Facilitating cancer pain control in the home: Opioid-related issues

The basic principles of pain management are the same whether the patient is in an acute care setting, their home, or a long-term care facility. Wherever the setting, pain management is part of the comprehensive care for the cancer patient. Successful therapy depends on a clear definition of treatment goals, an informed patient and family, collaboration and effective communication between the physician, home care nurse, patient and family, and ongoing monitoring to ensure effectiveness of pain relief measures. Careful discharge planning to ensure appropriate home care for the patient with pain and their family is critical.     

Development and evaluation of an innovative community-based PEG support service.

The Percutaneous Endoscopic Gastrostomy Care and Support Service was launched in March 1999 as a joint project of the Endoscopy Suite and Hospital at Home at Flinders Medical Centre South Australia. The Support Service was developed to provide, through integration of services, a link between the acute care setting and the community to ensure optimal management of patients with percutaneous endoscopic gastrostomy tubes. A percutaneous endoscopic gastrostomy coordinator was employed to undertake further development of the service.Integration of data from questionnaires and the percutaneous endoscopic gastrostomy data base was used to evaluate the service. Data indicated there was a need for a support service, not only for patients living with percutaneous endoscopic gastrostomy tubes, but also for the caregivers of those patients who require specialized knowledge to manage percutaneous endoscopic gastrostomy related problems. As a result of this project, percutaneous endoscopic gastrostomy management can now be provided in the patient's home setting, thereby improving patient and caregiver satisfaction and reducing hospital admissions.     

Continuous ambulatory gamma globulin infusion in the home setting: a treatment proposal for a high-risk patient

As infusion therapies increasingly move from the hospital to the home setting, home I.V. therapy nurses must frequently decide which therapies are appropriate for home delivery. These practitioners must find innovative, cost-effective, and, most important, safe methods of providing new I.V. therapies in the home. A medically complex patient with a strong desire to maintain the most normal lifestyle possible was introduced to our infusion team. We accomplished our goal--to institute and maintain home therapy on this patient--by designing a treatment proposal that outlined specific guidelines, criteria, and recommendations for all aspects of the infusion care. This proposal can serve as a model for any experimental or unusual treatment being considered for home therapy.     

Liaison nursing.

In reviewing my efforts to clarify the role of the nurse clinician as a psychiatric consultant in a hospital setting, I came away with many impressions. Inherent in my search was a desire to experiment with various means of providing nursing service and much of my time was spent examining the collaborative aspects of the nursing role that would add greater depth to patient care. This involved role experimentation and allowed me the opportunity to develop my role within the context of the guidelines of community organization and consultation in a hospital setting. Although much of the time I found that the liaison role has been aimed at the supportive level, I have also discovered that as I developed security in the role wherein I could function in new and more independent ways--the parameters of the role expanded. Whereas initially I envisioned working only with nursing staff, I have found myself collaborating with many disciplines and many levels of care givers and I have also been able to function collaboratively with other psychiatric liaison team members. Thus, at this time I see the liaison nurse functioning basically as a coordinator, who, at any time, may assume one or more of the following roles: 1) Integrator; 2) Provider of direct services; 3) Educator and consultant; 4) Change agent.     

What to do when the end is near: ethical issues in home health care nursing

As managed care shortens the length of hospital stays, home settings for the practice of nursing will become increasingly important. In spite of community health nursing's long tradition of family-centered care delivered in the home, many discussions of the nurse/patient relationship in the medical ethics literature assume the hospital setting for the practice of nursing and seem to neglect the impact of family and significant others for the nurse/patient relationship. Through a case-based analysis, this article highlights the special ethical and legal issues encountered in caring for patients who are dying at home. This analysis demonstrates that traditional frameworks for the nurse/patient relationship are inadequate for capturing the richness of the relationship the home health care nurse has with both patient and family. By developing a new framework for the nurse/patient/family relationship that (a) recognizes the patient's decision-making authority and autonomy, (b) allows the exercise of the nurse's moral rights, and (c) recognizes the patient's relationships to significant others, the authors attempt to resolve some challenging legal and ethical questions concerning who should be allowed to decide what to do when the end is near. The discussion details the implications of this framework for nursing assessment in the home care setting.     

Care coordination: Identifying and connecting the most appropriate care to the patients

Although nurses are increasingly expected to fulfill the role of care coordinator, the knowledge and skills required to be an effective care coordinator are not well understood. The purpose of this study was to describe the knowledge and skills required in care coordination practice using an interpretive phenomenological approach. Fifteen care coordinators from 10 programs were interviewed over a 6‐month period. Semi‐structured face‐to‐face interviews were audio recorded, transcribed, and analyzed using interpretive phenomenology. The central theme of care coordination practice was bridging the patient and the healthcare systems. To bridge, care coordinators needed to have knowledge of the patient and healthcare system as well as the skills to identify and negotiate treatments appropriate for the patient. The most salient finding and new to this literature was that care coordinators who used their medical knowledge about available treatment options to discern and negotiate for the most appropriate care to the patient made differences in patient outcomes. Nurses with medical and healthcare system knowledge, combined with the skills to navigate and negotiate with others in an increasingly complex healthcare system, are well situated to be care coordinators and generate optimal outcomes. Further investigations of critical care coordinator competencies are needed to support nurses currently enacting the role of care coordinator and to prepare future nurses to fulfill the role.     

Putting infection control principles into practice in home care.

Implementing sound, rational infection control practices in home care has been challenging since guidelines, standards, and most references have been developed for the acute care setting. This article provides guidance for adapting appropriate infection control interventions for patient care practices to the home care setting. Such practices include handwashing, home infusion therapy, respiratory care, wound care, urinary tract care, and isolation precautions. Assessment of the home care environment, cleaning and reprocessing of equipment, surveillance, implications for occupational health, and program design are also discussed.     

Home care of the patient with advanced lung cancer

Improvements in early detection and treatment of lung cancer, as well as health care cost containment, have combined to make home care of the patient with advanced disease common today. Treatments once performed only in medical centers are now routine parts of home care. Families are providing sophisticated bedside care under the guidance of the home care clinician. This article has highlighted home management for the respiratory-related problems of patients with advanced bronchogenic cancer: dyspnea, cough, and hemoptysis. Such patients experience many difficult physical and emotional problems. The home care nurse, as teacher and coordinator, assists the patient and family to live each day to the fullest.     

District nursing support for patients with cancer requiring palliative care

Patients with cancer spend the majority of the last year of life at home, with district nurses (DNs) as the main care coordinators and providers. However, there is a relative lack of empirical work on the DN role in this area. This study used qualitative, case-study methods to explore the role of district nurses caring for patients with cancer who require palliative care. The study focused on three patient cases and the researcher visited each patient with the DN on several occasions. The sample was three DNs and the principal data collection methods were episodes of participant observation (n=11) and in-depth interviews (n=12). The findings suggest that DN role was as linchpin or coordinator of palliative care at home. They were the main providers of physical and emotional support for the patients and families in this study. The supportive role of the DN involved referral to other agencies. Patient and carer preferences impacted on decision-making and care planning and reaching a compromise was often necessary.     

Risks for unplanned hospital readmission in a teaching hospital in southern Taiwan

The purpose of this study was to assess and analyse hospital readmission and its risk factors for patients who were visited by a discharge planning coordinator during hospitalization in a teaching hospital located in southern Taiwan. Results found that 67 patients (5.7%) were readmitted within 14 days of discharge during the data collection period. Twenty-eight patients (41.8%) were readmitted because of complications. Patients' previous diagnoses and complications were two major reasons for patients to be re-hospitalized within 14 days of discharge. In addition, significant predictors for unplanned hospital readmission within 14 days of discharge were patients who received care from home health care nurses or hospice home health care nurses.     

Timely admits, transfers, and discharges

Nurse managers implemented a critical care patient coordinator program that's improved patient flow, staffing, and problem identification. The hospital has increased the new department from 7 to 12 critical care nurses and applied the program to other units.     

Patient and caregiver outcomes 12 months after home-based therapy for hip fracture: a randomized controlled trial

OBJECTIVE: To compare the effect of early discharge and home-based therapy with conventional hospital rehabilitation on patient and caregiver outcomes at 12 months after hip fracture. DESIGN: Randomized controlled trial. SETTING: Acute and subacute care with follow-up in a community setting in Australia. PARTICIPANTS: Sixty-six older adults admitted to acute care after hip fracture who were assessed as needing rehabilitation. INTERVENTIONS: Eligible patients were randomized to either home-based (n=34) or hospital (n=32) rehabilitation. Patients assigned to the home-based group were discharged home within 48 hours of randomization. Patients assigned to hospital rehabilitation received usual care. MAIN OUTCOME MEASURES: Modified Barthel Index (MBI), timed up and go (TUG) test, Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and Caregiver Strain Index. RESULTS: At 12 months, 56 of 66 (85%) participants were available for follow-up assessment. Both groups achieved significant improvements in MBI and TUG test scores. Patients in both groups had a significant decline in the physical score of the SF-36 and there were no differences between groups. Caregivers of patients allocated to receive home-based therapy reported a reduction in burden after 12 months. Over that period, there was a significant reduction in the burden for caregivers of those patients who received home rehabilitation (P=.020). CONCLUSION: For patients who were previously functionally independent and living in the community, early return home with increased involvement of caregivers after hip fracture resulted in similar patient outcomes (home vs hospital) and less caregiver burden at 12 months.     

Home ventilator care.

The need for continuous home ventilatory care can arise when patients who are otherwise stable cannot be weaned from mechanical ventilatory support. Two cases are presented that show these patients can be cared for at home at a cost less than their care in the hospital. Before deciding on home ventilatory care for a patient, one should carefully consider all supportive measures, including drug therapy and psychosocial factors. The choice of home care equipment depends on many individualized considerations. The successful management of a patient on a home ventilator requires careful preparation, extensive home instruction, and continued follow-up by a home health care team.     

Working with volunteers: key issues for gerontological nursing - Application to practice the contribution of volunteers in a long-term care setting: a case study

Adopting a case study approach, this paper examines the impact of a volunteers scheme in a large Jewish care home within the UK. Good practice is articulated, opportunities and challenges identified, with specific reference to religious and cultural beliefs and the role of the volunteer coordinator is examined. The paper concludes that teamwork and the role of the volunteer coordinator is pivotal to the ongoing success of the volunteer scheme.     

Safe sleep practices for hospitalized infants

Guidelines were established over 10 years ago by professional and government agencies that have dramatically changed the practice of infant sleep positioning. Although these guidelines mainly focus care on the newborn and infant in their home by a parent, guardian or caregiver, hospital staff need to examine their compliance with these guidelines.The most controversial aspect of the "Back to Sleep" guidelines for the hospital setting is the parent and infant sharing a bed. Although parents may choose to sleep with their infant at home, the need for monitoring, ongoing assessment and care as well as the risk of entrapment or injury should be a priority in the delivery of optimal patient care in the hospital setting. The need for a policy was identified and developed by a multidisciplinary task force focusing on the physiological, behavioral and cultural aspects of cosleeping.     

The clinical nurse leader: a response from practice.

In October 2003, over 200 nurse leaders from education and practice met at the invitation of the American Association of Colleges of Nursing. A newly released white paper, describing the role of the clinical nurse leader, was discussed at the conference. This article outlines a response to that white paper from one practice setting. The article shares information about another role, that of team coordinator, that is similar to clinical nurse leader and has been implemented at an integrated not-for-profit health care system in 5 hospitals. The comparison of the team coordinator role to the clinical nurse leader role might assist in visualizing such a role in practice. Although the roles are not identical, many of the driving forces for change were similar; these included the need to meet the changing demands for improved patient outcomes and nurse retention. The team coordinator role has 4 domains of practice that are crosswalked against the clinical nurse leader 15 core competencies. An evaluation of the team coordinator role showed changes that need to be made, such as placing more emphasis on clinical progression of patients. Lessons learned are shared, including keeping the scope of the role manageable, providing documentation standards for new roles, and the leadership required of the nursing executive to implement change.     

Home care personnel's perspectives on successful discharge of elderly clients from hospital to home setting

The successful discharge of elderly patients from hospital to home care is a process requiring co-operation between health and social care personnel in addition to their commitment and skills. During the discharge process it is important that health and social care professionals have a shared view of the health and mental status and needs of the patient so that appropriate plans for meeting these needs can be made. The aim of the study was to investigate home care personnel's (health and social care workers) views of which practices between the discharging hospital and home care are associated with the successful discharge of clients. Home care personnel in 22 Finnish municipalities (n = 1890, response rate 63%) received a questionnaire in spring 2001. When the respondents' background factors were standardized, the best predictors of successful discharge from the home care personnel's point of view were adequate information received about the treatment of the patient's illnesses and their functional ability and cognitive potentials, timely information about the discharge, and good co-operation between the discharging hospital, and the home care, social care and health care workers working in home care. There were differences in the opinions of social care workers and health care workers working in home care. From the home care personnel's point of view the most important correlates of an elderly client's discharge from hospital to a home setting were factors associated with how they can best plan their work. Their perspective on the discharge process may diverge from clients and their informal care givers point of view. To ensure the successful discharge process we must take them all into account.     

Partnering for optimal respiratory home care: physicians working with respiratory therapists to optimally meet respiratory home care needs

The need for respiratory care services continues to increase, reimbursement for those services has decreased, and cost-containment measures have increased the frequency of home health care. Respiratory therapists are well qualified to provide home respiratory care, reduce misallocation of respiratory services, assess patient respiratory status, identify problems and needs, evaluate the effect of the home setting, educate the patient on proper equipment use, monitor patient response to and complications of therapy, monitor equipment functioning, monitor for appropriate infection control procedures, make recommendations for changes to therapy regimen, and adjust therapy under the direction of the physician. Teamwork benefits all parties and offers cost and time savings, improved data collection and communication, higher job satisfaction, and better patient monitoring, education, and quality of life. Respiratory therapists are positioned to optimize treatment efficacy, maximize patient compliance, and minimize hospitalizations among patients receiving respiratory home care.     

A clinical pathway for deep vein thrombosis

The use of low molecular weight heparin to treat deep vein thrombosis at home represents a relatively new patient population for home care agencies. Use of a clinical pathway provides a framework for defining expected outcomes of care and direction for patient assessment, care, monitoring, and documentation. Implementation and evaluation of a clinical pathway are described.