Grow your own experts in hospital elder care

I Geriatric clinical specialists can't be everywhere, but they can transform willing medical-surgical nurses into on-site geriatric resources. hile few hospital nurses would consider themselves geriatric nurses, they are, nonetheless, being called upon to provide the specialized care necessary to help elderly patients successfully recover and be discharged to an appropriate setting. Over 40 percent of all United States hospital beds are occupied by adults over 65, and each year the acuity level of elderly patients rises(l). Efforts to resolve one set of problems in acutely ill elders all too often provoke a new set. Consider, for example, the following case: Elsa Brown, 87, was admitted to the emergency department of a nursing home when she fell off the bedside commode after dinner. X-rays revealed a righthip fracture. It was 10 PM by the time Ms. Brown was prepared for surgery and 1:30 AM when she was brought to the very active recovery room. All the lights were on, and there were three other postoperative cases, plus a number of monitors and machines whooshing and beeping. Ms. Brown would awake intermittently from her anesthesia and Cl}1 out

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for "Annie, " her nurse from the nursing home where she had resided six years. The recovery room nurses reminded her that she was at the hospital because she had broken her hip and assured her that they would take good care of her. Though this seemed to comfort the woman, she continued to thrash throughout the night. Meperidine (Demerol) 50 mg. q 2-3 hours PRN to relieve pain was prescribed, but the recovery room nurses hesitated to give her much medication. They were afraid that a high dose might intensify her confusion. At 5 AM Ms. Brown was moved to the general unit, and at 5:30 A Nt the surgical team made rounds to check her postoperative course. By 6:30 AM, the day shift began to arrive. At 7 AM, the primary nurse came in to introduce herself, check Ms. Brown s vitalsigns, and start care. Soon, lunch activities were beginning. Then, Ms. Brown's family came in and were very concerned about their mother: They visited for the remainder of the afternoon. That evening Ms. Brown began to hallucinate, yelling, ccOperator; operator. " She was given haloperidol (Haldol) 2 mg. In less than 24 hours, this elderly woman was in five different settings: the nursing home, the emergency department, the operating suite, the recovery room, and the general unit. She was assaulted by a barrage of medications, procedures, and people; her sleep was, to say the least, disrupted. The main problem was her hip, but an iatrogenic confusion resulted. This case is an example of good intent with negative outcomes for the elder. Nursing care of elders in hospitals often must center around such issues as preventing confusion and encouraging mobility. As with Ms. Brown, an elder's function and behavior problems can eclipse the original admitting diagnosis. In the typical clinical course for hospitalized elders like Ms. Brown, however, staff overlook these critical issues. The first several days of Ms. Brown's has pitalization cen Lered around basic postoperative care: encouraging her to turn, cough, and breathe deeply; controlling pain; caring for wounds; and helping her out of bed. In the course of that time,

however, she may have episodes of incontinence, due in part to anesthesiainduced atonic bladder. Once an elderly patient is labelled incontinent in the nursing report, any expectation of changing that status is very low.The nurses' progress notes in the patient's record will often list the number of times the person was incontinent, but there may be little comment on interventionsto reverse it. Similarly, if the elder has difficulty sleeping, sleep deprivation may induce bizarre behavior. The nursing staff may obtain an order for flurazepam (Dalmane) or another hypnotic sedative, and they may administer it with resulting deleterious side effects. Finding a Better Way

Acute confusion is very common in hospitalized elders and can be an earlysign of acute illness,such as hypoxia or infection. Many studies suggest the postoperative incidence of delirium is about 25 percent in elders(2). A preoperative mental status examination helps in assessing confusion. When a patient with dementia becomes delirious, the acute confusion all too often is ignored or misdiagnosed due to the dementia label in the cardex. In a hospital, the common approach to confusion is to treat the behavior rather than the causes. Staff may use physical or chemical restraints that may then impede an elderly person's ability to feed himself, get to the bathroom, or care for himself. That may be just the beginning of iatrogenically induced disability. If the unit is short of nursing staff, the elder may not be given enough time or help to eat properly, which can lead to dehydration and weight loss. And worse, when the confused elder struggles to get physical restraints off, he may try to climb over the bedside rails on his way to the bathroom, slip, fall, and be injured and so prolong hospitalization. Eventually, the nursing home bed may no longer be available, and the elder becomes a "placement problem." If the Utilization Review Committee decertifies the beel, the hospital loses money. Soon the nursing staff may become

less sensitive to the care needs of this person labelled stable in the progress notes. I submit to you that such an individual is not stable. Clinical management of the hospitalized elderly patient can no longer be thought of as merely an extension of medical-surgical or adult nursing. It has become a subspecialty, but what facility can afford to hire geriatric experts for every unit? To change the way in which care is planned and delivered to hospitalized elders, the Yale-New Haven Hospital developed the Geriatric Resource Nurse (GRN) Program. The GRN program, launched in the summer of 1988, is a unit-based approach to improving geriatric care. The GRN is a staff nurse who volunteers to acquire advanced knowledge on geriatric care and share it with her peers. The GRN works with the geriatric clinical specialist to learn how to handle common geriatric care problems, such as falls, incontinence, confusion, and difficulty eating. Her presence on the unit reminds other nurses that there is a special approach to geriatric nursing. The goal of the program is to have a minimum of two GRNs on each unit with a high proportion of elders. The GRN program has brought several benefits: all nursing staff have become more sensitive to the needs of geriatric patients, geriatric nursing practice has improved, a critical mass of nurses now works together to formulate a program of nursing research on care of the elderly, and geriatric nursing has gained recognition. GRNs Are Created, Not Born

The development of GRNs is a gradual process. A nurse already expelt in geriatric nursing, such as a clinical specialist, helps to prepare the GRN-most intensively over the first four to six months, then on an ongoing basis. After the first six months, the GRN usually starts to feel comfortable with the role. TERRY T. FULMER, RN-C, PhD, FAAN, is associate professor and coordinator, Yale University, School of Nursing, and a clinical nurse specialist, gerontological nursing, at the YaleNew Haven Hospital.

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The nurse specialist, then, encourages the GRN to delve deeply into a specific area. For example, on an orthopedic unit, the GRN may notice that several of the patients who were continent when admitted became incontinent during hospitalization. With the staff, she could develop a protocol for evaluating this problem on her unit and make a difference in the clinical management of incontinence, with an emphasis on preventing it and retraining incontinent elders. This is much more useful than merely documenting the number of times an individual is wet in any 24-hour period. The GRN makes rounds daily on all elders on her unit to evaluate any special care problems that are related to aging or to disease in old age. Three times a week, she makes rounds with the geriatric nurse specialist to consult and evaluate the care. Plus, once a week the specialist offers a didactic session to augment the rounds. The GRN, in tum, provides clinical information to other primary nurses on her unit who may be overwhelmed by the needs of their geriatric patients. She also carries a regular caseload of elderly patients and serves as a role model for other nurses. Ms. Brown Reconsidered

Within this context, let us now reconsider Ms. Brown's clinicalmanagement. Ms. Brown's case could still occur in light of her late evening event and surgery. A GRN, however, would have the background and resources to break the chain of events early and prevent iatrogenic problems. A GRN would, as a first step, call the nursing home to get a baseline description of Ms. Brown's usual behavior and health. While referral forms always come with a patient transferred from a nursing home, nurseto-nurse consultation makes an important difference in developing a successful care plan for the patient. The GRN would record the series of events Ms. Brown had been through and let staff know that her behavior was not simply "senility" but extreme sleep deprivation worsened by medications and pain. The GRN would review the case with the geriatric nurse specialist and go over ap-

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propriate management strategies for delirium, pain. and impaired sleep. In this case, a GRN might recommend that Ms. Brown be provided a private room at least long enough to have the quiet she needs to recover from sleep deprivation. Safety precautions would be planned so that she would be under surveillance until her delirium subsides. Instead of restraints that would heighten her agitation, the G RN might recommend pinning the call light to Ms. Brown's

tions-and the pressure ulcers and incontinence that can ensue-occur less often. The elderly patient on a unit where there is a GRN is more likely to have common clinical problems prevented or identified earlier. Effective care plans are developed and implemented right away. A new episode of confusion, for example, can be evaluated instead of being labelled old age or dementia. A very popular label currently is Alzheimer's disease, and nearly every elder who cannot tell you today's date is saddled with this diagnosis. The In a hospita~ the common GRN can prevent mislabelling by knowing the right questions to ask and the appropriate people to whom approach to confusion the case should be referred, The nursing staff benefit from the is to treat the behavior GRN program by virtue of their ready access to the nurses with expertise in geriatric care. Sometimes, nurses feel rather than the causes. "foolish" asking the clinical specialist, or they hesitate to wait for the specialnightgown to serve as an alarm when ist. They may feel more comfortable she becomes restless. The G RN asking a peer they know well. Plus, might also propose that an aide be the immediacy of the response is a assigned or the family arrange to positive reinforcer.There is also contistay with Ms. Brown until the deliri- nuity of programming from year-toyear: as one GRN moves on, another um subsides. The GRN would elicit a drug history in her place keeps special projects from the nursing home so that any (e.g.,those on falls) alive. sensitivities could be known and subThe GRN benefits by the opportusequent reactions prevented. This his- nity to expand her knowledge and to tory is also important because certain see the quality of geriatric nursing drugs may cause perioperative com- care on her unit improve. Acting as a plications. Diuretic-induced hy- GRN demonstrates leadership and pokalemias, for example, can yield counts toward her progress on the arrhythmias during surgical stress. clinical ladder. The GRN program also provides the nurse with the opportunity to explore geriatric nursing as Everyone Wins an area of interest before committing At the Yale-New Haven Hospital, to graduate school. And when the all patients over 65 years are reviewed GRN decides to further her formal by the GRN with the nurse specialist education, collegiate admissions comuntil they are stable and show signs of mittees often view the GRN as an imrecovery. Then, the patient may be portant leadership experience, discussed at rounds only if a new REFERENCES event occurs. Throughout the hospitalization, the GRN communicates 1. U.s. National Institutes of Health. NIA Personnelfor Health Needs of the Elderly Through the Year 2020. with family and others who can help Report presented to U.S. Congress. Washington, DC: describe the elder's "usual" behavior, U.S.Government Printing Office,Sept. 1987. 2. Meneilly, G., and others. Anesthesia and surgery in preferences, and moods. the elderly. IN: Geriatric Medicine. 2nd edition, editJust having the GRN monitor the ed by 1. Rowe and R. Besdine. Boston, Little, elder's care seems to heighten staff Brown & Co., 1988,pp.122-135. awareness of problems that are likely 3. Pilbcam, c., and Resnick, A. Osteoporosis. IN: GeriatricMedicine. 2nd edition, edited by J, Rowe to occur. Such actions as automatic and R. Besdine, Boston. Little, Brown & Co., 1988, restraints and sedating medicapp.431-449.