Transcript Document

TO TREAT OR NOT TO TREAT: HOW
CLINICAL CONUNDRUMS BECOME
OPPORTUNITIES FOR QUALITY
IMPROVEMENT
Daniel Bluestein, MD, MS, CMD
Sabine M. von Preyss-Friedman, MD, CMD
Ashkan Javaheri, MD, CMD
Irene Hamrick, MD
Learning Objectives:
By the end of the session, participants will be able to:
1. Articulate a framework for evaluation of weight loss,
urinary tract infection, depression, & osteoporosis.
2. Summarize evidence for the pros and cons of doublesided therapeutic options regarding these entities.
3. Examine potential quality improvement opportunities in
relation to these entities.
4. Discuss how the interdisciplinary team can be engaged
in this process.
QI Caveats
• Understand variation: Example; My trip from EVMS to WC
• Is variation in rates within statistical limits?
• Or did the process change?
• Techniques for doing this beyond scope of this talk
• Recc workshop by Matt Wayne & Len Gelman at national meeting
• Understand the process
• Flow charts
• Fishbone diagrams
• Pareto charts
• MOST IMPORTANT
• Brainstorm w stakeholders
• Don’t rush to judgment (or blame)
WEIGHT LOSS
Daniel Bluestein, MD, MS, CMD, AGSF
Professor & Director, Geriatrics Division
Department of Family & Community Medicine
Eastern Virginia Medical School
Case
• On day on rounds, The team leader on 1-A tells me Ms. X
has lost 7 lb. over the past month (she’s 109 years old).
• She shows you the dietician progress notes that Mirtazapine be
considered
• Or if not Mirtazapine, then Megace or Marinol
My responses (a Parody of Kluber-Ross)
• Denial• Is this for real
• Anger• How could you all be so dumb
• Bargaining• If I put Ms. X on something, maybe they will shut up & leave me alone
• Depression• I need to go somewhere else
• Adaptation• Maybe I can make this better
E/M: Like some relationships “It’s
complicated”
frailty
cachexia
Rxable
anorexia
sarcopenia
E/M Overview
1.
2.
3.
Identify & anticipate at-risk pts (“SNAQ”)
Are weights accurate?
Is this fluid loss?
•
•
•
•
•
4.
5.
Vomiting & diarrhea
Diuretics
Osmotic losses (hyperglycemia)
Inadequate access
Physiologic effects of aging
How much food is he/she taking in?
Consider interventional strategies
• Condition specific
• Generic
• Dietary supplements
• Ambience/Assistance/Appeal
• Activity & exercise
• Drugs
Contributors: “the Ds”
1.
DiseasesHypermetabolic
a)
•
•
•
Wasting
b)
•
•
•
•
•
•
•
2.
3.
4.
Thyroid
Pheochromocytoma
Diabetes
Cancers
Collagen/vascular
infections
COPD
ESRD
Chronic infections
Pressure ulcers
Depression
Dementia
Digestive
a)
b)
c)
Diarrhea
Dysphagia
Other GI
5. Dysgeusia
6. Dentition
7. Drugs
• etoh
8. Deficiency states
9. Dysfunction
10. Distasteful Diets
11. Don’t know
Huffman. Am Fam Physician
2002;65:640-50
The Ds in LTC
• Depression
• Drugs
• Dysfunctions
• Dependent on others to feed (staff turnover, understaffed)
• Isolation/poor ambience
Tamura et al. JAMDA 2013; 14(9):649-55
• Dysmobility
Aoyama et al. JAMDA 2005; 6:566-72
• Dysphasia
• Dental/Oral
• Dementia/agitation/sedation
• Diseases-wounds, COPD, CHF…
• Distasteful Diets
• Deficiencies
• Don’t know
Common Sense Treatment
• Treat underlying disease.
• Endocrine, drug, GI disorder, depression most amenable.
• Functional
• Dental care/dentures-oral hygiene
• OT/PT/Speech/swallowing eval’ns
• Hearing aides & glasses
• Facilitate Bowel function
• Exercise even in frail elders
• Dietary
• Ambience
• Assistance
• Small, frequent meals
• Taste facilitators
Supplements-conflicting evidence
• Some studies show 1-2 kg gains in supplement group vs. 1 kg
loss in controls
• Small sample sizes
• 60 day f/u
• No real changes in functional status
• Others: supplements substitute for meals, caloric intake the
same
• Should use between meals, not with
• Cochrane (2009):
• Small increase wt
• Small mortality reduction
• Morley et al. JAMDA 2010; 11: 391–6, varied JAMDA editorials
• More sanguine about leucine-containing supplements in concert with
exercise
Drugs
• Mirtazapine• small wt gain –up to 7% at best
• ? any better than other antidepressants
• ? Effect in non-depressed
• Hyponatremia, sedation, orthostasis, serotonin syndrome
• Megestrol Acetate
• Yeh et al RCT: 4 lb wt gain @ 25 wks; no mortality difference
• DVT, CHF, Adrenal suppression, ↑mortality, large C/C study
• Dronabinol
• Mostly small studies: 5-10 ib gain at best
• MI, delirium, death
• http://www.uptodate.com/contents/geriatric-nutrition-nutritional-
issues-in-older-adults?source=see_link&anchor=H20#H20
What I did
• Read up on Dx & Rx of wt loss
• Went on “weight & wounds rounds” a few times
• (Usually on a Tuesday AM when I can’t easily attend)
• Some findings:
• Lack of real knowledge
• Good intentions
• External pressure
• Organizational culture; other priorities
• NO PROCESS
• They are really not used to a hands-on medical director
My intervention
• Educate & inform
• Develop & implement a rational, step-wise policy, Elements:
• Screen for nutr risk -SNAQ or tool of your choice
• When someone triggers on wt loss:
• Med review for new meds
• PHQ 2/9
• Note to provider to assess for other treatable causes as appropriate in
keeping with prognosis & philosophy of care
• Implement of non pharmacological interventions
• Reassess & consider
• Further evaluation on occasion
• Risk/benefit ratio of drugs
• In process: Goal:
• 1o: documentation this process has been followed
• 2o: stabilization/improvement
It remains to be seen…
• Whether this (& other QI measures discussed today)
improve care remains an open question at this time.
To Treat Or Not To Treat:
How Clinical Conundrums Become Opportunities For QI
URINARY TRACT INFECTION
OR
ASYMPTOMATIC BACTERIURIA?
Sabine von Preyss-Friedman MD, CMD
Associate Clinical Professor, Division of Gerontology and Geriatric Medicine,
University of Washington
Asymptomatic Bacteruria
• Prevalence (without catheters)
• 25-50% for women
• 15-40% for men.
• Prevalence (with Catheters)-100%
• Treatment does not improve outcomes
• Consequence: Frequent, unnecessary Abx
• Cost
• Resistance
• C Diff
• Adverse effects
• Drug Interactions (cipro-coumadin)
• Inadvertent nephrotoxic doses (flouroquinolones, nitrofurantion)
• Missed the real problem
Nicolle LE. Int J Antimicrob Agents. 1999
On the other hand….
• Non specific presentation of serious infection
• Dubious (or no) history in cognitive impairment
• True UTI & Urosepsis are alive & well
• Symptomatic UTI: 0.1-2.4 episodes/1000 resident days (variation
due to differences in definitions).
• Systemic infection: 0.49-1.04/10,000 noncatheterized-resident
days.
Problem, continued
• Serious complications from infections
• Death from potentially treatable cause
• Transfers
• Functional decline
• LTC:
• More limited diagnostic resources
• Telephone medicine (e.g. “empirical” abx)
Grey areas
• The febrile patient with a positive U/A or culture & no
other focus:
• Only 10% of such patients show rise in serum antibodies to
infecting urinary pathogens.
• Corollaries:
• Look hard for other reasons for fever
• Consider other studies such as a CBC
• Fever + hematuria does point more to UTI
• The patient who is acting “differently”
• Typically more advanced dementia, can’t give History
• Lots of other reasons to consider
• If UTI the cause, will have fever
• Treatment? Guidelines would say no.
How are Practitioners making decisions?
• 19 MDs, 3 PAs, 41 nurses.
• 5 most common triggers for suspect UTI, noncatheterized
pts.
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•
•
•
•
change in mental status (90%),
fever (76%),
change in voiding pattern (70%),
dysuria (65%),
Change in character of urine (59%)
• MDs, PAs significantly less likely to know or apply
diagnostic criteria.
• 55% would treat asymptomatic bacteruria
• Nurses more likely to urge treating asymptomatic
bacteruria
• See nonspecific changes in status as “symptoms”
• Juthani-Mehta et al. JAGS, 2005.
Why Antibiotic Overuse?
 Lack of up to date Medical Education
 Ingrained beliefs of Medical Providers,
Nursing, patients, families
 Geropsychiatry ”Due Diligence”
 Fear of rapid deterioration and poor outcomes
in frail elderly who have bacterial infection
Prior Criteria less than helpful
• 2013 study of Loeb criteria (data collected 2011)
• Often disregarded
• Even when taking into account, did not curb antibiotic use
• Olsho et al. JAMDA 2013; 14(4):309 e1-e7.
New McGeer Criteria, 2012
• Fever Definition
1. A single oral temperature greater than37.8°C (100°F) or
2. Repeated oral temperatures greater than37.2°C(99°F)or rectal
temperaturesgreaterthan37.5°C (99.5°F)or
3. A single temperature greater than 1.1°C(2°F) over baseline from any
site.
• Acute functional decline in activities of daily living (ADLs)
• A new 3-point increase in total activities of daily living (ADL) score
(range, 0-28) from baseline, based on the following 7 ADL items,
each scored from 0 (independent) to 4 (total dependence) Bed
mobility, Transfer, Locomotion within LTCF, Dressing, Toilet use,
Personal hygiene, Eating
• Use of CAM to define acute change in mental status
• Re. UTI-reliance on cx w appropriate symptom
combination (either alone is inconclusive)
UTI (No Indwelling Foley), Criterion 1,
Need Both:
 At least one of the following s/s:
 Acute dysuria or acute pain, swelling, or tenderness of testes,
epididymis, or prostate in men
 Fever or increased WBC and ONE of the following:
○ Acute costovertebral pain or tenderness
○ Suprapubic pain
○ Gross hematuria
○ New or increased incontinence
○ New or increased urgency
○ New or increased frequency
 No fever or increased WBC and TWO from the above list!
Criterion 2. One of the following microbiologic
subcriteria:
• At least 100,000 cfu/mL of no more than 2
species of microorganisms in a voided urine
sample.
• At least 100 cfu/mL of any number of
organisms in a specimen collected by in-andout catheter
UTI with foley
For residents with an indwelling catheter (both criteria 1
and 2 must be present):
Criteria1 (at least 1 of the following signs/symptoms):
• Fever, rigors, or new-onset hypotension, with no alternate site of
infection.
• Either acute change in mental status or acute functional decline,
with no alternate diagnosis and leukocytosis.
• New-onset suprapubic pain or costovertebral angle pain or
tenderness.
• Purulent discharge from around the catheter or acute pain,
swelling, or tenderness of the testes, epididymis, or prostate
With foley, continued
Criteria 2. Urinary catheter specimen culture with
at least:
• 100,000 cfu/mL of any organism(s).
• Recent catheter trauma, catheter obstruction, or
new onset hematuria are useful localizing signs
that are c/w UTI but are not necessary for
diagnosis.
• Urinary catheter specimens for culture should be
collected following replacement of the catheter (if
current catheter has been in place for >14 d).
interventions
 Inservices about UTI vs. ASB to nursing staff
 Medical Director provides attending physicians with
literature and personal education and discussion
 Medical Director inservices psychiatric consultants
• “MD compare”
• Protocols based on McGeer Criteria for when it is
appropriate to order a U/A
Alternatives to Rx for grey areas
• Examples:
• Isolated voiding symptoms,
• increased incontinence,
• change in urine odor,
• change in behavior…
• Watchful waiting for 24 hours
• No u/a or c/s
• Hydrate
• Perineal hygiene
• Address constipation
• Attend to comfort
• Q 8 VS
• Evaluate for UTI if go on fulfill criteria
• Look for alternatives if sx persist
It remains to be seen…
• We still lack a convincing
marker for UTI vs. colonization
in advanced dementia.
• Sx to meet minimum criteria for
UTI frequently absent in NH
residents w advanced dementia.
• Abx are prescribed for the
majority of suspected UTIs that
do not meet these minimum
criteria
• D’Agata et al. JAGS
61(1):62-6
2013;
To treat or not to treat:
How Clinical Conundrums become
Opportunities for Quality Improvement
Depression
Ashkan Javaheri, MD, CMD
Assistant Clinical Professor- UC Davis School of Medicine
Geriatric Division and Senior Care Program
Division Head
Mercy Medical Group
Sacramento, CA
Overview
• Prevalent
• Treatable
• Often under-recognized
Chronic Medical Illness and Depression
 Stroke 30 to 60 %
 Coronary heart disease 8 to 44 %
 Cancer up to to 40 %
 Parkinson’s disease 40 %
 Alzheimer’s disease 20 to 40 %

Boswell EB, Stoudemire A. Major depression in the primary care setting. Am J Med. 1996;101:3S–9S
7/18/2015
Consequences
• Decreased quality of life
• Decreased participation in activities
• Falls
• Malnutrition
• Dehydration
• Increased risk of intercurrent infections
• Behavioral symptoms
• Agitation
• Rejection of care
7/18/2015
Suicide
• Elderly 13% of US population; 24% of completed suicides
• Less often; more likely successful
• Elderly men highest suicide rate: 28.9/ 100,000.
• Yes it can happen in LTC
7/18/2015
Trends-LTC (1999-2007)
• Diagnosis of depression and antidepressant therapy in
residents diagnosed increased rapidly.
• By 2007, 51.8% of residents diagnosed with depression,
82.8% of whom received an antidepressant.
• Gaboda D et al. JAGS 2011; 59:673–680
Underuse/ Overuse




3692 LT residents in 133 VA facilities
877 depressed
25.4 % did not get treatment underuse
57.5% potential inappropriate use
 drug-drug and drug-disease interactions
 2,815 residents who did not have depression, 1,190
(42.3%) were prescribed one or more antidepressants
 Hanlon JT - J Am Geriatr Soc 2011
Not as safe as we once thought
 SSRI safer than older drugs, still first choice
 SSRIs have side effects;


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Falls,
hip fracture,
insomnia,
hyponatremia
GI bleeding,
worsen RLS,
serotonin syndrome
Evidence Base
 Available evidence offers weak support to the contention
that antidepressants are an effective treatment for
patients with depression and dementia and at best
moderate evidence in non demented patients.
 It is not that antidepressants are necessarily ineffective
but there is not much evidence to support their efficacy
either.
 Given that they may produce serious side-effects
clinicians should prescribe with due caution.
 Cochrane Database Syst Rev. 2002
 Hanlon et al, J Am Med Dir Assoc 2012
 Boyce et al, J Am Med Dir Assoc 2012
Why-depression a mixed bag
 Medical causes
 Major Depression
 Minor Depression (or Subsyndromal)
 Dysthymia
 Bereavement
 Vascular Depression
 Psychotic Depression
 Depression in AD
 Thakur M, Blazer D, J Am Med Dir Assoc 2008
Medical conditions associated with depression
symptoms
 Uncontrolled pain
 Medications
 Alcohol and substance abuse
 Thyroid disease
 Anemia (B12)
 Electrolyte abnormalities & organ failures
 (Cancers)
Major Depression DSM-IV
• Symptoms for > 2 weeks
• Other symptoms
• 5 or more symptoms
• Significant weight loss or weight gain
• At least one should be
(more than 5%)
Insomnia or hypersomnia
Psychomotor retardation or agitation
Fatigue or loss of energy
Feelings of worthlessness or
excessive or inappropriate guilt
Diminished ability to think or
concentrate, or indecisiveness,
nearly every day
Recurrent thoughts of death (not just
fear of dying), recurrent suicidal
ideation without a specific plan, or a
suicide attempt or a specific plan for
committing suicide
•
• Depressed Mood
•
• Anhedonia (lack of interest or
•
pleasure)
•
• Meds retain utility here
• Mild; 5% superior to placebo (46-
AND
41%)
• If major, severe, or prolonged
depression, 27% superior (58%31%)
• Nelson et al. Am J Psychiatry, 6-
13
•
•
Subsyndromal Depression/Dysthymia
 One of core symptoms (depressed mood / anhedonia)
plus 1 to 3 (other) symptoms
 Depression without sadness in elderly
 Risk factor for Major Depression
 For > 2 weeks => chronic
 Associated with
 Poorer health and social outcomes
 Functional impairment
 Higher health utilization and treatment costs
 Not very responsive to drugs in younger
populations
 Role for non-pharmacological therapies
Bereavement
• Usually time-limited
• Behavioral treatments, support groups treatments of
choice
• Now indications for meds if bereavement triggers major depression
• Likewise for complex or protracted bereavement
• Simon NM. JAMA 2013; 310(4):416-23.
Psychotic Depression
 Subtype of Major Depression
 Depression with delusions (somatic and persecutory)/
hallucinations
 Common in elderly
 Especially inpatient and long-term setting
 ECT
Vascular Depression (subcortical ischemic depression)
 Ischemic changes are detected with MRI
 Higher prevalence in patients with vascular dementia
 20%- 50% of patients develop depression within 1st year
after stroke
 Left hemisphere more chance of depression
 Associated with more cognitive impairment and disability,
more psychomotor retardation, less agitation, less guilt,
and less insight into their illness
 Some may have “silent stroke”
 No consensus of diagnosis
 Response to drugs?
Apathy
Ishii S et al. Apathy: A Common Psychiatric Syndrome in the Elderly.
JAMDA 2009; 10: 381–93.
Other considerations
• Short vs. Long-term residents
• Seasonal variation
Screening for depression
• The USPSTF recommends screening adults for
depression when staff-assisted depression care
supports are in place to assure accurate diagnosis,
effective treatment, and follow-up.
Grade: B recommendation.
• The USPTF recommends against routinely screening
adults for depression when staff-assisted depression
care supports are not in place. There may be
considerations that support screening for depression
in an individual patient.
Grade: C recommendation.
Tools
 Geriatric Depression Scale (GDS)
 www.stanford.edu/~yesavage/GDS.html
 GDS-15: sensitivity 84%, specificity 85.7%
 Limm PP et al, Int J Geriatr Psychiatry 2000
 Cornell Depression Scale
 http://img.medscape.com/pi/emed/ckb/psychiatry/2859111335300-1356106-1392041.pdf
 sensitivity 93%, specificity 97% with a cut-off value of ≥6
for patients with dementia
 PHQ-2/9
PHQ-9
• Total Score Depression Severity
• 0-4 None
• 5-9 Mild depression
• 10-14 Moderate depression
• 15-19 Moderately severe
depression
• 20-27 Severe depression
• Score >10 has 88% sensitivity
and specificity for major
depression diagnosis
• Part of MDS 3.0
• May be disconnect between MDS
process & clinical care
Evaluation and Treatment of Depression is
team work!
 CNAs
 Nursing staff and MDS coordinator
 Dietary
 Activity staff
 Pharmacists
 Social Workers
 MDs, NPs, and PAs
 Psychologist
 Psychiatrists
 Therapy staff (PT/OT/ST)
 Patients
 Families
Who should be part
of the team?
What is done with
positive screens?
Who is the
champion?
Process
• Create a team
• Identify champion
• Identify residents with PHQ-9
scores above 5 and 10
• Create communication system
• Tailor therapies:
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


Danger to self
Prior history of depression
Psychotic symptoms
Any past treatment(s)
• Screener RN  clinician 
RN/ Team
• Clinician may make the
diagnosis
• Behavioral consultant
• Care plan (all team members
should be involved)
• Monitor PHQ-9 score in
response to therapy
• Alternate and adjust you care
plan as you move forward
• Meet regularly and review data
Further considerations
 Accurate assessment
 Match variant to therapy
 Psychologist or psychiatrist in some cases
 May try empirical SSRIs
 Drug
 Safety
 Side effect profile for therapeutic advantage
 Avoid drug interactions
 Dose
 Duration
 Assess response-serial PHQ-9s
 How about other disciplines? Activities, …
 What if treatment fails?
American Medical Directors Association
Long Term Care Medicine
To Treat or not to treat: How clinical
conundrums become opportunities for QI
Osteoporosis in Frail LTC
Patients
Irene Hamrick, MD
[email protected]
Your thoughts? Clinical &
QI

97 year old bedbound patient sustains
femur fracture during diaper change
– admitted to Nursing facility area of CCRC
2 years ago after stroke

Family is outraged and demands to
know how this could happen
To not treat…

Do tools for screening in younger populations apply here?
– Bone Density measures, practical?
– FRAX

Side effects of antiresorptives
– Esophageal erosions
– Renal issues


Safety & practicality of administration
Paradoxical outcomes
– Jaw necrosis
– Atypical fractures


? Benefit during lifetime
Limited evidence for bisphosphonates
Or Treat?


Not doing so can lead to bad
outcomes as in this instance
In LTC
– Prevalence O/P 85%
– Rate of osteoporotic fractures 11%/yr in
NH vs. 2-3% in community.
– Nursing home residents who suffer Fx,
any site-15 fold increase in hospitalization
Vertebral Fx
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back pain,
dysphagia,
kyphosis,
reduced pulmonary function,
diminished quality of life.
Narcotic side effects
Vertebroplasty/Kyphoplasty?
Osteoporosis & Stroke
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
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Hip fracture increased 2 to 4 times
in stroke patients over age-matched
reference population, especially in
1st year after stroke
82% on hemiplegic side
84% due to falls
Ramnemark A et al. Osteoporos Int. 1998;8:92–95.
Kanis J, et al. Stroke. 2001;32:702–706.
Chiu KY, et al. Injury. 1992;23:297–299.
Question

How soon after stroke is most bone
lost in the paralyzed side?
a)
b)
c)
d)
4
4
1
4
weeks
months
year
years
Bone Loss
after
Stroke

Bone loss most severe in first 3-4 mo.
– Upper extremities ↓ by 9.3% (P = 0.01)
– Lower extremities ↓ 3.7% (P = 0.01)
Hamdy 1995 Am J Phys Med Reh 74;351-6
Guidance

Consider Rx for
– clinical hip or spine fracture,
– radiological evidence of a VF,
– BMD data if available.

Since O/P Rx demonstrate Fx
reduction in ~ 1 year, do not use if <
1 year life expectancy.
Greenspan et al. JAGS 2012; 60(4):684-90
CA + D

Cochrane review-reduction of hip and nonvertebral fractures when
vitamin D and calcium were taken together.
– subgroup analysis benefit most significant in institutionalized persons
– Avenell et al. Cochrane Database Syst Rev 2005;3:
– CD000227.


Feb 2013 USPSTF did not endorse but did not engender LTC
residents
Ca side effects
–
–
–
–


Constipation
Ca-carbonate
Ca-citrate
Binding effects
? Vit D levels vs. empirical supplementation
Uncouple Ca & D
Evidence for Bisphosphonates
in LTC admittedly thinner

alendronate (10 mg po qd) vs. placebo in elderly women
in LTC w O/P
– alendronate increased BMD in both spine and femoral
neck
– good tolerance,
– incidence of Fx lower in alendronate group but did not
reach statistical significance
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
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
limited # participants
short follow-up.
Greenspan et al. Ann IM 2002; 136(10):742-6.
Extrapolate from less frail pop’ns
Bisphosphonates post hip fx reduce recurrences
QI ramifications

Identify patients with a diagnosis of osteoporosis
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Consider 2o causes if appropriate
Look for risk factors
Assess if all patients in facility who have osteoporosis
are treated or have a documented reason for no
treatment
Recognize impact of immobility
Engage the IDT for suggestions re diet, weightbearing,
sun exposure
Pharmacy review
– Vitamin D and Calcium on MAR
– Minimize interactions
– Correct administration of other Osteoporosis meds
Conclusion



Vitamin D 800-1000 IU daily, higher in
deficiency
Calcium 500-600 mg twice daily if
inadequate dietary intake
Discuss high fracture risk, additional
medication treatment with family
In parting…



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Don’t get mad or despair-get creative
Keep up with developments & best practices
Goals are care processes rather than clinical outcomes
Engage the team
Be persistent