ACE-ing Elder Care

UTMB's Acute Care for Elders Un it aims to boost patients' quality of life and shorten hosptial stays

By Seena Simon

“They want me to get up and walk,” Mildred Fleeger says, echoing her doctors’ orders.

And so the sprightly ninety-two-year-old strolls down the carpeted hallway of the Acute Care for Elders (ACE) unit and roams around in her big, peach-colored UTMB hospital room.

Fleeger was scheduled for colon cancer surgery the following day. But she appeared a model of health and looked thirty years younger than she really is. The former nurse credits her vitality to “living a good, clean life” and staying active. Reared on a farm near Waller, Texas, Fleeger milked four cows every morning during her childhood before walking three miles to school. That walking was before her family bought a Model T around 1927, when she was sixteen years old. In her early twenties, she married Sam Fleeger, a Maytag washing machine salesman. She worked for twenty years as a nurse and gave birth to and reared two children. After her husband died in 1967, she lived alone for thirty-four years. Now in Crystal Beach with her daughter and son-in-law, Fleeger still cooks and makes her own bed. “I’m a very independent lady,” she said.

And that’s how ACE geriatric team members like their patients to be.

Even before meeting an ACE geriatric team that encourages them to stay active during their hospitalization, patients see that their rooms aren’t typical sterile, white hospital rooms with slippery floors.

Instead, ACE rooms have carpeting, soft lighting, comfy furniture, a sleeper couch, and bulletin boards with slogans including one urging patients to “get well soon.” Fleeger’s two children and other family members were able to use the fold-out couch when they visited her.

Fleeger’s surgery went well, and she was soon back home with her daughter.

The big, well-appointed rooms like Fleeger’s have a higher purpose than aesthetics, ACE staff say. Room to roam promotes muscle strength, balance and coordination, and blood circulation, and it provides other health benefits as well.

Making patients feel at ease reduces stress and depression and boosts motivation to get well. As patients age, those qualities are crucial to recovery, said Professor James S. Goodwin, chief of the Division of Geriatric Medicine and director of the Sealy Center on Aging.

“The issues of mobility, of avoiding delirium, of keeping these people moving, eating, and motivated become at least as important as the medical issues,” said Goodwin, the driving force behind creating the ACE unit at UTMB, which opened in October 2000.

Carpeting minimizes the danger that patients may slip and fall while they walk around their rooms, and it cushions the impact if they do fall.

UTMB promotes the ACE Unit as an effective way to get patients back on their feet faster and thus reduce the medical complications that often dog patients with long hospital stays.

“The ACE environment facilitates functionality,” said Assistant Professor Dr. Mukaila Raji, an attending geriatrician.
Physical therapists press ACE patients to be up and moving. Often this is not easy for a patient who is tired and doesn’t feel good. Yet the encouraged activity is crucial: older patients who stay in bed rapidly lose muscle mass and function. This downward spiral starts on the first day of hospitalization, when the patient takes to his or her bed.

“The success of the physical therapist in coaching patients to regain and maintain their physical function is extremely important to the outcome for the patient,” said physical therapist Niki Sinclair. She said it may mean “the difference between patients being able to return to their home and function as they did prior to their hospitalization or having to go to a nursing home because they can no longer take care of themselves.”

UTMB promotes the ACE Unit as an effective way to get patients back on their feet faster and thus reduce the medical complications that often dog patients with long hospital stays.

The unit relies on a core team with geriatric expertise and an inclination to take remedial action before a crisis requires it. Nurses, physical therapists, occupational therapists, social workers, and a pharmacist attend to psychological and social as well as medical needs.

The team runs the unit, helps doctors manage patients’ hospitalization, and influences patient care.

“We make sure that it’s safe for patients to go home when they’re discharged” and that they aren’t sent home prematurely, Sinclair said.

Patients may be admitted with a diagnosis such as anemia or a hip fracture. But in addition to the obvious complaint, the ACE core team will identify and treat patients for a second constellation of geriatric syndromes, some of which may be linked to the hospital stay itself. These include delirium, dementia, constipation, falls, and development of illnesses like pneumonia, skin infections, urinary tract infections, pressure ulcers, and depression.

Identifying these geriatric syndromes and treating them early is central to the success of the ACE model of care, staff members say. Early intervention is designed to get the patients quickly and safely out of the hospital and back to their homes.

The ACE core team works from written protocols containing step-by-step instructions for managing pain and other common geriatric problems. The protocol is “like the Holy Book—like the Bible,” Dr. Raji said. “It has to be written down.”
Protocols ensure that treatments are consistent and don’t vary depending on the resident physicians and other care providers who rotate in and out of the unit.

The unit doesn’t use physical restraints to tie down a delirious patient because restraints tend to exacerbate the patient’s problems. The staff avoids using Foley catheters in the bladder because the catheters can cause urinary tract infections. Treating pain appropriately is especially important. Pain relief is crucial, but pain medications must be used judiciously in older people. The ACE unit doesn’t use the opiate Demerol, for example, because that painkiller may trigger delirium.
Goodwin said the ACE system wouldn’t work in a traditional hospital hierarchy. To treat the elderly, a more collaborative approach with a multidisciplinary team is more effective, he said.

“It is critical that everything be patient-centered, not physician-centered, not nurse-centered,” Goodwin said.
Jeanne St. Pierre, a fomer UTMB nurse who helped set up UTMB’s ACE Unit in the late 1990s, visited pioneering ACE Units at University Hospitals of Cleveland, associated with Case Western Reserve University (the first ACE unit in the nation, created in 1990) and at Mount Sinai Hospital in New York. “It was a no-brainer that we wanted to do it,” St. Pierre said. “Executing it was difficult.”

When St. Pierre and colleagues floated the idea of creating an ACE unit to staff in the Geriatrics Division, “people were not automatically on board with this,” she recalled. “Some people were excited. Some people were wary.”
Clearly more staff expertise, training and accountability were going to be expected, St. Pierre said. A few employees left the unit.

Fast forward to today. Now there are no vacancies for registered nurses in UTMB’s ACE Unit, and nurse turnover generally is low, said ACE Unit Nurse Manager Jean Ann Glass. That’s largely because staff have more responsibility and more say in patient care than is typical in most hospitals, she said.

“It is critical that everything be patient-centered, not physician-centered, not nurse-centered,” Goodwin said.

At UTMB, the ACE Unit physical therapists, pharmacists, and social workers report to the director of the ACE Unit, not to the departments of Physical Therapy, Pharmacy, or Social Work. Having the same boss for the entire ACE team was a departure from other ACE units UTMB studied, said Susan Tyler, the administrative director of Geriatric Services. She believes the centralized approach builds staff loyalty to the unit’s mission and builds team cohesiveness.

A daily ACE Unit team meeting tracks patient progress. This day, nurse practitioner Paula Rupert led the twenty-person meeting, which included ACE Unit staff, Dr. Raji, residents, and students.

“We have big-time issues with this patient,” social worker Diana Reed began.

The patient came in with malnutrition and anemia, accompanied by assorted other ailments. The staff was concerned about whether her husband, who gets around using a walker, could care for her once she was discharged. Nurse Cleo Douglas recounted her talk with the family.

“I told them, ‘This is going to be a tremendous job for you guys,’” Douglas said.

The staff exchanged information about how well another patient was walking, what kind of room lighting another preferred, which relatives would care for the patients when they got home, whether yet another patient needed rehabilitation after discharge, and whether a patient possibly was a victim of elder abuse.

Overall, the ACE Unit slightly reduces the length of hospital stays because the staff identifies geriatric syndromes and social issues that might interfere with patients’ speedy recoveries, said Tyler, who is by training a gerontological nurse practitioner. In fiscal 2002, the average ACE patient stayed seven-tenths of a day less than the government expects for a patient population of the same age, Tyler said.

UTMB’s Sealy Center on Aging helps pay for continuing education for nurses and other ACE Unit staff. Of the seventeen ACE Unit nurses, ten were certified in geriatric nursing as of last July, and two more by the end of 2003. Before UTMB had an ACE unit, only one nurse in the Inpatient Geriatrics Service was certified in geriatrics.

The Sealy & Smith Foundation of Galveston provided a $3.8 million gift to pay for physically refurbishing the part of the hospital now comprising the existing twenty-bed ACE Unit. The foundation recently gave an additional $1 million to expand the ACE Unit to fifty-two beds by 2005.

Patients don’t need any convincing about the unit’s value. UTMB’s ACE Unit has been ranked No. 1 in patient satisfaction among similar units nationwide, according to a comprehensive survey conducted by Press Ganey Associates about everything from the quality of doctors to the temperature of hospital meals.

ACE staff have their own measures of success.

Douglas spots a patient leaving the hospital with his family. Beaming, she yells across the room to him: “Another satisfied customer!”

“That’s the most rewarding thing I see—when I see them leave on their own,” she said.