NICHE Nurses Improving Care of Health System Elders The SPICES Tool

1. 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 lareaur@bronsonhg.org

2. 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.

3. 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

4. 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

5. 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.

6. 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

7. Evidenced Based Resources • http://nicheprogram.org • http://www.consultgerirn.org • Hartford Institute Protocols Book • Evidenced Based NICHE Tools: Handout

8. Physical Restraints Pressure Ulcers Sleep Disturbances Advance Directives Pain Management Assessing Cognitive Function Functional Assessment Depression Incontinence Eating/Feeding Acute Confusion/ Delirium Medication Management Falls Discharge Planning Geriatric Syndromes

9. Bronson NICHE Program NICHE Program • Geriatric Independent Study Modules • NICHE AGEducation Day (8 hours) • Support for Gerontological Nurse Certification

10. 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

11. 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.

12. 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.

13. SPICES Tool GRN Core Screening Tool • Raises awareness and triggers further evaluation & documentation • Skin Impairment • Poor Nutrition • Incontinence • Confusion • Evidence of Falls • Sleep Disturbances

14. 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

15. 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/GetUp and Go • Sleep • Difficulty falling/ staying asleep • Sleep promotion interventions

16. Reasons for Geriatric Resource Nurse Consult Some potential reasons for consult: • Delirium • Dementia • Sitter • Falls • Sleep Problems • Problems with eating • Use of Diversional Activities

17. Evidence of Falls/Function

18. 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)

19. Cause of Death:Accidental Fall

20. Why Do We Need to Be Concerned? • Injuries • Deaths • Associated complications • Costs

21. 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 Source: Auerhahn C, Capezuti, E., Flaherty, E., and Resnick, b., eds. Geriatric Nursing Review Syllabus; A Core Curriculum in Advanced Practice Geriatric nursing, 2nd edition. New York: American Geriatric Society; 2007. American Academy of Orthopedic Surgeons: Don’t Let a Fall Be Your last Trip: Prevention Facts. Available at http://orthoinfo.aaos.org/brochure/thr_report.cfm?Thread_ID=21, Accessed, May 25, 2007.

22. Demographics • Falls are associated with: • Decline in functional status • Development of “fear of falling” • Greater likelihood of nursing home placement

23. 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 Source: Auerhahn C, capezuti, E., Flaherty, E., and resnick, b., eds. Geriatric Nursing Review Syllabus; A Core Curriculum in Advanced Practice Geriatric nursing, 2nd edition. New York: American Geriatric Society; 2007. Nurse Assist – Improving senior Care<safenet@nurseassist.com, A Weekly Q & A from Nurse Assist - The Clinical Experts in Fall Management. Available at file://C:\Documents and Settings\lareaur\localSettings\Temp\Xpgrpwise\45F5FEE3DOM

24. 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).

25. 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.

26. 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

27. 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

28. 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

29. 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

30. 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

31. Risk Factors Hendrich IIFall 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)

35. Fall Risk Interventions

36. 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

37. 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.

38. 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.

40. 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

41. Bronson Intranet Handouts

44. Questions? NICHE Nurses Improving Care of Health System Elders The SPICES Tool