The impact of telehealth care on escalation to emergency care: A systematic review and meta-analysis.

OBJECTIVE: We compared the impact of accessing healthcare (1) by telehealth (via telephone or video) vs face-to-face; and (2) by telephone vs video telehealth care, on escalation to emergency care. METHODS: We searched Medline, Embase and Cochrane CENTRAL to 24 July 2023; and conducted a citation analysis on 19 September 2023. We included randomised controlled trials. Risk of bias was assessed using Cochrane Tool 2. We calculated risk ratios for dichotomous outcomes and standardised mean difference for continuous outcomes. RESULTS: Ten trials compared telehealth (five telephone, four video, one both) to face-to-face care. Six were overall low, three some concerns and one high risk of bias. There were no differences between telehealth and face-to-face for visits to the emergency department (RR 1.07, 95% CI 0.89 to 1.29), hospitalisations up to 12 months (RR 0.89, 95% CI 0.56 to 1.41), deaths or other adverse events. Costs of care were similar, as were patient satisfaction scores.Six trials compared telephone to video telehealth: three were overall low, two some concerns, and one high risk of bias. There were no differences between telephone and video for visits to the emergency department (RR 0.67, 95% CI 0.41 to 1.12), hospitalisations (RR 1.04, 95% CI 0.73 to 1.48), deaths, other adverse events, costs, or patient satisfaction. Healthcare provider satisfaction was high. CONCLUSIONS: Telehealth care - delivered by telephone or by video - may be an appropriate alternative to face-to-face provision of care, as it does not increase the likelihood of escalation of care to the emergency department for patients in primary care, hospital outpatients, post-discharge patients or residents in aged care.

Implementation and evaluation of a nurse-led intervention to augment an existing residential aged care facility outreach service with a visual telehealth consultation: stepped-wedge cluster randomised controlled trial.

BACKGROUND: Up to 75% of residents from residential aged care facilities (RACF) are transferred to emergency departments (ED) annually to access assessment and care for unplanned or acute health events. Emergency department presentations of RACF residents can be both expensive and risky, and many are unnecessary and preventable. Processes or triage systems to assess residents with a health event, prior to transfer, may reduce unnecessary ED transfer. The Aged Care Emergency (ACE) service is a nurse-led ED outreach service that provides telephone support to RACF nurses regarding residents' health events. This service is available Monday to Friday, 8am to 4 pm (ED ACE hours). The primary objective of this study was to assess whether the augmentation of the phone-based ED ACE service with the addition of a visual telehealth consultation (VTC) would reduce RACF rate of ED presentations compared to usual care. The secondary objectives were to 1) monitor presentations to ED within 48 h post VTC to detect any adverse events and 2) measure RACF staff perceptions of VTC useability and acceptability. METHODS: This implementation study used a stepped wedge cluster randomised controlled trial design. Study settings were four public hospital EDs and 16 RACFs in two Local Health Districts. Each ED was linked to 4 RACFs with approximately 350 RACF beds, totalling 1435 beds across 16 participating RACFs. Facilities were randomised into eight clusters with each cluster comprising one ED and two RACFs. RESULTS: A negative binomial regression demonstrated a 29% post-implementation reduction in the rate of ED presentations (per 100 RACF beds), within ED ACE hours (IRR [95% CI]: 0.71 [0.46, 1. 09]; p = 0.122). A 29% reduction, whilst not statistically significant, is still clinically important and impactful for residents and EDs. A post-hoc logistic regression demonstrated a statistically significant 69% reduction in the probability that an episode of care resulted in an ED presentation within ED ACE hours post-implementation compared to pre-implementation (OR [95% CI]: 0.31 [0.11, 0.87]; p = 0.025). CONCLUSION: Findings have shown the positive impact of augmenting ACE with a VTC. Any reduction of resident presentations to a busy ED is beneficial to healthcare overall, but more so to the individual older person who can recover safely and comfortably in their own RACF. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ID ACTR N12619001692123) (02/12/2019) https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378629andisReview=true.

Does telehealth influence the decision to transfer residents of residential aged care facilities to emergency departments? A scoping review.

BACKGROUND: Emergency Departments (ED) can be crowded places and not ideal environments for Residential Aged Care Facilities (RACF) residents awaiting assessment. Assessment and care planning may be made available via telehealth thereby avoiding unnecessary transfer to ED, without compromising the quality of care for the older person. Telehealth is attractive addition to improving healthcare decision-making in RACFs. OBJECTIVES: The aim of this scoping review is to explore the evidence around the use of telehealth and whether it influences the decision to transfer residents of RACF to ED. METHODS: All peer reviewed literature that focused on RACFs, decision-making and assessment of residents using telehealth in real time, was included. All study designs, pilot studies and some systematic reviews were considered. Databases Medline, Embase and CINAHL were used in this search in June 2022. Search terms were a combination of the population: RACF residents, decision-making and assessments using telehealth, and or transfer to the ED. The search was assisted by a senior university research academic librarian/information specialist and reviewed by senior researchers. The PRISMA-ScR guidelines were used to report this study. RESULTS: Of the 124 articles initially identified, 31 were eligible for inclusion for synthesis. The date range of the included studies was 2001 to 2022, with 15 published in the last five years. Critical appraisal was conducted using the Mixed Methods Appraisal Tool. CONCLUSION: This scoping review has mapped evidence that telehealth has been widely used in multiple settings. The association between the use of telehealth with improved clinical outcomes highlights its potential utility in enhancing care delivery for an older population in RACFs. Telehealth has shown that it can improve the decision-making for residents in RACFS, but more robust research designs are needed. IMPLICATIONS FOR PRACTICE: Using video/telehealth appears to improve RACF staff access to expert clinicians who can then assess and jointly plan care/management that can be provided in the resident's home. Knowledge and skills of RACF staff appear to be improved through joint assessment and decision-making with the use of video/telehealth access to expert clinicians.

Experiences of nurses working in RACFs and EDs utilising visual telehealth consultation to assess the need for RACF resident transfer to ED: A qualitative descriptive study.

AIMS AND OBJECTIVES: This study aimed to explore whether an intervention using visual telehealth improves care outcomes for residents in residential aged care facilities during acute illness events from the perspective of the nurses from residential aged care facilities and emergency departments. The intervention was the addition of visual telehealth, to an already existing outreach service called Aged Care Emergency. BACKGROUND: Older people who are residents of residential aged care facilities commonly experience potentially avoidable visits and hospitalisations. Adopting visual telehealth or telemedicine has emerged as a care transition solution across several domains in health care, including residential aged care. METHOD: This study used an interpretive descriptive methodological approach and was part of a larger study called the PACE-IT project that implemented a visual telehealth assisted model of care in four emergency departments and 16 residential aged care facilities to prevent unnecessary resident presentations to emergency departments. We report findings from six focus groups that explored key issues relating to the experiences of emergency department and residential aged care nurses who participated in the PACE-IT project. This study adhered to COREQ research guidelines. RESULTS: There were four overarching themes that emerged from the six focus groups; facilitated person centred care; built confidence, relationships and trust; enabled bidirectional communication that strengthens decision making, but there were issues with technology access, connectivity and usability between the acute care setting and the residential aged care facility. RELEVANCE TO CLINICAL PRACTICE: Understanding the experiences of residential aged care facility and emergency nurses' experiences when using visual telehealth will better inform practice development in aged care, in particular enhancing decision making and increasing safe practices using telehealth. The knowledge gained in this study in terms of enhanced assessments for residents will provide policy makers with valuable insights for future health care planning and implementation of telehealth. TRIAL REGISTRATION: ACTRN12619001692123.

COVID-19 preparedness in aged care: A qualitative study exploring residential aged care facility managers experiences planning for a pandemic.

AIMS AND OBJECTIVES: The study aims to understand the changing context of RACFs and the role of RACF managers in preparing to confront the COVID-19 pandemic and to provide insights into how the use of visual telehealth consultation might be incorporated to assist with managing whatever might arise. DESIGN: An interpretive descriptive study design was employed, and data were collected using semi-structured interviews conducted via telephone or videoconference. Purposive recruitment targeted clinical managers responsible for the COVID-19 response in RACFs. METHODS: RACF clinical managers were invited to discuss their responses to COVID-19 including the management of RACF and staff. Semi-structured interviews explored the COVID-19-related challenges, the response to these challenges and how telehealth might assist in overcoming some of these challenges. This study followed Thorne's (2008) three-stage process of interpretive description. The COREQ checklist was used in preparing this manuscript. RESULTS: Two main themes were identified. The first theme 'keeping people safe' was comprised of three subthemes; fear and uncertainty, managing the risks and retaining and recruiting staff. The second theme was 'keeping people connected', had two subthemes; being disconnected and isolated and embracing technology. CONCLUSION: Findings from this study provide valuable insight into understanding the context and the challenges for RACFs and the staff as they attempt to keep residents safe and connected with healthcare providers and the outside world. RELEVANCE TO CLINICAL PRACTICE: Understanding the experiences of RACF managers in preparing to respond to the pandemic will better inform practice development in aged care in particular the use of telehealth and safe practices during COVID-19. Increased awareness of the challenges faced by RACFs during a pandemic provides policymakers with valuable insights for future planning of pandemic responses.

PACE-IT study protocol: a stepped wedge cluster randomised controlled trial evaluating the implementation of telehealth visual assessment in emergency care for people living in residential aged-care facilities.

BACKGROUND: Transfer of residential aged-care facility (RACF) residents to Emergency Departments (ED) is common, risky and expensive. RACF residents who present to ED are more likely to have hospital readmissions, longer stays and face major risks related to hospital acquired complications. Aged Care Emergency services (ACE) is a nurse led, protocol- guided, telephone RACF/ED outreach model that has been shown to be effective in reducing hospitalisation and length of hospital stay for RACF residents in the Hunter New England Local Health District, New South Wales (NSW). The Partnerships in Aged-Care Emergency services using Interactive Telehealth (PACE-IT) project enhances ACE by incorporating interactive video assessment and consultation. The PACE-IT project's primary aim is to assess whether augmentation of ACE services through the addition of protocol-guided interactive Visual Telehealth Consultation (VTC) for clinical decision-making, plus telephone follow-up, reduces RACF resident transfers to ED. METHODS: A stepped-wedge cluster randomised controlled trial will be conducted. The intervention will be delivered sequentially to 8 clusters; each cluster comprises one ED and two RACFs in NSW, Australia. The 16 RACFs in the study will be selected for order of implementation using a computer-generated randomisation sequence. A 2-step randomisation process will be undertaken, randomising the hospital EDs first and then randomising the RACFs aligned with each hospital. The PACE-IT intervention comprises: an initial phone call by RACFs to the ACE service in the ED; the ACE service in ED responds with a protocol-guided VTC, a management plan agreed between all participants; an automated consultation summary letter to the General Practitioner and the RACF; a post VTC 24 h follow-up phone call to the RACF. DISCUSSION: If shown to be effective, the intervention has the potential to improve the clinical care and quality of life for residents. Findings will provide high level evidence that will inform sustainable change and broad translation into practice across NSW. It will show how the change has been achieved and highlight success factors for scalability and sustainability. It will inform review of processes, the development of policy and guidelines that will integrate PACE-IT into existing service models in NSW. TRIAL REGISTRATION: The trial is registered with the Australian New Zealand Clinical Trials Registry (Trial ID ACTR N12619001692123 ) 02/12/2020.).