Belmont District Hospital, Belmont, New South Wales, Australia.
Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia.
J Am Geriatr Soc. 2021 Jan;69(1):201-209. doi: 10.1111/jgs.16890. Epub 2020 Oct 30.
BACKGROUND/OBJECTIVES: 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.
A stepped wedge nonrandomized cluster trial with 11 steps, implemented from May 2013 to August 2016.
A large regional and rural area of northern and western New South Wales, Australia.
Nine hospital EDs and 81 RACFs participated in the evaluation.
The ACE program is an integrated nurse-led intervention underpinned by a community of practice designed to improve the capability of RACFs managing 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.
ED transfers and subsequent hospital admissions were collected from administrative data including 13 months baseline and 9 months follow-up.
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%, and 30-day hospital readmissions fell from 12% to 10%.
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.
背景/目的：居住在养老院的老年人会经历需要评估和决策的急性恶化。我们评估了一项大规模区域老年保健紧急（ACE）计划在减少医院入院和急诊部（ED）转介方面的影响。
一项从 2013 年 5 月至 2016 年 8 月实施的 11 个步骤的阶梯式楔形非随机集群试验。
澳大利亚新南威尔士州北部和西部的一个大型区域和农村地区。
9 家医院 ED 和 81 家养老院参与了评估。
ACE 计划是一项以社区为基础的护士主导的干预措施，旨在提高养老院管理急性不适居民的能力，该计划包括电话支持、循证算法、为 ED 转介定义护理目标、ED 中的病例管理以及教育计划。
ED 转介和随后的医院入院情况从包括 13 个月基线和 9 个月随访的行政数据中收集。
共分析了 18837 例符合条件的 ED 就诊。在考虑到养老院的聚类并调整了一年中的时间以及养老院的特点后，医院入院率显著降低（调整后的发病率比=0.79；95%置信区间[CI]为 0.68-0.92）；P=0.0025）（即居民入院的可能性降低了 21%）。在 ED 就诊率中也观察到了同样的结果（调整后的发病率比=0.80；95%CI=0.69-0.92；P=0.0023）（即居民被转介到 ED 的可能性降低了 20%）。7 天 ED 再就诊率从 5.7%降至 4.9%，30 天医院再入院率从 12%降至 10%。
阶梯式楔形设计允许对真实世界中的大规模干预措施进行严格评估。这些结果证实，ACE 计划可以扩展到更大的地理区域，并可以减少养老院中患有复杂医疗需求的老年人的 ED 就诊和住院治疗。
