Despite recent reforms that have taken effect in Australian nursing homes, including the requirement for 24/7 registered nurse (RN) presence and mandated direct care minutes, high rates of transfers from nursing homes to emergency departments (ED) or hospitals persist.
Background
While some transfers may be necessary, expected, or unavoidable, transfers are occurring at rates far exceeding what could be considered appropriate particularly since many of the reasons residents are transferred could likely have been addressed by direct care staff onsite if they are supported with sufficient staffing levels, skills mixes, and resources. Reducing the number of avoidable transfers from nursing homes has a positive impact on residents and staff and also benefits the wider community by reducing pressure on emergency services, EDs, and hospitals which improves healthcare access for all. Researchers from the National Policy Research Unit of the ANMF Federal Office recently published an article in the CSIRO’s Australian Health Review exploring this issue.1
Research suggests around 40-75% of nursing home residents are transferred to EDs every year.2, 3 However, a 2019 systematic review identified up to 55% of these were avoidable.4 In 2021, the Australian Medical Association reported a total 27,569 potentially avoidable hospitalisations from Australian nursing homes, with an associated cost of around $312 million.5 Beyond health care costs, ED transfers are burdensome for staff,6, 7 stressful for family members and loved ones,8 and draw on wider health resources such as ambulance services, increasing risk for the wider community.6, 9 Most importantly, they are often highly distressing for older people; resulting in a significant and negative impact on health and wellbeing.9, 10
Research on reducing transitions from nursing homes to EDs shows considerable variability in strategies that have been used to mitigate the issue. This suggests that reducing avoidable transfers and hospital admissions from nursing homes likely requires a multifaceted approach.11 No single intervention will be universally effective; therefore, a combination of strategies is necessary to effectively address this challenge.
Improved staffing levels and skills mix
Increasing the level of clinical care available in nursing homes is one of the most effective approaches in reducing ED transfers.12 Lower nurse staffing in nursing homes is associated with increased adverse events requiring transfer including accidents, injuries, dehydration, fever, infection and shortness of breath.13-17 Therefore, ED presentations will be reduced by staffing sufficient numbers of RNs, enrolled nurses (ENs), personal care workers (PCWs) and advanced clinical practitioners such as nurse practitioners (NPs) equipped with the expertise, education and experience required to deliver more advanced levels of clinical care.12, 18, 19
While providers must comply with mandates in terms of RN 24/7 and direct care time, where cost or availability impacts feasibility of increasing the number of in-house practitioners, other viable approaches include integration with external healthcare initiatives such as telehealth, outreach teams or models such as the Aged Care Emergency (ACE) program or Aged Care Outreach Service (ACOS). These services demonstrably reduce ED transfers and lower readmission rates by improving the capability of nursing homes to manage acutely unwell residents in place. This is achieved through incorporating telephone support, evidence-based algorithms and educating staff through a multi-disciplinary coordination approach to deliver in-place medical care to residents.20, 21
As ED transfers are often contrary to the wishes of older people, with many preferring to receive care in place, up to date Advance Care Directives are required to provide clear direction on the preferences of older people and can prevent avoidable transfers.22, 23
Quality improvement initiatives
Supplemental support to nursing homes and alternative care delivery programs such as Care-in-Place or Hospital-in-the-Home tailored for nursing homes may be effective in reducing ED transfers. These programs provide for early intervention with residents at risk of transfer, supplement the skill set of nursing home staff, and provide early-stage expert coordination and advanced planning for transition back to the nursing home from ED where transfers do occur.24
One such program, the Care Home Innovation Program (CHIP), reported a 15% reduction in emergency calls and a 19% reduction in hospital transfers over a four-year evaluation period when compared to the previous 12 months.25 This program included new care protocols for 13 common presentations, a multidisciplinary approach to care, a 24/7 tele-video system for staff to access timely clinical advice, targeted training for nursing home staff in basic clinical assessment, collaborative training across multiple nursing homes and allocation of senior nurses to review residents, ensure advance care plans were in place and address acute minor illnesses.
Technological innovations such as telehealth and digital care apps have also shown promise in reducing avoidable ED transfers, in addition to reducing cost and workload for nursing homes. One retrospective analysis found app-based technology recording vital parameters for triage by remote clinical staff reduced ED attendance by 11%, ED admissions by 25% and length of stay by 11%.26
Conclusion
Notwithstanding the necessity of some ED transfers from nursing homes, many are avoidable, with care in place often the preferred option for residents when staff are supported to safely and effectively provide care. Minimising the number of avoidable transfers benefits all involved and also has wider benefits for all community members as it reduces pressure on emergency services, EDs, and hospitals which improves access to timely care. Enhanced integration with external healthcare providers, increased numbers of skilled staff in nursing homes, and continuing education opportunities for staff are all essential to ensure quality of care in-place and advocacy for residents’ best interests. Further government action tackling systemic issues within the aged care sector including commitment to educational opportunities and efforts to retain skilled staff will also further bolster other initiatives to reduce avoidable ED transfers from nursing homes.
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Authors
Alison Morris is a second-year undergraduate nursing student at the University of South Australia. She is undertaking a Vacation Research Scholarship based in the Rosemary Bryant AO Research Centre, Clinical and Health Sciences, University of South Australia.
Jarrod Clarke is a Research Assistant in the ANMF National Policy Research Unit (Federal Office) based in the Rosemary Bryant AO Research Centre, Clinical and Health Sciences, University of South Australia.
Associate Professor Micah DJ Peters is the Director of the ANMF National Policy Research Unit (Federal Office) based in the Rosemary Bryant AO Research Centre, Clinical and Health Sciences, University of South Australia.
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