SummaryHospital-based coaches at St. Luke’s Episcopal Hospital assist nurses in developing process improvement projects to enhance geriatric care, including an early sepsis recognition program and treatment order set, a protocol for hourly rounding to prevent falls, and a fall prevention staff education game. Although results are still being analyzed, the program led to anecdotal reports of lower sepsis mortality and to below-average fall rates and contributed (along with other factors) to a decline in nurse turnover.Suggestive: The evidence consists primarily of post-implementation declines in sepsis mortality, comparisons of fall rates to national averages, and a decline in nurse turnover that can be partially attributed to the program.
Developing OrganizationsSt. Luke's Episcopal Hospital, Houston, TX
Date First Implemented2007
Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Age > Senior adult (65-79 years)
Problem AddressedThe aging of the U.S. population will lead to a growing number of health challenges,1 but many nurses are not adequately prepared to provide appropriate care to the geriatric population.2
- Aging of the population, leading to unique health challenges: Between 2005 and 2030, the population of U.S. adults aged 65 years and older will almost double; by 2030, older adults will comprise 20 percent of the population.1 Elderly individuals face many unique health-related challenges (related to both physical and mental health) that require specialized care from providers.
- Need for engagement of nurses in improvement: Although nurses may obtain professional development training in geriatric care, often they are not equipped to translate new learning into practical application within their institutions.3 For example, as in many institutions, a majority of bedside nurses at St. Luke’s Episcopal Hospital do not routinely use computer-based information and data to analyze trends and develop new initiatives to improve geriatric care. Formal coaching, mentoring, and support programs can ensure that nurses are able to translate new learning into practice,4 but relatively few nurses have access to such support.
Description of the Innovative ActivityHospital-based coaches at St. Luke’s Episcopal Hospital assist and mentor nurses in developing projects that can meaningfully improve the quality of geriatric care provided on their units. Key elements of the program include the following:
- Internal coaching and mentoring: Two coaches (with master's degrees in nursing) who function in the role of education specialists at St. Luke’s provide ongoing coaching/mentoring to eligible nurses (see last bullet in the Planning and Development Process section to learn about required training to become eligible) to help them design and implement meaningful projects to improve care processes and outcomes for geriatric patients. Participants attend a 6-month geriatric resource nurse workshop at the University of Texas Health Science Center at Houston, School of Nursing. In addition, participants attend monthly 1-hour sessions that cover a range of different topics related to project development and quality measurement. Selected topics include determining project need, collecting and aggregating data, conducting a literature review, and developing presentations. Participants earn continuing education credit for participation and are encouraged to attend additional workshops beyond the 6-month period. Other St. Luke’s staff can attend these sessions as well. Between sessions, participants meet regularly with coaches to discuss and get support for ongoing projects, with additional followup phone calls/e-mails occurring on an as-needed basis.
- Care process changes as a result of projects: Examples of projects developed through the program that led to changes in care processes include the following:
- Early sepsis recognition program and treatment order set: Two intensive care unit (ICU) nurses and two floor nurses developed an initiative to improve sepsis recognition on two general acute care units. The nurses saw the potential for reducing sepsis on these units after implementation of the Surviving Sepsis Campaign Guidelines led to a significant reduction in ICU sepsis rates. In an effort to replicate this success, the nurses designed an education program geared toward acute care unit nurses that described the impact of sepsis, highlighted research and best practices, outlined the early warning signs of sepsis, and described clinicians’ appropriate response when these signs are identified. The project nurses facilitated the revision of the sepsis order set to enable acute care nurses in non-ICU settings to initiate appropriate sepsis treatment.
- Hourly rounding to prevent falls: Through a literature search, four night-shift nurses from three acute care units identified hourly rounding as a strategy that could reduce falls in geriatric populations. The nurses developed a protocol in which registered nurses and patient care assistants alternately perform hourly rounds on all geriatric patients. The protocol specifies that the clinician must enter the room and interact with the patient during rounds, rather than simply provide a brief check from the doorway. The clinician asks patients how they are, whether they need water or to go to the bathroom, whether they have easy access to the nurse call button, and whether they are in pain. After checking with the patient, the clinician specifies that another clinician will be back in an hour and notes that the patient should use the call light if any needs arise before then.
- Staff education game about fall prevention: Two nurses developed a staff education game based on “Who Wants to be a Millionaire?” The game incorporates patient fall data and prevention information to test nurses’ knowledge and provide education about fall prevention. The game, which is on a desktop flip-chart, can be taken to unit meetings or played during specially scheduled education sessions held in staff break rooms. The nurses have used the games to instruct all patient care staff on two units; staff now use the knowledge gained from the game in everyday patient care.
- Ongoing team to identify and spread best practices: After her 6-month course participation, one nurse spearheaded the creation of a Geriatrics Best Practice Team to ensure continuing education and quality improvement related to geriatric care at St. Luke’s. This interdisciplinary, interdepartmental team meets on an ongoing basis to study various geriatrics issues and develop additional quality improvement initiatives targeted at the geriatric population.
Context of the InnovationSt. Luke’s Episcopal Hospital is a 750-bed institution with nearly 3,000 patient discharges monthly; approximately 35 to 40 percent of patients are older than 65, with these patients being cared for throughout the hospital. The director of nursing research, an education specialist with a master’s degree in gerontology, identified an educational opportunity for nurses at the nearby University of Texas Health Sciences Center that would enable them to learn best practices for providing care to geriatric patients. The director and a colleague (also an education specialist) encouraged nurses to apply and attend the first program. Although the didactic sessions were excellent, the two leaders quickly realized that the nurses still did not know how to put together a meaningful project and lacked relevant research and computer skills. Accordingly, they agreed to serve as coaches and developed an internal program to teach relevant skills and offer coaching/mentoring, with the explicit goal of ensuring that projects would have a positive impact on patient care at St. Luke’s.
ResultsAlthough results are still being analyzed, the program led to anecdotal reports of lower sepsis mortality and to below-average fall rates and contributed—along with other factors—to a decline in nurse turnover.
Suggestive: The evidence consists primarily of post-implementation declines in sepsis mortality, comparisons of fall rates to national averages, and a decline in nurse turnover that can be partially attributed to the program.
- Decline in sepsis mortality: Pre-implementation data suitable for comparative purposes is not available. However, since implementation, sepsis mortality has declined. The mortality index for severe sepsis declined from 1.19 in 2007 to 0.9 in 2009 (first quarter), and the mortality index for septic shock declined from 1 in 2007 to 0.31 in 2009 (first quarter).
- Fall rates below national average: In two of three quarters in which data were tracked, fall rates on the three medical-surgical units where hourly rounding occurred were lower than the national average (mean, as measured by the National Database of Nursing Quality Indicators) for hospitals with more than 500 beds. In one unit, mean number of falls declined from 4.38 in first quarter 2007 (pre-implementation) to 4.02 in first quarter 2008 (post-implementation); in a second unit, mean number of falls declined from 2.69 in first quarter 2007 to 2.29 in first quarter 2008.
- Lower nurse turnover: The geriatric nurse coaching program contributed (along with other factors) to a decline in nurse turnover from 10.6 percent to 8.4 percent since January 2007.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Obtaining approval for nurse participation in University of Texas workshops: The director of nursing research at St. Luke’s asked the hospitals’ chief nursing officer if a few nurses could attend the 6-month University of Texas program. The director of nursing research also made a presentation to the hospital’s Nurse Manager Council in which she described the program and asked if nurse managers would support staff participation by allowing them time off the nursing schedule to attend workshops and develop projects.
- Securing program “slots”: The University of Texas allowed St. Luke’s nurses to fill six slots during the first educational session.
- Soliciting applications: The two coaches advertised the program to nurses, gathered applications, and selected six applicants from a cross-section of acute and critical care units.
- Participating in first program: The coaches attended the program and met with the nurse participants to discuss their projects.
- Developing internal coaching program: After observing that nurses were challenged in researching and designing their projects, the coaches determined what specific help was needed, designed training content, and arranged individual and group meetings to help the nurses develop research and project development skills. After that first cohort of nurses completed the program, the coaches formalized the training content and created the Evidence-Based Practice Research Series, a monthly lecture series on care process improvement project development that is open to all staff.
- Developing individualized mentoring: The coaches also developed a mentoring program to coach the nurses and offer assistance with their specific project needs.
- Completing initial (prerequisite) educational program: A prerequisite to being eligible for coaching is attendance at a geriatric care educational program at the University of Texas Health Science Center’s Houston School of Nursing. Groups of three to eight nurses participate in each 6-month session of the center's Geriatric Resource Nursing program, which is funded by a grant from the U.S. Health Resources and Services Administration. Over the 6-month session, participants attend four 8-hour workshops to learn geriatric best practices. Working in groups, participants design and develop geriatric care improvement projects to be presented at the end of the session.
Resources Used and Skills Needed
- Staffing: The program requires no new staff, as the coaches incorporated the development of the educational lecture series as well as ongoing coaching activities into their daily routines. The educational expertise of the specialists contributed to their ability to plan the program and coach the nurses. A total of 32 St. Luke’s nurses (five cohorts) have completed the program as of June 2009.
- Costs: The University of Texas Health Sciences Center does not charge program participants a fee. The primary costs to St. Luke’s consist of the time provided by the coaches related to program development and ongoing coaching and the cost of providing staff coverage for program participants during the 6-month program:
- Coach labor cost: These costs have been estimated at approximately $2,400 to $2,800 per cohort ($40/hour for 60 to 70 hours).
- Nurse participation cost: Over the 6-month program, each program participant spends 4 days (32 hours) obtaining formal training at the University of Texas and approximately 64 hours of paid time away from patient care; at $25/hour, the cost per nurse participant is estimated at $2,400.
Funding SourcesSt. Luke's Episcopal Hospital, Houston, TX
Tools and Other ResourcesA wide variety of geriatric care tools and resources are made available to University of Texas Geriatric Resource Nurse program participants.
The 2008 Surviving Sepsis Campaign Guidelines are available at:
Dellinger RP, Mitchell M, Levy MM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008 Jan;36(1):296-327. [Erratum appears in Crit Care Med. 2008 Apr;36(4):1394-6]. Available at: http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=12231
Getting Started with This Innovation
- Provide support after sessions: Many hospitals make a significant financial investment in staff education and training; hospital leaders should consider what mechanisms can be developed internally to ensure that this training yields real, practical value through improved patient care.
- Tie participation to implementation of projects: Encourage staff to develop projects based on what they have learned. Engage staff in making their learning actionable in a way that can improve patient care and outcomes.
Sustaining This Innovation
- Engage management by highlighting link to improved outcomes: Senior management will be more likely to offer ongoing financial and other support if participation can be directly tied to positive clinical and/or financial results.
References/Related ArticlesSmith CD, Jones GB. Coaching & Mentoring Support Staff Nurse-Driven Geriatric EB Projects (poster). Houston, TX: St. Luke’s Episcopal Hospital. Provided by Claudia DiSabatino Smith, PhD(c), RN, NE-BC. Poster presented at 2008 Summer Institute for Evidence-Based Practice, San Antonio, TX. Abstract available at: http://www.acestar.uthscsa.edu/institute/su08/AbstractsWinnersList2008.shtml
1 Institute of Medicine. Retooling for an aging America: building the healthcare workforce. Washington, DC: National Academies Press; 2008.
3 Interview with Claudia D. Smith, January 13, 2009.
Kowalski K, Capser C. The coaching process: an effective tool for professional development. Nurs Adm Q. 2007 Apr-Jun;31(2):171-9. [PubMed]
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Original publication: May 12, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: June 20, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: June 08, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.