Helping Older Persons in Emergency (iHOPE): iREDUCE unhelpful care for people who live in residential aged care facilities in Emergency Care.

The problem: Picture this… Cheng is an 83-year-old woman living with dementia in a residential aged care facility (RACF), she has frequent falls. Overnight, she falls after trying to go to the toilet without her frame. She is transported by ambulance to the ED as part of her RACF standing orders because her general practitioner is not available. In the ED, Cheng is left alone in an unfamiliar cubicle; the lights on the ceiling are blinding her and there is an intoxicated woman screaming abuse in the cubicle next to her. She has restricted access to staff for care, analgesia, warmth, toileting, and comfort. Cheng finds the narrow trolley hard and uncomfortable, and she doesn’t understand why she needs the tight collar on her neck. While waiting for a CT scan, she receives sedative injections for her agitation. Cheng has no access to family, and the hospital has no understanding of her (or her family’s) wishes. Cheng is not offered anything to drink, or her regular medications and she is unable to tell staff that her incontinence pad is soiled. She waits after the normal CT scan for her collar to be removed and a non-urgent ambulance to transport her back home. This was Cheng’s third transfer to the ED this year and it’s not yet Easter. The COVID-19 pandemic has laid bare the challenges of emergency care for a person (and their family) living in RACF. Older persons are over-represented in the ED attendances. The recent Royal Commission into Aged Care Quality and Safety called for the urgent need for improved support of older persons where they live.(33) Recommendations included the need for improved multidisciplinary outreach services, which “typically work out of a hospital to deliver specialist health care in the community” noting that currently, “outreach programs are not available to all people receiving aged care – coverage is patchy, haphazard, and subject to local funding restrictions”. Several models of care (33) have been tested with the aim of reducing unhelpful ED transfer and providing more humane in-home care. It is not clear which of these is the most effective or satisfactory for consumers and society. The Solution: The Helping Older Patients in Emergency (iHOPE) stream will reduce unhelpful care for people from RACFs and aim for excellence. We will use the LHS to engage with stakeholders, determine priorities, identify best practice, co-design a solution, use data to drive health care improvement, and determine cost effectiveness. Study 3.1 Helping Older Patients in Emergency: What Works? A two-week systematic review to determine the clinical and system effectiveness of interventions for older persons living in RACFs presenting for emergency care.(12) . Outcomes: This review will inform the outcome and exposure variables for which data will be collected in Studies 3.2 and 3.3. Study 3.2 Helping Older Patients in Emergency: What’s Happening? An observational study to describe the care and outcomes of older people visiting an ED. Outcomes: This study will establish the key determinants of receiving high value care (vs. unhelpful care) for the older patient in an ED. The results, in turn, will inform the interventions and their implementation for Study 3.4. Study 3.3 Helping Older Patients in Emergency: What Do Older People Want? A qualitative study to determine, for older persons and their families, the facilitators and barriers to receiving patient-centred care in the ED. Outcomes: The outcomes of this study will inform the why and how regarding the effective implementation of interventions to reduce unhelpful