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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:
Shellie Williams, M.D.
University of Chicago
Students on internal medicine service; Geriatric attending of the month and fellow.
(1) afternoon per week, 60min bedside teaching.
Students decide date/time that majority can meet. (1) student chooses a patient and we round 60min on patient case with entire group.
We focus on AAMC geriatric competencies for medical students on care of hospitalized elders.
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.
“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.
-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
AM review with nurse or family?
Screening: CAM, Mini-Cog
What was your function 2 weeks prior to hospital and now?
Screening: ADL/IADL; mobility status
What are potential hazards with the medications?
Screening: Medication reconciliation; Beers List risk drugs
Any pain in perineum, heels, elbows
See skin and Stage using Braeden system
What aides does the patient use, what is present in hospital?
Screen: Gait device, glasses, hearing aide, dentures
6point: describe, location, duration, exac/relieve, intensity
Screen: 6 point assess and Scale 0-10
How many restraints are present on this patient?
Screen: Assess need for: Foley, PICC< drains, SCDs, catheter/drains, wrist/hand restriant and discontinuation plan
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
Champ website pocket cards and
UCSF Geriatrics for Inpatient Medicine Card.
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:
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
Please review the MAR for Mrs. _____, can anyone identify any drugs which may predispose to adverse events during hospitalization?
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.
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
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.
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):
Perception of pain
Mobility potential in bed
Level physical activity
Friction/sheering forces on skin
Based on the above evaluation and patients pre-hospital living situation what do you feel is the most appropriate discharge setting?
Review criteria for:
Skilled Nursing (SNF)
Long-Term Care Nursing (ICF)