The Answer: If you are on a list for long-term care home, you stay on that list, no matter where you are residing – a hospital, home or retirement facility. According to Anne Marie MacLeod, operations director of the Holland Orthopaedic & Arthritic Centre at Sunnybrook, you do not lose your spot.

“The retirement home is often the next best choice, because they do have some supervision and they are not on their own,” Ms. MacLeod said in an interview. “If you put them in the retirement residence, where they are getting regular meals, help with activities of daily living (such as bathing) and some activity, they can do quite well.”

Your mother is what is called in health care circles as an “alternate level of care” patient, which means the hospital is not the best place for her. Depending on her choice of homes, the wait for a bed could be months or even years.

Her circumstance is faced by thousands of patients every day. According to a Canadian Health Services Research Foundation report, an estimated 7,500 hospital beds, representing 14 per cent of all acute care beds in Canada, have patients in them, awaiting care elsewhere.

From a system perspective, when patients are waiting in hospital beds, other patients have operations postponed, long delays are encountered in emergency and some patients have to be re-routed to other hospitals.

It sounds as if you recognize that the hospital is not the best place for your mother and the most preferred option – a long-term care facility – is not available. A retirement home concerns you because the level of care is not there.

“Two of the main reasons why people are admitted to long term care is cognitive impairment and incontinence of some sort,” said Donna Rubin, chief executive officer of the Ontario Association of Non-Profit Homes and Services for Seniors.

Ms. Rubin said that most retirement homes would not welcome medically complex patients unless the necessary support could be obtained. It is usually purchased through the home or an outside agency, she said, adding, “for a variety of reasons, they are generally not equipped to provide that level of care.”

The post Waiting for a nursing home bed in hospital appeared first on Your Health Matters.

The Answer: In this post, patient Emily Nicholas, who is a Patients’ Association of Canada board member, is one of the experts providing advice on how to navigate the health care system for pain management. As a patient, she knows this story because she lived it: she had a hip replacement in July 2010 at age 28 and was prescribed tramadol – similar to a narcotic – by an orthopaedic resident. It didn’t work very well and by hour three, the next pill couldn’t come soon enough. She was also placed on morphine for breakthrough pain, which made her so nauseous, she had to take gravol to help alleviate it. Ms. Nicholas was told to switch to ibuprofen when she felt ready but no one told her what ready felt like, leaving her to figure this out on her own.

“They can only give you a rough estimate of the length of time you will need the medication,” she said in an interview. “The amount of pain and suffering that came after was more intense and persisted for longer than I had expected.”

She points to information sheets from the pharmacy she was provided. For six, typed pages, in words that few would describe as patient friendly, the drug’s uses and precautions were explained.

“The patient often has a lot of insight into their condition, but is kept out of the loop,” said Ms. Nicholas, who has an interest in patient engagement and health policy design. “Just putting information out there, doesn’t mean you are communicating it.”

While the information sheets do note that tramadol can cause withdrawal reactions, especially when used regularly for a long time or in high doses, they suggest patients see a doctor to reduce the dose gradually. Now that Ms. Nicholas was no longer seeing the orthopaedic resident, what doctor was going to help her get off of the medication, a month after taking it?

Ms. Nicholas went cold turkey in late August 2010, dropping the tramadol. Within days, she felt like she had the flu and had this odd sensation of a shock-like pain in the back of her neck. She didn’t make the connection straight away ­ that she might be experiencing withdrawal symptoms.

“I thought I was getting the flu,” said Ms. Nicholas, now 30. “I was anxious and shaky, with the feeling of shocks up my head.”

Realizing she might be experiencing withdrawal, she went back on the pills, reducing their dose, until she was able to get off of them for good.

Ms. Nicholas wishes she had been given a plan for pain relief and weaning from the pain drugs. She also wished she was provided alternatives, including the shot bean bags, body pillows and deep breathing exercises she later discovered on her own.

Anesthesiologist Chris Idestrup, director of the Acute Pain Service at Sunnybrook, said patients are typically provided a bundled approach to pain management in a hospital setting consisting of a combination of acetaminophen, anti-inflammatory medication, plus nerve blocks and possibly opioids. When patients are ready to leave hospital, they typically go to one drug – be it tramadol, another drug that is a combination of oxycodone and acetaminophen or acetaminophen. He described the medication Ms. Nicholas was on as “middle of the road,” in regard to its strength, and one that is prescribed if patients “are not able to tolerate a stronger opioid.”

He indicated that post-surgical patients are typically started on stronger medicine, such as morphine, which would be reduced to a weaker opioid if it were too strong. He recommends patients ask their doctor if there are other medications they can take in addition: by throwing an anti-inflammatory into the mix – another drug that is a mixture of oxycodone and acetaminophen – that would help reduce the need for other pain medication and decrease the side effects of one drug.

“Realistically, after surgery, patients might need to use opioids to control pain for two or three weeks, some require it for longer,” Dr. Idestrup said in an interview.

Oftentimes, he says, patients can wean themselves off the drug by tapering it by about 20 per cent per day. Sometimes it is as simple as dropping one tablet each day so that by day 12, the patient is not taking any medication.

“Instead of taking two in the morning, take one in the morning,” he said. “Drop a pill each day and see how you deal with that.”

He recommends patients see their family physician, a week or two after being home, with their pain medication in hand. If still on the maximum dose, discuss whether they should be set up with a “weaning protocol” to get off of the medication.

“I wish I had known that it was okay to try to get your physician on the phone,” she adds, “And to ask for what you need and tell them what you want.”

The post The Patient as Expert appeared first on Your Health Matters.

My kids were playing doctor last weekend, and eventually turned the white plastic medical kit over to me. After pleading that I check for any boo-boo’s, I grabbed the miniature stethoscope and proceeded to evaluate heartbeats and breathing. It was all fun until I realized I had forgotten about the muffins I was baking downstairs. The terrible smell of burned banana-bran eventually wafted upstairs to our play area, as I dashed to the kitchen adorned in a play nurse cap. (The kids were amused, but the muffins were inoperable.)

I know the desire to be in two places at once isn’t restricted to busy, and often distracted, mothers like myself. Think of how much you could get done if you had a clone! Twice the work, twice the fun, and never burning another muffin again! Not wanting to wade into the murky waters of DNA ethics, however, I’ll take second best: a helping hand. In my case, it’s asking my husband to be where I can’t. It’s a common sense concept that has permeated hospital structure as well in the form of an increasingly popular role, called Physician Assistants (PA’s). They work under the supervision of physicians, and serve as an extension to the services doctors provide.

Zlata Janicijevic was the first PA Sunnybrook hired a year and a half ago. Working in the emergency department, which also happens to be Canada’s largest trauma centre, she says the beauty of her job is that more patients are seen. “I’ve had a lot of people who are surprised when I call to see them saying, ‘Wow! I didn’t have to wait for long at all today!’ And that’s the whole purpose, to see patients, especially the lower acuity patients, and get them in and out of the emergency department as quickly as possible.”

What PA’s do largely depends on what department they are working in. For Zlata, a typical shift can bring anything from minor cuts to major traumas, and she’s trained to deal with it all. PA’s have a long history in the military and the U.S, where tens of thousands are working. They are a more recent addition to the clinical world here in Canada, but evidence shows they do increase access to care and cut down on wait times.

Sunnybrook now employs 4 PA’s, all in the emergency department. That’s more than any other hospital in Ontario. Dr. Joshua Tepper, Sunnybrook’s VP of Education, tells me it’s all part and parcel to a team approach that puts patients first.

This weekend, I’ll happily play doctor with my kids again and delegate my husband to kitchen duty (or vice versa). As I learned from my muffin fiasco, four hands are better than two. And for a health care system stretched in its own ways, the proverbial helping hand that PA’s provide is a welcome and necessary one.

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In the world of holiday entertaining, a small oversight like this wouldn’t make the difference between life and death (unless dying from embarrassment counts…). In the world of medicine, however, the devil is truly in the details. And that’s especially true in the intensive care unit, or ICU, which houses the sickest patients in the hospital. If you’ve never been to one, consider yourself lucky. If you have, you’ll never take simple things like being able to breathe on your own for granted again.

Clinical teams in any ICU can be so busy treating the big problems they may overlook the small and relatively simple opportunities that can make a huge impact on patient outcomes. Consider this: for patients on a ventilator, raising the head of their bed can help prevent a serious lung infection called pneumonia. A simple 45 degrees can turn a situation 180. Who would have thought?

It was news to me, but not to Sunnybrook Intensive Care Specialist Dr. Damon Scales. He and his research team wanted to find a way to bring the little things back into focus. What followed was a very cool study that has never been done before. It linked the ICUs of 15 community hospitals across Ontario through videoconferencing. Through educational seminars and simple checklists (similar to those used by pilots before takeoff), 6 small but powerful interventions made it back on the radar.

Dr. Scales says this was an extremely rewarding project. The rates of complications and death are higher in the ICU than any other area of the hospital, so focusing on the details means the most vulnerable patients benefit. In the first year of this Sunnybrook-led study, more than 9,000 patients were impacted, and adherence to some of these practices more than doubled. And those benefits continue. After all, once you know better, you can do better.

Now that you know the big picture, read all about the study details here.

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There’s no doubt, waiting is a drag, especially when you’re not feeling well. But the simple truth is, if you’re waiting, it’s busy behind those closed emergency ward doors. Every patient is given a “score” when they arrive in emergency by a triage nurse, depending on how sick they are and how urgently they need to be seen. But even with my Aries mentality, here’s a situation where I wouldn’t want to be first in line.

Because Sunnybrook deals with the highest number of sick people in the province, that can slow things down. But let’s face it, the business of saving lives can’t thrive on the fast food model. Acutely ill patients need many resources, and good medicine takes time. If it’s taking a while, rest assured, there’s someone much sicker being taken care of before you.

It’s also a tough go for staff. As Teresa Korogyi, Patient Care Manager of Emergency told me, you don’t go into the medical profession to keep people waiting. You do it to help, and it’s hard when that can’t happen instantly. Having done her job for years, Korogyi has heard many complain about the waits. The only exception was during a 2-week period when Sunnybrook’s emergency room was being reconstructed, and trauma patients had to come in through the public entrance. “The trauma patients would come in, some of them quite horrific, and not one patient in the waiting room asked why they aren’t first. They didn’t want to be first.“

That said, there are things you can do as a patient to ease the gridlock. Make sure you really do need to be seen in emergency before you leave home. While you’re waiting in emergency, make a list of all the medications you are taking and your medical history. And tell the triage nurses if your situation gets worse while you wait. That may change your score, and how long it takes to be seen.

It’s tough enough being a patient, let alone doing it with patience. But before your inner Aries coming seeping out, know that at Sunnybrook, at least there’s a good reason for the wait.

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My parents have always been planners. Whenever they had to drive somewhere new, my dad would have the map out on the kitchen table, navigating the route hours before the rubber hit the road. And of course, a thorough check of the traffic reports was always mandatory. As a teenager, I used to roll my eyes. What’s life without some spontaneity? I’ve since learned that there are definitely times where it’s better to be prepared.

Visiting the emergency room is actually one of those times. Of course, when accidents or acute situations happen, the luxury of time and planning go out the window. Then it’s a case of getting help as quickly as possible. But many visits to emergency can actually be managed more efficiently.

Experts here at Sunnybrook say, it all starts with patients using their discretion. Is the problem you’re experiencing new? Is it serious? Those questions often need an expert to answer, but in some cases, like a flu or cold, it could be a better approach to call your family physician first. TeleHealth Ontario is another option for all those non-urgent problems that always seem to happen in the middle of the night.

If you are coming to emergency, it’s recommended that you bring a complete list of the medications and supplements you are currently taking, and as much information on your medical history as possible. Also, avoid eating or drinking. If certain tests need to be performed, that can actually delay the process of getting your diagnosis.

And while it’s tempting to bring as many people with you as possible for emotional support, remember that many hospitals have a 2-visitor policy. Here at Sunnybrook, the emergency department may be dealing with as many as 50 patients at a time, and providing the best care means having the space to do so. It’s also for the consideration of other patients being treated.

Sunnybrook has the highest acuity of ill patients in Ontario, likely because of the specialized programs available here. That includes being a Regional Stroke Centre and housing the largest trauma program in the country. Sunnybrook has also done some amazing things to reduce wait times, including incorporating different zones in the emergency department for different levels of illness, taking on more physician hours and new initiatives to improve patient flow.

That said, health care is always a partnership between the patient and provider. So back to the driving metaphor, take the wheel when you can. As I now carry on my parents’ tradition of checking roadmaps (OK, Google maps!) and weather reports, I fully know that unforeseen traffic problems could put a wrench in my plans. But I do what I can, and hope for the best.

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