Caritas Norwood Hospital HELP Team Members 15 March 2007

1. Hospital Elder Life Program:H.E.L.P.Interdisciplinary Team Approach to Decrease Delirium & Functional Decline In Hospitalized Elders Caritas Norwood Hospital HELP Team Members 15 March 2007

2. What Can we Do to Decrease the Incidence of Delirium & Prevent Functional Decline? • The clinical problem we face every day • “There’s so much delirium out there.” said L.Gimby, MSN, psych nurse liaison extraordinaire • “There are so many elders out there who suffer delirium & functional decline because they are in the hospital.” said trusty side kick, P.Calvert, MSN, gerontology

3. Problem Focused ID of clinical problems Risk Management Quality Improvement data Total quality mgmt Continuous quality imprvmt Financial data Knowledge Focused New information from literature Philosophies of Care ?s from institutional standards Nat’l agencies (JCAHO) or organizational standards & guidelines (AACN) Iowa Model for Research:Triggers

4. The Gerontology Performance Improvement Team • Followed the Iowa Model: • Identified the problem: delirium & functional decline • Searched the evidence • Critiqued the evidence • Use or do research • Can we change practice @ CNH • Institute change • Disseminate results • Evaluate: monitor, analyze structure, process & outcomes

5. Search the Evidence • Performance Improvement Project (PIP) team: • Sought to understand delirium & continue to learn more • Definition • Inouye research article (3.06) • Hip Fxs, anesthesia & delirium • Dementia vs Delirium • The Mini Mental Status Exam • Understanding screening & practice @ CNH

6. Delirium = Crisis • Neurological • Emotional • Family • Medical • Functional • Financial

7. Delirium vs. Dementia • Abrupt Onset • Fluctuating Course • Types: • Hyperactive • Hypoactive • Mixed • Often: • Perceptual distortions; dreamlike • Gradual Onset • Constant, Progressive • Vascular may be abrupt • Types: • Alzheimers • Lewy Body • Vascular • and Others • Often: • Delusional ideas and confabulation

8. Delirium vs. Dementia • Gradual Onset • Constant, Progressive • Vascular may be abrupt • Types: • Alzheimers • Lewy Body • Vascular • and Others • Often: • Delusional ideas and confabulation Often iatrogenic!

9. Cascade of Illness &Functional Decline • 25 - 60% of older patients undergoing care for an acute illness risk some loss of independent physical function which may lead to: • Prolonged hospital stay • Nursing home placement • Death • The risk of functional decline is related to the hospital environment, as well the patient’s physical frailty, disease severity, & cognitive impairment Palmer, R.M., (1995). Acute hospital care of the elderly: minimizing the risk of functional decline. Cleve Clin J Med. Mar-Apr; 62(2): 117-28

10. Cascade of Illness & Functional Decline Initial illness Medication Change inenvironment delirium Foley Antibiotics dehydration reduced PO UTI immobility incontinence compromised host defense constipation dehydration malnutrition anorexia/bloating N/V pneumonia aspiration depression Marsha Duke Fretwell, MD

11. Cascade of Illness &Functional Decline • To prevent functional decline: • Modify the environment • Prevent iatrogenic illness • Detect & treat functional impairments • Promote mobility • Assess & treat nutritional problems • Address the personal needs & values of the patient Palmer, R.M., (1995). Acute hospital care of the elderly: minimizing the risk of functional decline. Cleve Clin J Med. Mar-Apr; 62(2): 117-28

12. Critique of Evidence • What are the characteristics /value of evidence • ACE (Acute Care Elder) units • HELP (Hospital Elder Life Program) • What are the characteristics of Caritas Norwood Hospital • Feasibility • Fit

13. Use or Do Research • Hospital Elder Life Program • Orientation & socialization • Screening for mobility • Nutrition & hydration screening • Resources required • Elder Life Specialist to run the program • Resources available • Finite • U21 - rehab past - similar but different

14. Can We Change Practice?The Scope of the Imperative:45.46% of CNH In-Patients are >70

15. It Takes a Village

16. Or Maybe a TEAM Casey at the Bat: Building the Team

17. Institute Change • Implementing HELP • Pilot Unit 21 - medical patients • Recruiting volunteers • Training volunteers • Presenting to clinical staff • Layers of implementing change • Information boards in patient rooms • Communication tools for report & documentation

18. IOWA Model & Plan-Do-Study-Act AIM: What are we trying to accomplish? Improve care for hospitalized elders at risk for delirium and functional decline.

19. IOWA Model & Plan-Do-Study-Act • MEASURE: How will we know that a change is an improvement? • Mini Mental Status Exam • Decrease of 3 points or more comprises statistically significant decline. • Other measurable outcomes: functional decline, discharge disposition, patient satisfaction.

20. IOWA Model & Plan-Do-Study-Act IDEAS: What change can we make that will result in improvement? Hospital Elder Life Program: H.E.L.P

21. What’s Happening Now? • Evolving rounds - the trouble with change • We don’t live in a perfect world • Adding elements • Getting the word out • Holding the gains…hardwiring for success… planning for permanence

22. Casey at the Bat:Building the Team