Download Acute Care of the Elderly (ACE) Curriculum at The University of

Acute Care of the Elderly (ACE) Curriculum at The University of North Carolina
March 2013
The aim of the ACE curriculum is to ensure that Internal Medicine and Family
Medicine residents will be able to provide quality, safe, and comprehensive care to
acutely ill older adults, maintaining a focus on cognitive and functional status, caring
for patients both in the hospital setting and during the transition out of the hospital.
Rationale for Development of the ACE Curriculum:
Over a third of all hospitalized patients in the United States are over the age of 65.1 Despite
the ACGME requirement for a geriatrics medicine curriculum for all Internal Medicine and
Family Medicine residency programs, there is still concern that graduating residents will
not be adequately trained to care for the growing number of older patients.2,3 In response
to this, the American Geriatrics Society outlined essential geriatric competencies for all
Internal and Family Medicine residents in a 2010 position statement.
These competencies outline the specific expectations for residents that enable the
provision of quality care for older adults. A resident must be able to screen for delirium,
depression, and dementia. A resident must be able to recognize and manage delirium as an
emergency. A resident is expected to be able to discuss and document advanced care
planning. Specific to hospital based care, residents must evaluate all older patients for falls
risk, immobility, pressure ulcers, nutrition, pain, new urinary incontinence, constipation,
inappropriate medication prescribing, and inappropriate bladder catheter usage.
Emphasizing patient safety in transitions of care, a resident must be able to create a
discharge summary that reflects the special needs of this population. This summary must
include not only the clinical course, but also reconciled discharge medications, current
cognitive and functional status, advance directives, plan of care and scheduled follow up.4
Despite these expectations, residents report the need for better training in the assessment
of an older patient for hospital discharge and safe transitions of care.5 There have been
several studies looking at the impact of various geriatric rotations and curricula on resident
knowledge and attitudes. Most of these studies show improved scores after such
experiences, but less is known about the sustainability of these effects and actual impact
upon patient care.6-8 In a review of best practices for geriatrics education and integration
into residency programs, the three essential elements of a sustainable and valued
curriculum include the provision of model geriatric care, the focus on patient care across
transitions, and the reliance on interdisciplinary teamwork.9 Emphasizing quality
improvement, a requirement for all residents, is one potential strategy to teach the
curriculum and translate knowledge into practice. 10-12
This curriculum will therefore focus on the inpatient care of older adults by residents in
Internal Medicine, will begin with the competencies in geriatric medicine established by
the AGS as essential to resident training, and will rely upon quality improvement strategies
to reinforce knowledge and translate what is learned into patterns of sustainable behavior.
ACE Curriculum Committee: The ACE curriculum development, implementation, and
maintenance will be guided by the Program Director for the Geriatric Fellowship. The
committee will include one clinical faculty member from Geriatrics, one faculty member
with a PhD in education, two advanced Geriatric Fellows, and a current Geriatric Fellow in
training. Two resident members of the AGS Resident Chapter at UNC will serve as resident
representatives.
Learners, Instructors, Context
Learners:
Target audience: The ACE curriculum is focused primarily upon the resident in Internal
Medicine who is on a clinical rotation that centers upon the care of acutely ill older patients
in the hospital setting (the Acute Care of the Elderly service).
Prerequisites for learners: Residents on the service have all completed medical school
training, have a Medical Degree, and have either a training or full state license to practice
medicine in North Carolina
Instructors:
Prerequisites for Instructors: Instructors must have trained in either Family or Internal
Medicine, be board certified in Geriatric Medicine, and have an appointment through the
Division of Geriatric Medicine as clinical and teaching faculty. All instructors meet
regularly as part of the Division of Geriatric Medicine, receive faculty development for
teaching, and will receive all curricular goals and objectives prior to teaching.
Context, Structure, and Organization for the ACE Curriculum:
Context: Residents on the ACE inpatient service are the primary target learners for the
curriculum. The rotation is a month long block for residents that is required by the IM
residency program. This rotation may be done at any point in a resident’s training, therefore
some learners will be exposed to the curriculum early in their first year of training and others
not until later years.
Structure: The curriculum will be taught as part of a clinical rotation. Teaching activities
need to be flexible and fit within the structure of an interdisciplinary team with the
primary goal of caring for acutely ill hospitalized elders. The team also consists of third and
fourth year medical students as well as students and residents from other departments
such as Clinical Pharmacy, Physical Medicine and Rehabilitation, and Emergency Medicine.
The team is led by, and the curriculum taught by, a Clinician Educator with the Division of
Geriatric Medicine. Fellows in Geriatric Medicine are also on the service and will provide a
primarily educational role in the curricular activities.
Organization: The Division of Geriatric Medicine within the Department of Internal
Medicine will primarily be responsible for the development and implementation of the ACE
curriculum. All curricula for IM residents must ultimately be reviewed, approved, and
disseminated through the IM residency program.
National Guidelines: The ACGME requires all IM residency programs to have
geriatric curriculum that is ultimately developed and managed by faculty with expertise in
geriatrics. In addition, the foundation of this curriculum is based upon a standard of core
competencies set by the American Geriatrics Society for all residents in IM and FM.
Institutional, Social and Community context: This curriculum meets the demand for
improved care for older adults by community and social leaders as well as the ACGME and
AGS. The focus on quality indicators, evidence based medicine, communication skills, and
improvement in practice fits nicely with many of the ACGME core competencies as well as
the requirements being established for the Next Accreditation System (NAS).
UNC ACE Curriculum core competencies (based upon ACGME core competencies)
1. Patient Care: Residents will provide comprehensive, quality and evidence based
care to acutely ill older patients during hospitalization and discharge.
2. Knowledge: Residents will understand the core AGS competencies expected in the
care of older patients and will be able to identify common hospital problems for the
elderly, assess cognitive and functional status, and review medications.
3. Communication: Residents will work with interdisciplinary teams, patients and
families in the care of older hospitalized patients, and will effectively communicate
the hospital course and needs at the time of transfer out of the hospital setting.
4. Systems Based Practice: Residents will understand the quality standards
identified for the safe discharge of an older patient, appreciate potential safety
problems during transitions in care, and ensure improved communication with the
goal of improving patient safety during hospitalization and discharge.
5. Practice Based Learning and Improvement: Residents will be able to identify
core components required for quality care of older adults during hospitalization and
discharge, review their current practice, and utilize quality improvement strategies
to provide for more safe and standardized care to all older patients.
6. Professionalism: Residents will respect each older adult as an individual,
appreciate the impact that medical illness and functional decline can have upon
older adults and caregivers, and strive to provide patient and family centered care.
Aim: Internal Medicine residents will be able to provide quality, safe, and comprehensive
care to acutely ill older adults, maintaining a focus on cognitive and functional status,
caring for patients both in the hospital setting and during the transition out of the hospital.
Learning Outcomes for the ACE Curriculum: This curriculum will use the AGS core
competencies (see Appendix 1) as Learning Outcomes for internal medicine residents to
achieve with a focus on the care of acutely ill older adults in the hospital setting. During the
rotation on the ACE service, the internal medicine resident will develop the skills needed
for appropriate prescribing, cognitive and functional assessment, caring for the individual
with a focus on goals of care, and patient safety during hospitalization and transitions of
care.
Appropriate Prescribing:
The resident will be able to:
1. Appropriately prescribe drugs, considering age related changes, side effects, and
drug-drug interactions and if prescribing high risk drugs, discuss and document the
rationale for their use, alternatives, and ways to decrease side effects
2. Review medications with the patient and/or caregiver, assess for adherence, and
consider adverse medication reactions in the differential of new symptoms
Cognitive and Functional Assessment:
The resident will be able to:
3. Identify and understand how to use and interpret at least one tool each for the
assessment of delirium, dementia, depression and substance abuse
4. Recognize delirium as a medical urgency and evaluate and manage patients with
changes in affect, cognition, and behavior
5. Perform and document standard assessments of cognitive and functional status
6. Identify barriers to communication (hearing, speech, health literacy, cognition)
7. Determine whether an older adult has capacity
8. Assess, document, and manage fall risk, immobility, pressure ulcers, adequacy of
oral intake, pain, new urinary incontinence, and constipation
Caring for the individual older patient, understanding complexities of aging and
focusing on goals of care:
The resident will be able to:
9. In evaluating acute ill older adults, generate differential diagnoses that include
diseases that present atypically in older adults and demonstrate understanding of
the major age related changes in physical and laboratory findings
10. Individualize standard recommendations for screening tests and chemoprophylaxis
based on life expectancy, functional status, patient preference, and goals of care
11. Demonstrate respect for each older patient as an individual, avoiding stereotypes,
and understanding the core concept of function
12. Discuss and document advance care planning and goals of care with all patients
13. Develop a treatment plan that incorporates the patient’s and family’s goals of care,
preserves function, and relieves symptoms and in patients with life threatening
illness, assess pain and other distressing symptoms, institute appropriate treatment
based upon goals of care, and transition to comfort care when appropriate
Patient Safety during hospitalization and transition of care:
The resident will be able to:
14. In patients with a bladder catheter, discontinue or document indication for use
15. Before using or renewing physical or chemical restraints, assess for and treat
reversible causes of agitation and consider alternatives to restraints
16. Identify older persons at high safety risk, including unsafe driving or elder
abuse/neglect, and develop a plan for assessment and referral
17. When transferring a patient from the hospital, work with an interdisciplinary team
to create a plan of care with a written summary of the hospital course that is
transmitted to the patient and/or family caregivers as well as the receiving health
care providers. This summary should also communicate clinical status, discharge
medications, current cognitive and functional status, advance directives, plan of
care, scheduled or needed follow up, and hospital physician contact information.
Performance Indicators for the UNC ACE Curriculum:
At the end of the rotation on the Inpatient Geriatric (ACE) service, the resident will
specifically be able to do the following skills needed for:
Appropriate Prescribing:
1. Identify medications that are high risk for older adults, including commonly used
medications such as insulin, oral hypoglycemic agents, and warfarin
2. Document risks of potentially inappropriate medications and polypharmacy in
admission notes for older patients
Cognitive and Functional Assessment:
1. Use and interpret the Mini-Cog as a basic screening tool for cognitive assessment
and document the results in the discharge summary
2. Assess a patient for capacity and document specific concerns
3. Use and interpret the Confusion Assessment Method (CAM) to screen for
delirium at the time of admission and again at discharge, documenting results
for appropriate transfer of care
4. Perform and interpret a Get Up and Go screening test for gaits and falls
assessment on all patients, documenting assessment in the discharge summary
5. Perform and interpret a depression screen in an older patient (PHQ2 or PHQ9 or
Geriatric Depression Screen)
6. Create hospital progress notes that document fall risk, immobility, pressure
ulcers, adequacy of oral intake, pain, new urinary incontinence, and constipation
Caring for the individual older patient, understanding the complexities of aging and
focusing on goals of care:
1. Demonstrate clinical reasoning in oral presentations as well as written admission
notes of newly admitted patients that includes an understanding of atypical
presentations of common diseases in the elderly and common changes of aging
2. Demonstrate respect for the individual in oral presentations and communications
with team members, students, and other clinicians in the care of older adults
3. Describe to the team and include in the admission note patient and/or caregiver
goals of care for the hospitalization of an older patient
4. Perform and document an advanced care planning discussion with a patient and/or
caregiver, going beyond standard “Do Not Resuscitate” discussions
Patient Safety during hospitalization and transition of care:
1. Document the presence of any bladder catheter, physical or chemical restraints,
identify any indications for continued use or document discontinued use, and
identify alternatives when appropriate
2. Appropriately review medications in older adults at the time of discharge,
evaluating for and managing inappropriate prescribing, and document a medication
review and reconciliation (including new medications, stopped medications, and
final medication list) in the final discharge summary
3. Utilize a discharge template that includes quality indicators for care of older adults
who are transferring out of the hospital setting that accurately and concisely
communicates evaluation and management, clinical status, discharge medications,
current cognitive and functional status, advance directives, plan of care, scheduled
or needed follow up, and hospital physician contact information.
Primary Domains for Learning Outcomes (AGS competencies for residents) and
relationship to ACGME core competencies
•Appropriate
Prescribing
•Caring for the
Individual with
a focus on goals
of care
•Cognitive and
Functional
assessment
SBP
Knowledge
PBLI
Knowledge
Patient Care
Communication
professionalism
PBLI
SBP
Knowledge
communication
•Pateint safetfy
during
hospitalization
and discharge
Instructional Design:
Week 1: Sessions 1-5, Laying the Foundation
Session
Learning
Performance
Outcome, the
Indicator, the
resident will be
resident will:
able to:
1:
Generate
Demonstrate
Orientation:
differential
clinical
overview of
diagnoses that
reasoning in
learning
include diseases
oral and
outcomes
that present
written
and
atypically in older
presentations
performance adults and
indicators for demonstrate
Demonstrate
entire
understanding of
respect for the
rotation
major age related
individual in
changes in physical oral
and lab findings
presentations
and
Demonstrate
communication
respect for each
with team
older patient as an members,
individual,
students and
avoiding
other clinicians
stereotypes, and
understanding core
concepts of
function
2.
Use and interpret
Use and
Introduction at least one tool for interpret the
to Cognitive
assessment of
Mini cog as a
and
delirium and
basic screening
Functional
dementia
tool for
Assessment
cognitive
Perform and
assessment and
document standard document in
assessments of
d/c summary
cognitive and
functional status in Use and
all older adults
interpret the
CAM to screen
Recognize delirium for delirium at
as an emergency
admission and
discharge and
Determine whether document at
Activity (all
small group
activities)
Assessment
Introduction to
functional status:
watch video
http://www.nyti
mes.com/2009/
08/24/health/24
nursing.html?pag
ewanted=all&_r=
0
Clinical
evaluation by
faculty at mid
and end points
(resident
meeting
ACGME core
competencies
of
communication,
professionalism
, PBLI and SBP)
Overview, AGS
competencies,
ACE curriculum,
expectations,
Geriatric Tracker
Discussion: self
assessment:
what is
geriatrics,
interdisciplinary
care?
Discussion:
What is the minicog? What is the
CAM? How do
you know if
someone has
capacity? How do
you document
these
assessments?
Case examples:
capacity
Geriatric fellow
to demonstrate
assessment tools
Self assessment
as part of GeriTracker
Geri-Tracker to
document use
of Mini-Cog,
CAM, Get Up
and Go
Chart reviews
by attending on
daily basis (as
part of process
in which
attendings have
to sign off on all
patient notes)
Chart reviews
by fellow on
3.
Appropriate
Prescribing
an older adult has
capacity
time of transfer
of care
Assess, document,
and manage fall
risk
Assess a patient
for capacity,
document
concerns in the
medical record
Appropriately
prescribe drugs,
considering age
related changes,
common side
effects, and if using
high risk
medications
discuss and
document reason
for use
Review
medications,
consider drug side
effects in
differential of any
new symptom
4. Goals of
Discuss and
care and
document advance
advanced
care planning and
care planning goals of care with
patient/surrogate
Develop treatment
plan that
incorporates goals
of care, preserves
function, and
relieves symptoms;
Perform and
interpret a get
up and go for
gait and falls,
document in
d/c summary
Identify
medications
that are high
risk for older
adults,
including
commonly used
drugs
(warfarin,
insulin)
Document risks
of potentially
inappropriate
meds and
polypharmacy
in admission
notes
Describe to the
team and
include in the
admission note
goals of care for
hospitalization
Perform and
document an
advanced care
planning
discussion with
with group
Distribute and
review Teaching
Cards (Mini-Cog,
CAM, Get up and
Go)
service at the
beginning,
midpoint, and
end of rotation
Introduction of
the Discharge
Template
Reading
materials:
Revised Beers
List from the AGS
2012
Presentation:
Weighing risks
and benefits of
medications (15
minutes)
Problem Based
Learning (PBL)
exercise: Review
of sample
medication lists
Small group
discussion:
experience with
advance care
planning
discussions,
communication,
prognosis
Group exercise:
Chart audit –
how many have
Daily review of
notes by
attending
Chart audits by
fellow at
beginning,
midpoint, and
end of each
rotation (as
part of the
discharge
summary chart
review)
Geri-Tracker
5. Hospital
Discharge
and
Transitions
of Care
assess pain and
distressing
symptoms, treat
based on goals, and
transition to
comfort care when
appropriate
a patient
and/or
caregiver, going
beyond the
standard “DNR”
discussions and
orders
Work with an
interdisciplinary
team when
transferring a
patient out of the
hospital
Appropriately
review meds in
older adults at
d/c, evaluating
for
inappropriate
prescribing,
document med
review and
reconciliation
(new meds,
stopped meds,
final list) in the
final d/c
summary
Create d/c
summary that is
transmitted to
patient/caregiver
as well as receiving
health care team
that communicates
evaluation and
treatment, clinical
status, d/c meds,
cog and functional
status, advance
directives, plan of
care, f/u, physician
contact
information
advance care
planning
documented?
Are goals of care
discussed? How
many have DNR
order but no
documentation
of discussion?
PBL medication
reconciliation
exercise with
practice
discharge
summary
Review
medication
reconciliation
process
Chart audits by
fellows (review
of d/c
summaries) in
beginning,
midpoint, and
end of rotation
Review d/c
summary
template and
quality
Utilize d/c
indicators:
template that
Clinical summary
includes quality Med review,
indicators for
Cognitive status
care of older
Functional status
adults who are
Advance
transferring out directives
of hospital
Follow up,
contact
Week 2: Sessions 6-10, Hospital Complications and Patient Safety
Session
6. Catheters
and restraints
Learning
Outcome: The
resident will
be able to ….
In patients
with bladder
catheter,
Performance
indicator:
the resident
will….
Document
presence of
any bladder
Activity
Assessment
Small group exercise
with chart audits: Does
your patient have a
Geri-tracker
discontinue or
document
Before using or
renewing
restraints,
assess for and
treat reversible
causes of
agitation and
consider
alternatives
Session 7.
Assess,
Hospital
document, and
complications
manage
pressure ulcers,
nutritional
status, new
urinary
incontinence,
and
constipation
Session 8.
Identify and
Barriers to
assess barriers
communication to
communication
in the hospital
setting
Session 9.
Depression and
substance
abuse
Session 10.
Safety outside
the hospital—
screening for
Identify and
understand
how to use and
interpret at
least one tool
for delirium,
dementia,
depression,
substance
abuse
Identify older
persons at high
safety risk,
including
catheter and
discontinue or
document
indication
Identify
chemical and
physical
restraints,
discontinue or
document
indication
Create notes
that
document
assessment of
fall risk,
immobility,
pressure
ulcers, oral
intake, UI,
constipation
Identify and
assess for
hearing loss,
speech
problems,
health
literacy,
cognitive
disorders
Perform and
interpret
depression
screen (PHQ
2, PHQ 9,
geriatric
depression
scale), screen
for substance
abuse
Assess for
driving safety
Assess for
bladder catheter?
Oxygen tubing?
Compression stockings?
Telemetry leads? How
can these be restraints?
Attending
review of
daily
progress
notes
Discussion/presentation:
what are restraints?
what are chemical
restraints? What are
problems with
antipsychotics?
20 minute presentation: Geri-tracker
pressure ulcers,
nutrition, new UI,
Attending
constipation
review of
daily notes
Hands on review of
pressure ulcers with
Nurse Practitioner
Watch Health Literacy
video
GeriTracker
Small group
presentation: hearing,
sight, speech
Clinical
evaluations
Small group discussion:
What challenges so far?
Presentation/
Discussion: Depression,
Dementia Delirium and
substance abuse
GeriTracker
Review screening with
fellow role play
Presentation/discussion: GeriEM, driving assessments Tracker
(how do we think of
safety screening in
elder
mistreatment
and unsafe
driving
unsafe driving elder
or elder
mistreatment
abuse/neglect,
and develop a
plan for
assessment and
referral
young adults -seatbelt
use, drug use, etc-and
children -smoking in the
home, IPV in the home,
carseat-: Although EM
and driving seem
separate, think “safety”
Week 3, Sessions 11 and 12: Caring for the Individual patient, understanding the
complexities of aging
Session
Learning
Performance
Activity
Assessment
outcome, the
Indicator, the
resident will be
resident will….
able to….
11.
Individualize
Practice shared
Small group
Geri-Tracker
Understanding recommendations decision making, discussion
the Medicare
for screening
based upon life
centered
Annual
based on life
expectancy, goals around
Wellness Visit
expectancy,
of care,
Medicare
functional status,
functional status Wellness Visit
patient preference, and patient
guidelines
and goals of care
preference
12. Risks and
Individualize
Practice shared
Presentation
Geri-tracker
benefits of
recommendations decision making and discussion:
treatment
based on life
with knowledge
risks and
expectancy,
of risks and
benefits
functional status,
benefits
patient preference,
Sessions 13-18: Special topics that are common to the ACE service: These topics can
be taught at any point in the rotation. Presentation materials are available on the
website for faculty to use, and should be done when appropriate cases are admitted
to the hospital that can serve as examples (case based learning).
1. Hyponatremia and hypernatremia
2. Care of the patient with a hip fracture
3. Congestive Heart Failure: systolic and diastolic heart failure in older adults
4. Pneumonia, including aspiration pneumonia and feeding tubes
5. Tremors and movement disorders
6. Urinary incontinence
Sessions 19-20:
1. Final chart audit with the team to review their own progress
2. Meetings with individual residents and students for feedback and evaluations
Resources for Curricular Activities:
1.Video at orientation:
http://www.nytimes.com/2009/08/24/health/24nursing.html?pagewanted=all&_r=0
2. Video for health literacy
3. Readings: Geriatric At Your Fingertips (6 copies available to team on service)
4. Pocket Teaching Cards: Mini-Cog, CAM, Get Up and Go, Reconciliation, D/C template
5. Sample medication list for PBL exercise
6. Sample discharge summary for PBL exercise
7. Presentations : available on Geriatric website, link to website on IM Resident home page
8. Geri-Tracker (Appendix 2)
9. Discharge Summary Chart Audit Rubric
Learner Assessment and Evaluation
Summative Evaluation: The evaluation of IM residents on the ACE service will be done
with the UNC resident evaluation form that is organized by ACGME competency with
associated milestones (appendix 4), but with a specific focus on the care of the older
hospitalized patient. Evaluations of resident performance are based upon observations of
clinical care, sign off of clinical notes and documentation, and review of the Geri-Tracker by
the faculty.
Residents will need to demonstrate proficiency in core competencies as follows:
1. Patient Care: Residents will provide comprehensive, quality and evidence based
care to acutely ill older patients during hospitalization and discharge.
2. Knowledge: Residents will understand the core AGS competencies expected in the
care of older patients and will be able to identify common hospital problems for the
elderly, assess cognitive and functional status, and review medications.
3. Communication: Residents will work with interdisciplinary teams, patients and
families in the care of older hospitalized patients, and will effectively communicate
the hospital course and needs at the time of transfer out of the hospital setting.
a. Milestone 20: Communicates effectively with patients and caregivers
b. Milestone 21: Communicates effectively in inter-professional teams
c. Milestone 22: Appropriate utilization and completion of health records
4. Systems Based Practice: Residents will understand the quality standards
identified for the safe discharge of an older patient, appreciate potential safety
problems during transitions in care, and ensure improved communication with the
goal of improving patient safety during hospitalization and discharge.
a. Milestone 8: Works effectively within an inter-professional team
b. Milestone 11: Transitions patients effectively within and across health care
delivery systems
5. Practice Based Learning and Improvement: Residents will be able to identify
core components required for quality care of older adults during hospitalization and
discharge, review their current practice, and utilize quality improvement strategies
to provide for more safe and standardized care to all older patients.
a. Milestone 12: Monitors practice with a goal for improvement
b. Milestone 13: Learns and improves via performance audit
c. Milestone 14: Learns and improves via feedback
6. Professionalism: Residents will respect each older adult as an individual,
appreciate the impact that medical illness and functional decline can have upon
older adults and caregivers, and strive to provide patient and family centered care.
a. Milestone 16: Has professional and respectful interactions with patients,
caregivers, and members of the inter-professional team
b. Milestone 18: Responds to each patient’s unique characteristics and needs
Learner Assessment Tools: Faculty will use the following tools to assess the knowledge,
attitudes and skills that the resident has acquired during the rotation in order to gather
data for the summative evaluation
Outcome
PerforInstrument Description ComReSchedule
Domain
mance
pleted
ports
Indicator
by:
go to:
Appropri- Identify
Resident
Faculty obResident
Faculty Weekly
ate Prehigh risk
tracker
serves
and facreview of
scribing
medications
ulty
tracker
Cognitive
and functional assessment
Document
risks of
medications
Resident
tracker
Faculty observes
Resident
and faculty
Faculty
Weekly
review of
tracker
Use MiniCog
Resident
tracker
Faculty observes and
checks off
tracker
Resident
and faculty
Faculty
Weekly
review of
tracker
Assess Capacity
Resident
Tracker
Resident
and faculty
Faculty
Weekly
review of
tracker
Use CAM
Resident
Tracker
Resident
and faculty
Faculty
Weekly
review of
tracker
Use Get up
and Go
Resident
Tracker
Resident
and faculty
Faculty
Weekly
review of
tracker
Use depres-
Resident
Faculty observes and
checks off
tracker
Faculty observes and
checks off
tracker
Faculty observes and
checks off
tracker
Faculty ob-
Resident
Faculty
Weekly
Outcome
Domain
Caring for
the
individual,
focusing
on goals of
care
Performance
Indicator
sion screen
Instrument
Description
Tracker
Document
fall risk, immobility,
ulcers,
nutrition,
pain, UI,
constipation
Review of
clinical
notes (performance
audit)
Demonstrate clinical reasoning for complex older
adults
Clinical observations
of oral
presentations and
written
notes
Clinical observation of
oral presentations and
written
notes
Clinical observation
serves and
checks off
tracker
Faculty reviews all
notes written
by residents,
review appropriate
documentation
Clinical observations
Demonstrate respect
Describe
goals of care
for a patient
Discuss advance care
planning
Patient
Safety
Document
lines, catheters, restraints
Perform
medication
reconciliation
Clinical observation
and resident tracker
Review of
clinical
notes
Resident
tracker
Resident
tracker
Review of
Completed
by:
and faculty
Reports
go to:
Schedule
faculty
faculty
Daily review of
notes required for
co-signature
Faculty
Faculty
Daily
Clinical observations
Faculty
Faculty
Daily
Clinical observations
Faculty
Faculty
Daily
Clinical observation,
review of
tracker
Clinical observations,
review of
tracker, review of daily
notes
Faculty
and resident
Faculty
Weekly
review of
tracker
Faculty
and resident
Faculty
Daily
Review of
resident
tracker, review of dis-
Faculty
and resident
Faculty
Daily review of
discharge
summar-
review of
tracker
Outcome
Domain
Performance
Indicator
Use d/c
template
with quality
indicators
Instrument
Description
discharge
summaries
charge summaries prior
to co-sign
Resident
tracker
Resident
tracker, review of discharge summaries prior
to co-sign
Review of
discharge
summaries
Completed
by:
Faculty
and resident
Reports
go to:
Faculty
Schedule
ies,
Weekly
review of
tracker
Daily review of
summaries,
weekly
review of
tracker
Geriatrics Curriculum Program Evaluation:
Component
Instrument
Improvement Performance
in care of
Audits (chart
older adults
audits/reviews)
by residents
(meeting AGS
competencies)
Evaluation of
rotation
(teaching conferences, curriculum,
tracker system)
Rotation
evaluation form
Evaluation of
faculty teachers
Resident
tracker
Standard
evaluations of
teaching faculty
Review of resident trackers
Description
Review of charts
focusing on AGS
competency/
quality indicators
o before and
after rotation
o before and
after curriculum started
for the year
Standard rotation evaluation
forms; includes
evaluation of
teaching conferences and other
learning activities
Standard faculty
evaluations
within eValue
Review of resident trackers:
were goals met?
Completed
by:
Geriatric
supervising
faculty on
curricular
committee
Reports
Schedule
to:
Supervisor Monthly
of Curriculum
Academic
year
Geriatric
PD
Resident
IM program
director
then to
Geriatric
PD
Resident
IM PD and Monthly
geriatric
PD
Geriatric
Monthly
PD and
curriculum
Resident
Monthly
Component
Instrument
Description
Survey of resi- Survey
dents (repeat
needs assessment survey)
Survey of fac- Survey
ulty
Survey used in
needs assessment repeated
Geriatric
knowledge
before and
after
Review geriatric
component performance by
residents on ITE
In training
exam
Survey of geriatric faculty
Completed Reports
by:
to:
committee
Resident
Geriatric
PD and
curriculum
committee
Faculty
Geriatric
PD and
curriculum
committee
Residents
IM PD and
to IM PD
geriatric
fellowship
director
Schedule
Yearly
Yearly
Yearly
Bibliography:
1.
Russo CA, Elixhauser A. Hospitalizations in the Elderly Population, 2003: Statistical
Brief #6. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville
(MD)2006.
2.
Bragg EJ, Warshaw GA. ACGME requirements for geriatrics medicine curricula in
medical specialties: progress made and progress needed. Academic medicine :
journal of the Association of American Medical Colleges. Mar 2005;80(3):279-285.
3.
Warshaw GA, Bragg EJ, Thomas DC, Ho ML, Brewer DE, Association of Directors of
Geriatric Academic P. Are internal medicine residency programs adequately
preparing physicians to care for the baby boomers? A national survey from the
Association of Directors of Geriatric Academic Programs Status of Geriatrics
Workforce Study. Journal of the American Geriatrics Society. Oct 2006;54(10):16031609.
4.
Williams BC, Warshaw G, Fabiny AR, et al. Medicine in the 21st century:
recommended essential geriatrics competencies for internal medicine and family
medicine residents. Journal of graduate medical education. Sep 2010;2(3):373-383.
5.
Drickamer MA, Levy B, Irwin KS, Rohrbaugh RM. Perceived needs for geriatric
education by medical students, internal medicine residents and faculty. Journal of
general internal medicine. Dec 2006;21(12):1230-1234.
6.
Lindberg MC, Sullivan GM. Effects of an inpatient geriatrics rotation on internal
medicine residents' knowledge and attitudes. Journal of general internal medicine.
Jul 1996;11(7):397-400.
7.
Jellinek SP, Cohen V, Nelson M, Likourezos A, Goldman W, Paris B. A before and after
study of medical students' and house staff members' knowledge of ACOVE quality of
pharmacologic care standards on an acute care for elders unit. The American journal
of geriatric pharmacotherapy. Jun 2008;6(2):82-90.
8.
9.
10.
11.
12.
Duthie EH, Jr., Gambert SR. The impact of a geriatric medicine rotation on internal
medicine resident knowledge of aging. Gerontology & geriatrics education. Spring
1983;3(3):233-236.
Thomas DC, Leipzig RM, Smith LG, Dunn K, Sullivan G, Callahan E. Improving
geriatrics training in internal medicine residency programs: best practices and
sustainable solutions. Annals of internal medicine. Oct 7 2003;139(7):628-634.
Litvin CB, Davis KS, Moran WP, Iverson PJ, Zhao Y, Zapka J. The use of clinical
decision-support tools to facilitate geriatric education. Journal of the American
Geriatrics Society. Jun 2012;60(6):1145-1149.
Moran WP, Zapka J, Iverson PJ, et al. Aging Q3: an initiative to improve internal
medicine residents' geriatrics knowledge, skills, and clinical performance. Academic
medicine : journal of the Association of American Medical Colleges. May
2012;87(5):635-642.
Smith KL, Ashburn S, Rule E, Jervis R. Residents contributing to inpatient quality:
blending learning and improvement. Journal of hospital medicine : an official
publication of the Society of Hospital Medicine. Feb 2012;7(2):148-153.
Appendix 1:
AGS guidelines for the core competencies for IM and FM residents caring for older
adults in the hospital setting:
Residents caring for older adults are expected to be able to:
1. Prescribe appropriate drugs/ dosages considering: age-related changes, body
composition, and CNS sensitivity; common side effects in light of patient’s
comorbidities, functional status, other medications; and drug-drug interactions
2. When prescribing drugs which present high risk for adverse events and interactions
(such as coumadin, NSAID’s, opioids, digoxin, insulin, strongly anticholinergic drugs,
and psychotropic drugs), discuss and document the rationale for their use,
alternatives, and ways to decrease side effects.
3. Periodically review patient’s medications (including meds prescribed by other
physicians, OTC and CAM) with the patient and/or caregiver to assess adherence,
eliminate ineffective, duplicate and unnecessary medications, and assure that all
medically indicated pharmacotherapy is prescribed.
4. Appropriately administer and interpret the results of at least one validated screening
tool for each of the following: delirium, dementia, depression, and substance abuse.
5. Recognize delirium as a medical urgency, promptly evaluate and treat underlying
problem.
6. Evaluate and formulate a differential diagnosis and workup for patients with changes
in affect, cognition, and behavior (agitation, psychosis, anxiety, apathy).
7. In patients with dementia and/or depression, initiate treatment and/or refer as
appropriate.
8. Identify and assess barriers to communication such as hearing and/or sight
impairments, speech difficulties, aphasia, limited health literacy, and cognitive
disorders. When present, demonstrate ability to use adaptive equipment and
alternative methods to communicate (e.g., with the aid of family/friend, caregiver).
9. Determine whether an older patient has sufficient capacity to give an accurate history,
make decisions and participate in developing the plan of care.
10. In evaluating adults with undifferentiated illness, generate differential diagnoses that
include diseases that often present atypically in older adults (e.g., acute coronary
syndromes, the acute abdomen, urinary tract infection, and pneumonia).
11. Consider adverse reactions to medication in the differential diagnosis of new
symptoms or geriatric syndromes (e.g., cognitive impairment, constipation, falls,
incontinence).
12. Demonstrate understanding of the major age-related changes in physical and
laboratory findings during diagnostic reasoning (e.g., S4 does not reflect CHF, pulse
increase less common with orthostasis, pO2 declines with age, abdominal pain may be
less severe).
13. Discuss and document advance care planning and goals of care with all patients with
chronic or complex illness, and/or their surrogates.
14. Develop a treatment plan that incorporates the patient’s and family’s goals of care,
preserves function, and relieves symptoms.
15. In patients with life limiting or severe chronic illness, assess pain and distressing nonpain symptoms (dyspnea, nausea, vomiting, fatigue) at regular intervals and institute
appropriate treatment based on their goals of care.
16. In patients with life limiting or severe chronic illness, identify with the patient, family
and care team when goals of care and management should transition to comfort care.
17. As part of the daily physical exam of all hospitalized older patients, assess and
document whether delirium is present.
18. In hospitalized medical and surgical patients, evaluate - on admission and on a regular
basis - for fall risk, immobility, pressure ulcers, adequacy of oral intake, pain, new
urinary incontinence, constipation, and inappropriate medication prescribing, and
institute appropriate corrective measures.
19. In hospitalized patients with an indwelling bladder catheter, discontinue or document
indication for use.
20. Before using or renewing physical or chemical restraints on geriatric patients, assess
for and treat reversible causes of agitation (e.g., use of irritating tethers [including
monitor leads, blood pressure cuff, pulse oximeter, intravenous lines and in-dwelling
bladder catheters], untreated pain, alcohol withdrawal, delirium, ambient noise).
Consider alternatives to restraints such as additional staffing, environmental
modifications, and presence of family members.
21. In planning hospital discharge, work in conjunction with other health care providers
(e.g., social work, case management, nursing, physical therapy) to recommend
appropriate services based on: the clinical needs, personal values and social and
financial resources of the patients and their families (e.g., symptom and functional
goals in the context of prognosis, care directives, home circumstances and financial
resources); and the patient’s eligibility for community-based services (e.g., home
health care, day care, assisted living, nursing home, rehabilitation, or hospice).
22. In transfers between the hospital and skilled nursing or extended care facilities, ensure
that: for transfers to the hospital: the caretaking team has correct information on the
acute events necessitating transfer, goals of transfer, medical history, medications,
allergies, baseline cognitive and functional status, advance care plan and responsible
PCP; and for transfers from the hospital: a written summary of hospital course be
completed and transmitted to the patient and/or family caregivers as well as the
receiving health care providers that accurately and concisely communicates
evaluation and management, clinical status, discharge medications, current cognitive
and functional status, advance directives, plan of care, scheduled or needed follow-up,
and hospital physician contact information.
23. Yearly screen all ambulatory elders for falls or fear of falling. If positive, assess gait
and balance instability, evaluate for potentially precipitating causes (medications,
neuromuscular conditions, and medical illness), and implement interventions to
decrease risk of falling.
24. Detect, evaluate and initiate management of bowel and bladder dysfunction in
community dwelling older adults.
25. Identify older persons at high safety risk, including unsafe driving or elder
abuse/neglect, and develop a plan for assessment or referral.
26. Individualize recommendations for screening and chemoprophylaxis in older patients
based on life expectancy, functional status, patient preference and goals of care.4
Appendix 2:
Geri-Tracker: Keeping track of your experiences on the ACE service at UNC
Resident:
Attending:
Dates:
Goals for the rotation:
1.
2.
3.
Please check off and have your attending or fellow sign off when you have done the
following activities (you may complete these in any order, and at any point during the
month long rotation)
Activity
Resident Check Faculty/Fellow Resident notes Faculty/fellow
Check
comments
Self assessment:
What is
geriatrics?
What are AGS
competencies
Mini-Cog
Assess Capacity
CAM
Depression
screen
Get Up and Go
Medication
review
Medication
Reconciliation
Lead advance
care/goals of
care discussion
Review restraint
use
Utilize discharge
template
Assess pressure
ulcer with Nurse
Practitioner
Assess for elder
mistreatment
Assess driving
safety
Discuss
Medicare
Wellness visit
guidelines