TeamSTEPPS

Additional Information for Audiology:

Audiology:

Pure tone audiometry indicated that B.A. has a mild-to-moderate, gradually sloping, sensorineural hearing loss, bilaterally. Word recognition testing was not completed due to patient’s word finding difficulty and because the testing was completed bedside in the inpatient unit.  Communication difficulty was observed when visual cues were withheld and was more pronounced at the end of the test session when B.A. was fatigued.

Discussion Questions:

1. B.A.’s medical history suggests she has diagnosed with a hearing loss several years ago. You do not have access to her previous tests; however, why might she be experiencing more difficulty communicating now, even if her hearing loss has not  progressed?
2. Do you think her hearing loss will have an impact on her ability to carry out the recommendations of any of the other team members?
3. Do you think she is a candidate for hearing aids or other assistive devices? If so, what would be appropriate for her? What social and physical issues influence your recommendations in this regard and how can you meet her needs?
4. What non-technology based recommendations do you have for B.A. and her health-care team regarding ways to improve her ability to communicate and understand instructions? 

Additional Information for Dental Hygiene

Dental Hygiene:

She presents with a full upper denture and tooth pain.  In addition she has foul odor that she states her children have complained about.  You notice the odor as periodontal concerns.  You also notice an acetone odor from her mouth as well.   She states that her lower jaw aches as a generalized rule and the upper denture does not stay in.  Her hard palate has been sore as well with a white non removable lesion. She has extreme difficulty eating with the denture and her diet is mostly soft foods. You also note her ability to move her left side of her tongue is impaired and note food impaction on this side.

Discussion Questions:

1. What are the concerns you have with her oral health?   How would you address the oral pain on her mandibular arch if you are asked to screen her mouth?
2. What might the acetone odor indicate?  What lab values would indicate that this is becoming a medical emergency? Who would you notify about this problem?
3. What type of education would help her with the periodontal odor?  What recommendations could you give her in the acute care setting? What recommendations would you give for her at discharge?
4. What would be your recommendation for the left side of her mouth with chewing?
5. What questions would you ask her about the non removable lesion on her hard palate.  What recommendations would you have?

Additional Information for Medical Laboratory Sciences:

Type II Diabetes Overview

As an MLS, you know that Type II Diabetes is a condition which is associated with insulin resistance and glucose intolerance, which means that the cells are no longer responding to insulin’s signal to allow glucose in, so glucose stays in the plasma, meaning that the cells are intolerant to glucose.  

Glucose Results

All 3 glucose labs are elevated. Note: the case did not indicate that the patient was fasting, but based on the reference ranges listed, the patient was fasting - 8-hr. fast is recommended for glucose, and a 10-12 hr. fast is recommended for a lipid panel, which was also drawn on Day 3. The diabetic level for fasting specimens is >126 mg/dL, which all 3 levels on Day 1, Day 2, and Day 3 were higher than.

Hemoglobin A1C

An Hgb A1C was also drawn on Day 1. Hgb A1C is a test which indicates how well a diabetic patient has been keeping their blood glucose in check over a period of 2-3 months. Levels >7% indicate poor glycemic control. The patient’s result was 9.7% which indicates poor control of blood glucose levels.

Dyslipidemia and Cardiovascular Risk

Complications of Type II DM include dyslipidemia, which is associated with increased triglycerides and LDL. In the body, excess glucose gets stored as triglycerides. Triglycerides are the main component of VLDL, which then gets broken down to LDL. Increased levels of LDL are associated the development of atherosclerosis, when can lead to occlusion in the blood vessels causing heart attack, stroke, DVT, pulmonary embolism, et cetera.

HDL is our “good” cholesterol and helps to remove LDL from the body. The patient’s combination of elevated TC, triglycerides and LDL, and decreased HDL put a patient at increased risk of complications associated with dyslipidemia.

Note: scenario lists >40 mg/dL as the reference range for HDL, but NCEP optimal levels are actually >60 mg/dL.

Renal Impairment and Creatinine

Increased levels of creatinine are associated with renal impairment. Kidney function can be detrimentally affected by high glucose levels over an extended time period. Filtering capacity is diminished, so substances that normally would be easily filtered through the kidneys and excreted, get retained.

Creatinine is commonly measured as an indication of renal function, because creatinine is not normally retained in body. Typically, the main reason that we see increased levels is when normal kidney function is decreased.  

Questions:

1. Why are the creatinine levels often elevated in Type II Diabetic patients?
2. Explain the significance of getting fasting levels versus random when monitoring glucose and lipids levels?
3. Explain the significance of performing a HgbA1C? What does it tell us about how a diabetic patient is keeping their disease under control? What is the ideal level that diabetics should keep their Hgb A1C levels under? How often do Hgb A1C levels need to be monitored?
4. What other testing would be appropriate to monitor renal function and increasing permeability of the renal filtering system?
5. Establish a timeline for collecting follow-up lab after discharge 

Additional Information for Medicine and PA:

Medicine and PA:

The inpatient team began formulating a safe discharge plan at admission.  For BA, this is her second stroke.  To prevent further strokes, the inpatient Family Medicine team initiated interventions to reduce her risk for stroke and improve management of her chronic conditions of Hypertension, Hyperlipidemia and Type 2 Diabetes.    

Discussion Questions:

1. What medical interventions were initiated during the hospitalization to reduce her risk for recurrence of an ischemic stroke and improve management of her chronic conditions?
2. What barriers exist that may prevent her from benefiting from these interventions once discharged?
3. What resources exist that may facilitate benefit from these interventions once she is discharged?
4. What potential harm is associated with the medical interventions initiated during her hospitalization?
5. If so, what can we do to mitigate the risk of harm?  

Additional Information for Nursing:

Nursing:

As BA’s primary nurse, you assess her right arm and right lower leg weakness and inability to use her fine motor skills in signing her name for consent of treatment.  When you administer BA her morning medication, she mentioned that sometimes she was not the best at remembering some of her medications.  She was able to recall the majority of her medications and she recognized the remaining meds when you said their name.  However, she only knew she was taking aspirin to prevent another stroke and her inhalers for her “breathing” and her “hydrocodone when her knees ached real bad”.  She knew she was on meds for her “pressure” and diabetes but was not clear which one was for what. She tells you that she is not sure the she will be able to give herself that “diabetes shot”. You notice that BA has few visitors.  In visiting with BA about going home, you discover that she lives alone in an apartment and has never been married.  Her apartment is on one level but there are several steps to get into the front door.  She has expressed concern about “getting around” at home, and is hopeful that her time at the skilled nursing facility will get her stronger so she can manage on her own at home and get back to church.

Discussion Questions:

1. What education does BA need regarding her medications before she can return home?  What suggestions do you have to assist BA in taking her medications correctly?
2. What additional assessment need to made regarding BA’s ability to give her insulin injections?  What other professionals would you want to coordinate for this assessment and teaching?
3. What additional assessments of the home needs to be made before the patient can return to her home?  What professionals would you want to consult to prepare the home for BA?
4. In coordinating the transition-of-care planning, how will you coordinate care of all of the professionals that are working with BA to assist her transition from hospital to skilled nursing facility to home? 

Additional Information for Pharmacy:

Pharmacy:

Upon meeting with the patient for a detailed medication reconciliation and history during Day 1 you find out the patient fills her medications at Walmart Pharmacy.  She mentioned that sometimes she was not the best at remembering some of her medications and she just took all of them out of the pill bottles when she remembered.  She was able to recall the majority of her medications and she recognized the remaining meds when you said their name.  However, she only knew she was taking aspirin to prevent another stroke and her inhalers for her “breathing” and her “hydrocodone when her knees ached real bad”.  She knew she was on meds for her “pressure” and diabetes but was not clear which one was for what.  You called Walmart Pharmacy and determined the patient had not picked up the following medications regularly and adherence was an issue:  Atorvastatin, HCTZ, Symbicort, and Metformin.  When asked, the patient said she had difficulty remembering her meds and also had issues getting a ride to go pick up her meds at the pharmacy because she doesn’t have a car.  The patient understands that her medications are important and she is willing to listen to education and wants to do better, in addition you discussed the possibility of insulin therapy at home and the patient was open to this if it was the best thing for her health.

Discussion Questions:

1. What recommendations do you have for optimizing medications or the specific medication regimen for this patient?
2. What education does the patient need about her medications, how will you provide this education, and what other professions should you coordinate with?
3. What social issues does the patient have that influence her medication regimen?  What suggestions do you have and who should you coordinate with?
4. What physical limitations does this patient have that may influence some of her medications?  What suggestions do you have and who should you coordinate with? 

Additional Information for Physical Therapy:

Physical Therapy:

On Day 2, when testing her lower extremity strength sitting at the edge of the bed prior to attempting ambulation, she developed shortness of breath.  Throughout the day, the patient made steady progress and was able to go from sitting to standing with moderate assistance.  However, static standing balance was only fair.  Day 3 (Today), the patient needed only minimal assistance with bed mobility and sit to stand, but required moderate assistance and verbal cues during ambulation (< 20 feet). During ambulation, the patient used a right AFO and rolling walker.  The patient demonstrates mild ataxia during ambulation.  Due to a few episodes of postural hypotension, significant transition time has been allowed between supine to sit and sit to stand.  The patient has high fall risk and has fair safety awareness.   She has expressed concern about “getting around” at home, and is hopeful that her time at the skilled nursing facility will get her stronger so she can manage on her own at home and get back to church.  She is also concerned about falling at home. The patient understands that she may need to use an assistive device for a while, but wants to be able to “walk without a cane” as soon as possible.  She is highly motivated.  We have discussed the importance of “safety first” and she seems to be receptive to this. We’ve had some initial discussion about her home environment, and some modifications may be necessary.

Discussion Questions:

1. Do you need any additional information to better understand her clinical and/or home picture?  What other professions or people would you like to consult with?
2. Considering the information from her recent hospital stay and her past medical history, what PT recommendations would you make to ensure quality care and appropriate preparation for returning home in a couple weeks (after the SNF facility)?
3. What patient education will be needed related to her current functional status and/or returning home? With which other professions should you coordinate your patient education?

Additional Information for Speech:

Speech Note:

The patient’s speech is mildly dysarthric; articulation is mildly imprecise, speech AMRs are slow, mildly harsh vocal quality, and mild hyper nasality. Word-finding difficulty during conversational speech is evident, and she does not appear to be using any strategies for communicating her ideas when she becomes stuck on a word.

Discussion Questions:

1. What type of dysarthria does she have?
2. What is the prognosis for improvement of her dysarthria?
3. What other areas of speech-language and/or cognition do you want to assess? What measures (standardized or nonstandardized) will you use to assess each of these areas?
4. Do you think that her communication skills will have an impact on her ability to carry out the recommendations of any other of the team members?
5. Do you think she is a candidate for speech-language therapy? If so, which areas of speech, language, or cognition would you target? For each target area identified, what would be your short-term goals?
6. Can you partner with one or more members of the team to help the patient reach a goal that has been suggested by another team member?

Additional Information for Public Health Sciences

Public Health Sciences

As you assess the situation for BA, you notice there are several care providers. Communication among the care team is key. This includes BA. Education on the patient portal could be key prior to her dismissal and as a health manager, it’s key to consider drivers of health that resulted in her need for and access to care.   

There are also several components that require plain language communication techniques.  It is important to ensure that there is clear understanding of her medications, how to take her medications, her understanding of her current condition, and a plan for her care and safety when she arrives home. As discussed with the nursing staff, she does not remember the names of her medications but does remember them once the name is stated. It is key the care team assesses her health literacy and uses plain language to describe her medications, diagnosis and prognosis, and what she should do if she has another “episode” and is home alone. 

Discussion Questions:

1. What education does BA need regarding the use of a patient portal before she can return home? What suggestions do you have to assist BA in using the portal for tasks such as scheduling future appointments and reading appointment summaries? 
2. How could you advise the care team to assess BA’s health literacy for using a telehealth option?  
3. Consider the materials that need to be reviewed by the team with BA prior to her dismissal. Describe how you could encourage care team providers to incorporate the Teach Back and Show Me methods during BA’s dismissal. 
4. Consider the larger health services system implications in caring for BA.  Who else should be involved in coordinating the transition-of-care plan to assist her adjustments from hospital to skilled nursing facility to home? What drivers of health are “up-stream” or root causes of BA’s current health issues that should also be addressed?   
5. What services are available to BA upon her return home? How could policy change or infrastructure investment promote or improve elements of BA’s healthcare experience?