Will a geriatric focused educational intervention change nursing knowledge and confidence of PIMs and pharmacologic age-related changes, and have an effect on falls and PIM administration rates in older adults 65+ on one medical-surgical high acuity nursing unit?

By Yin Lo, RN

Background

By 2050, the population of older adults aged 65 and over is projected to almost double its estimated 2012 population.6 With this increase, there will undoubtedly be an increase in healthcare consumption.3 Older adults are at higher risk of adverse drug reactions due to physiological changes and are at increase vulnerability due to higher prevalence of co-morbidities and polypharmacy.6,7 It is important to focus efforts in providing safe care to this vulnerable population and help this group maintain as much health and independence as possible.

Nursing awareness of potentially harmful medications for older adults is one area we may be able to improve care. There is limited evidence of education related to potentially inappropriate medications (PIMs) use in older adults with nursing staff in acute care settings.2,4,5 Additionally, falls is one of the top adverse drug reactions associated with PIMs.1 This small test of change will examine if a geriatric focused educational intervention will impact nursing confidence and knowledge, and in turn impact falls and PIMs administrations as defined by the American Geriatrics Society (AGS) Beers Criteria on a medical-surgical high acuity nursing unit.

PICO Question

Will a geriatric focused educational intervention change nursing knowledge and confidence of PIMs and pharmacologic age-related changes, and have an effect on falls and PIM administration rates in older adults 65+ on one medical-surgical high acuity nursing unit?

Methods

Baseline data collection occurred from Jan-March 2017. A 13-question survey was electronically and physically distributed to nursing staff and included demographic, confidence, and knowledge questions. Data was also pulled from the Medical Administration Record (MAR) to gather number of falls and Beers Criteria medication administrations in patients aged 65+. All administrations were cross-matched with the Beers Criteria to determine the top 7 medications in order to target nursing education. Meetings with a geriatric pharmacist and UCSF pharmacists were the main sources of safer alternatives to the targeted medications.

Geriatric-focused education was presented in a practical and usable format by categorizing the top 7 Beers Criteria medications into three syndrome focused topics: 1) Pain, 2) Agitation, and 3) Pruritus. Avenues of education included spinning education mounts, banners, flyers, newsletters, badge buddies, emails, staff meetings, and staff huddles.

Post-intervention data collection occurred from June-Aug 2017 and mirrored that which was collected in the baseline data collection period.

Results

Overall, there appeared to be an increase in nursing confidence and knowledge related to the Beers Criteria PIMs and the physiological changes associated with aging. When we look at the targeted 7 PIMs, there was an overall increase in the opioid class of PIMs administration, but a decrease in the remaining 4 PIMs administrations. There was a decrease in the total number of PIMs administrations, the overall number of Beers Criteria PIMs, and total number of patients who received PIMs. As for falls, there was an initial decrease in the immediate post-intervention period, but an increase in the following post-intervention period.

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Discussion

There appears to already be a high baseline level of confidence and knowledge among this group of nurses so the changes in these areas were not as drastic. It was also a challenge to formulate a survey that tests accurately for confidence and knowledge, and to maintain engagement in the educational interventions and survey.

When considering the increase in the opioid class of PIMs, this could be attributed to a difference in patient type, where the medications that are ordered and administered depend on the clinical issues patients are dealing with, in this case: pain. Moreover, at a large academic medical institution, rotating providers may have prescribing preferences which impact what medications are ordered and therefore administered. When looking at fall rates, there are extraneous variables that could impact falls which were not accounted for in this project.

It is important to note that the Delirium initiative was ongoing during this project as well. During this time, the efforts from the Delirium Initiative could have heightened awareness and knowledge of deliriogenic medications and practices. Additionally, as part of the Delirium Initiative, UCSF pharmacists were performing medication reviews of patients who screened positive for delirium, referencing the Beers Criteria for their reviews.

Conclusion

Nursing care specific to older adults is an increasingly important aspect of healthcare. This project suggests Beers Criteria education could be a tangible way to promote one aspect of geriatric-focused care in a hospital setting. It is important to continue geriatric-focused education in continued tests of change on nursing units to promote care specific to this vulnerable population.