These days, everyone in long term and post-acute care is overstretched and overwrought. In this setting, computers and the Internet are used largely to enter print orders, transmit data for regulatory and quality requirements, and for financial and billing purposes. Providers hardly have time to even think about using the Internet for anything else.
The worldwide coronavirus outbreak has reminded everyone of how fortunate they are to have widespread, almost instantaneous access to news and information. Less well known are the tremendous everyday resources that can help providers improve their care and get better outcomes for their residents and patients.
This article will consider the numerous benefits for facilities, practitioners, and residents of online searching using Google.
A Faster Source
In earlier years, clinicians learned to read books and journal articles and to ask a lot of questions. These days, even after four decades in practice as a clinician and medical director, the author still asks lots of questions and looks a lot of things up.
He most often uses Google to look up both topical information and information that can help him care for individual residents and patients. In fact, he thinks Google may be one of the most valuable resources and remarkable lifesaving technologies available today.
Within the past 20 years, online searching has become an enormously valuable tool that has the potential not just to improve clinicians’ knowledge and skill, but to actually help patients in real time and even save lives. At least initially, searches are free and almost always take less than a minute.
A Case in Point
As an example of how it can be used, take this actual case. A nursing facility requested a review of a 68-year-old man with a history of alcoholism who had been admitted approximately two years earlier. Initially he had been fairly quiet, but had been yelling much of the day and night for the past year and a half. His medications included divalproex sodium extended-release 125 MG, levetiracetam 1000 MG nightly, hydroxyzine 50 MG tid, sertraline 25 MG daily, and risperidone 1 MG daily.
As with many similar patients, relevant questions included: Why is the resident yelling out frequently despite treatment? Are his current diagnoses correct? Why have his medications not helped reduce the problem? Could his medications possibly be part of the problem? What should be done next?
Using a remote connection, clinicians typed the following into the Google search bar: “hydroxyzine Medscape,” “Beers List 2019,” “drugs not indicated in the elderly,” “anticholinergic medications in the elderly,” “symptoms of anxiety and depression,” and “managing chronic anxiety disorder in the elderly.”
Revealing Results
These Google searches helped identify that hydroxyzine is a drug with high anticholinergic properties that is often used for anxiety but causes a lot of behavioral and psychiatric side effects, especially in the elderly.
It showed that hydroxyzine is on the Beers list of drugs not indicated in the elderly and that antiepileptics can cause significant psychiatric and behavioral side effects, both individually and when combined with other antiepileptics and other medications in other categories, such as opioids.
The searches identified verbal and physical aggression as being common symptoms of anxiety and mood disorders such as depression; that individuals who had seizures due to excessive drinking may not need as much seizure medication once they have stopped drinking; that antiepileptics such as valproic acid can depress mood and counteract the positive effects of antidepressants; and that antidepressants—not benzodiazepines such as lorazepam or clonazepam—are the preferred first line of treatment for chronic anxiety.
Based on this information, medication changes brought about remarkable improvement.
Basics of Searching
The box above lists the basic elements of a good online search.
The basics of doing a Google search are as follows:
First, as above, define the exact situation, topic, or problem.
Second, identify relevant questions and phrases (for example, to find out whether it is a good idea for a resident to be receiving lorazepam and morphine together, type in “risks of prescribing opioids and benzodiazepines together”).
Third, use relevant terminology. Searching involves either typing the search terms into Google and then choosing a website from among those that come up in the search results, or going directly to the website and then typing in topics into the search bar for that site.
For example, to search for uses and possible complications of various medications, type in the name of the medication and the words “indications” and “adverse consequences” or “side effects.”
Fourth, assess the pertinence of initial results. There are many reasons for not getting what is being looked for the first time around. For example, the search term may have been incorrect, or perhaps the search term was too broad or too narrow.
Modifying the Search
Fifth, modify the search, for example, by using synonyms and multiple versions of questions. For example, in addition to “heart disease,” type in “coronary artery disease” or “arteriosclerotic cardiovascular disease;” in addition to “schizophrenia,” type in “psychosis” and “conditions associated with psychosis” and “how common is new onset of schizophrenia in someone with dementia?”
As another example, behavior and psychiatric side effects of nonpsychiatric medications are very common. Suppose the facility’s staff and practitioners don’t know or don’t believe that some of the medications that a resident is taking could be causing agitated or combative behavior as a side effect.
Typing in “drugs that may cause psychiatric symptoms” will yield a large number of sites and articles related to adverse drug consequences, including those that may cause problematic behavior and psychiatric symptoms as a side effect.
Despite the current obsessive focus on a single category of medications (antipsychotics), medications in multiple categories (for example, drugs for Parkinson’s disease, cardiac conditions, and seizures) have a huge impact on behavior, mood, and cognition.
This search will even lead to a Medical Letter issue entitled, “Drugs That May Cause Psychiatric Symptoms.” This is a very handy reference that is relevant to essentially all 1.5 million residents of nursing facilities nationally.
Or, for example, suppose there is a resident in the facility who is constantly in motion, cannot seem to hold still, appears very restless, and always wants to stand up and move. This is actually a relatively common scenario, which most staff tend to call “anxiety.”
Typing the word “restlessness” into Google gives various results, including anxiety disorders and “restless legs.” But typing the words “motor restlessness” will lead to the word “akathisia” coming up. Then typing the words “akathisia signs and symptoms” will bring up a whole world about different kinds of movement disorders, many of which have little to do with anxiety and restless legs.
Examples of other searches might include “causes of motor restlessness” and “is akathisia the same as anxiety?”
Further exploration of “movement disorders” will show that there are several categories of movement disorders, including dyskinesia, tremors, myoclonus, and others. Additionally, it will show that akathisia and dyskinesia can be side effects of medications.
Sharing the Information
Sixth, save or print search results and use the information to improve care and overall quality. Read it carefully, and share it with practitioners, both generally and in relation to specific cases. Disseminate the information widely to the interdisciplinary team.
There are several ways to save search results. One way is to print the results directly to a printer. Using Adobe Acrobat or Adobe Acrobat Reader, it is possible to print to a PDF file. The Windows search function and other software (for example, dtSearch) can be used to index and search files to facilitate finding the file or its contents subsequently.
This is an excellent way to engage practitioners and to demonstrate that the facility staff and management are interested in finding the answers to challenging clinical issues. Medical practitioners are not necessarily aware of the literature or the more subtle details of medication indications and side effects. It can also be a good way to encourage reluctant practitioners to acknowledge the need for rethinking challenging clinical situations when the resident or patient is not doing as well as anticipated or appears to be declining despite treatment.
Doing searches is a very democratic process. All members of the interdisciplinary team can do it, both for their own education and as a way to contribute to the care of individual residents.
However—as with all information from any sources—a capable medical practitioner must interpret and determine its relevance to a specific clinical situation. It may help to first review information with the medical director, who can guide the interdisciplinary team about its relevance and how best to share the information with the attending practitioners.
Use the information to establish or modify policies and procedures regarding care-related topics. During the survey, it can also be helpful to show relevant information to the surveyors to justify appropriate interventions.
Seventh, understand what makes a site reliable. The Internet is a mixed bag of resources that range from very reliable to highly unreliable. Using unreliable information can put patients at risk by leading to incorrect conclusions and inappropriate interventions.
In general, reliable websites include those of government agencies, academic centers, and reputable professional organizations such as the Society for Post-Acute and Long-Term Care Medicine, American Geriatrics Society, and the American Society of Consultant Pharmacists. They provide citations of references, resources, and other websites where users can confirm what they have been told.
Practice Makes More Perfect
Searching knowledge bases takes some skill and a lot of practice, but it is good practice because every search can potentially be of use. In addition, learning to search effectively can help providers learn to interpret and apply information correctly.
The deeper they look and the more they explore, the more Google can improve precision in observing, documenting, reporting, and identifying causes of various symptoms in residents and patients. In turn, the end result is likely to be much more targeted interventions leading to much more person-centered care—not to mention saving lives.
This approach has worked very well in the author’s facilities, as it has helped establish a strong facility culture in which all staff and practitioners are open to seeking and sharing information that can be applied to improve patient care.
An organized process of obtaining, sharing, and critiquing information can also help the interdisciplinary team make its care plans and nonmedical approaches more person-centered.
After all, there is far too much to know and remember. Both staff and practitioners need reliable and relevant sources of information to support treatment and care decisions. They need an easy, effective, and reliable way to find information on demand. They cannot rely on memory alone and should not rely excessively on the limited information available in the Omnibus Budget Reconciliation Act of 1987 regulations or the personal opinions and limited perspectives of various interdisciplinary team members or even practitioners.
Google is one of the keys to self-reliance for all nursing facility staff, management, and practitioners. In an era when everyone is expected to know more and do more, there is a whole world of knowledge available to providers. It is to their advantage to apply it in their everyday practice.
Steven Levenson, MD, CMD, is the regional medical director for Kentucky and Tennessee for Genesis HealthCare, as well as a facility medical director and attending physician for several facilities in Maryland.