Archive | March 2012

Understanding and Preventing Measles

Cases of measles still continue to be identified in the United States. Measles is a highly contagious vaccine preventable disease.

Measles usually begins with a mild fever accompanied by a cough, runny nose, and conjunctivitis. Approximately three days after these symptoms appear Koplik’s spots may appear. These spots are clusters of blue/ white lesions located on the buccal mucosa (mucus membrane of the cheek). Following this the person may spike a fever as high as 104-105 degrees. Also at this time, a red blotchy rash appears, beginning on the face along the hairline and behind the ears. The rash may be slightly itchy and will move rapidly down to the chest, back, and finally to the legs and feet. The rash fades in the same sequence it appeared in about one week. The maculopapular rash has large plat blotches that often flow into one another.

If measles is suspected please call your family physician immediately as it is highly contagious and certain measures need to be followed to prevent the spread of the virus.

The incubation period for measles is about 7-21 days. The primary symptoms begin 8-12 days after exposure (day 0) and rash onset is typically 14 days (range 7-21 days) after exposure.
Exposure to Measles
Anyone who has shared the same airspace with a person infected with measles (during the 4 days prior through the 4 days after their rash). Example, being in the same classroom, home, airplane, or clinic waiting room where a person with the measles has been present up to 2 hours prior to you being in the area.
There has been no minimum time period established for exposure, but it is assumed that a longer exposure does increase the risk of infection.
 Prevention and Immunity
The MMR (measles, mumps, and rubella) vaccination is administered to children. The first dose is usually given at the age of 1 year, and the second does between the ages of 4 to 6 years old (the second dose is required prior to starting school). The vaccine is administered via injection. Although measles was thought to be eliminated from the U.S. , there has been a rise in outbreaks across of U.S. created by the higher number of parents who for various reasons have refused to vaccinate their children leaving them vulnerable to communicable diseases.
People who were born prior to 1957, have documentation of at least one dose of measles-containing vaccine, have a history of a physician diagnosed case of measles, have served in the arm forces, entered the United States in 1996 or later with an immigrant visa or have a green card, or are an infant who is under the age of three months whose biological mother has a documented 2 doses of MMR are considered immune. Please keep in mind that the infant will need to receive the normal vaccines at the appropriate times to build lasting immunity.
The only way to totally eradicate viral communicable disease such as measles is to protect ourselves via vaccination.

Residents have the right to be free from restraints

Many of us have heard stories of residents in a LTC (Long-term Care) or Assisted Living being restrained. What does that really mean? And if restraints are used are the residents’ rights being violated?

Per California regulations a resident has the right to be free from physical and chemical restraint. The patient has the right to decline their use. The nursing home must obtain informed consent from the patient, family, and/or POA prior to using any type of restraint to ensure that no resident’s rights are violated.

A physical restraint is anything that is attached to, placed next to, or restricts the patient’s movement or access to their body. Items such as hand mitts, vests, cloth ties, leg and/or arm restraints, wheelchair safety bars, or anything else that prevents the patient from moving around are considered physical restraints.  For example, placing a patient’s bed against a wall or using a bedrail, limiting their ability to get out of bed alone  is considered a restraint.    Another example is moving the resident’s wheelchair against a wall so that they patient cannot move. Nursing homes are not permitted to restrain or do anything that limits the patient’s movement unless the patient or their representative gives permission prior to their use.

Note: A patient’s representative may be a family member, a court appointed conservator, a person that the patient has chosen through an Advanced Health Care Directive, or some other person chosen by the patient that complies with the law.

Chemical restraints are any drugs that are used for discipline or convenience.  These medications are not necessary for the patient’s well being.  For example, they are not used to treat high blood pressure or a heart problem.

When can a restraint be used?

Restraints can only be used to treat the patient’s medical symptoms and only if the restraint will assist the patient in reaching their highest functioning potential.  The only exception to this is in a case of an emergency, where the patient is in danger of harming himself/herself or others.   Before using any restraints the nursing home must try all other methods of care.   This may include, but not limited to, therapy to improve the patient’s ability to stand or walk and lowering of the patient’s bed to decrease the likelihood of injury due to a fall.  The nursing home may use other methods such as pillows, pads, or lap trays to help the patient maintain good body positioning and balance without the use of restraints.

If all methods of non-restraint have be exhausted the nursing home may suggest the use of restraints.  Before any restraints can be used the primary care physician must be contacted and the options discussed.  The doctor must then write an order for the use of restraints.  The written order must contain the duration of use (i.e. a week, a month, etc.) and how often it is to be used (i.e. while in wheelchair).The doctor must also explain the symptoms that the restraint is being used for.  The patient and/or their representative have to have enough information to make an informed decision.  The side effects must also be discussed with the patient or their representative. Side effects vary and could include incontinence, reduced ability to walk or move your limbs, and an increase in depression.

Bottom line is the patient and/or representative must be given complete information and must understand the information before the use of any restraint.  There is only one exception, in the case of an emergency where the patient poses a risk to himself/herself or others.  The nursing home must ensure that the resident’s rights are protected at all times. The resident and/or representative have the right to refuse the use of restraints.  The facility must ensure that they are using the least restrictive measures. Help protect our elder population by being fully informed.

Below are some questions that patient and/or representative should ask the doctor and facility prior to the use of restraints:

  • What is the reason that the doctor believes the restraint is necessary?
  • Can the problem be treated without a restraint and has the facility used other alternatives which are not restraints to treat the problem? (Has the patient received any therapy such as Physical Therapy, Occupational Therapy, or Speech?)
  • What measures are being use and for how long? How often is the restraint going to be used? How restrictive is the restraint?
  • What are the benefits and risks in using the restraint?
  • Are there any side effects? If so, how long will they last and what are they?

The patient and their family/or representative are encouraged to write other questions they may have. Please do not be afraid to ask questions. Asking questions only helps the patient get better care.




When exteded care is needed- how to choose

Your loved one needs more care

Your loved one is hospitalized for what everyone thought was routine. A hip or knee replacement, or a recent bought of pneumonia. Yet, in comes the Case Manager or Discharge Planner who states that the patient needs “more “care but at a lower level. This person also states that the patient must be moved today and that you (the family) must find a place to go or if you are lucky they have found a facility that is willing to accept.

What does this mean? Most important, the patient and the family have the right to ask for more information. It is important for everyone involved to have correct information about the extended care being proposed because it could be as little 1 week or it could be a month or longer.

Next, be aware that the patient has every right to make his/her needs known and has the right to choose where they want to go. If the patient does not have the capacity to make their own decisions then the family will have to make these choices for them. In all cases, the family has the right to ask for a list of all the facilities in the area especially for the facility that has accepted the patient. The family should take the time to tour. Please do not leave this decision to the hospital personnel.The hospital personnel is not allowed to make recommendations, however,they are allowed to give the family facilities to choose from. The right facility will make a difference in the patients recovery.

What kind of care is needed?

Usually, when it comes to extended care the case manager or discharge planner is referring to a Long Term Care Facility that offers rehabilitation services. There are times where a lower level of care such as an Assisted Living is more appropriate.

An Assisted Living Facility does not normally offer extensive rehabilitation services nor do they offer 24 hours nursing care. This type of facility is great for the patient who needs minimal assistant with ADLS (Activities for Daily Living) such as dressing, eating, and taking their own medications. Most of these patients need only reminders and are able to make all their needs known. There are specialized Assisted Living Facilities that have memory units for Alzheimer patients. Even patients at this stage can make most of their needs known and still do most things for themselves like brushing their teeth and feeding themselves.

If the patient needs “more” care, which may require things such as I.V. antibiotics, physical therapy, occupational therapy, and/or speech therapy then a Long Term Care Facility that offers rehabilitation is appropriate. These facilities are often referred to as Nursing Homes, Long Term Care Facilities, or 24 hour nursing facilities. These types of facilities assist the patients with all medication needs including pain management as well as with their ADLS. They help the patient recover and regain their strength.

Who can reside in a LTC (Long-term Care)

Long Term Care Facilities are no longer just for the elderly. Patients of different ages may reside in the same facility as long as everyone’s nursing needs are met. Nursing Homes may only take patients that they can provide adequate care for. Adequate care refers to providing all necessary nursing care that are ordered by the attending physician. This would include their medications, therapy, and assisting the patient their ADLS (i.e. going to the bathroom/getting dressed). It does not refer to their age.

The age of the patient can be as young as 21, but the facility must make sure that the patient is compatible with the other patient(s). For example, a 21-year-old cannot share a room with a 76-year-old (unless both patients can make their needs known and have chosen to be in the same room). Typically younger patients share a room with other young patients or reside/ in a private room. Also, the facility must ensure that there is age appropriate activities for everyone. For example, providing video games or movies, such as Fast and the Furious, for the younger patient is great, but these same items would not be age appropriate for the elder patient. Activities for all age groups must be provided.

Long Term Care facilities in California must follow Title 22 regulations as well as Federal regulations.