None listed
Conditions
Brief summary
Background: Older people living in Residential Aged Care Facilities (RACF) are a vulnerable, frail and complex population. They are more likely than people who reside in the community to become acutely unwell, present to the Emergency Department (ED) and require admission to hospital. For many, hospitalisation carries with it risks. Importantly, evidence suggests that some admissions are avoidable. A new collaborative model of care, the Aged Care Emergency Service (ACE), was developed to provide clinical support to nurses in the RACFs, allowing residents to be managed in place and avoid transfer to the ED. The purpose of the study is to examine the effects of the ACE service on RACF residents’ transfer to hospital using a controlled pre-post design. Methods: Four intervention RACFs were matched with eight control RACFs based on number of total beds, dementia specific beds, and ratio of high to low care beds in Newcastle, Australia, between March and November 2011. The intervention consisted of a clinical care manual to support care along with a nurse led telephone triage line, education, establishing goals of care prior to ED transfer, case management when in the ED, along with the development of collaborative relationships between stakeholders. Outcomes included ED presentations, length of stay, hospital admission and 28-day readmission pre- and post-intervention. Generalised estimating equations were used to estimate mean differences in outcomes between intervention and controls RACFs, pre- and post-intervention means, and their interaction, accounting for repeated measures and adjusting for matching factors. Results: Residents of the aged care facilities were old with an average age of 86 years. ED presentations were common. With transfers ranging from between 16 and 211 visits for every 100 beds in the RACF beds/year across all RACFs. There was no overall reduction in ED presentations (OR=1.17, p=0.56) with the ACE intervention. However, when compared to the controls, the intervention group reduced their ED length of stay by 45 minutes (p=0.0575), and was 40% less likely to be admitted to hospital, .The latter was highly significant (p=0.0012). Transfers to ED and admission to hospital are common for residents of RACFs. A complex multi-strategy intervention led by nursing staff can successfully reduce hospital admissions for older people living in Residential Aged Care Facilities. By defining goals of care prior to transfer to the ED, clinicians have the opportunity to better deliver care that patients require. Integrated care requires accountability from multiple stakeholders.
Interventions
Intervention:
The ACE service model of care comprised
1. An ED advanced practice nurse with aged care skills, (ACE Clinical Nurse Consultant) who led and coordinated the ACE service.
2. More than twenty evidence based algorithms, developed in consultation with clinical experts, and RACF staff in the region, were standardized for the management of common problems for RACF residents: for example, falls, shortness of breath and indwelling urinary catheter issues. These are available at http://www.e
Intervention: The ACE service model of care comprised 1. An ED advanced practice nurse with aged care skills, (ACE Clinical Nurse Consultant) who led and coordinated the ACE service. 2. More than twenty evidence based algorithms, developed in consultation with clinical experts, and RACF staff in the region, were standardized for the management of common problems for RACF residents: for example, falls, shortness of breath and indwelling urinary catheter issues. These are available at http://www.ecinsw.com.au/ace 3. The ACE Clinical Nurse Consultant (CNC) who commenced in October 2010, 5 months prior to the intervention, worked with RACF and ED staff to develop, test and the refine the algorithms and provide education and training. The manual of algorithms guides and supports RACF staff to manage acutely unwell residents in situ and is used as a reference source by RNs, AINs, PCAs, GPs and ED staff. 4. An education program for clinical staff in RACFs, prior to the introduction of the model supported using the manual of algorithms. The education service provided onsite by the ACE CNC, for the study RACF staff. The program constituted two hours of presentation with ongoing education provide as required or requested provided in groups. 5. An ED RN led telephone consultation service for RACF staff, 12 hours during the day, 7 days a week to provide clinical support, assist decision making in the RACF as well as receive clinical handover when the resident required transfer. The four ED RNs were all advanced care nurses with skills and experience in aged care nursing. Their role included identification of care needs, care planning and advocacy for the older person. 5. Establishment of the purpose of the ED transfer based on the older person’s goals of care by the RACF staff, with support from the ED Registered Nurse (RN). 6. Proactive case management, aligned to the goals of care in the ED by the ED RNs. 7. A collaborative respectful relationship with RACFs, ambulance, EDs, GPs and the primary care organisation, working together to achieve optimal patient outcomes. 8. video-telehealth consultation was added to this study between July 2016 and August 2017 as an additional component to the ACE program for acutely unwell residents in RACs. The intervention occurred for 9 months. The program, including written material, presentations and phone support, was only available to the 4 intervention RACFs, maintaining fidelity of the study. It has since been rolled out to other sites. Staff worked only within the intervention RACFs.
Sponsors
Hunter New England Local Health District
Study design
Allocation
Non-randomised trial
Intervention model
Other
Primary purpose
Treatment
Masking
Open (masking not used)
Eligibility
Sex/Gender
All
Age
75 Years to No maximum
Healthy volunteers
No
Inclusion criteria
The intervention groups were four residential aged care facilities (RACFs) who frequently referred patients to the Emergency Department. All resident transfers were reviewed in the hospital information system. The 4 intervention RACFs were purposefully chosen as they frequently transferred patients to the ED, more commonly than other RACFs. They had previously participated in focus groups that identified barriers and facilitators to quality management of acutely unwell residents as RACFs that frequently transferred patients to the ED.
Exclusion criteria
Only residents from the 4 residential aged care facilities were included. All other Residential aged Care Facilities were excluded.
Outcome results
None listed