Integrated Care of Patients on Constant Observation in a General Hospital Setting Aaron Pinkhasov, MD

Transcription

1 Integrated Care of Patients on Constant Observation in a General Hospital Setting Aaron Pinkhasov, MD Chairman, Department of Behavioral Health NYU Winthrop Hospital Associate Professor of Psychiatry and Medicine Stony Brook School of Medicine

2 In compliance with ACCME Standards for Commercial Support of CME activities I have no relevant financial relationships to disclose. Aaron Pinkhasov, MD

3 Objectives By the end of this presentation the audience will be able to: Demonstrate understanding of the role of psychiatric services in management of patients placed on constant observation in a general hospital. Recite main strategies in management of patients on constant observation. List potential benefits of management protocol.

4 Est 1831 Est 1860

5

6 Est 1896

7 591-bed university-affiliated medical center which offers sophisticated diagnostic and therapeutic care in virtually every specialty and subspecialty of medicine and surgery Primary teaching affiliate of Stony Brook School of Medicine Clinical Campus Offering 24 residency and fellowships The prevalence of psychiatric co-morbidity in our hospital - 34% The psychiatry consultation rate at the time was only 1.36%

8 $2.3mln spent on sitters alone by Winthrop Hospital in 2014

9 Constant Observation (CO) Facts CO-utilization adds substantial burden on hospital finances and personnel resources. CO-cost may range from $2 to 6 million per year, not including the cost of CO in specialized psychiatric units. Studies fail to show a reduction in adverse events despite use of CO. Harding, A. D. (2010). Observation assistants: sitter effectiveness and industry measures. Nursing Economics, 28(5), 330. Adams, J., & Kaplow, R. (2013). A sitter-reduction program in an acute health care system. Nursing Economics, 31(2), 83.[5.] Rochefort et al (2012). Patient and nurse staffing characteristics associated with high sitter use costs. Journal of advanced nursing, 68(8),

10 QI Program Development Formalized policy - psychiatric CL services for any patient on CO Hiring a psychiatric NP for management of patients on CO Early/Proactive daily evaluation of CO patients by BH team Collaboration with patient, patient s family and medical team Implementing non-pharmacological as well as pharmacological Tx

11 QI Project Development BH-CO protocol was implemented daily on all patients who had at least 12 business hours of CO except weekends & holidays. All patients were followed until at least 1 business day after CO d/c Data on length of stay (LOS), CO cost, complications (falls, elopements or inadvertent extubations) and 30-day readmissions were collected over a 6-month study period. 533 patients were studied (42pts excluded <12business hrs of CO use) 491 patients were seen by the BH team and underwent the protocol. Data was compared with a similar sequential group of all patients placed on CO during the previous year.

12 Protocol Overview 1:1 one staff member directly observes patient within an arm's length at all times. SW one staff member observes up-to four patients cohorted in the same room. Both groups of CO patients are referred to and evaluated by the BH team (psychiatric nurse practitioner (NPP) with a board-certified psychiatrist)

13 40 Primary Reasons for 1:1 Order Percentage Agitation/Confusion Suicidal Risk Pulling out IV lines/tubes Trying to get out of bed Combative behavior Elopement Risk Fall Risk Acute Psychosis/Mania

14 Primary Reasons for Safety Watch Order Agitation/Confusion Trying to get out of bed Fall Risk Pulling out IV lines/tubes Combative behavior Elopement Risk

15 Overlap of Reasons for CO Agitated and a Elopement Risk Agitated and a Fall Risk Agitated and Combative Agitated and Confused Agitated Agitated and Pulling IV's 0

16 CO Protocol Overview A comprehensive evaluation and management protocol was developed as part of this QI project

17

18 Pharmacologic Intervention Minimize the use of benzodiazepines/opiates/anticholinergic Mx Melatonin receptor agonist for sleep phase disturbances Acetaminophen PO/IV when appropriate to avoid/minimize narcotic analgesics Judicious use of low dose antipsychotics for agitation/psychosis Use of dexmedetomidine in ICU settings for agitation

19 Low Dose Antipsychotics Use in CO Protocol Generic Name Usual Dose Range (mg/day) Route Extrapyramidal symptoms QTc Prolongations Orthostatic Hypotension Haloperidol PO/IM/IV (more with IV use) + Quetiapine PO +/ Risperidone PO

20 CO Age Distribution

21 CO Prevalence of Psychiatric Dx Psychosis 4.9% EtoH 7.9% Bipolar/Mania 3.5% Other Substance 3.3% Depression 25.1% Dementia 52.7% Anxiety 10.6% Delirium 62.1% Dementia (N, %) Delirium (N, %) Anxiety (N, %) Depression (N, %) Bipolar/Mania (N, %) Psychosis (N, %) Alcohol Use (N, %) Other Substance (N, %)

22 HIGH PREVALENCE OF DELIRIUM (62.1%) AND DEMENTIA (52.7%) N*PATIENTS REDUCTION DISCONTINUATION NO CHANGE Benzodiazepines 130 (26.8%) 24.6% 53.1% 22.3% Opiates 116 (23.9%) 33.6% 49.1% 17.2% Anticholinergics 12 (2.5%) % 8.3% *We also found that patients diagnosed with delirium treated with nightly ramelteon were less likely given as-needed antipsychotics for agitation (60% vs 86%)

23 Constant Observation Cost Reduction $300, $271, Program Implemented $250, $238, $200, $189, $150, $100, $141, $82, $114, $109, $105, $50, $0.00 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15

24 RESULTS: Average Monthly CO Cost STUDY GROUP CONTROL PERIOD $177,541 $118,847 $58,700 Monthly Difference 33.06% (p-value 0.045) $704,400 Annual Projected Savings

25 RESULTS Median Length of Stay STUDY GROUP CONTROL PERIOD 6 days 7 days 15% REDUCTION

26 Results: Complications ADVERSE EVENTS CONTROL PERIOD STUDY RESULTS FALLS 63 2 INADVERTENT EXTUBATIONS 10 0 ELOPEMENTS 3 1 READMISSION 20 of 553 patients (3.6%) 10 of 491 patients (2.0%)

27

28 Resistance from staff or family members towards discontinuation of co Delay in disposition due to non availability of beds and insurance issues Patients who remain difficult to redirect BARRIERS Patients who are an imminent danger to self and others, and need psychiatric hospitalization Patients with severe cognitive decline

29 CASE ILLUSTRATION A 72 yo female with history of Alzheimer s dementia x 2 yrs bib dtr because she found her house in disarray. She has been forgetful and paranoid towards neighbors for some time. Admitted for low Hb (7.8) and need for GI work up. Placed on 1:1 for agitation and poor c/w care. Other lab s WNL. PMHx: Migraine, OA Home Meds: Advil PRN; Aricept 5mg qd MSE: Pt. alert and oriented to person and place only. Word finding difficulties. Mild paranoia. No a/v hallucinations and/or s/h ideas. Poor I/J. MMSE 19/30 Diagnosis: Dementia with behavioral disturbances Recommendations: Increase Aricept to 10mg qhs Namenda 5mg qd Risperdal 0.5mg q12hrs Frequent reassurance, reorientation and redirection Discontinue 1:1 and place patient on q30 checks for safety Results of Interventions: Pt. had uneventful night. Dtr was encouraged to accompany pt and facilitated c/w Upper Endoscopy. Pt was stabilized and placed to NH.

30 CASE ILLUSTRATION Female in early 90s with history of age related memory loss admitted s/p fall and R- Hip Fx, had ORIF,POD-2; became very confused and disorganized post op. Relatively independent prior to fall. Placed on 1:1 for agitation and fall risk. She was up all night and given Benadryl 50mg x 1 stat. No PPHx. PMHx: mild HTN and OA. Meds included Methadone,Oxycodone,Tramadol 50mg TID, Ativan PRN, Dilaudid PRN MSE: Elderly woman, lethargic, disoriented. Trying to get out of bed. Responding to internal stimuli (reaching for imaginary objects). Diagnosis: Dementia with superimposed delirium Recommendations: d/c Methadone,Tramadol,Oxycodone,Ativan and Dilaudid Tylenol 1g IV q 8hrs Rozerem 8mg qhs and keep awake during daytime Quetiapine 25 mg PO qhs Frequent reorientation and redirection Adequate PO hydration and assistance with ADLs Remove Foley Results of Interventions: Became alert and cooperative with PT next day, then 1:1 was changed to q30 checks. D/C to Sub-acute Rehab day after.

31 MANAGEMENT OF PATIENTS WITH COGNITIVE DECLINE Frequent reorientation and redirection of confused patients. Use of bed checks and safety alarms to prevent them from getting out of bed without assistance. Use of hand mittens to prevent them from pulling out lines and tubes. Ordering q30 checks for patients with fall risk. Use of low dose anti-psychotics like Haldol for management of dementia with behavioral disturbances. Encouraging frequent family visits to provide patients with a familiar environment.

32 Suicidal Patients on Co Patients who are considered acutely suicidal kept on 1:1 observation until transfer to an inpatient psych. Unavoidable delays in disposition like 2 PC transfers of undocumented /uninsured patients and bed unavailability in inpatient facilities further increase the number of hours utilized.

33 CASE ILLUSTRATION 54 yo male with h/o Anxiety and ETOH abuse was admitted with PNA.Placed on 1:1 due to expressing suicidal ideas to RN. On evaluation stated: I just said I feel like jumping out of window to nurse, I don t mean it, I am just frustrated. No h/o prior psychiatric admissions or suicidal attempts. No signs of EtOH withdrawal. MSE: Pt Diagnosis: Adjustment d/o with depressed mood Recommendations: d/c 1:1 Ativan 1mg q6hrs PRN anxiety/alcohol withdrawal Lexapro 5mg PO qd Day after: 1:1 resumed as he was talking about jumping out of window to RN. 1:1 stopped and staff reassured Day 3: back on 1:1 I asked for it, I feel more comfortable when I have company. I like this nurse, she is cute. Pt was discharged with oral antibiotics 5 days later.

34 Interventions PHARMACOLOGICAL: These include use of various psychotropic medications broadly categorized as: Typical Antipsychotics Atypical Antipsychotics Antidepressants Melatonin Agonists Benzodiazepines Mood Stabilizers/Anticonvulsants Dementia Medications Strongly discouraging the use of benzodiazepines, sedative-hypnotics, anti-cholinergic or opiate analgesics in elderly patients who are at high risk of delirium.