Dispelling the Myths: Failure to Cope, Social admissions & Crisis placements

Transcription

1 Dispelling the Myths: Failure to Cope, Social admissions & Crisis placements GEM Nurse Orientation Wednesday September 21 st 2011 Clara Tsang Stella Cruz Rola Moghabghab

2 Case Scenario- Mr. Complex Request for GEM assessment to facilitate crisis placement Triage note: elderly presented with general malaise & fatigue x3days Disheveled and unkempt Difficulty with ADLs CTAS 3

3 ED Team assessment/investigations CBC, lytes, BUN, Cr, CXR, EKG, Urinalysis Increased urea (10.1) and Cr (134) Hgb 103 CXR- nil acute Urinalysis- mild leukocytosis Diagnosed with Failure to Cope

4 Failure to Cope Failure to Cope vs Failure to Thrive What does that mean to you? What patients presentations are associated with that label? What happens to patients with that label in your experience?

5 GEM Assessment What information do you need to gather? How would you gather this information? Why is this information important? What would be part of your objective & physical assessment?

6 Domain Management Model A framework for assessing older people (Siebens, 2005) Has been used in chronic disease management, ED/acute care, outpatient clinics, rehabilitation and LTC Medical/Surgical Issues Presenting health issues Past medical history Past surgical history Medications Signs and symptoms Living Environment Housing Social supports Formal supports Physical Function ADLs IADLs AADLs Mental & Emotional Status Cognition Psychiatric issues Communication Conflict/abuse Spirituality

7 Essential Question(s) What has changed? What is the persons baseline in all these categories? How are they different today? Can we target a return to the baseline with our interventions?

8 Case Scenario-Assessment For Mr. Complex Medical/Surgical Issues Mild dementia Increased cholesterol Hypertension Iron deficiency anemia Five medications Living Environment Lives alone Apartment (27 steps) PSW 1xW and RN Daughter out of town Physical Function ADLs independent except bathing IADLs assistance AADLs-assistance Mental & Emotional Status Mild dementia Complains of forgetting meds

9 Review of Systems/Symptoms Decreased appetite 15lb weight loss in 6 months Wears upper and lower dentures Eats lots of snacks but not much at meal times

10 GEM Physical/Objective Assessment: Functional Status Current mobility: 1 person assistance to transfer. Unable to ambulate safely with cane. Able to ambulate 10M with walker then required a rest. Standardized tools Katz ADL Scale Barthel Index Lawton IADL Scale Others?

11 GEM Physical/Objective Assessment: Mental Status Alert, able to attend to interview, CAM negative, scored 22/30 MMSE lost 4 points on orientation, 2 points on recall, 2 points on WORLD. Depressed mood, denied suicidal ideation What else do you need to know? Screen for cognitive impairment(3ds), decreased mood and addictions issues Standardized tools: CAM MMSE, Mini-Cog, MOCA etc GDS, 3 item screener, SIGECAPS

12 Collateral History (Dtr & PSW) More difficult for him to get outside Appears to be more confused and forgetful in past couple of weeks Noticed increased difficulty with walking around and getting to bathroom in past 3-4 days Fell last week

13 Geriatric Failure to thrive Describes a state that of decline that is multifactoral and may be caused by chronic concurrent diseases and functional impairments. Four syndromes are prevalent and predictive of adverse outcomes in patients with FTC. 1. Impaired physical function 2. Malnutrition 3. Depression 4. Cognitive impairment

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15 Initial assessment Information regarding: physical and psychological health Functional abilities Socio-environmental factors Nutrition Medication review Labs & Radiology: 1. CBC 2. Chemistry profile 3. TSH 4. Urinalysis 5. Diagnostic imaging as needed

16 What happened to Mr. Complex? Admission to Internal Medicine to assess cause of weight loss, acute functional decline, falls and treatment of dehydration Treated for depression Transferred to geriatric rehab Discharged to an accessible supportive housing building

17 Key Points FTC and FTT are complex syndromes Need to conduct a careful history and assessment to identify the underlying etiology/multiple etiologies Direct interventions to treatable causes Goal is to maintain or improve functional status Discussions about end-of life care is important Long term care home placement often not indicated

18 When is Long Term Care home placement indicated?

19 Home First Concept ALC to LTC in hospital should be considered only as a last resort. LTC placement is a social process and hospital is not the right place for this transition to occur. Legislation is designed for LTC placement from home via CCAC assessing eligibility.

20 Why Waiting at Home is the best option Increase acute care bed capacity Reduces the risk for hospital acquired infections. Allows the patient to wait for placement facility of their choice. Provides patient with time to attain optimal functioning status post acute event. Home provides the best environment to experience a significant transition such as a move to LTC.

21 Questions or Comments?

22 References Siebens(2005). The domain management model- a tool for teaching and management of older adults in emergency departments. Academic Emergency Medicine, 12, (2), Robertson, R.G. & Montagnini, M.D. (2004). Geriatric Failure to Thrive. American Family Physician, 70, (2), Rocchiccioli, J.T. & Sanford, J.T. (2009). Journal of Gerontological Nursing, 35, (1),