Medication Usage in Independent Living: A Continuing Care Retirement Community Aging in Place Initiative
Aarti Deshpande, Carrie B Rubenstein, Ruth Benfield, and Lee Burnside
Purpose: The purpose of the study was to identify medication use concerns in this community.
Background: In this study, Swedish Geriatric Medicine Fellow partnered with this community to identify medication use concerns in this population.
Continuing Care Retirement Communities (CCRCs) are intended to support residents as they age in place. These communities tend to be well resourced but less studied. This survey attempts to identify medication use concerns in this population. Mirabella CCRC has 324 Independent living (IL) residents, 82 of which are couples. The average age is 85 years. The current cost of an IL unit is from $4673- 6545 per month. This survey is part of a larger initiative to better understand barriers to aging in place in this specific population.
Methods: A ten-question survey was provided to all 324 residents. Residents self completed the survey. Questions included medication numbers, frequency, aid in administration, ease of access, and ease of self-administration, use of over-the-counter medications, supplements, and future concerns of medication management. Residents could leave comments.
Results: There was a response rate of 217 (67%). Thirty eight percent were taking more than 5 medications, 91% took medications once or twice a day, 9% took meds three times a day or more. Eighteen percent had aid in medication management, 22% and 20% had difficulty opening/closing and reading bottles respectively. Medication access was an issue for 1%. Nine percent experienced side effects, 5% of SE were CNS SE. Vitamins or supplements were taken by 85% with 14% taking OTC sleep aids. OTC pain medications (Tylenol, NSAIDS) were taken by 36%. Concerns about managing medicines in the future were noted by 23% with 5% having concerns that cognitive problems may affect self-medication management. Difficulty remembering medications was noted by 12%.
Conclusion: CCRCs represent unique communities requiring unique considerations for medication usage. Cost was not noted to be of concern. Opening/closing and reading labels was of concern. The common use of OTC medications for pain and sleep presents a potential area of intervention. Pharmacy involvement (newsletters, online talks) could address non-medication pain reduction, limitation of sleep medications, and aid in providing appropriate medication bottles. Qualitative analysis could be used to further address resident concerns of cognitive decline and ability to self manage medications.
Mary Alice Duthie and Debbie Shuster
Purpose: Transition to a new policy software that would enable staff to quickly as easily locate Swedish policies and provide policy authors with a practical tool to work more efficiently on policy revisions.
Background/Significance: Existing policy software for Swedish had limited search functionality that caused issues with staff not being able to locate policies quickly or easily. This outdated software had been in place from 2007 – 2021 and contained only basic operations that remained unchanged during this time. If staff had difficulty finding policies in the software then there was the potential for either relying on others on the unit for their experience or attempting to locate other outside resources online that may not be evidenced based practices or procedures. For policy authors, the software did not provide any automated notification of when policies were due for review and at times did not outline which stakeholders were required to review revised policies. These two factors impacted the timely review and revision of policies.
Objectives: The goal was to implement the enterprise-wide policy software solution that would provide superior ability to quickly and easily search for policy documents. The new software would include “google-type” search engine, built-in automatic notifications and approval process for revisions and would interface with the electronic medical record. For policy authors, the benefit of the new software included built-in automatic notifications at intervals prior to when their policy was due for revision and the ability to collaborate with others within the software during the revision process.
Implementation Strategies/Design: Worked on a timeline and transition plan for conversion to PolicyStat software that involved moving and reformatting 1500 policy documents and an additional 1700 attachments documents to those policies in a two month time period. It also comprised relocating 3300 forms documents including hundreds of translated documents and patient education documents into a separate new Sharepoint site. In order to facilitate a smooth transition with this change, another Sharepoint site was created that mirrored the familiar policy webpage but instead linked to the new PolicyStat software.
Results and Outcomes: Data on the effect of the transition was obtained using surveys feedback with caregivers who utilize PolicyStat software to determine the type of improvements gained by software implementation – time to search, ease of use and automated efficiency.
Significance: Moving to a new policy software, PolicyStat, potentially offered the benefit of staff being able to quickly and easily find policy documents. This not only saves staff time but also provides access to best practice policies that guide consistent quality patient care. For authors, the software could be both time-saving and streamline the process for policy revision.
Tonya Lawson, Harriette Lober, and Andrea Nordmark
Background: Blood administration is a high risk, low volume, complex procedure. It has strict regulatory requirements for documentation of at least 15 elements over the course of the procedure. There are frequently findings for deficient documentation during survey. Manual audits are time consuming and inaccurate. Every facility in the Providence system faces the same challenges to audit for compliance.
Problem: Detecting the rate of compliance for documentation of blood administration manually is difficult. Nursing documentation for blood administration is often incomplete. Manual audits are labor-intensive and have proven to have limited impact to increase documentation compliance.
Methods: We created an automated audit to replace the manual process: To do so, we identified the required elements of documentation and studied the electronic medical record for the location of the documentation. This allowed us to create electronic reports from the Corporate Data Warehouse to retrieve the documentation data. Using the data source, we developed visualizations and analysis using PowerBI to understand where documentation was missing. The final report with visualizations were published as a PowerBI app.
Results: Improved documentation completion compliance, brought awareness to the standards for blood administration documentation, and enabled managers to monitor the rate of compliance is near real-time. The report allows managers to understand compliance at various levels of granularity: patient, nurse, unit, campus. For units that have adopted the tool, compliance rates have steadily improved. See table for examples.
Rate of Compliance by Unit
Swedish Cancer Institute
Swedish Orthopedic Institute
Heme/Onc 12 East
Discussion: This has simplified the task of auditing for compliance. The results are timely (T-1). Nurse managers’ report tremendous ease of use of the tool; training to use the tool requires less than 15 minutes. The tool is available for qualified stakeholders throughout the Providence system.
Next Steps: Continue to socialize the tool throughout the Providence system. Continue to refine the tool to meet the needs of individual unit standards and workflows.
Water-Soluble Alternative to Simethicone to Safely Visualize GI-Tract. Have We Found Our White Whale?
Teri Mallard, Sandra Roswell, and Amarnath Ramakrishnan
Purpose: To evaluate a safe alternative to simethicone, that aligns with the scope manufacturer recommendations, and eliminates GI bubbles to improve provider visualization.
Hypothesis: GI Ease will improve bubble scale scores to improve visualization of the GI tract and facilitate polyp detection.
Background: Multiple independent studies have shown that simethicone, even when highly diluted, remains in the endoscope working channel after all manual cleaning and reprocessing protocols have been followed correctly. Although simethicone effectively eliminates gas bubbles, it carries unacceptable risks. It is insoluble in water and alcohol, challenging to remove, and may foster biofilm build-up and microbial proliferation. Due to these infection risks, and potential damage to scopes from over brushing, all endoscope manufacturers have recommended against simethicone use. GI Ease is a water-based, anti-gas product that is water-soluble and does not contain sugars, thickeners, or binding agents. It may be an alternative which improves visualization, without carrying the infection risks that simethicone poses.
Method: After receiving IRB approval, we used a prospective, quasi-experimental design with 100 subjects. Sixty-four mL of GI Ease was diluted in 1000 mL of sterile water. During the endoscopy procedure, we flushed GI Ease through the biopsy channel. Each flush was 50-60 mL. Using the bubble scale scoring system, ranging from 3 (bubbles filling the entire lumen) to 0 (no or minimal bubbles), a score was determined by the endoscopist.
Results: A bubble score was assigned before and after GI Ease was used. The number of flushes needed depended upon bubbles identified in the GI tract. In 99/100 participants, the bubble scale score was improved to 0-1, facilitating GI visualization. Our pre-post paired t-test of bubble scores showed significant bubble decline (t=27, p
Conclusions: GI Ease, a water-soluble solution, reduced GI gas bubbles and improved visualization. Manual cleaning of the endoscope post procedure was completed, with no variation of ATP test results. Results may cause endoscopy practice changes and the discontinuation of simethicone use, reducing the risk of infection and aligning with gastroenterology governing body and scope manufacturer recommendations.
Write Night: How a Writing Accountability Group (WAG) supports scholarly work and connection at a community residency program
Carrie B Rubenstein, Claire Thomson, Miranda D Lu, Anna McDonald, and Karl Dietrich
Purpose: The purpose of this innovative endeavor was to improve scholarly output and collaboration at the Swedish First Hill Family Medicine residency by establishing a Writing Accountability Group (WAG).
Background: While scholarly work during residency training is both required by the ACGME and important for producing physician leaders, many community-based residency programs have no formal structure to support such work and promote collaboration. At our program, faculty worked in functional silos and found it difficult to consistently involve residents in scholarly projects. WAGs have been studied in a variety of settings as a tool to increase scholarly output, improve writing habits, and provide mentorship for junior and senior faculty.
Objectives: We aimed to analyze the effectiveness of a WAG in promoting scholarly work and resident scholarly mentorship in a community-based residency program. By reporting this work, we hope to provide inspiration and a roadmap for other faculty to increase scholarly productivity and joy in their work.
Implementation/Design: After reviewing the literature regarding WAGs, a faculty member at Swedish First Hill Family Medicine invited other faculty to form a WAG at our community-based residency program. Over the next 18 months, a group of 4-6 faculty met every 2-3 weeks for 90-minute sessions to write, provide peer mentorship regarding scholarly pursuits, and collaborate on scholarly projects. Sessions were held on mutually convenient evenings at a faculty member’s home and over Zoom during the COVID-19 pandemic.
Results/Outcomes: To assess the efficacy of the WAG, we measured total scholarly activity in an academic year for the five faculty participants both before (2018-2019) and after (2019-2020) the implementation of the WAG. We used the ACGME template for faculty scholarly activity to identify and categorize different types of activity. The total number of faculty scholarly activities increased from 20 to 44 after the formation of a WAG, representing a 120% increase in our total activity. For scholarly activity that required peer review or conference acceptance, our total number of submissions increased from 14 to 28, yet maintained a similar acceptance rate (79% in 2018-2019, 85% in 2019-2020). While the majority of our scholarly activity consisted of national conference submissions, we also noted increases in publications, podcasts, and other writing submissions. In addition to increased faculty scholarly productivity, our WAG was associated with increases in faculty job satisfaction, faculty collaboration, and resident scholarly activity.
Significance: Creation of a WAG provided a structure for faculty scholarly collaboration and accountability for completion of scholarly projects. The WAG also provided a clear point of contact for other faculty and residents interested in scholarly work. In addition to increasing scholarly output and resident participation, our WAG improved wellness among faculty, providing a sense of collaboration and celebration of our scholarly work, particularly important during the COVID-19 pandemic. We plan to continue to evaluate the impact of the WAG in future years to look for sustained improvement.
Sean R. Smith, Mary Vargo, David S Zucker, Samman Shahpar, Lynn Gerber, Maryanne Henderson, Gina Jay, Minji Lee, and Andrea Cheville
Purpose: To develop an item response theory (IRT)-calibrated patient-reported outcome measure (PRO) that assesses cancer patient physical function, fatigue and social participation.
Problem Statement: The subspecialty of cancer rehabilitation medicine (CRM) has to date lacked a psychometrically validated patient-reported outcome measure that assesses patients’ physical function, fatigue, and social participation. A significant proportion of the 16.9 million US cancer survivors will experience, or have already experienced, impairments that compromise function, a predictable consequence of their disease and treatment. While each disease site and line of treatment may be associated with unique impairments, there are some that cut across several cancers within the diagnostic spectrum, while others are common in most. Examples include neuropathic pain, peripheral neuropathy, myalgia, arthralgia, deconditioning, altered biomechanics, lymphedema, cognitive impairment, insomnia, and bladder/bowel dysfunction. It is therefore critical to develop psychometrically sound outcome instruments that accurately measure rehabilitative outcomes across an episode of clinical care.
Background: Although the field of cancer rehabilitation is growing, its ability to meet clinical demands lags current and projected needs. There are many probable causes, but one that is potentially addressable in the near term is the lack of a scalable means of assessing physical and social function to align care with patients’ symptoms and goals. In 2015, the Cancer Rehabilitation Medicine Metrics Consortium (CRMMC) was formed to address this need. This study field tested a 21-item patient reported outcome tool previously created by CRMMC.
Methods: The 21 candidate items in addition to anchoring items were administered to participants at each of the 6 participating CRMMC institutions. Demographic and clinical information was abstracted from participant’s EHR. Data was anonymized and captured via REDCap. Data analysis methods included descriptive statistics for demographic and clinical data; IRT information curves and density plots for candidate items; and regression models to assess discrimination across anchoring variables and stepwise increases across ordered response options. Poorly performing, redundant or low information-containing items were discarded. A scoring algorithm was created.
Results: A total of 616 patients completed 21 items in the initial item pool. Nine items were removed because of comparatively lower information that they provide according to IRT item calibrations, low item-total correlations, or bimodal distributions. The remaining items generated a 12-item short form. Regression analyses determined that the items were responsive to and representative of the patient population across trait ranges and multiple domains/subdomains of function.
Conclusion/Discussion: This psychometric investigation supports use of the 12-item PROMIS Cancer Function Brief 3D Profile for evaluating function in outpatient cancer rehabilitation patients.
Significance: To our knowledge, the PROMIS Cancer Function Brief 3D Profile is the first specialized SF created from PROMIS item banks to meet the unique assessment and clinical decision-making needs of rehabilitation providers who treat cancer patients. We believe that the development of the PROMIS Cancer Function Brief 3D Profile is important, as it has high information density and requires minimal time for patients to complete. It’s been integrated into Epic QNRs and is being piloted in the SCI’s cancer rehabilitation medicine clinic.