Transcript Anne Scott's Powerpoint Presentation

Anne Scott
Advanced Nurse Practitioner
Medicine of the Elderly
Royal Infirmary of Edinburgh
Nurses General knowledge of
Elderly Care and specifics of the
Comprehensive Geriatric
Assessment process.
TarGetEd
Aims of presentation
• Why did I put myself forward?
• The process and how I engaged with it
• What question and perceived outcomes
1. Audit and questionnaire
2. Preliminary findings
3. Educational tools
• Next steps
• Summary and experience
• Questions
Why?
• Need for experience off and support in
research process (NMC and RCN)
• Keen to engage with research within
hospital setting regarding care of older
people.
• Wanted to look specifically at an element
of nursing role
Engagement – starting
the process
• Form from PROP
1. Question
2. Methods and data
3.
4.
sources
Out puts and
communications
Resources
• Own team (Medics and
•
•
nurse manager) agreed
to support
Met others in project
both in hospital and at
PROP study days in
Edinburgh University
Deciding on my
specific question
Questions!!!!!!!!
• Are older people different?
• What do we need to do to support them in
•
•
•
•
hospital and out of hospital?
How do we measure frailty? Fit 80 year old, 64
year old with multiple physical issues
What is in the community? Telecare, telehealth,
hospital at home, rehabilitation in the
community, Carer support
What do we assess? Do we know importance?
Do we respond to information gathered?
Comprehensive Geriatric Assessment – evidence
to support use of CGA improves outcomes in the
care of older people.
Literature search
• Meta analysis by Ellis showed benefit of
process
• Patients more likely to be in own home 12
mths after hospital if CGA occurred
• British Geriatric society recommends use
of CGA – ‘good Practice’
Comprehensive
Geriatric Assessment?
• Process used to identify and address
issues in older people – involves multi
disciplinary team
• Social, health, financial, psychological
aspects
• Aspects specific to nursing assessment in
first few days of hospital admission
What was the goal of my work?
• Highlight the importance of Comprehensive
•
•
•
Geriatric Assessment (CGA) within the nursing
population in hospital
Development of teaching tool and ongoing
educational support for nurses regularly caring
for older people
Improve patient experience and outcomes
Improve own practice, skills and knowledge
Start of the ‘work’
• Audit case notes and look at
documentation by nurses of ‘frailty
tools’. Specific elements of CGA to be
looked at
1.
2.
3.
4.
5.
Falls assessments
Nutrition
Tissue viability
Continence and toileting issues
Cognitive
Questionnaire
Use of CGA as guide to appropriate
questions
Design questionnaire (difficult!)
Target group of nurses cross specialities
in admission and assessment areas
Role out questionnaire
Analyse results
Who to ask?
• Trained nurses in Medical, surgical,
orthopaedic and Medicine of the elderly
• First few days/hours of admission crucial
to care
• Large numbers of older people at hospital
‘front door’
Role out
• Proposal to research team of own
speciality
• Explanation of work and proposal of
research and agreement from Nurse
managers and charge nurses
• Sent out 50 questionnaires to trained staff
in 4 distinct clinical areas
Audit and
Returns
• Audited 22 sets of notes over 72 hour
period
• Good response from Medical and surgical
areas
• 40 returned out of 55 sent
Results from notes
90
80
70
60
falls
must
cognitive
Tissue viability
continence
50
40
30
20
10
0
<24hrs
24hrs
48hrs
>48
Main results
Q1. On a usual day approximately how many patients are over >75
years within you clinical area?
Number of band 5, 6 or 7 nurses / clinical area
who completed a questionnaire
12
10
10
8
8
10
number
Number
12
6
10
7
7
6
4
4
2
2
0
0
2
<25%
60%
medical
50%
MoE
>70%
orthopaedic
1
medical
all patients
MoE
5
surgical
1
Q3. Do you approach the assessment of an elderly patient
(>75yrs) differently from younger patients?
1
orthopaedic
6
surgical
7
Q4. Frailty can be measured by scores.
Are you familiar with any of these?
8
12
7
10
8
5
number
number
6
4
3
6
4
2
2
1
0
0
depends
medical
no
no/depends
MoE
orthopaedic
yes
yes/depends
surgical
medical
MoE
no
orthopaedic
yes
surgical
1
Main results Frailty
Q5. What makes you consider a patient is frail?
MoE wards
Q5. What makes you consider a patient is frail?
Medical wards
co-morbidities/ frequent
admissions
mobility
mobility/co-morbidities/
frequent admissions
4
4
age/co-morbidities/
frequent admissions
1
mobility/co-morbidities/
frequent
admissions/cognitive
impairment
1
4
mobility/comorbidities/ frequent
admissions
all
all
2
1
2
Q5. What makes you consider a patient is frail?
Orthopaedic wards
Q5. What makes you consider a patient is frail?
Surgical wards
co-morbidities/ frequent
admissions
1
1
1
co-morbidities/ frequent
admissions/cognitive
impairment
1
4
co-morbidities/ frequent
admissions
1
co-morbidities/ frequent
admissions/cognitive
impairment
1
mobility/co-morbidities/
frequent admissions
2
mobility/co-morbidities/
frequent admissions
mobility/co-morbidities/
frequent admissions/cognitive
impairment
all
all
2
7
(blank)
Main results Nutrition
• Nutrition – effects
10
9
8
7
number
healing and ability to
respond to acute
physical insults,
particularly in the
elderly. Good
knowledge base
Q14. Can you describe why nutritional scores (MUST)
are necessary/indicated ?
6
5
4
3
2
1
0
medical
MoE
yes but basic
orthopaedic
yes with confidence
surgical
Main results –
bowels and bladder
Q16. What can altered bowel habit commonly indicate?
Clinical Area
me
dica
l
adverse effects
adverse effects/poor diet
M
o
E
orthop
aedic
surg
ical
Q15. Do you consider the assessment of bowel habit important?
1
3
14
2
12
1
All answered
"Yes"
cancer
1
cancer/adverse effects
2
4
1
number
10
8
6
4
cancer/adverse effects/poor diet
2
cancer/renal issues/adverse effects
1
2
4
2
0
medical
cancer/renal issues/adverse
effects/poor diet
3
1
1
cancer/renal issues/adverse
effects/poor diet/renal and CKD
1
surgical
14
12
1
1
extreme age/cancer/adverse effects/
10
number
extreme age/cancer/adverse effects
1
8
6
4
extreme age/cancer/adverse
effects/poor diet
1
2
extreme age/cancer/renal
issues/adverse effects/poor diet
1
1
none
orthopaedic
Q17. Do you consider assessment of urinary continence
important in the assessment of the older patient?
1
extreme age/cancer//adverse
effects/poor diet
MoE
2
0
medical
MoE
no
1
orthopaedic
yes
surgical
Main results cognitive
• Dementia and
Q7. Can you describe the difference between
dementia and delirium?
8
7
6
5
number
•
delirium – common
issues in older
patients in hospital
Important nurses
know the difference
between dementia
and delirium. Often
nurses first to identify
issue
4
3
2
1
0
no
yes - confident
medical
MoE
yes - basic
orthopaedic
aware but unclear
surgical
cognitive –
investigation and
reviews
Q9. If a patient is confused without a diagnosis of dementia
what investigations/assessments/reviews
would you consider/expect to be done in your clinical area?
Medical wards
1
urine
Q9. If a patient is confused without a diagnosis of dementia
what investigations/assessments/reviews
would you consider/expect to be done in your clinical area?
MoE wards
urine/bowel habits/fluid
intake/medication
1
1
1
1
urine/bowel habits/fluid
intake/medication
urine/bowel habits/fluid
intake/medication/referral
to psych
urine/fluid
intake/medication
2
urine/bowel habits/fluid
intake/medication/referral to
neuro/referral to psych
5
urine/fluid
intake/medication/referral
to neuro/referral to psych
3
3
1
urine/bowel habits/fluid
intake/medication/referral to
psych
urine/fluid
intake/medication/referral
to psych
Q9. If a patient is confused without a diagnosis of dementia
what investigations/assessments/reviews
would you consider/expect to be done in your clinical area?
Orthopaedic wards
urine/bowel habits/fluid
intake/medication
Q9. If a patient is confused without a diagnosis of dementia
what investigations/assessments/reviews
would you consider/expect to be done in your clinical area?
Surgical wards
urine/bowel habits/fluid
intake/medication/referral to
psych
1
urine
1
urine
urine/bowel habits/fluid
intake/medication
urine/bowel habits/fluid
intake/medication/
2
1
urine/bowel habits/fluid
intake/medication/referral to
psych
1
urine/bowel habits/medication
4
2
urine/medication/referral to
neuro/referral to psych
2
1
urine/fluid
intake/medication/referral to
psych
1
1
1
urine/medication/referral to
psych
3
urine/fluid intake/referral to
psych
urine/medication
urine/medication/referral to
psych
TarGetEd Prompt for elderly patient assessments
Confusion
screen
Bloods – routine and Vit B12, folate, TFT’s, Radiology – consider CT head
Cognitive testing AMT <7 MMSE<24 4@T >4, Micro – consider infection
screen inc MSU, Collateral history – include acute/chronic onset, alcohol,
meds, falls
Infection
screen
Bloods FBC, consider CRP, blood cultures, Micro - MSU, swab any wounds,
consider change of catheter, Skin – check for sites and signs of infections
Investigations – consider CXR, foreign travel Other - if pyrexial – is there a
pattern?
Falls
assessment
Bloods – include Calcium Falls check list – can include errect and suppine BP
>20 difference significant. Check foot ware, exclude altered sensation at
extremities, sit/stand test, environmental review, Cardiac investigations –
consider 12 lead ECG, ECHO, 24 hour tape Medications – particularly anti hypertensive's, sedatives
Eating and
drinking
Bloods – routine incl LFT’s – albumin particularly, Chewing and Swallowing
– solids and/or fluids? Cough present? Mechanical issue (e.g.teeth)
Weight loss and/or appetite concerns – food chart, weight chart, dietician
referral, Others – GI signs or symptoms? AUSS? Collateral history? History of
malignancy? Change in bowel habit or appearance
Continence
screen
Bloods – routine consider PSA (male), Radiology – renal ultra sound if
associated with AKI, Medications – diuretics, Micro – MSU, Others – bladder
scan, DRE (prostate, constipation) continence chart, symptoms of urgency,
frequency or discomfort, referral to continence service
[email protected] Advanced Nurse Practitioner, Medicine of the Elderly, Royal Infirmary Edinburgh.
(PROP)
Targeted
1. Hb115 – 160
2. WBC 4.0 - 11.0
3. Plate 150 - 350
1.
2.
3.
Reduced in anaemia. Blood loss? Chronic? Diet? Fluid
status can affect Hb – can drop acutely with hydration
Raised infection also can be decreased infection,
immuno suppression. Elderly sometimes delayed
response to acute sepsis
Low haematological issue – check for bleeding, bruises,
high - ?infection
4. Urea 2.5 - 6.6
4.
Low indicate alcohol/liver issues. High dehydration,
check meds – ongoing diuretics
5. Na 135 - 145
5.
Abnormal can cause confusion, drowsy/coma, falls,
suggests fluid problems, endocrine disorder
6. K+ 3.6 - 5
6.
7. Creat 60 - 120
7.
K+ changes due to medication, diabetic, hydration.
Can cause arrhythmias
Creatinine – raised in renal failure, changes can indicate
muscle loss
8. GFR >60
8.
GFR – often reduced in elderly as part of normal aging
process. Decrease can influence medication choices
and radiological investigations requiring contrast
d mobility
No issues
First fall but
independentl
y mobile
Uses aid but no falls.
Sensory problems
+/- falls score 1-2
General decline in
mobility over
weeks +/- falls
score 1-2
Acute decline +/- falls score
>3
Only mobile with
assistance of 2
/hoist
Bed/chair
nce
No issues
Stress
Chronic continence
previously
investigated/diagnos
ed
Acute incontinence with
no associated
symptoms
Acute incontinence with
symptoms –
discomfort, frequency,
smell colour
Incontinence of urine or
faeces. Acute or
chronic
Catheteriz
inc
an
Re
rec
and
rinking
No issues
Decreased appetite
over long
period of
time. MUST 0
General malaise with
associated appetite
changes and GI
symptoms. MUST
score triggered
Acute nausea and
vomiting.
+/- MUST score
triggered +/unplanned
weight loss
Problems due to physical
cause/swallow of
potentially
reversible/treatable
issues such as
Parkinson’s, stroke,
NBM order
Inability of patient to
maintain own
nutritional state –
e.g. blocked PEG
End of life
viability
No issues
Waterlow score
<10
Waterlow 10-14 and
mobility restricted
and/or repeated
friction to area.
Ulceration
Waterlow 15-19 but with
evidence of
tissue damage.
Cellulites and/or
‘wet’ legs.
Marked
peripheral
oedema
Waterlow >20
Pressure sore present on
admission
End of life
on
No issues
Slight decrease in
memory. No
diagnosis of
dementia.
AMT >8
Known cognitive
impairment and no
acute changes.
Acute changes from
patient base line
but obvious
cause for
delirium – e.g.
UTI/chest
infection
Confusion associated with
agitation and/or
increased drowsiness
not related to sedation.
Not orientated. Cognition
testing score
abnormal
Requires s
an
inc
nu
du
ag
>2 admissions in 6mths and
impact on
independence. Lives
alone
>2 admissions in 6mths. +/- patient hou
+/- daily in-put from district nurs
rm
ondition/m
ltiple comorbidities
incontinence
/ managed
with pad
No recurrent admissions (6mth
period)
2 admissions due to LTC in 6 mths. Presence of multiple
co-morbidities
patients should have had short period of post operative care before referral are made to attempt to gage patients need for rehab.
If considering rehab or identification of needs have been made please discuss/refer with therapy teams for assessments
The Poster!
Significant issue
• Prompt card and lanyard – not possible
Infection control, health and safety issues,
already several ‘prompt’ cards inexistence
Information and results
so far
•
•
•
•
1.
2.
3.
4.
•
Good level of knowledge and ability in cohort of nurses in front
door areas
High level of returns suggests an appetite for engagement from
nurses
Significant differences of approaches and knowledge– cognition,
frailty, knowledge of community services
Further investigation and progression would be beneficial
Short talks
Articles into local news letters
Sharing results
Further work especially regarding the community and hospital
interface
Own knowledge of research and CGA improved
Next steps
• Ongoing promotion of CGA through own role
• Further areas for research/investigation or
•
•
extension of excising work regarding CGA
Continued engagement from own work place in
support, skills and knowledge of research and
older people care
Development of closer ties with other hospitals
addressing similar patient population and
processes
What was the goal of my work?
• More recognition of the
comprehensive geriatric
assessment within the nursing
population in hospital
• Development of teaching tool
and ongoing educational
support for nurses regularly
caring for older people
• Improve patient experience
and outcomes
• Improve own practice, skills
and knowledge
• Yes
• Yes – even if its not what I’d
been aiming for
• Need further investigation
• Yes
Finally
• Would I do it again?
• Did I think the
•
•
•
process valuable?
What have I gained?
What has the
organisation gained?
What implications
does it have to older
people in hospital?
• Yes!
• Yes
• Knowledge of nurses
•
•
experience and
practices in
assessment areas
A poster!
Highlighted elderly
assessments
Thanks