GRNs Krista Walsh (r.) and Colleen Hogan walk with patient John Fitzpatrick to help him prevent losing physical strength during hospitalization.
Hospitalization has a greater cognitive and physical impact on geriatric patients than on those who are younger. Indeed, more than 40 percent of the elderly suffer from delirium while in the hospital. And even a short hospital stay could result in enough physical deconditioning so that a once-independent person will require assistance for basic activities after discharge. A new initiative at the Hospital of the University of Pennsylvania focuses on this group of especially vulnerable patients, using specially trained geriatric resource nurses (GRNs) to address these issues and more.
Providing specialty care for the geriatric patient is not new at HUP. In 2010, Nursing brought NICHE (Nurses Improving Care for Healthsystem Elders) on board, a nationwide program that helps meet the needs of older patients with proven programs and protocols. The GRN initiative takes this care to a new level. Rebecca Trotta, PhD, created the program at HUP with a $1.5M grant from the Health Resources and Services Administration, a federal agency.
Training to become a GRN requires 20 hours of evidence-based geriatric training available on the NICHE website and completion of a two-day class on the comprehensive geriatric assessment, which Trotta developed. “Ours is customized for our setting and our older patients,” she said. “What clinical nurses need to do for this population in the inpatient setting.”
GRNs usually target the oldest patient on the floor -- age alone is one of the highest risk factors for adverse events --but cognitive impairment and other factors are also considered. The initial comprehensive geriatric assessment comprises several components, include sensory (such as vision and hearing), cognition (delirium, depression, and dementia), functional status (activities of daily living), nutrition, and medication adherence. Each GRN spends, on average, two days a month in this role. The remainder of time is spent as a primary nurse.
Part of the cognitive assessment is the ability to recall three words and correctly draw the time 11:10 on a drawing of a clock (an executive function). An inability to perform this task could have a significant impact on everyday activities, such as the patient’s ability to know which medications to take when.
This thorough assessment often brings to light important issues that might not otherwise be known. For example, GRN Joan Brower said that prior to hospitalization a 79-year-old patient of hers was driving, cooking and caring for his wife who has Parkinson’s. Since being admitted, “he needs a wheelchair and can’t even lift his arms above his head. If we can get him physical therapy, maybe we can preserve some function.… The health-care team didn’t originally have this on their radar.”
GRNs also follow up on other patients who have already received the initial assessment. Part of this is a daily delirium assessment, which augments the standard nursing assessment process. They also address pain and mobility issues.
After the assessment and follow-ups, the GRN participates in interdisciplinary rounds with the care team to share findings and make recommendations. Said HUP social worker Christine Chevallier-Holmes, “The information that they collect during their assessments is greatly appreciated and valued by all the members of our multidisciplinary team.”
Caregivers are very much part of an elderly patient’s world and as a result they are part of the GRN’s focus as well. “The patient’s success at home -- nd whether he or she is readmitted -- is largely based on the caregiver’s ability and state of mind,” Trotta said.
Because the GRN also works as a primary nurse, other nurses on the unit learn about caring for the elderly as well. “It’s a diffusion effect,” Trotta said, adding that the nurses also appreciate the help with this population. The GRN program also addresses a key component of Penn Medicine’s Blueprint for Quality, a strategic plan which seeks to reduce mortality and reduce 30-day readmissions.
“Our hope is to develop an effective care model that meets the needs of our older adult patients and families, keeping them safe and facilitating successful transitions,” Trotta said.