Discussion
low back pain, abdominal pain, seizure, chest pain, dementia, pain, aggression, haemorrhage
HAEMORRHAGE, URINARY TRACT INFECTION, ACUTE UPPER RESPIRATORY INFECTION
The PACE-IT project analysis demonstrated that, with the addition of VTC to the usual MOC, there was an overall 29% relative reduction of the rate of ED presentations (per 100 RACF beds) when an ED ACE/VTC call was made within ED ACE hours (when this service is accessible). This result was not statistically significant; however, it represents a clinically important decrease in exposure of RACF residents to the ED environment. All episodes of care from RACFs were supposed to have an ACE call to the ED prior to attending the ED. Pre-implementation, 333 episodes of care occurred in ED ACE hours, only 98 of these had a prior ACE call made to the ED (29% of episodes of care). Post-implementation, 421 episodes of care occurred in ED ACE hours, and 222 of these had an ED ACE/VTC (53% of episodes occurring within ED ACE hours), reflecting a highly significant increase in the use of the ED ACE service, with or without VTC.The study aimed to detect a 35% reduction in ED presentations per 100 RACF beds from a baseline rate of 82 ED presentations per 100 beds, which was both clinically meaningful and practical. The observed 29% reduction, while not statistically significant, may be due to limited statistical power caused by a slightly smaller true effect and the lower baseline rate of ED presentations (around 41 per 100 RACF beds annually). The PACE-IT project started in 2019 during the COVID-19 pandemic, which led to fewer ED visits overall.This 29% reduction in ED presentations highlights the benefits of dedicated, constant support and education through visual assessments. Notably, the most significant reduction in hospital transfers (29%) occurred when ASET nurses conducted VTCs during ED ACE hours, in contrast to a 4% reduction during non-ED ACE and ED ACE hours combined. These findings suggest the potential to expand ASET nurse/ED ACE hours for more comprehensive coverage throughout the day and evening. Findings demonstrate that when RACF nurses undertake ED ACE/VTCs there is a reduction in RACF resident ED visits.Successful implementation relies on RACF staff's willingness and motivation to utilise the ACE service and the visual component of the consultation. VTCs helped develop relationships between RACF and ED nurses [Post-implementation the top five reasons for VTC calls for ED presentations from RACF residents were for; abdominal pain, chest pain, acute upper respiratory infection, low back pain, urinary tract infection. However not all ACE calls were deemed appropriate for VTC. There were times where VTC was deemed inappropriate, for example, if the resident had; an exacerbation of behavioural and psychological symptoms of dementia with excessive aggression that would be further agitated by a VTC, evidence of a haemorrhage, excessive pain, unexpected loss of consciousness/ sense of urgency, actively fitting/ seizure or simply a follow up call (e.g. medication script, x-ray report etc.). For this reason, it was important to allow for staff discretion and flexibility in choosing whether to use VTC during the ACE call and this needs to be considered by staff in both the ED and the RACF. Based on post-implementation feedback exclusion criteria have been developed and added to VTC guidelines.There were many missed VTC opportunities for which the RACF nurses presented a range of responses including: the iPad was not charged or no compatible device was available for a VTC, there was an agency nurse on duty who was new and not familiar with the procedure, the RACF nurse refused to attend a VTC as they were not trained, there was a technical system failure, the resident was already in an ambulance and on their way to hospital and the staff were “just handing over”.Including a VTC option as part of an assessment service for RACF residents that enhances telephone outreach services is a practical strategy. Nurse-led outreach models that include partnerships between ED and RACFs using existing ED Aged Care Specialist services, together with protocol driven guidelines have been shown to be both feasible [The PACE-IT intervention has the potential to improve the clinical care and quality of life of the frail older person and reduce ED presentations and their associated risks. It has provided evidence that can be used to inform sustainable change and translation into practice. PACE-IT has demonstrated how the change has been achieved and highlighted success factors for scalability and sustainability. Specifically, it has identified how PACE-IT reduces ED presentations and admissions to hospital for residents of RACFs [These findings have direct clinical implications as well as policy implications for those setting standards for the Australian National Safety and Quality Health Service Standards [This study has provided evidence for translation by generating new knowledge about how PACE-IT, provided to RACF residents with a general range of acute conditions, reduces ED presentations. The PACE-IT intervention can be transferred to many settings within metropolitan, rural and remote areas and in differently sized EDs and RACFs. However, the challenge is to ensure current interventions are embedded as normal practice to ensure that similar MOC are sustained into the future. Challenges include the lack of ongoing funding to scale up the intervention, incentives for implementation of leadership in this area and availability of appropriate champions to influence successful implementation and outcomes, common issues found in other studies [PACE-IT establishes a governance structure that engages all stakeholders (including consumer representation), a structure that is easily replicable nationally. Current members of the PACE-IT governance group have enthusiastically embraced their role in developing the study design and PACE-IT model and in making themselves available for consultation, indicating a high level of engagement and ongoing commitment. Establishment of the VTC upskilling education program and additional resources (e.g., Guidelines, RACF unit-posters, resident/family information brochures, media-briefing) will facilitate local engagement ensuring easy transfer and adaptability of PACE-IT across sites/LHDs. Integral to the success of this MOC is dedicated leadership that can drive the intervention and have time to review the processes and data whilst continuing to educate and liaise with ASET and RACF nurses.Once embedded, EDs across NSW may consider expanding to a 24/7 ACE service which would require additional resourcing. The cost/consequence analysis in this study (to be reported separately) will inform the feasibility of this action.This study represents a significant contribution to the literature by both presenting its findings and outlining a novel approach in providing care for RACF residents. The adoption of VTC has demonstrated a noteworthy reduction in hospital admissions for residents of residential aged care facilities, underscoring its clinical significance. These findings strongly support the broader implementation of visual telehealth consultations. This justification emphasises the importance of integrating VTC as a vital tool to aid RACF clinicians in their decision-making processes.