Optimizing Elder Friendly Approaches to Acute Care

1. Optimizing Elder Friendly Approaches to Acute Care Patricia A. Ford, RN-EC, MHSc, GNC(C) Susan Ritchie, RN, MN Tarrah Long, RN, MEd Ida Porteous, RN, BScN

2. Purpose • To share our experiences introducing and influencing senior friendly practices within our tertiary acute care teaching hospital

3. Overview • Background • Observational Studies • Learning Activities • Evaluation • Follow-up Study

4. BackgroundInternal Influences • Organizational consultation on corporate geriatric needs (2008) • Closure of Geriatric Assessment Unit (GAU) • Enhancement and spread of the Geriatric Consultation Service • Establishment of Corporate Geriatric Steering & Advisory Committee • Focus on quality & patient safety

5. External Influences • Aging at Home Strategy - 2007 • Aging at Home - 2008 focused on flow, ED wait times and reduced ALC • Provincial ALC Initiatives

6. Under the Lens: • Emergency Department Observational Study, 2009 • Evaluation of Standard Care of Older Persons in General Internal Medicine: an Observational Study, 2010

7. Research Design • A direct observational study • Concurrent chart audits were conducted on all patients 70 years of age and over • Emergency Department (2009) • General Internal Medicine (2010)

8. Methodology Data Collection Format 4 week period Randomized days, times Level 4 BScN students • Life Space assessment tool (Stalvey, 1999, Parker, 2001) • Spices Tool (Fulmer, 2007)

9. Data Collection Tool • Current cognition • Baseline cognition • Baseline mobility • History of falls • Life Space Assessment score • Activity in department • Food and fluids

10. Data Collection Tool con't • Family/visitor support • Sleep/rest • Skin breakdown present • Preventive skin care • Toileting • Mastery of the environment • Call bell

11. Results ED, 2009 GIM, 2010 83% Home Catheter use = 30% (56% met criteria for appropriate use) 36% = independent mobility (LSA=3) Falls History = 25% • 80% Home • Catheter use = 53% • 51% Independent (LSA=3) 74% Bedrest • Falls History = 11% • 18.6% known to CCAC

12. Combined Recommendations From ED Study, 2009 From GIM Study, 2010 Advocate for early ambulation by Nurses Standardize admission history to obtain patients’ baseline function to enable accurate goal setting to facilitate discharge planning Reduce the use of indwelling catheters as means of reducing morbidity due to CAUTIs Promote the use of BPG –Promoting Continence Improve patient/staff satisfaction levels with less deconditioning • Conduct follow up study on GIM to examine extent of issue with admitted patients over the age of 70. • Implement strategies to reduce catheters, prevent CAUTIs and promote continence • Audit Length of time in bed from admission to first time up. • Patient – family education /involvement about strategies to prevent delirium.

13. Next Steps Corporate Wide Knowledge Transfer Medical Grand Rounds Development of Nursing Educational Event (Nursing Enhancement Funding) focused on frailty and hazards of hospitalization • Disseminate results to Geriatric Steering Committee • Recommend and obtain support for enhanced learning • Nursing retreat with focus on Infection (CAUTIs) and falls prevention • Development of working groups

14. Learning Activities • Delivered as part of a strategy to improve the organization’s capacity to provide quality care for the elderly • Planning committee included director, program managers (medicine and surgery) , 2 Advanced practice nurses & nurse educator

15. Recruitment • Front line nursing staff were identified as key stakeholders and potential change agents in improving elder care • Areas identified as high risk, or high elder population were targeted • General Internal Medicine • Nephrology • Surgical Programs

16. Participants • Registration forms were provided to nurse managers and nurse educators • Attempt to include those identified as strong leaders who impact care • Open invitation to any nursing staff who were interested in the program • Preliminary readings were provided

17. Curriculum Development • Identification of content as identified in 2 projects • Theoretical framework – PARIHS Model • Format

18. Topics Covered • Intro to Elder-friendly care and HNHB LHIN Home First Initiative • Early assessment and prevention of delirium in the elderly • Prevention of deconditioning in the elderly, functional assessment and mobility • Promotion of continence • Role, support and inclusion of family

19. PARIHS FrameworkRycroft-Malone, 2004 • Dynamic balance between the implementation of evidenced –informed practice • within the unique context of a setting • with facilitators who support clinicians to their change practice through the identification of their learning needs by guiding the group process to encourage critical thinking and evaluation of the achievement of learning goals

20. Educational Format • Overview of topics provided in an interactive didactic format; encouraging unit specific examples • Small group work in program-specific groups, to identify feasible, realistic interventions that could be implemented on units to improve elder care • Planned Follow-up Focus group

21. Evaluation Measures • Pre-test based on the NICHE - GIAP Environmental Scan • Workshop evaluations • Focus Groups at 6 months • Follow-up GIM Study, 2011

22. Workshop Evaluation • 51/ 53 attendees submitted evaluation forms • 96% of respondents agreed that the program content was applicable to their practice setting • 100% of respondents agreed that the program was worthwhile, furthered learning, identified new elder friendly strategies

23. Evaluation – New Knowledge • Dementia and delirium: assessment, prevention, interventions • Confusion Assessment Method (CAM tool) • Reassess/discontinuation of Foley catheters • Deconditioning of the elderly • Mobility assessment and interventions • Importance of family communication, teaching and engagement in care

24. Focus Groups • 6 months post-intervention • 3 sessions • 10 staff attended • Successes and barriers

25. Focus Groups – Successes Individual Nurse Initiatives • Mobilizing patients more frequently • Chair for meals • Sink to wash • Discussing expectations for mobility with patient and family • Advocating for foley catheter removal

26. Successes – continued Unit-based Initiatives • Increased attendance at lunch program in dining room on rehab unit • Musculoskeletal unit • Delirium assessment cards provided to staff • Elder friendly bulletin board • Working on pre-printed orders so that everyone with a fractured hip will get a geriatric consultation

27. Focus Group - Barriers • Equipment – availability of chairs and commodes • Recreation activities for patients • Snacks • Time constraints • Continuity of care • Isolation

28. Reflections “It’s nothing new or different. It depends on patient load.” “Now that we know it, makes us feel guiltier.”

29. Follow-up Study Population Inclusion criteria Description 117/202 = 57.9% of all medical admits were over age 65 50 lost to inclusion* n = 67 (57.3% of all seniors admitted to GIM) 28 male & 39 female average age = 81.7 years • admitted to one of four internal medicine units at SJHH • 65 years of age or older • Charts were reviewed over a four-week period (4 weeks = 48 hours)

30. Follow-up Study Methodology • Same tools for Data collection to enable comparison (SPICES and LSA) • Included Yes/No question about attendance at workshop • Qualitative content asking how and if it influenced their practice

31. Rate of UTI Occurrence

32. Distribution of Catheter Days

33. Mobility in Hospital, 2011

34. Impact of Education on Nursing Practice ,2011

35. Impact of Education on Nursing Practice2011 • 25% of nurses surveyed had received the education • 6 Themes emerged: • increased ambulation • increased preference for intermittent catheterization • decreased time to first ambulation • increased use of continence training • decreased length of catheter in situ • avoided unnecessary use of indwelling catheter  

36. Change in Practice

37. Ripple Effects • Geriatric Advisory Retreat • LHIN Senior Friendly Survey

38. Contact Us pford@stjoes.ca sritchie@stjoes.ca