- Medical teams are encouraged to attend ACE unit rounds while on bedside rounds. This provides an opportunity to model the team-delivered care for house staff and medical students, an ACGME requirement;
- Suggestions to change medications are directly text-paged to the house staff; and
- Recommendations are summarized in a communication sheet left in the chart (this not a permanent part of the medical record).
We plan on using the text-paging more widely once the unit has wireless computer capability. Despite this, there are occasions where a team is not aware of a recommendation or new emphasis in the care plan. We are considering additional ways to improve communication such as attending the primary team attending rounds.
In California and other states there is a shortage of clinical pharmacists and masters-prepared nurses with expertise in geriatrics.14-16 The advanced practice nurse performs a vital role in raising the level of knowledge, skills, and attitudes for the nursing staff on the ACE unit.
In addition, we see the ACE unit as a drop in the pond; we feel a responsibility to expand nursing geriatric competency throughout appropriate hospital areas. Thus, this nursing role is at the center of preparing the hospital to care for an older patient population.
This position remained unfilled for almost a year despite an intensive national search. This prompted us to incorporate the geriatric resource nurse model into our unit while we continued our recruitment.
Although we have successfully concluded our search for a nursing leader for the ACE unit, we have yet to hire a clinical pharmacist.
The rehabilitation of the unit would not have been possible without foundation support. As a public hospital with many competing demands, monies are limited for the rehabilitation required to create a more welcoming, safer environment for the older patient. In this case, the hospital foundation and a local foundation made grants to the ACE unit to allow us to change the environment.
These grants have allowed for significant changes to the unit, including elevated toilet seats, high-backed chairs, handrails, unit-based physical therapy equipment, and activities to promote non-pharmacological approaches to agitation.
Readiness for Change
All levels of hospital staff embraced the ACE unit concept. Department leaders in rehabilitation, nutrition, social work, and pharmacy felt ACE unit principles would improve care delivery over usual care.
Early on, department leaders and medical staff enthusiastically participated on a steering committee to help guide implementation efforts. In addition, when we offered geriatric resource nurse training to our nursing staff, more than 20 out of 50 unit nurses expressed interest.
Staff from all departments represented on the ACE unit team also expressed interest in and attended the three days of training. This provided baseline knowledge of common geriatric syndromes in hospitalized older patients for all team members. This been helpful during ACE team discussions.
Although medical residents felt they could not consistently attend ACE rounds, they appreciated potential benefits of the unit:
- Different perspectives could provide a wider range of evaluation and treatment recommendations for their patients;
- The co-location of key disciplines could result in overall time savings in calling for and ordering evaluations;
- The reduced likelihood that key interventions such as mobilization, feeding, catheter removal, and medication review would be missed; and
- The opportunity to learn principles of geriatric care through attending ACE rounds (when possible).