Evaluation of the Aged Care Emergency (ACE) Program

The Aged Care Emergency (ACE) program is a complex intervention with seven elements designed to improve the capability of Residential Aged Care Facilities (RACFs) to avoid transferring acutely unwell residents to the Emergency Department (ED). When transfer is necessary, the ED is informed about the residents and their care needs, including advanced care planning, allowing residents to have their care coordinated in ED. This supports avoiding hospital admission where only ED care is required. The ACE advanced practice nurse from the local health district and the primary care organisation together coordinated the implementation with assistance of a nurse educator and administrative support. A governance committee representing the health service, primary care organisation, RACFs and ambulance oversaw the implementation. Essential elements of ACE 1. A 24-hour nurse-led telephone consultation service for staff in RACFs provided by registered nurses (RNs) in the ED during the day and after hours by RNs from the local general practice organisation. 2. Evidenced based algorithms for common acute symptoms and problems experienced by residents from RACFs, developed in consultation with multi-disciplinary hospital and community based clinicians along with RACF clinical leaders and the ambulance service. 3. If transfer is required, the telephone call also clarifies the reason for transfer to hospital through establishing the resident’s goals of ED care. 4. Once in the ED, the resident receives proactive case management, under the guidance of specialist aged care nurses. When the resident is transferred to the ED, the aged care nurse prioritises assessing the patients and managing them in accordance with the clinical handover from the RACF including care in line with their goals of care. They do not require referral from an ED doctor in order to see the patient. 5. Empowerment of RACF staff occurs through education in communication techniques including effective clinical handover, recognition of the deteriorating patient, and the evidence based ACE algorithms. 6. The community of practice supports relationships and collaboration across RACFs, GPs, ambulance, local hospitals and EDs with a shared understanding of the capability of each service. Quarterly meetings are held to identify barriers and facilitators of care. Regular governance and operational meetings are also held with clinicians and managers. Every RACF is assigned a home ED. 7. Ongoing change management and coordination for the ACE program key stakeholders. Prior to the intervention, participants receive usual care with staff in the RACF determining when patients are transferred to the ED, sometimes with the support of their families and General Practitioners when residents are acutely unwell. In the ED, they received usual care. The study design was a non-randomised stepped wedge design with 10 steps. Each step contained between 4 and16 RACFs, with an average of 7 RACFs in each sequence. RACFs allocated to each sequence had an average of 84.7 beds with a minimum of 31 beds and maximum of 188 beds. The duration between steps varied, ranging from one month to 21 months. There was a 12 months baseline period prior to the intervention as well as a 12 month follow up period. Each step had a 3 month transition period for the intervention to be implemented. All 10 steps were implemented over 48 months. Random allocation of RACFs to steps was not undertaken for logistical reasons, to ensure that the intervention could be adequately delivered and supported within constrained resources and to reduce the chances of contamination by keeping clusters from similar regions together. As each region received the intervention, the local hospital EDs were partnered with all RACFs and recruited into the program. For pragmatic reasons, early steps focussed on metropolitan RACFs while later sequences included regional RACFs.