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nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 1
An APN-physician Collaboration for Geriatric Trauma Patients
2015 Annual NICHE Conference
April 16, 2015
Diane Kuehnlenz MS, APN, CCNS, CWOCN
NICHE Coordinator
• 632 Beds
• Teaching Hospital
• Level I Trauma Center
• Top 100 Hospital (Thompson Reuters)
• Magnet designated, 3 times redesignation
• NICHE designated since 2011
• Exemplar status
Advocate Lutheran General Hospital
Advocate Lutheran General Hospital
• Part of the Advocate Health Care (AHC)
network, the largest hospital system in Illinois
nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 2
Objectives • Describe the background leading to the
geriatric/trauma collaboration
• State the role of the geriatric APN in trauma
consults
• List evidence-based medications that may be
appropriate for geriatric syndromes in trauma
patients
How Did It Happen?
Pieces in place • NICHE coordinator
• APN with collaborative agreement with a
geriatrician
• Level I trauma center, TRACT
• High volumes geriatric patients
nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 3
Initial Set-Up • Meeting held with all key players
• Geriatrician
• APN
• APN one-up (Director of Professional Development and
Service Excellence)
• Chief trauma surgeon
• Trauma nurse manager- alerted by ACS
conference and document
• Hospitalist
Role Expectations What is not –
• New hospitalist
• On-call service
What it is –
• Perform Comprehensive Geriatric exam on
select population
• Recommendations
• “Virtual” team rounding
nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 4
Exclusion Criteria • Sedated, ICU, ventilated, RASS -4, -5
• Unresponsive
• Terminal illness
• Actively withdrawing from alcohol/drugs
• Completely functional without co-morbidities
• Minor trauma, expected to be discharged in
24 hrs or observation status
Onboarding Process
• Shadow geriatrician – office, hospital
• Developed Progress Note template
• Learn to prioritize problems
• Appreciate consult role
Process for APN Role 1. Notification by trauma team
• Resident maintains a list in electronic medical
record
2. APN checks charts, patient selection
• Patients seen within 48-72 hours of admission
3. Perform patient visit, physician progress
note
nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 5
APN Patient Encounters • History – meds, baseline functional,
cognitive, co-morbidities
• Basic physical exam with focus evaluation of
geriatric syndromes
• Depression screen
• CAM
• Discharge issues
• Family concerns
APN Patient Encounters 3 levels of assessment
1. prior to accident
2. at time of accident
3. events of hospital stay
APN Patient Encounters #1 priority – mental status, cognition
• Assess need for
– therapies
– medication changes
– avoid restraints, Foley
– feeding issues, etc.
• Documentation
– Problem list
– Assessment/Plan
nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 6
Consults Considered • Pain – poor control, pre-existing meds –
acute pain service
• Multiple medications- pharmacy/hospitalist
• Co-morbidities – (IDDM, COPD, HF etc)
hospitalist
• PT, OT, SLT, nutrition, wound care
• Dr. Rhoades – complex dementia cases
Example • 89 y/o fall at home
• Lived alone
• Occipital bleed
• Hx right eye surgery, opacity, HTN, HL
• PT/OT – Pt. needs 24/7 care
Focus of consults • Head imaging results
• Opthomology
• Neuro-surg
• Neurology
• Hospitalist
nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 7
PE • General: No acute distress, Frail-looking alert, talkative woman,
pleasant.
• Eye: normal extraocular movements, right eye opacity, seems to
focus with left eye, states correct no. of fingers shown.
• Respiratory: Respirations are non-labored.
• Cardiovascular: Good pulses equal in all extremities.
• Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel
sounds, taking general diet, requesting prune juice.
• Genitourinary: voiding.
• Musculoskeletal moving all extremities.
• Integumentary: Warm, Dry.
Neurologic • Pain
– Denies h/a, pain to neck or other pain.
• Orientation
– Knows is in a hospital, states "Lutheran General",
states this is in Chicago, near Park Ridge, knows
month, close to day, knows just had Valentine's
Day
– acknowledges family members who enter room,
states their name
Neurologic • Motor and processing skills
– Holding hospital phone receiver when entered
room, states she had been talking to an old
friend but now did not know how to turn the
phone off, looking at receiver.
nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 8
Neurologic • Motor, visual
– Able to use call light, requires searches with
fingers to find the red call button.
• Cognitive
– Counts to 10 easily forward, less easily but
successful backward. States days of week easily
forward, unsuccessful with 2 attempts to do this
backward.
Psychiatric • Affect, attention
– Cooperative, appropriate mood & affect, good
eye contact, stays focused on the topic, uses
humor. Comprehension of current state
• Insight to impairments
– Discussed PT session, states "I had a little
therapy"
– States that unsteadiness in walking was d/t
unfamiliar surroundings
Psychiatric • Memory, baseline activity
– Much discussion on how much she likes to go
shopping and how this happens i.e. da takes her
or public transportation.
• Safety
– Accepted teaching on purpose of yellow socks
and need to call for help for out of bed.
nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 9
Assessment
• Formerly independently living 89 y/o woman
now s/p fall with occipital bleed
• demonstrating visual, balance, cognitive
deficits with likely poor insight to impairments
• uncertain chronicity of deficits vs. d/t to
current head injury and hospital stay
Assessment 1. Likely mild cognitive deficits, poor insight
2. Visual deficits d/t chronic vs. acute vs.
combination
3. recent mechanical fall with resulting occipital
area intracranial hemorrhage
4. impaired balance
5. requires 24/7 assistance
6. degenerative arthritis
7. hx. HTN (other co-morbidities)
Plan • Consider placing tray items toward the left
side as pt. focusing with left eye.
• Continue to include family on pt updates and
d/c plans as they apparently are very much a
part of pt's daily life and will need to have a
full understanding of her limitations.
nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 10
Lessons Learned • Takes a lot of time
• Focus on delirium
• Address discharge planning
concerns
• Focus on deficits
Along the Way… • Monthly meetings with geriatric/trauma team
• CAM
• CAM-ICU
• ISAR
• SOAP charting
• Role definition
• “Back pocket” tools
• Increased collaboration with pharmacy
Medication Protocol • Haldol/quetiapine (Seroquel)
• Used template
– Drug class, mechanism of action, indication,
dosing
nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 11
Haldol • For NPO
• Indication: Safety concern- agitated delirium
when potential harm to self or others
• Not approp for patients who are only verbally
agitated
• has 15-20 min onset IV or IM (less tardive
dyskinesia)
• Assess baseline QT interval
• Start with 0.25-0.5 mg IM
• Repeat in 20 mins x .5 mg
• If no action in 60 mins. Give double the last
dose (1.0 mg)
• If that is effective, use the cumulative dose
for q4hour prn dose. (e.g. 0.5+0.5+1.0=2.0)
• Once able to take po, transition to Seroquel
Seroquel • For po status
• To reduce the duration and effects of delirium
• May be useful in those pts who are delirious
and calling out
• 12.5 mg every 6 hrs prn and every hs
• Every 6 hrs for agitation
nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 12
Back pocket
Tools for Geriatric Syndromes • Senokot – 2 tabs/d
• Trazodone 50mg hs (sleep and
antidepressant)
• Tylenol 650 mg q 4hr
Next Steps • MUE – Medication Usage Evaluation
evaluating the use of benzodiazepines before
and after implementation of the
guidelines/protocol
• Outcomes from the CAM-ICU
nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 13
And What About the Future?
CHICAGO (February 18, 2015): Elderly patients who are admitted to the hospital for monitoring and surgical treatment of traumatic injuries could have better geriatric care if medical teams took one extra step—offering geriatric consultation, according to new research findings from surgical and geriatric medicine teams at the Ronald Reagan University of California at Los Angeles (UCLA) Medical Center.
NEWS FROM THE AMERICAN COLLEGE OF SURGEONS | FOR IMMEDIATE RELEASE
Geriatric – Trauma - A Purrfect Relationship
nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 14
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