New initiative provides best practices for elderly

Benchmarking, indicators, guidelines for geriatrics

Baby boomers: They changed everything they’ve touched.

And in 10 years to 30 years, their massive influx into the health care system will catch most facilities unaware unless they begin now to reorient their geriatric care with a system of structured benchmarking, best practices, and clinical outcomes indicators, says Terry Fulmer, PhD, RN, FAAN, a professor of nursing at New York University and co-principal investigator of a project called Nurses Improving Care to the Hospitalized Elderly, or NICHE.

"Today’s elders consume a tremendous amount of acute health care resources and tomorrow’s will consume even more," she warns. For example, patients who are 65 years and older make up about half of hospital admissions and two-thirds of all hospital days.

Yet few hospitals have specific programs to meet the care of their elderly patients, and many nurses have little exposure to principles of geriatric nursing, says Fulmer.

"As a result, frail elders often experience preventable complications of hospitalizations such as falls or adverse drug reactions that can increase morbidity and mortality," she says.

Common geriatric syndromes such as incontinence and pressure ulcers also contribute to longer lengths of stay and increase costs for both providers and patients.

Assess patients with a profile

So how can you help your health care system position itself to meet the needs of acutely ill elders? In addition to best practice models and research-based protocols, the NICHE project includes a unique benchmarking tool called the Geriatric Institutional Assessment Profile, (GIAP) says Melissa Bottrell, MPH, project director.

This 69-question survey is designed to assess the following about your hospital’s staff:

• attitudes regarding care of the elderly;

• knowledge of institutional guidelines for care of the elderly;

• knowledge of best practices of four common geriatric syndromes;

• perceived institutional barriers to "best practice" for care of elders. (See sample questions, at right.)

"The GIAP exposes barriers to providing good geriatric care, describes possible staff problems, and provides information about the capacity and quality of the institution," Bottrell says.

By comparing their data to similar community, regional, and academic medical centers, institutions can use their profile to benchmark for strategic planning, design of new services or redesign of current ones, and professional development, says Bottrell.

She lists a typical institutional comparison, using a sample regional medical center:

• A regional medical center may have good knowledge of the specifics of preventing pressure ulcers as compared with other regional centers as well as all NICHE hospitals generally.

• Staff may have better overall core knowledge of the four geriatric syndromes and better awareness of best practice principles in geriatric nursing than other regional medical centers, but much less than combined average for all NICHE hospitals.

"Thus, this profile would show that the hospital may provide excellent care in one specific area — pressure sore prevention — but the ability to deal with the entire range of geriatric care is limited," explains Bottrell.

Hospitals have used the benchmarking data in various ways, Bottrell says.

"Some use it to provide a baseline of staff strengths and weaknesses against which to judge subsequent CQI efforts," she says. "Others use the data to help overcome resistance to change by providing objective evidence of deficiencies in knowledge and the critical need to improve outcomes for elders. Still others offer it to present to [the Joint Commission on Accreditation of Healthcare Organizations] surveyors as evidence of improvement. Finally, it’s a strong negotiating tool for contracts with insurers."

Bottrell suggests benchmarking professionals begin assessing their institutions’ ability to provide geriatric care by asking the questions below and researching national as well as local demographics. (For more information on demographics, see the box, at left.)

1. What proportion of our patient load is 65 and older? Is that proportion projected to increase in the next five years?

2. What proportion of our total patient care costs are spent for patients 65 years and older?

3. How many master’s prepared geriatric nurses do you have, or how many nurses have had special training in geriatric care?