CHAMP: CHAMP: Care of the Hospitalized Aging Medical Care of the Hospitalized Aging Medical

PatientPatient

Leader’s Guide to Bedside Teaching Rounds Leader’s Guide to Bedside Teaching Rounds for Medical Studentsfor Medical Students

Shellie Williams, M.D.Shellie Williams, M.D.

University of ChicagoUniversity of Chicago

Overview Overview

• Who:Who: – Students on internal medicine service; Geriatric Students on internal medicine service; Geriatric

attending of the month and fellow.attending of the month and fellow.• When:When:

– (1) afternoon per week, 60min bedside teaching. (1) afternoon per week, 60min bedside teaching. • How:How:

– Students decide date/time that majority can Students decide date/time that majority can meet. (1) student chooses a patient and we meet. (1) student chooses a patient and we round 60min on patient case with entire group.round 60min on patient case with entire group.

• Where:Where: – Medicine WardMedicine Ward

• What:What: – We focus on AAMC geriatric competencies for We focus on AAMC geriatric competencies for

medical students on care of hospitalized elders.medical students on care of hospitalized elders.

Geriatric Inpatient Competencies for Geriatric Inpatient Competencies for Medical StudentsMedical Students

Recommendations of the July 2007 Geriatrics Recommendations of the July 2007 Geriatrics Consensus ConferenceConsensus Conference

2222 Identify potential hazards of hospitalization for all older adult Identify potential hazards of hospitalization for all older adult patients (including immobility, delirium, medication side effects, patients (including immobility, delirium, medication side effects, malnutrition, pressure ulcers, procedures, peri and post operative malnutrition, pressure ulcers, procedures, peri and post operative periods, and hospital acquired infections).periods, and hospital acquired infections).

2323 Explain the risks, indications, alternatives, and contraindications for Explain the risks, indications, alternatives, and contraindications for indwelling (Foley) catheter use in the older adult patient.indwelling (Foley) catheter use in the older adult patient.

2424 Explain the risks, indications, alternatives, and contraindications for Explain the risks, indications, alternatives, and contraindications for physical and pharmacological restraint use.physical and pharmacological restraint use.

2525 Communicate the key components of a safe discharge plan (e.g., Communicate the key components of a safe discharge plan (e.g., accurate medication list, plan for follow-up), including accurate medication list, plan for follow-up), including comparing/contrasting potential sites for discharge.comparing/contrasting potential sites for discharge.

2626Conduct a surveillance examination of areas of the skin at high risk Conduct a surveillance examination of areas of the skin at high risk for pressure ulcers and describe existing ulcers.for pressure ulcers and describe existing ulcers.

Teaching FormatTeaching Format

““Care of the hospitalized elder” Care of the hospitalized elder” lecture is emailed to students at the lecture is emailed to students at the beginning of the rotation.beginning of the rotation.

Students spend 1 hr rounding with a Students spend 1 hr rounding with a geriatric attending and fellow.geriatric attending and fellow.

1-2 patients seen during rounds, and 1-2 patients seen during rounds, and students are expected to complete students are expected to complete components of a geriatric inpatient safety components of a geriatric inpatient safety screens to optimize safety of elders on screens to optimize safety of elders on UCMC inpatient wards.UCMC inpatient wards.

Main Content Areas in CHAMPMain Content Areas in CHAMP

Hospital HazardsHospital Hazards-recognizing and preventing -recognizing and preventing

Foley catheter use in the elderlyFoley catheter use in the elderly-explaining risks, indications, alternative-explaining risks, indications, alternative

Use of restraintsUse of restraints-understanding the risks, indications and -understanding the risks, indications and alternativesalternatives

Key components of safe discharge planningKey components of safe discharge planning-what to communicate-what to communicate

Pressure ulcers and Braeden stagingPressure ulcers and Braeden staging-demonstrating surveillance exam of areas of skin at -demonstrating surveillance exam of areas of skin at risk risk

Geriatric Hospital Complications:Geriatric Hospital Complications:History Questions and ScreensHistory Questions and Screens

Delirium: Delirium: AM review with nurse or family?AM review with nurse or family?Screening: CAM, Mini-CogScreening: CAM, Mini-Cog

Deconditioning: Deconditioning: What was your function 2 weeks prior to hospital and now?What was your function 2 weeks prior to hospital and now?

Screening: ADL/IADL; mobility statusScreening: ADL/IADL; mobility status

Poly-pharmacy: Poly-pharmacy: What are potential hazards with the medications?What are potential hazards with the medications?

Screening: Medication reconciliation; Beers List risk drugsScreening: Medication reconciliation; Beers List risk drugs

Pressure ulcers: Pressure ulcers: Any pain in perineum, heels, elbowsAny pain in perineum, heels, elbows

See skin and Stage using Braeden systemSee skin and Stage using Braeden system

Geriatric Hospital Complications:Geriatric Hospital Complications: History Questions and Screens History Questions and Screens

Environmental Assessment: Environmental Assessment: What aides does the patient use, what is present in hospital?What aides does the patient use, what is present in hospital?Screen: Gait device, glasses, hearing aide, denturesScreen: Gait device, glasses, hearing aide, dentures

Pain: Pain: 6point: describe, location, duration, exac/relieve, intensity 6point: describe, location, duration, exac/relieve, intensity Screen: 6 point assess and Scale 0-10Screen: 6 point assess and Scale 0-10

Restraint Review: Restraint Review: How many restraints are present on this patient?How many restraints are present on this patient?Screen: Assess need for: Foley, PICC< drains, SCDs, Screen: Assess need for: Foley, PICC< drains, SCDs, catheter/drains, wrist/hand restriant and discontinuation plan catheter/drains, wrist/hand restriant and discontinuation plan

Nutrition: Nutrition: How is your appetite?How is your appetite?Screen: Observe patient eating, desired foods, dentures, last BMScreen: Observe patient eating, desired foods, dentures, last BM

Medical decision making:Medical decision making: What have the doctors told you about why you’re in the hospital?What have the doctors told you about why you’re in the hospital? Screen: Applebaum review of decision makingScreen: Applebaum review of decision making

Teaching MaterialsTeaching Materials

Champ website pocket cards and Champ website pocket cards and UCSF Geriatrics for Inpatient Medicine UCSF Geriatrics for Inpatient Medicine

Card.Card.

Attending Teaching Triggers:Attending Teaching Triggers:1. Hospital Discharge1. Hospital Discharge

What are potential obstacles to a safe and speedy discharge in this What are potential obstacles to a safe and speedy discharge in this particular patient?particular patient?

• Review pre-hospital living situation and supportsReview pre-hospital living situation and supports

• When you enter the room ask students to identify obstacles to the When you enter the room ask students to identify obstacles to the patient ambulating: foley, iv, compression boots, wrist restraintspatient ambulating: foley, iv, compression boots, wrist restraints

• Ask the students to screen the patient for 2-3 elements of pre-Ask the students to screen the patient for 2-3 elements of pre-hospital and current Adl and Iadl functionhospital and current Adl and Iadl function

Attending Teaching Triggers:Attending Teaching Triggers:2. Risk factors for delirium2. Risk factors for delirium

What are potential risk factors for delirium in this patient?What are potential risk factors for delirium in this patient?

Pre-hospital factors: Pre-hospital factors: poor vision, bun/cr >18, Charleston >4, baseline poor vision, bun/cr >18, Charleston >4, baseline dementiadementia

Hospital factors:Hospital factors: >3 new meds, restraints, foley, iatrogenic events, >3 new meds, restraints, foley, iatrogenic events, malnutritionmalnutrition

Post-Hospital factors for prolonged delirium:Post-Hospital factors for prolonged delirium:

Attending Teaching Triggers:Attending Teaching Triggers:3. Diagnosing delirium3. Diagnosing delirium

What elements are needed to diagnose delirium? What elements are needed to diagnose delirium?

A. A. Have one student give you the elements of the CAM:Have one student give you the elements of the CAM:

1.1. change in baseline cogntion/flucation/acute change in baseline cogntion/flucation/acute

2.2. Inattention +3 OR 4Inattention +3 OR 4

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3. disorganized thoughts3. disorganized thoughts

4. change level of consciousness4. change level of consciousness

B.B. Ask that student which elements were + in the patient Ask that student which elements were + in the patient you just evaluated, per there evaluation and nursing you just evaluated, per there evaluation and nursing account.account.

C.C. If patient + for delirium, Ask student 3 common causes If patient + for delirium, Ask student 3 common causes of delirium: of delirium:

1. Medications1. Medications 2. Infections2. Infections 3. Metabolic 3. Metabolic disturbancesdisturbances

Attending Teaching Triggers:Attending Teaching Triggers:4. Significance of delirium4. Significance of delirium

Why is delirium so important in hospitalized elders?

1. 2x increased risk for mortalityinstitutionalizationADL dependence

2. 20% physician recognition and even after recognition seldom documented

3. High risk for development of dementia subsequent to a delirium episode

4. 6-60 billion/yearly cost of care for delirium in elderly hospitalized

Attending Teaching Triggers:Attending Teaching Triggers:5. Medication Review5. Medication Review

Please review the MAR for Mrs. _____, can anyone Please review the MAR for Mrs. _____, can anyone identify any drugs which may predispose to adverse identify any drugs which may predispose to adverse events during hospitalization?events during hospitalization?

• Psychoactive effectsPsychoactive effects• Sedative-hypnoticsSedative-hypnotics• NarcoticsNarcotics• Anti-cholinergic drugsAnti-cholinergic drugsHow can we modify medication administration in elders to How can we modify medication administration in elders to

be safer?be safer?1.1. Start low dose/slow titration. Start 1/3-1/2 standard Start low dose/slow titration. Start 1/3-1/2 standard

prescribing dose for adult patient in elderlyprescribing dose for adult patient in elderly2.2. Remember elders renal and hepatic function declines Remember elders renal and hepatic function declines

with age and the alteration in Vd of water: muscle with age and the alteration in Vd of water: muscle mandates need for dose adjusting.mandates need for dose adjusting.

Attending Teaching Triggers:Attending Teaching Triggers:6. Medication Review6. Medication Review

Review primary classes identified in Review primary classes identified in Beers criteria for elder prescribing Beers criteria for elder prescribing problems:problems: – Benzodiazepines, especially long actingBenzodiazepines, especially long acting– High dose narcotics or long-acting, High dose narcotics or long-acting,

especially in narcotic naïveespecially in narcotic naïve– NSAIDSNSAIDS– Anti-cholinergicsAnti-cholinergics

Attending Teaching Triggers:Attending Teaching Triggers:7. Geriatric Review of Systems7. Geriatric Review of Systems

What is the geriatric review of systems? Please assess in patient _______.

How are you sleeping, difficulty initiating or staying sleep

Do you use walker, hearing aid or glasses at home? Are they here?

Are you having pain? Location + Pqrst

Have you been out of bed today? I or Assisted?

How is your appetite? Do you like the meals you are able to select?

Have you had a bowel movement? Any strain?

Review cognition above with CAM.

Attending Teaching Triggers:Attending Teaching Triggers:8. Skin Exam8. Skin Exam

Ask the students what key areas of the body should be screened for ulcerationAsk the students what key areas of the body should be screened for ulceration??– Perineum, heels, elbows, hipsPerineum, heels, elbows, hips

Review on the patient and discuss the Staging and Braeden Risk Scale.Review on the patient and discuss the Staging and Braeden Risk Scale.– Stage I:Stage I: Intact skin with non-blanchable redness Intact skin with non-blanchable redness – Stage II:Stage II: Partial thickness loss of dermis or intact or open/ruptured serum-filled Partial thickness loss of dermis or intact or open/ruptured serum-filled

blister.blister.– Stage III:Stage III: Full thickness tissue loss. Subcutaneous fat may be visible. May include Full thickness tissue loss. Subcutaneous fat may be visible. May include

undermining and tunneling.undermining and tunneling.– Stage IV:Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or Full thickness tissue loss with exposed bone, tendon or muscle. Slough or

eschar on some parts of or undermining may be present.eschar on some parts of or undermining may be present.

What is Braden Scale:What is Braden Scale: Risk assessment scale for Risk assessment scale for pressure ulcers. Lower pressure ulcers. Lower scores means higher risk of ulceration. Looks at following risk factors for scores means higher risk of ulceration. Looks at following risk factors for ulceration on scale 1(low fxn)-4 (high fxn):ulceration on scale 1(low fxn)-4 (high fxn):

– Skin moistureSkin moisture– Perception of painPerception of pain– Mobility potential in bedMobility potential in bed– Level physical activityLevel physical activity– NutritionNutrition

Friction/sheering forces on skinFriction/sheering forces on skin

Attending Teaching Triggers:Attending Teaching Triggers:9. Transitions to other care settings9. Transitions to other care settings

Based on the above evaluation and patients pre-Based on the above evaluation and patients pre-hospital living situation what do you feel is the hospital living situation what do you feel is the most appropriate discharge setting?most appropriate discharge setting?

Review criteria for: Review criteria for: • Inpatient settingInpatient setting• Acute rehabAcute rehab• Skilled Nursing (SNF)Skilled Nursing (SNF)• Long-Term Care Nursing (ICF)Long-Term Care Nursing (ICF)• Assisted LivingAssisted Living• Independent Living Independent Living • Home CareHome Care