SENIOR ER: THINK 3 D

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SENIOR ER THINK 3 D

• Advancing Excellence in Geriatric Care
  November 3, 2012

J. Michelle Moccia MSN, ANP-BC, CCRN Program
Director, Senior ER St. Mary Mercy Hospital,
Livonia Michiga Thank you to D. Cannatti, S.
Saltzman, Mekeia Foster, Meghan McGinn, Keyaria
and Holly Beversdorf, Denise Scott, Sue Penoza
for their contribution
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COURSE OBJECTIVES

• Outline the Graying demographics of the U.S.
  population and the impact on the ER
• Identify key organizational factors and
  implementation strategies for program success
• Discuss key components of geriatric nursing
  assessment using THINK 3 D ( a bundled care
  packet to help assess the older adult)

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• Adding life to years,
• not just more years to life
• (Gerontological Society of America)

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Gray Tsunami

• By 2030, nearly one in five Americans will be
  over the age of 65. (38.7 million)
• By 2050, this will double to 88.5 million
• Next 19 years, every single day 10,000 baby
  boomers reach the age of 65
• Centenarians is the fastest age group
• Every hour 10 more Michiganders turn 65
• By 2035, one in 4 Michiganders will be 65 and
  older

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Population age 65 and over in US
This chart for Indicator 1 - Number of Older
Americans shows the large growth of the
population 65 and older from 1900 to 2008 and the
even greater projected growth from 2008 to 2050.
It also shows the growing numbers of persons 85
and older and their large projected growth to
2050.
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ENA Position Statement (2003)

• ENA recognizes that optimal care of the older
  adult is best achieved by
• Members of the team collaborate to assess and
  treat
• ED nurses must be knowledgeable in physiologic,
  psychological, sociologic, and economic changes
  in older adult and how these changes impact
  assessment, interventions, teaching, discharge
  decisions, and community referrals

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ENA position statement

• Geriatric education needs to be included in basic
  and continuing education
• Recognize the patient, the spouse, or family
  members may need assistance the need for
  collaboration with other HCPs, organizations, and
  groups may be necessary to promote a safe and
  healthy environment
• Medication problems may go unrecognized
  screening for elder abuse and reporting must be
  carried out

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ER Nurses on the front line

• Front door of the hospital and to the community
• Encounter a variety of health issues from
  non-urgent, urgent to emergent
• Ranging from the frailest and functionally
  impaired to the healthiest and physically active
• The patients worldview can only be discovered
  during conversationsometimes awakened with
  reconnecting to their spirit

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Impact of Boarding Crowding

• Presentation more complex
• Higher acuity of care
• By 2013, number of visits could double reaching
  11.7 million annually
• Lack of PCP, business hours, homelessness,
  psychiatric disorders, substance abuse ED open
  24/7
• ED visits ages 65 and 74 have increased by 34
  between 1993 and 2003

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CONTROLLED CHAOS?

• Increased length of stay due to extensive
  evaluations
• Delayed time consuming care due to older adult
  physiologic needs
• Vital information missed due to poor handoff or
  unintentionally ignored
• Special needs not addressed baseline function,
  depression, dementia, delirium
• Risk of poor outcome, readmissions

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Risk Factors

• Older individuals are discharged are at greater
  risk for complications. Independent functioning
  may be threatened.
• Older adults that were discharged from an E.D.
  experienced a revisit, hospitalization or death
  within 3 months in 27 of the cases (Hwang U
  Morrison RS, 2007).
• In one month, office of Inspector General found
  14 of Medicare recipients experience and adverse
  event 44 were attributed to inadequate
  monitoring or patient 60-70 communication
  errors
• One needs to examine ones own values, attitude,
  perception and beliefs about caring for an older
  adult

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Aging is not a disease

• Aging is a process
• Interaction between environmental (extrinsic) and
  genetic (intrinsic) factors
• Older Americans living longer and healthier (Key
  Indicators of Well Being)
• Physicians, Nurses, and Researchers have
  concentrated on interventions and evidence-based
  protocols to improve the health and living
  conditions of older adults

We see the world not as it is but as we are
(Covey, 1990)
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Growth of SMML 65 age in 2009
FYI Every hour 10 more Michiganders turn 65
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(No Transcript)
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Focusing on Improving Services to Seniors is
Critical

• SENIOR ER The Trinity Health Perspective

• Senior population is growing (Baby boomers one
  turns 65 at a rate of 8,000 per day)
• Care needs are higher than those of younger
  people
• They drive most of the cost
• Their families are looking for safe alternatives
  for them
• They will be the biggest focus of CMS as it
  changes payment systems
• Providers that are sensitive to the needs of
  seniors will grow

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There is opportunity to improve the outcomes for
seniors

• Social services and support
• Optimizing health, wellness and fitness
• Chronic disease management
• Patient-centered medical homes
• PACE programs
• Palliative care

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Senior ER not invented here but still a good
idea (Dave Spivey, CEO SMML)

• Build on success of Holy Cross Hospital, Silver
  Springs, Maryland
• St. Mary Mercy Hospital in Livonia
• First Senior ER in the State of Michigan
  July 14, 2010
• Quickly followed by SJMO, SJMAA, Port Huron,
  Saline, Livingston, Chelsea, Brighton
• Focus on Safety, Patient loyalty, Growth,
  Financial, and Quality

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Current ER Flow

• Controlled chaos is a term frequently used by
  the Emergency HCP describe ER flow.
• Fast paced crowded facility risk for
  mismanagement and/or delayed cared.
• Vital information missed HCP may fail to
  identify any special needs i.e. geriatric
  syndromes baseline ADLs and unintentionally
  ignore signs of depression, dementia and delirium.

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Current Patient safety and concerns

• Cognitive impairment can complicate scenario if
  they are unable to describe their symptoms or
  self report their pain.
• Absence of advocate adds to their vulnerability.
  
• Poor hand-off communication in both directions
• The Emergency Nurses Association (ENA) created a
  Safer Handoff for the Older Adult (www.ena.org)
• SMML has created a STARForum group to work with
  nursing homes, assisted livings, independent
  livings, group homes etc. to create a seamless
  hand-off
• (Safe Transition of All Residents For U Me)

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How aging boomers will transform Michigan
Detroit Free Press, October 3, 2010A New Kind of
ER

• Glaring lights, crowds, the clacking of medical
  carts and wheelchairs and beds -- "a loud and
  chaotic ER is not a good place for an older
  person to be," said Michael Calice, medical
  director at St. Mary Mercy Livonia, part of the
  St. Joseph Mercy Health System.

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Need for enhanced Emergency Area for Seniors
(environment)

• Environment Changes
• Improve patient comfort pressure reducing
  mattresses, reclining chairs removal of noise
  distracters
• Reduce risks of fall (flooring, lighting,
  assistant devices, colors, hand rails)
• Reduce risk of delirium (visual aids, hearing
  device)

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Need for Cultural changes
Ageism the process of systemic stereotyping
and discrimination against people because they
are old Robert Butler, 1969 Dr. Bill
Thomas sessions

• Need to supplement education
• The ED physician and nurse must be well versed in
  the age-related physiologic changes, associated
  poor physiologic reserves and the high prevalence
  of comorbidities.
• Education modules (GENE and COMET) introduced to
  provide ED HCP with knowledge to care for the
  senior population.

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Senior ER (more than a space)

• Screenings to identify patients at risk for
  safety and poor outcomes that are not often
  captured with a medical screening
• Identify a decline in functioning may enable
  health care providers to provide a specific plan
  of care and thus improve the outcomes in the
  elderly.
• Evaluating multiple domains of behavior and
  function will assist in assurance of positive
  outcomes.

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S.E.N.I.O.R. FYI

• Senior ER Core Team used the word SENIOR to
  define the vision of the First Senior ER in the
  State of Michigan
• Specialized Emergency Nursing
• Improving Ones Resilience.
• Inpatient Team expanded and used the word SENIOR
  to define their vision?
• Sensitivity to Elders Needs
• Improving Opportunities for Resilience

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T.H.I.N.K . 3 D

• Triage risk screening Treatment
• Here for fall or at risk for falls?
• Inquire about medication, pain, alcohol use,
  advanced directive
• Nutrition assessment normal VS may not be so
  normal
• Katz functional assessment
• 3 D Dementia, Depression, Delirium
• (Thank you to Keyaria and Holly Beversdorf
  Nursing 4040 WSU)

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Treatment more complex in older adult than
younger adults

• Higher risk of complications from hospitalization
• Loss of physiologic reserves impaired renal
  flow, impaired hepatic flow, and poor homeostatic
  mechanisms
• Loss of functional ability that may be caused by
  disease or hospitalization.
• Cognitive impairment, hearing and visual
  impairment may affect stay in the ED

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Physiologic changes of Aging Cardiovascular

• Increased valve stiffness
• Heart valves thicken
• Less able to respond to volume changes
• SA node thickening, fewer pacer cells
• Barioreceptors less sensitive to BP changes
• Decreased CV reserve
• Emer Jour of Nursing

• Hypertension
• Murmurs
• Reduced SV CO
• Slow irregular HR
• Increased risk for orthostasis
• Heart failure

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Physiologic changes Neurologic

• Increased sensitivity to meds and toxins
• Pain sensation changes and less able to localize
  pain
• Risk of falls
• Processing is slower and possible memory changes

• Blood-brain barrier more permeable
• Fewer neurons and nerve fibers
• Slower reaction time decreased proprioception in
  lower limbs
• Decrease in neurotransmitter systems

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Physiologic changes Renal

• Decrease in GFR
• Decrease in renal blood flow
• Decrease in creatinine clearance
• Decrease in ability to concentrate/dilute urine
• Decrease in bladder capacity and increase in
  residual bladder volumes

• Drug doses will need to be adjusted
• Elimination of toxins is affected
• Dehydration and impaired ability to respond to
  volume changes
• Urinary frequency, urgency, or UTI

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Homeostasis regulation of body temperature,
blood pH, fluid balance and thirst

• Loss of physiologic and functional reserves
• Thermoregulatory response impaired
• Shivering less intense, sweating is reduced
• Renal changes (?GFR, blood flow, creatinine
  clearance)

• Body responds in more exaggerated manner to
  homeostatic challenges
• ? risk of hypothermia or hyperthermia
• Delayed speed of return to normal pH by 80

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Homeostasis continued

• Respiratory changes ?lung elasticity weakening
  of chest wall muscles
• Sensitivity of the brain is heightened by
  diminished capacity for homeostasis
• Alterations in tissue sensitivity to hormones
  (insulin response and glucose tolerance
  diminished sensitivity to ADH

• Less able to hyperventilate in response to
  metabolic acidosis, which leads to ?pH
• LOC changes (confusion, lethargy, agitation)
  often a sentinel sign of illness
• Changes in Blood Sugar and alterations in
  electrolyte levels

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THINK 3 D

• Triage Risk Screening Tool (TRST) Cleveland
  project developed to test the Systematic
  Intervention for a Geriatric Network of
  Evaluation and Treatment (SIGNET)
• Improves case finding cognitive impairment,
  environment (lives alone, support person, lives
  in senior apartment, assisted, skilled. Fall
  history ED or hospital history any special
  needs recognized i.e. caregiver strain abuse or
  neglect signs nutrition frailty
• The presence of two or more risk factors
  designates the older person as being at high
  risk.

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Advantages in screening the older adult emergency
patient

• Identification of a decline in functioning may
  enable ER providers to provide a specific plan of
  care
• Greater diagnostic accuracy
• Decreased mortality
• Decreased LOS in hospitals
• Prevention of injuries (slip and falls)

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Screening is important

• ED point of care for patient admitted,
  prehospital entry, or point of disposition to an
  extended or rehab care facility
• Special services may be required to support older
  adult through continuum of care i.e. housing,
  transportation, nutrition, durable medical
  equipment, counseling, caregiver support

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THINK 3 D Here for a Fall

• Leading cause of injury and injury related
  mortality
• Leading cause of head injuries
• Factor in over 90 fractures of distal forearm,
  proximal humerus, and hip
• Nonfatal injuries associated with loss of
  independence
• Not a normal part of aging
• More likely to be problematic
• As many as 50 who are hospitalized following a
  fall die within one year
• Highest risk especially those with physical and
  or cognitive impairment

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Here for fall? Extrinsic factors

• Gait and balance disorders
• Cluttered environment,
• Unfamiliar environment
• Stairs
• Throw rugs
• Unsuitable footwear
• Poor lighting, poor color distinction
• Restraints, side rails

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Here for fall? Intrinsic factors

• Cognitive impairment
• Polypharmacy four or more medications
• Sedatives, antihypertensive and psychotropic
  medications
• Alcohol
• Impaired mobility
• Fall history
• Sensory defects (hearing and vision)
• Frailty
• Postural hypotension

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ESI Severity Index 1, 2, or 3?

• 5 Level Triage System (2003 ACEP ENA)
• Witnessed?
• Loss of consciousness?
• Sitting or standing?
• Carpet or hard floor?
• Symptoms prior to fall?
• On Anticoagulant? (Coumadin, Pradaxa, Xarelto,
  including aspirin)

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HEAD INJURY FRACTURES

• R/O Subdural hematoma
• Brain loses volume with age,
• increased dural vein fragility
• Humerus
• Hip
• Femur
• Rib high risk pain, pneumonia due to
  inadequate respiratory effort, and risk for VTE
  due to lack of movement

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Evaluation

• Orthostatic BP
• Arrhythmias
• Gait and balance
• Prior to Discharge
• Timed Get Up and Go Test
• Tinetti Balance and Gait Evaluation
• www.ConsultGeriRN.org

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Here for abuse, neglect?

• 2.1 million older Americans are victims of abuse,
  only 10 is reported
• Elderly females are the most frequently abused
• 90 of the abusers are family members
• People over the age of 80 are abused 2 to 3 times
  more then any other age group
• Victims are often abused in several form

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Types of Abuse

• Physical
• Emotional/Psychological Abuse
• Sexual Abuse
• Financial Abuse
• Neglect of ADLs, confinement, abandonment
• Coercion abuse, verbal abuse
• Exploitation
• Elder abuse is defined as the action or the
  omission of actions that result in harm or
  threatened harm to the health or welfare of the
  older adult. American Medical Association

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Characteristics of abuse, neglect

• Extreme mood changes-withdraw, agitation,
  fearfulness
• and depression
• Health Care Shopping
• Series of missed appointments
• Unexplained Injuries
• Bruises in different stages of healing
• Poor Personal Hygiene
• Sexually transmitted disease
• Insomnia or excessive sleeping
• Weight gain or weight loss
• Documentation is key drawings, descriptions,
  photographs that include measurement of injury

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THINK 3 D Inquire about Medication History

• What medications are you currently taking?
• OTC?
• Vitamins, herbal, home remedies?
• Topicals, eye drops, patches?
• Med reminders i.e. mealtime, pill box?
• How do you know when you miss a med?

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Inquire about Med History

• Consider new symptoms as a possible drug to drug
  interaction.
• 5 medications 70 chance of drug interactions
• 7 medications 100 chance of drug interactions
• Dosing guidelines adjusted to creatinine
  clearance?
• Do they see another PCP?
• Any new med started recently?
• Beers Criteria created by Dr. Mark H. Beers,
  Geriatrician. (1991)
• Updated 2012 to assist HCP improving medication
  safety in older adult
• www.americangeriatrics.org

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THINK 3 D - Inquire about Advance Directive

• http//www.nhdd.org/

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Imagine you cannot speak

• Speak up and increase awareness
• Facilitate earlier treatment decisions
• Increase communication and understanding of
  patients prognosis
• Help reduce the use of resources and time spent
  by patients in undesirable states before death
• Referral to palliative care or hospice

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End-of-Life Decisions

• Aim for a good death defined by the Institute
  of Medicine
• one that is free from avoidable distress and
  suffering for pts, families, caregivers in
  accord with pts and families wishes and
  reasonably consistent with clinical cultural and
  ethical standards(Reisberg functional Assessment
  Staging scale of 1-7)
• http//geriatrics.uthscsa.edu/tools/FAST.pdf

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THINK 3 D - Inquire about Alcohol Use

• Heavy drinking is reported by 3-9 of people over
  65
• Alcohol abuse or dependence is reported by 2-4
• 1/3 of the elderly who abuse or have alcohol
  dependency started drinking after age 50
• 14 present to an ER with new diagnosable
• Alcoholism
• Serious cause of mortality and morbidity

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Signs and Symptoms of Alcohol

• Flushing
• Palmar eythema
• Sarcopenia
• Spider angiomas
• Altered level of consciousness
• Changes in mental status or mood
• Poor coordination
• Nystagmus
• Elevation of liver enzymes
• Increased MCV in presence of normal hemoglobin

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Screening, Referral and Brief Intervention (SBIRT)

• Older adult age 65 and gt
• More than seven drinks in a week
• 3 drinks on any occasion
• The American College of Surgeons Community on
  Trauma (ASCOT) mandate Level 1 and Level II
  Trauma centers identify patients who are problem
  drinkers screening, brief intervention, and
  referral (SBIRT)

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THINK 3 D - Inquire about pain

• The elderly under-report pain because it is
  thought to be a normal part of aging.
• The elderly may suffer because the cost of pain
  medications is too high.
• Those individuals with cognitive impairments may
  not be able to verbalize that they are in pain.
• The Visual Analogue Scale (VAS), the Numeric
  Rating Scale (NRS) and the Faces Scale have been
  used by nursing home patients

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Pain scale
The FACES or the Visual Analog or the Numerical
Rating Scale may be used even in the situation of
mild dementia.
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Pain Scales

• Verbal /Visual-Pain
• Distress IntensityScale
• Numeric 0-10
• Pain-AD
• (Combination of numeric,
• Verbal, and Iowa Pain
• Thermometer)

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PAIN FOR ADVANCED DEMENTIA
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Cognitive impairment signs of pain

• Look for non-verbal signs subtle signs such as
  wincing, moaning or guarding.
• A decrease in appetite and activity may be signs
  of pain.
• An inability to want to move may be related to
  pain.

(Ebersole, Hess, 1998)
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THINK 3 D Nutrition Normal VS

• Normal VS may not be so normal after all
• Determine baseline parameter
• Normal BP in normal hypertensive patient maybe a
  signal of volume loss
• Baseline lactate and base deficit levels
• Base deficit measure good predictor of life
  threatening injury

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Nutrition

• Unintentional weight change
• gt 10lbs within past 3 months?
• A reduction in food intake or
• hydration patient reported
• eating or drinking less than half
• of the usual intake for the past
• 7 days?
• Coughing or difficulty with
• swallowing when drinking
• fluids ?
• www.mypyramid.gov

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THINK 3 D What Kan they do?
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KATZ assessment

• FUNCTION FOCUSED CARE
• Inactivity rapidly contributes to muscle
  shortening
• Bed rest diminishes aerobic activity
• Loss of muscle strength leads to falls
• 40 of ER patients have functional
  decline within 30 days of ER discharge!!!
• Red Flag A decrease in function maybe the
  indicator the patient is ill
• GOAL Keep people functioning prevent the
  revolving door keep out of skilled facility

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KATZ Score
Normal aging changes and health problems
frequently show themselves as declines in the
functional status of older adults (Wallace
Shelkey, Hartford Institute of Geriatric Nursing,
2007).
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Why perform the Katz?

• The Katz Scale is utilized to determine if the
  patient can function independently, may require
  additional help to varying degrees or if the
  patient may need total assistance.
• Decline in functional status is often the first
  clue to health problems. The Katz scale measures
  the degree of function.
• A score of 6 indicates full function. A score of
  4 indicates moderate impairment and a score of 2
  or less is severe functional impairment.

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THINK 3 D Geriatric Depression Screen

• Depression is common late in life, affecting
  nearly 5 million of the 31 million Americans aged
  65 and older (Blazer, 2002).
• Depression may be reversed if identified early
  enough left untreated, depression may result in
  physical, social and cognitive impairment as well
  as cause delayed recovery from illness and may
  be severe enough to cause suicide (Kurlowicz
  Greenburg, 2007).

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DEPRESSIVE SYMPTOMS
Depressive Symptoms shows a modest increase in
clinically relevant depressive symptoms for older
age categories. Also shows lower levels for men
except at the 85 and over group where the levels
are similar.
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Geriatric Depression Screen
The Geriatric Depression Screen (GDS) consists of
15 questions. Answers in bold font may indicate
depression.
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3 D Dementia (Mini-Cog)

• Cognitive impairment increases with advancing age
  and increasing age is the greatest risk for
  Alzheimers disease. One in eight gt65 (13)
• Early identification of the disease may enable
  health care providers to start treatment in the
  early phase of the disease which usually results
  in a better response.(Cholinesterase inhibitors)
• The Mini-Cog consists of a three item recall in
  combination with a clock drawing exercise.
  www.alz.org

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The Mini-Cog Screening Tool

• Takes 3 minutes to complete
• Performs as well as or better than the
  Mini-Mental State exam that takes much longer to
  administer
• Results not affected by culture, ethnicity or
  education

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Mini-Cog Screening
Performing the screen tell the patient to listen
carefully and remember 3 unrelated words (I.e.
cup, train, blue). Have the patient repeat the
words to you prior to performing the CDT
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Mini-Cog Screening
Instruct the patient to draw the face of a clock,
placing the numbers at correct locations. Then
tell the patient to draw the hands of the clock
to represent 1110
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Scoring of Mini-Cog

• Unable to recall all 3 items scores as demented
• Successful recall of all 3 items non dementia
• Those who recall 1 or 2 items are classified
  based on the results clock-drawing test

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3D Delirium

• Delirium occurs frequently (25-60) in
  hospitalized adults (Waszynski, 2007). Delirium
  is often unrecognized by health care
  professionals and needs constant evaluation and
  re-evaluation.
• Acute, reversible and fluctuating central nervous
  system dysfunction with an organic cause.
• Lasts from a few hours to a few months if left
  untreated

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Types of Delirium

• The distinction between delirium and other
  disorders is often unclear
• Can resemble dementia (major risk factor)or
  depression
• Hyperactive form (Positive symptoms) Psychotic
  episode, agitated, high anxiety, aggressive or
  combative
• Hypoactive form (Negative symptoms) extreme
  lethargy, inability to focus attention or follow
  commands (Higher morbidity and mortality)
• Mixed Patient exhibits characteristics of both
  Hyper and Hypoactive

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Risk Factors

• Predisposing Factors

• Precipitating Factors

• Medications (Sedatives, antipsychotics,
  analgesics)
• Hypoxia
• Room changes
• Restraints
• Availability of clock
• Pain
• Electrolyte imbalance and dehydration
• Immobility
• Infection
• Fractures

• Advanced Age
• Dementia or family history
• Depression
• Co-Morbidities
• Severity of illness
• Hearing/visual impairment
• Smoking, ETOH, drug use
• Surgery
• Male gender

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Delirium Pneumonic

• Drug Use, dehydration
• Electrolyte Imbalance
• Lack of Drugs (withdrawal or PRN medications)
• Infection
• Reduced Sensory in patient
• Intra Cranial Events
• Urinary Incontinence/Fecal Impaction
• Myocardial Infarction, multiple
• comorbidities

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Delirium Assessment CAM

• The Confusion Assessment Method (CAM) is a tool
  designed for non-psychiatric trained individuals
  to recognize delirium quickly and accurately.
• The test only identifies if delirium may be
  present and not the degree of delirium.

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Confusion Assessment Method (CAM)
Four Features of Delirium Feature 1 and
Feature 2 need to be present plus Feature 3 or
Feature 4
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Geriatric Bundle Differentiating Depression,
Delirium and Dementia
Parameter Depression Delirium Dementia
Onset Weeks Short, rapid, abrupt, hours, days Months to years
Duration 3-6 months, may be chronic Days to 3 weeks 5-15 years
Initial Presentation Flat affect, hypochondrial, focus on symptoms, apathy, little effort to perform Disorientation, clouded, consciousness, fluctuation in moods, disordered thoughts Vague symptoms, loss of intellect, easily distracted, great effort to perform tasks
Recent Memory Normal or recent/past both altered Partial impaired or remains intact Impaired
Intellect Slower, may be unwilling to respond Impaired Impaired concrete thinking
Judgment Poor judgment, many I dont know answers Impaired, difficulty separating facts, hallucinations Impaired, had inappropriate decisions, denies problem
Pattern Worse in the morning, sleep impaired Day drowsiness, nighttime hallucinations, insomnia, nightmares Worse in the evening, sundowning, reverse sleep cycle
Attention/Affect Withdrawn, apathy, hopeless, distress Labile, fear/panic, periods of lucidity Easily distracted, labile, inappropriate, anxiety, depression, suspicious
Orientation Intact Disoriented but not to person. Periods of lucidity Disoriented
Level of Consciousness Intact Disturbed Intact
Psychiatric symptoms Delusions Delusions Hallucinations
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CARING FOR YOUR FUTURE SELF Dr. Daniel Keys
(EPMG)

• We should all be concerned about the future
  because we have to spend the rest of our lives
  there C.F. Kettering

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WERE ALL IN !!!
ARE YOU?
Because the Rewards are Endless
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Thank YOU for attending!