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Service Delivery Innovation Profile

Comprehensive Program Including Specialized Inpatient Unit, Standardized Protocols, and Interdisciplinary Team Improves Care Quality for Geriatric Patients


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Snapshot

Summary

As part of the Nurses Improving Care for Healthsystem Elders (more commonly known as NICHE) national initiative, Ocean Medical Center developed a comprehensive program to improve geriatric care. Key components include evidence-based clinical protocols to standardize care, specific programs focused on preventing common geriatric conditions/adverse events, an interdisciplinary team that takes responsibility for implementing these protocols and programs, direct admission to an inpatient unit specifically designed for elderly patients, training/education incentives and other support to ensure staff expertise in geriatric care, and community outreach about delirium. The program significantly increased the percentage of nurses credentialed in gerontology, enhanced patient mobility, reduced falls, and eliminated hospital-acquired wounds.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics, including the percentage of nurses certified in gerontology, the number of patients getting out of bed each day, falls, and hospital-acquired wounds.
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Developing Organizations

Ocean Medical Center
Brick, NJend do

Use By Other Organizations

More than 270 hospitals in 40 states participate in the NICHE initiative.

Date First Implemented

2001
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Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Age > Senior adult (65-79 years)end pp

Problem Addressed

Many hospitals, including Ocean Medical Center, serve a disproportionate number of patients over the age of 65 and often do not have an adequate number of nurses with training in managing these complex geriatric patients, many of whom have multiple chronic conditions that can quickly lead to functional decline and disability. In addition, the physical environment in many inpatient geriatric units remains unsafe and uninviting.
  • Disproportionately large elderly population: More than one in five (20.7 percent) residents in the geographic region served by Ocean Medical Center are over the age of 65, well above the national average of 12.4 percent.1
  • Shortage of nurses with geriatric training: Less than 1 percent of registered nurses in the United States are certified in gerontology.2 Yet older patients account for 35 percent of hospital stays, which prompted the Joint Commission to recommend that nurses and other health professionals gain competency in geriatric care.3
  • Functional decline during hospitalization: Older inpatients often experience functional decline after suffering an acute illness, which can severely restrict activities of daily living and result in dependence on a family member or home health care following discharge.4 In fact, the typical elderly patient requires almost 4 days to regain his or her strength and mobility for each day spent in bed.5
  • Unsafe physical environmental: Many geriatric inpatient units around the country have unsafe, uninviting physical designs that can jeopardize patient safety and well-being (e.g., by leading to falls) and slow the recovery of older patients (e.g., due to inadequate pain management, untreated depression, etc.).3,6

What They Did

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Description of the Innovative Activity

As part of the Nurses Improving Care for Healthsystem Elders (more commonly known as NICHE) national initiative, Ocean Medical Center developed a comprehensive program to improve geriatric care. Key components include evidence-based clinical protocols to standardize care, specific programs focused on preventing common geriatric conditions/adverse events, an interdisciplinary team that takes responsibility for implementing these protocols and programs, direct admission to an inpatient unit specifically designed for elderly patients, training/education incentives, and other support to ensure staff expertise in geriatric care, and community outreach about delirium.
  • Evidence-based clinical protocols: Nurses, physicians, and other staff implement evidence-based protocols to standardize practice and improve the quality of geriatric care. For example, the functional status protocol monitors a patient’s ability to carry out daily tasks such as bathing and dressing while in the hospital, and specifies steps to help improve or maintain this status so as to prevent functional decline.
  • Geriatric care programs: The goal of the Hospital Elderly Life Program is to improve the hospital experience for the elderly and reduce the decline in their physical and mental abilities that commonly occurs in the elderly while hospitalized. As a result, specific programs have been developed that focus on preventing common conditions and adverse events among elderly patients. One example is an out-of-bed program that promotes mobility to help prevent the development of pressure ulcers and functional decline that can commonly occur when a patient lies in bed too long.
  • Interdisciplinary team: An interdisciplinary team comprised of gerontology-certified nurses, a geriatrician, registered dietitian, social worker, pharmacist, physical therapist, occupational therapist, speech therapist, and two case managers, works together to implement the aforementioned clinical protocols and programs, with the goal of improving each patient’s medical condition and preventing and/or managing common geriatric syndromes (e.g., delirium, Parkinson disease).
  • Direct admission to Acute Care for the Elderly (ACE) unit: In December 2006, Ocean Medical Center opened an inpatient unit designed specifically for the unique medical needs of the elderly. The unit has 8 private and 16 semiprivate rooms with large bathrooms and showers to accommodate walkers or wheelchairs, beds that are low to the ground with mattresses that relieve pressure points (to reduce the risk of pressure ulcers) and a sensor to warn nurses should a patient attempt to get out of bed without assistance, flat screen televisions to reduce eye strain, and geriatric recliners at the bedside to encourage patient mobility. Low-glare lighting is used throughout the unit to improve sight for those with visual problems, while use of low-shine polish on the floors helps to reduce the risk of falls. In addition, the unit includes an activity room that doubles as a dining room to encourage socialization and improve well-being. Patients in need of acute care who do not require cardiac or cancer care can typically be admitted directly to the unit from a nursing home or assisted living center. Referring physicians can directly contact the bed manager at the hospital to admit patients who do not need emergency care directly to the unit, thus eliminating the stress that elderly patients often experience when admitted through a fast-paced, confusing emergency department (ED). Most patients admitted to the unit are over the age of 70, and many have multiple chronic conditions and/or other common geriatric syndromes (e.g., incontinence, malnutrition, delirium, dementia, depression).
  • Certification incentives and continuing education for nurses and other staff: As part of Meridian Health System, Ocean Medical Center offers significant incentives to encourage nurses to become certified in gerontology through the American Nurses Credentialing Center, including reimbursement of test fees and salary increases once certified. To ensure continued competence in geriatric care after certification is obtained, a nurse educator trained in gerontology holds regular review courses for nurses and other staff.
  • Outreach education about delirium: Nurses and other staff attend community health fairs, providing educational handouts designed to increase awareness about the signs, causes, and prevention and treatment options for delirium (the sudden onset of confusion that causes behavior change).

Context of the Innovation

Ocean Medical Center, located in Brick, NJ, is a 281-bed, full-service community hospital that handles more than 14,000 admissions and 40,000 ED visits each year. One of four hospitals in the Meridian Health System, Ocean Medical Center also runs a 40-bed acute rehabilitation center and a 24-hour satellite ED in Point Pleasant, NJ that handles more than 17,500 patient visits annually. In 2008, the New Jersey Department of Health and Senior Services ranked Ocean Medical Center first in hospital quality in Ocean County, and among the best in the state. With support from the chief nurse executive, Regina Foley, RN, CHE, this comprehensive geriatric program began in response to the large, rapidly growing elderly population in the local service area. The nurse executive recognized that the hospital's geriatric services and facilities needed to keep pace with this growth if the organization was to meet its goal of providing state-of-the-art care that addresses the specific needs of geriatric patients.

Did It Work?

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Results

The program significantly increased the percentage of nurses credentialed in gerontology, enhanced patient mobility, reduced falls, and eliminated hospital-acquired wounds.
  • Near universal certification of nurses: The incentives substantially increased the percentage of nurses certified in gerontology, which rose from 0 percent in 2001 to 96 percent in 2009.
  • Enhanced patient mobility: The out-of-bed program increased the average number of patients who get out of bed each day from 7 in March 2007 to 30 in February 2008.
  • Fewer falls: The fall rate (number of falls divided by patient days x 100) for patients declined from 4.5 percent in 2007 to 3.2 percent in the third quarter of 2008.
  • Elimination of hospital-acquired wounds: The rate of patients experiencing hospital-acquired wounds decreased from 1.43 percent in 2007 to 0 in the third quarter of 2008.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics, including the percentage of nurses certified in gerontology, the number of patients getting out of bed each day, falls, and hospital-acquired wounds.

How They Did It

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Planning and Development Process

Key steps in planning and developing this initiative included the following:
  • Joining NICHE initiative: Ocean Medical Center joined NICHE, a national program developed by the Hartford Institute for Geriatric Nursing at the New York University College of Nursing to promote sensitive and excellent geriatric care. A national nursing program that any hospital can join by paying a membership fee, NICHE provides access to a variety of tools, including a model for designing an ACE unit, a nurse educator model, evidence-based clinical protocols and programs, networking with other facilities, and other resources. NICHE hosts an annual conference during which participating sites present and learn about innovations and best practices in geriatric care and share ideas.
  • Planning quality improvement strategy: The Geriatric Institutional Assessment Profile was administered to the entire nursing staff at Ocean Medical Center. This profile identified areas of need for education and quality initiatives and benchmarked geriatric best practice initiatives compared with peer group hospitals. This led to the development of a strategic plan, and then a small team, which included a clinician, educator, and administrator, attended a 4-day leadership conference to learn about NICHE quality improvement work and tools, and how to develop an action plan.

Resources Used and Skills Needed

  • Staffing: This initiative requires nurses certified in gerontology, geriatricians, and clinicians with experience in quality improvement.
  • Costs: Training-related expenses were $250,000, which covered the dedicated nurse educator, review courses, certification fees, and salary increases after nurses became certified. The ACE unit cost $1.3 million, primarily for furnishings and special equipment.
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Funding Sources

Meridian Health System covers training costs while Ocean Medical Center paid for the creation of the ACE unit.

The Delirium Project is supported by the Practice Change Fellowship funded by the Atlantic Philanthropies and the John A. Hartford Foundation.end fs

Tools and Other Resources

The NICHE Web site is available at http://www.nicheprogram.org/about.

Adoption Considerations

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Getting Started with This Innovation

  • Educate staff first: Staff should understand quality improvement methodologies and geriatric care models, including why they are so important to improving care.
  • Assemble initial improvement list: Make and prioritize a list of things that can be improved, including both big and small problem areas.
  • Start small and build on accomplishments: Start with a small project that has a very high probability of success, and then use this small victory to motivate staff to engage in additional projects.
  • Seek advice: Contact other hospitals that have adopted these types of programs (including the ACE unit) to learn from their successes and failures.

Sustaining This Innovation

  • Encourage staff involvement: Encourage staff to attend external gerontology-related conferences to learn about innovations and best practices.
  • Provide ongoing education: Make sure a continuous education program is available to review best practices and introduce new protocols and guidelines to staff.
  • Celebrate successes: Celebrate every success with staff, no matter how small.

Use By Other Organizations

More than 270 hospitals in 40 states participate in the NICHE initiative.

More Information

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Contact the Innovator

Ellen Barrington, MSN, RN-BC, NEA-BC
Senior Manager of Patient Care Services
Bayshore Community Hospital
727 North Beers Street
Holmdel, NJ 07733
Phone: (732) 888-7365
E-mail: ebarrington@meridianhealth.com

Innovator Disclosures

Ms. Barrington has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Meyers S. New Jersey facilities offer ACE unit for elderly. Nursing Spectrum. April 20, 2009. Article available at: http://news.nurse.com/article/20090420/NJ01/104200051.

Kresevic DM. Assessment of function. In: Capezuti E, Zwicker D, Mezey M, et al, editors. Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York: Springer Publishing Company; 2008. p. 23-40. Available at: http://www.guideline.gov/content.aspx?id=43918.

Tullmann DF, Mion LC, Fletcher K, et al. Delirium: prevention, early recognition, and treatment. In: Capezuti E, Zwicker D, Mezey M, et al, editors. Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York: Springer Publishing Company; 2008. p. 111-25. Available at: http://www.guideline.gov/content.aspx?id=43920.

Hospital Elderly Life Program can be found on the Ocean Medical Center Web site at: http://www.oceanmedicalcenter.com/OMC/services/aceunit/HospitalElderlyLifeProgram.cfm. This program was originally developed by Dr. Sharon K. Inouye and colleagues, Yale University School of Medicine and referred to as The Hospital Elder Life Program, available at: http://www.hospitalelderlifeprogram.org/public/public-main.php.

The Ocean Medical Center Web site has links to information on their ACE Unit and delirium at: http://www.oceanmedicalcenter.com/OMC/.

Footnotes

1 U.S. Census Bureau Fact Sheet [Web site]. Data retrieved November 14, 2007. Available at: http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml.
2 Institute of Medicine. Retooling for an aging America: building the health care workforce. Washington, DC: National Academies Press, 2008.
3 Health care at the crossroads: guiding principles for the development of the hospital of the future. Oakbrook Terrace, IL: The Joint Commission, 2008.
4 Boyd CM, Landefeld CS, Counsell SR, et al. Recovery of activities of daily living in older adults after hospitalization for acute medical illness. J Am Geriatr Soc. 2008;56:2171-9. [PubMed]
5 Meyers S. New Jersey facilities offer ACE unit for elderly. Nursing Spectrum. April 20, 2009. Available at: http://news.nurse.com/article/20090420/NJ01/104200051.
6 Sadler BL, Joseph A, Keller A, et al. Using evidence-based environmental design to enhance safety and quality. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2009. Available at: http://www.ihi.org/knowledge/Pages/IHIWhitePapers
/UsingEvidenceBasedEnvironmentalDesignWhitePaper.aspx
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Original publication: November 25, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: November 06, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: October 10, 2013.
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.