This article describes the journey of Stanford Hospital to gain a Geriatric Emergency Department Accreditation and improve care for its older patients. It focuses on the role that nurse play in improving quality of geriatric care through rigorous quality improvement and research.
Stanford’s Emergency Department Nurses Improve Care for Older Patients Through Rigorous Inquiry
In his work as an emergency critical care RN, Chris Cinkowski noticed that many of the older patients presenting to Stanford’s Emergency Department (ED) had complex social and physical needs that were challenging to address. He thought “If only there was a way to identify high-risk geriatric patients earlier in their admission, then the clinical team would start the process of the transition back to health from the very beginning of their stay.” Chris wanted to make sure that any changes his team adopted would have a positive measurable impact on the health of his older patients.
Geriatric ED Accreditation
Chris was not alone in his thinking. Around the country, healthcare systems are beginning to transform their care processes to accommodate the growing numbers of seniors presenting to the ED. Interdisciplinary effort is required to provide quality care for older patients with multiple chronic conditions, frailty, polypharmacy, and social needs. Since the ED is the first point of entry into the health system for many older patients, hospitals focus on making it a “senior friendly” environment.
To support this goal, the American College of Emergency Physicians launched the Geriatric Emergency Department Accreditation (GEDA) program in 2018. This promotes a culture of care tailored to the specific needs of older adults in the ED through enhanced staffing and education, geriatric-focused policies and protocols, quality improvement and metrics, and optimal preparation of the physical environment. The accreditation is stratified into 3 levels, with Level 1 being the highest level. Geriatric-focused EDs have shown better patient outcomes, which positively impact hospitals, providers, family members and the local community.
Specialized equipment, staffing and physical modifications to the ED require resources and leadership support on multiple levels. However, some changes can be implemented more easily , including training existing staff in geriatric competencies and modifying the workflows to include geriatric assessments and interventions.
Transforming the Stanford ED
Stanford Health Care recognizes the importance of GEDA to demonstrate the quality care it offers to seniors in the surrounding community. SHC had over 75,000 emergency department visits in fiscal year 2018 and 22% of patients were over the age of 65. The Stanford ED currently has Level 3 GEDA certification but because the volume of geriatric patients is growing, it began an initiative to obtain Level 2 accreditation.
A large interdisciplinary team of ED clinicians, including pharmacists, registered nurses, rehabilitation therapists, and physicians, have created a plan for interventions to improve the care for older patients. Physical therapists are developing an early mobilization and fall prevention program. Pharmacists are working on a medication reconciliation pathway to reduce the number of inappropriate medications for the elderly. Social workers and case managers are looking at strengthening the elder abuse reporting and transitional care pathway. These interventions are vital to have a sizable impact on the diverse needs of older patients presenting to the ED.
For example, delirium is present in 10-31% of older adults at hospital admission, making it a significant health issue. Individuals with delirium and those at risk are often not identified early in their emergency department stay, and opportunities for prevention and early intervention are missed. Because nurses spend more direct care time with older patients, they can assess for sudden changes in status and provide non-pharmacological interventions. One of the goals for the level 2 GEDA accreditation to promote early identification of older adults who already have delirium and identify elders at risk for developing it, using interventions that can be implemented by nurses.
Geriatric Training for Nurses in the ED
To tackle this issue, Chris Cinkowski worked with Assistant Patient Care Manager, Hannah McClellen, to develop a quality improvement initiative to rapidly identify delirium among geriatric patients. They developed a new care pathway where nurses use the Confusion Assessment Method (CAM) and Six Item Screen (SIS) exams as part of the primary assessment of every patient 65+ presenting to the ED, followed by non-pharmacological interventions for patients that screen positive.
Chris and Hannah partnered with nursing education to develop immersive training that increases both knowledge and empathy for the staff. Approximately 250 RNs working in Stanford emergency department will go through the training assessment with the CAM. First, nurses will view one of three virtual reality scenarios in which they will observe what it is like to live with dementia in the community setting. The second modality is an in-person training session that focuses on three aspects of delirium and cognitive impairment: Importance, Screening and Documentation, and Interventions. However, culture change does not end with education, and there are multiple steps to ensuring that nurses will continue to perform these assessments.
Rigorous Evaluation of New Care Pathway
It is challenging to introduce a new care pathway in an already busy work environment like the ED. Barriers to timely screening include time constraints, competing priorities and not enough time to fully form the habit of screening each patient. That is why Chris and his team partnered with Maria Yefimova PhD, RN from the Office of Research, Patient Care Services to develop a comprehensive evaluation plan to make sure this new practice is sustained. They worked together to develop an implementation strategy that enhanced education with continuous positive feedback to ED nurses on their performance. It was also important to select measurable process and outcome measures to monitor progress as well as to track barriers or facilitators of success for this project.
To evaluate the effectiveness of the new training and care pathway, nurses will receive a pre-test prior to completing the educational session and a post-test 3 months after their completion to evaluate knowledge retention. Reminders at daily huddles during and after the intervention period (3 months) will focus on the new expectation that nurses complete the exam during their initial assessment or before departure from the ED. This will be included in the daily huddles every other week and talked about at shift change by the nurse manager. These huddles will provide opportunity for feedback on feasibility, barriers, and opportunities to improve the process. The team will also measure the effect of this intervention on referral to ancillary services and hospital length of stay for all patients over the age of 65. This will help determine the effect on patient outcomes and get more buy-in from leadership for other GEDA interventions.
Nurses are critical components in a large system transformation like the Geriatric Emergency Department Accreditation. When asked what parts of the GEDA process he enjoys best, Chris says “It has been a joy to work with multi-disciplinary teams to see everyone’s passion for geriatrics and learn what each role is already doing for this population at Stanford. It has also been amazing to see the enthusiasm for the process ahead.” Chris offers advice for nurses looking to participate in research or QI to stay observant in your daily work, look for something you are passionate about, and read the current literature on the topic. Once you have an idea, find partners that are just as passionate as you. Good quality improvement or research is about the team, with each member contributing to sculpt the final product.
Article By: Maria Yefimova