Anne Scott Advanced Nurse Practitioner Medicine of the Elderly Royal Infirmary of Edinburgh Nurses General knowledge of Elderly Care and specifics of the Comprehensive Geriatric Assessment process. TarGetEd Aims of presentation • Why did I put myself forward? • The process and how I engaged with it • What question and perceived outcomes 1. Audit and questionnaire 2. Preliminary findings 3. Educational tools • Next steps • Summary and experience • Questions Why? • Need for experience off and support in research process (NMC and RCN) • Keen to engage with research within hospital setting regarding care of older people. • Wanted to look specifically at an element of nursing role Engagement – starting the process • Form from PROP 1. Question 2. Methods and data 3. 4. sources Out puts and communications Resources • Own team (Medics and • • nurse manager) agreed to support Met others in project both in hospital and at PROP study days in Edinburgh University Deciding on my specific question Questions!!!!!!!! • Are older people different? • What do we need to do to support them in • • • • hospital and out of hospital? How do we measure frailty? Fit 80 year old, 64 year old with multiple physical issues What is in the community? Telecare, telehealth, hospital at home, rehabilitation in the community, Carer support What do we assess? Do we know importance? Do we respond to information gathered? Comprehensive Geriatric Assessment – evidence to support use of CGA improves outcomes in the care of older people. Literature search • Meta analysis by Ellis showed benefit of process • Patients more likely to be in own home 12 mths after hospital if CGA occurred • British Geriatric society recommends use of CGA – ‘good Practice’ Comprehensive Geriatric Assessment? • Process used to identify and address issues in older people – involves multi disciplinary team • Social, health, financial, psychological aspects • Aspects specific to nursing assessment in first few days of hospital admission What was the goal of my work? • Highlight the importance of Comprehensive • • • Geriatric Assessment (CGA) within the nursing population in hospital Development of teaching tool and ongoing educational support for nurses regularly caring for older people Improve patient experience and outcomes Improve own practice, skills and knowledge Start of the ‘work’ • Audit case notes and look at documentation by nurses of ‘frailty tools’. Specific elements of CGA to be looked at 1. 2. 3. 4. 5. Falls assessments Nutrition Tissue viability Continence and toileting issues Cognitive Questionnaire Use of CGA as guide to appropriate questions Design questionnaire (difficult!) Target group of nurses cross specialities in admission and assessment areas Role out questionnaire Analyse results Who to ask? • Trained nurses in Medical, surgical, orthopaedic and Medicine of the elderly • First few days/hours of admission crucial to care • Large numbers of older people at hospital ‘front door’ Role out • Proposal to research team of own speciality • Explanation of work and proposal of research and agreement from Nurse managers and charge nurses • Sent out 50 questionnaires to trained staff in 4 distinct clinical areas Audit and Returns • Audited 22 sets of notes over 72 hour period • Good response from Medical and surgical areas • 40 returned out of 55 sent Results from notes 90 80 70 60 falls must cognitive Tissue viability continence 50 40 30 20 10 0 <24hrs 24hrs 48hrs >48 Main results Q1. On a usual day approximately how many patients are over >75 years within you clinical area? Number of band 5, 6 or 7 nurses / clinical area who completed a questionnaire 12 10 10 8 8 10 number Number 12 6 10 7 7 6 4 4 2 2 0 0 2 <25% 60% medical 50% MoE >70% orthopaedic 1 medical all patients MoE 5 surgical 1 Q3. Do you approach the assessment of an elderly patient (>75yrs) differently from younger patients? 1 orthopaedic 6 surgical 7 Q4. Frailty can be measured by scores. Are you familiar with any of these? 8 12 7 10 8 5 number number 6 4 3 6 4 2 2 1 0 0 depends medical no no/depends MoE orthopaedic yes yes/depends surgical medical MoE no orthopaedic yes surgical 1 Main results Frailty Q5. What makes you consider a patient is frail? MoE wards Q5. What makes you consider a patient is frail? Medical wards co-morbidities/ frequent admissions mobility mobility/co-morbidities/ frequent admissions 4 4 age/co-morbidities/ frequent admissions 1 mobility/co-morbidities/ frequent admissions/cognitive impairment 1 4 mobility/comorbidities/ frequent admissions all all 2 1 2 Q5. What makes you consider a patient is frail? Orthopaedic wards Q5. What makes you consider a patient is frail? Surgical wards co-morbidities/ frequent admissions 1 1 1 co-morbidities/ frequent admissions/cognitive impairment 1 4 co-morbidities/ frequent admissions 1 co-morbidities/ frequent admissions/cognitive impairment 1 mobility/co-morbidities/ frequent admissions 2 mobility/co-morbidities/ frequent admissions mobility/co-morbidities/ frequent admissions/cognitive impairment all all 2 7 (blank) Main results Nutrition • Nutrition – effects 10 9 8 7 number healing and ability to respond to acute physical insults, particularly in the elderly. Good knowledge base Q14. Can you describe why nutritional scores (MUST) are necessary/indicated ? 6 5 4 3 2 1 0 medical MoE yes but basic orthopaedic yes with confidence surgical Main results – bowels and bladder Q16. What can altered bowel habit commonly indicate? Clinical Area me dica l adverse effects adverse effects/poor diet M o E orthop aedic surg ical Q15. Do you consider the assessment of bowel habit important? 1 3 14 2 12 1 All answered "Yes" cancer 1 cancer/adverse effects 2 4 1 number 10 8 6 4 cancer/adverse effects/poor diet 2 cancer/renal issues/adverse effects 1 2 4 2 0 medical cancer/renal issues/adverse effects/poor diet 3 1 1 cancer/renal issues/adverse effects/poor diet/renal and CKD 1 surgical 14 12 1 1 extreme age/cancer/adverse effects/ 10 number extreme age/cancer/adverse effects 1 8 6 4 extreme age/cancer/adverse effects/poor diet 1 2 extreme age/cancer/renal issues/adverse effects/poor diet 1 1 none orthopaedic Q17. Do you consider assessment of urinary continence important in the assessment of the older patient? 1 extreme age/cancer//adverse effects/poor diet MoE 2 0 medical MoE no 1 orthopaedic yes surgical Main results cognitive • Dementia and Q7. Can you describe the difference between dementia and delirium? 8 7 6 5 number • delirium – common issues in older patients in hospital Important nurses know the difference between dementia and delirium. Often nurses first to identify issue 4 3 2 1 0 no yes - confident medical MoE yes - basic orthopaedic aware but unclear surgical cognitive – investigation and reviews Q9. If a patient is confused without a diagnosis of dementia what investigations/assessments/reviews would you consider/expect to be done in your clinical area? Medical wards 1 urine Q9. If a patient is confused without a diagnosis of dementia what investigations/assessments/reviews would you consider/expect to be done in your clinical area? MoE wards urine/bowel habits/fluid intake/medication 1 1 1 1 urine/bowel habits/fluid intake/medication urine/bowel habits/fluid intake/medication/referral to psych urine/fluid intake/medication 2 urine/bowel habits/fluid intake/medication/referral to neuro/referral to psych 5 urine/fluid intake/medication/referral to neuro/referral to psych 3 3 1 urine/bowel habits/fluid intake/medication/referral to psych urine/fluid intake/medication/referral to psych Q9. If a patient is confused without a diagnosis of dementia what investigations/assessments/reviews would you consider/expect to be done in your clinical area? Orthopaedic wards urine/bowel habits/fluid intake/medication Q9. If a patient is confused without a diagnosis of dementia what investigations/assessments/reviews would you consider/expect to be done in your clinical area? Surgical wards urine/bowel habits/fluid intake/medication/referral to psych 1 urine 1 urine urine/bowel habits/fluid intake/medication urine/bowel habits/fluid intake/medication/ 2 1 urine/bowel habits/fluid intake/medication/referral to psych 1 urine/bowel habits/medication 4 2 urine/medication/referral to neuro/referral to psych 2 1 urine/fluid intake/medication/referral to psych 1 1 1 urine/medication/referral to psych 3 urine/fluid intake/referral to psych urine/medication urine/medication/referral to psych TarGetEd Prompt for elderly patient assessments Confusion screen Bloods – routine and Vit B12, folate, TFT’s, Radiology – consider CT head Cognitive testing AMT <7 MMSE<24 4@T >4, Micro – consider infection screen inc MSU, Collateral history – include acute/chronic onset, alcohol, meds, falls Infection screen Bloods FBC, consider CRP, blood cultures, Micro - MSU, swab any wounds, consider change of catheter, Skin – check for sites and signs of infections Investigations – consider CXR, foreign travel Other - if pyrexial – is there a pattern? Falls assessment Bloods – include Calcium Falls check list – can include errect and suppine BP >20 difference significant. Check foot ware, exclude altered sensation at extremities, sit/stand test, environmental review, Cardiac investigations – consider 12 lead ECG, ECHO, 24 hour tape Medications – particularly anti hypertensive's, sedatives Eating and drinking Bloods – routine incl LFT’s – albumin particularly, Chewing and Swallowing – solids and/or fluids? Cough present? Mechanical issue (e.g.teeth) Weight loss and/or appetite concerns – food chart, weight chart, dietician referral, Others – GI signs or symptoms? AUSS? Collateral history? History of malignancy? Change in bowel habit or appearance Continence screen Bloods – routine consider PSA (male), Radiology – renal ultra sound if associated with AKI, Medications – diuretics, Micro – MSU, Others – bladder scan, DRE (prostate, constipation) continence chart, symptoms of urgency, frequency or discomfort, referral to continence service anne.scott@luht.scot.nhs.uk Advanced Nurse Practitioner, Medicine of the Elderly, Royal Infirmary Edinburgh. (PROP) Targeted 1. Hb115 – 160 2. WBC 4.0 - 11.0 3. Plate 150 - 350 1. 2. 3. Reduced in anaemia. Blood loss? Chronic? Diet? Fluid status can affect Hb – can drop acutely with hydration Raised infection also can be decreased infection, immuno suppression. Elderly sometimes delayed response to acute sepsis Low haematological issue – check for bleeding, bruises, high - ?infection 4. Urea 2.5 - 6.6 4. Low indicate alcohol/liver issues. High dehydration, check meds – ongoing diuretics 5. Na 135 - 145 5. Abnormal can cause confusion, drowsy/coma, falls, suggests fluid problems, endocrine disorder 6. K+ 3.6 - 5 6. 7. Creat 60 - 120 7. K+ changes due to medication, diabetic, hydration. Can cause arrhythmias Creatinine – raised in renal failure, changes can indicate muscle loss 8. GFR >60 8. GFR – often reduced in elderly as part of normal aging process. Decrease can influence medication choices and radiological investigations requiring contrast d mobility No issues First fall but independentl y mobile Uses aid but no falls. Sensory problems +/- falls score 1-2 General decline in mobility over weeks +/- falls score 1-2 Acute decline +/- falls score >3 Only mobile with assistance of 2 /hoist Bed/chair nce No issues Stress Chronic continence previously investigated/diagnos ed Acute incontinence with no associated symptoms Acute incontinence with symptoms – discomfort, frequency, smell colour Incontinence of urine or faeces. Acute or chronic Catheteriz inc an Re rec and rinking No issues Decreased appetite over long period of time. MUST 0 General malaise with associated appetite changes and GI symptoms. MUST score triggered Acute nausea and vomiting. +/- MUST score triggered +/unplanned weight loss Problems due to physical cause/swallow of potentially reversible/treatable issues such as Parkinson’s, stroke, NBM order Inability of patient to maintain own nutritional state – e.g. blocked PEG End of life viability No issues Waterlow score <10 Waterlow 10-14 and mobility restricted and/or repeated friction to area. Ulceration Waterlow 15-19 but with evidence of tissue damage. Cellulites and/or ‘wet’ legs. Marked peripheral oedema Waterlow >20 Pressure sore present on admission End of life on No issues Slight decrease in memory. No diagnosis of dementia. AMT >8 Known cognitive impairment and no acute changes. Acute changes from patient base line but obvious cause for delirium – e.g. UTI/chest infection Confusion associated with agitation and/or increased drowsiness not related to sedation. Not orientated. Cognition testing score abnormal Requires s an inc nu du ag >2 admissions in 6mths and impact on independence. Lives alone >2 admissions in 6mths. +/- patient hou +/- daily in-put from district nurs rm ondition/m ltiple comorbidities incontinence / managed with pad No recurrent admissions (6mth period) 2 admissions due to LTC in 6 mths. Presence of multiple co-morbidities patients should have had short period of post operative care before referral are made to attempt to gage patients need for rehab. If considering rehab or identification of needs have been made please discuss/refer with therapy teams for assessments The Poster! Significant issue • Prompt card and lanyard – not possible Infection control, health and safety issues, already several ‘prompt’ cards inexistence Information and results so far • • • • 1. 2. 3. 4. • Good level of knowledge and ability in cohort of nurses in front door areas High level of returns suggests an appetite for engagement from nurses Significant differences of approaches and knowledge– cognition, frailty, knowledge of community services Further investigation and progression would be beneficial Short talks Articles into local news letters Sharing results Further work especially regarding the community and hospital interface Own knowledge of research and CGA improved Next steps • Ongoing promotion of CGA through own role • Further areas for research/investigation or • • extension of excising work regarding CGA Continued engagement from own work place in support, skills and knowledge of research and older people care Development of closer ties with other hospitals addressing similar patient population and processes What was the goal of my work? • More recognition of the comprehensive geriatric assessment within the nursing population in hospital • Development of teaching tool and ongoing educational support for nurses regularly caring for older people • Improve patient experience and outcomes • Improve own practice, skills and knowledge • Yes • Yes – even if its not what I’d been aiming for • Need further investigation • Yes Finally • Would I do it again? • Did I think the • • • process valuable? What have I gained? What has the organisation gained? What implications does it have to older people in hospital? • Yes! • Yes • Knowledge of nurses • • experience and practices in assessment areas A poster! Highlighted elderly assessments Thanks