Grace Rollout

• Created at BIDMC• Multidisciplinary input

–Nursing –Geriatrics –Hospital Medicine –Pharmacy –IS –Dept of Health Care Quality

• Hospitalization is a vulnerable time for elderly patients

• Older patients are at risk for:– Delirium (acute confusional state)– Physical deconditioning– Medication side-effects– Loss of function

• The GRACE initiative will address unique concerns of vulnerable elders

• Identify delirium (confusion) as soon as it develops

• Target finite resources• Implement programs to maintain function

and prevent delirium

• Three-pronged initiative– Provider Order Entry (POE)– Pharmacy– Bedside

• Three-pronged initiative– Provider Order Entry (POE)– Pharmacy– Bedside

• Bedside component– For patients ≥ 80 years– Roll-out on 11R, CC7, Farr 2 anticipated in

Oct/November – 2nd wave to rollout on all other floors (except

Deac-4, Oncology and ICUs) 1-2 mo later– Springtime rollout planned for subset of 65-79

year old patients

• Bedside component– Mainly the domain of nursing– Nurses will be the primary “go-to” for this

component but are encouraged to work with and utilize help from physicians, PT, NPs, PAs and PCTs

• Bedside GRACE flow sheet– One sheet per day – goes in blue vital signs book/clipboard– Use 1 copy of form each day for any patient

admitted to your unit 80 years or older

See handout of GRACE Flowsheet

• Bedside GRACE flow sheet– Multiple components

• 2 part Delirium screen • Morning “tether check”• Mobility protocol• Sleep protocol

• Bedside GRACE flow sheet– Multiple components

• 2 part Delirium screen • Morning “tether check”• Mobility protocol• Sleep protocol

2 Part Delirium (confusion) Screen1) RASS Score – two times per day2) Test of attention – once per day

2 Part Delirium (confusion) Screen1) RASS Score

Use the Richmond Agitation and Sedation Scale

First part of the delirium screen

2 Part Delirium (confusion) Screen1) RASS Score – Scored two times per day

• Once between 7 am - 3 pm • Once between 3 -11 pm

2 Part Delirium (confusion) Screen1) RASS Score– Scored two times per day

• Once between 7 am - 3 pm • Once between 3 -11 pm

– Write RASS score on Flowsheet

2 Part Delirium (confusion) Screen1) RASS Score– Scored two times per day

• Once between 7 am - 3 pm • Once between 3 -11 pm

– Write RASS score on Flowsheet– Any score that is NOT a 0, 1 or -1, if a NEW

score to that patient, is considered a positive screen for delirium Trigger

Daily screen for delirium (confusion)2) Test of attention – once per day

This is the second component of the delirium screen. RASS score is the first.

Test of Attention (second part of delirium screen)1) Ask patient to state the months of year backwards(e.g., December, November, October…January). Ifable, this becomes patient's daily Test of Attention.If unable,

2) Then ask to state days of week backwards (e.g.,Sunday, Saturday, Friday…Monday). If able, thisbecomes patient's daily Test of Attention. If unable,

3) Then, ask the patient to count from 10 to 1 (10, 9,8…1). If able, 10-1 becomes this patient's dailyTest of Attention.

• Daily screen for delirium (confusion)2) Test of attention – once per day

• Record which test of attention the patient could do.

• Daily screen for delirium (confusion)2) Test of attention – once per day

• Record which test of attention the patient could do.

• If unable to do the test of attention from the previous day, or unable to perform any test of attention, this is a positive screen for Delirium! Trigger!

• Bedside GRACE flow sheet• 2 part Delirium screen • Morning “tether check”• Mobility protocol• Sleep protocol

• Bedside GRACE flow sheet• 2 part Delirium screen • Morning “tether check”• Mobility protocol• Sleep protocol

Morning “Tether Check”• Background:

– Foleys, telemetry, IV lines and restraints are considered “tethers”

– A patient with 1 or more tethers is at increased risk for falling or developing delirium in the hospital

– We want to minimize the use of tethers in our most vulnerable patient population

Morning “Tether Check”• Each morning, the need for a tether must be

documented.• Who can complete this section of the flowsheet?

– RN after conversation with MD/NP/PA– MD/NP/PA can do so independently– If no MD/NP/PA has completed it, day RN should

speak with the responsible MD/PA/NP and review with him/her the need for any tethers that are in use.

• Bedside GRACE flow sheet• 2 part Delirium screen • Morning “tether check”• Mobility protocol• Sleep protocol

• Bedside GRACE flow sheet• 2 part Delirium screen • Morning “tether check”• Mobility protocol• Sleep protocol

Mobility Protocol• Background:

– Bedrest causes patients to lose function– Increases risks of pressure ulcers, pneumonia– Older patients are most vulnerable to losing

function while in the hospital– Loss of function leads to placement in nursing

homes after discharge from the hospital

Mobility Protocol• Get patient out of bed to chair two times

per day unless patient unable• Ambulate patient in hallway two times per

day, unless patient unable

Q: Who can do it? A: RN, or PCT, PT, or MD

• Bedside GRACE flow sheet• 2 part Delirium screen • Morning “tether check”• Mobility protocol• Sleep protocol

• Bedside GRACE flow sheet• 2 part Delirium screen • Morning “tether check”• Mobility protocol• Sleep protocol

Sleep Protocol• Background:

– Sleep deprivation can cause confusion in older patients

• Designed to normalize the sleep-wake cycle for elderly patients in the hospital

• Minimize noise, lights, lab draws, routine VS checks between 11 pm and 7 am

It is our hope that the bedside flowsheet will be utilized by all members of the care team, including nurses, doctors, PT, OT etc.

Nurses, however, are the cornerstone to bedside care and have primary “ownership” for the completion of this form.

Thank you!

Melissa Mattison, MDmmattiso@bidmc.harvard.eduPager 90141

Angela Botts, MDabotts@bidmc.harvard.eduPager 31458

Daniele Olveczky, MDdolveczk@bidmc.harvard.eduPager 38743

Julie Moran, MDjamoran@bidmc.harvard.eduPager 33000

Christine Kristeller, RNckriste1@bidmc.harvard.edu

Pager 39232

Questions: