Dr. Samir Sinha, Mount Sinai’s Director of Geriatrics walks through the Acute Care for Elders (ACE) unit at his hospital on December 6, 2016.JENNIFER ROBERTS
"Are we the Mount Sinai Hotel, or are we the Mount Sinai Hospital?"
Samir Sinha likes to drop that line whenever he is explaining one of his hospital's lowest-tech innovations in caring for the elderly: A ban on breakfast in bed. Encouraging seniors to sit up in a chair for meals keeps them mobile, the geriatrician says, and that helps prevent the physical decline that old patients often suffer while they are in the hospital.
"We know that bed rest can promote dysfunction," said Dr. Sinha, the director of geriatrics at Sinai Health System and the University Health Network, both in downtown Toronto. "If none of us actually eat breakfast, lunch and dinner in bed on a regular basis, why should we do that in the hospital?"
Rethinking the way elderly patients take their meals is just one of the dozens of changes Mount Sinai has made since 2010, when it began implementing its Acute Care for Elders (ACE) strategy.
By making small tweaks across the hospital – including clustering frail seniors on one ward, handing out no-slip socks, lowering beds to decrease falls and empowering geriatric-emergency-management nurses at the front door of the hospital – Mount Sinai has managed to discharge more patients over the age of 65 home more quickly, slashing the cost of care per patient by 23 per cent. The ACE strategy saved the hospital $6.7-million in 2014, the most recent year for which figures were available.
Now, 17 hospitals and health-care organizations in Canada and one in Iceland are beginning to copy Mount Sinai's ACE approach.
They are part of a "care collaborative" spearheaded by the Canadian Frailty Network and the Canadian Foundation for Healthcare Improvement (CFHI), a federally funded organization that looks for smart, money-saving health-care programs and tries to spread them around. Dr. Sinha and his Mount Sinai colleagues are acting as coaches for the other 18 teams, each of which has received just $40,000 to begin overhauling the way they care for the elderly.
Like health-care organizations across Canada, the 18 teams are bracing themselves for a wave of older, sicker patients.
The proportion of seniors in this country is expected to double over the next two decades, with the proportion of people over 85 projected to quadruple in the same period. As the baby boomers enter their 80s, they are likelier to rack up multiple chronic illnesses, placing a hefty burden on hospitals and long-term care homes. The Canadian Medical Association, which represents the country's 83,000 doctors, warns that by 2026, 2.4 million Canadians over the age of 65 will need some type of continuing care, up 71 per cent from 2011. By 2046, 3.3 million seniors will need continuing care, both paid and unpaid.
Providing that care in hospitals is not cheap, nor is it especially effective, Dr. Sinha said. Hospitals can be "hostile environments" for seniors, where infections lurk and a lack of physical and mental stimulation can accelerate their decline, often precipitating their move to a nursing home.
Elderly patients awaiting long-term care are already blocking beds in many acute-care hospitals, sometimes at alarming rates. The goal of ACE is to make frail seniors healthy enough to go home instead.
Yukon's largest hospital has seen first-hand how difficult it is to run a facility clogged with patients who should be in nursing homes, known in health-care parlance as alternate level of care (ALC) patients.
During one week last June, ALC patients occupied more than half of all beds – 31 of 55 – at Whitehorse General Hospital. That figure has now dropped to between 16 and 19 patients, thanks to the opening of new continuing-care beds elsewhere in Whitehorse.
But the ALC challenge, coupled with a rising tide of seniors in the territory, spurred Whitehorse General to apply for a spot in the ACE collaborative.
At the beginning of October, the hospital created a senior-friendly ACE unit, setting aside 11 existing beds on the same floor so nurses trained in the ACE principles could pay special attention to the needs of older patients.
The new approach has already led to a reduction in falls and medication errors, said Geoff Zaparinuk, the director of patient care for Yukon Hospital Corp., which includes Whitehorse General and two other facilities in Watson Lake and Dawson City.
The new ACE unit – which is, at the moment, filled with ALC patients – also started hosting lunch and dinner in a common room, encouraging frail patients to take a short stroll and chat over a meal.
"There's good conversations that go on. People strengthen by walking to the meeting room. You don't commonly see that in a hospital," Mr. Zaparinuk said. "But by all of us working together with our resources we were able to make this happen and it's made a really big difference for us."
The Queensway Carleton Hospital in Ottawa, which in late November opened its own purpose-built, 34-bed ACE unit, has already started to see some big differences, too.
"Even within the first couple of weeks of the program, we've discovered that patients are sleeping much better than they were on the other unit," said Fraser Miller, chief of geriatrics at Queensway Carleton.
The new ACE unit, only the second of its kind in Ontario after Mount Sinai's, has instituted quiet hours after 9 p.m. Nurses tuck the patients in, dim the lights and turn down the ringers on the phones at the nursing station. The patients, having being encouraged to get out of their beds during the day, are tired at night and sleep soundly.
If ACE works as its supposed to, frail elderly patients should heal enough to go home. But what happens then? Another of the ACE teams, based in a region south of Quebec City, is trying to ensure patients are not lost to follow-up care by outfitting them with a monitoring bracelet that connects to 24-hour-a-day nursing and social support.
The telemonitoring devices are already available in Chaudière-Appalaches, but a pilot project that aims to follow 30 patients over three months will offer patients the devices in the hospital, before they check out.
"I think our health-care system needs to rethink how we actually put the patient at the centre of our care so that the communication breakdowns that we're seeing are solved," said Patrick Archambault, an emergency physician and researcher with the Centre for Integrated Health Care and Social Services in Chaudière-Appalaches. "If we don't, I don't think we're using our resources efficiently."
Kelly Grant