This retrospective study was conducted over a randomly selected continuous 6-month period from 1 January 2022 to 30 June 2022.
A total of 66 patients were referred through the VEM–RATU pathway, 64 of whom were admitted directly to the RATU at Fremantle Hospital. These patients arrived via ambulance, bypassing the ED, acute medical unit (AMU), and geriatrics ward at Fiona Stanley Hospital. The two patients were excluded as they were referred through the VEM–RATU pathway and were not admitted to the RATU due to bed unavailability, being subsequently admitted to the general geriatrics ward at Fremantle Hospital.
During the same 6-month period, approximately 500 patients were admitted to the RATU via the non-VEM pathway. From this group, 80 patients were randomly selected for inclusion in the non-VEM group. All selected patients met the RATU-inclusion criteria upon presentation to the ED and were admitted exclusively from the ED, emergency short stay unit (ESSU), or AMU. Those admitted from general medicine, general surgery, or any other medical or surgical specialty were excluded from the study; patients transitioning from the ED to the AMU and then to the geriatrics ward at Fiona Stanley Hospital before transferring to the RATU were excluded as well.
To ensure comparability, the non-VEM group was matched with the VEM–RATU group based on the number of comorbidities on record. Patients in the non-VEM group were excluded one at a time in descending order, starting with the highest number of comorbidities, until both groups were equally matched in terms of comorbidities. Consequently, a total of 67 patients were selected for the non-VEM group.
Data collection
Data pertaining to VEM patients were systematically retrieved from the electronic medical record system. The comprehensive dataset encompassed various variables, including demographics, living arrangements (residing at home or at a nursing home), the presence of a caregiver, and availability of a home-care package. Key clinical information, such as the admission diagnosis (including delirium, common geriatric syndromes like cognitive impairment, incontinence, or immobility, or other conditions leading to hospitalisation), was meticulously documented. Additionally, data regarding the discharge destinations (same or a different destination) were collected. To facilitate group comparisons, numerical metrics including the number of comorbidities, hospital admissions in the previous two years, medications on discharge (including new medications), and complications for patients admitted via both pathways, were computed. This meticulously compiled and comprehensive dataset served as the cornerstone of the study’s analysis and findings. The dataset used and/or analysed during the current study is available from the corresponding author on reasonable request.
Service description
A patient in need of emergency care can contact St John’s Ambulance, Western Australia, after dialling triple zero (000), and St John’s Ambulance paramedics assess the patient upon arriving at the scene. If they determine that the patient could benefit from the streamlined VEM–RATU pathway, they establish contact with command-centre clinicians via telephone or video call. This expedites the patient’s access to care because ED staff can conduct a consultation and comprehensive assessment before the patient’s arrival at the hospital. A clinical nurse collaborates with a specialist emergency consultant to determine the most suitable course of care for the patient, involving their next of kin, caregiver, or general practitioner, as needed.
Subsequently, the emergency physician collaborates with the RATU geriatrician at Fremantle Hospital, and if the patient is deemed suitable, direct admission to the RATU ensues, bypassing the ED and traditional admission routes. The ambulance takes the patient directly to Fremantle Hospital instead of the Fiona Stanley Hospital ED. At the RATU, older patients receive a geriatric assessment, often followed by a comprehensive review by an allied-health team on the same day. This expedites patient management and the formulation of a discharge plan shortly after admission.
Alternatively, in the standard – the non-VEM – pathway, patients present to the ED either through ambulance services or using their own transport. Subsequently, these patients undergo an assessment in the ED, which occasionally necessitates an overnight stay in the ESSU and subsequent admission to the AMU. The identification of patients suitable for the non-VEM–RATU pathway can occur at various stages, including in the ED, ESSU, or AMU, and is followed by a transfer to the RATU at Fremantle Hospital. Moreover, patients can be transferred to the RATU from various medical and surgical specialties at Fiona Stanley Hospital.
A summary of inclusion and exclusion criteria is shown in Table 1.
Table 1
Rapid Assessment and Treatment Unit – Patient Inclusion and Exclusion Criteria
Inclusion criteria Age ≥ 65 years Infections – cellulitis, pneumonia, urinary tract infection (UTI), etc. (excluding septic shock) Mobility issues – falls, functional decline (clinical frailty score > 4) Cognitive issues – delirium, dementia (excluding patients needing a locked unit) Heart failure (if hemodynamically stable) Fractures (for conservative management) Parkinson’s disease and syndromes Other issues (identified in discussion with RATU geriatrician) Exclusion criteria Patients who require surgery or are immediately postoperative Bariatric patients (weight > 230 kg, shoulder width > 60 cm, or pelvic width > 55 cm) Patients who are haemodynamically unstable (Adult Deterioration Detection System score > 3), need telemetry, or require tertiary care Patients who require non-invasive ventilation (unless patient can self-manage their own CPAP machine) Patients with femur fractures or unstable pelvic fractures or those who need spinal precautions Patients who require complex disposition planning |
Data analysis
Categorical data were analysed using Fisher’s exact test, whereas continuous data were analysed using Student’s t-test. A two-tailed p value < 0.05 was considered statistically significant. Because LoS is not normally distributed, the t-test is unsuitable for analysis. Instead, t-tests were applied to age, comorbidities, drugs, and number of admissions.
The 80th percentile of LoS was selected to focus the on patients who required primarily acute and/or subacute care while excluding older inpatients who needed extended maintenance care as they awaited suitable accommodation for discharge. The study juxtaposed the mean, median, and 80th percentile of LoS observed in the VEM–RATU pathway with data from non-VEM admissions to the RATU over a 6-month period. Subsequently, the cohort’s data were compared with those of the broader Australian older inpatient population in the same year, utilising data from the Australian Institute of Health and Welfare (AIHW) for 2021–2022 26.
Ethics Approval
This quality activity (no. 50491) was approved by the South Metropolitan Health Service Human Research Ethics Committee. As this study is a retrospective study, and all participants were de-identified, informed consent to participate was not required.