APPLYING THE CTAS to Appropriately Prioritize the Elderly

Transcription

1 APPLYING THE CTAS to Appropriately Prioritize the Elderly Presenter: Michael J Bullard MD Professor, Department of Emergency Medicine, University of Alberta, Past Co-Chair and current member CTAS NWG

2 Faculty/Presenter Disclosure Faculty: Michael Bullard Relationships with financial sponsors: None 2

3 Disclosure of Financial Support This program has received financial support from CAEP in the form of administrative support This program has received in-kind support from CAEP, NENA, CPS, AMUQ, SRCPC, PCC in the form of hundreds of hours of volunteer work Potential for conflict(s) of interest: CAEP helps coordinate CTAS education provided by NENA instructors 3

4 Mitigating Potential Bias The CAEP 2018 Scientific Planning Committee/Program Chair mitigated potential bias by ensuring there was no industry involvement in the planning or education content. To comply with accreditation requirements of the College of Family Physicians of Canada and The Royal College of Physicians and Surgeons of Canada, the speaker was provided with a Declaration of Conflict of Interest and the 3-slide Disclosure, which were collected and reviewed. Presentation slide content was reviewed during planning discussions with Track Chairs/Scientific Planning Committee/Program Chair to ensure there is no evidence of bias. 4

5 Learning Objectives The affects of aging on physiologic response to stressors to better apply CTAS vital sign modifiers The challenges of cognitive changes to assign an appropriate presenting complaint and triage priority. Other important confounders with age atypical presentations, polypharmacy The definition and intent of the new Frailty modifier, intended to limit ED wait times for frail, vulnerable individuals. 5

6 The Aging Demographic % of Canadian population over 65 & will be 20% by 2030 (last of the baby boomers) Elderly patients account for 12-21% of ED visits 30% increase in elderly visits Over age 75 have higher than proportional ED visit rate Medical advances have led to increased patient complexity, comorbidities, cognitive impairment, and mobility problems These factors challenge us to effectively triage and prioritize patients in the ED 6

7 Case example 78-year-old-male was observed having a suddenly a sudden fall at the mall, and was unable to up get up. EMS were called. He complained of of of left sided chest and hip pain, causing obvious discomfort when they moved him. At triage able to give his name, address and phone number, but isn t sure why he is at the hospital or how he got here. No friends or family are present. He is well groomed but doesn t know the date and cannot spell WORLD backwards. He has equal strength in all 4 limbs Medical records show the following medications: metformin, lisinopril, metoprolol, warfarin, and l-dopa-carbidopa (sinemet). A finger stick glucose reads BS 15.8 mmol/l RR 22, HR 76, Temp 37.6 C, BP 107/78, O 2 Sat 94%, GCS 14 Triage / priority assessment? 7

8 First Order Modifiers Vital Signs Respiratory Distress...Airway Breathing Hemodynamic Status.Circulation Level of Consciousness.Disability Temperature Other Pain Score Bleeding Disorder Mechanism of Injury Frailty Modifier 8

9 Interpreting Vital Signs Respiratory stiffer lungs, increased dead space mean less responsive to hypoxia and hypercapnia RR > 27/ min more sensitive than BP or pulse predicting critically ill Cardiovascular hypertension, arterial wall stiffness and thick myocardium increase workload on the heart Resting HR increases & maximal HR decreases masking severely ill Temperature decreased metabolic rate and altered thermoregulatory responses may lower core temperatures Inability to mount a fever response make older persons more vulnerable when infected and subtle temperature changes often signify a serious infection 9

10 Falls and Trauma Major cause of trauma in elderly is falls with 1 in 5 falls causing serious injury 1 in 3 patients > 65; 1 in 2 patients > 85 fall each year with high rate of hospitalization Causes include: physical weakness, gait instability, balance issues, visual impairment, and cognitive impairment can also be due to an acute medical event: dysrhythmia, aortic dissection, TIA, CVA, medication side effects Trauma risks: SBP <110 mmhg conferred same mortality risk as <90 in under 65 Hip fractures most common with high morbidity and mortality risk 10

11 Cognitive Impairment Delirium and dementia reportedly present in 25% of elderly ED patients, but under diagnosed Even when ED physicians are given the diagnosis of delirium 15-30% of the time the patients are discharged Acute altered mental status should always be triaged as CTAS 2 (altered LOC GCS 9-13) or CTAS 3 (confusion GCS 14) Chronic confusion can be a CTAS 4 but needs clear verification 11

12 Pain Assessment Acute pain severity assessment complicated by: Older patients often stoic or difficulty expressing severity Evidence pain perception decreases with age Age-related decline in neural opioid and nonopioid analgesic mechanisms Neurogenic inflammation less pronounced = lower initial pain Implications and importance Failure to recognize serious conditions such as ACS, peptic ulcer, pneumothorax, etc. due to lack of pain Failure to treat pain adequately Longer periods of 2ndary hyperalgesia leading to greater frequency of persistent pain 12

13 Pain +/- Mild Cognitive Impairment Patients who are unable to readily voice their pain complaints can still be evaluated A number of visual scales can be utilized Scale of Pain Intensity (SPIN), Visual Analogue Scale (VAS), Numeric Rating Scale (NRS) or Iowa Pain Thermometer Faces Pain Scale Left to Right pain score 0, 2, 4, 6, 8,10 13

14 Pain Assessment & Dementia Attempt self reporting first Look for pain causing conditions (injury, inflammation, etc.) Direct observation or through care givers for pain behaviors (facial expressions, vocalizations, changes in activity, body movements, interpersonal interactions, mental status) Physiologic pain responses of diaphoresis, tachycardia and increased BP blunted in Alzheimer patients Ultimately may need to see response to trial of analgesia 14

15 Other Important Confounders Atypical presentations Pneumonia without respiratory symptoms, sepsis without history of fever, painless STEMIs, etc. Often presentation may be non specific or general weakness Polypharmacy More than 50% adults in US >65 on 5 or more meds Antihypertensives and opioids predispose to falls Anticholinergics risk of heat stroke Anticoagulants predispose to bleeds, especially after falls 15

16 Frailty Modifier ED overcrowding puts vulnerable patients at risk Homeless, disabled, frail elderly, substance abuse Prolonged delays can lead to LWBS, undue suffering or deterioration (increasing admission risk & functional decline) Definition of frailty modifier Any patient completely dependent for personal care; who is wheelchair-bound; suffers from cognitive impairment that limits their awareness of their surroundings or ability to appreciate time; is in the late course of a terminal illness; is showing signs of cachexia and general weakness; or is over 80 years of age unless obviously physically and mentally robust. Can be applied to patients otherwise triaged as CTAS 4 or 5 to a CTAS level 3 16

17 Case example 78-year-old-male with sudden fall; unable to get up; with pain in chest and hip when EMS moved him but equal strength in all 4 limbs. Able to give his name, address and phone number, but isn t sure why he is at the hospital or how he got here. No friends or family are present. Multiple medications: metformin, lisinopril, metoprolol, warfarin, and l-dopacarbidopa (sinemet). BS 15.8 mmol/l RR 22, HR 76, Temp 37.6 C, BP 107/78, O 2 Sat 94%, GCS 14 Triage priority assessment CEDIS Presenting Complaint Multisystem trauma blunt, Syncope / presyncope CTAS level 2 (emergent): i) HR and BP low for his age especially with pain and evidence of trauma (SBP < 110) [hemodynamic compromise modifier for age], ii) unknown prior cognition so concern re: head injury in patient on warfarin [bleeding disorder modifier], iii) Temp 37.6 C, RR 22, without tachycardia still potential concern re: elderly sepsis iv) description of fall suggests syncope without prodrome [syncope special modifier], 17

18 Summary Prioritizing elderly patients using CTAS requires Recognizing how physiological changes affect vital sign interpretation Sorting through cognitive changes to determine acuity, and also ways to evaluate pain Understanding how minor trauma in the young translates to major trauma in the elderly Recognizing atypical presentations of common diseases and the impact of polypharmacy A Frailty Modifier has been introduced as CTAS 3 To help protect our most vulnerable patients (especially if unaccompanied) with less urgent conditions, to limit the negative impacts of extended wait times 18

19 Questions?