NICHE
Nurses Improving Care of
Health System Elders
The SPICES Tool
February, 2011
Rita LaReau MSN GNP BC
Geriatric Clinical Nurse Specialist
Bronson Methodist Hospital
lareaur@bronsonhg.org
Learning Objectives
Upon completion of this program the
learner will be able to:
•
Describe a basic assessment tool for
assessment of the geriatric patient.
•
State demographics related to falls in
older adults.
•
State interventions to prevent a fall.
Older Adult Patients
 Older Adult Patients > age 65
 Challenge to health care providers
 Numerous & complex diagnoses
 Shorter hospital stays
 Navigation through hospital process
 Potential for cascade of poor outcomes
Hartford Institute
 Nurses Improving Care for Health System
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Elders (NICHE) 1992
Sponsored by John A. Hartford Foundation
Institute for Geriatric Nursing
@ New York University
National nursing led initiative: Nationally
Recognized Nursing Leaders
Currently over 200 NICHE sites
Geriatric Resource Nurse (GRN) Model
NICHE Outcomes
 Enhance Nursing Knowledge and Skills
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Regarding the Treatment of Common
Geriatric Syndromes
Increase Patient Satisfaction
Decrease Length of Stay
Reduce Readmission Rates
Reduce Costs Associated with Elder Care.
Evidenced Based Practice
 Research based protocols that focus
specifically on common geriatric care
syndromes
 Reflect current research and standards
including those developed by The Agency For
Health Care Policy Research (AHCPR)
 Accessible and usable by bedside nurses
Evidenced Based Resources
 http://nicheprogram.org
 http://www.consultgerirn.org
 Hartford Institute Protocols Book
 Evidenced Based NICHE Tools: Handout
Geriatric Syndromes
 Physical Restraints
 Depression
 Pressure Ulcers
 Incontinence
 Sleep Disturbances
 Eating/Feeding
 Advance Directives
 Acute Confusion/
 Pain Management
Delirium
 Medication Management
 Falls
 Discharge Planning
 Assessing Cognitive
Function
 Functional
Assessment
Bronson NICHE Program
NICHE Program
 Geriatric Independent Study Modules
 NICHE AGEducation Day (8 hours)
 Support for Gerontological Nurse Certification
NICHE Clinical Support
Geriatric Resource Nurse (GRN) Program
 Geriatric Clinical Nurse Specialist (GCNS)
 Certified GRNs
 GCNS supports GRNs in their new roles
– Instruction
– Nurse-to-Nurse Consultation
– Resource Development
– Geriatric Clinical Excellence
 Assesses selected geriatric patients in context
of geriatric syndromes
GRN Rounding/Consult
 Assist staff in assessing, planning,
implementing, and evaluating geriatric care
according to SPICES Tool
 Evaluate and provide feedback to staff
regarding SPICES Tool assessments and
interventions
 Augment staff knowledge and attitudes as
they relate to geriatric care.
GRN Rounding/Consult
 Disseminate information about geriatric
care management through a variety of
ways including
– Documentation
• Progress Notes
• CareGraph
 Collaborate with NICHE Council and
other resource people as necessary.
SPICES Tool
GRN Core Screening Tool
– Raises awareness and triggers
further evaluation & documentation
Skin Impairment
Poor Nutrition
Incontinence
Confusion
Evidence of Falls
Sleep Disturbances
Geriatric Assessment
Rounding
GRNs
 Use SPICES Tool for assessing patients > age 70
– Problems with
• Skin
– Skin Integrity Score < 18 (Braden Tool)
• Problems with Eating
– Less than 80% ideal Body Weight
– % food eaten < 25% > 6 days (25% > $
days (80+ Yrs)
• Incontinence
– Stress/Urge/Functional/Diarrhea/Foley
Geriatric Assessment
Rounding
• Cognition
– Mini-Cog, Geriatric Depression Scale (GDS)
– Positive Confusion Assessment Method (CAM), Anxiety
– Sensory Impairment
– Evidence of Dementia, Depression
• Evidence of Falls
– Confusion, Depression, Elimination, Dizziness, Gender,
Antiepileptics, BZD, Mobility/Get Up and Go
• Sleep
– Difficulty falling/ staying asleep
– Sleep promotion interventions
Reasons for Geriatric
Resource Nurse Consult
Some potential reasons for consult:
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Delirium
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Dementia
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Sitter
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Falls
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Sleep Problems
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Problems with eating
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Use of Diversional Activities
Evidence of Falls/Function
What Do These People Have
in Common?
 Laura Ashley (Fashion Designer)
 Robert Atkins (Doctor)
 George Washington Carver (Inventor)
 Genghis Khan (Royalty)
 Robert Peel (Head of State)
 Kurt Vonnegut (Author)
 William the Conqueror (Royalty)
 Malcolm Baldrige (Politician)
Cause of Death:
Accidental Fall
Why Do We Need to Be
Concerned?
 Injuries
 Deaths
 Associated complications
 Costs
Demographics
 Community-dwelling persons >
65 years:
– 30% - 40% fall each year
 Hip fractures:
– 90% result from a fall
– 20% die within one year
 Leading cause of death from
injury in those > 65 years old: A
fall
Demographics
 Falls are associated
with:
• Decline in functional
status
• Development of “fear
of falling”
• Greater likelihood of
nursing home
placement
Cost of a Fall
 Costs associated with fall-related
injuries in persons > 65 years old:
• Mean hospital cost: $15,938
• Lifetime costs: $12.6 billion
Fall - Defined
 Fall: A fall is an unplanned
descent to the floor ( or extension
of the floor, e.g., trash can or
other equipment) with or without
injury to the patient.
 All types of falls are to be
included whether they result from
physiological reasons (fainting) or
environmental reasons (slippery
floor).
Fall - Defined
 Include assisted falls – when a staff member
attempts to minimize the impact of the fall.
 Included in this definition are patients found
lying on the floor unable to account for their
situation.
Fall Prevention: All
Patients
Orient patient to environment
Educate patient/family using:
– The Fall Prevention Scripting
• Use TeachBack
– Prevent Falls in the Hospital handout
– Both located on the Nurses and Clinician’s
page under Fall Prevention Resource Tools
Orient to ‘Call to Stop a Fall’ sign
Maintain call light in reach and assess/ensure
ability to use.
Fall Prevention: All Patients
(1)
 Place bed in low position and lock
 Utilize non-slip well-fitted
footwear
 Leave bathroom or night light on
 Wipe up spills immediately
 Arrange furniture/objects safely
 Place patient items in reach
Fall Prevention: All
Patients (2)
 Teach transfer techniques prn
 Assist in meeting elimination needs
 Evaluate potential medication side
effects
 Assure ambulation as ordered
 Encourage use of handrails in
bathroom and hall
Fall Prevention: All Patients
(3)
 ROM BID by nursing staff if not out of
bed
 Keep assistive devices (glasses, canes
walkers etc.) at bedside within reach
 Evaluate patient’s ability to interpret
information (Can they hear, feel and
interpret? Need hearing amplifier or
hearing aides?)
 Utilize upper 2 of 4 side rails in raised
position, to maintain freedom of
movement
Hendrich II Fall Risk Model
 Fall Risk Assessment Tool used at
Bronson
 Identifies patient risk factors that
contribute to fall potential.
Hendrich, A., Bender, P., Nyhuis A., Validation of the Hendrich II Fall Risk Model: A Large Concurrent
Case/Control Study of Hospitalized Patients. 2003. Applied Nursing Research (16) 1, pp 9-21
Risk Factors Hendrich II
Fall Risk Model
•Confusion/Disorientation/
Impulsivity (4)
•Depression (2)
•Altered Elimination (1)
•Medications:
•Any Administered
Antiepileptics (2)
•Any Administered
Benzodiazepines (1)
•Gender (1)
•Dizziness/Vertigo (1)
•Unable to rise in a
single movement
•Get Up and Go Test)
(0-4)
Fall Risk Interventions
Fall Watch Option
 ‘Fall Watch’ Option: Reserved for
patients who require intensive
surveillance.
 ‘Fall Watch’ Criteria:
•
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Non-compliance of fall precautions
Impulsive or lack of safety
awareness
•
Discretion of nurse
Fall Watch Option
 A magnetic Fall Watch sign is
placed on the door frame of any
patient identified as high risk.
 When passing by that patient room,
all hospital employees are to look
into the room to observe if the
patient is safe.
Fall Watch Option
 If safe, employees continue on their
way.
 If patient is at risk, the employee is to
maintain patient safety and put on the
call light for assistance.
 ‘Fall Watch’ is the responsibility of
everyone on the unit to ensure patient
safety.
 Keep room doors and curtains open.
Community:Interventions to
Consider
 Cardiac evaluation
 Vision improvement
 Home safety modifications
 Medication reduction
 Physical Therapy
 Exercise
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Tinetti ME, Kumar C. The patient who falls: “It’s always a trade-off. JAMA 2010 Jan 20;303(3):258-66
Bronson Intranet Handouts
Questions?
NICHE
Nurses Improving Care of Health
System Elders
The SPICES Tool