Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of Acute Care for Elders (ACE) in a community hospital

BACKGROUND

Older persons frequently experience a decline in function following an acute medical illness and hospitalization.

OBJECTIVE

To test the hypothesis that a multicomponent intervention, called Acute Care for Elders (ACE), will improve functional outcomes and the process of care in hospitalized older patients.

DESIGN

Randomized controlled trial.

SETTING

Community teaching hospital.

PATIENTS

A total of 1,531 community-dwelling patients, aged 70 or older, admitted for an acute medical illness between November 1994 and May 1997.

INTERVENTION

ACE includes a specially designed environment (with, for example, carpeting and uncluttered hallways); patient-centered care, including nursing care plans for prevention of disability and rehabilitation; planning for patient discharge to home; and review of medical care to prevent iatrogenic illness.

MEASUREMENTS

The main outcome was change in the number of independent activities of daily living (ADL) from 2 weeks before admission (baseline) to discharge. Secondary outcomes included resource use, implementation of orders to promote function, and patient and provider satisfaction.

RESULTS

Self-reported measures of function did not differ at discharge between the intervention and usual care groups by intention-to-treat analysis. The composite outcome of ADL decline from baseline or nursing home placement was less frequent in the intervention group at discharge (34% vs 40%; P = .027) and during the year following hospitalization (P = .022). There were no significant group differences in hospital length of stay and costs, home healthcare visits, or readmissions. Nursing care plans to promote independent function were more often implemented in the intervention group (79% vs 50%; P = .001), physical therapy consults were obtained more frequently (42% vs 36%; P = .027), and restraints were applied to fewer patients (2% vs 6%; P = .001). Satisfaction with care was higher for the intervention group than the usual care group among patients, caregivers, physicians, and nurses (P < .05).

CONCLUSIONS

ACE in a community hospital improved the process of care and patient and provider satisfaction without increasing hospital length of stay or costs. A lower frequency of the composite outcome ADL decline or nursing home placement may indicate potentially beneficial effects on patient outcomes.

A patient-centered model of acute care for elders

The patient centered "Acute Care of the Elderly Unit" is a multifaceted process of care that combines optimal geriatric nursing and medical care of elders within an interdisciplinary model. Although functional decline has been previously assumed to be an inevitable consequence of hospitalization, preliminary findings suggest that a patient centered multidisciplinary model of geriatric care prevents functional decline of hospitalized elders. In addition, the "low tech" interventions and cost savings outcomes suggests the feasibility of implementing this model of care in hospitals serving a variety of patient populations.

Improving functional outcomes in older patients: lessons from an acute care for elders unit

BACKGROUND

Hospitalization often marks the beginning, and may be partially responsible for, a downward trajectory characterized by declining function, worsening quality of life, placement in a long term care facility, and death. At the University Hospitals of Cleveland, an Acute Care for Elders (ACE) unit that reengineered the process of caring for older patients (> or = 70 years of age) to improve functional outcomes was established in September 1990.

DESCRIPTION OF INTERVENTION

The general principles of ACE included an approach to care guided by the biopsychosocial model and recognition of the importance of fitting the hospital environment to the patient's needs. The design of the intervention was consistent with principles of comprehensive geriatric assessment and continuous quality improvement. Care, which focused on maintaining function, was directed by an interdisciplinary team that considered the patient's needs both at home and in the hospital. The major components of the ACE Unit intervention included patient-centered nursing care (daily assessment of functional needs by nursing, nursing-based protocols to improve outcomes, daily rounds by a multidisciplinary team), a prepared environment, planning for discharge, and medical care review.

RESULTS

In a randomized trial comparing ACE with usual care, patients receiving ACE had improved functional outcomes at discharge. The costs to the hospital for ACE unit care were less than for usual care. The functional status of ACE and usual care patients was similar 90 days after discharge.

FUTURE DIRECTIONS

The ACE unit intervention is being expanded to preserve the improvements observed during the hospitalization in the outpatient setting. In addition, needs other than function which are critical to patients' long-term quality of life are being considered.

Assessment of function: critically important to acute care of elders. The NICHE Faculty

Assessment of functional status in hospitalized elders provides essential information that can assist maintenance or restoration of self-care. Nurses in acute care settings are in a pivotal position to assess function and target interventions to prevent loss of function and maintain an individual's self-care ability. This article discusses critical issues in the functional assessment of hospitalized elders and provides a clinical practice protocol that includes nursing care strategies to prevent functional decline during hospitalization and assist with discharge planning.

Do acute care for elders units increase hospital costs? A cost analysis using the hospital perspective

OBJECTIVE

To compare the hospital costs of caring for medical patients on a special unit designed to help older people maintain or achieve independence in self-care activities with the costs of usual care.

DESIGN

A randomized controlled study.

PARTICIPANTS

A total of 650 medical patients (mean age 80 years, 67% women, 41% nonwhite) assigned randomly to either the intervention unit (n = 326) or usual care (n = 324).

MEASURES

The hospital's resource-based cost of caring for patients was determined from the hospital's cost-accounting system. The cost of the intervention program was estimated and included in the intervention patients' total hospital cost.

RESULTS

The development and maintenance costs of the intervention added $38.43 per bed day to the intervention patients' hospital costs. As a result, the cost per day to the hospital was slightly higher in the intervention patients than in the control patients ($876 vs $847, P = .076). However, the average length of stay was shorter for intervention patients (7.5 vs 8.4 days, P = .449). As a result, the hospital's total cost to care for intervention patients was not greater than caring for usual-care patients ($6608 in intervention patients vs $7240 in control patients, P = .926). Sensitivity analysis demonstrated that the cost of the intervention program would need to be 220% greater than estimated before intervention patients would be more expensive then control patients. There were no examined subgroups of patients in whom care on the intervention unit was significantly more expensive than care on the usual-care unit. Ninety-day nursing home use was lower in intervention than control patients (24.1% vs 32.3%, P = .034). Ninety-day readmission rates (36.7% vs 41.1%, P = .283) and caregiver strain scores (3.3 vs. 2.7, P = .280) were similar.

CONCLUSION

Caring for patients on an intervention ward designed to improve functional outcomes in older patients was not more expensive to the hospital than caring for patients on a usual-care ward even though the intervention ward required a commitment of hospital resources.

Relation between symptoms of depression and health status outcomes in acutely ill hospitalized older persons

BACKGROUND

Older patients often have poor health status outcomes after hospitalization. Symptoms of depression are common in hospitalized older persons and may be a risk factor for these poor outcomes.

OBJECTIVE

To determine whether symptoms of depression predict worse health status outcomes in acutely ill, older medical patients, independent of health status and severity of illness at hospital admission.

DESIGN

Prospective cohort study.

SETTING

Medical service of a teaching hospital.

PATIENTS

572 hospitalized medical patients older than 70 years of age.

MEASUREMENTS

15 symptoms of depression, health status, and severity of illness were measured at admission. The main outcome was dependence in basic activities of daily living at discharge and 30 and 90 days after discharge. Other outcome measures were dependence in instrumental activities of daily living, fair or poor global health status, and poor global satisfaction with life.

RESULTS

The median number of symptoms of depression on admission was 4. Patients with 6 or more symptoms on admission (n = 196) were more likely than patients with 0 to 2 symptoms (n = 181) to be dependent in basic activities of daily living (odds ratio, 2.47 [95% CI, 1.58 to 3.86]) after controlling for demographic characteristics and severity of illness. At each subsequent time point, patients with more symptoms of depression on admission were more likely to be dependent in basic activities of daily living. This association persisted after adjustment for dependence in basic activities of daily living, severity of illness, and demographic characteristics on admission. The odds ratios comparing patients who had 6 or more symptoms with those who had 0 to 2 symptoms were 3.23 (CI, 1.76 to 5.95) at discharge, 3.45 (CI, 1.81 to 6.60) 30 days after discharge, and 2.15 (CI, 1.15 to 4.03) 90 days after discharge. At each time point, patients with 6 or more symptoms of depression were more likely to have more dependence in instrumental activities of daily living, worse global health status, and less satisfaction with life.

CONCLUSIONS

Symptoms of depression identified a vulnerable group of hospitalized older persons. The health status of patients with more symptoms of depression was more likely to deteriorate and less likely to improve during and after hospitalization. This association was not attributable to health status or severity of illness on admission. The temporal sequence and magnitude of this association, its consistency over time with different measures, and its independence from the severity of the somatic illness strongly support a relation between symptoms of depression on admission and subsequent health status outcomes.

Preventing pressure ulcers through use of protocols in a mentored nursing model

Few conditions offer a better opportunity for nurses to have a dramatic and visible impact on quality care than skin care. Nursing interventions targeted to prevent pressure ulcers and their painful, costly complications are an expected standard of care in all care settings. Preventing pressure ulcers may be most important in the acute care setting, where previously healthy elders with acute illness, immobility, impaired appetite, and new-onset incontinence may suddenly and unexpectedly develop pressure ulcers. Often acute care nurses have not been fully cognizant of the threat that pressure ulcers can pose for acutely ill patients. Teaching nurses skills of prevention, including assessments, and interventions for this group of patients is critical. Traditional teaching methods supplemented with an innovative mentoring program and clinical protocols may be one way to accomplish this.

A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients

BACKGROUND

Older persons who re hospitalized for acute illnesses often lose their independence and are discharged to institutions for long-term care.

METHODS

We studied 651 patients 70 years of age or older who were admitted for general medical care at a teaching hospital; these patients were randomly assigned to receive usual care or to be cared for in a special unit designed to help older persons maintain or achieve independence in self-care activities. The key elements of this program were a specially prepared environment (with, for example, uncluttered hallways, large clocks and calendars, and handrails); patient-centered care emphasizing independence, including specific protocols for prevention of disability and for rehabilitation; discharge planning with the goal of returning the patient to his or her home; and intensive review of medical care to minimize the adverse effects of procedures and medications. The main outcome we measured ws the change from admission to discharge in the number of five basic activities of daily living (bathing, getting dressed, using the toilet, moving from a bed to a chair, and eating) that the patient could perform independently.

RESULTS

Twenty-four patients in each group died in the hospital. At the time of discharge, 65 (21 percent) of the 303 surviving patients in the intervention group were classified as much better in terms of their ability to perform basic activities of daily living, 39 (13 percent) as better, 151 (50 percent) as unchanged, 22 (7 percent) as worse, and 26 (9 percent) as much worse. In the usual care group, 40 (13 percent) of the 300 surviving patients were classified as much better, 33 (11 percent) as better, 163 (54 percent) as unchanged, 39 (13 percent) as worse, and 25 (8 percent) as much worse (P = 0.009). The difference between the groups remained significant (P = 0.04) in a multivariable model in which we controlled for potentially confounding base-line characteristics of the patients. Lengths of stay and hospital charges were similar in the two groups. Fewer patients assigned to the intervention group were discharged to long-term care institutions (43 patients [14 percent], as compared with 67 patients [22 percent] in the usual-care group; P = 0.01). Among the 493 patients discharged to private homes, similar proportions (about 10 percent) in the two groups were admitted to long-term care institutions during the three months after discharge.

CONCLUSIONS

Specific changes in the provision of acute hospital care can improve the ability of a heterogeneous group of acutely ill older patients to perform basic activities of daily living at the time of discharge from the hospital and can reduce the frequency of discharge to institutions for long-term care.