The Pennsylvania Society for Post-Acute and Long...

The Pennsylvania Society for Post-Acute and Long-Term Care Medicine

24TH ANNUAL PMDA SYMPOSIUM

A continuing education service of Penn State College of Medicine

THE HOTEL HERSHEY | 100 Hotel Road, Hershey, PA 17033

SATURDAY, OCTOBER 15, 2016

Who should attend? Medical Directors and Long-Term Care Health Professionals, Physical Medicine,

Rehabilitation Professionals, Geriatricians, NPs, PAs, Registered Nurses, Family Physicians & Nursing Home Administrators

Penn State Continuing Education staff involved in the planning of this activity have no financial relationships with any commercial interests relevant to this activity.

Speakers are required to inform the program audience when they are discussing off-label or investigational uses of devices or drugs.

24th Annual PMDA Symposium J5897-17-Z October 14 & 15, 2016 OBJECTIVES

• Differentiate and diagnose several types of dementia; use non-pharmacologic and pharmacologic treatment approaches; and consider facility physical design strategies to improve quality of living for patients with dementia in long term care settings

• Discuss alternative payment models and strategies to reduce costs and improve care through telemedicine • Utilize assistive devices in LTC settings even when PT/OT is not involved in the patient’s care • Review current public policy issues and current professional practice issues related to PA and LTC • Develop strategies to better manage demanding patients and families in the PA/LTC setting • Monitor and improve patient outcomes through antibiotic stewardship and reducing the number of lab tests,

diagnostic testing, and medications when appropriate • Identify indicators for pain that may be applied to the evaluation and management of quality of care for the elderly

and review the QAPI process for patients with pain DISCLOSURE Penn State College of Medicine is committed to offering CME programs that promote improvements or quality in health care and are developed free of the control of commercial interests. Reasonable efforts have been taken to ensure that our programs are balanced, independent, objective, scientific, and in compliance with regulatory requirements. Faculty and course directors have disclosed all relevant financial relationships with commercial companies, and Penn State has a process in place to resolve any conflict of interest. Disclosure of a relationship is not intended to suggest or condone bias in a presentation, but is made to provide participants with information that might be of potential importance to their evaluation of a presentation.

Devices or drugs that are still undergoing clinical trials should not be portrayed as standard, accepted therapy. Please consult full prescribing information before using any product mentioned in this activity. If using products in an investigational, off-label manner, it is the responsibility of the prescribing physician to monitor the medical literature to determine recommended dosages and uses of the drugs.

The information presented at this CME program represents the views and opinions of the individual presenters, and does not constitute the opinion or endorsement of, or promotion by, Penn State College of Medicine. Each participant must use his/her personal and professional judgment when considering further application of this information, particularly as it may relate to patient diagnostic or treatment decisions including, without limitation, FDA-approved uses and any off-label uses. The following speakers and planning committee members disclose: Daniel Haimowitz, MD, CMD** Speakers bureau – PharMerica

Steven Handler, MD, PhD, CMD Employment affiliation – Curavi Health

Wayne S. Saltsman, MD, PhD, CMD, FACP Speakers bureau – PharMerica

The following speakers and planning committee members have no conflicts of interest to disclose: Joe Angelelli, MS, PhD Margaret Calkins, PhD, CAPS, EDAC Grace Cordts, MD, MPH, CMD Lee Cowan, DO, CMD* Umar Farooq, MD, CMD* Mary Kender, NHA* Brian B. Kimmel, DO, CMD* David Luschini, MD, CMD, FACP* David A. Nace, MD, MPH, CMD Miguel Paniagua, MD, FACP Tracy M. Polak, CRNP, MSN**

Craig Ronco, MSN, CRNP Firas Saidi, MD, CMD* Daniel Steiner, MD, CMD* Joshua D. Uy, MD Charles M. Wasserman, DO, CMD* Deborah Way, MD, CMD, FAAHPM* Denise A. Weachter, MSN, CRNP* Amy M. Westcott, MD, CMD, FAAHPM Heidi White, MD, MHS, MEd, CMD

*planning committee member **speaker and planning committee member

Top Five Articles That Could Make A Difference in Your LTC PracticeDavid A. Nace, MD, MPH, CMD

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Division of Geriatric Medicine

LTC Research Influencing Practice

David A. Nace, MD, MPH


[email protected]

PMDA Annual SymposiumOct 15, 2016


Conflicts of Interest

• Dr. Nace does not have any current conflicts of interest to report.


Objective

• Discuss five articles that have the potential to change LTC practice.


Methods

• 5 LTC focused articles

• Potential practical implications

• Selection period Sept 2015 to Sept 2016

• English language

• Identified using an expanding search strategy

– Top rank medicine journals > JAMDA & JAGS > OVID Core > Pub Med


What Do I Do with Those Dementia Medications?

▪Do I Continue the Cholinesterase Inhibitor?

▪Do I Add Memantine?


Current State of Knowledge Cholinesterase Inhibitors (ACI) in NF

What We Know

• NF Residents w/Dementia

– Increased AD severity

– Greater functional impairment

– More medications

What We Don’t

• Benefits in NF Population

• Risks of Drug Withdraw in NF Residents


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• ACI do not impact mortality

• ACI do not increase survival

• ACI are not disease modifiers

• ACI have limited benefit

• Temporary stabilizers


A Randomized Placebo-Controlled Discontinuation Study of Cholinesterase

Inhibitors in Institutionalized Patients with Moderate to Severe Alzheimer Disease

Herrmann N, O’Regan J, Ruthirakuhan M, Kiss A, Eryavec G, Williams E, Lanctot KL.

J Am Med Dir Assoc

2016;17(2):142-147.


Design

• 8 week placebo controlled, double-blind RCT

– Continued ACI vs ACI withdrawal

• 2 NF in Canada

• Inclusion criteria

– >55 yr with probable AD

– ≤ 15 on MMSE

– ≥ 2 years on donepezil, rivastigmine, galantamine

– ACI dose stable ≥ 3 mos

– Concomitant psychotropics stable ≥ 1 mos


Outcome Measures

• Clinicians Global Impression

• Clinicians Global Impression of Change (CGIC)

• MMSE

• Severe Impairment Battery

• Udvalg (side effects)

• Neuropsychiatric Inventory-NH

• Cornell Depression Scale for Dementia

• Apathy Evaluation Scale

• Cohen-Mansfield Agitation Inventory

• ADCS-ADL-sev

• QUALID (QOL)

CGIC – primary outcome


Results

• 40 subjects with moderate to severe AD

• No significant difference in CGIC decline– 6 worsened in continuation grp

– 7 worsened in withdrawal grp

– Baseline hallucinations predicted CGIC decline

– Baseline delusions trended to predict CGIC decline

• No difference in adverse event rates

• No difference in other measures


Results

• Limitations– Sample size

– Duration of follow up = 6 weeks

– Mostly male population

• Differs from meta-analysis by same authors of 5 studies of ACI withdraw among community dwellers– Mostly earlier stage disease


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Summary

• ACI discontinuation is safe and well tolerated in NF residents

– with moderate to severe AD

– who have been stable, and treated for ≥ 2 yrs

– without psychotic features (hallucinations/delusions) at baseline

• Supports prior work showing ACI can attenuate behavioral symptoms


Criteria for Attempting ACI Withdraw

Yes No

Does the resident have moderate to severe dementia?

Has the resident been on an ACI for ≥ 2 years?

Has the ACI dose been stable ≥ 3 months?

Is the resident free of psychotic features (hallucinations, delusions)?

Have other psychotropic medications been stable ≥ 1 month?

• ACI = acetylcholinesterase inhibitor


Current State of Knowledge Combination Therapy with Memantine

What We Know

• Memantine approved for moderate to severe AD

• ACI approved for all stages of AD

• Conflicting results for combination therapy trials

What We Don’t

• Are there benefits with combination therapy?


Combination Therapy Showed Limited Superiority Over Monotherapy for Alzheimer Disease: A Meta-analysis of 14 Randomized

Trials

Tsoi KKF, Chan JYC, Leung NWY, Hirai HW, Wong SYS, Kwok TCY.

J Am Med Dir Assoc

2016;17(9):863.e1-863.e8.


Design

• Meta-analysis – through 2015

• Study inclusion criteria

– RCT

– Alzheimer Disease

– Compared effectiveness of combination therapy against monotherapy

– Measured change in assessment scores, or adverse events, from baseline to study endpoints

– Full text and details available

– Included advanced dementia stages


Results

• 4485 abstracts identified– 14 studies eligible

– 7 > moderate to severe

– 7 > mild to moderate

• 5019 patients• 42% male• 72-86 years of age• Baseline MMSE 9-21


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Outcomes Mean Difference

95% CI Significant?

Cognition

MMSE (Monotherapy with NMDA)

0.54 -0.19, +1.28

NS

MMSE (Monotherapy with ACI)

-0.02 -0.69, +0.66

NS

MMSE (Any Monotherapy)

0.06 -0.52, +0.65

NS

Function

ADCS-ADL(Monotherapy with NMDA)

-0.39 -1.01,+0.23

NS

ADCS-ADL(Monotherapy with ACI)

-0.14 -1.23, 0.95

NS

ADCS-ADL(Any Monotherapy)

-0.15 -1.08, +0.78

NS


Outcomes Mean Difference

95% CI Significant?

Neuropsychiatric & Behavior

NPI (Monotherapy with ACI)

-1.85 -4.83, +1.13

NS*

Global Changes

CIBIC-plus(Monotherapy with ACI)

0.01 -0.25, +0.28

NS

• Adverse events not different

• *Combination therapy was better on neuropsychiatric and behavior symptoms when restricted to studies of moderate to severe AD (excluding the mild to moderate AD studies)


Summary

• Combination therapy beneficial on neuropyschiatric and behavioral symptoms in those with moderate to severe disease

• No clear benefit to combination therapy in for other outcomes

• No major adverse events with combination therapy compared to monotherapy

• Combination therapy increases costs with limited benefit in most cases


Summary

• Careful assessment of individuals with moderate to severe disease

– In absence of behavioral and psychological symptoms of dementia, combined therapy not likely to benefit

• Combined therapy not likely to benefit those with mild to moderate disease


What Is This Patient’s Risk of 30 Day Readmission?

Who Should I Follow More Closely?


Current State of Knowledge 30 Day Readmissions

What We Know• 20% of hospitalized Medicare

pts are discharged to SNFs

• 23.5% of these are readmitted w/i 30 days

• SNF transfers have greater severity of illness c/w community discharges

What We Don’t

• No prediction tools for patients discharged to SNFs

• HOSPITAL Score developed, but not validated for SNF patients


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Validation of the HOSPITAL Score for 30-Day All-Cause Readmissions of Patients Discharged to

Skilled Nursing Facilities

Kim LD, Kou L, Messinger-Rapport BJ, Rothberg MB.

J Am Med Dir Assoc

2016;17(9):863.e15-863.e18.


Design

• Validation study

• HOSPITAL score developed in Boston

• Retrospective collection of administrative and clinical data

• Outcome was readmission w/I 30 days to Cleveland Clinic Health System hospital

• Variable was HOSPITAL score


HOSPITAL Score

Attribute Points

Hemoglobin < 12 g/dL at discharge 1

Discharge from oncology service 2

Na < 135 mEq/L at discharge 1

Any ICD9 coded procedure 1

Non-elective admission 1

Number hospital admissions in prior yr

0 0

1-5 2

>5 5

Length of stay ≥ 5 days 2

Total = ____ (Low Risk = 0-4; Intermediate Risk = 5-6; High Risk = ≥ 7)


Results

• 4208 discharges

• Mean age = 71.6

• 45.9% = African American

• Medicare primary payor = 75%

• 30-day readmit rate = 30.9%


Results

15.40%

28.10%

40.90%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

Low Risk Intermediate Risk Hi Risk

c-statistic = 0.65


Summary

• HOSPITAL Score stratifies NF patients regarding all-cause 30-day readmission risk

• Can be used by clinicians to identify those who may need “extra attention” in order to prevent readmissions

• Helpful given SNF VPB, 5 Star Measures, & narrowed network providers


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Long Acting Opioids &

Long Stay Residents

Always Start the Game in the First Inning


Current State of Knowledge Long Acting Opioids (LAO)

What We Know• LAO opioids should not be

started in opioid naïve patients

• FDA warnings, particularly about fentanyl patches

• In 2004-2005, 39% of RI NF residents started on LAO had not used any opioid in prior 60 days

What We Don’t

• What is happening nationally with LAO prescribing?

• Has there been any improvement in LAO prescribing?


New Initiation of Long-Acting Opioids in Long-Stay Nursing Home Residents

Pimentel CB, Gurwitz JH, Tjia J, Hume AL, Lapane KL.

J Am Geriatr Soc

2016; Aug 3. doi: 10.1111/jgs.14306 (epub ahead of print)


Design

• Analysis of NF residents via 4 national data sets

• Long stay NF residents (> 90 d)

– Minimize Part A covered meds

– Minimize uncaptured acute care meds

• Jan 1 to Dec 31, 2011

• 22,253 met inclusion criteria

• Opioid naïve = no short acting opioid w/i 60 days


Results

• Mean age = 75, 71% female• 73% mild to mod functional impairment• 19% mod to severe cognitive impairment• 83% had pain in prior 5 days

– 25% had constant pain

– 45% had frequent pain

– 26% had occasional pain


Results

31%

55%

72%

81%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

≤ 7 Days ≤ 30 Days ≤ 60 Days ≤ 90 Days

When LAO Are Prescribed Following Admission


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New Initiation of LAO in Long‐Stay

Nursing Home Residents

By Look Back Period

Overall 9.4% of LAO Prescriptions W/I 30 days Were in Opioid Naïve

PatientsJ Am Geriatr Soc 2016;64(9):1772-1778


Results

51.9%

28.2%

17.2%

2.7%

Most Common Long Acting OpioidsStarted in Opioid Naïve Residents

Fentanyl Patch

Morphine

Oxycodone

Others


Summary

• Rate of LAO use in opioid naïve residents may be declining…BUT

• > 9% of NF residents started on LAO in the first 30 days are opioid naïve

• 18.5% of NF residents prescribed LAO at any point, are opioid naïve

• Fentanyl patches comprise the largest category of potentially inappropriate LAO starts

– May be particularly true in hospice patients


Delusions About Reducing Antipsychotics

Can We Really Make a Difference?


Current State of Knowledge Antipsychotic (AP) Review

What We Know• Behavioral problems impact

90% of patients w/dementia

• AP medications have modest benefits, but also significant risks

• AP usage should be regularly reviewed and dose reductions attempted

What We Don’t• Is AP review effective in

reducing AP use?

• Can nonpharmacologicalinterventions reduce agitation among residents with dementia?

• Does exercise reduce depression?


Impact of Antipsychotic Review & Nonpharmacological Intervention on

Antipsychotic Use, Neuropsychiatric Symptoms, & Mortality in People with Dementia Living in

Nursing Homes: A Factorial Cluster-Randomized Controlled Trial by the Well-Being & Health for

People with Dementia (WHELD) Program

Ballard C, Orrell M, YongZhong S, Moniz-Cook E, et al.

Am J Psychiatry 2016;173(3):252-262.


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Design• Cluster randomized 9 month trial in 16 NF

• Residents with stage 4 dementia or greater

• 8 NF assigned to AP review

• 8 NF assigned to increased social interaction

• 8 NF assigned to exercise intervention

• All received person centered care training

• Outcomes– Primary = AP use.

– Secondary = Mortality & Neuropsych measures


Results

• 277 participants

– 195 (70%) completed the study

• Mean age = 85, Female = 74%

• Dementia (CDR) Severity

– Mild – 12%

– Mod – 40%

– Sev – 47%

• 18% were taking AP


Results

AP Review No AP Review

Number on AP at Start 20 20

Number Discontinued 10 0

New AP Starts 3 3

Final AP Use 13 23

• 50% reduction over 9 months• 3 residents discontinued had worsening of

NPI scores, but these residents had baseline scores above 14


Results

• In regression analysis, strongest association with mortality was social interaction.

• Exercise did not impact mortality

Mortality

No AP Review or Social Interaction

35%

AP Review 28%

AP Review and Social Interaction

19%


Results

• AP Review alone had worse NPI scores

– However, 3 residents were above 14 at baseline

• Group with AP Review & Social Interaction did not worsen

• Exercise improved NPI scores, but not depression


Summary

• AP Review effective >>> reduced AP use by 50%

– Even in population with low prevalence of AP use at baseline (18%)

• Mortality reduced with AP Review and Social Interaction

• Social Interaction didn’t improve agitation or total NPI scores

• Exercise helped NPI scores, but not depression


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Summary

• AP review is effective and should be part of a facility QAPI program

• May be harder in facilities with lower rates of AP use, but still worth attempting

• Non-pharmacological interventions complement AP review efforts, particularly when AP use is low

How to Work with Difficult Patients and Families: Building BridgesGrace Cordts, MD, MPH, CMD

Craig Ronco, MSN, CRNP

1

Grace A. Cordts MD, CMD Craig Ronco CRNPOctober 2016

Bridge Over Trouble Waters: Dealing with Difficult Patient and Family Encounters

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

NO DISCLOSURES TO REPORTCraig Ronco and Grace Cordts


Difficult Patient and Family Encounters

• Purpose: The purpose of this activity is to enable the

• learner to develop skills in handling difficult patients and family encounters.

• Learning Objectives: At the end of this presentation, the

• Learner will be able to:1. List four sources that can contribute to making interactions with patients and families challenging.2. List the three components of emotional intelligence that can help providers understand their role in challenging encounters with families and patients.3. List benefits of taking a team approach in the skilled nursing facility to approach difficult situations with families and patients.

3 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Facts about difficult encounters

• Clinicians report between 15-18% of their patients/families as difficult• Up to 40% of doctor-patient encounters may involve conflict• Patients/families perceived as difficult are associated with provider

burn-out, frustration and poor short term outcomes

(Groves NEJM 1978, O’Dowd BMJ 1988, Jackson and Kroenke Arch Int Med 1999)

4


“All patients make me happy, some when they come to the office, others when they leave”Quote from a practicing MD


Difficult Encounter

Better to conceive an encounter as difficult rather than to label patients or families as problematic. Difficulties are perceptions, similar encounters may be perceived as difficult by one clinician, but not another

Allows for an approach to handle the difficult encounter

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2


Examples of potentially difficult encounters

1. Angry patients and families.2. Overprotective families.3. Over-controlling or domineering families.4. People with unusual beliefs or personalities.5. Patients with diagnostic challenges6. Patients and families that cannot explain what is going on without

starting from when they or their family member was born7. Patients and families demanding certain treatments we don’t see as

effective8. Difficult patient to take care of in the SNF you send to the hospital

and they don’t want to take care of the patient anymore than you do


Coping with Difficult Situations

• We have several choices – Do nothing– Walk away– Change our attitude– Change our behavior

• Changing our behavior is the most-effective approach– The difficult person will have to

learn different ways of dealing with us


Case Example 1

• Betty is a 89 yo female currently residing in a secure dementia unit with Lewy Bodies Dementia – Consistent/worsening behaviors of impulsiveness, delusions,

eradicate sleep patterns. resistance to care with overall decline in health with wt loss, and gradual loss of ADLs

– Increase in falls– Additional Pmhx – HTN, CHF, PVD, OA OP, Kyphosis– Medications –Aricept, Namenda, Lisinopril, Furosemide, ASA,

OsCal with Vitd3, PRN Ativan (moderated by dght)– The resident was difficult for the staff to manage her care needs and

the Daughter presented another complexity to the care itself.


Daughter Interactions or Challenges

• Overbearing toward staff and mother – demanding, appeared very unappreciative, critical of care given

• Felt she knew “what was best” for mom• Difficult to have open discussion with• Demanding of unnecessary testing – mom always has a UTI• Not open to various treatment modalities – didn’t want to see mom

“snowed”• Had a medical background – can be a positive or a negative at times• Only child and this was her last living parent • Not accepting of disease trajectory – behavioral changes starting

happening quite quickly.

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Case Example 2

• 56 yo gentleman in SNF for long tern care• History of seizure disorder, head trauma, unable to participate in any

decision; functionally dependent in ADLs except is able to feed self after being set up

• Resident cooperative • Sister appointed guardian • Sister adamant about dose of phenytoin her brother should be on and

other issues• Her demands around the phenytoin dose were not based on any facts

but on what dose he was on as a child• Called several times a day to the floor her brother was on• Called the president of the hospital this SNF was associated several

times a day• Her calls made it difficult to care for other residents on the floor


Case 3

• 28 yo Type 1 DM on dialysis• Admitted to SNF because of multiple medical admissions related to her

DM and renal failure• She had a personality disorder. • Sullen, not communicative; often not showing for dialysis• Did not have a supportive family; had relatively few social support

systems

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3


What makes an interaction challenging

• Many different sources • Categorized broadly into 4 areas

– Patient

– Clinician

– Disease

– System


Patients

• Psychiatric disorders, multiple symptoms, poor functional status, unmet expectations, and high utilizers (Edgoose etal Fam Med 2014)

• Angry, argumentative, mistrustful anxious or depressed (Strous et al Eur J Int Med 2006; Hinchey and Jackson J Gen Int Med 2011)

• Patients who make repeated visits without apparent medical benefit, don’t want to get well; engage in power struggles or focus on issues unrelated to medical care (Haas et al Am Fam Med 2005)

• Challenge the physicians care plan (Wasan et al Reg Anesth Pain Med 2005)

• Another study identifies difficult patients as “invalidating, demanding, disruptive, attention-seeking, annoying, and manipulative” (Knesper Psych Clin North Am 2007)

• Certain categories of patients: drug addicts, non-adherent patients, and the homeless (Higashi et al Anthropol Med 2013)

Bottom line: raise negative feelings in us such as frustration, anxiety, guilt, and dislike

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Attitudes

– Emotional burnout– Insecurity– Intolerance of diagnostic

uncertainty– Negative bias toward certain

health conditions– Perceived time pressure

Conditions

– Anxiety/depression– Exhaustion/overworked– Personal health issues– Situational stressors– Sleep deprivation

Knowledge

– Inadequate training in psychosocial medicine

– Limited knowledge of the patient’s health condition

Skills

– Difficulty expressing empathy– Easily frustrated– Poor communication skills

Lorenzetti et al Am Fam Phy2013

Clinician

15


Disease

– The difficulty inherent in diagnosing and managing some diseases can make interactions with the affected patient and their family feel more challenging than straight forward conditions

– Working up some conditions in the SNF can be challenging– Goals of Care issues – Risk:Benefit ratio of pursuing workups and treatment can be

inherently difficult with some residents and families because of the emotional content of these discussions; can work both ways in that some families do not want anything done when we think the risk:benifit ratio is good

16


System/SNF

– System: resources, finances, support, time pressures, interruptions

• SNF

– Many staff to interact with in the facility: administration, bedside staff– Families are in a new environment and need to learn new roles and

relationships – If facility has high turnover this becomes more difficult

(Hertzberg and Ekman, J of Ad Nsg 2000)

– Staff-family interactions can produce tension and conflict between health care providers (Iecovich J Gerot SW, 2000; Hertberg et al, J of CL Nsg2003)

– Nurse managers spend time supporting direct care staff to cope with staff-family conflicts (Marzialli et al., JAMDA 2006)


Unique setting of the Skilled Nursing Facility

Medical Provider

Skilled Nursing Staff

Family

Resident

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4


Approach

When difficulty is perceived we should treat it like a diagnostic problem. Perceptions of potential difficulties should lead to diagnostic trials similar to those arising from key elements of history and physical exam

APPROACH

1. Recognize there is a problem2. Decide what might be causing the issue3. Come up with a Plan4. Implement the plan5. Evaluate what is working6. Change the plan as needed based on what is working or not

working

19


Diagnosis

Plan

ImplementEvaluation

Change as needed

20

•Recognize the Problem


1. Recognize the Problem

21


1. Recognizing Difficult encounters

No two difficult encounters are alike.An ability to work with uncertainty and complexity is critical• This requires reflective self-aware practitioners who can examine what

they are doing (Epstein Fam Med 2002; Hass et al Am Fam Phy 2005, Reiss JAMA 2010)

• Cultivating Emotional Intelligence –the capacity to recognize and adapt to one’s own and others’ emotional states- can help temper, analyze and de-escalate problematic interactions (Straton et al Teach Learn Med 2008)

22


•Neocortex and Amygdala

• Neocortex

– Complex thinking• Decision Making• Strategizing• Prioritize• Big picture

• Amygdala/Limbic System

– Emotions• Fight or flight• 100x faster than neocortex• No differential between real

or perceived threat


Emotional Intelligence

• One’s ability to recognize, understand and manage one’s personal emotions to then recognize, understand and influence the emotions of others.

• Three main components– Self Awareness

• Self assessment , emotional self assessment, self regard• Knowing one’s own responses, avoid the “emotional hijack”

– Emotional Management• Impulse control, flexibility/adaptability, authenticity• Controlling ones self to be able to most appropriately respond,

S.O.S.S strategy– Emotional Connection

• Empathy, communication, coaching others• Establishing collaboration to do what's best for the resident

24•Goleman 1998



5


SOSS: Stop the hijack

STOPDo something to disrupt the hijacking and ; relax your shoulders, open up your hands and place them on your legs, take a drink of water.

OXYGENATEDeep breathing always helpful!

STRENGTHENAPPRECIATION

Brain cannot experience appreciation and fear/anger at the same time

SEEK INFORMATIONAsking questions seek clarification, this engages the neocortex

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EI Observational Behaviors

• Self Awareness– Readily accepting feedback and criticism; is aware of strengths;

knows how their emotions impacts behavior; is aware of theirs emotions; speaks confidently; handles setbacks effectively

• Emotional Management– Does not act impulsively; can overcome difficult emotions in pursuit

of goals; maintains a sense of humor; keeps promises; remains flexible and adaptable to changing situations and problem solving; enjoys challenges; is goal oriented

• Emotional Connection– Non-judgmental; sees from others perspective; provides clear and

concise feedback; does not personalize disagreements; treats others with respect

26

•Goleman 100


2. Decide what might be causing the issue

27


2. What is the problem?

Approach just like diagnosing a problem– History– Exam – Talk with patient, family, staff

Approaches that can help: skills and techniques• Good communication skills/Active listening• Addressing emotions• Avoid the Righting Reflex• Perspective of the team

28

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Am I Taking Time to Understand?

• Communication Breakdown– 7% is verbal– 38% is from tone of voice– 55% is from body language

• Poor versus good communication– Poor

• Hurried• No engaged• Being distant• Using medical terminology

– Good• Not rushed• Simple words• Mostly listening• Being empathetic



6


Resist the Righting Reflex

•Pollak 2011 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Recognizing and attending to Emotions

• Acknowledgement of emotions: our own and patient/family• Enable people to process their emotions• Enable people to realize what they are most concerned

with

32


NURSE: Mnemonic for addressing emotions

Skill Example

N: name the emotion It sounds like you are frustrated.

U: understandThis helps me understand what you are thinking.

R: respect You are doing all the right thingsand asking the right questions.

S: support I am going to walk this road with you.

E: explore Could you say more about what you mean when you say that…..

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Angry family member/patient

• Anxiety or Grief• Bad experience with the health care system• Poor communication and conflicting information

• Approach– Acknowledge anger and distress as soon as possible– Listen intently– Invite them to raise all their concerns without interruption unless to

clarify what they are saying

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Discussion with team

•Get everyone's perspective; entire team•Are there staff that do not see this as difficult

– What is their perspective– What works for them

•Avoids splitting

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3. Make a plan

36



7


Plan

The plan is based on outcome of your evaluation1. Utilize a team approach

– Involve all members of the NH staff (SW, RD, Nursing)

2. Seek out Consultation– Utilize your collaborating Services (Pysch, Cards, Neuro)

3. Setting limits– Designate family spokesperson and interact with that person

4. Set specific meeting time– Initially frequent, over time usually can space out

5. Education: Knowledge gap6. Behavioral plan if it is a behavior of a resident7. Change providers.

37


Collaborative Effort

• Strength in numbers– Team Approach– Include your interdisciplinary team: Nursing staff, CNA, Director of

Nursing, Social Workers/Case Managers, Dietitians, Activities Directors.

– Creates a consistent message from all parties involved in care – Helps to demonstrates a level of increased overall communication,

empathy, and reassurance. – Avoids miscommunication – different stories from different parties– Prevent Provider Burn-out - Include Partners to review case and

speak with family/resident

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4. Implement the plan

39


TIPS for Providers to Implementation

• Be sure the goals are workable• Time frame

– Commit to when this will be implemented– When will you reevaluate the plan

• Check in with SNF to see what is going on: course correction– Shows your commitment to the facility, you are part of the team

• If a crucial conversation needs to happen: Do It.• If you have set up specific meeting times follow through on them.

– Shows accessibility and develops trust

40


SNF: Our and staff reflex is to run away

Include in any approach with difficult encounters1. Staff seek families out to share information2. Staff communicating face to face about resident’s condition

without family having to request3. Staff informing families when there is a change in condition4. Staff expressing an interest in how the family members coping

with residents stay5. Staff providing explanations in a treatment in a non-threatening

and relaxed manner

(Utley-Smith et al. J Aging Stud 2009)


5. Evaluate the plan.– Your assessment– Staffs assessment– Family’s assessment

• Ask family how everything is going6. Change the plan as needed based on the outcome

42



8


Diagnosis

Plan

ImplementEvaluation

Change as needed

43

•Recognize the Problem


Back to the Cases

44


Approach Case 1

• Communication, communication, communication• A new face• Validation and empathy – asking for and utilizing her input instead of

resisting it of completing shutting it down• Understanding the why to her thinking• Risk/benefit conversations • Leveraging what medical background she had• Comprehensive review of medication and disease trajectory• Collaborative effort / interdisciplinary approach• Staff education regarding disease process – approaches to the patient

and family• Time, weekly meetings/interactions initially


Outcome Case 1

• Improved communication with staff, provider, daughter• Daughter more open to alternative treatment plans and medication

adjustment• More understanding of the disease trajectory and what was going to

happen to her mother over time• Time frame: several months; still an ongoing issue but with the work up

front interactions were less frequent and far less contentious

46


Approach Case 2

• Team approach– Consistent approach to the sister

• Limits set on number of calls• Regular follow up with sister to discuss medical issues• Involved neurology


Outcome Case 2

• Not successful at all• Calls continued and escalated• Decision after months of trying to improve situation to remove the sister

as the guardian• Timeframe: probably about 10 months

48



9


Approach Case 3

• Team meeting with how we were going to address issues• Came up with a plan

– Psychiatric Clinical Nurse Specialist– Consistent staff– Consistent approach– Support for the staff in caring for her


Outcome Case 3

• After several months began to see a change in her; more interactive• Engaged in her health care• Staff became her family/support system• Saw regression in her behavior for a short time after her family would

come to visit• After about 10 months she decided she wanted to go and live

independently

50


Rules for Crossing the bridge/ Generic approaches

1. First Impressions count2. Assume positive intention: we as professionals should be trained and

competent in communication3. Never get angry; if we get angry recognize it and use it as a flag to

consider why4. Listen5. Stay calm 6. Strive to never appear rushed (no matter how rushed you feel)7. Consistent approach by all including staff at facility; may need to get

everyone on the same page8. Discuss difficult patients with a colleague or with peers in a group

(Balint groups)


References

Lorenzetti RC et al. Managing Difficult Encounters: Understanding Physician, Patient and Situational Factors. Am Fam Phys. 2013; 6:419-425Groves JE. Taking Care of the Hateful Patient. NEJM. 1978; 298:883-887.O’Dowd TC. Five years of heartsink patients in general practice. BMJ 1988;297:528

Jackson JL and Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes1999;159(10):1069-75.Edgoose JY et al. Difficult patients: exploring the patient perspective. Fam Med. 2014 May;46(5):335-9. Hinchey S and Jackson J. A Cohort Study of difficult patient encounters in a walk in primary care clinic. J Gen Int Med. 2011 Jun;26(6):588-94.Haas L et al. Management of the Difficult Patient. Am Fam Phys. 2005; 72(10): 2063-2068.

52


References

Knesper DJ. My Favorite Tips for Engaging the Difficult Patient on Consultation -Liaison Psychiatry Service. Psych Clin of No Am. 2007, 30(2):245-252.Wasan AD et al. Dealing with Difficult Patients in your Pain Practice. Reg Anesth Pain Med. 2005; 30(2):184-192.Higashi RT Et. Al. The “Worthy” Patient: rethinking the hidden curriculum in medical education. Anthro Med. 2013; 20(1):13-23.Utley-Smith Q. The Nature of Staff-Family Interactions in Nursing Homes: Staff Perceptions. J Aging Stud. 2009; 23(3):168-177.Reiss H. Empathy in Medicine- a neurobiological perspective. JAMA. 2010; 304(14):1604-1605.Goleman, D. (1998). Working with emotional intelligence. New York: Bantam.Pollak KI et. Al. Applying Motivational Interviewing Techniques to Palliative Care Communication. J of Pall Med. 2011 (14): 587-92.

53

Protecting the Patient From Standard Medicine: Less Is MoreJoshua Uy, MD

1

Managing Chronic DiseasesLess is more

Dr. Joshua Uy M.D.Clinical Assistant Professor of Medicine

University of PennsylvaniaMedical Director of

Renaissance Healthcare and Rehabilitation

Goals and Objectives

• Optimize care of chronic diseases in older frail adults

– Identify the relevant clinical questions of a long term care population

– Revisit the evidence to understand how it applies to our patients

– Develop a framework for ideal disease management

Tiny.cc/pmda2016

Introduction

• “Why don’t geriatricians care about blood pressure?” Anonymous medical student.

– What does it mean to care about blood pressure?

• Target of 140/90?

• But what should we care about?

• What is the goal of blood pressure management?

• What does it look like in frail elderly?

Introduction

• The usual…..

Disease Target

Hypertension <140/90, <150/90, <120/90

Hyperlipidemia Medium to high intensity statin

Diabetes Type 2 A1C < 7 or A1C < 6.5Aspirin, Ace inhibitor, statin

Systolic CHF Beta blocker, Ace inhibitor

IntroductionWhat do we do?

Lipska K. JAMA IM. January 2015.

Treat everyone to the SAME A1C


Lipska K. JAMA IM. January 2015.

Use IDENTICAL high risk medications


2


• Breast cancer screening– 18% of women with severe dementia >70 years old had a screening mammogram (45% in cog intact women)

– 3.3 year median survival• Mehta KM. Impact of cognitive impairment on screening mammography. Am J of Public

Health. 2010.

• Colon cancer screening in those older than 70– Those >5 year life expectancy: 47% screened– Those with severe comorbidities: 41% screened

• Walter LC. Impact of age and comorbidity on colorectal cancer screening among older veterans. Annals of Internal Medicine. April 2009.

• We treat people randomly! ˉ\_(ツ)_/ˉ

Introduction

• Why not use the same disease targets?

– It’s harmful‐Diabetes

• Rates of emergency hypoglycemia are 6.25 times more common than hyperglycemia

(Huang ES. JAMA IM. Feb 2014)

• 2nd most common complication for diabetes (MI is #1)

• Leads to 100,000 ED visits per year for hypoglycemia(Lee, Sei. JAMA IM. March 2014)

Introduction

• Why not use the same disease targets?

– It’s harmful‐Hypertension

• A target of 120 systolic compared to 140 systolic lead to more ER visits and hospitalizations. NNT 61 vs NNH 45 (SPRINT. NEJM. Nov 2015)

• Increases risk of serious falls (Tinetti. JAMA IM 2014)

– 28‐40% increase risk of falls

– 117‐124% increase risk of falls in those who have fallen

• Increases cognitive decline in those with dementia– 9 month study (Mossello. JAMA IM 2015)

Introduction

Clinical Questions

1. What is the clinical benefit in the context of older frail adults?

2. What is the time frame for benefit?

3. What is the efficacy? (NNT) and is it worth it to the patient?

4. What are the risks? Are active side effects worth tolerating? (hint: the answer is no)

Introduction

• Clinical Questions

5. Is the patient frail? What is their prognosis?

• How does that affect outcomes?

• Decreases benefits? Increases harms?

6. What is the multi‐morbidity context?

• Prioritization? Treat everything?

7. What are the goals of care?

IntroductionSolutions

• Disease targets for frailty

Not frail Frail

Hypertension BP<140, maybe<120

Hyperlipidemia Mod to high intensity statin

Diabetes Type 2 A1C<7

Systolic CHF Beta‐blocker and Ace inhibitor

BP between 140‐160

Any tolerable statin dose(or none at all)

• A1C 7‐8 on non sulfonylurea oral hypoglycemics

• A1C >8 with insulin• Asymptomatic (A1C 8‐12)

Same


3

IntroductionSolutions

Pathway for multimorbidity1. Active symptoms or acute illness

– Pain, dyspnea, constipation– Hip fractures, pneumonia, CHF exacerbations

2. Geriatric syndromes (affecting QOL)– Falls, weight loss, cognitive decline, functional decline,

polypharmacy

3. Chronic disease management– CHF, COPD, Depression>Htn>HL>>>>DM2

4. Primary prevention– Cancer screening, aspirin, low fat diets

Chronic DiseasesDeveloping a plan for frail elderly

• It starts with patient assessment1. Prognostication

2. Frailty assessment

3. Multimorbidity

4. Goals of care• Geriatric assessment of the evidence

1. Clinical benefit

2. Efficacy

3. Time to benefit

4. Adverse effects/risks

Focusing on patient assessment

• Prognosis

– http://eprognosis.ucsf.edu

Walter. JAMA. June 2001.


• Prognosis

– What is the time to benefit? (Lee Sei. JAMA 2013)

• Will out patients live long enough to see the utility of an intervention?

• Does it help the patient feel better now or later?

– Seems intuitive but hard to use in real life

• People do not actually have expiration dates

• What do you actually say?


• Is the patient frail?– Is there a frailty syndrome?

• Dementia, cognitive decline• Falls, functional decline, poor gait• Weight loss• Hip fractures, pressure wounds, aspiration

– Tests of frailty (NICE guidelines NG56)• Get up and go test (>12 sec)• Gait speed (>5 sec for 4 meters)• Self reported poor health• PRISMA 7 questionnaire (>3)

– http://www.bgs.org.uk/campaigns/fff/fff_short.pdf


• Is the patient frail?

– Outcomes are less certain

• Statins, BP control may not decrease CV disease

• Decreasing all cause mortality is unlikely

– Harms are increased

• Increase risk of hospitalization, falls and iatrogenesis– Won Won. Use of Frailty in Deciding Clinical Treatment Goals for Chronic Disease in Elderly

Patients in the Community JAMDA. 2016.

– Mitty. Geriatric Nursing. 2010

– Clegg. Lancet. 2013


4


• Multimorbidity and polypharmacy– Patients have more than one disease

• Leads to death, disability, poor QOL, higher rates of adverse events

(Guiding principles for the care of older adults with multimorbidity AGS 2012)

• Leads to increasing complexity of care(Boyd, Cynthia. JAMA. 2005)

– Polypharmacy, adherence issues

– Conflicting guidelines‐drug drug interactions

» (NSAIDS for OA and Aspirin for CV disease prevention)

• Polypharmacy is an issue of multimorbidity(Hayes. Clinics in Geriatric Medicine. 2007.)


• Goals of care– What does the patient care about?

– How would they choose between priorities?• Longevity, quality of life, function

• Quality of life now vs quality of life in the future?

• What are limits on intervention riskiness and pain?

– Risk tolerance• Side effects, adverse events

– (Are these worth tolerating to achieve benefit?)

• Low yield treatments (is it worth it to the patient?)

Chronic DiseasesDeveloping a plan for frail elderly

• It starts with patient assessment1. Prognostication

2. Frailty assessment

3. Multimorbidity

4. Goals of care

• Geriatric assessment of the evidence1. Clinical benefit

2. Efficacy

3. Time to benefit

4. Adverse effects/risks

Revisiting Evidence

• Defining clinical benefit– No biomarkers

• A1C, BP, LDL (it gets worse)

– Hard clinical outcomes• Death or hospitalization

• CV events (MI/CVA‐fatal/non fatal)

– Function• ADL’s/iADL’s, gait, independence, falls

– Quality of life• Comfort, dyspnea

Revisiting Evidence

• Efficacy

– Do not use relative risk values

– Use absolute numbers

• Number Needed to Treat (NNT)

• Absolute risk reductions

• Per 1,000 patient numbers

– Consider time to benefit

• Benefits accrue over time (months/years/decades)

• Sometimes they disappear over time (ie ICD’s)

Revisiting Evidence

• Visual representation of efficacy

% with events

Time

Treatment

Placebo

100%

No event

Event

PreventDelay


5

Revisiting Evidence

• Risks of treatment

– Side effects

• Nausea, pain, weakness, fatigue, constipation

– Adverse events

• Acute kidney injury, CHF, electrolyte abnormalities

• Emergency Room encounter, hospitalization, death

– Low yield treatments

• High NNT, low absolute risk changes

Revisiting Evidence

• Relevance to goals of care

– Curative (not relevant to chronic diseases)

– Preventative

• Benefit is future

– Palliative/functional

• Not a euphemism for non curative

• It means the patient feels better in some way

• Benefit is now

Revisiting Evidence

2nd handout‐Chronic diseases

http://tiny.cc/pmda16

Revisiting EvidenceHypertension

• Clinical benefit– Death, CHF, stroke

• (Not MI per HYVET/SPRINT)

• Efficacy– NNT 30 to prevent 1 out of 3 “events”– Time frame‐2 years– Treating 1000 patients would prevent 33 CV events over 2 years

• Risks– Orthostasis, falls, hypotension, AKI

• Relevance to goals of care– Preventative

Revisiting EvidenceHypertension

Hyvet study

Revisiting EvidenceHyperlipidemia

• Clinical benefit– Decreased non fatal MI– Not stroke, or mortality (PROSPER)

• Efficacy– NNT 48 to prevent 1 out of 6 MI– Time frame‐3.2 years– Treating 1,000 patients over 3.2 years would prevent 21 MI’s

• Risks– Low‐muscle aches, weakness, abnormal LFT’s

• Relevance to goals of care– Preventative


6

Revisiting EvidenceHyperlipidemia

PROSPER study

Revisiting EvidenceDiabetes Type 2

• Clinical benefit of tight control (A1C 7 vs 8)– Microvascular benefit only

• Loss of patellar or ankle reflex, 1 new retinal micro aneurysm, new microalbuminuria

– No macrovascular benefit (UKPDS, VADT, ACCORD)

• Efficacy– NNT 35 to prevent 1 out of 4 events (mostly retinopathy)

– Time frame 10 years (!!)

• Risks– Death, hospitalization, falls, dementia, institutionalization

• Relevance to goals of care– Preventative (I guess)

Revisiting EvidenceDiabetes Type 2

UKPDS

Revisiting EvidenceSystolic CHF

• Clinical benefit– Death, hospitalization– Exercise tolerance

• Efficacy‐BB– NNT 15 to prevent 1/3 events– Time frame‐7 months– Efficacy for ACE NNT 10 over 3‐6 months

• Risks– Hypotension, bradycardia, fatigue

• Relevance to goals of care– Both preventative and palliative

Revisiting EvidenceSystolic CHF

Revisiting Evidence

Hypertension Hyperlipidemia Diabetes Systolic CHF

Clinical benefit MortalityCHFStrokes

MI None really MortalityHospitalizationExercise tolerance

Efficacy NNT 30 NNT 48 NNT 35 10‐15

Time frame 2 years 3 years 10 years Months

Risks Low to mod Low High Low to mod

Goals of care Preventative Preventative Preventative PreventativePalliative

12 3 4


7

Management Summary

Pathway for multimorbidity1. Active symptoms or acute illness

– Pain, dyspnea, constipation– Hip fractures, pneumonia, CHF exacerbations

2. Geriatric syndromes (affecting QOL)– Falls, weight loss, cognitive decline, functional decline,

polypharmacy

3. Chronic disease management– CHF, COPD, Depression>Htn>HL>>>>DM2

4. Primary prevention– Cancer screening, aspirin, low fat diets

Management Summary

• Rationale for different disease targets

• For frail elderly, traditional targets– Do not achieve the same clinical benefit

– Are riskier

– Have value assumptions built in• Future benefit is worth current risk

• It is worth universally applying an intervention that benefits a very small minority of patients

• Benefits take time to accrue

– Do not reflect best evidence!

Management Summary

• Disease targets for frail elderly

Not frail Frail

Hypertension BP<140, maybe<120 BP between 140‐160

Hyperlipidemia Mod to high intensity statin

Any tolerable statin dose(or none at all)

Diabetes Type 2 A1C<7 A1C 7‐8 on non sulfonylurea oral hypoglycemicsA1C >8 with insulinAsymptomatic (A1C 8‐12)

Systolic CHF Beta‐blocker and ACE inhibitor

Same (with focus on tolerability)

Conclusion

• Communication– What not to say

• Management of chronic diseases does not matter• You are too old.• What’s the purpose?

– What to say• It matters A LOT that chronic diseases are well managed• Ideal care looks different• We care about QOL, function AND prevention and risks• When our patients are fragile, targets matter even more• For our peers‐deviating from guidelines reflects best evidence

Antibiotic StewardshipWayne S. Saltsman, MD, PhD, CMD, FACP

1

NEW CMS REQUIREMENTS FOR

ANTIMICROBIAL STEWARDSHIP PROGRAMS

WAYNE S SALTSMAN, MD, PHD, CMD, FACPCHIEF MEDICAL OFFICER, CONTINUING CARE

LAHEY HEALTH

SECTION CHIEF, GERIATRICS AND TRANSITIONAL CARE

LAHEY HOSPITAL AND MEDICAL CENTER

DOING THE RIGHT THING(WITH AND ABOUT ANTIBIOTICS)

WAYNE S SALTSMAN, MD, PHD, CMD, FACPCHIEF MEDICAL OFFICER, CONTINUING CARE

LAHEY HEALTH

SECTION CHIEF, GERIATRICS AND TRANSITIONAL CARE

LAHEY HOSPITAL AND MEDICAL CENTER

DISCLOSURE

DR SALTSMAN IS A SMALL, COUNTRY GERIATRICIAN

(TRYING TO DO THE RIGHT THING)IN HIS OWN WORLD:

DISCLOSURE

DR SALTSMAN IS A SMALL, COUNTRY GERIATRICIAN

(TRYING TO DO THE RIGHT THING)IN HIS OWN WORLD:

High‐Value Care Advice 1: Clinicians should not perform testing or initiate antibiotic therapy in

patients with bronchitis unless pneumonia is suspected.

High‐Value Care Advice 3: Clinicians should reserve antibiotic treatment for acute rhinosinusitisfor patients with persistent symptoms for more than 10 days, onset of severe symptoms or signs of high fever (>39 °C) and purulent nasal discharge or facial pain lasting for at least 3 consecutive days, or onset of worsening symptoms following a typical viral illness that lasted 5 days that was

initially improving (double sickening).

High‐Value Care Advice 2: Clinicians should treat patients with antibiotics only if they have confirmed Streptococcal pharyngitis

High‐Value Care Advice 4: Clinicians should not prescribe antibiotics for patients with the common cold.

AGENDA

• EXPLAIN THE IMPACT OF THE CURRENT LACK OF ANTIBIOTICSTEWARDSHIP ON PATIENTS, COLLEAGUES AND THE HEALTHCARE SYSTEM

• APPLY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)REGULATIONS FOR ANTIBIOTIC STEWARDSHIP IN THE LONG-TERM CARE(LTC) SETTING

• DESCRIBE SOME COMMON TACTICS TO MAKE SURE THAT PATIENTS AREBEING APPROPRIATELY TREATED ACROSS THE CONTINUUM

• IDENTIFY AREAS FOR IMPROVEMENT IN ANTIBIOTIC STEWARDSHIP IN LTC.

6


2

BEFORE THERE WERE “STEWARDS”

St. Peter’s Church, Bermuda

8

OUR POPULATION IS AGING

9

AGE AS A PREDICTOR OF HEALTHCARE COSTS

10

AHRQ, 2000

ANTIBIOTIC STEWARDSHIP

11

A COORDINATED PROGRAM THAT PROMOTESTHE APPROPRIATE USE OF ANTIMICROBIALS(INCLUDING ANTIBIOTICS), IMPROVESPATIENT OUTCOMES, REDUCES MICROBIALRESISTANCE, AND DECREASES THE SPREADOF INFECTIONS CAUSED BY MULTIDRUG-RESISTANT ORGANISMS.

WHAT’S ALL THE FUSS?

12

1. ELDERLY GENTLEMAN TRANSFERRED TO SNF WITH A UTI ONANTIBIOTIC. THE ORGANISM IS RESISTANT TO THE ANTIBIOTIC

2. ELDERLY LADY, IN THE NURSING HOME, TREATED FORBRONCHITIS WITH TWO DIFFERENT ANTIBIOTICS. SHE DEVELOPSC. DIFFICILE COLITIS

3. NO DURATION GIVEN FOR ANTIBIOTIC TREATMENT AND NOOVERSIGHT, RESIDENT IS ON AN ANTIBIOTIC FOR WEEKS.

4. “PATIENT HAS ASYMPTOMATIC BACTERIURIA, WILL TREAT WITHANTIBIOTIC FOR 7 DAYS.”

5. ANTIBIOTIC DOSING AND PATIENT PHYSIOLOGY NOT COMPATIBLE6. INCORRECT ANTIBIOTIC CHOSEN, ELDER WORSENS AND

REQUIRES HOSPITAL ADMISSIONTAKE HOME MESSAGE: THERE IS GREAT HETEROGENEITY IN THE

ASSESSMENT OF PATIENTS AND USE OF ANTIBIOTICS—WITHPOTENTIAL CONSEQUENCES


3

CHANGING THE MICROBIOME(CHECKS AND BALANCES)

13


14


15

1. ZAURA, ET. AL, AMERICAN SOCIETY OF MICROBIOLOGY, 2015:ANTIBIOTICS CAUSE REDUCTION IN BACTERIA DIVERSITY THAT LASTSFOR MONTHS

2. GURNEE, ET. AL., JOURNAL OF INFECTIOUS DISEASE, 2015: CHILDRENWITH ANTIBIOTIC RESISTANCE E. COLI WITHOUT PRIOR ANTIBIOTICEXPOSURE

3. JACKSON, ET. AL, GUT, 2015: GASTRIC ACID SUPPRESSION REDUCESTHE NUMBER OF INTESTINAL COMMENSALS AND DIVERSITY

4. LIU, ET. AL., LANCET ID, 2015: TRANSMISSION OF ANTIBIOTICRESISTANCE FROM FOOD ANIMALS TO HUMANS

5. SCHWARTZ, ET. AL., INT J OBESITY, 2015: ANTIBIOTICS INFLUENCE ONCHILDHOOD BMI TRAJECTORIES (THE INTESTINAL MICROBIOME PLAYS ANIMPORTANT ROLE IN HOST ENERGY METABOLISM)

CDC: ANTIBIOTIC RESISTANCE (AND MORE)

16

1. NATIONAL SUMMARY DATA, 20131. 2,049,442 ILLNESSES DUE TO ANTIBIOTIC RESISTANCE; 23,000 DEATHS2. 250,000 ILLNESSES DUE TO C. DIFFICILE; 14,000 DEATHS3. UP TO 70% OF RESIDENTS IN A NURSING HOME RECEIVING ONE OR MORE COURSES OF

SYSTEMIC ANTIBIOTICS WHEN FOLLOWED OVER A YEAR4. 40–75% OF ANTIBIOTICS PRESCRIBED IN NURSING HOMES MAY BE UNNECESSARY OR

INAPPROPRIATE

2. 1 OUT OF 5 ER VISITS FROM ADVERSE DRUG EVENTS FROM ANTIBIOTICS(SHEHAB, ET. AL., CLIN INFECT DIS, 2008)

3. ITS NOT JUST MRSA AND VRE ANYMORE!! SERIOUS/URGENT THREATSGONORRHOEAE, ACINETOBACTER, CAMPYLOBACTER, CANDIDA, ESBL, PSEUDOMONAS,SALMONELLA, SHIGELLA, STREP PNEUMO, TB

4. CARBAPENEM-RESISTANT ENTEROBACTERIACEAE (CRE)1. 9000 INFECTIONS/YEAR; 600 DEATHS2. CRE HAVE BECOME RESISTANT TO ALL OR NEARLY ALL AVAILABLE ANTIBIOTICS3. DOCUMENTED COLISTIN-RESISTANCE (ONE OF THE LAST-RESORT ANTIBIOTICS)

5. VANCOMYCIN-RESISTANT STAPH AUREUS (13 CASES)

IN THE LONG‐TERM CARE SETTING…

17

• IN 2012, 1.4 M RESIDENTS IN ~15K FACILITIES, HOUSING OVER 10PERCENT OF THE >85 YEAR OLD POPULATION, 3.8 M HEALTHCAREACQUIRED INFECTIONS FOR $2B IN HEALTHCARE COSTS (CMS, 2013)

• IN 1997-98, NATIONAL ANNUAL COST OF PNEUMONIA TREATMENTWAS$100-436M, WITH ANTIBIOTIC COSTS/RESIDENT UP TO $739. (KRUSE,ET. AL., JAMDA, 2003)

• AN ESTIMATED 25% TO 75% OF ANTIBIOTIC PRESCRIPTIONS DO NOTMEET CLINICAL GUIDELINES FOR APPROPRIATE PRESCRIBING (Mody and Crnich, JAMA IM, 2015)

• 100,000 RESIDENTS IN 600 FACILITIES HAD A 10 FOLD VARIABILITY INANTIBIOTIC USE, UP TO 24% ADVERSE DRUG EVENTS, AND LOCALMICROBIOME SELECTIVE PRESSURES (DANEMAN, ET. AL, JAMA IM, 2015)

• THE PREVALENCE OF C. DIFFICILE COLONIZATION IN RESIDENTS IN THEABSENCE OF A RECOGNIZED OUTBREAK HAS RANGED FROM 4% TO 20%.(SIMOR, ET. AL., ICHE, 2002)

THE WHITE HOUSE

Executive Order 13676, 2015

18

NATIONAL ACTION PLAN FOR COMBATING ANTIBIOTIC-RESISTANT BACTERIA

(5-YEAR ACTION PLAN)GOALS

1. SLOW THE EMERGENCE OF RESISTANT BACTERIA AND PREVENT THESPREAD OF RESISTANT INFECTIONS

2. STRENGTHEN NATIONAL ONE-HEALTH SURVEILLANCE EFFORTS TOCOMBAT RESISTANCE

3. ADVANCE DEVELOPMENT AND USE OF RAPID AND INNOVATIVEDIAGNOSTIC TESTS FOR IDENTIFICATION AND CHARACTERIZATION OFRESISTANT BACTERIA

4. ACCELERATE BASIC AND APPLIED RESEARCH AND DEVELOPMENT FORNEW ANTIBIOTICS, OTHER THERAPEUTICS, AND VACCINES

5. IMPROVE INTERNATIONAL COLLABORATION AND CAPACITIES FORANTIBIOTIC-RESISTANCE PREVENTION, SURVEILLANCE, CONTROL, ANDANTIBIOTIC RESEARCH AND DEVELOPMENT


4

THE WHITE HOUSE

19

“ANTIBIOTICS ARE OVERPRESCRIBED, AND EVERYONE IS LESS SAFE”

BY 2020 (KEY POINTS OVER FIVE YEARS)

• REDUCE INAPPROPRIATE ANTIBIOTIC USE BY 20-50%• ELIMINATE ANTIBIOTICS IN FOOD-PRODUCING ANIMALS• HHS/DOD/VA WILL PROPOSE NEW REGULATIONS TO IMPLEMENT “ROBUST

ANTIBIOTICS STEWARDSHIP PROGRAMS”• PROGRAMS WILL BE TRACKED• ALL CMS HOSPITALS WILL IMPLEMENT THE CDC CORE ELEMENTS PROGRAMS AND

WILL EXPAND TO LTC FACILITIES• CMS WILL REVISE ITS GUIDELINES AND TRAIN SURVEYORS IN ANTIBIOTIC

UTILIZATION MONITORING• ALL STATES WILL “ESTABLISH OR ENHANCE” ANTIBIOTIC STEWARDSHIP IN

HEALTHCARE SETTINGS

CMS IS MAD

20

OIG REPORT SUGGESTS NURSING HOMES “GAME” MEDICAREMODERN HEALTHCARE 9/2015

CMS IS MOVING IN FROM THE HORIZON

21

MODERNIZATION OF THE REGULATIONS (OBRA 1987)REPORTING ON “NURSING HOME COMPARE”• UNNECESSARY HOSPITALIZATIONS

– PHYSICIAN NOTIFICATION

– ROBUST INTERDISCIPLINARY TEAMS

– ASSESSMENT PRIOR TO TRANSFER

– NURSING COMPETENCIES

– APPROPRIATE INFORMATION IN TRANSFER

– QAPI PLANS

• ANTIPSCHOTIC REDUCTIONS

• HEALTHCARE ASSOCIATED INFECTIONS

• EHR INTEROPERABILITY

• PERSON-CENTERED CARE (CHANGE OF CULTURE)• DEMENTIA PROGRAMS

• TRANSITIONS OF CARE

A CASE ONANTIBIOTIC STEWARDSHIP

22

A 91 YEAR OLD GENTLEMAN, WHO IS A LONG-TERM CARE RESIDENT, WITHFAIRLY INTACT COGNITION, HAS URINARY RETENTION AND REQUIRESREGULAR, STRAIGHT CATHETERIZATIONS. HE HAS ONE EPISODE OFTRANSIENT CONFUSION. NO FEVER OR SIGNS/SYMPTOMS OF A URINARYTRACT INFECTION (UTI). FAMILY INSISTS ON A URINALYSIS, AND IT ISGROSSLY POSITIVE. URINE CULTURE, HOWEVER, SHOWS MULTIPLE, GRAMPOSITIVE AND NEGATIVE BACTERIA ONLY SENSITIVE TO POTENT ANDEXPENSIVE, INTRAVENOUS ANTIBIOTICS. HE HAS HAD CLOSTRIDIUMDIFFICILE COLITIS IN THE PAST. A DAUGHTER, WHO WORKS IN A LOCALHOSPITAL’S ANCILLARY SERVICES, REQUESTS A CALL TO DISCUSS ANTIBIOTICTREATMENT. NURSING REPORTS THAT SHE IS UPSET THAT ANTIBIOTICS HADNOT ALREADY BEEN INITIATED. HER FATHER REMAINS WELL AND CLINICALLYSTABLE. HE CONTINUES WITHOUT ANY EVIDENCE OF A UTI.

THE OPTIONS IN CARE

23

1. WHAT CAN WE DO?2. WHAT SHOULD WE DO?

• COMMUNICATION AND EDUCATION

• TIME

• TRANSPARENCY

• ADVANCE CARE PLANNING (CPT 99497/8)

3. WHAT WILL WE BE MANDATED TO DO?

CMS: REFORM OF REQUIREMENTSLONG-TERM CARE FACILITIES, 7/16/2015

PROPOSED RULE, Infection Control (§ 483.80 and .80b):WE PROPOSE TO REQUIRE FACILITIES TO HAVE A SYSTEM FOR PREVENTING,IDENTIFYING, REPORTING, INVESTIGATING, AND CONTROLLING INFECTIONSAND COMMUNICABLE DISEASES FOR ALL RESIDENTS, STAFF, VOLUNTEERS,VISITORS, AND OTHER INDIVIDUALS PROVIDING SERVICES UNDER ANARRANGEMENT BASED UPON ITS FACILITY AND RESIDENT ASSESSMENTS THATIS REVIEWED AND UPDATED ANNUALLY.EACH FACILITY MUST ALSO DESIGNATE ONE INDIVIDUAL AS THE INFECTIONPREVENTION AND CONTROL OFFICER (IPCO) FOR WHOM THE INFECTIONPREVENTION AND CONTROL PROGRAM (IPCP) IS A MAJOR RESPONSIBILITY.


5

CMS: REFORM OF REQUIREMENTSLONG-TERM CARE FACILITIES, 7/16/2015

“NURSING HOMES ARE THE NEXT FRONTIER WHERE NEW ANTIBIOTICRESISTANT ORGANISMS MAY EMERGE AND FLOURISH”• REVIEW AND UPDATE FACILITY INFECTION CONTROL PROGRAM

• INTEGRATED THE IPCO INTO QAPI AND A MEMBER OF QAA GROUP

• IPCO IS A HEALTHCARE PROFESSIONAL WITH SPECIALIZED TRAINING INPREVENTION AND CONTROL

• UTILIZING THE CDC CORE ELEMENTS FOR AN ANTIBIOTIC STEWARDSHIPPROGRAM THAT INCLUDES ANTIBIOTIC USE PROTOCOLS AND A SYSTEMFOR MONITORING ANTIBIOTIC USE

JOINT COMMISSION: ON THE BANDWAGON

THE CORE ELEMENTS OF ANTIBIOTICSTEWARDSHIP FOR NURSING HOMES

CDC, 2015

1. LEADERSHIP COMMITMENT

2. ACCOUNTABILITY

3. DRUG EXPERTISE

4. ACTION

5. TRACKING

6. REPORTING

7. EDUCATION

LEADERSHIP

“DEMONSTRATE SUPPORT AND COMMITMENT TO SAFEAND APPROPRIATE ANTIBIOTIC USE IN YOUR FACILITY”

WSS TRANSLATION:

THE EXECUTIVE DIRECTOR, DIRECTOR OF NURSING, ANDMEDICAL DIRECTOR MUST WORK TOGETHER TO SET THE TONE,AND CULTURE, AND DIRECTION FOR PATIENT-CENTERED, HIGHQUALITY CARE.

ACCOUNTABILITY AND DRUG EXPERTISE

“IDENTIFY PHYSICIAN, NURSING AND PHARMACY LEADSRESPONSIBLE FOR PROMOTING AND OVERSEEING ANTIBIOTICSTEWARDSHIP ACTIVITIES IN YOUR FACILITY AND ESTABLISHACCESS FOR ANTIBIOTIC STEWARDSHIP TRAINING”

WSS ACTION PLAN:EMPOWER “FRONT LINE” NURSING: SBAR/INTERACTQUESTION PROVIDER TEAMS ABOUT ANTIBIOTIC CHOICESDEMAND MORE FROM THE CONSULTANT PHARMACISTTHE “INFECTION PREVENTION PROGRAM COORDINATOR”PARTNERING WITH REFERRAL HOSPITALS/INFECTION CONTROL

ACTION AND TRACKING

“IMPLEMENT AT LEAST ONE POLICY OR PRACTICE TOIMPROVE ANTIBIOTIC USE, AND MONITOR AT LEAST ONEPROCESS MEASURE OF ANTIBIOTIC USE AND AT LEAST ONEOUTCOME FROM ANTIBIOTIC USE IN YOUR FACILITY”

WSS ACTION PLAN:IE. MCGEER CRITERIA FOR INFECTION IN LONG-TERM CAREIMPACT ACT OF 2014TRANSPARENCY: ADVERSE OUTCOMES AND COSTSBEHAVIORAL INTERVENTIONS: JUSTIFYING USE/PEER REVIEWPOPULATION HEALTH DEMANDS OF HIGH VALUE, PATIENT-CENTEREDCARE


6

MCGEER CRITERIA (2012)

THE CONSTITUTIONAL CRITERIA INCLUDES: • FEVER (WITH SPECIFICS)• LEUKOCYTOSIS• ACUTE CHANGE IN MENTAL STATUS FROM BASELINE (CAM CRITERIA ALSO FOUND IN

MDS 3.0) • ACUTE FUNCTIONAL DECLINE IN ACTIVITIES OF DAILY LIVING (ADLS)

URINARY TRACT INFECTIONS• NOT BASED ON CHANGES IN THE CHARACTER OF THE URINE• URINE CULTURE NEEDED FOR DIAGNOSIS

SPECIFIC “CRITERIA 1 AND 2” FOCUS ON URINARY SYMPTOMS AND FINDINGS

INCLUDE: EDUCATION OF STAFF, PERI-CARE, INCREASED HYDRATION, TAKING VITALS, SBAR/NOTIFICATION OF A PROVIDER, MEDICATION REVIEW

IMPACT ACT, 2014IMPROVING MEDICARE POST‐ACUTE CARE TRANSFORMATION

POPULATION HEALTH TO THE POST‐ACUTE ARENA

• NATIONAL QUALITY STRATEGY– BETTER CARE, HEALTHY HOMES/COMMUNITIES, AFFORDABLE CARE

• CMS QUALITY STRATEGY GOALS

– REDUCING HARM, PATIENTS AS PARTNERS, COMMUNICATION/COORDINATION OF CARE, PREVENTION/TREATMENT FOR LEADING CAUSES OF MORTALITY, PROMOTE BEST PRACTICES, AND

AFFORDABLE QUALITY CARE WITH NEW DELIVERYMODELS

– STANDARDIZATION OF DATAACROSS DOMAINS

• MAJOR DOMAINS TO STANDARDIZE

– SKIN INTEGRITY

– FUNCTIONAL/COGNITIVE ASSESSMENT

– MEDICATION RECONCILIATION

– INCIDENCE OF FALLS

– TRANSFER OF INFORMATION IN TRANSITIONS

– UTILIZATION

– DISCHARGE TO THE COMMUNITY

– PREVENTABLE HOSPITAL READMISSIONS

IMPACT ACTDISCHARGE PLANNING

• DEVELOP A DISCHARGE PLAN WITHIN 24 HOURS OF

ADMISSION AND COMPLETE THE PLAN PRIOR TO

DISCHARGE

– DISCHARGE INSTRUCTIONS TO PATIENTS

– HAVE A MEDICATION RECONCILIATION PROCESS

– SEND SPECIFIC INFORMATION TO A RECEIVING FACILITY

– ESTABLISH A POST‐DISCHARGE FOLLOW UP PROCESS

– CREATE REPORTABLE AND ACTIONABLE QUALITY METRICS

REPORTING AND EDUCATION

“PROVIDE REGULAR FEEDBACK ON ANTIBIOTIC USE ANDRESISTANCE TO PRESCRIBING CLINICIANS, NURSING STAFFAND OTHER RELEVANT STAFF, AND PROVIDE RESOURCES TOCLINICIANS, NURSING STAFF, RESIDENTS AND FAMILIESABOUT ANTIBIOTIC RESISTANCE AND OPPORTUNITIES FORIMPROVING ANTIBIOTIC USE”

WSS ACTION PLAN:ALLOW FOR THE CULTURE CHANGE DEMANDING THAT FACILITIES PLAY AMAJOR ROLE IN THE CARE OF THEIR OWN PATIENTS AND REQUIRINGMORE PROVIDER INTERACTION/OVERSIGHT THAT GOES BEYOND DIRECTNURSING CARE OR THERAPIES—CURRENT SKILLED CARE

35

GREATER THAN 10 SOCIETIES HAVE MADEAPPROPRIATE ANTIBIOTIC USE ONE OF THEIR

MAIN 5-10 PRIORITIES

EXAMPLE: 8/2015, AMERICAN ACADEMY OF DERMATOLOGY:

DON’T ROUTINELY USE ANTIBIOTICS TO TREAT BILATERAL

SWELLING AND REDNESS OF THE LOWER LEG UNLESS THERE IS

CLEAR EVIDENCE OF INFECTION

FINDING SOLUTIONSUSING EVIDENCE-BASED MEDICINE

IS THERE TRULY AN INFECTION CONCERN?WHAT ARE THE BEST LABORATORIES TO ORDER?SHOULD THE PATIENT (OR RESULT) BE TREATED?IF TREAT, WHAT IS THE BEST MEDICINE TO USE?ARE THE MEDICINES RECONCILED IN GENERAL?WHAT IS THE CORRECT DOSE TO USE FOR THIS PATIENT?WHAT IS THE APPROPRIATE DURATION OF THERAPY?IS THE WHOLE TEAM ON THE SAME PAGE?

ARE THERE POLICIES/PROCEDURES ENCOMPASSING THESECONSIDERATIONS AND ESTABLISHING STANDARD/BEST PRACTICES

FOR CARE IN THE FACILITY?


7

IT TAKES A VILLAGEUNDERSTANDING LONG-TERM CARE

COLLEAGUE INTERACTIONIMPROVED TRANSITIONS

WARM HAND-OFFS (NURSING AND PROVIDER)STANDARDIZED DISCHARGE SUMMARIES

EDUCATION ABOUT LTC FACILITIES

THE EMERGENCY ROOM (BURKE AND LEVY, JAMDA, 2015)

DOING THE RIGHT THING:PARTNERING WITH NURSING (OLANS, ET. AL, CLIN INFECT DIS. 2016)

COMMITTING TO LONG-TERM CARE PATIENTSWORKING WITH FAMILIES

COMMUNICATION AND EDUCATIONTIME

UTILIZING RESOURCES

ANTIBIOTIC STEWARDSHIP CHECKLISTS (AMDA-PALTC)

CLINICAL PRACTICE GUIDELINES (AMDA-PALTC, AGS, ID SOCIETIES)

OTHER FACILITY’S “BEST PRACTICES”HOSPITAL-BASED, INFECTIOUS DISEASE SPECIALISTS

PUBLIC HEALTH OFFICES, LOCAL AND STATE

CENTERS FOR DISEASE CONTROL

ANTIBIOT CONCLUDING THE CASE(DOING THE RIGHT THING)

• ASYMPTOMATIC BACTERIURIA

NO INDICATION TO TREAT WITH ANTIBIOTIC

• WORKING WITH UNINFORMED FAMILY/CAREGIVERS– NEEDING DISCUSSIONS RE: DEFINITIONS AND LITERATURE;

EDUCATION REQUIRES TIME

• SOLICITING THE FORMER PRIMARY MD FOR SUPPORT

• AGREEING ON A PLAN OF CARE MOVING FORWARD– ADVANCE CARE PLANNING (ACP)

• MAKING SURE THAT ALL MEMBERS OF THE TEAM ARECONVEYING THE SAME MESSAGE (AND WERE COMFORTABLEIN DOING SO)

SUMMARY

1. EVERYONE HAS THE BEST INTENTIONS IN MIND IN THECARE OF RESIDENTS IN LONG-TERM CARE

2. THUS FAR, PRINCIPLES OF ANTIBIOTIC STEWARDSHIPHAVE NOT BEEN STANDARDIZED, OR ADHERED TO,ACROSS THE HEALTHCARE CONTINUUM

3. CMS, AND OTHER AGENCIES, HAVE PUT FORTHREGULATIONS FOR SCRUTINY AND STANDARDIZATION

4. WE NEED TO WORK TOGETHER TO CONTINUE TOADVOCATE FOR RESIDENTS (AND FAMILIES), STABILIZETHE MICROBIOME, AND PROMOTE THE HIGHESTCALIBER, ANTIBIOTIC USE PRACTICES

EVERYTHING STARTS/ENDS WITH:

HAND-WASHING

HAND-WASHING, HAND-WASHING, HAND-WASHING, HAND-WASHING, HAND-WASHING, HAND-WASHING, HAND-WASHING,




HAND-WASHING

Managing Pain: Minimum Data Set and Quality Indicator ConsiderationsAmy M. Westcott, MD, CMD, FAAHPM

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Managing Pain: Minimum Data Set and Quality

Indicator Considerations

Amy M Westcott, MD CMD FAAHPMProgram Director, Hospice and Palliative MedicineAssociate Professor of Geriatric and Palliative Medicine

Disclosures

• I have no financial conflicts to disclose

Objectives

At the end of this session, participants will be able to:

• Describe pain assessment tools (1-10, thermometer, faces), including those utilized for cognitively impaired and nonverbal patients (PAIN-AD, CNPI)

• Create case-based pain management plans for those residing in post-acute care settings that include both pharmacological and non-pharmacological interventions

Background

• Think about a recent situation where you were managing pain in the post-acute care setting?

• What went well and what were some of the challenges?

• Please share with your neighbor.

The Context for Care

Nursing Home

Environment

Say NO to haldol!

Say NO to ativan!

Nursing Home Comparewww.medicare.gov/nhcompare/

F-tagsMDS

Maintain Function!

Advantages in Post-Acute Care

• Established relationship with patient and family

• Continuity of care (especially with transitions)

• Know patient/family preferences• Already managing communication with

family and interdisciplinary team


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Additional Advantages in Post-Acute Care

• Better able to assess patient for changes• Home-like atmosphere• Staff become like family• Staffing around the clock • May take the physical caregiver burden of

the family

Conflict in Goals of Care

Palliative/Comfort Care• Life closure• Comfort• Grief/bereavement

Post-Acute Care• Highest practicable

level of function• Rehab emphasis• State survey readiness

Perceptions of Unmet Needs

• Symptoms (particularly dyspnea and pain)

• Physician communication• Emotional and spiritual support• Resident being treated with respect• Assistance with personal cleanliness

Teno, J et al. JAMA. 2004.Reynolds K et al. J Palliat Med. 2002.

Evidence of “Added Value” of Hospice

• Better pain control• Reduction in hospitalization• Reduction in tube feeding, IVF and

physical restraints• Family perception of added value

Families' perception of the added value of hospice in the nursing home.Baer WM, Hanson LC. J Am Geriatr Soc. 2000 Aug;48(8):879-82.

8 Basic Principles of Pain Treatment

1. Every resident deserves adequate pain management

2. Base the treatment plan on the resident’s goals

3. Follow the principles of pain assessment4. Use both drug and nondrug therapies

Ersek M. NH Pain Management Algorithm Handbook. 2005.

8 Basic Principles of Pain Treatment5. Prevent and/or manage medication side

effects6. Evaluate the effectiveness of all therapies

to ensure that they are meeting the resident’s goals

7. Incorporate residents and family teaching throughout assessment and treatment

8. Address pain using a multi-disciplinary approach

Ersek M. NH Pain Management Algorithm Handbook. 2005.


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Case #1

• 80 year-old woman with pain after Varicella-zoster infection.

• How would you approach managing her pain?

What is your approach to postherpetic neuralgia?

• Topicals:– Capsaicin (0.0075%)– Lidocaine patch

• Oral medications:– Gabapentin or Pregabalin– Tricyclic Antidepressants (Nortriptyline)

• Other:– TENS– Nerve block or lysis

Case #290 year-old nursing home resident with end-stage

dementia. Her nursing aide is concerned that she is in pain.

She makes facial grimaces with personal care and any movement – especially her legs. She is sometimes moaning and inconsolable. This has happened before, but is becoming more frequent.

How do you assess her pain?What type of work-up would you want to pursue?

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Overview of Assessment Tools

• 1-10 Scale• Wong Faces• Thermometer• CNPI• PAIN-AD

Pain Assessment

• Pain History– Location– Duration– Frequency – Intensity– Quality

• Scales– Visual analog scale– Numeric rating scales– Pain thermometer– Facial pain scale

http://wongbakerfaces.org/

http://www.geriatricpain.org/Content/Assessment/Intact/Pages/PainThermometerScale.aspx

Pain Assessment in Advanced Dementia Scale (PAINAD)

Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc. 2003;4(1):9-15.

e1 Great caseersekm, 2/23/2009


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How does the MDS 3.0 assess pain?

• J0100: Pain Management 5-day look back:– Has the resident been on a scheduled pain

medication regimen?– Has the resident received PRN pain medication?– Has the resident received non-medication

intervention for pain?

• J0200: Should Pain Assessment Interview Be Conducted?

• J0300-J0600: Pain Assessment Interview • J0800 Non-verbal Pain Indicators

Acute vs. Chronic Pain

• Acute pain begins suddenly and is usually sharp in quality.

• Warning of disease or a threat to the body.• Might be caused by many events or

circumstances.– Complete history and physical– Consider imaging

Case #2

Given her history of osteoarthritis and old films that show hip/knee disease, you decide to start by treating her for chronic pain due to osteoarthritis.

What would be the best choice for her pain management?

WHO Analgesic Ladder

Nonopioid Analgesics:Appropriate for MILD Pain

• Acetaminophen

• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

• Other: Cymbalta, OTC patches, Tegretol, Depakote, etc.

Acetaminophen• First line therapy• Better safety profile, but no more than

3grams/24hours• Older adults spent more time in social

interaction and less time in their rooms• Older adults spent less time performing

personal care activities AGS Panel on Pharmacological Management of Persistent Pain, JAGS 2009;57:1331-1346British Geriatrics Society Guidance on the Management of Pain in Older People, Age and Ageing 2013;42:i1–i57Chibnall et al. JAGS. 2005


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What does AGE have to do with it?

Age-related Changes

• Kidney

• Liver

• CNS

• Protein Binding

• Body Composition

• Drug-drug Interactions

Case #3

78y/o recently diagnosed with metastatic breast cancer and living in assisted living. Although naproxen has given her some relief with the pain, she continues to feel pain “in her bones”. She has normal renal and hepatic function.

Do you have any concerns about NSAIDS in older adults?

• Limited to 1-2weeks with repeat labs to evaluate for renal insuffiency

• Other potential problems?

What are your options for treating bone pain?

Specific to Bone Pain• Bone Mets

– NSAIDS– Bisphosphonates—pamidronate, zalendronic acid– Radiotherapy (XRT)– Steroids

• Acute Fracture– Bisphosphonates– Calcitonin

• Paget’s Disease– Bisphosphonates


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Case #3 (cont)Her health deteriorates and she transfers to

the nursing home care section of her continuing care retirement community (CCRC).

She is still experiencing 8/10 pain.How would you approach her pain

management with opioids? What dose?How long does it take for opioids to take affect

given the route of administration?

Opioid Naïve Frail ElderOpioid Suggested starting dose

Morphine 2mg PO or SL

Oxycodone 2.5mg PO

Hydrocodone 2.5mg PO

Hydromorphone 0.5mg PO or SL

Adapted from AMDA Toolkit

Opioid Naïve Adult PatientOpioid Suggested starting dose

Morphine 5mg PO or SL

Oxycodone 5mg PO or SL

Hydrocodone 5mg

Hydromorphone 1mg PO or SL

Tramadol 26mg PO

Adapted from AMDA Toolkit

Opioid Pearls• Morphine-most studied, many different routes,

renal-cleared• Hydromorphine-more potent, better if CKD• Oxycodone-no SC or IV available• Fentanyl transdermal-cannot use in opioid

naïve patients• Methadone-mainly GI cleared, extended half-

life of up to 190 hours

What type of regimen would you start?• Oxycodone 5mg PO

How Frequently can you dose PRN opioids?• PO/SL—every 2-3hours given onset 30-60 minutes• SC/IV—every 10minutes given onset 10-15minutes

How often can you adjust the dose?• PO every 24-48hours for long-acting• Transdermal fentanyl every 72hours

What prn dose should you give for breakthrough pain for those on long-acting regimen?

• 10% of 24hour total dose


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What type of preventive medications or measures should you always consider

when prescribing opioids?

• Bowel regimen (senna at a minimum!)• How about nausea prophylaxis?

What is alert charting?

• Notify practitioner for pain >5/10 (depending on scale used in your community)

• Notify practitioner if prn opioid used 2x/12hours (or 3x/24hours)

How about holding parameters?

• Hold opioid dose and notify practitioner if:– RR<10/minute– Pulse ox <92% on RA– Acute change in mental status (more sedated,

confused, etc.)

Final Plan

• Oxycodone 5mg every 4hours scheduled AND 5mg every 3hours/prn pain

• “notify practitioner if patient requires 2 doses in 12 hours”

• BM prophylaxis:– Senna 2 tabs PO every night– Dulcolax suppository every evening

prn/constipation OR “if no BM x 48hours”

Side Effects!

She agrees to start the regimen and then develops diffuse itching after about 3 days

of the regimen….what do you do next?

• Stop the medication due to allergic reaction or continue?

• Treat with antihistamine for 3-5days (i.e. loratidine)NONPHARMACOLOGIC APPROACHES

Adapted from Heidi White, MD CMD


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Transcutaneous Electrical Nerve Stimulation (TENS)

Condition Evidence Outcomes Comment

Back Pain Small RCTs** Conflicting Against

PHN* Case reports one RCT

Positive Insufficient

PDN* Small RCTs Positive For

*PHN: Postherpetic Neuralgia; PDN: Painful Diabetic Neuropathy**RCTs: Randomized Controlled Trials

Dubinsky et al. Neurology 2010;74;173-176Khadilkar A et al. Cochrane Collaboration, 2008, DOI: 10.1002/14651858.CD003008.pub3

Acupuncture


Back Pain Meta-Analysis Positive For

PHN Case reports Positive Insufficient

OA* Meta-Analysis Positive For

Vickers AJ et al. Archives of Internal Medicine. 2012;172:1444-53 Furlan AD et al. Cochrane Collaboration, 2005 DOI: 10.1002/14651858.CD001351.pub2 Manheimer E Cochrane Collaboration, 2010 DOI: 10.1002/14651858.CD001977.pub2

*OA: Osteoarthritis

Percutaneous Electrical Nerve Stimulation (PENS)


Back Pain Small RCTs Positive Consider

PHN with myofascial pain

Case Reports Positive Consider

Weiner DK et al. Pain 2008;140:344-57.Weiner DK & Schmader KE. Pain Med 2006;7(3):243-9

Cognitive Behavioral Therapy*Condition Evidence Outcomes Comment

Back Pain Meta-analysis Positive For

PHN None N/A Insufficient

Arthritis Meta-analysis Positive For

*Patients attend 6–12 sessions to learn and practice pain-management skills, including relaxation, distraction, activity pacing, cognitive restructuring, problem solvingKeefe FJ et al. Br J Anaesthesia 2013;111:89–94 Dixon KE et al. J Pain Sympt Manage 2007;26:241–50Hoffman BM et al. Health Psychol 2007;26:1–9Eccleston C, et al. Cochrane Collaboration 2009; CD007407.Cipher DJ, et al. Clin Gerontol 2007;30:23–40.Cook AJ. J Gerontol B Psychol Sci Soc Sci 1998;53:51–9.

Tried and true…• Distraction• Relaxation• Heat/Cold• Repositioning• Rest/Pacing activities• Muscle strengthening

• Getting restful sleep• Physical therapy • Chiropractic care• Self management• Avoiding postures and

positions that provoke pain

Common Pitfalls in Pain Assessment and Management in Older Adults

• Failure to use quantitative pain scale• Failure to prescribe opioids for patients

whose pain levels are moderate to severe


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• Failure to provide aggressive bowel regimen

• Failure to discontinue medications that contribute to sedation


• Failure to schedule around the clock medications

• Failure to plan ahead (i.e. order prior to dressing change or personal care)

• Failure to re-assess clinically for effectiveness of pain regimen


QAPI: Interdisciplinary team approach necessary

Pain assessment and management includes all members of the IDT

• Physician/Advanced Practice Provider

• Licensed nurses• Nurse aides• Therapist-physical,

occupational, speech• Nutritionist• Pharmacist

Common Pitfalls• Inadequate recognition

– Pain behaviors– Adverse effects of medication

• Communication– Delays in provider notification– Delays in provider response– Dissemination of plan to the team

• Medication procurement– Delays due to lack of a written

prescription– Delays due to formulary issues– Delays due to allergy resolution

Buhr GT. White HK. Quality improvement initiative for chronic pain assessment and management in the nursing home: a pilot study. J Am Med Dir Assoc 2006;7(4):246-53..

Next up - for the panelists…

• Do you have a systematic way of tracking who is prescribing opioids in your clinical setting?

• Do you bring ‘challenging’ cases to QAPI meetings?

• How are you systematically incorporating some of the new PA initiatives into practice?

Other References• AGS Panel on Pharmacological Management of Persistent Pain, JAGS

2009;57:1331-1346• British Geriatrics Society Guidance on the Management of Pain in Older

People, Age and Ageing 2013;42:i1–i57• AMDA Palliative Care in the Long-term Care Setting Toolkit. 2003.• Cafiero, Angela C. PharmD, CGP. Geriatric Pharmacotherapy. Geriatric Secrets. 3rd

Edition. Henly and Belfus, Inc. 2004; 29-35.• Chibnall, John T. PhD, Raymond C. Tait, PhD, Bonnie Harman, PhD,w and Rebecca

A. Luebbert, MSN. Effect of Acetaminophen on Behavior, Well-Being, and Psychotropic Medication Use in Nursing Home Residents with Moderate-to-Severe Dementia. JAGS 53:1921–1929, 2005.

• Ersek, Mary PhD, RN, Anna Du Pen, ARNP, MN, and Keela Herr, PhD, RN. Nursing Home Pain Management Algorithm Handbook. Second Edition. Swedish Medical Center: Pain and Palliative Care Research Department. 2005.

• Kapo, Jennifer MD and Janet Abrahm, MD. Pain Management. Geriatric Secrets. 3rd Edition. Henly and Belfus, Inc. 2004; 87-94.

• Mercadante, S. and Fabio Fulfaro. Management of Painful Bone Metastases. Current Opinion in Oncology. 2007 (19):308-314.

• Upton et al. Population pharmacokinetic modeling of subcutaneous morphine in the elderly. Acute Pain. 2006 (8);109-116.

• www.erperc.mcw.edu

Acknowledgements

• Mary Ersek, PhD RN• Jennifer Kapo, MD• Jennifer Meka, PhD• Heidi White, MD CMD

Panel Discussion

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QAPI: THE PATIENT WITH PAIN

•Focus on non-cancer, non-palliative care

•Pain management practices across continuum of care

• Narcotic conversion in hospital vs. SNF

• Scheduled pain medication vs PRN

• Medication taper – in PA, upon discharge

•Methods to evaluate effectiveness• Goals• Managing difficult cases• Risks of under-prescribing

•Discuss role of the Physician, CRNP, DON, and NHA in QAPI Process

• Examples of Performance Improvement Projects (PIPs)

PANEL OBJECTIVES

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