Geriatric Nursing 39 (2018) 292–295

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Geriatric Nursing
j o u r n a l h o m e p a g e : w w w. g n j o u r n a l . c o m

Feature Article

Does acute care for the elderly (ACE) unit decrease the incidence of
falls?
Ahmed Abdalla, MD *, Mehul Adhaduk, MD, Raad A. Haddad, MD, Yanal Alnimer, MD,
Carlos F. Ríos-Bedoya, MPH, ScD, Ghassan Bachuwa, MD, MHSA, MS
Internal Medicine Residency Program, Hurley Medical Center, Michigan State University, 1 Hurley Plaza, Flint, MI 48503, USA

A R T I C L E I N F O A B S T R A C T

Article history: To determine whether acute care for the elderly (ACE) units decrease the incidence of patient falls com-
Received 5 July 2017 pared to general medical and surgical (GMS) units, a non-concurrent prospective study included individuals
Received in revised form 10 October 2017 aged 65 and older admitted to ACE or GMS units over a 2-year span was done. There were 7069 admis-
Accepted 16 October 2017
sions corresponded to 28,401 patient-days. A total of 149 falls were reported for an overall incidence
Available online 11 November 2017
rate (IR) of 5.2 falls per 1000 patient-days, 95% CI, 4.4/1000–6.1/1000 patient-days. The falls IR ratio for
patients in ACE unit compared to those in non-ACE units after adjusting for age, sex, prescribed psycho-
Keywords:
tropics and hypnotics, and Morse Fall Score was 0.27/1000 patient-days; 95% CI, 0.13–0.54; p < 0.001.
Acute care for the elderly
ACE So, an estimated 73% reduction in patient falls between ACE unit and non-ACE units. Hospitals may con-
Falls sider investing in ACE units to decrease the risk of falls and the associated medical and financial costs.
Morse Fall Score © 2017 Elsevier Inc. All rights reserved.
Older patients

Introduction counterparts.2 Hence the importance of preventing falls in this age

The geriatric population is at risk for many adverse events during
hospitalizations. Falls are one of the most common complications
of elderly patients during their stay in acute care settings. Besides
minor and major injuries, falls are also associated with increased
hospital length of stay, fear of immobilization, and inability to return
home quickly, leading to increasing healthcare costs.1–7
Patient falls during hospitalizations are common and have been
estimated at 3.56 falls/1000 patient-days for adult patients (21 years
old and older).8 In elderly patients, many factors contribute to a
higher incidence of falls, including immobilization and starting o
new medications.9 In addition, falls in the elderly are associated with
significant mortality and morbidity.10 For example, accidental falls
in institutional care could result in hip injury, with an estimated
incidence rate of 20 per 1000 person-years.11 Moreover, elderly pa-
tients experience delayed recovery and more long-term physical and
psychological effects as a result of falls than their younger
Abbreviations: ACE, acute care for the elderly; GMS, general medical and surgical;
MFS, Morse Fall Score.
Conflicts of interest: None.
Funding: This research did not receive any specific grant from funding agen-
cies in the public, commercial, or not-for-profit sectors.
* Corresponding author.
E-mail address: aabdall2@hurleymc.com (A. Abdalla).
group is paramount.
The Joint Commission International emphasizes fall risk pre-
vention among hospitalized patients. Fall prevention is now a
cornerstone in the hospital accreditation process. The Centers for
Medicare and Medicaid Services (CMS) have labeled falls during the
hospital stay as preventable events that should not occur. Conse-
quently, CMS is not reimbursing for healthcare costs associated with
hospital falls.8
To decrease the incidence of falls and other adverse outcomes
in the elderly while in the hospital, special units have been de-
signed and named Acute Care for the Elderly (ACE) units. These ACE
units are specially designed to provide better care and to improve
clinical outcomes in elderly patients.12 After comprehensive geri-
atric assessment with the complementary principles of quality
improvement, ACE units were developed in 1990. This system is
based on four main elements: patient-centered care, a specially de-
signed environment, review of medical care, and planning for
discharge to help patients maintain or achieve independence in basic
activities of daily living.13,14 A systematic review by Fox et al. showed
geriatric patients in ACE unit had almost 50% fewer falls than their
peers in usual care units.15 Another study in 2011, however, showed
no statistically significant difference in the risk of falls, with a fall
rate of 4.8 falls/1000 patient-days in the ACE unit compared to 6.7
falls/1000 patient-days in the usual care unit12 (see discussion). The
primary aim of this study was to evaluate whether an ACE unit at
a community-based teaching hospital decreased the risk of falls in

0197-4572/$ — see front matter © 2017 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.gerinurse.2017.10.011
 A. Abdalla et al. / Geriatric Nursing 39 (2018) 292–295
patients ages 65 years old and above during their hospital stay. The
secondary aims were to evaluate the effect of age, sex, length of stay,
use of psychotropic and hypnotic medication and Morse Fall Score
on the incidence of falls in the geriatric population during their hos-
pital admission.
Methods
Study setting and patient population
Following institutional review board approval, a non-concurrent
prospective study was conducted using the electronic medical record
(EMR) system at a community-based teaching hospital. Patients ages
65 years and older who were admitted to the institution’s ACE unit
between July 1, 2013, and August 31, 2015, were compared to those
admitted to the general medical and surgical (GMS) units. The start-
ing date for this study was July 1, 2013, as it was the opening date
for the institution’s ACE unit. All patients admitted to ACE or GMS
units during the study period were included. Patients from criti-
cal care units (intensive care unit, cardiac care unit, and progressive
care unit) were excluded because such patients receive a higher
acuity of care and are less likely to be ambulatory, hence they have
less of a risk of falls.8
Data collection and outcome measures
Patient falls were collected after the nurses assigned to the pa-
tients reported them in the hospital’s secure, online adverse event
reporting system and EMR. A fall was defined as a sudden, unin-
tentional coming down from a standing, sitting, or horizontal
position, slipping from a chair to the floor, a patient found on the
floor and an assisted fall.16 Data on age, sex, race/ethnicity, pre-
scribed psychotropic and hypnotic medications, and Morse Fall Score
(MFS) were collected from the EMR. A total of 7069 admissions cor-
responding to 28,401.61 patient-days and 149 falls were included
in this study.
Morse Fall Score
The MFS’s purpose is to predict the risk of falling. It consists of
six subscales, each of which identifies factors that increase the risk
of falling. Briefly, the MFS examines an individual’s fall history and
co-morbid conditions as indicators of disease severity. The MFS also
examines patient characteristics that might increase the risk of
falling. Specifically, it evaluates whether a patient moves with the
assistance of aids, needs treatment that requires physical ob-
stacles such as intravenous lines, and whether the patient is mentally
intact. The MFS maximum total possible score is 125. Morse and
colleagues suggested a cut-off score of 45 as indicative of a high risk
of falling.17 Generally, the MFS has shown poor predictability for
fall risk with variable sensitivity and specificity of this score.18,19 In
a study done by Kim et al. to evaluate sensitivity and specificity of
fall risk scores, the MFS was found to have a sensitivity and speci-
ficity of 88% and 48% respectively when using 25 as a cutoff for high
risk of falling.18 In another study by O’Connell, the MFS was found
to have a sensitivity and specificity of 83% and 29% respectively when
using 45 as the cutoff.20
At this institution, nursing staff assess adult inpatients using the
MFS on admission to the hospital, every 8 h, after any fall or change
in the medical status of the patient, and after every transfer from
one unit to another within the hospital. The patient’s MFS total score
is documented in the patient’s EMR.
293
ACE unit
An ACE unit was opened at the institution on July 1, 2013. It has
9 beds and was designed to improve the functional outcomes of
elderly patients 65 years and older. It has a specially designed
environment, interdisciplinary care, early discharge planning, and
ongoing review of medical care. The ACE unit uses the following
tools to reach its goals: specially trained nursing staff and senior-
friendly amenities, such as special lighting, non-skid flooring, low
beds, and soothing sounds/low noise policies. With the special train-
ing, ACE unit staff address seniors’ specific needs regarding nutrition,
proper sleep patterning, early delirium detection, skin integrity, and
medication management. The main services that differentiate the
ACE unit from GMS units and help to decrease the fall rate are early
physical and occupational rehabilitation to prevent functional decline,
patient-centered care to prevent cognitive decline and senior-
friendly environment to prevent mental and physical decline.15
Multidisciplinary rounds along with nurses specially trained in
elderly care also help to decrease the incidence of falls in ACE unit.
This institution’s ACE and GMS units have similar nurse to patient
ratios, both of which are about 1: 5. The decision to admit a patient
to ACE unit or a GMS unit depends mainly on an emergency de-
partment physician screening for the risk of developing geriatric
syndromes.
Data analysis
Before proceeding to do any statistical analysis, the presence of
data outliers and out-of-range values was assessed. Thereafter, data
cleaning and editing were performed through a series of frequen-
cies, proportions, descriptive statistics (e.g., mean, median, and
standard deviation) and figures (e.g., histograms and box and whisker
plots). After this process, bivariate analysis such as Fisher’s exact
tests for categorical variables and Student’s t-tests and analysis of
variance tests for continuous variables were performed to deter-
mine any associations between the study’s explanatory variables
(i.e., age, sex, prescription medications, and MFS) and the hospi-
talization unit (i.e., ACE and GMS).
To examine the relationship between admission to the ACE unit
and risk of patient falls after controlling for selected covariates, a
zero-inflated Poisson (ZIP) model was selected. The ZIP model was
chosen because falls are a count explanatory variable, the data on
falls was highly skewed with an excess number of zeros, and there
was no evidence of over-dispersion. This model has also been rec-
ommended to examine clinical data with these characteristics based
on its fit, decreased bias, smaller mean-squared errors, and higher
precision.21 All analyses were done using Stata statistical software
package (Stata Corporation, College Station, TX). The usual 0.05
Type I error threshold for statistical significance was used for
all analyses.
Results
From a study population of 7069 patients, a total of 149 falls were
reported during the study period for an incidence rate (IR) of 5.2
falls per 1000 patient-days (PD), 95% confidence interval (CI) 4.4/
1000 PD–6.1/1000 PD. The incidence rate ratio (IRR) for patients in
the ACE unit compared to those in non-ACE units was 0.96 (95% CI:
0.56, 1.63). Table 1 shows characteristics of patients in the ACE and
non-ACE units. The mean age of the study population was 76.4 years
(SD ± 8.3) with females composing 60.6% of the patients.
Given the high proportion of zeros and the count nature of the
response variable, the zero-inflated Poisson (ZIP) model was used
to control for potential confounders in the multivariate analysis. The
294 A. Abdalla et al. / Geriatric Nursing 39 (2018) 292–295

Table 1 Discussion
Comparison of patients in the acute care for the elderly (ACE) and general medical
and surgical (GMS) units on selected characteristics.
Assessing the efficacy of fall preventive strategies in hospital-
Total ACE Unit GMS Units P-value ized elderly patients is essential in improving healthcare for this
(n = 7069) (n = 941) (6,128)
age group. With an aging population, patients 65 years and older
Age (mean ± SD) 76.4 (8.3) 78.0 (8.4) 76.2 (8.2) <0.001 accounted for 78% of the total Medicare expenditure in 2011 and
Sex (%) 33% of it was for inpatient hospital care.23 To tackle this challenging
Female 60.6 65.6 59.8 0.001
Race (%)
age group, healthcare providers raised the issue of needing dedi-
White 50.0 59.0 48.6 cated units to provide better care and decrease unwanted events
African American 46.8 37.8 48.2 such as patient falls. Additionally, the literature describes many in-
Hispanic 0.5 0.6 0.5 terventions that have been implemented, such as hip protectors,
Other 2.7 2.6 2.7 <0.001
fall alarm devices and removal of physical restraints, and these
Psychotropic or 30.3 27.2 30.8 0.025
hypnotic medication interventions had variable results in reducing the risk of falls in acute
administered during care settings.3
hospitalization (%) The results of this study showed the ACE unit decreased the risk
Length of stay of falls by 73% compared to the GMS units. The decrease in risk of
(Mean ± SD) 6.8 (6.9) 6.9 (6.4) 6.8 (6.9) 0.581
Morse Fall Score (%)
falls could be mainly attributed to the senior-friendly environ-
Low risk (0–24) 9.6 10.8 9.4 0.002 ment and equipment, multidisciplinary care between health workers,
Moderate (24–44) 21.0 16.9 21.6 and the proper addressing of elder-specific needs. All of these re-
High (>44) 69.4 72.3 69.0 sulted in decreased impairment and increased functional outcomes.
(Mean ± SD) 56.3 (23.1) 57.9 (24.1) 56.0 (23.0) 0.018
Also, some fall preventive methods are available in the ACE unit as
Falls Incidence Rate per 5.2 (4.4, 6.1) 5.1 (2.5, 7.6) 5.3 (4.4, 6.2) 0.907
1000 patient-days well as in the GMS units but are usually followed more strictly in
(95% CI) the ACE unit. These measures, which include physical therapy, pro-
viding an assistive device when needed, avoiding restraints, avoiding
catheters, having bedside commodes, and daily reviewing of the
medication, play a critical role in preventing falls in the hospital.
Vuong test confirmed that this decision was the appropriate one.22 Introduced earlier, a meta-analysis done by Fox et al., in 2012
The unadjusted ZIP model estimated an IRR of 0.18 (95% CI 0.09, showed ACE units decrease the risk of falls in the hospital for older
0.37; P < 0.001) for falling among patients in the ACE unit com- adults by 49% without increasing the cost of hospitalizations.15 To
pared to those in the non-ACE units, a significant 82% reduction in measure the relative risk reduction of falls of ACE unit compared
the incidence of falls in the ACE unit. The final, adjusted ZIP model to usual care, they included two trials with a total sample size of
estimated a somewhat lower but significant 73% reduction in the 749. They reported a relative risk of 0.51; 95% CI, 0.29–0.88;
incidence of falls for patients in the ACE unit when compared to P = 0.02.15
patients in the non-ACE units; the IRR was 0.23 (95% CI 0.13, 0.54; There was also a quasi-randomized controlled study done in
P < 0.001) after adjusting for age, sex, medications, and MFS (see 2011 by Wald et al. that compared an ACE unit to a general medical
Table 2). unit. Although they found the ACE unit had improved recognition
There was a significant increase in the incidence of falls in pa- of abnormal functional and cognitive status, it did not show any im-
tients who received one dose or more of any psychotropic or provement in decreasing the risk of falls in patients admitted to the
hypnotic to those who did not receive any doses of these medica- ACE unit.12 However, their study had several limitations which af-
tions during their hospitalization (adjusted IRR: 1.67; 95% CI, 1.17– fected the generalizability of the results. It was a single-center, non-
2.37; P = 0.004). Male sex was also associated with decreased risk blinded retrospective study with a small sample size, as it included
of falls (adjusted IRR: 0.54; 95% CI, 0.38–0.76; P < 0.001). Table 2 only 217 patients. Additionally, the study was started 3 months after
shows factors associated with the incidence of falls, namely the type the unit being established with a follow up duration of 6 months
of unit, medications, sex, age, and MFS. only.12
A 2015 study that examined the two-year fall rate differences
between non-subspecialty units as well as hospital characteristics
found that 87% of the variation in fall rates could be attributed to
Table 2 between-unit differences. High fall rates were linked to higher patient
Adjusteda incidence rate ratio for selected variables related to the risk of hospital volume, which may indicate that variables such as patient turn-
falls. over could predict an increased risk of falls thus representing a
Variable Adjusted incidence P-value potential area for future study.24
rate ratio (95% CI) The use of one or more of psychotropic medications and hyp-
Acute care for the elderly (ACE) unit 0.23 (0.13, 0.54) <0.001 notics was associated with a higher risk of falls in the current study.
hospitalization Previous studies have also shown that these medications increase
Age 0.98 (0.96, 1.00) 0.056 the risk of falls in the geriatric population.25–31 Clinicians should
Sex
weigh the risks and benefits of adding or withdrawing these
Female (reference) –
Male 0.54 (0.38, 0.76) <0.001 medications in hospitalized elderly patients, taking in consider-
Medications ation the increased risk of falls and its mortality, morbidity, and
No (reference) – financial burden.
Yes (received one or more dose of 1.67 (1.17, 2.37) 0.004
The results of this study also showed female sex as a risk factor
any hypnotic or psychotropic)
Morse Fall Score
for falls in the geriatric population while they are admitted to the
Low (0−24) (reference) – hospital. This correlates with previous studies assessing gender dif-
Moderate (25–44) 1.41 (0.56, 3.56) 0.464 ferences and unintentional falls in elderly populations.32,33 This could
High (45–125) 2.06 (0.88, 4.80) 0.095 be attributed to muscle weakness, higher prevalence of osteopo-
a Adjusted for all variables in the table. rosis and loss of lower body strength in females compared to males.33
 A. Abdalla et al. / Geriatric Nursing 39 (2018) 292–295
The main limitation of this study is the way the effect of psy-
chotropics and hypnotics on the incidence of patient falls was
measured. Patients who received one dose or more of any psycho-
tropic or hypnotic were compared to those who did not. The details
of the prescribed drug were not specified (name of the drug, dose,
and the number of doses), therefore the medications that were as-
sociated with a greater risk of falls couldn’t be identified. Another
limitation of the study is that it did not adjust for other variables
that could potentially affect the incidence of falls, such as poly-
pharmacy and decline in cognitive status.
Conclusion
In summary, this study reported the benefit of the ACE unit in
reducing the incidence of falls in hospitalized elderly patients. In
this sample of older patients admitted to the institution, the ACE
unit was found to decrease the incidence of falls by 73% compared
to GMS units after adjusting for potential confounders. In addi-
tion, this study also highlighted the increased risk of falls in geriatric
patients when psychotropics and hypnotics are administered. Further
studies are needed to indicate whether hospitals should consider
having an ACE unit to decrease the risk of falls in the geriatric pop-
ulation without increasing the cost of hospitalization.
Acknowledgments
The authors would like to thank Kay Taylor and Katherine Negele
for their help in English language editing and proofreading this
manuscript.
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