cvim.orgcvim.org/.../uploads/2018/05/lunch-learn-minutes-sprin… · web viewlunch and learn –...

Lunch and Learn – Spring, 2018 MAY 2, 2018

As always, CVIM welcomes all of our amazing volunteers – we are so grateful for your contributions, time, and ‘heart’!!

A. Team News1. Sarah Poutasse, CRNP, was promoted to VP of Medical Services2. Marthe Adler, CRNP, joined the staff (formerly a volunteer) as Clinic Coordinator3. Lori Trevlyn, RN, joined the staff (formerly a volunteer) as Nurse Navigator

Sarah Poutasse Marthe Adler Lori Trevlyn

4. The Harrison Society recently honored Dr. Pete Hillyer for his dedication and service to CVIM for 20 years. Thank you Pete!

B. Hypertension Guidelines

Key HTN Facts

• HTN affects approximately 1 billion adults worldwide• Highly prevalent in adult population > 60 yrs• HTN is the leading cause of death and disability • HTN accounted for more CVD deaths than any other modifiable risk factor except for smoking.

CVIM Lunch & Learn - Spring, 2018

1. Recommended Guidelines for Taking Blood Pressure Step 1: Properly Prepare the Patient

a. Have the patient relax and sit in a chair (with their feet on the floor and the back supported) for at least 5 min

b. The patient should avoid caffeine, exercise, and smoking for at least 30 min before measurement

c. Ensure patient has emptied his/her bladderd. Neither the patient nor the observer should talk during the rest period or during the

measuremente. Remove all clothing covering the location of cuff placementf. Measurements made while the patient is sitting or lying on an examining table do not

fulfil these criteria Step 2: Use proper technique for BP measurements

g. Support the patient’s arm (e.g. let it rest on a desk)h. Position the middle of the cuff on the patient’s upper arm at the level of the right atrium

(midpoint of the sternum)i. Use the correct cuff size, such that the bladder encircles 80% of the arm, and note if a

larger or smaller-than-normal cuff size is used j. Either the stethoscope diaphragm or bell may be used for auscultatory readingsk. Separate repeated measurements by 1-2 minl. Take the average of at least 2 measurements on the first visitm. If a patient has HTN, diabetes mellitus, or a high BP reading in the office, the medical

provider must repeat the BP!n. Automated BP measurements are now considered acceptable

**FIRST APPT – take both arms; use the higher score.

Automatic cuffs are gaining favor, and we are getting a second one. Home monitoring is recommended too; we are trying to get a grant to buy some for our patients.


2. Lifestyle Interventions• Our goal is that every patient with HTN is seen or called by Rachel, our nutritionist, to

encourage the lifestyle changes that need to be made. Please consult Rachel when you see a patient with HTN.

• Please consider CareMessage for all of your hypertensive patients. There are many different CareMessage programs that could help them, such as nutrition, exercise, managing stress, or managing HTN.

Lifestyle Modification in the Management of Hypertension

Modification Recommendation Approximate systolic BP reduction, range

Weight reduction Maintain normal body weight (BMI 18.5 to 24.9 kg/m2)

5 to 20 mmHg per 10 kg weight loss

Adopt DASH eating plan

Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat

8 to 14 mmHg

Dietary sodium reduction

Reduce dietary sodium intake to no more than 100 mEq/day (2.4 g sodium or 6 g sodium chloride)

2 to 8 mmHg

Physical activityEngage in regular aerobic physical activity such as brisk walking (at least 30 minutes per day, most days of the week

4 to 9 mmHg

Moderation of alcohol consumption

Limit consumption to no more than 2 drinks per day in most men and no more than one drink per day in women and lighter-weight persons

2 to 4 mmHg


3. What Target BP Should be the Goal?a. JNC8 Overview

**Consider risk vs reward of medicating. Add Beta Blocker if patient has a history of MI or AFib; consider if diabetic.

b. ACC/AHA Recommendations

** 130-139 Medicate if risk is greater than 10% (use app); otherwise diet and lifestyle changes** Middle aged diabetics should be treated more aggressively


What Target Blood Pressure is Best?

c. These are just guidelines – Individualize Each Patient!a. CVIM recommends that for patients with low CVD risk and no CKD, to follow the

JNC8 guidelines i. Goal BP <140/90, if less than <60 y.o.

ii. Goal BP <150/90, if >60 y.o.b. For patients with CVD or CKD or have a cardiac risk >10%, use the ACC/AHC

guidelines. i. Goal BP <120/80

c. For patients with diabetes, the American Diabetic Association recommends a goal of 140/90, unless they have cardiovascular risk factors; then they recommend <130/80.

d. For each patient, evaluate their risk of CVD, CKD, and diabetes and individualize their target BP plan.

e. Medical providers need to repeat the blood pressure in patients with HTN, DM, CKD, and if high initial HTN.

4. Beta Blocker Usea. According to JNC 8 guidelines

i. Beta blockers are reserved for post-MI/CHF with HTNii. Beta-1 selective Beta-blockers

• Possibly safer for pt w/ COPD, asthma, diabetes, PVD• Metoprolol – use name and dose on RX – Toprol: 1/day (metoprolol

succinate), Lopressor (metoprolol tartrate): 2/day5. Chlorathalidone vs HCTZ

a. Pharmacokinetics/Pharmacodynamicsi. Chlorathalidone is 1.5 to 2 times more potentii. Chlorathalidone has longer duration of action

b. Both medications are clinically effective in HTN; we have both at CVIMc. Both medications have similar adverse profilesd. No direct comparison in clinical trials

>> Start low – 12.5, not 25 or higher


Top 5 Tips for Working with an Interpretera. Speak directly to and look at the patient, not the interpreterb. Speak in short phrases, allowing time to interpretc. Everything stated in the room will be interpreted word-for-word (if there is anything you do

not want repeated, do not say it in the room)d. If the interpreter does not understand something or if they sense that the patient has not

understood, they may ask you to rephrase the statemente. Most patients understand more English than they can speak – don’t speak assuming they

can’t understand what you are saying (in particular, using words like ‘cancer’) • Nurses can request interpreters; they should be asking the chief complaint• We also need to be determining their literacy – facesheet should say so• They may also have challenges with time and math; use Teachback, ask them to read

notes

C. Dispensary Newsa. Our beautiful Consult Room can be used for collaborating, training, notes, and writing Rx’s –

please visit the dispensary as needed but recognized that it can get crowded!b. Dx notation: Please note the indication/diagnosis on the Rx – the dispensary staff needs this

to appropriately consult; if they mention a different use, it confuses the patient!c. Rx Quantity: Patients should get enough meds to last until their next visit – please write the

RX accordingly>> e.g., If the provider wants to see the patient in 3 months, write for 90 days

>> 30 x 2 refills = two more visits >> 90 day supply = no extra visits!

D. ZOOM Newsa. ZOOM - our free rides program for our patients

• How it works: Patients sign a contract, then let us know they will need a ride – to/from home, work, school - whatever they need

b. How providers are involved: 1. Ask your patients if they have trouble getting to CVIM 2. Write Zoom on their appointment slip > The Front Desk will sign them up; Samantha Artze will then coordinate them3. Watch for the ZOOM Rider notes on your patient files

> Their appts need to run as on-time as possible > If you think they’ll run late, notify the front desk! Their volunteer drivers are waiting


E. Tobacco Dependence Updatea. Facesheet

• Mark Tobacco Exposure on Facesheet, type of tobacco, quantity, & if they are interested in the program. If they are no longer using tobacco, please write the quit date.

• Education – Please mark under education when you discuss tobacco use with a patient

• Referrals/Interested in TD Program – If the patient is interested in meeting with a counselor to discuss their tobacco use, please indicate it on the Facesheet, which in turn will generate a report for the Tobacco Dependence department to follow-up with the patient

b. Have the Conversation• “Let’s talk about your tobacco use” vs. “You need to quit smoking”• Pros & Cons – “What do you like about using tobacco?” “What do you dislike about

using tobacco?”• Folders in Room This is patient education on tobacco use and our Tobacco

Dependence program to give to patients. - While the patient is waiting to see the doctor, if they are a current

tobacco user, please see if they would be willing to fill out the Touch Base form in the folders and place the completed form (make sure their name and DOB is on it) on the Tobacco Dependence desk.

c. Connect Patient to a TD Counselor while they are HERE!• TD Counselors here Monday, Tuesday, & Thursdays• Dan is here DAILY & speaks Spanish

d. Medications require TD appt (give appt slip)• Medical providers are welcome to begin a TD medication


• Make sure the patient is aware that a TD counselor will be following up with them either In-Person or on the Phone. One of the two is required for the patient to continue receiving medications. • Give the patient an appt slip to make a TD appointment at the front desk

F. Behavioral Health a. Team

• Staff1. Miriam Geiger, BH Coordinator & Bilingual Counselor2. Sam Artze, Bilingual Social Services Coordinator

• Volunteer Counselors1. Barbara Weber, LCSW (Thurs)2. Joyce Kleiber, LCSW (Mon)3. Liz Caggiano, LCSW (Tues)4. Dr. Nancy Reynolds, Psychologist (Tues)

• Volunteer Counselors1. Barbara Weber, LCSW (Thurs)2. Joyce Kleiber, LCSW (Mon)3. Liz Caggiano, LCSW (Tues)4. Dr. Nancy Reynolds, Psychologist (Tues)

• Partnering Counseling Agencies ($10-$30/session for CVIM patients)1. Anxiety & OCD Center2. WCU Community Mental Health Center3. Peacemaker Center (Bilingual)4. Family Service of Chester County

b. Behavioral Health Referrals• Social Services – Sam

1. ASK PATIENT IF THEY ARE INTERESTED2. Complete Referral Form (found outside of Sam’s office)3. Write “Social Services” on appointment slip4. Front Desk may schedule appointment5. MARK ON FACESHEET

• Counseling & Psychiatry – Miriam1. ASK PATIENT IF THEY ARE INTERESTED2. Complete orange “Internal Referral” slip3. Write “Counseling” or “Psychiatry” on appointment slip4. Front Desk places patient on WAITLIST & Miriam follows up5. MARK ON FACESHEET


Facesheet Moments

G. Other Facesheet Updatesa. Order of Diagnoses has been rearranged (grouped related diagnoses)

• Including CareMessage referrals

H.

Volunteer Recruitinga. Clinical Volunteer Recruiting remains a top priority - we have lost several clinic volunteers

who are no longer able to work at CVIM. We have primary care shift shortages as well as needs for specialists in several areas.

b. The website will be updated with the latest needs, and all staff and volunteers are encouraged to spread the word and distribute some volunteer application packets!

• Go out and talk to your friends – hand out folders!• Volunteer social events at CVIM• Speak at your local hospital groups, rotary, church• Please consider extra shifts and coming in more!


MARK DIAGNOSIS ON FACESHEET

Anxiety/Stress Depression Domestic Violence Substance Abuse Suicidal Thoughts

c. Clinical hours were the only hours that did not increase; it is really important to record your hours!


cvim.orgcvim.org/.../uploads/2018/05/lunch-learn-minutes-sprin… · web viewlunch and learn –...

Documents