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If ACE Units Are So Great, Why Aren't They Everywhere?

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   April 25, 2013

"ACE" hospital units (Acute Care of the Elderly) reduce costs, drop lengths of stay, improve seniors' functional abilities, decrease need for anti-psychotic drugs, pare days on urinary catheters, reduce readmissions and slash adverse events.

These specialized units have been operating for about 20 years, improving outcomes and lowering costs most everywhere they're tried, we're told.

That's what various research papers show. Two studies published this week in JAMA Internal Medicine document similar benefits from Acute Care for Elders programs at Mount Sinai Hospital in New York and at the University of Alabama at Birmingham Hospital.

See Also: Hospital 'ACE' Teams Curb Adverse Events, LOS, Costs

So I have to ask.

If these concentrated efforts are so amazingly effective, why are there only about 200 in the country? Why aren't the rest of the nation's 4,000 hospitals establishing them for their growing populations of baby boomer patients, many cognitively-impaired, to improve their care and reduce costs?

"We aren't glitzy and we don't make a lot of money, like cardiac cath labs," replies Denise Kresevic, a clinical nurse specialist at University Hospitals Case Medical Center, which has two 15-bed ACE units, one of which began in 1993 and is thought to be the oldest in the nation.

"We get older people to return to their homes safely," she says. ACE teams with geriatric specialists aggressively urge patients to move about, assess them for delirium and confusion, and guard against adverse reactions to polypharmacy. Team members use restraints judiciously, talk at length with family members and loved ones, and contact community resources to supply services patients need after discharge

It's not sexy stuff. In fact it's really quite routine care, involving communication and discharge planning that should be the norm for all hospitals trying to do what's right for their patients.

But it's much tougher for this population.

Many care processes don't work for frail seniors in the same way they do with younger patients because the same rules don't apply. How medications affect them, how they understand instructions, their need for additional safety precautions in the hospital and at home, and their relative intolerance for invasive procedures may all get overlooked outside of these dedicated units, ACE unit researchers and advocates say.

That's why these teams employ geriatric-trained therapists, dieticians, social workers, physicians, and nurses, who intensely communicate daily as a team.

They also make sure that patients don't get care that won't benefit them or that they wouldn't want, such as feeding tubes or imaging studies.

Asked why more hospitals haven't established these services, Edgar Pierluissi, MD, medical director of the six-year-old, 22-bed ACE unit at San Francisco General Hospital, says they're starting to. There are 10 on the West Coast, including Oregon's Legacy Health, he says. And Aurora Health Care in Wisconsin has nine.

In Pierluissi's ACE unit, beds are near windows to orient patients to daylight. Patients eat meals with other patients in a communal area.

"We don't treat sleeping problems with a pill, we don't go overboard with pain medication, and we promote independence as much as we can by not doing things for patients they can do by themselves. And we really question the need for certain procedures, to make sure they are in line with the patients' goals for care," he says.

But ACE unit adoption has been slow because the fee-for-service system, Pierluissi says, "has been an impediment.

"If you're in the (healthcare) business, and people keep getting readmitted, cycling through nursing homes, that's all good. You keep charging for that stuff. But when people start looking at designs that keep patients out of the hospital, and keep folks from being admitted in the first place, they'll look for good models of care and they're going to land on ACE because the evidence is strong."

Kresevic and Pierluissi say ACE units are demanding. "The reason you don't see more of these is because it's a complicated intervention that requires a lot of teamwork and dedication over a long period of time. And it requires leadership commitment."

Kellie Flood, MD, is an author of the JAMA Internal Medicine paper that showed the University of Alabama at Birmingham Hospital's ACE unit saved $371 in direct costs per patient, totaling $148,000 for every 400 patients admitted to an ACE unit. That may not sound like much, but at least it's not a net cost. And the patients get better care, she says.

In an interview, she explains how the program is better than traditional hospital care by giving two real life examples.

She was performing a geriatric consult in a non-ACE unit of the hospital about 3:30 on a Friday afternoon when she overheard a nurse discussing a patient with a doctor or social worker on the phone.

" 'Are we sending Mr. So-and-So home today?' the nurse asked. Hearing that he was scheduled for discharge, the nurse said, 'Well, do you know he's only got 88% on room air, (meaning that he was getting oxygen assistance).

"The person on the other end of the line apparently knew that, but said he had an oxygen unit at home. The nurse replied, 'No, he doesn't. Are you sure he has home oxygen?'

"You can see how uncoordinated and inefficient that was, and would never happen on an ACE unit. Now the patient has to stay another half a day or longer to sort out the home oxygen situation, and every minute he's in the hospital is costing the hospital more money," Flood says.

UAB's ACE team would have been talking about the patient's need for home oxygen on day one, and assessing his need for it every day, she says.

Flood gave another actual case to illustrate the ACE care difference.

A 75ish man with chemotherapy-related nausea comes in. He gets Ativan, an anti-anxiety drug that also treats cancer-associated nausea.

"But what no one realizes is that this man has cognitive impairment, and when he gets up to go to the bathroom, he gets confused, loses his balance and falls.

"Now everyone has to make sure he hasn't injured himself, so he gets a head CT and an X-ray of his hip. That drives up costs. He's getting all these extra tests because he got a drug that would have worked fine in a 45-year old, but didn't in a 75-year-old with cognitive impairment.

"If he'd come to the ACE unit we would have given him Zofran instead," which wouldn't have prompted his confusion and loss of balance, Flood says. That's one way ACE units save money.

An emerging issue for Pierluissi, however, is that the proliferation of ACE units means each hospital is adopting their own version of the program, so it's hard to know which components works.

"Is it the pharmacist, or the person who pushed the patient to walk every day? If I have a limited amount of money and don't want to do the whole thing, what is it that really matters? It's hard to tease out what is the secret sauce."

"We don't know." There's no accreditation organization for ACE units. That will change, especially as healthcare reform penalties and incentive payments kick in at higher rates in coming years.

"All of the folks who have looked at the economics carefully show that it pencils out, and even more so in a setting of healthcare reform," Pierluicci says.

So why don't more hospitals have them?


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