The Grace Initiative aims to address the unique concerns of vulnerable elderly patients in hospitals by identifying and preventing delirium, maintaining function, and optimizing resources. It includes a three-pronged approach focusing on bedside assessment, mobility protocols, and a sleep protocol, specifically designed for patients aged 80 and older. Nurses will play a central role in implementing this program, utilizing the bedside Grace flow sheet for daily assessments and monitoring.

2. Created at BIDMC Multidisciplinary input Nursing Geriatrics Hospital Medicine Pharmacy IS Dept of Health Care Quality

3. Hospitalization is a vulnerable time for elderly patients Older patients are at risk for: Delirium (acute confusional state) Physical deconditioning Medication side-effects Loss of function

4. The GRACE initiative will address unique concerns of vulnerable elders Identify delirium (confusion) as soon as it develops Target finite resources Implement programs to maintain function and prevent delirium

5. Three-pronged initiative Provider Order Entry (POE) Pharmacy Bedside

6. Three-pronged initiative Provider Order Entry (POE) Pharmacy Bedside

7. Bedside component For patients ≥ 80 years Roll-out on 11R, CC7, Farr 2 anticipated in Oct/November 2 nd wave to rollout on all other floors (except Deac-4, Oncology and ICUs) 1-2 mo later Springtime rollout planned for subset of 65-79 year old patients

8. Bedside component Mainly the domain of nursing Nurses will be the primary “go-to” for this component but are encouraged to work with and utilize help from physicians, PT, NPs, PAs and PCTs

9. Bedside GRACE flow sheet One sheet per day goes in blue vital signs book/clipboard Use 1 copy of form each day for any patient admitted to your unit 80 years or older

11. See handout of GRACE Flowsheet

12. Bedside GRACE flow sheet Multiple components 2 part Delirium screen Morning “tether check” Mobility protocol Sleep protocol

13. Bedside GRACE flow sheet Multiple components 2 part Delirium screen Morning “tether check” Mobility protocol Sleep protocol

14. 2 Part Delirium (confusion) Screen 1) RASS Score – two times per day 2) Test of attention – once per day

15. 2 Part Delirium (confusion) Screen RASS Score Use the Richmond Agitation and Sedation Scale First part of the delirium screen

17. 2 Part Delirium (confusion) Screen 1) RASS Score Scored two times per day Once between 7 am - 3 pm Once between 3 -11 pm

18. 2 Part Delirium (confusion) Screen 1) RASS Score Scored two times per day Once between 7 am - 3 pm Once between 3 -11 pm Write RASS score on Flowsheet

19. 2 Part Delirium (confusion) Screen 1) RASS Score Scored two times per day Once between 7 am - 3 pm Once between 3 -11 pm Write RASS score on Flowsheet Any score that is NOT a 0, 1 or -1, if a NEW score to that patient, is considered a positive screen for delirium  Trigger

20. Daily screen for delirium (confusion) 2) Test of attention – once per day This is the second component of the delirium screen. RASS score is the first.

21. Test of Attention (second part of delirium screen) 1) Ask patient to state the months of year backwards ( e.g. , December, November, October…January). If able, this becomes patient's daily Test of Attention. If unable, 2) Then ask to state days of week backwards ( e.g. , Sunday, Saturday, Friday…Monday). If able, this becomes patient's daily Test of Attention. If unable, 3) Then, ask the patient to count from 10 to 1 (10, 9, 8…1). If able, 10-1 becomes this patient's daily Test of Attention.

22. Daily screen for delirium (confusion) 2) Test of attention – once per day Record which test of attention the patient could do .

23. Daily screen for delirium (confusion) 2) Test of attention – once per day Record which test of attention the patient could do . If unable to do the test of attention from the previous day, or unable to perform any test of attention, this is a positive screen for Delirium!  Trigger!

24. Bedside GRACE flow sheet 2 part Delirium screen Morning “tether check” Mobility protocol Sleep protocol

25. Bedside GRACE flow sheet 2 part Delirium screen Morning “tether check” Mobility protocol Sleep protocol

26. Morning “Tether Check” Background: Foleys, telemetry, IV lines and restraints are considered “tethers” A patient with 1 or more tethers is at increased risk for falling or developing delirium in the hospital We want to minimize the use of tethers in our most vulnerable patient population

27. Morning “Tether Check” Each morning, the need for a tether must be documented. Who can complete this section of the flowsheet? RN after conversation with MD/NP/PA MD/NP/PA can do so independently If no MD/NP/PA has completed it, day RN should speak with the responsible MD/PA/NP and review with him/her the need for any tethers that are in use.

28. Bedside GRACE flow sheet 2 part Delirium screen Morning “tether check” Mobility protocol Sleep protocol

29. Bedside GRACE flow sheet 2 part Delirium screen Morning “tether check” Mobility protocol Sleep protocol

30. Mobility Protocol Background: Bedrest causes patients to lose function Increases risks of pressure ulcers, pneumonia Older patients are most vulnerable to losing function while in the hospital Loss of function leads to placement in nursing homes after discharge from the hospital

31. Mobility Protocol Get patient out of bed to chair two times per day unless patient unable Ambulate patient in hallway two times per day, unless patient unable Q: Who can do it? A: RN, or PCT, PT, or MD

32. Bedside GRACE flow sheet 2 part Delirium screen Morning “tether check” Mobility protocol Sleep protocol

33. Bedside GRACE flow sheet 2 part Delirium screen Morning “tether check” Mobility protocol Sleep protocol

34. Sleep Protocol Background: Sleep deprivation can cause confusion in older patients Designed to normalize the sleep-wake cycle for elderly patients in the hospital Minimize noise, lights, lab draws, routine VS checks between 11 pm and 7 am

35. It is our hope that the bedside flowsheet will be utilized by all members of the care team, including nurses, doctors, PT, OT etc. Nurses, however, are the cornerstone to bedside care and have primary “ownership” for the completion of this form.

36. Thank you! Melissa Mattison, MD [email_address] Pager 90141 Angela Botts, MD [email_address] Pager 31458 Daniele Olveczky, MD [email_address] Pager 38743 Julie Moran, MD jamoran @bidmc.harvard.edu Pager 33000 Christine Kristeller, RN [email_address] Pager 39232 Questions: