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Can You Hear Me Now? Found: 2 ‘Lost’ Hearing Aids in Otic Canal of Elderly Woman with Mild Dementia
Design/Methodology: Primary data were obtained on 3230 residents scheduled for MDS assessments in 71 NHs across 8 states. Nurses completed the new MDS 3.0, identifying residents who ‘‘reject evaluation or care (e.g., blood work, taking medications, ADL assistance) that is necessary to achieve the resident’s goals for health and well-being’’. Measures of resident characteristics included mood (PHQ-9), cognition (structured cognitive testing or cognitive performance scale), and delirium (Confusion Assessment Method). Data were analyzed via multiple logistic regression models that accounted for clustering by NH. Results: Rejection of care was seen in 9.7%. Analyses identified presence of delirium (OR 1.8, 95%CI 1.3-2.4), minor and major depression (OR 2.1, 95%CI 1.5-2.8, OR 2.3, 95%CI 1.5-3.4, respectively), presence of delusion (OR 3.9, 95%CI 2.5-6.0), and severe to horrible pain (OR 1.6, 95%CI 1.12.3) as associated potentially mutable factors. Conclusion/Discussion: In this large geographically diverse sample, four potentially mutable resident-level factors (delirium, depression, delusions and pain) were associated with rejection of care. If the identified associations are causal, providers have an opportunity to modify rejection of care behaviors with appropriate targeted interventions for these mutable factors. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
Are You Ready for Pain Management Under F-Tag 309? Presenting Author: Frank Breve, PharmD, MBA, CCP, PharmaTech Consulting Group LLC Author(s): Frank Breve, PharmD, MBA, CCP; and Dean Gianarkis, PharmD, MS Introduction/Objective: Published research estimates that 45%-83% of nursing home residents experience pain. However, data suggests that clinicians tend to underestimate pain and often fail to recognize it in some individuals. This may be problematic for some nursing homes because of recently released pain management guidance that provides direction for surveyors known as F-Tag 309. This research was conducted to assess readiness for F-Tag 309 using a survey administered to nursing personnel. This survey was also designed to evaluate current practices related to the key components of pain management. Design/Methodology: Nursing personnel were randomly selected to participate in a survey to assess pain management practices at their long-term care facility. The questions were divided into five sections to evaluate screening, assessment, plan of care, monitoring and care planning associated with pain management. Each section in this paper-based survey accounted for 20 points. Choices provided for most, but not all questions included ‘‘often’’, ‘‘sometimes’’, ‘‘rarely’’ and ‘‘never.’’ Depending on the number of questions in each section, different point values were assigned to ‘‘often’’ and ‘‘sometimes’’ responses. Results for questions examined individually include ‘‘often’’ responses only. This data, along with demographic information about respondents and their estimate of the prevalence of moderate-severe pain in their facilities, was entered into a database used to perform the analysis. Results: There were 23 surveys returned, all of which were included in the analysis. The majority of respondents (83%) had 11 or more years of experience and most (61%) were LPNs. The mean percentage of residents with moderate-severe pain was estimated to be 58% (range 4%-95%). Overall, the total facility readiness score was 91/100. Points were derived from screening (16.2), assessment (17.5), plan of care (19.8), monitoring (19.1) and care planning (18.1). Specifically, residents are screened for pain upon admission (91%) and when their condition changes (78%), but 22% are not screened regularly. Respondents observe and interview residents rather than depend on chart review (30%) or the MDS (48%). However, only 43% can recognize target signs/symptoms of pain and screen for different types of pain. The numeric pain scale was selected by 91% of respondents as the most frequently used pain assessment tool, followed by Wong-Baker (43%) and Verbal Descriptor Scales (26%). All report using a standard pain protocol and 87% use a standardized pain assessment tool. Pharmacologic (56%) and non-pharmacologic (22%) approaches are used to treat pain but monitoring parameters are not included in 30% of care plans. Conclusion/Discussion: Based on these results, this facility appears to be prepared for F-Tag 309. However, educational efforts should be considered with
POSTER ABSTRACTS
a focus on screening for and assessing pain. Administration of this survey will be expanded to include other facilities, which will provide an opportunity to benchmark each as compared to the aggregate sample. Disclosures: Dean Gianarkis, PharmD, MD is a salaried employee at Pfizer, Inc. Frank Breve, PharmD, MBA, CCP has stated there are no disclosures to be made that are pertinent to this abstract.
Can You Hear Me Now? Found: 2 ‘Lost’ Hearing Aids in Otic Canal of Elderly Woman with Mild Dementia Presenting Author: Benito San Gil, MD, Baystate Medical Center/Tufts University School of Medicine, Springfield, MA Author(s): Benito San Gil, MD; and Sandra Bellantonio, MD Introduction/Objective: Innovation renders hearing aids inconspicuous so they are able to fit small auricular spaces, and have better cosmetic appeal. Long-term care providers strive to augment and correct sensory deficits. Apart from enhancing quality of life, intact hearing helps mitigate risk of delirium and depression. Hearing aids – unlike eyeglasses, are designed to be camouflaged by adaptation to skin color and miniaturization. When fractured, hearing aid parts may get concealed in constricted spaces like the ear canal. Furthermore, earwax can cover and cement broken parts, with potential for complications like otitis or perforation. Design/Methodology: An 88 yr old demented (MMSE 25/30) woman, independently living at a continuum-of-care retirement community had a routine office visit. She was asymptomatic, attentive, and followed conversation. A hearing aid worn in the left ear was removed for otoscopy, and found intact on inspection. There was greater build up of cerumen in the left ear compared to the right, with an uncharacteristic glisten to it. The glistening object was uncovered by gentle flushing with a bulb-syringe and body-temperature-tap-water. A 7-mm rubbery nodule surfaced and was gently removed by further flushing and flexible curette extraction. On repeat otoscopy, the left tympanic membrane (TM) remained obscure. More wax and another rubbery fragment blocked full view of the ear canal. Further attempts to remove obstruction sitting in the sensitive inner 3rd of the ear canal were ceased when efforts proved uncomfortable. Resident was referred to an ENT specialist who removed the 2nd nodule by flushing and soft curette. After discussion with the resident’s daughter, she confirmed the ‘‘loss’’ of 2 hearing aids in the past 6 months which had been promptly replaced by the vendor. Results: A Medline keywords search for ‘‘otic, foreign body, ear canal, and elderly’’ yielded 46 publications from 1982-2008. Otic retention of hearing aid molds, batteries and their complications have been reported but retention of hearing aids has not. Miniaturized parts tend to be fragile and easily detached. In the ear canal these parts can be obscured by wax buildup. In time, cerumen and foreign bodies could chemically react with potential morbid consequences such as otitis and perforation. The literature discourages instilling commonly used products to dissolve earwax in the context of a foreign body because of potentially corrosive reactions, resulting in further harm. Providers must be vigilant in otic examination of hearing aid users, especially in long-term care settings. There is high prevalence of cognitive impairment that may result in resident’s diminished capacity to manage hearing aids. Detached hearing aid fragments may go undetected as ‘lost’ units, with part(s) potentially concealed in the ear canal. Conclusion/Discussion: In long term care settings it is important to conduct careful ear examinations and to remove hearing aids when present, in order to fully visualize the external canal. Providers must be circumspect of finding obscured TMs on otoscopy. Earwax and obscure otic foreign bodies should not be left impacted as there is potential for migration to adjacent structures causing further morbidity. As hearing aids have become smaller, it is important to have a high index of suspicion for retained detached parts, especially in demented residents. It is important for longterm care providers to consider removing obstructions while being attentive to resident comfort. The literature does not support use of common cerumen softening agents thus, gentle flushing with body-temperature-tap-water should be considered. If comfort precludes further manipulation, referral to the ENT specialist is warranted. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
B5
Are You Ready for Pain Management Under F-Tag 309? Presenting Author: Frank Breve, PharmD, MBA, CCP, PharmaTech Consulting Group LLC Author(s): Frank Breve, PharmD, MBA, CCP; and Dean Gianarkis, PharmD, MS Introduction/Objective: Published research estimates that 45%-83% of nursing home residents experience pain. However, data suggests that clinicians tend to underestimate pain and often fail to recognize it in some individuals. This may be problematic for some nursing homes because of recently released pain management guidance that provides direction for surveyors known as F-Tag 309. This research was conducted to assess readiness for F-Tag 309 using a survey administered to nursing personnel. This survey was also designed to evaluate current practices related to the key components of pain management. Design/Methodology: Nursing personnel were randomly selected to participate in a survey to assess pain management practices at their long-term care facility. The questions were divided into five sections to evaluate screening, assessment, plan of care, monitoring and care planning associated with pain management. Each section in this paper-based survey accounted for 20 points. Choices provided for most, but not all questions included ‘‘often’’, ‘‘sometimes’’, ‘‘rarely’’ and ‘‘never.’’ Depending on the number of questions in each section, different point values were assigned to ‘‘often’’ and ‘‘sometimes’’ responses. Results for questions examined individually include ‘‘often’’ responses only. This data, along with demographic information about respondents and their estimate of the prevalence of moderate-severe pain in their facilities, was entered into a database used to perform the analysis. Results: There were 23 surveys returned, all of which were included in the analysis. The majority of respondents (83%) had 11 or more years of experience and most (61%) were LPNs. The mean percentage of residents with moderate-severe pain was estimated to be 58% (range 4%-95%). Overall, the total facility readiness score was 91/100. Points were derived from screening (16.2), assessment (17.5), plan of care (19.8), monitoring (19.1) and care planning (18.1). Specifically, residents are screened for pain upon admission (91%) and when their condition changes (78%), but 22% are not screened regularly. Respondents observe and interview residents rather than depend on chart review (30%) or the MDS (48%). However, only 43% can recognize target signs/symptoms of pain and screen for different types of pain. The numeric pain scale was selected by 91% of respondents as the most frequently used pain assessment tool, followed by Wong-Baker (43%) and Verbal Descriptor Scales (26%). All report using a standard pain protocol and 87% use a standardized pain assessment tool. Pharmacologic (56%) and non-pharmacologic (22%) approaches are used to treat pain but monitoring parameters are not included in 30% of care plans. Conclusion/Discussion: Based on these results, this facility appears to be prepared for F-Tag 309. However, educational efforts should be considered with
POSTER ABSTRACTS
a focus on screening for and assessing pain. Administration of this survey will be expanded to include other facilities, which will provide an opportunity to benchmark each as compared to the aggregate sample. Disclosures: Dean Gianarkis, PharmD, MD is a salaried employee at Pfizer, Inc. Frank Breve, PharmD, MBA, CCP has stated there are no disclosures to be made that are pertinent to this abstract.
Can You Hear Me Now? Found: 2 ‘Lost’ Hearing Aids in Otic Canal of Elderly Woman with Mild Dementia Presenting Author: Benito San Gil, MD, Baystate Medical Center/Tufts University School of Medicine, Springfield, MA Author(s): Benito San Gil, MD; and Sandra Bellantonio, MD Introduction/Objective: Innovation renders hearing aids inconspicuous so they are able to fit small auricular spaces, and have better cosmetic appeal. Long-term care providers strive to augment and correct sensory deficits. Apart from enhancing quality of life, intact hearing helps mitigate risk of delirium and depression. Hearing aids – unlike eyeglasses, are designed to be camouflaged by adaptation to skin color and miniaturization. When fractured, hearing aid parts may get concealed in constricted spaces like the ear canal. Furthermore, earwax can cover and cement broken parts, with potential for complications like otitis or perforation. Design/Methodology: An 88 yr old demented (MMSE 25/30) woman, independently living at a continuum-of-care retirement community had a routine office visit. She was asymptomatic, attentive, and followed conversation. A hearing aid worn in the left ear was removed for otoscopy, and found intact on inspection. There was greater build up of cerumen in the left ear compared to the right, with an uncharacteristic glisten to it. The glistening object was uncovered by gentle flushing with a bulb-syringe and body-temperature-tap-water. A 7-mm rubbery nodule surfaced and was gently removed by further flushing and flexible curette extraction. On repeat otoscopy, the left tympanic membrane (TM) remained obscure. More wax and another rubbery fragment blocked full view of the ear canal. Further attempts to remove obstruction sitting in the sensitive inner 3rd of the ear canal were ceased when efforts proved uncomfortable. Resident was referred to an ENT specialist who removed the 2nd nodule by flushing and soft curette. After discussion with the resident’s daughter, she confirmed the ‘‘loss’’ of 2 hearing aids in the past 6 months which had been promptly replaced by the vendor. Results: A Medline keywords search for ‘‘otic, foreign body, ear canal, and elderly’’ yielded 46 publications from 1982-2008. Otic retention of hearing aid molds, batteries and their complications have been reported but retention of hearing aids has not. Miniaturized parts tend to be fragile and easily detached. In the ear canal these parts can be obscured by wax buildup. In time, cerumen and foreign bodies could chemically react with potential morbid consequences such as otitis and perforation. The literature discourages instilling commonly used products to dissolve earwax in the context of a foreign body because of potentially corrosive reactions, resulting in further harm. Providers must be vigilant in otic examination of hearing aid users, especially in long-term care settings. There is high prevalence of cognitive impairment that may result in resident’s diminished capacity to manage hearing aids. Detached hearing aid fragments may go undetected as ‘lost’ units, with part(s) potentially concealed in the ear canal. Conclusion/Discussion: In long term care settings it is important to conduct careful ear examinations and to remove hearing aids when present, in order to fully visualize the external canal. Providers must be circumspect of finding obscured TMs on otoscopy. Earwax and obscure otic foreign bodies should not be left impacted as there is potential for migration to adjacent structures causing further morbidity. As hearing aids have become smaller, it is important to have a high index of suspicion for retained detached parts, especially in demented residents. It is important for longterm care providers to consider removing obstructions while being attentive to resident comfort. The literature does not support use of common cerumen softening agents thus, gentle flushing with body-temperature-tap-water should be considered. If comfort precludes further manipulation, referral to the ENT specialist is warranted. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
B5