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

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Acute Change of condition for
long-term carebest Practices ApproachRecognize
changes early
February 2008

• Mary-Lou van der Horst
• Regional Best Practice Coordinator for
  LTC-Central South

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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

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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.

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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)

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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.

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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).

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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.

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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.

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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)

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ACOCDecision Tree
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ACOC Decision Tree
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ACOC Reference ToolCommon Reasons for
Admission of LTC Residents to Acute Care Setting
and Pre-Existing Conditions That May Predispose
LTC Residents to ACOCs
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ACOC Reference ToolLinking Observed Signs and
Symptoms to the Residents Pre-existing
Conditions
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ACOC Decision Tree
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ACOC Reference ToolCategories of Symptoms
That May Indicate Acute Change of Condition
(Health Status)pg1
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ACOC Reference ToolCategories of Symptoms
That May Indicate Acute Change of Condition
(Health Status)pg2
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ACOC Reference ToolWhen to Report Changes in
Vital Signs and Laboratory Values
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ACOC Reference Tool ACOC Determination
Tool
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ACOC Reference Tool ACOC Determination
Tool
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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  
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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
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ACOC Decision Tree
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ACOC Decision Tree
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Case Scenario 3 partsAndrew 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

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Case Scenario 3 partsAndrew 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?

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Case Scenario 3 partsAndrew 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

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Case Scenario 3 partsAndrew 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?

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Case Scenario 3 partsAndrew 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?

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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

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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

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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.

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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.

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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.
•  

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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
•  

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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 
•