The NICHE Knowledge Center - Amazon S3 · The NICHE Knowledge Center Eugenia Bachaleda, MA...

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

• 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

Objectives

Welcome to the NICHE Knowledge Center

Educational Courses

Discussion Forums

Implementation ToolsLTP, Planning & Implementation Guide, Portfolio Series

Organizational Strategies

Clinical Improvement Models

Live and Archived Webinars

Measurement & Evaluation

Assessment

Operational ToolsNICHE Solutions Series, NICHE Hospitals Report,

Education Briefs, Joint Commission Crosswalk

Consumer Family ToolsNICHE for Patients+Family App, Need to Know by NICHE

Series

Media Kit & Marketing ResourcesNewsletters, Internal and External templates and samples

NICHE Coordinator’s Corner

Home to over 300 different NICHE resources and tools


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 Core 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 Specialty and Partner Courses

• 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

NICHE Discussion Forums


• LTP

– The first step in NICHE Designation

– 6 week online blended learning course

• Planning & Implementation Guide

– 9 chapters

– Post acute care version is in development

• NICHE Portfolio Series

– NICHE Portfolio Series: A catalog of all NICHE Resources

NICHE Implementation Tools

• Intro to NICHE

• GRN Model

• ACE Model

• Staff Development

• Geriatric Protocols

• Developing an Action Plan

• Obtaining Financial Support

• GIAP

• Magnet Alignment

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

Organizational Strategies

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

Clinical Improvement Models


Each year 20+ NICHE Online Connect Webinars are developed with NICHE member experts.

Topics include:

Webinars

• Catheters

• Comfort

• Communication

• Critical Care

• Delirium

• Dementia

• Emergency Department

• Environment

• Function and Falls

• GPCA

• GRN

• Heart Failure

• Integrated System

Implementation

• Long Term Care (LTC)

• Medication

• NICHE Resources

• Nutrition and Elimination

• Oral Health

• Orthopedics

• Pain/Palliative Care

• Patient and Family

Education

• Safety

• Skin

• Stroke

• Substance Abuse

• Transitions

• 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

Measurement & Evaluation

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


Solutions Series highlight the "success stories" that member hospitals have had

related to elder care as a result of NICHE programming.

Topics include:

Operational Tools: NICHE Solutions Series

• 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

NICHE Hospitals Report identify the positive outcomes and innovative initiatives

experienced at NICHE designated organizations in their care of older adult patients.

Topics include:

Operational Tools: NICHE Hospitals Report

• Delirium

• Dementia

• Function

• Length of Stay

• Operationalizing NICHE

• Readmissions

• Safety

• Transitions

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:

Operational Tools: Education Briefs

• COPD

• Function

• GPCA Sensory Training

• Heart Failure

• Medication

• Neglect

• Orthopedics

• Pain

• Palliative Care

• Safety

• “Teach-Back”

• Vaccination


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:

Operational Tools: JC Crosswalk

• 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

• Dementia • Delirium • Depression

NICHE Translates helps caregivers communicate with the healthcare team

around common geriatric syndromes.

Topics includes:

Future topics include:

Consumer Family Tools: NICHE Translates

• Falls

• Function

• Hydration

• Incontinence

• Nutrition

• Oral Health

• Pain

• Mobility

• Sleep


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:

Consumer Family Tools: App

• Need to Know by NICHE Series

• NICHE Translates

• NICHE Encyclopedia

• Going & Coming Home Checklist

• Find a NICHE Location

• 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:

Media Kit & Marketing Resources:

Newsletter

• Cognitive Behavior

• Geriatric Care Interventions

• Implementing NICHE

• Pain & Palliative Care

• Patient & Family

• Safety

• Healthcare Environments

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:

Media Kit & Marketing Resources:

Media Kit

• Guide to NICHE Marketing Materials

• Announce Your NICHE Designation Kit

• NICHE Customizable Templates

• NICHE Starter & Marketing Kits


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

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!

The Annual NICHE Conference

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


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 RestraintsTHE TURNING POINT JCAHO!!!

Posey Company

• Long term focus

• Inappropriate use

– Falls

– Agitation

• Use was too high

– Critical Care – 89%

– Medical Surgical – 26-49%

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

Clinical Improvement Model Restraints: Phase I


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


• 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



• 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 0.5 -1 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


DELIRIUM

the Real Issue

• Identified delirium as an issue which crossed all disciplines

• Worked to obtain data – used:

– Quality data

– Risk management

– Audits

• Quantified the problem

Delirium 2010

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


Delirium 2010

• 1/3 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


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


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)


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%


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?

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