Staffing is critical, but so is the design and equipping of rooms
Julie Lundvick, RN-BC, BSN, CDE, has a special sensitivity to the needs of elderly patients. That sensitivity led Lundvick and others at Saint Mary’s Health Care in Grand Rapids, Mich., to develop and open a senior adult unit two years ago.
The unit is specially designed to meet the needs of elderly patients. The emphasis is on nursing care. But many physical features of the unit are unique, and could be of interest to contracting executives whose facilities are opening similar units. Given demographic trends, more facilities will be doing just that.
The needs of senior patients
Lundvick has been an RN for 33 years, and has been at Saint Mary’s for the past 22 years in various management positions. She is a certified diabetes educator and a certified geriatric nurse. As clinical service director, her areas of responsibility include senior care services, diabetes and endocrinology, the kidney transplant program, and medicine, including heart failure and orthopedics.
“Having been a diabetes educator and actively involved in teaching and management, I saw the struggles the senior care patient faces with change, with making behavior changes in lifestyle modification, with exercise, with affording the meds and strips; as well as not being listened to by their physician,” she says. “They check their blood sugar, log it, and then the physician never looks at them.”
Two years ago, her 86-year-old mother had a severe fall, followed by many surgeries, rehab and then a return to her home. “There were many challenges in all settings, both with her and the healthcare system,” says Lundvick. The experience led her to seek change at Saint Mary’s.
“I felt senior patients needed to be cared for by nurses who understood their specific needs,” she says. “We had geriatricians who understood. But the nurses did not appreciate that the senior adult – like the pediatric patient – has many specific needs. As we were looking to develop a new inpatient patient care unit, the [chief nursing officer] and I both felt there was an untapped need that Saint Mary’s needed to embrace. Timing was perfect.”
Lundvick and Michelle Pena, director of emergency, trauma and critical care services, took it upon themselves to learn more about how to develop and enhance inpatient and emergency-department care for the geriatric patient. (Persons aged 75 years and over had an annual ED visit rate of 62 visits per 100 U.S. persons, per 2007 statistics from the National Center for Health Statistics.) They found an education resource in Nurses Improving Care for Healthsystem Elders, or NICHE – a program in which Bronson Hospital in Kalamazoo, Mich., was involved.
Based at the New York University College of Nursing, NICHE was created to provide the principles and tools – particularly education – necessary to stimulate a change in the culture of healthcare facilities to deliver patient-centered care for older adults. Roughly 450 hospitals and healthcare facilities throughout North America use NICHE resources, and have achieved NICHE designation, designating their commitment and progress in serving their elderly communities.
“We sent many of our nursing leaders to a NICHE conference to become familiar with the program, and we came back and signed up for the leadership training program,” says Lundvick. “This program walked us through numerous activities to identify and assess the current state at Saint Mary’s and our future vision and needs.”
NICHE’s Geriatric Institutional Assessment Profile helped Lundvick identify strengths and areas for improvement in its care for the elderly. Areas examined included patient restraints, pressure ulcer management, and incontinence management.
Planning a senior care unit
The Saint Mary’s team visited other ACE (Acute Care for Elderly) units, “but we realized we wanted to go further and think differently,” says Lundvick. Many of these units were basic nursing home inpatient units. “They looked medical; staffing ratios were high; and if the patient’s condition became worse, they were transferred to another unit, losing all the expertise needed to care for the patient.”
The team developed a vision statement and set of guiding principles, which they drew upon to design their own unit from a physical and management standpoint. Those guiding principles included:
- Safety first.
- Maintain and improve function.
- Calm, relaxed, unhurried environment.
- Minimize unit transfers.
- Shared team approach.
- Make time to listen, know and value the patients’ stories.
- Actively involved and include families.
“Our 3 Lacks [named for the Lacks Cancer Center, where the unit is located] vision is to provide a safe, respectful, patient-defined experience while ensuring a place of healing for the senior adult and their family, which honors their unique life experience, culture and beliefs,” she says. “Care is provided by a specialized team with advanced knowledge working together to help each individual reach optimal function and independence in an environment of dignity.”
Selecting the right team was crucial. For a year prior to opening the unit, Lundvick and her team interviewed every staff member who wanted to work there. “They had to have passion for the senior adult,” she says. They also had to commit to 25 hours of self-education using
NICHE modules, and additional classroom training by the Saint Mary’s staff. All RNs are requested to become
geriatric-certified. In fact, 26 are now geriatric-certified, and more than 50 have completed the 20 hours of education for certification.
“Even the multidisciplinary team had to apply, which included the case managers, social worker, and pharmacist,” she says. “We held day-long culture change workshops, so staff could discuss the changes as well as begin to develop relationships with their new staff partners.
“Even with all this planning, our biggest challenge was the first four months of opening the unit,” she says. “There were just too many changes, and many staff were frustrated….But we survived and, looking back one year later at a celebration, the staff verbalized they were glad we had made these changes.”
The fact that the unit’s 32 inpatient beds are “acuity-adaptable” means the unit can care for the general medical patient as well as an intermediate patient.
“One of the biggest risks to a patient is when they are transferred to another unit and different staff,” says Lundvick. “During the handoff, things can get missed and important relationships are lost. So our unit wanted to decrease handoffs and transfers…. [I]f the patient’s condition worsens, we can keep them on the unit. To do this, the skills of the staff must be much higher, and all staff must be expert in the care of IV drip medications and respiratory problems, and have excellent assessment skills to pick up subtle changes quickly. The only time we transfer patients is to ICU when they become critical.”
The unit’s most common diagnoses are heart failure, sepsis, pneumonia, gastrointestinal problems and other infections. “Our average daily census is 29, but it seems like we are always full,” she says. Turnovers average 10 patients per day.
Using evidence-based designs, the team focused on designing a healing environment that:
- Encourages family involvement.
- Promotes independence and safety.
- Ensures a work environment that minimizes distraction.
- Provides access to supplies and equipment at bedside.
- Has communication tools to maximize efficiency.
Input was elicited from key stakeholders, and proposals and equipment were tested in a room mock-up. (See accompanying table to view key physical features of the unit.)
The 3 Lacks senior adult unit is delivering results. In FY11, the fall rate in the unit was 5.52 per 1,000 patient days, says Lundvick. By the end of FY12, it had fallen to 4.03, a reduction of 27 percent. Further, none of the falls in FY12 resulted in injury. Length-of-stay in the unit fell from 5.97 to 4.5 days. And readmission for heart failure and pneumonia for patients discharged from the unit over a recent six-month period stood at zero. “An incredible outcome,” she says.
Saint Mary’s intends to roll out RN education on geriatric care to all units. In addition, the hospital is remodeling three other units, in which all design principles will be incorporated.
Stats tell the story
Between 2000 and 2010, the U.S. population age 65 and older grew 15.1 percent, while the total U.S. population grew 9.7 percent, according to the 2010 Census. There were 40.3 million people 65 and older on April 1, 2010, an increase of 5.3 million people since the 2000 Census. Put another way, in 2010, the older population represented 13 percent of the total population, an increase from 12.4 percent in 2000.
Comparisons across the nation’s four regions in 2010 show that the South contains the greatest number of people 65 and older at 14.9 million, followed by the Midwest at 9 million, and the West at 8.5 million, according to the 2010 Census. The Northeast has the smallest number of people 65 and older at 7.8 million but also has the highest percentage of people 65 and older at 14.1 percent. Following the Northeast is the Midwest at 13.5 percent and the South at 13 percent. The West has the smallest percentage of people 65 and older at 11.9 percent.
What’s more, the nation’s 90-and-older population nearly tripled over the past three decades, reaching 1.9 million in 2010, according to the U.S. Census Bureau and the National Institute on Aging. Over the next four decades, this population is projected to more than quadruple.
Because of increases in life expectancy, people 90 and older now comprise 4.7 percent of the older population (age 65 and older), as compared with only 2.8 percent in 1980. By 2050, this share is likely to reach 10 percent.
The majority of people 90 and older report having one or more disabilities, living alone or in a nursing home and graduating from high school. People in this age group also are more likely to be women and to have higher widowhood, poverty and disability rates than people just under this age cutoff.
Design principles of the geriatric care unit
Saint Mary’s Health Care used evidence-based designs to configure its senior care unit. Here are some key features, according to Julie Lundvick, RN-BC, clinical service director:
- It looks like a hotel, not a hospital. “More soothing and less stressful.”
- To promote safety and prevent stumbling, there is no carpeting in the rooms, nor any ridges, even from the bathroom to room. Bathroom flooring is similar to that used around swimming pools, which, even when wet, resists slipping.
- Carpet in the hallways decrease noise. Very low nap and no ridges make it easy to push carts and wheelchairs.
- All private rooms.
- In order to keep staff in the patient rooms as much as possible and decrease steps to get supplies, meds are stored in a locked area in the room. Space is adequate for nurses to prepare meds.
- Medication-scanning technology, so RNs have their computers with scanners with them at all times. “If funds allow, it would be nice just to have computers in each room as well as scanners at the bedside,” says Lundvick.
- Nurse servers at bedside hold all supplies, including IV materials, blood tubes, dressings, etc.
- Closets hold isolation gowns and equipment, eliminating unattractive isolation carts.
- Handrails around the room and in bathrooms.
- Night lights automatically come on when the room is dark.
- Focused lighting allows adequate lighting for staff, and adjustable lighting helps senior patients who have difficulty adjusting to light changes. Patients can turn lights off and on at bedside.
- Light-filtering shades can be automatically raised and lowered by patient. Second shades are darkening, especially for patients with glaucoma or cataracts.
- Light in bathroom is located directly over toilet, and automatically turns on so even a confused patient can find the toilet.
- Showers are handicap-accessible, with fold-down benches and adjustable shower heads. They are large enough so staff can shower patients easily.
- Brackets to place bedpan, urinal and measuring container in bathroom, so nothing is on the floor.
- Raised toilets.
- Patient lifts in all rooms can accommodate up to 500 lbs. Two rooms are set up as bariatric-care rooms, supporting up to 1,000 lbs.
- Gait belts for each patient.
- Handrails in hallway on inner wall.
- Soft benches every 25 feet, so patients can rest when walking. (“We also found out these are great for families when then are asked to leave the room. They can sit out of the way but near the room.”)
- Video cameras in each room are centrally monitored.
- Cardiac monitors in each room.
- “Garage door” design at the head of beds offers room for necessary equipment, such as thermometers, blood pressure machines, ophthalmoscopes. They can be lowered when not in use, so the room is clean and uncluttered.
- Hill-Rom beds.
- Overbed tables with place for cups result in less spilling. Drawers are easy to open and close.
- Bedside tables with protectors in drawer are easy to clean. Tables can lock, so if the patient leans on it, it won’t go out from under him or her.
- Patient chairs can be reclined with the touch of a finger. “Very easy for older people.”
- Recliners with heat and massage for patient and family members.
- Safes in each patient wardrobe.
- White boards are covered by glass material, with printing underneath; easy to clean, and words don’t rub off.
- Large clocks at end of bed.
- Flat-screen, 32-inch TVs with DVD players. (“We use a lot of DVDs,” says Lundvick.)
- Large print on wall with patient’s room number and phone number.
- Artwork that speaks to the older population. Enhances memory and story-telling.
- Two fish tanks in unit.
- Fireplace in family lounge.
- Hidden parked areas for wheelchairs, making them easy to find.
- Lounge with kitchen area offers gathering place for family and patients.
- Patients requiring dialysis can have their treatments in their room, thus eliminating transfer to the dialysis unit.
- No central nursing station. Computer units and alcoves outside every two rooms allow staff to work close to the room.