Opportunities in Geriatrics

...where will your career in Geriatrics take you?



Quality projects opportunities for the Geriatrics Fellows and other academic opportunities



1. Area: The QI Projects for the GEM Clinic


Faculty: Dr. Horton


1) Influenza vaccinations: Capture all and capture early
2) Reduction of ED visits
3) Bridging the Gap for Transitioning Post-hospitalization Care
4) Medication Curriculum for All Trainees
5) 360 degree multisource evaluation

  • We are in need of someone who is interested in improving the prevention & assessment of falls for the trainees in our clinic.  This is an area that needs an advocate.
  • We can also do medication utilization reviews or also other projects related to chronic disease management.



2. Area: The QI Projects for the ACE unit


Faculty: Dr. Oakes


1) Delirium prevention protocol implantation and campaign: mobile ACE. 1. Help to implement the 6 components 2. Staff education3. Analysis of the data
2) We are implementing phase 1 out 3 –cognition and mobility currently
3) Fellow will help with phases 2-3 and finish phase 1



3. Area: The QI Projects for LTC: Buena Vida Nursing Home


Faculty: Dr. Oakes


1) INTERACT (Interventions to Reduce acute care Transfers) project from theory to practice.


Proposed project:

  1. Look into data gather so far into inappropriate transfers analysis and implementation of changes.
  2. Educational initiatives to promote the care path ways.
  3. Medication reconciliation.
  4. Preparing for the future how to work with your hospital partners in transfer communications and discharge summaries.
  5. The fellow will also work with AFV with Dr. Ye to produce the poster/presentations.





Faculty : Dr. Suh


Background:  Resistant infections are an important cause of added morbidity and mortality in hospitalized older adults.  Various studies have been undertaken to reduce the incidence of infections caused by C. difficile, MRSA and VRE.


Infections targeted:  C. difficile, MRSA, & VRE


Location of the intervention:  ACE Unit, CHRISTUS Santa Rosa City Centre


Proposed intervention:  Multicomponent interventions have been shown to be useful in improving quality of elder care in a variety of settings.  For this project, our intervention will include:
1. Using probiotics in patients on antibiotic therapy (to prevent C. difficile).
2. Terminal clean of contaminated rooms by housekeeping, including use of Lysol as a disinfectant.
3. Family education on contact precautions (handouts/ poster for the family conference room).
4. Larger wastebaskets dedicated to gowns, masks and gloves.
5. Use mupirocin ointment to reduce nasal carriage of MRSA in pts with known MRSA.


Data needed:
1. # hospitalizations w/ resistant infections in the ACE Unit
2. # readmissions w/ resistant infections in the ACE Unit


Requirements: The fellow for this project will attend monthly ACE QI Meetings on Wed. afternoons.  He/she will also help gather data, and participate in the Clinical Safety & Effectiveness course.



5. UT Senior site Qi projects:


Faculty: Dr. Parker


Area of interest: Quality project of getting all of our patients having an advanced directive and documented in the chart. We can use



6. UT Senior site Qi projects:


Faculty: Dr. Parker


Area Of interest: Work with clinic manager to reduce same day cancellations and no shows.



7. UT Senior site Qi projects:


Faculty: Dr. Parker or ACE faculty


ACE unit: Getting patients discharged from ACE to see their PCP within a week of discharge.



8.Palliative Care in the MICU (Medical Intensive Care Unit).Quality Improvement Intervention


Faculty: Dr. Debra Villarreal


Rationale: Because of the high mortality and morbidity, palliative care is an important component in the intensive care. In fiscal year 2010, the South Texas Veterans Healthcare System had <10% of patients receive palliative care support (a consultation). Project started October 2010.


Overall goal:  To increase palliative care support/consultation for MICU patients, at risk for poor outcomes, from <10% to 50% or better. 


Methods:  The intervention targets inter-professional MICU healthcare teams (attending physicians, fellows, nurses, social workers, chaplains) using three components:

    1. To increase palliative care presence in the MICU:

    Palliative care attending (Dr. Villarreal), nurse specialist (Bonnie Howard), pharm D (Kristin Reid) are members of the MICU Interdisciplinary Committee.  The goal for palliative care participation in this committee is to integrate palliative care into daily MICU practice.  This committee defines standard operating procedures for the MICU and is involved in quality improvement.  Palliative care has become a key discipline in the agenda/minutes.   This participation has created changes to the MICU medical record and system.  For example, it established:

      a.) A refreshment money allowance and bereavement bag for families with an actively dying loved one in the MICU.

      b.) A Palliative care assessment to the daily physician critical care assessment note.  This reminds healthcare providers about palliative care services.  (still pending)

      c.) A Bereavement Note template.  The documentation contacts the palliative care bereavement team (Social worker Betty Beck leads this) about a MICU death.

      d.) A Family Meeting Note.  The note documents key elements of a family meeting.

      e.) A MICU Interdisciplinary Team Note.  This note documents progress and needs of patients who are admitted >30 days.

      f.) A Comfort Care Order Set. This pharmacy order will be added to the main MICU order set.

      g.) Pamphlets about MICU orientation, benefits and bereavement.

      h.) Inclusion of palliative care to the resident orientation presentation that is held the first week of the resident’s MICU rotation.

      i.) The Palliative/Geriatric care fellow collaborates weekly (face-to-face contact) with the MICU team/fellow to discuss which patients may benefit from a palliative care consultation.

      j.) Future Steps: Establishment of a set of clinical criteria triggers for assessing patient for palliative care consultation.

    2. Education of Critical Care team:

      1. This year 2011-2012, there will be two educational interventions for inter professional learners:

        a.) Observed Structured Clinical Examination (OSCE) on delivering bad news using an interdisciplinary approach.   The MICU team (critical care fellows and nurses, other staff) will participate in this.  This educational intervention will evaluate the physician’s comfort toward delivering bad news and working alongside other disciplines (nurse, social workers).

        b.) Didactic Teaching sessions about geriatric and palliative care principles for the MICU team.

    3. Feedback of quality performance data:  Dr. Villarreal maintains a database of quality indicators for all patients admitted to the MICU.  This database shows the effectiveness of the palliative care team and project.   The data is reported to the MICU Interdisciplinary Committee.

      a.) Some quality indicators are:  Patient demographics, length of stay, family meeting documentation, social work and chaplain support, re admission rates.  (See legend).


Results:  We have increased palliative care support/consultation for MICU patients, at risk for poor outcomes, from <10% to 54%.  When palliative care is involved in a patient’s care, MICU social work visits for families increased to 30% (pre intervention was 16%) and bereavement contact or support increased to 20% (pre intervention was 0%). 


Conclusions:  These are the first steps to more QI projects.  There is still a lot of work to be done that involves more direct contact with MICU teams, patients and families.   It is still not clear if our interventions ultimately improve patient outcomes and family satisfaction.   We have found that the MICU staff seeks assistance from palliative care mostly for dying patients and hospice patients admitted for symptom management.   We do not have ‘buy in’ from all the MICU attending because at first glance palliative care does not seem to impact patient outcomes.  



9. Area of interest: Project One:  Transitions of care.  Chart reviews for accurateness of transitions of care orders.  And, appropriate translation of orders.   


Faculty : Dr. Finley


Setting: Morningside Manor
Project Two:  Advance Directives; Spanish interpretation for families.  Future potential for research. 
Project Three:  A review of appropriate discharge into the community.  Chart reviews and development of discharge program. 



10. Area of interest: Documenting Behavioral Vital Signs.


Faculty. Dr. Prang


Setting: CLC ( VA nursing home care unit)

Statement of the problem:  Patients cared for in CLC (VA Nursing Home Care Unit) exhibit a number of  behaviors which may require interventions for their safety and the safety of others.  These behaviors may occur at any time.  They are frequently only observed by nursing staff.  Other members of the IDT including medicine, pharmacy, psychology, social work, recreation therapy participate in interventions to address these behaviors.   A note titled “Behavioral Vital Signs” is currently available for use in the EMR (CPRS).  Nursing has found this note to be too cumbersome to use regularly. PRN psychoactive meds are being administers without sufficient documentation of reason for use or outcome.


Since the intervention requested by nursing is a pharmacologic intervention in the form of a psychoactive medication. It is imperative that behavior and response to pharmacologic intervention be documented.


Proposed intervention:  The Fellow will collaborate with other member of the team to identify those aspects of the current note which make use of the note by bedside nursing burdensome.


The process for identifying overly burdensome aspects of the note will include:

    -- Identifying patients exhibiting behaviors that need to be documented by:
      -- Nursing alerting providers through adding as additional Signer to note
      -- Verbal information passed on to providers in care planning
      -- Requests for pharmacologic intervention by nursing
      -- Patient who required a “code green”
    -- Fellow will review EMR to determine if BVS note was used
    -- Fellow will interview nursing staff who cared for the patient
    -- The fellow and the nursing staff will then complete the current BVS note jointly
    -- Fellow will systematically identify aspects of the current BVS which make it to cumbersome
    -- Fellow will assist in revising the note to make it less cumbersome.


Evaluation of Effectiveness of intervention.


Baseline data: Frequency of use of current BVS note per the number of times behavior which is perceived as needing intervention occurs.


Outcome: Frequency of use of revised BVS note per the number of times behavior which is perceived as needing intervention occurs.



11. Current projects and ongoing projects: I would encourage our fellows to get involved in those ongoing projects


Faculty: Dr. Ye


  1. Implementation of INTERACT (Intervention to Reduce Avoidable Acute Care Transfer) Curriculum at two Community NHs in San Antonio


      a) Clinical outcome
      b) Educational outcome
      c) Comparisons of two NHs based on educational outcome (We use different modality during the learning process)

  1. Improve the completion rate of advance directive documentation for clinic, nursing home and hospital patients.  Improve the rate of carrying advance directive documentation across all care settings.


Other Areas of Interests (Dr. Ye)

  1. ACE project: Improve the signature completion rate on inpatient charts on the day of discharge (with goal of 100% compliance). TK and I have already started the process this week.
  2. ACE project: Improve the process of admitting patients to inpatient unit
  3. Transitions of Care project: Medication management across the care settings: Reduce the medications discrepancy during care transitions
  4. Preventative station service at UT medicine clinics: Provide efficiency and cost-effective are visits