Improving Geriatric Care Processes on Two Medical-Surgical Acute Care Units: A Pilot Study.

The Acute Care for Elders (ACE) Unit model improves cognitive and functional outcomes for hospitalized elders but reaches a small proportion of patients. To disseminate ACE Unit principles, we piloted the "Virtual ACE Intervention" that standardizes care processes for cognition and function without daily geriatrician oversight on two non-ACE units. The Virtual ACE Intervention includes staff training on geriatric assessments for cognition and function and on nurse-driven care algorithms. Completion of the geriatric assessments by nursing staff in patients aged 65 years and older and measures of patient mobility and prevalence of an abnormal delirium screening score were compared preintervention and postintervention. Postintervention, the completion of the assessments for current functional status and delirium improved (62.5% vs. 88.5%, p < .001) and (4.2% vs. 96.5%, p < .001). In a subsample analysis, in the postintervention period, more patients were up to the chair in the past day (36.4% vs. 63.5%, p = .04) and the prevalence of an abnormal delirium screening score was lower (13.6% vs. 4.8%, p = .16). The Virtual ACE Intervention is a feasible model for disseminating ACE Unit principles to non-ACE Units and may lead to increased adherence to care processes and improved clinical outcomes.

A Performing Arts Intervention Improves Cognitive Dysfunction in 50 Hospitalized Older Adults.

BACKGROUND AND OBJECTIVES: Arts in medicine programs have emerged as a patient-centered approach that aims to improve health-related quality of life for patients in U.S. hospitals. Storytelling and poetry/monologue recitation are forms of arts-based experiences designed to enhance healing and are delivered by an artist-in-residence. We evaluated the effect of a storytelling/poetry experience on delirium screening scores and patient satisfaction in hospitalized older adults. RESEARCH DESIGN AND METHODS: We conducted an observational pre-post study with a control group in the Acute Care for the Elders (ACE) unit at an academic medical center. A convenience sample of 50 participants was recruited to participate and complete two questionnaires measuring pain, anxiety, general well-being, and distress at hospital admission and at hospital discharge. Multivariable regression models were used to compare delirium screening score (primary outcome) between the control and intervention groups and to adjust for the differences in baseline characteristics between groups. RESULTS: At baseline participants in the intervention group were younger and had significantly lower cognitive impairment compared with those in the control group. Participants exposed to the storytelling/poetry intervention had a lower delirium screening score at hospital discharge compared with those in the control group. The result remained significant after adjusting for age, baseline cognitive impairment, and general well-being. Participants in the intervention group reported a high level of satisfaction with the interaction with the artist delivering the intervention. DISCUSSION AND IMPLICATIONS: An artist in residence-delivered storytelling/poetry experience was associated with a lower delirium score at discharge in this pilot study. Further larger studies in diverse inpatient settings are needed to examine whether storytelling/poetry interventions or other types of arts in medicine programs can prevent or reduce delirium in hospitalized older adults.

Acute Care for Elders (ACE) Team Model of Care: A Clinical Overview.

The Institute of Medicine (IOM) Reports of To Err is Human and Crossing the Quality Chasm have called for more interprofessional and coordinated hospital care. For over 20 years, Acute Care for Elders (ACE) Units and models of care that disseminate ACE principles have demonstrated outcomes in-line with the IOM goals. The objective of this overview is to provide a concise summary of studies that describe outcomes of ACE models of care published in 1995 or later. Twenty-two studies met the inclusion. Of these, 19 studies were from ACE Units and three were evaluations of ACE Services, or teams that cared for patients on more than one hospital unit. Outcomes from these studies included increased adherence to evidence-based geriatric care processes, improved patient functional status at time of hospital discharge, and reductions in length of stay and costs in patients admitted to ACE models compared to usual care. These outcomes represent value-based care. As interprofessional team models are adopted, training in successful team functioning will also be needed.

Using a resident discharge clinic for resident education and patient care: a feasibility study.

BACKGROUND: Many patients in internal medicine resident continuity clinics experience difficulty accessing care, making posthospitalization ambulatory follow-up challenging. Experiential learning in care transitions is also lacking for residents. OBJECTIVE: We sought to assess the feasibility and impact of a weekly Resident Discharge Clinic (RDC) in increasing access to early posthospitalization follow-up and providing learning opportunities for residents. METHODS: We staffed the RDC with an ambulatory block resident, an internal medicine preceptor, and a clinical pharmacist. We assessed time to posthospitalization follow-up, readmission rates, and resident perceptions of postdischarge care for resident-clinic patients, comparing data before and after RDC implementation. RESULTS: There were 636 discharges in the baseline group, 662 during the intervention period, and 56 in the RDC group. Six months after RDC implementation, the percentage of discharged resident-clinic patients with follow-up within 7 days improved from 6.6% at baseline to 9.7% (P  =  .04). The mean interval to the posthospitalization follow-up appointment in the RDC group was 7.4 days compared with 33.9 days in the baseline group (P < .001). The percentage of surveyed residents (n  =  72) who agreed that early follow-up was easy to arrange increased from 21% to 77% (P < .001). There was no significant decrease in the 30-day readmission rate for patients in the RDC group (18.1% versus 12.5%, P  =  .29). CONCLUSIONS: The RDC was easily implemented, increased access to timely posthospitalization follow-up, and provided a platform for resident learning about care transitions.

Using denosumab to treat immobilization hypercalcemia in a post-acute care patient.

BACKGROUND: Hypercalcemia in adults has several less common causes. Management in patients with chronic kidney disease (CKD) is challenging because bisphosphonates are contraindicated. This case presents an uncommon cause of hypercalcemia in a subacute rehabilitation patient who was managed with denosumab. CASE REPORT: A 79-year-old female with CKD stage 4 was admitted to a skilled nursing facility with a limited-weight-bearing status after right-hip arthroplasty. Four weeks later, she developed hypercalcemia (11.5 mg/dL; normal, 7.9-9.9 mg/dL) with serum albumin of 2.5 g/dL (corrected calcium, 12.7 mg/dL). Despite iv fluids, hypercalcemia worsened (corrected serum calcium, 14.5 mg/dL), and she was rehospitalized. Additional studies eliminated common causes of hypercalcemia, leading to the diagnosis of immobilization hypercalcemia. Due to CKD, a bisphosphonate was not given. She received 10 doses of calcitonin s.c. with mild improvement in her calcium, and she returned to the skilled nursing facility. Because hypercalcemia worsened within days, denosumab 60 mg was administered s.c., and her serum calcium level normalized. Over the next several weeks, her surgical wound worsened. Hip x-ray showed osteolysis of her residual right femoral head. In retrospect, hip x-ray during her hospitalization for hypercalcemia showed osteolysis, likely from osteomyelitis. A contribution of osteomyelitis to hypercalcemia could not be excluded. Despite resolution of hypercalcemia, she succumbed to sepsis. CONCLUSION: Immobilization hypercalcemia is underappreciated in post-acute care older adults. In this patient with CKD, denosumab reversed her hypercalcemia; however, the case highlights potential risks and limitations with this therapy and emphasizes the need for further studies in medically complex older adults.