National Nursing Week

C M Y K MAY 12-18, 2014 NURSING: A LEADING FORCE FOR CHANGE WINNIPEG FREE PRESS - SATuRDAY, MAY 10, 2014 9 When it comes to managing distressing behaviours that dementia patients can present, good communication and creative problem-solving have proven to be a kinder, gentler prescription than antipsychotic drugs. Preetha Krishnan, the nurse practitioner responsible for the medical care of approxi- mately 150 residents at Lions Personal Care Centre and Misericordia Place, writes very few antipsychotic prescriptions. But she talks to a lot of people every day. Along with residents, families and facility staff, she is in regular communication with more than 300 people. Krishnan is working to eliminate the use of antipsychotic drugs as a form of chem- ical restraint for personal care home resi- dents. She knew little about dementia and anti- psychotic drug use when she started work- ing in long-term care in 2007. But her pas- sion is to integrate evidence-based care with clinical practice, so she studied every- thing she could. She soon discovered prob- lems. "What I was seeing in the clinical area was an inappropriate and excessive use of antipsychotics. I believe that medication use must be an effort to promote the high- est well-being and I didn't see that in our residents at all," she says. Too many people were wheelchair-bound and weren't interacting with others. With the support of the director of care and the medical director, Krishnan began reviewing patient charts and asking questions. In many cases, she found that patients were being treated for behaviour that didn't call for antipsychotics. "The behaviour was layering more clothes, some inappropriate defecation and urina- tion. But it's not bothering the person," she says. "What I found was we were treating be- haviour that was disturbing, not disturbed." She believed that by using an evidence- based model, most patients could —and should — come off these medications. The trick is to find the underlying meaning be- hind the behaviours, not just use drugs to make them disappear. One story that troubled her was a patient who had been prescribed antipsychotic medication because she was looking for her husband. "I felt so sad. It was the last thing she remembered from her life —why would we take that away from her?" she says. "Some days, I cried myself." For Krishnan, the process quickly became more about humanitarian care, and not just about the scientific question of stopping the use of antipsychotics. She built a team with her staff and the families of the pa- tients. They were all understandably nerv- ous about what could happen. "I told them if they start the behaviours, I will give you the medications back. But right now, I can't give you something that we don't have an indication to prescribe." She started with residents who were stable and gradually reduced the medica- tions while at the same time monitoring their responses and adapting to their differ- ent needs for care. She recalls one wheelchair-bound patient who was on large doses of two different medications. The patient's decline, which included lack of interaction, lethargy and an inability to eat, was attributed to the progress of dementia. But when the medi- cation was slowly reduced, the patient was soon able to walk, self-feed and even dance. The resident lived for another four years. These days, staff no longer ask for anti- psychotic medications. Instead, they look for other strategies, and Krishnan mostly prescribes analgesics for pain and laxatives for constipation. Once patients are comfort- able, they are settled. Her results have been so good that at Lions, she is down to one patient on medi- cation. The facilities Krishnan works in have the lowest antipsychotic use in the region, and even in the country. She is confident that with teamwork and education, it is possible to put an end to the unnecessary prescrib- ing and prolonged use of antipsychotics in people with dementia. The team's success story has been pub- lished in journals, and Krishnan has pre- sented her work to many conferences, in- cluding the Ontario Long-Term Care Physicians' conference in 2010. She says she has an important message for prescribers. "Medication use must be an effort to pro- mote the highest well-being. And don't let the medication rob the quality of life of the long-term residents or the people with the dementia," she says. "Quality at the heart of everything we do — especially quality of life — is a critical outcome measure for determining the value of pharmacological treatments for behav- ioural problems in people with dementia." Drugs & Dementia Creative care and communication are better prescriptions By Wendy King – For the Free Press Nurse practitioner Preetha Krishnan takes a more humanitarian approach to patient care. Photo by Darcy Finley From the start, the SANE program has caught the attention of the medical community across the country. The initiative began when two emergency room nurses noticed the long wait time for patients who needed sexual assault exams, which require un- divided attention and specialized care. The ER nurses began to research existing nurse examiner and forensic nursing programs in the u.S., and they decided to start something similar them- selves. Smith says it's thanks to the hard work of the program's founders that the SANE team was formed. "The program in Winnipeg was the first of its kind in Canada, and now there's one or more programs in every province. They saw the need for it, and we continue to see that because our patients now don't have to wait in emergency for however many hours it may take," Smith says. 'We usually get to the hospital within an hour. That's our goal, unless the patient has other injuries that need to be assessed or treated. All of our nurs- es have specialized training so we provide the med- ical care, but we also do a forensic examination as well." Smith says it's important to educate patients about their options. "Our biggest goal is to give patients the best in- formation we can so that they can make the best choice for their care. One thing we offer them is to have a medical examination in which we do a head- to-toe and look for injuries. We also test and offer prophylactics for sexually transmitted infection and pregnancy," she says. "Then the second option we give them is if they would like to involve the police. We can assist them with contacting the police, and we will also do a forensic exam in which we collect evidence or swabs and specimens to give to the police." The team works closely with police when it comes to sex crimes and child abuse, and they have month- ly meetings with an interagency sexual assault re- sponse team to discuss what's working and what's not. On average, the sexual assault nurse examiners see about 350 patients per year. However, that probably represents only a small portion of people who have been sexually assaulted, since many cases are not reported. Smith stresses that the service is available to anyone of any age and background. "We see all genders. We want to let people know that even men can come see us. We see any age from a few months up to patients in their 80s and 90s," she says. "An important message we want to get out is that we are here. I think there are a lot of people who still don't know that a program like this exists in Winnipeg and don't know that there is this care that they can come and get." CARE ON CALL 24/7 — Continued from page 8 CELEBRATINGNURSING A LEADING FORCE FOR CHANGE TheFacultyofNursingattheUniversityofManitoba wouldliketoacknowledgeandcelebrateNational NursingWeekwiththenursingcommunity.Asleaders innursingeducation,wearecommittedtoworking withyoutopromoteexcellenceinnursingeducation, researchandpractice. Wearehonouredtosupporttheprofessionby educatingfuturenurses. Formoreinformation,visit umanitoba.ca/nursing

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