Skip to main content

A Trigger for Hospital Readmissions ID'd by Geriatric Experts

 |  By cclark@healthleadersmedia.com  
   October 15, 2012

A phenomenon in acute care—hospitalization-associated disability—raises an important question.  Might providers focus so intently on resolving patients' acute care issues that they ignore and thereby irrevocably damage patients' functional abilities in the process?

After discharge, patients' brains sometimes aren't working as sharply as they were prior to their admission or patients can't walk as far or manage steps like they did before, geriatric experts have long observed.

But why? Edgar Pierluissi, MD, medical director of the San Francisco General Hospital Acute Care for Elders unit, or ACE, says that this insidious process is a fact of life for about one-third of patients 70 and older after hospitalization. Often, it means they can't return home, and must spend the rest of their lives in skilled nursing care.

"You can't provide medical care in a hospital and not see this every day, or else you're not paying attention; you treat people (successfully) and yet they are worse off," Pierluissi says. "If you're really interested in reducing readmissions and hospital complications, you have to face these facts."

Undergoing the process of care can mean being bedbound in a noisy room that's depersonalizing and not conducive to deep sleep for durations of weeks or longer. Combined with eating restrictions and isolation, the environment can be a risk for falls and limit ambulation.

All combined, the care setting can threaten a previously independent patient's ability to return home. It deprives them of strength, control, and the thinking skills that they had prior to admission.

In an article in the Journal of the American Medical Associationa year ago, Pierluissi and UCSF colleagues Kenneth Covinsky, MD, and C. Bree Johnston, MD, described a kind of syndrome that occurs "even when the illness that necessitated the hospitalization is successfully treated."

How this process unfolds is unclear. But it can be such a serious transformation, a significant loss of strength and muscle mass, the patient may no longer be able to perform basic activities of daily living.

Some efforts in pockets around the country, such as the two ACE units at San Francisco General, seek to fix this problem.

At each of these 10-bed and 12-bed units at San Francisco General, there's a much tighter focus on getting the patient to walk so as not to lose muscle mass. They are encouraged to eat with other patients in a common area and visit with family and friends.

Games such as bingo or afternoon movies on TV are offered "to prevent isolation" Pierluissi says.  Falls and hospital-acquired infections have not risen as was feared.

Each patients' needs are assessed daily by an interdisciplinary team which includes social workers, pharmacists, occupational therapists, nurse practitioners, and a geriatrician, as well as the unit medical director.

The units are warmly decorated with faux wood finish instead of typical cold hallways, he says.

Sedative medications such as benzodiazepines are more judiciously used and more aggressively withdrawn.

And catheters, oxygen lines and other tethering devices are removed "to get the patient to that mobile state."

Pierluissi says that there are only about 70 to 100 focused ACE units in the country, the first of which were at Virginia Mason in Seattle and Case Western in Cleveland and Summa Health Akron, OH.

But clearly more research on improving these types of ACE models will come, he says. "As more baby boomers age, this question of what models work to reduce these kinds of complications in older people is one we'll have to address," he says.

In a commentary in last October's edition of JAMA, Walter Ettinger, MD, of the division of geriatric medicine at the University of Massachusetts Medical School agreed that new onset hospitalization-associated disability is a serious problem.

But he also noted that the phenomenon "is virtually ignored by healthcare professionals and policy makers."

"One reason for this lack of awareness is that health-related quality of life and sustainability of independence are not measured as outcomes of Care. The Centers for Medicare & Medicaid Services publishes hospital quality measures on its Hospital Compare Web site, but neither the current nor proposed hospital quality metrics measure health-related quality of life."

In their paper JAMA last year, the San Francisco physicians examined several ACE units around the country and concluded that ACE units can reduce hospital length of stay and the resulting cost savings may be greater than the added costs of the unit." They also can improve patient and provider satisfaction.

They advocate a re-engineering of hospital care "that focuses on function, including assessment on admission, and throughout the hospital stay, promoting physical activity, avoiding hospital processes and complications that impair functional recovery" are among strategies that "may reduce the incidence of hospitalization-associated disability."


Get the latest on healthcare leadership in your inbox.