University of Chicago & The Donald Wchamp.bsd.uchicago.edu/oste/documents/GeriatricsOSTE… ·...

University of Chicago & The Donald W

An Observed Structured Teaching Exercise (OSTE) Module in Geriatric Medicine

Curriculum For The Hospitalized Aging Medical Patient

CHAMP

The University of Chicago

with funding from

The Donald W. Reynolds Foundation

Don W. Scott, MD, MHS

Section of Geriatrics

University of Chicago

ACKNOWLEDGEMENT: I would like to thank the members of the CHAMP Core Group: Aliza Baron, MA; Catherine DuBeau, MD, Stacie Levine, MD, Paula Podrazik, MD, and Greg Sachs, MD for their contributions and review of this teaching module.

Please do not reproduce or use in any manner without permission of the author.

Table of Contents

Section:

1. Introduction…………………………………………pp 3-7

2. Geriatric G-OSTE Cases…………………………..pp 8-40

3A. Teaching about the Mini-Cog…pp 9-19

3B. Teaching about Delirium……….pp 20-25

3C. Teaching about the Foley………pp 26-34 Catheter

3D. Teaching about Transitions…..pp 35-40 of Care

3. Standardized Students

and/or Observers Checklist…………………..pp 35-38

4. Preceptor’s Guidelines…..…….………………….pp 39-40

5. QA for Preceptors Form……………………………pp 41

6. Teaching Aids: 3 X 5 Cards……………………....pp 42-52

7. Pre-Post G-OSTE Module ………………………...pp 53-54

Evaluation Forms

8. Sample Logistical Plans………………………......pp 55-56

Section 1. Introduction

Introduction

Goals of G-OSTE Module:

1. The participants will teach more geriatric medicine on the in-patient wards by

· Recognizing geriatric teachable moments

· Becoming more comfortable teaching specific geriatric content through practice

2. The participants will improve their in-patient teaching skills by

· Becoming more comfortable using the One-Minute Preceptor and Stanford Clinical Teaching Principles in a simulated ward rounds environment

This module has been designed to compliment specific components of the CHAMP Curriculum and assist in the formative assessment of these geriatric medicine teaching skills on the in-patient wards.

In this Geriatrics G-OSTE (G-OSTE) Module, participants complete a 4 station teaching exercise, participating as both teachers and observers providing feedback. Each G-OSTE scenario allows the teaching participant to practice teaching both specific geriatric content and to use specific clinical teaching principles and methods taught in CHAMP: the One Minute Preceptor Method and the 7 categories of the Stanford Clinical Teaching Curriculum. The cases in this G-OSTE Module include:

1) Dementia Screening--using the Mini-Cog at the bed-side,

2) Delirium, teaching about t the door-side,

3) The Uses & Misuses of Foley Catheters, a bed-side case and

4) Good Transitions of Care, a conference-room card-flip case.

Analogous to an Observed Structured Clinical Examination (OSCE), the Observed Structured Teaching Exercise (G-OSTE) is a performance-based teaching assessment, using standardized learners. This Geriatrics G-OSTE Module is based on the theory of deliberate practice and on the assessment theories of Miller and Kilpatrick.

G-OSTE’s provide an ideal framework for deliberate practice, which can be defined as an experiential teaching method for improving skill during which a motivated learner performs a well-defined task, at an appropriate level of difficultly, then receives informative feedback, and is given opportunities for repetition to correct errors and improve on the task1. The rationale for the use of deliberate practice in medical education, e.g., using G-OSTE’s (and OSCE’s), is based on adult education and cognitive psychology theory and research which has substantiated the role deliberate practice in the development of expert performance.1 A growing body of medical education research is examining the use of G-OSTE’s for accelerated teaching-skills development in both “resident-as-teacher” and faculty development programs .2-4

During an G-OSTE, participants engage in the deliberate practice of their geriatrics teaching-skills. Participants practice specific tasks, receive structured feed back from the precepting faculty, colleagues and/or from the standardized learners. The following schema is used for each individual G-OSTE exercise:

G-OSTE 1st Time Through(5-7 MIN)

(

Structured Feedback (10 MIN)

( Selection of Task(s) to Practice

G-OSTE 2nd Time Through (5-7 MIN)

(

Structured Feedback (10 MIN)

Notes on the role of the SL and the Simulated Assessment Environments:

1. This module is designed around a formative assessment approach, i.e., practice versus high stakes evaluation. As such, extensive training of Standardized Learners (SL’s), to achieve high levels of standardization, is not required. Approximately 3-4 hours of training—much of which can be done in a group setting—should be sufficient. This training should include a presentation on the 5 Micro-Skills for the 1-Minute Preceptor, a briefing on the script, a briefing on the evaluation (if any) the SL is to perform of the teacher and 3-4 run-throughs of the script.

2. The scripts are designed so that the SL presents the trigger for teaching, i.e., a door-side presentation of a patient who became delirious overnight, or bedside rounds on a patient with a Foley Catheter. After the presentation of the trigger to teach, the SL will need to engage in a certain amount of improvisation—portraying the learner as described in the case—as the teaching encounter proceeds. General guidelines are given in the cases below, but the entire encounter can obviously not be scripted. This of course means that the SL will need to have sufficient clinical knowledge and experience to represent the given clinical learner he or she is portraying. Fourth year medical students, residents, NP’s or PA’s can be used, and their appearance should be reasonably believable for the level of learner they are portraying.

3. These cases are not meant to challenge the teacher with problem behaviors or challenging attitudes from the learner.

4. Suspension of disbelief refers to making the simulated environment as realistic as possible. The cases in this module are designed to be either bedside, “door-side”, or conference room cases. The more closely you can replicate these environments the better. This includes the SL’s attire and demeanor. It is extremely important the SL’s stay “in role” during the entire exercise.

5. In general, the SL in these cases should represent an average student and one without any behavioral or attitudinal issues. It is important the SL provide the teacher opportunities to teach. If the SL is of a more advanced level of training, it is especially important they do not engage with the teacher at their actual level of training, but at the level of an average fourth year medical student. The SL’s must understand that this is not a “test” of their actual clinical skill.

6. Feedback: Common areas for improvement fro teachers include:

· Giving a mini-lecture versus teaching through dialogue / questioning

· Actually getting a commitment from the learner versus a list of options or possible answers

· Not correcting mistakes

· Not addressing the different levels of learners present

Section 2. Geriatrics OSTE Cases

Includes:

A) Standardized Student Scripts & Instructions

B) Standardized Patient Script & Instructions (If SP present in case)

C) Teachers Door Chart

D) Feedback Guidelines

Section 2. Geriatrics OSTE Cases

An important goal of this module includes the teacher recognizing the multiple geriatric teaching moments in these cases, in addition to practicing the teaching of specific geriatric content using the teaching methods of the One Minute Preceptor and the 7 categories of the Stanford Clinical Teaching Curriculum.

Included in each G-OSTE case in this section is the following:

a. the learning objectives for the case

b. the Standardized Learner’s (SL’s) Script

c. the SL’s Instructions

d. the Standardized Patient’s (SP’s) Instructions (if needed)

e. the Teacher’s Instructions / Door-Chart

f. feedback guidelines for both the precepting faculty member and/or

standardized learner

(The teaching aids for each case are found in section 7)

G-OSTE CASE # 1

Screening for Dementia using the Mini-Cog

A Bedside Case

Don Scott, MD, MHS

G-OSTE CASE # 1

Screening for Dementia using the Mini-Cog

A Bedside Case

Learning Objectives:

1. The faculty-learner will practice teaching the specified Geriatrics content, using the 5 Micro-skills of the One-Minute Preceptor Model.

2. The faculty-learner will identify one content area and/or one skill step for improvement and practice after Feedback 1.

3. The faculty-learner will articulate two (or more) options for geriatrics teachable moments.

Teaching Aid(s): Mini-Cog Form with Instructions (see Section 7)

G-OSTE SL Script

Setting: Work rounds with Sub-I at patient’s bedside, new admission

Standardized Learner: 4th year medical student during sub-internship

Standardized Patient: Older Hospitalized Adult

Script: [The medical student is summarizing a new admission; either at bedside or at door-side]

The Medical Student [To Attending Summarizing Case]:

So, in summary, Mr. Jones is a 85 year-old male with a h/o CAD, A-Fib and DM, admitted for a GI-Bleed, who was supra-therapeutic on his Coumadin with an INR of 17.

Problem #1 is the GIB. We’ve transfused him 2 units and his Hg has bumped from 7.5 to 9.5. We’ve held his Coumadin and he was given Vitamin K and FFP in the ER. He’s on the schedule for a colonoscopy tomorrow, and if that’s negative, GI is recommending an EGD.

Problem #2 is the new onset A-Fib. He’s been r/o for MI; his echo shows normal LV function and some apical hypokinesis. He came in on Digoxin and his rate control is fine on that.

Problem #3 is his h/o CAD—his enzymes are normal and his ECG is unchanged.

Problem #4 is his DM—he is on a sliding scale right now while he is NPO for the GI procedures.

Problem #5 is Medication Non-Compliance. When I look back at his INRs in the computer they’re all over the place. He lives with his daughter but he says takes his own medicine. We’ll need to get social work involved here I think-- probably have a visiting nurse go out. {Stops and looks at Attending; if done at door side, should proceed into patient’s room prior to screen for dementia}

G-OSTE CASE # 1

Screening for Dementia using the Mini-Cog—a bedside case

Standardized Learner’s (SL’s) Instructions

Gender: Either

Age: appears appropriate for 4th Year medical student

Appearance: Post-Call Scrubs or Standard Professional Dress; White Coat with stuffed pockets; Stethoscope around neck; Clipboard, Cards, Binder or other patient data organizing device.

Clinical Skill & Knowledge:

Clinical Skill:

· Using the RIME format of clinical skill evaluation, SL functioning at the Interpreter level of clinical skill (see Pangaro L. Acad. Med. 1999. Nov;74(11):1203-7.)

General Medical Knowledge:

· Knowledge as expected for level of training (4th year student), in relation to the biomedical issues listed above, e.g., GI Bleeding. Able to present clearly and concisely and able to reasonably prioritize biomedical problems. SL is reasonably familiar with presenting signs, symptoms and basic differential diagnosis for these problems, but has only a beginners knowledge of management and formulation. SL is limited in ability to consider psychosocial aspects of case, e.g., importance of relationship of patient to daughter in managing medications, i.e., is able to see the trees much better than the forest: does not recognize the primary importance of assessment of cognition regarding patient’s inability to adhere to Coumadin regimen.

· The plan articulated by the SL in the above script was put together with the help of the senior resident, and if details of reasoning are probed, the SL should offer a generally limited response. The SL should not appear “clueless”, at most give only one to two supporting pieces of information on clinical reasoning probes.

Geriatrics Specific Knowledge of dementia screening:

· Diagnosis: SL is not familiar with the Mini-Cog. SL knows about MMSE but calls it the “Mental Status Exam,” and has some confusion between the purpose and nature of the MMSE versus the mental-statues Exam. Knowledge of MMSE limited and has never heard of the Mini-Cog. Knowledge regarding diagnostic accuracy during acute illness is limited.

G-OSTE CASE # 1


Standardized Patient Instructions

The purpose of this exercise is to allow the teacher to practice his or her geriatric medicine teaching skills at the bedside. Therefore, extensive history taking will not occur. The majority of the interaction in this case will consist of the teacher or student administering the dementia screening tool called the “Mini-Cog” to you.

Sufficient details of medical and psychosocial history are provided below for the purposes of this exercise. (See letter A) under “KEY POINTS”.)

CASE NAME: Dementia Screening G-OSTE

CASE CHIEF COMPLAINT: Patient not sure why in hospital—if pressed, the CC= “I think I was dizzy or something”

PRESENTING SITUATION: Not really sure why in hospital, “I guess I just got sick.”

SUMMARY OF THE CASE: You have undiagnosed Alzheimer’s Disease. You have been hospitalized for gastrointestinal bleeding because your blood became much too “thin” secondary to taking too much of you blood thinner, Coumadin. The object of the case is for the teacher to teach about screening for dementia, using the dementia screening method called the “Mini-cog.”

KEY POINTS:

A) Keeping the encounter moving.

It is critical that no more than 1 minute be spent on casual conversation or history taking or any other element besides bed-side teaching. It is equally important to keep your responses short and to not engage in lengthy statements. In the beginning of he encounter, if you feel more than 1 minute has elapsed and the teacher is not engaged in actively teaching about dementia screening or administering the Mini-Cog, you should state, “Somebody told me my memory was shot,” as a cue for the teacher to begin teaching.

B) Tips on dialogue.

Patients with early dementia often respond to questions requiring use of short-term memory in a number of different ways. Sometimes they will answer in a vague, non-specific manner; at other times, they may use a dismissive approach to the information being asked. Examples:

Question: “So what causes you to be in the hospital?”

Answer: “I was just really sick.”

Question: “In what way did you feel sick?”

Answer: “I just didn’t feel well at all.”

Question: “What did you have for breakfast this morning?”

Response: “Oh, I just had the usual things.”

Question: “So what did you eat.”

Response: “It was just what was on the menu here.”

Question: “What did you have for breakfast this morning?”

Response: “Oh, I just had the usual things.”

Question: “So what did you eat.”

Response: “Oh I really didn’t pay any attention.”

PATIENT BEHAVIOR, AFFECT, MANNERISMS: You are calm at first, but when the subject of memory testing comes up, you are mildly apprehensive, but fully cooperative, You are frustrated when you can’t remember all the words or draw the clock correctly. If the term “dementia” is used, you become very apprehensive and defensive, and reluctant (but still willing) to cooperate.

PATIENT APPEARANCE: Should be in a gown, draped with a sheet or blanket, lying down, on an exam table (to simulate a hospital bed), or in a hospital bed if one is available in your center.

HISTORY OF THE PRESENT ILLNESS:

Chief Complaint/Reason for Visit or Admission: You are not sure why you were hospitalized, but do remember feeling sick and dizzy. All of your responses to any medical history questions, such as, “What caused you to be in the hospital?”,” should include vague statements and also include statements such as “As best I remember,” or “I think it was…,” etc…You currently feel fine.

Onset: “I think it was a few days ago, as best I remember.”

Duration: “That’s hard to say”

Location: DNA

Character: “Just didn’t feel good.”

Radiation: DNA

Intensity: DNA

Meaning of the illness: You believe any errors in medication is the fault of the pharmacy.

FUNCTIONAL HISTORY: You believe you are completely independent in ADL’s and IADL’s, though you let your daughter do the shopping, meal preparation and housework, because, “that’s the way she likes it.” YOU MANAGE YOUR OWN MEDICATION AND BELIEVE YOU HAVE ABSOLIUTELY NO PROBLEMS WITH THIS.

PSYCHO SOCIAL HISTORY:

Educational Background: I went to teacher’s college

Married or Single: Widowed

If married, how many years? “A long time”

Spouse Name =

Alice or Allen; married “a long time”

Any Children?

2 daughters

Any Grandchildren ?

“Yes” “Oh too many to remember”

Where do you live?

Own home & daughter lives with you

Occupation:

Retired (use an occupation with which you are familiar)

G-OSTE CASE # 1


SP Instructions for Responses on the Mini-Cog Exam

The instrument used for dementia screening in this case is called the “Mini-Cog.”

I consists of a memory test and a drawing test. The teacher or student will ask you to repeat three words and remember them, then draw a clock and set the hands to a specific time, and then remember the 3 words. Further details of the test, including the scoring are provided after these instructions—see next page.)

YOU SHOULD PERFORM IN THE FOLLOWING MANNER ON THE MINI-COG TEST.

1. When first asked to repeat the three words (ball. penny, tree), you should repeat all three correctly, and then say, “Is that what you said?”

2. When asked to draw the clock, you should draw (approximately) the following figure:

3. When asked to remember the 3 words, you should repeat only one of the three.

G-OSTE SP MATERIALS

G-OSTE CASE # 1


The Mini-Cog Assessment Instrument for Dementia

The Mini-Cog assessment instrument combines an uncued 3-item recall test with a clock-drawing test (CDT). The Mini-Cog can be administered in about 3 minutes, requires no special equipment, and is relatively uninfluenced by level of education or language variations.

Administration

The test is administered as follows:

1. Instruct the patient to listen carefully to and remember 3 unrelated words (e.g., Ball, Penny, Tree) and then to repeat the words.

2. Instruct the patient to draw the face of a clock, either on a blank sheet of paper, or on a sheet with the clock circle already drawn on the page. After the patient puts the numbers on the clock face, ask him or her to draw the hands of the clock to read a specific time, such as 11:20. These instructions can be repeated, but no additional instructions should be given. Give the patient as much time as needed to complete the task. The CDT serves as the recall distracter.

3. Ask the patient to repeat the 3 previously presented words.

Scoring

Give 1 point for each recalled word after the CDT distracter.

Score 1–3.

· A score of O indicates positive screen for dementia.

· A score of 1 or 2 with an abnormal CDT indicates positive screen for dementia.

· A score of 1 or 2 with a normal CDT indicates negative screen for dementia.

· A score of 3 indicates negative screen for dementia.

The CDT is considered normal if all numbers are present in the correct sequence and position, and the hands readably display the requested time.

Source: Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000; 15(11): 1021–1027.

CLOCK DRAW TEST

1) Inside the circle, please draw the hours of a clock as they normally appear

2) Place the hands of the clock to represent the time: “ten minutes after eleven o’clock”

Reproduced from: The Clock Drawing Test in : Palmer RM, Meldon SW. Acute Care. In: Principles of Geriatric Medicine and Gerontology , 5 the edition, 2003. Eds. Hazzard WR et al. McGraw-Hill Pub. pp 157-168. Inouye SK. Delirium in hospitalized older patients. Clin Geriatr Med 1998; 14:745-764

G-OSTE CASE # 1


(Teacher’s Preparatory Material: to be given to the teachers 1-2 days prior to the G-OSTE exercise and to be used as a door-chart.)

TEACHER’S DOOR CHART

CASE DESCRITION: This will be a door-side to bed-side teaching case. The purpose of the case is for you to practice teaching about screening for dementia using the Mini-Cog. You will be working with a 4th year sub-I, and a Standardized Patient will also participate in this case.

YOUR TEAM: Rounding with Sub-Intern

PATIENT: Mr. or Mrs. Jackson, admitted for supra-therapeutic Coumadin level and GIB requiring transfusion. There is a h/o “medication non-compliance”

SETTING: Attending Rounds at Doorside. One option is to explain the mini-cog at the door-side, and then have the intern try it at the bed-side. Another option would be to explain the Mini-Cog at the door-side and then demonstrate it yourself at the bed-side.

TEACHING TOOLS: The Mini-Cog Instrument and Clock Drawing Forms will be provided. Handout these out if you like.

TEACHER’S TASK:

1. Practice teaching about screening for dementia using the mini-cog, using the 5 Micro-skills of the One-Minute Preceptor Model and Stanford Clinical Teaching Principles

2. Attempt to recognize additional geriatrics teachable moments.

TIME ALLOTTED: You have approximately 7 minutes for each of your two teaching encounters in this exercise.

G-OSTE CASE # 1


A) PRINCIPLE GERIATRIC CONTENT:

Dementia Screening Teachable Moment

· Does the patient have dementia?

· Could teach about the Mini-Cog and MMSE.

· Could teach about value of history from daughter.

· Demonstrate Use of the Mini-Cog

· Describe Mini-Cog and ask Learner to administer & give feedback

B) OTHER POTENTIAL GERIATRIC TEACHABLE MOMENTS (You should focus on the above, but there are several additional teachable moments which you can help the teacher recognize.)

1. What are the patient’s goals for his own care? If he has Colon Cancer, would he want surgery and/or chemotherapy? What is his current life expectancy? Could teach about individualized decision making concepts.

2.Does the patient have capacity to consent to the GI procedures. If he’s confused about his meds, could he have dementia or be impaired so as to not be able to understand or reason through this situation ? Could teach about capacity assessment

3. Digoxin—is this the best drug, given he is already on another potential dangerous drug = Coumadin. What are the indications for Dig in an 85 yo man? What are the side effects of Dig? Is cardioversion a consideration?

4. “Non-Compliance”—Does this language de-humanize or cast the patient in an adversarial light?

C) HELP THE FACULTY LEARNER IDENTIFY GERIATRIC CONTENT AND AN ASPECT OF THE 5 MICROSKILLS THAT THEY WOULD LIKE TO FOCUS ON FOR THE SECOND TIME THROUGH.

One-Minute Preceptor Micro-Skills

1. Getting a Commitment—Learner verbally commits to an aspect of the case

· What do you think is going on with this patient?

· What other diagnoses would you consider?

· Based on that history, what parts of the physical should we focus on?

2. Probing for Supporting Evidence—question which seeks to explore reasoning and rationale

· What factors in the history and physical support your diagnosis?

· Why would you/ did you choose that particular medication?

3. Reinforcing What Was Done Right

· Comments should include specific behaviors that demonstrated knowledge, skills or attitudes valued by the preceptor

4. Correcting Mistakes: often the most difficult to do

· “will help” “it is preferred” “not best” “will be better” are less extreme than “bad” “poor”

· comments must be specific to the situation and to knowledge, skills or attitudes of the learner

· comments must give guidance or alternative behavior

· “At some point complete PFT’s may be helpful, but right now the patient is acutely ill and PFT’s would not reflect her baseline and be difficult for the patient, so the better course would be a peak flow and pulse–ox monitoring

5. Teach General Rules

· In this case, in addition to the dementia screening technique ( the Mini-Cog) other general rules could include

· Situations in which one needs to consider screening for dementia

· The applicability of the Mini-Cog to an acutely ill hospitalized elder

· Can also note

· Important not to give a Mini-Lecture

· 2-3 minutes at most

· importance of a general rule being general, i.e., should be able to apply to other cases

G-OSTE CASE #2

Teaching about Delirium

A Door-Side Case

Don Scott, MD, MHS

G-OSTE CASE #2

Teaching about Delirium—A Door-Side Case




3. The faculty-learner will articulate two (or more) options for geriatrics teachable moments.

Teaching Aid: May use Delirium Card, including passing out delirium card to learners as part of teaching

G-OSTE SL Script

Setting: Work Rounds at Door-Side--Outside of Patient’s Room

Standardized Learners: Senior Resident and Intern

Standardized Patient: None

[The Intern is presenting the patient on work rounds at the Dorr-Side]

The Intern [To Attending]: OK, so this is our 80 year old man with Parkinson’s, admitted with an aspiration pneumonia. He also has a history of CAD, dementia and diabetes. We’ve been broadly covering him and using a sliding scale for his diabetes. X-cover was called last night about a confusion episode…he was trying to pull out his Foley, so they gave him a milligram of Ativan and ordered a posey, mitts and prn soft restraints. They didn’t get called again, so he apparently did fine the rest of the night. This morning he’s a bit lethargic, but really doesn’t seem that far off his base-line. He’s been doing generally well. He’s been afebrile for 24-hours. Today he’s 36.7 140/65 84 20 and 96% on RA. He seems to be sundowning. [To Resident] Perhaps we should put him on some standing Haldol or resperidone?

Resident: [To Intern and Attending] I’m not sure that Ativan was really the best choice last night. I agree Haldol is better. The benzo’s are associated with delirium and delirious patients always do worse and end up staying longer. The last thing we want to do to him or us is to turn this poor old guy into a rock—the sooner we get him back home the better.

G-OSTE CASE #2


Standardized Learner’s Instructions

SL’s for this case: Senior Resident & Intern

Gender: Either

Age: appears appropriate for level of training

Appearance:

Both--Standard Professional Dress with Stethoscopes

Intern--White Coat with equipment / cards/ manuals in pockets; Clipboard, Cards, Binder or other patient data organizing device.


Clinical Skill: Using the RIME format of clinical skill evaluation (see Pangaro L. Acad. Med. 1999. Nov;74(11):1203-7.)

· Intern: functioning at the Reporter level of clinical skill

· Resident: functioning at the Educator level


· Intern: below average for level of training. Able to present clearly and concisely and able to prioritize biomedical problems, but seems limited in knowledge and evidences insecurity in own knowledge, clinical reasoning and plan formulation. SL is familiar with presenting signs, symptoms, but has limited differential diagnosis ability and rudimentary ability to formulate a plan independently. The intern should not appear totally “clueless”, but at most should give only one to two supporting pieces of information when questioned.

Geriatrics Specific Knowledge of Delirium:

· Risk Assessment: Limited Knowledge—one item at most

· Diagnosis: Delirium is equated with confusion and agitation. Does not know how to formally diagnose delirium and does not know about the CAM.

· Assessment: Knows that medications are an important consideration

· Plan: believes need to “wait out” resolution of underlying problem and/or primary treatment = medications. Does not recognize potential urgent nature of new delirium. Believes delirium is “par-for-the-course” in frail hospitalized older adults.

G-OSTE CASE #2




CASE DESCRIPTION: This will be a door-side teaching case, simulating one setting where teaching often takes place during attending rounds. The purpose of this case is for you to practice teaching bout delirium and to recognize other geriatric teachable moments that may be present.

YOUR TEAM: Intern and Resident

PATIENT: Mr. or Mrs. Batey, with h/o Parkinson’s Dz, CAD, Mild Dementia, DM, admitted with aspiration pneumonia two nights ago.

SETTING: Attending Rounds at Doorside. You are on work rounds with your team, consisting of an intern and a resident. This exercise will be conducted as a door-side teaching exercise.

TEACHING TOOLS: Delirium 3X5 Card—may also pass copies out to student as part of teaching

TEACHER’S TASK:

1. Practice teaching about a selected aspect of incident delirium in the hospitalized vulnerable Elder, using the 5 Micro-skills of the One-Minute Preceptor Model and Stanford Clinical Teaching Principles


TIME ALLOTTED: You have approximately 5 minutes for each of your two teaching encounters

G-OSTE CASE #2


Feedback Guidelines

Help the Faculty Learner identify Geriatric Content and an aspect of the 5 Microskills that they would like to focus on for the second time through.

A) Geriatric Content—Delirium Teachable Moments1. Value of collateral information—knowing the patient’s baseline

2. Diagnosis of Delirium versus Dementia with Agitation--CAM

3. Assessing Risk of Delirium at Admission

4. Diagnostic Approach to Delirium

5. Treatment of Delirium

6. Special Topic = Parkinson’s Disease and use of butyrophenones and risperdal at higher doses

B) Other Potential Geriatric Teachable Moments to note in feedback1. The effect of calling a patient a rock

-professionalism teachable moment

-in this case best done one-on-one and in private?

2. Foley Teachable Moment

-Does this patient have a Foley ?

-Does this patient need a Foley?

3. Effect of Restraints

-Indications and Alternatives

C) Ask the Faculty Learner to identify an item of geriatric content and an aspect of the 5 Microskills that they would like to focus on for the second time through.


1. Get a Commitment—Learner verbally commits to an aspect of the case




2. Probe for Supporting Evidence—question which seeks to explore reasoning and rationale



3. Reinforce What Was Done Right


4. Correct Mistakes: (often the most difficult to do)

· “will help” “it is preferred” “may not best” “will be better” are less extreme than “bad” “poor”


· comments must give guidance or alternative behavior

5. Teach a General Rule or Principle




G-OSTE CASE #3

The Foley Catheter: Indications & Inability to Void

A Bedside Case

Don Scott, MD, MHS & Catherine DuBeau, MD

G-OSTE CASE #3





3. The faculty-learner will identify two (or more) options for geriatrics teachable moments.

Teaching Aid: 3X5 Foley Catheter Card

G-OSTE SL Script

Setting: Work Rounds at the Bedside—the team should walk in to the room to begin the exercise.

SL’s: Senior Resident, Intern, Patient

[The resident begins by saying…]

The Resident [To attending] Good morning Mrs. Smith. I brought the whole team by to see you, dear.

Mrs. Smith: Good Morning everyone.

Intern: So Mrs. Smith is hospital day #4. She was transferred to us from the MICU two days ago. Her active problems are CHF and COPD exacerbation. She had to be BIPAP’d the first 24 hours in the unit because she was retaining and her sats took a while to come up. She responded well to diuresis and steroids, and she’s been off of Bi-Pap for 24 hours and is doing well. Her other problems are diabetes, A-Fib, DJD, and GERD. She’s on lasix 60 bid, Prednisone 60, lisinopril, dilt, glyburide, aspirin, SQ heparin, and prilosec. She was 1440 in and 2400 out.

Resident: I was going to continue the IV Lasix one more day and then switch to p.o. She still has mild crackles at the bases. [To the patient] Mrs. Smith, how is your breathing? Have you been up out of bed?

Patient: My breathing is OK. I haven’t been out of bed because I’m all hooked up to these things.

G-OSTE CASE #3



SL’s for this case: Resident & Intern

Gender: Either


Appearance:



Resident—White Coat, Index Cards (or the like) for Patient Information, Stethoscope



· Intern: functioning at the Reporter level of clinical skill



· Intern: average for level of training. Able to present clearly and concisely and able to prioritize biomedical problems; seems secure in own knowledge, clinical reasoning and plan formulation. SL is familiar with presenting signs, symptoms, and has good general knowledge of differential diagnosis and a beginners ability to ability and to formulate a plan independently. The intern should seem confident but not arrogant.

· Resident: Functioning at an educator level for General Medical Knowledge and Clinical Skill

Geriatrics Specific Knowledge: Appropriate Use of Foley Catheters:

· Intern

· Indications: Limited Knowledge—one item at most (either urinary incontinence “for the patient’s comfort” and/or “to monitor urine output.”)

· Risks: Limited to infection, believes or questions contributions to falls, i.e., “don’t Foley’s help prevent falls by patients not slipping urine if incontinent?”)

· Reasons for Inability to Void: knowledge limited to obstruction (e.g. BPH) and spinal cord processes

· Evaluation of Inability to Void: limited to assessing for obstruction with insertion of Foley Catheter

· Resident

· Indications: able to add the following—for relief of obstruction, for urinary incontinence, especially in presence of open “bed sores”

· Risks: able to add the following —trauma, e.g., pt’s pulling Foley’s out, association with discomfort

· Reasons for Inability to Void: able to add the following —meds, neuropathy (with DM as an example)

· Evaluation of Inability to Void: able to add the following —checking meds, PVR

G-OSTE CASE #3


G-OSTE SP MATERIALS

The purpose of this exercise is to allow the teacher to practice his or her geriatric medicine teaching skills at the bedside. Therefore, extensive history taking will not occur. The majority of the interaction in this case will consist of the teacher and students having a teaching dialogue about uses and misuses of the Foley Catheter.

Sufficient details of medical and psychosocial history are provided below, most of which you will not need for the purposes of this exercise. (See letter A) under “KEY POINTS”.)

CASE NAME: Uses & Misuses of the Foley Catheter

EQUIPMENT NEEDED: Foley Catheter and Bag, Yellow Food Coloring, O2 nasal Cannula and Tubing, IV Bag and Tubing, IV Pole, Paper Tape

CASE CHIEF COMPLAINT: Hospitalized because of shortness of breath

PRESENTING SITUATION: Progressive shortness of breath and leg swelling

SUMMARY OF THE CASE: The point of this case is for the teacher to teach about the indications, uses and misuses of the Foley Catheter. You will have a Foley Catheter taped to your leg. You have serious emphysema and mild congestive heart failure for which you have been hospitalized. You were hospitalized 4 days ago for shortness of breath and spent two days in the intensive care unit. You were transferred fro the ICU to the general medicine ward two days ago and are feeling much better. You have been given diuretic medications to remove excess fluid from your body, oxygen, steroids and “breathing treatments” (inhaled medication).

KEY POINTS:

· Keeping the encounter moving.

At the beginning of the encounter, it is critical that no more than 1 minute be spent on casual conversation or history taking. It is equally important to keep your responses short and to not engage in lengthy statements. In the beginning of the encounter, if you feel more than 1 minute has elapsed and the teacher is not engaged in actively teaching about dementia screening or administering the Mini-Cog, you should state, “Somebody told me my memory was shot,” as a cue for the teacher to begin teaching.

PATIENT BEHAVIOR, AFFECT, MANNERISMS: You are feeling much better and appear comfortable. You are pleasant. You are cognitively intact.

PATIENT APPEARANCE: Should be in a gown, draped with a sheet or blanket, lying down, on an exam table (to simulate a hospital bed), or in a hospital bed if one is available in your center. The SP should have a Foley Taped to inner thigh, with the Foley Bag full of water + yellow food coloring to simulate urine; may also tape an i.v. to arm and have oxygen cannula in nose.

HISTORY OF THE PRESENT ILLNESS:

Chief Complaint/Reason for Visit or Admission: About a week prior to admission you experienced increasing shortness of breath: first with usual activities and then progressing until you were short-of-breath with rest. At the same time your lower legs, ankle and feet were “swelling.” You had a mild cough, especially at night when you would lie down. You also experienced increasing problems lying flat at night and needed to prop yourself up on 4 pillows to be comfortable breathing. No chest pain, or productive or purulent cough, but you did have some wheezing. Your “puffers” helped at first but then became less effective.

Onset: about 1 week prior to admission

Duration: 1 week

Location: DNA

Character: Progressive Shortness of Breath

Radiation: DNA

Intensity: Progressive until so bad had to come to ER

PAST MEDICAL HISTORY:

1) Emphysema—diagnosed about 7-8 years ago

2) “Heart Problems” (Congestive Heart Failure)—diagnosed 3 years ago

3) High Blood Pressure

4) Diabetes

NO HISTORY OF URINARY INCONTINENCE OR ANY TYPE OF URINARY PROBLEMS

PSYCHO SOCIAL HISTORY:

Educational Background:

completed college

Married or Single: Widowed

If married, how many years? 45

Spouse Name

John or Jane; married 45 years

Any Children?

2 sons & 1 daughter

Any Grandchildren ?

5

Where do you live?

Live alone in own home in Hyde Park

Occupation:

Retired (use an occupation with which you are familiar)

FUNCTIONAL HISTORY: INDEPENDENT IN ADL’S & IADL’S

PHYSICAL EXAMINATION: NONE

G-OSTE CASE #3




CASE DESCRIPTION: This will be a bed-side teaching case. The purpose of this case is to practice teaching about the uses and misuses of the Foley Catheter in hospitalized vulnerable elders. You should also attempt to recognize other geriatric teachable moments that may be present. Particularlyhelpful to review would be “Indications for Foley Catheter Use” under the “Bedside Teaching Trigger.”


PATIENT: Mr. or Mrs. Johnson, admitted 4 days ago to the MICU with CHF and COPD exacerbation. She has been on your team for two days and is improving.

SETTING: Attending Rounds at the Bedside. The exercise will commence with you and the team entering the room.

TEACHING TOOLS: Foley 3X5 Card—may also pass copies out to student as part of teaching

TEACHER’S TASK:

1. Practice teaching about the uses and misuses of the Foley Catheter in the hospitalized vulnerable Elder, using the 5 Micro-skills of the One-Minute Preceptor Model and Stanford Clinical Teaching Principles


TIME ALLOTTED: You have approximately 5-7 minutes for each of your two teaching encounters

G-OSTE CASE #3


Feedback Guidelines

A. Geriatric Teachable Moments:

1. Why is this patient catheterized?

2. What are the indications for a Foley Catheter?

3. Why should Foley catheter use be minimized?

4. Who should be discharged with a Foley catheter?

5. How would you trouble shoot leakage around Foley Catheters?

6. How would you manage a Foley catheter pulled out by a patient?

B. Other Potential Geriatric Teachable Moments to note in feedback

1. Appropriateness of referring to patients as “dear.”

2. Planning for Good Transitions of Care

3. Falls

C. ASK THE FACULTY LEARNER TO IDENTIFY AN ITEM OF GERIATRIC CONTENT AND AN ASPECT OF THE 5 MICROSKILLS THAT THEY WOULD LIKE TO FOCUS ON FOR THE SECOND TIME THROUGH.


1. Get a Commitment—Learner verbally commits to an aspect of the

case




2. Probe for Supporting Evidence—question which seeks to explore reasoning and rationale



3. Reinforce What Was Done Right


4. Correct Mistakes: often the most difficult to do

· “will help” “it is preferred” “not best” “will be better” are less extreme than “bad” “poor”


comments must give guidance or alternative behavior

· “At some point complete PFT’s may be helpful, but right now the patient is acutely ill and PFT’s would not reflect her baseline and be difficult for the patient, so the better course would be a peak flow and pulse–ox monitoring

5. Teach General Rules




G-OSTE CASE #4

Transitions of Care—The Ideal Hospital Discharge

A Conference Room Case

Don Scott, MD, MHS

G-OSTE CASE #4





3. The faculty-learner will identify two (or more) options for geriatrics teachable moments.

Setting: Card-Flip at Conference Table

Standardized Learners: Intern and Senior Resident

Teaching Aid(s): Transitions of Care Pocket Card

G-OSTE SL Script:

Resident: OK, how about Mr. Jones, do you think he’s still ready for discharge today?

Intern (to resident and attending): Yeah, I think he’s ready. Mr. Jones is our 76 y/o admitted with a GIB and high Coumadin level. His Mini-Cog was off and we think he may have some dementia. The med-student checked his MMSE and it was 19. His Coumadin is at 2mg day and he’s back to therapeutic now. His colonoscopy and EGD were unremarkable and his Hg has been stable. We’ve adjusted his other meds--he’s back on his usual meds of lisinopril, lasix, atenolol and glyburide. We increased his Atenolol to 50 a day, and made his Lasix bid. We added spironolactone and Lipitor as well. His Cr is 1.7, his BG’s are all in the low 100s; he’s oxygenating OK and his Hgb is 9.5. His lungs are clear and he’s been eating OK.

Resident: What about his mental status?

Intern: His family seems to think he is at his baseline—the student did a MMSE yesterday. He was 19 out of 30—We think he has some dementia or effect of hospitalization. He’s definitely not delirious.

Resident: So, what’s your discharge plan?

Intern: We’ll send him home on his out-patient regimen and he has a follow-up appointment with cards. He lives in a Senior building and his daughter lives near-by and is involved. She will check on him. I’ve written out a med-list for him. Social work has been involved and PY and OT have seen him and recommend just home PT. (To Attending) I’m not sure what else we can do.

G-OSTE CASE #4



SL’s for this case: Resident & Intern

Gender: Either


Appearance:



Resident—White Coat, Index Cards (or the like) for Patient Information, Stethoscope



· Intern: functioning at the Interpreter level of clinical skill



· Intern: average for level of training. Able to present clearly and concisely and able to prioritize biomedical problems; seems reasonably secure in own biomedical knowledge, clinical reasoning and plan formulation. SL is familiar with presenting signs, symptoms, and has a good general knowledge of differential diagnosis and a beginners ability to formulate a plan independently: relies on resident for help with much of plan formulation. The intern is focused solely on biomedical issues, and is not skilled at integrating psychosocial information into the plan.

· Resident: Functioning at an educator level for General Medical Knowledge and Clinical Skill—also primarily focused on “fixing” of biomedical problems

Geriatrics Specific Knowledge: Transitions of Care:

· Intern

· Components of Ideal Hosp. D/C: limited in thinking to rudimentary issues, such as importance of acute medical issues being resolved, able to take p.o., have proper “discharge instructions,” be able to use bathroom, etc…

· Site of Discharge—limited in knowledge to this being a function of PT and OT to determine.

· Resident

· Components of Ideal Hosp. D/C: able to add the following—communication with family important, considering whether home nursing is needed or PT/OT

· Site of Discharge—able to add possible sites of D/C are Home, Nursing Home or Rehab; does not know much about distinction between Acute Rehab / Skilled or “Sub-Acute” Rehab and home with PT

G-OSTE Case 4: Transitions of Care—The Ideal Hospital Discharge



CASE DESCRIPTION: This will be a “card-flip” teaching case set in the conference room. The purpose of this case is to practice teaching about good transitions of care, specifically the ideal hospital discharge. You should also be able to recognize and name other geriatric teachable moments that may be present.

The Geri-content to focus on here is helping them work through the elements of a good discharge plan and/or the most appropriate site for this patient to go to at discharge. Especially helpful in this regard would be the Pocket Card on this subject.


PATIENT: Mr. or Mrs. Jones, admitted for supra-therapeutic Coumadin level and GIB requiring transfusion. There is a h/o “medication non-compliance.” Also has h/o CAD, CM, HTN & CRI.

SETTING: Conference Room Card-Flip

TEACHING TOOLS: The Ideal Hospital D/C Pocket Card be provided. Handout these out if you like.

TEACHER’S TASK:

1. Practice teaching about the components of the ideal hospital D/C and items to consider for best destination at discharge, using the 5 Micro-skills of the One-Minute Preceptor Model and Stanford Clinical Teaching Principles


G-OSTE CASE #4


Feedback Guidelines

A) PRINCIPLE GERIATRIC CONTENT: (see Pocket Card)

1. Components of the Good Hospital D/C for the Vulnerable Elder

· Active Advance Planning—including incorporation of psychosocial information, e.g., who lives with pt.?

· Communication—direct with PCP for solidity of f/u

· Medical Needs—including f/u appointments, follow-up labs,

· Functional Support—including medication management

· Nursing Needs

· Rehabilitative Needs

2. Transfer Destinations

· Acute Rehab

· SNF/Skilled Rehab

· Home c Services

· Home

3. ? Primary Role of the MD in D/C planning ? versus responsibility of Case Manager, Social Work…this = the issue of role of the MD as leader of the team

B) OTHER POTENTIAL GERIATRIC TEACHABLE MOMENTS (You should focus on the above, but there are several additional teachable moments which you can help the teacher recognize.)

1. Treatment of Patient’s Dementia

2. Anemia in the Elderly

3. Advance Care Planning

4. Assessment of Gait

C) HELP THE FACULTY LEARNER IDENTIFY GERIATRIC CONTENT AND AN ASPECT OF THE 5 MICROSKILLS THAT THEY WOULD LIKE TO FOCUS ON FOR THE SECOND TIME THROUGH.

Section 3. Observing Faculty or Standardized Learner Evaluation Form

G-OSTE: FEEDBACK INSTRUMENT FOR OBSERVING FACULT OR SL *

Please indicate your agreement with the following statements:

THIS TEACHER GENERALLY….

A. OBTAINED A COMMITMENT FROM THE LEARNER

1

2

3

4

5

STRONGLY DISAGREE:

STRONGLY AGREE:

No Commitment asked for--either Asked for a commitment, but little

Obtained a specific commitment, skillfully

began with “lecture” or overt judge-

specificity, vagueness accepted,

linking the commitment question to previously

mental criticism

did not obtain a specific commitment

presented material

B. EVALUATED LEARNER’S KNOWLEDGE OF FACTUAL MEDICAL INFORMATION

1

2

3

4

5

STRONGLY DISAGREE:

STRONGLY AGREE:

Did not ask learner helpful questions

Probed learner’s knowledge base of

Asked learner appropriate recall questions

to probe what learner recalled from

factual information with average skill.

to probe his/her knowledge base.

his/her knowledge base about back pain.

C. PROVIDED POSITIVE FEEDBACK

1

2

3

4

5

STRONGLY DISAGREE:

STRONGLY AGREE:

Did not provide positive feedback.

Provided general positive feedback but could

Provided specific, positive feedback that

have better reinforced what student did right.

clearly reinforced what student did right.

D. GAVE NEGATIVE (CORRECTIVE) FEEDBACK TO LEARNER

1

2

3

4

5

STRONGLY DISAGREE:

STRONGLY AGREE:

Failed to correct mistakes, or “corrected” them Partly corrected mistakes with average skill

Effectively corrected mistakes at appropriate

With inaccurate or otherwise useless information. and accuracy.

times, focusing on important issues. Had learner

give self-feedback before teacher’s feedback.

E. EXPLAINED TO LEARNER WHY HE/SHE WAS CORRECT OR INCORRECT

1

2

3

4

5

STRONGLY DISAGREE:

STRONGLY AGREE:

If gave positive or negative feedback, did so only Gave somewhat specific feedback.

When giving both positive and negative

in a general way and failed to explain specifically feedback, effectively explained specific

why learner was correct or incorrect, or did so

reasons why learner was correct or incorrect

Inaccurately (e.g., missed correcting important

(e.g., important points student left out of H&P).

points student failed to include in H&P).

F. OFFERED LEARNER SUGGESTIONS FOR IMPROVEMENT

1

2

3

4

5

STRONGLY DISAGREE:

STRONGLY AGREE:

Never gave specific recommendations for how

Gave somewhat specific suggestions

Gave specific, effective recommendations

learner might improve, or did so ineffectively.

for improvement.

for how learner might improve (e.g., asking about

onset of pain and treatments tried in past, and

including a more complete back examination).

G. TAUGHT A GENERAL RULE

1

2

3

4

5

STRONGLY DISAGREE:

STRONGLY AGREE:

No teaching of a general rule took place or

General Rule (s) taught, but delivered

One or two concise and generalizable rules

What was taught was based on idiosyncratic

in a “mini-lecture” style with little chance

taught interactively, allowing for questions

Opinion or grossly incorrect

for interaction or questions

H. EXPLICITLY ENCOURAGED FURTHER LEARNING

1

2

3

4

5

STRONGLY DISAGREE:

STRONGLY AGREE:

Failed to mention further learning in any way.

Explicitly encouraged further learning

Enthusiastically encouraged further learning

or actually discouraged it. (e.g., seemed to view

but in an indirect or general manner.

with specific, directed suggestions tailored to

student’s role as primarily “scut”).

this learner (e.g., learning more about back pain).

I. LISTENED TO LEARNER

1

2

3

4

5

STRONGLY DISAGREE:

STRONGLY AGREE:

Did not appear to listen to or look at learner Listened to and looked at learner somewhat

Listened to and looked at learner.

Monopolized discussion and/or interrupted

but was a little too dominant in the discussion.

Let learner do complete H&P without

learner. Did not let learner finish H&P.

Eventually let student finish doing H&P.

interrupting or monopolizing the session.

J. AVOIDED DIGRESSIONS

1

2

3

4

5

STRONGLY DISAGREE:

STRONGLY AGREE:

Went off on tangents, was easily distracted.

Showed only minor digressions.

Avoided digressions quite well. Had

Did not have learner help focus session.

learner help focus session as needed.

K. AVOIDED RIDICULE AND INTIMIDATION

1

2

3

4

5

STRONGLY DISAGREE:

STRONGLY AGREE:

Created a hostile climate of ridicule

Created a neutral climate in which

Created a positive climate free from ridicule

and/or intimidation.

learner usually did not feel ridiculed

or intimidation. If learner said something incorrect,

or intimidated.

gently channeled learner toward right answer.

OVERALL TEACHING EFFECTIVENESS

VERY POOR

EXCELLENT

1

2 3

4

5

Section 4. G-OSTE QA for Preceptors

To be used to provide feedback for those precepting the module, e.g., any faculty giving feedback to the teachers.

SECTION 4.

G-OSTE Feedback for Preceptors / QA Checklist

Time Started:________________Observer: □__________ □ ___________

Faculty “Learner” ________________________________

Case:

□ Dementia □ Delirium □ Transitions □ Foley

Topic(s) covered:

Tools Used:

□Mini Cog□Delirium Card

□Hospital Re-admissions

□Clock Draw□Transitions of Care□Foley

□None

Micro Skill Used:

□Commitment□Probe for Support

□Reinforce what was right

□

□Correct Mistakes

□Teach General Rules

Time Stopped: ____________

Feedback Session:

First Interaction:

· Asked faculty-learner to identify geriatric teachable moments

· Ask “learner” for self-reflection on performance.

· Ask observers for comments

· Reviewed teachable moments not brought up by group for consideration.

· Reviewed areas comfortable with

· Geriatric topics

· Tools

· Microskills

· Identified which teachable moment and micro skill he/she plans on using in the “re-take” and why (Describe which ones)

Second Interaction Time started: _______________

· Ask “learner” for self-reflection on performance.

· Ask observers for comments

· Reviewed teachable moments not brought up by group for consideration.

· Your final comments

Other Notes:

Time ended:_____________________

Section 5. Guidelines for OSTE Module Preceptors

To be used as a general set of guidelines for those giving feedback to the teachers.

Section 5.

Preceptor’s Guidelines

PLEASE KEEP YOU EYE ON THE CLOCK…IT IS ESSENTIAL THAT YOU LEAVE TIME FOR A SECOND RUN THROUGH WITH FEEDBACK & DISCUSSION !!

· These are meant to be brief teaching encounters, as one might expect during a busy day of rounding on patients. The teaching encounter itself should not be allowed to exceed 5-7 minutes, and the feedback / discussion should not exceed 10 minutes.

· Total Allotted Time for each G-OTES Station = 30 minutes

1. First Interaction Feedback & Discussion: (15 Minutes)

· 5-7 Minutes for Scenario and 10 Minutes for Feedback

· Ask “learner” for self-reflection on performance. Sample questions:

· How did it go? What went well?

· What were the geriatrics teachable moments you identified?

· What micro skill were you focusing on?

· How comfortable were you with trying out the geriatric topic and One Minute Preceptor method?

· How comfortable were you with using the “tool?”

· What would you like to work on?

· Ask observer and standardized learner for comments.

· Have the teacher commit to a micro skill or SFDP Principle and piece of geriatric content he/she plans on addressing in the “re-take.”

· The idea here is to practice something new and/or uncomfortable, not to demonstrate what one can already do well

· Encourage the teacher to “stretch”

2. Second Interaction (re-take): (15 Minutes)

· 5-7 Minutes for Scenario and 10 Minutes for Feedback

· Ask “learner” for self-reflection on performance. Sample questions:

· How did it go this time? What did you do differently?

· How did it seem to work?

· How comfortable were you with trying out the geriatric topic and One Minute Preceptor method?

· How comfortable were you with using the “tool?”

· Observer and SL comments

· Ask the Teacher and Observer to each name one or two things they have learned as result of this practice

Section 6. Teaching Aids

The pocket cards are laid out to facilitate two sided copying. Two copies of Side 1 of the card will be on the first page, and two copies of Side 2 of the card will be on the second page. By making a two-sided reproduction of these two pages (i.e., Side Two on the back of Side One), you can then cut a single sheet to produce two cards

The One Minute Preceptor

5 Micro-Skills for Teaching1

University of Chicago, CHAMP Program

Don Scott, MD, MHS

1. Get a Commitment

2. Probe for Supporting Evidence

3. Tell Them What They did Right

4. Correct Mistakes

5. Teach a General Rule

1. Get a Commitment

(Ask the learner what he/she thinks

· It is not asking for more data

· It is not offering your own opinion

-What do you think is going on?

-What other information do we need?

-What therapy do you feel is needed?


(Ask the learner for evidence that supports his/her opinion

· It is not Pimping

· It is not a judgment about learner reasoning

-What were the major findings that led you to that conclusion?

-What else did you consider and what kept you from that choice?

-What are the key features of this problem?

1. Irby D. and Greer T.Five Microskills of Clinical Teaching. http://clerkship. fammed.washington.edu/ teaching. Accessed 10/19/2005.

(over)

The One Minute Preceptor

5 Micro-Skills for Teaching1


Don Scott, MD, MHS

1. Get a Commitment


3. Tell Them What They did Right

4. Correct Mistakes


1. Get a Commitment

(Ask the learner what he/she thinks

· It is not asking for more data

· It is not offering your own opinion

-What do you think is going on?

-What other information do we need?

-What therapy do you feel is needed?


(Ask the learner for evidence that supports his/her opinion

· It is not Pimping

· It is not a judgment about learner reasoning

-What were the major findings that led you to that conclusion?

-What else did you consider and what kept you from that choice?

-What are the key features of this problem?

1. Irby D. and Greer T. Five Microskills of Clinical Teaching. http:// clerkship. ammed.washington.edu/ teaching. Accessed 10/19/2005.

(over)

3. Tell them What they did Right

(The SPECIFIC good work and the effect it had

· It is not a vague general phrase

Obviously you considered the patient’s finances when you selected that drug. Your sensitivity to this will certainly help with adherence.

4. Correct Mistakes

( Discuss what was wrong and how to avoid error in future

· It is not a vague judgmental statement

It is important in making the diagnosis of delirium to establish the patients baseline mental status, so in the future be sure to call the family right away if this is a question


(Target to learners level of understanding

· It is not a Mini-Lecture

· It is not an idiosyncratic approach

The key features of delirium are acute onset, fluctuating course and inattention while dementia is more often gradual in onset and etc…

1. Irby D. and Greer T. Five Microskills of Clinical Teaching. http://clerkship. fammed.washington.edu/ teaching. Accessed 10/19/2005.

3. Tell them What they did Right

(The SPECIFIC good work and the effect it had

· It is not a vague general phrase

Obviously you considered the patient’s finances when you selected that drug. Your sensitivity to this will certainly help with adherence.

4. Correct Mistakes

( Discuss what was wrong and how to avoid error in future

· It is not a vague judgmental statement

It is important in making the diagnosis of delirium to establish the patients baseline mental status, so in the future be sure to call the family right away if this is a question


(Target to learners level of understanding

· It is not a Mini-Lecture

· It is not an idiosyncratic approach

The key features of delirium are acute onset, fluctuating course and inattention while dementia is more often gradual in onset and etc…

1. Irby D. and Greer T. Five Microskills of Clinical Teaching. http://clerkship. fammed.washington.edu/ teaching. Accessed 10/19/2005.

Delirium in Hosp’d Seniors


Don Scott, MD, MHS; Andrea Bial, MD

Diagnosis--CAM: 1 + 2 + (3 or 4)

1= Acute Onset & Fluctuating Course

2= Inattention

3= Disorganized Thinking

4= Altered LOC

(Most Common = HYPOACTIVE Form)

Risk Assessment at Admission

1. ( Vision (<20/70)

2. Severe Illness

3. ( Cognition (< 24 MMSE)

4. Dehydration (BUN/Cr > 18)

1-2 = Int. Risk ( 2.5 X as likely vs 0

3-4 = High Risk ( 9.2 X as likely vs 0

Precipitating Risk Factors

1. Phys. Restraints

2. Malnutrition

3. > 3 Med Classes added

4. Bladder Catheter

5. Iatrogenic Event

Int. Risk = 1-2 ( 7.1 X as likely vs. 0

High Risk = 3-5 ( 17.5 X as likely vs 01

Delirium versus Dementia

Feature Delirium Dementia

Onset Acute Insidious

Course Fluctuating Constant

Attention Disordered Gen. Preservd*

Cons-ness Disordered Gen. Preservd*

Halluc’s Often Present Gen Absent*

Invol. Movmt Often Present Gen Absent*

(* = Variable in Advanced Dementia)



Don Scott, MD, MHS; Andrea Bial, MD

Diagnosis--CAM: 1 + 2 + (3 or 4)

1= Acute Onset & Fluctuating Course

2= Inattention

3= Disorganized Thinking

4= Altered LOC

(Most Common = HYPOACTIVE Form)

Risk Assessment at Admission

1. ( Vision (<20/70)

2. Severe Illness

3. ( Cognition (< 24 MMSE)

4. Dehydration (BUN/Cr > 18)

1-2 = Int. Risk ( 2.5 X as likely vs 0

3-4 = High Risk ( 9.2 X as likely vs 0

Precipitating Risk Factors

1. Phys. Restraints

2. Malnutrition

3. > 3 Med Classes added

4. Bladder Catheter

5. Iatrogenic Event

Int. Risk = 1-2 ( 7.1 X as likely vs. 0

High Risk = 3-5 ( 17.5 X as likely vs 01

Delirium versus Dementia

Feature Delirium Dementia

Onset Acute Insidious

Course Fluctuating Constant

Attention Disordered Gen. Preservd*

Cons-ness Disordered Gen. Preservd*

Halluc’s Often Present Gen Absent*

Invol. Movmt Often Present Gen Absent*

(* = Variable in Advanced Dementia)



Hx if Possible / Speak with Family

Focused Physical Exam (c Bladder, Rectal & Skin)

CBC, BMP c Ca, O2-Sat, ECG, U/A, ?CXR

REVIEW ALL MEDs

? Possible Presence (or absence) of

Offending Drug

Discontinue or Decrease Dose

(Don't Forget to consider Withdrawal &

Drug Levels / Tox Screen)

? Explained Fever

Consider Re-Culture

Image or Re-Image

Adequate Abx Coverage?

? UnExplained Fever

Pan-Cx; Image; Consider LP

Empiric Abx Coverage

? Volume Depletion / Over-

Diuresed?

? Electrolyte Disturbance?

? Focal Neuro Finding

? Reason to Suspect Stroke / Bleed

Gentle Volume Repletion

Correct Electrolytes

Neuro-Imaging; (EEG?)

Patient Improves ?

Appropriate Consultation

vs

Tincture of Time

No

? Hypoxemia or IschemiaRx as Appropriate

Pharm. Rx For Delirium (Only if Pt. at Risk)

Haldol

Resper-idal

Zyprexa

Seroquel

Ativan

Adv’s

( sedat;

less ΔBP; IM or IV (IV not apprvd)

( sedat.;

+/- EPS

( sedat.;

+/- EPS

( EPS; OK-PD

Useful in w/d; no 1st-pass; no renal adjust nec.

DisAdv

↓ seiz thrshld;

( EPS

( time to work; wt gain; DM;

Not-PD

Same as Risperid

Same as Risperid;

Most sedat of atypicals

(( sedat. disinhibit. possible;

+falls risk

DOSE

0.5-1 mg po, IM, IV; repeat in 30 mins x 1, then q4h

0.25-0.5 mg po bid

2.5-5mg po qd

25mg po bid to start

0.5-1mg po, IM, IV q6-8h

t-1/2 (range)

21h (10-30h)

20-30h

30h (21-54h)

6h

12h

N.B.

Use when patient is very agitat’d

Use

when med. needed but not urgently

Same as Risperid.

Same as Risperid; consider in PD

Only severe agitation or in w/d, or if others N/A.

*PD = Parkinson’s Disease



Hx if Possible / Speak with Family

Focused Physical Exam (c Bladder, Rectal & Skin)

CBC, BMP c Ca, O2-Sat, ECG, U/A, ?CXR

REVIEW ALL MEDs

? Possible Presence (or absence) of

Offending Drug

Discontinue or Decrease Dose

(Don't Forget to consider Withdrawal &

Drug Levels / Tox Screen)

? Explained Fever

Consider Re-Culture

Image or Re-Image

Adequate Abx Coverage?

? UnExplained Fever

Pan-Cx; Image; Consider LP

Empiric Abx Coverage

? Volume Depletion / Over-

Diuresed?

? Electrolyte Disturbance?

? Focal Neuro Finding

? Reason to Suspect Stroke / Bleed

Gentle Volume Repletion

Correct Electrolytes

Neuro-Imaging; (EEG?)

Patient Improves ?

Appropriate Consultation

vs

Tincture of Time

No

? Hypoxemia or IschemiaRx as Appropriate

Pharm. Rx For Delirium (Only if Pt. at Risk)

Haldol

Resper-idal

Zyprexa

Seroquel

Ativan

Adv’s

( sedat;

less ΔBP; IM or IV (IV not apprvd)

( sedat.;

+/- EPS

( sedat.;

+/- EPS

( EPS; OK-PD*

Useful in w/d; no 1st-pass; no renal adjust nec.

DisAdv

↓ seiz thrshld;

( EPS

( time to work; wt gain; DM;

Not-PD

Same as Risperid

Same as Risperid;

Most sedat of atypicals

(( sedat. disinhibit. possible;

+falls risk

DOSE

0.5-1 mg po, IM, IV; repeat in 30 mins x 1, then q4h

0.25-0.5 mg po bid

2.5-5mg po qd

25mg po bid to start

0.5-1mg po, IM, IV q6-8h

t-1/2 (range)

21h (10-30h)

20-30h

30h (21-54h)

6h

12h

N.B.

Use when patient is very agitat’d

Use

when med. needed but not urgently

Same as Risperid.

Same as Risperid; consider in PD

Only severe agitation or in w/d, or if others N/A.

*PD = Parkinson’s Disease

CHAMP: Foley Catheters

Catherine DuBeau, MD, Geriatrics, Univ of Chicago

1. Does this patient have a catheter?

· Incorporate regular catheter checks on rounds as a Practice-Based Learning and Improvement

· Exercise.

2. Does this patient need a catheter?

Only FOUR Indications

A. Inability to Void

B. Urinary Incontinence and

· Open Sacral or Perineal wound

· Palliative Care

C. Urine Output Monitoring

· Critical Illness—frequent/urgent monitoring needed

· Pt unable/unwilling to collect urine

D. After General or Spinal Anesthesia

2. Why should catheter use be Minimized?

a. Infection Risk:

· Cause of 40% nosocomial infections

b. Morbidity

· Internal Catheters

· Associated with Delirium

· Urethral & Meatal Injury

· Bladder & Renal Stones

· Fever

· Polymicrobial bacteruria

· External (condom) Catheters

· Penile Cellulitus / necrosis

· Urinary Retention

· Bacteruria & Infection

c. Foleys are Uncomfortable / Painful

d. Foleys are Restrictive(Falls & Delirium

e. Cost

CHAMP: Foley Catheters


1. Does this patient have a catheter?

· Incorporate regular catheter checks on rounds as a Practice-Based Learning and Improvement

· Exercise

2. Does this patient need a catheter?

Only FOUR Indications

A. Inability to Void

B. Urinary Incontinence and

· Open Sacral or Perineal wound

· Palliative Care

C. Urine Output Monitoring

· Critical Illness—frequent/urgent monitoring needed

· Pt unable/unwilling to collect urine

D. After General or Spinal Anesthesia

2. Why should catheter use be Minimized?

a. Infection Risk:

· Cause of 40% nosocomial infections

b. Morbidity

· Internal Catheters

· Associated with Delirium

· Urethral & Meatal Injury

· Bladder & Renal Stones

· Fever

· Polymicrobial bacteruria

· External (condom) Catheters

· Penile Cellulitus / necrosis

· Urinary Retention

· Bacteruria & Infection

c. Foleys are Uncomfortable / Painful

d. Foleys are Restrictive(Falls & Delirium

e. Cost

CHAMP: Inability to Void


1. Is there a medical reason for this patient’s inability to void?

Two Basic Reasons

( Poor Pump

· Meds: anticholinergics, Ca++ Blockers, Narcotics

· Sacral Cord Disease

· Neuropathy: DM, B12

· Constipation / Impaction

( Blocked Outlet

· Prostate Disease

· Supra-Sacral Spinal Cord Disease (e.g., MS) with detrusor-sphincter dyssynergia

· Women: scarring, large cystocele

Action Step

Possible Medical Reasons

Review Meds

(-cholinergics, narcotics, Ca-Ch Blockers, (-Blockers

Review Med Hx

Diabetes with Neuropathy, sacral/subsacral cord, B12, GU surgery or radiation

Physical Exam

Women-pelvic for prolapse; All-Sacral Root S2-4—Anal Wink & Bulbocavernosus reflexes

Postvoiding Residual

This should have been done in evaluation of patient’s inability to void, and repeated after catheter removal with voiding trial


Evaluation of Inability to Void

CHAMP: Inability to Void


1. Is there a medical reason for this patient’s inability to void?

Two Basic Reasons

( Poor Pump

· Meds: anticholinergics, Ca++ Blockers, Narcotics

· Sacral Cord Disease

· Neuropathy: DM, B12


( Blocked Outlet

· Prostate Disease

· Supra-Sacral Spinal Cord Disease (e.g., MS) with detrusor-sphincter dyssynergia

· Women: scarring, large cystocele


Evaluation of Inability to Void

Action Step

Possible Medical Reasons

Review Meds

(-cholinergics, narcotics, Ca-Ch Blockers, (-Blockers

Review Med Hx

Diabetes with Neuropathy, sacral/subsacral cord, B12, GU surgery or radiation

Physical Exam

Women-pelvic for prolapse; All-Sacral Root S2-4—Anal Wink & Bulbocavernosus reflexes

Postvoiding Residual

This should have been done in evaluation of patient’s inability to void, and repeated after catheter removal with voiding trial

The Ideal Hospital Discharge


Components

1. Active advanced planning

–Anticipation from admission

–SHx: lives whom? ADLs & IADLs?

–Hosp course: delirium, deconditioning, medical Rx

2. Communication

–In hospital and at D/C: case managers, family, PCP

–Inter-facility: paperwork; direct phone call

3. Core information elements:

• Medical needs

–Summary of admitting problems and course

–Active Problem list and allergies

–Recent important and pending labs

–Reconciled Med List (admit meds and all changes)

–Advance directives: DPOA-HC, preferences, goals

• Functional support (ADL, IADL)

–Disposition: where from and where next

–Functional status: baseline and present

–Social support and contact info

• Nursing needs: monitoring (BP, DM, CHF),

wounds, Ivs

• Rehabilitative needs: PT, OT, speech

Possible transfer destinations

(over)

The Ideal Hospital Discharge


Components

1. Active advanced planning

–Anticipation from admission

–SHx: lives whom? ADLs & IADLs?

–Hosp course: delirium, deconditioning, medical Rx

2. Communication

–In hospital and at D/C: case managers, family, PCP

–Inter-facility: paperwork; direct phone call

3. Core information elements:

• Medical needs

–Summary of admitting problems and course

–Active Problem list and allergies

–Recent important and pending labs

–Reconciled Med List (admit meds and all changes)

–Advance directives: DPOA-HC, preferences, goals

• Functional support (ADL, IADL)

–Disposition: where from and where next

–Functional status: baseline and present

–Social support and contact info

• Nursing needs: monitoring (BP, DM, CHF),

wounds, Ivs

• Rehabilitative needs: PT, OT, speech

Possible transfer destinations

(over)

Determining discharge destination

• Recovering ADL independence or stable baseline

• Sufficient and willing caregiver(s) to provide:

• Safety/supervision

• Meals

• Medication supervision

• ADLs and IADLs support

• No skilled nursing or PT/OT needs

Same as Home to Home except:

• Has Skilled nursing or PT/OT needs

• Skilled nursing care and PT covered by Medicare or insurance

• Needs and can tolerate intensive PT/OT(>1 hr/day)

• Medically unstable for SNF

• Needs frequent MD evaluation (> q2-4 wk)

• Rising Cr, dropping Hgb

• Meds need frequent adjustment (in < 24-48 hr)

• Needs telemetry, daily/STAT labs

• Newly im

Newly Impaired ADL

• No need or unable to tolerate acute rehab

• Lack of sufficient and willing caregiver(s)

• Skilled nursing needs (eg, wounds, IVs)

• 3-night stay for Medicare SNF coverage

Unless new Rx NH can’t support (eg, NGTube)

Determining discharge destination

• Recovering ADL independence or stable baseline

• Sufficient and willing caregiver(s) to provide:

• Safety/supervision

• Meals

• Medication supervision

• ADLs and IADLs support

• No skilled nursing or PT/OT needs

Same as Home to Home except:

• Has Skilled nursing or PT/OT needs

• Skilled nursing care and PT covered by Medicare or insurance

• Needs and can tolerate intensive PT/OT(>1 hr/day)

• Medically unstable for SNF

• Needs frequent MD evaluation (> q2-4 wk)

• Rising Cr, dropping Hgb

• Meds need frequent adjustment (in < 24-48 hr)

• Needs telemetry, daily/STAT labs

• Newly im

Newly Impaired ADL

• No need or unable to tolerate acute rehab

• Lack of sufficient and willing caregiver(s)

• Skilled nursing needs (eg, wounds, IVs)

• 3-night stay for Medicare SNF coverage

Unless new Rx NH can’t support (eg, NGTube)

The Mini-Cog Assessment Instrument for Dementia

The Mini-Cog assessment instrument combines an uncued 3-item recall test with a clock-drawing test (CDT). The Mini-Cog can be administered in about 3 minutes, requires no special equipment, and is relatively uninfluenced by level of education or language variations.

Administration

The test is administered as follows:

1. Instruct the patient to listen carefully to and remember 3 unrelated words (e.g., Ball, Penny, Tree) and then to repeat the words.

2. Instruct the patient to draw the face of a clock, either on a blank sheet of paper, or on a sheet with the clock circle already drawn on the page. After the patient puts the numbers on the clock face, ask him or her to draw the hands of the clock to read a specific time, such as 11:20. These instructions can be repeated, but no additional instructions should be given. Give the patient as much time as needed to complete the task. The CDT serves as the recall distracter.

3. Ask the patient to repeat the 3 previously presented words.

Scoring

Give 1 point for each recalled word after the CDT distracter.

Score 1–3.

· A score of O indicates positive screen for dementia.

· A score of 1 or 2 with an abnormal CDT indicates positive screen for dementia.

· A score of 1 or 2 with a normal CDT indicates negative screen for dementia.

· A score of 3 indicates negative screen for dementia.

The CDT is considered normal if all numbers are present in the correct sequence and position, and the hands readably display the requested time.

Source: Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000; 15(11): 1021–1027.

CLOCK DRAW TEST

1) Inside the circle, please draw the hours of a clock as they normally appear

2) Place the hands of the clock to represent the time: “ten minutes after eleven o’clock”

Reproduced from: The Clock Drawing Test in : Palmer RM, Meldon SW. Acute Care. In: Principles of Geriatric Medicine and Geronto l o g y , 5 th edition, 2003. Eds. Hazzard WR et al. McGraw-Hill Pub. pp 157-168. Inouye SK. Delirium in hospitalized older patients. Clin Geriatr Med 1998; 14:745-764

Section 7. OSTE Module Evaluation Instrument

Retrospective Pre-Post on Confidence

Section 7: Participant Retrospective Pre-Post Evaluation

CHAMP PRATICE TEACHING SESSION

RETROSPECTIVE PRE /POST QUESTIONNAIRE FOR FACULTY SCHOLARS

Your responses to this form will be used for research purposes only and will be entirely confidential.

Name __________________________ Age_______

Gender_______

Departme

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