acute care of the elderly (ace) - agency for clinical ... 4 executive summary 5 section one: the...

Acute Care of the Elderly (ACE)

NSW Department of Health73 Miller StreetNORTH SYDNEY 2060Tel: (02) 9391 9000Fax: (02) 9424 5994www.health.nsw.gov.au

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© NSW Department of Health

SHPN (HP) 060087ISBN 0 7347 3953 2

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Tel: (02) 9879 0443Fax: (02) 9879 0994

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Model of Care concept Angela Littleford and Judith Carll

Design by Elisabeth Sampson (02) 4968 1337

June 20062NSW Health

Clinical Services Redesign ProgramACE

Acknowledgments 4

Executive Summary 5

Section One: The need for change

Lorna’s Story Prior to ACE 6

Background to the Model 8

Hornsby Ku-ring-gai Health Service 11

Section Two: Acute Care of the Elderly

Lorna’s New Story Under ACE 12

What is ACE? 14

How Does ACE Work? 16

Multidisciplinary Care 18

Benefits 19

Establishing and Maintaining ACE 20

Implementing ACE 24

Staffing 26

Section Three: Resources

Resources 27

Table of Contents

3NSW HealthClinical Services Redesign ProgramACE

Acknowledgments and Advisors

This model of care is based on the modeldeveloped by the Hornsby Ku-ring-gai Health Service. The modelwas developed as a National HospitalDemonstration Project.

NSW Health would like to acknowledgethe contribution of the following peoplewho work in that service to thedevelopment of this model of care.

Associate Professor Susan KurrleClinical DirectorSenior Staff SpecialistRehabilitation and Aged Care

Jenny Houston CNCProject LeaderAcute Care of the Elderly

Dr. Cesar UyGeriatrician and Rehabilitation Physician

Brett GardinerDirector Medical Services

Mr Owen ThomasGeneral Manager

Carol King Nurse Unit ManagerWard IB/ACE

Carolyn OpieA/Nursing Unit ManagerWard 1B/ ACE

Kylie Ward Director of Nursing

Alison PowisNurse Manager Rehabilitation and Aged Care Services

Sharon Strahand CNCAged Care Services in Emergency Team

Sue CollinsBed Manager

Nursing and Allied Health Care staffWard 1B/ACE

Jane DaltonWard Clerk 1B/ACE

EndorsementsNSW Health would like to thank thefollowing people for their extensivecomments and endorsement of this model of care.

Dr Stephen Christley, Chief Executive,Northern Sydney Central Coast AreaHealth Service

Dr Helen Gillespie, Staff Specialist,Rehabilitation and Aged Care Services,Northern Beaches Health Service,Northern Sydney Central Coast AreaHealth Service.

4NSW Health


The population is ageing and older peoplerepresent a significant and increasingproportion of Emergency Department andhospital patients.

They often present with complex healthissues or illnesses that underly chronicdisease. In hospital, older patients havehigher rates of adverse events and aremore likely to become deconditioned.

Prolonging an older person’s stay inhospital must be avoided at all costs. Toimprove the journey for older people,models of care that avoid deconditioningand promote functioning need to besystematically established.

In early 2002, Hornsby Ku-ring-gaiHospital had 70% of bed days occupiedby people over the age of 70 years. Thehospital had a high level of people waitingin the Emergency Department for morethan eight hours and high occupancyrates in the Acute Medical and SurgicalWards.

This model of care is based on HornsbyKu-ring-gai Health Service’s Acute Care ofthe Elderly (ACE) Model of Care that wasdeveloped to address the above issues.

This model embraces the philosophy of‘total quality management’. Considerationmust be given to the entire patient journeyfrom admission, through the hospital stayand the discharge to appropriatecommunity resources.

ACE is a shared care model betweenphysicians, geriatricians and their teams.It integrates comprehensive geriatricassessment into the optimal medical andnursing care of patients in amultidisciplinary environment.

Under ACE the physical, chronic,psychological and other special conditionsof the patients are managed by amultidisciplinary team. The team focuseson:

• providing the right care at the right placeat the right time

• patient function

• patient safety.

As older patients recover medically beforethey recover functionality ACE requires achange of emphasis in care. Theemphasis is on maintaining a patient’slevel of independent functioning, musclestrength and independence while inhospital to help them to return homequickly. Discharge planning, includingliaison and referral with generalpractitioners and other communitysupport services, occurs soon afteradmission.

Initial ACE evaluation results have shownthe model can deliver a reduction inlength of stay and readmissions of DRGSfor Congestive Cardiac Failure andChronic Obstructive Airways Disease.Other ACE outcomes included improveddischarge planning, reduction in iatrogeniccomplications, increased patient and staffsatisfaction as well as overall hospitalreductions in both access block andoccupancy rates.

The ACE Model of Care can help to meetthe special requirements of the healthsystem’s most frequent users, the elderly.It can improve their journey whenadmitted to hospital and their overallhealth and well being.

Executive Summary


Lorna’s Story Prior to ACE

Everyone in the Emergency Departmentseemed busy and rushed. It was terrible,not being able to breathe properly.Thankfully within minutes of arrivingsomeone had put a mask on my mouth,and it was easier to breathe.

I sat for a long time on an uncomfortabletrolley with my feet dangling over theedge. I couldn’t understand why I couldn’tsit in a chair with my feet up. That wouldhave been much more comfortable. Atone stage, a nurse rushed in and told meto lie down. Before I could answer, shehad left again. I wanted to tell her that itfelt harder to breathe lying down and themattress was so thin I could feel the wireunderneath.

A nurse eventually arrived and I told herabout myself. I have a heart condition. MyGP tells me that I have high bloodpressure but “it isn’t too bad”. I told herabout the medicines I take and that I havebeen taking them for a long time.

A doctor came to see me but I don’tremember what she said. I was just tiredand wanted to put my feet up. A manarrived with a wheelchair and I was takenup to a bed in the hospital.

Lorna appears unwell and confused in theEmergency Department. Once thediagnosis of heart failure is made, Lorna isadmitted and treatment has a rapidimpact. Within two days her chest isclearer, the swelling in her ankles declinesand she is discharged home.

Two weeks later Lorna is back in theEmergency Department with exactly thesame symptoms.

Lorna’s Story

Lorna is 84 and livesalone in a unit. Lorna’sonly family is a niecewho lives in Melbourneand visits her Aunttwice a year.

Lorna arrives at a hospital EmergencyDepartment by ambulance withincreasing shortnessof breath, tirednessand swollen ankles.

This is her story.

This is based on a truestory, only names havebeen changed.

6NSW Health


Section One - The Need for Change

Lorna’s Story

Lorna’s journey couldhave been much better.

She is treated for the illness she presentswith at the EmergencyDepartment and recovers quickly.

Her underlying illnesses are not treated and she is notreferred to appropriatecommunity supportservices.

As a result, she is backin hospital two weekslater. Lorna’s return tohospital could havebeen avoided.

What’s wrong with this story• Lorna waits a long time for someone to

attend to her.

• No one introduces themselves to Lornaor asks her if she needs anything.

• Lorna isn’t told what’s happening to herand why, how long she has to wait, whyshe is being admitted to hospital, whatshe can expect to happen or when shemight be able to go home.

• Lorna’s medication is not reviewed whileshe is in hospital.

• Lorna’s presenting illness is treated rapidly in hospital and she gets well, butthe underlying cause of her illness is notestablished.

• Discharge planning is poor and occursat the end of her stay in hospital.

• There is no referral to her GP for ongoing management of her illness.

• She is not referred to other community services.

• Her subsequent presentation is 100%avoidable.


Background to the Model

Impacts of an Ageing PopulationConsistent with worldwide trends theNSW population is ageing. Populationprojections for NSW (Australian Bureau ofStatistics, 2005) indicate that:

• between 2002-2011, there will be a 22%increase in people aged 65 years andover

• between 2002-2021, there will be a 65%increase in people aged 65 years andover.

By 2011, people over 65 years areexpected to account for 52% of all beddays (NSW Health, 2004).

Advancing age is associated withincreasing rates of chronic disease andcomplex medical and care issuesrequiring innovative models of care.Reduced mortality rates have resulted in asignificant number of people living withchronic illnesses that have the potential torequire repeated hospital admissions forepisodic care (Williams, 2004).

In 2004/05, people aged 65 years andover accounted for 19% of all NSWEmergency Department presentations.Once an elderly person presents at anEmergency Department they are morelikely to experience access block. That is,they wait in an Emergency Department formore than eight hours for a hospital bed.

As Graph 1 below shows, in NSW, 41% ofpatients aged 65 years and over admittedto a ward or Intensive Care Unitexperienced access block in theEmergency Department compared with23% for people aged less than 65 years.

The NSW data is consistent withinternational experience. In England,people aged 65 years and over accountfor 18% of all Emergency Departmentpresentations (Downing and Wilson, 2005)with the highest attendance rates forthose aged over 80 years of age. Similartrends have been noted in the UnitedStates with the elderly accounting for themajority of the 26% increase between1993 and 2003 in Emergency Departmentpresentations (Roszak, 2005).

Elderly people coming to EmergencyDepartments have complex presentations.Roszak (2005) notes that there is anincreased likelihood of co-morbidity andthus complexity with ageing that requiresadditional time in the EmergencyDepartment to diagnose and treat.

Time is required to comprehensivelyassess the older person whose reason forpresentation may mask underlying chronicdisease processes. EmergencyDepartments are busy and noisyenvironments that may further disorientate

The population is ageing and older people represent a significant and increasing proportionof EmergencyDepartment patients.

They present with complex health issuesor illnesses that underly chronic disease. These are difficult to diagnoseand treat in anEmergencyDepartment.

In hospital, olderpatients have higherrates of adverseevents and are morelikely to becomedeconditioned. Olderpatients recover medically before theyrecover functionality.

Prolonging an olderperson’s length of staymust be avoided at allcosts. Models of carethat avoid deconditioning andpromote functioningneed to be systematicallyestablished.

8NSW Health


Graph 1: NSW Emergency Department Access Block by Age

Source: NSW Emergency Department Information System (EDIS) and Admitted Patient DataCollection (Year to Date March 2005).

Facts

Older people accountfor around 20% of allNSW EmergencyDepartment presentations.

By 2011 there will be22% more people aged65 years or more thanthere were in 2002.They are expected tothen account for 52%of all hospital beddays.

Each day an older person spends in a hospital bed results in a 5% decrease in muscle mass. The lossincurred with 10 daysbed rest takes fourmonths to restore.

and confuse elderly people. This in turnreduces their ability to fully disclose theirmedical history. Knowledge of the elderlyperson’s functional status during themonths preceding the EmergencyDepartment presentation can greatlyassist in determining the nature of theillness as either an acute event or as theend result of a gradual decline.

Once hospitalised, older people havehigher rates of adverse events (falls,medication errors, infections) and aremore likely to become deconditioned(Palmer et al., 1998). It has beenestimated that each day spent in bedresults in a 5% decrease in muscle mass.For example, the loss incurred with 10days bed rest requires four months torestore (Creditor, 1993). For elderlypeople, unnecessarily extended bed restcan reduce the likelihood of beingdischarged from hospital with pre-morbidfunctioning. Table 1, on the next page,shows the interaction of hospitalisationand elderly people.

Prolonging an elderly patient’s length ofstay in hospital must be avoided at allcosts. It is acknowledged that elderlypatients recover medically before theyrecover functionality. Palmer et al. (1998)have conceptualised the functional declinein the elderly patient as they journeythrough the hospital system in Figure 1below.

Models of care for elderly patients thatavoid deconditioning and promotefunction are not systematically establishedwithin hospitals. Furthermore, Redelmeieret al. (1998) assert that when a personwith a chronic illness is treated in adisease-specific model of care, unrelateddiseases are more likely to be leftuntreated. This increases the likelihood ofrepeated Emergency Departmentpresentations for elderly people.


Source: Palmer et al., 1998

Figure 1:

Hospitalisation has asignificant impact onelderly people.

Impacts can includedeconditioning, falls,infections, fractures,incontinence, pressure sores and family rejection.

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Table 1: Interaction of Ageing and Hospitalisation

Reduced musclestrength and aerobiccapacity

Vasomotor stability

Baroreceptorinsensitivity andreduced total bodywater

Reduced bonedensity

Reduced ventilation

Reduced sensorycontinence

Altered thirst, taste,smell and dentition

Fragile skin

Tendency to urinaryincontinence

Immobilisation, highbed and rails

Reduced plasmavolume

Inaccessibility offluids

Accelerated boneloss

Increased closingvolume

Isolation, lostglasses, lost hearingaid, sensorydeprivation

Barriers, tethers,therapeutic diets

Immobilisation,shearing forces

Barriers, tethers

Deconditioning, fall

Syncope, dizziness

Increased fracturerisk

Reduce PO2

Delirium

Dehydration,malnutrition

Pressure sore

Functionalincontinence

Dependency

Fall, fracture

Fracture

Syncope, delirium

False labelling,physical restraint,chemical restraint

Reduced plasmavolume, tubefeeding

Infection

Catheter, familyrejection

Changes withUsual Ageing

Contribution ofHospitalisation

PotentialPrimaryEffects

PotentialSecondary

Consequences

Source: Creditor, M.C.,1993.

Hornsby Ku-ring-gaiHealth Service has successfully implemented ACE.

In 2002, 70% of the service’s bed dayswere occupied by people aged 70 yearsand over.

The ACE project atHKHS grew out ofrecognition of theincreasing needs of theageing population andthe desire to improveelderly patient journeys.

In the 2000 Census, Hornsby and Ku-ring-gai local government areas wereidentified as having the highest proportionof people over 90 years of age inAustralia. In 2002, Hornsby Ku-ring-gaiHealth Service (HKHS) provided servicesto an ageing population with 70% of beddays occupied by people over the age of70 years.

Patients over the age of 65 years have special needs that are not always recognised in the mainstream hospitalsystem. Before implementation of theAcute Care of the Elderly (ACE) project atHKHS, the special needs of elderlypatients were not always recognised andpatient journeys were often unnecessarilyprolonged.

In September 2001, the HKHS CareProcess Working Party Review hadidentified significant organisational andclinical imperatives for change. There wassignificant frustration with the high levelsof access block and the winter peakpatient load.

In the Emergency Department, elderly people were seen as a lower priority forintervention. This often led to lengthywaits to access medical specialists that inturn resulted in delays in comprehensive assessment, diagnosis and treatment.

In the hospital ward, there was often fragmented care resulting from poor communication and working relationshipsbetween medical, nursing and alliedhealth professionals. There were also highrates of adverse events such as falls,pressure sores and medication errors.These in turn led to loss of functionalityand extended bed stays for elderlypeople.

At the time of discharge from hospital intothe community, there was often poor communication and care planningbetween medical, nursing, allied healthand community health professionals. Thismeant that elderly people were oftendischarged without the appropriatesupports leading to repeatedpresentations at the EmergencyDepartment.

Hornsby Ku-ring-gai Health Service


Lorna’s New Story Under ACE

In the Emergency Department theAgedcare Services in Emergency Team(ASET) nurse identifies Lorna as an ‘ACE’patient.

Lorna appears unwell and confused. Thenurse quickly establishes that Lorna has ahistory of ischaemic heart disease andmild hypertension. Lorna tells the nurseshe has been taking medicine for theseconditions for many years. The diagnosisof heart failure is made quickly and Lornais admitted under the care of aCardiologist and a Geriatrician. Hertreatment has a rapid impact.

In the ACE ward, Lorna’s cognitive statusis assessed and she is found to have amoderate degree of short-term memoryloss and some cognitive impairment thatare considered to be symptoms ofdepression.

Staff contact Lorna’s GP. He reports agradual deterioration in condition over theprevious six months but the cause is notclear. Six months ago Lorna used to enjoya daily walk to her local shops. She hasnot been able to do this for some time.

Lorna is also found to have proximalmuscle weakness. In hospital she receivesregular walking and quadricepsstrengthening exercises from thePhysiotherapist and the MobilityEnhancement Team. She is also found tobe Vitamin D deficient and is givensupplements.

Lorna improves significantly over the nextfew days with improved exercise toleranceand decreased shortness of breath. Hercognitive impairment is diagnosed as earlydementia rather than depression.

To prepare Lorna for her discharge fromthe hospital, the ACE team:

• makes a referral to the Aged CareAssessment Team for an assessment forcommunity services

• makes a referral for an OccupationalTherapy assessment of her home

Lorna’s new story

Lorna is 84 and livesalone in a unit.

Lorna’s only family is aniece who lives inMelbourne and visitsher Aunt twice peryear.

Lorna arrives at a hospital EmergencyDepartment by ambulance withincreasing shortnessof breath, tirednessand swollen ankles.

This is her story underthe ACE Model ofCare.

12NSW Health


Section Two - ACE Model of Care

Lorna’s new Story

Lorna’s journey underACE is much better.

She recovers quicklyunder the care of amultidisciplinary teamthat includes a geriatrician andconsultant physician.

Following a comprehensive geriatric assessmenther underlying illnessesare treated and she isreferred to appropriatecommunity supportservices.

Lorna’s function isimproved in hospital.Discharge planningstarts at admission soshe is able to go homequickly.

Five months after leaving hospital Lornais living well at homewith support services.

• organises a Webster pack to assistLorna with her medication

• contacts the Management of CardiacFailure Team (MACARF) to help monitorLorna’s cardiac failure

• makes a referral to a local communityactivity centre to help Lorna withsocialisation and meals

• liaises with Lorna’s GP.

The Aged Care Assessment Teamcompletes their assessment four weeksafter Lorna’s discharge. They organiseassistance with housekeeping andmonitoring of Lorna’s medication.

Five months after leaving hospital Lorna ismanaging well at home with the DementiaMonitoring Service checking hermedication compliance and a privatecleaner visiting fortnightly. Twice a weekLorna attends an activity centre and Mealson Wheels provides meals on the otherdays. She has not presented back to theEmergency Department.

What’s good about this story• Lorna is seen quickly by an ASET Nurse

who obtains her medical history andmakes her feel comfortable.

• Lorna is told why she is waiting, whatshe can expect and when she might beable to go home.

• Lorna is quickly taken out of theEmergency Department to a ward.

• Discharge planning commences soonafter admission.

• Medication is reviewed in hospital.

• Lorna’s presenting illness is treatedrapidly and the underlying cause ofillness is also diagnosed and treated.

• There is a focus on maintainingindependence and effective functioning.

• Liaison with Lorna’s GP and referral toongoing services before discharge.

• Five months after discharge, Lorna isliving well at home with a range ofsupport services. She has not beenback to hospital.


n at

On dischargeLorna goes

home

What is ACE?

What is ACE?

ACE is designed to foster the independentfunction of patients. Itis a multifaceted intervention that integrates geriatricassessment into the optimal medical andnursing care of patientsin an interdisciplinary environment. Itincludes a patientfriendly environment,multidisciplinaryassessment, medicalcare review, pharmacological reviewand early dischargeplanning (Palmer, 1998).

Under ACE, the journey for patients isimproved by focusingon four key principles.

14NSW Health


Admission under dual specialty

• Shared care between thephysicians, geriatricians and theirmultidisciplinary teams.

• Integrated geriatric assessment intothe optimal medical and nursingcare of patients in aninterdisciplinary environment.

Key Principle

Comprehensive holistic geriatric assessment beyondthe presenting illness

• A ‘total quality management’philosophy recognises older peoplewith an easily identified acute illnessmay have other chronic physical,psychological and social conditions.

• Focus is on the entire patientjourney from illness to wellness andhome, efficiently.

Key Principle

Optimise care by focusing onpromoting independence andfunction

• Older people are medically wellbefore they are physically able.

• Early mobilisation.

• Increased medication safety.

Key Principle

Early discharge planning

• Liaison with GP.

• Timely referral to appropriatecommunity services.

Key Principle

Under ACE the ‘whole’person and theirunique circumstancesare managed by a multidisciplinary team.

The team focuses on:

• providing the rightcare at the rightplace at the righttime

• patient function

• patient safety.


Figure 2: Key Principles of ACE

How Does ACE Work?

Use eligibility criteria in EmergencyDepartment to identify patients mostlikely to benefit from early geriatricassessment and multidisciplinary care.

ED staff, Agedcare Services EmergencyTeam (ASET) Nurse, nursing andmedical staff all identify ACE patients.

Patients aged 65 years + (55 years forAboriginal and Torres Strait Islanders)*that:

• are acutely ill and need general orspecialist medical management

• have pre-existing co-morbidities

• are at risk of functional decline whilstin hospital

• have experienced functional declinein the two weeks prior to EmergencyDepartment presentation.

*Accept younger patients if pre-existing medical co-morbidities.

Multidisciplinaryteamwork

“If the OccupationalTherapist says they arenot ready to returnhome, they don’t gohome – each teammember has an equalsay”.

Assoc. ProfessorSusan Kurrle,Geriatrician, HornsbyKu-ring-gai HealthService

16NSW Health


Early identification Multidisciplinary teams

Good communication is both informaland formal. Formal communicationincludes a:

• weekly multidisciplinary case conference and discharge planningreview

• multidisciplinary ward meeting

• weekly pharmacy ward round wherethe pharmacist and the geriatrician work in collaboration.

Good communication

All staff work proactively to promoteindependence and functioning. Eachteam member has a role and a uniquecontribution.

• Geriatricians

• ACE registrar

• nursing staff

• allied health staff, and

• pharmacist#.

Create Multidisciplinary Care Plans.

Occurs within 24 to 48 hours ofadmission to the ward.

Document the patient’s physical, cognitive, emotional and functionalstatus with medication review.

Comprehensive geriatric assessment

#A pharmacist was added to the

ACE team three months into the

initial project because during the

early stages of ACE, pharmacological

contra-indications were uncovered

that are unique to older patients. The

weekly pharmacy review ward round,

in partnership with medical staff, is

vital to ensure pharmacological

interventions do not inadvertently

lead to iatrogenic events, delirium,

confusion and falls.

PromotingIndependence

Promoting independence may bechallenging for patientsand be time consumingfor nurses, particularlyin the early days ofadmission. Howevertime is saved over theentire length of the hospital stay.

Patient education isessential to avoidissues like the encouragement ofphysical exercise beingseen by patients asnurses being “too lazy”to get them a bed pan.

Compromises can bemade. For example,rather than patientswalking both to andfrom the bathroom,they can walk to thebathroom for a showerand then return via a wheelchair.


Admit patients under the specialist orsub-specialist medical team with theGeriatrician, or ACE registrar, beinginvolved from admission day.

These two teams work together tointegrate a comprehensive geriatricassessment into the medical care ofthe patient.

Shared care model Maintain and improve function

Start discharge planning at admission.The patient’s general practitioner,family and carers participate indischarge planning. Use RiskAssessment and Discharge PlanningTool (see Toolkit) to assist with:

• ongoing multidisciplinary assessment

• identification of discharge barriers

• discussion of care/discharge planswith the patient and carers

• early identification of rehabilitationneeds including transfer to rehab

• liaison with the patient’s GP.

Early discharge planning

Encourage independence, mobilityand activities of daily living.

Encourage the timely removal ofpatient “tethers” such as IV fluids,catheters, restraints and cot sides thatreduce patient mobility.

As soon as medically possible walkpatients to a communal dining areafor meals as well as to the bathroomand shower.

Promote patient independence

Nurse patients out of bed where possible.

On admission to the ward, nurses identifypatient needs and make allied healthreferral.

Assessment and treatment begin onadmission day.

Discourage medical treatment regimesthat may have negative impacts on thepatient (e.g. bed rest, use of indwellingurinary catheters).

Geriatrician and pharmacist reviewmedication charts weekly to reducepolypharmacy and adverse events.

Multidisciplinary Care

18NSW Health


Figure 3: Multidisciplinary Care

After ACE was implemented at HornsbyKu-ring-gai Health Service the followingoutcomes were recorded in 2002/03. (SeeToolkit for more detailed data.)

• A reduction in re-admissions from 12.4%to 3% in the targeted Diagnostic RelatedGroups of Congestive Cardiac Failureand Chronic Obstructive Airways Disease.

• A three-hour decrease in the averagelength of Emergency Department stayfor ACE patients.

• A significant reduction in adverse eventsincluding an 80% reduction in falls andelimination of the development ofpressure areas.

• A 50% reduction in Nursing Homeplacement waiting times.

• A 74% compliance rate for the RiskAssessment and Discharge PlanningTool for ACE patients compared with ahospital wide uptake of 48%.

• Higher degree of consumer and staffsatisfaction with the hospital and itsservices.

• Staff and physician support for the ACEModel of Care.

Benefits


In 2005, the ACE Model at HKHS is able to demonstrate a reduction in access block(see Graph 2 below).

Graph 2: Hornsby Ku-ring-gai Hospital ED Access Block July 2002 - May 2005

The ACE Model of Carehas provided a range ofbenefits to patients, carers and staff atHornsby Ku-ring-gaiHealth Service.

• Improved journey forpatients and carers.

• Improved performance in keyareas including:reduced length of hospital stay; reducedaccess block;reduced readmissionrates; and improvedpatient and staff satisfaction.

• Allows specialists toconcentrate on theirspeciality area withthe ACE team providing the holisticcare, management ofco-morbidities and discharge planning.

Source: Hornsby Ku-ring-gai Health Service

Establishing and Maintaining ACE

20NSW Health


Clocks and calendars on the walls of all the wards to assist orientation.


22NSW Health


“Having consumersand carers on theSteering Committee,as well as communitybased serviceproviders brought thecommunity into thehospital.”

Jenny Houston, ACEProject Leader, HKHS

“I left a folder of information at thenurses desk so anyonecould read what ACEwas about on anyshift.”


Find clinical, senior management,and nurse unit managerchampions that will assist staff towork collaboratively.

Find a ward to “own” the model.

Collaboration with another healthservice can provide critical reviewand support.

Engage physicians. Geriatricians,specialists and consultants mustbe willing to participate in a sharedmodel of care where patients areadmitted under a dual specialitymodel. There must be acceptanceof the integration of acomprehensive geriatricassessment into medical andsurgical care.

Establish a Steering Committee.(See Toolkit for more information.)

Define project target group,location and milestones.

A dedicated project officer isessential to pull people together,document, plan, monitor, report ontargets and “put the legs on the ideas”.

Create a project plan that staff own.Involve them in the development butdon’t make it hard or timeconsuming. The plan should set out:• the burning platform for change -

evidence about the current patientjourney problems

• the vision and ideal patient journey • objectives and strategies• roles and responsibilities• baseline data and key performance

indicators.

Set firm but realistic timeframes forimplementation and stick to them.Allow time for initiation of the changeprocess, obtaining staff support,orientation to process mapping,developing the model of care as wellas documenting KPIs and baselinedata.

Key performance indicators needto be developed and strictlymonitored. These may include:• reduced length of stay in hospital

and ED• increased patient and carer

satisfaction• decreased adverse events• reduced access block.

Talk up the need for changeacross all facets of the hospital.Create a folder of evidence thatcan be reviewed by hospital staffat any time. Speak on all wards -particularly at change of shift.

Describe the current patientjourney and the need to preventdeconditioning if elderly patientsare to return to their pre-morbidaccommodation status.

Change management andcultural change takes time. Staffmay find it difficult to conceivethere is a better way to providecare, especially if they alreadyfeel that they are working beyondreasonable capacity.

Help staff to become changeagents rather than objects ofchange.

Take the time to educate andinform people, particularly the keyopinion leaders and the ‘naysayers’. The Ward Clerk is highlyvaluable.

“Timing is critical. If youstart too quickly youcan get it wrong. If youstart too late peoplethink you are all talk.Finding the right timeto start the project,once enough educationand discussion hasoccurred is absolutelycritical.”



Identify a ward for ACE.

Encourage local ownership ofexisting problems with the patientjourney.

Define ACE team members*.Commence with one or twospecialities and Geriatrician.

Hold regular/weekly teammeetings and review individualpatient journeys.

* see next page for staffing.

This is a critical role for the ProjectOfficer/Steering Committee.

Use ACE name badges. Producepatient information so theyunderstand the model of care.Produce regular updates for thehospital and community sector.

Foster good communication throughinformal and formal means includingnewsletters, staff meetings,presentations, staff in-service androtation. • Encourage the team to find their

own way of reporting on theirjourney and progress.

• Informal sessions over coffee cancreate the incentive for people totake time from their busyschedules to listen in a non-threatening and collaborativemanner.

• Communicating during a change ofshift when there is double the ratioof nursing staff and leaving writteninformation in the ward is alsouseful.

• Establish methods for rapidfeedback from patients and staff inaddition to surveys. Responddirectly to feedback.

Celebrate and communicate everytangible achievement of the projectthrough a variety of means includingmorning teas, awards, mentions atstaff meetings, and BBQs. Nominateyour model, champions and teamsfor internal and external awards.

Steering Committee and ACEproject team review initial dataresults, including results ofpatient and staff surveys. Refinemodel as required. Consideradditional specialities.

Nurse rotation

Rotate nurses throughthe community baseddischarge services.

“Do not underestimatethe value of nursesfrom the ward andcommunity based services meeting faceto face and understanding eachothers’ roles.

The quality of collaboration is greatlyimproved when youknow a face and aname.”


24NSW Health


Process Map

Visit the online version of thisprocess map on the ARCHIwebsite atwww.archi.net.au/elibrary/build/moc

Here you will be able toaccess more information oneach of the steps in imple-menting the model. You willhave access to tools andtemplates as well as hintsand lessons learned by oth-ers who have implementedthe model.

Governance Identify leaders.

Develop a Process Map.

Establish a Steering Committee.

Patient JourneyHow do patients flow

through the model

Policies and Protocols

PeopleUnderstand who the staff are, how

they function and what role theyplay in the patient journey

Resources

Communication

Map the Patient Journey

Identify and review current policies and protocoaffecting care of the elderly.

Engage key physicians

Stakeholder Analysis

Survey current resources

Identify resources needed to establish andmaintain Acute Care of the Elderly (ACE)

View literature the supports the ACE Model of C

Develop communication plan

PlanningWhere are you now?

Implementing ACE


Develop position descriptions for staff allocated toAcute Care of the Elderly (ACE)

Develop competencies and an educational program for staff

Deliver required resources

Execute communication plan

Identify how results will flow back to the project

Monitor and Evaluate against KPIs

Provide regular project reports andupdates for senior management

Regular monitoring of patientexperiences via regular patientjourney mapping.

Implement and monitor compliance withnew protocols.

See the SESIAHS Lessons Learnt - RiskManagement

Develop a review process.


Monitor resource use

Feedback and review process

ols

Care

Develop a Governance Plan.

Find a way to ‘own’ the model

Develop Key Performance Indicators (KPIs)

See the SESIAHS Lessons Learnt - Project Management

Incorporate findings from patient journey into TO BEprocess map

Develop policies and protocols

Staffing

Assumptions• These nominal Hornsby Ku-ring-gai

Health Services (HKHS) resourcerequirements for implementation of anACE Model are additional to thoserequired to run a "normal" acute careward.

• The resource requirements apply to anaverage ACE patient load of 16-18patients within a higher bed capacityacute ward.

• If an entire ward is proposed for ACE,the nominal ‘extra’ ACE resourcerequirements would cover a higher ACE

patient load of 20 patients i.e. additionalto the resources for a standard acuteward. This means that there areresource savings with a dedicated ACEward.

• The resource requirements are likely tovary from site to site due to variations inexisting staffing levels. The allocated‘therapy hours’ for the designated wardin each hospital is likely to be a keycomponent in the resource variations.

Staffing for a 20 bedward shouldinclude:

Geriatrician

Registrar

Clinical NurseConsultant

Social worker

Physiotherapist

OccupationalTherapist

Clinical NurseSpecialist

Psychologist

Therapy Aide.

26NSW Health


Staffing levels will depend upon the sizeof the unit and number of patients. Theseestimates are for the establishment ofACE within a metropolitan generalhospital. They take into account thepresence of dedicated ward therapystaffing.

• Geriatrician 16 hours (clinical) per week.This will increase to 20 hours per week ifthere is teaching, administration,education and paperwork to be carriedout. This allows time for:

- multidisciplinary ward meetings- three full ward rounds- a pharmacist round- a family conference each week.

• Registrar 0.8 FTE. This could be a fulltime position. For example at HKHS, theregistrar also spends 0.2 FTE with theAgedcare Services in Emergency Team.

• Full-time Project Officer (Clinical NurseConsultant).

• 0.3 FTE Social worker.

• 0.4 FTE Physiotherapist.

• 0.2 FTE Occupational Therapist.

• Therapy Aide 1.0 FTE. The Therapy Aidewalks patients regularly, encouragespatients to walk to lunch and generallysupports the philosophy of ACE. Theyalso support other therapists and theRegistered Nurses.

• Clinical Nurse Specialist 1.0 FTE.Inclusion of a Clinical Nurse Specialistwithout a clinical load takes some strainoff the registrar (select patients, checkpaperwork) and easily allows a load of20 patients.

• Psychologist (preferably neuro) 0.2 FTE(optional but recommended).

NOTE: Speech pathology and dietetics advice are providedas part of standard acute ward care.

Staffing (in addition to standard acute ward staffing)


Resources

Allen, C. Glasziou, P. and Del Mar, C. Bed rest: a potentially harmful treatment needingmore careful evaluation. The Lancet 1999; Vol 354, 1229-1233.

Australian Bureau of Statistics, 2005. Population Projections Australia 2004-2101,Catalogue No. 3222.0.

Counsell, S.R., Holder, C.M., Liebenauer, L.L., Palmer, R.M., Fortinsky, R.H., Kresevic,D.M., Quinn, L.M., Allen, K.R., Covinsky, K.E. and Landefeld, C.S. Effects of aMulticomponent Intervention on Functional Outcomes and Process of Care inHospitalised Older Patients: A Randomised Controlled Trial of Ace Care for Elders(ACE) in a Community Hospital, Journal of American Geriatric Society 2000; 48:1572-1581.

Creditor, M.C. Hazards of Hospitalization of the Elderly, Annuals of Internal Medicine1993; 118:219-223.

Downing, A. and Wilson, R. Older people’s use of Accident and Emergency Services.Age and Ageing 2005; 34:24-30.

Hoenig, H.M. and Rubenstein, L.Z. Hospital associated de-conditioning anddysfunction (Editorial), Journal of American Geriatric Society 1991; 38:1296-1303.

Landefeld, C.S., Palmer, R.M., Kresevic, D.M., Fortinsky, R.H. and Kowal, J. Arandomised trial of care in a hospital medical unit especially designed to improve thefunctional outcomes of acutely ill older patients, New England Journal of Medicine1995; May 332:1338-1344.

NSW Health. Framework for integrated support and management of older people in theNSW Health Care System 2004; North Sydney.

Palmer, R.M., Counsell, S. and Landefeld, C.S. Clinical Intervention Trials The Ace Unit,Clinics in Geriatric Medicine 1998; 14:831-849.

Palmer, R.M., Landerfeld, C.S., Kresevic, D. and Kowal, J. A Medical Unit for the AcuteCare of the Elderly, Journal of American Geriatric Society 1994; 42:545-552.

Redelmeier, D.A., Tan S.H. and Booth G.L. The treatment of unrelated disorder inpatients with chronic medical diseases. New England Journal of Medicine 1998;338:1516-1542.

Roszak, D.J. Americans concerned about overcrowding and boarding of patients in theED, Hospitals and Health Networks 2005; 79:94-96.

Spear, S.J. Fixing Health Care from the Inside, Today, Harvard Business Review 2005;83:78-91.

Williams, A. Patients with co-morbidities: perceptions of acute care services, Journal ofAdvanced Nursing, 2004; 46:13-22.

Section Three - Resources

For more information about ACE visit the Models ofCare section of the ARCHI website www.archi.net.au

Here you will find anelectronic copy of this document, aresource toolkit and have the opportunity to participatein online discussion groups.

acute care of the elderly (ace) - agency for clinical ... 4 executive summary 5 section one: the...

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