Transcript Geriatric Patients and the Emergency Department

Wasn’t she here last week?
Frequent Flyers and other Vexing Tales of the
Emergency Department
Geriatric Patients and the
Emergency Department
Optimizing Transitions from the Emergency
Department: Transitions/Frequent flyers – Part 1
# 3 in a 6 part series related to Geriatric Care and Emergency Medicine
About This Webinar Series
1. Assessment of the Older Veteran
2. Cognitive Status in the Older Veteran
4. Geriatric Medication Challenges
5. Pain Management Challenges
6. Optimizing Transitions from the Emergency
Department: Transitions/Frequent flyers –
Part 2
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Speakers
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Alan Hirshberg, MD, MPH, FACEP is the Associate Chief of Staff at the Lebanon VA
Medical Center, in Lebanon, PA. He is a residency trained Emergency Physician on the
VHA Emergency Medicine Field Advisory Council and ACEP Emergency Medicine Clinical
Practice Committee who regularly works with VHA facilities to assist them with challenges
related to Emergency Medicine practice.
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Carolyn K. Clevenger, DNP, GNP-BC is a Gerontological nurse practitioner whose
research and clinical interests center around care of persons with dementia. She is
Assistant Dean for MSN Education at the School of Nursing and Associate Program
Director for the Atlanta VA Quality Scholars Program.
Dr. Clevenger is the Principle Investigator of the HRSA-funded project to implement
Interprofessional Collaborative Practice for Primary Palliative Care. An initiative housed on
six inpatient services or units at Emory University Hospital. She serves on the Georgia
Older Drivers’ Taskforce, a committee of the Governors Office of Highway Safety, and the
Atlanta VAMC’s Dementia Committee.
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Nicki Hastings, MD, MHS is a Geriatrician at the Durham VA Medical Center in Durham,
NC. She is Director of the Durham Geriatrics PACT Clinic and an Investigator with the
Durham Geriatrics Research and Education Center (GRECC) and Center for Health
Services Research in Primary Care.
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Disclosures
• No financial relationships or conflicts to
disclose.
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Educational Objectives
Participants in this session will be able to:
• Recognize common factors associated with repeat visits to the
ED among Veterans 65 and older;
• Describe the roles of the Emergency Department Team physician, nurse, social worker, pharmacist, and psychologist in caring for older Veterans’ with dementia in the ED setting;
• Discuss best practices for management and discharge planning
for patients who are frequent fliers in the ED.
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The older patient (65+ years)
• Account for 13-15% of all ED visits nationally
• ED visits of patients 65-74 years of age increased
34% from 1993-2003
• Older patients have higher rates of test use and
longer ED stays than the general population
• 5x higher risk of ICU admission and 3.5 x the risk of
hospitalization
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The older patient
• May have difficulty communicating the nature of their needs to
the Emergency Department (ED) staff and may also be unable
to understand their treatment plans due to
visual/auditory/cognitive impairment.
• Repeat ED visits can be a marker of ongoing care failure and
should be reviewed
• Discharge plans may require coordination through community
agencies
• The older patient attempting suicide is at greater risk of
completion of the act
• May require admission
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Elders at Risk
• Homelessness
• Multiple co-morbid conditions – heart
failure and headache
• Low income
• Psychiatric illness – anxiety, bipolar
disorder, personality disorder, and
schizophrenia
• Prescription for opiod use
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Top conditions encountered
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Neuropsychiatric – delirium, dementia
Falls – main cause of admission 15-30%
Coronary disease – 20% c/o dyspnea or chest pain as principal complaints
Polypharmacy and adverse drug effects – 11% of ED visits for those older than
65 vs. 1-4% for those younger, 33% of adverse affects related to warfarin,
insulin, and digoxin.
Alcohol and Substance abuse – the children of the sixties are now elderly,
etiology up to 14% of presentations related to associated delirium as well as
withdrawal effects, associated mood disorder, or associated complications of
use
Abdominal pain – up to 13% of older patients, mortality 6-8x higher than
younger population
Infections – 4% main complaint of which 25% pneumonia, 22% urinary
infection, and 18% sepsis/bacteremia
Social cause/functional decline – 9% of social admissions resulted from
infectious,(24%) cardiovascular(14%), neurologic(9%), digestive(7%),
pulmonary(5%) or other causes. 1-year mortality was up to 34%
Elder abuse/neglect – 10% rate of elderly abuse per national statistics
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The Special Case of Dementia in the ED
Carolyn K. Clevenger, DNP, GNP-BC
Associate Program Director, Atlanta VA Quality Scholars
Assistant Dean and Associate Professor, Emory Nursing
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“But all of our patients drive
themselves here…”
• 26-40% of older ED patients have
cognitive impairment
– Dementia (21.8%)
– Delirium (24%)
– Delirium on top of dementia
Naughton BJ, Moran MB, Kadah H et al. Delirium and other cognitive
impairment in older adults in an emergency department. Ann Emerg Med. Jun
1995;25(6):751-755.
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Challenges
• Long wait times for people with atypical
presentations
– Wandering
• Fast-paced environment
– Slow thinkers
• Poor historians
– Transfer sheets
– Recognition of impairment
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Agenda
Study of Older ED Patients
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Systematic Literature Review
Dementia in the ED: Setting
• ED in academic medical center
– 28,500 visits annually
– 30% of visits made by persons over 65
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Dementia in the ED: Sample
• ED patients 70+ years old
• One or more visits to the ED over 6
months
• Two approaches
– ED Visits
– Individuals’ Patterns of ED Visits
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Dementia in the ED: Method
Retrospective chart review
• Age*, gender*, race*
• Length of stay*
• Tests ordered*
• Disposition*
*Based on NHAMCS (CDC, 2010)
Centers for Disease Control and Prevention, National Center for Health
Statistics. National Hospital Ambulatory Care Survey (NHAMCS). In: US
Department of Health and Human Services, editor.2010
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Dementia in the ED: Method
Study Additions
• Evidence of cognitive impairment in
ED, hospital or outpatient notes
• Comorbidity score (Charlson)
• Caregiver presence
Charlson ME, Charlson RE, Peterson JC, Marinopoulos SS, Briggs WM, Hollenberg JP.
The Charlson comorbidity index is adapted to predict costs of chronic disease in
primary care patients. J Clin Epidemiol. 2008;61(12):1234-40.
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Dementia in the ED: Results
• Average age
– 79 y.o. with no dementia
– 81 y.o. with dementia
• Gender
– 59.3% female
• Race
– 59.9% white
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Dementia in the Atlanta ED: Results
• Reasons for seeking care
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Dementia in the ED: Results
• ED Visits
– Sampled 300 visits
• 199 by persons with no evidence of
dementia
• 101 by persons with documentation
of dementia
– 75 Recognized as such
– 26 “Unrecognized”
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Dementia in the ED: Results
• During each visit
– No difference in number of diagnostic
tests by dementia status
• More testing if person with dementia was
not recognized/not documented as such
– Length of stay (in ascending order)
1.Those without dementia
2.Those with recognized/documented
dementia
3.Those with unrecognized/undocumented
dementia
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Dementia in the ED: Results
• Disposition
– Admission to hospital (in ascending
order)
1. Persons without dementia
2. Persons with recognized/documented
dementia
3. Persons with
unrecognized/undocumented dementia
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Dementia in the ED: Results
• Pattern and Volume of ED Visits by
Individuals
– Each person with dementia made twice
as many ED visits
– Four times as many if NO Caregiver
present
– Fewer days between visits (33 vs 41)
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Dementia in the ED: Results
• Individuals’ Patterns
– Persons with dementia had more ED visits
over the study period (1.63 vs 2.15)
• Selecting only persons with 2+ visits
during the year, persons with dementia
represent
– 38.3% of all visits
– 39.9% of 7-day revisits
– 43.4% of 30-day revisits
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Dementia in the ED: Discussion
• Longer stays and more testing
– History
– Unclear about residential options
• Potential for missed or delayed
diagnosis
– Evidenced by re-visits for similar
complaints
• Use of Observation status
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Dementia in the ED: Literature
• What can the ED nursing staff DO?
– Assessment
– Communication
– Adverse Events
– Physical Environment
– Education
Clevenger, C.K., Chu, T.A., Yang, Z. & Hepburn, K.W. (2012). Clinical Care of
Persons with Dementia in the Emergency Department: a Review of the Literature and
Agenda for Research. Journal of the American Geriatrics Society
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Dementia in the ED: Literature
• Assessment
– Screen likely suspects
• Six-item screener
• Mini-cog FAQ
• St Louis University Memory Screen or
Montreal Cognitive Assessment
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Screening tool for cognitive impairment
sensitivity 94%, specificity 86%
Six-Item Screener
Reproduced from Med Care, Callahan et al,
The interviewer says the following: I would like to ask you some questions that ask you
to use your memory. I am going to name 3 objects. Please wait until I say all 3 words
and then repeat them. Remember what they are because I am going to ask you to
name them again in a few minutes. Please repeat these words for me: apple, table,
penny. (Interviewer may repeat names 3 times if necessary, but repetition is not scored.)
Did patient correctly repeat all 3 words? Yes
No
Orientation
Incorrect Correct
What year is this?
What month is this?
What is the day of the week?
Memory
What are the 3 objects I asked you to remember?
Apple
Table
Penny
A score less than or equal to 4 (each correct answer counts as 1 point) corresponds
to a positive screen for cognitive impairment; adapted from Callahan CM, Unverzagt FW, Hui SL, et al. Sixitem screener to identify cognitive impairment among potential subjects for clinical research. Med Care. 2002;40:771-781.
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Dementia in the ED: Literature
• Communication
– Nonverbal
• Including touch, as appropriate
– Emotional truth
– If repeating, exactly same as the first
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Dementia in the ED: Literature
• Adverse Events (delirium,
wandering, incontinence)
– Nonverbal cues and nursing judgment
• Is the chief complaint likely to cause pain?
• Has the individual been in the ED for some
time?
– Anticipate and prevent dehydration
– Make toilets visible
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Dementia in the ED: Literature
• Physical Environment (A page from
Senior ED’s)
– Natural light and quiet, glare-free floors
– Clear signage for wayfinding
– Proximity to nursing station
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Dementia in the ED: Literature
• Education
– Geriatric Emergency Nursing Education
(GENE)
– Emergency Nurses Association &
Hartford Institute for Geriatric Nursing
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Dementia in the ED: Summary
• Early recognition is key
– Build in a standard measure
• Secondary history of present illness
– Caregiver
– Transferring facility
• Education
– Atypical presentation
– Residential care options for older
adults
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Improving Post-ED Transitions for
Older Patients
S. Nicole Hastings, M.D., M.H.S.
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Post-ED Transitions
• The majority of older adults evaluated in the
ED are not admitted to the hospital.
– In VAMC EDs, ~75% of older patients are treated
and released
• Outpatient ED visits are increasingly
intensive.
– In VAMC EDs, 45-65% of patients are prescribed
at least one new medication; 25% told to change
or stop a baseline medication
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Frequent Users
• Frequent Flyers, Super Users
• Use ED on multiple occasions; account
for a disproportionally high number of
ED visits
• Majority are not elderly, but some are
• Frequent users are sicker (physical and
mental), challenging life circumstances
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Obstacles to Safe and Effective
Transitions
• The medication maze
• Communication hurdles
• The follow-up leap of faith
• Scratching the surface
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The Medication Maze
New
medications
and dosage
changes
Common ED
discharge drugs
(e.g. NSAIDs,
opioid analgesics,
antibiotics) are
often risky for
older patients
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Different
prescribers
Multiple
medications and
chronic conditions
Over the
counter drugs
Medication
Reconciliation
Across Transitions
Communication hurdles
• Between providers
– Direct communication between ED and
PCP rare- not always possible; not always
necessary
– 17% of VA PCPs always/almost always
promptly notified of ED visits
• Between providers and patients and
their families
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Follow Up Leap of Faith
• Primary Care
– Poor patient understanding of whether it’s
needed, and if so, how soon
– Inefficiencies if providers unaware of
needs
• Specialty Referrals
– Patient’s role, timing
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Scratching the Surface
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Substance abuse
Depression
Housing or food insecurity
Elder abuse
Caregiver stress
Poorly controlled chronic diseases
Improving ED Transitions
• Get collateral history of medication use,
if possible, esp OTC
• Drug-drug, drug-disease interactions,
renally dose
• Educate about possible side effects,
and what to do if they occur
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Improving ED Transitions
• Enhanced communication between
providers
– Synchronous vs Asynchronous
– PCP notification of ED visits: necessary
but not sufficient
– Focus on quality of content and action
items for PCP
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Improving ED Transitions
• Enhanced communication with patients
and families
– Standardized content of discharge
instructions
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Improving ED Transitions
• Enhanced communication with patients and
families
– Screening for communication barriers such as
hearing and cognitive impairment
– Including companions/family members in
discharge discussions
– Communication methods such as the “teach
back”, asking patients or surrogates to repeat key
information in their own words
– Printed materials – attention to font size and
literacy level
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Follow-up Care
• Plan for how outstanding tests and
appointments to be completed
• Expectations for when/how they will be
contacted
• Explicit discussion regarding resolution of
sx/warning signs
• Updated telephone contacts, for patient
and/or caregiver
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Scratch below the surface
• Ask
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Substance abuse
Depression
Housing or food insecurity
Elder abuse
Caregiver stress
Poorly controlled chronic diseases
• Engage other team members
• Communicate concerns findings to PCP and
patient; direct referrals when appropriate
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Thanks for your Attention!
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Bibliography
•
“Review: Emergency Department Use by Older Adults: A Literature Review on
Trends, Appropriatness, and Consequences of Unmet Health Care Needs,”
Anrea Gruneir, Mara J. Silver and Paula A. Rochon, Med Care Res Rev 2011
68:131 http://mcr.sagepub.com/content/682/131
“Older Patients in the Emergency Department: A Review,” Nikolaos Samaras,
Thierry Chevalley, Dimitrios Samaras, and Gabriel Gold, Annals of Emergency
Medicine, September 2010, 56:3,261-269.
“Older Adults in the Emergency Department: A Systematic Review of Patterns
of Use, Adverse Outcomes, and Effectiveness of Interventions,” Faranak
Aminzadeh, William Dalziel, Annals of Emergency Medicine, March
2002;39:3,238-247.
“How Frequent Emergency Department Use by US Veterans Can Inform Good
Public Policy,” Jesse Pines, Annals of Emergency Medicine, 2013, pending
publication.
The Merck Manual, Hospital Care and the Elderly: Provision of Care to the
Elderly: Merck Manual Professional,
http://www.merckmanuals.com/professional/geriatrics/provision_of_care_to_the
_elderly/hospital_care_and_the_elderly.html
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Bibliography
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Survey: Many Elderly Are in the Dark at ED Discharge,
http://www.acep.org/content.aspx?id=46032
“What Patients Really Want From Health Care,” Allan Detsky, JAMA, Dec 14,
2011;Vol306, #22, p2500-2501.
“Health Services Use of Older Veterans Treated and Released from Veterans
Affairs Medical Center Emergency Departments.” Hastings SN et al. J Am
Geriatr Soc 2013; 61:1515-1521.
“Quality of Pharmacotherapy and Outcomes for Among Older Veterans
Discharged from the Emergency Department.” Hastings et al. J Am Geriatr Soc
2008; 56 (5):875-880.
“The evolution of changes in primary care delivery underlying the Veterans
Health Administrations’s quality transformation”.Yano EM et al. Am J Public
Health 2007;97:2151-2159.
“Older Veterans and Emergency Department Discharge Information.” Hastings
SN et al. BMJ Qual Saf 2012 Oct;21:835-842.
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Questions/Comments
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