Transcript CHAMP - Curriculum for the Hospitalized Aging Medical Patient

CHAMP:
Care of the Hospitalized Aging Medical Patient
Leader’s Guide to Bedside Teaching Rounds for
Medical Students
Shellie Williams, M.D.
University of Chicago
Overview
• Who:
– Students on internal medicine service; Geriatric
attending of the month and fellow.
• When:
– (1) afternoon per week, 60min bedside teaching.
• How:
– Students decide date/time that majority can meet. (1)
student chooses a patient and we round 60min on
patient case with entire group.
• Where:
– Medicine Ward
• What:
– We focus on AAMC geriatric competencies for
medical students on care of hospitalized elders.
Geriatric Inpatient Competencies for
Medical Students
Recommendations of the July 2007 Geriatrics Consensus
Conference
22 Identify potential hazards of hospitalization for all older adult patients
(including immobility, delirium, medication side effects, malnutrition,
pressure ulcers, procedures, peri and post operative periods, and hospital
acquired infections).
23 Explain the risks, indications, alternatives, and contraindications for
indwelling (Foley) catheter use in the older adult patient.
24 Explain the risks, indications, alternatives, and contraindications for
physical and pharmacological restraint use.
25 Communicate the key components of a safe discharge plan (e.g., accurate
medication list, plan for follow-up), including comparing/contrasting
potential sites for discharge.
26 Conduct a surveillance examination of areas of the skin at high risk for
pressure ulcers and describe existing ulcers.
Teaching Format

“Care of the hospitalized elder” lecture is
emailed to students at the beginning of the
rotation.

Students spend 1 hr rounding with a
geriatric attending and fellow.

1-2 patients seen during rounds, and
students are expected to complete components
of a geriatric inpatient safety screens to optimize
safety of elders on UCMC inpatient wards.
Main Content Areas in CHAMP
 Hospital Hazards
-recognizing and preventing
 Foley catheter use in the elderly
-explaining risks, indications, alternative
 Use of restraints
-understanding the risks, indications and alternatives
 Key components of safe discharge planning
-what to communicate
 Pressure ulcers and Braeden staging
-demonstrating surveillance exam of areas of skin at risk
Geriatric Hospital Complications:
History Questions and Screens
Delirium:
AM review with nurse or family?
Screening: CAM, Mini-Cog
Deconditioning:
What was your function 2 weeks prior to hospital and now?
Screening: ADL/IADL; mobility status
Poly-pharmacy:
What are potential hazards with the medications?
Screening: Medication reconciliation; Beers List risk drugs
Pressure ulcers:
Any pain in perineum, heels, elbows
See skin and Stage using Braeden system
Geriatric Hospital Complications:
History Questions and Screens
Environmental Assessment:
What aides does the patient use, what is present in hospital?
Screen: Gait device, glasses, hearing aide, dentures
Pain:
6point: describe, location, duration, exac/relieve, intensity
Screen: 6 point assess and Scale 0-10
Restraint Review:
How many restraints are present on this patient?
Screen: Assess need for: Foley, PICC< drains, SCDs, catheter/drains,
wrist/hand restriant and discontinuation plan
Nutrition:
How is your appetite?
Screen: Observe patient eating, desired foods, dentures, last BM
Medical decision making:
What have the doctors told you about why you’re in the hospital?
Screen: Applebaum review of decision making
Teaching Materials
Champ website pocket cards and
UCSF Geriatrics for Inpatient Medicine
Card.
Attending Teaching Triggers:
1. Hospital Discharge
What are potential obstacles to a safe and speedy discharge in this particular
patient?
• Review pre-hospital living situation and supports
• When you enter the room ask students to identify obstacles to the patient
ambulating: foley, iv, compression boots, wrist restraints
• Ask the students to screen the patient for 2-3 elements of pre-hospital and
current Adl and Iadl function
Attending Teaching Triggers:
2. Risk factors for delirium
What are potential risk factors for delirium in this patient?
Pre-hospital factors: poor vision, bun/cr >18, Charleston >4, baseline
dementia
Hospital factors: >3 new meds, restraints, foley, iatrogenic events,
malnutrition
Post-Hospital factors for prolonged delirium:
Attending Teaching Triggers:
3. Diagnosing delirium
What elements are needed to diagnose delirium?
Have one student give you the elements of the CAM:
1. change in baseline cogntion/flucation/acute
2. Inattention +3 OR 4
--------------------------------------------------------------------3. disorganized thoughts
4. change level of consciousness
B. Ask that student which elements were + in the patient you just
evaluated, per there evaluation and nursing account.
C. If patient + for delirium, Ask student 3 common causes of
delirium:
1. Medications
2. Infections 3. Metabolic disturbances

A.
Attending Teaching Triggers:
4. Significance of delirium
Why is delirium so important in hospitalized elders?
1. 2x increased risk for
mortality
institutionalization
ADL dependence
2. 20% physician recognition and even after recognition seldom
documented
3. High risk for development of dementia subsequent to a delirium episode
4. 6-60 billion/yearly cost of care for delirium in elderly hospitalized
Attending Teaching Triggers:
5. Medication Review
Please review the MAR for Mrs. _____, can anyone identify
any drugs which may predispose to adverse events during
hospitalization?
• Psychoactive effects
• Sedative-hypnotics
• Narcotics
• Anti-cholinergic drugs
How can we modify medication administration in elders to be
safer?

1.
2.
Start low dose/slow titration. Start 1/3-1/2 standard
prescribing dose for adult patient in elderly
Remember elders renal and hepatic function declines with age
and the alteration in Vd of water: muscle mandates need for
dose adjusting.
Attending Teaching Triggers:
6. Medication Review
 Review primary classes identified in Beers
criteria for elder prescribing problems:
– Benzodiazepines, especially long acting
– High dose narcotics or long-acting, especially in
narcotic naïve
– NSAIDS
– Anti-cholinergics
Attending Teaching Triggers:
7. Geriatric Review of Systems
What is the geriatric review of systems? Please assess in patient _______.
How are you sleeping, difficulty initiating or staying sleep
Do you use walker, hearing aid or glasses at home? Are they here?
Are you having pain? Location + Pqrst
Have you been out of bed today? I or Assisted?
How is your appetite? Do you like the meals you are able to select?
Have you had a bowel movement? Any strain?
Review cognition above with CAM.
Attending Teaching Triggers:
8. Skin Exam
Ask the students what key areas of the body should be screened for ulceration?

–
Review on the patient and discuss the Staging and Braeden Risk Scale.

–
–
–
–
Stage I: Intact skin with non-blanchable redness
Stage II: Partial thickness loss of dermis or intact or open/ruptured serum-filled blister.
Stage III: Full thickness tissue loss. Subcutaneous fat may be visible. May include
undermining and tunneling.
Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or
eschar on some parts of or undermining may be present.
What is Braden Scale: Risk assessment scale for pressure ulcers. Lower scores
means higher risk of ulceration. Looks at following risk factors for ulceration on
scale 1(low fxn)-4 (high fxn):


Perineum, heels, elbows, hips
–
–
–
Skin moisture
Perception of pain
Mobility potential in bed
–
–
Level physical activity
Nutrition
Friction/sheering forces on skin
Attending Teaching Triggers:
9. Transitions to other care settings
 Based on the above evaluation and patients pre-hospital
living situation what do you feel is the most appropriate
discharge setting?
 Review criteria for:
• Inpatient setting
• Acute rehab
• Skilled Nursing (SNF)
• Long-Term Care Nursing (ICF)
• Assisted Living
• Independent Living
• Home Care