Transcript Senior E.D.
SENIOR ER: THINK 3 D
“Advancing Excellence in Geriatric Care” November 3, 2012 J. Michelle Moccia MSN, ANP-BC, CCRN Program Director, Senior ER St. Mary Mercy Hospital, Livonia Michiga Thank you to D. Cannatti, S. Saltzman, Mekeia Foster, Meghan McGinn, Keyaria and Holly Beversdorf, Denise Scott, Sue Penoza for their contribution
COURSE OBJECTIVES
Outline the “Graying” demographics of the U.S. population and the impact on the ER Identify key organizational factors and implementation strategies for program success Discuss key components of geriatric nursing assessment using “THINK 3 D” ( a bundled care packet to help assess the older adult)
Adding life to years, not just more years to life (Gerontological Society of America)
Gray Tsunami
By 2030, nearly one in five Americans will be over the age of 65. (38.7 million) By 2050, this will double to 88.5 million Next 19 years, every single day 10,000 baby boomers reach the age of 65 Centenarians is the fastest age group Every hour 10 more Michiganders turn 65 By 2035, one in 4 Michiganders will be 65 and older
Population age 65 and over in US
This chart for Indicator 1 - Number of Older Americans shows the large growth of the population 65 and older from 1900 to 2008 and the even greater projected growth from 2008 to 2050. It also shows the growing numbers of persons 85 and older and their large projected growth to 2050.
ENA Position Statement (2003)
ENA recognizes that optimal care of the older adult is best achieved by: Members of the team collaborate to assess and treat ED nurses must be knowledgeable in physiologic, psychological, sociologic, and economic changes in older adult and how these changes impact assessment, interventions, teaching, discharge decisions, and community referrals
ENA position statement
Geriatric education needs to be included in basic and continuing education Recognize the patient, the spouse, or family members may need assistance – the need for collaboration with other HCPs, organizations, and groups may be necessary to promote a safe and healthy environment Medication problems may go unrecognized & screening for elder abuse and reporting must be carried out
ER Nurses on the front line
Front door of the hospital and to the community Encounter a variety of health issues from non urgent, urgent to emergent Ranging from the frailest and functionally impaired to the healthiest and physically active The patients worldview can only be discovered during conversation…sometimes awakened with reconnecting to their spirit
Impact of Boarding & Crowding
Presentation more complex Higher acuity of care By 2013, number of visits could double reaching 11.7 million annually Lack of PCP, business hours, homelessness, psychiatric disorders, substance abuse – ED open 24/7 ED visits ages 65 and 74 have increased by 34% between 1993 and 2003
CONTROLLED CHAOS?
Increased length of stay due to extensive evaluations Delayed time consuming care due to older adult physiologic needs Vital information missed due to poor handoff or unintentionally ignored Special needs not addressed – baseline function, depression, dementia, delirium Risk of poor outcome, readmissions
Risk Factors
Older individuals are discharged are at greater risk for complications. Independent functioning may be threatened.
Older adults that were discharged from an E.D. experienced a revisit, hospitalization or death within 3 months in 27% of the cases (Hwang U & Morrison RS, 2007).
In one month, office of Inspector General found 14% of Medicare recipients experience and adverse event; 44% were attributed to inadequate monitoring or patient; 60-70% communication errors One needs to examine one’s own values, attitude, perception and beliefs about caring for an older adult
Aging is not a disease
Aging is a process Interaction between environmental (extrinsic) and genetic (intrinsic) factors Older Americans living longer and healthier (Key Indicators of Well Being) Physicians, Nurses, and Researchers have concentrated on interventions and evidence based protocols to improve the health and living conditions of older adults
“We see the world not as it is but as we are” (Covey, 1990)
Growth of SMML 65+ age in 2009 SMML Market Share by Age Cohort: FY2009 SMML Market Share by Age Cohort SMML’s market share in the twice as high groups 65+ age group is nearly as its market share in all other adult age
25% 20% 15%
FYI: Every hour 10 more Michiganders turn 65
10% 5% 0% Market Share <18 3.86% 18-24 11.15% 25-44 11.84% 45-64 11.37% 65+ 21.16% Source: MIDB
Hospital Market Share of Patients 65+
25.00% 20.00% 15.00% 10.00% 5.00% 0.00% FY05 FY06 FY07 FY08 FY09 SMML 17.80% 18.54% 19.84% 20.78% 21.16% Botsford 12.32% 12.77% 12.98% 13.04% 12.21% Garden City SJMHS-AA 11.15% 10.41% 9.25% 9.49% 8.98% 9.06% 8.30% 8.75% 8.37% 8.29% Oakwood Annapolis 7.54% 8.13% 8.07% 7.69% 7.73% 9.08% 8.81% 8.24% 7.61% 7.53% Henry Ford Hospital 5.75% 5.97% 5.88% 5.87% 5.70% Beaumont RO 5.39% 5.14% 5.32% 5.31% 5.14% Providence 7.37% 7.07% 7.12% 7.27% 4.84% U of M 3.78% 4.24% 4.06% 4.20% 4.13% All Other 10.75% 10.63% 10.50% 10.36% 14.30% Source: IDS
Focusing on Improving Services to Seniors is Critical SENIOR ER – The Trinity Health Perspective •Senior population is growing (Baby boomers – one turns 65 at a rate of 8,000 per day) •Care needs are higher than those of younger people •They drive most of the cost •Their families are looking for safe alternatives for them •They will be the biggest focus of CMS as it changes payment systems •Providers that are sensitive to the needs of seniors will grow
There is opportunity to improve the outcomes for seniors
• Social services and support • Optimizing health, wellness and fitness • Chronic disease management • Patient-centered medical homes • PACE programs • Palliative care
“Senior ER not invented here but still a good idea” (Dave Spivey, CEO SMML) Build on success of Holy Cross Hospital, Silver Springs, Maryland St. Mary Mercy Hospital in Livonia – First Senior ER in the State of Michigan July 14, 2010 Quickly followed by SJMO, SJMAA, Port Huron, Saline, Livingston, Chelsea, Brighton Focus on Safety, Patient loyalty, Growth, Financial, and Quality
Current ER Flow
“Controlled chaos” is a term frequently used by the Emergency HCP describe ER flow. Fast paced crowded facility: risk for mismanagement and/or delayed cared. Vital information missed: HCP may fail to identify any “special needs” i.e. geriatric syndromes; baseline ADLs and unintentionally ignore signs of depression, dementia and delirium.
Current Patient safety and concerns
Cognitive impairment can complicate scenario if they are unable to describe their symptoms or self report their pain. Absence of advocate adds to their vulnerability. Poor “hand-off” communication in both directions The Emergency Nurse’s Association (ENA) created a Safer Handoff for the Older Adult (www.ena.org) SMML has created a STARForum group to work with nursing homes, assisted livings, independent livings, group homes etc. to create a seamless hand-off (
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afe
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ransition of
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esidents For U & M e)
How aging boomers will transform Michigan | Detroit Free Press , October 3, 2010 A New Kind of ER Glaring lights, crowds, the clacking of medical carts and wheelchairs and beds -- "a loud and
chaotic ER is not a good place for an older
person to be," said Michael Calice, medical director at St. Mary Mercy Livonia, part of the St. Joseph Mercy Health System.
…
Need for enhanced Emergency Area for Seniors (environment)
Environment Changes Improve patient comfort – pressure reducing mattresses, reclining chairs; removal of noise distracters Reduce risks of fall (flooring, lighting, assistant devices, colors, hand rails) Reduce risk of delirium (visual aids, hearing device)
Need for Cultural changes
Ageism: ‘the process of systemic stereotyping and discrimination against people because they are old” – Robert Butler, 1969
Dr. Bill Thomas sessions
Need to supplement education
The ED physician and nurse must be well versed in the age-related physiologic changes, associated poor physiologic reserves and the high prevalence of comorbidities. Education modules (GENE and COMET) introduced to provide ED HCP with knowledge to care for the senior population.
Senior ER (more than a space)
Screenings to identify patients at risk for safety and poor outcomes that are not often captured with a medical screening Identify a decline in functioning may enable health care providers to provide a specific plan of care and thus improve the outcomes in the elderly.
Evaluating multiple domains of behavior and function will assist in assurance of positive outcomes.
S.E.N.I.O.R. FYI
Senior ER Core Team used the word SENIOR to define the vision of the First Senior ER in the State of Michigan S pecialized E mergency N ursing S I mproving ensitivity to E O ne’s SENIOR to define their vision?
lders N R esilience.
Inpatient Team expanded and used the word eeds I mproving O pportunities for R esilience
T.H.I.N.K . 3 D
T riage risk screening & T reatment H ere for fall or at risk for falls?
I nquire about medication, pain, alcohol use, advanced directive N utrition assessment; normal VS may not be so normal K atz functional assessment “ 3 D ” Dementia, Depression, Delirium (Thank you to Keyaria and Holly Beversdorf Nursing 4040 WSU)
T
reatment more complex in older adult than younger adults
Higher risk of complications from hospitalization Loss of physiologic reserves: impaired renal flow, impaired hepatic flow, and poor homeostatic mechanisms Loss of functional ability that may be caused by disease or hospitalization.
Cognitive impairment, hearing and visual impairment may affect stay in the ED
Physiologic changes of Aging: Cardiovascular
Increased valve stiffness Heart valves thicken Less able to respond to volume changes SA node thickening, fewer pacer cells Barioreceptors less sensitive to BP changes Decreased CV reserve Emer Jour of Nursing Hypertension Murmurs Reduced SV & CO Slow irregular HR Increased risk for orthostasis Heart failure
Physiologic changes: Neurologic
Blood-brain barrier more permeable Fewer neurons and nerve fibers Slower reaction time; decreased proprioception in lower limbs Decrease in neurotransmitter systems Increased sensitivity to meds and toxins Pain sensation changes and less able to localize pain Risk of falls Processing is slower and possible memory changes
Physiologic changes: Renal
Decrease in GFR Decrease in renal blood flow Decrease in creatinine clearance Decrease in ability to concentrate/dilute urine Decrease in bladder capacity and increase in residual bladder volumes Drug doses will need to be adjusted Elimination of toxins is affected Dehydration and impaired ability to respond to volume changes Urinary frequency, urgency, or UTI
Homeostasis –
temperature, blood pH, fluid balance and thirst regulation of body Loss of physiologic and functional reserves Thermoregulatory response impaired Shivering less intense, sweating is reduced Renal changes ( clearance) GFR, blood flow, creatinine Body responds in more exaggerated manner to homeostatic challenges risk of hypothermia or hyperthermia Delayed speed of return to normal pH by 80%
Homeostasis continued
Respiratory changes: chest wall muscles lung elasticity & weakening of Sensitivity of the brain is heightened by diminished capacity for homeostasis Alterations in tissue sensitivity to hormones (insulin response and glucose tolerance diminished; sensitivity to ADH Less able to hyperventilate in response to metabolic acidosis, which leads to pH LOC changes (confusion, lethargy, agitation) often a sentinel sign of illness Changes in Blood Sugar and alterations in electrolyte levels
T
HINK 3 D
T
riage Risk Screening Tool (TRST): developed to test the Systematic Intervention for a Geriatric Network of Evaluation and Treatment (SIGNET) Cleveland project Improves case finding: cognitive impairment, environment (lives alone, support person, lives in senior apartment, assisted, skilled. Fall history; ED or hospital history; any special needs recognized i.e. caregiver strain; abuse or neglect signs; nutrition; frailty The presence of two or more risk factors designates the older person as being “at high risk”.
Advantages in screening the older adult emergency patient
Identification of a decline in functioning may enable ER providers to provide a specific plan of care Greater diagnostic accuracy Decreased mortality Decreased LOS in hospitals Prevention of injuries (slip and falls)
Screening is important
ED point of care for patient: admitted, prehospital entry, or point of disposition to an extended or rehab care facility Special services may be required to support older adult through continuum of care i.e. housing, transportation, nutrition, durable medical equipment, counseling, caregiver support
T
H
INK 3 D:
H
ere for a Fall
Leading cause of injury and injury related mortality Leading cause of head injuries Factor in over 90% fractures of distal forearm, proximal humerus, and hip Nonfatal injuries associated with loss of independence Not a normal part of aging More likely to be problematic As many as 50% who are hospitalized following a fall die within one year Highest risk especially those with physical and or cognitive impairment
H
ere for fall? Extrinsic factors
Gait and balance disorders Cluttered environment, Unfamiliar environment Stairs Throw rugs Unsuitable footwear Poor lighting, poor color distinction Restraints, side rails
H
ere for fall? Intrinsic factors
Cognitive impairment Polypharmacy – four or more medications Sedatives, antihypertensive and psychotropic medications Alcohol Impaired mobility Fall history Sensory defects (hearing and vision) Frailty Postural hypotension
ESI Severity Index 1, 2, or 3?
5 Level Triage System (2003 ACEP & ENA) Witnessed?
Loss of consciousness?
Sitting or standing?
Carpet or hard floor?
Symptoms prior to fall?
On Anticoagulant? (Coumadin, Pradaxa, Xarelto, including aspirin)
HEAD INJURY & FRACTURES
R/O Subdural hematoma Brain loses volume with age, increased dural vein fragility Humerus Hip Femur Rib – high risk – pain, pneumonia due to inadequate respiratory effort, and risk for VTE due to lack of movement
Evaluation
Gait and balance Prior to Discharge: Orthostatic BP Arrhythmias Timed Get Up and Go Test Tinetti Balance and Gait Evaluation www.ConsultGeriRN.org
H
ere for abuse, neglect?
2.1 million older Americans are victims of abuse, only 10% is reported Elderly females are the most frequently abused 90% of the abusers are family members People over the age of 80 are abused 2 to 3 times more then any other age group Victims are often abused in several form
Types of Abuse
Physical Emotional/Psychological Abuse Sexual Abuse Financial Abuse Neglect of ADLs, confinement, abandonment Coercion abuse, verbal abuse Exploitation
“Elder abuse is defined as the action or the omission of actions that result in harm or threatened harm to the health or welfare of the older adult.” American Medical Association
Characteristics of abuse, neglect
Extreme mood changes-withdraw, agitation, fearfulness and depression Health Care Shopping Series of missed appointments Unexplained Injuries Bruises in different stages of healing Poor Personal Hygiene Sexually transmitted disease Insomnia or excessive sleeping Weight gain or weight loss Documentation is key –drawings, descriptions, photographs that include measurement of injury
TH
I
NK 3 D – Inquire about Medication History
What medications are you currently taking?
OTC?
Vitamins, herbal, home remedies?
Topicals, eye drops, patches?
Med reminders i.e. mealtime, pill box?
How do you know when you miss a med?
I
nquire about Med History
Consider new symptoms as a possible drug to drug interaction.
5 medications = 70% chance of drug interactions 7 medications = 100% chance of drug interactions Dosing guidelines adjusted to creatinine clearance?
Do they see another PCP?
Any new med started recently?
Beers Criteria created by Dr. Mark H. Beers, Geriatrician. (1991) Updated 2012 to assist HCP improving medication safety in older adult www.americangeriatrics.org
TH
I
NK 3 D -
I
nquire about Advance Directive
http://www.nhdd.org/
I
magine you cannot speak
Speak up and increase awareness Facilitate earlier treatment decisions Increase communication and understanding of patients prognosis Help reduce the use of resources and time spent by patients in undesirable states before death Referral to palliative care or hospice
End-of-Life Decisions
Aim for a “good death” defined by the Institute of Medicine “one that is free from avoidable distress and suffering for pts, families, caregivers; in accord with pts and families’ wishes; and reasonably consistent with clinical cultural and ethical standards ”(Reisberg functional Assessment Staging; scale of 1-7) http://geriatrics.uthscsa.edu/tools/FAST.pdf
TH
I
NK 3 D Alcohol Use
I
nquire about
Heavy drinking is reported by 3-9% of people over 65 Alcohol abuse or dependence is reported by 2-4% 1/3 of the elderly who abuse or have alcohol dependency started drinking after age 50 14% present to an ER with new diagnosable Alcoholism Serious cause of mortality and morbidity
Signs and Symptoms of Alcohol
Flushing Palmar eythema Sarcopenia Spider angiomas Altered level of consciousness Changes in mental status or mood Poor coordination Nystagmus Elevation of liver enzymes Increased MCV in presence of normal hemoglobin
Screening, Referral and Brief Intervention (SBIRT)
Older adult age 65 and > More than seven drinks in a week 3 drinks on any occasion
The American College of Surgeons Community on Trauma (ASCOT) mandate Level 1 and Level II Trauma centers identify patients who are problem drinkers – screening, brief intervention, and referral (SBIRT)
TH
I
NK 3 D pain
I
nquire about
The elderly under-report pain because it is thought to be a “normal” part of aging.
The elderly may suffer because the cost of pain medications is too high.
Those individuals with cognitive impairments may not be able to verbalize that they are in pain.
The Visual Analogue Scale (VAS), the Numeric Rating Scale (NRS) and the Faces Scale have been used by nursing home patients
Pain scale
The FACES or the Visual Analog or the Numerical Rating Scale may be used even in the situation of mild dementia.
Pain Scales
Verbal /Visual-Pain Distress IntensityScale Numeric 0-10 Pain-AD (Combination of numeric, Verbal, and Iowa Pain Thermometer)
PAIN FOR ADVANCED DEMENTIA
Cognitive impairment signs of pain
Look for non-verbal signs: subtle signs such as wincing, moaning or guarding. A decrease in appetite and activity may be signs of pain.
An inability to want to move may be related to pain.
(Ebersole, Hess, 1998)
THI
N
K 3 D – Nutrition & Normal VS
Normal VS may not be so normal after all Determine baseline parameter Normal BP in normal hypertensive patient maybe a signal of volume loss Baseline lactate and base deficit levels Base deficit measure good predictor of life threatening injury
N
utrition
Unintentional weight change > 10lbs within past 3 months?
A reduction in food intake or hydration: patient reported eating or drinking less than half of the usual intake for the past 7 days?
Coughing or difficulty with swallowing when drinking fluids ? www.mypyramid.gov
THIN
K
do?
3 D – What K an they
KATZ assessment
FUNCTION FOCUSED CARE o Inactivity rapidly contributes to muscle shortening o o Bed rest diminishes aerobic activity Loss of muscle strength leads to falls 40% of ER patients have functional decline within 30 days of ER discharge!!!
* Red Flag: A decrease in function maybe the indicator the patient is ill GOAL: Keep people functioning – prevent the revolving door; keep out of skilled facility
KATZ Score
“Normal aging changes and health problems frequently show themselves as declines in the functional status of older adults”
(Wallace & Shelkey, Hartford Institute of Geriatric Nursing, 2007).
Why perform the Katz?
The Katz Scale is utilized to determine if the patient can function independently, may require additional help to varying degrees or if the patient may need total assistance. Decline in functional status is often the first clue to health problems. The Katz scale measures the degree of function.
A score of 6 indicates full function. A score of 4 indicates moderate impairment and a score of 2 or less is severe functional impairment.
THINK
3 D
Geriatric D epression Screen
Depression is common late in life, affecting nearly 5 million of the 31 million Americans aged 65 and older (Blazer, 2002).
Depression may be reversed if identified early enough; left untreated, depression may result in physical, social and cognitive impairment as well as cause delayed recovery from illness and may be severe enough to cause suicide (Kurlowicz & Greenburg, 2007).
D
EPRESSIVE SYMPTOMS
Depressive Symptoms – shows a modest increase in clinically relevant depressive symptoms for older age categories. Also shows lower levels for men except at the 85 and over group where the levels are similar.
Geriatric Depression Screen
The Geriatric Depression Screen (GDS) consists of 15 questions. Answers in bold font may indicate depression.
3 D D ementia ( Mini-Cog)
Cognitive impairment increases with advancing age and increasing age is the greatest risk for Alzheimer’s disease. One in eight >65 (13%) Early identification of the disease may enable health care providers to start treatment in the early phase of the disease which usually results in a better response.(Cholinesterase inhibitors) The Mini-Cog consists of a three item recall in combination with a clock drawing exercise. www.alz.org
The Mini-Cog Screening Tool
Takes 3 minutes to complete Performs as well as or better than the Mini-Mental State exam that takes much longer to administer Results not affected by culture, ethnicity or education
Mini-Cog Screening
Performing the screen: tell the patient to listen carefully and remember 3 unrelated words (I.e. cup, train, blue). Have the patient repeat the words to you prior to performing the CDT
Mini-Cog Screening
Instruct the patient to draw the face of a clock, placing the numbers at correct locations. Then tell the patient to draw the hands of the clock to represent 11:10
Scoring of Mini-Cog
Unable to recall all 3 items: scores as demented Successful recall of all 3 items: non dementia Those who recall 1 or 2 items are classified based on the results clock drawing test
3D D
elirium
Delirium occurs frequently (25-60%) in hospitalized adults (Waszynski, 2007). Delirium is often unrecognized by health care professionals and needs constant evaluation and re-evaluation.
Acute, reversible and fluctuating central nervous system dysfunction with an organic cause.
Lasts from a few hours to a few months if left untreated
Types of Delirium
The distinction between delirium and other disorders is often unclear Can resemble dementia (major risk factor)or depression Hyperactive form (Positive symptoms): Psychotic episode, agitated, high anxiety, aggressive or combative Hypoactive form (Negative symptoms): extreme lethargy, inability to focus attention or follow commands (Higher morbidity and mortality) Mixed: Patient exhibits characteristics of both Hyper and Hypoactive
Risk Factors
Predisposing Factors
Advanced Age Dementia or family history Depression Co-Morbidities Severity of illness Hearing/visual impairment Smoking, ETOH, drug use Surgery Male gender
Precipitating Factors
Medications (Sedatives, antipsychotics, analgesics) Hypoxia Room changes Restraints Availability of clock Pain Electrolyte imbalance and dehydration Immobility Infection Fractures
Delirium Pneumonic
D rug Use, dehydration E lectrolyte Imbalance L ack of Drugs (withdrawal or PRN medications) I nfection R educed Sensory in patient I ntra Cranial Events U rinary Incontinence/Fecal Impaction M yocardial Infarction, multiple comorbidities
Delirium Assessment “CAM”
The Confusion Assessment Method (CAM) is a tool designed for non psychiatric trained individuals to recognize delirium quickly and accurately. The test only identifies if delirium may be present and not the degree of delirium.
Confusion Assessment Method (CAM)
Four Features of Delirium Feature 1
and Feature
2 need to be present
plus
Feature 3 or Feature 4
Geriatric Bundle: Differentiating Depression, Delirium and Dementia
Parameter Onset Duration Initial Presentation Recent Memory Intellect Judgment Pattern Attention/Affect Orientation Level of Consciousness Psychiatric symptoms Depression
Weeks 3-6 months, may be chronic Flat affect, hypochondrial, focus on symptoms, apathy, little effort to perform Normal or recent/past both altered Slower, may be unwilling to respond Poor judgment, many “ I don ’ t know answers ” Worse in the morning, sleep impaired
Delirium
Short, rapid, abrupt, hours, days Days to 3 weeks Disorientation, clouded, consciousness, fluctuation in moods, disordered thoughts Partial impaired or remains intact Impaired Impaired, difficulty separating facts, hallucinations Day drowsiness, nighttime hallucinations, insomnia, nightmares Withdrawn, apathy, hopeless, distress Labile, fear/panic, periods of lucidity
Dementia
Months to years 5-15 years Vague symptoms, loss of intellect, easily distracted, great effort to perform tasks Impaired Impaired concrete thinking Impaired, had inappropriate decisions, denies problem Worse in the evening, sundowning, reverse sleep cycle Easily distracted, labile, inappropriate, anxiety, depression, suspicious Intact Disoriented but not to person. Periods of lucidity Disoriented Intact Disturbed Intact Delusions Delusions Hallucinations
“CARING FOR YOUR FUTURE SELF” Dr. Daniel Keys (EPMG)
“ We should all be concerned about the future because we have to spend the rest of our lives there” C.F. Kettering
WE’RE ALL IN !!!
ARE YOU?