This issue of Critical Care Nursing Quarterly focuses on the challenges of geriatric care in acute tertiary hospital settings. Featured are several complex issues that are being addressed at Penn State Hershey Medical Center (PSHMC), a 500-bed teaching and research hospital located in rural central Pennsylvania. Annually the PSHMC admits more than 26 000 patients, accepts more than 766 000 outpatient visits, receives nearly 48 000 patients for emergency department visits, and performs more than 23 000 surgical procedures. As in healthcare settings across the country, the predominant recipients of these services are older adults.

In their article, Kanaskie and Tringali present the complexities of nursing care of elderly cancer patients. They describe the importance that nursing care has to quality of life for elderly patients treated at the Penn State Cancer Institute. Humbert and her colleagues describe how nurses are making a difference in care outcomes for critically ill elderly diabetic patients through implementation of intensive intravenous insulin therapies. In another important area of nursing in acute care, Dawson describes an end-of-life situation when care and treatments for cancer or other chronic conditions are no longer tenable. In related articles, Schirm and colleagues provide evidence for use of a tool to initiate conversations and discern preferences for care at end of life. In addition, Espinosa and colleagues provide an evidence-based literature review on the difficulties that intensive care nurses frequently confront when it becomes necessary to provide end-of-life care. A multifaceted approach to falls reduction in acute care is presented by Murphy et-al. This article highlights the PSHMC TEACH (Transitioning Elders Across the Continuum of Healthcare) program and stresses the importance of nurse involvement in the sustainability of falls prevention and reduction programs. Ballentine also addresses in his article that active involvement by care providers at all levels is paramount to understanding appropriate medication use by elderly patients. In separate but related articles, Himes and Merriman show how PSHMC is dealing with the complexities associated with hospital discharge of elderly patients. They describe the components that are needed to ensure safe and cost-effective care to elderly patients after acute hospital care is no longer appropriate. Hertz and colleagues also offer nurses more information that can be used to better prepare patients and families for discharge. They present an updated evidence-based practice guideline to assess relocation risks of older patients. In comparison to these authors, who described the difficulties and solutions associated with the discharge process for older adults and their families, Sparks offers the admonition of "do not hospitalize" for dementia patients. Despite this caution, Sparks notes that it is well recognized that many elders with Alzheimer disease may need hospital care at some point, and she delineates several evidence-based nursing practices that can ease the distress associated with hospitalization. The article by Heffner and Rudy points out that knowledge and skill development in critical thinking help nurses provide age-appropriate care to hospitalized elders and their families. Sarsfield also describes the continuous improvement process as another nursing skill that is used to enhance care of older patients in critical care environments.

As these authors show, the care of increasing numbers of elders who are patients in critical care creates challenges within a complex health system. In the hospital environment, the focus is on technical care and cure, and disease and symptom management in elders are often complicated by multiple comorbidities. These factors make them more vulnerable to risks, such as polypharmacy, transitional stresses, and adverse events like falls. Nurses and other care providers in hospitals must understand and manage the array of complex needs of elders and their families. It is our hope that this issue of Critical Care Nursing Quarterly not only provides a thoughtful overview of these issues but also offers solutions that can be used and applied by nurses in other healthcare settings.

Victoria Schirm, PhD, RN

Judy Norris Himes, MSN, CNA, BC

Tamara H. Murphy, MS, APRN, BC, CCRN

Issue Editors, Department of Nursing, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania