quality care for the hospitalized older adult

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Quality Care for the Hospitalized Older Adult

Quality Care for the Hospitalized Older Adult

Sandhya Lagoo-Deenadayalan

All Rights Reserved, Duke Medicine 2007


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Objectives

• To define why the hospital is a dangerous place for older adults

• To recognize frailty

• To list at least 2 serious reportable events (“never events”)

• To identify ways to be part of improving the quality of care for the hospitalized older adult


Geriatric Issues

• Difficulty urinating or getting to the bathroom– Insert Foley >>> catheter associated urine

infection, immobility >>> URINARY INCONTINENCE

• Difficulty ambulating, deemed a fall risk– Stay in bed >>> pressure ulcers, loss of physical

function >>> HIP FRACTURE

• Confusion from dementia or delirium– Add sedatives, restraints >>> longer length of

stay, infections, immobility >>> NURSING HOME PLACEMENT!!!


Geriatric Issues

• Weakened muscles

• Weakened bones

• Weakened lung function

• Poor nutrition

• Dangerous medications

• Infections

LEAD TO WORSENING FUNCTION

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Frailty

• Frailty is a state of decreased physiologic reserves that makes a person vulnerable to stressors.

• Comorbidity is a risk factor for frailty

• Disability is an outcome of frailty


Phenotype of Frailty-unrecognized

• Weight loss (>10 lbs in past year)

• Decreased grip strength

• Self-reported poor endurance/exhaustion

• Slow walk speed (15 feet ≥ 6 sec (adj. gen/ht))

• Low physical activity

Considered frail if positive for 3 or more

Fried LP, et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56A:M146-M156.


Frailty and Surgical Outcomes

Non-frailN=346 (58.3%)

IntermediateN=186 (31.3%)

FrailN=62 (10.4%)

% Complication 19.5% 33.7% 43.5%

Length of Stay (days)

4.2 6.2 7.7

Disposition: Skilled Nursing Facility

2.9% 12% 42%

Makary M, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg 2010;210:901-908.

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Hospital Related Stressors

• Early AM blood draws and vital signs

• Daily blood draws• NPO• Fluid restriction• Bed rest• Insomnia• Physical restraints,

including “tethers”(catheters, IVs)

• Chemical restraints• Noise

• Polypharmacy

• Hospital gowns

• Hospital room

• Sensory deprivation (no glasses, HA)

• Nurses/CNAs treating pts as dependent

• MDs not trained to balance risks/benefits of test/treatments in older adults


Serious Reportable Events (SRE)---"Never Events"

• Introduced 2001 by Ken Kizer

– former CEO of the National Quality Forum (NQF)

• 6 categorical events (28 events total):

– surgical, product or device, patient protection, care management, environmental, and criminal

http://psnet.ahrq.gov/primer.aspx?primerID=3


Never Events are

• Clearly identifiable, measurable, reportable

• Usually preventable

• Serious – resulting in death or loss of a body part, disability, or more than transient loss of a body function;

AND- adverse and/or- indicative of a problem in a health care facility’s safety systems and/or,- important for public credibility or public accountability.

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• August 2007 – CMS no longer paying for costs associated with many preventable errors, including those considered Never Events

• In compliance with CMS billing guidelines, the recently approved State Plan Amendment and N.C. legislative mandates, all claims are required to reflect reporting indicators on diagnosis codes that are identified in the current ICD-9 Hospital Manual related to Health Care Acquired Conditions (HCACs) or never events - NO PAYMENT for costs associated with these 28 events

Never Events


Never Events

• Product or Device Events

– Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility

– Ex: catheter associated infections


Never Events

• Care Management Events

– Patient death or serious disability associated with a medication error (e.g. errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)

– Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility

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Where to Spend the Time

• Patients > 5 meds

• Medication Reconciliation

• Patients on:

– Anticoagulants

– Hypoglycemics

– Opiates and any CNS

acting med

– Anticholinergics

– Cardiovascular agents


Helpful Hints from Duke Pharmacists

• Assess timing of restarting home meds

• Don’t assume home meds are best therapy. Stop the prescribing cascade.

• When prescribing medications: Start low, go slow.

• Surgical Pain management

– Assess pain before prescribing. Caution with order sets in CPOE.


Take Home

• ADRs are common in older adults and often serious and preventable

• Take a complete medication history

• Apply the principles of appropriate prescribing

• Recognize the risk associated with transitions in care, particularly between hospital and home or nursing facility.

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http://srs.duhs.duke.edu

Key Features in SRS

Clicking on Review Dashboard will prompt you to login with your Lotus Notes Internet account:


Key Features in SRSThe SRS Dashboard

Color blocks represent the status of the incident review process of other reviewers


Safety Event Classification Process: Events Classify into 1 of 2 Groups

Severity Index 0 - 2

• Event may or may not have reached the patient

• Event did not result in direct patient harm

• Errors or Near Misses

• Secondary classification of Potential for Harm = LOW

Severity Index 3 ‐ 6

• Event reached the patient and resulted in harm

OR

Severity Index 0 – 2

• Secondary classification of Potential for Harm = HIGH

– If not corrected, such an event may lead to harm

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When A Serious Event Occurs

• Attend to patient’s needs.• Call the Risk Management Team • See policy “Disclosure of Unanticipated

Outcomes of Care”. • Preserve pertinent data (monitor strips,

medical devices, etc.)• Give clear, concise account of facts known

thus far to patient / family in timely, coordinated manner.

From Risk management New Resident Orientation talk


SRS and Corporate Risk Management

• SRS reports are reviewed and evaluated by Risk Management, as well as area leadership

• In the event of serious patient injury, call Risk Management for immediate investigation and follow-up

• Events may be reported to Risk Management by phone, page, email or office visit

• All communication with Risk Management is confidential and protected by attorney/client privilege

Normal business hours (M-F; 8:30a–5:30p): 684-3277

After hours, weekends and holidays: pager 970-2404

Email: [email protected]


Never Events

• Care Management Events

– Patient death or serious disability associated with a medication error (e.g. errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)

– Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility

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Pressure Sores

• Stages

– I = Red, but skin intact

– II = Through skin

– III = Into muscle

– IV = Bone showing or osteomyelitis

• Prevent

– Identify high risk patients

– Avoid wetness (condom catheter)

– Turn often, good nutrition, booties, mattress overlay

– Consult wound specialist if h/o pressure sores


Pressure Sores

Treatment

Identify cause (pressure, wetness, insensate, nutrition)

Consult wound care nurse Dressing varies with stage, cleanliness, exudate

Bed recommendations

Maximize nutrition ↑ nutrition needs correlated with surface area and stage

Caloric ↑~20-25%; Protein ↑50-100%; Fluid needs ↑ (e.g., high exudate, large surface area)


Never Events

• Environmental Events

– Patient death or serious disability associated with a fall while being cared for in a healthcare facility

– Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility

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Never Events

• Environmental Events

– Patient death or serious disability associated with a fall while being cared for in a healthcare facility

– Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility



Hospital Rehabilitation Goals

– Assess baseline function

– Avoid deconditioning

– Regain flexibility, strength, endurance

– Teach new methods to cope with new deficits to decrease dependancy

– Early ambulation >>>> earlier recovery >>> decreased length of stay

– Avoid pressure sores, contractures, fractures

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Primary Prevention – Baseline Information

• Ask about function!

– If you don’t ask, you won’t know• >50% of patients with disability unrecognized by MD

– “Do you need help from another person with <XYZ>?”• Best baseline question

– “How much difficulty do you have with <XYZ>?”• Best question for rehab & primary care staff


Mobility Questions & Why

• “Do you use any special equipment for mobility like a cane, walker or wheelchair?”

Bring their gait aid with them to the hospital• Hospital may not supply cane/walker for use in hospital

Consult PT if patient can’t bring device with them

• “Have you had any falls in the last year?”

Alert nursing – elevated fall risk• Supportive shoes/socks with tread, not slippers

• Orient to room, night light, + bed rails

Have gait aid available in room or consult PT


What to tell PT/OT on consult

• “Evaluate and treat as indicated”

– Outpatient PT/OT - may need to specify/approve number of sessions for payment

• If you have particular concerns, describe them

– Specific tasks that are problematic

– Needs for caregiver instruction

• Help us prioritize

– Discharge date if it known

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DELIRIUM

Acute disorder of attention and global cognitive function

DEMENTIA

Chronic cognitive impairment in 2 or more domains which effects functional status


Delirium or Dementia?

Delirium usually has

• Abrupt onset

• Fluctuation in level of alertness

• Improvement over time

• Identifiable precipitant(s)

Dementia usually has

• Gradual onset

• Less fluctuation in level of alertness

• Decline over time

• No identifiable precipitant


Risk Factors

Predisposing Factors

• Severe illness

• Cognitive impairment

• Age

• Dehydration

• ETOH abuse

• Functional status

• Abnormal Na+, K+, or glucose

Precipitating Factors

• Bladder catheters

• Restraints

• >3 new meds

• Malnutrition

• Any iatrogenic event

Inouye 1998, Marcantonio 1994

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Treatment Recommendations

• Discontinue/taper non-essential meds

• Minimize restraints, catheters, IV’s

• Utilize sitters, family members

• Low dose neuroleptics (black box )

• Benzodiazepines only for withdrawal syndromes

• Educate family

• Discharge planning


Conclusions

• Delirium is an important diagnosis that…

• Must be distinguished from dementia

• Requires systematic investigation to identify and correct underlying cause

• Can be prevented


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Hospital Pay for Performance

• Medicare Hospital Value-Based Purchasing (VBP) program

• Value = Quality/Cost

– Maximize quality, decrease cost = more value

• Provisions for measures adopted in the Affordable Care Act (ACA)

• 1-2% DRG payments withheld 2013-2017

Ryan A, Blustein J. making the best of hospital pay for performance.

NEJM 2012;366:1557-1559.

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Interventions

• Educate yourself and others on how hospital stressors can lead to cognitive decline, functional decline, and never events in the frail older adult

• Participate in limiting or eliminating hospital stressors for your frail older patient with the goal of preserving FUNCTION

• Establish realistic goals of care with your patient and the hospital team when considering tests and treatments

• Participate in team-based care!!!!!


The Acute Care Interdisciplinary Team

• Nurse, nurse specialist, nurse practitioner

– Assess functional status (basic and instrumental activities of daily living, risk of falling, cognition, mood, special senses, nutrition, skin condition)

– Implement guidelines to prevent functional decline

– Conduct daily interdisciplinary rounds– Teach patient self-care

http://www.hospitalmedicine.org/geriresource/toolbox/pdfs/acute_care_interdisciplinar.pdf



• Nurse case manager

– Participate in comprehensive discharge planning

– Assure smooth transition of care from the hospital to home.

– Coordinate patient’s care after discharge with physicians and other providers

http://www.hospitalmedicine.org/geriresource/toolbox/pdfs/acute_care_interdisciplinar.pdf

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• Social worker– Assess patient’s social support network,

health insurance coverage, care-giving needs– Review advance directives (living will, durable

power of attorney for health care)– Evaluate family dynamics (potential caregiver

stress or elder abuse)– Arrange referrals to community agencies (e.g.,

home care, meals-on-wheels)– Arrange transfer to nursing home or

rehabilitation hospital


The Acute Care IDT

• Physical Therapist– Evaluate gait and mobility– Help patient to maintain or improve strength,

flexibility, and endurance of muscles and range of motion of joints

– Recommend assistive devices for ambulation– Perform environmental assessment (home

visit); determine home safety,– Administer treatment modalities



• Occupational Therapist– Evaluate patient’s ability to perform activities

of daily living.– Fit splints for upper extremities– need for appliances and devices– Teach use of assistive aids and devices

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• Dietician– Assess nutritional status– Recommend nutritional interventions (e.g.,

special diets and food supplements)– Monitor enteral and parenteral alimentation

• Speech Pathologist– Evaluate patients with aphasia or dysphagia– Recommend swallowing techniques to prevent

pulmonary aspiration


Summary

• Recognize the frail older adult

• Limit stressors

• Report errors and adverse events to help improve care delivery to your patients

• Work with your interdisciplinary team to prevent “never events” and progression of frailty


Care of the Geriatric Patient

The patient will value the freedom to enjoy the most important gift – quality of life.

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Acknowledgements

BU CRIT Faculty

• Lisa Caruso, MD

• Winnie Suen, MD, MSc

• Lisa Strano-Paul, MD

• Andreas A. Theodorou, MD, FAAP, FCCM

• G. Henry, MD

Duke CRIT Faculty

• Helen Hoenig, MD, MPH

• Cathleen Colon Emeric, MD

• Mitchell Heflin, MD

quality care for the hospitalized older adult

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