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AACN Advanced Critical Care:
doi: 10.1097/NCI.0b013e31821455c9
Symposium: Geriatric Issues in Critical Care

A System-Level Approach to Improving the Care of the Older Critical Care Patient

Boltz, Marie PhD, CRNP

Section Editor(s): Hedges, Christine Symposium Editor

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Author Information

Marie Boltz is Associate Director of Practice, Hartford Institute for Geriatric Nursing, New York University College of Nursing, 726 Broadway, New York, NY 10003 (marie.boltz@nyu.edu).

The work of Dr Boltz, a Claire M. Fagin Fellow (2009–2011), was supported by the John A. Hartford Foundation's Building Academic Geriatric Nursing Capacity program.

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As the population continues to age, the specialized needs of older adult patients warrant the close attention of the critical care nurse. The combination of critical illness, age-related changes, multiple comorbidities, and the hospital environment can make the diagnosis and management of the older adult's critical illness challenging. The NICHE (Nurses Improving Care for Healthsystem Elders) program provides a framework to create an aging-sensitive care environment in the critical care setting. The Geriatric Resource Nurse model is the foundation of the program. The goals of NICHE are to support nursing departments to (1) bring evidence-based geriatric practice to the bedside; (2) build patient- and family-centered environments; (3) cultivate healthy and productive practice environments aligned with meeting the specialized needs of older adults and their families (“geriatric nursing practice environments”); and (4) conduct comprehensive measurement of geriatric initiatives.

Older adults represent the fastest-growing segment of the US population. Those aged 85 years and older comprise the fastest-growing cohort of the aging population; by the year 2025, they are expected to number 15 million.1 As the population continues to age, the specialized needs of older adult patients warrant the close attention of the critical care nurse. Those aged 65 years and older use almost 60% of all critical care days, represent 42% to 52% of intensive care admissions, and consume more than one-fourth of trauma and critical care resources.2 The combination of critical illness, age-related changes, multiple comorbidities, and the hospital environment can make the diagnosis and management of the older adult's critical illness challenging.36 The complex needs of the older adult are also typically complicated by social and economic issues.7,8 The older person with cognitive loss may not have established advance directives, and the need to identify a surrogate decision maker complicates the process of developing a treatment plan.

This combination of challenges places the older critical care patient at an increased risk for complications, including pressure ulcers, adverse drug events, infection, delirium, malnutrition, and functional decline, compared to their younger counterparts.913 In addition, they are more likely to experience prolonged recovery,13 increased use of postacute services,14 and shortened life expectancy.1517 The ever-increasing presence of older adults in the critical care setting and the complexity of their needs create an imperative for the critical care nurse to possess skills and knowledge in gerontological nursing. While building and maintaining the geriatric knowledge of individual clinicians is essential, it is also important to recognize the contribution of the institutional milieu influencing the outcomes and experience of the older adult patient.18 Thus, models of care that build geriatric-specific competence, while simultaneously changing philosophy and practices, are required to positively impact the care of critically ill older adults.19 The NICHE (Nurses Improving Care for Healthsystem Elders) program provides a framework to create an aging-sensitive care environment in the critical care setting.18 The purpose of this article is to present an overview and analysis of issues related to care of the critically ill older adult, describe select interventional research and initiatives to infuse evidence-based geriatric practice, and describe the role of the NICHE program in supporting these initiatives.

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Initiatives to Improve Care of the Critically Ill Older Adult

Despite an overall paucity of interventional research involving critically ill older adults, there is a growing awareness that many of the negative outcomes in older adults associated with a critical care stay can be avoided with evidence-based interventions. Bedrest is common in critical care, and therapeutic repositioning is considered to be essential to prevent complications.20 Elevation of the head of the bed should be at least 30° to minimize the incidence of ventilator-associated pneumonia21 and to improve oxygenation.22 Hardie and colleagues23 found, in healthy older adults, that oxygenation was better in the sitting position than in the supine position; however, further studies showing the same results in critically ill older patients are needed. Similarly, evidence supports the use of interventions to prevent pressure ulcers, including repositioning and pressure-relieving surfaces in the general population24,25; additional research examining the older adult's response to these interventions is needed.20

Huang and colleagues26 implemented a nurse-led, interdisciplinary initiative that prompted physicians to remove unnecessary urinary catheters, a common source of iatrogenesis in older adult patients.27 This intervention significantly reduced the duration of urinary catheterization, rate of catheter-associated urinary tract infection (CAUTI), and additional cost of antibiotics to manage CAUTI.26

The critical care setting also has important implications for the transitional care needs of the older adult patients. Kleinpell28 demonstrated that older patients who were screened in the intensive care unit (ICU) using the Discharge Planning Questionnaire reported more readiness for discharge than patients in the control group. They were also more likely to report that they had adequate information, were less concerned about managing their care at home, knew their medicines, and knew danger signals indicating potential complications.

A growing number of quality initiatives recognize the geriatric imperative to promote and maintain functional ability. Early mobilization, including for those patients who are mechanically ventilated, is not only feasible29 but also associated with a shorter critical care unit stay and hospital stay, at no extra cost.30 These types of interventions rely on nursing expertise and commitment. The critical care setting is highly collaborative, but it is the critical care nurse who plays a central role by coordinating care, making sure that guidelines are followed, anticipating problems, assessing response to treatment, and communicating with the patient and family on an ongoing basis.

Multiple national initiatives and organizations (eg, National Quality Forum,31 Institute for Healthcare Improvement,32 and Institute of Medicine33) have focused on patient safety and improving patient outcomes for patients in general. However, systemic barriers to improving the safety and overall quality of care persist, undermining efforts to embed evidence-based practices. Hospital staffing and expectations, organizational culture, ways in which teams work together, and institutional procedures all have a significant impact upon care delivery.34

Compounding the common organizational impediments to promoting practice change are 2 issues specific to the care of hospitalized older adults. First, given that the majority of clinicians (nurses, physicians, and others) have received very little formal educational preparation on the care of the hospitalized older adult, there is a pervasive geriatric knowledge gap.35 Second, although care of the older patient requires the collective expertise of an interdisciplinary team, this is not uniformly enforced or even recognized.36 Although disciplines such as rehabilitation and social work provide essential components to a comprehensive geriatric evaluation, they are not commonly included in the care delivery team, especially in the critical care setting.34 Other impediments to improving geriatric care include negative attitudes toward aging and competing initiatives, such as other organizational initiatives including specialty programs (eg, heart programs, stroke programs) that, when examined, typically include older adults as core consumers.

In summary, a combination of factors impacts practice change around care of older adults. These impediments have profound implications for the most vulnerable patient: the critically ill older adult in the critical care environment.37 Thus, initiatives designed to improve quality require a systemic approach, one that includes building geriatric competency at all levels, while modifying the social and physical environment to make it more elder friendly.

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NICHE: A System-Level Intervention

Nurses Improving Care for Healthsystem Elders (NICHE), a national program of the Hartford Institute for Geriatric Nursing at New York University College of Nursing (NYUCN),38 helps hospitals make positive, systemic changes in the way they care for older adults (http://www.nicheprogram.org). The program provides geriatric-specific educational, clinical, and organizational resources for more than 300 hospitals in the United States and Canada (Table 1). The goals of NICHE are to support nursing departments to (1) bring evidence-based practice to the bedside, (2) build patient- and family-centered environments, (3) cultivate healthy and productive practice environments aligned with meeting the specialized needs of older adult patients and their families (“geriatric nursing practice environments”), and (4) conduct comprehensive measurement of geriatric initiatives.

Table 1: Nurses Impr...
Table 1: Nurses Impr...
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Bringing Evidence-Based Geriatric Nursing Practice to the Bedside: The GRN Model

The foundation of the NICHE program is the Geriatric Resource Nurse (GRN) model.39 The GRN model is both an educational and clinical intervention that originated at Boston's Beth Israel Hospital in the late 1980s. It was born from a belief that nurses who feel passionate about the care of hospitalized older patients will excel in meeting the complex problems of this patient group. The model was fully developed at Yale-New Haven Hospital, under funding from the John A. Hartford Foundation's Hospital Outcomes Program for Elders (HOPE) project, and has been refined at the New York University College of Nursing. It is based on the premise that the primary nurse at the bedside is best positioned to assess and respond to the needs of the older adult patient.38,39

The GRN gains enhanced skills in the care of older adults through education and training programs administered by a geriatric advanced practice nurse (GAPN), using the NICHE GRN competency-based curriculum. The curriculum addresses common geriatric syndromes that are relevant to critical care including delirium, medications, pain, and restraints. Bedside coaching provided by the GAPN through regularly scheduled rounds is critical to the integration and application of knowledge.40 Because the GRN is unit-based and supported by an advanced practice nurse, she or he is more likely to integrate evidence-based practice. The GRN uses the SPICES (Sleep disorders, Problems with eating and feeding, Incontinence, Confusion, Evidence of falls, and Skin breakdown) model of screening developed by Fulmer,41 as a guide to identify patients who require additional assessment, preventive measures, and treatment.

The GRN also acts as a resource to other staff, providing consultation and training on issues related to care of the older adult patient. With support from the GAPN, the GRN is active in quality improvement activity. The GRN/GAPN partnership leads an interdisciplinary process that identifies areas for improvement, establishes measurable and time-specific aims and measures, and selects interventions that are based on evidence. They commonly use the PDSA (Plan-Do-Study-Act) cycle42 to test or evaluate the change on a small scale, using what is learned to modify the implementation before disseminating throughout the unit. Some examples of GRN quality initiatives include an oral care protocol to minimize the occurrence of ventilator-associated pneumonia and collaboration with a state quality initiative to reduce unit-acquired pressure ulcers. Experts recommend the GRN model as a leading approach to advancing care of the hospitalized older adult. Units that institute the model in the future could add to nursing science by measuring the model's effectiveness in the ICU.

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Building Patient- and Family-Centered Environments

The typically nontherapeutic nature of an ICU's physical environment, with its noise and sleep disruptions, is compounded by factors in the social environment. Staff are often challenged to communicate with patients and families because of the hectic pace, high patient acuity, and the sensory challenges of older patients.43 NICHE hospitals employ training that sensitizes staff to the specialized communication needs of the older patient, including the use of sensory and communication devices. NICHE webinars and other resources developed by experts in aging-specific design offer information on modifying unit design to minimize noise and promote comfort and sleep (see http://www.nicheprogram.org).

Increased contact with family visitors can yield opportunities for family education44 and improved satisfaction.45 NICHE hospitals use the educational modules that address family needs to better communicate, and they include families in care decisions and often care provision (eg, bathing). Patient and family councils have been implemented in NICHE hospitals to provide former patients and their families with the opportunity to provide feedback, which are used to inform relevant policies. NICHE educational resources for family members address issues on caregiving as well as issues related to hospitalization.

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Cultivating Geriatric Nursing Practice Environments

NICHE nurses have identified key organizational supports or dimensions of the nursing practice environment associated with improved care for older adults. These dimensions include institutional values related to the care of older adult patients, access to geriatric-specific resources, and methods of interdisciplinary collaboration.46

Institutional values that support the well-being and autonomy of older adults are associated with aging-sensitive care delivery.18 Institutional commitment to these values is reflected in the mission and vision statement of NICHE hospitals. NICHE hospitals recognize that quality care of older adults is aligned with their central mission of meeting the health care needs of the communities they serve. Furthermore, these hospitals recognize the specialized needs of older adult patients and the moral and financial imperative of addressing these needs in all areas that serve them.

Institutional valuing of older adult patients also includes the presence of a dedicated, nursing-led, interdisciplinary steering committee to oversee aging initiatives across the hospital setting. With project management tools provided by NICHE, the committee supervises the development of the GRN model, evaluates the quality of elder care, and guides initiatives to make the hospital more elder friendly. The committee is represented by all patient care areas, including critical care, and various levels and disciplines. Advanced practice nurses, often dually certified (eg, gerontology and critical care), provide essential clinical leadership as members of the NICHE steering committee. The steering committee collaborates with hospital administration to provide the physical and human resources to build geriatric capacity as well as measure the effectiveness of these endeavors.

Access to aging-specific resources is another component of a geriatric-specific practice environment. Continuing education (eg, NICHE conferences and cost-effective educational webinars) specialized in care of the older adult is essential. The NICHE Web site also provides an “encyclopedia” of tools, equipment options, and techniques specific to critical care of the older adult. Many NICHE hospitals incorporate GRN status and certification status (gerontological and critical care) into their career ladders. NICHE nurses present their quality initiatives at national NICHE conferences, on webinar presentations, and in publications.

Finally, methods of interdisciplinary collaboration, including clinical protocols and methods of shared decision making, are important elements of the practice environment. NICHE's evidence-based protocols47 used in the critical care setting include advance directives, delirium, heart failure, pressure ulcer prevention, safe medication use, iatrogenic infections, and preventing functional decline. The protocols guide the standardized use of valid and reliable geriatric assessment tools that are critical to develop and evaluate treatment plans. Interdisciplinary rounds promote communication between disciplines, patients, and families. Such communication is essential to prevent errors36 and to create a better experience for patients, families, and staff.48 Interdisciplinary collaboration also creates opportunities for interprofessional research to strengthen the evidence base in care of the critically ill older adult.

The dimensions of the geriatric nursing practice environment are consistent with the standards of a healthy work environment established by the American Association of Critical-Care Nurses: skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership.49 Both entities emphasize the connection between the work environment, nursing practice, and patient outcomes. NICHE specifically aims to provide the aging-sensitive principles, clinical resources, and management tools to create elder-friendly work environments that enable effective and satisfying nursing practice.

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Measuring Geriatric Initiatives

Before implementing a NICHE program, a hospital uses the Geriatric Institutional Assessment Profile (GIAP) to assess its organizational readiness to improve geriatric care.50,51 The GIAP is an online survey, completed by staff, that assesses attitudes regarding the care of the older adult patient, knowledge of best practices, and perceived institutional strengths and barriers to evidence-based care of older adults. Results are benchmarked against other hospitals (similar in size and teaching status) and provide information to prioritize educational and operational initiatives. To date, approximately 50 000 respondents have completed the GIAP, of which about 7500 work in critical care.

The GIAP is offered to NICHE hospitals on an annual basis, along with benchmarked data on pressure ulcers, falls, injurious falls, CAUTI, and restraint use. Thus, clinical data are triangulated with staff knowledge and perceptions of the care environment to establish educational and clinical priorities for improvement. Other measures used by NICHE sites include patient satisfaction, staff satisfaction, length of stay, and readmission rates. In addition, case studies supplement the data providing compelling information about “lessons learned” and the experiences of both patient and staff.

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Case Example: NICHE Quality Initiative in Critical Care

At one hospital, the NICHE steering committee identified the problem of frequent readmissions of older patients with respiratory failure to the critical care unit. A root-cause analysis identified that a common factor associated with readmissions was the presence of delirium during the ICU stay. The steering committee identified the need to decrease the incidence and severity of delirium. They reviewed the Evidence-Based Geriatric Nursing Protocols for Best Practice47 used by NICHE sites to identify needed clinical interventions. They then used the Framework for a Geriatric Acute Care Model48 (see Figure 1) developed by Hartford Institute faculty to guide the components of a multifaceted delirium interventional model.

Figure 1:. Framework...
Figure 1:. Framework...
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1. Organizational structures. The steering committee appointed an interdisciplinary subcommittee to upgrade practices to prevent delirium, using the NICHE protocol.

2. Interdisciplinary protocols and processes. The subcommittee approved the use of the confusion assessment method for the ICU (CAM-ICU) to screen for delirium in mechanically ventilated patients.52 The CAM-ICU is used by bedside nurses and physicians and is known for its reliability, validity, speed, and ease of use.53 In addition, an interdisciplinary team consisting of a nurse, pharmacist, respiratory therapist, and critical care physicians conducted rounds to assess for etiologies of delirium, including medications, infection, and electrolyte imbalance. The GRNs routinely reported the CAM result (delirium vs no delirium) in each shift-to-shift nursing report, and the ICU flowchart was revised to include the CAM-ICU screen.

3. Geriatric staff competence. The ICU GAPN conducted training on delirium prevention and management and assisted the GRNs in gaining proficiency in the use of the CAM-ICU to screen for delirium. When questions arose from the GRNs regarding administration or interpretation of the CAM, they consulted with the GAPN for assistance.

4. Physical environment. Review of the literature revealed that “talking” and “TV” contribute to 49% of noise in the ICU.54,55 A rest period (quiet, undisturbed rest, no TV, and dimmed lights) was implemented on a twice daily basis, and earplugs were available as a low-cost way to decrease noise level.56 Also, family members were encouraged to bring in a meaningful photo, to be kept at the bedside.

5. Patient- and family-centered approaches. Visiting hours were improved to support family contact with patients.44,45 Families receive education on delirium: prevention, signs, and family involvement (including facilitating the use of sensory aids and communication).

6. Aging-sensitive practices. A process to care for sensory aids and use of hearing amplifiers was implemented. Also, medication use was addressed as a potential contributing factor to delirium. The Beers criteria for potentially inappropriate medication use in older adults were reviewed by the committee. Educational drug warnings were embedded in a computerized physician order entry system to alert physicians when a potentially inappropriate drug is prescribed for older adult patients.57

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NICHE as a Journey

NICHE designation means that a hospital is part of a national movement to improve geriatric care in the hospital setting. The process of implementing a NICHE program is fairly straightforward, but it does require organizational commitment. NICHE coordinators have reported that the support of administration, including the highest executive levels, is essential to successful program implementation.58 NICHE faculty, both seasoned NICHE coordinators and NYUCN faculty, provide consultation to help hospitals prepare for startup. Critical first steps include developing an interdisciplinary steering committee and identifying a site coordinator. The NICHE leadership training program, an online interactive course, provides the opportunity for new NICHE teams to learn from mature NICHE sites. The NICHE Planning and Implementation Guide provides a blueprint for startup and includes activities such as developing a vision for geriatric care, internal evaluation, building a business case, defining measures, and developing a 2-year action plan.

Sustaining a program is supported by the collaborative nature of the NICHE community. Hospital clinicians and managers engage with NYUCN faculty at the Hartford Institute to identify and develop resources on an ongoing basis and to take part in NICHE research. NICHE sites also share innovations and practical advice through ongoing listserv dialogue, national and regional conferences, webinars, and discussion boards.

The critical care unit provides the opportunity for nurses to blend the science of geriatrics with the highly developed expertise associated with the care of the critically ill. NICHE provides resources, tools, and the cooperation and collaboration of a national network to support an emerging specialty—gerontological critical care.

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critical care; model; NICHE; older adults; quality initiatives

© 2011 American Association of Critical–Care Nurses


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