Aged Care Emergency (ACE)

Service

Jacqui Hewitt

ACE CNC, Patient Flow, HNE

Dr Carolyn Hullick

Senior Staff Specialist Belmont ED and Clinical Governance

Mr B, 82, COPD sufferer. In the last year of his life…

38

18

160

25

2

ED presentations

hospital admissions

blood tests

x-rays

ultrasounds

Mr B died in the

emergency department

Background

• Hospital transfers and admission pose risks for older people

with complex health problems living in Residential Aged Care

Facilities (RACFs)

• Risks include delirium, falls, pressure injuries, medication

errors

• Potentially avoidable presentations to ED include:

management of chronic conditions, infections, wound

management, cough, urinary symptoms etc.

• Can often be safely and effectively managed in the RACF

ACE model

• Previously RACF staff recognised a deterioration patient and

called 000

• Using ACE; http://ace.healthpathways.org.au/

– Complete a full assessment for clinical handover and contact

GP. Patient Goals of Care essential part of conversation

– GP unavailable, call ACE on 1300 223 555

– During business hours: call directed to ASET nurse in local

ED

– After hours: call directed to ACE RN at GP Access After

Hours in Newcastle

– Clinical support provided using algorithms and decision

made to transfer to ED or treat in RACF

ACE model

• ACE nurse coordinates sharing of clinical information

between RACFs, GPs and ED

• RACFs organise Ambulance if necessary and organise all

supporting documents

• ACE resources: evidence based clinical manual, website,

newsletters, interagency meetings, brochures, posters,

training workshops and the telephone support provided by

RNs

• Collaborative partnership between Hunter Primary Care,

Hunter New England Local Health District, RACFs,

Ambulance NSW and GPs

• MoU between HNELHD and HPC guides practice and policy

ACE Model

• ACE

Stakeholders

History of ACE

• 2012- A 2 year pilot concluded at JHH Newcastle

• Now, approx. 80% of RACFs in Hunter region (Newcastle,

Lake Macquarie, Maitland, Upper Hunter,Tomaree, Armidale

Tamworth and Manning region) have implemented the

system (6500 RACF beds)

• EDs participating include JHH, Belmont, Calvary Mater,

Maitland Hospital and Manning Rural Hospital, Tamworth,

Armidale, Singleton and Tomaree Community Hospital

• ACE is an established and successfully integrated service

and in 2014/15 was awarded; – The Medicare Local Innovator of the Year ( National)

– 2 Hunter New England Quality Award for Building Partnerships and Integrated health care

– Innovation grant to introduce telehealth

– A National Better practice award from the Aged Care Quality Agency “EmbrACE the ACE” submitted by BUPA

2012: Pilot Results and Evaluation

JHH ACE pilot in 2011 from the 4 RACFs compared with 2009

and 2010 ACE pilot with 4 RACFs: 1st April to 31st December 2011

2009 2010 2011 2010 to 2011

ED presentations

Case study

group 399 421 353 16% down (p=0.009)

Control group 402 403 419 4% up

All patients over

75s 12538 12994 13696 5% up

ED admissions

Case study

group 233 278 226 19% down

Control group 229 245 282 15% up

All patients over

75s 7054 7766 8515 10% up

Total inpatient bed

days

Case study

group 1764 1725 1135 35% down

Control group 2001 1814 2074 14% up

ACE Evaluation 2015

• Key results from Hunter Medical Research Institute's (HMRI)

Evaluation of ACE

• Measured costs/savings and stakeholder perceptions

• ACE has resulted in annual savings of $920,000

• Calls to ACE that resulted in residents being managed in the

RACF (i.e. ED transfer prevented)

during business hours- 74%

after hours- 86%

Stakeholder perceptions

• “If ACE was stopped we would likely get a whole lot more,

mostly inappropriate, presentations for things that could be

readily managed in the aged care home….it would impact on

our ability to manage the rest of our activity and meet our

targets.” (ED staff member)

• “ACE is like having another RN on staff to speak with about a

patient. Often we can’t access the RN or they only work days

so it is important we have access to clinical advice and ACE

provides this.” (RACF staff)

Key messages

• Reduced potentially avoidable presentations to ED with;

– Reduced associated risks

– Reduced ED congestion

– Reduced demand on Ambulance service

– Reduced economic burden on health services

– Improved access to resources for those in most urgent need

• Improved quality of clinical handover with better informed decision making

• Ensuring residents of RACFs receive the most appropriate care in the right

setting

• ED management accountable for ensuring the ACE phone is answered

ACEM: Choosing Wisely Commitment

• For Emergency Department patients

approaching end-of-life, ensure clinicians,

patients and families have a common

understanding of the goals of care.

Patient centred care

• When ACE is used - Care occurs in the RACF 86% of the

time( ACE evaluation 2015)

• If transfer is necessary - it will be to a hospital much closer to

home (Tomaree Ambulance P3 data)

• 70% of people would prefer to die at home if they were

comfortable and well supported. Despite this, around 54% of

Australians die in hospitals.

Tomaree ACE experience

Ambulance

transfers

To

Tomaree

To JHH

or CMN

11/12 to 1/13 50 114

11/14 to 1/15 29 31

Reduction in

transfers

31 83

Ambulance

Km saved

17 900

Conclusions

• RACF patients are increasingly frail and complex

– Acute hospitalisation is risky and often not the best place

• Build relationships, collaboration and trust

– Understanding the strengths and challenges of each environment has

improved the care for our patients

• ACE is about Clinical Handover

– GPs, HPC Streaming Service call staff and ASET have already

praised improved handover from RACF staff as a result of ACE

education. Improves more timely review by GP

• Goals of Care essential part of the conversation

Mrs G, 84, complex needs in residential aged care

5

19

15

6

3

2

ED presentations & admissions

bed days

medications

abdominal x-rays

abdominal CT scans

MRIs

Couldn’t come to the phone

She was shopping

Publications

2015 Publications

Conway, J; Dilworth S, Hullick C, Hewitt J, Turner C, Higgins I. A multi-organisation aged

care emergency service for acute care management of older residents in aged care

facilities. Australian Health Review 2015, 39, 514–516

Conway J, Higgins I, Hullick C, Hewitt J, Dilworth S. Nurse-led ED support for Residential

Aged Care staff: AN evaluation study. International Emergency Nursing 2015, 23 (2) 190-

196

Stokoe A, Hullick C, Higgins I, Hewitt J, Armitage D, O’Dea I Caring for acutely unwell older

residents in residential aged care facilities: Perspectives of staff and general practitioners,

Australian Journal of Ageing Published ahead online 9 JUN 2015 DOI: 10.1111/ajag.12221

Briggs S, Pearce R, Dilworth S, Higgins I, Hullick C, Attia J Clinical pharmacist review: A

randomised controlled trial, Emergency Medicine Australasia 2015 27 (5) 419–426

Kable A, Chenoweth L, Pond D, Hullick C. Health professional perspectives on systems

failures in transitional care for patients with dementia and their carers: a qualitative

descriptive study BMC Health Services Research 2015 15:567

References

There are 70 current references. If you

would like me to send you the list

Please contact me at

Jacqueline.hewitt@hnehealth.nsw.gov.au

Thank you!!!

Hunter Medicare Local (Now Hunter Primary Care) , Hunter New England

Central Coast Primary Health Network, Australian Government, NSW Health,

NSW Ambulance, HNE Health and all the staff, patients and their families in

RACFs for funding and support