Transcript Transitional Care

TRANSITIONAL CARE:
HOW TO MOVE ELDERLY
PATIENTS THROUGH THE
EMERGENCY
DEPARTMENT
AGS
Michael A. LaMantia, MD, MPH
Kevin Biese, MD, MAT
Ellen Roberts, PhD, MPH
Jan Busby-Whitehead, MD
University of North Carolina at Chapel Hill
Division of Geriatric Medicine
Center for Aging and Health
Department of Emergency Medicine
THE AMERICAN GERIATRICS SOCIETY
Geriatrics Health Professionals.
Leading change. Improving care for older adults.
OUTLINE
• Aging: Global and American Perspectives
• Elderly Patients and the ED
• Case 1 — Getting it Wrong
• Transitional Care: Definitions and Quality
Indicators
• Case 2 — Getting it Right
Slide 2
LEARNING OBJECTIVES
• To identify ways in which the care of older
patients in the ED differs from that of younger
patients
• To define key components of effective
transitional care of elderly patients
• To identify potential strategies to improve the
coordination of care for elderly patients who
are seen in the ED
Slide 3
AGING: INTERNATIONAL AND
DOMESTIC SCOPE (1 of 2)
• Baby Boom generation
 Born between 1946 and 1964
 Quickly approaching age of retirement
• World Health Organization (WHO) report (2002):
 Age cohort >60 is fastest-growing population segment
worldwide
 Decreases in fertility rates and increases in life expectancy
will change age compositions of many nations
Slide 4
AGING: INTERNATIONAL AND
DOMESTIC SCOPE (2 of 2)
• WHO and United Nations estimate:
 35% of Japan’s population >60 in 2025
 34% of Italy’s population >60 in 2025
 China’s population >60 will increase from 134 million in
2002 to 287 million in 2025
• WHO calls for “healthy and active ageing” to be key
worldwide policy concern
Slide 5
AGING: IMPACT ON ED
Compared with younger patients, the elderly:
•
•
•
•
•
•
•
•
Are more ill at presentation
Arrive by ambulance more frequently
Receive more tests
Suffer from more chronic medical comorbidities
Are admitted to the hospital at higher rates
Experience longer ED stays
Incur higher medical bills
Return more frequently to the ED
Slide 6
CASE 1 (1 of 6)
Mr. S: Friday, 7:30 pm
• 85-year-old with a past medical history of moderate
dementia arrives via ambulance from an assisted
living facility
• Arrives with no paperwork or medication
administration list
• Patient can’t give chief complaint
• Person on call from the facility who knows patient has
gone home
• Grandson states patient has been coughing and that
doctor at facility suspected pneumonia
Slide 7
CASE 1 (2 of 6)
• Past medical history:
 Coronary artery disease
 Hypertension
 Moderate dementia
• Allergies: no known drug allergies
• Medications (grandson believes he remembers these):




Metoprolol
Aricept
Aspirin 81 mg/day
Simvastatin
Slide 8
CASE 1 (3 of 6)
Physical exam:
• BP 130/70, pulse 76, respirations 18, oxygen saturation 96% on
room air, afebrile
• Patient slightly confused (this is change from baseline according
to grandson)
• Pupils equal/round/reactive to light, moist mucous membranes
• Regular S1 S2, no murmurs/rubs/gallops
• Some very mild crackles at right base, otherwise clear; normal
work of breathing
• Rest of exam: unremarkable
Slide 9
CASE 1 (4 of 6)
• Labs:
 White blood cells: 10.0 (differential: neutrophils 8.7,
lymphocytes 1.0, eosinophils 0.3)
 Hemoglobin: 12.0
 Hematocrit: 36.0
 Platelets: 350
• Blood chemistry: within normal limits
• Chest x-ray: Possible developing right lower lobe
infiltrate vs. atelectasis. Clinical correlation
recommended.
Slide 10
CASE 1 (5 of 6)
• Pneumonia Severity Index score: 105 points ― Risk
Class IV ― approximately 8%9% mortality
• You recommend hospitalization, but:
 Grandson states he holds health care power of
attorney and patient would not wish to be
hospitalized. He wishes to take patient home and
care for him there. Patient is confused but
agreeable.
 You prescribe course of levofloxacin and ask that
they see their primary care provider on Monday
Slide 11
CASE 1 (6 of 6)
• Patient goes home and does well for 3 days
• He does so well, family does not follow up with
primary care provider on Monday
• Tuesday evening: Patient returns with skin bruising
and blood in his urine
 Platelets: within normal limit
 INR: 7.2
• When the patient’s pills are brought from home, it is
discovered he is taking warfarin
Slide 12
CASE 1 — BREAKDOWN
• What went well?
• What could have gone better?
Slide 13
DEFINITION OF
TRANSITIONAL CARE
“A set of actions designed to ensure the
coordination and continuity of healthcare
as patients transfer between different
locations or different levels of care within
the same institution.”
American Geriatrics Society (2003)
Slide 14
RISKS OF TRANSITIONS
• Medical errors
• Service duplication
• Inappropriate care
• Critical elements of care plan “falling though
the cracks”
American Geriatrics Society (2003)
Slide 15
CONCEPTUAL MODEL OF EFFECTIVE
TRANSITIONAL CARE
 Communication between sending and receiving
clinicians
 Preparation of the caregiver and patient for
transition
 Reconciliation of medication lists
 Arranging a plan for follow-up of outstanding tests
 Arranging an appointment with receiving physician
 Discussing warning signs that might necessitate
more emergent evaluation
Coleman (2003)
Slide 16
HOW TO IMPROVE
TRANSITIONAL CARE (1 of 6)
Suggestions:
• Changes to health care delivery systems
 For example, use of nurses to follow patients and/or expanding
Program of All-Inclusive Care of the Elderly programs
• Adoption of information transfer technology
• Changes to health care policy
 For example, pay for coordination of care or make providers
responsible for coordinating transitional care
Slide 17
HOW TO IMPROVE
TRANSITIONAL CARE (2 of 6)
Society for Academic Emergency Medicine (SAEM)
Geriatric Task Force:
• Developed at recommendation of SAEM and
American College of Emergency Medicine
• Identified and adopted quality measures to allow
assessment of care provided to elderly patients
• Quality measures were vetted by/at:
 SAEM Geriatric Task Force
 SAEM annual meeting
 American Geriatric Society annual meeting
Slide 18
HOW TO IMPROVE
TRANSITIONAL CARE (3 of 6)
Quality Measures 14: If nursing home patient goes
to ED, then paperwork should state:
• Reason for transfer
• Code status
• Medication allergies
• Contact information for:
 Nursing home
 Primary care or on-call MD
 Resident’s health care power of attorney or closest
family member
Terrell et al. Acad Emerg Med. 2009;16:441-449.
Slide 19
HOW TO IMPROVE
TRANSITIONAL CARE (4 of 6)
Quality Measures 56:
• If nursing home patient goes to ED, then paperwork
should include:
 Patient’s medication administration record
• If nursing home patient goes to ED for requested
studies, then:
 Document the performance of requested tests or the reason
why such tests were not performed
Terrell et al. Acad Emerg Med. 2009;16:441-449.
Slide 20
HOW TO IMPROVE
TRANSITIONAL CARE (5 of 6)
Quality Measures 79:
• If nursing home patient goes to ED and then will be released
from the ED, then:
 ED provider should speak with the nursing home provider,
primary care provider, or on-call MD for the nursing home
prior to discharge
• If nursing home patient goes to ED and then will be released
from the ED, then written paperwork should state:
 ED diagnosis
 Tests performed with results (and tests with pending results)
Terrell et al. Acad Emerg Med. 2009;16:441-449.
Slide 21
HOW TO IMPROVE
TRANSITIONAL CARE (6 of 6)
Quality Measures 1011:
• If nursing home patient goes to ED and then is
released back to the nursing home, then:
 The patient should receive the recommended follow-up
 The recommended changes to the patient’s medications or
plan of care should be followed (or the reason why not
followed should be documented)
Terrell et al. Acad Emerg Med. 2009;16:441-449.
Slide 22
CASE 2 (1 of 3)
Mrs. J: Saturday morning, 4 am
• 92-year-old woman who presents from local nursing home
for “evaluation of increasingly combative behavior”
• Past medical history:




Parkinsonism
Diabetes
Urinary incontinence
Chronic back pain secondary to osteoarthritis and degenerative
joint disease
• Little accompanying paperwork ― no medication
administration record
• Call to the facility ― the staff who are there don’t know the
patient ― they give you her son’s phone number
Slide 23
CASE 2 (2 of 3)
• Vital signs: BP 124/78, pulse 84, respirations 16,
afebrile
 Elderly woman lying on stretcher. Awake, but does not
interact much with you or other staff.
 Remainder of exam: within normal limits
 Labs and urinalysis: unrevealing
• Reach son ― he is thankful and says he will be over
in about 1 hour
• Patient awakens and starts to pull at lines ― request
is made for risperidone 1.0 mg
• Patient receives risperidone, calms down, and
eventually goes to sleep
Slide 24
CASE 2 (3 of 3)
• Son arrives ― you offer hospitalization ― he says
that is not what his mother would want
• He asks that she be transferred back to the nursing
home and that you provide a prescription for
risperidone
• What do you do?
Slide 25
REVIEW QUESTIONS,
VIGNETTE 1 (1 of 2)
• Mr. S is an 85-year-old man with mild dementia who is
sent to the ED from an assisted living facility without a
medication record. When the facility is called, the staff
do not know why Mr. S. was sent.
• Lab work and chest X-ray reveal a mild leukocytosis
and a right lower lobe infiltrate.
• The patient’s vital signs are within normal limits and
he is breathing easily. He is, however, slightly more
confused than usual, according to his grandson.
Slide 26
REVIEW QUESTIONS,
VIGNETTE 1 (2 of 2)
• The patient’s grandson states that he holds the
patient’s health care power of attorney and that Mr. S.
would not wish to be hospitalized.
• The decision is made to discharge the patient home to
the care of his grandson with levofloxacin.
• In 3 days, Mr. S returns to the ED with skin bruising
and blood in his urine. His platelets are WNL, but his
INR is 7.2.
• When his pills are brought from home, it is found that
he is taking warfarin.
Slide 27
VIGNETTE 1, QUESTION 1
Which of the following is not considered to be
a quality indicator for a patient transfer from a
nursing home to the ED? Select the one best
answer.
A.
B.
C.
D.
E.
Contact information for the facility
Medication list
Reason for visit
Resuscitation/code status
Vaccination history
Slide 28
VIGNETTE 1, QUESTION 2
In the above scenario, which provider action
could have best prevented the patient from
returning to the ED with hematuria? Select the
one best answer.
A. Asking the patient whether he was on warfarin.
B. Communicating with the referring physician from
the assisted living facility.
C. Confirming the patient’s medication allergies.
D. Suggesting that the patient have his INR checked
in 1 week’s time.
Slide 29
VIGNETTE 1, QUESTION 3
Which one precautionary action, listed below, would
have been the best action taken to increase the safety of
the patient’s discharge to his grandson’s home?
A. Ensuring that the patient’s grandson understands the warning
signs for bringing his grandfather back to the ED
B. Explaining to the patient the list of commonly prescribed drugs
that interact with levofloxacin
C. Making sure the patient and his grandson understand the need
to follow up with the patient’s primary care doctor within 1 week
D. Speaking with the patient’s referring physician when the
decision was made to discharge the patient home
Slide 30
REVIEW QUESTIONS,
VIGNETTE 2 (1 of 2)
• Mrs. J. is a 92-year-old woman with parkinsonism,
chronic back pain, and urinary incontinence who is
sent to the ED because of increasingly combative
behavior. She has no accompanying paperwork.
• She is lying on a stretcher with a subdued affect. Vital
signs are within normal limits, and physical exam,
blood work, and radiographic studies are unrevealing.
• Mrs. J becomes agitated and pulls at her lines and
catheter. She is given 1.0 mg of risperidone, which
calms her down.
Slide 31
REVIEW QUESTIONS,
VIGNETTE 2 (2 of 2)
• When the patient’s son arrives he states that his
mother would not wish to be hospitalized. He asks for
her to be transferred back to her nursing home with a
prescription for risperidone.
• The next night, Mrs. J returns to the ED after suffering
a fall, with a resulting foreshortened and externally
rotated right leg. Reviewing the medication record
from the nursing home, you see that she takes
cyclobenzaprine in addition to the risperidone that was
prescribed last evening.
Slide 32
VIGNETTE 2, QUESTION 1
When the patient was initially transferred from
her nursing home to the ED, which piece of
information would have affected her care in
the ED?
A.
B.
C.
D.
Contact information for the facility
Medication list
Occupational history
Resuscitation/code status
Slide 33
VIGNETTE 2, QUESTION 2
In the above scenario, which emergency provider
action contributed to the patient’s return to the ED with
a fractured hip? Select the one best answer.
A. The provider asked that the patient’s Foley catheter be
removed before the patient’s transfer back to the nursing home.
B. The provider did not ask the patient which medications she was
taking.
C. The provider did not confirm medication allergies before
discharging the patient.
D. The provider did not speak with the referring physician before
the patient’s transfer back to the facility.
Slide 34
ANSWER KEY
• Case 1
 Question 1: E
 Question 2: B
 Question 3: D
• Case 2
 Question 1: B
 Question 2: D
Slide 35
ACKNOWLEDGMENTS
AND DISCLAIMER
• This project was supported by funds from the American Geriatrics
Society John A. Hartford Geriatrics for Specialists Grant. This
information or content and conclusions are those of the authors
and should not be construed as the official position or policy of
the American Geriatrics Society or John A. Hartford Foundation,
nor should any endorsements be inferred.
• The UNC Center for Aging and Health and UNC Department of
Emergency Medicine also provided support for this activity. This
work was compiled and edited through the efforts of Jennifer
Link, BA.
Slide 36
THANK YOU FOR YOUR TIME!
Visit us at:
www.americangeriatrics.org
Facebook.com/AmericanGeriatricsSociety
Twitter.com/AmerGeriatrics
linkedin.com/company/american-geriatricssociety
Slide 37