Transitions of care case study: Aged Care Emergency service

Conjoint Associate Professor Carolyn Hullick is an emergency physician and was clinical lead on the work to develop ACE. Dr Hullick is also the Commission’s Chief Medical Officer.              

What has been your involvement with ACE?

As Director of Emergency Medicine at John Hunter Hospital in Newcastle, I worked with Aged Care Services Emergency Team (ASET) nurses to investigate why some residential aged care facilities (aged care facilities) were sending so many residents to ED. We had focus groups with all the different providers – GPs, ED nurses, aged care workers and paramedics – and we talked about how they managed acutely unwell older people and what they needed. The findings of those focus groups laid the groundwork for the ACE program.

Why was ACE needed?

We heard in the focus groups that if a resident became acutely unwell, facilities would invariably call an ambulance to transfer that person to ED and that the GP was often not involved. Aged care facility staff were skilled in caring for people with dementia – and knew and respected the residents – but most lacked acute care skills. In contrast to ED, which is all about teamwork, nurses in an aged care facilities are often on their own, some of them with complex behaviours. We needed to provide training and structure to manage acutely unwell residents. We need to build a team around them.

What has been the main impact of ACE?

ACE has connected aged care facilities and the health system and has trained and empowered aged care facility staff to care for acutely unwell residents. The 24-hour ACE telephone line has provided an opportunity for aged care facility staff to ‘phone a friend’ when they need support to manage an acutely unwell resident and to be part of a team. There are also agreed clinical pathways that underpin these calls. 

It has achieved a 20% reduction in hospital admissions and transfers to the ED. Importantly, it has successfully connected all parts of the system involved in caring for acutely unwell people living in aged care facilities. That network has been strong now for more than 10 years.

What have been the key elements in the success of ACE?

The ASET nurses and the community of practice are integral to its success. The community of practice oversees the program and supports relationships and collaboration across all stakeholders, including aged care facilities, primary care, hospitals, ambulance and the Local Health District. We need this collaboration because no individual provider can manage people who live in aged care facilities in isolation.

What elements of ACE promote safe and high-quality transitions of care?

ACE is all about transitions of care, especially improving clinical handover. Before ACE, ED staff often didn’t know why a resident had been transferred. One of the stories that stands out for me was an older man who had been sent to the ED with a sore hip but came back with a pacemaker. Without knowing why he was in ED, hospital staff recognised he had a heart problem and admitted him under a cardiologist. The cardiologist put in a pacemaker and sent them back to the aged care facility, but he still had a sore hip.

ACE requires nurses in aged care facilities to define the purpose of the ED transfer and the older person’s goals of care before transfer. They call and discuss this with the ASET nurse. Once in ED, the ASET nurse provides case management aligned with those goals of care. 

Final word

There are messages in the media that older people are filling up ED. Older people have every right to be in ED. ACE is not about stopping older people from going to hospital. It’s about only transferring those who need to be there, and once in ED, that we do the right thing by them in line with their values and goals of care.

What has been your involvement with ACE?

I work as the Aged Care Emergency (ACE) Clinical Nurse Consultant. The ACE service is a partnership between Hunter New England LHD, Hunter New England Central Coast PNH and Hunter Primary Care. My role is to work with our partners to provide the ACE service, build the capacity of aged care facility staff, improve communications and collaborations, and reduce avoidable presentations of aged care residents to EDs. I’m a conduit between the aged care facilities and the health system. Much of my role involves care navigation, building relationships, reviewing and maintaining the currency of the ACE website and manual, and accessing training opportunities for aged care staff and our community of practice.

What has been the main impact of ACE?

ACE has supported aged care facility staff to provide the care for residents at home and reduce unnecessary transfers to hospital. A lot of people think that for ACE to be effective, we need to stop a transfer to hospital. That's not the case. ACE’s primary role is to support and empower and build the skills of aged care facility staff. By doing that, we have successfully reduced the number of unnecessary transfers to hospital.

What have been the key elements in the success of ACE?

Mutual respect is really important. The ACE community of practice has built connections and relationships between the health system, our primary health partners and aged care facilities.

The focus on communication and clinical handover has also been critical. The ACE model encourages the facility to have structured information available to share with the health system, so we can make the informed decisions. The clinical algorithms in the ACE manual and support at the end of the phone has meant RNs in aged care facilities feel more confident to make decisions.

What elements of ACE promote safe and high-quality transitions of care?

ACE promotes structured clinical handovers and clear goals of care for the resident. The ISBAR (Identify, Situation, Background, Assessment and Recommendation) training and documentation encourage staff to have all the correct information for their clinical handover. The algorithms promote conversations with the resident and the family to identify the goals of care before the resident is transferred to ED.

Final word

I see myself as a strong advocate for aged care in the health system. We need to acknowledge the wonderful work that aged care staff are doing and the challenges they experience and that they provide a very complex service in the community.

What has been your involvement with ACE?

Hunter Primary Care runs the GP Access After Hours service. Calls from aged care facilities have always been a large part of our role in the after-hours service.

Why was ACE needed?

Calls from aged care facilities to the GP Access After Hours line were often frustrating, essentially due to poor clinical handover. GPs were part of a four-week roster and often didn’t know the patient. They were being contacted by an RN who frequently also did not know the patient because they hadn't been rostered on for a few days or they were agency staff. Patients were being transferred to ED without the GP’s knowledge.

What has been the main impact of ACE?

My feeling is that the volume of calls from aged care facilities to the GP Access After Hours service has gone down and call quality has gone up due to ACE.

The aged care facility nurse now has a clear process to follow to collect relevant clinical information before they call the ACE line or GP Access. They are often able to resolve many issues without calling. When aged care facility nurses do call, they are usually able to communicate the history clearly and succinctly and it’s often relatively easy to make a clinical decision without needing a face-to-face visit. That has been a significant difference. 

What have been the key elements in the success of ACE?

A package of measures is contributing to its impact. Most RNs in aged care facilities are able to deal with clinical problems within their scope of practice. ACE provides a systematic process and education that support RNs to use their clinical judgement before calling ACE or GP Access. 

What elements of ACE promote safe and high-quality transitions of care?

ACE has emphasised goals of care – consideration of what the patient and/or the family want in terms of escalation of care. The ISBAR-type communication has emphasised goals of care. This is extremely helpful for GPs taking calls after hours.

Final word

I’ve had feedback from GPs who work in aged care facilities that they are under a lot of stress. Many are at breakpoint. It could be reasonably argued that, without ACE, they would have hit that breakpoint some years ago, but it’s hard to quantify. ACE is an important initiative to be considered seriously and rapidly in the context of workforce issues for both aged care facility staff and GPs providing primary care services in aged care.

What has been your involvement with ACE?

I was the original clinical nurse consultant for the ACE program and worked in that role until the end of 2017. In my current role with the Hunter New England and Central Coast PHN, 
I work with the Hunter New England Local Health District (LHD) to coordinate the ACE community of practice.

Why was ACE needed?

When I was an Aged Services Emergency Team (ASET) nurse at John Hunter Hospital ED, I saw a lot of patients from aged care facilities with hospital-avoidable issues, such as replacing indwelling catheters, simple UTIs and simple wound management after a fall. We often didn't know why they had come to the ED because there was little or no handover. 

How did the ACE model come about?

At John Hunter Hospital ED, the doctors would work with the ASET nurses to plan what we needed to do for each older patient. It was the most collaborative teamwork between nursing staff and medical staff in my 35 years of nursing. Out of those efforts to get the right outcome for patients, ED Director Dr Carolyn Hullick and I started talking about how we could make it better and improve communication between the aged care facilities and the hospital. We met with four aged care facilities and some resident GPs and held focus groups to work through the issues and discuss possible solutions. 

What have been the key elements in the success of ACE? 

I think there are three key elements: standardised clinical handover by using the ISBAR (Identify, Situation, Background, Assessment and Recommendation) framework for aged care; being clear in defining the goal of care if a resident is transferred to ED; and the ACE community of practice and the relationships it has built.

What elements of ACE promote safe and high-quality transitions of care?

ACE focuses on ensuring we ask: what are we doing for this patient and is it line with what the patient and their family wants? While everyone in an aged care facility is on an end-of-life trajectory, not every issue is an end-of-life issue. It's working out the mixture of comfort care versus active treatment to bring them back to baseline.

Can you describe a patient who benefited from ACE? 

The patient I have in mind is an example of common transfers from aged care to ED before ACE. This man had chronic obstructive pulmonary disease and had 38 ED visits and 164 blood tests in the final six months of his life. He was treated as a new patient with an acute issue every time he was sent to ED. He died alone in a hospital corridor on one of those visits. At no time had anyone asked the man or his wife about his goals of care. The ACE process makes people ask questions around the goal of care. This man’s goal of care should have been comfort measures. ACE would have prompted the facility to question whether ED was the right place for this person and to talk to his family. 

Final word

We've got to be careful that the ACE nurse does not become the gatekeeper for ED. That's not what ACE is about. It should be a collaborative discussion and doing what's right for the patient. Frequently, due to pressure in the ED, there can be pressure to push back and not be collaborative.

What has been your involvement with ACE?

The three Northern Coalfields Community Care facilities work with ACE. I've worked with the ACE model since it started. In my previous role, I was a general manager across 12 facilities and was involved with the ACE program. 

Why was ACE needed?

ACE was needed to support RNs in aged care facilities because there are so many reasons not to transfer a resident to ED if we can avoid it: our residents are on an uncomfortable bed in line for a long time; there’s an increased risk of infection and pressure injuries; and being in an unfamiliar environment affects their cognitive impairment.

Before ACE, if a resident was unwell, we would always send them to hospital. We would ring an ambulance – 000 if it was an emergency or book transport. There was never any communication with the hospital to notify them of the transfer. A lot of people who went to hospital were sent back without having a thorough review.

What has been the main impact of ACE?

Now when a resident is unwell, our nurse contacts the ACE nurse and uses the ISBAR (Identify, Situation, Background, Assessment and Recommendation) system to provide the clinical details and observations of the resident’s situation. 

The most important thing is that ACE has reduced unnecessary transfers. There is better communication between our facilities and the hospital system and increased support and education for RNs in our facilities. 

There are benefits beyond ED transfers. The ACE operational meetings have kept us up to date about key issues, such as changes to psychotropic medications and the COVID-19 pandemic. ACE provides information and education to the aged care sector and organised for PPE and rapid tests to be provided to the aged care facilities.

What have been the key elements in the success of ACE?

A key factor is that ACE has opened up communications between aged care facilities and the health system and brought the two systems together. If we have any concerns, we can contact the ACE team and they can contact us. The clinical support and education provided to our RNs has changed the way we work. Our nurses have someone to call, but they're also learning all the time so that they can handle things on their own. 

What elements of ACE promote safe and high-quality transitions of care?

ACE focuses on providing education and support to RNs in aged care facilities so they have the confidence to monitor residents and to not always send people to ED, particularly when they are end of life. 

Can you describe a patient who benefited from ACE? 

We had a resident who had an infected wound. By using telehealth and ACE, we were able to arrange a GP in the after-hours service to look at the wound and chart the antibiotics. The GP sent the scripts and the patient was managed in the facility. The communication between the GP, aged care and the acute care sector using ACE and telehealth avoided the transfer and the resident was happy with the service. 

Final word

ACE is a tremendous system that has the support of the aged care sector. 

What has been your involvement with ACE? 

Hunter Primary Care coordinates the ACE phone service, which sends phone calls to the aged care facility’s designated ED during business hours and then to the GP Access After Hours phone line. The phone calls are recorded so we can improve the service and address concerns if they are raised. 

My role in the ACE program is to facilitate and coordinate the community of practice. I also conduct a lot of the education. I work very closely with Roslyn Barker, the ACE CNC in the Hunter New England LHD. 

What are the benefits of ACE?

ACE provides clinical decision support and support for clinical handover if transfer of a resident to hospital is required. The clinical decision support is especially important for new graduates, overseas-trained nurses new to the Australian health system and carers. In aged care, often the RN is on their own so that support and decision making is critical when they don’t have a peer to consult.

The ACE community of practice has also been a key channel for updates during the COVID-19 pandemic. The LHD arranged for the HNE Public Health Unit to provide updates to our regular meetings, for example, from the head of the Public Health Unit and the Director of Nursing. We had up to 100 people online every week to listen to the latest advice at the peak of the pandemic.

What have been the key elements in the success of ACE?

A key factor has been the connections that ACE has formed through the community of practice. It has brought everyone together – from aged care facilities, EDs and hospital staff, to paramedics and GPs. Before ACE, we didn't understand the constraints of the different clinical environments and resources each organisation had access to. ED thought aged care nurses transferred residents to ED because it was easier, which is just not the case. And a lot of aged care facilities staff didn’t understand the role of ED and how busy it is. It really isn't the best place to manage older people with chronic illnesses. 

What elements of ACE promote safe and high-quality transitions of care?

Everyone can do a good clinical assessment and handover if they follow the ACE process. We've had some brilliant handovers from assistants in nursing (AINs) I remember one case where a facility manager asked why a person wasn’t transferred to hospital after a fall. When I listened to the call, the AIN had completed a great ISBAR (Identify, Situation, Background, Assessment and Recommendation) handover. The resident had bruising on the leg, but there was no significant injury that required transfer to ED. The call taker was able to make a sound clinical decision based on the information provided. 

Final word

ACE is about developing and maintaining a community of practice that focuses on improving the healthcare experience for residents and sharing the latest evidence-based information to support older people living in aged care facilities. Those relationships take ongoing commitment. 

What has been your involvement with ACE?

Our three facilities use the ACE service. I’m a residential care representative on the ACE operational committee. I attend meetings and give insights about what's happening in our area. I've made it a policy that new RNs must complete ACE education and that RNs have to call ACE before they transfer anyone to hospital unless it's a triple zero call. 

Why was ACE needed?

Before ACE, if a resident became unwell and we couldn't arrange a GP review, we would always call an ambulance and transfer the resident to hospital. At times the emergency department wasn’t notified to say that we were sending them.

What has been the main impact of ACE?

The major impact has been that our residents are not being transferred unnecessarily to hospital. 

We always ring the ACE number if a resident is unable to get in touch with the GP and the resident requires medical treatment above the RN’s scope of practice. Sometimes, the resident, their family or a GP requests a transfer and we feel the resident would be better off staying at home. ACE has empowered the RNs to talk to GPs and say when they don't think a transfer to hospital is appropriate. 

We don't want to send our residents unnecessarily to hospital because we know how that can affect them physically and mentally. There's no place like home.

What have been the key elements in the success of ACE?

A key factor has been building relationships with ED staff and understanding each other’s worlds. There can be one RN to more than 80 residents depending on the facility. With ACE, ED staff now understand that we have skills and look after residents day in day out. We look out for these people and advocate for them to receive appropriate treatment. 

What elements of ACE promote safe and high-quality transitions of care?

ACE focuses on communication for handover, supporting RNs in aged care facilities to make sure they have all the documentation ready before they talk to the ACE nurse or GP. It ensures that ED staff have the appropriate information about the resident and what we hope to achieve by the transfer. The ACE resources are invaluable. 

Can you describe a patient who benefited from ACE? 

One of our residents had a fall and we needed to rule out a fracture. If there was a fracture, the family didn't want surgery – they wanted them to be kept comfortable at the facility. Before ACE, we would have just sent that person to hospital and they would have had to go through ED. In this case, the ACE nurse spoke to a doctor in the ED about the family’s wishes and explained the advanced care plan, which said no surgery. We were able to organise it so that this person was sent straight in, had the scan and was transferred straight home to the facility.

In another example, we had a resident who was mentally competent but was in high care because she had constantly leaking wounds from oedema. She developed chest pain one day and we called the ambulance. The ambulance refused to take her to hospital because she was in high care. I contacted ACE and explained that she was still capable of making decisions. ACE helped me to advocate for that resident to be sent to hospital. 

Final word

I don't know what we'd do without ACE. It's been a lifesaver for aged care. 

What has been your involvement with ACE?

I answer calls on the ACE phone line Monday to Friday, supporting nurses in residential aged care facilities. I also led a study that augmented the ACE service with the addition of visual telehealth.

How did the telehealth study work?

The study, called the Partnerships in Aged Care Emergency using Interactive Telehealth (PACE-IT), added vision to telehealth as part of the assessment and planning process. The visual telehealth platform connected the resident and their family, the residential aged care nurse and the ACE nurse in the local ED. Hunter New England LHD partnered with Western NSW LHD to conduct the project in four EDs and 16 aged care facilities.

What were the benefits of adding video calls to ACE?

We found that adding visual telehealth to ACE improved assessments and decision-making, and relationships and trust between the ED staff and the aged care nurses. It particularly helped new, inexperienced nurses or nurses who didn’t have English as a first language. A lot of them felt initially intimidated by the nurses in the ED and there was misunderstanding in different areas. The use of telehealth helped the ACE nurses to build rapport and trust with the aged care facility nurses because they could see each other and get to know each other. Telehealth also enabled the resident to be more involved in decision-making and gave them choice about their healthcare needs. A lot of the patients I spoke to over telehealth said they didn’t want to go to hospital. 

What elements of ACE – and the video calls – promote safe and high-quality transitions of care?

Some of the ASET (Aged Care Services Emergency Team) nurses valued the opportunity to see the residents. They felt that they needed to have their eyes on someone to do an assessment. Telehealth increases safety through enhanced communication and building on the ISBAR (Identify, Situation, Background, Assessment and Recommendation) handovers. 

Final word

ACE is an unsung hero of ED. Some days I might spend an hour and a half on one patient to find a safer management plan that doesn't include a visit to ED if the patient doesn’t need to go. When residents present to ED, they may interact with and rely on up to 30 ED staff and also be exposed to lots of health risks. One and a half hours is a small price to pay to avoid an ED visit and stay safe in the aged care facility. 

What has been your involvement with ACE? 

I’ve been involved in the development and the assessment of the ACE manual, and how we can encourage paramedics to use the manual and support RNs working in aged care facilities. I also work with ACE and the Public Health Unit during COVID outbreaks in aged care facilities.

What has been the main impact of ACE?

With ACE, when paramedics go to an aged care facility, we have the confidence that the RN has been well supported by a strategic and well-placed team within the LHD before the ambulance was called. We usually find that the RN has started patients on a treatment path and may request specific services from ambulance rather than just transport. We've got a team of Extended Care Paramedics, who offer care to our aged care facilities and people in the community who can remain out of the hospital. That means fewer visits to the emergency department for low acuity injuries or problems, and a reduction in the unnecessary transport of patients from an aged care facility into overstretched emergency departments. 

We still transport people to hospital from aged care facilities, but now we transport them with a package of information and expectation of care for each patient. This streamlines their care. 

What have been the key elements in the success of ACE?

ACE has enhanced integration for paramedics, nurses, doctors and ED with care in aged care facilities. It has created a shared philosophy of care for an older patient. It’s woven into the fabric of the system now.

What elements of ACE promote safe and high-quality transitions of care?

Understanding each other’s roles is important for safe transitions of care. We now understand the challenges GPs face and why they can’t come to see the patient. We also understand more about the pressure of being an RN in an aged care facility. 

Is there a particular patient who benefited from ACE?

At 7am one Sunday, an aged care facility nurse called ACE about a resident in her late 80s who was having a hypoglycaemic event. ACE said to ring the ambulance. The paramedics spent about an hour in the facility with the patient, the RN and the AIN. They gave her a high complex carbohydrate breakfast to increase her blood sugars and liaised with the ACE RN to discuss the change in the patient. We decided she didn’t need to go to ED. The RN was delighted because the patient’s family was arriving that day from Victoria. The RN kept that piece of information to herself until everything had worked out. ACE is not just about keeping people out of ED. It's a holistic approach of saying this is going to do this patient more good to stay here and see her family.

Final word

With ACE, a team of people cares for the patient supported by a long-term plan and goal for that patient. We are working together to better cater to that patient's needs in their residential environment. The aged care facility, the ED and the ambulance now have a shared philosophy of care tailored to each patient. 

How has Maroba been involved in ACE?

Maroba was one of the original ACE pilot sites and we are still part of the ACE program.

What are the benefits of ACE?

Viv: From my perspective, ACE has been a positive arrangement, apart from a few hiccups – having to get permission to get an ambulance can be frustrating when you've got an emergency on your hands. There is great information provided and exchanged in the ACE regular meetings. ACE has enabled a small service like ours to get to know our colleagues in other parts of the system and for them to get to know us and our capabilities. 

Linda: Most registered nurses in aged care are sole practitioners. But it's better to bounce things off another clinician to feel more comfortable in the decisions you're making. Having ACE on the end of the phone enables us to do that. The ACE manual is excellent for training. All new RNs are given a copy of that manual and the education that is organised through ACE is excellent.

But there are challenges. The biggest issue I have is when me as a senior clinician and a nurse practitioner and a very experienced GP want to transfer a resident to a hospital and ACE tells us that we can't. Sometimes we have to sell when we want a patient transferred. 

It’s always important to remember that the philosophy is to support aged care and deliver good quality care to residents irrespective of their age.

What have been the key elements in the success of ACE?

Viv: ACE has helped us develop a relationship with our health partners and that is enormously important. They know us and our capacity. It's been great through COVID because our colleagues in NSW Health have been confident with our decision-making around how we're managing an outbreak. We’ve heard from other colleagues who are unhappy with those interactions with the system because nobody knows their capacity. 

Linda: The ACE network has provided the opportunity for communication, networking and support – which has been so valuable to us, especially during COVID. The networking has enabled us to understand each other a lot better.

What elements of ACE promote safe and high-quality transitions of care?

Viv:  ACE has built a bridge between the acute sector and the aged care sector that enhances transitions of care. For the most part, it is an important pillar of how we operate because we need the acute sector to get the best for our residents. 

ACE aims to keep residents of aged care facilities out of EDs because of the risk to them. That is a great aspiration, but sometimes that becomes the block to someone getting into ED. We can't let that be a barrier to residents getting good care when they need it.

Final word

Viv: I can sleep at night knowing that my registered nurses can make that call to ACE for further advice.