Tuesday, November 03, 2009

GRACE: Will it be amazing?

Our folks are working on an important new project. It derives from a number of adverse events, cases in which elderly patients fell and were injured. Our review process often indicated that the staff had done just the right things with regard to fall prevention and supervision of patients. Using the "5 Why" process of Lean, they kept digging into the cause of these falls. A hypothesis emerged: Perhaps we were contributing to the likelihood of falls by over-medicating geriatric patients or missing important parts of their supervision and therefore causing them or allowing them to be disoriented.

Our group began to construct a new "geriatric bundle" of care. (You have seen this be tremendously effective in other arenas, like avoiding
Ventilator Associated Pneumonia.) But what should it look like, and what should it include? Well, we have just started rolling it out on an experimental basis, and we will report the results as things progress. Here's a summary from the staff:

The Geriatric Bundle now has a new name - GRACE (Global Risk Assessment and Careplan for Elders). This program is designed to improve the care of all hospitalized elders admitted to the BIDMC, with the hope that we will reduce the risk of delirium, falls, pressure ulcers, functional decline, etc.

There are three main components of the initiative:
- Provider Order Entry (POE) enhancements
- Improved Pharmacy/Medication safety
- Bedside care protocol

The bedside care component is a major piece and through the diligent work of many is well on its way to implementation. A tool is a GRACE bedside flow sheet that will be used for all patients 80 and older each day. You can see it and the other elements at this link to Slideshare, where you can read the entire presentation that was shared with our clinical staff on several floors.


Anonymous said...

The falls issue is a complex one, as there is only so much you can do, and restraints are discouraged for obvious reasons. I am sympathetic to the dismay engendered by its inclusion in Medicare's "non-reimbursable complication" list.
However, recently my 87 year old mother was hospitalized to R/O stroke; her ultimate diagnosis was drug-induced delirium caused by over-prescription by her PCP for back pain. I told them up front, of course, that she was a high fall risk. But the problem was that the hospital appeared to deal with the fall risk by simply telling her she couldn't get up, and then not answering her bell when she needed to use the bath or was otherwise in need. They finally put an "elopement sitter" in with her, who was male and (?untrained), therefore couldn't/didn't help her with the bathroom issue. It was quite a scene, with which I was very unhappy - and I am familiar with hospitals' problems.
It seems like this is going to cause staffing issues and therefore induce more hospitals to simply leave the patient in bed, which of course raises their risk too. I don't know what a good answer is. I will be interested to see if GRACE is amazing, because it will be great if successful.


Anonymous said...

I don't see any mention here of involving the family or the PCP in discussion of these issues. Taking a person's care away from the folks who deal with an elderly person on a routine basis is disturbing and disruptive for them. Hospitalists tend to treat for the admission trigger - not the overall patient condition. My aunt broke her hip and was sent to rehab having been constipated for 6 days - no one cared about anyting but the hip. The hospitalist did not listen to or work with the family when we raised concerns. This checklist would be one more set of tasks my elderly relative could not do and it would have added to her frustration and confusion. I can't see this protocol being at all helpful if the issues of caring for the person's condition overall and involving the PCP and family aren't addressed. Personal opinion....

Melissa Mattison, MD said...

Thank you for raising this important issue. Some of the details of the initiative may not be conveyed in a blog post. One of the key components we have been training our staff to incorporate into the bedside GRACE component is determining from family, prior caregivers etc, the patient’s baseline level of cognitive and physical function. This clearly impacts the patient’s ability to comply with the check-list. There is an “opt-out” for the aspects for patients who are unable or in whom it would be medically unsafe for them to comply.

And, your concerns about physicians in the hospital not being concerned about “the overall patient condition” may certainly be reflective of your experience with your aunt. It sounds like it was not a good one. Yet, physicians, and hospitalists in particular, are trained to care for the whole patient. This is something we strive for here at the BIDMC. If you have a poor experience with a physician or staff at a hospital, you should feel free to let Patient Relations know of your concerns so that they can be addressed.