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Acing Acute Care for Elders

Cheryl Clark, for HealthLeaders Media, September 9, 2013

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.

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