Prehab Program’ can slow down functional decline in geriatric patients
Here’s how to create a healing environment
[Editor’s note: The following model was one of four recommended by Nurses Improving Care to the Hospitalized Elderly (NICHE), a national initiative designed to help hospitals prepare for the nation’s burgeoning aging population. For more information on other NICHE models, see the January issue of Patient-Focused Care and Satisfaction.]
Unless acute care facilities provide an innovative setting for interdisciplinary geriatric care, they may inadvertently worsen outcomes for elderly patients and increase lengths of stay, says Denise Kresevic, RN, CS, PhD, clinical nurse specialist at the University Hospitals of Cleveland.
Kresevic is one of the developers of a model called Acute Care of the Elderly (ACE) that uses appropriate environmental design and interdisciplinary patient-focused care to prevent or reduce the 40% incidence of functional decline among frail hospitalized elders.
"Many older patients never regain the level of independence they enjoyed before the acute episode," she says. "They have diminished homeostatic reserves and multiple co-morbidities; their bodies are simply not able to cope with the very elements of hospitalization."
For example, cluttered hallways might discourage independent ambulation and contribute to the risk of falls, while raised beds make getting up and down risky and difficult, she explains.
In addition to the depersonalized institutional environment, the process of care itself may contribute further to the elderly patient’s decline. "For many of them, enforced bedrest leads to deconditioning and loss of muscle mass and vascular tone. It begins the cascade of functional decline often observed in the first two days of hospitalization," explains Kresevic. A change in diet or inadequate caloric intake can exacerbate the problems of an already undernourished elder and result in partial starvation, while medications may cause delirium or cognitive dysfunction.
Lack of interdisciplinary care, including a comprehensive assessment and interventions for typical geriatric problems such as delirium, incontinence, and pressure ulcers, also contribute to a rapid decline, she adds.
To counter the debilitating effect of typical hospitalization on the elderly, the 30-bed geriatric unit at Cleveland Hospital was designed with the special needs of elders in mind, she says.
"Our goal with the renovation was to prevent functional decline," says Kresevic.
For example, the patients’ rooms are painted with soothing soft colors instead of the usual bland institutional shades. Automatic night lights on low beds make toileting easier. Levers, rather than doorknobs, encourage access to bath and hallway. Bathroom doors are large enough to accommodate walkers, and showers include a bench. Recliners offer an alternative yet comfortable place to rest, and large clocks and calendars on the walls help patients stay oriented. In the corridors, carpet with geometric designs helps patients pace their ambulating, and benches placed strategically along the hallway allow patients to stop and rest.
"These simple design elements can help allay the often disorienting and depersonalizing effects of an unfamiliar institutional environment," points out Kresevic. "We recognize that the hospitalization not the illness may be the deciding factor in the functional ability of the frail elder at discharge."
Not just another pretty face
But an elder-friendly environment is just one component of ACE. Without emphasizing the process of care itself, the model could not prevent or reduce decline among hospitalized elders, she stresses.
The interdisciplinary team a clinical nurse specialist, a geriatrician, social worker, nutritionist, and physical therapist are at the heart of this model, she adds. "We hand-picked the original members of the team so we could all start with a clean slate," she says. "We looked for experience in rehab, geriatrics, but also for those who had an appreciation for other disciplines."
Kresevic explains the elements of the "Prehab Program" that allow staff to tailor care to individual patients’ needs. They are:
1. Multidisciplanary assessment and discharge planning.
Upon admission, the care team assesses each patient for the following:
• bathing/dressing;
• mobility/transferring;
• toileting/continence;
• feeding/nutrition;
• skin care/wound;
• falls;
• depression;
• delirium.
These categories form the basis of nurse-initiated guidelines. "They specify preventative and restorative measures designed to foster as high a level of ADL (Activities of Daily Living) status as possible at discharge.
A quick checklist also provides daily evaluation of these items and reduces the need for time-consuming handwritten summaries. "The checklist also serves as documentation of changes in the patient’s functional status during the preceding shift and triggers an evaluation on the current shift," Kresevic explains.
Team members review the patient’s initial assessment during team rounds and channel recommendations through the patient’s primary nurse, who in turn communicates with the nurse on the subsequent shift.
For example, the dietitian may recommend a late night snack for the malnourished patient, or the physical therapist might recommend a walker for a patient who is at risk of a fall.
"In the ACE model, it’s important to note that the team doesn’t meet because there is a problem; it meets to keep problems from coming up," she stresses. "We also meet regularly as a reminder that we are all working toward the same goal."
Typically, 10 patients are discussed in rounds that take about half an hour, she says.
The clinical nurse specialist also reviews the functional status of each patient the following morning and provides bedside consultation and role-modeling for staff nurses and aides. The skill mix at University Hospitals is about 60% to 70% RNs, she notes.
2. Medical care review.
In addition to regular assessments of functional status, the team conducts a medical review to prevent iatrogenic complications of common diagnostic and therapeutic procedures such as utilization of medication and physical restraints.
The medication guidelines for prescribing psychotropics are based on principles of drug management in the elderly: A low starting dose, subsequent incremental doses, and a final threshold dose. "The threshold dose is the usual maximum dose of medication used in elderly patients above which the risk of an adverse drug event rises to an unacceptable level," she says.
Restraints are also used cautiously. "They are applied only when other less restrictive measures have been tried and are not adequate," she says. Before using a restraint, we discuss the reason with the patient, family, and physician and then use it for the shortest possible time." The indications are reviewed on each shift as well as each team daily meeting.
To minimize the risk of morbidity from diagnostic procedures, the model also stipulates protocols for those procedures performed on and off the ACE unit. "We use small tubes for venipunctures. We review fluid and nutritional status of each patient before administering cathartics or other bowel preparation orders. We also check nutritional status and vital signs after the diagnostic procedure," she explains.
In fact, frequent nutritional assessment and intervention can’t be overemphasized, she says.
"Food and fluids are among our most important medicines," she notes. "We have a kitchen on the unit that is open 24 hours, and we keep it well equipped with comfort foods like ice cream, toast, mashed potatoes, and, of course, chicken soup."
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