It used to be common practice for hospitals in Mercy Health Services in Michigan to use a catheter whenever an elderly patient seemed to be having trouble urinating.
This occurred even though lack of urination in an elderly patient doesn't always mean a full bladder and catheters raise the risk of infection and physical trauma.
Then a Mercy nurse made a practical suggestion that would eventually change the whole hospital system's approach to using catheters on older people. The nurse suggested using bladder scanners first to determine whether a patient's bladder is full, recalls Gay Landstrom, then with Mercy and now the chief nursing officer for Trinity Health, which was formed in 2000 from Mercy and the Holy Cross Health System.
What convinced Mercy officials to change the protocol was the research supporting scanner use, says Landstrom.
The nurse who made the suggestion heard about the research while attending a conference held by NICHE, a national program that aims to enhance care for the elderly by improving hospital practices. NICHE, which stands for Nurses Improving Care for Healthsystem Elders, was started in 1992 at the Hartford Institute for Geriatric Nursing at New York University's College of Nursing.
As the first wave of baby boomers reaches 65 and hospitals search for safer, better ways to care for the aged, a good number are gaining insight through NICHE. More than 300 hospitals in the U.S. participate in NICHE, according to Marie Boltz, the program's associate director of initiatives.
Landstrom believes so strongly in NICHE that she predicts the program will eventually go system-wide throughout Trinity.
"It has changed nursing practice in the care of older adults," says Landstrom. "NICHE is not a flash in the pan."
Tuning in to the elderly
Boltz said that because the elderly have special needs due to age-related physical changes, a hospital's approach to care also needs to be specialized. The NICHE philosophy is based on the premise that nurses at the bedside are the most critical in terms of impacting care of the older adult, says Boltz, but all areas of the health system have roles to play in making a hospital more supportive of elderly patients.
For instance, it's important for hospital housekeepers to know that high-gloss polish on floors can cause glare and may contribute to falls in people with cataracts, says Boltz. Cutting down on background noise helps the elderly who have difficulty hearing, and some NICHE hospitals have started using "yacker-trackers," that show a red light when the noise level is too high and a green light when it's good, says Boltz.
"That's the kind of thing that NICHE identifies and members share with one another," says Boltz. "NICHE also uses protocols on how to prevent falls, how to use the right medications, and how to avoid delirium" in elderly patients.
When a hospital decides to join NICHE, the program recommends that at least three staffers participate in a six-week online leadership training course, during which they develop an action plan for improving care for the elderly.
With guidance from NICHE, the leadership team also surveys hospital nurses on their knowledge and attitudes toward older adults, as well as on how current hospital structure responds to elderly patient issues. The survey helps hospitals learn their strengths and weaknesses, says Boltz.
One of the key techniques that NICHE promotes is the online training of geriatric resource nurses among a hospital's staff. These nurses share their expertise with other staff, says Boltz.
A collaborative effort
NICHE encourages and promotes collaboration and sharing of ideas among its members though its Listserv and discussion boards on its website. That willingness to share information impresses members, says Brenda Belbot, a clinical practice manager at St. John Hospital & Medical Center in Detroit. St. John, which is part of Ascension Health, has been a NICHE member since 2002.
"You can put a query out on the Listserv and have answers back from 12 different people within an hour," says Belbot.
Belbot found NICHE extremely valuable when she and a colleague, Jenna Godfryd, documented the value of creating a 24-hour rapid response team to treat delirium, which is a common problem in the hospitalized elderly.
Julie Lundvick, a clinical service director at Saint Mary's Health Care in Grand Rapids, Michigan, says she's been amazed at "how freely information is shared. We've just found that with NICHE, what's theirs is yours."
Saint Mary's, which is also part of Trinity, joined NICHE in April and has since trained 50 of its 800 staffers to be geriatric resource nurses, says Lundvick. There are plans to expand that number to include all units in the hospital. Saint Mary's has also started sensitivity training for 60 patient care assistants or nursing aides. They attend day-long workshops that involve such things as wearing goggles covered with Vaseline or putting cotton in ears to simulate what it's like to be an older person and have poor vision or hearing.
Why not the best?
Each hospital decides what elements of NICHE suit it. "Everyone knows their market best," says Joanne Grosh, an administrator in senior services for the seven-hospital Saint Joseph Mercy Health System of Ypsilanti, Mich., part of Trinity. This year, Saint Joseph Mercy became the first hospital system in Michigan to create senior emergency departments in each of its emergency rooms, says Grosh.
Four St. Joseph Mercy hospitals are NICHE members. Says Grosh: "We would like all seven of our hospitals to be NICHE-designated hospitals. It's just a very valuable resource."
Julie Trocchio, CHA senior director of community benefit and continuing care, said the NICHE approach is to treat the whole person, not just the illness that sent them to a hospital. "What NICHE says is, 'You have a frail elder here, and you don't just look at one condition, you have to look at their skin, their hydration."
NICHE fits in well with the mission statements of many Catholic hospitals, who seek to heal, to reduce suffering and to protect the vulnerable.
"What excites me about NICHE is this attitude of "Why not the best?'" says Trocchio. "It's saying, the people who are very old and very frail, don't they need the very best care we can give and shouldn't we be giving that to them?"