A Virtual Acute Care for Elders Program Reduces Hospital Length of Stay

General Information 

Institution Name: University of Alabama at Birmingham

Submitter Name: Melanie Morris, MD

Authors: Melanie Morris, MD; Lauren Wood, MPH; Emily Simmons, MSN, RN, CNL, FGNLA; Shari Biswal, MSN, RN, PCCN, CNL; David James, DNP, RN-BC, CCNS, LSSGB; Jasmine Vickers, MPH, CHES; John Russell, MBA, CPA; Katrina Booth, MD; and Kellie Flood, MD

Name of the Case Study: A Virtual Acute Care for Elders Program Reduces Hospital Length of Stay

What Was Done? 

Global Problem Addressed 

The population in the U.S. is aging; 38 percent of surgeries are performed on older adults. Traditionally, patients are cared for on a surgical ward postoperatively.

Nurses and other members of the interprofessional health care team are trained to provide postoperative care of surgical patients but may not receive special training related to preventing or managing existing geriatric syndromes (in other words, cognitive impairment, delirium, functional decline). Additionally, even if trained, these health care professionals must be working in microsystems that support the delivery of evidence-based geriatric care processes to achieve quality outcomes.

Identification of Local Problem 

We recognized an opportunity to redesign geriatric care delivery at the microsystem level (a surgical ward) with the goal to provide care that is safe, timely, effective, efficient, equitable, and patient-centered in an older surgical patient population. For this initial project implementation, we specifically wanted to focus on reducing delirium, improving patient mobility, decreasing length of hospital stay, and improving rates of discharge to home.

How Was the Quality Improvement (QI) Activity Put in Place? 

Context of the QI Activity 

University of Alabama at Birmingham (UAB) Hospital is a large public hospital and tertiary referral center with almost 1,200 beds. We perform more than 36,000 operations annually. We are the only Level I trauma center in our state. Our hospital is continually full, with 95 to 98 percent occupancy on most days. We have embarked on a throughput initiative to decrease our lengths of stay to create more bed availability to serve more patients in our large catchment area.

UAB Hospital has an Acute Care for Elders (ACE) Unit designed to care for older adults admitted with medical problems to the hospitalist service with daily team meetings that include geriatric physician or nurse practitioner care guidance. The UAB ACE Unit has demonstrated this model increases the delivery of evidence-based geriatric care processes with subsequent reductions in cost and 30-day readmissions.¹ This model was used to design the Virtual ACE Intervention with the goal to deliver the core ACE care processes to surgical patients admitted to a surgical ward without the daily presence of a geriatric provider (physician or nurse practitioner).

Planning and Development Process 

Based on well-established improved outcomes from ACE Unit care and a growing geriatric-surgical literature, including best practice guidelines for optimal perioperative management of geriatric surgical patients, our team recognized the need to disseminate ACE-like care (Virtual ACE) to surgical patients on surgical wards.²

As a means to prepare the hospital system for this care delivery redesign, a core team comprised of geriatricians, geriatric nurse practitioner, and geriatric- trained nurses used the Institute for Healthcare Improvement (IHI) model for improvement with iterative Plan, Do, Study, Act (PDSA) cycles to implement standardized geriatric screens into the electronic medical record for use by nurses on our ACE and other pilot units. These include standardized screens for cognitive impairment, functional impairment, and mobility. Each PDSA cycle worked to ensure the new screens fit into nursing workflow. The geriatric team also joined a collaborative with Aurora Health System in Wisconsin and embedded the “ACE Tracker” report into the hospital electronic medical record. The “ACE Tracker” is an electronic report that displays the results of geriatric assessments (in other words, screens for function, delirium) and process and outcome metrics (in other words, current length of stay; utilization of tethers such as Foleys, restraints, oxygen; administration of potentially inappropriate medications for older adults, and so on) for all patients on a specific unit.³

With this infrastructure in place, the geriatric team then engaged stakeholders from other interprofessional disciplines (rehab therapists, pharmacists, dietitians, care coordinators, social workers, nurses, nurse practitioners, and physicians) and family caregivers in an iterative process to inform and pilot test the development of the Virtual ACE Intervention care processes, workflows, and nurse-driven care algorithms. These care pathways targeted four geriatric domains: (1) function/ mobility, (2) pain management, (3) delirium prevention and management, and (4) interprofessional team approach for care transitions planning. Finally, the developed and vetted care algorithms for each of these domains were packaged into the Virtual ACE Intervention.

Next, implementing the Virtual ACE Intervention was pilot tested on orthopaedic and then trauma surgery units to learn and refine the implementation process.⁴ This step resulted in a revised implementation strategy that was then brought to the gastrointestinal (GI) surgery units.

Stakeholder engagement meetings with the members of the GI surgery unit began in January 2016. These initial meetings began with first seeking guidance, feedback, interest, and support from the surgical medical director. The next step involved engaging representation from frontline staff and leadership of the unit interprofessional healthcare team members. Members of the unit interprofessional team also served as the liaisons for their disciplines throughout the education and implementation phases of Virtual ACE. We framed the Virtual ACE care processes as a model of care for all vulnerable patients—making geriatric care just routine care. In addition, Virtual ACE is designed to align with priorities of hospital and providers (in other words, length of stay reduction, restraint reduction, early mobility, and so on). Buy-in was immediate.

Description of the Quality Improvement Activity 

After securing key stakeholder support in individual meetings, a Virtual ACE kick- off meeting was held with the entire unit-based interprofessional team leadership in March 2016. One role of this team was to review and provide feedback and advise on the roles and responsibilities of each discipline and key components and goals of Virtual ACE, and to help develop the project educational plan for their leadership and frontline staff. 

The Virtual ACE Intervention implementation includes: (1) interprofessional team training and (2) up to six months of intensive coaching followed by three to six months of surveillance and re-training/coaching where needed to ensure the new care processes are hardwired. The team training was delivered in groups of the varied disciplines together in the same teaching sessions, further enforcing the role of working as a team to address geriatric syndromes. The core curriculum includes cases and data designed to create a sense of urgency for change, followed by knowledge and skills required to implement the care processes and algorithms for the targeted geriatric syndromes. Specifically, three nurse-driven care algorithms are included in the intervention that target: (1) non-pharmacological pain management, (2) early safe mobility, and (3) delirium prevention and management, including avoidance of potentially inappropriate medications for older adults (Beers Criteria® medications).5 These pathways include geriatric screens for function (Katz Index for basic activities of daily living), mobility (Johns Hopkins Highest Level Mobility Scale), cognition (Six Item Screen) and delirium (Nursing Delirium Screening Scale).6-9 Based on screen results, the care algorithms include steps to guide nurses and other disciplines in preventing and addressing any identified risk factors or existing syndromes. For example, the early safe mobility algorithm includes setting goals for patient mobility, optimizing pain, verifying mobility orders, and educating patients and families on the benefits of mobilization while in the hospital. The ACE Tracker report provided the most updated results of all these screens and other care processes for use by the interprofessional team, especially nurse leaders for the unit, to help coordinate the daily plan of care.

The Virtual ACE curriculum was delivered in three one-hour repeated sessions between April 10 and May 15, 2016. The recipients of the training included all staff from the core disciplines on these two GI surgical units (nurses, patient care technicians, unit secretaries, rehabilitation therapists, pharmacists, dietitians, chaplains, care coordinators/managers, social workers). Virtual ACE training designed for physicians was delivered in two one-hour didactic sessions in

April and May 2016. The education was provided by the Virtual ACE core team. One goal was to equip and empower the care team to provide evidence- based geriatric care as much as possible without requiring daily oversight by a geriatrician, thereby expanding the capacity of the formal geriatric consult service by reserving it’s use for the most complex or vulnerable patients.

Following the training, the units then received support from the Virtual ACE coach. The coach is a master’s prepared nurse who has training in geriatrics and quality improvement, is a member of the core geriatric team, and has responsibilities for the day-to-day management of the Virtual ACE initiative.

These coaching sessions included rounds with staff and one-on-one consultation with how to utilize the ACE Tracker report to identify at-risk patients and activate the clinical algorithms to prevent and/or manage existing geriatric syndromes.

The Virtual ACE coach also worked with unit leadership to remove barriers to implementing the Virtual ACE model, such as hardwiring the process for obtaining gait belts and items for delirium prevention toolbox. In June 2017, these GI surgical units implemented the final unit-based change in structure to further enhance use of ACE Tracker and geriatric interprofessional team care, the daily interprofessional team rounds that occur every morning, Monday through Friday. These are known as Transition of Care (ToC) rounds and were implemented across all medical-surgical units at UAB Hospital from 2016 to 2107. These ToC rounds serve as the foundational structure for interprofessional team coordination of Virtual ACE care. The GI surgical units’ staff received booster coaching in use of these daily team meetings to voice identified issues, especially those related to pain, mobility, and delirium in their geriatric patients. 

Resources Used and Skills Needed

The time and effort to develop and implement the Virtual ACE Intervention was part of the routine leadership and quality improvement job duties of the core geriatric team who is charged with operationalizing multiple hospital-based geriatric programs, of which Virtual ACE is just one. This core team includes 0.3 full-time employee (FTE) geriatrician and three FTE geriatric-trained clinical nurse leaders, with approximately 0.5 FTE nurse time dedicated to Virtual ACE teaching and coaching. The additional project-specific costs included staff time for the education sessions, food provided during training, and supplies such as gait belts and items for a delirium prevention toolbox. The funding for all these costs was provided by the hospital.

What Were the Results?

Overall Results 

Methods: Our primary outcome measure for this case study is hospital and postoperative length of stay (LOS). Our balancing measure was 30-day readmissions. To determine these outcome measures, we queried our institutional American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) data for patients aged ≥70 years who underwent: colectomy, proctectomy, esophagectomy, hepatectomy, or pancreatectomy from January 1, 2013, to October 23, 2018, and stratified them into standard care or Virtual ACE care. Demographics, hospital LOS, postoperative LOS, and readmission rates were recorded and compared. Binomial regression models were performed for LOS. Our overall cohort included 676 patients: 318 standard care and 358 Virtual ACE care, with a 3 percent overall mortality rate. The two cohorts were similar in age (74.9 vs. 75.1 years, p=0.83), sex (57% vs. 56% male, p=0.79), and comorbidities. More patients had independent functional status in the standard care cohort (99% vs. 97%, p=0.015).

Results: Overall hospital LOS (median 7 days [5-10 IQR] vs. 5 days [3-8 IQR], p<0.001) and postoperative LOS (median 7 days [5-10 IQR] vs. 4 days [3-7 IQR]) were significantly shorter in patients admitted post-Virtual ACE Intervention. Readmission rates were similar (11% vs. 12%, p=0.1), signaling that reducing LOS did not adversely impact 30-day readmissions. Our model of LOS found that Virtual ACE care independently decreased both hospital LOS (IRR 0.74 [0.66- 0.83]. p<0.0001) and postoperative LOS (IRR 0.69 [0.61-0.71], p<0.0001). 

Setbacks

The barriers encountered during Virtual ACE implementation included the challenge of finding ideal time to deliver the training to care providers from all disciplines on two busy acute care units. Another initial challenge was re- supplying in a timely manner tools such as gait belts and items for the delirium prevention toolboxes. This latter challenge has led to new and sustainable processes for securing these items through hospital central supply. These units, as is typical for hospital units, continue to undergo staff turnover, prompting the need to develop a process for onboarding new staff on Virtual ACE initiatives as well has providing at least annual booster training for existing staff. Both of these processes now exist.

Limitations

A limitation to our case study that is common to pragmatic studies of quality improvement interventions is the challenge in accounting for all possible confounding variables from other hospital or unit interventions that may have also impacted length of stay. Of note, while ERAS is also known to reduce LOS, the GI surgical service implemented ERAS for colorectal surgery patients in 2015, prior to launch of Virtual ACE Intervention. While Virtual ACE also includes care processes addressing mobility, it supports and complements ERAS with training, screening, and care algorithms that address the unique vulnerability of older adults.

Cost Savings

The Virtual ACE initiative approximate costs related to training staff and supplies was around $6,000.

To estimate current potential cost savings for reduction in LOS, we utilized our cost accounting system to identify patients from fiscal year 2018 who were 70 years of age or older and had a surgery performed by GI surgeon. This yielded a sample of 221 patient encounters. The average direct cost for the last full day of this group of patients’ hospitalization was $1,053. So, each hospital day of hospital stay decrease saves $1,053.

Tips for Others 

There are several lessons learned that we have utilized in each iterative PDSA cycle. Below is an outline of key tips for others interested in implementing Virtual ACE at their organization:

• Stakeholder engagement from the beginning and throughout is critical for success
  • Speak the language that is important to your institutional leaders. While delirium reduction is a key quality outcome for patients, it also leads to significant reductions in LOS, which is a strategic priority for our senior leaders. So communicating the benefits of Virtual ACE with a focus on impact on LOS is important for stakeholders from hospital leadership.
  • Speak the language that is important to your frontline care providers. While LOS is a key priority to senior leaders, the challenge of managing delirious patients is a chief concern of frontline nurses. Thus, communicating the benefits of Virtual ACE on delirium reduction will be different for this group of stakeholders.
  • Allow frontline staff to participate in developing how to implement Virtual ACE care into the workflows and patient populations that are unique to each hospital unit microsystem.
• Sustainment
  • Providing frequent measures of progress, celebrating successes, and actively partnering to overcome barriers will help keep stakeholders and staff engaged, as they can celebrate their progress.
  • Manage up the unit leaders and staff to their supervisors and senior leaders so they are the recipients of the system-wide recognition they deserve for leading change.
  • Create a process to onboard new staff and provide booster training at least annually and also as needed regarding the Virtual ACE care processes.
  • Create a unit-based accountable care team structure and culture, including providing process and outcome measures in accessible data reports and/or dashboards, so the unit-based interprofessional team leaders transition from dependency on the Virtual ACE coach to truly owning and driving the ongoing improvements independently. This is a transition from buy-in to ownership by a team that is now knowledgeable, equipped, and empowered.

References

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2. Mohanty S, Rosenthal RA, Russell MM, Neuman MD, Ko CY, Esnaola NF. Optimal Perioperative Management of the Geriatric Surgical Patient: A best practices guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. J Am Coll Surg. 2016;222(5):930-947. 
3. Malone ML, Vollbrecht M, Stephenson J, Burke L, Pagel P, Goodwin JS. Acute care for elders (ACE) tracker and e-geriatrician: Methods to disseminate ACE concepts to hospitals with no geriatricians on staff. J Am Geriatr Soc. 2010:58(1):161-167. 
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5. American Geriatrics Society 2019 Updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019;67(4):674-694. 
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8. Carpenter CR, DesPain B, Keeling TN, Shah M, Rothenberger M. The Six-Item Screener and AD8 for the detection of cognitive impairment in geriatric emergency department patients. Ann Emerg Med. 2011;57(6):653-661. 
9. Gaudreau JD, Gagnon P, Harel F, Tremblay A, Roy MA. Fast, systematic, and continuous delirium assessment in hospitalized patients: the nursing delirium screening scale. J Pain Symptom Manage. 2005;29(4):368-375.