Geriatric Patients and the Emergency Department # 3 in a 6 part series related to Geriatric Care and...
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Geriatric Patients and the Emergency Department # 3 in a 6 part series related to Geriatric Care and Emergency Medicine Wasn’t she here last week? Frequent
Geriatric Patients and the Emergency Department # 3 in a 6 part
series related to Geriatric Care and Emergency Medicine Wasnt she
here last week? Frequent Flyers and other Vexing Tales of the
Emergency Department Optimizing Transitions from the Emergency
Department: Transitions/Frequent flyers Part 1
Slide 2
About This Webinar Series 2 2
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Speakers 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.
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 VAMCs Dementia Committee. 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. 3
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Disclosures No financial relationships or conflicts to
disclose. 4
Slide 5
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. 5
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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 6
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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 7
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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 8
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Top conditions encountered 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 9
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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 10
Slide 11
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.
11
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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 12
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Agenda Systematic Literature Review 13 Study of Older ED
Patients
Slide 14
Dementia in the ED: Setting ED in academic medical center
28,500 visits annually 30% of visits made by persons over 65
14
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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 15
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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 16
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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. 17
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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
18
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Dementia in the Atlanta ED: Results Reasons for seeking care
19
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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
20
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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 21
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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 22
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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) 23
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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 24
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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 25
Slide 26
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 26
Slide 27
Dementia in the ED: Literature Assessment Screen likely
suspects Six-item screener Mini-cog FAQ St Louis University Memory
Screen or Montreal Cognitive Assessment 27
Slide 28
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 OrientationIncorrect 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. Six- item
screener to identify cognitive impairment among potential subjects
for clinical research. Med Care. 2002;40:771-781. 28
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Dementia in the ED: Literature Communication Nonverbal
Including touch, as appropriate Emotional truth If repeating,
exactly same as the first 29
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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 30
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Dementia in the ED: Literature Physical Environment (A page
from Senior EDs) Natural light and quiet, glare-free floors Clear
signage for wayfinding Proximity to nursing station 31
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Dementia in the ED: Literature Education Geriatric Emergency
Nursing Education (GENE) Emergency Nurses Association &
Hartford Institute for Geriatric Nursing 32
Slide 33
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 33
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Improving Post-ED Transitions for Older Patients S. Nicole
Hastings, M.D., M.H.S. 34
Slide 35
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 35
Slide 36
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 36
Slide 37
Obstacles to Safe and Effective Transitions The medication maze
Communication hurdles The follow-up leap of faith Scratching the
surface 37
Slide 38
The Medication Maze New medications and dosage changes Common
ED discharge drugs (e.g. NSAIDs, opioid analgesics, antibiotics)
are often risky for older patients Medication Reconciliation Across
Transitions Different prescribers Multiple medications and chronic
conditions Over the counter drugs 38
Slide 39
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 39
Slide 40
Follow Up Leap of Faith Primary Care Poor patient understanding
of whether its needed, and if so, how soon Inefficiencies if
providers unaware of needs Specialty Referrals Patients role,
timing 40
Slide 41
Scratching the Surface Substance abuse Depression Housing or
food insecurity Elder abuse Caregiver stress Poorly controlled
chronic diseases 41
Slide 42
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 42
Slide 43
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 43
Slide 44
Improving ED Transitions Enhanced communication with patients
and families Standardized content of discharge instructions 44
Slide 45
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 45
Slide 46
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 46
Slide 47
Scratch below the surface Ask 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 47
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Thanks for your Attention! 48
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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/682/131http://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
http://www.merckmanuals.com/professional/geriatrics/provision_of_care_to_the
_elderly/hospital_care_and_the_elderly.html 49
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Bibliography Survey: Many Elderly Are in the Dark at ED
Discharge, http://www.acep.org/content.aspx?id=46032
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
Administrationss 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. 50