Acute Care for the Elderly Unit (ACE Unit)
(Medical Director:  Franklin Watkins, M.D.)

Overview: 

During the second or third year of residency, each resident spends one month on the Acute Care for the Elderly Unit (ACE Unit).  An overview of the structure and functioning of the unit is as follows:

The Acute Care of the Elderly Unit (ACE Unit) of the J. Paul Sticht Center on Aging is a 16-bed specialized hospital unit for patients over the age of 65.  Patients are admitted to the ACE Unit in the same fashion that they would be admitted to a general medicine ward service.  The Unit and staff are fully equipped to provide all services that are provided on general medicine, including telemetry.  In addition to this basic level of service, there are several specialized services aimed at the elderly population.  All of our nursing and ancillary staff are in tune to the needs of this frail population and aware of the higher level of morbidity and social/family issues that they have.

Geriatric units have been shown to improve functional status after discharge for elderly patients.  (Landefeld, et al NEJM 1995)  The mechanism for this improvement centers on the realization that good geriatric care involves a multidisciplinary approach focused on needs of the elderly.  For this reason, in addition to delivery of expert geriatric acute medical care, our ACE unit focuses on several core components to improve outcomes.  These are as follows:

1. Maximize functional status

2. Identify cognitive impairment

3. Identify affective disorders

4. Discuss advance directives

5. Identify & address social issues

6. Begin discharge planning on the day of admission

Practical execution of the above components involves cooperation between the physician team, nursing, and ancillary staff.  Almost all patients will have an assessment by physical therapy and occupational therapy to assess functional needs early on during their hospitalization.  All patients have a full Folstein Mini-Mental State Exam (MMSE) done on the day of admission and a 10-point orientation battery (the "Top Ten") done each hospital day thereafter by the nursing staff to follow cognition and to identify delirium and assist with the evaluation of dementia.  A 15-item Geriatric Depression Scale (GDS) is additionally performed.  The physician and nursing staff will address advance directives/code status on admission and as appropriate.  Social work is also involved in the care of every patient to assess needs.  To ensure psychological well being and to accentuate coping skills with illness, recreation therapy and pastoral care are available for consultation.

The coordination of the multidisciplinary team occurs at the team meeting, which is led by the Geriatric fellow and residents daily at 11:00 a.m.  This 30-minute meeting allows the team to communicate vital patient care information and coordinate patient needs to optimize care with the ultimate goal of discharge from the acute care setting.

Two to three residents are assigned to this service per month, and patients are divided between the residents.  The maximum number of new patient admissions in a day for each resident on the service is 5, and the maximum number of patients followed by a single resident is 10.  For the majority of the time, the patients will be equally divided between the residents.  Acting Interns (AIs) may rotate on the service and share patient responsibilities; however, all patients must also be followed by a primary resident who supervises and directs the plan of care with the AI, and the supervising resident for the AI should be denoted on the daily census.

Clinical progress notes will be performed using the electronic system.  The plan of care must be updated and edited before sending to the attending for signature, including deletion of unnecessary information which can confuse the reader.  In addition, the physical examination section should never include items copied forward that were clearly not performed.

Residents are expected to pre-round on their patients before Attending rounds, and all residents are expected to be on the unit at least until 4 pm each day (except continuity clinic days) to be actively involved in new admissions, family meetings, etc.  If the daily work for the primary patients of the residents on ACE is complete and the load of admissions is 1 patient or less, one resident may be designated to cover the unit after 4 pm and to check out to the on-call resident after 6 pm.   This decision must be communicated to the attending and to the nursing staff BEFORE the resident leaves the building. These are minimum expectations for presence on the unit, and, of course, the prevailing workload may require the need for greater resident presence as dictated by the supervising attending.
 

Principal Teaching/Learning Activities:

• Morning Report (MR):  Four mornings each week (M, T, W, F) from 8:00-9:00 AM upper level residents on the ACE Unit will attend morning report.  In morning report, case presentations will be performed by either a HO2 or a HO3 and the discussions are precepted by the Assistant Chiefs of Medicine and other faculty.
   
• Grand Rounds (GR):  Are scheduled every Thursday 8:00 a.m.-9:00 a.m. from September through the first week of June. 
   
• Noon conferences (NC):  House staff on the ACE Unit are expected to attend a minimum of 60% of noon conferences. 
   
• Attending Teaching Rounds (ATR):  The teaching attending rounds with the patient and team daily.  Typically, teaching rounds and ward work rounds are separated, although some attendings combine these two activities.  Ward work rounds typically occur as a conference meeting to discuss patients.  Teaching rounds encompass both conference-based teaching centered around patient cases and formal bedside teaching.  Bedside teaching is performed generally as follows:  The medical student should select a new patient (with the advice of the team) to present at the bedside.  Questions about the history, PMH, SH, FH, meds, ROS are entertained in a spontaneous fashion generated by the presentation.  Patients are encouraged to participate.  The physical examination is presented and the fellow selects a portion or portions of the exam to focus on related to a geriatric disease or syndrome.  The session is concluded with a discussion of the labs and other testing as well as differential diagnosis and treatment options.  Scheduling times can be coordinated with the resident and student teams for the month, so that ATR comprises a minimum total of 4.5 hours per week. 
   
• Multidisciplinary Disciplinary Rounds (MDR):  Daily at 11:00 a.m., the multidisciplinary team meets to discuss the needs of the patients on the ACE Unit.  This meeting is led by the Geriatrics Fellow and residents provide the medical reports on the patients.  The unit manager, social worker, staff nurses, physical therapy/occupational therapy, recreational therapy, pharmacy, and case management representatives interact on each patient each day.  MDR highlight teamwork and demonstrate the importance of the healthcare system in patient care. 
   
• Ace Transitional Program Rounds (ATPR):  The Geriatric Fellow and interns from the Ambulatory Geriatric Experience (AGE) rotation visit patients that are discharged from the Winston-Salem within 10 days of discharge.  ATP Rounds are held on Fridays after the team meeting to go over issues related to discharge and to teach around topics of interest in rehabilitation and the system of healthcare.
   
• Research Teaching Rounds (RTR):  Each week, a guest speaker from the Section on Gerontology in Geriatric Medicine presents a cutting-edge research topic or a review of research methodological issues in Geriatric Medicine for the team.  These meetings occur at 9:00 a.m. and are coordinated with other ward activities. 
   
• Aging Conference (AC):  The aging conference occurs biweekly on Wednesday afternoon from 1:30 p.m.-2:30 p.m. from September through the first week of June.  In this conference, both research and clinical topics in Geriatric Medicine are covered.  ACE Unit residents are expected to attend.
   
• Geriatric Journal Club (GJC): Geriatrics Journal Club occurs biweekly on Wednesday afternoon from 1:30-2:30 p.m. between September and June.  The purpose of this conference is to provide a review of new research in Geriatric Medicine, and to learn critical appraisal and research methodology skills. 

 
Principal Educational Goals by Relevant Competency

In the table below, the principal educational goals for the ACE Unit Services and the relevant principal teaching/learning activity is indicated by each goal using the legend below.

*Legend for Learning Activities

MR - Morning Report	ATR - Attending Teaching Rounds	AC - Aging Conference
MDR - Multidisciplinary Rounds	ATPR - Ace Transitional Program Rounds	NC - Noon conferences
GR - Grand Rounds	RTR – Research Teaching Rounds	GJC – Geriatric Journal Club

1) Patient Care  

2) Medical Knowledge

 **Please see Appendix A for specific learning objectives**

3) Practice-Based Learning and Improvement 

 
4) Interpersonal Skills and Communication

 
5) Professionalism 

6) Systems-Based Practice

Recommended Resources:

1. We recommended each resident routinely read about clinical issues that arise in patient care through use of appropriate review program such as UpToDate as well as individual strategies through the National Library of Medicine Pub Med.  These resources are available at our library website.

2.  We also recommend Principles of Geriatric Medicine and Gerontology 5^th Edition, W.R. Hazzard, et al as a resource for reading about clinical geriatrics topics.

Evaluation Methods

Evaluations are based on personal observation by the Geriatric Medicine faculty of the resident’s performance on the ACE Unit.  Medical knowledge is also assessed based on the resident’s performance in the board review format of the Geriatric Teaching Rounds.  Input from the multidisciplinary team is taken into consideration when assessing interpersonal skills and communication, professionalism, and systems-based practice. 

APPENDIX A

Specific Learning Objectives

In addition to demonstration of general medical knowledge in inpatient care of older adults, there are several specific aspects of care of older adults that we expect residents to accomplish.  These are as follows:

Advance directives in DNR orders:

1. Demonstrate general knowledge regarding prognosis after in hospital CPR.

2. Enumerate specific elements of an advanced directive discussion.

3. Use suggested phraseology in counseling about advance directives.

4. Demonstrate documentation of advanced directives and DNR orders by writing a

5.      standard note. 

 Comprehensive geriatric assessment:

1. Recognize the impact of geriatric syndromes on the presentation of illness, treatment and decisions, environment of care, and outcomes.

2. Appreciate the impact of functional changes on health outcomes for older adult patients.

3. Routinely evaluate mental status using the Folstein Mini-Mental State Examination and other assessment tools.

4. Routinely evaluate functional status using activities of daily living, instrumental activities of daily living and objective physical performance testing such as the “Get Up and Go” test. 

5. Routinely evaluate social support networks and economic status of hospitalized older adult patient in conjunction with the multidisciplinary team.

Deconditioning:

1. Recognize the serious consequences of bed rest. 

2. Explain to patients and families the serious consequences to bed rest including approaches to prevention.

3. Mobilize older adult patients early to prevent deconditioning.

Delirium:

1. Appraise the risk of delirium by applying an evidenced-based risk stratification scheme.

2. Recognize and diagnose delirium in hospitalized older adult patients.

3. Employ a systematic approach to differential diagnosis of delirium.

4. Employ a systematic approach to nonpharmacological and pharmacologic treatment of delirium in hospitalized older adult.

5. Employ delirium prevention strategies.

Dementia:

1. Develop an appreciation of dementia as a common but generally overlooked condition in hospitalized older adults.

2. Recognize dementia in hospitalized older adults by identifying clues in patient presentations. 

3. Conduct cognitive assessments in hospitalized older adult patients.

4. Formally assess decision making capacity of persons with dementia.

5. Incorporate the presence of dementia in the formulation of treatment plans in patients with multiple comorbid conditions. 

Depression:

1. Identify older adults of risk of depression.

2. Screen for depression among high risk geriatric patients with risk factors comorbities including history of dementia, cardiovascular disease, CVA, cancer, and neurological disorders such as Parkinson’s disease. 

3. Use the Geriatric Depression Screen (GDS).

4. Treat depression in older adults with methods including medications, psychotherapy, and electroconvulsive therapy (in consultation with the inpatient psychiatry team).

5. Understand the common side effects of commonly used antidepressants and drug interactions, particularly with SSRIs. 

Drugs in Aging:

1. Identify risk factors for adverse drug reactions/drug effects, including polypharmacy, aging pharmacology, and drugs to avoid for older adult patients (updated Beers Criteria, Archives of Internal Medicine 2003).

2. Review medication list daily.

3. Reduce polypharmacy and use of high risk/low benefit drugs in hospitalized older adult patients.

Fall in the Hospitalized Senior:

1. Define “Geriatric Syndrome” and describe falls as a type of geriatric syndrome.

2. Name formal and informal restraints.

3. Understand relationship between restraints and falls.

4. Name preventative actions to avoid falls in the hospital.

5. Follow up appropriately after a fall.

Foley Catheter Use:

1. Name short and long-term risks of bladder catheterization.

2. Perform a bedside evaluation of need for catheter and provide a plan for catheter removal. 

3. Differentiate the medical reasons for incomplete voiding. 

4. Analyze catheter problems. 

5. Demonstrate knowledge of the differential diagnosis of urinary incontinence in older adults and specific subtypes including urge, stress, functional, overflow, and mixed types.

Transitions of Care:  Hospice Care:

1. Identify older adult patients for whom Hospice Care is appropriate.

2. Discuss Hospice Care with older adult patients and their families.

3. Assist healthcare professionals, patients, and families in overcoming barriers to enrolling in Hospice.

Transitions of Care:  Multidisciplinary Collaboration and Discharge Planning:

1. Involve families of older adult patients early in the discharge planning process.     

2. Lead the team in multidisciplinary collaboration, including communicating with primary care physicians to plan safe and appropriate discharges for older adult patients. 

3. Communicate clearly and supportively with older patients and their families to develop safe and appropriate discharge plans.

4. Appreciate the negative consequences of poorly planned hospital discharges for older adult patients.

Transition of Care:  Nursing Home Care:

1. Appreciate why direct communication by telephone and in writing is critical when transferring care from one level to another. 

2. Avoid frequent dosing and reliance on IVs when planning discharge.

3. Understand how funding and reimbursement differs between acute care at all levels and long-term care settings. 

4. Understand the differences between supportive care, palliative care, skilled nursing, acute and subacute rehabilitation, and intermediate care.

5. Understand the discharge planning process involved in transferring to intermediate care. 

6. Inform patients and families about what to expect from nursing home care while recognizing cultural predispositions and financial considerations.

7. Provide up to date, correct and legible patient care information early in the day to the receiving nursing home.

Non-Pain Symptoms in Advanced Disease:

1. Assess and manage non-pain symptoms in patients with advanced diseases.

2. Determine treatment plans for non-pain symptoms based on probable etiology and with consideration of risk and benefits.

Pain Management Use:

1. Demonstrate pain intensity assessment skills at bedside with older adult patients.

2. Recognize pain in persons with dementia. 

3. Use the World Health Organization 3 Step Ladder for Pain Management.

4. Use the opiate conversion table.

5. Manage side effects from opiates.

Palliative Care and Changing Goals of Care:

1. Incorporate prognosis into plan of care. 

2. Emphasize palliation in the care of patients with advanced disease.

3. Weigh the benefits and burdens of diagnostic testing in patients with advanced disease.

Wound Care:

1. Routinely perform a complete skin examination in hospitalized older adult patients.

2. Perform a wound evaluation at bedside.

3. Formulate an effective plan of wound care including a prognosis for wound healing.

4. Recognize harmful or ineffective management techniques for wound care.

5. Include wound care and prevention in the problem list and management plan.

6. Appreciate the magnitude of the cost and care burden for chronic wounds. 

This set of specific learning objectives has been adapted from the Curriculum for the Hospitalized Aging Medical Patient (CHAMP) curriculum developed at the University of Chicago and supported by the Donald W. Reynolds Foundation.

10/16/08