1)H&P/Soap Note

Markenzie J. LTC H&P revision.ejd

 

2) Journal Article and Summary

Sepsis in Older Adults in Long-Term Care Facilities: Challengesin Diagnosis and Management

Title: Sepsis in Older Adults in Long-Term Care Facilities: Challenges in Diagnosis and Management

This article was published in the Journal of the American Geriatrics Society in October 16, 2019. It discusses a problem that faces many long-term care facilities which is determining the best course of care for patients who may have sepsis.  This of great concern because sepsis is a common cause of hospitalization in older adults and the most common diagnosis among residents transferred to the hospital from long-term care facilities.  Also, the outcome of sepsis are worst in older adults with higher mortality, organ dysfunction, cognitive impairment and permanent disabilities.

The major problems with diagnosis and treatment of sepsis in Long Term Care Facilities are:

• they face financial and regulatory requirements to reduce preventable emergency department visits
• The human and financial costs of ER visits and hospital admission and readmission from LTC facilities are high
• As value-based payment models increase, more long term care facilities will need to manage acute changes without transferring patient to the hospital.
• Long term care facilities will need to have an infection control practitioner based omn new federal regulations,

 

The challenges in making a decision on site to transfer a patient to emergency room or have them stay in LTC for treatment are:

1The definition of sepsis has changed throughout the years. In the 1900’s , the definition of sepsis was limited to an inflammatory process called sepsis that could be complicated by organ dysfunction. The most recent definition is the present of life-threatening organ dysfunction caused by a dysregulated host response to infection.

2) There is no validated diagnostic test for sepsis. A 2016 task force recommends the use of systemic organ failure assessment (SOFA) and it’s abbreviated version quick SOFA(qSOFA- GCS under 15, RR greater than or equal to 22, systolic blood pressure less than or equal to 100.

3) Elderly patients often present with atypical or absent clinical manifestation of disease. Residents are often the most physically and cognitively impaired. Vitals signs are not performed daily in long term care facilities. A geriatric patients baseline temp may be below 98 and a rise in 2F from this baseline may be a febrile response. Also certain medications like b-blockers and cholinesterase inhibitors may prevent tachycardia from showing which can be a sign of fever and sepsis.

3)Site Visit Evaluation: My Summary

In this rotation, I had 2 site visits. In the first visit, I presented a case about an 86 y/o F with PMHx  of CHF, CAD, high degree AV heart block s/p permanent pacemaker in 2018, dementia, schizophrenia, constipation, DM, GERD, osteoporosis, hyperlipidemia, parkinsonism and HTN, who was sent to Flushing Hospital Medical Center ER from her residing nursing home by EMS on 9/29/2020 presenting with SOB x 1 day. The patient was diagnosed with CHF exacerbation due to health care associated pneumonia. Her chest x-ray showed a left basilar infiltrate and small effusion noted. She was treated with Lasix. I liked presenting this patient because I was able to see the patient’s progression from being discharged from the hospital and needing oxygen therapy to her no longer needing it as her symptoms improved.

During my second site visit I presented a case about a 53 y.o. female, dependent in ADL’s and IADLs, with PMHx of prolonged hospitalization with COVID-19, complicated by fall from LT sided hemiparesis due to R MCA infarct CVA and worsening ESRD requiring hemodialysis via L permacath in April 2020, chronic anemia, asthma, HTN, T2DM, hyperlipidemia, migraines, depression, GERD, dysphagia and constipation. She was sent to St. John’s Episcopal Hospital from her residing nursing home by EMS on 10/22, after being found to have low BP with MAP of 51. The patient ended up being diagnosed with hypotensive shock and was given pressor support with levophed and treated with suspected sepsis. Her showed pancytopenia, so she was treated with methylprednisolone along with antibiotics as well.  In the visit, her labs also showed chronic anemia with RBC 2.45, Hgb 6.9 and HCT 23.1. So, the plan was to treat her with Procrit 10, 000 units to be given with hemodialysis.

My site evaluator was able to provide me with constructive feedback regarding the writing of my H and P and also how I delivered the case that I thought was very helpful. Regarding the writing, the long-term care HPI has specific details that need to be included which include the patient’s functional status with ADL’s and IADL’s, hospital course and discharge to nursing home. The geriatric patient often come with large medication lists and medical problems. Also they may have more presenting issues so i have to get more use to better organizing the data in order to not miss out on anything important pertaining to the patient. This is true especially when it comes to all the medications the patients take as it is common for geriatric patients to have a lot of medications.

4)Typhon Report

Long Term Care 10.19.2020-11.20.2020

 

5) Rotation Reflection: Long Term Care

For my long-term care rotation, I had the opportunity to work at Far Rockaway Nursing and Rehabilitation Center. My preceptor was nice and taught me a lot about the common problems affecting geriatric patients including Parkinson’s disease, Alzheimer’s dementia, osteoporosis, urinary incontinence, CHF, diabetes, hypertension, COPD, Asthma and more. I also had the opportunity to do online clinical cases using a resource called Aquifer Geriatrics. With Aquifer, I was able to learn about these common problems as well as other topics surrounding geriatric patients including polypharmacy, frailty, fall risk, feeding issues, agitation, pressure ulcers, advance care planning and more.

Exposure to new techniques or treatment strategies – how did that go?

For this rotation, I was able to get more experience writing a Long-Term Care H and P. For the history part, it was a little different than the other H and P’s I did before as I had to include the patient’s recent hospital course that lead them to being admitted to the nursing home.  I also had to include the patient’s functional status, cognitive status and any impairment with ADL’s and IADL’s. One issue that came up for me in my H and P was that many of the patients had long medication lists so I had trouble keeping it organized at first. I realized that in my plan section, there was benefit in listing out a problem list that I could match with the medications the patients were on to be sure that I included them all.

The nursing home did use an electronic medical database (EMR) but also had still kept full charts of patient history in binders. It was a humbling experience having to search thought the binders to find patient history and it made me appreciate even more the luxury we have now in being able to have access to technology and an electronic medical database.

What was a memorable patient or experience that I’ll carry with me?

I had 2 memorable patients from this rotation. The first was of an 86 y/o female with PMHx of CHF, CAD, high degree AV heart block s/p permanent pacemaker in 2018, dementia, schizophrenia, constipation, DM, GERD, osteoporosis, osteoarthritis, hyperlipidemia, parkinsonism and HTN, hypothyroidism who was recently in the hospital for CHF exacerbation due to healthcare acquired pneumonia which was diagnosed by chest x-ray in the Long Term Care Facility. The patient ended up being treated with Lasix, antibiotics and oxygen therapy, diagnosed with sepsis, eventually recovered and was discharged back to the nursing home.While there I was able to see her recovery since I saw her on multiple days. On the first week, she was c/o of feeling shortness of breath and was recieving oxygen with nasal cannula  with a pulse ox at 96% room air. When I saw her the following week, she was at the point where she no longer needed oxygen therapy and expressed that she was feeling much better. I also was unable to appreciate a JVP which is indicative of fluid back up and a sign of CHF.

The second memorable patient was of a 53 y/o female dependent in ADL’s and IADLs, with PMHx of prolonged hospitalization with COVID-19, complicated by fall from LT sided hemiparesis due to R MCA infarct CVA and worsening ESRD requiring hemodialysis via L permacath in April 2020, chronic anemia, asthma, HTN, T2DM, hyperlipidemia, migraines, depression, GERD, dysphagia and constipation, who was sent to St. John’s Episcopal Hospital from her residing nursing home by EMS on 10/22, after being found to have low BP with MAP of 51. She was diagnosed with hypotensive shock due to bacteremia and Sepsis, treated with PO/IV antibiotics, pressor support, hemodialysis and methylprednisolone. Her Recent labs revealed low RBC 2.45, Hgb 6.9 and HCT 23.1 so it was decided to treat her with Procrit 10, 000 units to be given during hemodialysis once weekly. I found this patient very interesting because she represented to me how life can change so suddenly due to a medical issue.  While battling COVID-19, she also suffered a stroke( R-MCA infarct) in april 2014 which caused her to have to  live in the nursing home for rehabilitation. Her social history is important here because I learned that she was previously independent in ADL’s and IADLs and living with her son in 3^rd floor elevator accessible apartment prior to COVID-19 infection. She is now living in skilled nursing facility on the ground floor, needs assistance with ADL’s and IADL’s and needs max assist and mechanical lift for transfers in the nursing home. This was also my first time interacting with a patient who suffered a stroke. Being that she did have a R-MCA infarct CVA, she did present with LT sided facial numbness, LT sided hemiplegia and LT sided hemiparesis on exam.