Transcript Nurses Improving Care of Health Systems Elders

NICHE
Nurses Improving Care of
Health System Elders
The SPICES Tool
February, 2011
Rita LaReau MSN GNP BC
Geriatric Clinical Nurse Specialist
Bronson Methodist Hospital
[email protected]
Learning Objectives
Upon completion of this program the
learner will be able to:
•
Describe a basic assessment tool for
assessment of the geriatric patient.
•
State demographics related to falls in
older adults.
•
State interventions to prevent a fall.
Older Adult Patients
 Older Adult Patients > age 65
 Challenge to health care providers
 Numerous & complex diagnoses
 Shorter hospital stays
 Navigation through hospital process
 Potential for cascade of poor outcomes
Hartford Institute
 Nurses Improving Care for Health System




Elders (NICHE) 1992
Sponsored by John A. Hartford Foundation
Institute for Geriatric Nursing
@ New York University
National nursing led initiative: Nationally
Recognized Nursing Leaders
Currently over 200 NICHE sites
Geriatric Resource Nurse (GRN) Model
NICHE Outcomes
 Enhance Nursing Knowledge and Skills




Regarding the Treatment of Common
Geriatric Syndromes
Increase Patient Satisfaction
Decrease Length of Stay
Reduce Readmission Rates
Reduce Costs Associated with Elder Care.
Evidenced Based Practice
 Research based protocols that focus
specifically on common geriatric care
syndromes
 Reflect current research and standards
including those developed by The Agency For
Health Care Policy Research (AHCPR)
 Accessible and usable by bedside nurses
Evidenced Based Resources
 http://nicheprogram.org
 http://www.consultgerirn.org
 Hartford Institute Protocols Book
 Evidenced Based NICHE Tools: Handout
Geriatric Syndromes
 Physical Restraints
 Depression
 Pressure Ulcers
 Incontinence
 Sleep Disturbances
 Eating/Feeding
 Advance Directives
 Acute Confusion/
 Pain Management
Delirium
 Medication Management
 Falls
 Discharge Planning
 Assessing Cognitive
Function
 Functional
Assessment
Bronson NICHE Program
NICHE Program
 Geriatric Independent Study Modules
 NICHE AGEducation Day (8 hours)
 Support for Gerontological Nurse Certification
NICHE Clinical Support
Geriatric Resource Nurse (GRN) Program
 Geriatric Clinical Nurse Specialist (GCNS)
 Certified GRNs
 GCNS supports GRNs in their new roles
– Instruction
– Nurse-to-Nurse Consultation
– Resource Development
– Geriatric Clinical Excellence
 Assesses selected geriatric patients in context
of geriatric syndromes
GRN Rounding/Consult
 Assist staff in assessing, planning,
implementing, and evaluating geriatric care
according to SPICES Tool
 Evaluate and provide feedback to staff
regarding SPICES Tool assessments and
interventions
 Augment staff knowledge and attitudes as
they relate to geriatric care.
GRN Rounding/Consult
 Disseminate information about geriatric
care management through a variety of
ways including
– Documentation
• Progress Notes
• CareGraph
 Collaborate with NICHE Council and
other resource people as necessary.
SPICES Tool
GRN Core Screening Tool
– Raises awareness and triggers
further evaluation & documentation
Skin Impairment
Poor Nutrition
Incontinence
Confusion
Evidence of Falls
Sleep Disturbances
Geriatric Assessment
Rounding
GRNs
 Use SPICES Tool for assessing patients > age 70
– Problems with
• Skin
– Skin Integrity Score < 18 (Braden Tool)
• Problems with Eating
– Less than 80% ideal Body Weight
– % food eaten < 25% > 6 days (25% > $
days (80+ Yrs)
• Incontinence
– Stress/Urge/Functional/Diarrhea/Foley
Geriatric Assessment
Rounding
• Cognition
– Mini-Cog, Geriatric Depression Scale (GDS)
– Positive Confusion Assessment Method (CAM), Anxiety
– Sensory Impairment
– Evidence of Dementia, Depression
• Evidence of Falls
– Confusion, Depression, Elimination, Dizziness, Gender,
Antiepileptics, BZD, Mobility/Get Up and Go
• Sleep
– Difficulty falling/ staying asleep
– Sleep promotion interventions
Reasons for Geriatric
Resource Nurse Consult
Some potential reasons for consult:

Delirium

Dementia

Sitter

Falls

Sleep Problems

Problems with eating

Use of Diversional Activities
Evidence of Falls/Function
What Do These People Have
in Common?
 Laura Ashley (Fashion Designer)
 Robert Atkins (Doctor)
 George Washington Carver (Inventor)
 Genghis Khan (Royalty)
 Robert Peel (Head of State)
 Kurt Vonnegut (Author)
 William the Conqueror (Royalty)
 Malcolm Baldrige (Politician)
Cause of Death:
Accidental Fall
Why Do We Need to Be
Concerned?
 Injuries
 Deaths
 Associated complications
 Costs
Demographics
 Community-dwelling persons >
65 years:
– 30% - 40% fall each year
 Hip fractures:
– 90% result from a fall
– 20% die within one year
 Leading cause of death from
injury in those > 65 years old: A
fall
Demographics
 Falls are associated
with:
• Decline in functional
status
• Development of “fear
of falling”
• Greater likelihood of
nursing home
placement
Cost of a Fall
 Costs associated with fall-related
injuries in persons > 65 years old:
• Mean hospital cost: $15,938
• Lifetime costs: $12.6 billion
Fall - Defined
 Fall: A fall is an unplanned
descent to the floor ( or extension
of the floor, e.g., trash can or
other equipment) with or without
injury to the patient.
 All types of falls are to be
included whether they result from
physiological reasons (fainting) or
environmental reasons (slippery
floor).
Fall - Defined
 Include assisted falls – when a staff member
attempts to minimize the impact of the fall.
 Included in this definition are patients found
lying on the floor unable to account for their
situation.
Fall Prevention: All
Patients
Orient patient to environment
Educate patient/family using:
– The Fall Prevention Scripting
• Use TeachBack
– Prevent Falls in the Hospital handout
– Both located on the Nurses and Clinician’s
page under Fall Prevention Resource Tools
Orient to ‘Call to Stop a Fall’ sign
Maintain call light in reach and assess/ensure
ability to use.
Fall Prevention: All Patients
(1)
 Place bed in low position and lock
 Utilize non-slip well-fitted
footwear
 Leave bathroom or night light on
 Wipe up spills immediately
 Arrange furniture/objects safely
 Place patient items in reach
Fall Prevention: All
Patients (2)
 Teach transfer techniques prn
 Assist in meeting elimination needs
 Evaluate potential medication side
effects
 Assure ambulation as ordered
 Encourage use of handrails in
bathroom and hall
Fall Prevention: All Patients
(3)
 ROM BID by nursing staff if not out of
bed
 Keep assistive devices (glasses, canes
walkers etc.) at bedside within reach
 Evaluate patient’s ability to interpret
information (Can they hear, feel and
interpret? Need hearing amplifier or
hearing aides?)
 Utilize upper 2 of 4 side rails in raised
position, to maintain freedom of
movement
Hendrich II Fall Risk Model
 Fall Risk Assessment Tool used at
Bronson
 Identifies patient risk factors that
contribute to fall potential.
Hendrich, A., Bender, P., Nyhuis A., Validation of the Hendrich II Fall Risk Model: A Large Concurrent
Case/Control Study of Hospitalized Patients. 2003. Applied Nursing Research (16) 1, pp 9-21
Risk Factors Hendrich II
Fall Risk Model
•Confusion/Disorientation/
Impulsivity (4)
•Depression (2)
•Altered Elimination (1)
•Medications:
•Any Administered
Antiepileptics (2)
•Any Administered
Benzodiazepines (1)
•Gender (1)
•Dizziness/Vertigo (1)
•Unable to rise in a
single movement
•Get Up and Go Test)
(0-4)
Fall Risk Interventions
Fall Watch Option
 ‘Fall Watch’ Option: Reserved for
patients who require intensive
surveillance.
 ‘Fall Watch’ Criteria:
•
•
Non-compliance of fall precautions
Impulsive or lack of safety
awareness
•
Discretion of nurse
Fall Watch Option
 A magnetic Fall Watch sign is
placed on the door frame of any
patient identified as high risk.
 When passing by that patient room,
all hospital employees are to look
into the room to observe if the
patient is safe.
Fall Watch Option
 If safe, employees continue on their
way.
 If patient is at risk, the employee is to
maintain patient safety and put on the
call light for assistance.
 ‘Fall Watch’ is the responsibility of
everyone on the unit to ensure patient
safety.
 Keep room doors and curtains open.
Community:Interventions to
Consider
 Cardiac evaluation
 Vision improvement
 Home safety modifications
 Medication reduction
 Physical Therapy
 Exercise

Tinetti ME, Kumar C. The patient who falls: “It’s always a trade-off. JAMA 2010 Jan 20;303(3):258-66
Bronson Intranet Handouts
Questions?
NICHE
Nurses Improving Care of Health
System Elders
The SPICES Tool