Wednesday, April 23, 2014

GRACE: It all started by asking why, five times

Back in 2010, I reported on a protocol developed by Dr. Melissa Mattison and others called GRACE (Global Risk Assessment and Careplan for Elders). As noted then, this program was designed to improve the care of all hospitalized elders, with the hope of reducing the risk of delirium, falls, pressure ulcers, functional decline, etc.

But let's go back to the genesis of GRACE, when the staff wondered what might be the cause of many of the falls experienced by older patients.  As I noted in 2009:

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.

The GRACE protocol was the result of this root cause analysis.  I'm now happy to provide a progress report, in the form of an article in the Journal of the American Geriatric Society. The program has been shown to make a difference.  Here are some excerpts.

Recognizing that older adults have specific care needs that are distinct from the needs of younger adults, a group of geriatricians, hospitalists, and nurses designed a supplemental checklist to accompany the standard bedside monitoring form.

Specifically, the bundle provides staff with a bedside checklist for individuals aged 80 and older admitted to the hospital and decision support in the CPOE system. The bedside check-
list prompts staff to screen for delirium and to implement delirium prevention and management strategies. The CPOE system provides decision support for antipsychotic and opioid analgesic ordering.

There were four main components of the intervention that were critical to its success. First, the intervention was targeted to a population likely to benefit from the intervention and that staff and the CPOE system are likely to identify easily. Units where individuals were already receiving specialized care plans (e.g., intensive care units, inpatient psychiatry) were excluded. Second, the decision support required for success of the intervention was carefully designed for this target population. Third, outcomes focused on critical intervention components were predetermined and monitored. Finally, throughout the intervention, educational curricula were created and offered to staff across clinical disciplines—including nursing, physician staff, and residents.

The findings indicate that the intervention improved prescribing of sedating medications—participants were significantly less likely to be prescribed haloperidol in excess of 0.5 mg or intravenous morphine in excess of 2 mg. There were more triggers for acute change in mental status, but this was seen in individuals receiving the intervention and in the concurrent controls. Significantly more individuals receiving the intervention were discharged to home than to ECFs [extended care facilities] than would have been expected, suggesting less in-hospital functional decline.

1 comment:

Anonymous said...

I hope this becomes widely disseminated. When my mother experienced a series of hospitalizations over two years, she suffered from repeated episodes of delirium. Although even I, a pathologist, could recognize it, the physicians and staff did not. I had to be constantly vigilant that she would not be prescribed sedatives. One nurse even told her 'we are not going to chase you around the hospital.' On every admission I told them she had this problem and not to prescribe sedatives. It was exhausting.
Imagine if the health care team could actually provide the appropriate health care without being prompted.

nonlocal MD