Transcript Senior Emergency Rooms: Building a Care System for our

Senior Emergency Rooms:
Building a Care System for our
Senior Adult Patients
Debra Steveson, BSN
Objectives
• Describe the reasons for a senior emergency
room
• Explain the special components of care in a
senior emergency room
• Discuss the evidence on which the senior
emergency room is based
• Discuss current issues with drug utilization in
the elderly
• Relate information presented to a patient case
Last year was the first year the Baby Boomers
hit the market. Are we prepared for this new
adventure in healthcare? We have two
choices at this juncture in the road: we can
simply hang on and hope the ride is not too
bumpy or we can help drive the process….
“The Little Boy and the Old Man”
– Shel Silverstein
Said the little boy, "Sometimes I drop my spoon."
Said the old man, "I do that too."
The little boy whispered, "I wet my pants."
I do that too," laughed the little old man.
Said the little boy, "I often cry."
The old man nodded, "So do I."
But worst of all," said the boy, "it seems
Grown-ups don't pay attention to me."
And he felt the warmth of a wrinkled old hand.
I know what you mean," said the little old man.”
U.S. Department of Health & Human Services
2011
Older Population by Age: 1900-2050 - Percent 60+, Percent 65+, and 85+
30%
25%
20%
15%
10%
% 60+
% 65+
% 85+
5%
0%
1900
1910
1920
1930
1940
1950
1960
1970
1980
1990
2000
2010
2020
2030
2040
2050
Quick Facts
Exempla hospitals
• Lutheran Medical Center’s ED population 21% are greater than 65 years of age
• St. Joseph’s ED population – 37% are 65 or
older
• Good Samaritan Medical Center’s ED
population – 29% are greater than 65 years of
age
Primary
Service
Area (PSA)
where 75%
of EGSMC
Inpatients
Reside
SENIOR ED PROJECT
EGSMC Primary Service Area
(PSA) Statistics:
• About 68,900 residents are age
65+, representing 9% of the
population.
• Seniors in the PSA are
estimated to generate 37,900
ED visits annually.*
• 65+ population is expected to
grow 5% per year during the
next five years, generating an
additional 10,600 ED visits per
year by 2017.*
• In five years, seniors will
represent 12% of the total PSA
population.
*Based on 550 ED visits per 1,000 population for residents age 65+
Source: Healthcare Cost and Utilization Project (HCUP) 2008
Nationwide Emergency Department sample (NEDS) for Community
Hospitals
Slide 7
Seniors Represent Nearly 40% of the Total
Population Growth between 2012 and 2017
Age 65 +
39%
Age 0-14
23%
Age 15-24
1%
Age 25-44
1%
Age 45-64
36%
Source: Truven/Claritas, 75% 2010 Total PSA
Pop EGSMC Total SA by Age & Race 2012-17 vMetro.xls
CONFIDENTIAL
For Internal Use Only
Slide 8
Patients age 65+ Represent 29% of Total EGSMC
Emergency Department Visits
EGSMC ED Volume by Age Group
November 2012 YTD (11 Months)
29%
Total ED Visits (IP and OP)
30%
KP
25%
Community
22%
20%
17%
14%
15%
10%
10%
10%
7%
6%
5%
5%
4%
5%
0%
<18
18-24
Source: Decision Support, Trendstar Data (note, total ED visit volume of
36,766 is low er than the Budget Comparison Report figure by 2.6%)
EGSMC ED Graphs.xls
25-44
Age Group
45-64
65+
CONFIDENTIAL
For Internal Use Only
Slide 9
U.S. Population 65+ in millions
The U.S. population of adults 65+ is projected
to double by 2050
Why a Senior ER?
• The challenge: Older adults use the ED more
than any other age group.
• True or False?
– Older adults use the ED more appropriately than
any other age group.
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Why a Senior ER?
• The challenge: Older adults use the ED more
than any other age group.
• True or False?
– Older adults use the ED more appropriately than
any other age group.
• How can these two statements both be true?
Seniors visit the ED more because they are sicker than all other
age groups.
• The solution - we need a better continuum of care to be
able to take care of these patients.
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Senior Emergency Room:
A unit or a paradigm shift
• Physical changes of aging
• Psychosocial needs
• Co-morbidities
How Is It Different?
Clinical Modifications
•
Direct support
-Certified Nurses Aid
-Volunteers
•
Consultative Services
-Palliative/Hospice Care
-Geropsychiatry/Behavioral Health
-PT/OT
-Clinical Pharmacy
•
Care Coordination
-Senior ER Care Coordinator through KP and Exempla
-Community Based Referral and Care Coordination Services
The Case of Gertrude
Current ED Paradigm
• 82 year old female via EMS from home after a trip
and fall on throw rug. No head trauma. Denies LOC.
Complains of right hip pain
• Medical history: diabetes, a-fib, coronary artery
disease, depression, chronic low back pain
• Social history: lives alone, daughter is out-of-state
• Meds: coumadin, metformin, metoprolol, aspirin,
simvastatin, fluoxetine, hydrocodone/acetaminophin
The Case of Gertrude
Current ED Paradigm
• Roomed next to suicidal, intoxicated patient
• Initial vitals stable, complains of 5/10 hip pain
• Initial exam: anxious, trouble following directions,
right forearm skin tear, right hip contusion
• Medicated with 4mg IV morphine
• X-ray of hip negative for fracture
• Continues to be agitated and anxious; medicated
with 1mg IV ativan
• Physical therapy consulted for exam
The Case of Gertrude
Current ED Paradigm
• Physical therapy notes patient is difficult to arouse and
confused
• Head CT ordered, results negative for bleed
• Return from CT, oxygen sats low, placed on oxygen
• Incontinent of urine, straight cath for UA and culture
• Admitted secondary to altered mental status and
hypoxia
• Treated for catheter associated UTI
• Discharged to SNF for rehab after 2-day inpatient stay
Senior Emergency Room Goal
• Transform care for our senior population in
the ER in a manner that improves the quality,
safety, and coordination of care by providing:
• Safe, quiet, comfortable and supportive care
environment
• Screening for early identification of seniors at risk
• Education for patients and family
• Coordination and mobilization of appropriate post
discharge resources
• Effective transition back into the community
• Provider of choice for our senior population
EGSMC Senior ER Screening
ED RN
ED RN
ED RN
Screening 65+
Braden
Current Process
Morse Fall
Current Process
Abuse questions
Current Process
ISAR
3 or above
KATZ
PHQ2
Positive
Notify ED & PCP
Mini-Cog
Positive
Notify ED & PCP
CAM
Positive
Notify ED & PCP
PT/OT referral
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Disorders of Cognition
• Depression
- disorder of mood
• Dementia
- multiple cognitive deficits that include
memory disturbance
• Delirium
- disturbance in consciousness and cognition
that develops acutely
Depression
•
•
•
•
Serious illness
Not part of aging
Affects 3-5% of people over 65 years of age
Most common cause of unexplained weight
loss
• Can be observed and measured
Delirium
• Acquired syndrome with altered level of
alertness, attention and perception.
• Develops over short period of time
• Fluctuates over course of the day
• Sleep/awake cycle disturbance
• Psychomotor
• Mental status
Confusion Assessment Method
• Most widely accepted diagnostic instrument
1) acute onset and fluctuating course
2) inattention
3) disorganized thinking
4) altered level of consciousness
• Diagnosis of delirium by CAM requires
presence of numbers 1 and 2 and either 3 or 4
Dementia
• Development of memory problems AND at
least one additional cognitive deficit
- Aphasia
- Apraxia
- Agnosia
Stages of Dementia
• Early Stage
-Appropriate social conversation, but longer pauses
-Tendency to wander off topic
-Trouble recalling names of people or places or things
• Middle Stage
- Difficulty finding words
- May have difficulty following directions
-Reading may still be preserved
• Late Stage
- Unable to complete activities of daily living, totally dependent
- Very limited, if any, communication
- Does not recognize self or others
- Facial expression no longer change – flat affect
Mini Cog
• 3 minute instrument to screen for cognitive
impairment in older adults.
• Detects people with mild cognitive
impairment, too mild to meet diagnostic
criteria for dementia.
– A 3 item recall test for memory
– And a simply scored Clock-drawing test (CDT)
• Normal clock drawing- the patient places the correct
time and the clock appears grossly normal
Mini Cog
• If patient answers incorrectly, do not correct
the response, if the patient asks if the answer
was correct, something like, “ that was pretty
close” is sufficient.
• Do not provide any clues or hints to the
correct answer
• Do not allow family or friends to provide hints.
• What were the 3 words I asked you to
remember? The order of the words do not
matter.
Mini Cog Scoring
•
•
•
•
Number of correct items recalled____.
If 3 then negative screen. STOP
If number of correct items recalled is 1-2
Is Clock Drawing Test abnormal?
-no then screen is negative
- yes with an abnormal Clock Drawing then
the screen is positive
Notify ED physician
Case Review
• 68-yr-old female presents to ED, referred by residential
assisted living facility.
- was in the dining room of the facility wearing only a bed
sheet, claiming that she was the Virgin Mary and that
somebody had kidnapped baby Jesus.
- In the ambulance on the way to the ED, patient abruptly fell
asleep and when she woke up didn’t know who or where
she was.
- has history of mild dementia and depression.
• How would you go about differentiating
dementia/delirium/depression?
• How would you communicate and care for this patient?
• What would you communicate to the attending physician?
Greatest Issues to aging
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Loosing Family Members, Friends,
Loss Of Mobility
Loss Of Drivers License
Boomers Caring For Parents
Parents In Nursing Homes
Decrease In Reimbursement
Family Changes
Retirement
Widowhood
Declining Physical Reserves
Changes In Income
Shrinking Social World For Some
Benefits of aging
• Peace Comes With Age
– Just being able to feel at peace with myself and the world.
Staying healthy is a good way to ensure a good quality of
life for the long term.
• Retirement
• Time
• Discounts
• Grandchildren
• Financial Stability?
• Lack Of Urgency (not bladder related!)
Normal changes of aging
•
•
•
•
•
Vision
Hearing
Smell and Taste
Touch
Communication
Vision
•
•
•
•
•
Macular Degeneration
Cataracts
Glaucoma
Diabetic Retinopathy
Hemianopsia
Myths of aging
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•
•
•
•
•
•
•
Old people are sick and disabled
Most are in nursing homes
Senility comes with old age
Old people are unhappy
Old people get very tranquil or very cranky
No interest in sex and can’t have it anyway
Few satisfactions in old age
By age 70 psychological growth is complete
Biases
• Bias in Providing Preventive Care
– Older adults are often excluded from disease screening
tests. As a result, diseases are diagnosed when they have
reached their later stages, therefore treatment becomes
expensive.
– Part Of Their Social History.
• Dr.’s Are For Sickness
• Lack Of Funding
• Bias From Lack Of Geriatric Training
• Gap In Primary Care Availability
• Medical Intervention
• Training For Nursing
Different approach to senior adults
• Triage interview
• Assessment
- slower response to questions
- listen to entire answer
- more history, medications, and allergies
- seek treatment later
Assessment and Interventions
• A–I
- different approach
- different challenges
- safety considerations
• M–O
• Atypical presentations
• Therapies that could aggravate
Special considerations
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Pain
Skin care
Sexuality
Abuse
Skin Care in the Senior Adult
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Abuse in the Senior Adult population
• True or False
•
•
•
•
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The majority of maltreatment of seniors occur in SNF.
Sexual and physical abuse are the most common.
Colorado does not have mandatory reporting of senior abuse.
Interview of the abused senior should never occur apart from
the caregiver.
Medication considerations
• Beers criteria
- Identifies medications and drug classes that are
potentially inappropriate based on best available
studies.
- Lists medications that exacerbate common
disease states in the elderly
- Lists medications that increase delirium and
altered mental status
- Reports medications that have been statistically
associated with falls.
Beware of Drug-Drug Interactions
• Chance of DDI nearly 100% with 8 or more drugs1
• Almost 50% of community-dwelling geriatric patients
had at least one DDI2
• DDI can result in ADR or suboptimal dosing
• >80% of computerized DDI alerts ignored3
1Sloan
RW. Drug Interactions. Am Fam Physician 1983; 27:229-38.
NSAIDS and the elderly
• Congestive Heart Failure:
– 10-fold increased risk of CHF exacerbation requiring
hospitalization in elderly
• Chronic Kidney Disease:
– Most nephrologists recommend avoiding NSAIDs when CrCl <60
ml/min (Stage 3 CKD)
• GI Bleed:
– ↑bleeding risk:
• Age>60
• Concurrent anticoagulants
• Prior ulcer or hemorrhage
• Concurrent steroids
• ↑ bleeding risk correlates with↑duration of use!
Renal considerations
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Morphine
Methadone
Digoxin
Bactrim
Ciprofloxacin
Levofloxacin
Nitrofurantoin
Acyclovir
Famciclovir
Colchicine
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Gabapentin
Metoclopramide
Glyburide
Enoxaparin (Lovenox)
Fondaparinux (Arixtra)
Metformin
Thiazide diuretics
NSAIDs
Spironolactione
Bisphosphonates (ie.
Alendronate)
Pain management in the elderly
• Increased risk of adverse effects due to increased
sensitivity to opioids
– Sedation, confusion, delirium, constipation, pruritus,
nausea
• Recommendations:
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–
–
–
–
–
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“Start low, go slow”
Manage fears, expectations
Avoid long-acting opioids unless chronic pain in opioid-tolerant patient
Treat “incident” pain with short-acting agents
Use only ONE agent
Prescribe laxatives (senna, bisacodyl)
NEVER use meperidine (Demerol)
Drugs and Delirium in the Elderly
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Anticholinergics (oxybutynin)
TCAs (amitriptyline)
Antipsychotics
Antihistamines (Tylenol PM)
H2 blockers
Opioids (MS Contin)
Digoxin (dose > 0.25mg/d)
•
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Antihypertensives (hypotension)
Alcohol
Benzodiazepines (diazepam)
Antiparkinsonian drugs
Antibiotics
Corticosteroids
Combining these drugs can have additive / synergistic
effects!
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Drugs and Falls in the Elderly
• Anticholinergics (oxybutynin, amitriptyline)
– Visual changes, sedation
• Anticonvulsants
– Ataxia, sedation
• Alcohol, aminoglycosides, loop diuretics, high-dose ASA
– Vestibular dysfunction (balance/posture)
• Benzodiazepines (diazepam), antihistamines (Tylenol PM), opioids
(MS Contin)
– Cerebral impairment - leading to instability and
sedation
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Medication List for 80 year old
• Diazepam 5mg Q8H
prn
• Metformin 1,000mg
BID
• Lisinopril 10mg QD
• Metoprolol 50mg BID
• Warfarin 2mg QD
• Simvastatin 40mg QHS
• Oxybutynin 5mg Q8H
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• Amitriptyline 75mg
QHS
• MS Contin 15mg Q8H
• Tylenol PM QHS
• Alendronate 70mg
QOW
• Calcium + VitD BID
• Digoxin 0.25mg QD
Suggestions for management
• Discontinue Tylenol PM, consider trazodone 25mg QHS as
needed
• Taper diazepam – start with reducing to 5mg Q12H
• Decrease digoxin to 0.125 mg daily
• Adjust HTN medications (HR / BP low – orthostatic risk)
• Discontinue Metformin, consider low-dose Glipizide
• Change MS Contin to fentanyl 12.5 mcg Q72H and add Senna
• Add oxycodone IR 5 mg Q6H prn for knee pain
• Change amitriptyline to nortriptyline and decrease dose to
20mg QHS
50
How do we keep up?
Point-of-care medication list including:
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Herbals and Supplements
Over-the-counter Medications
“As Needed” Medications
Date/time of last dose taken
Vaccination History
Drug/food Allergies
Sometimes it may be necessary to contact SNFs,
Nursing homes, outpatient pharmacies, or family
members if patient has altered mental status or does
not know what is being taken
References
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ENA
AARP www.aarp.org
Administration on Aging - www.aoa.gov
Independent Sector - www.independentsector.org
National Council on Aging (NCOA) - www.ncoa.org
Senior Corps - www.seniorcorps.org
Questions?