Mrs. Perdito
You pick up the chart of this 79 year old woman in the Fast Track area. It reads “UTI”; normal Vital signs on Nurse’s Notes; Bloodwork done on arrival is normal and the urine is positive for WBCs and bacteria.
- Watch the video below, and be prepared to comment on the interaction.
- What do think is missing from this assessment? What would you do differently?
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Outcome
This patient was found wondering on the road near the hospital. She was taken to a different hospital where some effort was put in to finding her family members. Her daughter identified that this was not much different from her usual condition and that sometimes she just wandered off from home. They submit a letter of complaint to the first hospital.
- What would happen if you took 30 seconds longer with this same patient?
- What do you see the doctor doing well here?
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Outcome
This patient’s daughter was contacted by ED staff. She came and said that there wasn’t much different from usual with her mother and took her home. She expressed gratitude for looking after her mother so well.
Important Concepts
- Dementia is frequently overlooked in the Emergency Department because we have such a short exposure to the patient: being attentive to subtle signs (“vague” responses, historical elements that don’t fit together, unkempt appearance) may prompt you to screen for some sort of cognitive impairment
- Dementia is common (1 in 4 over the age of 80) and frequently not diagnosed in the community
- Dementia has a significant impact in the assessment and management of the patient in the ED – from how you acquire the history to how you ensure the patient participates in discharge planning
Discussion: Mrs. Perdito
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See what happens when patients are treated like human beings?
a big difference from the first video.
yes
ok
Next interview so much better. Took time to listen and direct interview toward patients responses. Getting history from family very important to know if change in mental status.
agree
Didnt take so long to assess and changed the outcome
2nd interview was much more thorough.
Historia clínica completa y siempre excluyendo otros diagnóstico diferénciales
Siempre pensar en las causas de delirium sin excluir la demencia.
Assessment makes a lot of difference in management
second interview better
second interview was much better
agreed
good.
good comparison between a good and bad approach to history taking + assessment
ok
patient centered
2nd interview much better
n/a
see above comments
Na
well done
patient appears confused but dr was able to pick up on it, good job
much better interview at the second try
the second assessment is calm, deliberate, and more patient-oriented.
much better the second interview. really important to get down to level of patient and pick up subtle findings.
second intervew more thorough
Much more bang for buck in the second interview. Didn’t take long.
Second Assessment didn’t take long and much more informative.
really takes home to point that engaging (for as short as 30sec) in a busy ED makes all the difference.
better second time
I agree
lack of bias
good rapport and use of screening questions
Good video
Liked the way the doctor sat at the patient’s eye level and assessed her ability to be able to answer the assessment questions appropriately. \Based on his assessment was able to determine that he had to speak to the patients daughter for more accurate information.
Better assessment, able to determine pts mental status.
nonew
Much better interaction with the patient, sat at the bedside, looked at the patient, accesses her cognitive status and talked to family members
THIS VIDEO REVEALS BETTER DOCTOR-PATIENT COMMUNICATION;ACTIVE LISTENING,ASSESSMENT OF COGNITIVE IMPAIRMENT AND INVOLVEMENT OF THE PATIENT AND RELATIVES IN HER MANAGEMENT.
It is NOT necessary to comment in every Discussion box to obtain credit.
Perfect
great practice
Agreed
Testing
good
there is a better contact with the patient and applies questions in order to explore dementia
true
Good info
ok
difficult but informative
Doctor is at eye level with pt, sitting down, more eye contact, and allowing more time for pt to talk. Much better the second time.
good hx taking
great point
yes, it is much better than the first video
Agreed
agree
good presentation
Took time with pt to explore history
better the second time
Challenging
professionlism
Improvement noticed in second video
More physicians need to ask the patients prior to leaving the room questions before they just read a chart and then prescribe. Patients will either tell you what is wrong or you will get an idea of their cognition. A few minutes in conversation with a patient is so very important.
agree
Good
These are great examples of how to do a proper interaction with a patient
yes it is
Good
ok
second video is much more professional
great approach
doc is very busy
Didn’t give her time to talk.
Effective communication
good interview
Second scenario was well done and how this type of assessment should always be done.
Talking to patients and listening to them. Weird!
better to give the patient time to respond and speak
This was a much better assessment.
take away: taking a little more time with each pt results in a more in depth assessment and clearer picture of what is actually going on
The second screening was much more thorough.
much better in 2nd video
good
Good
bETTER
Video clips make the learning applicable
good easy to understand
I like having the two videos to show comparison of what could happen when you’re not aware of screening tools and subtle hints that can go unnoticed and the difference in outcome that results in increased morbidity and mortality rates versus using quick screening tools to help identify an issue resulting in better outcome.
I totally agree with you
good example
Thanks!
Good example – it’s so easy for these patients to fall through the cracks.
.
good video of what should happen
the second video was a good reflection on what should have happened.
helpful
improved
a significant difference in assessing the pt
I liked that we got to see two sides of the same coin with regards to care. Too often we are quick to diagnose based on initial presentation and move on
I agree, I liked that the doctor asked her what was wrong and didn’t just assume he Knew. We often forget to practice narrative competence, especially in a fast paced environment
Did great job getting down to patient level, good bedside manner, makes patient more comfortable. Good listening and questioning patient LOA and mental status.
Better job on second video. He understands pt much better.
Our cognitive biases can hurt patients, Osler told us the patient tells us the problem, we need to listen.
Good videos and a great opportunity to view different presentations.
na
good video
Short and sweet videos that provide a quick look at how to improve interactions/ assessments of dementia pts.
good video
appropriate 2nd interview for visit.
a comment
patient centered approach
good examples
In this day and age where more and more geriatric patients are flooding the ER, it’s imperative as clinicians to obtain a thorough history and screen for cognitive impairment and rule out delirium before discharging them home.
The difference in asking open ended questions and closed ones, gives a much different history. In the first interview all the patient is agree with everything the doctor said. In the second one he could see more that the patient was not able to give a good history, didn’t know how she had got to the emergency or specifically what was bothering her.
THIS JUST ILLUSTRATES WHAT I TRY TO TEACH TO RESIDENTS: LISTEN TO THE PATIENT AND IF SOMETHING DOES NOT FIT IN THEIR BERING OR HOW THEY ANSWER ASK YOURSELF QUESTIONS.
Only an additional 30 seconds more to consider a more serious problem than UTI.
good video, good overview
A well structured patient interview does not take that much longer and is important in a busy and hectic ER. A substandard patient interaction could potentially result in bad patient outcomes.
Good videos
good video
agree
true
yes
agreed
Good videos
Really liked the second video. I should a more realistic interaction. It also showed how you are able to gain a lot in a short period of time if you are attentive and are looking for little clues
agreed
I really liked the explanations provided after each video and the videos as well.
agreed
agreed
agree
second interview much more holistic, able to gain more information from patient.
I would use open ended questions to probe more. Involve family members to get the full history
helpful
Glad MD notified family and interacted better.
Better assessment
The first encounter happens so frequently. The second is a better representation of what should happen.
helpful
important to listen to the patient and family
Sitting down with a patient is important.
great video shows right and wrong approch giving patient a little time
good videos
Very common approach in the ER
Unfortunately, all too common an approach
30 more seconds and the physician easily clued in to cognitive impairment
taking the time with the patient made a big difference and the screening tools helped a lot.
It makes a significant difference when the MD takes the time with a patient.
Sitting and being open to the patient rapidly raised the suspicion of an underlying cognitive issue, facilitating more direct assessment of her cognitive impairment
Spending a little more time with the pt the second time caught a lot of red flags that was missed in the first round.
MD was inattentive and was not thorough..missed a few signs.
He barely let her speak. Plus, there was no physical exam.
it doesn’t take long to listen and discover important clinical information
interesting – good summary
Love it!
Asking open ended questions great way to get feedback
Interaction was client and family centred with enhanced therapeutic conversation.
Informative.
Listening and being attentive to a patient can go a long way.
Much better with pt, not rushed and more engaged. More thorough assessment. Appeared to develope a care plan with follow-up.
Physician needs to be more patient centered
Much better assessment than first
The second interview shows the importance of engaging in a history to pick up on subtle signs such as cognitive impairment. Do not approach a patient with a diagnosis based on vital signs and investigations but assess the patient thoroughly. See beyond the UTI
What has brought you here today? More opened questions more better outcomes. Redirecting if the patient is wandering on long conversations.
I would use open ended questions to probe more. Screen for demetia using minicog – clock drawing test. Involve family members to get the full history.
In elderly patient, I almost always start with checking orientation. If they can’t tell me the year, month/, & location, the rest of the history is sketchy and collateral information is needed. As seen in the video, quick cognitive screening can just add a minute to early time but save you lots of frustration when patient starts giving vague answers and you either end up having to ask a lot more questions or take the lazy approach of just calling it a UTI and punting the patient.
I am always skeptical about the diagnosis of UTI, especially in women. It is definitely a common diagnosis but it is also a convenient one — too easy to anchor on a positive urine analysis which is a pretty nonspecific test, especially when used as a screening test in older women.
It is easy in busy emerg or clinic to do a one problem assessment, however, this can have significant consequences. Cognitive issues should always be a concern in patients over 80
patient centred does not necessarily mean longer assessment.
The second interview was much better because he asked open ended questions and was able to be more patient focused.
detailed interview is important
This was a very realistic presentation of a typical patient you might see in our ER. It really emphasized the importance of taking the time to observe and listen to the patient, even in a busy ED!
Excellent lesson of how little additional effort is required to improve patient-centric care.
More patient focused in second interview
Could have a longer interview in the 2nd interview
well done
The doctor builds a good rapport by asking open ended questions. Screens for delirium. Shared decision making “shall I call your daughter”
improvement from video 1 to 2, shows concern for cognitive impairment,
Better interaction with the patient during the second interview
pick up subtle changes in patient asnwer
shows progress
Much improvement from first video to second.
I enjoyed the video. the actors were very believable. I enjoyed wondering what the doctor would do to pique my interest next. thank you.
ensuring that the patient has an understanding of their condition and what you are prescribing to them and that they are able to safely treat their condition and themselves demonstrates professional responsibility
First video shows the reality of our ED’s today. The second video demonstrates what should happen.
Did you hear about the Unicorn joining the Military?
She had to wear a U-Ni-Form!
.
Some simple observations of appearance are great clues. A few cognitive assessment questions take little time, but make a big difference.
The first video really showed how we sometimes ignore older people – he was talking down to the patient, not making eye contact and did not explore the patient’s issues beyond the initial complaint. In the second video he was much more empathetic – sat at eye level, asked the patient what was wrong, explored mental status and also offered to contact the patient’s relative.
Approch was really better and taking time
good example instead of rushing through and landing on a diagnosis based on what is probably a normal urine for her
Sitting down is always a good idea!
Doing a functional hx is so important for all older adults- can be a quick way to gain further cclues into coginitive status as well as needs for further supports
liked this approach
for being a frequent pathology diagnosis in emergencies must know more of the characteristics of the same
Less leading questions, and need collatoral history to assess cognition/ascertain if she is a reliable historian.
Oops, this was for the last video. This was done much better!
Better assessment technique
better\1
I learned a lot.
Nice videos
Doctor seems to be understanding and compassonate, paces the question and simplifies them. gives patient time to respond
great video
xxx
good PCC
Way more patient centred
Great stuff
Better the second time
It is much different having the patient centered than just treating labs
Much more pt centred
Even in the fast pace of the ED, there is room for a quick 30 sec cognitive screen as was demonstrated or fu call to the LTC home/family, this will inevitably save the ER MD time later when it comes to disposition and will resonate with the families.
Agreed. Getting the collateral on patient’s baseline so we can piece together if something has changed or this is indeed how patient normally is is so important and in best interest of the patient.
Much better second time
Better second time,engaged pt & asked relavant questions
Good lesson
see above please.
Also Imagine elderly presenting alone with cognitive impairment waiting for hours in ER.They probably would not remember why they originally came for!
95% of emerg docs would have just treated the UTI. I would hope the nursing staff in triage would have picked up on this and perhaps clue the doc that something else was going on
in my opinion it is usualy nursing staff,who should be trained re Asymptomatic Bacteriuria,but occ.rather try to push MD to get ” OLD” and potentially problematic people from ER.As per ER ..there is unfortunately not too much time to do cognitive assessment and it is not proper environment no multidisciplinary assessment,rather very rushy place and no ” collateral Hx available if patient shows there herself.
Screen for Dementia can be initiated by Nursing staff during triage in nonextremely busy ER.
Patient should be preferably refered and managed in ” special ER Geri friendly with proper F/U…
Much more patient centred.
I think it makes a difference just by sitting at the patient’s level vs standing.
Much better approach second time around!
much better the second interview. really important to get down to level of patient and pick up subtle findings.
Agree
love it! Had me laughing this am.