Table 2.

Examples of typical hospital processes that have created a culture of how we care for acutely ill older adults, and possible solutions for change

Processes	Possible solutions for change
Admission processes
Patients from home, facilities or clinics	Set up admission processes that avoid the ED, such as use of telemedicine or internet applications to communicate with patients and providers at home, facilities and clinics to expedite triage decisions
ED processes
Use of typical gurneys, wait times, typical triage processes (prioritization), competing interests	Geriatric EDs are becoming more common
	Other ideas
	Develop protocols/pathways for quicker admission processes With the presence of hospitalists, could some subset of patients be evaluated on various wards or locations within various wards, thus bypassing ED?
Physician-centered routines or physician-based processes
Tradition or routine of early morning rounds by physicians	Was once necessary for physicians who had outpatient clinic responsibilities
	Use of hospitalists allows for changing the time of patient rounds
	This has potential for a better assessment (mid-morning, patients may be more alert and out of bed for functional assessment)
Bed rest or other restricted mobility orders by physicians	Protocols for immediate baseline assessment and evaluation of mobility status; highest possible level ordered by interprofessional team member, usually therapist
Required physician order for physical therapy, occupational therapy or speech therapy	Develop protocols/pathways that a medical director of a floor could sign
	Develop screening done by these therapists that allow them to improve efficiency of patients being seen
	This would need oversight and monitoring
	Mobility teams for daily ambulation instead of relying on therapists for daily ambulation/mobility
Early morning blood tests Need for frequent blood tests	Adjust times to meet patients' needs
	Examine and modify current internal medicine practices related to frequent blood tests (e.g. CBC every 6 hours for suspected bleeding; cardiac enzymes every 8 hours for suspected myocardial inschemia)
Admission diet orders delayed or restricted diet ordered	Protocols for immediate baseline assessment and evaluation of nutrition and swallowing status; highest possible level ordered by interprofessional team member
Nurse processes
Fasting (“NPO”) before procedures or surgeries	Individualize for patients and procedures
	Critically analyze current routines
	Early recovery after surgery protocols already limit this practice
	Could geriatric hospitals develop further protocols for safely limiting current fasting procedures?
Nurse:patient ratios and nurse assignments are typically based on having some patients with heavier or lighter care needs than others This can create variation from day to day	Although older patients are not a homogenous group, not having younger adult patients in the equation for nurse patient ratios may allow for more consistent determination of needs
	This may also allow for developing new ideas to typical nurse:patient ratios
	For example, increasing nurse aides with more care responsibilities instead of registered nurses
Routine vital signs and overutilization of vital signs	Use of “non-touch” technology to monitor RR and HR and T
	Individualize vitals sign frequency
	Avoid middle-of-the-night vital signs when appropriate
Routine medication times based on nurses' schedules and availability/prioritization of tasks	Individualize medication times to match what the patient does at home
	Individualize patient care plans to allow self-administration of certain medications
“Sitters” or one-to-one observers	Enhance training of these “care partners” who are the constant eyes and ears on the patient and who could implement mobility programs and other geriatric-based protocols
Bed alarms	Close constant observation
	Wireless technology
Direct patient care processes
The bed as the center of the room The bed as the primary location for patient care	Develop patient rooms where bed is not the center
	Develop or create ways to give care outside the bed. (e.g. IV treatments in a chair)
Sleep schedules that are not similar to home and lack of healthy sleep environment	Night time sleep is a priority
	Individualize sleep schedules
	Modify routine care to avoid sleep disruptions
Routine meal times Suboptimal quality of meals, lack of preference for what older person might want	Individualize meal times to match what the patient does at home
	Small kitchens where food is available and can be prepared anytime
	Expectation that families bring food from home
Hospital gowns Gowns add to dehumanizing effect of the hospital and may add to sick behavior	Use of gowns that are more dignified
	Use of a variety of gowns to give patients choice
	Discourage use of gowns; encourage use of patients' usual clothing
Not allowing the family or significant others to be involved in direct patient care	Involve family as part of the health care team from admission
	Would include some basic training and consent process
	Could be useful for basic activities such as feeding, bathing, toileting
Adverse events (AEs) of older adults are diluted because hospital rates are based on all inpatients, most of whom are adults younger than age 65 years, who’s risk for AEs is very low (e.g. catheter-associated urinary tract infections, adverse drug events, falls with injury)	Although “higher” rates seem contradictory to improvement, having higher rates creates an importance to these AEs for which focused interventions targeted at a higher risk population can be done to lower rates
	These lower rates could become new age-based goals for other adult hospitals
Indirect patient care processes
Transportation around the hospital	Use this as an opportunity
	Getting outside of the hospital room could have health benefits
	Transporters could play an important role in this if they receive training in geriatric principles
How patients are scheduled for procedures tests or surgeries Usually first come first serve, or no apparent process	Develop scheduling systems based on factors such as frailty or risk of delirium, especially if procedures absolutely require NPO
Division of labor for jobs in hospital	Consider education and training of any employees that have any type of contact with patients
	For example, housekeeping employees could be trained on how to interact with people who have dementia or delirium
Traffic into and out of the patients room is random and not monitored	Limited access to patient rooms; for example, housekeeping only during times when patient is not in room
	Close monitoring through windows
	Having staff stay in a room is different than staff entering/leaving a room frequently
Discharge processes
Perception that discharge to post-acute care is common and expected	Many hospitals understand the benefit of starting discharge planning early
	Could be done day one, with an emphasis on “our hospital’s goal is to help people return home after a hospitalization. Is that your goal?"
Discharge follow up not standardized	Develop standardized protocols for follow up based on geriatric based goals identified in studies of geriatric models of care (such as function, return to home)
	Develop systems that follow the patient for extended periods (e.g. 3 months, or even 1 year)

Abbreviations: ED, emergency department; IV, intravenous; CBC, complete blood count; NPO, latin for “nil per os” meaning nothing orally; RR, respiratory rate; HR, heart rate; T, temperature