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 Improving Acute Skills to Achieve Better Outomes

In light of new quality measures, providers should evaluate the current level of care their facilities are producing.

 

Skilled nursing facility nurses, as well as acute care nurses and their physician partners, need to take an increased focus on evaluating the current care that is being provided to older adults. Is this care evidence-based?
 
Research strongly supports the implementation of evidence-based nursing practice as an instrumental guide to providing safe, quality patient care with positive patient outcomes.
It is clear that these outcomes of care are now gaining ever-increasing attention and are of primary interest to providers as the health care industry continues its ongoing move toward pay-for-performance value-based purchasing, bundled payment reimbursement programs, and additional quality measure performance incentive programs.

Nursing professionals need to be supported by a structure that provides a vision for continuous improvement; empowers them to make changes; and delivers ongoing, reliable outcome information, according to a2006 article in the Journal of Nursing Care Quality.

The need for both skilled care and acute care providers to strengthen their partnership and develop a focused, collaborative, patient- and family-centered effort has become increasingly evident. The Affordable Care Act has increased the incentives for acute care systems to work closely with post-acute care providers.

New Measures

There are four new functional outcome measures regarding the skilled care resident’s self-care function and mobility status recently required of In-Patient Rehab Facilities (IPRFs). Facilities must fully document and report their up-to-date status and achieved efforts toward patient performance and discharge goals. 
The new mandate is a result of the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), according to the Centers for Medicare & Medicaid Services, in guidance released last year for compliance in 2020.

IPRFs are now striving to focus on encouraging and maintaining patient mobility and self-care ability at the highest level of function the patient can ultimately achieve or maintain. Similarly, the stimulus to also get acute care facilities fully focused on early mobility has since traveled quickly throughout the country.

Essentially, this is exactly what should be happening in all health care settings, including skilled nursing facilities, as this is what the public expects to see occurring on their behalf: anticipation of an expected return to a patient’s prior or optimal level of function.

Mobility Loss: A Common Condition

Mobility loss is particularly common in older adults during acute illness and hospitalization. Mobility loss can readily occur from patient falls experienced while in the health care environment.

Research published in a 2012 issue of Clinical Nursing Research indicates ground-level falls from a standing position among adults over 70 contribute to more severe injuries. In addition, research published in Essentials of Clinical Neurology also confirms that even seemingly minor strikes to the head can yield tears in cranial blood vessels and subdural matter.

Older adults require a needs assessment for fall risk, as well as an assessment for injury risk. Stepped-up educational changes and awareness are needed for health care workers to be alert to all types of injury outcomes and, most specifically, traumatic brain injury, as well as hip fracture.

Thus pending type, location, and severity of the injury, a CAT scan (CT) of the head or an x-ray of the hip assessing for fracture may be indicated. The patient’s medications should also be reviewed and evaluated for ongoing need.

A 2010 Clinical Geriatric Medicine study reviewed medications and fall risks and found strong evidence that benzodiazepines, antidepressants, and antipsychotics increase the risk of falls. Ongoing neurological assessments should be considered.

The use of an empirically tested fall-risk assessment tool (there are many in the literature) can be a great guide in identifying risk status upon admission and again reassessed on an on-going basis during the patient or resident stay.

Vital signs with apical pulse rates and oxygen saturation levels are critical. The apical pulse is the heartbeat heard at the apex or bottom left of the heart and taken with a stethoscope. Post-fall staff huddles, assessments, and debriefing (especially after falls with injury) are very important learning opportunities.

Significant observations that should be relayed to the primary care provider include observation or verbalizations of pain, extremity swelling, unstable vital signs, discolored skin, temperature, skin laceration or contusions, loss of consciousness, decreased range of motion, gait disturbances, evidence of head or neck injury and abnormal or erratic neurological response, bleeding that cannot be stopped, and bowel or bladder incontinence at the time of the fall. 
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Mobility Assessment Training

In the 2018 American Geriatric Society White Paper Summary titled, “The Case for Mobility Assessment in Hospitalized Older Adults,” seven recommendations were shared regarding assessing and preventing mobility loss in the hospital:
  • Promote mobility assessment in acute care;
  • Advocate for more research funding;
  • Develop consensus of standard methods to assess mobility;
  • Minimize the burden of mobility measurement;
  • Reframe the current regulatory focus on falls in acute care to a focus on safe mobility; 
  • Evaluate the feasibility of a mobility quality measure; and
  • Develop resources for acute care providers.
On the post-acute side, skilled nursing facilities can look at fostering geriatric simulation training labs to help build their staff assessment and treatment practice for more complex patient care. Some hospitals have developed a registered nurse (RN) shadowing and education program to teach both acute and skilled care nurses about the cardiac and/or respiratory care issues in each others’ settings.

Fall Prevention Program Effectiveness

Emerging hospital-based studies provide solid scientific evidence on the effect of fall prevention programs on fall rates and, more importantly, fall-related injuries. In a 2004 U.S. Department of Health and Human Services RAND Report, fall prevention programs reduced either the number of older adults who fell or the monthly rate of falling.

A 2010 study in the Clinics in Geriatric Medicine identified the key components guiding multifactorial interventions used to prevent falls in hospitals: staff education on increasing mobility, use of toileting schedules, alarm devices, and equipment.

Equipment ideally includes a walker being placed in every patient room. Toileting schedules should include no patient left in the bathroom alone (nurse with a foot or presence in the doorway) as a number of patient falls occur related to toileting needs.

Physiological Changes Associated with Aging

Further educational patient-centered knowledge of the older adult population and opportunity for increased educational awareness exist for both new and experienced nurses in both acute and skilled care regarding the changes in organ structure and function the aging process actually creates. NICHE fully addresses the older adult assessment component in its Geriatric Resource Nurse (GRN) Course Series offered through membership.

These aging changes influence the pathology perspective in regard to their atypical disease presentation and altered responses to treatment plans with varying patient outcomes encountered. This is a key element in proper diagnosis and treatment of the older adult, indicating the need to readily recognize and directly address the fact that these very real age-related changes have distinct meaning and significance in each patient’s unique care plan.

The Beers List Criteria for Potentially Inappropriate Medication Use in Older Adults, published by the American Geriatrics Society, helps clinicians determine safe medication options for older adults. Medscape also has an article by Brookes on “The 2019 Beers Criteria: What You Need to Know” and offers free access to the article at www.medscape.com.

Atypical Disease Presentation in the Older Adult

Atypical disease presentation for pneumonia, dehydration, urinary tract infection, hyperthyroidism, and also hypothyroidism is noted for older adults compared with younger. In order to deliver effective patient-centered, age-related care, health care workers need to understand and appreciate the normal age-related changes that occur in vision, hearing, smell, and taste, as well as the various bodily system changes of the oropharyngeal and gastrointestinal, cardiovascular, pulmonary, endocrine, musculoskeletal, nervous, and renal and genitourinary systems.

These significant implications make care of the older adult much more challenging and of an equally unique specialty practice for which all nurses caring for older adults really need to be enlightened and
educated on.

Older patients may also present with atypical symptoms of confusion or fatigue for a number of disease processes when ill. Aging also causes a number of changes in the oropharyngeal swallow over time. Oropharyngeal dysphagea (difficulty swallowing) is common among older adults, and the incidence is higher in patients who have had strokes, according to R. Martino et al., 2005. When untreated, it can clearly contribute to a patient’s death.

Aspiration needs very early recognition, addressing, and treatment by the patient’s or resident’s health care team. It is great to provide opportunities whereby a speech therapist can work directly with nursing staff (RNs and certified nurse assistants) and additional staff who may assist with patient-feeding needs to teach them the basic elements of the swallow assessment. This is already typically performed for stroke patient assessments, particularly in acute care.

Cardiovascular, Pulmonary Changes

The cardiovascular changes older patients undergo can contribute to orthostatic symptoms (blood pressure and pulse pressure changes may be noted in the lying, sitting, and standing positions), especially after prolonged bedrest, dehydration, or cardiovascular drug use. Falls-risk potential can rise. The pulmonary changes incurred can restrict the amount of oxygen available to the patient. There is often a notable decreased cough reflex.

The need to maintain the patient’s airways through upright positioning, frequent repositioning, and properly performing suctioning cannot be overstated. These patients need to be up in the chair for their meals. Those with significant airway disease may need to sleep sitting up in recliners.

The effects of aging on brain function can be difficult to separate from the effects of various common disorders—such as depression or stroke—among older adults. Older adults have significant reduction in their renal function. Even without the presence of disease, some adults over the age of 65 have only 60 percent renal function compared with young adults, according to a 2007 article published in Ageing Research Reviews.

The 2014 Hartford Geriatric Nurse Materials conclude that older adults suffer twice as many diagnostic complications in their experience with the medical care system. They have 1.5 times as many medication reactions and four times as many therapeutic mishaps, and they experience nine times as many falls compared with younger people.

Polypharmacy issues can be significant for these patients with their multiple comorbidities and multiple evaluations from a number of different physicians that may occur throughout their hospitalization.

The Importance of Frailty Screening

The health care team also needs to be able to recognize and address frailty onset. The onset of frailty increases with age and is highest amongst adults aged 85 years and beyond. According to a 2014 article titled, “The Frailty Syndrome,” published in Today’s Geriatric Medicine, Linda Fried, MD, originator of the Frailty Syndrome term, requires three of the following five characteristics for this diagnosis:
  • Unintentional weight loss, noting a loss of at least 10 pounds or greater than 5 percent of body weight in the prior year;
  • Muscle weakness, measured by reduced grip strength in the lowest 20 percent at baseline, adjusted for gender and body mass index;
  • Physical slowness, based on measured time it takes to walk a distance of 15 feet;
  • Poor endurance, indicated by self-reported exhaustion; and
  • Low physical activity, scored using a standardized assessment questionnaire.
Among the study population of more than 5,300 participants, there were several significant findings regarding frailty. Those meeting the Frailty Syndrome criteria were more likely to be older and in poorer health and had higher rates of comorbid chronic disease and disability.

Diagnoses of cardiovascular disease, pulmonary disease, diabetes, and arthritis, as well as impaired cognition and depression, were found to be more prevalent in this group.

Post-Acute Care Opportunities

Through partnerships with post-acute care providers that have the operational alignment (for example, 24/7 referrals) and clinical offerings (such as ventilator care units) to admit patients sooner, hospitals can limit the length of the patient stay in a much more clinically grounded, appropriate, and efficient manner.

Hence, there is a significant need for increased training on both ends of the spectrum to bring the partnership of acute and skilled care closer and closer to the public’s safety expectation of clinical and complementary skills delivery capabilities and truly collaborative practice partnerships.

Resources

■ The 5th Edition of “Evidence-Based Geriatric Nursing Protocols for Best Practice” from the American Health Care Association (Product #8233) can be purchased at AHCAPublications.org. Click the Care Practice tab to the left to learn more about the book and purchase it. Or call 800-321-0343.
Becoming a member organization of the Advisory Board Company as accessed through  www.advisory.com provides considerable information concerning the creation of a post-acute network collaborative.
RNs who care for elders can prepare for and attain board certification
in Gerontological Nursing with the AHCA/NCAL GeroNursePrep online training course. Get details and register at GeroNursePrep.com.
 
Betty Halvorson, RN, MSN, ACNS-BC, MMGT, is an adult health clinical nurse specialist to a large progressive care and medical/surgical unit and has a skilled and transitional care background. She can be reached at betty.halvorson@tmmc.com.
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