nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 1

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1 NICHE 101: Resources & Tools: The NICHE Knowledge Center Eugenia Bachaleda, MA Assistant Director, Education and Resources Deirdre M. Carolan, PhD, ANP, BC, GNP, BC Nurse Practitioner, Geriatrics, Clinical Nurse Specialist, Geriatrics Inova Fairfax Hospital Objectives Detail NICHE online educational programs, methodologies, and tools, including: Courses and other resources to achieve organizational change Toolkits that lead you step by step through a specific innovation Market your program both internally and externally Introduce ways to utilize NICHE platforms to foster collaboration with NICHE mentors and other NICHE organizations Discussion forums to connect to other NICHE mentors Case histories to stimulate ideas and establish a network of peers Welcome to the NICHE Knowledge Center Home to over 300 different NICHE resources and tools Educational Courses Discussion Forums Implementation Tools LTP, Planning & Implementation Guide, Portfolio Series Organizational Strategies Clinical Improvement Models Live and Archived Webinars Measurement & Evaluation Assessment Operational Tools NICHE Solutions Series, NICHE Hospitals Report, Education Briefs, Joint Commission Crosswalk Consumer Family Tools NICHE for Patients+Family App, Need to Know by NICHE Series Media Kit & Marketing Resources Newsletters, Internal and External templates and samples NICHE Coordinator s Corner nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 1

2 NICHE Core Courses What s New: Now includes acute care, post acute care, and home healthcare settings All have a robust series of case histories for both user and coordinator The Core Courses: Introduction to Gerontology: 5 modules, 5 ANCC CEs for RNs, 5 contact hours for interdisciplinary team Geriatric Resource Nurse (GRN) 16 modules, 20 ANCC CEs for RNs Geriatric Patient Care Associate (GPCA) 17 modules, 16 contact hours for nurse assistant NICHE Specialty and Partner Courses Specialty Curriculum Care of the Older Adult with Cancer: 6 Modules, 6 ANCC CEs for RNs Critical Care Nursing of Older Adults: 6 Modules, 6 ANCC CEs for RNs Partner Curriculum Primary Care for Older Adults (PCOA) Elder Mistreatment Geriatric Emergency Nursing Education (GENE) NICHE Discussion Forums General Course Geriatric Resource Nurse (GRN) Introduction to Gerontology Geriatric Patient Care Associate (GPCA) Critical Care Nursing of Older Adults Nursing Care of the Older Adult with Cancer Resource Planning and Implementation Guide nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 2

3 NICHE Implementation Tools LTP The first step in NICHE Designation 6 week online blended learning course Planning & Implementation Guide 9 chapters Intro to NICHE Staff Development Obtaining Financial Support GRN Model Geriatric Protocols GIAP ACE Model Developing an Action Plan Magnet Alignment Post acute care version is in development NICHE Portfolio Series NICHE Portfolio Series: A catalog of all NICHE Resources Organizational Strategies These toolkits provide comprehensive guidance in the development of key initiatives within your organization. Topics include: Behavioral Health Rapid Response Certification Toolkit ED Transition of Care (both US and Canadian versions) Medications Medication Reconciliation Patient Family Advisory Councils Vaccines Clinical Improvement Models Provide a road map to system-level adoption of clinical best practices. Topics include: Restraint Reduction Pressure Ulcer Prevention Reducing the Risk of Fall-Related Injuries New for 2016 Delirium Dementia nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 3

4 Webinars Each year 20+ NICHE Online Connect Webinars are developed with NICHE member experts. Topics include: Catheters Comfort Communication Critical Care Delirium Dementia Emergency Department Environment Function and Falls GPCA GRN Heart Failure Integrated System Implementation Long Term Care (LTC) Patient and Family Medication Education NICHE Resources Safety Nutrition and Elimination Skin Oral Health Stroke Orthopedics Substance Abuse Pain/Palliative Care Transitions Measurement & Evaluation Geriatric Institutional Assessment Profile (GIAP) Assesses, knowledge of best practices in four older adult patient care areas, attitudes regarding care practices, professional issues, environment of care for older adult patients Benchmarking provided by facility size, teaching status and across internal units Unit Performance Survey Measures staffing characteristics as well as patient outcomes and provides important context when comparing and tracking unit results Annual Program Self-Evaluation Done after the first year of implementation, and then every year on the anniversary date Determines the dose of NICHE in your organization: Early, Progressive, Senior Friendly, and Exemplar Assessment Try This: Series offers assessment tools on a variety of topics relevant to the care of older adults. How to Try This Series is comprised of articles and videos presenting cases studies demonstrating the use of the Try This: series. Series include: General Assessment Series Specialty Practice Series Dementia Series Quality Improvement Series nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 4

5 Operational Tools: NICHE Solutions Series Solutions Series highlight the "success stories" that member hospitals have had related to elder care as a result of NICHE programming. Topics include: Catheters Communication Critical Care Delirium Dementia Emergency Department Environment Function and Falls Geriatric Practice GPCA GRN Medication Nutrition and Elimination Orthopedics Pain and Palliative Care Respiratory Skin Stroke Transitions Operational Tools: NICHE Hospitals Report NICHE Hospitals Report identify the positive outcomes and innovative initiatives experienced at NICHE designated organizations in their care of older adult patients. Topics include: Delirium Dementia Function Length of Stay Operationalizing NICHE Readmissions Safety Transitions Operational Tools: Education Briefs NICHE Education Briefs are concise in-service training pdfs focused on clinical care issues and trends pertinent to the Geriatric Resource Nurse (GRN) and bedside caregivers' ability to provide evidence-based care. Topics include: COPD Function GPCA Sensory Training Heart Failure Medication Neglect Orthopedics Pain Palliative Care Safety Teach-Back Vaccination nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 5

6 Operational Tools: JC Crosswalk NICHE Joint Commission Crosswalk aligns NICHE principles, standards and resources comply with the Joint Commission Standards in terms of care of the older adult hospital patient. Standards include: Environment of Care (EC) Human Resources (HR) Information Management (IM) Leadership (LD) Medication Management (MM) Nursing (NR) Performance Improvement (PI) Provision of Care (PC) Rights and Responsibilities of the Individual (RI) Consumer Family Tools: Need to Know Need to Know by NICHE are simple, easy-to-understand information bulletins designed to help prepare patients and families for the realities of hospitalization. Series include: The Basics for Older Adults Dementia: Transitions Older Adults with Illness Palliative Care Consumer Family Tools: NICHE Translates NICHE Translates helps caregivers communicate with the healthcare team around common geriatric syndromes. Topics includes: Dementia Delirium Depression Future topics include: Falls Incontinence Function Hydration Nutrition Oral Health Pain Mobility Sleep nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 6

7 Consumer Family Tools: App NICHE for Patient+Family App gives patients, families, and caregivers access all of the NICHE Consumer Family Tools on their smartphones and tablets. App includes: Need to Know by NICHE Series NICHE Translates NICHE Encyclopedia Going & Coming Home Checklist Find a NICHE Location Media Kit & Marketing Resources: Newsletter Online monthly topic specific newsletter, highlights a NICHE organization s innovation and identifies NICHE resources specific to the topic Delivers news of events, awards, tools and resources Features the latest research findings, highlights accomplishments of leaders in geriatrics Recognizes NICHE sites for efforts in promoting higher quality geriatric care Categories include: Cognitive Behavior Implementing NICHE Geriatric Care Interventions Pain & Palliative Care Patient & Family Safety Healthcare Environments Media Kit & Marketing Resources: Media Kit Designed to promote your organization as a NICHE designated facility to both internal and external audiences. Optimize the NICHE training program Recruit staff to expand NICHE internally Build support and engage internal stakeholders for sustainability Market your hospital as a quality elder care facility Materials include: Guide to NICHE Marketing Materials Announce Your NICHE Designation Kit NICHE Customizable Templates NICHE Starter & Marketing Kits nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 7

8 Houses variety of different resources, pertinent pdfs, videos, and interactive discussion forums specific to NICHE Coordinators. Resources include: Coordinator tools Instructor led course files Benchmarking Coordinator only discussion forums Marketing your program LTP: New and retraining Systems Webinars FAQs The Annual NICHE Conference Clinicians, administrators, and researchers present evidence based approaches to promote positive outcomes and achieve true patient centered care. Innovative solutions and higher quality care initiatives Emerging trends and challenges inherent in healthcare reform Policies affecting the delivery of care across healthcare systems Network with over 900 interdisciplinary healthcare providers across the continuum Meet the special and diverse needs of the older adult today! Upcoming NICHE Conferences Save the Date 2017, April 19-22, Austin, TX: Join us in 2017 for our 25th Celebration! 2018, April 10-13, Atlanta, GA 2019, April 9-12, Walt Disney World, FL nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 8

9 NICHE 101: Resources & Tools: Using NICHE Resources & Tools Eugenia Bachaleda, MA Assistant Director, Education and Resources Deirdre M. Carolan, PhD, ANP, BC, GNP, BC Nurse Practitioner, Geriatrics, Clinical Nurse Specialist, Geriatrics Inova Fairfax Hospital Physical Restraints Long term focus Inappropriate use Falls Agitation Use was too high Critical Care 89% Medical Surgical 26-49% THE TURNING POINT JCAHO!!! Posey Company Clinical Improvement Model Restraints: Phase I INTRODUCTION Determine Priority Area for Improvement Data on use Data on attitudes Data on adverse events Data, related Overcome Institutional Barriers - root cause for use? Maximize Institutional Resources Administrative Support Clinical Director as part of your Charter Implementation Team Staff Support -- Shared Governance Team with administrative support of Clinical Director Information Technology (IT)/Medical Records Support --EMR documentation tools Consider External and Internal Consultants nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 9

10 Clinical Improvement Model Restraints: Phase I NICHE listserv to garner information on member sites restraint practices Best Practices by Springer to validate our baseline against goal baseline Data collection on restraint use, reasons given and documentation compliance or noncompliance Identified root causes for issues Presented all these to everyone who would listen Clinical Improvement Model Restraints: Phase II PLAN Incorporate Patient, Family. and Staff Concerns Define Target Population and Methods for Identification Develop Adherence and Outcome Measures Develop Policies, Procedures, Tools, and Protocols Identify Equipment Needs and Modify Environment Prevent Treatment Interference/Disruption Reduce Risk of Delirium Delirium Management Reduce Likelihood of Side Rail Related Injury Reduce / Maintain Restraint Reduction Decrease Fall Risk Clinical Improvement Model Restraints: Phase III IMPLEMENT Provide Education to Staff, Patients, and Facilities Facilitate Implementation of Evidence- Based Knowledge Collaborate with Interdisciplinary Team Non-pharmacological Interventions Orientation Environment Clinical Parameters Address Related Issues nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 10

11 Clinical Improvement Model Restraints: Phase III Staff support with daily rounding Restraint logs on each unit Unit managers, charge RNs rounding and including restraints in rounding Department director rounds restraints included Supervisor rounding restraints included CNS rounding on all patients Informal and formal education based on rounding by CNS and leadership rounding Clinical Improvement Model Restraints: Phase III Restraints in ICU dropped to average of 20 per 1000 pt days Restraint in non ICU dropped to average of 3 per 1000 pt days Current restraint rates on non ICU average per 1000 pt days Blips have occurred and this led to further investigation Clinical Improvement Model Restraints: Phase IV EVALUATE AND SUSTAIN BEST PRACTICES Measure Performance, Integrity, and Quality Meet with Team and Review Results Ensure Sustainability Celebrate Successes nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 11

12 DELIRIUM the Real Issue Delirium 2010 Identified delirium as an issue which crossed all disciplines Worked to obtain data used: Quality data Risk management Audits Quantified the problem Delirium 2010 Researched the literature, then listserv, then all NICHE resources Need to Know distributed to everyone, families, staff and MDs Piloted and selected assessment tools and implemented into EMR Educated using NICHE webinars, posted Need to Know in addition to providing data nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 12

13 Delirium /3 of older patients presenting to the ED are delirious 1/3 of inpatients aged 70+ 1/2 of patients at time of admission 10 fold risk of death in the hospital 3-5 fold risk of nosocomial complications, extended LOS, NH placement Poor functional recovery Increased risk of death up to 2 years post discharge DELIRIUM IS NOT RECOGNIZED BY 80% OF MDs and 50% of RNs Delirium Baseline Data Literature prevalence: 40-50% (X 45%) Recognition by RN-<50% Recognition by MD- <20% IFH prevalence: 49-67% (x 58%) IFH Recognition by RN-<57% IFH Recognition by MD- <21% Delirium The Data Delirious patients fell 48% more frequently than those non-delirious Delirious patients had longer length of stay (+3-4 days) Delirious patients were more likely to go to higher level of care both inpatient (ICU 28% vs 13%) and upon discharge (NH 79% vs 34%) Delirious patients were more likely to be readmitted (31% vs 16%) Delirious patients had higher mortality rate (1.5% higher) These patients were restrained, having sitters and being sedated nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 13

14 Delirium Presenting the Data Use articles / literature specific to the audience Address the particular group s priorities Align with institutional priorities Identify key stake holders Provide clear data at every opportunity NICHE Network News: Delirium The NICHE Newsletter highlights a specific geriatric topic or syndrome with the following: Description of the topic An innovation from a NICHE Member facility NICHE related tools and resources NICHE Delirium Online Connect Webinars A Pilot Program Engaging Families to Collaborate in Delirium Recognition An Interdisciplinary Model for Delirium Management - Measuring Effectiveness of a Structured Interdisciplinary Process A Nursing and Occupational Therapy Collaboration to Improve Delirium Care Dilemma of Delirium in the Geriatric Hip Fracture Patient Integrative Healing Arts and the Geriatric Patient Nurse Recognition of Acute Delirium - A Pilot Study Patient Activity Cart (PAC) for Better Care Screening of Older Adults for Delirium Risk Prior to Orthopedic Surgery Utilizing the Safety Bundle - A New Model for Patient Safety Developing an Order Set for Management of Delirium with an Interdisciplinary Team nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 14

15 NICHE Delirium Solutions Sheets Solutions No. 8: Patient Activity Cart (PAC) for Better Care Solutions No. 14: Use of the Best Practice Team for the Care of Older Adults Solutions No. 19: Screening of Older Adults for Delirium Risk Prior to Orthopedic Surgery Solutions No. 23: A Nursing and Occupational Therapy Collaboration to Improve Delirium Care Solutions No. 30: Dilemma of Delirium in the Geriatric Hip Fracture Patient NICHE Delirium Resources NICHE Hospitals Report Series Report: Delirium Report: Summary Report: Operationalizing NICHE Critical Care Nursing of Older Adults Module: Delirium in Critical Illness Organizational Strategies NICHE Module: Behavioral Health Rapid Response Introduction to Gerontology (2nd Edition) Module: Age-Related Changes NICHE Delirium Resources Geriatric Resource Nurse (GRN) Module: Depression, Delirium, & Dementia Education Briefs Brief: The GRN's Bedside Guide - Simple Environmental Modifications to Enhance Safety for Older Adults Geriatric Patient Care Associate (GPCA) Module: Is Your Patient Confused? Planning & Implementation Guide The NICHE Guide: Geriatric Nursing Protocols for Best Practice A Crosswalk: Joint Commission Standards and NICHE Resources: The Provision of Care section deals with delirium. Joint Commission Crosswalk (Free) Joint Commission Crosswalk (Members) nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 15

16 Solutions CAM and CAM-ICU, Healthstream modules made mandatory Follow up audits showed need for classes and one on one coaching done Order sets created for ICU and for non-icu CAM and CAM- ICU in EMR Need To Know given to all patients and families Improved hydration, increased comfort Pharmacy review of medications Ambien limited to 5mg PRN only Mobility protocols Encouraging greater family involvement Outcomes Increased awareness on part of all disciplines More communication when mental status change noted More consistent and correct use of CAM by nursing Benzodiazepines use in delirium decreased Ambien use decreased Falls have declined Outcomes Data: 12 Months Post Implementation Delirium recognition by MD from 21% to 32% Delirium recognition by RN from 57% to 64% Falls reduced by 34% Benzo use in delirious patients declined by 21% Units with highest focus maintained restraint rates of 0.2/1000 days Unclear data on discharge level of care, mortality, and readmissions Length of stay of adult medical surgical patients was reduced by 24% nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 16

17 Summary Improved care of our older adults is attainable Improved quality of life is attainable The resources, the tools, the instruments and evidenced based practice is contained in the NICHE website The community of support is NICHE and NICHE members Questions? nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 17