NICE to HELP: operationalizing National Institute for Health and Clinical Excellence guidelines to improve clinical practice.

The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom developed guidelines for the diagnosis, prevention, and management of delirium in July 2010 that included 10 recommendations for delirium prevention. The Hospital Elder Life Program (HELP) is a targeted multicomponent strategy that has proven effective and cost-effective at preventing functional and cognitive decline in hospitalized older persons. HELP provided much of the basis for seven of the NICE recommendations. Given interest by new HELP sites to meet NICE guidelines, three new protocols addressing hypoxia, infection, and pain that were not previously included in the HELP program were developed. In addition, the NICE dehydration guideline included constipation, which was not specifically addressed in the HELP protocols. This project describes the systematic development of three new protocols (hypoxia, infection, pain) and the expansion of an existing HELP protocol (constipation and dehydration) to achieve alignment between the HELP protocols and NICE guidelines. Following the Institute of Medicine recommendations for developing trustworthy guidelines, an interdisciplinary group of experts conducted a systematic review of current literature, rated the quality of the evidence, developed intervention protocols based on the highest-quality evidence, and submitted the protocols first to internal review and then to external review by an interdisciplinary panel of experts. The protocols were revised based on the review process and incorporated into the HELP materials. Inclusion of these protocols enhances the scope of the HELP program and allows fulfillment of NICE guideline recommendations for delirium prevention. The rigorous process applied may provide a useful example for updating existing guidelines or protocols that may be applicable to a broad range of clinical applications.

Learning from the closure of clinical programs: a case series from the Hospital Elder Life Program.

Clinical programs in geriatrics face a challenging fiscal environment. Although recent research offers lessons from successful programs to help others like them sustain operations, it is not clear whether these lessons apply to programs that are beginning to fail. This study takes an approach that is frequently recommended, but rarely applied: examining failed programs to develop guidance for those at risk. It uses the example of an evidence-based, cost-effective geriatrics program that has been successfully implemented at more than 200 sites: the Hospital Elder Life Program (HELP). Data come from 14 in-depth interviews conducted between January and May 2011 with staff and hospital administrators affiliated with the six fully operational sites that closed between 2006 and 2011. Using the constant comparative method, researchers identified major themes suggesting that former HELP sites closed because of two interrelated problems centered on a major financial crisis or restructuring at the hospital or health system level. First, the crisis created challenges, such as the removal of program champions and a new focus on revenue-generating programs. Second, there were on-going vulnerabilities that the crisis revealed but that had not previously posed a threat to program viability. These included problems such as insufficient support from physicians and nursing leaders and limited documentation of program outcomes. Results suggest that, to protect against closure, clinical programs need to prepare for major crises at the hospital or health system level by ensuring support from multiple senior champions, with a special emphasis on nursing and physician leaders.

Sustaining clinical programs during difficult economic times: a case series from the Hospital Elder Life Program.

OBJECTIVES: To explore strategies used by clinical programs to justify operations to decision-makers using the example of the Hospital Elder Life Program (HELP), an evidence-based, cost-effective program to improve care for hospitalized older adults. DESIGN: Qualitative study design using 62 in-depth, semistructured interviews conducted with HELP staff members and hospital administrators between September 2008 and August 2009. SETTING: Nineteen HELP sites in hospitals across the United States and Canada that had been recruiting patients for at least 6 months. PARTICIPANTS: HELP staff and hospital administrators. MEASUREMENTS: Participant experiences sustaining the program in the face of actual or perceived financial threats, with a focus on factors they believe are effective in justifying the program to decision-makers in the hospital or health system. RESULTS: Using the constant comparative method, a standard qualitative analysis technique, three major themes were identified across interviews. Each focuses on a strategy for successfully justifying the program and securing funds for continued operations: interact meaningfully with decision-makers, including formal presentations that showcase operational successes and informal means that highlight the benefits of HELP to the hospital or health system; document day-to-day, operational successes in metrics that resonate with decision-maker priorities; and garner support from influential hospital staff that feed into administrative decision-making, particularly nurses and physicians. CONCLUSION: As clinical programs face financially challenging times, it is important to find effective ways to justify their operations to decision-makers. Strategies described here may help clinically effective and cost-effective programs sustain themselves and thus may help improve care in their institutions.