University of Chicago & The Donald W

advertisement
An Observed Structured Teaching Exercise (OSTE)
Module in Geriatric Medicine
Curriculum For The Hospitalized Aging Medical Patient
CHAMP
The University of Chicago
with funding from
The Donald W. Reynolds Foundation
Don W. Scott, MD, MHS
Section of Geriatrics
University of Chicago
ACKNOWLEDGEMENT: I would like to thank the members of the CHAMP Core Group: Aliza
Baron, MA; Catherine DuBeau, MD, Stacie Levine, MD, Paula Podrazik, MD, and Greg Sachs, MD
for their contributions and review of this teaching module.
Please do not reproduce or use in any manner without permission of the author.
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
1
Table of Contents
Section:
1. Introduction…………………………………………pp
3-7
2. Geriatric G-OSTE Cases…………………………..pp
3A. Teaching about the Mini-Cog…pp 9-19
3B. Teaching about Delirium……….pp 20-25
3C. Teaching about the Foley………pp 26-34
Catheter
3D. Teaching about Transitions…..pp 35-40
of Care
8-40
3. Standardized Students
and/or Observers Checklist…………………..pp 35-38
4. Preceptor’s Guidelines…..…….………………….pp 39-40
5. QA for Preceptors Form……………………………pp 41
6. Teaching Aids: 3 X 5 Cards……………………....pp 42-52
7. Pre-Post G-OSTE Module ………………………...pp 53-54
Evaluation Forms
8. Sample Logistical Plans………………………......pp 55-56
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
2
Section 1. Introduction
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
3
Introduction
Goals of G-OSTE Module:
1. The participants will teach more geriatric medicine on the in-patient
wards by
 Recognizing geriatric teachable moments
 Becoming more comfortable teaching specific geriatric content
through practice
2. The participants will improve their in-patient teaching skills by
 Becoming more comfortable using the One-Minute Preceptor and
Stanford Clinical Teaching Principles in a simulated ward rounds
environment
This module has been designed to compliment specific components of the CHAMP
Curriculum and assist in the formative assessment of these geriatric medicine teaching
skills on the in-patient wards.
In this Geriatrics G-OSTE (G-OSTE) Module, participants complete a 4 station
teaching exercise, participating as both teachers and observers providing feedback. Each
G-OSTE scenario allows the teaching participant to practice teaching both specific
geriatric content and to use specific clinical teaching principles and methods taught in
CHAMP: the One Minute Preceptor Method and the 7 categories of the Stanford Clinical
Teaching Curriculum. The cases in this G-OSTE Module include:
1)
2)
3)
4)
Dementia Screening--using the Mini-Cog at the bed-side,
Delirium, teaching about t the door-side,
The Uses & Misuses of Foley Catheters, a bed-side case and
Good Transitions of Care, a conference-room card-flip case.
Analogous to an Observed Structured Clinical Examination (OSCE), the Observed
Structured Teaching Exercise (G-OSTE) is a performance-based teaching assessment,
using standardized learners. This Geriatrics G-OSTE Module is based on the theory of
deliberate practice and on the assessment theories of Miller and Kilpatrick.
G-OSTE’s provide an ideal framework for deliberate practice, which can be defined
as an experiential teaching method for improving skill during which a motivated learner
performs a well-defined task, at an appropriate level of difficultly, then receives
informative feedback, and is given opportunities for repetition to correct errors and
improve on the task1. The rationale for the use of deliberate practice in medical
education, e.g., using G-OSTE’s (and OSCE’s), is based on adult education and cognitive
psychology theory and research which has substantiated the role deliberate practice in
the development of expert performance.1 A growing body of medical education research
is examining the use of G-OSTE’s for accelerated teaching-skills development in both
“resident-as-teacher” and faculty development programs .2-4
During an G-OSTE, participants engage in the deliberate practice of their geriatrics
teaching-skills. Participants practice specific tasks, receive structured feed back from the
precepting faculty, colleagues and/or from the standardized learners. The following
schema is used for each individual G-OSTE exercise:
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
4
G-OSTE 1st Time Through(5-7 MIN)

Structured Feedback (10 MIN)
 Selection of Task(s) to Practice
G-OSTE 2nd Time Through (5-7 MIN)

Structured Feedback (10 MIN)
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
5
Notes on the role of the SL and the Simulated Assessment Environments:
1. This module is designed around a formative assessment approach, i.e., practice
versus high stakes evaluation. As such, extensive training of Standardized
Learners (SL’s), to achieve high levels of standardization, is not required.
Approximately 3-4 hours of training—much of which can be done in a group
setting—should be sufficient. This training should include a presentation on the
5 Micro-Skills for the 1-Minute Preceptor, a briefing on the script, a briefing on
the evaluation (if any) the SL is to perform of the teacher and 3-4 run-throughs
of the script.
2. The scripts are designed so that the SL presents the trigger for teaching, i.e., a
door-side presentation of a patient who became delirious overnight, or bedside
rounds on a patient with a Foley Catheter. After the presentation of the trigger
to teach, the SL will need to engage in a certain amount of improvisation—
portraying the learner as described in the case—as the teaching encounter
proceeds. General guidelines are given in the cases below, but the entire
encounter can obviously not be scripted. This of course means that the SL will
need to have sufficient clinical knowledge and experience to represent the given
clinical learner he or she is portraying. Fourth year medical students, residents,
NP’s or PA’s can be used, and their appearance should be reasonably believable
for the level of learner they are portraying.
3. These cases are not meant to challenge the teacher with problem behaviors or
challenging attitudes from the learner.
4. Suspension of disbelief refers to making the simulated environment as realistic
as possible. The cases in this module are designed to be either bedside, “doorside”, or conference room cases. The more closely you can replicate these
environments the better. This includes the SL’s attire and demeanor. It is
extremely important the SL’s stay “in role” during the entire exercise.
5. In general, the SL in these cases should represent an average student and one
without any behavioral or attitudinal issues. It is important the SL provide the
teacher opportunities to teach. If the SL is of a more advanced level of training,
it is especially important they do not engage with the teacher at their actual
level of training, but at the level of an average fourth year medical student.
The SL’s must understand that this is not a “test” of their actual clinical skill.
6. Feedback: Common areas for improvement fro teachers include:

Giving a mini-lecture versus teaching through dialogue /
questioning

Actually getting a commitment from the learner versus a list of
options or possible answers

Not correcting mistakes

Not addressing the different levels of learners present
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
6
Section 2. Geriatrics OSTE Cases
Includes:
A) Standardized Student Scripts & Instructions
B) Standardized Patient Script & Instructions (If SP present in case)
C) Teachers Door Chart
D) Feedback Guidelines
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
7
Section 2. Geriatrics OSTE Cases
An important goal of this module includes the teacher recognizing the multiple
geriatric teaching moments in these cases, in addition to practicing the teaching of
specific geriatric content using the teaching methods of the One Minute Preceptor
and the 7 categories of the Stanford Clinical Teaching Curriculum.
Included in each G-OSTE case in this section is the following:
a. the learning objectives for the case
b. the Standardized Learner’s (SL’s) Script
c. the SL’s Instructions
d. the Standardized Patient’s (SP’s) Instructions (if needed)
e. the Teacher’s Instructions / Door-Chart
f. feedback guidelines for both the precepting faculty member and/or
standardized learner
(The teaching aids for each case are found in section 7)
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
8
G-OSTE CASE # 1
Screening for Dementia using the Mini-Cog
A Bedside Case
Don Scott, MD, MHS
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
9
G-OSTE CASE # 1
Screening for Dementia using the Mini-Cog
A Bedside Case
Learning Objectives:
1. The faculty-learner will practice teaching the specified Geriatrics content, using the
5 Micro-skills of the One-Minute Preceptor Model.
2. The faculty-learner will identify one content area and/or one skill step for
improvement and practice after Feedback 1.
3. The faculty-learner will articulate two (or more) options for geriatrics teachable
moments.
Teaching Aid(s):
Mini-Cog Form with Instructions (see Section 7)
G-OSTE SL Script
Setting: Work rounds with Sub-I at patient’s bedside, new admission
Standardized Learner: 4th year medical student during sub-internship
Standardized Patient: Older Hospitalized Adult
Script: [The medical student is summarizing a new admission; either at bedside or at
door-side]
The Medical Student [To Attending Summarizing Case]:
So, in summary, Mr. Jones is a 85 year-old male with a h/o CAD, A-Fib and DM, admitted
for a GI-Bleed, who was supra-therapeutic on his Coumadin with an INR of 17.
Problem #1 is the GIB. We’ve transfused him 2 units and his Hg has bumped from 7.5 to
9.5. We’ve held his Coumadin and he was given Vitamin K and FFP in the ER. He’s on the
schedule for a colonoscopy tomorrow, and if that’s negative, GI is recommending an EGD.
Problem #2 is the new onset A-Fib. He’s been r/o for MI; his echo shows normal LV
function and some apical hypokinesis. He came in on Digoxin and his rate control is fine on
that.
Problem #3 is his h/o CAD—his enzymes are normal and his ECG is unchanged.
Problem #4 is his DM—he is on a sliding scale right now while he is NPO for the GI
procedures.
Problem #5 is Medication Non-Compliance. When I look back at his INRs in the computer
they’re all over the place. He lives with his daughter but he says takes his own medicine.
We’ll need to get social work involved here I think-- probably have a visiting nurse go out.
{Stops and looks at Attending; if done at door side, should proceed into patient’s room
prior to screen for dementia}
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
10
G-OSTE CASE # 1
Screening for Dementia using the Mini-Cog—a bedside case
Standardized Learner’s (SL’s) Instructions
Gender: Either
Age: appears appropriate for 4th Year medical student
Appearance: Post-Call Scrubs or Standard Professional Dress; White Coat with stuffed
pockets; Stethoscope around neck; Clipboard, Cards, Binder or other patient data
organizing device.
Clinical Skill & Knowledge:
Clinical Skill:

Using the RIME format of clinical skill evaluation, SL functioning at the
Interpreter level of clinical skill (see Pangaro L. Acad. Med. 1999.
Nov;74(11):1203-7.)
General Medical Knowledge:

Knowledge as expected for level of training (4th year student), in relation
to the biomedical issues listed above, e.g., GI Bleeding. Able to present
clearly and concisely and able to reasonably prioritize biomedical
problems. SL is reasonably familiar with presenting signs, symptoms and
basic differential diagnosis for these problems, but has only a beginners
knowledge of management and formulation. SL is limited in ability to
consider psychosocial aspects of case, e.g., importance of relationship of
patient to daughter in managing medications, i.e., is able to see the trees
much better than the forest: does not recognize the primary importance
of assessment of cognition regarding patient’s inability to adhere to
Coumadin regimen.

The plan articulated by the SL in the above script was put together with
the help of the senior resident, and if details of reasoning are probed, the
SL should offer a generally limited response. The SL should not appear
“clueless”, at most give only one to two supporting pieces of information
on clinical reasoning probes.
Geriatrics Specific Knowledge of dementia screening:

Diagnosis: SL is not familiar with the Mini-Cog. SL knows about MMSE
but calls it the “Mental Status Exam,” and has some confusion between
the purpose and nature of the MMSE versus the mental-statues Exam.
Knowledge of MMSE limited and has never heard of the Mini-Cog.
Knowledge regarding diagnostic accuracy during acute illness is limited.
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
11
G-OSTE CASE # 1
Screening for Dementia using the Mini-Cog—a bedside case
Standardized Patient Instructions
The purpose of this exercise is to allow the teacher to practice his or her
geriatric medicine teaching skills at the bedside. Therefore, extensive history
taking will not occur. The majority of the interaction in this case will consist of
the teacher or student administering the dementia screening tool called the
“Mini-Cog” to you.
Sufficient details of medical and psychosocial history are provided below for the
purposes of this exercise. (See letter A) under “KEY POINTS”.)
CASE NAME:
Dementia Screening G-OSTE
CASE CHIEF COMPLAINT: Patient not sure why in hospital—if pressed, the CC= “I
think I was dizzy or something”
PRESENTING SITUATION: Not really sure why in hospital, “I guess I just got sick.”
SUMMARY OF THE CASE: You have undiagnosed Alzheimer’s Disease. You have been
hospitalized for gastrointestinal bleeding because your blood became much too “thin”
secondary to taking too much of you blood thinner, Coumadin. The object of the case is
for the teacher to teach about screening for dementia, using the dementia screening
method called the “Mini-cog.”
KEY POINTS:
A) Keeping the encounter moving.
It is critical that no more than 1 minute be spent on casual conversation or history
taking or any other element besides bed-side teaching. It is equally important to
keep your responses short and to not engage in lengthy statements. In the
beginning of he encounter, if you feel more than 1 minute has elapsed and the
teacher is not engaged in actively teaching about dementia screening or
administering the Mini-Cog, you should state, “Somebody told me my memory was
shot,” as a cue for the teacher to begin teaching.
B) Tips on dialogue.
Patients with early dementia often respond to questions requiring use of short-term
memory in a number of different ways. Sometimes they will answer in a vague,
non-specific manner; at other times, they may use a dismissive approach to the
information being asked. Examples:
Question: “So what causes you to be in the hospital?”
Answer: “I was just really sick.”
Question: “In what way did you feel sick?”
Answer: “I just didn’t feel well at all.”
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
12
Question: “What did you have for breakfast this morning?”
Response: “Oh, I just had the usual things.”
Question: “So what did you eat.”
Response: “It was just what was on the menu here.”
Question: “What did you have for breakfast this morning?”
Response: “Oh, I just had the usual things.”
Question: “So what did you eat.”
Response: “Oh I really didn’t pay any attention.”
PATIENT BEHAVIOR, AFFECT, MANNERISMS: You are calm at first, but when
the subject of memory testing comes up, you are mildly apprehensive, but fully
cooperative, You are frustrated when you can’t remember all the words or draw the
clock correctly. If the term “dementia” is used, you become very apprehensive and
defensive, and reluctant (but still willing) to cooperate.
PATIENT APPEARANCE: Should be in a gown, draped with a sheet or blanket, lying
down, on an exam table (to simulate a hospital bed), or in a hospital bed if one is
available in your center.
HISTORY OF THE PRESENT ILLNESS:
Chief Complaint/Reason for Visit or Admission: You are not sure why you were
hospitalized, but do remember feeling sick and dizzy. All of your responses to any
medical history questions, such as, “What caused you to be in the hospital?”,” should
include vague statements and also include statements such as “As best I remember,”
or “I think it was…,” etc…You currently feel fine.
Onset: “I think it was a few days ago, as best I remember.”
Duration: “That’s hard to say”
Location: DNA
Character: “Just didn’t feel good.”
Radiation: DNA
Intensity: DNA
Meaning of the illness: You believe any errors in medication is the fault of the
pharmacy.
FUNCTIONAL HISTORY: You believe you are completely independent in ADL’s and
IADL’s, though you let your daughter do the shopping, meal preparation and
housework, because, “that’s the way she likes it.” YOU MANAGE YOUR OWN
MEDICATION AND BELIEVE YOU HAVE ABSOLIUTELY NO PROBLEMS WITH THIS.
PSYCHO SOCIAL HISTORY:
Educational Background:
Married or Single:
If married, how many years?
Spouse Name =
Any Children?
I went to teacher’s college
Widowed
“A long time”
Alice or Allen; married “a long time”
2 daughters
Any Grandchildren ?
Where do you live?
Occupation:
“Yes” “Oh too many to remember”
Own home & daughter lives with you
Retired (use an occupation with which you are familiar)
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
13
G-OSTE CASE # 1
Screening for Dementia using the Mini-Cog—a bedside case
SP Instructions for Responses on the Mini-Cog Exam
The instrument used for dementia screening in this case is called the “Mini-Cog.”
I consists of a memory test and a drawing test. The teacher or student will ask you to repeat three
words and remember them, then draw a clock and set the hands to a specific time, and then remember
the 3 words. Further details of the test, including the scoring are provided after these instructions—see
next page.)
YOU SHOULD PERFORM IN THE FOLLOWING MANNER ON THE MINI-COG TEST.
1. When first asked to repeat the three words (ball. penny, tree), you should repeat all
three correctly, and then say, “Is that what you said?”
2. When asked to draw the clock, you should draw (approximately) the following figure:
3. When asked to remember the 3 words, you should repeat only one of
the three.
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
14
G-OSTE SP MATERIALS
G-OSTE CASE # 1
Screening for Dementia using the Mini-Cog—a bedside case
The Mini-Cog Assessment Instrument for Dementia
The Mini-Cog assessment instrument combines an uncued 3-item recall test with a
clock-drawing test (CDT). The Mini-Cog can be administered in about 3 minutes,
requires no special equipment, and is relatively uninfluenced by level of education or
language variations.
Administration
The test is administered as follows:
1. Instruct the patient to listen carefully to and remember 3 unrelated words (e.g.,
Ball, Penny, Tree) and then to repeat the words.
2. Instruct the patient to draw the face of a clock, either on a blank sheet of paper, or
on a sheet with the clock circle already drawn on the page. After the patient puts
the numbers on the clock face, ask him or her to draw the hands of the clock to
read a specific time, such as 11:20. These instructions can be repeated, but no
additional instructions should be given. Give the patient as much time as needed to
complete the task. The CDT serves as the recall distracter.
3. Ask the patient to repeat the 3 previously presented words.
Scoring
Give 1 point for each recalled word after the CDT distracter.
Score 1–3.




A
A
A
A
score
score
score
score
of
of
of
of
O indicates positive screen for dementia.
1 or 2 with an abnormal CDT indicates positive screen for dementia.
1 or 2 with a normal CDT indicates negative screen for dementia.
3 indicates negative screen for dementia.
The CDT is considered normal if all numbers are present in the correct sequence and
position, and the hands readably display the requested time.
Source: Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive “vital signs”
measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000; 15(11): 1021–1027.
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
15
CLOCK DRAW TEST
1) Inside the circle, please draw the hours of a clock as they normally appear
2) Place the hands of the clock to represent the time: “ten minutes after eleven
o’clock”
Reproduced from: The Clock Drawing Test in : Palmer RM, Meldon SW. Acute Care. In: Principles of Geriatric
Medicine and Gerontology , 5 the edition, 2003. Eds. Hazzard WR et al. McGraw-Hill Pub. pp 157-168. Inouye SK.
Delirium in hospitalized older patients. Clin Geriatr Med 1998; 14:745-764
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
16
G-OSTE CASE # 1
Screening for Dementia using the Mini-Cog—a bedside case
(Teacher’s Preparatory Material: to be given to the teachers 1-2 days prior to the G-OSTE
exercise and to be used as a door-chart.)
TEACHER’S DOOR CHART
CASE DESCRITION: This will be a door-side to bed-side teaching case. The purpose of the
case is for you to practice teaching about screening for dementia using the Mini-Cog. You will
be working with a 4th year sub-I, and a Standardized Patient will also participate in this case.
YOUR TEAM: Rounding with Sub-Intern
PATIENT: Mr. or Mrs. Jackson, admitted for supra-therapeutic Coumadin level and GIB
requiring transfusion. There is a h/o “medication non-compliance”
SETTING: Attending Rounds at Doorside. One option is to explain the mini-cog at the doorside, and then have the intern try it at the bed-side. Another option would be to explain the
Mini-Cog at the door-side and then demonstrate it yourself at the bed-side.
TEACHING TOOLS: The Mini-Cog Instrument and Clock Drawing Forms will be provided.
Handout these out if you like.
TEACHER’S TASK:
1. Practice teaching about screening for dementia using the mini-cog, using
the 5 Micro-skills of the One-Minute Preceptor Model and Stanford Clinical
Teaching Principles
2. Attempt to recognize additional geriatrics teachable moments.
TIME ALLOTTED: You have approximately 7 minutes for each of your two teaching
encounters in this exercise.
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
17
G-OSTE CASE # 1
Screening for Dementia using the Mini-Cog—a bedside case
A) PRINCIPLE GERIATRIC CONTENT:
Dementia Screening Teachable Moment



Does the patient have dementia?
 Could teach about the Mini-Cog and MMSE.
 Could teach about value of history from daughter.
Demonstrate Use of the Mini-Cog
Describe Mini-Cog and ask Learner to administer & give feedback
B) OTHER POTENTIAL GERIATRIC TEACHABLE MOMENTS (You should focus on
the above, but there are several additional teachable moments which you can help the
teacher recognize.)
1. What are the patient’s goals for his own care? If he has Colon Cancer, would
he want surgery and/or chemotherapy? What is his current life expectancy?
Could teach about individualized decision making concepts.
2.Does the patient have capacity to consent to the GI procedures. If he’s
confused about his meds, could he have dementia or be impaired so as to not
be able to understand or reason through this situation ? Could teach about
capacity assessment
3. Digoxin—is this the best drug, given he is already on another potential
dangerous drug = Coumadin. What are the indications for Dig in an 85 yo
man? What are the side effects of Dig? Is cardioversion a consideration?
4. “Non-Compliance”—Does this language de-humanize or cast the patient in an
adversarial light?
C) HELP THE FACULTY LEARNER IDENTIFY GERIATRIC CONTENT AND AN
ASPECT OF THE 5 MICROSKILLS THAT THEY WOULD LIKE TO FOCUS ON
FOR THE SECOND TIME THROUGH.
One-Minute Preceptor Micro-Skills
1. Getting a Commitment—Learner verbally commits to an aspect of the case
• What do you think is going on with this patient?
• What other diagnoses would you consider?
• Based on that history, what parts of the physical should we focus on?
2. Probing for Supporting Evidence—question which seeks to explore reasoning and
rationale
• What factors in the history and physical support your diagnosis?
• Why would you/ did you choose that particular medication?
3. Reinforcing What Was Done Right
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
18

Comments should include specific behaviors that demonstrated knowledge, skills
or attitudes valued by the preceptor
4. Correcting Mistakes: often the most difficult to do
 “will help” “it is preferred” “not best” “will be better” are less extreme than
“bad” “poor”
 comments must be specific to the situation and to knowledge, skills or attitudes
of the learner
 comments must give guidance or alternative behavior
 “At some point complete PFT’s may be helpful, but right now the patient is
acutely ill and PFT’s would not reflect her baseline and be difficult for the patient,
so the better course would be a peak flow and pulse–ox monitoring
5. Teach General Rules

In this case, in addition to the dementia screening technique ( the Mini-Cog)
other general rules could include



Situations in which one needs to consider screening for dementia
The applicability of the Mini-Cog to an acutely ill hospitalized elder
Can also note
 Important not to give a Mini-Lecture
 2-3 minutes at most
 importance of a general rule being general, i.e., should be able to apply to
other cases
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
19
G-OSTE CASE #2
Teaching about Delirium
A Door-Side Case
Don Scott, MD, MHS
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
20
G-OSTE CASE #2
Teaching about Delirium—A Door-Side Case
Learning Objectives:
1. The faculty-learner will practice teaching the specified Geriatrics content, using
the 5 Micro-skills of the One-Minute Preceptor Model.
2. The faculty-learner will identify one content area and/or one skill step for
improvement and practice after Feedback 1.
3. The faculty-learner will articulate two (or more) options for geriatrics teachable
moments.
Teaching Aid: May use Delirium Card, including passing out delirium card to
learners as part of teaching
G-OSTE SL Script
Setting: Work Rounds at Door-Side--Outside of Patient’s Room
Standardized Learners: Senior Resident and Intern
Standardized Patient: None
[The Intern is presenting the patient on work rounds at the Dorr-Side]
The Intern [To Attending]: OK, so this is our 80 year old man with Parkinson’s,
admitted with an aspiration pneumonia. He also has a history of CAD, dementia and
diabetes. We’ve been broadly covering him and using a sliding scale for his diabetes.
X-cover was called last night about a confusion episode…he was trying to pull out his
Foley, so they gave him a milligram of Ativan and ordered a posey, mitts and prn soft
restraints. They didn’t get called again, so he apparently did fine the rest of the night.
This morning he’s a bit lethargic, but really doesn’t seem that far off his base-line.
He’s been doing generally well. He’s been afebrile for 24-hours. Today he’s 36.7
140/65 84 20 and 96% on RA. He seems to be sundowning. [To Resident] Perhaps
we should put him on some standing Haldol or resperidone?
Resident: [To Intern and Attending] I’m not sure that Ativan was really the best
choice last night. I agree Haldol is better. The benzo’s are associated with delirium
and delirious patients always do worse and end up staying longer. The last thing we
want to do to him or us is to turn this poor old guy into a rock—the sooner we get him
back home the better.
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
21
G-OSTE CASE #2
Teaching about Delirium—A Door-Side Case
Standardized Learner’s Instructions
SL’s for this case: Senior Resident & Intern
Gender: Either
Age: appears appropriate for level of training
Appearance:
Both--Standard Professional Dress with Stethoscopes
Intern--White Coat with equipment / cards/ manuals in pockets; Clipboard,
Cards, Binder or other patient data organizing device.
Clinical Skill & Knowledge:
Clinical Skill: Using the RIME format of clinical skill evaluation (see Pangaro L.
Acad. Med. 1999. Nov;74(11):1203-7.)


Intern: functioning at the Reporter level of clinical skill
Resident: functioning at the Educator level
General Medical Knowledge:
 Intern: below average for level of training. Able to present clearly and
concisely and able to prioritize biomedical problems, but seems
limited in knowledge and evidences insecurity in own knowledge,
clinical reasoning and plan formulation. SL is familiar with presenting
signs, symptoms, but has limited differential diagnosis ability and
rudimentary ability to formulate a plan independently. The intern
should not appear totally “clueless”, but at most should give only one
to two supporting pieces of information when questioned.
Geriatrics Specific Knowledge of Delirium:

Risk Assessment: Limited Knowledge—one item at most

Diagnosis: Delirium is equated with confusion and agitation. Does not
know how to formally diagnose delirium and does not know about the
CAM.

Assessment: Knows that medications are an important consideration

Plan: believes need to “wait out” resolution of underlying problem
and/or primary treatment = medications. Does not recognize potential
urgent nature of new delirium. Believes delirium is “par-for-thecourse” in frail hospitalized older adults.
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
22
G-OSTE CASE #2
Teaching about Delirium—A Door-Side Case
(Teacher’s Preparatory Material: to be given to the teachers 1-2 days prior to the G-OSTE
exercise and to be used as a door-chart.)
TEACHER’S DOOR CHART
CASE DESCRIPTION: This will be a door-side teaching case, simulating one setting where
teaching often takes place during attending rounds. The purpose of this case is for you to
practice teaching bout delirium and to recognize other geriatric teachable moments that may
be present.
YOUR TEAM: Intern and Resident
PATIENT: Mr. or Mrs. Batey, with h/o Parkinson’s Dz, CAD, Mild Dementia, DM, admitted with
aspiration pneumonia two nights ago.
SETTING: Attending Rounds at Doorside. You are on work rounds with your team, consisting
of an intern and a resident. This exercise will be conducted as a door-side teaching exercise.
TEACHING TOOLS: Delirium 3X5 Card—may also pass copies out to student as part of
teaching
TEACHER’S TASK:
1. Practice teaching about a selected aspect of incident delirium in the
hospitalized vulnerable Elder, using the 5 Micro-skills of the One-Minute
Preceptor Model and Stanford Clinical Teaching Principles
2. Attempt to recognize additional geriatrics teachable moments.
TIME ALLOTTED: You have approximately 5 minutes for each
of your two teaching encounters
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
23
G-OSTE CASE #2
Teaching about Delirium—A Door-Side Case
Feedback Guidelines
Help the Faculty Learner identify Geriatric Content and an aspect of the 5
Microskills that they would like to focus on for the second time through.
A) Geriatric Content—Delirium Teachable Moments
1. Value of collateral information—knowing the patient’s baseline
2. Diagnosis of Delirium versus Dementia with Agitation--CAM
3. Assessing Risk of Delirium at Admission
4. Diagnostic Approach to Delirium
5. Treatment of Delirium
6. Special Topic = Parkinson’s Disease and use of butyrophenones and
risperdal at higher doses
B) Other Potential Geriatric Teachable Moments to note in feedback
1. The effect of calling a patient a rock
-professionalism teachable moment
-in this case best done one-on-one and in private?
2. Foley Teachable Moment
-Does this patient have a Foley ?
-Does this patient need a Foley?
3. Effect of Restraints
-Indications and Alternatives
C) Ask the Faculty Learner to identify an item of geriatric content and
an aspect of the 5 Microskills that they would like to focus on for the
second time through.
One-Minute Preceptor Micro-Skills
1. Get a Commitment—Learner verbally commits to an aspect of the case
• What do you think is going on with this patient?
• What other diagnoses would you consider?
• Based on that history, what parts of the physical should we focus on?
2. Probe for Supporting Evidence—question which seeks to explore reasoning and
rationale
• What factors in the history and physical support your diagnosis?
• Why would you/ did you choose that particular medication?
3. Reinforce What Was Done Right
• Comments should include specific behaviors that demonstrated knowledge, skills
or attitudes valued by the preceptor
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
24
4. Correct Mistakes: (often the most difficult to do)
• “will help” “it is preferred” “may not best” “will be better” are less extreme
than “bad” “poor”
 comments must be specific to the situation and to knowledge, skills or
attitudes of the learner
 comments must give guidance or alternative behavior
5. Teach



a General Rule or Principle
Important not to give a Mini-Lecture
2-3 minutes at most
importance of a general rule being general, i.e., should be able to apply to
other cases
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
25
G-OSTE CASE #3
The Foley Catheter: Indications & Inability to Void
A Bedside Case
Don Scott, MD, MHS & Catherine DuBeau, MD
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
26
G-OSTE CASE #3
The Foley Catheter: Indications & Inability to Void
Learning Objectives:
1. The faculty-learner will practice teaching the specified Geriatrics content, using
the 5 Micro-skills of the One-Minute Preceptor Model.
2. The faculty-learner will identify one content area and/or one skill step for
improvement and practice after Feedback 1.
3. The faculty-learner will identify two (or more) options for geriatrics teachable
moments.
Teaching Aid: 3X5 Foley Catheter Card
G-OSTE SL Script
Setting: Work Rounds at the Bedside—the team should walk in to the room to begin
the exercise.
SL’s: Senior Resident, Intern, Patient
[The resident begins by saying…]
The Resident [To attending] Good morning Mrs. Smith. I brought the whole team by
to see you, dear.
Mrs. Smith: Good Morning everyone.
Intern: So Mrs. Smith is hospital day #4. She was transferred to us from the MICU
two days ago. Her active problems are CHF and COPD exacerbation. She had to be
BIPAP’d the first 24 hours in the unit because she was retaining and her sats took a
while to come up. She responded well to diuresis and steroids, and she’s been off of
Bi-Pap for 24 hours and is doing well. Her other problems are diabetes, A-Fib, DJD,
and GERD. She’s on lasix 60 bid, Prednisone 60, lisinopril, dilt, glyburide, aspirin, SQ
heparin, and prilosec. She was 1440 in and 2400 out.
Resident: I was going to continue the IV Lasix one more day and then switch to p.o.
She still has mild crackles at the bases. [To the patient] Mrs. Smith, how is your
breathing? Have you been up out of bed?
Patient: My breathing is OK. I haven’t been out of bed because I’m all hooked up to
these things.
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
27
G-OSTE CASE #3
The Foley Catheter: Indications & Inability to Void
Standardized Learner’s (SL’s) Instructions
SL’s for this case: Resident & Intern
Gender: Either
Age: appears appropriate for level of training
Appearance:
Both--Standard Professional Dress with Stethoscopes
Intern--White Coat with equipment / cards/ manuals in pockets; Clipboard,
Cards, Binder or other patient data organizing device.
Resident—White Coat, Index Cards (or the like) for Patient Information,
Stethoscope
Clinical Skill & Knowledge:
Clinical Skill: Using the RIME format of clinical skill evaluation (see Pangaro L.
Acad. Med. 1999. Nov;74(11):1203-7.)


Intern: functioning at the Reporter level of clinical skill
Resident: functioning at the Educator level
General Medical Knowledge:
 Intern: average for level of training. Able to present clearly and
concisely and able to prioritize biomedical problems; seems secure in
own knowledge, clinical reasoning and plan formulation. SL is familiar
with presenting signs, symptoms, and has good general knowledge of
differential diagnosis and a beginners ability to ability and to
formulate a plan independently. The intern should seem confident but
not arrogant.

Resident: Functioning at an educator level for General Medical
Knowledge and Clinical Skill
Geriatrics Specific Knowledge: Appropriate Use of Foley Catheters:

Intern
o
Indications: Limited Knowledge—one item at most (either
urinary incontinence “for the patient’s comfort” and/or “to
monitor urine output.”)
o
Risks: Limited to infection, believes or questions contributions
to falls, i.e., “don’t Foley’s help prevent falls by patients not
slipping urine if incontinent?”)
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
28

o
Reasons for Inability to Void: knowledge limited to obstruction
(e.g. BPH) and spinal cord processes
o
Evaluation of Inability to Void: limited to assessing for
obstruction with insertion of Foley Catheter
Resident
o
Indications: able to add the following—for relief of obstruction,
for urinary incontinence, especially in presence of open “bed
sores”
o
Risks: able to add the following —trauma, e.g., pt’s pulling
Foley’s out, association with discomfort
o
Reasons for Inability to Void: able to add the following —meds,
neuropathy (with DM as an example)
o
Evaluation of Inability to Void: able to add the following —
checking meds, PVR
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
29
G-OSTE CASE #3
The Foley Catheter: Indications & Inability to Void
G-OSTE SP MATERIALS
The purpose of this exercise is to allow the teacher to practice his or her geriatric
medicine teaching skills at the bedside. Therefore, extensive history taking will not
occur. The majority of the interaction in this case will consist of the teacher and
students having a teaching dialogue about uses and misuses of the Foley Catheter.
Sufficient details of medical and psychosocial history are provided below, most of
which you will not need for the purposes of this exercise. (See letter A) under “KEY
POINTS”.)
CASE NAME: Uses & Misuses of the Foley Catheter
EQUIPMENT NEEDED: Foley Catheter and Bag, Yellow Food Coloring, O2 nasal
Cannula and Tubing, IV Bag and Tubing, IV Pole, Paper Tape
CASE CHIEF COMPLAINT: Hospitalized because of shortness of breath
PRESENTING SITUATION: Progressive shortness of breath and leg swelling
SUMMARY OF THE CASE: The point of this case is for the teacher to teach
about the indications, uses and misuses of the Foley Catheter. You will have a
Foley Catheter taped to your leg. You have serious emphysema and mild congestive
heart failure for which you have been hospitalized. You were hospitalized 4 days ago
for shortness of breath and spent two days in the intensive care unit. You were
transferred fro the ICU to the general medicine ward two days ago and are feeling
much better. You have been given diuretic medications to remove excess fluid from
your body, oxygen, steroids and “breathing treatments” (inhaled medication).
KEY POINTS:

Keeping the encounter moving.
At the beginning of the encounter, it is critical that no more than 1 minute be
spent on casual conversation or history taking. It is equally important to keep
your responses short and to not engage in lengthy statements. In the
beginning of the encounter, if you feel more than 1 minute has elapsed and the
teacher is not engaged in actively teaching about dementia screening or
administering the Mini-Cog, you should state, “Somebody told me my memory
was shot,” as a cue for the teacher to begin teaching.
PATIENT BEHAVIOR, AFFECT, MANNERISMS: You are feeling much better and
appear comfortable. You are pleasant. You are cognitively intact.
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
30
PATIENT APPEARANCE: Should be in a gown, draped with a sheet or blanket, lying
down, on an exam table (to simulate a hospital bed), or in a hospital bed if one is
available in your center. The SP should have a Foley Taped to inner thigh, with the
Foley Bag full of water + yellow food coloring to simulate urine; may also tape an i.v.
to arm and have oxygen cannula in nose.
HISTORY OF THE PRESENT ILLNESS:
Chief Complaint/Reason for Visit or Admission: About a week prior to admission
you experienced increasing shortness of breath: first with usual activities and then
progressing until you were short-of-breath with rest. At the same time your lower
legs, ankle and feet were “swelling.” You had a mild cough, especially at night when
you would lie down. You also experienced increasing problems lying flat at night and
needed to prop yourself up on 4 pillows to be comfortable breathing. No chest pain,
or productive or purulent cough, but you did have some wheezing. Your “puffers”
helped at first but then became less effective.
Onset: about 1 week prior to admission
Duration: 1 week
Location: DNA
Character: Progressive Shortness of Breath
Radiation: DNA
Intensity: Progressive until so bad had to come to ER
PAST MEDICAL HISTORY:
1) Emphysema—diagnosed about 7-8 years ago
2) “Heart Problems” (Congestive Heart Failure)—diagnosed 3 years ago
3) High Blood Pressure
4) Diabetes
NO HISTORY OF URINARY INCONTINENCE OR ANY TYPE OF URINARY PROBLEMS
PSYCHO SOCIAL HISTORY:
Educational Background:
Married or Single:
If married, how many years?
Spouse Name
Any Children?
Any Grandchildren ?
Where do you live?
Occupation:
completed college
Widowed
45
John or Jane; married 45 years
2 sons & 1 daughter
5
Live alone in own home in Hyde Park
Retired (use an occupation with which you are familiar)
FUNCTIONAL HISTORY: INDEPENDENT IN ADL’S & IADL’S
PHYSICAL EXAMINATION: NONE
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
31
G-OSTE CASE #3
The Foley Catheter: Indications & Inability to Void
(Teacher’s Preparatory Material: to be given to the teachers 1-2 days prior to the G-OSTE
exercise and to be used as a door-chart.)
TEACHER’S DOOR CHART
CASE DESCRIPTION: This will be a bed-side teaching case. The purpose of this case is to
practice teaching about the uses and misuses of the Foley Catheter in hospitalized vulnerable
elders. You should also attempt to recognize other geriatric teachable moments that may be
present. Particularly helpful to review would be “Indications for Foley Catheter Use” under the
“Bedside Teaching Trigger.”
YOUR TEAM: Intern and Resident
PATIENT: Mr. or Mrs. Johnson, admitted 4 days ago to the MICU with CHF and COPD
exacerbation. She has been on your team for two days and is improving.
SETTING: Attending Rounds at the Bedside. The exercise will commence with you and the
team entering the room.
TEACHING TOOLS: Foley 3X5 Card—may also pass copies out to student as part of teaching
TEACHER’S TASK:
1. Practice teaching about the uses and misuses of the Foley Catheter in the
hospitalized vulnerable Elder, using the 5 Micro-skills of the One-Minute
Preceptor Model and Stanford Clinical Teaching Principles
2. Attempt to recognize additional geriatrics teachable moments.
TIME ALLOTTED: You have approximately 5-7 minutes for each of your two teaching encounters
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
32
G-OSTE CASE #3
The Foley Catheter: Indications & Inability to Void
Feedback Guidelines
A. Geriatric Teachable Moments:
1. Why is this patient catheterized?
2. What are the indications for a Foley Catheter?
3. Why should Foley catheter use be minimized?
4. Who should be discharged with a Foley catheter?
5. How would you trouble shoot leakage around Foley Catheters?
6. How would you manage a Foley catheter pulled out by a patient?
B. Other Potential Geriatric Teachable Moments to note in feedback
1. Appropriateness of referring to patients as “dear.”
2. Planning for Good Transitions of Care
3. Falls
C. ASK THE FACULTY LEARNER TO IDENTIFY AN ITEM OF GERIATRIC
CONTENT AND AN ASPECT OF THE 5 MICROSKILLS THAT THEY WOULD
LIKE TO FOCUS ON FOR THE SECOND TIME THROUGH.
One-Minute Preceptor Micro-Skills
1. Get a Commitment—Learner verbally commits to an aspect of the
case
• What do you think is going on with this patient?
• What other diagnoses would you consider?
• Based on that history, what parts of the physical should we focus on?
2. Probe for Supporting Evidence—question which seeks to explore reasoning and
rationale
• What factors in the history and physical support your diagnosis?
• Why would you/ did you choose that particular medication?
3. Reinforce What Was Done Right
 Comments should include specific behaviors that demonstrated knowledge, skills
or attitudes valued by the preceptor
4. Correct Mistakes: often the most difficult to do
 “will help” “it is preferred” “not best” “will be better” are less extreme than
“bad” “poor”
 comments must be specific to the situation and to knowledge, skills or attitudes
of the learner
 comments must give guidance or alternative behavior
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
33

“At some point complete PFT’s may be helpful, but right now the patient is
acutely ill and PFT’s would not reflect her baseline and be difficult for the patient,
so the better course would be a peak flow and pulse–ox monitoring
5. Teach General Rules
 Important not to give a Mini-Lecture
 2-3 minutes at most
 importance of a general rule being general, i.e., should be able to apply to other
cases
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
34
G-OSTE CASE #4
Transitions of Care—The Ideal Hospital Discharge
A Conference Room Case
Don Scott, MD, MHS
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
35
G-OSTE CASE #4
Transitions of Care—The Ideal Hospital Discharge
Learning Objectives:
1. The faculty-learner will practice teaching the specified Geriatrics content, using
the 5 Micro-skills of the One-Minute Preceptor Model.
2. The faculty-learner will identify one content area and/or one skill step for
improvement and practice after Feedback 1.
3. The faculty-learner will identify two (or more) options for geriatrics teachable
moments.
Setting:
Card-Flip at Conference Table
Standardized Learners: Intern and Senior Resident
Teaching Aid(s): Transitions of Care Pocket Card
G-OSTE SL Script:
Resident: OK, how about Mr. Jones, do you think he’s still ready for discharge today?
Intern (to resident and attending): Yeah, I think he’s ready. Mr. Jones is our 76 y/o
admitted with a GIB and high Coumadin level. His Mini-Cog was off and we think he
may have some dementia. The med-student checked his MMSE and it was 19. His
Coumadin is at 2mg day and he’s back to therapeutic now. His colonoscopy and EGD
were unremarkable and his Hg has been stable. We’ve adjusted his other meds--he’s
back on his usual meds of lisinopril, lasix, atenolol and glyburide. We increased his
Atenolol to 50 a day, and made his Lasix bid. We added spironolactone and Lipitor as
well. His Cr is 1.7, his BG’s are all in the low 100s; he’s oxygenating OK and his Hgb is
9.5. His lungs are clear and he’s been eating OK.
Resident: What about his mental status?
Intern: His family seems to think he is at his baseline—the student did a MMSE
yesterday. He was 19 out of 30—We think he has some dementia or effect of
hospitalization. He’s definitely not delirious.
Resident: So, what’s your discharge plan?
Intern: We’ll send him home on his out-patient regimen and he has a follow-up
appointment with cards. He lives in a Senior building and his daughter lives near-by
and is involved. She will check on him. I’ve written out a med-list for him. Social
work has been involved and PY and OT have seen him and recommend just home PT.
(To Attending) I’m not sure what else we can do.
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
36
G-OSTE CASE #4
Transitions of Care—The Ideal Hospital Discharge
Standardized Learner’s (SL’s) Instructions
SL’s for this case: Resident & Intern
Gender: Either
Age: appears appropriate for level of training
Appearance:
Both--Standard Professional Dress with Stethoscopes
Intern--White Coat with equipment / cards/ manuals in pockets; Clipboard,
Cards, Binder or other patient data organizing device.
Resident—White Coat, Index Cards (or the like) for Patient Information,
Stethoscope
Clinical Skill & Knowledge:
Clinical Skill: Using the RIME format of clinical skill evaluation (see Pangaro L.
Acad. Med. 1999. Nov;74(11):1203-7.)


Intern: functioning at the Interpreter level of clinical skill
Resident: functioning at the Educator level
General Medical Knowledge:
 Intern: average for level of training. Able to present clearly and
concisely and able to prioritize biomedical problems; seems
reasonably secure in own biomedical knowledge, clinical reasoning
and plan formulation. SL is familiar with presenting signs, symptoms,
and has a good general knowledge of differential diagnosis and a
beginners ability to formulate a plan independently: relies on resident
for help with much of plan formulation. The intern is focused solely on
biomedical issues, and is not skilled at integrating psychosocial
information into the plan.

Resident: Functioning at an educator level for General Medical
Knowledge and Clinical Skill—also primarily focused on “fixing” of
biomedical problems
Geriatrics Specific Knowledge: Transitions of Care:

Intern
o
Components of Ideal Hosp. D/C: limited in thinking to
rudimentary issues, such as importance of acute medical issues
being resolved, able to take p.o., have proper “discharge
instructions,” be able to use bathroom, etc…
o
Site of Discharge—limited in knowledge to this being a function
of PT and OT to determine.
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
37

Resident
o
Components of Ideal Hosp. D/C: able to add the following—
communication with family important, considering whether
home nursing is needed or PT/OT
o
Site of Discharge—able to add possible sites of D/C are Home,
Nursing Home or Rehab; does not know much about distinction
between Acute Rehab / Skilled or “Sub-Acute” Rehab and home
with PT
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
38
G-OSTE Case 4: Transitions of Care—The Ideal Hospital
Discharge
(Teacher’s Preparatory Material: to be given to the teachers 1-2 days prior to the G-OSTE
exercise and to be used as a door-chart.)
TEACHER’S DOOR CHART
CASE DESCRIPTION: This will be a “card-flip” teaching case set in the conference room. The
purpose of this case is to practice teaching about good transitions of care, specifically the ideal
hospital discharge. You should also be able to recognize and name other geriatric teachable
moments that may be present.
The Geri-content to focus on here is helping them work through the elements of a good
discharge plan and/or the most appropriate site for this patient to go to at discharge.
Especially helpful in this regard would be the Pocket Card on this subject.
YOUR TEAM: Intern and Resident
PATIENT: Mr. or Mrs. Jones, admitted for supra-therapeutic Coumadin level and GIB requiring
transfusion. There is a h/o “medication non-compliance.” Also has h/o CAD, CM, HTN & CRI.
SETTING: Conference Room Card-Flip
TEACHING TOOLS: The Ideal Hospital D/C Pocket Card be provided. Handout these out if
you like.
TEACHER’S TASK:
1. Practice teaching about the components of the ideal hospital D/C and
items to consider for best destination at discharge, using the 5 Micro-skills of
the One-Minute Preceptor Model and Stanford Clinical Teaching Principles
2. Attempt to recognize additional geriatrics teachable moments.
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
39
G-OSTE CASE #4
Transitions of Care—The Ideal Hospital Discharge
Feedback Guidelines
A) PRINCIPLE GERIATRIC CONTENT: (see Pocket Card)
1. Components of the Good Hospital D/C for the Vulnerable Elder
 Active Advance Planning—including incorporation of psychosocial
information, e.g., who lives with pt.?
 Communication—direct with PCP for solidity of f/u
 Medical Needs—including f/u appointments, follow-up labs,
 Functional Support—including medication management
 Nursing Needs
 Rehabilitative Needs
2. Transfer Destinations
 Acute Rehab
 SNF/Skilled Rehab
 Home c Services
 Home
3. ? Primary Role of the MD in D/C planning ? versus responsibility of
Case Manager, Social Work…this = the issue of role of the MD as leader
of the team
B) OTHER POTENTIAL GERIATRIC TEACHABLE MOMENTS (You should focus on
the above, but there are several additional teachable moments which you can help the
teacher recognize.)
1.
2.
3.
4.
Treatment of Patient’s Dementia
Anemia in the Elderly
Advance Care Planning
Assessment of Gait
C) HELP THE FACULTY LEARNER IDENTIFY GERIATRIC CONTENT AND AN
ASPECT OF THE 5 MICROSKILLS THAT THEY WOULD LIKE TO FOCUS ON
FOR THE SECOND TIME THROUGH.
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
40
Section 3. Observing Faculty or Standardized
Learner Evaluation Form
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
41
G-OSTE: FEEDBACK INSTRUMENT FOR OBSERVING FACULT OR SL *
Please indicate your agreement with the following statements:
THIS TEACHER GENERALLY….
A. OBTAINED A COMMITMENT FROM THE LEARNER
1
2
3
4
STRONGLY DISAGREE:
5
STRONGLY AGREE:
No Commitment asked for--either
began with “lecture” or overt judgemental criticism
Asked for a commitment, but little
specificity, vagueness accepted,
did not obtain a specific commitment
Obtained a specific commitment, skillfully
linking the commitment question to previously
presented material
B. EVALUATED LEARNER’S KNOWLEDGE OF FACTUAL MEDICAL INFORMATION
1
2
3
4
STRONGLY DISAGREE:
5
STRONGLY AGREE:
Did not ask learner helpful questions
to probe what learner recalled from
his/her knowledge base about back pain.
Probed learner’s knowledge base of
factual information with average skill.
Asked learner appropriate recall questions
to probe his/her knowledge base.
C. PROVIDED POSITIVE FEEDBACK
1
2
3
4
STRONGLY DISAGREE:
5
STRONGLY AGREE:
Did not provide positive feedback.
Provided general positive feedback but could
have better reinforced what student did right.
Provided specific, positive feedback that
clearly reinforced what student did right.
D. GAVE NEGATIVE (CORRECTIVE) FEEDBACK TO LEARNER
1
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]dicine.bsd.uchicago.edu
2
3
4
CHAMP
University of Chicago
Section of Geriatrics
5
42
STRONGLY DISAGREE:
STRONGLY AGREE:
Failed to correct mistakes, or “corrected” them
With inaccurate or otherwise useless information.
Partly corrected mistakes with average skill
and accuracy.
Effectively corrected mistakes at appropriate
times, focusing on important issues. Had learner
give self-feedback before teacher’s feedback.
E. EXPLAINED TO LEARNER WHY HE/SHE WAS CORRECT OR INCORRECT
1
2
3
4
STRONGLY DISAGREE:
5
STRONGLY AGREE:
If gave positive or negative feedback, did so only
in a general way and failed to explain specifically
why learner was correct or incorrect, or did so
Inaccurately (e.g., missed correcting important
points student failed to include in H&P).
Gave somewhat specific feedback.
When giving both positive and negative
feedback, effectively explained specific
reasons why learner was correct or incorrect
(e.g., important points student left out of H&P).
F. OFFERED LEARNER SUGGESTIONS FOR IMPROVEMENT
1
2
3
4
STRONGLY DISAGREE:
5
STRONGLY AGREE:
Never gave specific recommendations for how
learner might improve, or did so ineffectively.
Gave somewhat specific suggestions
for improvement.
Gave specific, effective recommendations
for how learner might improve (e.g., asking about
onset of pain and treatments tried in past, and
including a more complete back examination).
G. TAUGHT A GENERAL RULE
1
2
3
4
STRONGLY DISAGREE:
5
STRONGLY AGREE:
No teaching of a general rule took place or
What was taught was based on idiosyncratic
Opinion or grossly incorrect
General Rule (s) taught, but delivered
in a “mini-lecture” style with little chance
for interaction or questions
One or two concise and generalizable rules
taught interactively, allowing for questions
H. EXPLICITLY ENCOURAGED FURTHER LEARNING
1
2
3
4
STRONGLY DISAGREE:
Failed to mention further learning in any way.
or actually discouraged it. (e.g., seemed to view
student’s role as primarily “scut”).
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
5
STRONGLY AGREE:
Explicitly encouraged further learning
but in an indirect or general manner.
CHAMP
University of Chicago
Section of Geriatrics
Enthusiastically encouraged further learning
with specific, directed suggestions tailored to
this learner (e.g., learning more about back pain).
43
I. LISTENED TO LEARNER
1
2
3
4
STRONGLY DISAGREE:
5
STRONGLY AGREE:
Did not appear to listen to or look at learner
Monopolized discussion and/or interrupted
learner. Did not let learner finish H&P.
Listened to and looked at learner somewhat
but was a little too dominant in the discussion.
Eventually let student finish doing H&P.
Listened to and looked at learner.
Let learner do complete H&P without
interrupting or monopolizing the session.
J. AVOIDED DIGRESSIONS
1
2
3
4
STRONGLY DISAGREE:
5
STRONGLY AGREE:
Went off on tangents, was easily distracted.
Did not have learner help focus session.
Showed only minor digressions.
Avoided digressions quite well. Had
learner help focus session as needed.
K. AVOIDED RIDICULE AND INTIMIDATION
1
2
3
4
STRONGLY DISAGREE:
5
STRONGLY AGREE:
Created a hostile climate of ridicule
and/or intimidation.
Created a neutral climate in which
learner usually did not feel ridiculed
or intimidated.
Created a positive climate free from ridicule
or intimidation. If learner said something incorrect,
gently channeled learner toward right answer.
OVERALL TEACHING EFFECTIVENESS
VERY POOR
1
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
EXCELLENT
2
3
4
CHAMP
University of Chicago
Section of Geriatrics
5
44
Section 4. G-OSTE QA for Preceptors
To be used to provide feedback for those precepting the module, e.g., any faculty
giving feedback to the teachers.
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
45
SECTION 4.
G-OSTE Feedback for Preceptors / QA Checklist
Time Started:________________
Observer: □ __________ □ ___________
Faculty “Learner” ________________________________
Case:
□ Dementia
□ Delirium
□ Transitions
□ Foley
Topic(s) covered:
Tools Used:
□
Mini Cog
□
Delirium Card
□
Hospital Re-admissions
□
Clock Draw
□
Transitions of Care
□
Foley
□
None
Micro Skill Used:
□
Commitment □
□
□
Probe for Support
□
Reinforce what was right
Correct Mistakes
□
Teach General Rules
Time Stopped: ____________
Feedback Session:
First Interaction:
Asked faculty-learner to identify geriatric teachable moments
Ask “learner” for self-reflection on performance.
Ask observers for comments
Reviewed teachable moments not brought up by group for consideration.
Reviewed areas comfortable with
o Geriatric topics
o Tools
o Microskills
 Identified which teachable moment and micro skill he/she plans on using in the “re-take”
and why (Describe which ones)





Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
46
Second Interaction




Time started: _______________
Ask “learner” for self-reflection on performance.
Ask observers for comments
Reviewed teachable moments not brought up by group for consideration.
Your final comments
Other Notes:
Time ended:_____________________
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
47
Section 5. Guidelines for OSTE Module Preceptors
To be used as a general set of guidelines for those giving feedback to the teachers.
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
48
Section 5.
Preceptor’s Guidelines
PLEASE KEEP YOU EYE ON THE CLOCK…IT IS ESSENTIAL THAT YOU LEAVE TIME FOR A
SECOND RUN THROUGH WITH FEEDBACK & DISCUSSION !!

These are meant to be brief teaching encounters, as one might expect during a busy
day of rounding on patients. The teaching encounter itself should not be allowed to
exceed 5-7 minutes, and the feedback / discussion should not exceed 10 minutes.

Total Allotted Time for each G-OTES Station = 30 minutes
1. First Interaction Feedback & Discussion: (15 Minutes)

5-7 Minutes for Scenario and 10 Minutes for Feedback

Ask “learner” for self-reflection on performance. Sample questions:
o
o
o
o
o
o
How did it go? What went well?
What were the geriatrics teachable moments you identified?
What micro skill were you focusing on?
How comfortable were you with trying out the geriatric topic and One Minute Preceptor
method?
How comfortable were you with using the “tool?”
What would you like to work on?

Ask observer and standardized learner for comments.

Have the teacher commit to a micro skill or SFDP Principle and piece of geriatric content he/she
plans on addressing in the “re-take.”
o
o
The idea here is to practice something new and/or uncomfortable, not to demonstrate
what one can already do well
Encourage the teacher to “stretch”
2. Second Interaction (re-take): (15 Minutes)

5-7 Minutes for Scenario and 10 Minutes for Feedback

Ask “learner” for self-reflection on performance. Sample questions:
o
o
o
o


How did it go this time? What did you do differently?
How did it seem to work?
How comfortable were you with trying out the geriatric topic and One Minute
Preceptor method?
How comfortable were you with using the “tool?”
Observer and SL comments
Ask the Teacher and Observer to each name one or two things they have learned as result of
this practice
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
49
Section 6. Teaching Aids
The pocket cards are laid out to facilitate two sided copying. Two copies of Side 1 of
the card will be on the first page, and two copies of Side 2 of the card will be on the
second page. By making a two-sided reproduction of these two pages (i.e., Side Two
on the back of Side One), you can then cut a single sheet to produce two cards
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
50
1.
2.
3.
4.
5.
The One Minute Preceptor
5 Micro-Skills for Teaching1
The One Minute Preceptor
5 Micro-Skills for Teaching1
University of Chicago, CHAMP Program
Don Scott, MD, MHS
University of Chicago, CHAMP Program
Don Scott, MD, MHS
Get a Commitment
Probe for Supporting Evidence
Tell Them What They did Right
Correct Mistakes
Teach a General Rule
1. Get a Commitment
Ask the learner what he/she thinks


It is not asking for more data
It is not offering your own opinion
-What do you think is going on?
-What other information do we need?
-What therapy do you feel is needed?
2. Probe for Supporting Evidence
Ask the learner for evidence that supports
his/her opinion


It is not Pimping
It is not a judgment about learner
reasoning
-What were the major findings that led you to
that conclusion?
-What else did you consider and what kept you
from that choice?
-What are the key features of this problem?
1. Irby D. and Greer T.Five Microskills of Clinical Teaching.
http://clerkship. fammed.washington.edu/ teaching. Accessed
10/19/2005.
(over)
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
1.
2.
3.
4.
5.
Get a Commitment
Probe for Supporting Evidence
Tell Them What They did Right
Correct Mistakes
Teach a General Rule
1. Get a Commitment
Ask the learner what he/she thinks


It is not asking for more data
It is not offering your own opinion
-What do you think is going on?
-What other information do we need?
-What therapy do you feel is needed?
2. Probe for Supporting Evidence
Ask the learner for evidence that supports
his/her opinion


It is not Pimping
It is not a judgment about learner
reasoning
-What were the major findings that led you to
that conclusion?
-What else did you consider and what kept you
from that choice?
-What are the key features of this problem?
1. Irby D. and Greer T. Five Microskills of Clinical Teaching.
http:// clerkship. ammed.washington.edu/ teaching. Accessed
10/19/2005.
(over)
CHAMP
University of Chicago
Section of Geriatrics
51
3. Tell them What they did Right
The SPECIFIC good work and the effect it
had

It is not a vague general phrase
Obviously you considered the patient’s finances
when you selected that drug. Your sensitivity to
this will certainly help with adherence.
4. Correct Mistakes
 Discuss what was wrong and how to avoid
error in future

It is not a vague judgmental
statement
It is important in making the diagnosis of delirium to
establish the patients baseline mental status, so in
the future be sure to call the family right away if this
is a question
5. Teach a General Rule
Target to learners level of understanding


It is not a Mini-Lecture
It is not an idiosyncratic approach
The key features of delirium are acute onset,
fluctuating course and inattention while dementia
is more often gradual in onset and etc…
1. Irby D. and Greer T. Five Microskills of Clinical Teaching.
http://clerkship. fammed.washington.edu/ teaching. Accessed
10/19/2005.
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
3. Tell them What they did Right
The SPECIFIC good work and the effect it
had

It is not a vague general phrase
Obviously you considered the patient’s finances
when you selected that drug. Your sensitivity to
this will certainly help with adherence.
4. Correct Mistakes
 Discuss what was wrong and how to avoid
error in future

It is not a vague judgmental
statement
It is important in making the diagnosis of delirium to
establish the patients baseline mental status, so in
the future be sure to call the family right away if this
is a question
5. Teach a General Rule
Target to learners level of understanding


It is not a Mini-Lecture
It is not an idiosyncratic approach
The key features of delirium are acute onset,
fluctuating course and inattention while dementia
is more often gradual in onset and etc…
1. Irby D. and Greer T. Five Microskills of Clinical Teaching.
http://clerkship. fammed.washington.edu/ teaching. Accessed
10/19/2005.
CHAMP
University of Chicago
Section of Geriatrics
52
Delirium in Hosp’d Seniors
Delirium in Hosp’d Seniors
University of Chicago, CHAMP Program
Don Scott, MD, MHS; Andrea Bial, MD
University of Chicago, CHAMP Program
Don Scott, MD, MHS; Andrea Bial, MD
Diagnosis--CAM: 1 + 2 + (3 or 4)
1=
2=
3=
4=
Acute Onset & Fluctuating Course
Inattention
Disorganized Thinking
Altered LOC
(Most Common = HYPOACTIVE Form)
Diagnosis--CAM: 1 + 2 + (3 or 4)
1=
2=
3=
4=
Acute Onset & Fluctuating Course
Inattention
Disorganized Thinking
Altered LOC
(Most Common = HYPOACTIVE Form)
Risk Assessment at Admission
Risk Assessment at Admission
Precipitating Risk Factors
Precipitating Risk Factors
1.
2.
3.
4.
1.
2.
3.
4.
5.
 Vision (<20/70)
Severe Illness
 Cognition (< 24 MMSE)
Dehydration (BUN/Cr > 18)
1-2 = Int. Risk  2.5 X as likely vs 0
3-4 = High Risk  9.2 X as likely vs 0
Phys. Restraints
Malnutrition
> 3 Med Classes added
Bladder Catheter
Iatrogenic Event
Int. Risk = 1-2  7.1 X as likely vs. 0
High Risk = 3-5  17.5 X as likely vs 01
Delirium versus Dementia
Feature
Delirium
Dementia
Onset
Acute
Insidious
Course
Fluctuating
Constant
Attention
Disordered
Gen. Preservd*
Cons-ness
Disordered
Gen. Preservd*
Halluc’s
Often Present
Gen Absent*
Invol. Movmt Often Present
Gen Absent*
(* = Variable in Advanced Dementia)
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
1.
2.
3.
4.
1.
2.
3.
4.
5.
 Vision (<20/70)
Severe Illness
 Cognition (< 24 MMSE)
Dehydration (BUN/Cr > 18)
1-2 = Int. Risk  2.5 X as likely vs 0
3-4 = High Risk  9.2 X as likely vs 0
Phys. Restraints
Malnutrition
> 3 Med Classes added
Bladder Catheter
Iatrogenic Event
Int. Risk = 1-2  7.1 X as likely vs. 0
High Risk = 3-5  17.5 X as likely vs 01
Delirium versus Dementia
Feature
Delirium
Dementia
Onset
Acute
Insidious
Course
Fluctuating
Constant
Attention
Disordered
Gen. Preservd*
Cons-ness
Disordered
Gen. Preservd*
Halluc’s
Often Present
Gen Absent*
Invol. Movmt Often Present
Gen Absent*
(* = Variable in Advanced Dementia)
CHAMP
University of Chicago
Section of Geriatrics
53
Delirium in Hosp’d Seniors
Delirium in Hosp’d Seniors
University of Chicago, CHAMP Program
University of Chicago, CHAMP Program
Hx if Possible / Speak with Family
Focused Physical Exam (c Bladder, Rectal & Skin)
CBC, BMP c Ca, O2-Sat, ECG, U/A, ?CXR
REVIEW ALL MEDs
Hx if Possible / Speak with Family
Focused Physical Exam (c Bladder, Rectal & Skin)
CBC, BMP c Ca, O2-Sat, ECG, U/A, ?CXR
REVIEW ALL MEDs
? Possible Presence (or absence) of
Offending Drug
Discontinue or Decrease Dose
(Don't Forget to consider Withdrawal &
Drug Levels / Tox Screen)
Consider Re-Culture
Image or Re-Image
Adequate Abx Coverage?
? Explained Fever
? Volume Depletion / OverDiuresed?
? Electrolyte Disturbance?
Patient Improves ?
? Volume Depletion / OverDiuresed?
? Electrolyte Disturbance?
Appropriate Consultation
vs
Tincture of Time
Patient Improves ?
P
Ph
haarrm
m.. R
Rxx FFoorr D
Deelliirriiu
um
m ((O
On
nllyy iiff P
Ptt.. aatt R
Riisskk))
H a ld ol
Adv’s
DisAdv
DOSE
t-1/2
(range)
N.B.
 sedat;
less ΔBP;
IM or IV
(IV not
apprvd)
↓ seiz
thrshld;
 EPS
0.5-1 mg
po, IM, IV;
repeat in
30 mins x
1, then q4h
21h (1030h)
Use when
patient is
very
agitat’d
Resper
-id a l

sedat.;
+/- EPS
Zyprex
a

sedat.;
+/- EPS
Seroquel
Ativan
 EPS;
OK-PD
 time
to work;
wt gain;
DM;
Not-PD
0.250.5 mg
po bid
Same as
Risperid
Same as
Risperid;
Most
sedat of
atypicals
25mg po
bid to
start
Useful in
w/d; no
1st-pass;
no renal
adjust nec.
 sedat.
disinhibit.
possible;
+falls risk
20-30h
30h (2154h)
Same as
Risperid.
Use
when
med.
needed
but not
urgently
*PD = Parkinson’s Disease
2.5-5mg
po qd
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
6h
Same as
Risperid;
consider
in PD
Rx as Appropriate
? Focal Neuro Finding
? Reason to Suspect Stroke / Bleed
Neuro-Imaging; (EEG?)
No
Gentle Volume Repletion
Correct Electrolytes
? Hypoxemia or Ischemia
Rx as Appropriate
? Focal Neuro Finding
? Reason to Suspect Stroke / Bleed
Pan-Cx; Image; Consider LP
Empiric Abx Coverage
? UnExplained Fever
Gentle Volume Repletion
Correct Electrolytes
? Hypoxemia or Ischemia
Consider Re-Culture
Image or Re-Image
Adequate Abx Coverage?
? Explained Fever
Pan-Cx; Image; Consider LP
Empiric Abx Coverage
? UnExplained Fever
Discontinue or Decrease Dose
(Don't Forget to consider Withdrawal &
Drug Levels / Tox Screen)
? Possible Presence (or absence) of
Offending Drug
0.5-1mg
po, IM, IV
q6-8h
12h
Only
severe
agitation or
in w/d, or if
others N/A.
Neuro-Imaging; (EEG?)
Appropriate Consultation
vs
Tincture of Time
No
P
Ph
haarrm
m.. R
Rxx FFoorr D
Deelliirriiu
um
m ((O
On
nllyy iiff P
Ptt.. aatt R
Riisskk))
H a ld ol
Adv’s
DisAdv
DOSE
t-1/2
(range)
N.B.
 sedat;
less ΔBP;
IM or IV
(IV not
apprvd)
↓ seiz
thrshld;
 EPS
0.5-1 mg
po, IM, IV;
repeat in
30 mins x
1, then q4h
21h (1030h)
Use when
patient is
very
agitat’d
Resper
-id a l

sedat.;
+/- EPS
Zyprex
a

sedat.;
+/- EPS
Seroquel
Ativan
 EPS;
OK-PD*
 time
to work;
wt gain;
DM;
Not-PD
0.250.5 mg
po bid
Same as
Risperid
Same as
Risperid;
Most
sedat of
atypicals
25mg po
bid to
start
Useful in
w/d; no
1st-pass;
no renal
adjust nec.
 sedat.
disinhibit.
possible;
+falls risk
20-30h
30h (2154h)
Same as
Risperid.
Use
when
med.
needed
but not
urgently
2.5-5mg
po qd
6h
Same as
Risperid;
consider
in PD
0.5-1mg
po, IM, IV
q6-8h
12h
Only
severe
agitation or
in w/d, or if
others N/A.
*PD = Parkinson’s Disease
CHAMP
University of Chicago
Section of Geriatrics
54
CHAMP: Foley Catheters
Catherine DuBeau, MD, Geriatrics, Univ of Chicago
1. Does this patient have a catheter?
 Incorporate regular catheter checks on rounds as a
Practice-Based Learning and Improvement
 Exercise.
CHAMP: Foley Catheters
Catherine DuBeau, MD, Geriatrics, Univ of Chicago
1. Does this patient have a catheter?

2. Does this patient need a catheter?
Only FOUR Indications
A. Inability to Void
B. Urinary Incontinence and

Open Sacral or Perineal wound

Palliative Care
C. Urine Output Monitoring

Critical Illness—frequent/urgent monitoring
needed

Pt unable/unwilling to collect urine
D. After General or Spinal Anesthesia
2. Why should catheter use be Minimized?
a.
c.
Infection Risk:

Cause of 40% nosocomial infections
Morbidity

Internal Catheters
o Associated with Delirium
o Urethral & Meatal Injury
o Bladder & Renal Stones
o Fever
o Polymicrobial bacteruria

External (condom) Catheters
o Penile Cellulitus / necrosis
o Urinary Retention
o Bacteruria & Infection
Foleys are Uncomfortable / Painful
d.
e.
Foleys are RestrictiveFalls & Delirium
Cost
b.

2. Does this patient need a catheter?
Only FOUR Indications
A. Inability to Void
B. Urinary Incontinence and

Open Sacral or Perineal wound

Palliative Care
C. Urine Output Monitoring

Critical Illness—frequent/urgent monitoring
needed

Pt unable/unwilling to collect urine
D. After General or Spinal Anesthesia
2. Why should catheter use be Minimized?
a. Infection Risk:

Cause of 40% nosocomial infections
b. Morbidity

Internal Catheters
o Associated with Delirium
o Urethral & Meatal Injury
o Bladder & Renal Stones
o Fever
o Polymicrobial bacteruria

External (condom) Catheters
o Penile Cellulitus / necrosis
o Urinary Retention
o Bacteruria & Infection
c. Foleys are Uncomfortable / Painful
d.
e.
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
Incorporate regular catheter checks on
rounds as a Practice-Based Learning and
Improvement
Exercise
Foleys are RestrictiveFalls & Delirium
Cost
CHAMP
University of Chicago
Section of Geriatrics
55
CHAMP: Inability to Void
CHAMP: Inability to Void
Catherine DuBeau, MD, Geriatrics, Univ of Chicago
Catherine DuBeau, MD, Geriatrics, Univ of Chicago
1. Is there a medical reason for this patient’s inability to
void?
1. Is there a medical reason for this patient’s inability to
void?
Two Basic Reasons
Two Basic Reasons
 Poor Pump

Meds: anticholinergics, Ca++ Blockers, Narcotics

Sacral Cord Disease

Neuropathy: DM, B12

Constipation / Impaction
 Blocked Outlet

Prostate Disease

Supra-Sacral Spinal Cord Disease (e.g., MS) with
detrusor-sphincter dyssynergia

Women: scarring, large cystocele

Constipation / Impaction
Evaluation of Inability to Void
 Poor Pump

Meds: anticholinergics, Ca++ Blockers, Narcotics

Sacral Cord Disease

Neuropathy: DM, B12

Constipation / Impaction
 Blocked Outlet

Prostate Disease

Supra-Sacral Spinal Cord Disease (e.g., MS) with
detrusor-sphincter dyssynergia

Women: scarring, large cystocele

Constipation / Impaction
Evaluation of Inability to Void
Action Step
Possible Medical Reasons
Review Meds
-cholinergics, narcotics, Ca-Ch
Blockers, -Blockers
Review Med Hx
Diabetes with Neuropathy,
sacral/subsacral cord, B12, GU
surgery or radiation
Women-pelvic for prolapse; AllSacral Root S2-4—Anal Wink &
Bulbocavernosus reflexes
This should have been done in
evaluation of patient’s inability to
void, and repeated after catheter
removal with voiding trial
Physical Exam
Postvoiding Residual
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
Action Step
Possible Medical Reasons
Review Meds
-cholinergics, narcotics, Ca-Ch
Blockers, -Blockers
Review Med Hx
Diabetes with Neuropathy,
sacral/subsacral cord, B12, GU
surgery or radiation
Women-pelvic for prolapse; AllSacral Root S2-4—Anal Wink &
Bulbocavernosus reflexes
This should have been done in
evaluation of patient’s inability to
void, and repeated after catheter
removal with voiding trial
Physical Exam
Postvoiding Residual
CHAMP
University of Chicago
Section of Geriatrics
56
The Ideal Hospital Discharge
The Ideal Hospital Discharge
Catherine DuBeau, MD, Geriatrics, Univ of Chicago
Catherine DuBeau, MD, Geriatrics, Univ of Chicago
Components
1. Active advanced planning
–Anticipation from admission
–SHx: lives whom? ADLs & IADLs?
–Hosp course: delirium, deconditioning, medical Rx
2. Communication
–In hospital and at D/C: case managers, family, PCP
–Inter-facility: paperwork; direct phone call
Components
1. Active advanced planning
–Anticipation from admission
–SHx: lives whom? ADLs & IADLs?
–Hosp course: delirium, deconditioning, medical Rx
2. Communication
–In hospital and at D/C: case managers, family, PCP
–Inter-facility: paperwork; direct phone call
3. Core information elements:
3. Core information elements:
• Medical needs
• Medical needs
–Summary of admitting problems and course
–Active Problem list and allergies
–Recent important and pending labs
–Reconciled Med List (admit meds and all changes)
–Advance directives: DPOA-HC, preferences, goals
• Functional support (ADL, IADL)
–Summary of admitting problems and course
–Active Problem list and allergies
–Recent important and pending labs
–Reconciled Med List (admit meds and all changes)
–Advance directives: DPOA-HC, preferences, goals
• Functional support (ADL, IADL)
–Disposition: where from and where next
–Functional status: baseline and present
–Social support and contact info
–Disposition: where from and where next
–Functional status: baseline and present
–Social support and contact info
• Nursing needs: monitoring (BP, DM, CHF),
wounds, Ivs
• Rehabilitative needs: PT, OT, speech
• Nursing needs: monitoring (BP, DM, CHF),
wounds, Ivs
• Rehabilitative needs: PT, OT, speech
Possible transfer destinations
Possible transfer destinations
Home
Home w/
services
SNF
Rehab
(over)
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
Acute
Rehab
Home
Home w/
services
SNF
Rehab
Acute
Rehab
(over)
CHAMP
University of Chicago
Section of Geriatrics
57
Determining discharge destination
Home
Home
• Recovering ADL independence or stable baseline
• Sufficient and willing caregiver(s) to provide:
• Safety/supervision
• Meals
• Medication supervision
• ADLs and IADLs support
• No skilled nursing or PT/OT needs
Home
•
•
•
•
•
•
Home
SNF Rehab
• Newly
im
Newly Impaired ADL
• No need or unable to tolerate acute rehab
• Lack of sufficient and willing caregiver(s)
• Skilled nursing needs (eg, wounds, IVs)
• 3-night stay for Medicare SNF coverage
SNF Rehab
Unless new Rx NH can’t support (eg, NGTube)
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
Home
• Recovering ADL independence or stable baseline
• Sufficient and willing caregiver(s) to provide:
• Safety/supervision
• Meals
• Medication supervision
• ADLs and IADLs support
• No skilled nursing or PT/OT needs
Home
Home w/ services
Same as Home to Home except:
• Has Skilled nursing or PT/OT needs
• Skilled nursing care and PT covered by Medicare or
insurance
Acute Rehab
Needs and can tolerate intensive PT/OT(>1 hr/day)
Medically unstable for SNF
Needs frequent MD evaluation (> q2-4 wk)
Rising Cr, dropping Hgb
Meds need frequent adjustment (in < 24-48 hr)
Needs telemetry, daily/STAT labs
Nsg Home
Home
Home w/ services
Same as Home to Home except:
• Has Skilled nursing or PT/OT needs
• Skilled nursing care and PT covered by Medicare or
insurance
Home
Determining discharge destination
Home
•
•
•
•
•
•
Acute Rehab
Needs and can tolerate intensive PT/OT(>1 hr/day)
Medically unstable for SNF
Needs frequent MD evaluation (> q2-4 wk)
Rising Cr, dropping Hgb
Meds need frequent adjustment (in < 24-48 hr)
Needs telemetry, daily/STAT labs
Home
SNF Rehab
• Newly
im
Newly Impaired ADL
• No need or unable to tolerate acute rehab
• Lack of sufficient and willing caregiver(s)
• Skilled nursing needs (eg, wounds, IVs)
• 3-night stay for Medicare SNF coverage
Nsg Home
SNF Rehab
Unless new Rx NH can’t support (eg, NGTube)
CHAMP
University of Chicago
Section of Geriatrics
58
The Mini-Cog Assessment Instrument for Dementia
The Mini-Cog assessment instrument combines an uncued 3-item recall test with a clockdrawing test (CDT). The Mini-Cog can be administered in about 3 minutes, requires no special
equipment, and is relatively uninfluenced by level of education or language variations.
Administration
The test is administered as follows:
1. Instruct the patient to listen carefully to and remember 3 unrelated words (e.g., Ball,
Penny, Tree) and then to repeat the words.
2. Instruct the patient to draw the face of a clock, either on a blank sheet of paper, or on a
sheet with the clock circle already drawn on the page. After the patient puts the numbers
on the clock face, ask him or her to draw the hands of the clock to read a specific time,
such as 11:20. These instructions can be repeated, but no additional instructions should be
given. Give the patient as much time as needed to complete the task. The CDT serves as
the recall distracter.
3. Ask the patient to repeat the 3 previously presented words.
Scoring
Give 1 point for each recalled word after the CDT distracter.
Score 1–3.




A
A
A
A
score
score
score
score
of
of
of
of
O indicates positive screen for dementia.
1 or 2 with an abnormal CDT indicates positive screen for dementia.
1 or 2 with a normal CDT indicates negative screen for dementia.
3 indicates negative screen for dementia.
The CDT is considered normal if all numbers are present in the correct sequence and position,
and the hands readably display the requested time.
Source: Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive “vital signs” measure for
dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000; 15(11): 1021–1027.
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
59
CLOCK DRAW TEST
1) Inside the circle, please draw the hours of a clock as they normally appear
2) Place the hands of the clock to represent the time: “ten minutes after eleven o’clock”
Reproduced from: The Clock Drawing Test in : Palmer RM, Meldon SW. Acute Care. In: Principles of Geriatric Medicine and
Geronto l o g y , 5 th edition, 2003. Eds. Hazzard WR et al. McGraw-Hill Pub. pp 157-168. Inouye SK. Delirium in hospitalized
older patients. Clin Geriatr Med 1998; 14:745-764
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
60
Section 7. OSTE Module Evaluation Instrument
Retrospective Pre-Post on Confidence
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
61
Section 7: Participant Retrospective Pre-Post Evaluation
CHAMP PRATICE TEACHING SESSION
RETROSPECTIVE PRE /POST QUESTIONNAIRE FOR FACULTY SCHOLARS
Your responses to this form will be used for research purposes only and will be entirely confidential.
Name __________________________
Age_______
Gender_______
Department______________________ Division___________________________
Academic Rank__________________
Specialty__________________________
Total Years Teaching as Faculty______
A. Please rate the benefits of this Teaching Practice Session
Definitely
Not
Definitely
Yes
1. Was this experience useful?
1
2
3
4
5
2. Prior to this session did you think it would be useful?
1
2
3
4
5
3. Would you recommend a similar experience
to your colleagues?
1
2
3
4
5
B. In which G-OSTE Cases did you participate as the Attending (the teacher)?
1. Screening for Dementia
_____
2. Delirium
_____
3. Foley Catheters
_____
4. Transitions of Care
_____
C. Please rate your confidence (1) before participating in this Teaching Practice Session (as viewed retrospectively)
and (2) currently
Before this Session
Currently
Low
High
Low
High
1. Identifying Geriatrics
teachable moments
1
2
3
4
5
1
2
3
4
5
2. Incorporating geriatric content
learned in CHAMP into your teaching
on the wards
1
2
3
4
5
1
2
3
4
5
3. Using the “One Minute Preceptor”
method for teaching
on the wards
1
2
3
4
5
1
2
3
4
5
4. Using concepts & skills
from the Stanford Faculty Development
program, on the wards
1
2
3
4
5
1
2
3
4
5
5. Your ability to teach at the bedside
1
2
3
4
5
1
2
3
4
5
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
62
Before this Session
Low
High
Currently
Low
6. Your ability to teach dementia screening
in vulnerable elders, on the wards
1
2
3
4
5
1
2
3
4
5
7. Your ability to teach concepts related to
delirium in hospitalized vulnerable elders,
on the wards
1
2
3
4
5
1
2
3
4
5
8. You ability to teach concepts related
to Foley Catheter use in vulnerable elders,
on the wards
1
2
3
4
5
1
2
3
4
5
9. Your ability to teach concepts related
to appropriate discharge planning for
older adults.
1
2
3
4
5
1
2
3
4
5
High
Please Rate (circle) your Faculty Preceptors Overall Performance
Made session interesting
and comfortable
(Name)
(Name)
1 2 3 4 5
1 2 3 4 5
(Name)
1 2 3 4 5
(Name)
1 2 3 4 5
Made efficient use of time
Explained concepts clearly
Provided effective feedback
Provided useful suggestions for
Improvement
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
63
SECTION 8. SAMPLE LOGISTICS
(SHOWING FLOW OF 8 PARTICIPANTS THROUGH FOUR STATIONS)
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]d.uchicago.edu
CHAMP
University of Chicago
Section of Geriatrics
64
A1 and B1 Begin Here
As and B2 Begin Here
G-OSTE Station 1
Dementia
G-OSTE Station 2
Delirium
Fac A1 = Teacher
Fac B1 = Observer
SWITCH TEACHER &
OBSERVER
1 SL: Sub-I
1SP
Time = 30 mins
5 Mins
5 Mins
SWITCH TEACHER &
OBSERVER
Fac B2 = Teacher
Fac A2 = Observer
2 SL’s: Intern and
Resident
Time = 30 Mins
5 Mins
SWITCH TEACHER &
OBSERVER
A4 and B4 Begin Here
A3 and B3 Begin Here
G-OSTE Station 4
Foley
G-OSTE Station 3
Transitions
Fac A4 = Teacher
Fac B4 = Observer
SL = Res + Intern
SP = 1
Time = 30 Mins
SWITCH TEACHER &
OBSERVER
5 Mins
Fac B3 = Teacher
Fac A3 = Observer
SL = Res + Intern
Time = 30 Mins
•
2 Participants per Station: 1 Teacher & 1 Observer
•
Switch roles at each station  Teach X 2 & Observe--Give Feedback X 2
•
G-OSTE’s will allow Faculty-Learner to practice teaching twice at each station
•
Faculty will be given topics, but not complete scenario, in advance (see G-OSTE
Cases)
•
Faculty will have 5 Micro-Skills Instructional Materials to Review
•
All G-OSTE’s can be video-taped for Faculty-Learner Self-Assessment,
subsequent to this session
•
Total time = 3.5 Hours
Don W. Scott, MD, MHS
Assistant Professor of Medicine
[email protected]
CHAMP
University of Chicago
Section of Geriatrics
65
Download