Thora Warrington gets patient Donald Mattia out of bed and walking, and engaged in conversation.  Hospitalization poses greater risks for older adults than for other patient populations. For example, their skin is more fragile and prone to skin breakdown. They become easily confused in the strange environment. They’re at greater risk for falls. To help resolve these challenges -- and others -- HUP has implemented NICHE (Nurses Improving Care for Healthsystem Elders), a front line, nurse-driven initiative that helps hospitals meet the needs of older patients with proven programs and protocols.

Getting Started

To prepare for NICHE designation, staff were asked to complete a Geriatric Institutional Assessment Profile, which analyzes where an organization falls in terms of its staff’s knowledge, attitudes and perception in the care of older hospitalized adults. “The results helped us identify what areas we should focus on,” said AnnMarie Papa, DNP, RN, CEN, NE-BC, interim clinical director of Emergency Medicine.

HUP began piloting the program in three areas that were shown to have the highest population of patients 65 and older:  Silverstein 9, Founders 12 and the ED. Nurses and certified nursing assistants (CNAs) from each of these areas went through NICHE leadership training, a 60-hour program that prepares staff members to serve as the clinical resource person for geriatric issues to other nurses on their unit. “They are our program champions,” Papa said.

Understanding the Challenges

Numerous challenges exist when caring for elderly patients, including their response to medications, their limited range of motion, and their functional status. The staff on HUP’s pilot units are using a comprehensive assessment tool and NICHE resources to address each of these areas.

Medications affect the elderly differently than other patients. “For example, an elderly patient's liver may metabolize medications slower than the average adult, potentially prolonging its half life and causing toxic levels.”- Barbara Young, BSN, RN, CEN

Barbara Young, BSN, RN, CEN, who leads the NICHE effort in the Emergency Department, said that medications affect the elderly differently than other patients. “Physiologic changes occur in the elderly that can affect the absorption, metabolism and clearance of medications,” she said. “For example, an elderly patient's liver  may metabolize medications slower then the average adult, potentially prolonging its half life and causing toxic levels.”

Young plans to reach out for expert advice in this area. “We’re examining the possibility of the ED pharmacist reviewing the medication list of every patient over 65 and red flag any on the Beers list,” she said. “We may be able to switch the patient to a safer medication or possibly eliminate it.” The Beers list specifies a group of medications that have been identified as potentially inappropriate for older adults.

Getting patients out of bed and moving is another NICHE goal. “If our older patients can walk, we want to get them up,” Young said. “For instance, instead of always offering a bed pan, we’d rather help walk to the bathroom.”

According to Paul Harrington, RN, MSN, MBA, clinical director of surgical nursing, certified nursing assistants play a key role in this initiative. Thora Warrington, RN, CNRN, who is NICHE program leader on Silverstein 9, said that a newly created staff position on her unit -– charge CNA -- will help with patient mobility. “With no patient assignment, the charge CNA can help other CNAs on the unit with their responsibilities,” she said. “This allows them more free time to spend with patients, getting them up and moving.”

For patients who can’t get out of bed, “we make sure they are turned every couple hours,” Warrington said. “We make sure that staff always use the lift to raise and reposition patients. Boosting up elderly patients shears the skin and causes breakdowns that lead to a pressure ulcer.”

Protecting Mental Capacity

Preserving a patient’s cognitive function is a key component of NICHE. “The elderly are used to their own environment,” Papa said. “In the hospital, they’re in a strange place, with background noise, different schedules, and it upsets their whole body rhythm.”

“The last thing we want is to keep these patients lying in bed and staring at the ceiling,” added Harrington. “You have to keep them engaged to maintain their functional status … and  it can be as simple as bringing them to the conference room to play some games, such as bingo, or watch a movie.”

Warrington took engagement to a new level when she hosted a New Year’s Eve party for her patients. “We had party hats, ice cream, sparkling cider, music, horns…. The patients loved it!” she said. “We did it to help their cognitive status but also to let them know they’re not forgotten.”

Understanding the sensory capabilities of the elderly patient is important. “Can they hear what I’m saying? Can they read? During the assessment, we determine their abilities and then implement plans to support their needs,” Warrington said.

“In the ED, we make sure discharge instructions are printed in a larger type so it’s easier to read,” Young said. “If we find that they forgot their hearing aid or hear out of one ear better than the other, we’ll stand on the better side. Or we’ll sit directly and in front of them and speak slowly so they can read our lips. It’s really just little changes that can make the difference.”

NICHE is very much a multidisciplinary effort. For example, Warrington plans to work with Occupational Therapy to plan other activities for her elderly patients. Young said that she depends on volunteers to walk with ED patients who have been there for an extended period of time.

The program has proven to be a win-win situation on many levels for the 300 hospitals that currently participate, and those involved in the initiative at HUP look forward to similar results. “NICHE provides structured educational programs that allow us to bring hands-on learning to the bedside,” Warrington said. “The more resources and knowledge we have to care for our older patients, the better the outcomes and the higher the level of both patient and employee satisfaction.”

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