Redesigning Care for Cognitively Impaired in Sub
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Transcript Redesigning Care for Cognitively Impaired in Sub
Redesigning Care for Cognitively
Impaired in Skilled Nursing Facilities
Arif Nazir MD
Assistant Professor,
IU School of Medicine
Feb 18, 2014
Mr. Polly
78 yoWidower lives alone in a single story home
Retired realtor, Mr. P is fully independent and drives
Daughter lives 20 miles away and visits 2/week
Diabetes, heart disease, high cholesterol and blood pressure
Admitted to hospital with fever and pneumonia
Daughter states “No memory problems but…forgets
occasional appointments, twice lost his keys, once got lost
while driving”
Mr. P (contd.)
3rd hospital day he has no fever
“Slept like a baby” but in morning confused about where he
was; calling his wife
Weak and poor balance; therapy recommends sub-acute care
in a nursing facility
For skilled rehab and ongoing IV antibiotics
Daughter selects Shabby Meadows close to her home
Mr. P is discharged at 4 pm
Shabby Meadows
Nurse Rhonda receives Mr. P
Was reported to her, “78 yo demented male with sundowning”
Calls Dr. Z to confirm orders
Requests a “sleeping pill” so she doesn't have to “bother” Dr. Z
“Xanax 0.5 mg as needed every 4 hrs” ordered
At 10 pm Mr. P starts calling for “dead wife”
Receives Xanax at 11 pm and 4 am
Mr. Polly is too sick
At 7 am half naked, with legs hanging off the bed
Incontinent, drooling & “swings” at the nurse
The director of nursing (DON) calls Dr. Z who cant visit
As per his request Mr. P transferred to inpatient psych
1 week later pt. returns with 3 new meds (2 antipsychotics)
Now “calm and friendly” with “no complaints”; poor intake
2 weeks later patient found unresponsive and 911 is called
Delirium and SNFs
Delirium: A serious and sudden disturbance in
a person's mental abilities that results in a
decreased awareness of one's environment and
confused thinking.
Onset: Within hours or days
15-23% on admission to SNF have delirium
Only <30% recognized by clinical teams
Persists weeks to months
In >60% it will persist or be worse in 1 week
Marcantonio et al. JAGS 2003; Kiely et al. J Gerontol A Biol Sci Med Sci. 2004
Consequences of Delirium in SAR
Persistent delirium confers 2.9 greater risk of death
Poor functional recovery
Higher long-term placement
Association of persistent delirium with more geriatric
syndromes (falls, ulcers, pain, depression, malnutrition,
urinary retention)
Higher healthcare costs
More survey deficiencies for SAR
Anderson et al. JAGS 2012; Jones et al. JAMDA 2010
Usual Care in SNFs
>90% nursing homes provide rehab
Of 15 M annual Medicare admits
>20% (500,000) require SAR
Most care provided by Licensed Practice Nurses (LPNs)
Certification entails 5 semester training (45 credit hrs)
Can collect data but cannot assess patients
Regulation mandates “interdisciplinary” care:
Physicians to sign orders in 48 hours (can be via fax)
At least monthly visit for 3 months
Barriers to Effective SNF care
Inadequate staff training
Staffing levels
Lack of protocols for admission and f/u assessments
Multidisciplinary care, as opposed to interdisciplinary
Resource adequacy
Level of Physician supervision
On-call teams
Regulatory “distractions”
Lack of evidence-base
Enhancing Care of Cognitively
Impaired in SAR
DELIRIUM
DEMENTIA
Back to the Drawing Board?
Imagine it is 2063 and you get admitted to a
SNF with delirium. You get terrible care and
you are DYING!
You want to come back to 2014 and “fix” the
issues
Clarifying Questions
How will you redesign care for cognitively
impaired patients in SNFs?
Key elements will you focus on
New resources will you provide
Other healthcare venues that we can learn from
Regulations you will lobby for
Other industries that can guide us?
Full Definition of REDESIGN
: to revise in appearance, function, or content
— redesign
noun
Evidence for High Quality geriatrics Care in
SAR
Interdisciplinary care
Involvement of facility physicians and pharmacists
Potential Ingredients for an Effective
Model for Delirium Care in SAR
-Environmental Modifications
-Staff training
- Systems for hand-off to other shifts
and weekend staff
Better recognition:
• CI (cognitive screens)
• Geriatric syndromes
(Geriatric evaluation)
True Interdisciplinary
Care:
Team rounds with
physician (focus on
hearing, vision,
hydration, and pain)
Medication
management
Delirium Abatement in SAR
1 Randomized trial in 8 Boston facilities
Delirium Abatement Program (DAP)
Nurse-led intervention for early detection and screening
Primary outcome: persistence of delirium
Assessment and treatment of reversible causes; prevention and
management of complications; and restoration of function
Delirium education for all staff
Facility handouts and environmental modifications
Did not achieve the outcome to decrease length of duration
Less than ideal adherence with protocols
Models that can be used as examples
Healthcare
ICU model
Inpatient rehabilitation Care
Acute care for elders (ACE) model
Outside Healthcare:
Adherence to protocols (six sigma, Lean)
Evidence for Delirium Prevention
RCT with protocols for 6 risk factors for delirium
CI, sleep deprivation, immobility, visual and hearing impairment
and dehydration
Intervention decreased incidence, and duration of delirium
Geriatric consultation decreased delirium by 30% in hip
fracture patients (NNT=5.6)
Mean of 10 recommendations with 77% acceptance
Nurse-led consultation in hip fracture patients
Staff education, pain control, cognitive screening
Decreased delirium duration and severity
Marcantonio et al. JAGS 2001; milisen et al. JAGS 2001