Geriatric Rapid Acute Care Evaluation

Northern Sydney Central Coast Area Health Service

This project was entered in the Baxter 2006 NSW Health Awards, Best Innovation to improve Patient Care and Patient Journeys category.

 Presentation given at the 2006 NSW Health Expo.

Contact: J Houston

Abstract

The Geriatric Rapid Acute Care Evaluation (GRACE) prioritises the journey of acutely ill nursing home and hostel patients to optimise acute management and treatment.

GRACE provides telephone triage, rapid geriatric assessment, diagnosis and management either in their facility, Emergency Department (ED) and/or Emergency Medical Unit (EMU) allowing more appropriate care, and ongoing facility support.

General Practitioners and aged care facility staff express high satisfaction with an increased percentage of residents maintained at home. A reduction in length of admissions (ALOS from 7.0 to 4.2 days) and total bed days (from average of 536 to 300 per month) for nursing home residents has been achieved. The GRACE Emergency Department stay has reduced to <8hrs contributing to access block improvements.

What was the problem?

High numbers of care facilities patients were admitted to Hornsby Ku-ring-gai Hospital with long waiting times in ED.

GP and facilities surveyed reported a need to improve care.

How did you know?

Data collection indicated that Hornsby Ku-ring-gai Hospital has a high number of admissions from nursing homes and hostels. In the period from July 2003 to June 2004 there were in excess of 1,800 patients admitted from nursing homes or hostels. Statistically, these patients had an average LOS of 7.96 days in 2003/04, which extrapolates to 14,266 occupied bed days.  On a daily basis there is an average of 39 beds utilised for this sub group. This category represents 10.3% of all admissions to the hospital, and 18% of all occupied bed days.

General practitioners surveyed at a GP Forum in 2004 indicated their belief that their patients in nursing homes could be better managed in the nursing home than in hospital, by staff who knew them and understood their needs. Nursing home staff surveyed also indicated their preference for caring for their elderly patients within the nursing home where possible.

What did you do?

Rehabilitation and Aged Care Service, Hospital Executive, Emergency Department, Residential Aged Care Facilities (RACFs), and the Division of General Practice formed a steering committee.

Facility Directors of Nursing and Care Managers met with hospital staff and GP representatives. Issues around management of acutely ill residents were reviewed. A draft protocol was discussed and refined using Plan, Do, Study, Act. 

The GRACE project commenced on the 5th August 2005 with the appointment of a Clinical Nurse Consultant and Project Leader. A RACF Director of Nursing (DON) was a GRACE champion and advised on engaging RACFs and promotion of the GRACE model of care. Quarterly meetings and newsletters facilitated communication between hospital and facility staff. A GRACE GP Practice Nurse (0.3 FTE) is developing educational resources for the nurse educators working in the facilities.

A General Practitioner Liaison Officer facilitates communication with the local Division of General Practice and Aged Care Panels promoting the use of Advanced Care Planning/Directives within the facilities. The Geriatric Registrar facilitates geriatric assessment and GP communication.

Criterion for inclusion: All residents from nursing homes and hostels are eligible

A Clinical Nurse Consultant provides telephone triage for GPs and RACFs. Referral baseline information is collected including Advanced Care Directive or plan information. Treatment options such as early symptom and/or pain relief are discussed and a decision is made whether to transfer the patient to hospital. If the patient remains in the facility, hospital services can be accessed that are not usually available to a RACF, such as the supply of consumables or consultative services.

On admission, the triage nurse notifies the GRACE Team who work with the ED nurses to fast track the patient either to the Emergency Medical Unit (EMU) or back to the facility with a care plan. EMU is a short stay unit with quarantined GRACE beds and increased medical and aged care support. EMU provides a comfortable safe environment to assess and observe older patients. Staff have a “Fast Track” philosophy. The ratio of nursing staff is flexible to match fluctuating numbers and acuity of GRACE patients.

A daily “after hours” service is available through the combination of GRACE and Agedcare Services in the Emergency Team (ASET). ED nurses complete an Aged Care Preceptorship focusing on aged care assessment skills and community services building aged care capacity within the ED/EMU. During low activity periods the “after hours” nurses can assist the ED staff.

How do you know you succeeded?

• Average Length of Stay (LOS) for GRACE patients in ED is 7.25 hours compared to  23 hours for patients over 65 years in 2003 .
• Average LOS for patients admitted from nursing homes has reduced from 7 days in  November 2005 to 4.2 days in April 2006. Team advocacy  efficiently returns patient back to the RACF.
• Monthly bed days used by nursing home patients has decreased from 536 in November 2005 to 300 bed days in April 2006 which supports the reduction in LOS.

• 55% of GRACE EMU patients were admitted for less than 48 hours. Patients are assessed, stabilised and returned to their facilities for GP management.
• HKR Division of General Practice surveyed 15 nursing homes who indicated strong satisfaction with GRACE.
• GRACE has contributed significantly to reducing access block, 30% in August 2005 to 17% in May 2006.
• Patients and family have expressed gratitude to GRACE.
• The telephone triage calls have increased from (August 2005) 12 to (April 2006) 52 calls/month.
• At the request of RACFs acute assessment educational resources are being developed.
• GRACE reportable incidents, via IIMS, were 1% in ED and 4.2% in EMU.

What did you learn?

When transferred to hospital RACF patients place of residence is often inaccurately recorded. Ambulances don’t record the name of the facility, only the address. There was not a process for admission staff to identify the RACFs or their type of accommodation except personal knowledge. A system to ensure correct RACF identification was established, along with the development of appropriate management plans for the patient on admission. This has significantly assisted with the discharge planning process and subsequent evaluation of interventional strategies.

Advanced Care Directives (ACDs) were identified as a major tool that would assist in the appropriate management of facility residents both within the facility and on presentation to hospital. It was found that most RACFs did not discuss ACDs and/ or Plans, and documentation that existed was not standardised. Information sessions have been held for GPs and RACFs to foster the development of ACD/plans within the facilities. Engagement of the RACFs increases, as the benefits become evident.

Previous communication between the RACFs and hospital was extremely poor. The RACFs have welcomed the opportunity to met hospital staff.Hospital and RACF staff had little knowledge of the others work conditions, resources or staffing levels.

What plans have you to sustain the change?

GRACE is an integral part of the health service integrated aged care model. The collaborative approach has ensured General Practitioners and RACF staff have been involved and led many of the initiatives adopted. Ongoing meetings and local communication networks will ensure further adoption of successful interventions. Pathways to ensure appropriate support and intervention when required have been established, and education programs are being developed to assist facilities manage common medical conditions.

The GRACE Model of Care has been written up by NSW Health Clinical Redesign Unit for use by other Health Services and is available on the ARCHI website.