September 01, 2010

Mrs. QR, a 92-year-old, long-term resident, suffered from a multitude of medical problems. She was legally blind from macular degeneration. She had had coronary angioplasty, twice. Because of chronic stable atrial fibrillation, she was receiving anticoagulation therapy. She had mild to moderate dementia and worsening cardiac function and renal function.

She consistently had physical complaints and symptoms such as feeling “woozy,” short of breath, and “just not right.” She also had a sole, hypervigilant child who disliked our skilled nursing facility but accepted it as her mother's choice.

As Mrs. QR's heart and kidney function deteriorated, she suffered from increasing leg edema and stasis dermatitis, despite high doses of diuretic and heart failure medications. Since she didn't like to keep her legs elevated, she agreed to three-layer compression dressings on her lower legs.

As her attending physician, I observed her increasing weight and upped the diuretics. Mrs. QR's renal function continued to deteriorate (estimated glomerular filtration rate of less than 25 mL/min) and her congestive heart failure remained uncompensated (B-type natriuretic peptide of greater than 750). The unit nurses informed me that she had occasional loose stools.

I discussed our plight with her daughter, who, with her mother, declined treatment with intravenous ionotropic medicines. We planned to continue palliative care until Mrs. QR's death. We held an interdisciplinary team (IDT) meeting on the case, but nothing said there surprised me or prompted any change in Mrs. QR's palliative care.

Soon afterward, I learned that Mrs. QR had become unresponsive and that her daughter wanted her transferred to the local hospital. There she was found to be in severe, anuric renal failure with marked dehydration. Cultures of her watery stools were positive for Clostridium difficile. Emergency dialysis was initiated. Mrs. QR never regained consciousness and succumbed to her multiple medical conditions on the fourth hospital day.

“How could this have happened?” asked the daughter. “How could this have happened?” asked the IDT members.

The IDT got together to review our skilled nursing facility charts (part electronic, part printed, and part handwritten) on our resident. We learned that Mrs. QR's certified nursing assistants (CNAs) had been aware that she was having “occasional loose stools” for more than 3 weeks before her hospitalization.

We also learned that the CNAs diligently recorded their daily findings in the section of the electronic medical record devoted to CNA observations. All the other disciplines also duly recorded their findings in their own sections of the record, but only the CNAs' entries failed to gain the attention of nursing, the attending physician, or the medical director prior to the review. No other member of the IDT ever reviewed the CNAs' notes.

In this case, our facility's care was multidisciplinary but not truly interdisciplinary.

 

 

Another Way

Where we came up short, another facility appears to be doing things right, after it too found out that its quality of care was suffering because the input of direct caregivers was being ignored. Leaders of the Adventist Senior Living nursing homes in Maryland had their epiphany after a particularly dismal state survey at a Rockville, Md., facility, said the organization's chief clinical officer, Sandi Bieganski, RN, MSN.

After an analysis of the root cause of the problems behind the bad survey, Adventist initiated what it calls “morning rounds,” a best practice that has been copied at some of the Maryland chain's other facilities and deserves to be copied beyond.

Every morning in participating facilities, key decision makers go as a group to each nursing unit. In an area that affords discussion while maintaining patient privacy, the administrator, the director of nursing, the assistant director of nursing, the social worker, the dietician, the food services manager, the activities manager, the admissions coordinator, and the therapy manager gather. A nurse (either an RN or an LPN) gives the 24-hour report for all the patients on the unit. Each direct-caregiver—at Adventist, a geriatric nurse assistant (GNA)—attends the meeting at least while his or her patients are presented.

This is not your typical morning report with the nurse manager reading indecipherable notes to silent, nodding coworkers. Topics are discussed, resident by resident: changes of condition, falls, wounds, medication changes, therapy issues, and anything that would typically be listed on a unit's report of condition changes over the past 24 hours.

The nurse supervisor's report, delivered to other nurses, the supervisory hierarchy (including social work, dietary, and activities leaders), and each patient's direct caregiver, breaks down barriers between the disciplines. The observations of the GNAs are actively solicited and the unit nurse, not the nurse manager, is expected to solve unit problems revealed by the discussion. This time also is an opportunity for brief teaching sessions and spot chart audits.

At each unit, after the report and discussions, the administrative team, the nurses, and the GNAs spend a few minutes announcing admissions, discharges, and anything else necessary.

How long does all of this take, when everyone has so much work to do and so many other meetings to sit through? According to Ms. Bieganski, morning rounds originally took about 45 minutes. With practice, the team is now able to report on the building's entire population in 20–30 minutes, tops.

Started as a 5-days-a-week routine, it is now done all 7 days, and at some Adventist facilities, evening shift reports have been added to morning reports.

At the latest state survey, the Adventist skilled nursing facility that started the process received no deficiency grade worse than E, and one surveyor reported that “it is evident that all the staff know their residents.”

Yes, all of us in skilled nursing facilities work hard to evaluate our residents' needs so they can get the best care possible. But too often, because we evaluate residents from the perspective of our own specialty, we work in isolation from people in other disciplines. This duplicates our work and increases our frustration, but worst of all, reduces the quality of the care we provide to our residents.

The type of teamwork that Adventist has embarked on looks like a way toward true interdisciplinary functioning, and the IDTs there should be proud of it. Can morning reports work in other facilities as well? Probably, if the members of your IDT learn to listen, no matter who is talking.

 

 

Follow-Up on Foley-Fond Mrs. OP

I enjoyed reading the e-mails from Caring for the Ages readers who responded to my July query on Mrs. OP, the morbidly obese patient with hemiparesis who insisted on keeping her Foley indwelling even though she no longer needed it medically.

Recall that she said that she was unable to use a bedpan and couldn't get to the toilet quickly enough to avoid an accident (Caring for the Ages, July 2010, p. 6).

Comments I received came from both coasts and both sides of the stalemate.

Several writers thought that the decision of whether to force her off the catheter would depend on whether she would have 24-hour help or a bariatric bedside commode available at home. Most writers mentioned the need for both education on and documentation of the risks of chronic indwelling catheter vs. the indignity of incontinence. Bladder retraining was suggested.

Many writers stressed that our discussions with Mrs. OP and her decisions needed to be documented and that her care plan be reviewed by the interdisciplinary team at least quarterly. One writer suggested that this issue is sufficiently important to require a formal informed consent document.

A writer was concerned that Mrs. OP's stated reason for keeping the catheter in place meant that the facility's staff is failing to meet her needs; that is, they're not getting her to the toilet quickly enough.

I was told by another reader, “This is a no-brainer: It's her right, it's her decision, and the Foley stays in place.”

But my favorite response is the one from a physician who wrote, “Tell Mrs. OP that if she agrees to remove the catheter, you (the physician) will issue a STAT order to all nursing staff to respond to her call to empty her bladder with the same speed they [use to] respond to a cardiac arrest code.”

Indeed. If all the call lights requesting toileting assistance were answered with Cardiac Arrest speed, how many fewer complaints would we hear about the care at the skilled nursing facilities?

Thank you for your comments.

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