ACE unit: Acute care of the elder

1
ACE unit Acute care of the elder

• Yuri R. Nakasato
• Assistant Professor
• Department of Geriatrics

2
Objectives

• Problem
• Possible solutions
• ACE unit our progress
• Barriers

3
Problems

• Hospitalized elders are at increased risk of
  functional decline, both during hospitalization
  and following discharge.
• Creditor M. Hazards of hospitalization of the
  elderly. Ann Intern Med.1993118219-223.
• Older patients have longer and more frequent
  hospitalizations and higher rates of inhospital
  mortality and nursing home discharge.
• Graves EJ et al. National Hospital Discharge
  Survey Annual Summary, 1994. National Center for
  Health Statistics. Vital Health Stat 1997.
  13128.

4
Function another vital sign

• Many hospitalized older patients are discharge
  with ADL function that is worse than their
  baseline function. The oldest patients are at
  particular high risk of poor functional outcomes
  because they are less likely to recover ADL
  function lost before admission and more likely to
  develop new functional deficits during
  hospitalization.
• Covinsky KE et al. J Am Geriatr Soc
  200351451-458.

5
American Hospital a hostile environment

• Raised beds
• Cold, shiny floors
• Cluttered hallway corridors
• Lack of orienting clues
• Disturbing, unfamiliar procedures
• Depersonalization

6
American Hospital a hostile environment

• Constant interruption
• Access to family members
• Bed rest
• Starvation and undernutrition
• Medicines
• Unnecessary procedures

7
Possible solutions

• In 1990, the first acute care for the elderly
  (ACE) unit was established and shown to improve
  functional outcomes and decrease discharge to LTC
  of older hospitalized patients.
• Landefeld CS et al. A randomized trial of care in
  a hospital medical unit especially designed to
  improve the functional outcomes of acutely ill
  older patients. N Engl J Med 19953321338.

8
The ACE unit

• Based on quality improvement and comprehensive
  geriatrics assessments principles, the ACE unit
  was implemented with four key elements
• Specially designed environment
• Patient-centered care
• Planning for discharge
• Review of medical care

9
The delirium room

• A 3-4 bed unit free of restraints
• A CNA to oversee patients
• Minimize chemical restraints
• Train nurses and staff to use an ultrasound
  device

10
The common room

• An environment close to the main nurse station
  converted into an area for meals and an area
  where patients could get out of bed during
  nonmeal times.

11
Multidisciplinary team meetings

• Meeting held from Monday to Friday
• Focus on geriatric principles and issues related
  to the dangers of hospitalization
• Geriatrics nurse especialist or fellow or
  Geriatrics physician leads the meetings
• Team members include patients physicians,
  nurses, dietitian, pastoral care, social worker,
  case managers and therapists.

12
ACE unit current progress

• Opened in February 2003 at the VAMC
• 10 Geriatricians committed to the ACE unit
• 10-bed unit
• Assigned permanent case manager, social worker
  and head nurse
• Implementation of interdisciplinary meetings

13
Barriers to implement an ACE unit

• Shortage of nurses
• Administrative support for the delirium and the
  common room
• Coordination of other services PT/OT, nutrition,
  and pharmacy
• Participation of other teams in the
  multidisciplinary meetings.