SENIOR ER: THINK 3 D

1. SENIOR ER: THINK 3 D “Advancing Excellence in Geriatric Care” November 3, 2012 J. Michelle Moccia MSN, ANP-BC, CCRN Program Director, Senior ER St. Mary Mercy Hospital, Livonia Michiga Thank you to D. Cannatti, S. Saltzman, Mekeia Foster, Meghan McGinn, Keyaria and Holly Beversdorf, Denise Scott, Sue Penoza for their contribution

2. COURSE OBJECTIVES Outline the “Graying” demographics of the U.S. population and the impact on the ER Identify key organizational factors and implementation strategies for program success Discuss key components of geriatric nursing assessment using “THINK 3 D” ( a bundled care packet to help assess the older adult)

3. Adding life to years, not just more years to life (Gerontological Society of America)

4. Gray Tsunami By 2030, nearly one in five Americans will be over the age of 65. (38.7 million) By 2050, this will double to 88.5 million Next 19 years, every single day 10,000 baby boomers reach the age of 65 Centenarians is the fastest age group Every hour 10 more Michiganders turn 65 By 2035, one in 4 Michiganders will be 65 and older

5. Population age 65 and over in US This chart for Indicator 1 - Number of Older Americans shows the large growth of the population 65 and older from 1900 to 2008 and the even greater projected growth from 2008 to 2050. It also shows the growing numbers of persons 85 and older and their large projected growth to 2050.

6. ENA Position Statement (2003) ENA recognizes that optimal care of the older adult is best achieved by: Members of the team collaborate to assess and treat ED nurses must be knowledgeable in physiologic, psychological, sociologic, and economic changes in older adult and how these changes impact assessment, interventions, teaching, discharge decisions, and community referrals

7. ENA position statement Geriatric education needs to be included in basic and continuing education Recognize the patient, the spouse, or family members may need assistance – the need for collaboration with other HCPs, organizations, and groups may be necessary to promote a safe and healthy environment Medication problems may go unrecognized & screening for elder abuse and reporting must be carried out

8. ER Nurses on the front line Front door of the hospital and to the community Encounter a variety of health issues from non-urgent, urgent to emergent Ranging from the frailest and functionally impaired to the healthiest and physically active The patients worldview can only be discovered during conversation…sometimes awakened with reconnecting to their spirit

9. Impact of Boarding & Crowding Presentation more complex Higher acuity of care By 2013, number of visits could double reaching 11.7 million annually Lack of PCP, business hours, homelessness, psychiatric disorders, substance abuse – ED open 24/7 ED visits ages 65 and 74 have increased by 34% between 1993 and 2003

10. CONTROLLED CHAOS? Increased length of stay due to extensive evaluations Delayed time consuming care due to older adult physiologic needs Vital information missed due to poor handoff or unintentionally ignored Special needs not addressed – baseline function, depression, dementia, delirium Risk of poor outcome, readmissions

11. Risk Factors Older individuals are discharged are at greater risk for complications. Independent functioning may be threatened. Older adults that were discharged from an E.D. experienced a revisit, hospitalization or death within 3 months in 27% of the cases (Hwang U & Morrison RS, 2007). In one month, office of Inspector General found 14% of Medicare recipients experience and adverse event; 44% were attributed to inadequate monitoring or patient; 60-70% communication errors One needs to examine one’s own values, attitude, perception and beliefs about caring for an older adult

12. Aging is not a disease “We see the world not as it is but as we are” (Covey, 1990) Aging is a process Interaction between environmental (extrinsic) and genetic (intrinsic) factors Older Americans living longer and healthier (Key Indicators of Well Being) Physicians, Nurses, and Researchers have concentrated on interventions and evidence-based protocols to improve the health and living conditions of older adults

13. Growth of SMML 65+ age in 2009 FYI: Every hour 10 more Michiganders turn 65

15. Focusing on Improving Services to Seniors is Critical SENIOR ER – The Trinity Health Perspective • Senior population is growing (Baby boomers – one turns 65 at a rate of 8,000 per day) • Care needs are higher than those of younger people • They drive most of the cost • Their families are looking for safe alternatives for them • They will be the biggest focus of CMS as it changes payment systems • Providers that are sensitive to the needs of seniors will grow

16. There is opportunity to improve the outcomes for seniors Social services and support Optimizing health, wellness and fitness Chronic disease management Patient-centered medical homes PACE programs Palliative care

17. “Senior ER not invented here but still a good idea” (Dave Spivey, CEO SMML) Build on success of Holy Cross Hospital, Silver Springs, Maryland St. Mary Mercy Hospital in Livonia – First Senior ER in the State of Michigan July 14, 2010 Quickly followed by SJMO, SJMAA, Port Huron, Saline, Livingston, Chelsea, Brighton Focus on Safety, Patient loyalty, Growth, Financial, and Quality

18. Current ER Flow “Controlled chaos” is a term frequently used by the Emergency HCP describe ER flow. Fast paced crowded facility: risk for mismanagement and/or delayed cared. Vital information missed: HCP may fail to identify any “special needs” i.e. geriatric syndromes; baseline ADLs and unintentionally ignore signs of depression, dementia and delirium.

19. Current Patient safety and concerns Cognitive impairment can complicate scenario if they are unable to describe their symptoms or self report their pain. Absence of advocate adds to their vulnerability. Poor “hand-off” communication in both directions The Emergency Nurse’s Association (ENA) created a Safer Handoff for the Older Adult (www.ena.org) SMML has created a STARForum group to work with nursing homes, assisted livings, independent livings, group homes etc. to create a seamless hand-off (Safe Transition of All Residents ForU & Me)

20. How aging boomers will transform Michigan | Detroit Free Press, October 3, 2010A New Kind of ER Glaring lights, crowds, the clacking of medical carts and wheelchairs and beds -- "a loud and chaotic ER is not a good place for an older person to be," said Michael Calice, medical director at St. Mary Mercy Livonia, part of the St. Joseph Mercy Health System. …

21. Need for enhanced Emergency Area for Seniors (environment) Environment Changes Improve patient comfort – pressure reducing mattresses, reclining chairs; removal of noise distracters Reduce risks of fall (flooring, lighting, assistant devices, colors, hand rails) Reduce risk of delirium (visual aids, hearing device)

22. Need for Cultural changes Need to supplement education The ED physician and nurse must be well versed in the age-related physiologic changes, associated poor physiologic reserves and the high prevalence of comorbidities. Education modules (GENE and COMET) introduced to provide ED HCP with knowledge to care for the senior population. Ageism: ‘the process of systemic stereotyping and discrimination against people because they are old” – Robert Butler, 1969 Dr. Bill Thomas sessions

23. Senior ER (more than a space) Screenings to identify patients at risk for safety and poor outcomes that are not often captured with a medical screening Identify a decline in functioning may enable health care providers to provide a specific plan of care and thus improve the outcomes in the elderly. Evaluating multiple domains of behavior and function will assist in assurance of positive outcomes.

24. S.E.N.I.O.R. FYI Senior ER Core Team used the word SENIOR to define the vision of the First Senior ER in the State of Michigan Specialized Emergency Nursing Improving One’s Resilience. Inpatient Team expanded and used the word SENIOR to define their vision? Sensitivity to Elders Needs Improving Opportunities for Resilience

25. T.H.I.N.K . 3 D Triage risk screening & Treatment Here for fall or at risk for falls? Inquire about medication, pain, alcohol use, advanced directive Nutrition assessment; normal VS may not be so normal Katz functional assessment “3 D” Dementia, Depression, Delirium (Thank you to Keyaria and Holly Beversdorf Nursing 4040 WSU)

26. Treatment more complex in older adult than younger adults Higher risk of complications from hospitalization Loss of physiologic reserves: impaired renal flow, impaired hepatic flow, and poor homeostatic mechanisms Loss of functional ability that may be caused by disease or hospitalization. Cognitive impairment, hearing and visual impairment may affect stay in the ED

27. Physiologic changes of Aging: Cardiovascular Increased valve stiffness Heart valves thicken Less able to respond to volume changes SA node thickening, fewer pacer cells Barioreceptors less sensitive to BP changes Decreased CV reserve Emer Jour of Nursing Hypertension Murmurs Reduced SV & CO Slow irregular HR Increased risk for orthostasis Heart failure

28. Physiologic changes: Neurologic Blood-brain barrier more permeable Fewer neurons and nerve fibers Slower reaction time; decreased proprioception in lower limbs Decrease in neurotransmitter systems Increased sensitivity to meds and toxins Pain sensation changes and less able to localize pain Risk of falls Processing is slower and possiblememory changes

29. Physiologic changes: Renal Decrease in GFR Decrease in renal blood flow Decrease in creatinine clearance Decrease in ability to concentrate/dilute urine Decrease in bladder capacity and increase in residual bladder volumes Drug doses will need to be adjusted Elimination of toxins is affected Dehydration and impaired ability to respond to volume changes Urinary frequency, urgency, or UTI

30. Homeostasis – regulation of body temperature, blood pH, fluid balance and thirst Loss of physiologic and functional reserves Thermoregulatory response impaired Shivering less intense, sweating is reduced Renal changes (GFR, blood flow, creatinine clearance) Body responds in more exaggerated manner to homeostatic challenges  risk of hypothermia or hyperthermia Delayed speed of return to normal pH by 80%

31. Homeostasis continued Respiratory changes: lung elasticity & weakening of chest wall muscles Sensitivity of the brain is heightened by diminished capacity for homeostasis Alterations in tissue sensitivity to hormones (insulin response and glucose tolerance diminished; sensitivity to ADH Less able to hyperventilate in response to metabolic acidosis, which leads to pH LOC changes (confusion, lethargy, agitation) often a sentinel sign of illness Changes in Blood Sugar and alterations in electrolyte levels

32. THINK 3 D Triage Risk Screening Tool (TRST):Cleveland project developed to test the Systematic Intervention for a Geriatric Network of Evaluation and Treatment (SIGNET) Improves case finding: cognitive impairment, environment (lives alone, support person, lives in senior apartment, assisted, skilled. Fall history; ED or hospital history; any special needs recognized i.e. caregiver strain; abuse or neglect signs; nutrition; frailty The presence of two or more risk factors designates the older person as being “at high risk”.

33. Advantages in screening the older adult emergency patient Identification of a decline in functioning may enable ER providers to provide a specific plan of care Greater diagnostic accuracy Decreased mortality Decreased LOS in hospitals Prevention of injuries (slip and falls)

34. Screening is important ED point of care for patient: admitted, prehospital entry, or point of disposition to an extended or rehab care facility Special services may be required to support older adult through continuum of care i.e. housing, transportation, nutrition, durable medical equipment, counseling, caregiver support

35. THINK 3 D: Here for a Fall Leading cause of injury and injury related mortality Leading cause of head injuries Factor in over 90% fractures of distal forearm, proximal humerus, and hip Nonfatal injuries associated with loss of independence Not a normal part of aging More likely to be problematic As many as 50% who are hospitalized following a fall die within one year Highest risk especially those with physical and or cognitive impairment

36. Here for fall? Extrinsic factors Gait and balance disorders Cluttered environment, Unfamiliar environment Stairs Throw rugs Unsuitable footwear Poor lighting, poor color distinction Restraints, side rails

37. Here for fall? Intrinsic factors Cognitive impairment Polypharmacy – four or more medications Sedatives, antihypertensive and psychotropic medications Alcohol Impaired mobility Fall history Sensory defects (hearing and vision) Frailty Postural hypotension

38. ESI Severity Index 1, 2, or 3? 5 Level Triage System (2003 ACEP & ENA) Witnessed? Loss of consciousness? Sitting or standing? Carpet or hard floor? Symptoms prior to fall? On Anticoagulant? (Coumadin, Pradaxa, Xarelto, including aspirin)

39. HEAD INJURY & FRACTURES R/O Subdural hematoma Brain loses volume with age, increased dural vein fragility Humerus Hip Femur Rib – high risk – pain, pneumonia due to inadequate respiratory effort, and risk for VTE due to lack of movement

40. Evaluation Orthostatic BP Arrhythmias Gait and balance Prior to Discharge: Timed Get Up and Go Test Tinetti Balance and Gait Evaluation www.ConsultGeriRN.org

41. Here for abuse, neglect? 2.1 million older Americans are victims of abuse, only 10% is reported Elderly females are the most frequently abused 90% of the abusers are family members People over the age of 80 are abused 2 to 3 times more then any other age group Victims are often abused in several form

42. Types of Abuse Physical Emotional/Psychological Abuse Sexual Abuse Financial Abuse Neglect of ADLs, confinement, abandonment Coercion abuse, verbal abuse Exploitation “Elder abuse is defined as the action or the omission of actions that result in harm or threatened harm to the health or welfare of the older adult.” American Medical Association

43. Characteristics of abuse, neglect Extreme mood changes-withdraw, agitation, fearfulness and depression Health Care Shopping Series of missed appointments Unexplained Injuries Bruises in different stages of healing Poor Personal Hygiene Sexually transmitted disease Insomnia or excessive sleeping Weight gain or weight loss Documentation is key –drawings, descriptions, photographs that include measurement of injury

44. THINK 3 D – Inquire about Medication History What medications are you currently taking? OTC? Vitamins, herbal, home remedies? Topicals, eye drops, patches? Med reminders i.e. mealtime, pill box? How do you know when you miss a med?

45. Inquire about Med History Consider new symptoms as a possible drug to drug interaction. 5 medications = 70% chance of drug interactions 7 medications = 100% chance of drug interactions Dosing guidelines adjusted to creatinine clearance? Do they see another PCP? Any new med started recently? Beers Criteria created by Dr. Mark H. Beers, Geriatrician. (1991) Updated 2012 to assist HCP improving medication safety in older adult www.americangeriatrics.org

46. THINK 3 D - Inquire about Advance Directive http://www.nhdd.org/

47. Imagine you cannot speak Speak up and increase awareness Facilitate earlier treatment decisions Increase communication and understanding of patients prognosis Help reduce the use of resources and time spent by patients in undesirable states before death Referral to palliative care or hospice

48. End-of-Life Decisions Aim for a “good death” defined by the Institute of Medicine “one that is free from avoidable distress and suffering for pts, families, caregivers; in accord with pts and families’ wishes; and reasonably consistent with clinical cultural and ethical standards”(Reisberg functional Assessment Staging; scale of 1-7) http://geriatrics.uthscsa.edu/tools/FAST.pdf

49. THINK 3 D - Inquire about Alcohol Use Heavy drinking is reported by 3-9% of people over 65 Alcohol abuse or dependence is reported by 2-4% 1/3 of the elderly who abuse or have alcohol dependency started drinking after age 50 14% present to an ER with new diagnosable Alcoholism Serious cause of mortality and morbidity

50. Signs and Symptoms of Alcohol Flushing Palmar eythema Sarcopenia Spider angiomas Altered level of consciousness Changes in mental status or mood Poor coordination Nystagmus Elevation of liver enzymes Increased MCV in presence of normal hemoglobin