Anne Scott Advanced Nurse Practitioner Medicine of the Elderly Royal Infirmary of Edinburgh

Anne Scott Anne Scott Advanced Nurse PractitionerAdvanced Nurse Practitioner

Medicine of the ElderlyMedicine of the ElderlyRoyal Infirmary of EdinburghRoyal Infirmary of Edinburgh

Nurses General knowledge of Nurses General knowledge of Elderly Care and specifics of Elderly Care and specifics of the Comprehensive Geriatric the Comprehensive Geriatric

Assessment process.Assessment process.TarGetEdTarGetEd

Aims of Aims of presentationpresentation

• Why did I put myself forward?Why did I put myself forward?• The process and how I engaged with itThe process and how I engaged with it• What question and perceived outcomesWhat question and perceived outcomes1.1. Audit and questionnaireAudit and questionnaire2.2. Preliminary findingsPreliminary findings3.3. Educational toolsEducational tools• Next stepsNext steps• Summary and experience Summary and experience • Questions Questions

Why?Why?

• Need for experience off and support Need for experience off and support in research process (NMC and RCN)in research process (NMC and RCN)

• Keen to engage with research within Keen to engage with research within hospital setting regarding care of hospital setting regarding care of older people. older people.

• Wanted to look specifically at an Wanted to look specifically at an element of nursing roleelement of nursing role

Engagement – Engagement – starting the processstarting the process

• Form from PROPForm from PROP1.1. Question Question 2.2. Methods and data Methods and data

sourcessources3.3. Out puts and Out puts and

communicationscommunications4.4. ResourcesResources

• Own team (Medics Own team (Medics and nurse manager) and nurse manager) agreed to supportagreed to support

• Met others in project Met others in project both in hospital and both in hospital and at PROP study days at PROP study days in Edinburgh in Edinburgh UniversityUniversity

• Deciding on my Deciding on my specific questionspecific question

Questions!!!!!!Questions!!!!!!!!!!

• Are older people different?Are older people different?• What do we need to do to support them in What do we need to do to support them in

hospital and out of hospital?hospital and out of hospital?• How do we measure frailty? Fit 80 year old, How do we measure frailty? Fit 80 year old,

64 year old with multiple physical issues64 year old with multiple physical issues• What is in the community? Telecare, What is in the community? Telecare,

telehealth, hospital at home, rehabilitation in telehealth, hospital at home, rehabilitation in the community, Carer supportthe community, Carer support

• What do we assess? Do we know importance? What do we assess? Do we know importance? Do we respond to information gathered? Do we respond to information gathered?

• Comprehensive Geriatric Assessment – Comprehensive Geriatric Assessment – evidence to support use of CGA improves evidence to support use of CGA improves outcomes in the care of older people.outcomes in the care of older people.

Literature Literature searchsearch

• Meta analysis by Ellis showed benefit Meta analysis by Ellis showed benefit of processof process

• Patients more likely to be in own Patients more likely to be in own home 12 mths after hospital if CGA home 12 mths after hospital if CGA occurredoccurred

• British Geriatric society recommends British Geriatric society recommends use of CGA – ‘good Practice’use of CGA – ‘good Practice’

• Process used to identify and address Process used to identify and address issues in older people – involves multi issues in older people – involves multi disciplinary teamdisciplinary team

• Social, health, financial, psychological Social, health, financial, psychological aspectsaspects

• Aspects specific to nursing Aspects specific to nursing assessment in first few days of assessment in first few days of hospital admissionhospital admission

Comprehensive Comprehensive Geriatric Geriatric Assessment?Assessment?

What was the goal of my What was the goal of my work?work?• Highlight the importance of Comprehensive Highlight the importance of Comprehensive

Geriatric Assessment (CGA) within the Geriatric Assessment (CGA) within the nursing population in hospitalnursing population in hospital

• Development of teaching tool and ongoing Development of teaching tool and ongoing educational support for nurses regularly educational support for nurses regularly caring for older peoplecaring for older people

• Improve patient experience and outcomesImprove patient experience and outcomes• Improve own practice, skills and knowledgeImprove own practice, skills and knowledge

Start of the Start of the ‘work’‘work’

• Audit case notes and look at Audit case notes and look at documentation by nurses of ‘frailty tools’. documentation by nurses of ‘frailty tools’. Specific elements of CGA to be looked at Specific elements of CGA to be looked at

1.1. Falls assessmentsFalls assessments2.2. Nutrition Nutrition 3.3. Tissue viabilityTissue viability4.4. Continence and toileting issuesContinence and toileting issues5.5. Cognitive Cognitive

Questionnaire Questionnaire Use of CGA as guide to appropriate Use of CGA as guide to appropriate

questionsquestionsDesign questionnaire (difficult!)Design questionnaire (difficult!)Target group of nurses cross specialities Target group of nurses cross specialities

in admission and assessment areasin admission and assessment areasRole out questionnaireRole out questionnaireAnalyse resultsAnalyse results

Who to ask?Who to ask?• Trained nurses in Medical, surgical, Trained nurses in Medical, surgical,

orthopaedic and Medicine of the orthopaedic and Medicine of the elderlyelderly

• First few days/hours of admission First few days/hours of admission crucial to carecrucial to care

• Large numbers of older people at Large numbers of older people at hospital ‘front door’hospital ‘front door’

Role outRole out• Proposal to research team of own Proposal to research team of own

specialityspeciality• Explanation of work and proposal of Explanation of work and proposal of

research and agreement from Nurse research and agreement from Nurse managers and charge nursesmanagers and charge nurses

• Sent out 50 questionnaires to trained Sent out 50 questionnaires to trained staff in 4 distinct clinical areasstaff in 4 distinct clinical areas

Audit and Audit and ReturnsReturns

• Audited 22 sets of notes over 72 Audited 22 sets of notes over 72 hour periodhour period

• Good response from Medical and Good response from Medical and surgical areassurgical areas

• 40 returned out of 55 sent40 returned out of 55 sent

Results from Results from notesnotes

0102030405060708090

<24hrs 24hrs 48hrs >48

fallsmustcognitiveTissue viabilitycontinence

Main resultsMain resultsQ1. On a usual day approximately how many patients are over >75

years within you clinical area?

0

2

4

6

8

10

12

<25% 60% 50% >70% all patients

Num

ber

medical MoE orthopaedic surgical

Q3. Do you approach the assessment of an elderly patient (>75yrs) differently from younger patients?

0

1

2

3

4

5

6

7

8

depends no no/depends yes yes/depends

num

ber


Q4. Frailty can be measured by scores. Are you familiar with any of these?

0

2

4

6

8

10

12


num

ber

no yes

Number of band 5, 6 or 7 nurses / clinical area who completed a questionnaire

10

7 7

10

2

1 11 1

0

2

4

6

8

10

12


num

ber

5 6 7

Main results FrailtyMain results FrailtyQ5. What makes you consider a patient is frail?

Medical wards

4

21

4

co-morbidities/ frequentadmissions

mobility/co-morbidities/frequent admissions

mobility/co-morbidities/frequentadmissions/cognitiveimpairment

all

Q5. What makes you consider a patient is frail?Orthopaedic wards

4

2

1

1 co-morbidities/ frequentadmissions

co-morbidities/ frequentadmissions/cognitiveimpairment


all

Q5. What makes you consider a patient is frail?Surgical wards

1

1

1

2

7

1

co-morbidities/ frequentadmissions

co-morbidities/ frequentadmissions/cognitiveimpairment


mobility/co-morbidities/frequent admissions/cognitiveimpairment

all

(blank)

Q5. What makes you consider a patient is frail?MoE wards

1

1

2

4

age/co-morbidities/frequent admissions

mobility

mobility/co-morbidities/ frequentadmissions

all

Main results - Main results - NutritionNutrition

• Nutrition – effects Nutrition – effects healing and ability healing and ability to respond to acute to respond to acute physical insults, physical insults, particularly in the particularly in the elderly. Good elderly. Good knowledge baseknowledge base

Q14. Can you describe why nutritional scores (MUST) are necessary/indicated ?

0

1

2

3

4

5

6

7

8

9

10


num

ber

yes but basic yes with confidence

Main results – Main results – bowels and bladderbowels and bladder

Q15. Do you consider the assessment of bowel habit important?

All answered "Yes"

0

2

4

6

8

10

12

14


num

ber

Q16. What can altered bowel habit commonly indicate?Q16. What can altered bowel habit commonly indicate?

Clinical AreaClinical Area

memedicdicalal

MMooEE

orthoorthopaedipaedi

cc

sursurgicgical al

adverse effectsadverse effects 11 adverse effects/poor dietadverse effects/poor diet 33 22 11cancercancer 11 cancer/adverse effectscancer/adverse effects 22 44 11cancer/adverse effects/poor dietcancer/adverse effects/poor diet 22 22 44cancer/renal issues/adverse cancer/renal issues/adverse effectseffects 11 cancer/renal issues/adverse cancer/renal issues/adverse effects/poor dieteffects/poor diet 33 11 11 11cancer/renal issues/adverse cancer/renal issues/adverse effects/poor diet/renal and CKDeffects/poor diet/renal and CKD 11extreme age/cancer//adverse extreme age/cancer//adverse effects/poor dieteffects/poor diet 11extreme age/cancer/adverse extreme age/cancer/adverse effectseffects 11 extreme age/cancer/adverse extreme age/cancer/adverse effects/effects/ 11 extreme age/cancer/adverse extreme age/cancer/adverse effects/poor dieteffects/poor diet 11 22extreme age/cancer/renal extreme age/cancer/renal issues/adverse effects/poor dietissues/adverse effects/poor diet 11 11nonenone 11

Q17. Do you consider assessment of urinary continence important in the assessment of the older patient?

0

2

4

6

8

10

12

14


num

ber

no yes

Main results - Main results - cognitivecognitive

• Dementia and Dementia and delirium – common delirium – common issues in older issues in older patients in hospitalpatients in hospital

• Important nurses Important nurses know the difference know the difference between dementia between dementia and delirium. Often and delirium. Often nurses first to nurses first to identify issueidentify issue

Q7. Can you describe the difference between dementia and delirium?

0

1

2

3

4

5

6

7

8

no yes - confident yes - basic aware but unclear

num

ber


cognitive – cognitive – investigation and investigation and reviewsreviews

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

5

1

2

1

1

urine

urine/bowel habits/fluidintake/medication

urine/bowel habits/fluidintake/medication/referralto psych

urine/fluidintake/medication

urine/fluidintake/medication/referralto neuro/referral to psych

urine/fluidintake/medication/referralto psych


would you consider/expect to be done in your clinical area?MoE wards

1

33

1

urine


urine/bowel habits/fluidintake/medication/referral toneuro/referral to psych

urine/bowel habits/fluidintake/medication/referral topsych


would you consider/expect to be done in your clinical area?Orthopaedic wards

1

2

1

4



urine/medication/referral toneuro/referral to psych

urine/medication/referral topsych


would you consider/expect to be done in your clinical area?Surgical wards

2

2

1

3

1

1

1

1

1

urine


urine/bowel habits/fluidintake/medication/


urine/bowel habits/medication

urine/fluidintake/medication/referral topsych

urine/fluid intake/referral topsych

urine/medication

urine/medication/referral topsych

Confusion Confusion screenscreen

BloodsBloods – routine and Vit B12, folate, TFT’s, – routine and Vit B12, folate, TFT’s, RadiologRadiologyy – consider CT – consider CT headheadCognitive testingCognitive testing AMT <7 MMSE<24 4@T >4, AMT <7 MMSE<24 4@T >4, MicroMicro – consider infection – consider infection screen inc MSU, screen inc MSU, Collateral historyCollateral history – include acute/chronic onset, – include acute/chronic onset, alcohol, meds, fallsalcohol, meds, falls

Infection Infection screenscreen

BloodsBloods FBC, consider CRP, blood cultures, FBC, consider CRP, blood cultures, MicroMicro - MSU, swab any - MSU, swab any wounds, consider change of catheter, wounds, consider change of catheter, SkinSkin – check for sites and signs of – check for sites and signs of infections infections IInvestigationsnvestigations – consider CXR, foreign travel – consider CXR, foreign travel OtherOther - if pyrexial – is - if pyrexial – is there a pattern?there a pattern?

Falls Falls assessmentassessment

BloodsBloods – include Calcium – include Calcium Falls check listFalls check list – can include errect and – can include errect and suppine BP >20 difference significant. Check foot ware, exclude altered suppine BP >20 difference significant. Check foot ware, exclude altered sensation at extremities, sit/stand test, environmental review, sensation at extremities, sit/stand test, environmental review, Cardiac Cardiac investigationsinvestigations – consider 12 lead ECG, ECHO, 24 hour tape – consider 12 lead ECG, ECHO, 24 hour tape MedicationsMedications – – particularly anti -hypertensive's, sedativesparticularly anti -hypertensive's, sedatives

Eating and Eating and drinkingdrinking

BloodsBloods – routine incl LFT’s – albumin particularly, – routine incl LFT’s – albumin particularly, Chewing and Chewing and SwallowingSwallowing – solids and/or fluids? Cough present? Mechanical issue – solids and/or fluids? Cough present? Mechanical issue (e.g.teeth)(e.g.teeth)Weight loss and/or appetite concernsWeight loss and/or appetite concerns – food chart, weight chart, dietician – food chart, weight chart, dietician referral, referral, OthersOthers – GI signs or symptoms? AUSS? Collateral history? – GI signs or symptoms? AUSS? Collateral history? History of malignancy? Change in bowel habit or appearanceHistory of malignancy? Change in bowel habit or appearance

Continence Continence screenscreen

BloodsBloods – routine consider PSA (male), – routine consider PSA (male), RadiologyRadiology – renal ultra sound if – renal ultra sound if associated with AKI, associated with AKI, MedicationsMedications – diuretics, – diuretics, MicroMicro – MSU, – MSU, OthersOthers – – bladder scan, DRE (prostate, constipation) continence chart, symptoms bladder scan, DRE (prostate, constipation) continence chart, symptoms of urgency, frequency or discomfort, referral to continence service of urgency, frequency or discomfort, referral to continence service [email protected] Advanced Advanced Nurse Practitioner, Medicine of the Elderly, Royal Infirmary Edinburgh. (PROP)Nurse Practitioner, Medicine of the Elderly, Royal Infirmary Edinburgh. (PROP)

TarGetEd Prompt for elderly patient assessments

mailto:[email protected]

TargetedTargeted1.1. Hb115 – 160Hb115 – 160

2.2. WBC 4.0 - 11.0 WBC 4.0 - 11.0

3.3. Plate 150 - 350 Plate 150 - 350

4.4. Urea 2.5 - 6.6 Urea 2.5 - 6.6

5.5. Na 135 - 145 Na 135 - 145

6.6. K+ 3.6 - 5 K+ 3.6 - 5

7.7. Creat 60 - 120 Creat 60 - 120

8.8. GFR >60 GFR >60

1.1. Reduced in anaemia. Blood loss? Chronic? Diet? Fluid Reduced in anaemia. Blood loss? Chronic? Diet? Fluid status can affect Hb – can drop acutely with hydrationstatus can affect Hb – can drop acutely with hydration

2.2. Raised infection also can be decreased infection, Raised infection also can be decreased infection, immuno suppression. Elderly sometimes delayed immuno suppression. Elderly sometimes delayed response to acute sepsisresponse to acute sepsis

3.3. Low haematological issue – check for bleeding, Low haematological issue – check for bleeding, bruises, high - ?infectionbruises, high - ?infection

4.4. Low indicate alcohol/liver issues. High dehydration, Low indicate alcohol/liver issues. High dehydration, check meds – ongoing diureticscheck meds – ongoing diuretics

5.5. Abnormal can cause confusion, drowsy/coma, falls, Abnormal can cause confusion, drowsy/coma, falls, suggests fluid problems, endocrine disordersuggests fluid problems, endocrine disorder

6.6. K+ changes due to medication, diabetic, hydration. K+ changes due to medication, diabetic, hydration. Can cause arrhythmiasCan cause arrhythmias7.7. Creatinine – raised in renal failure, changes can Creatinine – raised in renal failure, changes can

indicate muscle lossindicate muscle loss

8.8. GFR – often reduced in elderly as part of normal aging GFR – often reduced in elderly as part of normal aging process. Decrease can influence medication choices process. Decrease can influence medication choices and radiological investigations requiring contrastand radiological investigations requiring contrast

Falls and Falls and mobilitmobilityy

No No ississueuess

First fall First fall but but indepeindependently ndently mobile mobile

Uses aid but no Uses aid but no falls. falls. Sensory Sensory problems problems +/- falls +/- falls score 1-2score 1-2

General General decline in decline in mobility mobility over over weeks +/- weeks +/- falls score falls score 1-21-2

Acute decline +/- Acute decline +/- falls score >3falls score >3

Only mobile Only mobile with with assistance assistance of 2 /hoistof 2 /hoist

Bed/chair Bed/chair boundbound

ContinencContinence e

No No ississueuess

Stress Stress incontiincontinence/ nence/ managmanaged with ed with padpad

Chronic Chronic continence continence previously previously investigatedinvestigated/diagnosed/diagnosed

Acute Acute incontineincontinence with nce with no no associateassociated d symptomssymptoms

Acute Acute incontinence incontinence with with symptoms – symptoms – discomfort, discomfort, frequency, frequency, smell coloursmell colour

Incontinence of Incontinence of urine or urine or faeces. faeces. Acute or Acute or chronicchronic

Catheterized Catheterized due to due to incontinincontinence ence and or and or RequireRequires rectal s rectal tubetube

Eating and Eating and drinkindrinkingg

No No ississueuess

Decreased Decreased appetitappetite over e over long long period period of time. of time. MUST 0MUST 0

General malaise General malaise with with associated associated appetite appetite changes and changes and GI GI symptoms. symptoms. MUST score MUST score triggeredtriggered

Acute nausea Acute nausea and and vomiting.vomiting.

+/- MUST +/- MUST score score triggered triggered +/- +/- unplanneunplanned weight d weight loss loss

Problems due to Problems due to physical physical cause/swallocause/swallow of w of potentially potentially reversible/trereversible/treatable issues atable issues such as such as Parkinson’s, Parkinson’s, stroke, NBM stroke, NBM order order

Inability of Inability of patient to patient to maintain maintain own own nutritional nutritional state – e.g. state – e.g. blocked blocked PEGPEG

End of life End of life eventevent

Tissue Tissue viabilitviabilityy

No No ississueuess

Waterlow Waterlow score score <10<10

Waterlow 10-14 Waterlow 10-14 and mobility and mobility restricted restricted and/or and/or repeated repeated friction to friction to area. area. UlcerationUlceration

Waterlow 15-Waterlow 15-19 but 19 but with with evidence evidence of tissue of tissue damage. damage. Cellulites Cellulites and/or and/or ‘wet’ legs. ‘wet’ legs. Marked Marked peripheral peripheral oedemaoedema

Waterlow >20Waterlow >20 Pressure sore Pressure sore present on present on admissionadmission

End of life End of life eventevent

Cognition Cognition No No ississueuess

Slight Slight decreadecrease in se in memormemory. No y. No diagnodiagnosis of sis of dementdementia. ia. AMT >8AMT >8

Known cognitive Known cognitive impairment impairment and no and no acute acute changes.changes.

Acute changes Acute changes from from patient patient base line base line but but obvious obvious cause for cause for delirium – delirium – e.g. e.g. UTI/chest UTI/chest infectioninfection

Confusion Confusion associated associated with with agitation agitation and/or and/or increased increased drowsiness drowsiness not related to not related to sedation. sedation.

Not orientated. Not orientated. Cognition Cognition testing testing score score abnormalabnormal

Requires Requires sedation sedation and/or and/or increaseincreased d nursing nursing needs needs due to due to agitatioagitationn

Long term Long term conditicondition/mulon/multiple tiple co-co-morbidmorbiditiesities

No recurrent No recurrent admissions admissions (6mth period)(6mth period)

2 admissions due to LTC in 6 2 admissions due to LTC in 6 mths. Presence of multiple mths. Presence of multiple co-morbiditiesco-morbidities

>2 admissions in >2 admissions in 6mths and 6mths and impact on impact on independencindependence. Lives e. Lives alone alone

>2 admissions in 6mths. +/- >2 admissions in 6mths. +/- patient house bound +/- patient house bound +/- daily in-put from district daily in-put from district nursesnurses

Risk of Risk of long long stay stay admissiadmission on (likely (likely need need for for rehab)rehab)

Mostly green results Mostly green results - likely short stay - likely short stay admission admission

Mostly yellow/amber patient may Mostly yellow/amber patient may require a period of require a period of assessment/treatment/rehabiassessment/treatment/rehabilitation within hospital litation within hospital setting. If clinically stable setting. If clinically stable consider referral to consider referral to therapist/ECAT/specialist therapist/ECAT/specialist nurse. For discharge nurse. For discharge planning from admission planning from admission area please consider if area please consider if community services requiredcommunity services required

Mostly pink Mostly pink patient likely patient likely has physical has physical illness that illness that requires in-requires in-patient stay patient stay of >1 week of >1 week +/- period of +/- period of rehabilitationrehabilitation. Refer MoE . Refer MoE for for assessmentassessment

Mostly red. Prolonged Mostly red. Prolonged admission and/or admission and/or palliative care palliative care required/possible. Refer required/possible. Refer MoE. Prompt LCP if MoE. Prompt LCP if clinically indicated clinically indicated

Surgical 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!The Poster!

Significant issueSignificant issue• Prompt card and lanyard – not Prompt card and lanyard – not

possiblepossibleInfection control, health and safety Infection control, health and safety

issues, already several ‘prompt’ issues, already several ‘prompt’ cards inexistencecards inexistence

Information and Information and results so farresults so far

• Good level of knowledge and ability in cohort of nurses in Good level of knowledge and ability in cohort of nurses in front door areasfront door areas

• High level of returns suggests an appetite for High level of returns suggests an appetite for engagement from nursesengagement from nurses

• Significant differences of approaches and knowledge– Significant differences of approaches and knowledge– cognition, frailty, knowledge of community services cognition, frailty, knowledge of community services

• Further investigation and progression would be beneficialFurther investigation and progression would be beneficial1.1. Short talksShort talks2.2. Articles into local news lettersArticles into local news letters3.3. Sharing resultsSharing results4.4. Further work especially regarding the community and Further work especially regarding the community and

hospital interfacehospital interface• Own knowledge of research and CGA improvedOwn knowledge of research and CGA improved

Next stepsNext steps• Ongoing promotion of CGA through own roleOngoing promotion of CGA through own role• Further areas for research/investigation or Further areas for research/investigation or

extension of excising work regarding CGAextension of excising work regarding CGA• Continued engagement from own work Continued engagement from own work

place in support, skills and knowledge of place in support, skills and knowledge of research and older people careresearch and older people care

• Development of closer ties with other Development of closer ties with other hospitals addressing similar patient hospitals addressing similar patient population and processespopulation and processes

What was the goal of my What was the goal of my work?work?• More recognition of the More recognition of the

comprehensive geriatric comprehensive geriatric assessment within the assessment within the nursing population in nursing population in hospitalhospital

• Development of teaching Development of teaching tool and ongoing tool and ongoing educational support for educational support for nurses regularly caring for nurses regularly caring for older peopleolder people

• Improve patient experience Improve patient experience and outcomesand outcomes

• Improve own practice, Improve own practice, skills and knowledgeskills and knowledge

• Yes Yes

• Yes – even if its not what Yes – even if its not what I’d been aiming forI’d been aiming for

• Need further investigationNeed further investigation

• Yes Yes

• Would I do it again?Would I do it again?• Did I think the Did I think the

process valuable?process valuable?• What have I gained?What have I gained?• What has the What has the

organisation gained?organisation gained?• What implications What implications

does it have to older does it have to older people in hospital?people in hospital?

• Yes! Yes! • YesYes• Knowledge of Knowledge of

nurses experience nurses experience and practices in and practices in assessment areasassessment areas

• A poster!A poster!• Highlighted elderly Highlighted elderly

assessmentsassessments

Finally Finally

Thanks Thanks

Documents

Anne Scott Advanced Nurse Practitioner Medicine of the Elderly Royal Infirmary of Edinburgh