The Hospital Elder Life
Program© (HELP), Delirium and
Falls: From a One Unit Pilot to a
Hospital Wide Practice Change
MAINE MEDICAL CENTER
PORTLAND, ME
APRIL 19, 2017
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC
Clinical Nurse Specialist, Geriatrics
Center for Clinical & Professional Development
Learning Objectives
This presentation will…
• Discuss the ways in which the Hospital Elder Life Program© (HELP) can
improve delirium prevention, encourage mobilization and reduce inpatient
falls.
• Describe the development of strategies, supported by research for
implementing an effective institution wide practice change over a four year
period.
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
Guiding Principles of NICHE
•
Evidence-based geriatric care at the bedside
•
Patient & family centered environments
•
Healthy and productive practice environments
•
•
•
Implementation of best practices, including prevention and management of pain, pressure ulcers, adverse
medication events, delirium, urinary incontinence, and falls
Physical and social environments to maintain and enhance patient function
•
Values related to older adult and staff autonomy
•
Interdisciplinary collaboration
•
Access to geriatric specific resources
Multidimensional metrics of quality
•
Quality measures including: patient outcomes, patient/family/staff satisfaction, cost-avoidance and compliance with
regulations
Nurses Improving Care for Healthsystem Elders. Available at: http://www.nicheprogram.org/guiding-principles/
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
1
Hospital Elder Life Program©
• Team based model of care
• Prevents delirium & functional decline in hospitalized older adults
• Patients are screened for modifiable delirium risk factors
• Cognitive impairment, sleep deprivation, immobility, vision impairment,
hearing impairment and dehydration
• Interventions
• Targeted toward identified risk factors
• Implemented by trained volunteers
• Orientation, therapeutic activities, sleep/relaxation techniques, provide
hearing and vision assistance, assist with mealtime and fluid repletion,
encourage patients with walking or exercises
Inouye SK, Bogardus ST, Baker DI, Leo-Summers L, Cooney LM. The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized
patients. Hospital Elder Life Prgram. J Am Geriatr Soc 2000;48(12):1697-1706
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
MAINE
Oldest State by Median Age: 44.6 years
2015 – U.S. Census
Maine Medical Center
• 637 Bed Tertiary Care Teaching Hospital
• Level 1 Trauma Program
• U.S. News & World Report “One of America’s Best Hospitals”
Number one Hospital in Maine
• Awaiting 3rd Magnet® Designation
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
2
Hospital Elder Life Program© at
Maine Medical Center
• Implementation 2002
• Recognized as a site of excellence since 2010
• Enrolls approximately 1500 older adults annually
• Delirium prevention rate of 96-97%
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
HELP© Prevent Falls by Preventing Delirium Project
• Three month project in 2010 on one 24 bed medical telemetry unit
• The purpose was to explore if specific HELP© interventions (orientation,
therapeutic activities and active range of motion) when more broadly
applied to all patients over 70 regardless of their delirium status, could:
• reduce the incidence of delirium,
• improve mobility, and
• reduce falls
Babine, R., Farrington, S., Wierman, H. HELP prevent falls: applying HELP principles to reduce falls in an inpatient setting.
Nursing 2013. May 2013;43(5):18-21.
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
HELP© Prevent Falls by Preventing Delirium Project (con’t)
• Staff Education
• Delirium prevention, identification & management
• How to administer and interpret the Confusion Assessment Method (CAM)
• Evidence-based interventions to prevent delirium & maintain physical function
• Nursing Practice
• Assessed patient function and sensory abilities; initiate appropriate interventions
• Delirium was assessed utilizing the CAM on admission, every 12 hours, and with
any cognitive changes
Babine, R., Farrington, S., Wierman, H. HELP prevent falls: applying HELP principles to reduce falls in an inpatient setting. Nursing 2013.
May 2013;43(5):18-21.
Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AO, Horwitz RI. Clarifying confusion: the confusion assessment method.
A new method for detection of delirium. Ann Intern Med 1990;113:941-948.
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
3
HELP© Prevent Falls by Preventing Delirium Project (con’t)
•
HELP© Enrollment process
•
All patients over the age of 70 (n=158) were evaluated and enrolled in either
•
Full HELP with all interventions
•
•
Friendly visits – limited volunteer interventions including
•
•
Orientation, therapeutic activities, sleep/relaxation techniques, hearing and
vision assistance, assist with mealtime and fluid repletion, encourage patients
with walking or exercises
Orientation, sensory device distribution, therapeutic activities, and active
range of motion exercises
Volunteer visits were conducted twice daily 7 days a week
Babine, R., Farrington, S., Wierman, H. HELP prevent falls: applying HELP principles to reduce falls in an inpatient setting.
Nursing 2013. May 2013;43(5):18-21.
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
HELP© Prevent Falls by Preventing Delirium Project (con’t)
•
During the project period:
•
The fall rate decreased from 5.15 to 2.49 per 1,000 patient days
•
Nursing staff were consistently evaluating patients for delirium and functional decline then
initiating appropriate interventions
•
Feedback surveys indicated that nursing staff felt satisfied regarding the provided
education, tools and resources
•
5 total falls which included: 3 patients w/delirium, 1 patient with advanced dementia,
and 1 patient who was discharged the same day
Babine, R., Farrington, S., Wierman, H. HELP prevent falls: applying HELP principles to reduce falls in an inpatient setting.
Nursing 2013. May 2013;43(5):18-21.
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
A Closer Look at Delirium & Falls Through Patient Records
Lakatos BE, Capasso V, Mitchell MT, et al. Falls in the general
hospital: association with delirium, advanced age, and specific
surgical procedures. Psychosomatics. 2009;50(3):218-226.
• Retrospective chart review in 2003 of 237 patients
who fell while in the hospital
• This study reported:
• 96% of patients who fell had symptoms of
delirium
• Advanced age (50% >70)
Babine, R.L., Hyrkäs, K.E, Bachand, D.A, Chapman, J.L,
Fuller, V.J, Honess, C.A., Wierman, H.R. Falls in A Tertiary
Care Hospital – Association with Delirium: A Replication
Study. Psychosomatics. May-Jun 2016;57(3):273-82. doi:
10.1016/j.psym.2016.01.003
• Retrospective chart review in 2009-2010 of 99
patients who fell while in the hospital
• Our study showed:
• 73% of patients who fell had symptoms of
delirium,
• Advanced age (64.5% >70)
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
4
Lower Delirium Rate?
• The replication study at Maine Medical Center indicated a delirium
rate of 73% compared to 96% at Massachusetts General Hospital
• Hospital Elder Life Program©
• Multicomponent delirium prevention interventions
• Implementing evidence-based interventions (early
mobilization, frequent reorientation, and addressing
sensory deficits
• Avoiding polypharmacy and medications known to be
deliriogenic
• Increasing the presence of family & staff at the bedside
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
Interprofessional Delirium & Falls Prevention Program
• Comprehensive interprofessional education
• “Concepts in Common”
• Nurses, resident physicians, nursing assistants, rehabilitation, and social workers
• Delirium prevention (HELP©), identification (CAM), and management
• Multiple formats (live, PowerPoint w/voice over, express in-service, brochure, posters)
• Scripting to improve team communication (SBAR)
• Policy development
• Systematic implementation throughout institution
• Education did not include fall prevention
Babine, R. L., Honess, C., Wierman, H., Hallen, S. (2014), The Role of Clinical Nurse Specialists in the Implementation and Sustainability of a Practice Change. Journal of Nursing
Management. January 2016;24(1):39-49. DOI: 10.1111/jonm.12269. Pages 1–136, E1–E100.
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
Measuring the Success of Staff Education
• Comfort with delirium knowledge and communication
• Multiple choice questions (6 questions)
• Likert 1-5 scales (6 questions)
• Pre-test, post-test given at time of initial education
• 3-month, 6-month (and 12-month) post-tests were given to a convenience sample of floor
staff regardless of attendance
• Assess team impact of education/utility of other presentation methods (peer-to-peer)
Babine, R. L., Honess, C., Wierman, H., Hallen, S. (2014), The Role of Clinical Nurse Specialists in the Implementation and Sustainability of a Practice Change. Journal of Nursing
Management. January 2016;24(1):39-49. DOI: 10.1111/jonm.12269. Pages 1–136, E1–E100.
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
5
Staff Education Attendees on Adult Inpatient Medicine Units
• 3 nursing units (78 beds)
• 115 participants
• 55 staff nurses
• 15 providers
• 3 nursing assistants
• 22 rehabilitation specialists (PT, OT, SLP)
• 20 others
• HELP volunteers, nutrition, social workers, companions, pharmacists,
chaplains, care coordinators
Babine, R. L., Honess, C., Wierman, H., Hallen, S. (2014), The Role of Clinical Nurse Specialists in the Implementation and Sustainability of a Practice Change. Journal of Nursing
Management. January 2016;24(1):39-49. DOI: 10.1111/jonm.12269. Pages 1–136, E1–E100.
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
Knowledge of Clinical Features of Delirium (CAM)
90%
79% (p<0.001)
80%
Percent Correct
70%
58% (p<0.001)
60%
58%(p<0.01)
51% (p<0.001)
50%
40%
30%
24%
20%
10%
0%
Pre-test
Post-test
3 months
6 months
12 months
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
1 not comfortable - 5 expert
Comfort Administering the CAM
4.5
mean 3.82 (p<0.001)
4
mean 3.46 (p<0.001)
3.5
3
mean 3.05 (p<0.05) mean 3.04 (p=0.05)
mean 2.68
2.5
2
1.5
1
0.5
0
Pre-test
Post-test
3 months
6 months
12 months
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
6
Knowledge of Team Responsibilities
100%
86% (p<0.001)
90%
91% (p<0.05)
87%
79%
Percent Correct
80%
70%
69%
60%
50%
40%
30%
20%
10%
0%
Pre-test
Post-test
3 months
6 months
12 months
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
Measuring and Auditing the Success of the Practice Change
• Policy compliance
• Practice change: staff assessing patients for delirium
• Completion of CAM audited in all medical records (approx. 78 patients)
• Weekly audits until goal of 75% for 3 consecutive weeks
• Every other week for one year
• Monthly
• Audit results disseminated immediately to nursing units
Babine, R. L., Honess, C., Wierman, H., Hallen, S. (2014), The Role of Clinical Nurse Specialists in the Implementation and Sustainability of a Practice Change. Journal of Nursing
Management. January 2016;24(1):39-49. DOI: 10.1111/jonm.12269. Pages 1–136, E1–E100.
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
Sustained Change in Practice
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
7
Accuracy of CAM Assessments
• Assessment of staffs’ understanding of the use and criteria of the CAM
• 1 year after implementation, concurrently
• CAM independently administered by geriatrician and nurse
• Results recorded for later comparison by CNS
• CNS performed medical record review
• Review of written documentation for “presence of delirium”
• Presence of one or more of the CAM clinical features in past 24 hours
• 83% (n=48) of the time CAM screening similar
Babine, R. L., Honess, C., Wierman, H., Hallen, S. (2014), The Role of Clinical Nurse Specialists in the Implementation and Sustainability of a Practice Change. Journal of Nursing
Management. January 2016;24(1):39-49. DOI: 10.1111/jonm.12269. Pages 1–136, E1–E100.
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
A Longitudinal Review of the Presence of Delirium in Patient Falls
Babine, R.L., Hyrkäs, K.E, Bachand, D.A, Chapman, J.L,
Manuscript in process
Fuller, V.J, Honess, C.A., Wierman, H.R. Falls in A Tertiary
Care Hospital – Association with Delirium: A Replication Study. • Retrospective chart review in 2012 of 108 patients
who fell while in the hospital
Psychosomatics. May-Jun 2016;57(3):273-82. doi:
10.1016/j.psym.2016.01.003
• Our second chart review showed:
• Retrospective chart review in 2009-2010 of 99
patients who fell while in the hospital
• Our first chart review showed:
• 73% of patients who fell had symptoms of
delirium,
• 56% of patients who fell had symptoms of
delirium,
• Mean age 64.23
• Overall length of stay decreased by 7.33 days
• Mean age 66.79
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
Fall Rate
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
8
Conclusions
• In reviewing the patients enrolled in the HELP©, program staff identified that by preventing
delirium falls were also reduced.
• This observation was instrumental in laying the groundwork for the other projects that
followed, expanded, and changed the practice throughout the institution.
• A systematic approach and leadership by a team of experts in geriatric care were
instrumental in the implementation and sustainability of the change in practice over a four
year period.
• Providing the interventions in HELP© including mobilization have also improved the
delirium prevention and falls.
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
Thank you!
PODIUM PRESENTER:
Rhonda Babine, MS, APRN, ACNS-BC, Clinical Nurse Specialist, Geriatrics
NICHE and HELP
Better Together
ABINGTON – JEFFERSON HOSPITAL
ABINGSTON, PA
APRIL 19, 2017
PODIUM PRESENTER:
Annmarie Chavarria, MSN, CMSRN
9
• The hospital has 665 beds
• Over 5,500 employees, including more than 1,100 physicians, and is one of the largest employers
in Montgomery County.
• It has the only Level II trauma center in Montgomery County.
• Pennock Emergency Trauma Center
• Services offered at the hospital include
• The Pilla Heart Center,
• The Rosenfield Cancer Center,
• Neurosciences Institute,
• Orthopaedic and Spine Institute,
• Diamond Stroke Center,
• Muller Institute for Senior Health, and the
• Institute for Metabolic and Bariatric Surgery.
• Magnet designated,
• NICHE designated since 2011
• Exemplar status
• Abington Hospital-Jefferson Health is a non-profit, regional referral center and teaching hospital
with five residency programs and operates the Dixon School of Nursing.
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
LEARNING OBJECTIVES
• Understand the dynamics of how the NICHE Council and
HELP Staff can work together to achieve better patient
outcomes.
• Identify the process and initial data
• Discuss the approach and methods
• Present findings and outcomes
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
1st NICHE/HELP PROJECT
Delirium was often unrecognized
ELS, CNL, and Physicians came together through the NICHE Council to
discuss the presenting problem
• Previous studies have shown that in affected persons, the delirium is only
recognized by:
• About 1/3 of physicians
• About 1/3 of nurses
• AMH Research- Jaspreet Virdi M.D. / Ellen Mangin D.O.
• Issues associated with Delirium
• CAM not completed at all
• CAM not completed accurately
• Confusing dementia and delirium
• Assuming all elderly have dementia
• Prescribing inappropriate medications
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
10
Delirium Task Force
• NICHE Council (March 2014)
• Identified Delirium as a patient safety issue
• Implemented multidisciplinary group
• Geriatrician
• Geropsychiatrists
• Pharmacist
• Nursing Informatics
• Nurse Practitioner
• Nurse Director
• Social Gerontologist/Elder Life Specialist
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
Goals of Delirium Task Force
• Update the Delirium Order Set
• Teach staff to recognize delirium
• Teach staff to use the Delirium Assessment Tool
(CAM)
• Improve communication about delirium with
Physicians, patients, and families
• Learn to manage the patient with delirium
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
DESCRIPTION OF THE INITIATIVE
In November of 2015 two units (2WE and 5B) began a pilot program
which included unit based education regarding delirium and the
proper use of the Confusion Assessment Method (CAM).
The unit based education was delivered by the Clinical Nurse Leader
(CNL) through a power point and a video.
In addition to the general education the CNL assessed the CAM for
every patient daily and then rounded with each nurse and educated
them regarding the accuracy of their assessment.
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
11
DESCRIPTION OF THE INTERVENTION/INITIATIVE
In addition to checking for the accuracy of the CAM assessment the
CNL also provided real time education daily which reinforced the
need to consult the hospital elder life program (HELP), adding the
Acute Confusion Clinical Practice Guideline, and notifying the
physician for all patients with a positive CAM.
A change was implemented in the clinical documentation system
which allowed the nurse to document whether a CAM was positive or
negative. This positive or negative status was then able to be
populated on the unit status board so delirium could be discussed at
shift handoff and unit based safety briefings daily
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
Accurate CAMs
Total CAMs
250
200
150
100
50
0
3000
2500
2000
1500
1000
500
0
% Assessed
100%
80%
60%
40%
20%
0%
2361
2849
Overall total accurate percentage assessed 83%
Overall Overall Total
Accurate
CAMs
CAMs
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
DELIRIUM HAPPENS
ADMITTED WITH A CHANGE OF MENTAL STATUS
• Don’t assume the patient has dementia. He or she might not be able to hear or understand your
words. Seniors respond slower than younger people.
• Be aware of any new medications that the patient is taking.
• Listen to the family’s or nursing home’s report of any recent changes in the patient’s behavior.
• Knowing the patient’s baseline mental status is essential
• Ask questions. Encourage the family to ask questions and get involved
• Obtain a patient history.
• Document all episodes of hallucinations and change in mental status.
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
12
DELIRIUM HAPPENS
ADVERSE EFFECTS OF HOSPITALIZATION
Hospitalization and bed rest superimpose factors such as;
• enforced immobilization,
• reduction of plasma volume,
• accelerated bone loss, and
• sensory deprivation.
Any of these factors may thrust vulnerable older persons into a state of irreversible functional decline.
Hospital delirium is especially common among older people who’ve had surgeries such as hip replacement
or heart surgery, or those who are in intensive care.
• The factors that contribute to a cascade to dependency are identifiable and can be avoided by
modification of the usual acute hospital environment by deemphasizing bed rest, and actively facilitating
ambulation and socialization.
• UNLESS HARMFULLY CONTRAINDICATED ALL PATIENTS SHOULD
HAVE AN “OUT OF BED” (OOB) ORDER.
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
Average Rate of Hospital Acquired Delirium
40.00%
35.00%
Intervention
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
IDENTIFYING DELIRIUM
The Confusion Assessment Method (CAM)
TYPES OF DELIRIUM
DELIRIUM DEFINITION
Research implicates an imbalance in
cholinergic and neurotransmitter
pathways in delirium’s pathogenesis,
so it is organic brain failure.
Is there evidence of an acute
change in mental status from
the patient's baseline?
Delirium costs Medicare about $164
billion (2011 US dollars) and more than
$182 billion (2011 Euros in 18
European countries) per year,
attributed to:
Did the (abnormal) behavior
fluctuate during the day, that
is, tend to come and go, or
increase and decrease in
severity?
WHAT CAUSES
DELIRIUM
•
•
•
•
•
•
Feature 1: Acute Onset
and Fluctuating Course
Delirium is common in the hospital
setting, with occurrence rates ranging
from 29-64% of older persons. More
than 7 million hospitalized Americans
suffer from delirium each year.
PREDISPOSING
FACTORS
•
•
The diagnosis of delirium by CAM requires the presence of features 1
and 2 plus either 3 or 4
Older age
Cognitive
impairment
Physical/Psychiatri
c comorbidity
Sensory
impairment
Functional
dependence
Dehydration /
Malnutrition/Consti
pation
Drugs and drugdependence.
Alcohol
dependence
PRECIPITATING
FACTORS
•
•
•
•
•
•
•
•
Physical/psychol
ogical stress
Pain
Iatrogenic event,
esp. postoperative,
mechanical
ventilation in ICU
Post-traumatic
event,
fall/fracture
Immobilization/re
straint
Traumatic head
injury
Medications
Infections
Feature 2: Inattention
Did the patient have difficulty
focusing attention?
Was the patient easily distracted?
Was the patient having difficulty
keeping track of what was being
said?
PLUS
Feature 3: Disorganized
thinking
Was the patient's thinking
disorganized or incoherent,
such as rambling or irrelevant
conversation, unclear or
illogical flow of ideas, or
unpredictable switching from
subject to subject?
Is the patient having
hallucinations?
Feature 4: Altered Level of
consciousness (LOC)
OR
This feature is shown by any answer
other than "alert" to the following
question:
Overall, how would you rate this
patient's level of consciousness?
vigilant [hyperalert]
lethargic [drowsy, easily aroused]
stupor [difficult to arouse]
coma [unarousable])
Pharmacologic Interventions are useful ONLY when: Behaviors
reflect psychotic thinking and perceptual disturbances; Behavior
interferes with treatment; Nondrug interventions fail.
Delirium Treatment -First line drug therapy: Haloperidol is an antipsychotic,
which in very small doses is used once the patient is observed becoming
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
agitated, combative, etc.
HYPER ACTIVE DELIRIUM-Patient
may become physically aggressive at
any moment, and become dangerous
to other patients and staff.
HYPO ACTIVE DELIRIUM-In hypoactive delirium, the patient will often
appear sluggish and lethargic, to the
point of stupor.
Like hyperactive delirium, the onset is
sudden. The patient is often
perceived to be depressed so
psychiatric consultation is often
requested to treat the patient for
depression.
Hypo-active is the least recognized
of the deliria but deadly because of:
DVTs; Pressure ulcers
High mortality rate
Pulmonary emboli
MIXED DELIRIUM-These patients are
the most challenging of the three
types. And require the closest
surveillance. Because you have a
combination of hypo-active and
hyperactive types, you never know
when the patient will change from one
to the other.
Sudden onset distinguishes
delirium from dementia,
which is characterized by a
slow and insidious course.
13
PHARMOCOLOGIC INTERVENTIONS OF DELIRIUM
• Supportive Care is the first line therapy for delirium.
• Pharmacologic Interventions are useful ONLY when:
• Behaviors reflect psychotic thinking and perceptual disturbances
• Behavior interferes with treatment
• Nondrug interventions fail
• Low dose of potent neuroleptic may be used with caution.
• Shortest possible periods.
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
SUPPORTIVE MANAGEMENT OF DELIRIUM AND
DEMENTIA
Provide Hydration
Identify and Explain
Don’t Crowd
Educate Family
Involve Families
Ambulate
Orient
Stay Calm
Reassure
Talk to Patient
Validate Feelings
Distract/Delay
Speak Slowly
Good Eye Contact
Provide Sensory Aides
Wait for Response
Smile – Don’t Rush
Be Consistent
Keep Promises
DELIRIUM/CONFUSION
MEDICATION C0NSIDERATIONS
• This list is intended to provide the user with guidance on identifying potential medications that may be
implicated in delirium
• Key points:
• Delirium is often multifactorial
• Some medications used for treatment are also a cause
• Some medications may be necessary - Danielle Schulingkamp, Pharmacy Clinical Coordinator should be notified
with patient’s name and room number to check if the medications are appropriate. Danielle’s ext. is 7120.
• Appropriate dosing may also be a factor (high doses may contribute to delirium)
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
14
PHYSICIAN’S ASSESSMENT
Assessment should focus on identifying delirium’s cause.
•Practitioners should turn attention first to:
•
•
•
•
Current Medications take,
substance abuse or withdrawal,
existing co-morbid illnesses, and
symptoms of infection.
•Laboratory work-up—including electrolytes, glucose, renal and liver function tests, and toxicology—
are used, frequently augmented by imaging studies to detect stroke, hemorrhage, and structural
lesions.
•SEE DELIRIUM ORDER SET and ALGORITHM
•http://bing.hosp.amh.org/app/files/public/14266/Delirium-Algorithm.pdf
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
15
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
16
Hospital Elder Life Program
www.hospitalelderlifeprogram.org
HELP ext. 7534
• Hospital Elder Life Program (HELP) as a comprehensive patient-care program to help the
elderly avoid the adverse effects of hospitalization mainly delirium and functional decline.
• HELP does this by keeping hospitalized older people oriented to their surroundings,
meeting their needs for nutrition, fluids, sleep and keeping them mobile within the
limitations of their physical condition.
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
HELP INTERVENTIONS
• Daily Visitor Program: cognitive orientation, communication, and social support .
• Therapeutic Activities Program: cognitive stimulation and socialization.
• Early Mobilization Program: daily exercise and walking assistance. (CALL 7534)
• Non-Pharmacologic Sleep Protocol: promotes relaxation and sufficient sleep. When evening volunteers
are available.
• Hearing and Vision Protocol: hearing and vision adaptations and equipment.
• Oral Volume Repletion and Feeding Assistance (CALL 7534)
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
600
400
200
0
HELP
PATIENTS
YR 2015
YR 2016
YR 2017
HELP CONSULTS
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
17
2nd NICHE/HELP PROJECT
WHAT IS WANDERING ?
Wandering is defined as “meandering, aimless or repetitive locomotion
that exposes the individual to harm; frequently incongruent with
boundaries, limits, or obstacles” ( North American Nursing Diagnosis
Association (NANDA), 2009).
• Wandering is a behavioral problem of Alzheimer’s Disease
• Premorbid lifestyle may help identify those likely to wander
• Patients
•
•
•
•
with the following premorbid characteristics may be more likely to wander:
Physically active in social or leisure activities
Experienced a number of stressful events throughout their lifetime
An extroverted personality
An active interest in music
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
Wandering at Abington Hospital Jefferson Health
• Patients are screened on admission to see if they have a history of “wandering”
• For those patients who screen positive the wandering guideline is put in place.
• These guidelines are meant to help manage wandering behaviors and keep patients safe.
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
WHAT TRIGGERS WANDERING?
• Saw coat and hat and decided to leave
• Change in schedule or routine
• Placed in an unfamiliar
environment
• Confronting situation
• Change in medication
• Need exercise
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
18
WANDERING GUIDELINES
RECOMMENDED
INTERVENTIONS:
MANDATORY INTERVENTIONS:
• Call security to obtain a picture of patient
• Post at front desk; Copy on chart
• Place patient in maroon colored gown
(supply kept on nursing units)
• Discuss/educate family and patient
regarding wandering risk
• Implement Q 15 minute checks
• Bed alarm/posey sitter alarm
• Patient room assignment to enable visibility,
frequent monitoring, and a calm environment
• Offer diversional activities
• Consult HELP program (will be triggered
automatically if yes to either question)
• Review of scheduled and PRN medications
• Patient clothing in a secure place that is
“out of sight/out of mind”
• Optional: consult Geriatrician or
Geropsychiatry
• Add significant event “Wandering Risk”
(automatic), will populate on Kardex and
Hall Pass if yes to either question
• Sitter if other interventions ineffective to
prevent wandering
• Invite family to stay overnight
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
WANDERING GUIDELINES
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
MISSING PERSON PROCEDURE
CODE FIND
• Upon determining that a patient is missing after a thorough unit search:
• Dial 777 and notify the Operator to activate and announce an Adult CODE FIND.
• Provide the operator with a much descriptive information about the patient.
• Identify where the patient was last seen.
• If patient has been identified as a “wandering risk”
• Call security at 2828 to post the patient’s picture ASAP.
• Refer to the picture of the patient on the chart to help with patient description.
• The patient should be in a maroon patient gown.
• Notify the charge nurse or department supervisor ASAP
• Refer to Abington Policy #30.01 and Security Policy #92
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
19
3RD NICHE/HELP PROJECT
Why Geriatric Resource Nursing?
• There are an estimated 5.3 million Americans with Alzheimer's disease, and as the population
ages, that number is expected to reach 7.7 million by the year 2030. Older adults with Alzheimer's
and other dementias are 3.1 times more likely to have a hospital stay than those without the
condition.
• The Nurses Improving Care to Healthsystem Elders (NICHE) geriatric resource nurse (GRN) model
is a proven framework to prepare acute care hospital registered nurses to care for this special
population of older adults.”
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
INFORMATION MEETING
• ATTENTION GERIATRIC CERTIFIED NURSES
• OR
• NURSES INTERESTED IN BECOMING
• A GERIATRIC RESOURCE NURSE (GRN)
• YOUR ARE INVITED TO ATTEND AN
• INFORMATION MEETING
• Topics for Discussion:
• How to integrate your skill set into patient care
• How to assist staff with geriatric issues
• Introduction of the NICHE Knowledge Center
• How to become a GRN or receive your Geriatric Certification
• Learn about the CARE Program
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
Benefits Of Becoming A GRN & Geriatric Certified
Geriatric and gerontological nurses are educated to understand and treat the many and varied health
needs of older adults.
• As seniors age, their health needs change and evolve.
• Geriatric and gerontological nurses observe changes in behavior on a regular basis and can
quickly recognize the progression of diseases and recommend treatments that are effective for
older adults.
• A geriatric nurse treats the whole person by: assessing changing health needs as a person ages,
managing medications, adjusting care plans as needs change, providing education and disease
prevention, and guiding and monitoring transitions of care with the older adult and their family.
• A Geriatric Nurse acts as the liaison between resident, family, and physician.
• Why Consider Certification:
• In any industry, certification in a specialization is a tool to show you have gained expertise in a
particular area. A gerontological nursing certification will set you apart from other general nurses in
the field.
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
20
How To Become A GRN
• “Geriatric Resource Nurse (GRN) The Geriatric Resource Nurse (GRN)
Core Curriculum is designed for use by NICHE members who educate
nurses in best practices for older hospitalized adults. The GRN Core
Curriculum is based on the book Evidence-Based Geriatric Nursing Protocols
for Best Practice. The fourth edition, published in 2012, includes the most
current evidence-based nursing protocols known to experts. The completed
GRN Core Curriculum provides 20 contact hours.”
• These resources are available only to NICHE member organizations, luckily
Abington Jefferson is a member.
• http://www.nicheprogram.org/knowledge_center
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
How To Become Geriatric Certified (RN-BC)
• Great News!
• Abington Jefferson Health will pay for you to become
certified!
•
•
•
•
Go To: http://www.nursecredentialing.org/Certification
Under the Success Pays Click on Gerontological Nursing.
Click Apply then the Apply On-Line tab.
The payment code is ------------.
• Submit application.
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
Eligibility Criteria
• Hold a current, active RN license in a state or territory of the United
States or hold the professional, legally recognized equivalent in
another country.
• Have practiced the equivalent of 2 years full-time as a registered
nurse.
• Have a minimum of 2,000 hours of clinical practice in the specialty
area of gerontological nursing within the last 3 years.
• Have completed 30 hours of continuing education in gerontological
nursing within the last 3 years
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
21
GRN RECRUITMENT
• RESULTS OF MEETINGS
• 80 NURSES SIGNED UP TO BECOME GRN CERTIFIED
• The units signed up to have a GRN are: all Med- Surg, 2L Trauma, 5L
(tele) ,3L (ortho), 2WW (oncology), PCU, 4we (rehab), ETC, CSU,
educators, informatics, and the school of nursing.
• ALL 80 WERE REGISTERED WITH A USERNAME AND PASSWORD
• INCREASED ATTENDANCE AT NICHE COUNCIL
• GOAL IS TO PROVIDE A RESOURCE ON EACH UNIT
• CREATED A “CARING FOR THE ELDERLY MANUAL” AS A
RESOURCE
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
STRATEGIES TO MANAGE
PROBLEM BEHAVIORS
Identify Behavior
• Assess triggers
• Physical
• Emotional
• Environmental
• Task
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
22
Fatigue
Communication
Problems
Environmental
Issues
FACTORS
THAT COULD
CAUSE
CHALLENGIN
G BEHAVIORS
Physical
Discomfort/PAIN
Over/Under
Stimulation
Fear/Anger
Frustration
With
Tasks
Agitated
Caregiver
OOB/WALKING INITIATIVE
The following process could be used to make staff, patients and families aware that bed rest is
not the optimal position to promote health in the hospitalized patient:
10:30 am daily – a Unit announcement similar to the following:
“Good morning patients – this is a reminder to ring your call bell and ask your
nurse or care aide to help you get out of bed. The bed is not your friend and being out of
bed daily will help optimize your health. Please do not attempt to get out of bed yourself.
Thank you.”
11 am weekdays – nurses should identify what patients can be walked and call the HELP
Program, 7534 and ask that their patient be walked. Please indicate name, location and time of
call.
Volunteers will walk patients and on return patients will be placed in their chair for their lunch
meal.
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
OOB/WALKING INITIATIVE
This process can occur again at 2:30 pm for the Unit announcement and 3
pm for the walking with the patient again being seated in their chair for
dinner.
During the course of the day, Nurses, Care Aides and HELP volunteers
should continuously encourage patients to perform ROM exercises.
Upper and Lower body ROM exercises can be found on patients’ TVs. It can
be accessed by using the following simple process:
Push Menu
Push 1 – TV and Entertainment
Push 5 – Relaxation
Push 1 – Upper Body ROM
Push 2 – Lower Body ROM
Push Next
Push 1 – Trivia
Staff and Volunteers are encouraged to instruct patients on how to utilize these menu items.
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
23
PATIENT WALKING PROGRAM
Studies show that increasing patient activity while in the hospital not
only reduces the chances of developing further medical
complications, such as blood clots, pneumonia, bedsores, urinary
tract infections, delirium, etc., but also improves the overall quality of
life for patients.
To schedule your patient for a walk please call the
Hospital Elder Life Program at 7534
No Doctor or PT order needed, just an OOB order.
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
BREAKING DOWN THE MYTHS OF AGING
Myth 1 – To be old is to be sick. -
Decades of research clearly discredit this myth. We are
observing increasing momentum toward the emergence of a physically and cognitively fit,
nondisabled, active elderly population.
Myth 2 – You can’t teach an old dog new tricks. –
Research shows that the capacity to learn
is lifelong.
Myth 3 – The horse is out of the barn. – Nature is remarkably forgiving.
Research shows that it
is almost never too late to begin healthy habits and benefit form those changes.
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
BREAKING DOWN THE MYTHS OF AGING
Myth 4 – The elderly don’t pull their own weight. –
Companies that have emphasized
the recruitment and retention of older workers confirm that older employees meet or surpass
expectations, often bringing the added value of increased insight and experience to the work
environment.
Myth 5 – To be old is be senile – The majority of older
people will not get a serious memory
problem. Elderly people will have Senior Moments where they forget things. The body slows down,
the brain slows down but in the absence of a disease, the elderly will not lose their intelligence.
PODIUM PRESENTER:
Annmarie Chavarria, MSN, RN, CMSRN
24
25