Eisenberg Acute Care for Elders (ACE) Service

Transcription

1 Eisenberg Acute Care fr Elders (ACE) Service Welcme t the Eisenberg ACE Service! The Eisenberg Service was develped and is staffed by Geriatric Medicine attendings with the specific gal t increase learners knwledge f cre principles in the care f hspitalized lder adults. This teaching service was initially develped as ne part f a larger teaching grant, the UT-SAGE (UT-Suthwestern Aging and Geriatrics Educatin) Grant prvided by the Dnald W. Reynlds Fundatin, whse stated gal was t imprve the quality f life f America s grwing elderly ppulatin thrugh better training f physicians in geriatrics. Care f acutely ill lder adults emphasizes principles f patient safety and patient-centered care. These principles benefit f any age, but when they are lacking, it is ften the lder patient ppulatin wh suffers mst. As ur ppulatin cntinues t age, it is imperative that all future clinicians, regardless f specialty, have a better understanding f hw t care fr the acutely ill lder adult. Seymur Eisenberg, M.D. (September 19, 1918 January 5, 1999) The Eisenberg Service is named in memry f Dr. Seymur Eisenberg, a UT Suthwestern faculty member fr 48 years and the first Sectin Chief in Geriatric Medicine. Dr. Eisenberg graduated frm Bwman Gray Schl f Medicine in Frm there he mved t Bstn City Hspital fr internship befre cmpleting his residency at Parkland Hspital in Thugh he riginally planned t mve back t Nrth Carlina and pen a private practice, he instead jined the faculty in 1950 and became ne f the mst distinguished teachers in the histry f medicine in Dallas (Dr. Mark Feldman, Vice-Chair, Internal Medicine, 1999). As the first physician at UTSW t take an interest in the burgening field f geriatrics, he recgnized that special needs within this ppulatin were unmet - There will be 32 millin Americans ver 65 by the year 2000, Eisenberg said, and the elderly tend t develp multiple chrnic illnesses against the backgrund f aging changes. Currently their needs are inadequately met except fr acute illness. With the rise t CEO f anther geriatrician, Dr. Rn Andersn, the tw wrked tgether t imprve care fr lder adults in Dallas Cunty The elderly are the mst rapidly grwing ppulatin in Dallas Cunty, said Dr. Andersn, We need t prvide them a cntinuum f care. Psychscial and sciecnmic issues have t be dealt with. If nt, when an elderly patient is discharged they ll be back. Hspitalizatin is an easy answer. Smetimes it takes mre care t keep peple ut f the hspital. Hspitalizatin is dehumanizing. They wrked tgether t establish a cre gerntlgy center that tk a geriatric team apprach t health t imprve utpatient care, prevent hspitalizatin, and prevent institutinalizatin after hspitalizatin, ften the utcme f inadequate geriatric care. In additin t his wrk at UT Suthwestern and Parkland Hspital, Dr. Eisenberg als established a nursing facility at the Dallas VA and headed the VA geriatrics sectin fr many years. Dr. Eisenberg was well-knwn fr his teaching - I m a bedside clinician wh listens. That s what I d best. And I train yung physicians t d that and enjy what they d. Listening t the patient is an imprtant part f geriatrics. Dr. Feldman estimated in 1999 that Dr. Eisenberg trained 1000 internal medicine residents and thusands f medical students. His sn, a sprts writer in Baltimre, described him as a warm and gentle persn with a terrific sense f humr and a strng set f pririties family first, medicine secnd, and pr ftball third. He retired at the age f 80 and died a few mnths later after being admitted t Zale-Lipshy fr a minr peratin. His memrial service was packed with frmer students, a testimnial t his cntributins. There is a blssming crdinated effrt in this schl t imprve geriatric care, Dr. Eisenberg said in This Eisenberg ACE Service, as well as the rest f The Reynlds UT-SAGE initiative, cntinues his visin fr the training f physicians in geriatric care at UT Suthwestern. Surces: Center Times, May 1983 Baltimre Sun, January 24, 1999 Dallas Mrning News, January 8, 1999 UT Suthwestern News, December 9, 1983

2 Backgrund n ACE Units Acute Care fr Elders (ACE) Units emerged in the early 1990s as a nvel mdel f care aimed at addressing the prblem f hspital-acquired disability (HAD) amngst acutely-ill lder adults. Initial studies demnstrated that the ACE interventin culd reduce HAD and imprve physical functin fr lder hspitalized adults withut increasing csts cmpared t receiving usual care. Several subsequent studies have shwn that the ACE mdel f care has ther imprtant benefits when it cmes t caring fr hspitalized elders, such as decreasing rates f delirium, falls, and pressure ulcers; imprving patient, family, prvider and nurse satisfactin; and even lwering per capita cst f care. The ACE Unit n 12 Suth at Clements University Hspital began when the hspital pened in December The missin f this unit is threefld: first, t help define and prvide the highest level f acute care t lder adults admitted t ur hspital thrugh thughtful interprfessinal cllabratin and harnessing the principles f cntinuus quality imprvement; secnd, t disseminate best practices related t the care f acutely ill lder adults thrughut the UT Suthwestern health system and beynd; and third, t educate and train healthcare prfessinals hw best t care fr acutely ill lder adults. Faculty Tm Daltn, MD (Directr) Assistant Prfessr, Geriatric Medicine cell: (text r call with? s) Craig Rubin, MD Prfessr, Geriatric Medicine Lynne Kirk, MD Prfessr, General Internal Medicine Sarah Wingfield, MD Assistant Prfessr, Geriatric Medicine Belinda Vicis, MD Prfessr, Geriatric Medicine Ramna Rhdes, MD Assciate Prfessr, Geriatric Medicine Namirah Jamshed, MD Assciate Prfessr, Geriatric Medicine Jessie Vit, MD Assistant Prfessr, Geriatric Medicine

3 Eisenberg Service Learning Objectives (These learning bjectives were develped based n natinal recmmendatins fr geriatric cmpetencies fr internal medicine residents, geriatrics cntent n the American Bard f Internal Medicine exam, and a needs assessment f residents in ur prgram.) Medicatin Management Gal: Learn t prescribe apprpriately fr lder adults. Cnsider the physilgic changes f aging that affect pharmackinetics and pharmacdynamics, drug-drug interactins, cmmn side effects, and the risk fr adverse events in the cntext f a patient s medical histry and functinal status. Gal: Learn t de-prescribe medicatins that are inapprpriate r nt indicated. Objectives: Identify and use the Beers criteria and the START/STOPP criteria as resurces t guide apprpriate prescribing in lder adults. Use accurate calculatins f renal functin t crrectly dse medicatins fr lder adults. Demnstrate a thrugh admissin medicatin recnciliatin, updating the medicatin list fr adherence and ver the cunter and cmplementary and alternative medicatins. Demnstrate a thrugh discharge medicatin recnciliatin, ensuring that all medicatins have an apprpriate indicatin and that alternatives t high risk medicatins have been cnsidered. Cgnitive, Affective, and Behaviral Health Gal: Learn t identify, evaluate, treat, and prevent delirium in hspitalized lder adults. Objective: Define delirium. Objective: Describe the evidence fr preventin and management f delirium. Objective: Regularly use the Cgnitive Assessment Methd (CAM) t identify delirium in acutely ill lder adults. Objective: Identify and minimize delirium risk factrs in each patient. Gal: Distinguish delirium frm dementia with behaviral prblems. Objective: Define dementia. Objective: List and describe types f dementia (Alzheimer s, vascular, Lewy bdy, frnttempral, etc.) Objective: Evaluate a patient fr dementia. Hspital Patient Safety Gal: Appreciate the hazards f hspitalizatin fr lder adults and describe ways t prevent cmmn negative utcmes related t hspitalizatin (delirium, falls, catheter-related cmplicatins, medicatin errrs, pressure ulcers, decnditining, disability, etc.) Objective: Define hspitalizatin-assciated disability. Objective: Describe the evidence fr the preventin f hspitalizatin-assciated disability. Objective: Regularly evaluate fall risk, immbility, pressure ulcers, adequacy f ral intake, pain, urinary incntinence, cnstipatin, and apprpriateness f medicatins in hspitalized lder adults and institute crrective measures as needed. Objective: Regularly use the Cgnitive Assessment Methd (CAM) t identify delirium in acutely ill lder adults. Objective: Regularly dcument the presence f and indicatin fr indwelling bladder catheters in hspitalized lder adults and discntinue use as sn as apprpriate.

4 Transitins f Care Gal: Wrk as part f an interdisciplinary team t facilitate safe and apprpriate hspital discharges, taking int accunt a patient s clinical needs, functinal status, persnal values, and scial and financial resurces. Objective: Lead multidisciplinary runds each day with efficiency and an understanding f each team member s rle and the infrmatin they require t d their jb. Objective: Describe the similarities and differences between the fllwing terms: hspice, lngterm acute care hspital, acute rehabilitatin, skilled nursing facility, nursing hme, assisted living, and hme health. Objective: Describe the Medicare system and the impact it has n functinally-impaired lder adults with respect t acute care, pst-acute care, transitins f care, and lng-term disability. Objective: Write discharge summaries that are cncise but prvide all pertinent infrmatin fr the setting f care t which the patient is being discharged. Objective: Ensure that discharge paperwrk includes an accurate and apprpriate medicatin list. Cmplex r Chrnic Illnesses in Older Adults Gal: Priritize and manage the care f acutely ill lder adults by integrating the patient s gals and values, c-mrbidities, and prgnsis. Objective: Assess a patient s baseline functinal status n admissin using the Activities f Daily Living and Instrumental Activities f Daily Living. Objective: Estimate a patient s prgnsis. Objective: Demnstrate a gals f care cnversatin, implementing evidence-based techniques. Objective: Determine whether each patient has decisin-making capacity. Gal: Understand that caregivers are an integral part f taking care f the lder patient with cmplex r chrnic illnesses. Objective: Identify each patient s primary caregiver and the level f care required. Gal: Identify and address barriers t cmmunicatin that cmmnly affect lder adults (e.g. nn-verbal, hearing impairment, visual impairment, cgnitive impairment.) Objective: Obtain cllateral infrmatin, including histries and gals f care, frm the medical pwer f attrney r caregiver when necessary. Objective: Assess and address hearing and visual impairment in each patient by ensuring that they have hearing aids and glasses as apprpriate. Wund Care Gal: Recgnize, treat, and prevent pressure ulcers. Objective: Stage a pressure ulcer. Objective: Prescribe apprpriate treatment fr a pressure ulcer. Objective: Implement pressure ulcer preventin strategies. Systems Based Practice/Interdisciplinary Teamwrk Gal: Wrk effectively as part f an interdisciplinary team t ptimize hspital-based care f the lder adult. Objective: Describe the rle f the physical therapist, ccupatinal therapist, dietitian, speech therapist, pharmacist, and scial wrker.

5 Objective: Apprpriately cnsult physical therapy, ccupatinal therapy, speech therapy, and nutritin. Objective: Interpret the recmmendatins f physical therapy, ccupatinal therapy, speech therapy, and nutritin, and use them t ptimize the patient s management. Teaching and Learning Strategies Direct patient care Prmpts in nte templates are intended t be instructive but d nt necessarily have t be cmpleted in full n each patient H&P template =.gerihp Prgress nte template =.geriprg Discharge summary template =.geridc Attending physician teaching sessins T be scheduled at the attending s discretin Interdisciplinary team teaching sessins (PT, OT, Speech, Nutritin, Nursing, Pharmacy, Wund Care) Scheduled at 1:15 pm per the calendar psted in the rm Designed t be nly minutes in duratin s that residents can give their undivided attentin t learning (shuld be interrupted nly in a true medical emergency) Resurce ntebk in the runding rm Includes infrmatin that will be frequently utilized n the rtatin (e.g. Shrt-CAM frm, Beers list, START/STOPP list, MOCA, PT/OT infrmatin, ASPEN malnutritin criteria, wund staging infrmatin, etc.) Wund care bx Cntains examples f varius wund care supplies and their indicatins Online resurce tlkit (see OneDrive) Key geriatrics articles by tpic Links t helpful websites Duplicates f the resurces prvided in the resurce ntebk Opprtunities t bserve interdisciplinary team members in actin PT, OT, Speech, and Nutritin are all happy t have yu shadw them as they evaluate and treat yur. Lk under Treatment Team in Epic t find ut wh the therapist is, and reach ut t set up a time. All team members are expected t attend the required cnferences as dictated by the internal medicine residency prgram r clerkship directrs including Mrning Reprt, Grand Runds, Nn Cnferences and Weissler Cnference. Learners wh rtate n the service may be asked t cmplete a pre- and pst-rtatin survey/test that will have n bearing n their evaluatin but will be used t imprve the service and the experience fr future rtatrs. Please answer the questins thughtfully, hnestly, and withut the use f reference material.

6 Admissins and Schedule Criteria fr admissin t the Eisenberg Service: Patients age 70 r lder Patients shuld be cmmunity-dwelling (this includes wh live in a private hme r assisted living but excludes wh live in nursing hmes) Any patient wh has a primary care prvider in the UT Suthwestern Geriatric Care Center, regardless f their age r place f residence Any patient whm the attending accepts as an admissin t the service In general, residents shuld accmmdate admissins utside f the strict admissin plicies in rder t prmte a reasnable census size and learning pprtunities fr students and trainees while still adhering t wrk hur rules. If there are cncerns r questins, discuss with the attending. Timing and prcedures fr admissins: Admissins can cme Mnday Friday between 7am and 5pm. Direct admissins frm the Geriatric Care Center can ccur in crdinatin between the admitting clinic prvider and the attending r resident n service. The admitting hspitalist and bed cntrl must be made immediately aware f any direct admissins accepted by the team. We d nt admit n Saturdays r Sundays. We can accept transfers frm ther hspital services, but they must be apprved by the attending. The team cap is 12. On Fridays, there is a sft cap f 10, meaning we will nt accept any new admissins abve 10 in rder t have a reasnable census fr the weekend resident. Residents shuld use the Geriatrics Admissin Order Set when admitting. Residents can wrk tgether t decide hw t divvy up admissins, but in general, this is what is expected f the residents: Mnday Tuesday Wednesday Thursday Friday Saturday Sunday Prjected Duty Hurs Resident A Resident B befre 5 pm (nly 1 admit after 3 pm) ICU transfer prir t nn N admits befre 5 pm (nly 1 admit after 3 pm) befre 5 pm (nly 1 admit after 3 pm) N admits ICU transfer prir t nn befre 5 pm (nly 1 admit after 3 pm) befre 5 pm (nly 1 admit after 3 pm) N admits Off Cver all 7 am until dne (shuld be by 5 pm) Cver all 62 7 am until dne (shuld be by 5 pm) Off 58

7 Runds: Runds will ccur daily at 10am, fllwing mrning reprt, unless instructed therwise. Each attending will handle daily runding and teaching as they see fit. The residents shuld crdinate with the attending early in the rtatin t determine hw runds will wrk, what is expected f each member f the team during and prir t runds, and whether any time fr teaching will be set aside in advance. ACE Interprfessinal Runds ccur M - F at 11am. The whle team shuld strive t be present and ready t start at 11am. Residents shuld be prepared t help lead these runds daily alng with the Care Crdinatr. Days ff and duty hur adherence: The residents must have ne day ff per week fr a ttal f 4 days ff in a 4-week rtatin. Adherence t all duty hur regulatins as dictated by the internal medicine residency prgram is abslutely expected and required. If yu feel yu have vilated r will vilate any duty hur restrictin, then yu must infrm the attending n service and/r Dr. Daltn immediately. Medical students must receive at least ne day ff a week, n average, fr a ttal f 4 days ff in a 4- week rtatin. Days ff will be at the discretin f the residents and the attending. Expectatins fr All Team Members Hspitalizatin is a significant event in the life f an lder adult and represents an OPPORTUNITY t address bth acute and chrnic medical cnditins. Residents shuld see their primary duty as t the patient and nt the hspital; it is nt abut getting the patient ut as sn as pssible. The hspital team shuld use the pprtunity t assess a patient s living situatin, scial supprts, apprpriateness f medicatin prescribing, and gals f care. The fllwing are tasks that ught t be cnsidered rutine fr every patient admitted t ur service. Review all medicatins t assess fr apprpriateness f use and dsing and ptential drug-drug r drugdisease interactins. Determine patient s r caregiver s methd fr assuring medicatin adherence. Ask abut and dcument ADLs and IADLs, and dcument wh helps and hw. Ask if feel free and safe. In review f systems, ask abut weight lss ver past 6 mnths, dietary change, incntinence, prblems with memry r cnfusin, falls, difficulty walking, prblems with visin r hearing. On exam, check fr rthstasis, weight change, muscle wasting, edema, pressure ulcers; assess gait; assess visin and hearing; screen fr cgnitive impairment, delirium and depressin when indicated. Identify and dcument the surrgate decisin maker. Learn frm the ther prfessinals yu interact with. Mre than any ther service yu rtate n, this is the pprtunity t learn what Nursing, PT, OT, ST, Nutritin, Care Crdinatin, etc can and shuld d fr and the physician team in rder t ptimize the care prvided fr ur. We have champins fr all f these prfessins ready and eager t wrk with yu and imprve yur knwledge abut their rles and yur interprfessinal skills. Discharge summaries Discharge summaries are a key cmmunicatin between the inpatient team, the accepting prvider (if applicable), and the patient s primary care prvider. The discharge summary shuld be cmpleted at the time f discharge. A succinct narrative summary f the hspital curse that includes medicatin changes with ratinale, key diagnstics and prcedures, and items that will need t be addressed in fllw up The discharge summary is nt a cpy f the daily prgress nte.