1. Virtual ACE Update

2. Demo ACE Tracker

3. How we are trying to make your life better 
Implementing Virtual ACE on Hospitalist Units at UAB Hospital also known as…..
How we are trying to make your life better 

4. Immobility/Functional Decline
Major, Potentially Life-Threatening Geriatric Syndromes That are Linked and Impact Care Transitions
Care Transition Plan
Pain
Immobility/Functional Decline
Delirium

5. A Real Case: Mr. S: Mobility, Pain, and Delirium are LINKED
Privileged Patient Safety Work Product Document
This information and any attachments are prepared and maintained for use in the quality improvement process of the UAB Health System Patient Safety Organization, and University Hospitals and its’ clinics, considered privileged and confidential pursuant to the Code of Alabama, Sections , , , and the Patient Safety and Quality Improvement Act of 2005.

6. What is the Virtual ACE Intervention?
Unit-Based Care Delivery Redesign that trains all providers in:
The “Why”
Function/Safe Mobility
Pain Assessment and Management
Delirium Prevention and Management
Care Transitions
Delirium Prevention Toolbox

7. Ortho units outcomes

8. Post-Training (5M + OSCU)
Variable
Pre-Training
(5M + OSCU)
N=53
Post-Training (5M + OSCU)
N=138
P-value
Age, years
Mean
Range
73.9 ± 7.4
65-94
74.6 ± 7.4 NS
Female Gender, N(%)
37 (70%)
73 (53%)
P=.03
Service, N(%)
Ortho Service
Other Surgery Service
Medicine Service
Bedded ED
35 (66%)
1 (2%)
17 (32%)
94 (68%)
5 (4%)
38 (28%)
1 (1%)
Unit, N(%)
OSCU
5 Main
31 (59%)
22 (41%)
61 (44%)
77 (56%)
History of Fall in last 3 months, N(%)
25 (47%)
51 (37%)
Mean Baseline Katz Score
10.28 ± 3.5
10.00 ± 3.5
Mean Current Katz at index visit
7.28 ± 4.7
8.18 ± 4.2
Abnormal SIS
8 (15%)
22 (16%)
Mean # of sched meds at index visit
8.77 ± 4.0
9.64 ± 4.0
Includes some hospitalist patients
Data through

9. Geriatric care process outcomes

10. Geriatric Processes of Care All Patients, 5 Main and OSCU Completion at Index Visit
Data as of

11. Mobility outcomes

12. Mobility in the Prior 24 Hours All Patients, All Visits, 5 Main and OSCU
Pre: 65 encounters in 50 patients
Post: 115 encounters in 81 patients
Data as of

13. Cognition outcomes

14. Delirium Documentation Status All Patients, All Visits, 5 Main and OSCU
Pre: 44 patients, 60 NUDESCs by RA
Post: 61 patients, 84 NUDESCs by RA; 93 patients, 116 NUDESC by staff
Data as of

15. Early ACE Unit Outcomes

16. Patient Descriptors: 4 Main through 7-7-15
Variable
4 Main Pre-Training
(N=84)
4 Main During Training
(N=34)
4 Main Post-Training
(N=106)
Age
Mean
Range
79.9 ± 8.6
65-97
79.5 ± 7.7
65-95
79.7 ± 8.4
65-96
Gender, N (%) Female
59 (70%)
22 (65%)
71 (67%)
Race, N(%)
White
Black
Other
48 (57%)
33 (39%)
3 (4%)
20 (59%)
13 (38%)
1 (3%)
65 (63%)
39 (38%)
0 (0%)
Cogn Impairment documented in Problem List in chart
15 (18%)
2 (6%)
23 (22%)
SIS performed on admit
77 (92%)
33 (97%)
97 (92%)
% Patients with abnormal SIS score
44%
48%
46%
NUDESC performed
10 (12%)
4 (12%)
88 (83%)

17. Virtual ACE Mobility Data: 4 Main Through 7-7-15
Characteristic
4 Main Pre-Training
(N=84)
4 Main During Training (N=34)
4 Main Post-Training
(N=106)
N (%) Patients with Geri Screen completed on admission
Baseline Katz
Current Katz
69 (82%)
68 (81%)
32 (94%)
29 (85%)
96 (91%)
95 (90%)
Hospital Day at time of first mobility screen, days
Mean
Range
2.9 ± 2.9
1-18
4.0 ± 3.6
1-12
3.7 ± 6.5
1-59
Baseline Katz Score
8.4 ± 4.5
0-12
9.3 ± 3.7
8.3 ± 4.3
Current Katz Score
6.7 ± 4.9
6.9 ± 4.5
6.5 ± 4.4
History of a fall in last 3 months, N (%)
28 (33%)
10 (29%)
48 (45%)

18. Virtual ACE Mobility Data 4 Main Through 7-7-15: All Patients Age ≥ 65
Pre-Training: 85 encounters in 64 patients
During Training: 25 encounters in 25 patients
Post-Training: 108 encounters in 89 patients

19. Virtual ACE Mobility Data 4 Main Through : All Patients Age ≥ 65 AND Current Katz Index Score ≥ 9
Pre-Training: 31 encounters in 23 patients
During Training: 8 encounters in 8 patients
Post-Training: 37 encounters in 33 patients

20. 4 Main: Promoting Safe Mobility and Cognitive Stimulation
Note this data is a convenience sample of random, one-time visits and observations

21. Virtual ACE Nurse-Driven Care Protocols

22. Pain Assessment and Management

23. Algorithm for Pain Management

24. Cmax Half-life (t1/2) IV SC / IM Plasma Concentration po / pr Time
6 mins
Key to proper med frequencies IV
30 mins
SC / IM
Cmax
po / pr
Plasma Concentration
60 mins
Half-life (t1/2)
Time

25. Maintaining Mobility
This allows patients to remain independent and be able to return to the activities they enjoy.

26. Safe Mobility Care Protocol

27. Safe Mobility Care Protocol

28. Delirium
Delirium may be the only sign of an acute medical emergency in older adults
Despite its importance, delirium is under-recognized by nurses and physicians. Personal philosophies about aging as well as the inability to distinguish delirium from dementia are contributing factors. The hypoactive subtype of delirium may not be readily identified due to the absence of agitated behavior, a characteristic that usually serves as an alert to staff. In addition, time constraints and a lack of systematic screening are barriers to the early recognition of delirium in older hospitalized adults. Low physician support may also be a factor in some clinical areas.

29. What are the clinical criteria for delirium?
Every care provider at UAB Hospital MUST commit to knowing these criteria for diagnosing delirium
Ely et al, Crit Care Med 2001;29(7): ; Pun, Ely. Chest 2007;132:624-36

30. Nursing Delirium Screening Scale (NUDESC): The Early Warning System for Delirium

31. DELIRIUM PREVENTION TOOLBOX
Nurses are using these tools in patients with ANY ONE of the following risk factors for delirium:
SIS ≥ 2
NUDESC ≥ 2
Katz score < 9
Vision impairment
Hearing impairment
BUN/Cr ratio ≥ 18
Anyone else you see as frail, bored, or at risk

32. EVERY patient deserves STOP DELIRIUM Care!

33. If the NUDESC Score is ≥ 2, then….

34. Demo Delirium Order Set

35. QU E S T I ON