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Improving Clinical Communication at the Aged Care Emergency Service

Hunter New England Local Health DistrictHunter New England and Central Coast Primary Health Network
Project Added:
6 October 2015
Last updated:
21 October 2015

Improving Clinical Communication at the Aged Care Emergency (ACE) Service

Summary

This project trained residential aged care facility (RACF) and emergency department (ED) staff in the Identify, Situation, Background, Assessment and Recommendation (ISBAR) clinical handover tool to enhance the effectiveness of the Aged Care Emergency (ACE) service. 

Aim

To improve clinical communication between RACFs, general practitioners (GPs) and EDs to decrease the number of potentially avoidable transfers of elderly residents to the ED.

Benefits

  • Ensures residents in RACFs receive quality care in the most appropriate setting.
  • Reduces the rate of potentially avoidable transfers to the ED.
  • Reduces adverse effects of ED visits on elderly residents.
  • Reduces ED congestion and use of NSW Ambulance service, ensuring resources are readily available to those with more urgent needs.
  • Improves quality of clinical handover between RACFs, GPs and EDs.
  • Strengthens the skills of RACF staff in recognising the deteriorating resident and providing evidence-based care.
  • Contributes to cost savings for the health system.

Project status

Dates

The ACE Program was launched in 2010 and ISBAR added in 2013 as part of a partnership initiative with Hunter New England Local Health District (HNELHD). 

Status

Sustained - The project has been implemented and is sustained in standard business. 

Background

The ACE service was developed in 2010 to help staff in RACFs and EDs provide quality care to older people in the most appropriate setting. The service trains RACF staff to recognise a deteriorating resident, conduct health assessments that follow evidence-based clinical pathways and communicate important information to other health workers such as telephone advisors, GPs, ED nurses and ambulance staff.

Using this training, staff involved in the care of the resident decide whether to treat them at the RACF or transfer them to the ED. The ACE service has prevented many avoidable transfers of elderly people to EDs and has resulted in better outcomes for residents, families and the health system. This translates to reduced waiting times and costs, as resources can be redirected to patients with more urgent health needs.

In 2013, following the partnership of HNELHD and Hunter Medicare Local (HML), a needs assessment of the ACE service was conducted that formally identified the need for standardised communication between RACFs, GPs and EDs. The ISBAR clinical handover tool was selected as the preferred method of communication, to promote the efficient transfer of key information between these stakeholders.

Implementation

  • Developed an ISBAR training program for RACF managers, ED nurses and NSW Ambulance staff using a ‘train the trainer’ approach, so they can train care staff at their facility. Real-life scenarios were used to train participants in placing a call with the ACE service using the ISBAR format.
  • Held quarterly interagency meetings with stakeholder to exchange information, discuss issues and propose solutions.
  • Educated RACF and ED staff on recognising unexpected deterioration in residents, ISBAR clinical handover, communication, clinical guidelines and telephone triage skills.
  • Developed a manual with evidence-based flowcharts and clinical guidelines that guide staff through a decision-making process to determine the most appropriate treatment. The guidelines were approved by the Department of Health, Quality Use of Medicines.
  • Developed a range of marketing materials including brochures, postcards, posters and other resources to help staff implement the ISBAR tool in daily communication with clinicians.

Implementation sites

Emergency departments at John Hunter Hospital, Belmont Hospital, Calvary Mater Newcastle, Maitland Hospital, Manning Rural Hospital, Tamworth Hospital, Armidale Hospital, Tomaree Community Hospital and Singleton District Hospital. 

Partnerships

  • Hunter Medicare Local (HML)
  • NSW Ambulance
  • Hunter New England Local Health District

Evaluation

An evaluation of the ISBAR Integrated Care Project (incorporating ACE and ISBAR) has achieved positive results.

  • Over 80% of RACFs in HNELHD received ISBAR training and implemented the tool in their operations.
  • The use of ISBAR when using the ACE service resulted in 74% of calls resolved by treating residents in the RACF, with after-hours calls resolved within the RACF 86% of the time.
  • Use of ISBAR in the ACE service resulted in an annual savings to health services of $920,000.
  • ISBAR training provided to over 250 people with evaluation following each module. The ISBAR module received very good or excellent rating each time.
  • The ISBAR Integrated Care Project received two awards: Australian Doctor 2014 Medicare Local Innovator of the Year and HNELHD Building Partnerships award.

ISBAR was a significant and important component in establishing trust and accuracy in clinical handover and phone advice and, thus, ensured the success of the ACE service.  It has not been possible to evaluate just the ISBAR component.

Lessons learnt 

  • Change management plays an important role in the successful implementation of ISBAR as a communication tool.
  • Joint training conducted with all services helped promote the message that, by working together, quality of care can be improved.
  • Providing opportunities for staff to visit another service provider was an effective method of gaining support for the program. RACF staff who visited the ED were aware of what a confronting environment it can be for those in their care.
  • A mixture of approaches were employed to recruit RACFs to the program, including direct approaches, presentations at regional level meetings, as well as meetings with GP groups, health services and EDs.
  • It is more difficult to introduce ISBAR in urban areas, where there are a large number of practices and after-hours providers, than in smaller rural areas where there are few service providers and relationships are strong.  In addition, GPs in rural areas are usually the doctors who staff the ED, so they are more likely to have had ISBAR training as part of their employment with HNELHD.
  • While the project has been widely embraced by health service providers, ongoing challenges include:
    • ensuring residents’ end of life goals are documented, communicated  and observed
    • ensuring RACFs receive quality discharge letters and instructions about change of treatment
    • the requirement for ongoing training and support due to frequent staff turnover.
  • Communication and effective relationships between stakeholders is vital to the success of the project. These take time to develop and time to repair if there is a breach of confidence in the service.
  • Education will need to be adapted as the ‘train the trainer’ model was not successful in all facilities. In the short term, HML has provided on-site training on request but this is not sustainable.

Further Reading

Contacts

Jacqui HewittAged Care Emergency Clinical Nurse Coordinator (CNC)
Patient Flow Unit
Hunter New England Local Health District
Phone: 02 4922 3749
Jacqueline.hewitt@hnehealth.nsw.gov.au

Keith Drinkwater
Primary Care Executive
Hunter Primary Care Ltd
Phone: 02 4935 3231
kdrinkwater@hunterml.com.au

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