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Geriatric Resource Nurse Led Hospital Elder Life Programme: Effect in Reduction of Delirium Occurrence and Restraints Use in Hospitalized Older Adults
Lim Shi Ling, GRN, RN,BSN
Ong Poh Poh, GRN, RN, BSN
Tan Tock Seng Hospital, Singapore
16,009 km
Tan Tock Seng Hospital
• TTSH is one of Singapore’s largest multi-disciplinary hospitals with 173 years of pioneering medical care and development
• TTSH is part of the National Healthcare Group, providing holistic and integrated patient care.
• >1500 beds
• 50 inpatient units
•45 clinical and allied health departments
• > 9,000 healthcare staff
• >3000 nurses
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A day at TTSH
160 Admissions 2,613 Specialist clinic Attendances
• 458 ED Attendances
• 109 Ambulance Cases
• 1,331 Radiological
Investigations
• 13,700 Lab Tests
321 Operations
• 31.9% Inpatients
• 68.1% Ambulatory (Day Surgery)
1,518 Therapy Attendances
As at May 2017
Agenda
• GRN-HELP implementation in TTSH
• GRN-HELP Research
• Conclusions and Discussions
GRN-HELP Implementation in TTSH
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TTSH population health
CGH (0.94
M)
SGH(0.68M)
TTSH (1.40M)
NUH (1.46M) AH
KTPH(0.69M)
Total Pop: 5.18M (2011)
>65yr (168K)
>65yr (42K)
>65yr (82K)
>65yr (71K)
>65yr (118K)
Source: Ministry of Health, 2013
15% above 65y
(10% Nationally)
53% of Inpatients
above 65y
(29% Nationally)
NICHE & HELP in TTSH
NICHE
• TTSH: > 50% inpatient are 65years and above
• TTSH has the 1st geriatric department in Singapore since 1988
• ACE & GMU cover 10% of patient above 65years old
• Another 40% is outside ACE/GMU
• TTSH is NICHE Hospital since 2014
HELP• The small fire: GRNs’ passion &
interest
• In Tan Tock Seng Hospital, a random survey showed 15% of our elderly patients are diagnosed with delirium.
• Nurse (RN+ enrolled nurse = LPN/LVN): patient ratio= 1:4
Initial inspirations…. Items:•Antibiotic caps•Colourful Pebbles•Chinese Chess•Radio•Beans•Waste paper•Newspaper
Positive Outcomes:• Reduced and better controlled restless behavior • Improve patients’ mood and sleep• Passive influence to other nurses in the unit
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More Inspirations….
Origami Beans Sorting
Colouring
And Innovations….
According to colour
Simpler way
Line Me Up• Blood tube Styrofoam rack• Antibiotic caps
Pin It Up/ Fill Me In• Blood tube styrofoam rack• Lancet caps
Pin It Up Fill Me In
Innovation AwardScrew and Bolt
Lock and Key
Design and handcrafted by GRN
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Form a team & Brainstorm
• GRNs with common interest form a team
• Adopt a structured program: GRN-HELP program
• Source for funding for therapeutic activity box
• Collaborated with Volunteer Office, involving volunteers
Hospital Elder Life Program (HELP)
Early mobilisation
Reality orientation
Provide adequate sleep
Correct sensory impairment
Therapeutic activity
Adequate hydration
Sit out of bed
Orientation
Sleep hygiene
See and hear
Activities
Drink
TTSH NICHE GRN course notes
Collaboration with Volunteer Office
• Volunteer office generously sponsor the starter funds
• 15 therapeutic activities boxes delivered to identified wards
• Linked up with short and long terms volunteers
Memory Cards Domino 4 in a row
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Volunteer Trainings • Since November 2015
• Total training sessions: 18
• Training conduct in English or Chinese
• Total volunteers: 240 (till 2017)
• Total hours that volunteer has contributed : 1176
Content of Volunteer HELP Training
• Simulation Activity- Age-related Sensory Impairment
• Classroom training
• Hands-on session in ward
• Volunteer buddy system
VOLUNTEER REQUIREMENT REWARDS SKILLS SET TRAINING
GRADE 1
GREEN TAG
- Good communication starter
- Love elderly- Able to work
independently
Green Tag / Vest Current HELP-Sit up in bed-Thin fluids
- Classroom (transition to Video)
- Hands on- With a buddy
GRADE 2
BLUE TAG
- 40 hours / 6 months- Competent as grade 1
volunteer
Blue Tag / VestOrGreen/blue tag
-Certificate
- Sit out of bed (with a nurse)
- Feed modified fluids (prepare by nurse)
- Grade 2 buddy Grade 1 volunteer
- Watch video prepared by Physiotherapist, Occupational Therapist, Speech Therapist, nurses
- Competency Assessment on modified fluid/transfer patient
GRADE 3
RED TAG
- Another 40 hours / 6 months
- Competent as Grade 2 volunteer
Red Tag / VestOrGreen/ blue/ red tag
-Reward Ceremony at Patient Conference
- Trainer/buddy/ assign roster/ coordinate volunteer
- Identify cases for Grade 1
- Train the trainer by GRN- Train by GRN to pick
cases
GRN-HELP Volunteer Matrix
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GRN-HELP Research
GRN-HELP research
HELP- Inoyue
• Interventions are targeted at risk factors of delirium
• Rate of incidence of delirium: 9.9% in intervention group vs 15.0% in usual group (1999)
GRN-HELP TTSH
• Building culture
• Aging sensitive care
• GRN lead the program
• GRNs’ involvement in research
• Involving of volunteers
Geriatric Resource Nurse Led Hospital Elder Life Programme: Effect in Reduction of Delirium Occurrence and Restraints use in Hospitalised Older Adults
Study Team PI: Liu YunXia Co PI: Ong Poh Poh Co PI: Lim Shi Ling Co PI: Siah Cai Yun Co PI: Alma Angsiangco NicolCo PI: Jodelyn Losbanes LibrodoCollaborator: Dr Margaret Soon Collaborate: Tan Hongyun
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Aim of the Study
• To evaluate the outcome of Hospital Elder Life Programme (HELP) led by Geriatric Resource Nurses (GRNs).
• Hypothesis
• HELP intervention led by GRNs will decrease delirium occurrence and restraints use in the interventions wards.
Study Methodology
• NICHE implementation in TTSH is divided into experimental wards and control wards
• 10 medical surgical wards has GRNs
• 10 medical surgical wards has NO GRNs
• GRN-HELP study: quasi-experimental design
• 4 wards with GRNs are experimental wards; 4 wards without GRNs are control wards
• Intervention: HELP
Inclusion and Exclusion Criteria
Inclusion Criteria
• Inpatient elderly aged 70 and above
• Admitted to these 8 study wards
• With at least one of the risk factors
• Cognitive impairment
• Visual impairment
• Dehydration
Exclusion Criteria
• Patient with delirium on admission
• Extremely violent/uncooperative behaviour
• Alcohol dependency
• Dangerous ill
• Patient with respiratory/contact precaution
• Patient who are dependent on all activity of daily living
• Patient who are unable to engage/decline HELP intervention
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Measurement Tools • This study has approved by hospital IRB ethical board
• Inform consent will be taken from patient or the legal acceptable representative (LAR).
• HELP study data collection form.doc
Study Period• Based on the sample size calculation, the minimal number of subjects
required is 342 for each group (total = 684) at 5% significance and 80% of power.
• The study was carried out for the last 15months based on the current inpatient inflight number and sample size requirement.
• This study will also include pre and post feedback of nurses and volunteers from the intervention wards. This will add up the sample size of 804 including 100nurses and 20 volunteers.
Study Schema
WARDS w GRNs
9C/9D/12C/12D
Not Eligible Eligible
WARDS w/o GRNs
8C/8D/11C/11D
Eligible Not Eligible
Intervention Control
2 medical
2 surgical
2 medical
2 surgical
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Study Recruitment4745 subjects screened over 15
months
826 subjects eligible for study
228 subjects consented into study
0 patient drop off study
228 patients are included in the analysis
(September 2016 till December 2017)
Baseline Demographic Experimental (n =122) Control (n = 106) p Value
Age (years)Mean (SD)
81.5 (6.3) 81.9 (6.8) p = 0.806
GenderMale, n (%) 42 (43%) 43 (40%) p = 0.206Female, n (%) 80 (77%) 63 (60%)EthnicityChinese, n (%) 114 (94%) 95 (89%) p = 0.605Malay, n (%) 5 (4%) 6 (6%)Indian, n (%) 3 (2%) 4 (4%)Eurasian, n (%) 0 1 (1%)Education levelNo formal education, n (%) 82 (67%) 64 (60%) p = 0.502
Primary, n (%) 26 (21%) 24 (23%)Secondary, n (%) 12 (10%) 14 (13%)Diploma, n (%) 2 (2%) 2 (2%)Bachelors’ and above, n (%) 0 2 (2%)Charlson's comorbidity index (CCI)Mean (SD)
1.83 (1.6) 2.06 (1.6) p =0.47
CCI weightLow, n (%) 23 (19%) 14 (13%) p = 0.211Medium, n (%) 73 (60%) 57 (55%)High, n (%) 19 (15%) 27 (25%)Very high, n (%) 7 (6%) 8 (7%)Severity Illness indexLevel 1, n (%) 1 (1%) 0 p =0.001Level 2, n (%) 118 (97%) 88 (83%)Level 3, n (%) 3 (2%) 18 (17%)Level 4, n (%) 0 0
Delirium Risk Factors Experimental (n =122) Control (n = 106) p Value
Cognitive Impairment
Yes, n (%) 83 (68%) 58 (55%) p = 0.027
No, n (%) 39 (32%) 48 (45%)
Visual impairment
Yes, n (%) 22 (18%) 35 (33%) p = 0.007
No, n (%) 100 (82%) 71 (67%)
Dehydration
Yes, n (%) 35 (29%) 34 (32%) p = 0.340
No, n (%) 87 (71%) 72 (68%)
Total risk factors
Low risk, n (%) 107 (88%) 89 (84%) p = 0.680
Intermittent risk, n (%) 13 (10%) 14 (13%)
High risk, n (%) 2 (2%) 3 (3%)
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Outcomes Experimental (n =122) Control (n = 106) p Value
Delirium incidences
Yes, n (%) 6 (5%) 6 (6%) p = 0.944
No, n (%) 116 (95%) 100 (94%)
Delirium daysMean (SD)
0.06 (0.2) 0.24 (2.5) p =0.965
Total delirium days 7 days 28 days
Average delirium days/ case1.16 days/ case 4.66 days/ case
RestraintMean (SD)
0.18 (1.4) 1.26 (8.6) p = 0.531
Total restraint hours 22 hours 130.8 hours
Total numbers of patient on restraints
2 patients 3 patients
Average restraint hours 11 hours /case 43.36 hours/ case
Outcomes Experimental (n =122) Control (n = 106) p Value
Delirium incidences
Yes, n (%) 6 (5%) 6 (6%) p = 0.944
No, n (%) 116 (95%) 100 (94%)
Delirium daysMean (SD)
0.06 (0.2) 0.24 (2.5) p =0.965
Total delirium days 7 days 28 days
Average delirium days/ case1.16 days/ case 4.66 days/ case
RestraintMean (SD)
0.18 (1.4) 1.26 (8.6) p = 0.531
Total restraint hours 22 hours 130.8 hours
Total numbers of patient on restraints
2 patients 3 patients
Average restraint hours 11 hours /case 43.36 hours/ case
Correlation between risk factor and delirium
Delirium Yes Delirium No p Value
Cognitive impairment
Yes (n=142) 12 (8%) 130 (92%) p = 0.008
No (n= 87) 0 (0%) 87 (100%)
Visual impairment
Yes (n= 57) 3 (5%) 54 (95%) p = 0.548
No (n= 171) 8 (5%) 163 (95%)
Dehydration
Yes (69) 1 (1%) 68 (99%) p =0.117
No (159) 10 (6%) 149 (94%)
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Delirium Risk Factors Experimental (n =122) Control (n = 106) p Value
Cognitive Impairment
Yes, n (%) 83 (68%) 58 (55%) p = 0.027
No, n (%) 39 (32%) 48 (45%)
Visual impairment
Yes, n (%) 22 (18%) 35 (33%) p = 0.007
No, n (%) 100 (82%) 71 (67%)
Dehydration
Yes, n (%) 35 (29%) 34 (32%) p = 0.340
No, n (%) 87 (71%) 72 (68%)
Total risk factors
Low risk, n (%) 107 (88%) 89 (84%) p = 0.680
Intermittent risk, n (%) 13 (10%) 14 (13%)
High risk, n (%) 2 (2%) 3 (3%)
Conclusion & Discussions
Conclusions• GRN HELP study did not show any statistically significance in decreasing
in delirium incidences and restrainer usage between experimental group and control group at this point of time.
• There is a decrease trend in delirium days and restraint usage demonstrated in experimental group with HELP intervention.
• Cognitive impairment is the high risk factor for delirium so therefore HELP interventions should be rendered to this group of patients at regular basis.
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Discussions• Limitations
• Study design is limited by pre-allocation of NICHE wards
• Distribution of subjects in experimental ward and control ward is not homogenous
• E.g. Severity illness index score are different among the 2 groups. Experimental group has more cognitive impairment cases.
• Small sample size- yet to reach calculated sample size
• Interventions: limited by maturity of volunteers and nurses over study period
• E.g. Volunteers attritions, competing workload for nurses
• Patient who is subjected to anesthesia during operation is a high risk factor for delirium in the process of retrospective data collection
• Future studies: to compare patient volunteer exposure time with delirium rates/days
Discussions• Strengths
• Create positive geriatric nursing culture
• Less restraint usage
• Promote of non-pharmacological method of engagement/ behaviour management: nurses use the tools for engaging elderly with cognitive impairment and behavior issue too
• Promote nursing governance: GRNs are the leaders of this program
• Encouraging of innovations: innovation of various of activities tools for engaging elderly
• Attracts volunteers to join HELP program
• 1st Hospital in Singapore has structured HELP program that involves volunteers
• Positive feedback from patients/ caregivers/ healthcare workers/ volunteers
Response from Patients
“…The radio is playing my favourite
Hokkien songs that I used to sing at
karaoke.”
“…I enjoy doing this. I will continue this
activity at home.”
“…This is my artwork. I
learnt to make
something today.”
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Response from Families
“…I saw my mother could do colouring in the hospital so I
brought her more. This is the first time I see hospital have
such activities.”
“…These activities are beneficial
to stimulate my mother’s mind..”
“…I really appreciate your effort in helping my dad by
sitting him out of bed..”
Response from Volunteers
“…Today I learnt that I can do more than just
chatting with the patients...”
“…I have a better understanding
and experience to communicate
with elderly patients...”
“…I enjoyed engaging with patients. We
will get more classmates to join us!.....”
Grandma, let’s see who
can stack more cups!
Simple activity using cardboard and red thread created smiles on grandma’s face.
It was her proud work and a blessing for her
Retired wholesale fishmonger. Being fast in calculation is a daily chore without difficulty.
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Let’s work
together to
complete
this!!
Reminisce
nce puzzle
Something
familiar?
Cereal box!
You can put it
to good use
1Hou
r15mi
n
30mi
n
45mi
n
Satisfaction
and Smiles
Shape
recognition
Experience of Successful Story
Madam T, 87 year old/ Chinese/ female, known
to Alzheimer’s dementia with BPSD.
She has back eczema that cause itchiness.
The nurses restraint her to prevent her from
scratching.
However, she enjoyed playing with activities like “fill me in” “pin it up”, that she forget to
scratch herself.
Thereafter, she is not longer restrained.
The ward nurses, student nurses and
family all learnt about using the tools to
engaging Madam T.
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Experience of Successful Story• We believe that HELP interventions
make hospitalisation experience better,
manage behaviour and prevent delirium
and functional decline.
TTSH GRN-HELP Journey
1st Batch
GRN
NICHE
Jan 2015
Small scale
Implementation
With Positive
Outcome
April 15
Formed a team
July 2015
Sought for
Funding
Aug 2015
Sharing to
FIFE
Steering
Committee
Oct 2015
Volunteer Office
collaboration
-Activity box
Oct 2015
Distributed 15
activity boxes
Nov 15
1st volunteer
training
Nov 2015
Mandarin
training
session
Feb 2016
Started research
on HELP
effectiveness
Sep 2016
SHBC
presentation
Sep 2016
Key
bolt/screw
set
innovation
funding
May 2016
SNDP on
delirium
prevention
April 2017
SNDP
application
June 2016
Internal
volunteer
training
Mar 2016
Nurses day
event
July2016
SG Fiesta
Mar 2016
NICHE
conference
April
2018
To care for
those who
once cared
for us is
one of the
highest
honor!
