NICHE project helps improve geriatric outcomes
Are you prepared for the aging baby boom?
Despite the fact that patients who are 65 years and older make up about half of hospital admissions and account for two-thirds of all hospital days, few hospitals have specific programs to meet the care of their elderly patients, and many nurses have little exposure to principles of geriatric nursing.
"As a result, frail elders often experience preventable complications of hospitalizations such as falls or adverse drug reactions that can increase morbidity and mortality," says Terry Fulmer, PhD, RN, FAAN, a professor of nursing at New York University. (See story on Fulmer’s pain management protocols, p. 3)
Also contributing to longer lengths of stay and increased costs are common geriatric syndromes such as incontinence and pressure ulcers.
But a project funded by the John A. Hartford Foundation called Nurses Improving Care to the Hospitalized Elderly (NICHE) can help hospitals prepare for the country’s burgeoning aging population. (See related story on upcoming NICHE training conference, p. 11.)
By assessing staff perceptions through an institutional assessment profile, nursing practices can then be modified with models tested by geriatric leaders, explains Melissa Bottrell, MPH, NICHE project director.
The project’s pilot sites reported shorter hospital stays, reductions in urinary tract infections, decreased severity and incidence of delirium, and reductions in iatrongenic complications, she says.
Yet the project does not prescribe how hospitals should go about reorienting themselves to geriatric care but rather "provides materials and services that stimulated and supported the effort," says Bottrell.
For example, its Geriatric Institutional Assessment Profile is a 69-question self-administered survey designed to assess the following:
• attitudes regarding care of the elderly;
• knowledge of institutional guidelines for care of the elderly;
• knowledge of best practices of four common geriatric syndromes;
• perceived institutional barriers to "best practice" for care of elders.
"We wanted to get a sense of where our deficits or misperceptions were and in what direction we should move" says Deborah Francis, RN, gerontological nurse specialist at University of California Davis in Sacramento, one of the eight facilities selected to pilot the program. "For example, we discovered we really needed to work on the way we exchanged information about geriatric care among staff."
Concurrent with the assessment, Francis also heavily marketed the NICHE project to nurses with memos, posters, and fliers. "We handed out label pins that said, Have you found your NICHE?’" she says.
Next, the project calls for selecting one of the four NICHE nursing models most suited to an individual hospital’s setting, needs, and available resources, Bottrell says.
UC Davis selected the Geriatric Resource Nurse (GRN) Model. On selected medical and surgical floors, two to four GRNs act as bedside nurses and as consultants and role models for other nurses, explains Fulmer who developed the model while at Yale New Haven (CT) Hospital.
"These nurses are regular staff nurses who have demonstrated an interest in the care of the elderly," Fulmer says. "They do not have to be masters prepared with a specialty in gerontological nursing."
Yet they receive extensive inservice from the institution’s gerontological nurse specialist as well as NICHE. The GRNs also meet monthly for a geriatric nursing interest group to discuss challenges and solutions of elder care.
As part of their educational outreach to other nurses and staff, GRNs use a simple mnemonic device called SPICES to remind coworkers of the following six conditions that serve as markers for a functional decline:
S kin impairment such as pressure ulcers.
P oor or undernutrition.
I ncontinence (fecal or urinary).
C onfusion such as delirium or dementia.
E vidence of falls or functional impairment such as assistance in one or more activities of daily living.
S leep disturbances including insomnias, hypersomnias, and disrupted sleep-wake cycles.
The acronym SPICES doesn’t directly contain all the common geriatric problems, says Fulmer who developed the concept. But it still can serve as an effective triggering device for raising awareness and documenting conditions, she explains.
"For example, it doesn’t specifically mention depression, yet it reminds nurses to look for changes in sleeping or eating patterns, which can be a symptom of depression," she adds.
Fulmer also explains that keeping the concept short was intentional. "Staff told us they wanted a concise model they could remember quickly and easily," she says.
By reminding nurses to document instances of these conditions, GRNs are also helping them to shift their thinking about the total quality of geriatric care, not just the DRG, points out Fulmer.
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