Background/introduction
Research aims and objectives
Methods
Setting
Study design
Quantitative data collection
Quantitative analysis
Qualitative data
Research participants
Interviews
Analysis
Results
Quantitative data analysis
MED telehealth service engagement
RACF | Total residents in RACF (n)a | Total GPs in RACF (n)a | Referred residents (n)a | Referring GPs (n)a | RACF on boarding | Time to first MED call (days) | Total calls |
---|---|---|---|---|---|---|---|
1 | 58 | 11 | 48 | 9 | April 2020 | 61 | 2 |
2 | 144 | 21 | 131 | 18 | April 2020 | 7 | 7 |
3 | 125 | 4 | 125 | 4 | February 2020 | 4 | 169 |
4 | 68 | 6 | 47 | 3 | February 2020 | 6 | 22 |
5 | 135 | 22 | 109 | 18 | May 2020 | 133 | 7 |
6 | 68 | 7 | 62 | 7 | March 2020 | 39 | 2 |
Totals | 598 | 71 | 522 | 59 | x̄ = 41.7 | 209 |
Presentations and diagnoses
Higher order SNOMED category | Subcategory according to SNOMED |
---|---|
Falls (95/209) | Elderly (85); mechanical fall (4); unwitnessed fall (2); minor fall (1); recurrent fall (1); falling injury (1); pushed over (1) |
Pain (15/209) | Chest (5); abdominal (5); shoulder, neck, hip, headache, lower back (5) |
Pharmacological assessment (11/209) | Medication review (10) and scripts (1) requested |
Bleeding (8/209) | Haemoptysis (2); haematuria (4) blood in stool (1); rectal bleed (1) |
Vomiting (8/209) | Vomiting (7); nausea (1) |
Urinary (7/209) | Complication of catheter, blocked catheter, urethral discharge, urinary retention, reduced urine volume, dysuria, UTI, |
Endocrine (6/209) | Hypoglycaemia (3); hyperglycaemia (1); diabetes mellitus (2) |
Cardiovascular (5/209) | hypertension (3); hypotension (2) |
Swelling (5/209) | Leg (2), toe, facial, neck |
Fever (4/209) | (nonspecific) |
Other (45/209) |
Higher order SNOMED category | Subcategory according to SNOMED |
---|---|
Falls (61/209) | Elderly (38); fall (14); mechanical fall (5); recurrent fall (4) |
Injury (33/209) | Head (6); head minor (10); shoulder (1); soft tissue (2); contusion (2); tear skin (1); no apparent injury (11) |
Pharmacological assessment (33/209) | Chart meds (28); script (3); chart and script (2) |
Pain (14/209) | Chest (4); abdominal (1); shoulder (2) hip (2), migraine (1), lower back (1) post fall (1); knee (1); neck (1) |
Urinary (9/209) | Complication of catheter (1); blocked catheter (2); injury urethra (1); UTI (5) |
Vomiting (6/209) | Vomiting (3); nausea (1); coffee ground vomit (2) |
Infectious disease (5/209) | Sepsis (4); clinical sepsis (1) |
Endocrine (4/209) | Hyperglycaemia (1); diabetes mellitus (2); poor glycaemic control (1) |
Disorder respiratory System (4/209) | Hypoxia (1); cough (1); lower respiratory tract infection (1); COVID risk assessment /flu (1) |
Inflammatory Disorder (4/209) | Cellulitis (3); periapical abscess (1) |
Other (36/209) |
Patient management
Reason for urgent ED Transfer | Residents (n) |
---|---|
Sepsis | 4 |
Haemoptysis | 2 |
Coffee ground vomiting | 2 |
Infection, source unknown (with vomiting) | 1 |
Periapical abscess | 1 |
Gastric ulcer with haemorrhage | 1 |
Gastrointestinal haemorrhage | 1 |
Rectal haemorrhage | 1 |
Cardiac syncope | 1 |
Hypoxia | 1 |
Lower respiratory tract infection | 1 |
Post Operative (Cystoscopy) Bleed | 1 |
Haematuria | 1 |
Hip pain | 1 |
Low back pain post fall | 1 |
RACF | In-situ | Medication | Imaging | Pathology | GP Review | Recommended ED Transfers Emergency/NEPT | Actual ED Transfers | Cases where RACF would have normally called ambulance |
---|---|---|---|---|---|---|---|---|
1 | 2 | 0 | 0 | 0 | 0 | 0/0 | 0 | 1 |
2 | 5 | 3 | 0 | 0 | 1 | 1/1 | 2 | 4 |
3 | 147 | 23 | 2 | 0 | 12 | 15/7 | 26 | 58 |
4 | 17 | 7 | 0 | 0 | 4 | 2/3 | 6 | 18 |
5 | 6 | 0 | 0 | 0 | 0 | 1/0 | 1 | 6 |
6 | 2 | 0 | 0 | 0 | 0 | 0/0 | 0 | 0 |
Totals | 179 | 33 | 2 | 0 | 17 | 19/11 | 35 | 87 |
Use of ambulance service
Qualitative data analysis
Participant Group | “N” | Target |
---|---|---|
RACF- Manager (RACF MG) | 4 | 8–10 |
RACF Manager/Registered Nurse (RACF MG-RN) | 2 | |
RACF- Registered Nurse (RACF RN) | 1 | |
MED manager (1) or FACEM (2) (MED) | 3 | 5–6 |
Participating GP (GP-P) = those opting in to MED | 5 | 5–7 |
Non- Participating GP (GP-NP) = those not opting in to MED | 2 | 3 |
Resident/guardian (RG) | 1 | 8–10 |
Total | 18 |
Systems issues related to care in RACFs | Issues related to the MED Model of Care | Implementing the MED program | Experience of the MED program |
---|---|---|---|
Challenges of delivering care in the RACF -Resourcing including RACF funding and pressure on staffing numbers and time, and poor availability of medication | Principles of management in RACFs -Choosing the right locus of care -Team based care including residents and families | Expectations of MED | Lack of GP engagement MED assists with specific needs |
Some GPs often unwilling to provide afterhours care in RACFs | Scope of MED -Perceptions of MED Role -Challenges with telehealth and role of video-health -Face to face contact -Complementary to usual care | Promoting MED | MED program is reliable and provides valuable outcomes -Communication from MED is efficient -Satisfaction of RACF staff |
GP Model of Care Compared to MED Model of Care -Local knowledge -Skill sets for RACF care -Continuity of care -Costs of service | Process of implementing the program in RACFs -Training -Consent -Privacy -Communications | Improving the Afterhours MED program |
Systems issues related to care in RACFs
the big challenge is there is not enough money in residential aged care … so the nurse-to-patient ratio is very low and that is a barrier…the nursing homes are 10 to one or 20 to one. Maybe two RNs on for 80 patients and the others are ENs, maybe seven or eight ENs. So 10 to one patient to nurse ratio as opposed to three to one in the public hospitals. (GP-P3)
These patients are sick, quite sick and really intensive. If I was seeing these patients in general practice each one would be my difficult patient for the day. Every patient at the nursing home is my difficult patient for the day. (GP-P3)
…I suggested that they should take his blood pressure more often and check his urine more often so we get a clearer picture, they obviously, haven't got the time to do that. (RG1)
the instructions and medications to give them, there’d be lot of delay by the time they implement it, so they will call you in the Sunday morning… but they won’t get the antibiotics until Tuesday. (GP-P5)
I don’t want to do afterhours, I don’t want to be in the middle of the night, as much as possible, I don’t want that (GP-P1)
They want to report every single thing; even minor things they report to you… It generally means that, for me, it’s taking a lot of my time (GP-P4)
Our nurses would normally ring the doctors and if we couldn’t get the doctors, and the clinical decision was that the resident was unwell and needed GP interactions, they would go into hospital, ambulance (RACF-MG2)
I'm much happier doing telehealth these days in the nursing homes… beforehand you're so bitter about all this telehealth that we did being effectively unpaid…but now if they [RACF] call me…I know I'm getting paid for it, I'll call them back and we'll go through it (GP-P3)
Issues related to the MED model of care
it’s quality of life around the residents because they’re not going into the hospital. They don’t have that disruption. Often when they go in an ambulance to hospital, they’re not taking sometimes dentures with them or glasses with them, just things like that, because everything is just quite rushed. So this way they stay in their home. Their quality of life while they’re just recovering from whatever the incident is or the deterioration is, it’s far healthier for them (RACF MG2)
Everyone is involved in the care…it’s a chain of professionals that do the care for the residents. Obviously, at the front are the RNs and then it goes to the doctors and then next-of-kins (RACF MG4)
and I've suggested things that nobody seems to want to listen to me. Because I'm only a relative, sort of thing. And maybe I haven't got the right to do that, I don't know. (RG1)
we have a doctor’s book for the GPs that they look at every time they come. So they can see what we were wanting them to do for each resident, we’ve also got our handover sheet which gets discussed at each handover and as well as being documented in the progress notes and care plan (RACF MG6- RN3)
Not for the chronic problems at all. It’s only meant for acute issues…purely meant to provide an opinion, advice in an emergency situation, really can’t do much for the normal case-to-case management in the long term at all. It has no role in that (GP-P5)
It’s being used after hours and where we would normally have rung an ambulance and/or a GP at this point. (RACF MG2)
That’s where I think there’s a lot of difficulty, when the patient is on 20 different medications and you’ve got a relatively junior nurse trying to read them all out to us. And the past medical history, it’s just very, very complex. That can be very time consuming (MED1)
I just worry because Telehealth is not 100% fool-proof, in the sense that some conditions really need to be assessed physically by a doctor to see what’s wrong with this patient – whether there’s a life-threatening condition or whether it’s just a simple thing. I’m just worried that one day the Telehealth doctors will miss something more serious, and the patient dies the next day (GP-P4)
they can actually speak to a doctor rather than talking over the phone. They can actually see the doctor and they can actually explain what’s going on and show the doctor the resident rather than just doing something by phone. (RACF MG6-RN3)
I personally like to do face-to-face medicine, not so much Telehealth, because you learn so much looking at the patient. And with Telehealth you can’t really get that idea from what they are in or other things they are describing. (GP-NP2)
they all love their GPs and they would prefer to see their GP, but it’s the difficulty of trying to get a GP out here when you need them. (RACF-MG2)
it [MED] has a big role to assist decision-making to the RNs [Registered Nurses] and the nursing staff. Even if it is emotionally taking the responsibility and the burden off the shoulders, it’s already a big role. (GP-NP1)
it would probably be better delivered by GPs than emergency specialists … I just think GPs are better trained for nursing home work than emergency doctors are…It's community medicine, not hospital medicine that we're doing. (GP-P3)
we would definitely be complementing the face-to-face GP – it will always be necessary to have a local GP looking after a resident to have that continuity of care and ongoing management plan, so our service will never replace that and that’s definitely not our aim (MED3)
We’ve got a system where the senior clinical group, with MED, will audit the paperwork, a discharge summary and all their notes, to make sure that it includes everything relevant and necessary (MED1)
it would be more cost-effective because we [GPs] don't bill as much as emergency specialists do. Even if you compromised and met them halfway it would still save a lot of money I would think…it's quite an expensive service. (GP-P3)
the after-hours Telehealth [MED] could occasionally be a duplicate service because they will ring Telehealth – I’m talking a lot of Telehealth consults is at night. And then the next day, when I come back, obviously I have to review the patient again the next day, I look at the report and I have to review the patient (GP-P4)
Implementing the MED program
really I expect them to call the whole after hours completely without me getting the calls in between (GP-P5)
I think my expectations are…it’s not just about the calls, it’s about the framework that we provide and medico-legal structure, follow up, access to notes. (MED2)
We initially talked about it at resident meetings and we sent out a flyer, we put flyers up about it. And we also put it in our newsletter …to remind the residents …and the families, that that service was in place. (RACF-MG6 RN3)
I don’t know whether the nursing home or the staff are aware of the services, because…what I find is in the middle of the night, they would fax me about what is happening to this resident….I don’t know whether they are aware (GP-P1)
facilities with higher staff turnover –we do offer regular refresh training sessions for the staff, just so that any new members of staff who come through are aware of the service (MED3)
most of the local protocols would still be for the nursing staff to phone the local GP in the first instance, and when they are not available, to then approach My Emergency Doctor. (MED3)
initially he [another practice doctor] said, "Look, I'm not going to do it. I'm really pissed off. Bugger paying them. They can pay me." (GP-P3)
you need to speak to the nurse as the patient’s communicator most of the time to tell us exactly and that, I think, for some nurses… they feel like it’s a bit more time consuming. They need to spend time on the phone, looking through medications, talking to us, I think, they are feeling they can’t deliver care to other residents. I think they really feel a sense of pressure and rush (MED2)
they provided us with the iPad and then they did training with me specifically and I then trained my deputies and my RNs. (RACF MG2)
And we’ve done that again more recently because we’ve had new RNs starting and just to refresh all of us to make sure that we all remembered how to do it so (RACF MG6-RN3)
they would have had some training and would have had some expectations, I think, they use an ISBAR [Introduction, Situation, Background, Assessment, Recommendation] format, and so even when they speak, obviously they are pressured, I spend the first three minutes just listening and absorbing. I’ve never had a consult without vital signs (MED2)
[RACF] has developed a telehealth policy, that’s only just come out a couple of months ago, around use of telehealth and confidentiality and stuff like that (RACG MG6-RN3)
You just have to make sure when people are recording a resident they are in dignified manner, the roommate is not being shown, it’s only focussing on what the issue in relation to that resident that they’re calling for (RACF MG3)
we got that in place, so everything is documented, the time that it was called, whatever ambulance has been called or after hour doctors have been called so that’s all been logged in. (RACF MG4)
we look at the advanced care plan and if it says palliative, not for hospitalisation, whatever, then we discuss that with the Emergency doctor, we talk to the family member as well, and the resident if the resident’s able to talk (RACF MG6-RN3)
we always send a clinical record or discharge summary to the aged care facilities, and a copy of that usually goes to the GP if we’ve got the GP’s number, and often if I’ve had the chance to speak to the GP looking after them, I will ask for their fax numbers. It’s not always readily available (MED2)
Experience of the MED program
There were a number of GPs at each of the facilities who just point blank refused to sign any consent (MED-3)
We need to attract GPs to work in nursing homes and the after-hours service is actually an incentive because if you can say to GPs, "Well, you're not on call in the middle of the night, you're not on call 24/7 365 days a year," then it's much more attractive for GPs to work in nursing homes (GP-P3)
nursing home patients need 24-h care. If there is a case where I am away at night-time, they still can find someone if they have any problem and if there is any need of care, they can contact someone to review the patient, I’m happy. The patient is happy; the family are happy. (GP-P4)
I’ve been really surprised at how much we are able to make a difference without the patient leaving their home and without us leaving our home. That’s been, for me, a real surprise and makes it incredibly satisfying as a job. (MED1)
it’s [MED] a great app –very versatile for everyone. Anyone can use it. I hundred percent love it and support it because it’s something that it can be used from toddlers right up to elderly and all culture and backgrounds (RACF MG4)
We have been called for routine medications and that has created a bit of angst amongst us, but I see it is as if the patient or the resident does not have any other options. And for some reason, due to their aged care facilities, if it’s inherent busyness or their time constraints are unable to get a GP to fill out the medication charts, and I will just say look, I will just do it. (MED2)
They [MED]… might write down “I prescribe Endone” for a few days or weeks…. I usually don’t like to write S8 myself unless I feel that it’s necessary. I have to go and check because I didn’t prescribe (GP-P4).
I have to say that in the case of My Emergency Doctor, when they review a patient they direct your attention to what you need to review the patient because sometimes the patient may have a poly pharmacy and medication and they tell what you should do. So the general healthcare, the help is good because they direct your attention to what you need to do. (GP-P2)
… where the nurse is very worried, I’ve actually called back in three or four hours to check how the patient’s doing and I’ve found that just that one or two-minute call back after that, they found really reassuring, and it’s often the patient has picked up. (MED1)
it's great to have it there to know that we can ring somebody and they can actually visually see the resident after-hours if we need them, it's a great backup tool to have (RACF MG6-RN3)
feedback from the relatives or the guardians…from the nursing staff feedback, they always say, “Look, I’ve rung the guardian or the next of kin,” that this patient has been relieved by the after-hours Telehealth (GP-P4)
by the end of the day it saves time for the patient by having to wait for the emergency and gives them the service at the facility. (GP-P2)
It’s cost effective because it will save people going to hospital, use the resources or the ambulance because we know how expensive it is, and the hospital, stretching the facilities the emergency (GP-P2)
When they go to hospital, particularly if they remain in ED all day, they come back distraught. They come back upset. It’s an unsettling experience for them. And it’s not necessary when you’ve got something like My Emergency Doctor (RACF MG2)
One of the good things that have come out is it has improved my communication. It improves my emphasis of certain things. I need to think out of the box when I look at a patient, or how else can I provide care remotely. (MED2)
I found actually the nurses have been really happy – I personally felt a lot of positive feedback from the staff, and especially because it is out of hours and it must be quite isolating for the nurse. You know, they’re often one nurse, to a whole nursing home. (MED1)
So what it’s done is allowed us to just give the RNs the confidence that you can monitor them like you would normally do in hospital and then go from there (RACF MG2)
facilities with higher staff turnover – so re-engaging with the new staff, so we do offer regular refresh training sessions for the staff, just so that any new members of staff who come through are aware of the service (MED3)
I would love for [MED] doctors who know the locality and the area, it’s very important. I trust their medical knowledge, but one thing I am a little bit reluctant or hesitant is that they don’t have the knowledge of locality. (GP-NP1)
I think if there are some facilities which have the My Health Record and if there’s no opt out, the notes are on the My Health Record, that’s useful for the next clinician who sees the patient, whether it’s through the My Emergency Doctor or somewhere else to access the notes. (MED2)
I personally think palliative care via video consult with someone who is pretty sick or they are expected to pass away, I think there is value in us trying to save them to go to hospital. (MED2)
It would be so good if it was available throughout the day and we had our GPs on board to do that, then we could make a call through to them without having to present at ED, instead of waiting and chasing GPs to get things done and residents looked at, I think for me it’d certainly reduce day admissions. (RACF MG2)
My Emergency has been financially subsidised by the PHN. At the end of this trial or pilot trial any aged care facility who would like to continue on, will have to pay themselves, and the cost is not cheap – any future decision about continuity with financial sustainability has to be considered well. (GP-NP1).
…the actual thing we really need is more staff in the nursing homes. All that money could have been spent on some extra nurse practitioners (GP-P3)
It’s important I think to fund afterhours consults with GPs (MED2)