The Aged Care Emergency (ACE) service provides clinical support and advice to staff in Residential Aged Care Facilities (RACFs) in the Hunter region, helping to determine whether a patient requires emergency department transfer or can be safely treated in the RACF. An evaluation found ACE reduced potentially avoidable ED presentations by 16-19% and hospital admissions by 19%, saving $920,000 annually. When contacted, ACE nurses help coordinate care between RACFs, GPs and hospitals to safely manage patients in the right setting according to their goals of care. The ACE model has improved outcomes for older patients in RACFs through reducing risks of hospitalization and supporting appropriate care in the community.

1. Aged Care Emergency (ACE)
Service
Jacqui Hewitt
ACE CNC, Patient Flow, HNE
Dr Carolyn Hullick
Senior Staff Specialist Belmont ED and Clinical Governance

2. 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

3. 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

4. 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

5. 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

6. ACE Model
• ACE
Stakeholders

7. 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

8. 2012: Pilot Results and Evaluation
JHH ACE pilot in 2011 from the 4 RACFs compared with 2009
and 2010ACE 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

9. 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%

10. 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)

11. 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

12. 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.

13. 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.

14. 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

15. 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

16. 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

17. Couldn’t come to the phone
She was shopping

18. 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

19. 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

20. 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