Hospitals that use special Acute Care of the Elderly teams to target complex needs of their frail, elderly patients can see a drop in adverse events and shorter lengths of stay, even if the patients aren't housed in a dedicated unit but are scattered throughout the hospital.
And if the targeted care takes place in a distinct hospital unit, average costs for treating those patients, as well as 30-day readmissions, can drop too.
Those are separate conclusions from two reports on ACE units published in the JAMA Internal Medicine.
Researchers in the first study used a mobile version of the ACE team, or MACE, at 1,200-bed Mount Sinai Hospital in New York. The mobile unit was led by a hospitalist who specialized in geriatric medicine, along with a clinical nurse specialist who made daily rounds on patients who were not in a special physical unit of the hospital but scattered throughout the facility, says William W. Hung, MD, the study's corresponding author.
See Also: If ACE Units Are So Great, Why Aren't They Everywhere?
Hung says the experienced team was able to better understand the risk factors for developing adverse events, and took special attention to assure patients were moving as soon as possible.
Because of that, he says, they avoided complications. They also focused on making sure that these patients, all of whom were over the age of 75, avoided polypharmacy with medications that counteract or adversely react with each other.
"The MACE service does offer an alternative for hospitals that don't have an ACE unit developed and want to be able to serve older adults with significant health problems better," Hung says. "It's a much more transportable model."
Hung explains that Mount Sinai had a special dedicated ACE unit for about eight years, but disbanded it in 2006 because it was too resource-intensive, and its beds were frequently needed by younger, non-frail patients who didn't need those targeted services.
So this was the MACE was deployed. The experiment paired a group of 173 frail, elderly patients who received care from the MACE unit with a matched group of 173 who received usual care.
There were 17.06 adverse events of any kind in the group receiving usual care, but only 9.5 in the MACE group. For CAUTIs, the usual care group developed 4.6 while the MACE group had 1.7. As for use of restraints, the usual care group had 2.9 compared with .6 and for falls. The usual care group had 10.9 compared with 8.7 in the MACE group.
Patient experience scores were higher in the MACE group as well, especially in questions about how well physicians and nurses communicated.
Length of stay in the MACE group was two days shorter. Patients stayed in the hospital 4.6 days instead of 6.8 for the usual care group.
Hung says that his research group could not yet say whether having a MACE unit reduces overall cost of care, the topic of a separate research project. But he says it probably does in a high occupancy hospital that will promptly fill an empty bed once a patient is discharged.
The second study, conducted at the 1,114-bed University of Alabama at Birmingham by Kellie Flood, MD, and colleagues, looked at costs and 30-day readmissions in patients treated within a special 25-bed ACE unit, versus a similar group of elderly patients treated in usual care hospital settings.
An interdisciplinary team in an ACE unit, they concluded, "significantly reduces variable direct costs and 30-day readmission rates for patients 70 years or older" by about $371 per patient, or the difference between $2,480 and $2,109 per DRG.
For every 400 patients admitted to an ACE unit, the amount saved would be $148,400. The interdisciplinary team consists of an ACE nurse coordinator, geriatricians, nurses, physical and occupational therapists, pharmacists, a registered dietician, and social workers.
The ACE unit team provided geriatric assessments including cognitive and functional exams, geriatrician-led rounds focusing on geriatric care five days a week, discharge planning starting on the day of admission, and communication of team recommendations to the appropriate caregiver.
For the control group, hospitals admitted patients of all ages to usual care units, which were staffed with the same disciplines. "But geriatric screens and daily interdisciplinary team rounds focusing on geriatric syndromes were not conducted, nor were the volunteer-staffed care processes used."
For the 25 most common DRGs, cost saving was even greater with the use of an ACE unit, $1,693 compared with $2,138 for usual care, or $445.
Readmissions appeared to drop with ACE unit use as well. For example, while 12.8% of the patients who received usual returned to a UAB hospital within 30 days of discharge, for those patients treated in the ACE unit, the readmission rate was 7.9%.
In an accompanying editorial, Lisa Walke, MD, and Mary Tinetti, MD of the Yale University School of Medicine, wrote that the idea is great except for a significant problem:
"Currently there are not enough geriatric specialists to provide this care; all clinicians caring for older adults will need to acquire geriatric knowledge and skills."
Also, they wrote, communications systems to share information across sites of care "is lacking; efficient communication remains a challenge. Moreover, the financial incentive to create a seamless system of care does not exist."
Better utilization of electronic health records, they wrote, "should facilitate timely and effective communication among providers." They also expect that the rising number of aging baby boomers will make a difference as well.
"Possibly the most promising indications that the delivery of care to older adults will change are older adults themselves," they wrote. "Baby boomers, now starting to turn 65 years old, have redefined the norms at every stage of their lives. There is no reason to believe this will change."