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A BSTRACTS
D114
Fall Reduction in an ACE Unit-A Model for Quality Improvement
1,2 J.R Ortiz, 1,2T. Efeovbokham, 1 C.Stephens-Kelly, I,Rohner
1,2Theodore Suh 1 UT Health Science Center in San Antonio &
2CSRHCC.
J. R. Ortiz, 1,2 T. Efeovbokham, 1,2 C. Stephens-Kelly, 1 I. Rohner, 2
T. Suh . 1,2 1. Geriatrics, UTHSCSA, San Antonio Texas, TX; 2.
Geriatrics, Cristus Santa Rosa, San Antonio, TX.
PURPOSE: Identifying specific risk factors for those who fall in
a hospital Acute Care of the Elderly (ACE) Unit can lead to a targeted
intervention to prevent falls among hospitalized older adults.
BACKGROUND: Falls are a common problem in hospitalized
older adults, with about a third of hospital falls resulting in injuries
such as fractures, head and soft tissue trauma, which contribute to increased
length of stay (LOS), impaired rehabilitation, greater comorbidity,
more transitions to long-term care and greater hospital costs.
The main risk factors for falls in the hospital include gait instability,
confusion, urinary incontinence, previous falls and certain drugs.
METHODS: At the start of this study, our 10-bed ACE Unit at
Christus Santa Rosa Hospital-City Centre had the highest fall rate in
the hospital at just over 10 /1000 bed days. Our goal was to lower the
fall rate to 3.4 /1000 bed days. The ACE team developed a multicomponent
intervention, consisting of differentiating very high from high
fall risk patients, hourly rounding and mandatory use of bed alarms
for very high fall risk patients, and an incentive for ACE Unit nurses
consisting of a free lunch at the end of a month without any falls.
RESULTS: This intervention began on March 1/2011. For over 4
consecutive months (March-June), there were no falls in our ACE
Unit. We had one fall each in the months of July-Sept. and no falls in
Oct. For the last quarter (July-Oct.), the fall rate for our ACE Unit
was 3.5 /1000 bed days. The estimated cost to implement this change
was $850, plus $100 monthly to maintain it. If a fall adds an average of
4 days to the LOS, each prevented fall saves ~$12,800. If one conservatively
estimates that 2 falls were prevented monthly with this intervention,
then the annual projected cost savings is over $307,000.
CONCLUSION: Specific strategies to reduce falls in hospitalized
older adults have been successful. Differentiating those at highest
risk for falls is essential. Increased nurse rounding and diligent
bed alarm use for those at highest fall risk can reduce falls. A nominal
reward to nursing staff for their efforts to reduce falls was also effective.
There are potentially large cost savings to hospital from the prevention
of falls and resulting injuries.
D115
CARE: A Volunteer Approach to Reducing Delirium in the
Emergency Department.
J. Arnold, M. Sanon, A. Chun. Department of Geriatrics and Palliative
Medicine, Mount Sinai School of Medicine, New York, NY.
Supported By: The Medical Student Training in Aging Research
program of the the American Federation for Aging Research
The emergency department is a critical point of care for the elderly
and delirium is of particular concern in the chaotic ED environment.
Patients who develop delirium in the ED have been shown to
be at increased risk of adverse outcomes, have a more complicated
clinical course, and a higher likelihood of being sedated to control agitation.
The Care and Respect for Elders with Emergencies (CARE)
program is an ongoing effort jointly developed by the Department of
Geriatric and Palliative Medicine and Department of Emergency
Medicine at The Mount Sinai Medical Center specifically designed to
reduce the incidence of delirium in the ED. CARE adapts the successful
approaches from inpatient volunteer programs to the ED environment.
The goals of this retrospective cohort study were to understand
which elderly ED patients were being visited by CARE
volunteers and to characterize their clinical outcomes compared the
the general elderly ED population for evidence that the volunteer
program was having an impact on delirium. We looked at EMR data
from 8009 visits to the ED by elderly patients over an 11 month period
which included 104 volunteer visited patient visits. We found significant
differences in the ethnic composition of the volunteer visited
and non-visited populations with volunteers less likely to visit Hispanic
patients. Volunteer visited patients had lower ESI scores at
triage (were more urgently ill), had significantly longer ED lengths of
stay, were significantly more likely to be admitted to the hospital and
more likely to return to the ED within 30 days. Despite a seemingly
more complicated clinical course, volunteer visited patients were less
likely to be sedated during their ED visit. The results of this study
agree with the expectation that volunteers are visiting more acutely
ill patients but also raise questions about the selection bias that warrants
further investigation. While the intentional and potentially unintentional
volunteer assignment bias limits the value of comparing
clinical course, the difference in sedation rate suggests that the
CARE volunteer program may be reducing the incidence of delirium
in the ED.
D116
Palliative Care Interventions in Advanced Chronic Diseases: A
Systematic Review.
J. E. Roberts, M. C. Reid, R. D. Adelman. Weill Cornell Medical
College, New York, NY.
PURPOSE: Palliative care’s (PC) potential to improve quality
of life and provide symptom relief has received increased attention,
but it remains unclear how commonly such interventions target diverse
chronic illnesses. This study determines the occurrence and efficacy
of PC interventions for chronic non-cancer and cancer disorders.
METHODS: PubMed, MEDLine, CINAHL and Abstracts in
Social Gerontology were searched (1/80-10/11) where terms included
palliative care, chronic obstructive pulmonary disease (COPD), end
stage renal disease (ESRD), advanced heart disease (AHD) and cancer.
Studies were limited to English-language papers reporting on
multi-component PC interventions for adults with cancer, COPD,
ESRD or AHD. Study quality was assessed.
RESULTS: 1613 citations were identified. 41 met eligibility criteria
and described 35 unique interventions. 21 targeted patients with
cancer, and fewer targeted patients with AHD (n=4), ESRD (n=6), or
multiple diseases (n=4). No study enrolled COPD patients exclusively,
but multiple disease interventions included COPD patients.
Five were RCTs and 30 were observational studies. Four of 30 observational
studies and 4 of 5 RCTs were of high methodologic quality.
Interventions were delivered in inpatient units (43%), outpatient
clinics (51%), and home visits (46%), and by nurses (34%), physicians
and nurses (17%), physicians (6%), or multidisciplinary teams
(43%). The mean number of intervention components was 3.8 (range
2-7), common components included symptom management (77%),
advance care planning (49%), psychological support (49%), and care
coordination (43%). Symptom burden was the most common outcome
(46%), followed by medical care utilization (34%) and care satisfaction
(31%). Fifteen studies reported improvements on all or
most outcomes, 12 reported some improvements, and 1 showed no
improvements. The most common symptom improvements were in
pain (n=9) and nausea (n=7). Advance care planning increased as a
result of interventions in 6 studies spanning all disease categories.
CONCLUSIONS: Most PC interventions continue to target patients
with cancer. While 77% report positive effects, methodologic
quality was judged to be poor and only 14% employed an RCT design.
Over half lacked data on the schedule and intensity of the intervention
sufficient for replication. Research on multi-component PC
interventions targeting chronic non-cancer illnesses and employing
rigorous research methods is urgently needed.
D117
Home Based Transitional Care.
J. Leland, J. Cariaga, D. Davis. James A Haley VA, Tampa, FL.
June Leland MD, Jose Cariaga MD, Darlene Davis MHA
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AGS 2012 ANNUAL MEETING