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NICHE Initiatives Improve Geratric Care in a Community-Teaching Hospital

Rationale / Objectives

Improving clinical and fiscal outcomes for the elder population is essential. Hunterdon Healthcare in New Jersey took action in response to a letter from a patient’s family indicating that specialized needs of the elderly population should be a priority. A search was conducted to assist the organization in furthering its efforts in this regard. The NICHE evidence-based program was selected. This case study reports on results from a number of related initiatives most prominently the issue of medication surveillance. Adverse Drug Reactions (ADRs) occur in older adults due to a number of factors including: age-related changes in the predictability of drug response at usual or lower concentrations; drug half-life may increase related to disease processes resulting in accumulation of drug levels; older patients are more sensitive to medications that affect neurologic and cardiovascular systems. Hunterdon Healthcare aimed to address the problem of the potential for inappropriate medication prescribing for older adult patients. A related article on harm reduction from high-risk medications can be found here as well as a how-to guide to aid in prevention efforts. 

Project/Program Description & Major Achievements

The Geriatric Medication Surveillance Program at Hunterdon Healthcare provides a medication review process that identifies and resolves pharmacy-related issues. Through the Surveillance Program, predefined triggers were built into the computerized-patient record system to identify patients on any risk medications. A clinical intervention documentation and reporting tool assessed cost-savings. The NICHE Geriatric Resource Nurse (GRN) core curriculum is designed for use by those at NICHE sites who train nurses in best practices for hospitalized older adults. GRNs are the foundation of system-wide improvement to achieve positive outcomes for hospitalized older adults. The NICHE program, available to hospitals internationally, offers evidence-based, interdisciplinary approaches to promote improved care for the hospitalized older adult. The program fostered support and communication across all disciplines, increased staff education on medication management and yielded over $5,000 in cost-savings. The program also decreased the use of the medication. For example, with the FDA warning on zolpidem, education was provided and a lower starting dose was recommended, plus the use is cautioned in older adult patients. During the study, a 100% physician acceptance rate occurred. Patient satisfaction scores have improved and falls have also been reduced as a result of NICHE initiatives at Hunterdon Healthcare. There has also been a 17% decrease in length of stay in the ICU for patients with DRG codes of Delirium. 

Lessons Learned

The NICHE program success has led to an increased engagement by critical team members which is essential to continued sustainability. Tapping into the team approach enables the focus to be on patient- centered care, emphasizing the value each discipline offers.

Further Description

Hunterdon Medical Center, the flagship hospital, treats over 8,600 inpatients annually with 33,000 Emergency Department visits and over 292,000 outpatient visits per year. The 178-bed teaching hospital provides a full range of preventive, diagnostic and therapeutic inpatient and outpatient hospital and community health services. The hospital achieved NICHE designation in 2009. NICHE facilities demonstrate organizational commitment to the quality care of older adults. Progressing through Early Implementation, Progressive, and Senior Friendly levels to achieve Exemplar designation recognizes a hospital’s ongoing, high level dedication to geriatric medical care and pre-eminence in the implementation and quality of system wide interventions and initiatives. Click here for a relevant geriatric case study of another NICHE organization, Mount Sinai Hospital.

Clinical Nurse Leader (CNL) and NICHE coordinator roles were combined at Hunterdon to promote awareness of geriatric issues in the acute clinical care setting. In 2009, the Geriatric Institutional Assessment Profile survey revealed nurses’ strengths and knowledge deficits. Organizational groups including NICHE coordinators and an advisory interdisciplinary team were formed to review survey results and plan systematic implementation of the NICHE program. With CNL guidance, six nurses received certificates of completion (this will soon be spread to 30 nurses), identified a project of interest, prepared a poster, and will be implementing their respective projects.

A NICHE volunteer program was developed in 2010 as a further opportunity to improve the geriatric in-patient experience and since implementation patient satisfaction scores rose from 84% to 90% in an 8-month period after initiation. Other relevant NICHE related initiatives include weekly Interdisciplinary Geriatric Rounds and a falls prevention program (In 2009 there were 29 falls, 23 in 2010 and in 2011 there have been eight falls for the first nine months since implementation). The development of a Standard of Care for Delirium at Hunterdon resulted in a 17% decrease in length of stay for ICU patients with a DRG code of delirium. Types of interventions implemented as part of the medication surveillance program included:

 
  • No indication for PRN order
  • Dose adjustment
  • Discontinue medication
  • Drug order clarification
  • Drug recommendation
  • Medication reconciliation error

Major Achievements

Next steps with respect to medication surveillance include:
 
  • Streamline trigger points in the queue to support pharmacist review and determination of medication-related outcomes
  • Continue to identify and report issues in older adult patients by staff nurses

 

Various NICHE related achievements from Hunterdon Healthcare are highlighted in the table below:

Metric

Result

Detail

Cost savings

increased by $5000

*as a result of the medication surveillance program

Physician acceptance rate

100%

*with the medication surveillance program

Patient satisfaction rate

increased by 6%

*following implementation of the NICHE volunteers in 2010

LOS for ICU patients with Delirium

decreased by 17%

*as a result of implementation of a Delirium Standard of Care

Falls rate

decreased from 29 falls to 8 falls

*between 2009-2011 following fall prevention program