title: Emergency department transfers and hospital admissions from residential aged care facilities: a controlled pre-post design study.
abstract: BACKGROUND
  Older people living in Residential Aged Care Facilities (RACF) are a vulnerable, frail and complex population. They are more likely than people who reside in the community to become acutely unwell, present to the Emergency Department (ED) and require admission to hospital. For many, hospitalisation carries with it risks. Importantly, evidence suggests that some admissions are avoidable. A new collaborative model of care, the Aged Care Emergency Service (ACE), was developed to provide clinical support to nurses in the RACFs, allowing residents to be managed in place and avoid transfer to the ED. This paper examines the effects of the ACE service on RACF residents' transfer to hospital using a controlled pre-post design.
  
  
  METHODS
  Four intervention RACFs were matched with eight control RACFs based on number of total beds, dementia specific beds, and ratio of high to low care beds in Newcastle, Australia, between March and November 2011. The intervention consisted of a clinical care manual to support care along with a nurse led telephone triage line, education, establishing goals of care prior to ED transfer, case management when in the ED, along with the development of collaborative relationships between stakeholders. Outcomes included ED presentations, length of stay, hospital admission and 28-day readmission pre- and post-intervention. Generalised estimating equations were used to estimate mean differences in outcomes between intervention and controls RACFs, pre- and post-intervention means, and their interaction, accounting for repeated measures and adjusting for matching factors.
  
  
  RESULTS
  Residents had a mean age of 86 years. ED presentations ranged between 16 and 211 visits/100 RACF beds/year across all RACFs. There was no overall reduction in ED presentations (OR = 1.17, p = 0.56) with the ACE intervention. However, when compared to the controls, the intervention group reduced their ED length of stay by 45 min (p = 0.0575), and was 40 % less likely to be admitted to hospital, . The latter was highly significant (p = 0.0012).
  
  
  CONCLUSIONS
  Transfers to ED and admission to hospital are common for residents of RACFs. This study has demonstrated that a complex multi-strategy intervention led by nursing staff can successfully reduce hospital admissions for older people living in Residential Aged Care Facilities. By defining goals of care prior to transfer to the ED, clinicians have the opportunity to better deliver care that patients require. Integrated care requires accountability from multiple stakeholders.
  
  
  BACKGROUND
  The Australian New Zealand Clinical Trials Registration number is ACTRN12616000588493 It was registered on 6(th) May 2016.
authors.affiliation: The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia. Carolyn.hullick@hnehealth.nsw.gov.au.|John Hunter Hospital, Hunter New England Health, Locked Bag 1, HRMC, NSW, 2310, Newcastle, Australia. Carolyn.hullick@hnehealth.nsw.gov.au.|Hunter Medical Research Institute, Locked Bag 1000, New Lambton, NSW, 2305, Australia. Carolyn.hullick@hnehealth.nsw.gov.au.
authors.forename: Carolyn
authors.initials: C
authors.lastname: Hullick
authors.affiliation: The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.|University of New England, Armidale, NSW, 2351, Australia.
authors.forename: Jane
authors.initials: J
authors.lastname: Conway
authors.affiliation: The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.|John Hunter Hospital, Hunter New England Health, Locked Bag 1, HRMC, NSW, 2310, Newcastle, Australia.|Hunter Medical Research Institute, Locked Bag 1000, New Lambton, NSW, 2305, Australia.
authors.forename: Isabel
authors.initials: I
authors.lastname: Higgins
authors.affiliation: John Hunter Hospital, Hunter New England Health, Locked Bag 1, HRMC, NSW, 2310, Newcastle, Australia.
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Hewitt
authors.affiliation: The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.|Hunter Medical Research Institute, Locked Bag 1000, New Lambton, NSW, 2305, Australia.
authors.forename: Sophie
authors.initials: S
authors.lastname: Dilworth
authors.affiliation: The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.|Hunter Medical Research Institute, Locked Bag 1000, New Lambton, NSW, 2305, Australia.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Holliday
authors.affiliation: The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.|John Hunter Hospital, Hunter New England Health, Locked Bag 1, HRMC, NSW, 2310, Newcastle, Australia.|Hunter Medical Research Institute, Locked Bag 1000, New Lambton, NSW, 2305, Australia.
authors.forename: John
authors.initials: J
authors.lastname: Attia
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D040561:Assisted Living Facilities / Q000458:organization & administration*; D001315:Australia; D004632:Emergency Medical Services / Q000458:organization & administration*; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D017146:Models, Organizational; D010346:Patient Care Management / Q000379:methods / Q000592:standards; D010360:Patient Transfer / Q000379:methods / Q000458:organization & administration; D058996:Quality Improvement; D012107:Research Design; D014218:Triage / Q000379:methods
keywords: Acute care; Avoidable admissions; Clinical handover; Emergency Department; Homes for the aged; Hospitalization; Integrated care; Model of care; Nursing home; Patient transfer; Pre-post study residential aged care; Telephone triage