilators, and IV's. That would mean having to staff with RN's and respiratory therapists around the clock. It also costs money - lots and lots of money - to care for individuals with complex needs. That is why you will find many variations in the acuity of residents from state to state and home to home. Many nursing home owners and administrators want to staff with the bare minimum. In this day and age, it is sure to backfire. Sounds like the UK does not want to take responsibility for these people either.I have found that when done the right way, LTC's are the best solution for people who need much more intense care. These places you describe sound more like assisted living centers. And they probably can't cope with anything special at all, due to the fact that they probably lack staff qualified to do more for them than serve their meals and help them dress. Yes, Anne. The UK is going to have a rough time of it soon if this is the only care your LTC facilities can provide at this point. The bottom line is: M O N E Y.
Casey in the USA

Nurse Anne said...

You are spot on Casey,

No one wants to invest in facilities for these people nor do they want to invest in staff to take care of them. Society doesn't even want to treat staff that cares for elderly people as human beings.

But frontline nurses who are in well over their heads in short staffed hospitals are, of course, to blame for all this aren't they. What a way for society to scapegoat.

Anonymous said...

I suppose that's why I hear the word "care home" in British publications, because it seems that's all they're set up for.

Thanks, it's been enlightening.

I work on a Medicare Rehab unit which is attached to a hospital but we're the ugly sister, so to speak.

We do IV meds, tube feeds, TPN OT, PT. We only started taking TPN patients as of last year and we've only had three or four. It does become too much when we have one of those.

What we do not do is vents and we do not hang blood. I have a 12ish patient ratio along with 1.5 patient care assistants. Of course, if a nurse calls in you can bet yer bum me and another nurse take half those patients each. Of course, we're backed up with a useless charge nurse saying she'll help but doesn't really know how, so just takes orders off and calls pharmacy and stuff like that. Most of the time however, we can hold our own.

Diane in USA

the a&e charge nurse said...

There are two worrying trajectories - a shrinking hospital bed base (equivalent to the loss of x6 hospitals if we look at London)

Allied to a growing demand for community based institutional care - presently 430,000 residents (rising to almost half a million by 2020 according to some projections)

We already know that care standards amongst institutionalised oldies is patchy at best.
One group of researchers found;
"elderly people in nursing homes receive poorer quality care in terms of underuse of beneficial drugs (such as β blockers after heart attack), overuse of inappropriate drugs (such as neuroleptics), and poor monitoring of chronic disease such as diabetes".

Perhaps there are very good services out there? but in my experience A&E is used all too often as the first port of call (when problems arise) rather than the final straw when a variety of community based solutions have been exhausted.

Needless to say at 3hrs and 59mins these problems inevitably become the problem of the ward nurses. Now, if planners are just waking up to these facts, I dread to think how far they must have had their head stuck up their arse?

Since it is the advocates of oldies, rather than the oldies themselves who complain about this unsatisfactory situation I do not expect conditions to change a great deal in the current economic climate (now matter how many glossy reports the DoH publishes).

the a&e charge nurse said...

And by the way why do we have to go to Slovenia?

Couldn't we have figured it out for ourselves?

Nurse Anne said...

"Needless to say at 3hrs and 59mins these problems inevitably become the problem of the ward nurses. Now, if planners are just waking up to these facts, I dread to think how far they must have had their head stuck up their arse?"

But isn't it just easier for fucktards to run around saying that frontline nurses just don't care because they have degrees now. Never mind that said frontline nurse has 20 patients that all require one to one care and piles of paperwork to get through just to get a lifesaving drug that is needed immediately for one of those people.

Sometimes I think I want to move to a small island and just sit back and watch all the fucktards shoot themselves in the foot.

the a&e charge nurse said...

"But isn't it just easier for fucktards to run around saying that frontline nurses just don't care because they have degrees now".

You know my feelings on this one, Anne - nowadays I simply refer said fucktards to your posts especially when hollow cliches, like 'too posh to wash', or, not as good as nurses from ye olden days are trotted out.

I'm convinced your stuff expresses the frustration of the silent, long suffering majority of nurses - the more who read it, the better.

Anonymous said...

I remember back in 1981 when I graduated as SRN in UK and all the talk of Project 2000 and nurses being "proper students" instead of "apprentices" doing all the work on the wards. We asked then - so if the students are gone to Uni - who will do the work on the wards? No-one could ever answer that one and I guess they didnt think it through because the remaining 1 or 2 staff nurses are doing it ALL apparently.... In my day there were about 4-5 students taking 4-6 patients each. The Staff nurses were charge RNs.

Nurse Anne said...

Sometimes we have 3 students or so and they are expected to do as you said.

The mentor, cannot supervise them or mentor them properly or teach them anything when she is running between many patients and having to answer the phone every 3 minutes.

The uni trained nurses still have to do 2500 placement hours or they do not graduate.

The third year student student I have now is wonderful. He jumps right in their and takes control. Have reinterated the fact that you cannot assess your patients properly without doing basic care yourself but he already knows that very well and really enjoys the hands on side of things. They also know that they need to prioritise and that means that basic care is impossible for the nurse to carry out much of the time.

I have been mentoring for years and have yet to meet a student who is too posh to wash or doesn't want to get their hands dirty.

Matt said...

"The third year student student I have now is wonderful. He jumps right in their and takes control. Have reinterated the fact that you cannot assess your patients properly without doing basic care yourself but he already knows that very well and really enjoys the hands on side of things. They also know that they need to prioritise and that means that basic care is impossible for the nurse to carry out much of the time.

I have been mentoring for years and have yet to meet a student who is too posh to wash or doesn't want to get their hands dirty."

Anne, I'm exactly the same as a student, I love getting stuck in, I love the contact I have with patients and love the time I get with them because I know, once I'm qualified, I'm going to be run around like a bluearsed fly trying to get stuff done whilst making sure the apathetic HCA does their job. The phrase, too posh to wash riles me so much that if I hear it even once more i think my entire body may burst into flames though anger. Elderly care was a placement that I hated, not because of the work, but because of the pure frustration that I could not wash/toilet/feed patients without detriment to others because of the shite staffing. The answer to it is so pissing obvious, but is any trust going to pay for there to be ten members of staff on for evening meals?

Nurse Anne said...

Matt how does one RN only sound as the entire ward staff for a 20 + bed ward with cdiff on a night shift. All patients requiring total care, two to transfer, obese, confused and demanding the commode every 5 minutes? For a whole 12 hours?
Welcome to our world.

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