Acute hospital care for the elderly patient: its impact on clinical and hospital systems of care.

A significant portion of hospital care involves elderly patients who have frequent and severe disease presentations, higher risk of iatrogenic injury during hospitalization, and greater baseline vulnerability. These risks frequently result in longer and more frequent hospitalizations. The frailty and complication rates of the elderly population underscore the importance of hospital-based programs of education and screening for cognitive and functional impairments to determine risk and needed additional care and services during hospitalization and at discharge. In addition, physicians are needed to take the lead in instituting programs of prevention and improving the systems of care. It is such a multi-tiered approach, with interventions in the areas of education, screening, prevention, and systems of care improvements, that is needed to improve the clinical care and outcomes of the hospitalized elderly patient.

Cardiopulmonary resuscitation requiring extracorporeal membrane oxygenation in the elderly: a review of the Extracorporeal Life Support Organization registry.

The role of extracorporeal membrane oxygenation (ECMO) as part of cardiopulmonary resuscitation (ECPR) among the elderly is not clearly defined. We sought to query the international Extracorporeal Life Support Organization (ELSO) registry database to investigate the use of ECMO support among the elderly. The objective of this study was to investigate survival to hospital discharge among the elderly supported on ECMO. The ELSO registry database was queried, identifying all elderly patients (>65 years of age) supported on ECMO for ECPR from 1998 to 2009. The primary outcome variable was survival to hospital discharge. Clinical characteristics between survivors and nonsurvivors were compared using univariate analysis. Ninety-nine elderly patients requiring ECPR were identified from the ELSO registry for the study period. The median age of the cohort was 70 years (range 65-86 years). The median admission to time on ECMO was 32 hours (range 1-998 hours), median time on ECMO was 69 hours (range 1-459 hours), and median time off to discharge for survivors was 587 hours (range 3-2,166 hours). Overall, survival at hospital discharge was 22.2% (22/99). No significant differences were noted between survivors and nonsurvivors for demographics, secondary diagnoses, pre-ECMO variables, complications on ECMO, as well as the type and duration of ECMO support. Among listed comorbidities, only the presence of pre-ECMO acute renal failure was significantly more frequent in nonsurvivors compared with survivors (14 vs. 0; p = 0.04). Survival to hospital discharge among the elderly supported on ECMO is lower than that for younger adult patients (28.7% vs. 40.0%). However, it is higher than that after conventional CPR (17%), suggesting that age should not be a bar against consideration for the use of ECMO in older patients but should be considered on a case-by-case basis.

The Curriculum for the Hospitalized Aging Medical Patient program: a collaborative faculty development program for hospitalists, general internists, and geriatricians.

BACKGROUND: The University of Chicago Curriculum for the Hospitalized Aging Medical Patient (CHAMP) faculty development program (FDP) is targeted at hospitalists and other internists who teach residents and students in the hospital setting. The aim of CHAMP is to increase the quantity and quality of teaching of geriatric medicine pertinent to the inpatient setting. METHODS: Hospitalist and general internist faculty members who attend on the University of Chicago Medicine teaching service were invited to participate. The CHAMP FDP consisted of twelve 4-hour sessions. Two hours of each session covered inpatient geriatrics content, and 2 hours addressed improving clinical teaching (both general teaching skills and challenges specific to the inpatient wards) and teaching the Accreditation Council for Graduate Medical Education core competencies with geriatrics content. The evaluation included a self-report survey of the impact on the graduates' teaching and clinical practice. RESULTS: The FDP was piloted in early 2004 with a core group of geriatrics and hospitalist faculty. Three subsequent cohorts totaling 29 hospitalist and general internal medicine faculty members completed the FDP by the fall of 2006. Faculty participants evaluated the program positively, and significant improvements in knowledge, attitudes to geriatrics, and perceived behavior in teaching and practicing geriatrics skills were found. CONCLUSIONS: The integration of teaching techniques and geriatrics content was enthusiastically accepted by University of Chicago hospitalists and general internists who teach residents and medical students in the inpatient setting. The program has potential for widespread suitability to all teaching faculty who care for the older hospitalized patient.

Using assessing care of vulnerable elders quality indicators to measure quality of hospital care for vulnerable elders.

OBJECTIVES: To assess the quality of care for hospitalized vulnerable elders using measures based on Assessing Care of Vulnerable Elders (ACOVE) quality indicators (QIs). DESIGN: Prospective cohort study. SETTING: Single academic medical center. PARTICIPANTS: Subjects aged 65 and older hospitalized on the University of Chicago general medicine inpatient service who were defined as vulnerable using the Vulnerable Elder Survey-13 (VES-13), a validated tool based on age, self-reported health, and functional status. MEASUREMENTS: Inpatient interview and chart review using ACOVE-based process-of-care measures referring to 16 QIs in general hospital care and geriatric-prevalent conditions (e.g., pressure ulcers, dementia, and delirium); adherence rates calculated for type of care process (screening, diagnosis, and treatment) and type of provider (doctor, nurse). RESULTS: Six hundred of 845 (71%) older patients participated. Of these, 349 (58%) were deemed vulnerable based on VES-13 score. Three hundred twenty-eight (94%) charts were available for review. QIs for general medical care were met at a significantly higher rate than for pressure ulcer care (81.5%, 95% confidence interval (CI)=79.3-83.7% vs 75.8%, 95% CI=70.5-81.1%, P=.04) and for delirium and dementia care (81.5%, 95% CI=79.3-83.7 vs 31.4% 95% CI=27.5-35.2%, P<.01). According to standard nursing assessment forms, nurses were responsible for high rates of adherence to certain screening indicators (pain, nutrition, functional status, pressure ulcer risk; P<.001 when compared with physicians), although in patients with functional limitations, nurse admission assessments of functional limitations often did not agree with reports of limitations by patients on admission. CONCLUSION: Adherence to geriatric-specific QIs is lower than adherence to general hospital care QIs. Hospital care QIs that focus on screening may overestimate performance by detecting standard nursing or protocol-driven care.