Critical Path Network: ACE unit seeks to reduce elderly functional decline

Interdisciplinary team determines interventions

An ACE (acute care of elders) unit at DeKalb Medical Center in Decatur, GA, has helped maintain functionality while reducing average length of stay, thus achieving its overriding goal of reducing the incidence of functional decline in its elderly patients. The 12-bed unit, soon to expand to 24, has been operating for about 2½ years.

Why acute care for elders? "We know from experience and from the literature that older patients in hospitals are beset with complications associated with longer stays and nursing home stays," says Robert A. Zorowitz, MD, MBA, FACP, AGSF, CMD, medical director for senior services at DeKalb Regional Healthcare System.

Build upon the cornerstone’

"The cornerstone of geriatric medicine is to assess the patient’s function in terms of activities of daily living and to try to maintain that level of functionality," he adds.

The loss of function during hospital stays is associated with prolonged stay, nursing home placement, mortality, and progression or persistence of functional decline.

The complications of hospitalization can include:

• Muscle strength and aerobic capacity.

Decreased muscle strength; muscle shortening and changes in joint structure; and diminished aerobic capacity occur.

• Vasomotor stability.

Loss of plasma volume averaging about 600 ml; postural hypotension and syncope take place.

• Respiratory function.

Supine position increases closing volume.

• Demineralization.

Vertebral bone loss accelerated; loss incurred with 10 days’ bed rest requires four months to restore; increased risk of falls plus demineralization increase the risk of fracture.

Changing the environment

The typical primary care approach to elderly patients, Zorowitz explains, is "to get them back to where they were."

He offers this hypothetical example: "Mrs. Jones, 90 years old, is hospitalized for pneumonia and given antibiotics. Her fever and white count go down, and she is switched to oral medication. The doctor says she’s well enough to go home, but there’s one problem: She can’t walk anymore. Too often, we treat the disease, but we forget about function."

The first recommendations to change the hospital environment for elderly patients were outlined by Morton C. Creditor, MD, in the Annals of Internal Medicine in 1993. They covered four major areas:

  • ambulation;
  • reality orientation;
  • increased sensory stimulation;
  • functional change.

Zorowitz says the concept for his own unit was inspired by this and other studies. For example, the original description of an ACE unit appeared in 1994 in the Journal of the American Geriatrics Society.1 The model it described was at the University Hospitals of Cleveland.

An article describing the improved functional outcomes achieved by that model appeared in 1995 in the New England Journal of Medicine.2 One of the authors of that article, Seth Landefeld, MD, later recreated the same model at Summa Health System in Akron, OH.

"When we decided to create an ACE unit at DeKalb Medical Center, a group of us spent a couple of days in Akron studying their system and their protocols," Zorowitz relates.

While DeKalb Medical Center draws upon previous models, there are distinct differences, he notes.

"First, there are not that many ACE units in the country, and those that exist are in teaching hospitals," he observes. "To my knowledge, we are the first and only nonteaching hospital to have an ACE unit."

Second, most existing ACE units are led by clinical nurse specialists. The unit at DeKalb is run by a gerontological nurse practitioner. "This happened almost by accident, as we broadened our search," Zorowitz recalls.

"But a nurse practitioner is trained to give hands-on care; she functions under my license and those of our hospitalists. They love having someone specifically trained to do what she does; it sort of flattens out the organizational structure, placing the decisions as close to the patient as they can possibly be," he says.

Interdisciplinary team rounds

Zorowitz notes that the other unique aspects of his ACE unit are cross-training of the nursing staff and daily interdisciplinary team meetings. "The team members actually talk to each other every day," he explains.

At these daily meetings, the team discusses interventions and therapies. Interdisciplinary team rounds include Zorowitz, the nurse practitioner, physical and occupational therapists, the nurses, the nutritionist, the social worker, and case managers.

"We discuss every patient, particularly the new ones," Zorowitz says. "We discuss home planning — after all, our goal is to get them home — and the pathways for most of the common complications of hospitalization."

The nurse practitioner, with the assistance of the team, makes decisions about intervention. "The physicians see patients once a day as a general rule, and they write a series of orders," he notes.

"Under normal circumstances, if a patient has trouble walking and needs therapy, the nurse would have to call the physicians, and it may be another day before the therapy is ordered. So we asked ourselves, What if we trained our nurses to be able to determine when patients needed these interventions?’ We designed our protocols so that, under certain conditions, the nurse could initiate interventions. We have pre-printed orders the physicians sign and agree to. This way, things like physical therapy can be called that same day," Zorowitz says.

Training staff to spot potential problems

A key to this system working properly is training nurses to be able to recognize the most common issues that may lead to the need for additional intervention. "For example, they are trained to assess the patient’s home situation. They know when a social worker is needed, and they can call one right away," he says.

The ACE team reports also are unique, he says. "In reports like these, you usually get nothing about the patient himself," Zorowitz notes.

"The typical report is task-oriented; what do we have to do for this patient today? It’s not patient-centered. We ask ourselves questions like, Who is this patient, why is he here, and what can we do to facilitate his stay?’ These are very different orientations," he explains.

Admission criteria are based on who will benefit from the program, Zorowitz notes. "We want transfers from day one," he asserts.

Results to date encouraging

Zorowitz is pleased with what his team has accomplished. "We have addressed problems often not recognized in the hospitalized elderly," he asserts. "We believe the ACE unit has reduced length of stay by an average of at least 0.5 to 0.9 days."

In addition, surveys have shown a high level of patient and nursing satisfaction. "We have had very little turnover," Zorowitz asserts.

In addition, he says, the attending physicians like the new approach.

"It results in fewer phone calls, and they know their patients are getting the appropriate care." The ACE unit also has created an opportunity for multidisciplinary education at DeKalb, "because we have provided a model for hospitalization that others can come to us to learn," Zorowitz points out.

Outcomes measures have been most difficult, although he notes such data are available from previous studies. "They show, for example, that an ACE unit is probably cost-neutral," Zorowitz observes.

In fact, the authors of one study wrote, "Caring for patients on an intervention ward designed to improve functional outcomes in older patients was not more expensive to the hospital than caring for patients on a usual-care ward, even though the intervention ward required commitment of hospital resources."2

The cost analysis was based on the work done at the University Hospitals of Cleveland.

[For more information, contact:

Robert A. Zorowitz, MD, MBA, FACP, AGSF, CMD, Senior Health Center, 1045 Sycamore Drive, Decatur, GA 30030. Telephone: (404) 501-1900. E-mail: zorowitz@dkmc.org.]

Hospital Environment for Elderly Patients

1. Ambulation

  • low beds without rails
  • carpeting
  • encouragement and assistance
  • minimization of "tethers"

2. Reality orientation

  • clocks
  • calendars
  • dressing and undressing
  • communal dining

3. Increased sensory stimulation

  • proper lighting and decorating
  • attention to glasses and hearing aids
  • newspapers and books
  • available recreation

4. Functional change

  • primary care concept
  • team management
  • interdisciplinary rounds
  • sharing of objectives
  • family participation
  • early discharge planning

Source: Creditor M. Hazards of hospitalization of the elderly. Ann Intern Med 1993; 118:219-223.

ACE Unit Patient Criteria

Admission Criteria

  • > 65 living at home or assisted living
  • Admitted as inpatient or observation with medical diagnosis
  • Direct admits through emergency department, day treatment center, or office

Exclusion Criteria

  • Requiring specialty care: intensive care unit, oncology, etc.
  • Patients from nursing home or terminally ill patients
  • Transfers from other units

Source: DeKalb Medical Center, Decatur, GA.

References

1. Palmer RM, Landefeld CS, Kresevic D, Kowal J. Medical unit for the acute care of the elderly. J Am Geriatr Soc 1994; 42:545-552.

2. Covinsky KE, King JT, Quinn LM, et. al. Do acute care for elder units increase hospital costs? A cost analy sis using the hospital perspective. J Am Geriatr Soc 1997; 45:729-734.