“You have a patient who is acutely ill and in whom multiple organ systems are all functioning with a tenuous degree of reserve,” said Ethan Cumbler, FACP. “As such, our management has to be perfect, because our patient simply can't handle further stresses on their system and the failure of one system puts increased pressure on other organ systems.”
Dr. Cumbler, a hospitalist at the University of Colorado in Denver, isn't describing an intensive care or other unusually sick patient, but a typical geriatric admission. As director of an Acute Care for the Elderly (ACE) service, he knows how easily negative outcomes can result from hospitalization of elderly patients.
“All too often we see this culminate in what I call the catastrophic geriatric hospital decline spiral, where a patient will come in with one seemingly treatable problem and two weeks later, they will have met their end from a constellation of other organs failing and complications,” he said.
But that spiral is neither unforeseeable nor unavoidable. Hospitals and hospitalists already know how to optimize care for the elderly, according to Anne Fabiny, MD, chief of geriatrics at the Cambridge Health Alliance in Massachusetts. “Awareness of the special needs of older adults is much higher than when I first started doing this work 15 years ago.…We have the knowledge base. We have evidence-based practices that can improve outcomes,” she said.
The challenge is for physicians and hospitals to develop systems to ensure that these practices are implemented for every patient who needs them. The traditional solution has been an ACE unit, but some physicians and hospitals are also working on new methods of optimizing care as they prepare for a growing elderly inpatient population.
Research has shown that elderly patients benefit from spending their admission on an ACE unit, where the processes of care have been specially designed to meet their needs. “About 15% or more folks are better in terms of their ability to care for themselves after discharge from an ACE than from usual care. About 10% fewer will go to a nursing home. People also report being better able to walk and having fewer depressive symptoms,” said Seth Landefeld, FACP, chief of geriatrics in the University of California San Francisco department of medicine.
With their special focus, ACE units have the potential to eliminate many of the issues that make hospitalization more difficult for elderly patients. “If you walk into a hospital room, often the lighting is not very good, the toilets are not situated in convenient places. We put people on funny schedules that they're not accustomed to at home. We often restrict visitors,” described J. Rush Pierce Jr., FACP, a geriatrician and hospitalist at the University of New Mexico in Albuquerque.
In addition to correcting those physical issues, ACE units can also differ in their staffing and approach to care. “We have on our ACE unit a physical therapist, a nurse manager (a nurse practitioner), nutrition, and they round on a daily basis on every patient on the unit,” said Corey Romesser, MD, director of the ACE unit at Highland Hospital in Rochester, N.Y. “Just having an ACE unit with trained professionals that are always thinking of discharge planning, maintenance of function—not only does it improve outcomes, it just makes sense.”
But according to Dr. Landefeld, research has not entirely borne out that common-sense assumption. “The evidence that ACE units [improve outcomes] every time or consistently from one place to another is not so compelling,” he said. “The big challenge, like with many complex medical interventions, is that, in the studies, the same effects have not been able to be duplicated every time from one hospital to another.”
There's also the money issue. ACE units have been shown to reduce length of stay, but there are start-up—and ongoing—costs to setting aside those beds. “The traditional closed ACE unit has not gained much traction in the United States and my guess is that's because a dedicated closed unit represents an allocation of resources that many hospitals are hesitant to commit,” said Dr. Cumbler.
Even some hospitals that have committed to ACE units have found difficulties. “The ACE unit that we had, which is your traditional geographic-based ACE unit, wasn't working for us,” said Jeffrey Farber, ACP Member, a geriatrician and hospitalist at Mount Sinai. “A bed is a bed and when [elderly patients] are in the emergency room and they need to get admitted, they about half the time got admitted outside the unit, and then half the patients on the ACE unit weren't ones that needed to be on the ACE unit because of the same reason.”
There are potential disadvantages to keeping all your geriatric expertise in one space-limited unit, agreed Dr. Fabiny. “If you're an 85-year-old, it would be great if you were on the geriatric unit. If that is full, then you go to a unit that's not trained or doesn't have the sensitivity to care for older adults.”
ACE on the move
In an effort to bring an ACE unit's expertise and sensitivity to the whole hospital, Dr. Farber and colleagues developed a mobile ACE unit, of which he is the director. “We decided to take a lot of the approaches that we use on the ACE unit and geographically delocalize that to deal with the reality,” he said.
Like a traditional ACE unit, the mobile ACE unit (also known as MACE) has a team of geriatric experts (attending, fellow, nurse coordinator, social worker) who round on patients and focus on issues such as transition planning and medication management. The difference is that the clinicians go out to the elderly patients, on whatever unit they've been placed.
“On any given day, I have 12 patients and they're in two different hospital buildings and they're on five different hospital floors,” said Dr. Farber. “We get a lot of exercise in a day.” The disadvantage, of course, is that the running around can be inefficient. “You get more pages: ‘You just missed somebody.’ I was there. I'll come back,” he described.
On the plus side, an analysis of the Mount Sinai MACE service found that it reduced length of stay and costs compared to usual care. Another study, currently under way, is using follow-up phone interviews to assess the service's impact on patient satisfaction and functional outcomes.
Another advantage is that a MACE unit disperses expertise around the hospital. “Our nurse coordinator takes the lead role and some of her time is dedicated to educating nurses on other units throughout the hospital about things like skin care and pressure ulcer prevention, falls, delirium, other hazards of hospitalization. By having our patients throughout different places, we interact with the teams who work there,” said Dr. Farber.
Although it's called an ACE unit, Dr. Romesser's Rochester program has evolved in a somewhat similar manner. “We've manipulated it to meet our needs as we've gone along,” he said. “The admitting department tries to place the older adults from skilled nursing facilities and the community on the ACE unit, but there is some crossover with other units, depending on where the beds are most available.”
To try to ensure that the elderly patients who don't get on the unit don't miss out on the benefits, the ACE clinicians consult and teach on other units in the hospital. “A lot of the practices that we started on the ACE unit, we try to spread out onto the other units,” said Dr. Romesser. Examples include avoiding medications that are inappropriate for the elderly, keeping patients mobile, and focusing on nutrition.
“It's just a matter of teaching people that it's easy to do and that it can be done anywhere. The ACE units really need to serve as a model to spread the care to other units,” Dr. Romesser said.
Spreading the wealth
ACE units can spread their benefits to elderly patients in the rest of the hospital in multiple ways, according to Dr. Cumbler, who offered a scientific metaphor to describe the phenomena. “They are analogous to methods of heat transfer if you are a fan of physics,” he said.
First, there's conduction, in which the ACE team directly cares for patients, as in Rochester. Or, in a process like convection, clinicians can rotate through the service and pick up knowledge. “All of the first-year medicine housestaff rotate for a week on the ACE service during their internship. This exposes large numbers of future residents and physician faculty to the concepts of good geriatric care which they carry with them throughout their training,” Dr. Cumbler said.
Finally, there's radiation, which doesn't require contact between the ACE team and patients or movement of clinicians. “The ACE unit serves as a crucible to test change and once a new best practice is identified, it can be disseminated throughout the hospital through new practice protocols. As an example, to help streamline geriatric care on our ACE service we created a geriatric order set which bundled together elements such as a sleep protocol, a delirium protocol, a bowel protocol. The ‘geriatric medicine admission order set’ can be used for any elderly patient hospital-wide,” said Dr. Cumbler.
Hospital-wide system changes were the option that Beth Israel Deaconess Medical Center in Boston chose to optimize its geriatric care. “We have our own ACE unit, which we've had on and off for probably close to a decade, but we've run into some of the same challenges that ACE units nationwide have,” including the fact its benefits are limited to 15 patients at any given time, said Melissa Mattison, ACP Member, a hospitalist and geriatrician at Beth Israel.
“We actually like having our ACE unit quite a bit. It serves purposes of education for fellows and students, as well as helps us try new protocols, but there are more than 15 older people in our 500-bed hospital,” Dr. Mattison said.
A MACE service could help reach a larger number of patients, but still has limitations as a model, she added. “They also require dedicated, specialized staffing. They also have a limit to the number of patients they can serve.”
A team of Beth Israel's geriatric experts, including physicians, nurses, pharmacists and therapists, met and developed some interventions, including modifications to the computer physician order entry system to warn prescribers about medications that might be unsafe for the elderly. They also created a bedside checklist to encourage screening and prevention of delirium. “We came up with this overall program trying to hit as many of the pieces that we thought were likely to contribute to cognitive and functional decline during hospitalization,” said Dr. Mattison.
The intervention, which was implemented in April 2010, has shown benefits anecdotally, such as nurses identifying medication-related delirium through the checklist, but data are still being gathered and assessed. “We're hopeful that we'll be able to help other hospitals use some of the footwork that we've already done and adapt this to their own institutions. Obviously, providing care to older patients is on some level exactly the same no matter where you are, yet different institutions have different systems of care,” Dr. Mattison said.
The coming wave
Whether or not the specifics of the Beth Israel program work for another hospital, Dr. Mattison believes the model of hospital-wide intervention may be a good solution to future geriatric care challenges. “As we move forward, we're going to have more older patients in the hospital and not enough specially trained geriatric specialists,” she said. “We need to create systems of care that provide really the optimal care for older patients as the default as opposed to creating a system of care for a 45-year-old.”
Of course, ACE units will also likely be an important component in future geriatric care. Dr. Cumbler's service at the University of Colorado is doubling in size to increase the number of patients it can serve.
The growing patient population may also make ACE units feasible in situations where they weren't before. Designating beds for an ACE unit has posed particular problems for small hospitals and those that don't treat a sizable number of older patients, Dr. Landefeld noted. “As there are more older people in the hospital, that becomes less of an issue.”
The financial picture may also change. The Medicare Payment Advisory Commission (MedPAC), which advises the Centers for Medicare and Medicaid Services (CMS), has recommended more funding for residency training in geriatric inpatient care. “MedPAC has said to Medicare, ‘You need to require of training programs that they have a significant proportion of their curriculum and training devoted to care of older adults,” said Dr. Fabiny.
Other changes could also be coming, she added. “CMS is going to start to say, ‘We pay [hospitals] a lot of money to take care of older adults and we think we're not getting what we're paying for.’ There'll be outcome measures that hospitals will have to start providing. Not paying for nosocomial infections and not paying for injuries due to falls is the start of that.”
If the money comes, the next necessity for improving inpatient care for the elderly will be leadership, which hospitalists are in a good position to provide. “The key role that hospitalists can play is advocating for a unit, or for the whole hospital or teams to engage in this quality improvement work together,” said Dr. Fabiny.