The Issue

Clinicians at both ends of the transfer of a resident from a Residential Aged Care Facility (RACF) to a hospital Emergency Department (ED) for acute assessment are exasperated. The current use of different paper based forms by RACF do not provide the clinical and other information that ED doctors, nurses and allied health professionals need. This not only delays and frustrates the assessment and treatment of the patient but also necessitates multiple calls to the RACF and the patient’s GP to get the information needed.

What are the key elements of the problem? 

• Older people require emergency care more often than other populations. They have longer ED lengths of stay and higher admission and readmission rates.
• Older people account for greater than 60% of hospital admissions and many are at risk from hospitalisation itself, in particular delirium and falls. Older people who become acutely unwell in RACFs are a considerable proportion of ED presentations.
• The current transfer forms are not providing transparent information to hospital clinicians in the order and format that they need so that they can assess and treat the patient quickly and effectively.
• Medication charts are not always attached.
• Resuscitation orders/Advanced Care Directives (ACD) are often missing.
• Contact details for the resident’s GP, next of kin and additional numbers are not always provided.
• Observations, diagnostic test results and treatment information required prior to transfer are not always provided.
• The reason for transfer is key information and not always easy to find, if at all.
• There is not a simple solution to gather the information needed from multiple sources. People need to collate, condense and format this information into an easy to read and comprehensive format.

Residential Aged Care Facilities (RACFs) are home to residents with chronic and complex conditions and care needs. The majority of residents are aged over 80 and many have dementia. They are frequently on more than 10 medications and are recurrently transferred to Emergency Departments for acute assessment.  A literature review in 2010 identified that up to 30% of RACF residents are transferred to an ED over a 12 month period ⁽¹⁾. A 2011 study by the Western Australia Department of Health identified that over 1500 transfers to EDs from RACF were potentially avoidable each year ⁽²⁾.

By 2050 there is projected to be a 400% increase in the number of people over 85 years of age. The proportion of the population aged over 65 will account for one third of admissions and half the total bed days in acute care facilities.

RACF residents are routinely sent to ED via the ambulance service accompanied by numerous forms with a variety of information, that then need to be interpreted by the ambulance paramedics and, in turn, the ED nurses, registrars, specialists, allied health staff and administrative staff. The problem is each RACF has a different form, which captures different information in a different order, making it difficult to locate the information necessary to commence effective assessment and treatment for a resident. What is thought to be relevant information by one care worker or health professional, is not necessarily what is needed by another.

When the resident arrives at the ED it is not uncommon for the forms to be missing or for the required clinical information to be incomplete. This will often result in the patient being placed in a holding bay, and a call logged to the RACF to verbally provide information on why the resident has been transferred. This wastes valuable time in commencing assessment and treatment.

Lack of information on recent pathology and diagnostic tests will often lead to these being repeated by the ED. Lack of accurate medication information increases the risk of medication errors, and may also lead to unnecessary requests to community pharmacies to duplicate medication supplies to the RACF.

A recent survey of 37 RACFs in Sydney’s City and Eastern Suburbs, showed their transfer to hospital forms are all different and are normally personal care and nursing based which leads to multiple forms that are difficult to interpret quickly. The survey also notes that EDs advise that they need more clinical information upon admission.

All 37 RACFs surveyed said they would adopt a Transfer of Care Form with relevant standardised clinical information.

The Solution

The solution should contain the essential clinical information up front including the reason for transfer, the observations, diagnostic tests and treatment prior to transfer and the current medication chart and Advanced Care Directive (ADC) - if there is one.

This kind of solution requires software integration with Community and ACD information from RACFs.

The best value proposition for residents in RACFs is for their clinical information to be shared point to point between medical professionals involved in their treatment. 

The Benefits

The benefits span across RACF residents, RACF facilities, hospital ED clinicians, ambulance paramedics , GPs and RACF resident family members.

• Importantly, RACF residents w would benefit from receiving a more rapid and better informed clinical assessment by the ED clinical staff.
• The provision of better and more clinically relevant information should, over time and reduce the proportion of RACF residents who need to be admitted from the ED, reduce the incidence of medication errors.
• Residents would benefit from improved processing times in the ED which will have a positive influence on their patient journey and experience in an acute setting.
• An important benefit is the ability over time to better identify reasons for transfer of RACF residents to hospital EDs. More appropriate interventions and support services can be implemented to reduce the need to transfer the RACF resident and to strengthen the capability of the RACF to manage particular clinical conditions and problems.

The New South Wales Emergency Care Institute has confirmed these benefits from organising an Aged Care Emergency (ACE) telephone support service to RACF, reducing the need for transfer to EDs for further assessment and treatments that can be undertaken at the RACF ⁽³⁾.

A reduction in admissions to ED will reduce the number of hospital acquired infections for RACF residents.

The key areas of economic benefit potentially are:

• Reducing transfers and admissions from the RACF cost setting, to the higher acute hospital cost setting
• Reduction in the time that patients wait  to receive medical and clinical interventions
• Reducing the time spent by EDs trying to track down family or carers to discuss medications and care
• Reduction in unnecessary use of ambulance services for transfer to the ED and return to the RACF
• Avoided treatment costs and hospitalisation related adverse events
• Reduction in unnecessary duplication of pathology, medical imaging and other diagnostic tests
• Reduction in medication errors due to accurate information being available to the ED clinicians
• Improved turnaround times for residents in hospital EDs resulting in improved NEAT times for hospitals

To improve this chain of care, health information needs to be standardised and put in an electronic, interoperable and scalable format. This will allow it to be shared and accessed electronically and effectively with the many different types of Electronic Medical Record (EMR) solutions that exist, which in turn will improve their patient journey and treatment outcomes.  With the focus on interoperability, there are now solutions built on modern technologies and at low cost such as Vitro that can finally address this gap in the clinical information paradigm.  

Jeff Smoot- VP Sales and Marketing, Sláinte Healthcare

Jeff joined Sláinte as Global Vice President of Sales & Marketing. He has extensive experience in Healthcare, previously working for companies such as Allscripts, Cerner and Fujitsu Technology Solutions. Jeff was awarded a BSBA by the University of Denver and an MBA from the Loyola College in Maryland in the USA, he has responsibility for the sales and marketing strategy throughout Europe, the Middle East, Australia and the UK.

Linkedin: http://au.linkedin.com/pub/jeffrey-smoot/17/239/5aa

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⁽¹⁾ Arendts G, Howard K. The interface between residential aged care and the emergency department: a systematic review. Age and Ageing 2010; 39:306-12.
⁽²⁾ Review of admission and discharge referral practices for the metropolitan emergency departments. Professor Bryant Stokes. WA Department of Health July 2011
⁽³⁾ See the Aged Care Emergency Service Manual 2014 at www.ecinsw.com.au