"On the Front Line of Change" was the theme of the 14th annual conference of NICHE (Nurses Improving Care for Healthsystem Elders), held last month in Las Vegas, Nevada. The conference brought together hundreds of nurses, nursing administrators, educators and other healthcare professionals from across the US and Canada, whose shared passion and purpose is to improve the quality of care for hospitalized older adults.
Over the course of the two-day conference, the 400 + attendees heard from leading researchers and practitioners in gerontology about current evidence-based practices to identify, prevent, reduce and manage the incidence of common geriatric syndromes and complications including atypical presentations of disease, dementia, delirium and depression, falls, pressure sores, drug reactions and interactions and functional decline.
They also heard directly from front line nurses who have successfully implemented the NICHE program.
"Bettering care for older patients is a complex challenge that demands the combined dedication, determination and resolve of all the stakeholders in a healthcare facility," says Marie Boltz, PhD, RN, GNP-BC, Associate Director, Practice, Hartford Institute for Geriatric Nursing at the New York University College of Nursing. "It's a commitment to changing hospital practices and culture. And getting those pieces in place requires knowledge, leadership skills, tenacity and a healthy dose of creativity."
All of those skills and qualities were on full view in a packed pre-conference session led by Christine M. Waszynski, MSN, APRN, BC, Geriatric Nurse Practitioner and Coordinator of the Inpatient Geriatric Consult Service at Hartford Hospital in Connecticut. Ms. Waszynski, the hospital's NICHE coordinator, and three of her colleagues explained how implementing the NICHE program at Hartford Hospital has not only improved care and outcomes for older patients, it has also created a more engaged, energized and empowered nursing staff.
The View from the Front Line
Hartford Hospital is an 867-bed capacity, inner-city teaching hospital and trauma center. Patients age 65 and over make up about 45% of emergency department visits and inpatient days.
In 2003, Ms. Waszynski, the hospital's sole Geriatric Nurse Practitioner and Clinical Specialist, was searching for a way to maximize her impact on the care of older patients. "I was only one person," she said, "And I knew that while I could do a geriatric consult here and there, that wasn't going to do much to change the system."
While researching what other hospitals were doing, she found NICHE and discovered the program's popular Geriatric Resource Nurse (GRN) model. GRNs are existing staff that undergo additional training in geriatrics and act as roving resources and mentors for hospital staff.
Hartford Hospital achieved NICHE designation in 2003. Now, nearly eight years later, Ms. Waszynski has personally trained 160 GRNs who work across 29 inpatient units. "The GRNs are my 'scouts,' said Ms. Waszynski. "They identify older patients who may be at risk for complications or who may need additional intervention." The GRN reviews the reasons why the patient is at risk, speaks with the nurse caring for the patient, implements standard care measures and monitors the situation. "If the issue does not resolve, the GRN notifies the appropriate staff and may request a geriatric medicine consult," said Ms. Waszynski.
In addition to "scouting," mentoring and advising, Hartford Hospital GRNs have initiated and helped implement many of the Hartford Institute's "Try This" tools including the one that describes the Confusion Assessment Method (CAM), a screening tool used to identify delirium. This medical emergency that affects from 40 to 80% of hospitalized older patients is often missed. Undiagnosed delirium is associated with increased hospital length of stay, medical complications, physical restraint use, prolonged neurocognitive deficit and contributes to falls. In collaboration with the GRNs, Ms. Waszynski provided education to staff through case scenarios, role-playing and bedside demonstrations. Staff also received training in the CAM assessment while physicians and pharmacists were advised about medications to avoid. Thanks to GRN intervention, two drugs associated with age-related adverse effects have now been banned completely for older patients.
A trial of the CAM assessment on one pilot unit resulted in a significant decrease in falls between over a four-year period. Hartford Hospital also adapted "Try This" tools to reduce the incidence of catheter acquired urinary tract infections (CAUTI).
Along with improved delirium identification and falls prevention protocols, the GRNs have served up innovative, creative and fun ways to maximize both adherence to safety measure and to the use of comfort measures for patients with cognitive impairment. GRNs Wioletta Chrostowski, BSN, RN and Susan Mullin BSN RN, created a Geriatric Closet outside the Cardiac Intensive Care Unit and stocked it with "distracter items" such as Fur Real pets, Twiddle Muffs and other tactile items that help redirect cognitively impaired patients who've become agitated.
Agitation is what Mary Kate Eanniello RN, MSN, OCN, feels whenever she sees "bed rest" orders on a cancer patient's chart. Ms. Eanniello, the Nurse Educator of the Cancer Program, was in the very first group of Geriatric Resource Nurse trainees. At the pre-conference session, Ms. Eanniello, described her mobility program for hospitalized cancer patients. "About 60% of our cancer patients are over 65," said Ms. Eanniello. Two to three times a week, Ms. Eanniello hits the cancer ward to drum up participants for her exercise program. "You should see me cajoling the patients to join the class," she said. And she reels them in. Lately she's taken to snagging the caregivers too. "It's good for both of them," said Ms. Eanniello who plans to apply for a grant to buy pedometers to encourage patients to get up and walk around the floor.
Wioletta Chrostowski, Sue Mullin and Mary Kate Eanniello credit Ms. Waszynki for her brilliant leadership, unwavering support and uncanny ability to find funding for geriatric initiatives. Ms. Waszynski lauds her GRNs and credits NICHE with the hospital's success in improving care for their hospitalized older patients. "NICHE can take full credit for all this," she said. "They've always provided me with the support, resources and information I needed. Without NICHE we would not have achieved all this."
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