The Patient Protection and Affordable Care Act Is

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Objectives

To Transfer • Highlight key factors related to acute care or Not To Transfer: transfers That Is the Question

• Discuss ways the Affordable Care Act addresses hospital re-admissions

• Identify the key clinical competencies related to management of CHF, Pneumonia, Acute MIs, UTIs, and Sepsis as well as those associated with LeadingAge New York –The Sagamore Resort advance care planning discussions DNS/DSW Annual Conferences November 14, 2013 Louann A. Lawson, BA, RN, RAC‐CT • Identify ways to incorporate INTERACT Version Nurse Consultant/Clinical Reimbursement Team Leader 3.0 into your organization’s quality improvement [email protected] 2 ©Pathway Health 2013 efforts ©Pathway Health 2013

Some Facts Some Facts

25% of Medicare patients admitted to SNFs from Up to 67% of hospital transfers are rated as hospitals are readmitted to a hospital within 30 potentially avoidable by expert LTC professionals days

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Some Facts Health Care Reform

The Patient Protection and Affordable Care Act is focused on a triple aim: Medicare has financial incentives in place to reduce potentially avoidable hospital transfers through • Improving quality of care pay-for-performance, bundled payments, and other strategies • Improving health • Making care affordable

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HRRP – Part of ACA Key Points: Day-to-Day

Hospital Readmission Reduction Program

• Began October 1, 2012 • Set up a systematic, self-sustaining process • Medicare recovers payments from hospitals for unnecessary re-admissions within 30 days of • Anticipate, Prevent, Intervene Early discharge. • Pneumonia, CHF, and Acute MI were the first • Improve and Celebrate diagnoses to be monitored • Recovery amounts will increase, the number of Once the situation deteriorates, it’s very diagnoses being monitored will increase, and there may be recovery of payments from other difficult to prevent a transfer providers.

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A Quality Improvement Program Quality Improvement & INTERACT

• The INTERACT Version 3.0 tools are meant to be used together in your daily work in the nursing home

http://interact2.net

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Safe Reduction of Hospital Transfers A Tale of Three Siblings

• Preventing conditions from becoming severe enough to require hospitalization through early identification & assessment of changes in resident condition • Sadie • Managing some conditions in the NH without • Sara transfer when this is feasible and safe • Sam

• Improving advance care planning and the use of palliative care plans when appropriate as an alternative to hospitalization for some persons

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Sadie INTERACT Strategy

96-year-old Long-Stay NH Resident • Hospitalized for UTI and dehydration • Discharged back to the NH after 4 days • Re-hospitalized 7 days later for Prevent conditions from becoming dehydration and recurrent UTI severe enough to require hospitalization through early detection and evaluation

Preventable?

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Sara INTERACT Strategy

98-year-old Long-Stay NH Resident • Hospitalized for a lower respiratory infection, but had normal vital signs and oxygen saturation Manage some conditions in the NH • Developed delirium in the hospital, fell, without transfer when it is feasible and fractured her pubis, and developed a safe pressure ulcer

Preventable?

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Sam INTERACT Strategy

101-year-old Long-Stay NH Resident • Hospitalized for the 4th time in 2 months for aspiration pneumonia related to end- Improve advance care planning and stage Alzheimer’s disease the use of palliative care plans when • Transferred to hospice on the day of re- appropriate as an alternative to admission hospitalization

Preventable?

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Common Trends Stop and Watch

• Delay in identifying change in condition

• Lack of evaluation before calling physician

• Physician insistence on transfer

• Resident or family expectations • Communication problems between nurses, or between nurses & primary care clinicians

• Services needed are not available or timely in the facility

• Delay in advance care planning

• Others?

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STOP and

• Seems different than usual • Ate less

• Talks or communicates less • No bowel movement in 3 days; or diarrhea • Overall needs more help • Drank less • Pain – new or worsening; Participated less in activities

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WATCH STOP and WATCH Purpose

• Weight change • To guide direct care staff • Agitated or nervous more than usual through a brief review of early changes in a resident’s Begins the assessment process condition • Tired, weak, confused, or drowsy Shortens response time • To improve communication between frontline staff and Clinical care to reduce • Change in skin color or condition the nurse in charge about avoidable hospital early changes in condition transfers begins with this tool • Help with walking, transferring, toileting more than usual 23 24 ©Pathway Health 2013 ©Pathway Health 2013

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INTERACT Early Warning Tool Decision Support Tools

• Addresses relevant changes in condition • Change in • Care Paths Condition File • Actions and behaviors that are not part of Cards the resident’s normal routine

• A change from the resident’s baseline

• Consistent assignment is a key concept for effect use

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Change in Condition File Cards Change in Condition File Cards INTERACT Decision Support Tools • When to Report to MD/NP/PA • The INTERACT Change – Immediate vs. Non-Immediate in Condition File Cards are meant to be • Vital Signs visible and to sit next – B/P, Pulse, Respirations, Temperature to the phone for quick reference. – Weight loss or gain • Lab Tests & Diagnostic Procedures • New version based on AMDA Clinical Practice – CBC, Chemistry, Consults, INR, Urinalysis, Urine Guidelines Culture, X-Ray • Signs & Symptoms A - Z

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Care Paths Expanded List of Care Paths

• Acute Mental Status Change • Change in Behavior: New or Worsening Behavioral Symptoms • Dehydration • Fever • GI Symptoms – Nausea, Vomiting, Diarrhea • Shortness of Breath • Symptoms of CHF • Symptoms of Lower Respiratory Illness • Symptoms of UTI

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Case Study: Rose, 92, LT NH Resident Case Study: Rose, 92, LT NH Resident

• Rose has a history of COPD • Two days later, the and CAD and had an acute MI nurse notes that Rose’s 6 months ago breathing is a little more • At 8 P.M. she complains of increased shortness of breath labored after an upsetting phone call • Her respiratory rate is with her daughter 30 and her oxygen • Her respiratory rate is 26, her saturation is 89%. She oxygen saturation is 92%, both unchanged from her has faint wheezes on baseline lung exam. • The nurse finds no abnormal • She also has the new lung sounds on exam onset of pedal edema

• Does the clinician on call need to be notified • Does the clinician on immediately? call need to be notified immediately?

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Change in Condition File Cards Shortness of Breath

• Immediate – Abrupt onset of s.o.b. with pain fever, or respiratory distress

• Non-Immediate – Recently progressive or persistent minor s.o.b. without other symptoms OR with progressive leg edema

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Care Paths Critical Component of Strategic Plan INTERACT Decision Support Tools

Refer also to the CHF and Lower Respiratory Increase Nursing Staff Competency Infection Care Paths

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Where Do We Begin? Education Plan

Know Where Your Participants Stand

• Why are they there?

• What do they believe?

• What do they know?

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Education Plan Adult Learning Cycle

3 Domains of Learning Experience – Past & Present • Knowledge – Evidence-based

Application Reflection • Attitudes – Core beliefs

• Skills Generalization – Tools, Resources, Implementation strategy

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Suggested Competencies

• “The Basics” – Hand Washing, Vital Signs, Weights

• Specific Disease States – Pneumonia, CHF, AMI, UTI, Sepsis The Department of Veterans Affairs National Center for Patient Safety • Change in Condition (SBAR) Hierarchy of Actions – Mental status, Functional status, Respiratory, GI/Abdomen, GU/Urine Changes ©Pathway Health 2013 42 • Professional Communication – Internal and External • Advance Care Planning

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The Weakest Link WEAK Actions

Weak actions enhance or enforce existing processes: The weakest link in the process is implementing solutions that are centered on • Double checks training & education, or asking clinicians to “be • Warnings/labels more careful.” • New policies / procedures / memoranda • Training/education

Depend on staff to remember their training or what is written in the policy.

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WHY? Human Error

These solutions don’t impact the system, & are based Solutions that rely on vigilance or memory are on two assumptions- equally problematic because they create expectations for staff to remember more or be more careful. 1. Lack of knowledge contributed to the event, This is not always realistic when staff are in stressful and situations or when multi-tasking.

2. If a person is educated or trained, the mistake If the system doesn’t provide support, it is part of won’t happen again. the problem.

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INTERMEDIATE Actions STRONG Actions

Somewhat dependent on staff remembering to do the Do not depend on staff to remember to do the right right thing, but provide tools to help staff remember thing. or to promote clear communication. May not totally eliminate the vulnerability but provide Intermediate actions modify existing processes: strong controls.

• Decrease workload Change or re-design the process - help detect & warn • Software enhancements & modifications so there is an opportunity to correct before the error • Checklists, cognitive aids, triggers, prompts reaches the patient. • Read back • Enhanced documentation & communication

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Strong Actions = Hard Stops Leadership Buy-In

Won’t allow the process to continue unless something is corrected or signals intervention to prevent • There will be an investment of time. significant harm: • Involve staff at all levels in change process • Physical changes: grab bars, nonslip strips • Be transparent: share goals, timeline, all • Forcing functions: only O2 can be run to oxygen lines data, and results (good and bad) with staff frequently as change is implemented across facility • EMR: cannot save unless all fields are filled in • Ask for and listen to staff input throughout • Simplifying: unit dose implementation process

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Pneumonia

Specific Disease States

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Pneumonia & the ACA Pneumonia

Lower respiratory tract infection is one of the leading causes of preventable hospital readmissions. • Mortality rate 30-50%

• Pneumonia is the 6th leading cause of death in the • Risk factors: United States. – Emphysema • CDC recommends high risk groups get vaccinated – Chronic bronchitis against the flu and bacterial pneumonia – Diabetes

• Most pneumonias are due to aspiration (CDC)

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Pneumonia Pneumonia

• Pneumonia is an inflammation of the lungs • Pneumonia can range in seriousness from mild to caused by infection. life-threatening.

• Battling the infection, the alveoli (air sacs in the • Pneumonia often is a complication of another lungs) fill up with mucus, pus, white blood cells, condition, such as the flu. and other liquids. • Antibiotics can treat most common forms of • Makes it difficult for oxygen to reach the bacterial pneumonias, but antibiotic-resistant bloodstream. Causes risk for infection to spread strains are a growing problem. to the entire body. • The best approach is to try to prevent infection.

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Pneumonia Rule Out Other Conditions

• Collapse of lower airways • Noninfectious cardiac and pulmonary disorders, • Weakened chest muscles such as CHF.

• Decreased swallowing ability • Asymptomatic acute myocardial infarction—fever, shortness of breath, and chest pain—may mimic pneumonia • Decreased elastic tissue surrounding alveoli – ECG & cardiac enzyme levels help rule out MI • Pulmonary embolism • ↑ Fibrous connective tissue of rib cage: ↓ bronchial – Arterial blood gas analysis or lung scanning may movement, ↓air exchange, ↑residual air rule out pulmonary emboli as a cause of the patient's pulmonary symptoms. • At end of expiration, 80 year old has 50% more air 57 58 left in lungs than 25 year©Pathway Healthold 2013 ©Pathway Health 2013

New McGeer Criteria (1 of 2) New McGeer Criteria (2 of 2)

• Must have CXR demonstrating pneumonia or a new infiltrate • AND • AND • Must have at least one of the • One of following: Constitutional Criteria – New or increased cough – Fever – Pleuritic chest pain – Leucocytosis – New or increased sputum production – Acute change in mental status from baseline – O2 Sat < 94% RA or reduction of >3% baseline – Acute functional decline – New or changed abnormal chest exam(Lung • Bed mobility, transfer, locomotion, dressing, sounds) toilet use, personal hygiene, eating – Respiratory rate ≥ 25

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Presenting Symptoms Symptom Progression

• Pain is usually sharp and worsens when taking a • Symptoms may be masked due to co-existing deep breath and is known as pleurisy pain disease states, corticosteroids, and anti- inflammatory medications • In other cases of pneumonia, depending on the causative organism, there can be a slow onset of • May first present with failure to thrive, increased symptoms. rate of respirations, altered mental status, dehydration • A worsening cough, headaches, and muscle aches may be the only symptoms. • Chest x−rays, complete blood count, and pulse oximetry are basic diagnostic tools. • Productive cough – Noisy, expulsive, forceful and involves blood, sputum *First symptom of weakness may be a fall – Observe for color, odor, consistency of sputum – Note frequency and intensity 61 62 ©Pathway Health 2013 ©Pathway Health 2013

Pneumonia Complications Position Matters

• Bacteremia – Bacteria in the bloodstream • Right-sided lying – Infiltrates most likely involve the • Lung abscess right upper lobe. – A cavity containing pus (abscess) that forms within the area affected by pneumonia is another potential complication • Left-sided lying • Acute respiratory distress syndrome (ARDS) – Most likely location of the infiltrates is the left – The pneumonia involves most areas of both lungs, upper lobe. making breathing difficult and depriving their body of oxygen. Underlying lung disease of any kind, but especially COPD, increases susceptibility to ARDS. • Supine – Multiple lobes involved • Pleural effusion Cunha, B.,MD, Bronze, M., MD, (2012) – Fluid collects in the pleural space around the lung as a result of the inflammation from pneumonia 63 64 ©Pathway Health 2013 ©Pathway Health 2013

Aspiration Pneumonia Aspiration Alerts

• Inflammation of the lungs and airways to the • Past episodes of aspiration, aspiration pneumonia bronchial tubes from breathing in foreign material. • Cerebral palsy, muscular dystrophy, epilepsy, GERD, dysphagia or hiatal hernia • Aspiration pneumonia occurs when foreign materials (usually food, liquids, vomit, or fluids • Inappropriate food textures or fluid consistency from the mouth) are breathed into the lungs or airways leading to the lungs. • Drowsiness, lethargy (may be medication-related)

• Unable to sit upright while eating

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Aspiration Warning Signs Pneumonia & Oral Hygiene

• Rhinitis while eating • Intermittent fevers • Yale Study linked oral care and respiratory illness

• Persistent coughing during • Chronic dehydration • The Dental Health Foundation has warned that or after meals poor oral hygiene could cause respiratory infection • Unexplained weight loss after research found a link between bacteria in the • Irregular breathing, mouth and the lung disease turning blue, moist • Vomiting, regurgitation, respirations, wheezing or rumination and/or odor of rapid respirations, chronic vomit or formula after • Study states more research is needed to know asthma, congestion meals exact link between the two.

• Food or fluid falling from mouth or drooling

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Admission Risk Factors Respiratory Assessment

• When measuring and recording respirations the • Viral infections • Drug addiction rate, depth and pattern of breathing should be • COPD, emphysema • Stroke recorded for a full minute • Heart disease • Seizure • A respiratory rate of 12-18 breaths per minute in • Diabetes • Poor oral health a healthy adult is considered as normal (Blows, 2001) • Alcoholism • Feeding Tubes • Tachypnea the rate is regular but over 20 • Smoking breaths per minute • Pain • Bradypnea - the rate is regular but less than 12 breaths per minute. • Apnea - there is an absence of respiration for several seconds this can lead to respiratory arrest. 69 70 ©Pathway Health 2013 ©Pathway Health 2013

Respiratory Assessment Respiratory Assessment

• Dyspnea - difficulty in breathing, the patient gasps for air. • Observe the breathing • Cheyene-Stokes Respiration - – Is the person mouth breathing, pursing the lips breathing is shallow, very slow and on expiration, using the abdominal muscles or labored with periods of apnea. This flaring the nostrils? type of breathing is often seen in the dying patient.

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Respiratory Assessment Respiratory Assessment

• Note the color of the person's lips Oxygen Saturation

• They may be cyanotic (blue) or discolored if the • The oxygen saturation (SaO2) may be recorded patient has respiratory problems using a pulse oximeter.

• Cyanosis can also be observed in the nail bed, tip • This will provide an accurate reading of of the nose and ear lobes oxygenation in the red blood cells. (Woodrow, 2005)

• With pneumonia, often the O2 sat is < 94%

(McGeer, 2012)

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Respiratory Assessment Respiratory Assessment

Oxygen Lung Sounds

• If a patient has been prescribed oxygen, ensure • Clean stethoscope the oxygen mask or nasal cannula is correctly placed prior to recording respirations • Correct placement of stethoscope • Have return demonstration • Check that the oxygen flow rate is set as • Use youtube.com for educational prescribed and recorded resources • Frequent checks if abnormal lung sounds • Observe if resident compliant with use of NC or are heard. (Not just on admission) mask

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Pneumonia Diagnosis Focus on Prevention

• Coarse or crackling sounds, wheezing, or faint breathing sounds

• Chest x-ray reveals congestion and fluid, inflammation

• Sputum contains organisms

• WBCs – ↑ neutrophils are seen in bacterial infections, – ↑ lymphocytes are seen in viral infections, fungal infections, & some bacterial infections (like tuberculosis).

• Bronchoscopy-examination & specimens from infected area.

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Interventions for Prevention Prevention - Enteral Feedings

Standard aspiration precautions • Good hand washing! – Audit, Audit, Audit! – Administer tube feedings in an upright sitting position • Review respiratory assessments – Keep HOB elevated at least 45 degrees or per orders

• Treat pain (Review therapy schedules) – Check for placement & residual with each infusion • Have pillows for repositioning – Don’t feed too rapidly • Hug pillow for pain • Use of incentive spirometer – Administer meds one at a time to gravity • Encourage turning, coughing and deep breathing – Feedings should be administered over at least 30 • Immunization! minutes or as ordered

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Interventions for Prevention Interventions for Prevention

• Involve speech therapy • Ensure caregivers are following precautions for assisting with eating/drinking • Audit for proper technique for enteral feedings

• Report weak or absent coughing/gagging • Audit direct care staff with ADLs (HOB up) reflexes, changes in chewing or swallowing skills

• Review who is feeding those at risk • Report food stuffing, rapid eating/drinking, pocketing or pooling of food • Staff access to feeding techniques from ST

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Prevention – Oral Hygiene CDC Recommendations

• Teach good oral care • Hand hygiene after contact with respiratory • Audit that it is being performed- return secretions demonstration • Wearing gloves for suctioning • Change toothbrush after any type of illness • Elevating the head of the bed 30 to 45 degrees • Routine dental care by dental hygienist or during tube feeding and for at least 1 hour after to dentist decrease aspiration

• Good hydration • Vaccination of high-risk residents with pneumococcal vaccine.

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Pneumococcal Vaccine CDC Recommendations

Oxygen Administration • The pneumococcal vaccine protects against multiple bacteria species, the most • Humidity common cause of respiratory infections. – Sterile water (not distilled or tap) • Humidifier • Experts now recommend that more – Clean according to manufacturer people, including healthy elderly people, – Sterile be given the pneumococcal vaccine, particularly in light of the increase in antibiotic-resistant bacteria.

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CHF CHF & ACA

Understanding and Management of • Primarily a condition of the elderly Heart Failure • Incidence of Heart Failure is 1 per 100 population after age 65 (2009 Update to American Heart Association 2005 Guidelines) • The most common Medicare hospital discharge diagnosis

• More Medicare dollars being spent on this diagnosis than on any other single diagnosis

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What Is Heart Failure? What Is Heart Failure?

• May be referred to by several names: http://www.youtube.com/watch?v=GnpLm9fzYxU

– Heart Failure • Heart failure is a condition in which the heart – Congestive Heart Failure can't pump enough blood to meet the body's – Left-sided Heart Failure or needs. – Right-sided Heart Failure • In some cases, the heart can't fill with enough blood. In other cases, the heart can't pump blood to the rest of the body with enough force. • We will focus on heart failure as a general • Some people have both problems. condition

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What Is Heart Failure? Overview of Heart Failure

The term "heart failure" doesn't • Right-side heart failure occurs if the mean that the heart has stopped heart can't pump enough blood to the or is about to stop working. lungs to pick up oxygen. However, heart failure is a serious • Left-side heart failure occurs if the condition that requires medical heart can't pump enough oxygen-rich care. blood to the rest of the body.

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Overview of Heart Failure Overview of Heart Failure

• Right-side heart failure may cause fluid to • Heart failure develops over time as the heart's build up in the feet, ankles, legs, liver, abdomen, pumping action grows weaker and the veins in the neck

• The condition can affect the right side of the heart • Right-side and left-side heart failure also may only, or it can affect both sides of the heart cause shortness of breath and fatigue (tiredness). • Most cases involve both sides of the heart.

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Ejection Fraction (EJ) Ejection Fraction (EF)

• What is it? – A measurement of how much blood the left • What's too low? ventricle pumps out with each contraction. – A measurement under 40 may be – Measured as a percentage % evidence of heart failure or cardiomyopathy. – An EF between 40 and 55 indicates damage, perhaps from a previous heart attack, but it • What it means may not indicate heart failure. – An ejection fraction of 60 percent means that 60 – In severe cases, EF can be very low. percent of the total amount of blood in the left • What's too high? ventricle is pushed out with each heartbeat. – EF higher than 75 percent could indicate a heart condition like hypertrophic • Normal EF = 55 to 70 percent cardiomyopathy.

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Ejection Fraction and Heart Failure Leading Causes of Heart Failure

• You can have a normal EF reading and still have • The leading causes of • Examples include: heart failure. heart failure are – Coronary heart diseases that damage disease (CHD) • If heart muscle becomes so thick and stiff that the heart. – High blood pressure the ventricle holds a smaller-than-usual volume – Diabetes of blood it might still seem to pump out a normal – Faulty heart valves % of the blood that enters it. In reality, the total amount of blood pumped isn't enough to meet – Cardiomyopathy your body's needs. – Myocarditis – Congenital heart defects – Heart arrhythmias

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Risk Factors for Heart Failure Risk Factors for Heart Failure

• Anemia • Fluid volume overload with non-cardiac causes • Arrhythmia (e.g., a-fib) • Idiopathic dilated cardiomyopathy • Chronic hypertension • Medications • Chronic lung disease • Other cardiomyopathy (e.g., Sarcoidosis is a • Coronary artery disease (Angina or MI) disease of unknown cause that leads to • Diabetes mellitus inflammation. This disease affects your body’s organs.) • Excessive alcohol intake • Sleep-disordered breathing • Thyroid disease (hypo or hyperthyroidism) • Valvular Heart Disease (e.g., aortic stenosis, mitral regurgitation)

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Reversible Causes of Heart Failure Reversible Causes of Heart Failure

• Arrhythmia (e.g. Atrial Fibrillation) • Severe anemia • Coronary artery disease • Thyroid disease • High salt intake • Uncontrolled hypertension • Medications (e.g., antiarrhythmic drugs, calcium • Valvular heart disease channel blockers, NSAIDs, thiazolidinediones-DM Type II drugs) • Pulmonary embolism • Renal Failure

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Signs That Suggest Heart Failure Signs That Suggest Heart Failure

• Ascites or sacral edema • Rales on lung exam – Fluid that pools in the abdominal or sacral area. Sacral – Wet and moist edema may be seen when patient is supine.) • Hypoalbuminemia (Low albumin) • Tachycardia • Increased jugular venous pressure • Laterally displaced apical impulse • Third heart sound (S3) (Pulse displaced from midclavicular line@ 5th intercostal space) • Weight gain – 2 lbs. in one day or • Peripheral edema not due to venous insufficiency – 5 lbs. in one week

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Symptoms That Suggest Heart Failure Symptoms of Heart Failure

• Fatigue • Abdominal symptoms (nausea, abdominal pain or • Orthopnea distention) • Unexplained cough, especially at night • Acute confusion, delirium • Paroxysmal nocturnal dyspnea • Anorexia • Weakness • Decline in functional status • Decreased exercise tolerance • Decreased food intake • Dyspnea at rest • Dyspnea on exertion

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Potential Risks What to Teach Direct Care Staff

• Falls • Direct-care staff should be trained to recognize and report subtle differences in a patient’s • Decline in energy levels condition, such as: – Clothing (e.g., shoes, pants) appears tight • Decline in ability to participate in ADLs or – New or increasing lower-extremity swelling activities – Patient appears lethargic or mentally sluggish – Patient is less active • Decrease in sleep quality

• Depression and/or anxiety

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What to Teach Direct Care Staff Assessment

– Patient has more difficulty breathing with or without exertion • Monitor and document the following: – Vital Signs

– Unexplained cough – Oxygen saturation level (O2 sats) – Peripheral pulses – Unexpected weight gain – Heart and Lung sounds • Patients should be weighed at the same time of day, in – Blood glucose level the same state of dress, with the same – Shortness of breath at rest and with activity equipment/devices, and on the same scale.) – Edema or swelling (lower extremities, sacral, • Weight gain of 2 lbs. in one day or 5 lbs. in one week abdominal, periorbital, etc.)

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Assessment Lab Tests

• Complete Blood Count – Pain level (chest pain, shoulder pain, etc.) – A reduced red blood cell count (anemia) may – Cough and sputum production mean that heart failure is caused or aggravated by a decrease in the oxygen- – Cyanosis carrying capacity of the blood. – Daily weights – Even if this is not the case, a low blood count – Intake and output can make the heart work harder and can be dangerous – Activity tolerance, increased lethargy • Thyroid – Capillary refill – Abnormal findings may be a sign that heart – Jugular vein distention failure is caused or made worse by an – Skin turgor underactive thyroid (hypothyroidism) or an overactive thyroid (hyperthyroidism) 111 112 ©Pathway Health 2013 ©Pathway Health 2013

Lab Tests Lab Tests

• Serum levels of BNP- B-type Natriuretic Peptide: • Serum electrolytes – BNP is a substance secreted from the ventricles or lower chambers of the heart in response to changes in pressure – People with heart failure need to maintain the that occur when heart failure develops and worsens. concentration of electrolytes in the blood – BNP is made by the heart and tells how well the heart is (particularly sodium, potassium, and working. Normally, only a low amount of BNP is found in magnesium) the blood. – However, if the heart has to work harder over a long period • Creatinine of time, such as from heart failure, the heart releases – High levels of creatinine may indicate that a more BNP and the blood level of BNP will get higher. kidney problem is responsible for fluid buildup – The BNP level may drop when treatment for heart failure is in the body, not heart failure working. – BNP levels below 100 pg/mL indicate no heart failure – BNP levels of 100-300 suggest heart failure is present – BNP levels above 300 pg/mL indicate mild heart failure – BNP levels above 600 pg/mL indicate moderate heart failure. – BNP levels above 900 pg/mL indicate severe heart failure. 113 114 ©Pathway Health 2013 ©Pathway Health 2013

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Medical Treatments Medications

• Treat exacerbating conditions (e.g., anemia, • Angiotensin-Converting Enzyme (ACE) Inhibitors diabetes, cardiac arrhythmia, infection, fever) – These drugs help people with heart failure live longer and feel better. – ACE inhibitors are a type of vasodilator, a drug that • Treat fluid volume overload, if present. widens blood vessels to lower blood pressure, improve – Start on loop diuretic as prescribed blood flow and decrease the workload on the heart. – Examples include enalapril (Vasotec), lisinopril (Prinivil, – Monitor weight and blood pressure Zestril) and captopril (Capoten).

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Lab Rationales Lab Rationales

• BUN / Creatinine • Potassium – Elevated due to decreased perfusion of the kidneys & – Low value may be due to non-potassium sparing diuretic use or low with fluid overload diuretics & certain cardiac drugs • Hemoglobin / Hematocrit – High value may be due to potassium sparing diuretics & – Elevated with dehydration or low with fluid overload certain cardiac drugs • Glucose • Sodium – May be elevated with stress, diabetes – Low value may indicate fluid overload and dilutional • Chloride hyponatremia – Low value may indicate increasing or new CHF – Low value may be a side effect of ACE Inhibitors – High value may indicate dehydration due to diuretics

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Myocardial Infarction Myocardial Infarction

• http://www.youtube.com/watch?v=V_1 hxz8XxVk&feature=endscreen&NR=1

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Myocardial Infarction Myocardial Infarction

• Myocardial infarction • Most common due to (MI) or acute myocardial occlusion (blockage) of a infarction (AMI), coronary artery following the commonly known as a rupture of a vulnerable heart attack, results from atherosclerotic plaque, which the interruption of blood is an unstable collection of supply to a part of the white blood cells (especially heart, causing heart cells to macrophages) in the wall of die. an artery.

Symptoms of MI Symptoms of MI

• The resulting ischemia • Typical symptoms of acute myocardial infarction (restriction in blood supply) include: and ensuing oxygen shortage, • Sudden chest pain (typically radiating to the left if left untreated for a sufficient arm or left side of the neck), period of time, can cause • Shortness of breath damage or death (infarction) of heart muscle tissue • Nausea/vomiting (myocardium). • Palpitations • Sweating • Anxiety • Feeling of indigestion, and fatigue

Management of MI Cardiac Medications

– Anticoagulants: Decreases the clotting (coagulating) ability of the blood – Antiplatelet Agents: Keeps blood clots from forming by preventing blood platelets from sticking together. – Angiotensin-Converting Enzyme (ACE) Inhibitors: Expands blood vessels and decreases resistance by lowering levels of angiotensin II. Allows blood to flow more easily and makes the heart's work easier or more efficient.

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Cardiac Medications Cardiac Medications

– Angiotensin II Receptor Blockers (or – Calcium Channel Blockers: Interrupts the Inhibitors): Rather than lowering levels of movement of calcium into the cells of the heart angiotensin II (as ACE inhibitors do) and blood vessels. May decrease the heart's angiotensin II receptor blockers prevent this pumping strength and relax blood vessels. chemical from having any effects on the heart – Diuretics: Causes the body to rid itself of and blood vessels. This keeps blood pressure excess fluids and sodium through urination. from rising. Helps to relieve the heart's workload. Also – Beta Blockers: Decreases the heart rate and decreases the buildup of fluid in the lungs and cardiac output, which lowers blood pressure other parts of the body, such as the ankles and and makes the heart beat more slowly and legs. Different diuretics remove fluid at varied with less force. rates and through different methods.

Cardiac Medications Cardiac Medications

– Vasodilators: Relaxes blood vessels and • Statins: Various medications can lower blood increases the supply of blood and cholesterol levels. They may be prescribed oxygen to the heart while reducing its individually or in combination with other drugs. They work in the body in different ways. Some workload. Can come in pills to be affect the liver, some work in the intestines and swallowed, chewable tablets and as a some interrupt the formation of cholesterol from topical application (cream). circulating in the blood. – Digitalis Preparations: Increases the force of the heart's contractions, which can be beneficial in heart failure and for irregular heart beats.

Cardiac Medications Cardiac Procedures

• Thrombolysis: – Coronary Catheterization (Angiogram): A – Many heart attack patients have undergone procedure that doctors do first to locate thrombolysis, a procedure that involves narrowed arteries to the heart. injecting a clot-dissolving agent to restore – Coronary Angioplasty and Stenting: blood flow in a coronary artery. Emergency angioplasty opens blocked – This procedure is administered within a few coronary arteries, letting blood flow more (usually three) hours of a heart attack. freely to your heart. • Depending on your condition, your doctor may opt to place a stent coated with a slow-releasing medication to help keep your artery open.

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Cardiac Procedures Cardiac Procedures

– Coronary Artery Bypass Graft (CABG): Bypass – Artificial Heart Valve Surgery surgery involves sewing veins or arteries in – Atherectomy place at a site beyond a blocked or narrowed – Cardiomyoplasty coronary artery (bypassing the narrowed section), restoring blood flow to the heart. – Heart Transplant • Once blood flow to your heart is restored and your – Radiofrequency Ablation condition is stable following your heart attack, you – Transmyocardial Revascularization (TMR) may be hospitalized for observation.

Implantable Medical Devices Implantable Medical Devices

– Pacemaker: A small device that has wires which are implanted in the heart tissue to send • Implantable Cardioverter Defibrillator: A device electrical impulses that help the heart beat in a that has wires which are implanted into the heart regular rhythm. The device is powered by a tissue and can deliver electrical shocks, detect battery. the rhythm of the heart and sometimes "pace" the heart's rhythms, as needed. – Left Ventricular Assist Device (LVAD): A left ventricular assist device (LVAD) is a battery- operated, mechanical pump-type device that's surgically implanted. It helps maintain the pumping ability of a heart that can't effectively work on its own.

Cardiac Rehabilitation Benefits of Cardiac Rehab

• Professionally supervised program • Increase physical fitness • A program divided into phases that involve • Reduce cardiac symptoms various levels of: • Improve health – monitored exercise • Reduce the risk of future heart problems – nutritional counseling – emotional support and counseling – support and education about lifestyle changes to reduce the risks of heart problems

23 10/30/2013

Urinary Tract Infections UTIs

• Urinary tract infections are a significant cause of morbidity in this population

• UTI’s can cause complications such as urosepsis and the need for hospitalization.

New Surveillance Definitions Constitutional Criteria

• Fever • Surveillance Definitions of Infections in Long- Term Care Facilities: Revisiting the McGeer • Leucocytosis Criteria • Acute change in mental status from baseline • First update since 1991 • Acute functional decline – Bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, eating

New Fever Definition CAM – Confusion Assessment Method

1. Old definition (from 1991) • MDS 3.0, Section C, Cognitive Patterns Temp.> 100.4 in criteria from 1991 – Inattention • Easily distracted, out of touch or difficulty following what 2. New definition (from 2012) was said 1. A single oral temperature greater than – Disorganized thinking 0 37.8C (100 F) or • Rambling or irrelevant conversation, unclear or illogical 2. Repeated oral temperatures greater than flow of idea, or unpredictable switching from subject to subject 37.2C (990F) or rectal temperatures greater than 37.5C (99.50F) or – Altered level of consciousness • Vigilant, lethargic, stuporous, comatose 3. A single temperature > 1.1C (2.00F) from – Psychomotor retardation baseline 3. Lower febrile response in the elderly

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New UTI Criteria (1 of 2) New UTI Criteria (2 of 2)

• At least one of the following – Acute dysuria or acute pain, swelling, or • AND tenderness of testes, epididymis, or prostate – Fever or leukocytosis and at least one of the • One of the following microbiologic subcriteria following: – At least 105 cfu/mL of no more than 2 species • Acute costovertebral angle pain or tenderness, of microorganisms in a voided urine sample suprapubic pain, gross hematuria, new or marked 2 increase in incontinence, new or marked increase in – At least 10 cfu/mL of any number of urgency, new or marked increase in frequency organisms in a specimen collected by in-an-out – If no fever or leukocytosis, then 2 or more of catheter the following: • Suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency

New UTI Criteria with Catheter UTI Presentation in the Elderly

• At least one of the following: – Fever, rigors, or new onset hypotension, with no • Symptoms of a urinary tract infection, can be alternate site of infection easily overlooked, causing a delay in diagnosis. – Either acute change in mental status or acute functional decline with no alternate diagnosis and leukocytosis – New onset suprapubic pain or costovertebral angle pain • Elderly people with a UTI are more likely than or tenderness younger people not to be diagnosed until the – Purulent discharge from around the catheter or acute complication of sepsis occurs. pain, swelling, or tenderness of the testes, epididymis, or prostate • May exhibit vague symptoms; May mimic many AND diseases • Urinary catheter specimen culture with at least 105 cfu/mL of any organism(s) • May be assumed to be due to the aging process.

UTIs Urinary Catheters

• “Urine specimens for culture should be processed • “Recent catheter trauma, catheter obstruction, or as soon as possible, preferably within 1–2 h. new onset hematuria are useful localizing signs that are consistent with UTI but are not necessary for diagnosis. • If urine specimens cannot be processed within 30 min of collection, they should be refrigerated. Refrigerated specimens should be cultured within • Urinary catheter specimens for culture should be 24 h.” collected following replacement of the catheter (if current catheter has been in place for >14 d).”

Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria, pg. 971 Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria, pg. 971

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Follow Up of UTIs Sepsis

• Goal of treating a UTI is to alleviate systemic or local symptoms, not to eradicate all bacteria.

• An illness in which the body has a severe • A post-treatment urine culture is not routinely response to bacteria or other germs. necessary

• This response may be called systemic • Continued bacteriuria without residual symptoms inflammatory response syndrome (SIRS). does not warrant repeat or continued antibiotic therapy.

• Recurrent UTI’s (2 or more in 6 months) may warrant further evaluation -- PVR or referral to urologist.

Causes of Sepsis Symptoms of Sepsis

• B/P drops, resulting in shock. • The symptoms of sepsis are not caused by the germs themselves. Instead, chemicals the body • Major organs and body systems, including the releases cause the response. kidneys, liver, lungs, and central nervous system, stop working properly because of poor blood flow.

• A bacterial infection anywhere in the body may set off the response that leads to sepsis. • A change in mental status and very fast breathing may be the earliest signs of sepsis.

• Chills, confusion or delirium, fever, light- headedness, rapid heartbeat, shaking, skin rash, warm skin

Signs & Tests for Sepsis Treatment of Sepsis

• The person will look very sick! • ICU • IV antibiotics • Antibiotics may mask signs of infection in a blood • Oxygen test. • IV fluids • Medications to increase B/P • Blood differential, blood gases, kidney function • Dialysis if there is kidney failure tests, platelet count, WBC • Mechanical ventilation (vent) if there is lung failure

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Prognosis Prevention of Sepsis

• Sepsis is often life threatening, especially in people with a weakened immune system or a • Immunizations chronic illness. • Careful hand washing • Damage caused by a drop in blood flow to vital organs such as the brain, heart, and kidneys may • Proper care of urinary catheters and IV lines take time to improve. • Early interventions • There may be long-term problems with the above organs.

• No all persons survive an episode of sepsis.

Advance Care Planning Concerns Advance Care Planning

Advance Directives have not delivered on their To make a difference, we must change our focus away promise from forms and toward work systems –Approximately 25% of adults have an AD –Most do not understand how they will be used – Proactive communication about stages of illness and progressive frailty –Often not available when needed –Not useful for medical decisions in progressive – Anticipate complications illness – Use values to set goals

ADVANCE CARE PLANNING Wilkinson A, Wenger N, Shugarman LR; – Use goals to make decisions U.S. Department of Health and Human Services; RAND Corporation. Literature Review On Advance Directives. – Offer specific alternatives http://aspe.hhs.gov/daltcp/reports/2007/advdirlr.htm Published June 2008.

Medical Staff Responsibilities

• The MD is responsible for discussing the illness, future issues, risks and benefits of various Advance Care Planning treatments and writing orders consistent with preferences

A process of communication about • But, ACP is an interdisciplinary team anticipated medical choices throughout responsibility the adult lifespan, focused on patient goals and values • Good decisions that honor resident preferences must be made with a health care team the resident and their decision makers trust

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Advance Care Planning Seven Steps to Improve ACP

1. Assess the Current Situation • Staff Roles with ACP – Number and percent of residents with Physician/Nurse Practitioner/Physician Assistant Educate resident and family on what to expect documentation of initial discussion Document discussions – Number and percent of residents with advance directives, living will, and a health care • Advance Care Planning Key Resources surrogate decision maker Conduct Advance Care Planning discussions – Deceased chart review – were decisions • All Clinical Staff documented and honored? Be knowledgeable about treatment options – Approaches currently used and people responsible for implementation • All Staff Be alert for changes, signs of changing goals http://www.nhqualitycampaign.org/files/impguides/6_AdvanceCarePl anning_TAW_G

Seven Steps to Improve ACP Seven Steps to Improve ACP

2. Select ACP as an area for potential 4. Identify areas for improvement in processes improvement based upon preliminary and practices including: assessment – buy- in and accountability • Current policies and protocols needed • Actual practice related to ACP

3. Review state laws and regulations & current • Issues that have arisen related to ACP information on ACP (see Resources) • Previous attempts to address need for improvement

Seven Steps to Improve ACP INTERACT ACP Tools

5. Identify the desired process and outcomes • Communicating with residents, families, and other •Identify barriers and challenges health care decision makers •Develop strategies to overcome issues • Providing examples of comfort care measures 6. Reinforce practices that are already optimal • Hard wire ACP initiation, review and communication 7. Implement needed changes and re- into facility practices evaluate; Be specific about what is being measured

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Advance Care Planning Physician Orders

Comfort care orders should also anticipate symptoms Comfort care, whether or not the resident is enrolled that can cause distress and discomfort, such as: in a hospice program, should include standard orders that address: • Nutrition and hydration • Shortness of breath, dyspnea, & terminal stress

• Activity • Pain

• Monitoring in the least • Anorexia disruptive way • Anxiety

• Hygiene • Seizures • Comfort and safety

Advance Care Planning Advance Care Planning

Advance Care Planning Thoughts

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Thank You

Pathway Health White Bear Lake, MN www.pathwayhealth.com 877-777-5463