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CHAMP: Care of the Hospitalized Aging Medical Patient Leader’s Guide to Bedside Teaching Rounds for Medical Students PowerPoint Presentation
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CHAMP: Care of the Hospitalized Aging Medical Patient Leader’s Guide to Bedside Teaching Rounds for Medical Students. Shellie Williams, M.D. University of Chicago. Overview . Who: Students on internal medicine service; Geriatric attending of the month and fellow. When:

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

Shellie Williams, M.D.

University of Chicago

overview
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.

geriatric inpatient competencies for medical students
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.

teaching format
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.

main content areas in champ
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

geriatric hospital complications history questions and screens
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

geriatric hospital complications history questions and screens7
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

teaching materials
Teaching Materials

Champ website pocket cards and

UCSF Geriatrics for Inpatient Medicine Card.

attending teaching triggers 1 hospital discharge
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
attending teaching triggers 2 risk factors for delirium
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:

attending teaching triggers 3 diagnosing delirium
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

attending teaching triggers 4 significance of delirium
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
attending teaching triggers 5 medication review
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.

attending teaching triggers 6 medication review
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

attending teaching triggers 7 geriatric review of systems
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.

attending teaching triggers 8 skin exam
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

attending teaching triggers 9 transitions to other care settings
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