Reducing Hospital Transfers from Aged Care Facilities: A Large-Scale Stepped Wedge Evaluation

Abstract

<p><b>BACKGROUND/OBJECTIVES:</b> Older people living in residential aged care facilities (RACFs) experience acute deterioration requiring assessment and decision making. We evaluated the impact of a large-scale regional Aged Care Emergency (ACE) program in reducing hospital admissions and emergency department (ED) transfers.</p><p><b>DESIGN:</b> A stepped wedge nonrandomized cluster trial with 11 steps, implemented from May 2013 to August 2016.</p> SETTING: A large regional and rural area of northern and western New South Wales, Australia.</p><p><b>PARTICIPANTS:</b> Nine hospital EDs and 81 RACFs participated in the evaluation.</p><p><b>INTERVENTION:</b> The ACE program is an integrated nurse-led intervention underpinned by a community of practice designed to improve the capability of RACFs man-aging acutely unwell residents. It includes telephone support, evidence-based algorithms, defining goals of care for ED transfer, case management in the ED, and an education program.</p><p><b>MEASUREMENTS:</b> ED transfers and subsequent hospital admissions were collected from administrative data including 13 months baseline and 9 months follow-up.</p><p><b>RESULTS:</b> A total of 18,837 eligible ED visits were analyzed. After accounting for clustering by RACFs and adjusting for time of the year as well as RACF characteristics, a statistically significant reduction in hospital admissions (adjusted incident rate ratio = .79" 95% confidence interval [CI] = .68–.92)" P = .0025) was seen (i.e., residents were 21% less likely to be admitted to the hospital). This was also observed in ED visit rates (adjusted incidence rate ratio = .80" 95% CI = .69–.92" P = .0023) (i.e., residents were 20% less likely to be transferred to the ED). Seven-day ED re-presentation fell from 5.7% to 4.9%, and30-day hospital readmissions fell from 12% to 10%.</p><p><b>CONCLUSION:</b> The stepped wedge design allowed rigorous evaluation of a real-world large-scale intervention. These results confirm that the ACE program can be scaled up to a large geographic area and can reduce ED visits and hospitalization of older people with complex healthcare needs living in RACFs.</p>