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

Indwelling Bladder Catheters

The potential harms of catheters have been described for over 50 years, yet remain frequently used.^36,37 Previous studies have shown success in decreasing catheter days with computer-based and multidisciplinary protocols.^36-39

Our health system’s EMR has built-in “soft” and “hard” alerts for indwelling bladder catheters, so we did not expect intervention-associated changes in compliance.

Mobilization

Hospitalization in older adults frequently results in functional decline.^4,5,40 In response, the mobilization QI recommends an ambulation plan within 48 hours for those patients who were ambulatory prior to admission; it does not specifically define the components of the plan.²⁶ There are several multicomponent interventions that have demonstrated improvement in functional decline, yet they require skilled providers.^41,42 Our intervention implemented specific ambulation plan components: daily ambulation and documentation reminders and early PT evaluation.

While functional status measures have existed for decades, most are primarily geared to assess community-residing individuals and not designed to measure changes in function during hospitalization.^43,44 Furthermore, performance-based hospital measures are difficult to integrate into the daily nursing workflow as they are time consuming.^45,46 In practice, nurses routinely use free text to document functional status in the hospital setting, rendering comparative analysis problematic. Yet, we demonstrated that nurses were more engaged in reporting mobilization (increased documentation of ambulation distance and a decrease in time to PT). Future research should focus on the development of a standardized tool, integrated into the EMR, to accurately measure function in the acute care setting.

Delirium Evaluation

Delirium evaluation remains one of the most difficult clinical challenges for healthcare providers in hospitalized individuals, and our study reiterated these concerns. Previous research has consistently demonstrated that the diagnosis of delirium is missed by up to 75% of clinicians.^47,48 Indeed, our study, which exclusively examined nursing documentation of the delirium evaluation QI, found that both groups showed strikingly low compliance rates. This may have been due to the fact that we only evaluated nursing documentation of suspected or definite diagnosis of delirium and a documented attempt to attribute the altered mental state to a potential etiology.³¹ By utilizing the concept of “key words,” as developed by Puelle et al.³⁰, we were able to demonstrate a statistically significant improvement in nursing delirium documentation in the intervention group. This result should be interpreted with caution, as this approach is not validated. Furthermore, our operational definition of delirium compliance (ie, nurse documentation of delirium, requiring the launching of a separate parameter) may have been simply too cumbersome to readily integrate into the daily workflow. Future research should study the efficacy of a sensitive EMR-integrated screening tool that facilitates recognition, by all team members, of acute changes in cognition.

Although a number of QI improved for the intervention group, acute care utilization measures such as LOS, discharge disposition, and 30-day readmissions did not differ between groups. It may well be that improving quality for this very frail, vulnerable population may simply not result in decreased utilization. Our ability to further decrease LOS and readmission rates may be limited due to restriction of range in this complex patient population (eg, median LOS value of 5 days).

Limitations

Although our study had a large sample size, data were only collected from a single-center and thus require further exploration in different settings to ensure generalizability. In addition, QI observance was based on the medical record, which was problematic for some indicators, notably delirium identification. While prior literature highlights the difficulty in identifying delirium, especially during clinical practice without specialized training, our compliance was strikingly low.⁴⁷ While validated measures such as CAM may have been included as part of the assessment, there is currently no EMR documentation of such measures and therefore, these data could not be obtained.

In summary, our study demonstrates the successful integration of the established ACOVE QIs as an intervention, rather than as an assessment method, for improving care of hospitalized older patients. By utilizing a checklist-based tool at the bedside allows the multidisciplinary team to implement evidence-based practices with the ultimate goal of standardizing care, not only for VEs, but potentially for other high-risk populations with multimorbidity.⁴⁹ This innovative approach provides a much-needed direction to healthcare providers in the ever increasing stressful conditions of today’s acute care environment and for the ultimate benefit and safety of our older patients.

Disclosure

The authors declare no conflicts of interest. This study was supported by New York State Empire Clinical Research Investigators Program (ECRIP). The sponsor had no role in the conception, study design, data collection, data analysis, interpretation of data, manuscript preparation, or the decision to submit the manuscript for publication.