Poster Abstracts / JAMDA 15 (2014) B3eB28B20

confined to room. This level also includes those residents that staff believeto be at risk evenwithout the above categorizations, and those who have aresident or family request for more frequent monitoring. In addition to theusual care and services, residents in these level 3 risk categories receiveevery 1 to 2 hour checks by staff. We correlated the number of falls withthe ‘Level of Care’ to determine if this can be used as a risk factor or anintervention to prevent falls in patients that are high risk.Results: We were unable to determine a correlation between the numberof falls and the ‘Level of Care’ offered for our individual residents. A ‘Levelof Care’ did not allow a risk stratification for the residents who would fallnor did it allow us to prevent falls by intensifying the interventions basedupon the ‘Level of Care’.Conclusion: There are factors that may affect falls in an ALF that are notusually present in a SNF. Due to the independence of residents living in thisALF there were factors, such as alcohol use, that we were not able to fullymonitor and track. The independence of AL residents in our facility doesnot allow a strategy connected to a ‘Level of Care’ to help predict or preventfalls. Our observationmay be valid for many reasons. Our levels of caremaybe not specific enough to address fall risk. We could have the wrong in-terventions in place to address this unique population. On the other hand,our small study is consistent with many other studies that show that thereis no consistent fall prevention bundle that prevents falls in all residents.Author Disclosures: All authors have stated there are no financial dis-closures to be made that are pertinent to this abstract.

Heart Failure in Long Term Care: Limited Adherence to the DEFEAT-Heart Failure Protocol

Presenting Author: Jowairiyya Ahmad, MD, Montefiore Medical CenterAuthor(s): Jowairiyya Ahmad, MD, Claudene George, MD, RPh,Helena Blumen, PhD; and Roy J. Goldberg, MD, CMD

Background: Over 2 million long term care residents in the geriatric agegroup have heart failure (HF). Variations in adherence to evidence basedguidelines, and complicating factors such as multiple co-morbidities andmedication tolerability can lead to variations in quality of care and patientoutcomes. The DEFEAT-HF protocol (Diagnosis, Etiology, Fluid, EjectionfrAction, and Treatment) provides a useful tool for simplification of themanagement of HF.Objective/Aim: This study examines physicians’ practice regarding themanagement of heart failure in long term care residents as indicated by theDEFEAT-HF Protocol.Quality Improvement Methods: A retrospective chart review was per-formed to identify patients at a long term care facility with a diagnosis ofHF between 2012 and 2013. We examined 3 measures of the DEFEATprotocol; Diagnosis, Ejection Fraction (EF), and Treatment.Results: Fifty-six residents with a diagnosis of HF were identified. Averageage 81.86 (+/- 8.0), average pulse 75.3 (+/- 4.3), target systolic BP 124.1 (+/-6.7). Among the 56 residents, 8.9% had diastolic HF, 5.4% systolic HF, and76.8% were not specified. Only 10% had an EF documented. For treatment,42.8% were on a diuretic, 35.7% on an ACE Inhibitor or angiotensin receptorblocker (ARB), and 58.9% were on a beta blocker. Twelve percent of resi-dents were on triple therapy with a diuretic, beta blocker and ACEI/ARB,41.0% were on two agents, and 23% were on one out of the three classes. Inhouse consultationwith a cardiologist was noted for 16.1% of the residents.Among the residents with a cardiology consult, 33.3% were on tripletherapy, while only 8.5% of those without a cardiology consult were ontriple therapy. Forty-three percent of the residents had one or more hos-pitalizations over the past year for a respiratory condition but diagnosis ofheart failure was not specified.Conclusion: Few residents in this LTC facility with a diagnosis of HF had adocumented ejection fraction or specification of whether HF was systolicor diastolic. Slightly more than half were treated with two or more med-ications indicated for HF without a documented contraindication. Therewas little use of an in house cardiology consult which could presumablyhelp optimize medical therapy, prevent hospitalization, and improvediagnostic accuracy. A potential limitation of this study is that some resi-dents had an unverified diagnosis of HF, which might represent use of a HFmedication for another indication. Physicians should document

echocardiogram results when available to clarify diagnosis, guide therapy,minimize inappropriate medication use, and establish prognosis. Cardi-ology consultations for residents on complicated HF regimens or withfrequent hospitalizations should be considered. Applying DEFEAT-HFprotocol can simplify the management of geriatric HF.Author Disclosures: All authors have stated there are no financial dis-closures to be made that are pertinent to this abstract.

Improving MOLST Implementation in a PACE Program

Presenting Author: Albert Feng, University of CincinnatiAuthor: Albert Feng

Background: Advanced care planning is an important part of caring forelderly patients with multiple medical conditions, such as patients thatparticipate in PACE (Program of All-Inclusive Care for the Elderly) pro-grams. Traditional DNR (Do-Not Resuscitate) forms are limited to speci-fying the patients’ desire to be resuscitated or not resuscitated in the eventthat they stop breathing and their heart stops beating. The MOLST (Med-ical Orders for Life-Sustaining Treatment) form allows patients to expresstheir specific wishes regarding resuscitation, medical interventions, anti-biotic use, and artificial feeding and hydration.Objective/Aim: To evaluate the effectiveness of MOLST implementationand documentation of end-of-life care preferencesQuality Improvement Methods: Clinical staff completed an 8-questionsurvey on advanced care planning topics before and after MOLST imple-mentation. Data was compared between pre-MOLST (n¼32) and post-MOLST staff (n¼43). Before the introduction of the MOLST form, clinic staffmembers were educated on proper use of the MOLST form in advancedcare planning. In the analysis, 9 were excluded from the post-MOLSTgroupbecause they did not attend MOLST training.Results: Significant differences between pre- and post-MOLST resultsindicated: increased staff understanding of advanced care planning topics;increased ease of having end-of-life discussions with patients; increasedsatisfaction with the current system of documenting end-of-life wishes;increased ease of educating patients on life-sustaining treatment;increased satisfaction with educational methods and materials; decreasedsupport for standing medical orders that apply regardless of patient’sdecision-making capacity. Non-significant results included a perception ofdecreased patient understanding of advanced care planning topics andincreased accuracy of documenting end-of-life wishes using MOLST.Conclusion: The staff responses indicate that the MOLST form representsan improvement over the traditional DNR form in advanced care planning.However, it is necessary to increase patient awareness and educationregarding the MOLST form and advanced care topics in order to accuratelydocument the patients’ wishes regarding end-of-life care.Author Disclosures: University of Cincinnati Geriatric scholars por-gramUrban Health project.

Improving Wound Care in a Skilled Nursing Facility

Presenting Author: Kim Petrone, MD, CMD, St. Anns CommunityAuthor(s): Kim Petrone, MD, CMD, Cheryl Nolan, GNP; andLeanne Mathis, RN, BSN

Background: Delivery of wound care in many skilled nursing facilites re-mains highly variable and fragmented. Despite this lack of coordinated care,the population residing in skilled nursing facilites remains vulnerable todeveloping complex wounds due to the preponderance of comorbid dia-betes, atherosclerosis, venous insufficiency, protein malnutrition, andlimitedmobility. In addition, pressure ulcers rates remain a key determinantin auditing skilled nursing facilities and thus have a direct impact on theirfinancial viability. As such, a comprehensive organized approach to com-plex, chronic wounds is necessary to improve clinical outcomes and containcosts.Objective/Aim: To develop a comprehensive approach to wound care bycreating a dedicated wound care team, a formulary of wound care products,an electronic wound care form, and weekly rounds of all residents withwounds to include assessment and evaluation of wounds as well as bedside

Poster Abstracts / JAMDA 15 (2014) B3eB28 B21

teaching with the residents’ primary caregivers. Our primary aim was toshow that prevalence rates of pressure ulcers decreased with these in-terventions without increasing costs for wound care treatments.Quality Improvement Methods: We developed a wound care teamcomprised of a medical provider (NP or MD) with specialized training inwound care (certified wound specialists), dietician, nurse, and physicaltherapist to examine every resident with awound on aweekly basis. Duringthese visits, the primary etiology of the woundwas defined and a treatmentplan created. Topical treatments for the woundwere selected from a refinedformulary that was honed to include one main product from each broadcategory of topical therapies. The dietician made recommendations toenhance nutrition and the physical therapist evaluated offloading strategies,utilization of electrical stimulation, and gait retraining. During each evalu-ation, the primary caregivers including nurses and certified nursing assis-tants were included in discussions of the etiology of the wound and theprescription/treatment plan.Results: As a result of the above interventions, the point prevalence ofpressure ulcers decreased while the costs for wound care decreased. Fromthe first quarter of 2011 through the third quarter of 2013 the percent ofshort stay residents with new or worsening pressure ulcers decreased from2.5% to 0.6%. The percent of high risk residents with pressure ulcersdecreased from 9.1% to 5.5%. The percent of residents with one or moreunhealed pressure ulcer stage 1 or greater decreased from 11.5% to 5.1% .Costs for wound care products utilized in long term care decreased by 9%from 2009 to 2012. While not systematically evaluated, we have alsoobserved a greater understanding of the evaluation and managment ofcomplex wounds on the part of the residents’ primary care providers.Conclusion: By emphasizing a comprehensive and consistent approach towound care in a skilled nursing facility we have been able to show areduction in pressure ulcers and their complications without an increase inwound care product costs. Moreover, we have also noted enhancement ofthe understanding of basic wound care by residents’ primary care providers.Given the general frailty and morbidity of most skilled nursing facilitiesresidents, such an approach is of paramount importance.Author Disclosures: All authors have stated there are no financial disclo-sures to be made that are pertinent to this abstract.

Music and Art in Medicine (MAM): A Medical Student Initiative toImprove Quality of Life (QOL) for Nursing Home (NH) and AssistedLiving (AL) Residents

Presenting Author: Amy Yu, University of Texas Health Science Center atSan AntonioAuthor(s): Florence Y. Ling, Amy Yu, Wen Zhang, Margaret S. Kim, MS,Nicholas J. Rojas, Jade M. Heverly-Campbell; andM. Rosina Finley, MD, CMD

Background: As the U.S. geriatric population continues to increase in size,the demand for long term healthcare services continues to rise. According toSandberg et al., 2001, more than 40% of adults age 65 or above will spend aportion of their life in a NH. Pain, depression, and cognitive decline, commonsymptoms among NH residents, often go unrecognized and undertreated;therefore, it is important to explore and support complementary avenues toenhance resident quality of life (QOL).Objective/Aim: Our purpose was to bring music and art-based in-terventions to improve overall QOL of residents at a local Long Term CareFacility (LTCF) NH.Quality Improvement Methods: The LTCF medical director and medicalstudents from the University of Texas Health Science Center at San AntonioSchool of Medicine (UTHSCSA SOM) developed a quality improvementproject and implemented the program in conjunction with the facilityleadership and activities director. The program consisted of two cycles offour-session participatory courses in music and visual arts for the residents.NH residents within the LTCF as well as AL residents (at their request uponlearning of the project) within the Continuing Care Retirement Community(CCRC) were invited and participated on a voluntary basis. Each sessionconsisted of a 30-minute music or art activity led by medical students fromUTHSCSA SOM and volunteer certified pre-medical students from the Uni-versity of Texas at San Antonio (UTSA). As a part of course participation,residents were asked to complete a Geriatric Depression Scale (GDS) to

measure depression and a Mini-Cognition (Mini-Cog) Test to measurecognition. Resident pain levels were assessed via administration of theWong-Baker Faces Pain Rating Scale, and responses were recorded. Positivethresholds were chosen as >2 for pain (i.e. hurts little bit or more) and >5for depression. For the Mini-Cog Test Recall portion, 0 and 3 items recalledwere considered significant or non-significant memory loss, respectively.Residents scoring a 1 or 2 on the recall portion were evaluated based ontheir clock drawing. Trained student volunteers were responsible foradministering pre- and post-surveys, transporting residents, and conversingwith the residents through the activities.Results: A total of 25 residents participated in the program: 17 inmusic and8 in art. Of the music participants who met threshold, there were aggregatedecreases of one level in pain and one point in depression between pre- andpost-surveys. Of the art participants who met threshold, there was anaggregate decrease of one and a half points on the depression scale and animprovement in Mini-Cog recall between pre- and post-surveys. Art par-ticipants showcased their artwork and received praise and encouragementfrom other residents. Qualitative feedback in the form of verbal commentsand physical response to activities was overall positive.Conclusion: TheMAMprogram provided opportunities to improve the QOLof NH and AL residents. Despite the small number of participants and shortintervention period, the program was well-received by residents anddemonstrated promising modest improvements in pain, depression, andcognition. This suggests that future student-driven music and art pro-gramming can be integrated into the CCRC activity schedule on a regular andrecurring basis to enhance resident QOL.Author Disclosures: The Music and Art in Medicine quality improvementproject was funded by the Community Service Learningmidi-grant from thedepartment of Medical Humanities and Ethics at the University of TexasHealth Science Center at San Antonio to cover project materials and relatedproject expenses.

Point Prevalence of Risk: Combined Effects of Antipsychotics,Antidepressants, Anxiolytics, Narcotics and Sedative-hypnotics onFalls in a Nursing Home Long Term Care Unit. An InterdisciplinaryTeam Approach to Patient Safety and Quality Improvement

Presenting Author: Khaled Sherif, MD, The University of OklahomaHealth Sciences CenterAuthor(s): Khaled Sherif, MD, Saleem Qureshi, MD, MS,Bich-Thy Ngo, MD; and Andrew N. Dentino, MD, CMD

Background: Much has been reported regarding the risks of antipsy-chotics, antidepressants, anxiolytics, narcotics and sedative-hypnotics,medications which may potentially confer risk to the patient, in the longterm care environment. However, when taken as separate variables,assessing these classes of medications might not reflect the total risk ofthese medicines when prescribed concomitantly to an individual patient.Objective/Aim: This topic looks at the total potential risks for the classes ofmedications which include antipsychotics, antidepressants, anxiolytics,narcotics and sedative-hypnotics which, when prescribed concomitantly inthe samepatients,maycreate risk burdens incrementally greater thanwhenassessing the singular risks of each of these medication classes separately.Quality Improvement Methods: Steps in analysis: identify all antipsy-chotics, antidepressants, anxiolytics, narcotics and sedative-hypnotics pre-scribed at a givenpoint in time (point prevalence) for a nursing home unit; atlevel of recipient (deidentified patient as unit of measurement), assess prev-alences of recipients who are being prescribed 2, 3, 4 or 5 of these classes ofmedications concomitantly; assess an outcome (falls) as a function of at-riskmedication load burden; team approaches to identification, surveillance anddevelopment/institution of non-pharmacologic interventions, (as below).Results: Of 20 residents on this unit in this point-prevalence assessment: A)Regarding medications: 2 residents were on antipsychotics; 6 were on an-tidepressants; 2 were on anxiolytics; 12 were on narcotics; and 8 were onsedative-hypnotics (note: numbers total more than 20, as many residentswere on more than 1 class of these at-risk medications). B) Regardingnumber of classes of at-riskmedications per recipient: 1 (5%) residentwas on1 class of these medications; 7 (35%) were on 2 classes of these medications;3 (15%) residents were on 3 classes; and 1 (5%) resident was on 4 classes of