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  • Guideline Summary
  • NGC:009730
  • 2012

Function-focused care (FFC) interventions. In: Evidence-based geriatric nursing protocols for best practice.

Boltz M, Resnick B, Galik E. Interventions to prevent functional decline in the acute care setting. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editor(s). Evidence-based geriatric nursing protocols for best practice. 4th ed. New York (NY): Springer Publishing Company; 2012. p. 104-21.

View the original guideline documentation External Web Site Policy

This is the current release of the guideline.

Age Group

UMLS Concepts (what is this?)

ICD9CM
SNOMEDCT_US
Acting as individual patient advocate (370770001), Activity of daily living (129025006), Assistive equipment (360296002), Care of the elderly nurse (224545006), Communication (263536004), Discharge planning (371754007), Education of family (460616007), Environment (276339004), Functional assessment (12894003), Functional disorder (386585008), Geriatric screening (171313004), Goal (410518001), Inpatient care (394656005), Patient discharge (58000006), Patient education (311401005), Risk assessment (225338004), Risk factor (80943009), Safe environment (224780008), Social assessment (406551008)

Major Recommendations

Levels of evidence (I–VI) are defined at the end of the "Major Recommendations" field.

Function-focused Care (FFC) Interventions

  • Hospital care systems and processes
    • Evaluation of leadership commitment to rehabilitative values (Boltz, Capezuti, & Shabbat, 2011 [Level IV]; Resnick, 2004 [Level VI]).
    • Interdisciplinary rounds that address functional assessment (baseline and current), evaluate potentially restrictive devices and agents, and yield a plan for progressive mobility (McVey et al., 1989 [Level II]).
    • Well-defined roles, including areas of accountability for assessment and follow-through for function-promoting activities (Jacelon, 2004 [Level IV]; Resnick et al., 2011 [Level III]).
    • Method of evaluating communication of patient needs among staff (Boltz, Capezuti, & Shabbat, 2011 [Level IV]).
    • Process of disseminating data (e.g., compliance with treatment plans and functional outcomes) (Boltz, Capezuti, & Shabbat, 2011 [Level IV]).
  • Policy and procedures to support function promotion
    • Protocols that minimize adverse effects of selected procedures (e.g., urinary catheterization) and medications (e.g., sedative-hypnotic agents) contribute to positive functional outcomes (Kleinpell, 2007 [Level V]).
    • Supporting policies: identification and storage of sensory (e.g., glasses, hearing aids/amplifiers) and mobility devices and other assistive devices (Boltz, Capezuti, & Shabbat, 2011 [Level IV]; St. Pierre, 1998 [Level V])
    • Discharge policies that address the continuous plan for function promotion (Boltz, Capezuti, & Shabbat, 2011 [Level IV]; Boltz et al., 2010 [Level IV]).
  • Physical design
    • Toilets, beds, and chairs at appropriate height to promote safe transfers and function (Capezuti et al., 2008 [Level IV])
    • Functional and accessible furniture and safe walking areas with relevant/interesting destination areas (Gulwadi & Calkins, 2008 [Level V]; Ulrich et al., 2008 [Level V]) and with distance markers (Callen et al., 2004 [Level III])
    • Adequate lighting, nonglare flooring, door levers, and hand rails (including in the patient room) (Gulwadi & Calkins, 2008; Ulrich et al., 2008 [Level V])
    • Large-print calendars and clocks to promote orientation (Kleinpell, 2007 [Level V])
    • Control of ambient noise levels (Gabor et al., 2003 [Level III])
  • Education of nursing staff, and other members of the interdisciplinary team (e.g., social work, physical therapy), regarding:
    • The physiology, manifestations, and prevention of hospital-acquired deconditioning (Boltz, Capezuti, & Shabbat, 2011 [Level IV]; Gillis, MacDonald, & Macisaac, 2008 [Level IV]; Resnick et al., 2011 [Level III]; Weitzel & Robinson, 2004 [Level V])
    • Assessment of physical capability (Resnick et al., "Implementation," 2009 [Level III]; Resnick et al., 2011 [Level III])
    • Rehabilitative techniques and use of adaptive equipment (Weitzel & Robinson, 2004 [Level V]; Resnick et al., 2011 [Level III]; Resnick et al., "Implementation," 2009 [Level III])
    • Interdisciplinary collaboration (Resnick et al., 2011 [Level III]; Resnick et al., "Implementation," 2009 [Level III])
    • Engagement in decision making (Boltz, Capezuti, & Shabbat, 2011 [Level IV]; Boltz et al., 2010 [Level IV]; Jacelon, 2004 [Level IV])
    • Communication that motivates is associated with a function-promoting philosophy (Boltz, Capezuti, & Shabbat, 2011 [Level IV]; Gillis, MacDonald, & Macisaac, 2008 [Level IV]; Jacelon, 2004 [Level IV]; Weitzel & Robinson, 2004 [Level V])
  • Education of patients and families regarding FFC (Resnick et al., "Implementation," 2009 [Level III]), including the benefits of FFC, the safe use of equipment, and self-advocacy (Boltz et al., 2010 [Level IV]).
  • Clinical assessment and interventions
    • Assessment of physical function and capability (baseline, at admission, and daily) and cognition (at a minimum daily) (Boltz, Capezuti, & Shabbat, 2011 [Level IV]; Covinsky et al., 2003 [Level IV]; Fortinsky et al., 1999 [Level IV]; Sager et al., 1996 [Level IV]; Wakefield & Holman, 2007 [Level IV])
    • Establishing functional goals based on assessments and communication with other members of the team and input from patients (Resnick et al., "Implementation," 2009 [Level III]; Resnick et al., 2011 [Level III]; Resnick et al., "Changing," 2009 [Level III]; Resnick et al., 2007 [Level III]; Resnick & Simpson, 2003 [Level III])
    • Social assessment: history, roles, values, living situation, and methods of coping (Boltz, Capezuti, & Shabbat, 2011 [Level IV]; Boltz et al., 2010 [Level IV])
    • Addressing risk factors that impact goal achievement (e.g., cognitive status, anemia, nutritional status, pain, fear of falling, fatigue, medications, and drug side effects such as somnolence) by the interdisciplinary team to optimize patient participation in functional and physical activity (Boltz et al., 2011 [Level IV]; Resnick et al., "Implementation," 2009 [Level III]; Resnick et al., 2011 [Level III]; Resnick et al., "Changing," 2009 [Level III]; Resnick et al., 2007 [Level III]; Resnick & Simpson, 2003 [Level III])
    • Development of discharge plans that include carryover of functional interventions, and addressing the unique preferences and needs of the patient (Nolan & Thomas, 2008 [Level III])

Definitions:

Levels of Evidence

Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/consensus panels

AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from http://www.agreetrust.org/?o=1397 External Web Site Policy.

Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.

Clinical Algorithm(s)

None provided

Disease/Condition(s)

Functional decline

Guideline Category

Evaluation

Management

Prevention

Clinical Specialty

Family Practice

Geriatrics

Nursing

Intended Users

Advanced Practice Nurses

Allied Health Personnel

Health Care Providers

Hospitals

Nurses

Physician Assistants

Physicians

Guideline Objective(s)

To provide a standard of practice protocol to help nurses collaborate with the interdisciplinary team to implement interventions that restore or maximize the older adult's functional abilities and performance and prevent or minimize decline in activities of daily living (ADL) function

Target Population

Older adults

Interventions and Practices Considered

  1. Hospital care systems and processes
    • Evaluation of leadership commitment
    • Interdisciplinary rounds
    • Well-defined roles
    • Evaluation of communication of patient needs
    • Processes for disseminating data
  2. Policy and procedures to support function promotion
    • Protocols to minimize adverse effects of procedures
    • Identification and storage of sensory devices
    • Discharge polices that address the continuous plan for function promotion
  3. Physical design (accessible toilets and furniture, lighting, noise levels, large print)
  4. Education of nursing staff and other members of the interdisciplinary team (e.g., social work, physical therapy)
  5. Education of patients and families regarding function-focused care (FFC), including the benefits of FFC, the safe use of equipment, and self-advocacy
  6. Clinical assessment and interventions
    • Assessment of physical function
    • Functional goals
    • Social assessment
    • Addressing risk factors that affect achievement of goals
    • Discharge plans that include carryover of functional interventions

Major Outcomes Considered

  • Functional trajectory of the hospitalized older adult
  • Use of collaborative plan/interventions to maximize function and performance
  • Use of transitions of care plans

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)

Hand-searches of Published Literature (Secondary Sources)

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Although the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument (described in Chapter 1 of the original guideline document, Evidence-based Geriatric Nursing Protocols for Best Practice, 4th ed.) was created to critically appraise clinical practice guidelines, the process and criteria can also be applied to the development and evaluation of clinical practice protocols. Thus, the AGREE instrument has been expanded (i.e., AGREE II) for that purpose to standardize the creation and revision of the geriatric nursing practice guidelines.

The Search for Evidence Process

Locating the best evidence in the published research is dependent on framing a focused, searchable clinical question. The PICO format—an acronym for population, intervention (or occurrence or risk factor), comparison (or control), and outcome—can frame an effective literature search. The editors enlisted the assistance of the New York University Health Sciences librarian to ensure a standardized and efficient approach to collecting evidence on clinical topics. A literature search was conducted to find the best available evidence for each clinical question addressed. The results were rated for level of evidence and sent to the respective chapter author(s) to provide possible substantiation for the nursing practice protocol being developed.

In addition to rating each literature citation as to its level of evidence, each citation was given a general classification, coded as "Risks," "Assessment," "Prevention," "Management," "Evaluation/Follow-up," or "Comprehensive." The citations were organized in a searchable database for later retrieval and output to chapter authors. All authors had to review the evidence and decide on its quality and relevance for inclusion in their chapter or protocol. They had the option, of course, to reject or not use the evidence provided as a result of the search or to dispute the applied level of evidence.

Developing a Search Strategy

Development of a search strategy to capture best evidence begins with database selection and translation of search terms into the controlled vocabulary of the database, if possible. In descending order of importance, the three major databases for finding the best primary evidence for most clinical nursing questions are the Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Medline or PubMed. In addition, the PsycINFO database was used to ensure capture of relevant evidence in the psychology and behavioral sciences literature for many of the topics. Synthesis sources such as UpToDate® and British Medical Journal (BMJ) Clinical Evidence and abstract journals such as Evidence Based Nursing supplemented the initial searches. Searching of other specialty databases may have to be warranted depending on the clinical question.

It bears noting that the database architecture can be exploited to limit the search to articles tagged with the publication type "meta-analysis" in Medline or "systematic review" in CINAHL. Filtering by standard age groups such as "65 and over" is another standard categorical limit for narrowing for relevance. A literature search retrieves the initial citations that begin to provide evidence. Appraisal of the initial literature retrieved may lead the searcher to other cited articles, triggering new ideas for expanding or narrowing the literature search with related descriptors or terms in the article abstract.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence

Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/consensus panels

AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from http://www.agreetrust.org/?o=1397 External Web Site Policy.

Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses

Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review

Internal Peer Review

Description of Method of Guideline Validation

Not stated

References Supporting the Recommendations

Boltz M, Capezuti E, Shabbat N, Hall K. Going home better not worse: older adults' views on physical function during hospitalization. Int J Nurs Pract. 2010 Aug;16(4):381-8. PubMed External Web Site Policy

Boltz M, Capezuti E, Shabbat N. Nursing staff perceptions of physical function in hospitalized older adults. Appl Nurs Res. 2011 Nov;24(4):215-22. PubMed External Web Site Policy

Boltz M, Resnick B, Capezuti E, Shabbat N, Secic M. Function-focused care and changes in physical function in Chinese American and non-Chinese American hospitalized older adults. Rehabil Nurs. 2011 Nov-Dec;36(6):233-40. PubMed External Web Site Policy

Callen BL, Mahoney JE, Wells TJ, Enloe M, Hughes S. Admission and discharge mobility of frail hospitalized older adults. Medsurg Nurs. 2004 Jun;13(3):156-63; quiz 164. PubMed External Web Site Policy

Capezuti E, Wagner L, Brush BL, Boltz M, Renz S, Secic M. Bed and toilet height as potential environmental risk factors. Clin Nurs Res. 2008 Feb;17(1):50-66. PubMed External Web Site Policy

Covinsky KE, Palmer RM, Fortinsky RH, Counsell SR, Stewart AL, Kresevic D, Burant CJ, Landefeld CS. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 2003 Apr;51(4):451-8. PubMed External Web Site Policy

Fortinsky RH, Covinsky KE, Palmer RM, Landefeld CS. Effects of functional status changes before and during hospitalization on nursing home admission of older adults. J Gerontol A Biol Sci Med Sci. 1999 Oct;54(10):M521-6. PubMed External Web Site Policy

Gabor JY, Cooper AB, Crombach SA, Lee B, Kadikar N, Bettger HE, Hanly PJ. Contribution of the intensive care unit environment to sleep disruption in mechanically ventilated patients and healthy subjects. Am J Respir Crit Care Med. 2003 Mar 1;167(5):708-15. PubMed External Web Site Policy

Gillis A, MacDonald B, MacIsaac A. Nurses' knowledge, attitudes, and confidence regarding preventing and treating deconditioning in older adults. J Contin Educ Nurs. 2008 Dec;39(12):547-54. PubMed External Web Site Policy

Gulwadi GB, Calkins M. The impact of healthcare environmental design on patient falls. Concord (CA): The Center for Health Design; 2008.

Jacelon CS. Managing personal integrity: the process of hospitalization for elders. J Adv Nurs. 2004 Jun;46(5):549-57. PubMed External Web Site Policy

Kleinpell R. Supporting independence in hospitalized elders in acute care. Crit Care Nurs Clin North Am. 2007 Sep;19(3):247-52, v. PubMed External Web Site Policy

McVey LJ, Becker PM, Saltz CC, Feussner JR, Cohen HJ. Effect of a geriatric consultation team on functional status of elderly hospitalized patients. A randomized, controlled clinical trial. Ann Intern Med. 1989 Jan 1;110(1):79-84. PubMed External Web Site Policy

Nolan J, Thomas S. Targeted individual exercise programmes for older medical patients are feasible, and may change hospital and patient outcomes: a service improvement project. BMC Health Serv Res. 2008;8:250. PubMed External Web Site Policy

Resnick B, Cayo J, Galik E, Pretzer-Aboff I. Implementation of the 6-week educational component in the Res-Care intervention: process and outcomes. J Contin Educ Nurs. 2009 Aug;40(8):353-60. PubMed External Web Site Policy

Resnick B, Galik E, Enders H, Sobol K, Hammersla M, Dustin I, Boltz M, Miner L, Trotman S. Pilot testing of function-focused care for acute care intervention. J Nurs Care Qual. 2011 Apr-Jun;26(2):169-77. PubMed External Web Site Policy

Resnick B, Gruber-Baldini AL, Galik E, Pretzer-Aboff I, Russ K, Hebel JR, Zimmerman S. Changing the philosophy of care in long-term care: testing of the restorative care intervention. Gerontologist. 2009 Apr;49(2):175-84. PubMed External Web Site Policy

Resnick B, Rogers V, Galik E, Gruber-Baldini AL. Measuring restorative care provided by nursing assistants: reliability and validity of the Restorative Care Behavior Checklist. Nurs Res. 2007 Nov-Dec;56(6):387-98. PubMed External Web Site Policy

Resnick B, Simpson M. Restorative care nursing activities: pilot testing self-efficacy and outcome expectation measures. Geriatr Nurs. 2003 Mar-Apr;24(2):82-9. PubMed External Web Site Policy

Resnick B. Restorative care nursing for older adults: a guide for all care settings. New York: Springer Publishing; 2004.

Sager MA, Franke T, Inouye SK, Landefeld CS, Morgan TM, Rudberg MA, Sebens H, Winograd CH. Functional outcomes of acute medical illness and hospitalization in older persons. Arch Intern Med. 1996 Mar 25;156(6):645-52. PubMed External Web Site Policy

St. Pierre, J. Functional decline in hospitalized elders: preventive nursing measures. MCN Clin Issue. 1998;9(1):109-18.

Ulrich RS, Zimring C, Zhu X, DuBose J, Seo HB, Choi YS, Quan X, Joseph A. A review of the research literature on evidence-based healthcare design. HERD. 2008 Spring;1(3):61-125. PubMed External Web Site Policy

Wakefield BJ, Holman JE. Functional trajectories associated with hospitalization in older adults. West J Nurs Res. 2007 Mar;29(2):161-77; discussion 178-82. PubMed External Web Site Policy

Weitzel T, Robinson SB. A model of nurse assistant care to promote functional status in hospitalized elders. J Nurses Staff Dev. 2004 Jul-Aug;20(4):181-6. PubMed External Web Site Policy

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for selected recommendations (see the "Major Recommendations" field).

Potential Benefits

Patients

Maximum function at discharge

Health Care Providers

  • Improved competence in assessing physical function and developing an individualized plan to promote function, in collaboration with the patient and interdisciplinary team
  • Provision of physical and social environments that enable optimal physical function for older adults
  • Provision of individualized discharge plans

Institution

  • Reduced incidence and prevalence of functional decline
  • Reduced use of physical restraints, prolonged bed rest, Foley catheters
  • Decreased incidence of delirium and other adverse events (pressure ulcers and falls)
  • Increased prevalence of patients who leave hospital at their baseline or with improved functional status
  • Provision of physical environments that are safe and enabling
  • Increased patient satisfaction
  • Enhanced staff satisfaction and teamwork

Potential Harms

Not stated

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Chart Documentation/Checklists/Forms

Mobile Device Resources

Resources

For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

IOM Care Need

Getting Better

Living with Illness

Staying Healthy

IOM Domain

Effectiveness

Patient-centeredness

Bibliographic Source(s)

Boltz M, Resnick B, Galik E. Interventions to prevent functional decline in the acute care setting. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editor(s). Evidence-based geriatric nursing protocols for best practice. 4th ed. New York (NY): Springer Publishing Company; 2012. p. 104-21.

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2012

Guideline Developer(s)

Hartford Institute for Geriatric Nursing - Academic Institution

Guideline Developer Comment

The guidelines were developed by a group of nursing experts from across the country as part of the Nurses Improving Care for Health System Elders (NICHE) project, under sponsorship of the Hartford Institute for Geriatric Nursing, New York University College of Nursing.

Source(s) of Funding

Hartford Institute for Geriatric Nursing

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Primary Authors: Marie Boltz, PhD, RN, APRB-BC, Assistant Professor, New York University, College of Nursing; Barbara Resnick, PhD, CRNP, FAAN, FAANP, Professor and Sonya Ziporkin Gershowitz Chair in Gerontology, University of Maryland; Elizabeth Galik, PhD, CRNP, Assistant Professor, University of Maryland

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Hartford Institute for Geriatric Nursing Web site External Web Site Policy.

Copies of the book Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th edition: Available from Springer Publishing Company, 536 Broadway, New York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web: www.springerpub.com External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Try This® - issue 2: Katz Index of Independence in Activities of Daily Living (ADL). New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2012. Electronic copies: Available in Portable Document Format (PDF) from the Hartford Institute of Geriatric Nursing Web site External Web Site Policy.
  • Try This ® - issue 31: Reducing functional decline in older adults during hospitalization: a best practices approach. New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2012. Electronic copies: Available in PDF from the Hartford Institute of Geriatric Nursing Web site External Web Site Policy.

The ConsultGeriRN app for mobile devices is available from the Hartford Institute for Geriatric Nursing Web site External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on June 26, 2013. The information was verified by the guideline developer on August 6, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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