Assessment that Counts

Transcription

1 Assessment that Counts Suzanne Beyea, RN, PhD, FAAN Justin Montgomery RN-BC Dartmouth-Hitchcock Medical Center & Northern New England Geriatric Education Center

2 Objective Operationalize previously known and newly acquired knowledge into an assessment that captures key components of care for older adults

3 A Question

4 Do we treat everyone the same? Chang, D., et. Al. (2008) The Occurrence of Potential Patient Safety Events Among Trauma Patients Evaluated patterns of AHRQ patient safety indicators (PSI) among adult trauma patients nationwide (37 states & 1.35 million trauma pt.) Results (PSI s should be random): Increasing age, black, and male associated with increased safety events In fact, as age increased, so did the number of safety events.

5 Are we missing something? Hustey, F., et al. (2003) published in ACEP The effect of mental status screening on the care of elderly emergency department pt. Prospective study to evaluate care and recognition of mental status impairment in older adults by emergency physicians n=271 enrolled, 74 had impaired cognition by screening, only 28 identified by physicians Of the 74, 19 had delirium (only 3 identified), and 5 were discharged home» Of those dc d, 2 returned two days later and were hospitalized» One (hx colon ca) was given a new dx of metastatic disease 3 days later

6 Do we always know everything there is to know? Cohen, V. et al. (2008), published in Am J of Health-System Pharm. Variation in medication information for elderly patients during initial interventions by emergency department physicians Evaluated discrepancies received from patients and those available from pharmacies ~1/3 of patient provided information differed from information available at pharmacy at time of initial therapeutic and diagnostic intervention Most common med discrepancies: antihypertensives, anticoagulants, analgesics, nitrates, and supplements

7 Wrong Drug for the Wrong Patient Rothberg, M., et al (2008), published in Journal of Hospital Medicine. Evaluate the prescribing of potentially inappropriate (PIM) medications in pt 65 y/o and older with 1 of 7 common diagnosis utilizing Beers criteria Results 49% received at least 1 PIM and 6% received 3+ Most common: promethazine, diphenhydramine, and propoxyphene Large variation in the number of PIM depending on the prescribing provider, hospital, region, and diagnosis

8 How do you eat an elephant?

9 Geriatric Syndromes Geriatric Syndrome: A combination of symptoms and signs that often reflects impairment or disease in multiple systems. Ham, 2006

10 Loss of Function Any acute change in functional status Unable or unwilling to participate in ADL s Unexplained falls Changes in gait or mobility

11 Change in Cognition Acute change from baseline mental status Key is to know baseline mental status May mask this very well

12 Dizziness and/or Syncope Dizziness Vertigo, presyncopal lightheadedness, imbalance, or some combination Syncope Multifactoral and difficult to accurately diagnose

13 Urinary Incontinence Always be suspicious of new onset urinary incontinence Different types Urge Stress Overflow There is treatment

14 Falls Why did they fall? Is there is a history, did they fall indoors, or did they have a difficult time getting off the floor? If yes to any of these three things then that is predictive of worse outcomes and increased likelihood of another fall

15 Syndromes These are a few of the identified syndromes, others include (Ham, 2006): Delirium Alzheimer s disease Depression Constipation Hearing impairment Persistent pain Malnutrition Pressure Ulcers Sleep Disorders Substance abuse

16 Your work now We have assembled an expert panel of emergency department nurses, as well as nurses from other locations, and we are going to create an Assessment that Counts. You know the unique environment that is the modern ED You have learned and/or already knew the challenges associated with caring for older adults in the ED

17 Your Mission: Identify the absolute can t miss components of an assessment for an older adult in the emergency department Come up with as many as you want, but remember it may be a busy shift!

18 Resources Hand outs Patient self-assessment Geriatrics at your Fingertips Upper Valley Memory Center Handbook