"We wanted to make it easier for people to care for themselves and be mobile," he says. "Most hospitals use hallways as closets, but we removed all the stuff so people could get up and walk around."
"We trained nurses to—instead of asking someone who was having trouble sleeping at night if they want a sleeping pill—offer them warm milk, soft music, or maybe to rub their back, and not give them medicine that would confuse them," Landefeld says. A medical review every day "eliminates drugs that aren't necessary and makes sure dosages are appropriate for 88-year-old Aunt Mary, who is 95 pounds instead of 135 pounds."
The team also made sure that procedures with few risks when performed for younger patients don't backfire when they're performed on frail seniors. "For example, special care is taken for a patient about to undergo a colonoscopy to make sure they don't get too dehydrated or receive too much of a sedative usually given for that procedure," Landefeld says.
Other techniques developed at the Cleveland ACE unit include large clocks, communal dining areas so patients can eat meals outside their rooms, elevated toilet seats, door levers instead of handles, protocols to improve skin care and cognition, and use of an interdisciplinary team comprising a geriatrician, nurse, social worker, nutritionist, physical therapist, and visiting nurse liaison.
Despite the success of that 1995 paper and subsequent research efforts that demonstrated that ACE units reduce hospital costs by between 5%–10% primarily by reducing average length of stay, only about 200 units have been established, Landefeld says.
That's because the concept "doesn't fit the conventional paradigm of how we do things in medicine," he says. "If someone has an infection, we treat it with antibiotics. We don't ask how the pneumonia could be prevented, or what is the role of nutrition or exercise. These things are on the minds of patients and families, but not so much on the minds of doctors and hospitals."
Also, he says, "starting an ACE unit is not a procedure for which one can bill; it's not a DRG that someone can collect funds for. A variety of studies have also shown beneficial effects on people's ability to care for themselves when they go home, which is a great example of something that hospitals have not conventionally cared about."