The Art of Communicating Geriatric Vital Signs (An Age Friendly Health System Approach) Michelle Moccia DNP, ANP-BC, CCRN Program Director, Senior ER St. Mary Mercy Hospital Livonia, MI michelle.moccia@stjoeshealth.org President, GAPNA Acknowledgments: EMRAP program (Eric James, Fatima Saad, Michael Mastrogiovanni, Lainey Gossett, Jessica Cristiu, Jordan Ansheurser, Daniella Gomez Zubieta, Niveen Elder, Belinda Dokic, (Six Sigma)
Learning Objectives 1. Identify effective strategies to improve communication of positive Geriatric Vital Signs (Delirium, Depression, Dementia) 2. Describe the importance of rapid cycling PDCA (Plan, Do, Study, Act) to implement change 2015 2
Trinity Health s 22-state diversified system $17.6B In Revenue 1.3M Attributed Lives $1.1B Community Benefit Ministry 131K Colleagues 7.5K Employed Physicians and Clinicians 25.6K Affiliated Physicians 93 Hospitals* 22 Clinically Integrated Networks 13 PACE Center Programs 109 Continuing Care Locations *Owned, managed or in JOAs or JVs. 2018 Trinity Health 3
Our Community: The SJMHS Regional service area and most of SE Michigan continues to see % of people 65+ increase
Population Change by Age Group 24% of the population in SE Michigan will be elderly (65+) in 2040. An Aging Region: 2010-2040 -242,884-14,418 75+ 65-74 60-64 35-59 170,380 331,247 Counties Included in Data Set: Livingston Macomb Monroe Oakland Washtenaw Wayne -10,264 25-34 -48,141 18-24 -128,123 5-17 -25,038 0-5 -300,000-200,000-100,000 0 100,000 200,000 300,000 400,000 Source: SEMCOG 2040 Forecast 2015 5
Percent Population Growth by Age Group: 86% increase for 65+ and 12% decrease <65 Represent 37% of current ED visits; 52% hospital discharges Population Growth by Age Group 2010-2040 100.0% 85.5% 80.0% 60.0% 40.0% Counties Included in Data Set: Livingston Macomb Monroe Oakland Washtenaw Wayne 20.0% 0.0% -20.0% 0-17 18-24 25-64 65+ -14.0% -11.4% -11.0% Source: SEMCOG 2040 Forecast 65+ populations have the highest use rates for various health care services. 2015 6
ED visits across the Nation ED can be sole source for medical care PCP lack of availability Primary care offices with business hour (closed on week-ends) Direction from answering recording Homeless Psychiatric illness ED is open 24/7 even on holidays and week-ends.
ED: Front porch of community Geriatric EDs Uniquely positioned to improve care Opportunity to set the stage Recognize inpatient care may be detrimental ED usual care modified with their needs in mind Screen for high-risk conditions Identify age related changes Staff education 4 M s: Mobility, Medication, Mentation, Matters (Age Friendly Health System)
Senior (Geriatric) ER (more than a space) Address health & social needs Screenings: identify seniors at risk for safety and poor outcomes Not often captured with a medical screening Assess Geriatric Vital Signs 3 D s (mentation) Status enables HCP to provide specific plan of care http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/edenvironmentalscan/edenvironmentalscan.pdf
Geriatric Vital Signs: 3 D s Delirium Dementia Depression Common and undetected Screening provides baseline for future visits Unreported can lead to adverse outcomes
DELIRIUM A Medical emergency High morbidity and mortality $38 billion and $152 billion in health-related costs annually 7% to 10% in ED Most prominent risk factor in dementia Evaluation & management critical Unrecognized more likely to die at 6 months compared with recognized (30.8% vs 11. 8%) JAGS.2014 March: 62,(3):462-469 SAEM Geriatric Emergency Department Guidelines 2013 Nat Rev Neurol. 2009 April ; 5(4): 210 220. doi:10.1038/nrneurol.2009.24. Kuma and colleagues. 2003
Confusion Assessment Method (CAM)
Failure to Recognize Major Prognostic Implications Cognitive and functional decline Longer LOS Greater healthcare use Increase in institutionalism Cost equivalent to CHF and COPD http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3614410/ http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4806806/ 2015 13
The Cost of Not Knowing and Acting Case 1 14
Dementia: Significant burden to health care Sixth leading cause of death in U.S. AD: fifth leading cause of death Frequent and potentially avoidable hospitalizations and ED visits Early diagnosis allows a care plan for the future Medications http://www.ninds.nih.gov/disorders/dementias/detail_dementia.htm 2015 15
Determining Cognition: OMCT The Orientation Memory Concentration Test (also referred to as the Blessed Test and Six-item Cognitive Impairment Test) Endorsed by AGS, ENA, SAEM, and ACEP newly published "Geriatric Emergency Guidelines" as a screening test to use in older adults https://www.ena.org/about/media/pressreleases/documents/geri_ed_guid elines.pdf
Orientation Memory Concentration Test
The Cost of Not Knowing Not Acting Case 2 18
Geriatric Depression: Stats and Prognostic Implications Common late life nearly 5 million Not a normal part of aging Major health issue Often reversible with prompt and appropriate treatment. Untreated = poor outcomes Suicide Rate: approximately 1 in 12 (all ages) Older adults 1 in 4 (every 90 minutes) Higher rate of suicide completion (Omega (Westport) 2013;66(2):121-33 CDC WISQARS 2010. www.cdc.gov/injury/wisqars
Geriatric Depression Scale (Rinaldi P 1, Mecocci P, Benedetti C, Ercolani S, Bregnocchi M, Menculini G, Catani M, Senin U, Cherubini A. (2003). Validation of the five-item geriatric depression scale in elderly subjects in three different settings. Journal of American Geriatric Society, 51 (5): 694-8).
Self-Harm Risk
The Cost of Not Knowing Not Acting Case 3 22
Art of Communicating A3 form PDSA Process flow Run/Control Charts 23
2015 24
PDSA 25
Process Improvements PDSA cycles Email results Weekly Run charts Betty White Reminder Reached out to Patient IDT EMR request ED "H" icon handoff form Avoid using abbreviations Reach out to other SJMHS EDs on their process Yellow hand added to top of all computers
Communicating Delirium Vital Sign 7 months 28
Communicating Cognitive Impairment VS 7 months 29
Communicating Depression Vital Sign - 7 months 30
Introduce Yellow Hand-off Form 31
DELIRIUM : 3/5/17-2/21/18 n= 282 (Yellow arrow = implementation Handoff form) 32 Delirium RN Notification to ED PHY Delirium PHY docum. in progress 1 1 0.00% UCL=107.68% 1 40.00% UCL=129.62% 1 00.00% 1 20.00% 90.00% 85.00% 1 00.00% 80.00% _ X=81.08% 80.00% 85.00% _ X=76.92% 70.00% 60.00% 60.00% 40.00% 50.00% MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB LCL=54.49% 20.00% MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB LCL=24.21%
33 DELIRIUM ADMIT DIAGNOSIS Delirium Admit DX order 1 00.00% UCL=101.34% 80.00% 85.00% 60.00% _ X=52.50% 40.00% 20.00% 0.00% MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB LCL=3.66%
OMCT COGNITIVE IMPAIRMENT n= 359 OMCT RN notf. to ED PHY OMCT PHY Documentation 1 1 0.00% UCL=108.82% 1 00.00% UCL=97.04% 1 00.00% 90.00% 90.00% 85.00% 80.00% 85.00% 80.00% 70.00% _ X=71.58% 70.00% 60.00% _ X=61.50% 60.00% 50.00% 50.00% 40.00% 40.00% 30.00% MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB LCL=34.35% 30.00% 20.00% MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB LCL=25.96% 2015 34
35 DEPRESSION: n= 502 GDS RN Notification to ED PHY GDS PHY Documentation 1 00.00% 1 1 0.00% 90.00% UCL=93.73% 1 00.00% UCL=101.05% 80.00% 85.00% 90.00% 85.00% 70.00% 80.00% 60.00% _ X=58.92% 70.00% _ X=65.75% 50.00% 60.00% 40.00% 50.00% 30.00% 40.00% 20.00% MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB LCL=24.10% 30.00% MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB LCL=30.45%
Yellow hand off form usage summary 36 DELIRUM Form Use N RN to Physician Physician Documentation Admitted With Diagnosis Pre-Intervention (9/27/17-11/28/2018) First 3 Months (11/29/17-2/28/18) DEMENTIA (OMCT) Pre-Intervention (9/27/17-11/28/2018) First 3 Months (11/29/17-2/28/18) N/A 52 69.23% 50.00% 28.85% YES 37 100.00% 78.38% 62.16% NO 48 50.00% 39.58% 31.25% Form Use N RN to Physician Physician Documentation D/C Instructions N/A 64 57.81% 28.13% 7.81% YES 46 100.00% 71.74% 19.57% NO 63 47.62% 30.16% 1.59% DEPRESSION Pre-Intervention (9/27/17-11/28/2018) First 3 Months (11/29/17-2/28/18) Form Use N RN to Physician Physician Documentation D/C Instructions N/A 116 55.17% 38.79% 6.03% YES 54 100.00% 70.37% 20.37% NO 103 27.18% 25.24% 5.83%
37 Delirium 3/28-5/22 Delirium (CAM) N ED RN to ED Physician Notification ED Physician Documentation in MDM ED Physician Admitted w/ Diagnosis 3/28-4/3 7 6/7 (85.71%) 5/6 (83.33%) 4/6 (66.66%) 4/4-4/10 5 4/5 (80%) 4/4 (100%) 3/4 (75%) 4/11-4/17 2 1/2(50%) 1/1(100%) 0/1(0%) 4/18-4/24 2 2/2(100%) 1/2(50%) 1/2(50%) 4/25-5/1 4 2/4 (50%) 2/2(100%) 1/2(50%) 5-2-5/8 1 1/1 (100%) 1/1 (100%) 0/1 (0%) 5/9-5/15 7 5/7 (71%) 5/5 (100%) 2/5 (40%) 5/16-5/22 2 2/2 (100%) 2/2 (100%) 0/2 (0%) 85% 75-84% 50-74% <50%
38 Depression 3/28-5/22 Possible Depression (GDS) N ED RN to ED Physician Notification ED Physician Documentation in MDM ED Physician Discharge instructions 3/28-4/3 17 8/17 (47.06%) 5/8 (62.5%) 2/4 (50%) 4/4-4/10 14 10/14 (71.4%) 6/10 (60%) 6/10 (60%) 4/11-4/17 13 5/13(38%) 5/5(100%) 1/3(33%) 4/18-4/24 12 10/11(91%) 6/10(60%) 1/3(33%) 4/25-5/1 7 5/7(71.4%) 5/5(100%) 2/2(100%) 5/2-5/8 14 7/13 (54%) 8/8 (100%) 2/3 (66%) 5/9-5/15 5 2/4 (50%) 2/2 (100%) 1/1 (100%) 5/16-5/22 10 6/10 (60%) 5/6 (83%) 1/1 (100%) 85% 75-84% 50-74% <50%
39 Cognitive Impairment 3/28-5/22 Cognitive impairment (OMCT) N ED RN to ED Physician Notification ED Physician Documentation in MDM ED Physician Discharge instructions 3/28-4/3 6 3/6 (50%) 3/3 (100%) 1/3 (33.33%) 4/4-4/10 8 7/8 (87.5%) 4/7 (57.14) 3/4 (75%) 4/11-4/17 10 9/10 (90%) 7/9 (77%) 3/3 (100%) 4/18-4/24 4 4/4(100%) 1/4(25%) 0/2(0%) 4/25-5/1 9 9/9(100%) 6/9(66.6%) 4/4(100%) 5/2-5/8 4 3/4 (76%) 2/3 (66%) 1/2 (50%) 5/9-5/15 8 4/8 (50%) 4/4 (100%) 3/5 (60%) 5/15-5/22) 15 13/15 (86%) 9/13 (69%) 3/5 (60%) 85% 75-84% 50-74% <50%
How can you help improve communication? Avoid common missteps in solving problems Try not to assume You know what the problem is before seeing what s happening You know how to fix the problem without understanding the root causes The 1 st action plan you develop will address the problem perfectly 2015 40
In conclusion: To help improve communication Everyone is on the same page Start small, analyze, and then scale up Leadership buy in Share metrics and ask why? Evaluate PDSA with every new change EMR enhancements Storytelling Acknowledge, Celebrate 2015 41