Improving Care in Nursing Homes in Singapore - Role of the Physician

Improving Care in Nursing Homes in Singapore - Role of the Physician

Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract. How did this Happen? Root Cause Analysi...

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Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.

How did this Happen? Root Cause Analysis of a Thirty-five Pound Weight Gain in a Skilled Nursing Facility Presenting Author: William Swart, MD, UMDNJ-RWJMS at CentraState Author(s): William T. Swart, MD, Joshua J. Raymond, MD, MPH, Bennett S. Shenker, MD, MSPH; and Nilay Thaker, MD Introduction/Objective: Congestive heart failure (CHF) is a common syndrome among skilled nursing facilities (SNF) patients. Exacerbations of CHF leading to hospital admissions are common. We use the case of a 35 pound weight gain in a SNF patient with CHF to illustrate risk factors for CHF exacerbations despite the presence of skilled nursing. The goal of this poster is to highlight the need for standardized care of SNF patients with heart failure such as the DEFEAT protocol. Design/Methodology: A root cause analysis was performed using a 90 year old patient with CHF who was admitted to a SNF for rehabilitation of his right femur fracture. He was admitted on 20 March 2009. The case was selected based on a weight gain of 35 pounds (166 to 201 lbs) in 22 days which led to a transfer to the emergency department on 10 April 2009. We interviewed the attending physician, director of nursing, and a nurse and nursing assistant involved in the case. We also interviewed a nurse who was not directly involved with the case to learn the process of weighing patients in the facility. We reviewed the facility’s policy on weighing patients. We accessed the patient’s electronic health record to review all nursing and medical progress notes, physician orders, care plans, medications, and vital signs. Finally, we reviewed records from the patient’s hospital stay prior to his SNF admission. Results: The root cause analysis of this case of CHF exacerbation revealed that deficiencies in the CHF policy at the facility contributed to the outcome. The patient’s ACE inhibitor was stopped prior to surgery and never restarted. His care plan did not address CHF because it was not the primary diagnosis of admission to the facility. Accuracy of weight measurement was lessened due to varied weight times, inaccurate scales, and the presence of external orthopedic devices. The facility’s policy only required comparing the current weight to the day prior. Daily weight orders were not carried out routinely. The attending physician was unfamiliar with the patient. Nursing assessments of physical findings were inconsistent. There was a lack of nursing continuity with nine nurses involved in his care. Conclusion/Discussion: This case illustrates the need for objective data and reliance on nursing assessments to quickly identify those patients who may be showing signs of early CHF exacerbation. The DEFEAT protocol could be used as a reference for SNF to base CHF policy. It suggests the use of jugular venous pressure in assessing fluid volume status as an assessment tool for geriatric heart failure. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.

Identifying Patterns of Re-Hospitalization from Skilled Rehabilitation Units Presenting Author: Nancy Istenes, DO, Summa Health System, Northeastern Ohio Universities College of Medicine Author(s): Nancy Istenes, DO, Teresa Albanese, PhD, Deepa Patadia, MS; and Sara Snyder, DO Introduction/Objective: Re-hospitalization within 30 days of discharge to skilled rehabilitation facilities is common and occurs in over 20% of cases per CMS. These re-admissions increase cost, prevent functional recovery and are becoming performance indicators. Preventing re-hospitalization is challenging due to the many potential contributing factors that are not well identified. Objective: To conduct a preliminary review of re-hospitalization within 30 days of discharge to one of 3 skilled geriatric rehabilitation units (GRUs) and identify correlates that could be targeted to reduce re-admissions.


Design/Methodology: GRU and hospital data were obtained on 125 patients re-hospitalized between January 2008 and June 2009. GRU data included reason for re-admission, date of readmission, GRU length of stay (LOS), and number of evaluation and management (E & M) visits prior to readmission. Hospital data included LOS, and patient discharge disposition. Results: On average, patients spent 11 days in the GRU and received 4 E and M visits before being re-hospitalized. Monday and Tuesday were the most common days of re-admission (18% each). The most common reasons for their re-admission were dyspnea, SOB, hypoxia or respiratory distress (30%); mental status change (24%); nausea, vomiting, or abdominal pain (17%) and sepsis, UTI, fever or pneumonia (15%). Seventy-one patients (57%) returned to the GRU. Twenty patients (16%) expired during rehospitalization after a mean 3 day LOS. Their most common reasons for re-admission were mental status change (40%) and dyspnea, SOB, hypoxia or respiratory distress (30%). Ten patients (8%) were discharged from the hospital to hospice. The most common reasons for their re-admission were sepsis, fever or pneumonia (60%) and dyspnea, SOB, hypoxia or respiratory distress (40%). Eighteen patients were discharged to home, 4 to a gero-psych unit and 2 patients went to another hospital and were lost to follow-up. Conclusion/Discussion: LOS and number of E and M visits prior to re-admission suggest medical stability at GRU admission but an acute status change causing re-admission. Patients are most likely to be re-admitted with respiratory distress and mental status change and these patients are at increased risk to expire or become hospice patients. This may represent missed opportunities for palliative medicine in the skilled facility. Addition of a palliative care consultation service to the GRU may allow earlier identification of patient goals or hospice referral. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.

Improving Care in Nursing Homes in Singapore - Role of the Physician Presenting Author: David H. Yong, MBBS, Mmed, Changi General Hospital Author(s): David H. Yong, MBBS, Mmed Introduction/Objective: Nursing homes (NH) face many challenges. The frail elderly residents may have potentially treatable conditions like recent decline, medication side-effects, pain, and mood disorders besides acute illness episodes. There is increased expectation from healthcare funders and the public for higher standards of care and more efficient use of resources. Acute hospitals want them to take more complex and sicker patients. Doctors generally are not keen to do NH visits. Those who do provide medical services come from various backgrounds and practices. For several reasons including lack of time and know-how they often focus on acute care. NHs may not be prepared to deal with many of these issues including palliative care for end stage conditions. The author, a community aged care physician with interest in intermediate and long term care has adopted an approach to maximize physician time in NH visits in three nursing homes over the past five years. This paper describes the approach used and its outcomes over the years. Design/Methodology: Three nursing homes A, B, C had a total of 470 residents. Weekly visits (2.5 hr) to see cases and address clinical problems, supported by the director of nursing and the multidisciplinary team of the respective NH. The major components of this approach include prioritizing cases for clinic consults, physician leadership and working through the NH’s own quality assurance team, using guidelines to set minimum standards, adopting clinical indicators and doing audits, developing innovative approaches to staff training (eg bedside problem solving sessions, tutorials and quiz, monthly challenging case discussions) and making available relevant resources for knowledge and practice. Besides these, quality improvement projects were carried out such as fall and injury prevention and the promotion of continence. Audits for ED visits by residents and diabetic care were also done. These initiatives were physician guided but championed senior staff nurses of the NH working with teams. Results: There is improved practice standards, increased staff satisfaction including more competent and motivated staff in an empowered environment.

JAMDA – March 2010

These have produced positive effects like reduction in fall and injury rate and acute emergency department visits.

Nursing Home A (absolute nos.) Adm Deaths ED Visits Falls Fractures Discharges 2005 2006 2007 2008 2009

83 24 19 5 10

26 16 17 17 11

135 144 110 108 67

24 22 19 20 13

4 3 3 1 0

2 5 3 1 2

Nursing Home B Adm Deaths ED visits Falls Fractures Discharges 2007 2008 2009

13 20 12

11 16 6

72 68 34

12 10 4

1 1 0

3 1 1

Conclusion/Discussion: An approach with the visiting physician taking leadership and using key strategies in collaboration with the multidisciplinary staff will improve care for residents of NHs. Disclosures: David H.Yong, MBBS, Mmed has stated there are no disclosures to be made that are pertinent to this abstract. Improving End-of-Life (EOL) Care in California Nursing Homes through Education: The End-of-Life Nursing Education Consortium (ELNEC) Geriatric Program Presenting Author: Kathe Kelly, RN, BSN, City of Hope Author(s): Kathe Kelly, RN, BSN, Mary Ersek, PhD, RN, Rose Virani, RNC, MHA, Pam Malloy, RN, MN; and Betty Ferrell, PhD, MA Introduction/Objective: Nursing’s mandate is to provide compassionate care and dignity to persons at the EOL. Approximately, 25% of US deaths occur in nursing homes and the proportion increases with age of residents. The ELNEC Project is a partnership of the City of Hope and the American Association Colleges of Nursing (AACN). ELNEC’s Geriatric train-the-trainer program is a synthesis of knowledge in EOL care and teaching methodology to develop expertise and skills for nurses responsible for care of older adults in nursing homes, skilled nursing facilities, hospices, home care, assisted living, etc., as well as in staff education programs. In 2003, Robert Wood Johnson Foundation funded a report, Means to a Better End, grading states on their ability to provide end-of-life care. Most states’ grades indicated a need for improvement including California which rated a ‘‘C.’’ From 2007 through 2009 four ELNEC Geriatric courses supported by grants from the California HealthCare Foundation and the Archstone Foundation have been offered to California nurses and nursing home staff. The purpose of this presentation is to describe the curriculum, implementation, survey results pre and post course and examples of ELNEC trainers’ work following ELNEC Geriatric training. Design/Methodology: The ELNEC Team and the Palliative Care Education Resource Team (PERT), created the ELNEC-Geriatric curriculum with nine EOL core areas: nursing EOL care; pain and symptom management; cultural factors; communication; ethical/legal issues; grief, loss, bereavement; care at the time of death; and achieving quality care including modules for teaching nursing assistants. Four hundred and five (405) California nurses and nursing home staff have received ELNEC Geriatric training. Summary statistics presented will be on pre and post course attitudes toward ability to provide EOL care. Participants have been contacted at 6 months and 12 months to assess use and applications of the ELNEC training. The number and type of ELNEC based educational programs utilized to educate nurses, nursing assistants and other staff will be summarized along with barriers to application and dissemination of the ELNEC curriculum. Additionally, examples of the ELNECGeriatric trainers’ work will be provided. Results: The one year follow-up of the 2007 pilot cohort reported using the ELNEC-Geriatric curriculum to hold 302 educational programs reaching over 5000 nurses, nursing assistants and other staff. This poster will be updated to reflect the data from all four California courses in 2007, 2008 and 2009. POSTER ABSTRACTS

Conclusion/Discussion: The results of the four courses presented demonstrate a model of dissemination for EOL education as well as describe barriers of a train-the-trainer model of EOL education in geriatric care settings by nurses and other staff who have received ELNEC Geriatric training in California. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.

Indications and Contraindications for Anti-Thrombotic Therapy to Prevent Venous Thromboembolism (VTE): Observations in Long-Term Care Facilities (LTCF) based on Clinical Practice Guidelines (CPG) Presenting Author: T. Dharmarajan, MD, Montefiore Medical Center North & NY Medical College Author(s): T. S. Dharmarajan, MD, Larry Lawhorne, MD, Aman Nanda, MD, Bikash Agarwal, MD, Parag Agnihotri, MD, Gaileen Doxsie, GNP, Murthy Gokula, MD, Ashkan Javaheri, MD, Madhusudhana Kanagala, MD, Anna Lebelt, MD, Prasuna Madireddy, MD, Sourya Mahapatra, MD, Padmavathi Murak, MD, Ram Rao Muthavarapu, MD, Meenakshi Patel, MD, Christopher Patterson, MD, Kathleen Soch, MD, Anna Troncales, MD, Kamal Yaokim, MD, Robin Kroft, PhD; and Edward P. Norkus, PhD Introduction/Objective: Recent guidelines recommend antithrombotic prophylaxis for VTE based on risk assessment, in absence of contraindications. Practices in the long term care setting are unclear. This report summarizes current practices addressing VTE in 17 LTCFs after phase 1 of a 3-phase educational project aimed to improve practice patterns consistent with CPGs. Design/Methodology: Phase 1 determined current practices in implementing risk assessment and prophylaxis for VTE in 17 geographically diverse LTCF (3260 total beds). Phase 2 provided intervention (education through current CPGs) and phase 3 will attempt post-education effects on practice. Phase 1 results on use of antithrombotic drugs (warfarin, heparin, LMWH or fondaparinux) for VTE prevention (VTE-P) in the context of indications and contraindications to therapy are presented. Contraindications include bleeding, thrombocytopenia, life expectancy, QOL, and others. Results: (Phase 1): Sites reported on 377 new admissions/readmissions [resident ages 78  12(sd) years, 67% female, 9 states represented]. The observed patterns for implementing VTE-P in presence of indications and Contraindications (C) for anti-thrombotic therapy are: 19 orthopedic surgery cases: 18 had VTE-P with 0 C, 17 non-ortho surgery cases: 6 had VTE-P with 1 C, 1 gynecologic surgery case had VTE-P, 18 medical illness (heart failure, acute MI, etc) cases: 7 had VTE-P with 3 C, 6 cancer cases: 2 had VTE-P with 3 C, 20 neurological cases (stroke, CVA, paraplegia, etc): 5 had VTE-P with 3C, 46 previous DVT cases: 38 had VTE-P with 10 C, 3 COPD exacerbation cases: 1 had VTE-P with 0 C, 37 sepsis cases: 22 had VTE-P with 10 C, 56 recent severe trauma cases: 43 had VTE-P with 10 C, 53 recent trauma to hip/leg/pelvis cases: 50 had VTE-P with 5 C, 41 bed-bound cases: 14 had VTE-P with 15 C; 8 morbid obesity cases: 5 had VTE-P with 3 C. VTE-P therapy was administered to some with contraindications, individualized to risks vs. benefits. Conclusion/Discussion: 1) Phase 1 data suggests significant co-morbidity in residents in LTC posing risk for VTE, with many getting prophylaxis. 2) Contraindications (relative or absolute) were common, deserving individualized consideration for VTE-P in LTC. 3) The highest likelihood of receiving VTE-P was after orthopedic surgery, prior DVT and trauma to hip/legs. 4) An opportunity to improve implementation of measures consistent with CPGs through education (Phase 2) exists; Phase 3 will study this impact on practice patterns in preventing VTE in LTC (data to be presented, AMDA, March 2010). Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract. Initial Diagnosis and Treatment Patterns in Parkinson’s Disease Presenting Author: Marcy Tarrants, PhD, MPA, Teva Neuroscience Author(s): Maureen Lage, PhD, Marcy Tarrants, PhD, MPA; and Jane Castelli-Haley, MBA Introduction/Objective: To our knowledge, nationwide patterns of initial Parkinson’s Disease (PD) treatments were last described from B13