An APN-physician Collaboration for Geriatric Trauma Patients · nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 4 Exclusion Criteria • Sedated,

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


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


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


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


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


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


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.


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.


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.


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


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


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


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


References Cotton, D., Taichman, D., Williams, S. & Marcantonio, E. (2011). In the clinic: Delirium, Annals of Internal Medicine, June 7.

Chow, W. et al. (2011) ACS NSQIP®/AGS Best Practice Guidelines: Optimal preoperative assessment of the geriatric surgical patient. Devlin, J., Roberts, R, et al. (2010). Efficiacy and safety of quetiapine in critically ill patients with delirium: A prospective, multicenter,

randomized, double-blind, placebo-controlled pilot study, Critical Care Medicine, 38(2), 419-427.

Devlin, J., Skrobik, Y., et al. (2011). Impact of quetiapine on resolution of individual delirium symptoms in critically ill patients with delirium: A

post-hoc analysis of a double-blind,randomized, placebo-controlled study, Critical Care 2011, http://ccforum.com/content/15/5/R215

Devlin, J., Skrobik, Y., et al. (2011). Antipsychotics for the prevention and treatment of delirium in the intensive care unit: What is their role?

Harvard Review of Psychiatry 19(2), 59-67. DOI: 10.3109/10673229.2011.565247

Ghandour, A., Saab, R., Mehr, D. (2011). Detecting and treating delirium—Key interventions you may be missing, Journal of Family Practice

60(12), 726-734.

Kim, S., et al. (2014). Multidimensional frailty score for the prediction of postoperative mortality risk, Journal of the American Medical

Association Surgery, doi:10.1001/jamasurg.2014.241, accessed 05/12/2014, http://archsurg.jamanetwork.com/ by Advocate Library Network

User.

Lin, M. et al. (2015). Quality of Care Delivered Before Versus After a Quality Improvement Intervention for Acute Geriatric Trauma. Journal of

American College of Surgeons. DOI: http://dx.doi.org/10.1016/j.jamcollsurg.2014.12.041 from web site https://www.facs.org/media/press-

releases/jacs/geriatric0218#viewport, accessed 2.20.2015.

Schiemann, A. et al. (2011). Managing ICU delirium, Current Opinion in Critical Care, 17:131–140. DOI:10.1097/MCC.0b013e32834400b5

Wan, R. et al. (2011). Quetiapine in refractory hyperactive and mixed intensive care delirium: a case series Critical Care 2011,

http://ccforum.com/content/15/3/R159.

Ward, K. et al. (2015). Comprehensive geriatric assessment, UpToDate, accessed 2/20/2105,

http://www.uptodate.com/contents/comprehensive-geriatric-

assessment?source=machineLearning&search=comprehensive+geriatric+assessment&selectedTitle=1%7E55&sectionRank=1&anchor=H8#H8

http://ccforum.com/content/15/5/R215


http://archsurg.jamanetwork.com/

http://archsurg.jamanetwork.com/

http://dx.doi.org/10.1016/j.jamcollsurg.2014.12.041

https://www.facs.org/media/press-releases/jacs/geriatric0218#viewport




Documents

An APN-physician Collaboration for Geriatric Trauma Patients · nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 4 Exclusion Criteria • Sedated,