Overview
Initiative type
Service Improvement
Status
Deliver
Published
June 2026
Summary
Bringing it home the Acute Patient Assessment for Care in the Home Environment (APACHE) is a streamlined referral process, based on ieMR, that provides a bridge to HITH and other community care options previously underutilised by our Emergency Departments.
Dates: February 2025 - ongoing
Implementation sites: North Lakes Health Precinct - Metro North Hospital and Health Service
Partnerships: MNHHS Critical Care Stream (Emergency Sub-Stream); Redcliffe Emergency Department, Caboolture Emergency Department, Virtual Emergency Care Services (VECS), OPEN, COH BPIO and Systems Support
This project was presented as a Poster at CEQ Showcase 2026 (PDF 397KB)
Aim
To facilitate safe and timely senior clinical review for a wide range of acute conditions that would otherwise require inpatient admission.
Outcomes
A highly successful digital referral process has been established, with 430 referrals for patients with acute conditions received in the first 12 months. There were only 5 (1.1%) patients who failed to attend and 15 (3.5%) who required return to hospital, with no clinical incidents resulting from APACHE referral recorded to date. 61% of referrals related to infections, but a broad range of conditions made up the remainder of referrals suggest opportunity to expand patients utilising the service. 243 (57%) of patients proceeded to HITH admission, doubling the acute HITH separations for the initial implementation site (Redcliffe Hospital). Patient satisfaction is high, with 99% recommending the service to others. Implementation has expanded to all ieMR enabled sites at Metro North HHS.
Background
Increasing healthcare demands are placing significant pressures on patient flow in the healthcare system. In the 2024 financial year, the median ED length of stay (LOS) in the Metro North HHS (MNHHS) was 311 minutes. Ambulance ramping was a common occurrence with almost half (42.8%) of patients waiting longer than 30 minutes to be transferred off stretcher after arrival at the ED.
Strategies developed to address increasing pressures on bed capacity and patient flow have included HITH and telehealth services, which form part of the acute ambulatory care environment. As these services expand and increase their scope of practice, clinicians face an ever-growing array of options available and may require assistance to identify the most suitable service for their patient. This can create barriers locally, leading to underutilisation of available services. These challenges are further compounded by a lack of streamlined referral processes and limited clinician awareness of available community-based options.
Data from Redcliffe Hospital, the initial focus for APACHE implementation, revealed a low proportion of acute separations were referred to the existing HITH services at only 0.46% in the 2024 calendar year. ED presentation and disposition data showed that only a small proportion of cases suitable for HITH were being referred. For example, between July and December 2024, the six-month period prior to commencement of APACHE, less than 1% of ED cellulitis presentations were referred to HITH, while 21-39% were admitted to hospital. These figures were well below the Queensland benchmark of 2% of separations to HITH, highlighting a missed opportunity to reduce inpatient admissions through greater utilisation of ambulatory care.
Feedback from staff working in the Redcliffe Hospital ED and HITH highlighted challenges in accessing acute ambulatory services. Pre-existing factors contributing to this issue included the difference in location of responsible medical officers and difficulties in transmission of patient information due to paper-based documentation. Specifically, the HITH medical officer responsible for receiving referrals and coordinating care of patients on the service was based off site with the HITH team, given the logistical complexities of managing care for patients admitted under that service. Patient information also required physical transportation between sites leading to potential delays in care, as each patient only had one physical chart available, prior to ieMR implementation. Therefore the implementation of ieMR at Redcliffe Hospital, and MNHHS more broadly, provided a significant opportunity to review existing processes and redefine pathways to acute ambulatory care not previously deemed possible.
Methods
Early consultation on the development of APACHE began in late 2024 in collaboration with key stakeholders, including the MNHHS Critical Care Emergency Sub-Stream and HITH. Redcliffe Hospital ED was identified as an initial site for intervention design and implementation, given this was the only site with full ieMR implementation in MNHHS at that stage and historically had low HITH utilisation, particularly from the ED. Implementation was planned according to the RE-AIM framework, while an agile methodology was utilised to guide development of the referral process. Significant APACHE clinician visibility and availability in the Redcliffe ED during the early phases of implementation was a key strategy to promote adoption, co-design of the referral process and implementation consistency.
From the outset of initiative development, it was apparent that ieMR functionality could overcome many of the previous barriers to referrals to acute ambulatory care services. Seamless availability of all clinical information during an ED presentation enabled the minimum referral criteria to be boiled down to three key questions to appropriately plan next day APACHE review:
1. Patient consent to be seen by the service
2. Suitability for telehealth
3. Need to consider security presence at the time of patient review
The ability to generate a referral without duplicating/summarising already documented clinical information was seen as highly desirable by ED clinicians. Utilising ieMR to its full scope rather than relying on additional systems to enable referral was also seen as a key enabler to adoption, which was able to be realised through the use of AutoText and Message Pool functionality. All stakeholders agreed that APACHE should be established as an outpatient, rapid access clinic, given the variety of patient dispositions that might result from the assessment - this allowed bookings in the Enterprise Scheduling Management (ESM) system of the Cerner ieMR suite, further enhancing referrer visibility of processes related to the service for their patients.
The question of patient suitability for APACHE was debated amongst stakeholders prior to implementation. Previous approaches to increase HITH utilisation relied on a limited range of condition-based clinical pathways, with a significant number of inclusion/exclusion criteria that the ED clinicians reported difficulties in assessing. Therefore a holistic, senior clinician-led suitability assessment in the ED with respect to the question "is my patient suitable for next day senior medical review?" was agreed to be a fundamental underpinning to enhance the reach of APACHE. However, a pragmatic approach was adopted to provide suggested referral criteria and initial management advice for three common conditions amenable to acute ambulatory care (cellulitis, urinary tract infection and heart failure) ' this was designed to ensure early referral efficacy and build stakeholder trust in the process, providing a solid basis for a greater diversity of referral reasons as volumes expanded. All resources developed for patients and clinicians relating to APACHE, including these referral criteria, were made freely available on Microsoft SharePoint to all Queensland Health clinicians to help minimise access barriers.
Discussion
APACHE commenced in February 2025 at Redcliffe Hospital and has now extended across MNHHS to facilitate referrals from other ieMR enabled services, including Caboolture Hospital and Satellite Health Centres. APACHE has received over 430 referrals from a broad range of clinical services across MNHHS, with very low failed to attend rates (1.1%) and acceptable return to hospital rates (3.5%), with no reported clinical adverse events. While the most common referral indications were related to infections, a diverse variety have been successfully managed through the service, culminating in the development of referral guidance for a further eight common conditions to help promote service reach as APACHE expands (wounds, diabetes mellitus, acute kidney injury, COPD, pneumonia, anaemia, VTE and hyperemesis gravidarum). Given these conditions are common across Queensland, the statewide enablement of ieMR and broad geographic presence of acute ambulatory care services (e.g. HITH), it seems likely that interventions similar to APACHE could be successfully implemented across Queensland Health.
Most patient reviews occurred face to face in a clinic environment (80%), with a small but increasing proportion conducted in patients' homes (6.7%). The low uptake of telehealth (7.3%) likely relates to the preponderance of referrals for conditions requiring intravenous antibiotic therapy, but warrants further exploration to see if other unrealised opportunities exist to expand APACHE referrals and utilise this modality of review. 57% of referred patients were admitted to HITH for ongoing assessment and management, again representative of referral patterns and a likely opportunity to expand virtual acute care direct from the ED ' only 3.5% of APACHE patients were referred on to the MNHHS Virtual Ward. Patient satisfaction was very high with 99% recommending the service to others. The service generated an additional 1,000 occupied HITH bed days in 2025 for Redcliffe Hospital (approximately 2.7/day), doubling HITH separations for that service alone.
APACHE uptake at the second major site of implementation, Caboolture Hospital, has been significantly slower than Redcliffe Hospital. Resourcing to support APACHE did not grow during the intervening period, limiting clinician presence during the early implementation at Caboolture. Despite broad agreeance on the principles and design of APACHE at this site, it is clear that adoption of a novel referral pathway requires clinician trust and an efficacy that is difficult to achieve without in person presence. These lessons have been learnt and recent growth of the service has allowed greater presence at Caboolture and other sites of referral, which has led to a significant acceleration in referral rates. A disproportionate representation of conditions encompassed by newly developed APACHE referral guidelines has also been seen during this period, demonstrating the importance of developing such artifacts to promote both adoption and sustainability in clinical environments with high staff turnover and high cognitive load.
References
RE-AIM ' Home ' Reach Effectiveness Adoption Implementation Maintenance
Frontiers | RE-AIM in the Real World: Use of the RE-AIM Framework for Program Planning and Evaluation in Clinical and Community Settings
Implementation of Agile in healthcare: methodology for a multisite home hospital accelerator - PMC
Key contact
Dr Julian de Looze
Clinical Director Hospital in the Home
Metro North Hospital and Health Service