Special hospital units designed and staffed to treat geriatric patients are improving outcomes and reducing costs.
This article appears in the July/August issue of HealthLeaders magazine.
The unnecessary suffering of one special patient 14 years ago haunted Aurora Health Care's Senior Services director Michael Malone, MD. It put him through "days of heart-wrenching reflection" about how poorly the healthcare system in general, and the currently 15-hospital system in Wisconsin in particular, was taking care of its seniors.
An octogenarian had been admitted for treatment of a hand infection, but he became confused, agitated, and delirious, probably because of the strangeness of his new hospital environment. But instead of digging in to find the cause, staff dosed him with antipsychotic drugs, oversedating him, Malone recalls. The patient then slept four days straight, and when he woke up, his ability to function had degraded significantly.
It was, Malone says, a preventable adverse event.
Before admission, the patient had some dementia but was functional and mobile in an assisted-living home. But after the antipsychotic drugs, he required a long rehabilitation and a lengthy stay in a nursing home to try to restore his activities of daily living, Malone says.
"This was the bell ringer for me, a compelling case," Malone says. "I realized we've got to figure out a better way to provide high-quality, safe care to older adults during their acute illness. We have a responsibility to make sure care is optimal, and this wasn't; but we acknowledged that and set forth a trajectory that has helped our organization provide better care for vulnerable elders."
At that time, Malone remembered an article he'd read about ACE units, parts of hospitals dedicated to acute care for elders, in a 1995 issue of the New England Journal of Medicine. The piece described how elder patients randomly assigned for treatment at a specially designed and staffed 14-bed ACE unit at University Hospitals of Cleveland were discharged with higher functional abilities than a matched cohort of patients who received typical care at that hospital. Also, ACE unit patients were more often discharged home than to a long-term care facility.
C. Seth Landefeld, MD, the author of that paper and who developed the concept more than 20 years ago, now chairs the department of medicine at the University of Alabama, Birmingham, which has its own 26-bed ACE unit.
Although each facility that has launched such a unit may modify the components and services provided because there is no accreditation or firm definition, Landefeld's concept has four essential components: a friendlier physical environment that includes details such as carpets and handrails; special protocols centered on the patient, such as concerted efforts to help patients move; planning for going home; and daily evaluation and minimal use of catheterization and sedative-hypnotic drugs.
"We wanted to make it easier for people to care for themselves and be mobile," he says. "Most hospitals use hallways as closets, but we removed all the stuff so people could get up and walk around."
"We trained nurses to—instead of asking someone who was having trouble sleeping at night if they want a sleeping pill—offer them warm milk, soft music, or maybe to rub their back, and not give them medicine that would confuse them," Landefeld says. A medical review every day "eliminates drugs that aren't necessary and makes sure dosages are appropriate for 88-year-old Aunt Mary, who is 95 pounds instead of 135 pounds."
The team also made sure that procedures with few risks when performed for younger patients don't backfire when they're performed on frail seniors. "For example, special care is taken for a patient about to undergo a colonoscopy to make sure they don't get too dehydrated or receive too much of a sedative usually given for that procedure," Landefeld says.
Other techniques developed at the Cleveland ACE unit include large clocks, communal dining areas so patients can eat meals outside their rooms, elevated toilet seats, door levers instead of handles, protocols to improve skin care and cognition, and use of an interdisciplinary team comprising a geriatrician, nurse, social worker, nutritionist, physical therapist, and visiting nurse liaison.
Despite the success of that 1995 paper and subsequent research efforts that demonstrated that ACE units reduce hospital costs by between 5%–10% primarily by reducing average length of stay, only about 200 units have been established, Landefeld says.
That's because the concept "doesn't fit the conventional paradigm of how we do things in medicine," he says. "If someone has an infection, we treat it with antibiotics. We don't ask how the pneumonia could be prevented, or what is the role of nutrition or exercise. These things are on the minds of patients and families, but not so much on the minds of doctors and hospitals."
Also, he says, "starting an ACE unit is not a procedure for which one can bill; it's not a DRG that someone can collect funds for. A variety of studies have also shown beneficial effects on people's ability to care for themselves when they go home, which is a great example of something that hospitals have not conventionally cared about."
As Malone walked down the hallway 14 years ago frustrated about his patient's oversedation and resulting decompensation, he was thinking about the ACE concept when he saw a medical resident exiting a mothballed med-surge unit that was being used as an on-call sleeping area.
This would be the perfect place to dedicate specialty care for frail elders, Malone thought. The administration "agreed that we have to do a better job, and we started on this journey we've been on for the past 14 years."
Not only did Aurora establish two ACE units at two facilities—a 16-bed unit in 2000 at the 145-staffed-bed Aurora Sinai Medical Center in Milwaukee and a 28-bed unit in 2005 at its 197-staffed-bed Aurora West Allis Medical Center—its teams also created the ACE Tracker, a telemedicine, electronic health record system that enables the interdisciplinary ACE care team to deliver ACE care to patients in any Aurora hospital across a 150-mile swath of eastern Wisconsin from Kenosha to Green Bay.
"This has helped us move from an ACE unit to a system that deploys the ACE model of care to all our hospitals," Malone says.
One goal is to reduce the use of urinary catheters, which impair seniors' mobility and can lead to falls and infections. The ACE unit's dedicated efforts in this area has dropped utilization of urinary catheters from about 30% throughout the system to 20%, and within the Sinai ACE unit, it's now 10%. Likewise, the hospital system has seen a drop in central line bloodstream infections between 2010 and 2013.
Early physical therapy assessment for each older patient is up to 72%, "when it used to be closer to 40% when we started," Malone says.
Aurora Health's Bruce Van Cleave, MD, chief clinical officer, says the C-suite is delighted with the ACE units and ACE Tracker because they've helped reduce readmissions, hospital-acquired conditions, and catheter-associated urinary tract infections.
Asked whether ACE units provide positive return on investment, Van Cleave says Aurora just doesn't think about the unit in those terms. "There's a part of this that speaks to the idea that the care we are delivering today is the care we will be receiving eventually. We want to have a healthcare system we are proud to send our friends and family to."
Van Cleave says Aurora is trying to expand the program still. "It's a challenge to constantly make sure that the lessons we know are consistently applied. But we're still learning."
At 336-licensed-bed Virginia Mason Medical Center in Seattle, Senior Vice President, Hospital Administrator, and Chief Nursing Officer Charleen Tachibana, RN, MN, FAAN, says a huge problem that led her hospital to create an ACE unit was the negative attitudes some caregivers and the general population had toward seniors, especially more than a decade ago.
"The population in general 12 to 13 years ago had a different attitude about older people—you can think of some of the phrases: old geezer, dirty old man, people who are confused, they dribble or can't feed themselves—and certain impressions formed over time; at times, we carried that into our work.
"But there are psychological and psychosocial reasons that explain these behaviors that can lead to providers managing them or addressing them differently. For example, understanding that there's a high rate of depression and alcoholism among elders who are lonely is an important part of this care.
"Providers need to think in terms of how seniors will get nutrition if they can't get to the grocery store."
In nursing education, she says, there has been no concentrated skill-building effort around care of elders. "It's never been considered a subgroup with unique needs, [one] that physiologically functions differently, like pediatrics. So we had a lot of work to do with our nursing staff." Virginia Mason started first with the Nurses Improving Care for Healthsystem Elders, or NICHE, training model, to educate nurses, therapists, nursing assistants, and social workers on how to deal with the unique needs of the elderly.
Tachibana says Virginia Mason administrators realized "we had to create a physical environment to help support these processes, and we knew we'd need to make staffing changes to better meet those needs."
Susan Abolafya, RN, MN, the director of the Virginia Mason ACE unit, and Kellie Meserve, MN, RN-BC, the unit's clinical leader, say the unit's success in preventing functional decline is also saving money because the hospital's strategies to assess patients and prevent delirium mean it reduces the time patient care technicians, or sitters, need to sit with patients considered unsafe to be alone because they are agitated or restless.
That amounted to about a $73,000 saving in 2011, Abolafya says.
Much of the trick in getting to the root of an elderly person's agitation and delirium requires a kind of detective work to determine whether there might be a physical reason why the patient is in anguish.
Abolafya recalls the very large man, a former athlete with cognitive issues, who became delirious and combative when he came to the floor. He was spewing profanities and grabbing people and was becoming threatening to staff.
"We got his wife involved in his care to provide some reality orientation, but nothing worked for quite a while," says Abolafya. After several hours, the ACE unit staff decided to check his urine output and realized he was having trouble emptying his bladder. Once that discomfort was removed, "he became very cooperative and friendly. It was a simple fix, and we got him a urology consult."
Meserve says that in the ACE unit, investigation, specialized training, and detective work happen "right up front and immediately." In another unit, the combative patient might have been put in restraints or given antipsychotic medications, which can launch a negative spiral.
The hospital also has seen a reduction in falls through mobility encouragement strategies in the unit. For example, the number of falls occurring within the ACE unit has gone from 48 in 2006 to 25 in 2009 to 13 in 2012.
Earlier this year, a study at the University of Alabama at Birmingham by the unit's director, Kellie L. Flood, MD, found that, compared with usual care, an interdisciplinary team working on the hospital's 26-bed ACE unit can prevent readmissions and reduce costs in part by lowering length of stay.
The trick, she says, is the interdisciplinary team—the nurse, physical therapist, occupational therapist, pharmacist, dietician, social worker, an ACE unit coordinator, and geriatrician—sitting at the table every day talking about that patient's needs and discharge plans.
Landefeld says that the idea of an ACE unit isn't rocket science and it's not expensive. It's drawn from educational and sociological theories of both Maria Montessori and Erving Goffman. "It's about building an institutional environment that will allow people to achieve the goals that they have," he says.
Institutions like schools, asylums, and even hospitals, he says, are set up to benefit people inside, "but they often function in ways that are intended to control behavior.
"Think about how hospitals often function: A common response to a confused, delirious patient is to tie them down. And there is nothing worse. They can injure themselves or become even more delirious."
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This article appears in the July/August issue of HealthLeaders magazine.