Download 48/6 Clinical Care Management Guideline

Hospital Care for Seniors Clinical Care Management Guideline:
48/6 Model of Care
British Columbia Provincial
Seniors Hospital Care Working Group
September 2012
V6
Table of Contents
1.
2.
Hospital Care for Seniors Clinical Care Management Guideline: The 48/6 Model of Care .... 2
1.1
PRACTICE STATEMENT: BLADDER AND BOWEL MANAGEMENT ..................................... 7
1.2
PRACTICE STATEMENT: COGNITIVE FUNCTIONING ....................................................... 10
1.3
PRACTICE STATEMENT: FUNCTIONAL MOBILITY ........................................................... 13
1.4
PRACTICE STATEMENT: MEDICATION MANAGEMENT .................................................. 16
1.5
PRACTICE STATEMENT: NUTRITION AND HYDRATION MANAGEMENT ........................ 19
1.6
PRACTICE STATEMENT: PAIN MANAGEMENT ............................................................... 22
Glossary ................................................................................................................................. 25
Hospital Care (48/6) CCM
1.
Hospital Care for Seniors Clinical Care Management Guideline:
The 48/6 Model of Care
DESCRIPTION: The 48/6 Model of Care for hospitalized seniors (aged 70 and older) in BC is an
integrated care initiative which addresses six care areas of functioning through patient
screening and assessment (assessments are completed only where screening shows areas of
concern). Screening and/or assessments are then supported by the development of an
individualized care plan to address key areas of health for the senior. Care Plans must be
developed within 48 hours of decision to admit and further supported by a discharge and/or
transition plan to ensure the senior can return to home safely with established access to the
health resources in the community they require.
The 48/6 Model of Care will improve health outcomes for seniors, reduce readmissions and
provide a consistent approach to addressing six key areas of care that are known to have
interrelated impacts on health for many seniors. The six care areas are:
1. Bowel and Bladder Management: working with the patient to maintain their usual bowel
and bladder function, intervening where necessary with additional interventions.
2. Cognitive Functioning: refers to the mental processes including memory, thinking,
judgement, calculation, and visuospatial skills. Attention must be paid to the possibility of
delirium, depression, dementia, and mild cognitive impairment.
3. Functional Mobility: a person’s ability to stand, walk, and transfer from bed to a chair. Bed
rest inhibits a person’s capability to perform these functions as it contributes to muscle
atrophy and reduced endurance.
4. Medication Management: reviewing each person’s medication list, dosages (dose and dose
interval), potential medication interactions and balancing the benefits versus the risks of
medications.
5. Nutrition and Hydration: ensuring adequate amount and type(s) of food and liquid
consumed, assessing for any swallowing difficulties and/or food allergies, and
supplementing intake, where necessary.
6. Pain Management: refers to the use of medications and other interventions (such as
massage, exercise, or physiotherapy) to prevent, reduce, or stop acute or chronic pain.
PURPOSE: To improve early identification of care needs in these six care areas and develop
individualized care plans to improve the senior’s safety and maintenance of their normal level
of functional status. Care Plans will be complimented by active Discharge and/or Transition
Planning based on the individualized assessments – ensuring that seniors can return to home or
other care location with the information and resources they need provided before they leave
the hospital.
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TARGET AUDIENCE: This package of work has been developed for the inter-professional health
care team. As such, all references to guidelines, practice standards and policies should be
considered within each regulated discipline. A number of examples are provided for your
consideration.
SUPPORTING EVIDENCE: In Canada, over 50% of acute care hospital beds are currently
occupied by seniors on any particular day. Moreover, 30% of seniors admitted to acute care will
be discharged at a significantly reduced level of functional ability and most will never recover to
their previous level of independence.
The six care areas outlined in this CCM have been shown to have interrelated effects on health
which, when addressed, reduce functional decline and improve patient outcomes. Managing
these key areas of care includes consideration of:
1. Bowel and Bladder Management: Inability to maintain usual bowel and bladder function as
well as use of urinary catheters which restricts independent ambulation and may increase
prevalence of a urinary tract infection (UTI), as well as delirium.
2. Cognitive Functioning: UTIs, medication mismanagement, or inadequate amounts of
food/water consumed all increase the prevalence of cognitive impairment, including
delirium.
3. Functional Mobility: Use of restraints decreases the senior’s opportunity to mobilize
independently which results in decreased muscle mass and limited range of motion. Use of
medically-unnecessary catheters is another interrelated area which decreases activity and
may cause irreversible loss of mobility.
4. Medication Management: Adverse medication side effects inhibit functional mobility, may
increase prevalence of falls and level of cognitive impairment.
5. Nutrition and Hydration Management: Frail seniors commonly receive all of their hospital
meals in bed, contributing to the risk of poor nutritional intake, aspiration and immobility.
This leads to general functional decline.
6. Pain Management: Seniors frequently may not accurately articulate their level of pain,
which may impair functional mobility, and further contribute to delirium and depression.
TARGET POPULATION: All individuals aged 70 years and older.
RESPONSIBILITY: The initial 48/6 screening, and where screening is positive, an assessment, is
to be completed by the nurse and physician. Interdisciplinary care planning, implementation
and on-going daily monitoring are to be carried out by the inter-professional health care team.
Refer to individual 48/6 Practice Statement(s) (below) for relevant guidelines, targeted
assessment tools and recommended interventions for each of the six care areas.
SCREENING AND ASSESSMENT PROCEDURE:
STEP 1 - Within the first 48 hours of hospital admission:
a) Use a standardized approach (i.e., screening and assessment tools validated in the literature
or validated internally), screen all six care areas and further assess where a concern is
indicated. Screening and/or assessments examine the senior’s level of function in the six
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care areas to determine the senior’s baseline status, reported changes over the past 14
days, and current state.
b) All concerns in the six care areas noted during the assessment process must be documented
in the care plan. If no concerns are identified in a care area, a note should be left on the
care plan to indicate the same.
STEP 2 - Throughout the hospital stay:
STEP 2 - Throughout the hospital stay:
Care planning is where 48/6 comes together. Combining all assessments into one place allows
the inter-professional health care team to develop a comprehensive and evidence informed
individualized care plan based on clinical best practice.
Combining all information into one place allows the inter-professional health care team to
develop a comprehensive and evidence informed individualized care plan based on clinical best
practice. Daily assessments as well as planned or completed interventions should all be
recorded as part of the Care Plan development. If anything changes in a patient’s condition
during their stay, interventions should be identified and the care plan updated accordingly.
STEP 3 – Establish communication needs in preparation for successful discharge:
Establish an effective and timely discharge and/or transition planning process. This includes a
timely communication between hospital and home. “Home” is defined by the patients needs.
A safe return home may need to be supported by community-based resources including the
patient’s Primary Care Practitioner(s), community-based rehabilitation resources, family
members and primary caregivers, or a residential care facility. Effective Discharge and/or
Transition Planning includes establishing systems for the transfer of information contained
within the care plan and the discharge and/or transition plan to community based care
providers or other resources the patient may need upon discharge. The goal is to ensure the
patient has the information they need, established access to services, and a thorough
understanding of what to expect, and where to get information upon discharge.
MEASURES:
Process Measures:
Initially (Phase I), six process measures will be tracked to assess the success of the
implementation of 48/6. Screening (and assessment of the care area(s), where the senior
screens positive) must be completed in the first 48 hours of hospital admission and include the
reported baseline status, reported changes over the past 14 days, and current state:
1. Percent of patients screened for bowel and bladder function using a standardized
approach.*
2. Percent of patients screened for cognitive changes (including dementia, delirium,
and depression) using a standardized approach.*
3. Percent of patients screened for functional mobility using a standardized
approach.*
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4. Percent of patients screened for medication management using a standardized
approach.*
5. Percent of patients screened for nutrition and hydration using a standardized
approach.*
6. Percent of patients screened for pain using a standardized approach.*
*See the Practice Statements below for further detail.
Phase I measurement will provide a baseline of where effective screening and assessment is
being completed. This will allow work units to celebrate the good work currently being done,
and plan how to expand the 48/6 approach further, if necessary.
For Phase II, it is anticipated that these six process measures will be replaced with a bundled
process measure. The bundled process measure that will be tracked to assess the success of
the implementation of the Hospital Care for Seniors 48/6 Model of Care in Phase II of
implementation is the development of an individualized Care Plan. This Care Plan must address
the following:
 Screening of each of the six areas of care.
 In depth assessments conducted for any area of concern.
 Continual monitoring of all six areas of care to ensure that emerging conditions do
not go unaddressed throughout the hospital stay.
 An individually targeted plan of care to address each area of concern and the
interrelated aspects of each.
This process must be completed in the first 48 hours of hospital admission and include the
reported baseline status, reported changes over the past 14 days, and current state. The
indicator is:
 Percent of patients with care plans completed within 48 hours of admission to
hospital.
Outcome Measures:
Measure(s) of health outcomes resulting from this initiative are still in development and will be
included in Phase II.
REFERENCES
BC Guidelines and Protocols Advisory Committee Guidelines:
http://www.bcguidelines.ca/alphabetical.html
Brown, C., Williams, B., Woodby, L., Davis, L., & Allman, R. (2007). Barriers to mobility during
hospitalization from the perspective of older patients and their nurses and physicians. Jnl
Hospital Medicine, 2(5), 305-313.
Brown, T. & Boyle, M. (2007). Delirium. British Medical Journal. 325, 644-647.
Brownie, S. (2005). Why are elderly individuals at risk of nutritional deficiency? Intl Jnl Nursing
Practice, 12, 110-118.
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Chen, C., Schilling, L., & Lyder, C. (2001). A concept analysis of malnutrition in the elderly. Jnl
Advanced Nursing, 36(1), 131-142.
CIHI Data Quality Study of the DAD 2008-2009 Discharge Abstract Database, 2008-2009.
Retrieved 23 July 2012 at: https://secure.cihi.ca/estore/productSeries.htm?pc=PCC228.
Conn, D. & Lief, S. (2001). Diagnosing and managing delirium in the elderly. Canadian Family
Physician, 47, 101-108.
Covinsky, K. E., Newcomer, R. et al. (2003). Patient and caregiver characteristics associated with
depression in caregivers of patients with dementia. J Gen Intern Med, 18(12), 1006-14.
Gary, R., & Fleury, J. (2002). Nutritional status: Key to preventing functional decline in
hospitalized older adults. Geriatric Rehabilitation, 17(3), 40-71.
Graf, C. (2006). Functional decline in hospitalized older adults: It’s often a consequence of
hospitalization, but it doesn’t have to be. American Journal of Nursing, Jan. 106(1), 58-67.
Inouye, S. (2006). Delirium in older persons. New England Journal of Medicine, 354, 1157-65.
Inouye,S. & Carpentier, P. (1996). Precipitating factors for delirium in hospitalized elderly
persons: Predictive model and interrelationship with baseline vulnerability. JAMA, 275,
203-208.
King, D. (2006). Functional decline in hospitalized elders. MedSurg Nursing, Oct. 15(5), 265-271.
Korevaar, J.C., van Munster, B.C., & de Rooij, S.E. (2005). Risk factors for delirium in acutely
admitted elderly patients: A prospective cohort study. Geriatrics, 5(6), Retrieved 5 July
2012 at: http://www.biomedcentral.com/1471-2318/5/6
Markey, D. & Brown, R. (2002). An interdisciplinary approach to addressing patient activity and
mobility in the medical-surgical patient. Jnl Nursing Care Quality, 16(4), 1-12.
Mentes, J., Culp,K., Maas,M., & Rantz, M. (1999). Acute confusion indicators: Risk factors and
prevalence using MDS data. Research in Nursing and Health, 22(2), 95-105.
McLafferty, E. (2007). Delirium part one: Clinical features, risk factors and assessment. Nursing
Standard, Jan. 21(29), 35-40.
McLafferty, E. (2007). Delirium part two: Nursing management. Nursing Standard, Feb. 21(30),
42- 47.
Newman, D. (2005). Urinary incontinence and indwelling catheters: CMS guidance for long-term
care. Jnl Extended Care Product News, June, 50-55.
Saint, S. Lipsky, B.A. & Goold, S.D. (2002). Indwelling urinary catheters: A one-point restraint?
Annals Internal Medicine, July, 137, 125-127.
Shuurman, M., Duursma, S. & Shortridge-Bagget, L. (2001). Early recognition of delirium: review
of the literature. Jnl Clinical Nursing, 10(6), 721-729.
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1.1 PRACTICE STATEMENT: BLADDER AND BOWEL MANAGEMENT
If, through the initial 48/6 screen, the senior (or a close family member or friend on their
behalf) reports or demonstrates any recent changes in bowel and/or bladder management, the
following practice statement has been developed to help the care team assess and manage this
aspect of care.
PURPOSE OF THIS PRACTICE STATEMENT:
 To maintain bowel and bladder health through attention to continence care (especially
regular toileting), appropriate use of laxatives, and healthy lifestyle practices.
 To ensure indwelling urinary catheters are only used when medically necessary.
 To prevent any adverse conditions or events in hospital that create or exacerbate bowel
and/or bladder issues.
WHY BOWEL AND BLADDER MANAGEMENT IS IMPORTANT TO SENIORS’ HEALTH:
Undiagnosed constipation can have a major impact on nutrition, overall health and quality of
life. Effective treatment of constipation results in improved cognition, quality of life,
continence, mood and sexual health. Untreated constipation increases the risk of urinary
retention, urinary and fecal incontinence and possibly, delirium. Be aware that severe
constipation can lead to impaction, with bypassing of liquid stool around impacted stool. This
can result in diarrhea and fecal incontinence.
Constipation increases with age, particularly in institutionalized, chronically ill and immobile
patients. Polypharmacy and inadequate fibre intake also contribute. Women are more likely to
be constipated than men.
Indwelling urinary catheters are frequently used in hospitalized seniors without specific medical
indication and increase the risk of urinary tract infections (UTIs) which may result in delirium
and urethral trauma, perforation and fistulae.
RELEVANT GUIDELINES:
Existing Guideline and Protocols Advisory Committee (GPAC) and Health Authority clinical
practice guidelines, practice standards and policies pertinent to your regulated discipline.
TARGETED ASSESSMENTS INCLUDE:
 Use a clinically-valid assessment tool (e.g., VIHA’s Bowel/Bladder Screening Tool)
RECOMMENDED INTERVENTIONS, DEPENDENT ON THE RESULTS OF THE ASSESSMENT,
INCLUDING BUT NOT LIMITED TO:
Provider/Patient Level for Bowel Management:
 Determine continence history or usual pattern (e.g. history of UTIs, voiding pattern, use of
containment products).
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




Perform confirmatory physical exam and/or abdominal X-ray.
Differentiate persistent bowel incontinence from transient bowel incontinence (a common
result of limited mobility).
Intervene with non-pharmacologic and pharmacologic therapies in a graded fashion
depending on constipation severity.
Include bowel and bladder management in an individualized plan of care to which the
interdisciplinary team can contribute.
Provide education for the patient, family, and/or caregiver(s) about maintaining regular
bowel health after discharge.
Provider/Patient Level for Bladder Management:
 Use established criteria to determine the appropriate use of an indwelling urinary catheter.
 Consider alternative strategies to indwelling catheter insertion (e.g. regular mobility, regular
toileting schedule, using a toilet rather than containment products).
 Assess male patients for prostate health.
 Use intermittent catheterization for collection of urine culture specimens and for the initial
management of urinary retention.
 Change the long-term catheter (14 days and over) prior to collection of urine for culture
from a patient with a symptomatic UTI. This practice prevents specimen contamination
from bacteria growth on the inner and outer surface of a long-term catheter and improves
clinical outcomes for anti-microbial therapy. Secure catheter using a catheter securement
device to: prevent injury to the urethra, prevent inadvertent removal of catheter and
increase comfort.
 Provide education for patient, family, and/or caregiver(s) including signs and symptoms of
UTI.
System-Level for Bowel and Bladder Management:
 Institute a reminder system (electronic or written), which tracks catheter duration for each
patient with a short-term catheter. The reminder system prompts for daily assessment of
catheter removal.
 Establish a timely communication process between hospital and the receiving community
care setting/service for the transfer of information contained within the care plan and the
discharge and/or transition plan to relay any concerns the senior continues to experience in
this care area post-discharge.
REFERENCES
Bouras, E.P. & Tangalos, E.G. (2009). Chronic constipation in the elderly. Gastroenterol Clin
North Am, 38(3), 463-80.
Catheter-Associated Urinary Tract Infection (CAUTI) Event.
Dennison, C., Prasad, M., Lloyd, A., et al. (2005). The health-related quality of life and economic
burden of constipation. Pharmacoeconomics, 23(5), 461-76.
GPAC Guidelines:
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Infectious Diarrhea - Guideline for Ordering Stool Specimens
Macroscopic and Microscopic Urinalysis and the Investigation of Urinary Tract Infections
Microscopic Hematuria (Persistent)
Rao, S.S. & Go, J.T. (2010). Update on the management of constipation in the elderly: New
treatment options. Clin Interv Aging, 5, 163-171.
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1.2 PRACTICE STATEMENT: COGNITIVE FUNCTIONING
If, through the initial 48/6 screen, the senior (or a close family member or friend on their
behalf) reports or demonstrates any recent cognitive changes, the following practice statement
has been developed to help the care team assess and manage this aspect of care.
PURPOSE OF THIS PRACTICE STATEMENT:
 To support the senior to maintain optimal level of cognitive functioning through the
effective use of care strategies which promote functional independence, including the
senior with mild to moderate dementia.
 To prevent adverse conditions/events in hospital that create or exacerbate the onset of
delirium.
 To prevent, detect and manage delirium, both within hospital and at points of transitional
care, through:
o the early identification of common risk factors (social, environmental, etc.);
o planned targeted interventions;
o consistent monitoring and surveillance of client status (“Delirium Watch”); and
o evaluating the effectiveness of targeted interventions.
WHY COGNITIVE FUNCTIONING IS IMPORTANT TO SENIORS’ HEALTH:
By the time a person is 85 years old the probability of their having dementia is 30% – 40%, with
the majority of these people able to remain in their own home until well-advanced stages. The
prevalence of dementia is even higher amongst the residential care population.
The cognitively-impaired senior will demonstrate better outcomes when they are included in
decision-making by health care staff who anticipate and can mitigate the risks posed for the
senior being in the acute care environment. As well, health care professionals should adapt
their usual communication style and pace to ensure that with any level of cognitive impairment,
the senior will understand the care they are receiving.
Delirium is a medical emergency.
Any confused hospitalized senior should be assumed delirious until proven otherwise.
Delirium is under-recognized and preventable, and can develop in seniors with and without
prior cognitive loss. Approximately 10% of seniors come to the ED with delirium as part of their
symptoms and 14%-56% of seniors develop delirium while in hospital. Poor cognitive
functioning is related to poorer hospital outcomes and contributes to a deterioration in the
other 48/6 care areas.
Common precipitating factors that may impact cognition include: infection, medications, pain,
dehydration, immobility, constipation, urinary retention, sleep deprivation, vision and hearing
impairment, depression, dementia and sudden changes in environment, including
hospitalization.
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While delirium is the most common form of cognitive impairment bringing seniors to hospital,
other forms of cognitive impairment should be considered: dementia, the impact of depression,
or some combination of all three.
RELEVANT GUIDELINES:
Existing Guideline and Protocols Advisory Committee (GPAC) and Health Authority clinical
practice guidelines, practice standards and policies pertinent to your regulated discipline (e.g.,
Delirium, Falls Prevention, Least Restraint, and appropriate Medication Protocols (e.g.,
antipsychotics), etc.).
TARGETED ASSESSMENTS INCLUDE:
 Assess baseline level of pre-hospital cognitive status.
 Assess the change between pre-hospital status and current cognitive status, including the
timeline of changes to differentiate between dementia, delirium or depression, or
combination.
 Selection and use of a valid and reliable cognitive screening tool for cognitive change:
 For delirium:
o Confusion Assessment Method (CAM)
o Pain/Retention-Restraints/Infection-Illness-Immobility/Sleep-SkinSensory/Mental Status-Medications-Metabolic/Environment (PRISME)
 For depression: Cornell Geriatric Depression Scale
 For dementia: standardized Mini Mental Status Examination (sMMSE)
 Assess family member’s willingness and/or ability to participate in delirium screening and
interventions.
 Support the senior’s safety by proactively managing their physical and social environments
to meet their assessed individual needs.
RECOMMENDED INTERVENTIONS, DEPENDENT ON THE RESULTS OF THE ASSESSMENT,
INCLUDING BUT NOT LIMITED TO:
Provider/Patient Level:
 Prevent delirium in hospital by early identification of the senior’s specific risk factors
(dementia, medication changes, dehydration, severe illness, vision impairment, and
environmental factors such as lighting and noise) and intervene to modify those risk factors
and monitor effectiveness of interventions.
 Screen for delirium on admission and minimum of once daily or as per local protocols, and
contact the primary physician immediately to seek rapid treatment for all seniors who
screen positive or with possible/probable delirium.
 If screened positive, further assess the client for underlying predisposing and precipitating
factors as possible causes of delirium and address reversible causes in the care plan.
 Communicate cognitive changes and their timelines through appropriate referrals to the
inter-professional health care team.
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Educate and involve patient, family, and/or caregiver(s) in management of delirium.
Include management of the underlying precipitating causes of delirium (i.e. constipation,
malnutrition, dehydration, indwelling urinary catheter, polypharmacy, pain or elevated
glucose) in an individualized plan of care to which the interdisciplinary team can contribute.
Use non-pharmacological and environmental strategies as a first line of intervention to
address responsive behaviours for both delirium and dementia.
System-Level:
 Educate staff re: prevention of delirium, screening tools for cognitive impairment, early
identification of delirium, understanding of dementia and the effectiveness of interventions
for delirium.
 Develop a culture of avoiding the use of restraints (restraints contribute to agitation and
increase safety risks).
 Establish a timely communication process between hospital and the receiving community
care setting/service for the transfer of information contained within the care plan and the
discharge and/or transition plan to relay concerns the senior continues to experience in this
care area post-discharge.
REFERENCES:
American Geriatrics Society 2012 Beers Criteria Update Expert Panel. (2012).American
Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in
Older Adults. JAGS, 60:616–631.
Fick, D.M. & Semla, T.P. (2012). 2012 American Geriatrics Society Beers Criteria: New Year, New
Criteria, New Perspective. JAGS, 60,614–615.
British Columbia’s Provincial Dementia Action Plan (currently in press as at June 27, 2012)
Canadian Coalition for Seniors Mental Health: National Guidelines and practice support
documentation for each of delirium, depression and dementia, 2006.
British Columbia’s Dementia Services Framework (2007) unpublished.
American Psychiatric Association. (2000) Diagnostic and Statistical Manual of Mental Disorders,
4th Edition. Retrieved 17 August 2012 at: http://www.dsmiv.net/
GPAC Guideline:
 Cognitive Impairment in the Elderly - Recognition, Diagnosis and Management
Resnick, B. & Pacala, J.T. (2012). 2012 Beers Criteria. JAGS, 60, 612–613.
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1.3 PRACTICE STATEMENT: FUNCTIONAL MOBILITY
If, through the initial 48/6 screen, the senior (or a close family member or friend on their
behalf) reports or demonstrates any recent changes in functional mobility, the following
practice statement has been developed to help the care team assess and manage this aspect of
care.
PURPOSE OF THIS PRACTICE STATEMENT:
 To promote and support functional independence.
 To recognize hospital practices which contribute to a loss of functional mobility.
WHY FUNCTIONAL MOBILITY IS IMPORTANT TO SENIOR’S HEALTH:
Loss of functional mobility can have serious implications for seniors. The failure to recover
functional mobility, following an acute event, can result in poor outcomes, such as: increased
risk for falls, greater dependency on others, diminished quality of life and an increased risk of
facility placement and the likelihood of increased hospital stays.
Functional mobility is primarily diminished through prolonged periods of inactivity or bed rest
which can result in irreversible loss of functional mobility for seniors. Additional factors
associated with loss of functional mobility include adverse medication side effects, chemical
restraints, pain, malnutrition, and dehydration. Complications associated with low mobility
levels are delirium, pressure ulcers, incontinence, falls, and muscle mass wasting (i.e., up to
5% per day).
Medical devices such as urinary catheter tubing, urinary drainage bags, and intravenous lines
and pumps restrict independent ambulation and adversely impact ability to ambulate.
Environmental barriers to mobility include: cluttered hallways, lack of hand rails, lack of grab
bars and raised toilet seats in bathrooms, beds in high position, bed side rails up, and physical
or environmental restraints.
RELEVANT GUIDELINES:
Existing Guideline and Protocols Advisory Committee (GPAC) and Health Authority clinical
practice guidelines, practice standards and policies pertinent to your regulated discipline.
TARGETED ASSESSMENTS INCLUDE:
 Monitor functional status on a daily basis through the use of a validated screening tool (e.g.
Quick Mobility Test; Hierarchical Assessment of Balance and Mobility; CSHA Clinical Frailty
Scale)
 Identify risk factors for functional mobility loss (e.g. prolonged time in bed, not getting up
for meals) and individualize interdisciplinary interventions to promote optimal mobility.
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RECOMMENDED INTERVENTIONS, DEPENDENT ON THE RESULTS OF THE ASSESSMENT,
INCLUDING BUT NOT LIMITED TO:
Provider/Patient Level:
 Establish goals towards the senior’s level of function prior to acute onset (“What activities
does the patient want to get back to doing?”) and integrate these into the care plan.
Monitor mutually established goal attainment and document progress daily.
 Mobilize as soon as possible after acute event unless medically contraindicated.
 Provide appropriate mobility aids, if necessary.
 Encourage use of appropriate footwear; discuss use of hip protectors with patient and
family.
 Identify risk factors and obstacles for functional mobility loss and individualize
interdisciplinary interventions (i.e., individualized exercise regime) to promote optimal
mobility.
 Avoid use of physical restraints. Assess family member’s ability to participate in mobility
interventions. Involve family members in mealtimes, exercise regimes, and if safe to do so,
in ambulation.
 Provide information for patient, family, and/or caregiver(s) regarding the risks of mobilizing
and not mobilizing.
System-Level:
 Establish a timely communication process between hospital and the receiving community
care setting/service for the transfer of information contained within the care plan and the
discharge and/or transition plan to relay concerns the senior continues to experience in this
care area post-discharge.
 Implementing and evaluating a fall prevention strategy to minimize the impact of falls is
now a Required Organizational Practice (ROP) that is part of Accreditation Canada
Standards. ROPs are minimal patient safety practices that must be in place in all relevant
areas across the health system.
REFERENCES
Bortz, W. (1982). Disuse and ageing. JAMA, 248, 1203-1208.
Brown , C. et al. (2007). Barriers to mobility during hospitalization from the perspective of older
patients and their nurses and physicians. Jnl of Hospital Medicine, Sept/Oct, 2(5), 305313.
Brown, C., Friedkin, R. & Inouye, S. (2004). Prevalence and outcomes of low mobility in
hospitalized older patients. Jnl of the American Geriatric Society, Aug. 52(8), 1263-1270.
Callen, B.L. et al. (2004). Frequency of hallway ambulation by hospitalized older adults on
medical units of an academic hospital. Geriatric Nursing, Jul/Aug, 25(4), 212-217.
Callen, B.L. et al. (2004). Admission and discharge mobility of frail hospitalized older adults.
MedSurg Nursing, June, 13(3), 156-163.
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Clinical Practice Guideline: Prevention and Management and Interventions Falls to Reduce
Harm and Injuries for Acute Hospitals and Sub Acute Care Areas, Fraser Health Authority,
2010.
Gillis, A. & MacDonald, B. (2005). Prevention of de-conditioning in the hospitalized elderly. Cdn
Nurse, June, 101(4), 16-20.
GPAC Guidelines:
 Osteoarthritis in Peripheral Joints - Diagnosis and Treatment
 Diabetes Care
 Frailty in Older Adults – Early Identification and Management
 Iron Overload - Investigation and Management
Graf, C. (2006). Functional decline in hospitalized older adults: It’s often a consequence of
hospitalization, but it doesn’t have to be. American Jnl of Nursing, Jan. 106(1), 58-67.
Harper, C. & Lyles,Y. (1988). Physiology and complications of bedrest. Jnl of the American
Geriatric Society, 36, 1047-1054.
Inouye, S.K. et al. (1999). A multicomponent intervention to prevent delirium in hospitalized
older patients. New England Jnl of Med, 340, 669-76.
King, D. (2006). Functional decline in hospitalize elders. MedSurg Nursing, Oct. 15(5), 265-271.
Kresevic, D. (2008). Assessment of Function. Nursing Standard of Practice Protocol. Hartford
Institute for Geriatric Nursing. www.consultgerirn.org.
Markey, D. & Brown, R. (2002). An interdisciplinary approach to addressing patient activity and
mobility in the medical-surgical patient. Jnl of Nursing Care Quality, 16(4), 1-12.
Mudge, A., Giebel, A., & Cutler, A. (2008). Exercising body and mind: An integrated approach to
functional independence in hospitalized older people. Jnl of the American Geriatric
Society, April 56(4), 630-635.
Siebens, H. (1990). Deconditioning. In B. Kemp, K Brummel-Smith & J. Ramsdell (Eds), Geriatric
Rehabilitation: College Hill Press.
Takuya, H. & Tomoaki, S. (2007). Effects of exercise on the improvement of the physical
functions of the elderly. Jnl of Physical Therapy Science, 19(1), 15-26.
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1.4 PRACTICE STATEMENT: MEDICATION MANAGEMENT
If, through the initial 48/6 screen, the senior (or a close family member or friend on their
behalf) reports or demonstrates any recent changes in medication management, the following
practice statement has been developed to help the care team assess and manage this aspect of
care.
PURPOSE OF THIS PRACTICE STATEMENT:
 To improve medication management in all sectors caring for seniors and to limit risk for
medication reconciliation errors during transitions in care.
 To complete an informed medication review to address potential medication adverse
events.
 To reconcile all medications on admission and at discharge.
 To prevent adverse medication events in hospital.
 To optimize the medications and simplify the regimens to make it easiest for the senior to
adhere to their medication plan, making as few errors as possible.
WHY MEDICATION MANAGEMENT IS IMPORTANT TO SENIOR’S HEALTH:
Medication errors are one of the leading causes of injury to patients. Experience from
organizations across Canada and the US has shown that poor communication of medical
information at transition points (i.e. admission, transfer, discharge) is responsible for as many
as 50% of all medications errors in the hospital and up to 20% of all adverse drug events.
Currently, multiple individuals from different disciplines take medication histories and
document them in various locations. The prescriber writes medication orders on a separate
form, allowing discrepancies to occur without any effective way of identifying or resolving
them.
The prevalence of medical errors related to discontinuing care and mismanagement of
medications upon discharge is high and may be associated with an increased risk of rehospitalization. The more medications prescribed is correlated with an increased chance of
error in managing them correctly.
Upon discharge, 49% of seniors experience at least one adverse event including medication
errors, confusing follow-up instructions, or unnecessary testing emphasizing the importance
of good transition planning. Medication reconciliation is recognized as an effective strategy
to deal with these discrepancies.
RELEVANT GUIDELINES
Existing Guideline and Protocols Advisory Committee (GPAC) and Health Authority clinical
practice guidelines, practice standards and policies pertinent to your regulated discipline.
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TARGETED ASSESSMENTS INCLUDE:
 Use a valid and reliable screening tool to assess medication management (e.g., VIHA’s Initial
Medication Assessment Flowchart; PHC’s 10 Tips for Med Reconciliation; PHC’s Admission
and Discharge Med Reconciliation Forms, PHC’s Pre-op Med Reconciliation Form; CAGE
tool; Confusion Assessment Method; OPQRST; Abbey Pain Scale; STOPP).
RECOMMENDED INTERVENTIONS, DEPENDENT ON THE RESULTS OF THE ASSESSMENT,
INCLUDING BUT NOT LIMITED TO:
Patient/Provider Level:
 Include in an individualized plan of care that the care team has worked with the patient,
family, and/or caregiver(s) to educate them on their medication.
 Work with Pharmacist or Most Responsible Physician (MRP) to review medications and
develop a sustainable strategy for the patient to manage their medications.
 Promote medication reconciliation at every handoff and/or transition to ensure safety.
 Continue to reassess and document daily.
System-Level:
 Establish a timely communication process between hospital and the receiving community
care setting/service for the transfer of information contained within the care plan and the
discharge and/or transition plan to relay concerns the senior continues to experience in this
care area post-discharge.
 Implementing and evaluating a medication management strategy to minimize the impact of
medication errors is now a Required Organizational Practice (ROP) that is part of
Accreditation Canada Standards. ROPs are minimal patient safety practices that must be in
place in all relevant areas across the health system.
REFERENCES
American Geriatrics Society 2012 Beers Criteria Update Expert Panel. (2012).American
Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in
Older Adults. JAGS, 60:616–631.
BC Patient Safety and Quality Council. Clinical Care Management Guideline for Medication
Reconciliation in Residential Care (http://www.bcpsqc.ca/quality/medrecguidelines.html)
Fick, D.M. and Semla, T.P. (2012). 2012 American Geriatrics Society Beers Criteria: New Year,
New Criteria, New Perspective. JAGS, 60, 614–615.
Forster, A, et al. (2004). Adverse events among medical patients after discharge from hospital.
CMAJ, 170, 345-349.
GPAC Guidelines:
 Cognitive Impairment in the Elderly - Recognition, Diagnosis and Management
 Frailty in Older Adults – Early Identification and Management
 Primary Care Management of Sleep Complaints in Adults
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Hamilton, H. et al. (June 13, 2011). Potentially Inappropriate Medications Defined by STOPP
Criteria and the Risk of Adverse Drug Events in Older Hospitalized Patients. Arch Intern
Med, 171(11), 1013-1019.
Marcantanio, E.R., et al. (1999). Factors associated with unplanned hospital readmission among
patients 65 years of age and older in a Medicare managed care plan. American Journal of
Medicine, 107, 13-17.
Moore, C., Wisnivesky, J., Williams, S., & McGinn, T. (2003). Medical errors related to
discontinuity of care from an inpatient to an outpatient setting. Jnl General Internal
Medicine, 18, 646-651.
Resnick, B. & Pacala, J.T. (2012). 2012 Beers Criteria. JAGS, 60, 612–613.
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1.5 PRACTICE STATEMENT: NUTRITION AND HYDRATION
MANAGEMENT
If, through the initial 48/6 screen, the senior (or a close family member or friend on their
behalf) reports or demonstrates any recent changes in nutrition and/or hydration management,
the following practice statement has been developed to help the care team assess and manage
this aspect of care.
PURPOSE OF THIS PRACTICE STATEMENT:
 To establish a pre-hospital baseline of the patient’s nutrition and hydration.
 To promote and facilitate adequate nutrients and fluid intake.
 To recognize and avoid hospital practices which contribute to dehydration and inadequate
nutrition.
WHY NUTRITION AND HYDRATION MANAGEMENT IS IMPORTANT TO SENIOR’S HEALTH:
Seniors are vulnerable to malnutrition and dehydration; both can be causes and outcomes of
illness and functional impairment. The prevalence of malnutrition in hospitalized seniors ranges
from 25% to 50%.
Nutrition and hydration status is an important consideration in maintaining a senior’s
independence and preventing functional decline. Malnutrition can impact the senior’s
functional abilities and quality of life as well as increasing health care costs and increasing
length of stay in acute care hospitals. Dehydration is the most common fluid and electrolyte
imbalance in seniors, and can have serious consequences, precipitating emergency
hospitalization and increasing the risk for repeated hospitalization.
RELEVANT GUIDELINES:
Existing Guideline and Protocols Advisory Committee (GPAC) and Health Authority clinical
practice guidelines, practice standards and policies pertinent to your regulated discipline.
TARGETED ASSESSMENTS INCLUDE:
 Use a clinically validated assessment tool (e.g., Providence Health Care Elder Care Nutrition
Assessment).
RECOMMENDED INTERVENTIONS, DEPENDENT ON THE RESULTS OF THE ASSESSMENT,
INCLUDING BUT NOT LIMITED TO:
Patient/Provider Level:
 Assess patient’s weight and height at admission to obtain a baseline and establish preadmission levels.
 On a daily basis and at regularly set intervals, monitor food and fluid intake and weight for
malnourished seniors until stable to prevent complications associated with increased
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



dependency, such as pressure ulcers, unless clinical indicators suggest more frequent
monitoring.
Assess for risk factors (e.g. dehydration, IV fluids, constipation, swallowing difficulties, oral
health and delirium) that may impact nutrition and fluid balance.
Collaborate with senior to develop an individualized care plan including goals for food and
fluid intake, set goals of care and document progress towards goal attainment.
Involve patient, family, and/or caregiver(s) in nutrition and hydration planning, assess
willingness to visit and assist at meal times.
Document nutrition/hydration status and nutrition/hydration plan on transfer and
discharge forms.
System-Level:
 Establish a timely communication process between hospital and the receiving community
care setting/service for the transfer of information contained within the care plan and the
discharge and/or transition plan to relay concerns the senior continues to experience in this
care area post-discharge.
REFERENCES
Babineau, J., Villalon,L., Laporte, M., & Payette, M. (2008). Outcomes of screening and
nutritional intervention among older adults in health care facilities. Cdn Jnl Dietetic
Practice Research, Summer 69(2), 89-94.
Bennett, J.A., Thomas, V. & Riegel, B. (2004). Unrecognized chronic dehydration in older adults:
examining prevalence rate and risk factors. Jnl Gerontological Nursing, Nov.30(11), 22-8.
Brownie, S. (2005). Why are elderly individuals at risk of nutritional deficiency? Intl Jnl Nursing
Practice, 12, 110-118.
Corish, C.A. & Kennedy, N.P. (2000). Protein-energy undernutrition in hospital in-patients.
British Journal Nutrition, June 83(6), 575-591.
Ferry, M. (2005). Strategies for ensuring good hydration in the elderly. Nutrition Review, 63(6),
S22-S29.
Furman, E. (2006). Undernutrition in older adults across the continuum of care. Jnl
Gerontological Nursing, 32(1), 22-27.
Gary, R. & Fleury, J. (2002). Nutritional status: Key to preventing functional decline in
hospitalized older adults. Geriatric Rehabilitation, 17(3), 40-71.
GPAC Guidelines:
 Gastroesophageal Reflux Disease - Clinical Approach in Adults
 Diabetes Care
 Iron Overload - Investigation and Management
 Problem Drinking
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Hodgkinson, B., Evans, D., & Wood, J. (2003). Maintaining oral hydration in older adults: A
systematic review. Intl Jnl Nursing Pract, 9, S19-S28.
Hodgkinson, B., Evans, D., & Wood, J. (2003). Maintaining oral hydration in older adults: A
systematic review. Intl Jnl of Nursing Practice, 9, S19-S28.
Holmes, S. (2006). Barriers to effective nutritional care for older adults. Nursing Std, 21(3), 5054.
Korevaar, J.C., van Munster, B.C., & de Rooij, S.E. (2005). Risk factors for delirium in acutely
admitted elderly patients: A prospective cohort study. Geriatrics, 5(6). Retrieved 5 July
2012 at: http://www.biomedcentral.com/1471-2318/5/6
Mentes, J. (2006). Oral hydration in older adults: Greater awareness is needed in preventing,
recognizing and treating dehydration. American Jnl Nurs, June 106(6), 40-49.
Mentes, J., Culp, K., Maas, M. & Rantz, M. (1999). Acute confusion indicators: Risk factors and
prevalence using MDS data. Research in Nursing and Health, 22(2), 95-105.
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1.6 PRACTICE STATEMENT: PAIN MANAGEMENT
If, through the initial 48/6 screen, the senior (or a close family member or friend on their
behalf) reports or demonstrates any recent changes in pain management, the following
practice statement has been developed to help the care team assess and manage this aspect of
care.
PURPOSE OF THIS PRACTICE STATEMENT:
 To assess and manage acute and chronic pain.
 To recognize the common contributing factors affecting both acute and chronic pain, using
a broad, person-centered approach which involves the individual and family/caregiver,
including any contributing hospital practices/procedures.
WHY PAIN MANAGEMENT IS IMPORTANT TO SENIORS’ HEALTH:
Unrelieved pain in seniors is more than just being uncomfortable; it affects quality of life and
ability to recover. Pain has been associated with heightened anxiety, depression, increased risk
of falls, slower recovery from surgery, altered immune function, malnutrition, reduced
independence and changes in cognition. Managing pain appropriately will assist in regaining
functional independence.
In addition to acute pain, seniors are more likely to experience health conditions that can cause
chronic pain.
RELEVANT GUIDELINES:
Existing Guideline and Protocols Advisory Committee (GPAC) and Health Authority clinical
practice guidelines, practice standards and policies pertinent to your regulated discipline.
TARGETED ASSESSMENTS INCLUDE:
 Use the correct, valid and reliable tool for the appropriate population (e.g. cognitively
intact, cognitively impaired, identified language barrier) and consistently use the same tool
for the same patient at each assessment.
 Recognize pain presentation in the cognitively impaired older adult.
 Assess the senior’s (and family/caregiver, where appropriate) preferences, cultural beliefs,
attitudes and expectations/goals about pain, pain expression, coping responses and pain
management.
 Assess effects of pain on functional ability.
 Assess for and treat anticipatory pain prior to treatments or therapeutic interventions (e.g.
activation and mobilization, bathing, wound care).
 Assess and treat post-operative pain, especially in the first 48 hours, to prevent delirium.
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RECOMMENDED INTERVENTIONS, DEPENDENT ON THE RESULTS OF THE ASSESSMENT,
INCLUDING BUT NOT LIMITED TO:
Patient/Provider Level:
 Include pain management in an individualized plan of care to which the interdisciplinary
team can contribute.
 Document and consistently communicate all pain-related findings across shifts and
transitions in care.
 Use a variety of non-pharmacological approaches as a first line intervention for effective
pain management.
 When non-pharmacological approaches are insufficient, use appropriate pharmacological
agents to augment the pain care plan.
 Use a “start low, go slow” approach to medication dosage and titration.
 Begin with regularly prescribed dose and a PRN dose for breakthrough pain and before
activities.
 Monitor the potential reactions, side effects and medication interactions of
pharmacological pain management.
 Monitor and evaluate effectiveness of all pain management interventions.
 Promote and facilitate pain self-management options to actively involve the individual in
their own care as appropriate.
 Provide pain education for the patient, family, and/or caregiver(s).
System-Level:
 Each site must establish a timely communication process between hospital and the
receiving community care setting/service for the transfer of information contained within
the care plan and the discharge and/or transition plan to relay concerns the senior
continues to experience in this care area post-discharge.
REFERENCES
American Geriatrics Society 2012 Beers Criteria Update Expert Panel. (2012).American
Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in
Older Adults. JAGS, 60:616–631.
Canadian Pain Society. (2005). Accreditation pain standard: making it happen! Retrieved
October 5, 2011 at: http://www.canadianpainsociety.ca/pdf/accreditation_manual.pdf
Fuchs-Lacelle, S., et al. (2008). Pain assessment as intervention: a study of older adults with
severe dementia. , 24(8), 697-707.
Guidelines and Protocols Advisory Committee Guidelines:
 Acute Chest Pain - Evaluation and Triage
 Osteoarthritis in Peripheral Joints - Diagnosis and Treatment
 Frailty in Older Adults – Early Identification and Management
 Problem Drinking
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 Palliative Care for the Patient with Incurable Cancer or Advanced Disease - Part 2: Pain
and Symptom Management
Harmon, J.R., Higgins, I., Summons, P. & Bellchambers, H. (2012). Efficacy of the use of evidence
based algorithmic guidelines in the acute care setting for pain assessment and
management in older people: a critical review of the literature. Intl Jnl of Older People
Nursing, 7, 127–140.
Vaurio, L.E. et al. (2006). Postoperative delirium: the importance of pain and pain management.
Anesth Analg, Apr; 102(4), 1267-73.
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2.
Glossary
Screening: A series of questions administered to the senior to understand their baseline status
over the 14 days prior to coming to hospital, with respect to each of the six care areas.
Assessment: If a senior demonstrates concern in one or more of the care areas during the
screening stage, an assessment is administered to gain a better understanding of the challenge
this area represents to the senior.
Care Plan: Completed care plans must address, at a minimum, each of the six care areas (bowel
and bladder management, cognition, functional mobility, nutrition and hydration management,
medication management, pain management). If no concerns are initially identified in a care
area, a note should be left on the care plan to indicate same and the team should continue to
monitor the patient for decline in this area throughout their hospital stay. If anything changes,
interventions should be identified and the care plan updated accordingly. Care Plans will
document the care goals of the senior and the interventions which will be used to return the
senior to pre-hospital or best possible functioning.
Decision to Admit: A decision on whether a patient requires admission to a hospital bed.1
Delirium: A state of mental confusion that develops quickly and usually fluctuates in intensity.2
Dementia: A loss of mental ability severe enough to interfere with normal activities of daily
living, lasting more than six months, not present since birth, and not associated with a loss or
alteration of consciousness.3
Discharge and/or Transition Plan: The written plan to facilitate a patient's movement from one
health care setting to another, or to home. It is a multidisciplinary process involving physicians,
nurses, social workers, and possibly other health professionals; its goal is to enhance continuity
of care (i.e., transitional care) and begins on admission.4
Inter-Professional Health Care Team: All health care professionals involved with the patient’s
care journey.
Muscle Atrophy: Wasting or loss of muscle tissue.
Transitional Care: Refers to the actions of healthcare providers designed to ensure the
coordination and continuity of health care during the movement, called care transition,
between health care practitioners and settings as their condition and care needs change during
the course of a chronic or acute illness.
1
Audit Commission. (2011). By definition - Improving data definitions and their use by the NHS: A briefing from the
Payment by Results - data assurance programme. Retrieved 15 August 2012 at:
http://www.auditcommission.gov.uk/sitecollectiondocuments/downloads/20120419ByDefinition.pdf
2
Retrieved 14 August 2012 at: http://medical-dictionary.thefreedictionary.com/delirium
3
Retrieved 14 August 2012 at: http://medical-dictionary.thefreedictionary.com/dementia
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