Addressing unnecessary and avoidable transfers from residential aged care to emergency departments and hospitals

Background

The aging population is becoming frailer and increasingly more likely to enter aged care with a greater range of physical and mental or cognitive health conditions and complex presentations, requiring a high degree of clinical and personal care.¹ While recent reforms have taken effect in Australian residential aged care facilities (RACF), including the requirement of 24/7 registered nurses (RN) presence and mandated direct care minutes, high rates of transfers from RACFs to emergency departments (ED) or hospitals have still been observed. While some transfers may be necessary, expected, or unavoidable, transfers are occurring at rates that far exceed what would be ideal given the important role of clinical care in Australian residential aged care.

Research has suggested that around 40–75% of aged care residents are transferred to EDs every year.^2,3 A 2019 systematic review identified that up to 55% of ED transfers from an RACF may have been avoidable; where clinical care in place should have been possible and preferable in the RACF.⁴ Further, in 40% of cases, transfers do not result in subsequent hospital admission with the older person being discharged back to the RACF.⁵ Comparatively, among ED presentations of older adults from the general public, in 48% of cases for those aged 65 and over, and 37% of those aged 85 and above, the older person was not subsequently admitted to hospital.⁶ While it may appear that there is a lower rate of potentially avoidable transfers from RACFs compared to the general public, it is important to consider the differing circumstances. Residential aged care is a healthcare setting with round-the-clock nursing care, allowing for proactive assessment and management of health issues that could reduce the need for emergency interventions. Furthermore, nurses are trained to conduct health needs assessments, enabling them to evaluate whether a transfer is necessary, unlike older adults in the general public who often have to navigate their health challenges independently. Despite this access to nursing care, the high rate of potentially avoidable ED transfers from RACFs highlights underlying systemic issues that need to be addressed.

In 2021, the Australian Medical Association reported 27,569 potentially avoidable hospitalisations from Australian RACFs, resulting in significant costs (around 159,693 hospital patient days at a cost of around A$312 million).⁷ Beyond healthcare costs, ED transfers are burdensome for staff,^8,9 stressful for family members and loved ones,¹⁰ and draw on wider health resources such as ambulance services which increases risk for the wider community.^8,11 Most importantly, they are often highly distressing for older people and can significantly and negatively impact their health and well-being.^11,12

While terms referring to transfers from RACFs, including ‘unnecessary’, ‘avoidable’, or ‘unwarranted’ are often used interchangeably throughout the literature, there is a lack of consistency in these definitions. These terms account for a large range of situations and could be better delineated. For example, a transfer from an RACF to ED could be defined as ‘unnecessary’ if the older person’s condition could have been more safely and appropriately addressed in place.^13,14 ‘Avoidable’ transfers might be best defined as transfers resulting from the progression of underlying conditions that could have been mitigated through preventative measures, thus avoiding the need to transfer the older person to an ED.¹⁴ ‘Unwarranted’ transfers could be considered to refer to those that occur when residents should not have been transferred. For example, a transfer that occurs against the wishes of a resident and contrary to an up-to-date Advance Care Directive. As no specific and consistent definition is used in the wider literature for each term, this paper will refer to transfers encompassing these situations as ‘avoidable’, unless explicitly stated otherwise in the cited source.

It is important to recognise that there are instances when transfers to ED or hospitalisations are necessary/unavoidable. Older people are entering RACFs with an increasing number of comorbidities and complexity of health needs, highlighting their need for monitoring and preventative healthcare that focuses on re-enablement.¹ This complexity means that some transfers to hospitals or emergency departments may be necessary, where health needs outweigh the capacity or capability of RACF staff. Some older people may also require specialist treatments only available in acute care settings. Moreover, older adults are at a higher risk of falls and fall-related injuries which may necessitate some form of emergency care or longer-term hospitalisation that cannot be handled in place, for example, if the fall leads to a fracture.¹⁵ While, in this paper, we emphasise the benefits of care in place, it is important to note that some transfers to ED or hospitalisation are not only justified but essential for the well-being and safety of older residents.

Research on reducing transitions from RACFs to EDs shows considerable variability in methodology and focus. A recent scoping review of 28 studies reveals that mixed or non-significant results hamper the formulation of concrete recommendations and may discourage intervention efforts.¹⁶ This underscores the complexity inherent in this space, indicating that reducing avoidable transfers and hospital admissions from RACFs requires a multifaceted approach. No single intervention will be universally effective; therefore, a combination of strategies will be necessary to address this challenge effectively.

Improved staffing levels and skills mix

Research has displayed that an effective approach in reducing ED presentations is increasing the level of clinical care delivered in RACFs.¹⁷ As lower nurse staffing is associated with increased adverse events,^18–21 and the most common reasons for transfers include accidents and injuries, dehydration, fever, infection, and shortness of breath,²² employing appropriate levels of nursing staff should be seen as an important preventative measure. An RACF that is adequately staffed and equipped can provide a level of care that reduces risks of adverse events and is better able to provide effective, dignified care in place.

RACFs must be staffed with a sufficient number of RNs, enrolled nurses, and personal care workers who have the appropriate expertise, education, and experience to deliver high-quality care.²³ To achieve this, significant investment is required, as well as reform efforts to ensure that mandated care minutes are adhered to and representative of best-practice care in every setting for every resident.^17,24 This reform includes recognition of the unique roles of enrolled nurses in the operation of Australian RACFs.²⁵ Further, while current legislation requires at least one RN to be present 24/7, consideration should be given to differing mandates based on resident numbers, needs, and facility layouts.

RACFs are also likely to benefit from improved interfaces with advanced clinical expertise, such as nurse practitioners (NPs), general practitioners (GPs) and other medical specialists, and allied health professionals.²⁶ Having an NP based at RACFs has been found to decrease avoidable ED presentations and enhance timeliness of care where access to GPs is limited due to difficulties accessing facilities after hours or low staff availability to manage resident handover.²⁶ While direct employment of these professionals may not always be feasible, strong integration with external healthcare services through initiatives such as Medicare rebates, telehealth, and outreach teams is vital in enhancing clinical expertise and reducing unnecessary transfers. An example of such a staffing model is the Aged Care Emergency (ACE) program; an integrated nurse-led intervention designed to improve the capability of RACFs to manage acutely unwell residents by incorporating telephone support, evidence-based algorithms, managing ED transfers, and educating staff. The ACE program was shown to reduce hospital admissions and ED presentations and lead to lower readmission rates.²⁷ Further, initiatives that include integration with local health districts, such as the Aged Care Outreach Service (ACOS) implemented by New South Wales Health, have been shown to reduce ED presentations; with 80% of the 981 residents referred to the service able to be managed in place without needing to be admitted to the ED or hospital. The ACOS program involves a team of specialist nurses, doctors, and other clinicians who coordinate with RACF to deliver in-place medical care to residents.²⁸

An often overlooked factor in reducing avoidable ED transfers is the preferences of family and loved ones.^10,29 Many family members hold the perception that a hospital or ED can provide the highest quality of care and is always the most appropriate and safest place to receive care, despite evidence to the contrary.¹¹ Because of this, conflict can arise between staff and family members over differences in perspective and interpretation of the resident’s best interests.^30,31 A study conducted using 2017 and 2018 New South Wales resident data, found that 97% of residents would prefer to receive ‘care in place’ rather than be transferred in case of an expected decline in health.³² The study found, however, that family members often overrode this preference, resulting in transfers to hospitals, often against the wishes of the resident and advice by staff.³² Having an NP based at the RACF has also been found to result in fewer transfers initiated by family members.²⁶ NPs, available in place or through strong interfaces with healthcare, can provide expert guidance and facilitate discussions with family members regarding the resident’s prognosis and care options, helping to align family expectations with clinical practice, leading to more informed decision-making and potentially reducing the number of avoidable transfers. Having clear and up-to-date advance care directives/plans in place may be one way of facilitating planning discussions and decisions with families; however, due to staff and resource shortages these are not always in place.³³

Quality improvement initiatives

Several interventions have been evaluated for their effectiveness in reducing ED transfers. Research indicates that integrated care and quality improvement programs that provide supplemental support to care homes appeared to be largely effective in reducing avoidable ED transfers, often due to the inclusion of advance care planning.³⁴ Further, nurse-led models of care, directed by highly qualified nurses, have also been found to be beneficial in terms of resident, staff, and process-related outcomes, including resident transfers.³⁵

Alternative care delivery, such as Care in Place/Hospital in the Home programs adapted or tailored for RACFs may be effective in reducing ED transfers and hospital admissions in Australian contexts. These programs allow for early management of residents who are assessed as at risk of transfer, support and education for RACF staff, early-stage expert coordination (e.g. ED nurse with experience and expertise in care for older adults), and advance planning around discharge from ED/hospital and transition back to the RACF.³⁶ One such program, the Care Home Innovation Program, reported a reduction of 15% in emergency calls and 19% in hospital transfers compared to 12 months before implementation over the 4-year evaluation period.³⁷ This program combined a number of interventions including new care protocols for 13 common presentations, a multidisciplinary team approach to care, a 24/7 tele-video system to help staff access timely clinical advice, targeted training for staff in basic clinical assessment, regular collaborative training across multiple RACFs to share good practices and experiences, and ‘community matrons’ (generally a senior nurse with non-medical prescribing qualifications or NP) allocated to several RACFs each who reviewed residents, supported primary care to put in place an advance care plans, and addressed acute minor illnesses.

Technological innovations such as telehealth and digital care apps also have the potential to help reduce avoidable ED transfers. Data from 8702 residents used in a retrospective analysis found that an app-based technology (Health Call Digital Care Homes) that recorded observations such as vital parameters for triage by remote clinical staff reduced ED attendance by 11%, ED admissions by 25%, and length of stay by 11%.³⁸ The app was used by RACF staff, replacing the need to telephone off-site clinicians, helping to alleviate some workforce strain. Telehealth programs, that allow advanced practitioners such as GPs or specialists to be virtually available, have also been found to reduce ED transfers and reduce costs.^2,39,40 Telehealth may be an effective method of improving available clinical expertise where in-person visits by practitioners is not feasible.

Conclusion

While some transfers from RACFs to EDs may be necessary, many are avoidable, and can place older people at greater risk of harm in comparison to care that may have been more appropriately delivered in place. Addressing these issues requires improving staffing standards. It is also important that RACF staff are provided with continuing education opportunities, access to point-of-care information and advice, and opportunities to collaborate with internal and external health staff. Further, with a greater capacity to address healthcare needs in RACFs, older people and their loved ones can be informed and educated regarding best practices regarding ED/hospital transfers, and advance care directives can be put in place to help guide decision-making when a transfer may or may not be necessary or warranted. Additionally, enhancing integration with external healthcare services, such as the scale-up and incorporation of NPs working in and with aged care and in-reach from hospitals, primary healthcare, allied health, and specialist services, can also help reduce unnecessary transfers. Systemic issues within the aged care sector must also be addressed through stronger government action.

While ED transfer avoidance has received attention in the literature, much of the current evidence is of low quality, based on uncontrolled study designs, small sample sizes, and precluding meta-analysis.^34,35 Knowledge users must also be aware that due to contextual differences across jurisdictions, particularly when considering evidence from international studies and their suitability for translation to Australian settings, direct comparison or transfer of evidence from one context to another is not always possible or straightforward. Further research is required to determine the best approach to reducing unnecessary hospital transfers, accounting for the scope of practice and the Australian healthcare regulatory environment. This should include further trials of innovative healthcare technologies such as virtual care within the aged care setting.