Improving care of the older adult

Improving care of the older adult

Denise L. Lyons

Patients age 65 and older account for 44% of all medical-surgical hospital admissions and 52% of hospitalized patient days at Christiana Care Health System (CCHS), a not-for-profit health care provider based in Wilmington, DE. The increase in the geriatric population prompted the health system to further educate staff regarding care of the older adult. Based on the Nurses Improving Care to Health System Elders (NICHE) initiative (Mezey et al., 2004), a program was developed in September 2001 to assist with assessment, planning, education, implementation, integration, and evaluation of the care of the geriatric population for the staff at CCHS. The We Improve Senior Health (WISH) Program is a collaborative effort among nursing, physicians, pharmacists, rehabilitative therapists, social workers, dietitians, and other disciplines to improve care to older adult patients in all settings. The WISH Program focuses on preventing and managing common geriatric syndromes. Evidence-based geriatric practice is integrated into the development and revision of care management guidelines, clinical practice guidelines, policies, and procedures to help staff maintain current knowledge of geriatrics. In addition, an Acute Care of the Elderly (ACE) unit model was implemented based on the WISH Program in July 2004.

Senior Health Resource Team

The key to implementing WISH was the development of the Senior Health Resource Team (SHRT). SHRT comprises health care professionals committed to improving geriatric care. To become a SHRT member, the staff member must complete a 16-hour course in specialized geriatric training (see Table 1). The curriculum focuses on evidence-based clinical practice for common geriatric syndromes. These geriatric syndromes are highlighted in the acronym “SPECIALS” (see Table 2).

In the last 4 years, the WISH Program has trained over 475 SHRT members systemwide. This specialized training assists other staff to care for the diverse problems of older adult patients on the inpatient units and in home care. The 16-hour course also prepares the SHRT member to pass the gerontological nursing certification exam offered by the American Nurses Credentialing Center.

Clinical Resources

Additional clinical resources available for complex geriatric issues include geriatric advanced practice nurses, a geriatric clinical pharmacist, and a geriatrician. These clinical experts round with the unit-based senior health resource team members to make recommendations to assist with adapting interventions to the geriatric patient. Additionally, quarterly “Lunch & Learns” provide an hour of lecture from a topic picked by SHRT members. These lectures are evidence-based and clinically relevant. Geriatric “Tips of the Month” provide evidence-based updates via e-mail. The bi-annual Update and Retreats provide an additional 4 hours of education for the SHRT members. Since initiation of the WISH Program, the care of the geriatric population has been enhanced through the following initiatives, algorithms, and guidelines utilizing evidence-based geriatric models and information: Constipation Algorithm; Continence Initiative; Delirium Algorithm; Skin Integrity Guideline; Sleep Initiative; and Falls Prevention, Evaluation, and Treatment Guideline. The development of a “High Risk Medications in the Elderly” table was also created as a resource for the SHRT and is available to all staff on the I-Net.

WISH Outcomes

The WISH program participants monitor progress related to these and other initiatives through regular review of outcome measures. Outcomes are analyzed by the WISH Executive Committee and shared with all SHRT members and other unit-based staff, as well as CCHS leadership. Patient outcomes analysis focuses on those WISH units with a high percentage of geriatric patients and a relatively large number of SHRT members. Indicators include:

* Fall rates: Acute care fall rates on the WISH units have decreased by an average of 15% since program implementation.

* Skin breakdown: Incidence of hospital-acquired pressure ulcers on the WISH units decreased 69%.

* Restraint use: Due to the WISH Program emphasis on alternatives to restraints, WISH unit restraint rates are below the hospital average.

* Use of incontinence briefs: The use of incontinence briefs on WISH units is below the hospital average.

* Use of indwelling urinary catheter. Patients on WISH units have fewer indwelling urinary catheters than patients on other hospital units.

* Potentially high-risk medications: Diphenhydramine (Benadryl[R]) use dropped by 54.7% since WISH Program implementation. Meperidine (Demerol[R]) use dropped by 29%, with some units decreasing use to only 1% of patients. Use of propoxyphene/acetaminophen (Darvocet[R]) decreased by more than 66%.

Overall use of other potentially high-risk medications (including antipsychotics and sedatives/hypnotics) also has declined, and a shift to more appropriate low dosages has been seen.

* Length of stay. The average length of stay of geriatric patients on the WISH units has decreased by 0.7 days. This corresponds to an annual savings of more than 4,000 patient days for the geriatric population.

Acute Care of the Elderly Unit

In addition to the WISH/SHRT model, a 31-bed ACE unit was created in July 2004 for older adults experiencing diagnoses such as change in mental status, urosepsis, pneumonia, chronic pulmonary disease, congestive heart failure, or ambulatory dysfunction. The majority of patients on this unit are admitted from extended-care and assisted-living facilities. Patients age 70 years or older entering CHHS through the emergency department are prioritized to be admitted to the ACE unit. The goal for patients admitted to the ACE unit is a return to their maximum level of functioning and former living environment as soon as possible. A geriatric nurse specialist is assigned to the ACE unit to assess all patients admitted to the unit, mentor staff, and assist in the coordination of care with the patient’s health care team. Other involved disciplines include a medical director (geriatrician), geriatric pharmacist, dietician, physical therapist, social worker, and case manager. The geriatric-trained staff works with the specialists and utilizes an interdisciplinary team approach to patient care based on the WISH Program initiatives.

They are knowledgeable about geriatric syndromes and medication side effects and complications, and work to integrate interdisciplinary evidence-based care planning.


The WISH Program and ACE unit at CCHS demonstrate a response to the unique needs of the geriatric population. The implementation of evidence-based geriatric models, policies, and procedures and the resulting decline of restraint usage, skin breakdown, falls, and use of potentially inappropriate medications demonstrate the value of focused care initiatives.

Acknowledgment: The authors would like to acknowledge the John A. Hartford Foundation Institute for Geriatric Nursing, Division of Nursing, New York University, for their support and leadership in the care of older adults.


Mezey, M., Kobayashi, M., Grossman, S., Firpo, A., Fulmer, T., &

Mitty, E. (2004). Nurses improving care to health system elders (NICHE): Implementation of best practice models. Journal of Nursing Administration, 34(10), 451-457.

Denise L. Lyons, MSN, APRN,BC, is a Board-Certified Clinical Specialist, Gerontological and Medical-Surgical Nursing, Christiana Hospital, Wilmington, DE.

Theressa Blum, MSN, APRN,BC, is a Board-Certified Nurse Practitioner, Christiana Care Health System, Wilmington, DE.

Patricia M. Curtin, MD, FACP, CMD, is a Board-Certified Geriatrician and Internist; and Section Chief, Geriatric Medicine, Christiana Care Health System, Wilmington, DE.

Shannon M. Grimley, PharmD, CGP, is a Clinical Pharmacy Specialist, Geriatric Care, Christiana Care Health System, Wilmington, DE.

Table 1.

Education of the SHRT Using

the NICHE Curriculum

[] Normal aging changes

[] Falls

[] Skin care

[] Diversional activities

[] Functional assessment

[] Depression and dementia

[] Delirium

[] Interdisciplinary collaboration

[] Medication safety

[] Continence

[] Nutrition

[] Constipation

[] Sleep

[] Pain

[] Palliative care

[] Teaching older adults

Table 2.



Pharmacy/Pain/Palliative care/Psychiatry


Cognition/Communication/Caregiver stress

Intake/Interdisciplinary collaboration


Labs/Levels/Quality of Life


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