ACE Service Can Improve Processes of Care in Elderly

CHICAGO — A hospitalist-run geriatrics service significantly improved the recognition and treatment of functional and cognitive status abnormalities in a retrospective analysis of 217 elderly inpatients.

Documentation and treatment of abnormal functional status was reported in 69% of patients assigned to an acute care for the elderly (ACE) service vs. 36% of those who received usual care. For abnormal cognitive status, the corresponding results were 56% vs. 40%.

There was a trend favoring ACE for the identification and treatment of delirium (27% vs. 17%), although neither model was outstanding, particularly with regard to hypoactive delirium, geriatrician and hospitalist Dr. Heidi Wald said at the annual meeting of the Society of Hospital Medicine.

There were no differences in use of sleep aids, physical restraints, or documentation of code status, although ACE patients had a significantly higher rate of do-not-resuscitate orders, compared with usual care patients (39% vs. 25%).

ACE and usual care patients had similar lengths of stay (mean 3.4 days vs. 3.1 days), although 30-day admission rates were slightly higher with ACE (12.3% vs. 9.5%).

Notably, mean hospital charges were not significantly higher with ACE, at $24,617 vs. $21,488 for usual care, said Dr. Wald, of the University of Colorado at Denver Health Sciences Center in Aurora.

“Existing resources can be leveraged to improve geriatric care,” she said.

ACE units have been shown to improve functional outcomes in vulnerable hospitalized elders, but widespread adoption has been slow because of the need for and cost of a dedicated unit staffed by geriatricians and geriatric nurses.

Dr. Wald described the ACE service, now in its third year at her institution, as a hybrid between a general medical inpatient service and a traditional ACE unit. Key components include a core group of hospitalists with an interest in geriatric medicine, interdisciplinary rounds, a novel educational curriculum, and a standardized geriatric assessment approach. Patients are treated on a single medical inpatient unit when possible, something that occurred with two-thirds of ACE patients in the analysis.

In all, 122 patients were assigned to ACE and 95 to usual care during the study period of Nov. 1, 2007, to April 15, 2008. Their mean age was 80.5 years, slightly more than half were female, and the primary ICD-9 code was pulmonary disease in 28% of patients.

Dr. Wald observed that one of the keys to sustaining an ACE service is having a dedicated nursing staff, as many of the quality indicators for geriatric patients are nursing sensitive.

“Nursing staff loved this model and are very interested in increasing their nursing education around geriatric issues, and [are] happy to have a core group of physicians to work with on this,” she said.

The researchers disclosed no conflicts of interest.

'Existing resources can be leveraged to improve geriatric care.' DR. WALD

CHICAGO — A hospitalist-run geriatrics service significantly improved the recognition and treatment of functional and cognitive status abnormalities in a retrospective analysis of 217 elderly inpatients.

Documentation and treatment of abnormal functional status was reported in 69% of patients assigned to an acute care for the elderly (ACE) service vs. 36% of those who received usual care. For abnormal cognitive status, the corresponding results were 56% vs. 40%.

There was a trend favoring ACE for the identification and treatment of delirium (27% vs. 17%), although neither model was outstanding, particularly with regard to hypoactive delirium, geriatrician and hospitalist Dr. Heidi Wald said at the annual meeting of the Society of Hospital Medicine.

There were no differences in use of sleep aids, physical restraints, or documentation of code status, although ACE patients had a significantly higher rate of do-not-resuscitate orders, compared with usual care patients (39% vs. 25%).

ACE and usual care patients had similar lengths of stay (mean 3.4 days vs. 3.1 days), although 30-day admission rates were slightly higher with ACE (12.3% vs. 9.5%).

Notably, mean hospital charges were not significantly higher with ACE, at $24,617 vs. $21,488 for usual care, said Dr. Wald, of the University of Colorado at Denver Health Sciences Center in Aurora.

“Existing resources can be leveraged to improve geriatric care,” she said.

ACE units have been shown to improve functional outcomes in vulnerable hospitalized elders, but widespread adoption has been slow because of the need for and cost of a dedicated unit staffed by geriatricians and geriatric nurses.

Dr. Wald described the ACE service, now in its third year at her institution, as a hybrid between a general medical inpatient service and a traditional ACE unit. Key components include a core group of hospitalists with an interest in geriatric medicine, interdisciplinary rounds, a novel educational curriculum, and a standardized geriatric assessment approach. Patients are treated on a single medical inpatient unit when possible, something that occurred with two-thirds of ACE patients in the analysis.

In all, 122 patients were assigned to ACE and 95 to usual care during the study period of Nov. 1, 2007, to April 15, 2008. Their mean age was 80.5 years, slightly more than half were female, and the primary ICD-9 code was pulmonary disease in 28% of patients.

Dr. Wald observed that one of the keys to sustaining an ACE service is having a dedicated nursing staff, as many of the quality indicators for geriatric patients are nursing sensitive.

“Nursing staff loved this model and are very interested in increasing their nursing education around geriatric issues, and [are] happy to have a core group of physicians to work with on this,” she said.

The researchers disclosed no conflicts of interest.

'Existing resources can be leveraged to improve geriatric care.' DR. WALD

CHICAGO — A hospitalist-run geriatrics service significantly improved the recognition and treatment of functional and cognitive status abnormalities in a retrospective analysis of 217 elderly inpatients.

Documentation and treatment of abnormal functional status was reported in 69% of patients assigned to an acute care for the elderly (ACE) service vs. 36% of those who received usual care. For abnormal cognitive status, the corresponding results were 56% vs. 40%.

There was a trend favoring ACE for the identification and treatment of delirium (27% vs. 17%), although neither model was outstanding, particularly with regard to hypoactive delirium, geriatrician and hospitalist Dr. Heidi Wald said at the annual meeting of the Society of Hospital Medicine.

There were no differences in use of sleep aids, physical restraints, or documentation of code status, although ACE patients had a significantly higher rate of do-not-resuscitate orders, compared with usual care patients (39% vs. 25%).

ACE and usual care patients had similar lengths of stay (mean 3.4 days vs. 3.1 days), although 30-day admission rates were slightly higher with ACE (12.3% vs. 9.5%).

Notably, mean hospital charges were not significantly higher with ACE, at $24,617 vs. $21,488 for usual care, said Dr. Wald, of the University of Colorado at Denver Health Sciences Center in Aurora.

“Existing resources can be leveraged to improve geriatric care,” she said.

ACE units have been shown to improve functional outcomes in vulnerable hospitalized elders, but widespread adoption has been slow because of the need for and cost of a dedicated unit staffed by geriatricians and geriatric nurses.

Dr. Wald described the ACE service, now in its third year at her institution, as a hybrid between a general medical inpatient service and a traditional ACE unit. Key components include a core group of hospitalists with an interest in geriatric medicine, interdisciplinary rounds, a novel educational curriculum, and a standardized geriatric assessment approach. Patients are treated on a single medical inpatient unit when possible, something that occurred with two-thirds of ACE patients in the analysis.

In all, 122 patients were assigned to ACE and 95 to usual care during the study period of Nov. 1, 2007, to April 15, 2008. Their mean age was 80.5 years, slightly more than half were female, and the primary ICD-9 code was pulmonary disease in 28% of patients.

Dr. Wald observed that one of the keys to sustaining an ACE service is having a dedicated nursing staff, as many of the quality indicators for geriatric patients are nursing sensitive.

“Nursing staff loved this model and are very interested in increasing their nursing education around geriatric issues, and [are] happy to have a core group of physicians to work with on this,” she said.

The researchers disclosed no conflicts of interest.

'Existing resources can be leveraged to improve geriatric care.' DR. WALD