Sunday, June 06, 2010

Update on GRACE

This is an update on an experimental protocol I mentioned last fall, called GRACE (Global Risk Assessment and Careplan for Elders). As noted then, this program is designed to improve the care of all hospitalized elders admitted to BIDMC, with the hope that we will reduce the risk of delirium, falls, pressure ulcers, functional decline, etc.

When I have mentioned this program in my various speeches, there has been tremendous interest from doctors and nurses across the country. I recently asked Dr. Melissa Mattison, who is part of the working group that has designed and is implementing the program, for an update. I provide it here for the benefit of those hospitals who are following the experiment.

Global Risk Assessment and Careplan for Elders (GRACE) is a multidisciplinary approach to standardize and improve care for hospitalized elder patients. GRACE Includes:

* Computerized Provider Order Entry modifications to assist MDs, NPs, and PAs by encouraging care that helps patients maintain their physical and mental capabilities including early and frequent ambulation, limiting the use of potentially inappropriate medications, and limiting the use of indwelling urinary catheters;

* A bedside checklist that prompts bedside staff to screen patients daily for the presence of delirium and to use proven strategies to prevent delirium;

* Pharmacy modifications to ensure that MDs and pharmacists are aware of geriatric warnings when ordering potentially inappropriate medications;

* Nursing Initial Patient Assessment (IPA) customizations so that nursing staff are prompted at admission that the patient is a “GRACE patient” and provide a customized Nursing care plan addressing the patient's needs.

Phase 1 - Successfully deployed on November 10, 2009 -Bedside checklist for delirium assessment and prevention has been used on the three main Medicine units.
Phase 2 - Successfully deployed on April 6, 2010 - POE Rollout to Medical units for patients 80 and older.
Phase 3 - Successfully deployed on April 26, 2010 - Bedside Flow sheet and POE rollout to all units except Deac-4, ICUs, Oncology for patients 80 years and older.
Phase 4 - Scheduled to be deployed in Fall 2010 - Bedside checklist and POE rollout for 65-79 year old vulnerable elders to all Units (automatically classified as GRACE patients based upon certain comorbidities).

Ongoing - Educational campaign to help house staff and Nursing understand the components of the GRACE intervention and how to recognize and treat delirium.

Since November 2009, we have improved the program in several ways. We have worked with Nursing to modify the Nursing Initial Patient Assessment (IPA). This prompts the bedside team to recognize when a patient is a “GRACE patient.” It also provides a standard Nursing care plan for these patients. When the floor nurse completes the IPA, s/he is prompted to print the bedside checklist and place it in the vital signs book at the patient's bedside. This went live on 3 pilot units in early April and hospital-wide with the rest of the CPOE modifications on April 26.

Because the BIDMC Pharmacy is overhauling and standardizing their warning systems within CPOE, we are working with them to ensure there will be geriatric-specific medication warnings available to both ordering providers and pharmacists. Deployment of this is expected in 2011 due to the programming requirements of this project. We are also collaborating with IS for a CPOE GRACE opt-in for patients who are not otherwise identified as GRACE patients.

Nearly 80% of Medicine house staff said the GRACE bedside checklist has increased their awareness of the presence of delirium in their elderly patients.

Numerous providers (MDs, and RNs) have asked if they could use the GRACE bedside checklist in patients who are not currently “GRACE patients” (80 and older). MDs have asked to be allowed access to the CPOE modifications (an opt-in) for non-GRACE patients. We expect to have additional data later in June.


Pat Kelleher said...

Curious as to how this great initiative translates into improved transitioning of patient home? What is involvement of home care? Does GRACE record follow them home?

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Anonymous said...


At this time GRACE is an inpatient initiative, though we recognize the importance of transitions of care, and the care of older persons in their home. Perhaps at some point in the future we can develop a post-discharge GRACE program.

pjh said...

Hi Paul! I have been following your interesting blog for a while. It is interesting too see this health intitiative for elders. You could see some of the iniatives for elders in Jonkoping, Sweden -
i)Developing a nation-wide system for assessing and preventing falls, malnutrition and pressure ulcers
ii)The "Esther" project. Esther is a persona that clinicians in Jönköping invented to help them improve patient flow and coordination for seniors in six of the county's municipalities.

Hava a nice weekend and hopefully the US Soccer team will reach the playoffs,


Unknown said...

This sounds like a great initiative and meshes well with a timely NYT article on Hospital Delirium.

I would like to point out that there is a transitions of care program using the same acronym, GRACE, from Indiana University. GRACE stands for "Geriatric Resources for Assessment and Care of Elders. For more information, here is their website:

jaring safety said...

Nice article, thanks for the information.