Acing Acute Care for Elders

Cheryl Clark, for HealthLeaders Media , September 9, 2013

"We got his wife involved in his care to provide some reality orientation, but nothing worked for quite a while," says Abolafya. After several hours, the ACE unit staff decided to check his urine output and realized he was having trouble emptying his bladder. Once that discomfort was removed, "he became very cooperative and friendly. It was a simple fix, and we got him a urology consult."

Meserve says that in the ACE unit, investigation, specialized training, and detective work happen "right up front and immediately." In another unit, the combative patient might have been put in restraints or given antipsychotic medications, which can launch a negative spiral.

The hospital also has seen a reduction in falls through mobility encouragement strategies in the unit. For example, the number of falls occurring within the ACE unit has gone from 48 in 2006 to 25 in 2009 to 13 in 2012.

Earlier this year, a study at the University of Alabama at Birmingham by the unit's director, Kellie L. Flood, MD, found that, compared with usual care, an interdisciplinary team working on the hospital's 26-bed ACE unit can prevent readmissions and reduce costs in part by lowering length of stay.

The trick, she says, is the interdisciplinary team—the nurse, physical therapist, occupational therapist, pharmacist, dietician, social worker, an ACE unit coordinator, and geriatrician—sitting at the table every day talking about that patient's needs and discharge plans.

Landefeld says that the idea of an ACE unit isn't rocket science and it's not expensive. It's drawn from educational and sociological theories of both Maria Montessori and Erving Goffman. "It's about building an institutional environment that will allow people to achieve the goals that they have," he says.

Institutions like schools, asylums, and even hospitals, he says, are set up to benefit people inside, "but they often function in ways that are intended to control behavior.

"Think about how hospitals often function: A common response to a confused, delirious patient is to tie them down. And there is nothing worse. They can injure themselves or become even more delirious."

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This article appears in the July/August issue of HealthLeaders magazine.

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