Virtual ACE Update

Demo ACE Tracker

How we are trying to make your life better  Implementing Virtual ACE on Hospitalist Units at UAB Hospital also known as….. How we are trying to make your life better 

Immobility/Functional Decline Major, Potentially Life-Threatening Geriatric Syndromes That are Linked and Impact Care Transitions Care Transition Plan Pain Immobility/Functional Decline Delirium

A Real Case: Mr. S: Mobility, Pain, and Delirium are LINKED Privileged Patient Safety Work Product Document This information and any attachments are prepared and maintained for use in the quality improvement process of the UAB Health System Patient Safety Organization, and University Hospitals and its’ clinics, considered privileged and confidential pursuant to the Code of Alabama, Sections 6-5-333, 22-21-8, 34-24-58, and the Patient Safety and Quality Improvement Act of 2005.

What is the Virtual ACE Intervention? Unit-Based Care Delivery Redesign that trains all providers in: The “Why” Function/Safe Mobility Pain Assessment and Management Delirium Prevention and Management Care Transitions Delirium Prevention Toolbox

Ortho units outcomes

Post-Training (5M + OSCU) Variable Pre-Training (5M + OSCU) N=53 Post-Training (5M + OSCU) N=138 P-value Age, years Mean Range 73.9 ± 7.4 65-94 74.6 ± 7.4 NS Female Gender, N(%) 37 (70%) 73 (53%) P=.03 Service, N(%) Ortho Service Other Surgery Service Medicine Service Bedded ED 35 (66%) 1 (2%) 17 (32%) 94 (68%) 5 (4%) 38 (28%) 1 (1%) Unit, N(%) OSCU 5 Main 31 (59%) 22 (41%) 61 (44%) 77 (56%) History of Fall in last 3 months, N(%) 25 (47%) 51 (37%) Mean Baseline Katz Score 10.28 ± 3.5 10.00 ± 3.5 Mean Current Katz at index visit 7.28 ± 4.7 8.18 ± 4.2 Abnormal SIS 8 (15%) 22 (16%) Mean # of sched meds at index visit 8.77 ± 4.0 9.64 ± 4.0 Includes some hospitalist patients Data through 8-12-15

Geriatric care process outcomes

Geriatric Processes of Care All Patients, 5 Main and OSCU Completion at Index Visit Data as of 8-12-15

Mobility outcomes

Mobility in the Prior 24 Hours All Patients, All Visits, 5 Main and OSCU Pre: 65 encounters in 50 patients Post: 115 encounters in 81 patients Data as of 8-12-15

Cognition outcomes

Delirium Documentation Status All Patients, All Visits, 5 Main and OSCU Pre: 44 patients, 60 NUDESCs by RA Post: 61 patients, 84 NUDESCs by RA; 93 patients, 116 NUDESC by staff Data as of 8-12-15

Early ACE Unit Outcomes

Patient Descriptors: 4 Main through 7-7-15 Variable 4 Main Pre-Training (N=84) 4 Main During Training (N=34) 4 Main Post-Training (N=106) Age Mean Range 79.9 ± 8.6 65-97 79.5 ± 7.7 65-95 79.7 ± 8.4 65-96 Gender, N (%) Female 59 (70%) 22 (65%) 71 (67%) Race, N(%) White Black Other 48 (57%) 33 (39%) 3 (4%) 20 (59%) 13 (38%) 1 (3%) 65 (63%) 39 (38%) 0 (0%) Cogn Impairment documented in Problem List in chart 15 (18%) 2 (6%) 23 (22%) SIS performed on admit 77 (92%) 33 (97%) 97 (92%) % Patients with abnormal SIS score 44% 48% 46% NUDESC performed 10 (12%) 4 (12%) 88 (83%)

Virtual ACE Mobility Data: 4 Main Through 7-7-15 Characteristic 4 Main Pre-Training (N=84) 4 Main During Training (N=34) 4 Main Post-Training (N=106) N (%) Patients with Geri Screen completed on admission Baseline Katz Current Katz 69 (82%) 68 (81%) 32 (94%) 29 (85%) 96 (91%) 95 (90%) Hospital Day at time of first mobility screen, days Mean Range 2.9 ± 2.9 1-18 4.0 ± 3.6 1-12 3.7 ± 6.5 1-59 Baseline Katz Score 8.4 ± 4.5 0-12 9.3 ± 3.7 8.3 ± 4.3 Current Katz Score 6.7 ± 4.9 6.9 ± 4.5 6.5 ± 4.4 History of a fall in last 3 months, N (%) 28 (33%) 10 (29%) 48 (45%)

Virtual ACE Mobility Data 4 Main Through 7-7-15: All Patients Age ≥ 65 Pre-Training: 85 encounters in 64 patients During Training: 25 encounters in 25 patients Post-Training: 108 encounters in 89 patients

Virtual ACE Mobility Data 4 Main Through 7-7-15: All Patients Age ≥ 65 AND Current Katz Index Score ≥ 9 Pre-Training: 31 encounters in 23 patients During Training: 8 encounters in 8 patients Post-Training: 37 encounters in 33 patients

4 Main: Promoting Safe Mobility and Cognitive Stimulation Note this data is a convenience sample of random, one-time visits and observations

Virtual ACE Nurse-Driven Care Protocols

Pain Assessment and Management

Algorithm for Pain Management

Cmax Half-life (t1/2) IV SC / IM Plasma Concentration po / pr Time 6 mins Key to proper med frequencies IV 30 mins SC / IM Cmax po / pr Plasma Concentration 60 mins Half-life (t1/2) Time

Maintaining Mobility This allows patients to remain independent and be able to return to the activities they enjoy.

Safe Mobility Care Protocol

Safe Mobility Care Protocol

Delirium Delirium may be the only sign of an acute medical emergency in older adults Despite its importance, delirium is under-recognized by nurses and physicians. Personal philosophies about aging as well as the inability to distinguish delirium from dementia are contributing factors. The hypoactive subtype of delirium may not be readily identified due to the absence of agitated behavior, a characteristic that usually serves as an alert to staff. In addition, time constraints and a lack of systematic screening are barriers to the early recognition of delirium in older hospitalized adults. Low physician support may also be a factor in some clinical areas.

What are the clinical criteria for delirium? Every care provider at UAB Hospital MUST commit to knowing these criteria for diagnosing delirium Ely et al, Crit Care Med 2001;29(7):1370-79; Pun, Ely. Chest 2007;132:624-36

Nursing Delirium Screening Scale (NUDESC): The Early Warning System for Delirium

DELIRIUM PREVENTION TOOLBOX Nurses are using these tools in patients with ANY ONE of the following risk factors for delirium: SIS ≥ 2 NUDESC ≥ 2 Katz score < 9 Vision impairment Hearing impairment BUN/Cr ratio ≥ 18 Anyone else you see as frail, bored, or at risk

EVERY patient deserves STOP DELIRIUM Care!

If the NUDESC Score is ≥ 2, then….

Demo Delirium Order Set

QU E S T I ON