Download Transitional Care - 634.5 KB

Michael A. LaMantia MD, MPH
Kevin Biese MD, MAT
Ellen Roberts PhD, MPH
Jan Busby-Whitehead MD
University of North Carolina at Chapel Hill
Division of Geriatric Medicine
Center for Aging and Health
Department of Emergency Medicine
With Support from John A. Hartford Foundation
& American Geriatrics Society
Disclosures
• Work supported by:
» NIA Grant # 2T32AG000272-06A2
» UNC John A. Hartford Foundation Center of
Excellence in Geriatric Medicine and Training
» John A. Hartford Foundation Geriatrics for
Specialists Grant
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Outline
• Aging: Global and American Perspectives
• Elderly Patients and the Emergency
Department
• Case Study One --- Getting it Wrong
• Transitional Care: Definitions and Quality
Indicators
• Case Study Two --- Getting it Right
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Learning Objectives
1. To identify ways in which the care of older
patients in the emergency department differ
from that of younger patients
2. To define key components of effective
transitional care of elderly patients
3. To identify potential strategies to improve the
coordination of care for elderly patients who
are seen in the emergency department
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Aging: International and
Domestic Scope
• Baby Boom Generation
» Born between 1946 and 1964
» Quickly approaching age of retirement
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Aging: Worldwide Issue
• World Health Organization (WHO) report
(2002):
» Age cohort >60 fastest growing population
segment worldwide
» Decreases in fertility rates and increases in life
expectancy will change age compositions of
many nations
• WHO and United Nations estimate:
» 35% of Japan’s population >60 in 2025
» 34% of Italy’s population >60 in 2025
» China’s population >60 will increase from
134 million in 2002 to 287 million in 2025
• WHO calls for “healthy and active ageing” to
be key world-wide policy concern
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Aging: Impact on Emergency
Departments
• Elderly patients:
»
»
»
»
»
»
»
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Are more ill at presentation
Arrive by ambulance more frequently
Receive more tests than younger patients
Suffer from more chronic medical
comorbidities
Are admitted to the hospital at higher rates
Experience longer ED stays
Incur higher medical bills
Return frequently to the ED
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Case One – Mr. S
• Mr. S: Friday, 7:30pm
» 85 year old with a past medical history of
moderate dementia arrives via ambulance
from an assisted living facility
» Arrives with no paperwork or medication
administration list
» Patient can’t give chief complaint
» Person on call from the facility who knows
patient has gone home
» Grandson states patient has been coughing
and that doctor at facility suspected
pneumonia
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Case One – Mr. S
• Past Medical History:
» Coronary Artery Disease
» Hypertension
» Moderate Dementia
• Allergies: No Known Drug Allergies
• Medications: (grandson believes he
remembers these)
»
»
»
»
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Metoprolol
Donepezil
Aspirin 81 mg
Simvastatin
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Case One – Mr. S
» Physical Exam:
BP130/70, Pulse 76, Respirations18,
Oxygen Saturation 96% on room air, afebrile
• Patient slightly confused (this is change from
baseline according to grandson)
• Pupils equal/round/reactive to light, moist
mucous membranes
• Regular S1S2, no murmurs/rubs/gallops
• Some very mild crackles at right base otherwise
clear, normal work of breathing
• Rest of exam: unremarkable
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Case One – Mr. S
» Labs:
White Blood Cells: 10.0 (Differential: neutrophils 8.7,
lymphocytes 1.0, eosinophils 0.3)
Hemoglobin: 12.0
Hematocrit: 36.0
Platelets:
350
» Blood chemistry: within normal limits
» Chest X-ray: Possible developing right lower
lobe infiltrate vs. atelactasis. Clinical
correlation recommended.
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Case One – Mr. S
• Pneumonia Severity Index score: 105 points --- Risk
Class IV – approximately 9% mortality
• You recommend hospitalization ---- but
• Grandson states he is health care power of attorney
and patient would not wish to be hospitalized. He
wishes to take patient home and care for him there.
Patient is confused but agreeable.
• You prescribe course of Levofloxacin and ask that they
see their provider on Monday
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Case One - Resolution
• Patient goes home and does well for 3 days
• He does so well, family does not follow-up
with primary care provider on Monday
• Tuesday evening: Patient returns with skin
bruising and blood in his urine.
» Platelets: within normal limit
» INR: 7.2
• When the patient’s pills are brought from
home, it is discovered he is taking warfarin
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Case One – Breakdown
• What went well?
• What could have gone better?
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Transitional Care
• Definition:
“A set of actions designed to ensure the
coordination and continuity of healthcare as
patients transfer between different locations or
different levels of care within the same
institution.”
–American Geriatrics Society (2003)
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Transitional Care
• During transitions, patients are at risk for:
•
•
•
•
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Medical errors
Service duplication
Inappropriate care
Critical elements of care plan “falling though
the cracks”
-AGS (2003)
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Transitional Care
• Conceptual model of effective transitional
care (Coleman 2003):
• Communication between sending and receiving
clinicians
• Preparation of the caregiver and patient for
transition
• Reconciliation of medication lists
• Arranging a plan for follow-up of outstanding
tests
• Arranging an appointment with receiving
physician
• Discussing warning signs that might
necessitate more emergent evaluation
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How to Improve Transitional Care
• Suggestions:
» Changes to health care delivery systems (i.e.
use of nurses to follow patients and/or expanding
Program of All-Inclusive Care of the Elderly programs)
» Adoption of information transfer technology
» Changes to health care policy (i.e. pay for
coordination of care or make providers responsible for
coordinating transitional care)
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How to Improve Transitional Care
• Society for Academic Emergency Medicine
(SAEM) Geriatric Task Force:
» Developed at recommendation of SAEM and
American College of Emergency Medicine
» Identified and adopted quality measures to
allow assessment of care provided to elderly
patients
» Quality measures were vetted by/at:
• SAEM Geriatric Task Force
• SAEM annual meeting
• American Geriatric Society annual meeting
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How to Improve Transitional Care
• Quality Measures 1-4:*
» If nursing home patient goes to emergency
department, then paperwork should state:
•
•
•
•
Reason for Transfer
Code Status
Medication Allergies
Contact Information for:
» Nursing home
» Primary care or on-call MD
» Resident’s health care power of attorney or
closest family member
*Terrell et al. Quality Indicators for Geriatric Emergency Care. Academic
Emergency Medicine 2009; 16:441-449.
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How to Improve Transitional Care
• Quality Measures 5-6:
» If nursing home patient goes to emergency
department, then paperwork should include:
• Patient’s medication administration record
» If nursing home patient goes to emergency
room for requested studies, then:
• Document the performance of requested tests
or the reason why such tests were not
performed
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How to Improve Transitional Care
• Quality Measures 7-9:
» If nursing home patient goes to emergency department
and then will be released from the emergency
department, then:
• Emergency department provider should speak with
the nursing home provider, primary care or on-call
MD for the nursing home prior to discharge from the
emergency department
» If nursing home patient goes to emergency department
and then will be released from the emergency
department, then written paperwork should state:
• Emergency department diagnosis
• Tests performed with results (and tests with pending
results)
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How to Improve Transitional Care
• Quality Measures 10-11
» If nursing home patient goes to emergency
department and then is released back to the
nursing home, then:
• The patient should receive the recommended
follow-up
• The recommended changes to the patient’s
medications or plan of care should be followed
(or the reason why not followed documented)
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Case 2 – Mrs. J
• Mrs. J: Saturday morning, 4am
» 92 year old woman who presents from local nursing
home for “evaluation of increasingly combative
behavior”
» Past Medical History:
• Parkinsonism
• Diabetes
• Urinary incontinence
• Chronic back pain secondary to osteoarthritis and
degenerative joint disease
» Little accompanying paperwork --- no medication
administration record
» Call to the facility --- the staff who are there don’t know
the patient --- they give you son’s phone number
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Case 2 – Mrs. J
• Vital Signs: Blood pressure124/78, Pulse 84,
Respirations 16, afebrile
» Elderly woman lying on stretcher. Awake, but does
not interact much with you or other staff
» Remainder exam: within normal limits
» Labs and urinalysis: unrevealing
• Reach son – he is thankful and says he will be over in
about 1 hour
• Patient awakens and starts to pull at lines --- request is
made for risperidone 1.0 mg
• Patient receives risperidone, calms down, and
eventually goes to sleep
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Case 2 – Mrs. J
• Son arrives --- you offer hospitalization – he
says that this is not what his mother would
want.
• He asks she be transferred back to the
nursing home and that you provide a
prescription for risperidone.
• What do you do?
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Review Questions Vignette 1
Mr. S. is an 85 yo man with mild dementia who is sent to the
ED from an assisted living facility without a medication
record. When the facility is called, the staff do not know why Mr.
S. was sent. Lab work and chest X-ray reveal a mild
leukocytosis and a right lower lobe infiltrate. The patient’s vital
signs are within normal limits and the patient is breathing
easily. He is, however, slightly more confused than usual.
The patient’s grandson arrives and states that he is the
patient’s health care power of attorney and that Mr. S. would
not wish to be hospitalized. The decision is made to discharge
the patient home to the care of his grandson with levofloxacin.
In three days, Mr. S. returns to the ED with skin bruising and
blood in his urine. His platelets are WNL, but his INR is
7.2. When the patient’s pills are brought from home, it is found
that the patient is taking warfarin.
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Vignette 1 / Question 1
Which of the following is not considered to be
a quality indicator for a patient transfer from a
nursing home to the ED? Select the one best
answer.
a)
b)
c)
d)
e)
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Contact information for the facility
Medication list
Reason for visit
Resuscitation/code status
Vaccination history
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Vignette 1 / Question 2
In the above scenario, which provider action
could have best prevented the patient from
returning to the emergency department with
hematuria? Select the one best answer.
a) Asking the patient if he was on warfarin.
b) Communicating with the referring
physician from the assisted living facility.
c) Confirming the patient’s medication
allergies.
d) Suggesting that the patient have his INR
checked in one week’s time.
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Vignette 1 / Question 3
Which one precautionary action, listed below, would have
been the best action taken to increase the safety of the
patient’s discharge to his grandson’s home?
a) Ensuring that the patient’s grandson understands
the
warning signs for bringing his father back to
the ED
b) Explaining to the patient the list of commonly
prescribed drugs that interact with levofloxacin
c) Making sure the patient and his grandson
understand the need to follow-up with the patient’s
primary care doctor within 1 week
d) Speaking with the patient’s referring physician when
the decision was made to discharge the patient
home
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Review Questions Vignette 2
Mrs. J. is a 92 yo woman with Parkinsonism, chronic back pain,
and urinary incontinence who is sent to the ED because of
increasingly combative behavior. She has no accompanying
paperwork. She is lying on a stretcher with a subdued affect. Vital
signs are within normal limits and physical exam, blood work, and
radiographic studies are unrevealing.
Mrs. J becomes agitated and pulls at her lines and catheter. She
is given 1.0 mg of risperidone which calms her down. When the
patient’s son arrives he states that his mother would not wish to
be hospitalized. He asks for her to be transferred back to her
nursing home with a prescription for risperidone, as it worked well
this evening.
The next night Mrs. J returns to the ED after suffering a fall with a
resulting foreshortened and externally rotated right leg. Reviewing
the medication record from the nursing home, you see that she
takes cyclobenzaprine in addition to the risperidone that was
prescribed last evening.
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Vignette 2 / Question 1
When the patient was initially transferred
from her nursing home to the ED, which
piece of information would have affected her
care in the ED?
a) Contact information for the facility
b) Medication list
c) Occupational history
d) Resuscitation/code status
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Vignette 2 / Question 2
In the above scenario, which emergency provider
action contributed to the patient returning to the
emergency department with a fractured hip? Select the
one best answer.
a) The provider asked that the patient’s Foley
catheter be removed before the patient’s
transfer back to the nursing home.
b) The provider did not ask the patient which
medications she was taking.
c) The provider did not confirm medication allergies
before discharging the patient.
d) The provider did not speak with the referring
physician before the patient’s transfer back to the
facility.
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Answer Key
• Case 1
» Question 1: e
» Question 2: b
» Question 3: d
• Case 2
» Question 1: b
» Question 2: d
Acknowledgements and
Disclaimer
This project was supported by funds from the
American Geriatrics Society/John A. Hartford
Geriatrics for Specialists Grant. This information or
content and conclusions are those of the authors and
should not be construed as the official position or
policy of, nor should any endorsements be inferred by
the American Geriatrics Society or John A. Hartford
Foundation.
The UNC Center for Aging and Health and UNC
Department of Emergency Medicine also provided
support for this activity. This work was compiled and
edited through the efforts of Jennifer Link, BA.
• Copyright © 2011 The University of North
Carolina School of Medicine at Chapel Hill
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