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Associate Professor
Susan KurrleCurran Chair in Health Care of Older People
Faculty of Medicine, University of Sydney
Director, Rehabilitation
and Aged Care Service
Hornsby Ku-ring-gai Health Service
GRACE@Hornsby Geriatric Rapid Acute Care Evaluation
Jenny HoustonGRACE Project Leader/CNC
Anne BruceGRACE Clinical Nurse Consultant (CNC)
Access Block - % Ward Admitted Patients
staying longer than 8 hrs in ED
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%Ja
n-0
2
Ma
r-0
2
Ma
y-0
2
Jul-
02
Se
p-0
2
No
v-0
2
Jan
-03
Ma
r-0
3
Ma
y-0
3
Jul-
03
Se
p-0
3
No
v-0
3
Jan
-04
Ma
r-0
4
Ma
y-0
4
Jul-
04
Se
p-0
4
No
v-0
4
Jan
-05
Ma
r-0
5
Ma
y-0
5
Jul-
05
Se
p-0
5
ACE Aged Care Liaison Nurse
EMU & ASET
Ortho geriatric service
GRACE
ED Nurse Practitioner
Rehabilitation and Aged Care
ServiceGRACE commences
GRACE Aims
To reduce hospital access block by supporting General Practitioners (GPs) and Residential Aged Care Facilities (RACFs) with enhanced hospital resources to avoid an unnecessary hospital admission (pre-hospital)
To reduce the ALOS in the ED when the nursing home and hostel pts presents to hospital
To reduce the ALOS of admitted nursing home and hostel pts
GRACE Aims
To collaborate with the GPs and RACFs to develop a model of care that:
- provides a decision support system
- provides hospital resources to assist with assessment & care provision
- provides coordinated management plans
Increases the uptake of Advanced Care Directives in the Residential Aged Care Facilities
GRACEGeriatric Rapid Acute Care Evaluation
Commenced on 5th August 2005
Criterion for inclusion: all residents from nursing homes are eligible (hostels “by arrangement”)
Through out the pt journey the GRACE Team liaise with the RACFs and GPs
(GRACE)Nursing Home & hostel pathway to standardise care
Unwell Resident
in a Nursing
Home
Geriatric Rapid Acute Care Evaluation (GRACE) Nursing Home to the Hospital Flow Chart
GP Contacted GP unavailable Yes
Nursing Home/Hostel Staff contact the GRACE Team to discuss resident
management.Phone No : 0434 183 549
GP visits/assess the resident. GP/ NH discusses treatment plan with GRACE Team.
Phone No : 0434 183 549
1. GRACE Clinical Nurse Consultant (CNC) records medical history, normal function and observations Identifies presenting problem/s and action already implemented.2. Management options discussed with Specialists as required
Patient transferred to Hornsby Hospital for assessment and
Specialist Consultation.
Support Residents care plan with appropriate hospital resources in the N/home
Yes No
Usual assessment and management according to diagnosis.
Option One EDD < 4 hours
1. GRACE nurse with ED staff develop care plan and liaises with the Nursing
Home 2. ED Medical Officer discusses care
plan with GP. 3. Patient returns to Nursing Home with appropriate HKH/Area support, such as Specialist Consult, subcut fluids, CNC review eg CNC Wound etc, APAC or
NSHNS
Option Two Acute Medical EDD> 4 hours1. Medical Pts will be admitted to the
Emergency Medical Unit (EMU).2. GRACE nurse with EMU staff develops care
plan and discusses with Nursing Home.Stabilise in EMU. Consider Geriatrician if
appropriate3. EMU Medical Officer discusses care plan
with GP4. Patient discharged to Nursing Home with appropriate HKH/Area support see Option1.
Option Three- Acute
Surgical Admission Fast Tracking:
1. Orthopaedic / Surgical admit to
an acute ward
GP and Nursing Home contacted prior to discharge Care Plan
Transfer to
Hornsby Hospital?
GRACE Nurse liaises with Nursing Home as required
Arrival/reception
RACFs contact the GRACE nurse (phone) to assist with decision of whether to transfer a pt to ED
GRACE nurses who have aged care assessment skills advise re the course of action (can also access ED staff specialists)
enquires if Advanced Care Directive or plan is in place - indicates level of intervention required
may discuss early symptom relieve such as pain relief or subcutaneous fluids (RACF liase with GP)
Arrival/reception II
Fast track patients:
If contacted by phone then GRACE triage sheet is completed. If the pt is being transferred to hospital pre-admission information is written in the notes
pt notes flagged with a green GRACE sticker
pt put in EDIS “pt expects”
Triage nurse will notify GRACE nurse when pt arrives
GRACE nurse regularly checks EDIS/ED/EMU for nursing home patients not identified on admission
Triage, treat & 3-2-1 process
GRACE Nurses:
if GRACE is not contacted prior to presentation GRACE nurses contact RACFs to gain baseline information eg function, behaviours etc (only one phone call for ED and RACF to cope with)
work with ED nurses and medical staff to establish a discharge time < or > than 4 hours.
document a preferred plan from an aged care perspective
access to rapid geriatric support (GRACE dedicated geriatrician (.5) starts April)
Triage, treat & 3-2-1 process
If the GRACE patient remains in the community:
RACF liases with GPs - GRACE does not take over care, increases capacity of the RACFs to maintain their residents
may provide access to hospital staff eg clinical nurse consultant, geriatrician etc
may provide consumables to prevent an ED presentation eg subcutaneous fluids
may refer to Northern Sydney Home Nursing Service or Acute Post Acute Care to support the RACFs
EMU is GRACE’s short stay ward
4 quarantined short stay GRACE Beds, classified as EMU X- GRACE team remain involved in care
GRACE pts may stay longer than 48 hours
EMU provides a comfortable safe environment to assess and observe older patients
EMU staff have a “Fast Track” philosophy
the ratio of nursing staff is flexible to match fluctuating numbers and acuity of GRACE pts
GRACEGeriatric Rapid Acute Care Evaluation
Total of bed days used is 2,268
Total monthly bed days for GRACE Nursing Home Pts Aug 05-Jan 06
0
100
200
300
400
500
600
Aug Sept Oct Nov Dec Jan
Bed
Days Total monthly
bed days
Note: ALOS 2003/04 was 6 days
ALOS for GRACE Nursing Home Pts Aug 05 - Jan 06
0
1
2
3
4
5
6
7
8
Aug Sept Oct Nov Dec Jan
Be
d D
ays
ALOS
Grace - ED Avoids by Month
0
2
4
6
8
10
12
Aug Sep Oct Nov Dec Jan
Hostel Nurs Home
Process Executive support essential - EMU Admission and
Discharge Policy states that GRACE pts requiring admission must be assessed in EMU
ED & EMU NUMs and Staff Specialists and Bed Manager are GRACE “champions”
GRACE CNC works closely with ASET CNC - GRACE/ASET “after hours nurses” are ED nurses with an aged care interest. GRACE & ASET CNCs preceptor “out of hours nurses” which builds aged care capacity in ED
Outcomes monitored and feedback given to staff and RACFs eg GRACE newsletter
Getting started with “GRACE”?
create a tension for change - review your RACF pts journeys, process map it - Is it optimal?
discuss the idea of GRACE with Executive, GPs and RACFs located in your area
express interest in the GRACE Model of Care workshop that Angela Littleford from NSW DoH will be convening later this year
