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Acute Change of condition for longterm care best Practices Approach Recognize changes early

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Title: Acute Change of condition for longterm care best Practices Approach Recognize changes early


1
Acute Change of condition for
long-term care best Practices Approach Recognize
changes early
February 2008
  • Mary-Lou van der Horst
  • Regional Best Practice Coordinator for
    LTC-Central South

2
Learning Objectives
  • Acute change of condition may occur abruptly or
    over several hours to several days. ACOCs are
    very common in LTC residents. Although some
    ACOCs are unpredictable, many can be anticipated.
    By identifying ACOCs, residents maybe managed in
    the LTC home and avoid transfer to a hospital.
    AMDA 2003
  • Gain a better understanding of ACOC in LTC
  • Definitions (including MDS)
  • Background Information
  • ACOC Decision Tree
  • ACOC Determination Tool
  • ACOC Reference Tools
  • ACOC Case Scenario 3 parts

3
What is ACOC?
  • An acute change of condition (ACOC) is a sudden,
    clinically important deviation from a residents
    baseline in physical, cognitive, behavioural or
    functional domains. Clinically important
    means a deviation that, without intervention, may
    result in complications or death. (AMDA 2003)
  • ACOCs can occur suddenly or rapidly several hours
    or across several days. Signs and symptoms are
    often ambiguous and non-specific (e.g., decreased
    appetite, agitation, lethargy, falls, weakness,
    disorientation) but are important to observe and
    monitor as they may be early indications of ACOC
    and acute illness.

4
ACOC and MDS
  • ACOC is often linked to MDS and is described as a
    significant change in status. It is a major
    change that is not self limiting, impacts on more
    than one area of the residents health status,
    and requires interdisciplinary review or revision
    of the care plan. Status change has been defined
    as a non-chronic condition that calls for medical
    follow-up by a physician, or as a condition that
    leads to death (Cohen-Mansfield, Lipson and
    Horton, 2003). MDS requirements call for an
    update of the resident. A full assessment must
    be initiated and completed in the case of
    significant change of status.
  • (go to SECTION 3-6 CIHI 2005 RAI-MDS 2.0 Users
    Manual)

5
Background Information
  • LTC residents are at high risk for ACOCs
  • Frail , older, cognitive impairment and/or
    physical illness and disability.
  • Severity of medical illness among is increasing
    in LTC
  • 25-49 of LTC residents are hospitalized each
    year
  • Up to 50 of residents may experience an ACOC q2
    mos
  • 14-38 of the ACOCs lead to transfer to hospital
  • more hospital utilization
  • have decreased survival
  • risk of hospitalization is believed to be highest
    immediately following admission to LTC as
    residents have to adapt to a new environment or
    may be recovering from acute medical problems
    such as a stroke or fracture.

6
Background Information
  • Early detection of ACOC signs and symptoms can
    help to advert poor outcomes and negative impact
    on quality of life.
  • Primary goals of identifying ACOCs is to
  • enable staff to evaluate and manage a resident in
    the home
  • avoid transfer to a hospital or emergency room
    (ER)
  • To achieve this goal
  • staff and practitioners must recognize an ACOC
    and identify it nature, severity and cause(s).
  • Observe behavioural and functional health
    symptoms and dont underestimate their importance
  • Residents tend to underreport their physical
    complaints largely due to cognitive and
    communication impairments or inability to
    distinguish symptoms due to multiple physical and
    functional conditions (Alessi and Harker, 1998
    Boockwar , Brodie and Lachs, 2000 Boockwar and
    Lachs, 2002 2003 Longo et al., 2004).

7
Background Information
  • Many ACOCs can be anticipated managed within the
    LTC home
  • Hospitalization of LTC residents should be
    avoided
  • Transfer to the ER or hospital is disruptive,
    costly, exposes residents to many risks including
    delirium, undernutrition, serious infections,
    skin breakdown and adverse drug reactions.
  • By contrast, care in the LTC home occurs in a
    familiar environment, involves family and is more
    comforting.
  • Timely evaluation and intervention is necessary
    to address ACOCs effectively in the LTC home.
  • Most often, an ACOC represents a change from a
    residents well-established and documented
    baseline.

8
Background Information
  • Many hospitalizations occur soon after LTC
    admission and before staff have collected
    information about the residents baseline status.
  • Despite the potential benefits of treating ACOCs
    in LTC homes, the hospitalization rates for LTC
    residents can be high
  • Ranging from 12 to 59
  • 40 of hospitalizations occur within 90 days of
    admission to the LTC home
  • 75 of hospital stays occur during the residents
    first year in the LTC home.

9
Background Information
  • Communication is critical with ACOCs
  • Need effective and clear verbal communication
    between
  • multidisciplinary team members
  • nurse and physician, and
  • leads to better
  • recognition and timely intervention and treatment
    decision-making, and
  • effective identification and management of ACOCs
  • (taken from AMDA 2003)

10
ACOC Decision Tree
11
ACOC Decision Tree
12
ACOC Reference Tool Common Reasons for
Admission of LTC Residents to Acute Care Setting
and Pre-Existing Conditions That May Predispose
LTC Residents to ACOCs
13
ACOC Reference Tool Linking Observed Signs and
Symptoms to the Residents Pre-existing
Conditions
14
ACOC Decision Tree
15
ACOC Reference Tool Categories of Symptoms
That May Indicate Acute Change of Condition
(Health Status) pg1
16
ACOC Reference Tool Categories of Symptoms
That May Indicate Acute Change of Condition
(Health Status) pg2
17
ACOC Reference Tool When to Report Changes in
Vital Signs and Laboratory Values
18
ACOC Reference Tool ACOC Determination
Tool
19
ACOC Reference Tool ACOC Determination
Tool
20
ACOC Reference Tool ACOC Determination
Tool
ACOC Determination Tool can be used in a variety
of ways, such as   A resource tool use
terminology from the ACOC tool to document
residents ACOC changes on the chart   A resource
tool use the ACOC tool as a reminder to staff as
to what ACOC signs and symptoms should be
observed and monitored   A communication tool-
use it between shifts to report and alert
incoming staff of a residents changing
condition and ensures monitoring continues with
no loss of information   A communication tool
use the ACOC tool to report objective information
to physicians   A communication tool - RPNs use
the ACOC tool to report objective information to
RNs  
21
ACOC Reference Tool ACOC Determination
Tool
ACOC Determination Tool can be used in a variety
of ways, such as     A communication tool use
the signs and symptoms terminology from the ACOC
as the standard for describing and reporting
resident ACOC changes among staff   A
documentation tool- directly record information
on the ACOC tool and place it on the residents
chart   A prompting tool for MDS Significant
Change of Status - use as prompt to initiate MDS
Significant Change in Status - Full Assessments
and/or   An education tool - RNs use the ACOC
to educate RPNs on key ACOC signs and symptoms
and when to report changes
22
ACOC Decision Tree
23
ACOC Decision Tree
24
Case Scenario 3 parts Andrew Hamilton
  • Your resident is Andrew Hamilton. He is 5 10
    and 185 lbs. He is 86 years old and has a
    history of CHF (Congestive Heart Failure) with 2
    previous MIs (Myocardial Infarctions). He has
    hypertension and diabetes, both controlled by
    oral medications. He also takes Plavix. He
    walks using a cane, but often does not use it in
    his room, preferring to hold onto furniture.
    Andrew has very mild dementia and is a quiet man
    who does not socialize much. He has never
    married and has no regular family who visits. He
    lives in a semi-private room with Frank, who has
    been his room-mate since he arrived at your LTC
    Home 18 months ago. He is prescribed a no-added
    sugar or salt diet, but does love his desserts.
    __________________________________________________
    __________________________________________________
    __________________________________________________
    _____
  • Case Scenario developed by Wendy MacDougal BP
    Coord LTC-Central West

25
Case Scenario 3 parts Andrew Hamilton
  • Part 1
  • Today staff found Andrew on the floor in his
    bathroom at 0530. He appeared distraught about
    the fall, but denied hitting his head. He blamed
    his slippers as the cause of the fall, and the
    fact that he was without his cane. He denies any
    pain, but does have a small bruise forming on his
    right knee. He has full range of motion.
  • Vital signs are BP 182/92 T 36.8 P 89 R
    16 CBG 8.1 pupils equal and reactive
    oriented x3.
  • What actions would you expect staff to take at
    this point?
  • What assessment tools, if any would you use? 
  • What follow-up would you recommend?

26
Case Scenario 3 parts Andrew Hamilton
  • Part 2
  • Staff from day shift report that Andrew ate well
    at both breakfast and lunch. They did note that
    he also had a nap both before and after lunch.
    There were no further falls. Vital signs taken at
    lunch time were BP 160/72 T 36.7 P 78 R
    14 CBG 9.2 pupils equal and reactive
    oriented x3.
  • Staff on afternoon shift noted that he ate less
    than half of his dinner and went to bed early.
    The RN decided against waking him, and so no
    vital signs were taken on afternoon shift nor
    night shift.
  • The next morning, Andrew is irritated with staff
    when they wake him. This is unusual for him, but
    no one reports it to the nurse. At breakfast he
    eats less than his full meal and as he is leaving
    the dining room, he stumbles and falls. He
    blames another resident for bumping him. Since
    it is a witnessed fall, the staff know he has not
    hit his head. The bruise on his right knee has
    worsened, but he denies pain and has full range
    of motion, and is able to walk when the staff

27
Case Scenario 3 parts Andrew Hamilton
  • Part 2
  • assist him from the floor. BP 182/96 T
    37.2 P 92 R 18 CBG 9.5 pupils equal and
    reactive oriented x3. The nurse suggests he
    rest and she will check on him later. She finds
    him sleeping soundly at 10 am and so leaves him
    alone.
  • Staff report to the nurse at 1230 that he is
    refusing lunch. When she gets to his room at
    1315, she finds Andrew sleeping again. She wakes
    him, and he is angry and responsive with her,
    striking out when she attempts to do his BP. She
    decides to leave him until later.
  • What actions would you expect staff to take at
    this point?
  • What assessment tools, if any would you use?
  • What follow-up would you recommend?
  • What may be going with Andrew?

28
Case Scenario 3 parts Andrew Hamilton
  • Part 3
  • Andrew gets up at 1600 and demands some lunch
    from staff. While they are getting something
    from the kitchen, the nurse gets his vitals.
    They now are BP 164/78 T 37.0 P 88 R
    16 CBG 9.6 pupils equal and reactive
    oriented x2. Andrew is very irritable. Staff
    note he has had some urinary incontinence, but he
    declines to allow them to assist him to wash or
    change his clothing. He eats and goes back to
    sleep.
  • At 1930, staff find Andrew on the floor in his
    bathroom. He has a small cut on his forehead.
    He is clearly distraught and confused. Vitals
    BP 184/98 T 37.2 P 96 R 18 CBG 9.5
    pupils equal and reactive oriented x1.
  • What actions would you expect staff to take at
    this point?
  • What assessment tools, if any would you use? 
  • What do you think may be going with Andrew?
  • What follow-up would you recommend?
  • Is there anything from this case that you will
    use to set up a protocol for incidents at your
    LTC home?

29
References and Resources
  • American Medical Directors Association. (2003).
    Acute change of condition in long-term care
    setting. Clinical practice guideline. Columbia,
    MD Author.www.amda.com
  •  
  • American Medical Directors Association (1998).
    Altered mental states. Clinical practice
    guideline. Columbia, MD AMDA. www.amda.com
  •  
  • American Medical Directors Association. (2003).
    Pain management in the long-term care setting.
    Clinical practice guideline. Columbia, MD
    Author.www.amda.com
  •  
  • American Medical Directors Association. (2003).
    Pain management in the long-term care setting.
    Clinical practice guideline. Columbia, MD
    Author.www.amda.com
  •  
  • American Medical Directors Association (2005).
    Urinary incontinence. Clinical practice
    guideline. Columbia, MD AMDA. www.amda.com

30
References and Resources
  •  
  • Registered Nurses Association of Ontario.
    (2002). Assessment and management of pain.
    Toronto, ON Author.www.rnao.org
  •  
  • University of Iowa. (2003). Evidence-based
    protocol. Acute pain management in the elderly.
    Iowa City, Iowa University of Iowa
    Gerontological Nursing Interventions Research
    Center. www.nursing.uiowa.edu
  •  
  • Texas Nurses Association. (2005). Long term care
    protocols (3rd ed.). Austin, TX Author.
    www.texasnurses.org

31
References and Resources
  • Ackermann, R.J. (2001). Nursing home practice.
    Strategies to manage most acute and chronic
    illnesses without hospitalization. Geriatrics,
    56(5), 37-48.
  •  
  • Alessi, C.A., Haker, J.O. (1998). A
    prospective study of acute illness in the nursing
    home. Aging Clin. Exp. Res., 10 (6), 479-489.
  •  
  • Boockvar, K., Brodie, H.D., Lachs, M. (2000).
    Nursing assistants detect behavior changes in
    nursing home residents that precede acute
    illness Development and validation of an illness
    warning instrument. Journal of the American
    Geriatrics Society, 48, 1086-1091.
  •  
  • Boockvar, K., Burack, O.R (2007).
    Organizational relationships between nursing
    homes and hospitals and quality of care during
    hospital-nursing home patient transfers. Journal
    of the American Geriatrics Society, 55, 1078-1084.

32
References and Resources
  •  Boockvar, K., Lachs, M. (2002). Development of
    definitions for acute illness. Journal of the
    American Medical Directors Association, 2,
    279-284.
  •  
  • Boockvar, K., Lachs, M. (2001). Hospitalization
    risk following admission to an academic nursing
    home. Journal of the American Medical Directors
    Association, 3, 130-135.
  •  
  • Boockvar, K., Lachs, M. (2000). Predictive
    value of nonspecific symptoms for acute illness
    in nursing home residents. Journal of the
    American Geriatrics Society, 51, 1111-1115.
  •  
  • Cohen-Mansfield, J., Lipson, S., Horton, D.
    (2003). Which signs and symptoms warrant
    involvement of medical staff? The definition and
    identification of status-change events in the
    nursing home. Behavioral Medicine, 29 Fall,
    115-120.

33
References and Resources
  •  Longo, D.R., Young, J., Mehr, D., Lindbloom, E.,
    Salerno, L. (2004). Barriers to timely care of
    acute infections in nursing homes A preliminary
    qualitative study. Journal of the American
    Medical Directors Association, 5, S5-S10.
  •  
  • McLeod, E., Sebastian, S. (2007). Assessment
    of changing health status actions Beyond the
    tip of the iceberg. Perspectives, 31(2), 10-21
  •  
  • Montalto, M. (2001). Hospital in the nursing
    home. Treating acute hospital problems in nursing
    home residents using a Hospital in the Home
    model. Australian Family Physician, 30 (10),
    1010-1012.
  •  

34
References and Resources
  •  Acute Change of Condition
  • Copies of this education presentation, ACOC
    Decision Tree, ACOC Reference Tools, ACOC
    Determination Tool, Case Scenario and other
    related information are available for download
    from
  • www.rgpc.ca
  • CLICKgtgt Best Practices gtgt LTC BP Resource Centre
    gtgtResources gtgt Acute Change of Condition
  •  

35
Contact Information
  • Mary-Lou van der Horst, RN, BScN, MScN, MBA
  • Regional Best Practice Coordinator Long-Term
    Care
  • Central South Region-Ministry of Health and
    Long-Term Care
  • Village of Wentworth Heights
  • 1620 Upper Wentworth Street, Hamilton, ON  
    L9B 2W3
  • email    mvanderhorst_at_oakwoodretirement.com      
      
  • work    905.541.0656 
  •  
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