The current landscape of Acute Care for Elders units in the United States.

BACKGROUND: The clinical benefits of Acute Care for Elders (ACE) units have been established for over 25 years. However, how widely disseminated ACE units are in the United States and the degree of fidelity to the key elements of this model of care are unknown. Our objective was to identify all existing ACE units in the United States and to obtain detailed information about variations in implementation. METHODS: The strategy to identify current ACE units began with online searches and snowball sampling using contacts from professional societies and workgroups. Next, a request for information regarding the existence of ACE units was sent to the remaining US hospitals listed in a national hospital database. An online survey was sent to identified ACE unit contacts to capture information on implementation characteristics and the five key elements of ACE units. RESULTS: There were 3692 hospitals in the database with responses from 2055 (56%) hospitals reporting the presence or absence of an ACE unit. We identified 68 hospitals (3.3%) with an existing or previous ACE unit. Of these 68 hospitals, 50 (74%) completed the survey and reported that 43 ACE units were currently open and 7 had been closed. Of the 43 currently open ACE units, most are affiliated with an academic hospital and there is variable implementation of each of the five key ACE elements (from 69% to 98%). CONCLUSIONS: Among the 50 hospitals to complete the survey, 43 current ACE units were identified, with variable fidelity to the key elements. Estimates of prevalence of ACE units and fidelity to key elements are limited by nonresponses to the national survey request by nearly half of hospitals.

Trauma Consults by Geriatricians: Looking Into the Black Box.

The conceptual framework, targeting of older adults, and content of a targeted geriatric trauma consult (GTC) performed by geriatricians at a Level 1 trauma center are highlighted. The GTC is designed to optimize patient care through comprehensive assessment and to interrupt the disablement process. In a performance improvement study, fellowship-trained and certified geriatricians conducted the GTC in 98 patients ranging in age from 68 to 100 years. Most common recommendations by the geriatricians were for transitions of care (e.g., home health, skilled nursing facility, hospice), changes in medications (e.g., antihypertensives, antidepressants/antipsychotics), advanced care planning, and specialist referral. Targeted GTC performed by a geriatrician is an efficient approach to comanagement of complex older trauma patients, in contrast to mandated geriatric team consultation. In settings of value-based care, GTC by a geriatrician has potential to reduce patient disability and health care costs compared with usual care of older trauma patients.

The Acute Care for Elders Unit Model of Care.

Older patients are at risk for loss of self-care abilities during the course of an acute medical illness that results in hospitalization. The Acute Care for Elders (ACE) Unit is a continuous quality improvement model of care designed to prevent the patient's loss of independence from admission to discharge in the performance of activities of daily living (hospital-associated disability). The ACE unit intervention includes principles of a prepared environment that encourages safe patient self-care, a set of clinical guidelines for bedside care by nurses and other health professionals to prevent patient disability and restore self-care lost by the acute illness, and planning for transitions of care and medical care. By applying a structured process, an interdisciplinary team completes a geriatric assessment, follows clinical guidelines, and initiates plans for care transitions in concert with the patient and family. Three randomized clinical trials and systematic reviews of ACE or related interventions demonstrate reduced functional disability among patients, reduced risk of nursing home admission, and lower costs of hospitalization. ACE principles could improve elderly care in any acute setting. The aim of this commentary is to describe the ACE model and the basis of its effectiveness.

Screening elders in the emergency department at risk for mistreatment: a pilot study.

Impaired functional status is associated with risk of elder mistreatment. Screening for functional impairment in elderly patients admitted to emergency departments could be performed to identify patients at risk for elder mistreatment who might benefit from further evaluation. This study utilized a modified Identification of Seniors at Risk (ISAR) screening tool to identify the proportion of elderly at risk for mistreatment due to functional difficulties presenting to two emergency departments in southeastern Virginia, one urban, the other rural. Of a 180-patient cohort (90 per site), 82 screened positive (46%), ISAR > 2 (range 0-6), indicating nearly half of all patients enrolled are at risk for mistreatment. Patients presenting to the urban emergency departments were potentially more at risk than their rural counterparts (p < 0.01). Health care professionals, particularly in urban settings, should consider screening seniors with a simple tool to identify patients at risk of elder mistreatment.

A new tool to asses risk of wandering in hospitalized patients.

This article describes the development and implementation of a wandering screening and intervention program based on identifying hospitalized patients with impaired cognition and mobility. A wandering screening tool developed by a multidisciplinary team was linked to appropriate levels of interventions available in the electronic health record. Advanced practice nurses (APNs) confirmed the accuracy of screening and interventions by bedside nurses for all patients who screened positive. Of 1,528 patients hospitalized during a 3-week period, 48 (3.1%) screened positive for wandering. At-risk patients were older (age ≥ 65) (66.7%), those admitted to surgical units (41.7%), Caucasian (89.6%), and men (58.3%). Thirteen (27.1%) had dementia and 45 (93.8%) had impaired cognition. Of those patients who screened positive for wandering, the APNs agreed with the bedside nurses' assessment in 79.2% of cases (38/48) about wandering risk and 89.5% (34/38 true positives) for the interventions. A two-item wandering screening tool and intervention was feasible for use by bedside nurses. Further studies are needed to determine whether this tool is effective in preventing wandering.

Screening for injurious falls in acute care hospitals.

BACKGROUND: Injurious fall is a serious hospital-acquired condition. Screening tools for injurious falls in hospitalized patients have received limited evaluation. OBJECTIVE: To compare operating characteristics of a succinct screening tool for injurious falls, the University of Pittsburgh Medical Center (UPMC) screening tool (based on mobility, fall history, and nursing judgment), with the ABCS injurious fall screening tool (based on Age, Bone, Coagulation, and recent Surgery). DESIGN: Case control study. METHODS: Hospitalized patients with injurious falls were identified from the UPMC adverse events database for 2007-2008 (N = 43). Controls (n = 86) matched for age, location, and period of fall event were selected from the hospital's administrative database. Tools were evaluated independently by 2 screeners using electronic charts. Interrater agreement, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and c-statistics for the screening tools were calculated. RESULTS: Case and control groups were similar in age, sex, and race. Interrater agreement was 71% for ABCS and 72% for UPMC screens. ABCS and UPMC screens had sensitivity of 60.5% (95% CI, 52.0%-68.9%) and 62.8% (95% CI, 54.5%-71.1%), specificity of 41.9% (95% CI, 33.4%-50.4%) and 58.1% (95% CI 49.6%-66.7%), and c-statistics of 51.2% and 59.3%, respectively. With a 33% prevalence of injurious fall, the PPV was 34.2%, and NPV was 67.9% for ABCS, and the PPV was 42.9%, and NPV was 75.8% for UPMC. Operating characteristics were not statistically significantly different, although the UPMC screen was 8% more accurate in predicting injurious falls and had a lower false-positive rate (44.2% versus 65.1%). CONCLUSIONS: Compared with the ABCS screen, the UPMC screen is a simple, practical tool. Prospective studies are needed to establish the UPMC tool's predictive value in hospital practices with lower rates of injurious falls. In general, better screening tools for injurious falls should be developed to meet quality standards.

Prediction of recovery, dependence or death in elders who become disabled during hospitalization.

BACKGROUND: Many older adults become dependent in one or more activities of daily living (ADLs: dressing, bathing, transferring, eating, toileting) when hospitalized, and their prognosis after discharge is unclear. OBJECTIVE: To develop a prognostic index to estimate one-year probabilities of recovery, dependence or death in older hospitalized patients who are discharged with incident ADL dependence. DESIGN: Retrospective cohort study. PARTICIPANTS: 449 adults aged ≥ 70 years hospitalized for acute illness and discharged with incident ADL dependence. MAIN MEASURES: Potential predictors included demographics (age, sex, race, education, marital status), functional measures (ADL dependencies, instrumental activities of daily living [IADL] dependencies, walking ability), chronic conditions (e.g., congestive heart failure, dementia, cancer), reason for admission (e.g., neurologic, cardiovascular), and laboratory values (creatinine, albumin, hematocrit). Multinomial logistic regression was used to develop a prognostic index for estimating the probabilities of recovery, disability or death over 1 year. Discrimination of the index was assessed for each outcome based on the c statistic. KEY RESULTS: During the year following hospitalization, 36 % of patients recovered, 27 % remained dependent and 37 % died. Key predictors of recovery, dependence or death were age, sex, number of IADL dependencies 2 weeks prior to admission, number of ADL dependencies at discharge, dementia, cancer, number of other chronic conditions, reason for admission, and creatinine levels. The final prognostic index had good to excellent discrimination for all three outcomes based on the c statistic (recovery: 0.81, dependence: 0.72, death: 0.78). CONCLUSIONS: This index accurately estimated the probabilities of recovery, dependence or death in adults aged 70 years or older who were discharged with incident disability following hospitalization. This tool may be useful in clinical settings to guide care discussions and inform decision-making related to post-hospitalization care.

Depressive symptoms after hospitalization in older adults: function and mortality outcomes.

OBJECTIVES: To determine the relationship between depressive symptoms after hospitalization and survival and functional outcomes. DESIGN: Secondary analysis of a prospective cohort study. SETTING: General medical service of two urban, teaching hospitals in Ohio. PARTICIPANTS: Hospitalized individuals aged 70 and older. MEASUREMENTS: Ten depressive symptoms, instrumental activities of daily living (IADLs), and basic activities of daily living (ADLs) were measured at hospital discharge and 1, 3, 6, and 12 months later. Participant-specific changes in depressive symptoms (slopes) were determined using all data points. Four groups were also defined according to number of depressive symptoms (≤3 symptoms, low; 4-10 symptoms, high) at discharge and follow-up: low-low, low-high, high-low, and high-high. Mortality was measured 3, 6, and 12 months after hospital discharge. RESULTS: Participant-specific discharge depressive symptoms and change in depressive symptoms over time (slopes) were associated (P < .05) with functional and mortality outcomes. At 1 year, more participants in the low-low depressive symptom group (49%) were alive and independent in IADLs and ADLs than in the low-high group (37%, P = .02), and more participants in the high-low group (39%) were alive and independent in IADLs and ADLs than in the high-high group (19%, P < .001). CONCLUSION: Number of depressive symptoms and change in number of depressive symptoms during the year after discharge were associated with functional and mortality outcomes in hospitalized older adults. Fewer participants with persistently high or increasing depressive symptoms after hospitalization were alive and functionally independent 1 year later than participants with decreasing or persistently low symptoms, respectively.

Acute care for elders units produced shorter hospital stays at lower cost while maintaining patients' functional status.

Acute Care for Elders Units offer enhanced care for older adults in specially designed hospital units. The care is delivered by interdisciplinary teams, which can include geriatricians, advanced practice nurses, social workers, pharmacists, and physical therapists. In a randomized controlled trial of 1,632 elderly patients, length-of-stay was significantly shorter-6.7 days per patient versus 7.3 days per patient-among those receiving care in the Acute Care for Elders Unit compared to usual care. This difference produced lower total inpatient costs-$9,477 per patient versus $10,451 per patient-while maintaining patients' functional abilities and not increasing hospital readmission rates. The practices of Acute Care for Elders Units, and the principles they embody, can provide hospitals with effective strategies for lowering costs while preserving quality of care for hospitalized elders.

Implementing an Internet-based communication network for use during skilled nursing facility to emergency department care transitions: challenges and opportunities for improvement.

OBJECTIVES: To explore the feasibility of implementing an Internet-based communication network for communication of health care information during skilled nursing facility (SNF)-to-ED care transitions, and to identify potential barriers to system implementation. METHODS: Qualitative. SETTING: The largest SNF affiliated with the ED of an urban tertiary care center. PARTICIPANTS: Consecutive sample of all patients transferred from SNF to ED over 8 months between June 2007 and January 2008; ED and SNF care providers. INTERVENTION: The development and implementation of an Internet-based communication network for use during SNF-to-ED care transitions. This network was developed by adapting a preexisting Internet-based system that is widely used to facilitate placement of hospitalized patients into SNFs. Internet-based SNF and ED surveys were used to help identify barriers to implementation. RESULTS: There were 276/276 care transitions reviewed. The Internet-based communication network was used in 76 (28%) care transitions, with usage peaking at 40% near the end of the study. Barriers to success that were identified included lack of an electronic medical record (EMR) at the SNF; pervasive negative attitudes between ED and SNF personnel; time necessary for network use during care transitions; frustration by emergency physicians at low system usage rates by SNF personnel; and additional login requirements by ED personnel. CONCLUSIONS: Although implementing an Internet-based network for nursing home to ED communication may be feasible, significant barriers were identified in this study that are likely generalizable to other health care settings. Understanding such barriers is an essential first step toward building successful electronic communication networks in the future.

A clinical index to stratify hospitalized older adults according to risk for new-onset disability.

BACKGROUND: Many older adults who are independent prior to hospitalization develop a new disability by hospital discharge. Early risk stratification for new-onset disability may improve care. Thus, this study's objective was to develop and validate a clinical index to determine, at admission, risk for new-onset disability among older, hospitalized adults at discharge. DESIGN: Data analyses derived from two prospective studies. SETTING: Two teaching hospitals in Ohio. PARTICIPANTS: Eight hundred eighty-five patients aged 70 years and older were discharged from a general medical service at a tertiary care hospital (mean age 78, 59% female) and 753 patients discharged from a separate community teaching hospital (mean age 79, 63% female). All participants reported being independent in five activities of daily living (ADLs: bathing, dressing, transferring, toileting, and eating) 2 weeks before admission. MEASUREMENTS: New-onset disability, defined as a new need for personal assistance in one or more ADLs at discharge in participants who were independent 2 weeks before hospital admission. RESULTS: Seven independent risk factors known on admission were identified and weighted using logistic regression: age (80-89, 1 point; ≥90, 2 points); dependence in three or more instrumental ADLs at baseline (2 points); impaired mobility at baseline (unable to run, 1 point; unable to climb stairs, 2 points); dependence in ADLs at admission (2-3 ADLs, 1 point; 4-5 ADLs, 3 points); acute stroke or metastatic cancer (2 points); severe cognitive impairment (1 point); and albumin less than 3.0 g/dL (2 points). New-onset disability occurred in 6%, 13%, 18%, 34%, 35%, 45%, 50%, and 87% of participants with 0, 1, 2, 3, 4, 5, 6, and 7 or more points, respectively, in the derivation cohort (area under the receiver operating characteristic curve (AUC)=0.784), and in 8%, 10%, 27%, 38%, 44%, 45%, 58%, and 83%, respectively, in the validation cohort (AUC=0.784). The risk score also predicted (P<.001) disability severity, nursing home placement, and long-term survival. CONCLUSION: This clinical index determines risk for new-onset disability in hospitalized older adults and may inform clinical care.

An internet-based communication network for information transfer during patient transitions from skilled nursing facility to the emergency department.

OBJECTIVES: To determine whether the implementation of an Internet-based communication system improves the amount of essential information conveyed between a skilled nursing facility (SNF) and the emergency department (ED) during patient care transitions. DESIGN: Interventional; before and after. SETTING: ED of an urban teaching hospital with approximately 55,000 visits per year and a 55-bed subacute free-standing rehabilitation facility (the SNF). PARTICIPANTS: All patients transferred from the SNF to the ED over 16 months. INTERVENTION: An Internet-based communication network with SNF-ED transfer form for communication during patient care transitions. MEASUREMENTS: Nine elements of patient information assessed before and after intervention through chart review. SECONDARY OUTCOMES: changes in efficiency of information transfer and staff satisfaction. RESULTS: Two hundred thirty-four of 237 preintervention and all 276 postintervention care transitions were reviewed. The Internet communication network was used in 78 (26%) of all care transitions, peaking at 40% by the end of the study. There was more critical patient information (1.85 vs 4.29 of 9 elements; P<.001) contained within fewer pages of transfer documents (24.47 vs 5.15; P<.001) after the intervention. Staff satisfaction with communication was higher among ED physicians after the intervention. CONCLUSION: The use of an Internet-based system increased the amount of information communicated during SNF-ED care transitions and significantly reduced the number of pages in which this information was contained.

Perioperative care of the elderly patient: an update.

Elderly patients pose unique challenges perioperatively. They are more likely than younger surgical patients to be mentally and physically compromised at baseline, which increases the risk of delirium and postoperative cognitive dysfunction. Postoperative cognitive risk can be predicted, however, and effective strategies exist to reduce this risk. Elderly patients are also at increased risk of a precipitous postoperative decline in physiologic reserve, which can lead to organ failure. General recommendations for the perioperative care of elderly patients include avoiding drugs that raise the risk of delirium, ensuring adequate caloric and fluid intake, getting the patient out of bed and into physical therapy as soon as possible, and early planning for discharge. An elderly patient's postoperative cognitive risk and its impact on quality of life should be factored into the decision whether to undergo surgery. Family conferences are recommended to address the many questions and challenges that surgery in an elderly person can pose.

Potentially inappropriate medication prescribing in outpatient practices: prevalence and patient characteristics based on electronic health records.

BACKGROUND: Some older adults receive potentially inappropriate medications (PIMs), increasing their risk for adverse events. A literature search did not find any US multicenter studies that measured the prevalence of PIMs in outpatient practices based on data from electronic health records (EHRs), using both the Beers and Zhan criteria. OBJECTIVES: The aims of the present study were to compare the prevalence of PIMs using standard drug terminologies at 2 disparate institutions using EHRs and to identify characteristics of elderly patients who have a PIM on their active-medication lists. METHODS: This cross-sectional study of outpatients' active-medication lists from April 1, 2006, was conducted using data from 2 outpatient primary care settings: Intermountain Healthcare, Salt Lake City, Utah (center 1), and the Cleveland Clinic, Cleveland, Ohio (center 2). Data were included from patients who were aged > or =65 years at the time of the last office visit and had > or =2 documented clinic visits within the previous 2 years. The primary end point was prevalence of PIMs, measured according to the 2002 Beers criteria or the 2001 Zhan criteria. RESULTS: Data from 61,251 patients were included (36,663 women, 24,588 men; center 1: 37,247 patients; center 2: 24,004). A total of 8693 (23.3%) and 5528 (23.0%) patients at centers 1 and 2, respectively, were documented as receiving a PIM as per the Beers criteria; this difference was not statistically significant. Per the Zhan criteria (P < 0.001), these values were 6036 (16.2%) and 4160 (17.3%). Eight of the most common PIMs were the same at both institutions, with propoxyphene and fluoxetine (once daily) being the most prescribed. Female sex, polypharmacy (> or =6 medications), and multiple primary care visits were significantly associated with PIM prescribing. CONCLUSIONS: In this analysis of data from elderly patients at 2 outpatient centers, a small set of 8 medications accounted for the majority of PIMs at both centers, irrespective of geographic and demographic variations. Female sex, polypharmacy, and number of primary care visits were significantly associated with PIM prescribing. In this analysis of data from elderly patients at 2 outpatient centers, a small set of 8 medications accounted for the majority of PIMs at both centers, irrespective of geographic and demographic variations.

Recovery of activities of daily living in older adults after hospitalization for acute medical illness.

OBJECTIVES: To compare functional outcomes in the year after discharge for older adults discharged from the hospital after an acute medical illness with a new or additional disability in their basic self-care activities of daily living (ADL) (compared with preadmission baseline 2 weeks before admission) with those of older adults discharged with baseline ADL function and identify predictors of failure to recover to baseline function 1 year after discharge. DESIGN: Observational. SETTING: Tertiary care hospital, community teaching hospital. PARTICIPANTS: Older (aged >or=70) patients nonelectively admitted to general medical services (1993-1998). MEASUREMENTS: Number of ADL disabilities at preadmission baseline and 1, 3, 6, and 12 months after discharge. Outcomes were death, sustained decline in ADL function, and recovery to baseline ADL function at each time point. RESULTS: By 12 months after discharge, of those discharged with new or additional ADL disability, 41.3% died, 28.6% were alive but had not recovered to baseline function, and 30.1% were at baseline function. Of those discharged at baseline function, 17.8% died, 15.2% were alive but with worse than baseline function, and 67% were at their baseline function (P<.001). Of those discharged with new or additional ADL disability, the presence or absence of recovery by 1 month was associated with long-term outcomes. Age, cardiovascular disease, dementia, cancer, low albumin, and greater number of dependencies in instrumental ADLs independently predicted failure to recover. CONCLUSION: For older adults discharged with new or additional disability in ADL after hospitalization for medical illness, prognosis for functional recovery is poor. Rehabilitation interventions of longer duration and timing than current reimbursement allows, caregiver support, and palliative care should be evaluated.

A brief risk stratification tool to predict functional decline in older adults discharged from emergency departments.

OBJECTIVES: To determine the effectiveness of the six-item Triage Risk Screening Tool (TRST) to assess baseline functional status and predict subsequent functional decline in older community-dwelling adults discharged home from the emergency department (ED). DESIGN: Secondary data analysis of a randomized, controlled trial. SETTING: EDs of two urban academic hospitals. PARTICIPANTS: Six hundred fifty community-dwelling adults aged 65 and older presenting to the ED and discharged home. Patients were categorized a priori as "high risk" if they had cognitive impairment or two or more risk factors on the TRST. MEASUREMENTS: Functional status: summed activity of daily living (ADL) and instrumental activity of daily living (IADL) scores at baseline, 30 days, and 120 days. Self-perceived physical health: standardized physical health component of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Functional decline: loss of one or more ADLs and one or more IADLs from ED baseline at 30 and 120 days. Decline in self-perceived physical health: follow-up SF-36 standardized physical health component scores four or more points lower than baseline. RESULTS: TRST scores correlated with baseline ADL impairments, IADL impairments, and self-perceived physical health at all endpoints (P<.001). A TRST score of two or more was moderately predictive of decline in ADLs or IADLs (30-day ADL area under the receiver operating characteristic curve (AUC)=0.64; 95% confidence interval (CI)=0.56-0.72; 120-day ADL AUC=0.66; 95% CI=0.58-0.74) but not perceived physical health. CONCLUSION: The TRST identifies baseline functional impairment in older ED patients and is moderately predictive of subsequent functional decline after an initial ED visit. The TRST provides a valid proxy measure for assessing functional status in the ED and may be useful in identifying high-risk patients who would benefit from referrals for further evaluation or surveillance upon ED discharge.