Singing a Song to the Tune of....PROGRESS!!!

            Hello everyone! Well, after a bit of a lull, it has turned out to be a very exciting week in the research world for those of us involved in the UAB ER quality improvement project! And, perhaps most exciting (at least for me anyway), is that I FINALLY gained access to view the electronic medical record system so I’m ready to rock and roll now!

            Before this point, we knew that we needed to measure changes in mental status in elderly patients admitted to the emergency department, we just weren’t sure exactly how to do that because there are so many different screening tools out there, but surprisingly, not a lot of literature on using them especially with elderly patients in an ER setting (which is why our research is so important and groundbreaking J).

            While reading into what little research has already been published about our topic, the main cognitive impairment screening tool that seemed to be used was the Confusion Assessment Method (CAM), but the main problem with this tool is that it is VERY subjective. Another screening tool that has been proven to be tried and true is the Richmond Agitation and Sedation Scale (RASS), but this tool can also be subjective. So, we started looking into more objective tests such as the Six Item Screen (SIS) and the clock-drawing test, which is a very reliable indicator of cognitive impairment. The only problem with the clock drawing test was that there would be no way to enter the results into the electronic medical system that UAB uses, so that screening tool had to be automatically excluded.

            I think our “ah-ha!” moment came after we finally came across an article that directly related to our project (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088375/), and while reading the limitations of the study, we realized that we needed to include both subjective and objective screening tools in our research project to ensure accurate and reliable results. So, we have decided to use the CAM, RASS, and the SIS cognitive screening tools for our project, and we have created a data collection form to record our results of each as well as other important patient information.

            So next week begins my test run of using these three tools congruently! While I am using each one, it will be important for me to time how long it takes me to complete each assessment so that we can see if they would be feasible to perform in a busy ER (and if they are, then the data supporting this will make instituting them an easier sell). This weekend I’ll be busy thoroughly studying how to use each screening method so that by next week I’ll feel comfortable in real-life situations using them and making modifications to our data collection sheet when needed. I do have to say though, that I am a little nervous now that the time has finally come to test our methods…worried I will mess something up or forget to record something, or take too long performing the assessment, or not establish rapport with the patients, or fall in front of a moving stretcher and cause a catastrophe of epic proportions…if you haven’t picked up on my satire, I get extremely nervous before big things like this (and public speaking, eeek!). Let’s pray that Murphy’s Law has no jurisdiction at UAB’s ER!

            As of now, we are one step closer in discovering the most effective way to screen for mental status change at UAB Hospital…and it’s starting with elderly patients in the emergency department! Amid all of this excitement, I had another very important lesson learned this week; sometimes the important thing isn’t having to know which direction you (or your project) is moving in, but more often it’s simply having faith that you (or your project) is moving.

            Look forward to more exciting updates next week as I blog about my first experiences actually implementing our project out in…drumroll please…the real world!

Small Update

Hello everyone! It’s been a couple of weeks since I’ve posted, so I thought I would give an update. This week my main goal has been trying to obtain access to view online medical charts so that while I’m in the ER, I’m able to gather important data that will be vital to making the quality improvements that we’re striving for. Nursing students, such as myself, typically do not have access to this system, so gaining access has been challenging to say the least –but what would a good research project be without a few challenges? Next week hopefully this issue will be resolved, and we can get going on our prospective October 1^st start date! I’m counting down the days…I’m REALLY excited to get started!

Until I dive further into the research and really get going with the project, I found another video on Youtube, right from the ER here at UAB, that I thought was educational and entertaining J Enjoy!

Questions and feedback are always appreciated.

A Few Tips for Families

This week, I've been thinking a lot about what it means to have an elderly family member admitted to the emergency room, and when I think of hypothetical situations, one question seems to be recurring; "Is there/would there be anything that I could do to help?" 

In the situation that your elderly loved one is admitted to the ER, of course the “ideal” situation would be that you could be there with them to assist in their admission assessment and provide emotional support. In the even that you couldn’t physically be there, I found this video on youtube that gives some extremely useful tips that you as a family member can do to help promote a better outcome for your elderly loved one, especially if they are experiencing an alteration in mental status.
          Here are the tips from www.emergencycareforyou.org, the website named in the video, on how you, and your elderly loved one can be more prepared for emergency room visits:

Tip 1: Medical History Form: You and your parent's physicians can complete the Medical History Form, which lists the medications your parent is taking, allergies as well as past and current medical conditions. Bring this form to the emergency department with your parent and give to the emergency physician. Also keep track and make sure your parent is taking medications correctly.

Tip 2: Bring Reading Materials: Make sure you have a book, magazine, or a newspaper to read while you are waiting for results or to see a physician. It will make the time pass more quickly and help keep your stress level lower.

Tip 3: Anticipate Admission: Bring a change of clothes and some personal items in case your parent is admitted to the hospital. You can always leave them in the car.

Tip 4: Know Physician Contacts: Do you know all the names of the doctors your parents see? You should. Take some time now and find out their names, contact information, why your mother or father sees them and how long they have been seeing them. Write it down and hand it to the doctor or nurse in the emergency department. If you are traveling, have copies of the most recent doctor summary and a copy of an EKG if it is abnormal.

Tip 5: Convey Parent's State of Mind: You know your parent better than the doctor. If he or she seems confused, explain to the physician what "normal" behavior is like. If the doctor is talking to you, make sure you are talking to your parent. Do your best to make sure they understand what is going on. The doctors may have to run tests, conduct an examination or be admitted to the hospital. Keep the conversation open with your parent.

Tip 6: Consider Living Wills: A difficult thought, but important nonetheless. It's one to prepare for. If a condition is life-threatening, you need know what the plan will be and what your parents' wishes are. Do your parents have living wills or known care desires if conditions become critical?

Tip 7: Report on Recent Surgeries: Keep track of surgeries, especially ones involving implanted devices such as hip replacements, or pace makers.

Tip 8: Simplify Insurance Information: Have a single sheet of paper with insurance and identification information.

Tip 9: Resist Downplaying: Realize that elderly patients often will talk down their symptoms to doctors or nurses and only tell it like it is to family members. Be ready to fill in the additional information if necessary.

Tip 10: Be Patient: Realize the more the complaints (almost always the older the patient), the longer it takes to work up the problems. Be patient with your physicians and your parent.        

 Questions, comments, and feedback are welcome! 

The First Post

Hello everyone! My name is Lauren Shestak and I am an Honors in Nursing student at the University of Alabama at Birmingham. This blog will be dedicated to my personal experience working on a quality improvement research project in the emergency department at UAB hospital; I will be working with Dr. Kellie Flood and Dr. Alexander Lo.

The patient population we will be focusing on, the elderly population, grew up in the aftermath of World War II, they witnessed the Vietnam War, the Civil Rights Movement, saw the first man walk on the moon, saw technology advance in leaps and bounds, and the list could go on. These patients are our grandmothers and grandfathers, mothers, fathers, aunts and uncles; they are our loved ones. These patients helped shape the history of the United States and paved the way for our generation and even for generations to come. They helped shape our history, and now it is time for us to help shape medical care for them. 

The purpose of our initial research is to see how older adults, particularly those experiencing changes in mental status, are being medically treated when they are admitted to the emergency room (medicines given, level of confusion/disorientation, etc.). It is our hope that at the end of our research, we can implement a standardized tool that will assist the emergency department team in identifying mental status change in older adults that will thus improve their outcome post discharge.

This is important because over 10,000 elderly patients are admitted to the ER at UAB every year, and this number is expected to rise as the baby-boomer generation, also known as the “Silver Tsunami”, continues to age. It has been estimated that by the year 2030, the number of people over the age of 65 will have doubled, leading to 4 million additional emergency department visits annually by the elderly. When older adults are admitted to the ER, many have alterations in mental status that may mask the underlying reason for their visit, and as of now, there is no standardized method of determining the patient’s mental status in the ER at UAB. Without the patients altered mental status being properly identified, they may have a poorer outcome than their counterparts.

So far, I have met with both of the doctors that I will be working with, have toured the ER, and have met a few of the charge nurses that work there. Right now I am still sifting through research to figure out what will be important to look for when elderly patients are admitted to the ER. In the near future, I will be in the hospital working with the patients and helping to collect data.

This project is very near and dear to my heart, and I cannot express how much I look forward to working with the team I’ve become involved with. I also look forward to giving you all weekly updates on my progress and the progress of the project. Feedback and questions are openly welcomed! More updates coming soon…

Photo courtesy of:http://main.uab.edu/Sites/MediaRelations/photos/41949.jpg