As more and more older adults are admitted to the hospital, the risk of developing geriatric syndromes has increased substantially.
Geriatric syndromes such as delirium, malnutrition, functional dependence, and depression are the most common adverse events of hospitalization for older patients (Chen, Yen, Dai, Wang, & Huang, 2011) and may lead to the overarching geriatric syndrome of frailty and its attendant disability (Inouye, Studenski, Tinetti, & Kuchel, 2007).
One successful complex intervention designed to reduce the development of delirium and functional decline in older hospitalized patients is the Hospital Elder Life Program (HELP), which was first developed and tested at Yale University (Inouye et al., 1999) and has been disseminated to more than 100 sites worldwide (SteelFisher, Martin, Dowal, & Inouye, 2011). The HELP is administered by multidisciplinary hospital staff and trained volunteers, utilizing a multicomponent strategy of six intervention protocols (daily visits and orientating communication, therapeutic activities, early ambulation, oral intake and feeding assistance, sleep enhancement, and vision and hearing adaptation) and five program components (including geriatric nursing assessment and intervention, interdisciplinary rounds, discharge planning and community linkage, provider education, and geriatrician and interdisciplinary consultations).
Because the HELP does not require a dedicated unit and involves minimal change in hospital infrastructure, this program is feasible to disseminate to other health care systems, such as Taiwan. However, given local circumstances, organizational flexibility and readiness to change, and the needs of special populations (e.g., surgical patients), it might not be feasible to replicate the HELP in all settings.
On the other hand, our previous studies suggested that poor geriatric outcomes are mediated by a pathophysiological mechanism based on shared risk factors (Chen, Dai, Yen, Huang, & Wang, 2010). As a proof-of-concept study, we selected three key elements based on our prior work and modified the HELP to include only three shared risk factors (functional, nutritional, and cognitive status) that were targeted by three modified nursing protocols: early mobilization, oral and nutritional assistance, and orienting communication. Our targeted population includes older patients who were scheduled for major abdominal surgery in Taiwan. These patients were chosen because they are at high risk of developing delirium and other geriatric syndromes, including frailty (Partridge, Harari, & Dhesi, 2012). The aim of this article is to describe in detail how HELP, a well-established complex intervention, was adapted to address the special needs of the surgical population and to be feasible for implementation in the surgical setting.
The United Kingdom Medical Research Council (MRC) framework, designed to evaluate complex interventions, was used to guide the evaluation of the modified HELP model developed for this study. The MRC framework has four phases: development, feasibility assessment, evaluation, and implementation (Craig et al., 2008). Development includes (a) identifying evidence to support the intervention, (b) identifying the underlying theory, and (c) modeling process and outcomes. As shown in the Figure, this report details the first and second phases of this framework with a focus toward evaluating and implementing the protocols.
Overview of Hospital Elder Life Program (HELP) adaptation based on the Medical Research Council Framework (Craig et al., 2008).
Step I: Identifying the Evidence Base and Theory
The theoretical foundation for the modifications of HELP originated with the conceptual model of shared geriatric risk factors, first proposed by Tinetti, Inouye, Gill, and Doucette (1995) and further developed by Inouye et al. (2007). This conceptual model proposes that shared risk factors lead to common geriatric syndromes and eventual frailty. The resulting frailty may have feedback loops that in turn lead to increased shared risk factors and geriatric syndromes, ultimately resulting in disability and death (Inouye et al., 2007). Based on previous results (Chen et al., 2010), we hypothesized that improving geriatric patients’ cognitive, nutritional, and functional abilities would reduce the overall rates of geriatric syndromes and frailty. Therefore, we opted to focus on interventions to improve cognitive, nutritional, and functional status with the goal of improving outcomes for older surgical patients.
Step II: Adapting Three Key HELP Interventions
The first author (C.C.C.) chose to focus on three areas to simplify the HELP model for application by nurses (Table). The protocols were drafted after intensive research meetings and focus group discussion involving multidisciplinary professionals such as nurses, physicians, dieticians, physical therapists, and speech-language therapists. To develop these protocols, the original HELP protocols were adapted by the research team using “nursing time and acceptance to patients” as the primary criteria for orienting communication and early mobilization protocols, whereas the “intervention potency” criterion was used to adapt the oral and nutritional assistance protocol. We then conducted several field tests to ensure protocol acceptance, a pilot study was conducted on the orienting communication protocol in a similar population, and refinements were further completed based on the feedback of the HELP nurse once implemented. Feedback from nurses at all levels was incorporated in an iterative fashion. The process of adaptation is outlined in the Table. Supporting evidence for three modified nursing interventions is further described below.
Comparison of Original Hospital Elder Life Program (HELP) and Modified Help Protocols
Orienting Communication. Sustained engagement in cognitive activities enhances neural structure (Hillman, Erickson, & Kramer, 2008). Older hospitalized patients who remain engaged in simple cognitive activities (e.g., recalling, expressing a viewpoint, or word games) may have lower risk of cognitive impairment (Cheng et al., 2012). However, older patients admitted to the hospital receive little to no cognitive activities. At best, some special geriatric units have reorientation strategies, which involve presenting and repeating time, place, and person-related orientation materials to patients (e.g., clocks and calendars). However, these approaches have been criticized for their passivity, one-way communication, and insensitivity to the needs of individuals (Powell-Proctor & Miller, 1982). To address these shortcomings, we implemented an adapted version of the HELP orienting communication protocol, which included an active form of reality orientation and simple cognitively stimulating activities considered feasible in the context of hospital practice. The HELP nurse inquired about time-, place- and person-related information (including relationships, feelings, and viewpoints), thus reinforcing cognitive activity and orientation. The orientation and conversation were embedded in events that interested patients (e.g., the day the patient underwent surgery). Discussion of current or past events and talking with patients to stimulate categorizing objects (e.g., naming seasonal food in the autumn) were also included. This protocol was designed to engage participants actively in recalling or discussing issues that interested them.
Early Mobilization. Many older hospitalized patients scheduled for abdominal surgery have had prolonged illness, thus, weakness and weight loss are often concomitant problems. These problems are often compounded by inactivity and bed rest following surgery. In fact, 10 days of bed rest in even healthy older adults results in loss of almost 1 kg of lean muscle mass from lower extremities and a substantial loss of strength, power, and aerobic capacity (Kortebein et al., 2008). Early mobilization is also essential for enhanced recovery and is a cornerstone of the fast-track surgery, a multimodal intervention strategy to reduce morbidity and length of hospital stays (Kehlet & Wilmore, 2008). Therefore, the goal of early mobilization protocol is for patients to get up and moving as quickly and as safely as possible through ambulation or active and passive range-of-motion exercises three times per day. The HELP nurse assesses patients’ ability to participate in the mobility protocol and physically assists them in performing activities (i.e., range-of-motion exercises, riding a stationary bicycle, standing, and ambulation) consistent with their capacities and postoperative rehabilitation schedule as soon as they return to the surgical ward.
Oral and Nutritional Assistance. Nutrition is essential to health. Low dietary intake (<21 kcal/kg) is associated with geriatric syndromes as well as frailty (Bartali et al., 2006). We implemented adapted versions of the HELP protocols for nutrition and volume repletion and added oral care to the protocol. Oral hygiene and oral function have been related closely to intake and nutritional status (Chen, Tang, Wang, & Huang, 2009), as well as cognitive and physical functioning (Sumi, Miura, Nagaya, Nagaosa, & Umemura, 2009). Another major oral complaint among older patients is swallowing difficulty or impaired swallow response (Chen, Yen, et al., 2011). This problem has many causes, but one main, modifiable factor is weak muscle strength in the lips, tongue, and jaw caused by sarcopenia, the pervasive loss of muscle mass in older adults (Robbins et al., 2005). Therefore, this intervention protocol included daily oral care (tooth brushing and oral-facial range-of-motion exercises for the tongue, lips, and jaw) along with diet education and feeding assistance (see the Table for details).
Step III: Modeling Process and Outcome
Our work in this step was to ensure program feasibility and acceptability by nurses and to identify suitable processes and outcome measures for use in the implementation and evaluations (Craig et al., 2008). To ensure buy-in from the interventionist, we involved the HELP nurse early on. We recruited a motivated, professional nurse (with more than 2 years of experience in medical-surgical nursing) as the HELP nurse and trained her in the program. For her training, we first reviewed the modified HELP manuals detailing the goals, objectives, rationale, and step-by-step care protocols to guide the intervention efforts for 3 days. We then provided weekly individual mentor-ship for the HELP nurse through 2 months of on-site training prior to intervention start-up, with ongoing and regular supervision, positive feedback, and supportive peers. We incorporated her feedback into our procedures, and she actively participated in the research team meetings.
After training of the HELP nurse was completed, we conducted several field tests to specify the details of protocols to enhance the feasibility of the intervention. All of the protocols were implemented by the HELP nurse on the floor as part of her daily care. We integrated orienting communication into the mobilization and nutrition assistance protocols so a given HELP nurse could manage up to 4 to 5 patients per day. While walking with older patients, for example, the HELP nurse deliberately engages patients in orienting activities (i.e., recalling or discussing issues that interests them, such as events on the operative day or preparing a favorite meal). Given that the study hospital has no restricted visiting hours and family members are often present at bedside in Taiwan, we involved family members in the intervention, so that they could assist with hallway ambulation while the nurse worked with another patient. We estimate that the new HELP protocols added 10 to 15 minutes per shift to patient care for each patient, for a total of approximately 30 to 45 minutes per day. On average, HELP patients received protocols for approximately 7 days per hospitalization.
To identify suitable processes and outcome measures to test the implementation of protocols, we first defined the target group and enrolled consecutive patients ages 65 and older who had undergone common elective abdominal surgical procedures such as gastrectomy, cholecystectomy, or Whipple procedure. Second, we tracked two process measures: (a) adherence to protocols and consistent implementation, and (b) contamination effects (e.g., cointerventions, rotating staff). To track success of implementation, the HELP nurse completed protocol checklists daily, which enabled us to monitor adherence to the interventions. If any problems with adherence were detected, these were reviewed with the nurse, and corrective actions were put into place. To ensure consistent application of intervention delivery to each patient, all protocols were provided by the same HELP nurse and a standardized performance check was conducted every 3 months. As a result, protocols were administered 100% by the same HELP nurse and contamination was minimal given that no cointerventions or staff turnover occurred during the implementation. Lastly, we will test for differences in the rates of delirium, functional decline, and frailty between the intervention and control groups. If superior outcomes are demonstrated for intervention group and protocols are well perceived, feasibility evaluation is completed and the program can move on to the next phases where a formal evaluation and wide implementation take place (Figure).
Drawing on the MRC framework, we described the adaptation of a theory-derived modified HELP that aimed at reducing rates of common but distinct geriatric syndromes in an older surgical population. This modified HELP focused on three nursing protocols that were designed to be logistically feasible and have been successfully evaluated (Chen, Lin, et al., 2011; Chen et al., in press). Although a few institutions have addressed the prevention of geriatric syndromes and frailty in a proactive, multidisciplinary manner, wide-scale implementation still lags across most hospitals. This lag is likely due to the complexity of such interventions. The proposed modified HELP program might enhance care for surgical populations by providing three simplified nursing protocols. We hope that this work will provide a model for approaches to adapt and evaluate other successful complex nursing interventions.
For institutions that wish to implement the modified HELP, five process facilitators are key components of successful implementation. The first is to engage resource networks from the parent HELP program. We signed the copyright agreement with the HELP, and obtained full access to all of the HELP resources that helped us overcome barriers at our site. These resources included educational and training materials, the virtual HELP community via Google Groups, mentoring through the HELP Centers of Excellence, annual HELP conference, and biannual HELP Special Interest Groups at international conferences.
The second facilitator is to secure program funding. We obtained an external research grant for the first 3 years and after efficacy was demonstrated, another 4 years were approved. With funding, we managed to have a 0.5 full-time equivalent (FTE)–trained HELP nurse to deliver three simplified protocols for a 36-bed unit and another 1 FTE staff dedicated to enrollment and outcome data collection. Hospital budget allocation, donor support, and in-kind support from other programs (i.e., shared staff and resources) are alternatives. If paid staff members are not available, trained volunteers have been used successfully to deliver protocols in the HELP model (Inouye, Baker, Fugal, & Bradley, 2006). For bedside nurses to implement the protocols on their shift/work day, extra nursing time is needed for successful implementation.
The third process facilitator is to ensure buy-in from physicians, nursing leadership, and hospital administration. We managed to obtain department approval from all surgeons, floor nurses, and nursing leadership to implement HELP on our target floors. Space in the surgical ward was granted for storage of our program materials purchased by the grant (i.e., stationary bike) so the HELP nurse could easily make equipment available to patients. Recruitment and daily operations were greatly enhanced with availability of this dedicated program space close to our intervention unit.
The fourth facilitator is to ensure a motivated interventionist. As in many intervention programs, consistent delivery of high-quality protocols is key to success. A geriatric nurse competent in working with older patients and families is ideal. However, availability of geriatric nurses in Taiwan is limited, so instead we recruited a motivated, experienced nurse as the HELP nurse and trained her for the program. We involved the HELP nurse early on to ensure buy-in from the interventionist. We incorporated her feedback into the procedure and she actively participated in the team meetings. Patients and family also thanked her in many ways. Her desk was often flooded with thank you cards, candy, or food from the families. With proper training, regular supervision, and ongoing empowerment, the HELP nurse was motivated to provide care to all participants.
The fifth facilitator is to document effectiveness. Funders, hospital administrators, and stakeholders are interested in knowing whether the program is effective. To ensure that the evaluation was methodologically sound, we first used the MRC framework to guide the development, evaluation, and implementation of complex interventions and then opted for a pre- and postintervention study. In the absence of such resources, evaluation would include patient and family stories and narrative of what the interventions have done to improve their hospital experiences; staff feedback on their own observations, ideas for practice innovation, struggles, and successes; and hospital administrative data on quality indicators such as length of stay and readmission rates.
Although the precise pathophysiology of these geriatric syndromes is not fully understood, they share several common pathways (Cappola et al., 2003). This overlap was considered to be highly relevant to developing this nursing intervention program to prevent common geriatric syndromes and eventual frailty. A major challenge, as in most intervention programs, is to ensure buy-in from all stakeholders. Physicians, front-line nurses, nursing leadership, hospital administration, as well as the interventionists themselves are essential to program success. Countless meetings, briefings, visits to key members of the group, and willingness to listen, compromise, and incorporate feedback are critical to implementing a successful program. Nevertheless, by careful development, nursing intervention programs have high potential to improve important patient outcomes.
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Comparison of Original Hospital Elder Life Program (HELP) and Modified Help Protocols
|Original HELPa Standardized Protocols||Modified HELP Standardized Protocols||Adaptation: Rationale and Process|
Orientation board with names of care team members and daily schedule
Cognitively stimulating activities three times daily (e.g., discussion of current events, structured reminiscence, word games, socialization)
|Orienting communication protocol|
Active orientation to time, place, people, and feelings (embedded in events that interest patients)
Daily discussion about current/past events and initiating conversation to categorizing objects (e.g., what are seasonal foods in autumn?)
Time/acceptance as criteria for adaptation
Find feasible but effective cognitive activities from a pilot trialb
Field test on the study ward
Refine protocol based on the feedback of HELP nurse and research team
Finalize modified HELP manual
Ambulation or active range-of-motion exercises three times daily
Minimal use of immobilizing equipment (e.g., bladder catheters or physical restraints)
|Early mobilization protocol|
Assess patient’s ability
Physically assist patient to carry out activities three times per day (from range-of-motion exercise in bed, riding a stationary bicycle by hand/foot, sitting out of bed, standing, to ambulation)
Time/acceptance as criteria for adaptation
Eliminate activities that require a physician’s order (i.e., remove bladder catheters)
Field test/refine protocol based on the feedback of HELP nurse, physical therapist, and research team
|Oral volume repletion and feeding assistance|
Early recognition of dehydration and volume repletion (i.e., encouragement of oral intake of fluids, feeding assistance and companionship during meals)
|Oral and nutritional assistance protocol|
Daily oral care involving tooth brushing and range-of-motion exercises for lips, tongue, and jaw
Facial and lingual sides of teeth are cleansed with a soft pediatric toothbrush and toothpaste
The tongue is cleaned and gums and mucosa are massaged using the same toothbrush
Ask patients to smile and pucker their lips (using exaggerated movements) and end by puffing out cheeks
Ask patients to stick out their tongue as far as possible and hold it; retract tongue inside and hold it against the palate; continue to stretch the tongue by working it side to side and up and down
Ask patients to open jaw wide, move it side to side
Diet education for postsurgical intake
Dumping syndrome diet
Diet after pancreatic surgery
Tips for digestive distress
Encourage oral intake and companionship during meals, feeding assistance
Potency as a criterion for adaptation
Aim to facilitate oral intake
A focus group meeting with nurses, dietician, respiratory therapist, speech-language therapist, and research team to draft protocol activities
Train the HELP nurse carefully
Field test on the study ward
Refine protocol based on the feedback of HELP nurse, therapists, and research team
Finalize the modified HELP manuals