According to the Agency for Healthcare Research and Quality, more than 40% of hospitalized adults now are age 65 or older. Theres no doubt this number will increase significantly in the future. The challenge for healthcare professionals now is to make sure they can care for these patients.
Older patients demonstrate increased vulnerability. Lack of recognition of geriatric syndromes such as delirium, frailty and dementia during hospitalization is common and can contribute to poor outcomes, which, in turn, lead to increased length of stay and higher costs, according to a study published in 2007 in the Internal Medicine Journal. The specialized and complex care needs of the hospitalized older adult require specialty education for healthcare providers of all disciplines, and the University of Alabama at Birmingham Health System is facing this challenge head on.
UAB Hospital, a 1,157-bed Magnet facility, has launched several educational initiatives to better prepare its students and staff to provide expert care for the geriatric population and to ensure best practices at its facilities. Our educational initiatives came out of the national imperative set forth by the Institute of Medicine in its Retooling for an Aging America consensus report, said Kellie Flood, MD, an associate professor of medicine and medical director of the Acute Care for Elders unit at UAB Hospital. We aligned our mission to not only train all disciplines in geriatric knowledge but to train them to function as teams.
Another initiative, Reynolds Program, is aimed at developing and implementing an innovative Care of the Complex Older Adult curriculum that targets medical students, residents, faculty members and community physicians across Alabama and Mississippi. UAB also has a Geriatric Education Center that provides interprofessional training for the faculty of its medical and allied health schools.
Other intiatives at UAB bring nurses into the mix. One such initiative in its initial launch phase is the UAB Health Coordinating Committee, composed of the deans of the schools of optometry, dentistry, medicine, nursing, public health and health professions and the CEO of the health system, with a primary goal of improving education of all disciplines to function as interprofessional teams. An associate dean for the UAB School of Nursing leads the incorporation of nursing care principles in all aspects of interprofessional training for this initiative.
A fourth initiative, the Geriatric Scholars Program, is a competitive clinical recognition program designed to identify champions in geriatric care from the hospitals existing workforce and develop their skills. Candidates must complete an application in which they detail specific examples of previous extraordinary care they have delivered; teaching, leadership and quality improvement roles; career goals; and statements indicating their commitment to the two-year program. They also need recommendations from their direct supervisors. If they pass the initial screening, they are interviewed by the Scholar Selection Committee.
Geriatric scholars train for two years. The program requires about 40 hours of education in the first year and begins with a two-day workshop that covers core concepts of gerontological nursing, including delirium prevention, polypharmacy, depression, pain management, recognition of dementia, incontinence and ethical considerations. Scholars then continue with monthly lunch-and-learn sessions followed by three, 4-hour clinical rotations. They can choose two rotations from primary care, wound care, palliative/comfort care, the ACE unit, the geriatric consult service, and geriatric psychiatry (inpatient). The third rotation is a nursing home experience.
To date, 32 nurses have completed the program and are sharing what they learned with another 600 nurses and staff. When a class completes the program, the health system hosts a celebration and invites health system leaders and donors from the community to see what the participants have accomplished. Process improvement projects and improved patient outcomes are presented, which has helped build support for the program.
Finding their NICHE
The Geriatric Scholars Program evolved after UAB received designation as a NICHE hospital. The Nurses Improving Care for Healthsystem Elders program of the Hartford Institute for Geriatric Nursing at New York University College of Nursing provides principles, tools and resources to promote best practices in the care of older adults.
In 2008, UAB sent a small group of nurses to their first NICHE conference. The nurses came back eager to learn more. One of the nurses invited to attend was Advanced Nursing Coordinator Melanie Schultz, RN, MSN, ACNS-BC, CN, who was UABs NICHE coordinator during that time and since has retired. We wouldnt have the Geriatric Scholars Program without NICHE, she said. Our program is based on NICHEs Geriatric Resource Nurse Model, and our geriatric scholars essentially study and implement the GRN curriculum.
The GRN Model is an educational and clinical intervention model that prepares staff nurses to act as the clinical resource person on geriatric issues for other nurses on their unit. It is the foundation for implementing systemwide improvements. GRNs are trained to identify and address geriatric risks and syndromes, such as falls and confusion, and to implement care strategies that discourage the use of restrictive devices and promote patient mobility. NICHEs GRN curriculum includes 14 evidence-based protocols developed for bedside nurses. Topics include assessment of function, excessive sleepiness, urinary incontinence, assessing cognitive function, and preventing pressure ulcers and skin tears among others. A vast portfolio of educational materials and resources to support GRNs, patient care associates and other staff is available to all NICHE hospitals through the NICHE Knowledge Center.
UAB became Alabamas first NICHE-designated healthcare system in 2008. We wanted to be a leader in geriatric care, Schultz said. UABs geriatric education effort has been growing ever since.
Getting off the ground
Because of the size of its health system, UAB decided to take the scholars approach teaching one student and having that student teach others because they believed they could disseminate NICHE principles and education throughout a large multifacility complex more efficiently this way rather than teaching unit-by-unit.
Although its still a young program, the program already has yielded positive outcomes. In its second year of operation, the UAB Acute Care for Elders Unit, which has a concentration of geriatric scholars on staff, demonstrated a significant reduction in length of stay by one day for patients age 65 and older who are discharged from the ACE Unit compared to a similarly staffed control unit. The ACE model also has demonstrated reduced costs of care and no longer restrains patients.
Hospitalwide, the catheter-associated urinary tract infections observed-to-expected ratio decreased from 1.1 from January through June 2011 to 0.48 during the same months in 2012. Based on its Press Ganey scores, UAB Hospitals overall patient satisfaction, including pain management and overall patient experience, has risen consistently since 2009. By using educational drug alerts embedded in the hospitals Physician Computer Order Entry system, the use of high-risk drugs, such as diphenhydramine and promethazine, in older adults has been significantly reduced.
There also has been a 50% reduction in the fall rate on the vascular surgery unit since April 2011 after a targeted fall-prevention program developed and implemented by geriatric scholars on the unit. The great thing is that not only are we working toward superior outcomes, but we are reducing costs, said Velinda Block, RN, DNP, NEA-BC, CNO of the hospital. I think thats going to be really important in the future. UABs mission is about caring for patients. These efforts toward geriatric education have benefited UAB because they have benefited our patients.
Regarding benefits that rebound to the staff from the facilitys NICHE designation, she said, I think it has given our staff the opportunity to participate in activities and training at the national level. They are able to interact with people across the country, which exposes them to new ideas. Being part of NICHE has provided an avenue to present their work at the national level. It has raised our visibility.
Eventually, UAB would like to see every unit have several geriatric scholars and more in areas that have higher older adult populations. More disciplines including social workers, pharmacists, a sleep lab technician, physician assistants, patient care technicians, as well as physical, occupational and speech therapists already have joined the program. Ultimately, Id like to see more geriatric-specific protocols and every caregiver here be able to talk about the special needs of the older patient, Schultz said.