NICHE: Nurses Improving Care for Healthsystem Elders

Troy Brown, RN


October 21, 2016

In This Article

Improving Outcomes

One large academic medical center formed an interprofessional leadership workgroup to identify evidence-based best practices and current knowledge gaps.[9] They simultaneously began a process to become designated as a NICHE facility and also developed an interprofessional plan to identify within 24 hours of admission patients who were at risk for adverse events and extended stays during hospitalization.

Nurses used the SPICES[10] risk screening tool in their admission assessment to identify skin integrity issues, problems with eating, incontinence, confusion, evidence of falls, and sleep disturbance. Team members had 24 hours to complete a standardized comprehensive geriatric evaluation of patients who screened positive for one or more criteria, and nurses gathered additional information on cognitive status, identification of delirium, delirium risk, and function.[9] Nurses also used standardized hospital screening checklists to identify the potential need for specialty services, including physical therapy, occupational therapy, and nutrition services.[9]

Pharmacists received training in medication issues of concern to geriatric patients and reviewed medical records for the presence of potentially inappropriate medications. Social work assessments included patient supports and care planning issues.[9]

On approximately the second day of admission, the interprofessional unit-based care team met briefly in a "huddle" to discuss their findings and make recommendations on the basis of team consensus. Team members assumed responsibility for implementing recommendations that fell within their specialty scope of practice.[9]

The authors wrote[9]:

[R]ecommendations requiring physician orders were communicated to the attending physicians responsible for managing the patients' diagnoses by whichever team member had been delegated with this task during the huddle. Central to these interactions was the recognition that the attending physician was the person responsible for the plan of care. All communication with attending physicians resulting from this [quality improvement] initiative was intended to relate the interprofessional team's recommendations and the rationale behind them, to supplement and broaden the scope of care to include comorbid risk prevention not necessarily associated with the primary reason for hospital admission.

Ten general medical inpatient units were randomly assigned to either implement the intervention (intervention units) or continue with their usual care (comparison units). Among patients admitted to intervention units, the mean difference in observed vs expected hospital length of stay was 1.03 days shorter (P = .001) compared with those admitted to comparison units. The incidences of complications (odds ratio [OR], 0.45; 95% CI, 0.21-0.98) and transfer to intensive care (OR, 0.45; 95% CI, 0.25-0.79) were also lower among patients admitted to intervention units compared with patients admitted to comparison units.[9]

The incidence of discharge to institutional care (OR, 1.43; 95% CI, 1.06-1.93) was higher among patients admitted to intervention units compared with those admitted to comparison units. There was no significant difference in mortality during hospitalization (OR, 0.64; 95% CI, 0.37-1.11) between the groups.[9]

As a result of NICHE program implementation, care coordination is tighter, so hospitals see improvements in their efficiency as well as the effectiveness of care. Hospitals are able to improve such outcomes as reductions in fall rates, infection rates, and length of stay, Dr Gilmartin said.

"For example, one of our members...saw a 50% reduction in length of stay and a 20% reduction in restraint use in their cardiovascular surgical patients after putting the NICHE delirium and mobility protocols in place. Now they are using their resources more effectively," Dr Gilmartin explained. "According to the [Centers for Disease Control and Prevention], the average cost for one fall for a hospital is $35,000.[11] So if you prevent one fall, NICHE would more than pay for itself."


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