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After Hours Program

Western NSW Medicare Local
Project Added:
2 September 2015
Last updated:
3 September 2015

After Hours Program

Aged Care Identify, Situation, Background, Assessment and Recommendation (ISBAR) and Emergency Guideline Training


The online training program was created to train residential aged care facility (RACF) staff in the implementation of these guidelines.


To improve clinical communication among healthcare providers in the after hours period, which intern may help to reduce unnecessary after hours hospital admissions.


  • Reductions in avoidable hospital admissions, would improve health outcomes for residents in RACFs.
  • After hours primary care providers will receive succinct and timely information in the after hours period.
  • Cost savings for hospitals due to possible decrease in avoidable hospital admissions.
  • More efficient information sharing and general practitioner (GP) will receive more succinct information about a residents medical condition.
  • Offers professional development and recognition for staff, making them more employable as they move between facilities.
  • Streamlines work processes, by using ISBAR tools across disciplines.
  • The After Hours Program developed emergency guidelines and online training modules for the most common aged care presentations to emergency departments (EDs), including chest pain, stroke, abdominal pain, confusion and tubes.

Program status

Program dates

  • Start: 2013
  • Implementation: 2014
  • Finish: 30 June 2015

Program status

Sustained - The program has been implemented, is sustained in standard business.


A number of GPs providing after hours services for the Western NSW Medicare Local After Hours program (through a collaborative roster) were expressing concern in regards to the clinical information given to them about residents deteriorating health status when phoned by staff in residential aged care facilities in the after hours period. Examples given were that staff would phone the on-call doctor and not be able to provide a brief history of the resident’s condition or may not have undertaken any routine observations or assessment prior to making the phone call.

On investigation, it was identified that:

  • many RACFs do not have a registered nurse on staff 24 hours a day
  • residents are entering RACFs at much later age and have more acute health problems and multi-morbidities
  • GPs throughout the region are an aging workforce and often work part-time, which means much of the work falls on after-hours RACF staff who are not as skilled and more inclined to send the resident to the ED
  • there was a lack of training available in the aged care environment and RACF were often not equipped to provide their own training
  • aged care residents who have had a bad experience in the ED, often due to effects of dementia, were less likely to report when they were feeling ill, which may add to deterioration of health status in the after hours
  • there were some barriers to communication for those staff for whom English is a second language
  • anecdotal feedback from GPs indicated that they often had to make multiple calls to get all the information they required from RACFs to make a clinical decision, which was particularly difficult in the after hours.


  • Development of Emergency Guidelines for the most common emergency presentations in RACFs, including chest pain, stroke, abdominal pain, confusion and tubes. The guidelines help RACF staff identify when a situation needs to be acted on and escalated immediately, or when it is appropriate to report, observe and monitor.
  • Development of online training modules tailored for RACFs, using ISBAR clinical handover tools. Training modules were based on guidelines originally developed by Hornsby Ku-ring-gai Health Service and was provided free of charge to RACFs in Western NSW Local Health District.
  • Online training comprised two components with 16 interactive modules, related to ISBAR and Emergency Guidelines. The time required to complete each module is between 90 minutes and two hours. Content is periodically refreshed and quizzes are randomized, making it difficult for participants to cheat.
  • Training was conducted onsite in RACFs, with clinical, administrative and ancillary staff. Each facility received a temporary licence, username and login to access the online training.
  • The training package contributes to two hours of professional development, education and training for registered nurse or enrolled nurse registration purposes.

Implementation sites

ISBAR training has been conducted in twenty six residential aged care facilities throughout the Western NSW Medicare Local region. A total of 395 staff have completed the training program. More remote facilities and facilities with limited after hours supports were offered and undertook training first and then facilities in larger regional towns were offered and undertook training. Training was facilitated in the following towns: Condobolin, Narromine, Gilgandra, Coonabarabran, Gulgong, Kandos, Mudgee Parkes, Peak Hill, Cowra, Carcoar, Forbes, Dubbo, Wellington, Yeoval, Molong, Bathurst and Orange.

Training was not offered to residential aged care facilities within multi-purpose services as these services often had better access to resources and training.

The Emergency Guidelines are based on those originally drawn up by Hornsby and Ku-ring-gai Health Service and as amended (2011) by Southern Tasmania Area Health Service Nurse Practitioner – Aged Care and General South and by Hunter Medicare Local and Country North SA Medicare Local.


  • General practitioners
  • Residential aged care facilities


  • To date, 395 staff (e.g. registered nurses, enrolled nurses, assistants in nursing) from 26 residential aged care facilities throughout the Western NSW Medicare Local region have completed online training, with a number of sites expressing desire to undertake training if the program continues post June 30th 2015.
  • Competency is evaluated using a variety of assessment tasks, with drag and drop, multiple choice and short answer responses. Participants engage with video, text and animated PowerPoint activities. In most instances they receive immediate feedback, while others require short answer responses which are marked by the trainer.
  • The online training component of the project is evaluated in two ways:
    • an online pre-training questionnaire and an online post-training evaluation completed by participants after the final unit of work
    • a survey completed by the facility manager or nominated contact to gauge their perceptions of the training, its value to staff and the value to the facility along with any changes as a result of the training.

Formal evaluation is yet to be completed of the impact of the training on ED presentations, improving health outcomes for residents and reducing GP after hours services.

Anecdotal feedback on the online training

“The ISBAR training at Maranatha House was very positive. We trained 54 staff including myself. The feedback was excellent. The staff stated they felt more confident in communicating to others and learning how to communicate in the correct manner to ensure the right information was given. The posters and notepads have also reinforced what they have learnt and the staff are using these resources every day.

The staff also enjoyed the first aid refresher questions, this also provided them with more confidence in their skills. There were many staff not confident in computer skills and using their own small computer during the course also made them feel more self-confident. It was the staff themselves that talked the other staff in completing the course; hence we were very lucky to be able to put as many staff through this course as we did. Management of Maranatha House would like to thank you for including us in this training.”

Leonie Williams, Assistant General Manager, Maranatha House

“Feedback from all staff is all very positive they found the training most helpful. After discussion at our staff meeting, I have implemented the ISBAR process and supplied staff with your forms and document/information folder you provided. It is kept with our transfer envelopes folder so that everything is readily available when needing to call for assistance."

Di Southcombe, Practice Manager, Uralba Retirement Village, Carcoar

Lessons learnt

  • Where possible, use a registered nurse with an aged care background in the RACF to support the training. They have a shared language and experience with RACF staff and management.
  • Don’t be afraid to cold call RACFs. We had a greater success using an aged care registered nurse to call facilities directly, with only two out of 44 not responding to this method.
  • Provide opportunities for peer feedback and support.
  • Work with facilities that can make local decisions, as support from multinational head offices can be difficult to obtain.
  • RACFs often do not have the knowledge or resources to organise online training and require support from Medicare Locals to implement.
  • Try to conduct training before the participant starts their shift and offer three training sessions per day to accommodate staff shifts.
  • Make post-training evaluation part of the last module so that participant feedback is not optional. Post-training feedback can be difficult to obtain from facility managers, so provide multiple options for the collection of this data, e.g. paper, online, telephone etc.
  • Ensure management and senior clinical staff complete the training, to reinforce the importance of using ISBAR as the preferred communication tool.
  • It’s better to engage a trainer with an aged care nursing background rather than a professional trainer, as they can field participant questions correctly and avoid potential de-valuing of the product and philosophy of ISBAR.
  • Currently, RACFs, EDs and GPs are all required to complete different forms and there is no standardised form that all services can use.
  • Considerable time and resources are required to build relationships and trust. Providers become disgruntled when funding is withdrawn once they have invested in an initiative, so it’s important to judge the environment before promoting services to a facility.
  • It’s important for GPs to be aware of ISBAR training and the RACFs in their area that have undertaken training. This allows GPs to reinforce the use of ISBAR when communications to RACFs
  • Make sure all information on ISBAR notepads remains confidential and is securely stored in the resident’s file.
  • Although originally intended to be a non-facilitated, self-paced online training course, it soon became apparent that support was required to:
    • schedule training
    • support staff on site with the training
    • provide computer access
    • resolve intermittent internet access (typical for rural areas)
    • support participants with low computer literacy.
  • To date, issues impacting the collection of quantitative data includes:
    • lack of accurate records at RACFs
    • Pen clinical audit tool not targeting aged care
    • incomplete after-hours service records by GPs.


Maree Earle
Clinical Operations Manager
Marathon Health, Bathurst
Phone: 02 6333 2800

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