Improvement of Communication about Safety Issues in Cognitively Impaired Patients in a General Hospital Clinic Setting

In the United States, Alzheimer’s Disease represents the most common type of dementia, accounting for 60 to 80 percent of cases with a prevalence of at least 5 million over the age of 65 [1]. Internationally, over 44 million individuals have dementia with predictions that this number will triple by 2050 [2]. Moreover, compared to other major causes of mortality, AD may rank as high as third after heart disease and cancer, because death certificates may not be accurate [3]. Without a cure emerging in the near future, strategies to prevent, diagnose, and manage AD are limited to clinical and behavioral interventions. A major concern of caregivers and physicians is the safety of patients who are cognitively impaired. Multiple safety issues exist in this group of patients such as falling, wandering, inappropriate self-administration of medications, aggression, and accidents in the kitchen such as leaving a pot or an oven burning [4].


Introduction
In the United States, Alzheimer's Disease represents the most common type of dementia, accounting for 60 to 80 percent of cases with a prevalence of at least 5 million over the age of 65 [1]. Internationally, over 44 million individuals have dementia with predictions that this number will triple by 2050 [2]. Moreover, compared to other major causes of mortality, AD may rank as high as third after heart disease and cancer, because death certificates may not be accurate [3]. Without a cure emerging in the near future, strategies to prevent, diagnose, and manage AD are limited to clinical and behavioral interventions. A major concern of caregivers and physicians is the safety of patients who are cognitively impaired. Multiple safety issues exist in this group of patients such as falling, wandering, inappropriate self-administration of medications, aggression, and accidents in the kitchen such as leaving a pot or an oven burning [4].

Background
This project was conducted in the memory disorders clinic at Olive View-UCLA medical center, a general hospital within the Los Angeles county department of health services. The medical center is a teaching hospital affiliated with UCLA school of medicine. The memory disorders clinic operates two days a week, and primary care providers refer caregivers of elders suspected as having pathological cognitive impairment. The target population were caregivers of elders with dementia of the Alzheimer's type. Prior to the initiation of this project, the safety check procedure in the outpatient clinics, including our Memory Disorders Clinic began with the nurse asking the patient and family about falls during the previous month. The nurse checked to see if the patient had any assistive devices such as a cane or walker. If there were recent falls, or if the patient had an assistive device, this was recorded in the nurses' notes. The patient was then seen by a physician. This physician was unaware of the nurses' safety check. A survey of attending physicians in the neurology department did not reveal any physician who either looked at the nurses' notes or, indeed, knew where they were So there was no communication about safety issues between nurses and physicians.

Project Design and Goals
A project was begun, in the memory disorders clinic with these goals: 1. Better identification of safety problems in cognitively impaired patients. 2. Improved communication between nurses and physicians about safety issues. The successful results of this evaluation have been published in a separate paper [5]. The purpose of this paper is to describe our procedures in attempting to achieve goals [1][2][3]6].

Procedure
From October 2011 to May 2013 197 patients were seen in the Olive View-UCLA Memory Disorders Clinic because of cognitive impairment. The patients were predominantly Latino, with little education, and poor. After the patient was checked into the clinic, the triage nurse completed a much more comprehensive safety questionnaire, together with the patient and caregivers (Supplementary File).
This safety questionnaire was printed on vivid pink paper. The pink sheet with the answers to the safety questionnaire was attached to the chart and given to the physician who was to see the patient. The vivid pink color of the questionnaire guaranteed the doctors' attention. The physician then reviewed the safety issues during the clinic visit, identified important problems, and counseled the patient and caregivers. In addition, as the second part of this project, if significant safety problems were present, the family was referred to the Alzheimer's Association for counseling and education in order to improve safety at home.

Results
From October 2011 to May 2013 the triage nurse completed 440 pink safety questionnaires for the 197 patients. These patient visits were both new and return. In 263 questionnaires, for 148 patients (75%) safety problems were shown.
There were 60 patients with safety issues which were judged to be severe.

Discussion
The stimulus for this project was the realization that 1. safety problems are common in the elderly cognitively impaired and 2. Doctors and other providers as nurse practitioners may be frequently unaware of these problems or fail to inquire about them in the course of a busy and time pressured visit. This method, of a vivid pink safety questionnaire filled out by the nurse and given to the doctor