by Timothy Gieseke, MD, CMD

As a senior clinician and Medical Director, I’ve observed quite a bit of confusion on the part of my facility teams when I have vacationed.   I initially attempted to minimize the confusion by sending out vacation announcements by email, but found that announcements sent to DONs and Administrators stayed with them and didn’t consistently reach frontline nurses or the rest of the team.  I have continued emailing management, but in recent years have been faxing announcements to each nursing station.  This has improved frontline nurse awareness, but I still receive calls from an uninformed nurse on my cell (if I’m not off the grid).  Other team members who may not be reached by these emails or faxes include:  the rehab team, medical records, admission office, & pharmacy providers.  This has rarely resulted in an admission not being seen until the facility discovers I’m not available and reassigns the patient.  

by Michael Wasserman, MD, CMD

One of the ongoing challenges in the delivery of care to residents of nursing facilities is to sort out where the care needs of a resident mesh with their medical needs.  One thing is certain, and that is for a nursing home to provide the best care for its residents, it requires a team approach.  Clearly, the front-line staff are responsible for most of the direct care that residents receive.  Nurses and therapists are on-site to provide necessary and prescribed medically oriented care.  The residents have an attending physician who is responsible for their medical needs. The facility has a medical director.  

St Jude Medical Center is a 320 bed, nonprofit Catholic community hospital.  A member of St Joseph Hoag Health System, it serves a large senior population and is located in a zip code with twice the percentage of individuals 65 and older as compared with the rest of Orange County.

Polypharmacy has become a potential risk factor for QT prolongation in our aging population leading to increased risk of Torsades de Pointes. According to the Agency for Healthcare Research and Quality, 543,000 adults over the age of 65 were hospitalized for an irregular heartbeat in 2009. The core of this Quality Assurance study was to identify the impact of pharmacist recommendations on polypharmacy-induced QTc prolongation, as measured by a reduction in QTc interval, in elderly patients at a skilled nursing facility.  This study was a retrospective chart review performed for all patients in one skilled nursing facility, taking two or more QTc prolonging medications with: 1) at least one being an atypical antipsychotic; 2) QTc interval greater than 450 msec; 3) age >70 years, and 4) pharmacist recommendation for dose reduction, change in therapy or discontinuation of an offending agent.