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Clinical Assessment:

Unmask This Health Bandit Before It Hurts Residents And Your Quality Outcomes

Published on Sun Aug 14, 2005

These multiple MDS items may clue you in to undetectable anemia.

What do falls, cognitive decline, depression, weakness, weight loss and skin breakdown potentially have in common?

They can all be tied to a single cause: anemia, which can wreak havoc on residents' health and your facility's quality outcomes if you don't detect and treat the condition in time.

The consequences of anemia show up in numerous MDS items, quality indicators and RAPs, according to Barbara Phillips, DNSc, in a presentation, "Anemia in Long Term Care: A Silent Epidemic," at the March 2005 American Association of Nurse Assessment Coordinators annual conference in Chicago. (For a list of the involved RAPs, please see the next article.)

Tip: "Falls are a huge indicator of anemia and one of the first signs you may see," cautions Jacqueline Vance, RN, director of clinical affairs for the American Medical Directors Association.

Target These MDS Sections

Look for MDS items where you may see changes in a resident with anemia, which include the following:

  •  Cognitive status in Section B

  •  Changes in mood/anxiety and sleep patterns in Section E

  •  Decreased function and changes in ADL status in Section G

  •  Infections in Section I. Also look for a diagnosis of left ventricular hypertrophy. Studies show that even a .5 gram drop in hemoglobin (going from12 to 11.5, for example) increases a person's risk for LVH by 32 percent, cautions Vance.

  •  Falls in Section J

  •  Appetite and weight loss in Section K

  •  Skin changes (pressure ulcers) in Section M

  •  Shortness of breath or syncope in Section J

    Watch for this: Patients with undetected anemia causing multiple symptoms and problems may end up with several diagnoses and treatments, cautioned Phillips. For example, the resident may have an appetite stimulant for anorexia, a sleep aid for insomnia, and an inhaler for shortness of breath, she noted.

    Develop Proactive Assessment Protocols

    Assess residents at admission for baseline CBCs and hemoglobins, suggests Vance. Hemoglobin provides your best indicator of oxygenation because the hemoglobin carries oxygen. "If the resident comes from the hospital, you probably have a CBC," she adds. If not, try to get one from the resident's physician.

    QA tip: Do chart audits to make sure residents have baseline blood work at admission, and you didn't miss a case of anemia.

    Facilities should also check residents for anemia any time they suffer an ADL decline or loss of function in other areas or a fall, advises Vance. That's where the baseline comes in handy because you can tell if the person has a new onset of anemia, a recurrence - or a worsening problem.

    Tip: Don't forget to look for other potential causes of a fall - forexample, infection, poor nutrition or dehydration, advises Kathy Hurst, RN, JD, director of operations and human resources for Anaheim, CA-based TSW Management Group, which manages several nursing facilities in California.

    Identify the Cause of Anemia

    Facilities create liability if staff order lab work to detect anemia and then don't further assess and treat the condition, cautions Hurst.

    Avoid this common mistake: Never assume the resident's anemia is due to iron deficiency and simply put the resident on iron, advises Vance. Iron deficiency anemia comprises only about 15 to 30 percent of cases of anemia in the elderly population, according to Phillips presentation. "Anytime the patient's lab work shows anemia, the physician should order iron studies to determine if the person has iron-deficiency anemia," counsels Vance.

    Look for this common cause: Chronic kidney disease causes about one-third or more of anemia in the elderly population, according to Vance. You can easily detect a resident with potential renal impairment by using his serum creatinine lab value to calculate his glomerular filtration rate (GFR). The National Kidney Disease Education Program provides a simple online GFR calculator where you key in the person's serum creatinine value, age, gender and race (African American or not). "The GFR value will show if the resident" needs additional testing to diagnose CKD, says Vance.

    "If you don't have access to the Internet, ask the consultant pharmacist to calculate the resident's GFR using the serum creatinine value," Vance suggests.

    To use the NKDEP calculator, go to     www.nkdep.nih.gov/professionals/gfr_calculators/mdrd.htm.

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