The U.S. surgical patient population is aging, with 38 percent of operations performed on older adults. Traditionally, postoperative patients have received care in a surgical ward. Nurses and other members of the multidisciplinary health care team are trained to provide postoperative care to surgical patients but may not receive special training to prevent or manage preexisting geriatric syndromes, such as cognitive impairment, delirium, and functional decline. Furthermore, even if trained, these health care professionals must work in microsystems that support the delivery of evidence-based geriatric care processes to achieve quality outcomes.
The University of Alabama at Birmingham (UAB) recognized an opportunity to redesign geriatric care delivery at the microsystem level (a surgical ward), with the goal of providing care that is safe, timely, effective, efficient, equitable, and patient-centered for an older surgical patient population. For this initial project implementation, the focus was on reducing delirium, improving patient mobility, decreasing hospital length of stay (LOS), and improving rates of discharge to home.
Putting the quality improvement (QI) activity in place
UAB Hospital is a large public health care and tertiary referral center with approximately 1,200 beds. More than 36,000 operations are performed annually at the facility. It is the only Level I trauma center in Alabama. The hospital is continually full, with a 95–98 percent occupancy most days. We have embarked on a throughput initiative to decrease LOS to create more bed availability to serve more patients in the large catchment area.
For this initial project implementation, the focus was on reducing delirium, improving patient mobility, decreasing hospital LOS, and improving rates of discharge to home.
UAB Hospital has an acute care for elders (ACE) unit designed to care for older adults admitted to the hospitalist service. Health care personnel in the unit have daily team meetings guided by a geriatric physician or nurse practitioner. The UAB ACE unit has demonstrated that 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 of delivering 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).
Based on well-established, improved outcomes from the ACE unit care and the growing geriatric surgery literature, including best practice guidelines for optimal perioperative management of geriatric surgical patients,2 the team recognized the need to disseminate ACE-like care (Virtual ACE) to surgical patients admitted to surgical wards.
To prepare the hospital system for this care delivery redesign, a core team of geriatricians, geriatric nurse practitioners, and geriatric-trained nurses used the Institute of Healthcare Improvement model for improvement with iterative Plan, Do, Study, Act (PDSA) cycles to implement standardized geriatric screens into the electronic health record (EHR) for use by nurses on our ACE and other pilot units. More specifically, patients were screened for cognitive impairment, functional impairment, and mobility. Each PDSA cycle worked to ensure the new screens fit into the nursing workflow. The geriatric team also joined a collaborative with Aurora Health System, headquartered in Milwaukee, WI, and embedded the ACE Tracker report into the hospital EHR. The ACE Tracker is an electronic report that displays the results of geriatric assessments, including screens for function and delirium; process and outcome metrics, such as LOS; use of tethers, such as Foleys, restraints, and oxygen; and administration of medications for all patients on a specific unit.3
With this infrastructure in place, the geriatric team then engaged stakeholders from other interprofessional disciplines (rehabilitation 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: function/mobility, pain management, delirium prevention and management, and 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 orthopaedic4 and then trauma surgery units to learn and refine the implementation process, which resulted in a revised implementation strategy that was then brought to the gastrointestinal (GI) surgery units.
Stakeholder engagement meetings with members of the GI surgery unit began in January 2016. These initial meetings centered on attaining guidance, feedback, interest, and support from the surgical medical director, followed by engaging frontline staff and leadership of the unit interprofessional health care 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 hospital and health care professional priorities, including reduced LOS, less use of restraints, early mobility, and so on. Buy-in was immediate.
Description of the QI activity
After securing key stakeholder support in individual meetings, a Virtual ACE kick-off meeting took place in March 2016, with the entire unit-based interprofessional team leadership in attendance. One role of this team was to review and provide feedback and advice on the roles and responsibilities of each discipline and key components and goals of Virtual ACE, and help develop the project educational plan for the leadership and frontline staff.
One goal was to equip and empower the team to provide evidence-based geriatric care as much as possible without daily oversight by a geriatrician, thereby expanding the capacity of the formal geriatric consult service for the most complex or vulnerable patients.
The Virtual ACE intervention implementation included interprofessional team training and up to six months of intensive coaching, followed by three to six months of surveillance and retraining/coaching as needed to ensure the new care processes are hardwired into the teams’ approach. Team training was delivered to groups of the varied disciplines, further enforcing the role of working as a team to address geriatric syndromes. The core curriculum included 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.
- Three nurse-driven care algorithms included in the intervention target were as follows:
- Nonpharmacological pain management.
- Early safe mobility.
- Delirium prevention and management, including avoidance of potentially inappropriate medications for older adults (Beers Criteria medications). These pathways include geriatric screens for function (Katz Index of basic activities of daily living), mobility (Johns Hopkins Highest Level Mobility Scale), cognition (Six Item Screen), and delirium (Nursing Delirium Screening Scale).5-9
Based on screen results, the care algorithms include steps to guide nurses and other disciplines toward 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 management, verifying mobility orders, and educating patients and families about the benefits of mobilization while in the hospital. The ACE Tracker report provided the most up-to-date results of these screens and other care processes for the interprofessional team, especially nurse leaders of the unit, to coordinate the daily plan of care.
The Virtual ACE curriculum was delivered in three one-hour sessions April 10 to May 15, 2016. Trainees 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, and social workers). Virtual ACE training for physicians was delivered in two one-hour didactic sessions in April and May 2016. The education was provided by the core Virtual ACE team. One goal was to equip and empower the team to provide evidence-based geriatric care as much as possible without daily oversight by a geriatrician, thereby expanding the capacity of the formal geriatric consult service for the most complex or vulnerable patients.
Following the training, the units received support from the Virtual ACE coach. The coach is a master’s prepared nurse who has training in geriatrics and QI, is a member of the core geriatric team, and has responsibilities for the day-to-day management of the Virtual ACE initiative. Coaching sessions included rounds with staff and one-on-one consultation on using the ACE Tracker report to identify at-risk patients and activate the clinical algorithms to prevent and manage 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 a delirium prevention toolbox. In June 2017, these GI surgical units implemented the final unit-based change in structure to further enhance use of the ACE Tracker and geriatric interprofessional team care, conducting daily interprofessional team rounds every weekday morning. These transition of care rounds were implemented across all medical-surgical units at UAB Hospital in 2016–2017 and serve as the foundational structure for interprofessional team coordination of Virtual ACE care. The GI surgical units’ staff receive booster coaching in use of these daily team meetings to identify patient care issues, especially those related to pain, mobility, and delirium in 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 QI responsibilities of the core geriatric team charged with operationalizing multiple hospital-based geriatric programs, including Virtual ACE. This core team includes a 0.3 full-time equivalent (FTE) geriatrician and three FTE geriatric-trained clinical nurse leaders, with approximately 0.5 FTE nurse time dedicated to Virtual ACE teaching and coaching. Additional project-specific costs included staff time for the education sessions, food provided during training, and supplies. The hospital provided funding for all these costs.
The primary outcome measure for this case study is hospital and postoperative LOS, and the balancing measure was 30-day readmissions. To determine these outcome measures, we examined institutional American College of Surgeons National Surgical Quality Improvement Program data for patients ages 70 and older who underwent colectomy, proctectomy, esophagectomy, hepatectomy, or pancreatectomy from January 1, 2013, to October 23, 2018, and stratified the information 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. The 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 versus 75.1 years, p = 0.83), gender (57 percent versus 56 percent male, p = 0.79), and comorbidities. More patients had independent functional status in the standard care cohort (99 percent versus 97 percent, p = 0.015).
Allow frontline staff to participate in developing the plan to implement Virtual ACE care into the workflows and patient populations that are unique to each hospital unit microsystem.
Overall hospital LOS (median seven days [5–10 interquartile range [IQR] versus five days [3–8 IQR] p < 0.001) and postoperative LOS (median seven days [5–10 IQR] versus four days [3–7 IQR]) were significantly shorter in patients admitted post-Virtual ACE intervention. Readmission rates were similar (11 percent versus 12 percent, p = 0.1), signaling that reducing LOS did not adversely affect 30-day readmissions. The LOS model showed that Virtual ACE care decreased both hospital LOS (incident rate ratio [IRR] 0.74 [0.66–0.83], p < 0.0001) and postoperative LOS (IRR 0.69 [0.61–0.71], p < 0.0001).
Barriers encountered during Virtual ACE implementation included the challenge of finding ideal times to train health care providers from all disciplines on two busy acute care units. Another initial challenge was resupplying tools in a timely manner. 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 introducing new staff to Virtual ACE initiatives, as well as providing at least annual booster training for existing staff. Both processes are now in place.
A limitation to the case study, which is common to pragmatic QI studies, is the challenge in accounting for all possible confounding variables from other hospital or unit interventions that also may have affected LOS. Of note, enhanced recovery after surgery (ERAS) is known to reduce LOS, and the GI surgical service implemented ERAS for colorectal surgery patients in 2015, prior to launch of the Virtual ACE intervention. Whereas 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.
The Virtual ACE initiative approximate costs related to training staff and supplies were $6,000.
To estimate potential cost savings for reduction in LOS, we used our cost accounting system to identify patients from fiscal year 2018 who were 70 years of age or older and underwent a GI operation, yielding a sample of 221 patient encounters. The average direct cost for the last full day of each patient’s hospitalization was $1,053. So, each hospital day of shortened hospital stay saves $1,053.
Tips for others
We have learned several lessons that we have used in each iterative PDSA cycle. They are as follows:
Provide frequent measures of progress, celebrate successes, and actively partner to overcome barriers to keep stakeholders and staff engaged.
- Stakeholder engagement from the beginning and throughout is critical for success.
- Speak the language that is important to your institutional leaders. Although 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 LOS impact is important to hospital leadership stakeholders.
- Speak the language that is important to your frontline care providers. The challenge of managing delirious patients is a chief concern of frontline nurses. Thus, communicating the benefits of Virtual ACE on delirium reduction is important to achieve buy-in from this group of stakeholders.
- Allow frontline staff to participate in developing the plan to implement Virtual ACE care into the workflows and patient populations that are unique to each hospital unit microsystem.
- Provide frequent measures of progress, celebrate successes, and actively partner to overcome barriers to keep stakeholders and staff engaged.
- Manage-up the unit leaders and staff to their supervisors and senior leaders so they are the recipients of system-wide recognition they deserve for leading change.
- Create a process to onboard new staff and provide booster training at least annually and 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 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. This transition moves the team from buy-in to ownership.
- Flood KL, MacLennan PA, McGrew D, Green D, Dodd C, Brown CJ. Effects of an acute care for elders unit on costs and 30-day readmissions. JAMA Intern Med. 2013;173(11):981-987.
- 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.
- 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.
- Booth KA, Simmons EE, Viles AF, et al. Improving geriatric care processes on two medical-surgical acute care units: A pilot study. J Healthcare Qual. 2019;41(1):23-31.
- 2019 American Geriatrics Society Beers Criteria Update Expert Panel. 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.
- Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. The Index of ADL: A standardized measure of biological and psychological function. JAMA. 1963;185:914-919.
- Hoyer EH, Friedman M, Lavezza A, et al. Promoting mobility and reducing length of stay in hospitalized general medical patients: A quality-improvement project. J Hosp Med. 2016;11(5):314-317.
- 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.
- 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.