One important goal of the Wake Forest Geriatrics Principles for Specialists program is to train faculty, chief residents and fellows in the use of quality improvement techniques to enhance care for older adult patients that they serve.  As a product of this effort, chief residents and their faculty mentors in General Internal Medicine developed functional assessment and delirium risk assessment tools that have been incorporated into the history and physical template of the electronic medical record (EMR) to identify pre-hospital functional and cognitive limitations that affect admitted patients age 65 or older.  At present these tools are found in the note template of the following services: four general medicine teaching services, two cardiology services, the renal service, the hematology oncology service, the leukemia service, the Acute Care for the Elderly service, the cardiac critical care service, and the medical intensive care service. 

The functional assessment, implemented in July 2014, includes four questions to help determine a patient’s baseline functional status, including ability to complete activities of daily living and independent activities of daily living, ambulation status, and pre-hospital residence.  Analysis involving chart reviews pre-and post- functional assessment tool implementation showed increased documentation of functional history data in the EMR. 

The delirium risk assessment, implemented in July 2015, includes four items to help identify a patient’s cognitive status, including age greater than 80, a reverse spelling task, orientation to location, and illness severity.  Analysis of delirium incidence of hospitalized patients pre- and post- delirium risk tool implementation is planned for fall 2015.  Our hypothesis is that delirium incidence will rise as awareness and watchfulness by providers increases with use of the tool. 

While the results of implementing these physical and cognitive assessment tools are preliminary or still in process, anecdotal feedback received from case managers and other stakeholders in the discharge planning process indicate that they find such information incorporated in the H&P by admitting physicians to be valuable.  Further study is needed to determine whether such documentation expedites discharge planning, improves use of therapy services, or improves readmission rates or morbidity outcomes.  Next steps planned beyond testing of the delirium assessment tool include implementing a delirium prevention order set to standardize measures taken to decrease delirium among inpatients, followed by further evaluation of changes in delirium incidence, and eventual implementation of a delirium management order set.  The success of these measures within Internal Medicine could encourage roll-out of these tools institution-wide.

An additional benefit of this effort has been the educational value of supporting the training of residents in informatics so that they can contribute to developing solutions for improving patient safety and quality of care.  

Falls in older adults have significant outcomes including injury, isolation due to the fear of falling, and an increase in morbidity and mortality. In this mandatory experience for third-year medical students rotating through Geriatrics, the student accompanies an assessor for the local Meals-on-Wheels (MOW) program to evaluate homebound seniors for their fall risk. The student obtains subjective and objective information including the number of falls, medications, visual acuity (using Snellen vision chart), cognition (using the Mini-Cog assessment instrument), and physical function. The student then determines the client's risk of falls as indicated by assigned readings and resources on falls prevention guidelines and the Beers List. The information obtained by the student is discussed and turned in at the wrap-up meeting with a faculty member at the end of the weeklong Geriatrics rotation.

This is a web-based lesson on the principles of rational prescribing. It includes three cases and addresses polypharmacy, adverse drug events, and off-label prescribing. The principles apply to all patient populations, but this lesson focuses on older adults because they constitute a large and growing population at high risk of polypharmacy and unwanted side effects of medications. The lesson utilizes PowerPoint slides, audio, and interactive features including focus questions within the cases and a specially created drug interaction game. Printable resources available for download include the American Geriatrics Society's Beers Criteria Pocket Card and a sample medication grid for patient use. The lesson is free and requires about 15 minutes to complete.