Veronica Armas

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Evidence-Based Practice in Geriatric Care

• Veronica Armas
• Janet Knappier
• Candace McNeese
• Sara Ralph
• University of Oklahoma
• College of Nursing
• Spring 2009

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Identification of the Problem
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PICO QUESTION

• In the hospitalized patient age 65 years or
  older, what is the effect of the NICHE model of
  care on patient outcomes compared with a
  non-NICHE model of care?

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Evidence from Literature

• According to the U.S. Census Bureau News, the
  projected population of people 65 and older in
  2050 will be 85.5 million.
• From 2002-2027, inpatient acute care admissions
  are expected to increase 78 in those aged 65 and
  older and 16 in those aged 64 and younger.
• The U.S. Administration on Aging projects that
  more than 20 of the population will be aged over
  65 years by year 2030.

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Evidence from Literature

• Older adults comprised 50 of hospital patients,
  70 of home care patients, and 90 ambulatory
  patients.
• Functional decline in the elderly leads to
  prolonged lengths of stay, increased hospital
  costs, and frequent nursing home placement.
• Physical environment and delivery of care
  contributes to the functional decline of elderly
  patients.

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Information Regarding the Problem

• Chronic illnesses, age related changes, and
  impaired functional status intensify throughout
  hospitalization.
• Appropriate resources for the complex needs of
  older patients may be lacking.
• Healthcare professionals often lack the knowledge
  to provide the necessary individualized geriatric
  nursing care.

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Information Regarding the Problem

• Fewer than 1.3 million professional nurses
  working in hospitals have received educational
  preparation in geriatrics.
• Hospitalized elderly patients use more resources
  and have higher charges and longer stays than any
  other age group.
• Adults aged 65 years and older use 48 of the
  nations total healthcare resources.

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Review of Literature
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Study of the Problem

• The John A. Hartford Foundation Institute for
  Geriatric Nursing
• Nurses Improving Care for Healthsystem Elders
  (NICHE)
• Geriatric Resource Nurse Model (GRN)
• Geriatric Syndrome Management Model
• The Acute Care for the Elderly Model (ACE)
• Comprehensive Discharge Planning/Quality Cost
  Model of Transitional Care

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Pros for Patients

• Increased patient satisfaction
• Improved functional status
• Decreased iatrogenic illnesses

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Pros for Patients

• Decreased restraint use
• Decreased discharges to long term care facilities
• Improved continuity of care

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Pros for Providers

• Increased collaboration and staff satisfaction
• Improved geriatric practice knowledge
• Improved nurse competency in providing safe
  patient care

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Pros for Hospital

• No significant difference in hospital costs
  between a NICHE model of care and a non-NICHE
  model of care
• Decreased length of stay and readmission rate
• Reduced nursing staff turnover
• Potential use of a NICHE model of care in other
  areas of the hospital unrelated to geriatrics

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Cons

• Cost to implement the program
• Initial set-up expenses
• Need for additional staff members
• Education of current staff members on geriatric
  care
• Finding healthcare workers interested in working
  with the geriatric population

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Research Critiqued

• Study by Palmer, Landefeld, Kresevic, and Kowal
  (1994)
• 655 patients aged 70 years and older admitted for
  acute medical illnesses
• ACE Unit vs. Usual Care Unit
• Findings
• Independent physical functioning declines during
  hospitalization.
• The intervention unit improves independent
  functioning of patients.
• Less evidence was found to support the use of
  acute care medical units for geriatric patients.

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Research Critiqued

• Study by Landefeld, Palmer, Kresevic, Fortinsky,
  and Kowal (1995)
• Randomized trial of 651 patients aged 70 years
  and older
• ACE Unit vs. General Care Unit
• Findings
• Improved performance of ADLs was revealed in the
  intervention group.
• Fewer discharges to long term care were found for
  the intervention group.
• Length of stay was shortened by one day for the
  intervention group, and the hospital charges were
  similar for both groups.

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Research Critiqued

• Study by Counsell, Holder, Liebenauer, Palmer,
  Fortinsky, Kresevic et al. (2000)
• Randomized controlled trial of 1,531 patients
  aged 70 years or older admitted for acute medical
  illnesses
• ACE Unit vs. Usual Care Unit
• Findings
• ADL decline in the intervention group following
  discharge was less than the usual care group.
• There was no significant difference in length of
  stay, readmission rate, or cost.
• A higher satisfaction rate was reported among
  patients and staff in the intervention group.

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Research Critiqued

• Study by Swauger and Tomlin (2002)
• Elderly patients 65 and older admitted to Forsyth
  Medical Center in Piedmont, N.C.
• Implementation of Together We Improve Care of the
  Elderly (TWICE)
• Findings
• Reduced length of stay by one day was found.
• There was a decreased incidence of nosocomial
  infections.
• Restraint use was decreased.

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Recommended Protocols, Procedures, and
Interventions
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Recommendations

• Environment geared towards geriatric patients
• Patient-centered care
• Pre-planning for discharge preparation
• Assessing and educating healthcare professionals
  to be knowledgeable in geriatric care
• Review of medical care

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Evaluation

• Improved ability of patients to perform ADLs at
  the time of discharge
• Reduced frequency of discharges to long term care
  facilities
• No added expense to the hospital
• Increased patient and staff satisfaction

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Suggestions for Further Study
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Other Approaches to Studying the Problem

• Implement NICHE models of care in nursing homes
• Perform follow-up studies after patient discharge
• Improve patient/family education

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New Emerging Research Questions

• How can a NICHE model of care be applied to other
  areas within the hospital?
• How can we encourage and influence nurses to
  pursue further education in the specialty of
  geriatrics?
• How will collaboration with nursing facilities
  and agencies in the community impact healthcare
  delivery and successful continuity of care?

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References

• Barba, B., Tesh, A., Kohlenberg, E. (2007).
  Recognize the many facets of gerontological
  nursing. Nursing Management, 38(1), 36-41.
• Boltz, M. Harrington, C. (2005). Nurses
  improving care for health system elders (NICHE).
  American Journal of Nursing, 105(5), 101-102.
• Callahan, E., Thomas, D., Goldhirsch, S.,
  Leipzig, R. (2002). Geriatric hospital medicine.
  Medical Clinics of North America, 86, 707-729.
• Counsell, S., Holder, C., Liebenauer, M., Palmer,
  R., Fortinsky, R., Kresevic, D., et al. (2000).
  Effects of a multicomponent intervention on
  functional outcomes and process of care in
  hospitalized older patients A randomized
  controlled trial of acute care for elders (ACE)
  in a community hospital. Journal of American
  Geriatrics Society, 48(12), 1572-1581.
• Covinsky, K., King, J., Quinn, L., Siddique, R.,
  Palmer, R., Kresevic, D., et al. (1997). Do
  acute care for elders units increase hospital
  costs? A cost analysis using the hospital
  perspective. Journal of the American Geriatrics
  Society, 45(6), 729-734.
• Covinsky, K., Palmer, R., Kresevic, D., Kahana,
  E., Counsell, S., Fortinsky, R. et al. (1998).
  Improving functional outcomes in older patients
  Lessons from an acute care for elders unit. Joint
  Commission Journal on Quality Improvement, 24(2),
  63-76.
• Foreman, M., Kresevic, D., Mion, L., Naylor, M.,
  Cesta, T., Vince-Whitman, C., et al. (1994).
  Geriatric models of care Which ones right for
  your institution? American Journal of Nursing,
  21-23.

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References

• Landefeld, S., Palmer, R., Kresevic, D.,
  Fortinsky, R., Kowal, J., et al. (1995). A
  randomized trial of care in a hospital medical
  unit especially designed to improve the
  functional outcomes of acutely ill older
  patients. The New England Journal of Medicine,
  332(20), 1338-1344.
• Lopez, M., Delmore, B., Ake, J.M., Kim, Y.,
  Golden, P., Bier, J., et al. (2002).
  Implementing a geriatric resource nurse model.
  Journal of Nursing Administration, 32(11),
  577-585.
• Mezey, M., Mia, K., Grossman, S., Firpo, A.,
  Fulmer, T., Mitty, E., et al. (2004). Nurses
  improving care to health system elders (NICHE)
  Implementation of best practice models. Journal
  of Nursing Administration, 34(10), 451-457.
• Mezey, M., Quinlan, E., Fairchild, S. Vezina,
  M. (2006). Geriatric competencies for RNs in
  hospitals. Journal for Nurses in Staff
  Development, 22(1), 2-10.
• National Guideline Clearinghouse. (2008).
  Assessment of function. In Evidence-based
  geriatric nursing protocols for best practice.
  Retrieved March 8, 2009, from http//www.guideline
  .gov/summary/summary.aspz?ss15doc_id12259nbr0
  06343stringNICHE
• Palmer, R., Landefeld, S., Kresevic, D., Kowal,
  J. (1994). A medical unit for the acute care of
  the elderly. Journal of American Geriatric
  Society, 42(5), 545-552.
• Swauger, K. Tomlin, C. (2002). BEST CARE for
  the elderly at forsyth medical center. Geriatric
  Nursing, 23(3), 145-150.
• U.S. Census Bureau. (2009). Facts for features.
  Retrieved April 3, 2009, from http//www.census.go
  v/

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To know how to grow old is the master work of
wisdom, and one of the most difficult chapters in
the great art of living. Henry Fredric Amiel