Every day over one and a half million Americans awaken in the over 18,000 nursing homes in this country. Although only 5% of those older than 65 are in a nursing home at any one time, the actual chance of an American spending some time in a nursing home during his or her life is 20% to 40%.1
Recently, there has been growing attention focused on the quality of care provided in nursing homes. Despite this attention, medical care in particular continues to be inadequate. Relatively few physicians provide care to patients in nursing homes. Most of those who do, visit only briefly and are not educationally prepared to deal effectively with the complex health problems of the elderly.2 Undiagnosed, potentially remediable medical and psychiatric conditions and the overprescription of drugs are all too common.
Identifying Educational Deficiencies
Nursing and medical education have lacked geriatric specialization. Until recently, very few schools have offered any elective or required courses in geriatric health care. This has created a pool of physicians and nurses who have little understanding of how the care of the elderly should differ from that of a younger adult.3 Nursing educators are just beginning to design educational programs to meet these needs. One such nursing program developed by the Mountain States Health Corporation and sponsored by the WK Kellogg Foundation, prepares registered nurses as geriatric nurse practitioners (GNPs).4
The Robert Wood Johnson Foundation has developed a Teaching Nursing Home Program to evaluate what happens to the care of nursing home residents when nursing homes and nursing schools collaborate in clinical care.5 In addition, many universities offer a master's in nursing along with clinical specialization as a GNP. Only since 1981 have GNPs received American Nurses' Association recognition for certification.
Medical education programs have also begun to design programs to enhance the teaching of geriatrics at all levels. Educators have realized the value of expanding training for medical students beyond the walls of the hospital.6 Several nursing and medical schools have formed formal affiliations with long-term care institutions to create teaching or academic nursing homes.7 In March 1984, Sepulveda Veterans Administration Medical Center in Sepulveda, California, introduced GNPs and the teaching nursing home concept on a 60-bed nursing home unit. (In July 1984, the program was expanded to 160 beds.) The program is now called the Academic Nursing Home (ANH).
Prior to the change, the units were staffed by nonacademic-affiliated physicians and the usual nursing staff of registered nurses, licensed vocational nurses, and nursing assistants. Initially, two master's-prepared GNPs were hired to provide day-to-day comprehensive assessment and management of chronic and acute physical and psychosocial problems that commonly occur in a long-term care setting. With the expansion of the ANH in July, four more GNPs were hired.
The Setting- The Sepulveda VA ANH is located on the campus of the VA Medical Center. The acute hospital is about 300 yards from the ANH, and the two buildings are connected by a tunnel. The ANH serves as a clinical training center for students in:
1. Nursing (RN and LVN students);
3. GNP master's program; and
4. Other disciplines including social work, psychology, speech pathology, audiology, pharmacy, gerodentistry, and occupational therapy.
The ANH is staffed by a full-time faculty in the division of geriatric medicine. A clinical gerontological nurse specialist and the GNPs provide in-service training to nursing and other ANH staff. Two of the GNPs hold faculty appointments in the UCLA School of Nursing and act as preceptors for GNP students in the UCLA master's program.
ACADEMIC NURSING HOME GNP PROTOCOL
ACUTE ONSET OF FEVER
Medical residents in the UCLA-San Fernando Valley Program serve as primary care physicians for five to seven nursing home patients during the second and third year of their residency program. The residents are expected to see their patients at least once per month and to communicate regularly with the GNPs as needed during the interim. The attending geriatricians meet biweekly with the GNPs to discuss acute or subacute medical problems, and they make formal attending rounds with each medical resident once per month. The attending geriatricians or the residents are expected to cosign the orders written by the GNPs within 24 hours. A fellow in geriatric medicine is also available to evaluate acute problems when the patient's primary resident is unable to break away from his or her regular duties.
The Population - The ANH patient population is over 90% male, has a mean age of approximately 70 years, and is dependent on nursing staff for basic activities of daily living. Over 75% of the patients have a primary neurological diagnosis: stroke, multiple sclerosis, primary dementia, parkinsonism, or brain-spinal cord trauma. Because the ANH selectively admits patients with unstable medical problems (as opposed to placing them in community nursing homes), and because of the recent shift of the acute hospital to diagnostic related group (DRG) based reimbursement, there is a relatively high incidence (approximately six to ten episodes per week) of acute medical conditions that arise in the ANH.
Developing the Protocols
The board of registered nursing recognizes and endorses the existence of overlapping functions between physicians and registered nurses within organized healthcare settings. Two of the functions of nursing practice, outlined in the state of California Business and Professions Code, are implementing a treatment regimen in accordance with standardized procedures and initiating emergency procedures. Standardized procedures are policies and protocols developed by a healthcare facility or through the cooperation of health professionals, including physicians and nurses.8
Consequently, not only were the GNPs mandated by the state of California to have written procedures and protocols, but they themselves recognized the need for concise, clear guidelines for the assessment and management of the sudden onset of acute problems. The flow-chart, algorithm-type format seemed to lend itself to the rapid decision making that the GNPs required. Because of the physical distance between the ANH and the acute hospital, the GNPs knew that initial treatment would fall to them prior to the arrival of the medical residents assigned to the patient.
A literature review revealed that most assessment algorithms were quite long, difficult to read rapidly, and were written by doctors, for doctors.9 Most did not address the types of acute problems that nursing home patients frequently develop. Therefore, the GNPs, along with a panel of medical experts, decided to develop nine protocols that would cover common acute problems seen in a nursing home population. Protocols were developed for the following conditions: fever, seizures, acute dyspnea, chest pain, abdominal pain, gastrointestinal bleeding, loss of consciousness, sudden mental status change, and focal neurological deficits.
ACADEMIC NURSING HOME GNP PROTOCOL
The following case examples illustrate how the GNPs assessed and managed three patients with acute conditions in the ANH.
Fever (Figure 1) - MrJ. is a 73-year-old male with a diagnosis of right hemispheric stroke with left hemiparesis and aphasia. He has a gastrostomy tube because of dysphagia, and an indwelling Foley catheter secondary to a neurogenic bladder with urinary retention. On a routine check of vital signs, a staff member reported to the GNP that Mr J. had an elevated temperature of 102.2 rectally. His blood pressure and pulse were within normal limits.
The GNP did a rapid physical exam at the bedside. The patient was lethargic, but had no other mental status changes. His physical exam was significant only for cloudy urine with heavy sediment. His lungs were clear, his gastrostomy stoma was clean and without inflammation, his abdomen was not tender, and he had no skin lesions. The GNP then ordered and drew the stat laboratory work, which included a complete blood count, urinalysis, urine for culture and sensitivity, electrolytes, blood urea nitrogen, creatinine, and two sets of blood cultures.
Even though the patient's blood pressure was within his usual normal range, an IV of 5% dextrose in 0.45% normal saline was started in anticipation that intravenous antibiotics would be initiated. At this point, the primary resident (PR) was notified of the patient's condition. The resident responded, saw the patient, and reviewed the laboratory results, which were significant for pyuria, bacteriuria, and indicated a white blood count of 22,000.
Twenty-four hours after the initiation of intravenous antibiotics, the patient was afebrile and feeling much better. His acute condition was managed in the nursing home in familiar surroundings, thus sparing him the emotional and physical trauma of being transferred to the acute hospital.
Seizures (Figure 2) - At 11:40 am, the nursing staff alerted the GNP that a 41year-old male, multiple sclerosis patient with a known seizure disorder, on phenytoin therapy, had begun to seize during routine am care. At the bedside, the GNP assessed the patient's vital signs: BP, 130/108; pulse, 136/ min; and 30/min respirations. The patient was exhibiting generalized tonic-clonic movement of all four extremities with a loss of consciousness.
ACADEMIC NURSING HOME GNP PROTOCOL
ACUTE ABDOMINAL PAIN
After establishing that the patient was not in acute cardiopulmonary distress, an oral pharyngeal airway was inserted to facilitate breathing and minimize injury to the tongue. Attempts to establish an IV line were virtually impossible because of the patient's vigorous body movements, and diazepam had to be given by direct intravenous push into a prominent vein in the left antecubital fossa.
The PR was stat-paged because of the difficulties encountered in carrying out the protocol. While awaiting the arrival of the PR, the GNP mobilized a cutdown tray, obtained additional nursing staff, prepared an IV of 0.45% normal saline, and monitored the patient. The patient had seized for a total of 12 minutes, and low-flow nasal O2 and nasotracheal suctioning were initiated.
Once the PR arrived, a left subclavian IV was inserted from which necessary lab studies were drawn, and additional IVs of diazepam and phenytoin were pushed. The patient regained consciousness within minutes. After a neurological exam had been conducted on the unit, the patient was transferred to the medical intensive care unit within 1 ½ hours of the seizure onset.
Abdominal Pain (Figure 3) - A 66year-old white male with right spastic hemiplegia and severe dysarthria secondary to stroke and organic brain syndrome had complained of abdominal pain to the nursing staff for approximately two hours before the GNP 's arrival on the unit. He had no vital sign changes from baseline, and he was afebrile. The nurses denied any signs of fever, chills, vomiting, or change in stool character; and the abdominal, rectal, and genitourinary exams were benign.
Results of the stat lab work, however, revealed consistent pyuria and bacteriuria without leukocytosis. A stat abdominal X-ray revealed a staghorn calculus of the right kidney. All findings were reported to the PR who made the final diagnosis of acute urinary tract infection with nephrolithiasis and a urology consult was requested. The patient was started on the appropriate antimicrobial regimen awaiting further evaluation by the urology service for a nephrolithotomy.
Impact of the Protocols
These and other protocols have been used effectively for over 18 months. They have proven to be an efficient means for rapid assessment and initial management of acute problems prior to the arrival of the patient's PR, the geriatric fellow, or the attending physician. The GNPs have used them as guides, but have also learned by exercising independent judgment in modifying the approach dictated by the status of each individual patient.
The protocols have also fostered more in-depth clinical judgment on the part of the GNPs. For example, when a patient presents with multiple symptoms (eg, fever and seizures), the GNP must refer to more than one protocol. Rapid management of acute patient problems has contributed directly to significantly fewer transfers to the acute hospital than before the ANH program was initiated. When the patient must be transferred, he or she has already had an appropriate initial diagnostic evaluation and the stay in the acute hospital is usually shorter. This has benefited the ANH patient immensely since remaining in the nursing home environment with familiar personnel and surroundings maximizes the patient's feelings of well-being.
Keeping these nursing home patients from inappropriate hospitalization also avoids the substantial risk of iatrogenic illnesses, especially adverse drug reactions and complications of immobility.10,11 Finally, the costs of caring for these patients in the nursing home are, in the long run, less than if they were hospitalized.
GNPs are, first and foremost, nurses - nurses who analyze problems using the familiar nursing process model. The GNP learns to combine the nursing model with the medical model when approaching patient problems. The total patient is assessed, and the impact of interventions on his or her physical and psychosocial well-being is considered. The impact these interventions have on the staff and the family is also an important consideration. For example, if the staff is already overburdened with several sick patients, some of whom might be on intravenous therapy, transfer to the acute hospital may be the best, and only, solution. In this situation, the GNP, having been a staff nurse, can become the spokesperson for the nursing home nursing staff in achieving the transfer.
The protocols have proven to be an effective tool for implementation of bedside learning by the staff nurse. The nurses have become more aware of the signs and symptoms of impending patient problems, and have learned what is expected of them when each protocol is used. They often anticipate the GNP's needs, mus adding to the efficiency of management.
Straightforward and efficient protocols such as those described for assessment and management of acute problems are tools that are exportable to other similar settings. These protocols can also be used as a basis for the development of criteria maps that can provide a checklist for monitoring the quality, both in terms of process and outcome, of patient care. Thus, the protocols may be extremely useful in the development of strategies to assess the quality of nursing home care and the utilization of healthcare resources in nursing home settings. Further development and testing of these and other protocols may lead to improved nursing and medical care in nursing homes, and are likely to validate and expand the role and effectiveness of GNPs in the long-term care setting.
- 1. Vladek BC: Unloving Care- The Nursing HomeTragedy. New York, Basic Books, Inc. 1980.
- 2. Rabin DL: Physician care in nursing homes. Ann Intern Med 1981; 94:126-127.
- 3. Ebersole P: Geriatric Nurse Practitioner. Long-term care currents. 1983; 6(July-September):11-14.
- 4. Enloe C: Curriculum and training. The Journal of Long-Term Care Administration 1983; 11(3):5-9.
- 5. Huey F: What teaching nursing homes are teaching us. Am J Nurs 1985; 6:26, 35.
- 6. Coe R: Medical education on aging: Problems and progress. Generations 1980; V(2).
- 7. Schneider E (ed): The Teaching Nursing Home. New York, Raven Press, 1985.
- 8. Board of Registered Nursing: Nursing Practice Act. Section 1480-1485, California Department of Consumer Affairs, Sacramento, 1973-74.
- 9. Patient Care Flow Chart Manual, ed 3. Oradell, NJ, Medical Economics Co Book Division, 1982.
- 10. Steel K, Gertman PM, Crescenzi C, et al: Iatrogenic illness on a general medical service at a university hospital. N Engl J Med 1981; 304:638-642.
- 11. Kane RL, Ouslander JG, Abrass IB: Essentials of Clinical Geriatrics. New York, McGraw-Hill Book Co, 1984, chap 13.