CHAMP: Care of the Hospitalized Aging Medical Patient Leader’s Guide to Bedside Teaching Rounds for Medical Students

1. CHAMP: Care of the Hospitalized Aging Medical PatientLeader’s Guide to Bedside Teaching Rounds for Medical Students Shellie Williams, M.D. University of Chicago

2. Overview Who: Students on internal medicine service; Geriatric attending of the month and fellow. When: (1) afternoon per week, 60min bedside teaching. How: Students decide date/time that majority can meet. (1) student chooses a patient and we round 60min on patient case with entire group. Where: Medicine Ward What: We focus on AAMC geriatric competencies for medical students on care of hospitalized elders.

3. Geriatric Inpatient Competencies for Medical Students Recommendations of the July 2007 Geriatrics Consensus Conference Identify potential hazards of hospitalization for all older adult patients (including immobility, delirium, medication side effects, malnutrition, pressure ulcers, procedures, peri and post operative periods, and hospital acquired infections). Explain the risks, indications, alternatives, and contraindications for indwelling (Foley) catheter use in the older adult patient. Explain the risks, indications, alternatives, and contraindications for physical and pharmacological restraint use. Communicate the key components of a safe discharge plan (e.g., accurate medication list, plan for follow-up), including comparing/contrasting potential sites for discharge. 26 Conduct a surveillance examination of areas of the skin at high risk for pressure ulcers and describe existing ulcers.

4. Teaching Format “Care of the hospitalized elder” lecture is emailed to students at the beginning of the rotation. Students spend 1 hr rounding with a geriatric attending and fellow. 1-2 patients seen during rounds, and students are expected to complete components of a geriatric inpatient safety screens to optimize safety of elders on UCMC inpatient wards.

5. Main Content Areas in CHAMP Hospital Hazards -recognizing and preventing Foley catheter use in the elderly -explaining risks, indications, alternative Use of restraints -understanding the risks, indications and alternatives Key components of safe discharge planning -what to communicate Pressure ulcers and Braeden staging -demonstrating surveillance exam of areas of skin at risk

6. Geriatric Hospital Complications:History Questions and Screens Delirium: AM review with nurse or family? Screening: CAM, Mini-Cog Deconditioning: What was your function 2 weeks prior to hospital and now? Screening: ADL/IADL; mobility status Poly-pharmacy: What are potential hazards with the medications? Screening: Medication reconciliation; Beers List risk drugs Pressure ulcers: Any pain in perineum, heels, elbows See skin and Stage using Braeden system

7. Geriatric Hospital Complications: History Questions and Screens Environmental Assessment: What aides does the patient use, what is present in hospital? Screen: Gait device, glasses, hearing aide, dentures Pain: 6point: describe, location, duration, exac/relieve, intensity Screen: 6 point assess and Scale 0-10 Restraint Review: How many restraints are present on this patient? Screen: Assess need for: Foley, PICC< drains, SCDs, catheter/drains, wrist/hand restriant and discontinuation plan Nutrition: How is your appetite? Screen: Observe patient eating, desired foods, dentures, last BM Medical decision making: What have the doctors told you about why you’re in the hospital? Screen: Applebaum review of decision making

8. Teaching Materials Champ website pocket cards and UCSF Geriatrics for Inpatient Medicine Card.

9. Attending Teaching Triggers:1. Hospital Discharge • What are potential obstacles to a safe and speedy discharge in this particular patient? • Review pre-hospital living situation and supports • When you enter the room ask students to identify obstacles to the patient ambulating: foley, iv, compression boots, wrist restraints • Ask the students to screen the patient for 2-3 elements of pre-hospital and current Adl and Iadl function

10. Attending Teaching Triggers:2. Risk factors for delirium What are potential risk factors for delirium in this patient? Pre-hospital factors: poor vision, bun/cr >18, Charleston >4, baseline dementia Hospital factors:>3 new meds, restraints, foley, iatrogenic events, malnutrition Post-Hospital factors for prolonged delirium:

11. Attending Teaching Triggers:3. Diagnosing delirium What elements are needed to diagnose delirium? A. Have one student give you the elements of the CAM: change in baseline cogntion/flucation/acute Inattention +3 OR 4 --------------------------------------------------------------------- 3. disorganized thoughts 4. change level of consciousness Ask that student which elements were + in the patient you just evaluated, per there evaluation and nursing account. If patient + for delirium, Ask student 3 common causes of delirium: 1. Medications 2. Infections 3. Metabolic disturbances

12. Attending Teaching Triggers:4. Significance of delirium • Why is delirium so important in hospitalized elders? • 2x increased risk for • mortality • institutionalization • ADL 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

13. Attending Teaching Triggers:5. Medication Review Please review the MAR for Mrs. _____, can anyone identify any drugs which may predispose to adverse events during hospitalization? Psychoactive effects Sedative-hypnotics Narcotics Anti-cholinergic drugs How can we modify medication administration in elders to be safer? Start low dose/slow titration. Start 1/3-1/2 standard prescribing dose for adult patient in elderly Remember elders renal and hepatic function declines with age and the alteration in Vd of water: muscle mandates need for dose adjusting.

14. Attending Teaching Triggers:6. Medication Review Review primary classes identified in Beers criteria for elder prescribing problems: Benzodiazepines, especially long acting High dose narcotics or long-acting, especially in narcotic naïve NSAIDS Anti-cholinergics

15. Attending Teaching Triggers:7. 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.

16. Attending Teaching Triggers:8. Skin Exam Ask the students what key areas of the body should be screened for ulceration? Perineum, heels, elbows, hips Review on the patient and discuss the Staging and Braeden Risk Scale. Stage I: Intact skin with non-blanchable redness Stage II: Partial thickness loss of dermis or intact or open/ruptured serum-filled blister. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible. May include undermining and tunneling. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar on some parts of or undermining may be present. What is Braden Scale: Risk assessment scale forpressure ulcers. Lower scores means higher risk of ulceration. Looks at following risk factors for ulceration on scale 1(low fxn)-4 (high fxn): Skin moisture Perception of pain Mobility potential in bed Level physical activity Nutrition Friction/sheering forces on skin

17. Attending Teaching Triggers:9. Transitions to other care settings Based on the above evaluation and patients pre-hospital living situation what do you feel is the most appropriate discharge setting? Review criteria for: Inpatient setting Acute rehab Skilled Nursing (SNF) Long-Term Care Nursing (ICF) Assisted Living Independent Living Home Care