Transcript Current Topics In Geriatrics
Risk Management and Quality Improvement in LTC
Karl E. Steinberg, MD, CMD
Associate Medical Director, Scripps Coastal Medical Center, Oceanside President, California Association of Long Term Care Medicine (CALTCM) Medical Director, Las Villas de Carlsbad HC, Village Square Nursing Center, Hospice by the Sea Editor-in-Chief, Caring for the Ages
Objectives
Consider When to Call Doctor & What to Say Review Notification Requirements Importance of Informed Consent & Refusal Discuss Common Documentation Problems/Errors Realistic Goals for Care Plans Explore Issues With Unrealistic Residents & Families
Objectives
Associated Documentation Issues & Risk Management Strategies
Vital Signs, O 2 Sats
Assessments
I/Os, Hydration, Nutrition
Turning & Repositioning, Pressure Ulcers
UTI vs. Asymptomatic Bacteriuria
Issues in Diabetes, Anticoagulants, Depression
Recognize Current Negative Public Opinion of our Industry & Strive to Improve It!
Compassion, Empathy, Human Touch Go a Long Way
Contacting the Physician
True Emergencies: Obviously, Use Most Immediate Method (Pager, etc.) May Need to Take Action without Orders Significant but not truly Emergent symptoms: Consider Personal Preferences of MD/DO, but do not compromise patient safety Moderate Symptoms, Need System to Ensure Follow-Up is Obtained! (& Documented) Minor Symptoms (Skin Tears, Weight Fluctuations, Non-Injury Falls) Consider Fax with Printed Confirmation Sheet
Methods of Communication
Direct/Immediate (In Person, 2-Way) By Telephone (Direct Conversation, 2-Way) By Voice Mail Message (Indirect/One-Way) Via Fax (Indirect/Passive, One-Way) Log Book or Communication Book (One-Way) E-mail (One-Way) Via EHR System Via Alpha Pager or Text Message (One-Way)
Different Situations Require Different Documentation
Notification of changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative interested family member when there is— or an (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in § 483.12(a).
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Notification of changes.
When in Doubt, Notify!
Failure to Timely (“Immediately”) Notify Physician & Family Member May Result in Deficiencies/Citations Can also Result in Successful Lawsuits Important to Document Notification If Unsuccessful, Keep Trying
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And Keep Documenting!
Use Nursing Judgment Call for Backup if Needed
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DON, Medical Director
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Administrator/Executive Director
Other Times to Initiate Contact
Abnormal Vital Signs (What Does This Mean?)
Skin Breakdown
Poor Dietary or Fluid Intake
Weight Loss
Falls/Near-Falls
Abnormal Laboratory Studies
***Family Concerns ***
Usually OK to let Family Know How to Contact Doc
Usually NOT OK to Page Doc from Nurses’ Station for Family & Hand Phone Over! (Ambush!)
Other Times to Initiate Contact
Resident Symptoms (Pain, Cough, Dyspnea, Bowel Irregularities, Dysuria, Confusion, etc.)
When an Order is Not Carried Out as Directed
Labs Not Drawn for any Reason
Medication Not Administered or Delivered (Timely)
Can Solicit a Substitute from E-Kit if Appropriate (esp. for Pain or when Serious Infection is Suspected)
Refusals of Medication or Treatment
Refusals of Turning & Repositioning or Use of Splints, Adductor Pillows, Heel Protectors, etc.
Unexpected Delays in Appointments for Test/Consult
Sophie & Tessa
Established Principles for Effective Communication
Except in Emergencies, Take Time to Prepare!
Do An Appropriate Assessment Before Calling
Have All Information Ready for Provider
Consider Calling Responsible Party First
Assess and Mention All Relevant Diagnoses
Know the Preferred Intensity of Treatment!
It’s OK to Have an Agenda, but Be Flexible
Worth Having it Written Down Beforehand
Consider SBAR or Similar Pre-Printed Forms
Specific Strategies for Effective Communication/Notification
Have All Information Ready for Physician
Chief Complaint & Associated History
Vital Signs, Full Set, Recent!
Actually Do a Respiratory Rate
Include Orthostatics if Appropriate
Oxygen Saturation
Results of Focused Physical Assessment
e.g., Lung Sounds, Abdominal Exam (Bowel Sounds, Tenderness, Distention), Cardiac Rhythm/Sounds
Check for Impaction, Check for Bladder Distention
Assess Mental Status in Comparison to Baseline
Actually Assess Orientation—Residents Can Fool You!
Delirium Grossly Underdiagnosed & Carries Poor Prognosis
Specific Strategies for Effective Communication/Notification
Have Medication List Handy
Know if Resident is on Coumadin (Antibiotic Interactions)
Know if Resident is or has been on Antibiotics recently
(Increased Risk of C. diff., Yeast, Drug Reaction, etc.)
Have MARs with recent Blood Glucose values if applicable, and Current Sliding Scale Coverage
Know when last BM & Void Occurred, Meal Intake
Know Hx of Previous Impaction, Retention, Infections
Consider the Use of a Standardized Form
Can Create Facility-Specific, Symptom-Specific Forms
Get Medical Director to Provide Input!
Specific Strategies for Effective Communication/Notification
Consult with Other Personnel if Available
CNA Usually Knows Resident Best! Talk to Them!
Therapy Staff
Social Services or Case Manager: Is Discharge Looming?
Talk to Resident and/or Family (if Non-Emergent)
Know Code Status and Preferred Intensity of Treatment
Consider Diagnostic & Therapeutic Measures In-House
Obtaining Labs/X-Rays
IV Hydration
IV Antibiotics
Respiratory Therapy (Nebulizers, Incentive Spirometry, Steroids, O 2 ) More Frequent Monitoring: Vitals, Sats, Mental Status, etc.
Define Callback Parameters
Specific Strategies for Effective Communication/Notification
Have Most Recent and Older Labs/XRs at Hand
Important to Provide Baseline & Comparative Values
Have a Summary of Your Impressions & Concerns
Have an Idea of What Your Wish List for the Situation Is—Offer it if Appropriate
Must Consider Individual Practice/Personality Styles of Providers: In Some Instances, Tread Lightly
Also Consider Individual Factors of Resident/Family
Be an Advocate for Your Residents
Have a Policy Mandating Read-Back of All New Orders, and Enforce It! (Safety First!)
Specific Strategies for Effective Communication/Notification
If Nurse is Uncomfortable with MD/DO/NP/PA Response—Call an Authority within the Facility to Discuss (DON, Admin., Medical Director, etc.)
Need to Practice in Accordance with Your Principles
If Something Doesn’t Feel Right, It May Not Be Right
But Also Need to Consider Your Own Limitations
In Some Cases, Turn Care Over to Another Nurse
Need to Consider Your Own Professional License
Need to Consider Facility/Corporate P&P
Sometimes Involves Taking Alternative Action
If You Have Corporate Backup, Use It! (Consultant, Regional Nursing or Risk Management Professional, etc.)
P O L S T
Growth Areas for Quality
Hold Parameters on Medications
An Excellent Idea in Principle, Should Improve Safety Needs to Be Consistently Implemented May Require More Frequent Monitoring Generally Physician-Driven Most Commonly Used with Antihypertensives, Digoxin
May Hold Antihypertensive for SBP<95-120 May Hold Digoxin or Beta-Blocker for AP<50-60 Also Consider What Holding Medication May Do Should Consider Holding Opioids for Excess Sedation or RR<8-10 Nebulizers, Sliding Scale Insulin are Grossly Overutilized. Rarely Truly Necessary.
Dehydration a Common Problem & Cause of Change in Condition
Can Present as Lethargy, Abnormal VS (
↑ HR,
↓
BP)
Vicious Cycle as Intake Diminishes Further
CNAs Often the First to Notice Subtle MS Changes, ↓
CNAs Also First Line of Defense in Prevention & Tx
Empower CNAs — Encourage Communication, Listen To & Appreciate Their Input!
Intake
Snack/Hydration Carts A Good Idea
Sometimes, Relative “Dehydration” is Desirable (Diuretics, CHF)
Clinical Signs of Dehydration Somewhat Unreliable Until It is Advanced, But their Presence or Absence Should Be Documented
Skin Turgor (Consider Forehead)
Mucous Membranes, Sunken Eyes, Dry Axilla
Lab Work More Definitive, (Not Just BUN & Creatinine: Sodium, Urine Specific Gravity, sometimes Urine Sodium)
Dehydration Is Sometimes Unavoidable: Document Discussion w/Responsible Party When This Occurs
Educate Family About Options
When CHF is Present, Some Degree of Iatrogenic Dehydration Is Desirable
Dehydration Has a Bad Reputation as Cause of Death
Largely Undeserved Reputation: Educate!!
Enlist MD/DO/NP/PA Assistance
Consider IV Hydration in Facility, or Hypodermoclysis (Subcutaneous Infusion) …Rather Than Automatic Shipping to ER
Nutrition: ‘Therapeutic’ Diets Not Helpful
Usually Do More Harm than Good
Families/Residents May Need Education
Growth Areas for Quality
Dehydration Is Sometimes Unavoidable: Document Discussion w/Responsible Party When This Occurs
Educate Family About Options
When CHF is Present, Some Degree of Iatrogenic Dehydration Is Desirable
Dehydration Has a Bad Reputation as Cause of Death
Largely Undeserved Reputation: Educate!! Enlist MD/DO/NP/PA Assistance
Consider IV Hydration or Hypodermoclysis (Subcutaneous Infusion) Rather Than Automatic Shipping to ER Nutrition: ‘Therapeutic’ Diets Not Helpful
Growth Areas for Quality
Falls: Complete post-fall analysis before calling unless severe injury suspected or transfer required
Check vitals including orthostatics
Full Body Check
If unwitnessed, careful consideration of possible head injury
Fingerstick Blood Sugar if diabetic
Current Fall Prevention Measures
History of Previous Falls
Anticipate what an IDT would do
Help Doc Make Appropriate Choices (Add Tab Alarm, Low Bed, Mats, Lap Buddy, etc.)
If your facility is “Restraint-Free,” make sure Resident/Family aware, and that other facilities may not have that policy (Medicolegal and Liability Issues)
Documentation Quality Issues
Important to Individualize Charting (esp. Narrative) Care Plans Are Often Highly Generic, Goals Unrealistic Narrative Notes Should Include Some Physical Assessment!
“Call Light Within Reach”—A (Usually) Meaningless Notation “Alert & Verbally Responsive”: Not Enough! Tell More! “URI”—Usually Not Really Upper Respiratory Tract Alert Charting Should Actually Be On the Alert for Something!
Turning & Repositioning: Protocols Should Be Used and Documented. In High Risk Residents, Maybe Every Turn!
Education & Discussion of Risks, Benefits, Alternatives Should Always Be Documented
Basic Risk Management
Accept That SNFs Are Viewed Negatively by Public Make an Effort to Humanize Care & Caregivers Clarify HIPAA Issues Early On, Obtain Permission to Discuss Resident w/All Appropriate Parties
If You Don’t, There Will Be Bad Blood!
Don’t Be a HIPAA Zealot! Consider Risks vs. Benefits of Discussing Help Create Realistic Expectations Some Complications Unavoidable Train All Staff to Be Compassionate, Empathetic & Respectful
Foster an Attitude of Compassion
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Provide the kind of care you’d want your family to get
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Always greet residents/visitors and ask if they need help Respond promptly to phone calls and other concerns Treat everyone in the building with respect
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Have a Greeter/Receptionist (a Friendly One!) Convene Ethics Committees when appropriate
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Use Medical Director in complex or sticky situations
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A Good Ombudsman Can Be a Great Asset Avoid Value Judgment in Documentation Be complete in Documentation whenever possible
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Avoid “Charting Parties” and “Shadow Charting” Ensure Adequate Staffing, but Avoid Registry
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Good Evidence Exists that Consistency/Continuity of Staff with Individual Residents Results in Improved Outcomes
You Know Who the Problem Families Are!
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Be Proactive With These People!
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Do Extra Charting, Extra Vitals, Extra Calls to Doc if needed Document Conversations with Resident/Family Document Conversations with Attending Physician Involve Ombudsman When Appropriate Try to Work Collaboratively, Do Not Bad-Mouth Anyone
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Have Extra Team Meetings to Address Specific Concerns Have People Sign Waivers When Doing Something that’s Against Medical Advice
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Be Caring! Or Act Like It!
Even Though They Will Claim You Never Explained It, Can Be Helpful in a Lawsuit
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Get Attending MD/DO and/or Medical Director to Assist with Documentation on Problem Residents
Growth Areas for Quality
Pressure Ulcers are a Huge Source of Pain, Medical Expenses & Liability Also Not All Avoidable Some Good Evidence that ‘Skin Failure’ is Part of Dying Process, Interventions May Not Work Always Care-Plan & Manage Pain!
Education of Resident/Family is Useful Create Realistic Expectations Documentation & Care Planning Critical (T&R!!) Use Specialty Mattresses, Wound Consults Early Saving One Lawsuit Is Worth Expense Make Sure Physician Kept In The Loop
Participate as a Facility
CAHF: QCHF & Other Offerings
California Association of Long Term Care Medicine ( CALTCM ) www.caltcm.org
Education, Advocacy, Cutting-Edge Medical Updates, Networking, Medical Directorship
Annual Meeting July 10-12 in LA at Omni.
Save the Date!
POLST Implementation Pre-Conference July 10
Advancing Excellence Program
www.nhqualitycampaign.org
Multiple Goals/Parameters to Improve Quality
American Medical Directors Assoc. (AMDA)
National Organization for Medical Directors
Clinical Practice Guidelines, Toolkits
Take-Home Messages
Transfers & Other Transitions in Care Settings are a Major Source of Errors …and a Great Opportunity for Growth!
Documentation is Critical: Accurate, Complete, Individualized, Relevant, Resident-Centered
Team Approach is Optimal: Consider and Respect All Opinions, Especially CNAs
Create (& Document) Realistic Expectations
When Not Possible, Document Unrealistic Ones
Take-Home Messages
Engage Medical Director, Ensure Interest & Participation in Education, Organizations
Join CALTCM as a Facility: www.caltcm.org
Medical Director Should Consider CMD Certification
If Medical Director Not Active, Change That!
Get Outside Help When Appropriate
Devise Action Plans for Building-Specific Issues
Falls, Pressure Ulcers, Dehydration, Bacteriuria/UTI, Identification of Delirium are Good Places to Start
Policies & Procedures Should Be Current, Evidence-Based, and Actually Followed!
Consider Using AMDA’s Clinical Practice Guidelines and Tool Kits www.amda.com
Take-Home Messages
Maintain Attitude of Empathy and Humanity
Consider Palliative Care Early When Appropriate
Our Work Is Valuable, Important, Compassionate and Loving Culture Change Is Upon Us: Let’s Work to Improve Public Perception of Our Industry!
Keep Striving to Improve Quality and Reward Innovation
Get Support and Input from Medical Director