Implementing ACOVE quality indicators as an intervention checklist to improve care for hospitalized older adults

Subject matter experts (hospitalists, geriatricians, researchers, administrators, and nurses) reviewed the ACOVE QIs and agreed upon the adaptation of the QIs from a quality measure assessment into a feasible and acceptable intervention checklist tool (Table 1). The checklist was reviewed during daily interdisciplinary rounds for all patients 75 years and older. While ACOVE defined vulnerable elders by using the Vulnerable Elder Screen (VES), we wanted to apply this intervention more broadly to all hospitalized older adults who are most at risk for poor outcomes.²⁷ Patients admitted to the intensive care unit, inpatient psychiatry, inpatient leukemia/lymphoma, and surgical services were excluded.

Daily interdisciplinary rounds are held on every one of the five 40-bed medical units; they last approximately 1 hour, and consist of a lead hospitalist, nurse manager, nurse practitioners, case managers, and the nursing staff. During interdisciplinary rounds, nurses present the case to the team members who then discuss the care plan. These 5 medical units did not differ in terms of patient characteristics or staffing patterns; the intervention unit was chosen simply for logistical reasons, in that the principal investigator (PI) had been assigned to this unit prior to study start-up.

Prior to the intervention, LS held an education session for staff on the intervention unit staff (who participated on interdisciplinary rounds) to explain the concept of the ACOVE QI initiative and describe the four QIs selected for the study. Three subsequent educational sessions were held during the first week of the intervention, with new incoming staff receiving a brief individual educational session. The staff demonstrated significant knowledge improvement after session completion (pre/post mean score 70.6% vs 90.0%; P < .0001).

The Clinical Information System for the Health System EMR, The Eclipsys SCM, has alerts with different levels of severity from “soft” (user must acknowledge a recommendation) to “hard” (requires an action in order to proceed).

To measure compliance of the quality indicators, we collected the following variables:

QI 1: VTE prophylaxis

Through SCM, we collected type of VTE prophylaxis ordered (pharmacologic and/or mechanical) as well as start and stop dates for all agents. International normalized ratio levels were checked for patients receiving warfarin. Days of compliance were calculated.

QI 2: Indwelling Bladder Catheters

SCM data were collected on catheter entry and discontinuation dates, the presence of an indication, and order renewal for bladder catheter at least every 3 days.

QI 3: Mobilization

Ambulation status prior to admission was extracted from nursing documentation completed on admission to the medical ward. Patients documented as bedfast were categorized as nonambulatory prior to admission. Nursing documentation of activity level and amount of feet ambulated per nursing shift were collected. In addition, hospital day of physical therapy (PT) order and hospital days with PT performed were charted. Compliance with QI 3 in patients documented as ambulatory prior to hospital admission was recorded as present if there was a PT order within 48 hours of admission.

QI 4: Delirium Evaluation

During daily rounds, the hospitalist (PI) questioned nurses about delirium evaluation, using the first feature of the Confusion Assessment Method (CAM) as well as the “single question in delirium,” namely, “Is there evidence of an acute change in mental status from the patient’s baseline?” and “Do you think [name of patient] has been more confused lately?”^28,29 Because EMR does not contain a specified field for delirium screening and documentation, and patients are not routinely included in rounds, documentation with QI 4 was recorded using the “key words” method as described in the work by Puelle et al.³⁰ To extract SCM key words, nursing documentation of the “cognitive/perceptual/neurological exam” section of the EMR on admission and on all subsequent documentation (once per shift) was retrieved to identify acute changes in mental status (eg, “altered mental status, delirium/delirious, alert and oriented X 3, confused/confusion, disoriented, lethargy/lethargic”).³⁰ In addition, nurses were asked to activate an SCM parameter, “Acute Confusion” SCM parameter, in the nursing documentation section, which includes potential risk factors for confusion.

In addition to QI compliance, we collected LOS, discharge disposition, and 30-day readmission data.

Generalized linear mixed models (GLMM) for binary clustered (ie, hierarchical) data were used to estimate compliance rates (ie, nurse adherence) for each group (intervention group or control group) in the postintervention period, along with their corresponding 95% confidence intervals. GLMM was used to account for the hierarchical structure of the data: nursing units within a hospital. In order to calculate the Charlson Comorbidity Index, we extracted past medical history from the EMR.³¹

Subjects (N = 2,396) were included in the comparison of the intervention group vs control group for each of the following 4 ACOVE QI compliance measures: DVT, mobilization, bladder catheter, and delirium.