Copyright © eContent Management Pty Ltd. Contemporary Nurse (2013) 45(2): 228–233.
Referrals to hospital emergency departments from residential aged care facilities: Stuck in a time warp BEVERLY O’CONNELL*,+, MARY HAWKINS!, JULIE CONSIDINE# AND CATHERINE AU! *Deakin University, Melbourne, VIC, Australia; +Faculty of Nursing, University of Manitoba, Winnipeg, MB, Canada; !Deakin University – Southern Health Nursing Research Centre, Deakin University, Melbourne, VIC, Australia; #Eastern Health – Deakin University Nursing and Midwifery Research Centre, School of Nursing and Midwifery, Deakin University, Melbourne, VIC, Australia
Abstract: This research aimed to describe the number and type of residents admitted to emergency departments (EDs) over 2 years; and to explore nurses’ perceptions of the reasons why residential aged care facility (RACF) residents are referred to EDs. The research objective was addressed in a retrospective exploratory study using data on admissions to EDs from RACFs (N = 3,094) at the participating organisation over a 2-year period, and interview data on seven RACF and four ED nurses’ perceptions of the issues involved. Most residents presenting at EDs required urgent medical attention. Major themes identified by RACF and ED nurses included issues related to staff competency, availability of general practitioners, lack of equipment in RACFs, residents and family members requesting referrals, communication difficulties, and poor attitudes towards RACF staff. There is a need to use strategies to detect residents whose conditions are deteriorating and treat them promptly in RACFs.
Keywords: residential aged care, nursing home, emergency department, transfer, aged
I
ndividuals in residential aged care facilities (RACFs) are reported to be more likely to present to emergency departments (EDs) than those living in the community (Crilly, Chaboyer, Wallis, Thalib, & Green, 2008; Ingarfield et al., 2009). This is not surprising given that many RACF residents are frail, vulnerable elderly people; 55% are 85 years or older (Australian Institute of Health and Welfare, 2009). However, approximately 15% of presentations to EDs from RACFs are classified as potentially preventable (Finn et al., 2006; Ouslander et al., 2009). Given that RACF residents are cared for by nursing staff and have access to attending general practitioners (GPs), the reasons for their repeated referrals to EDs needs further examination. EDs are extremely busy settings in Australian hospitals and people aged over 65 years make up an increasing proportion of those presenting for health care (up to 18%) (Finn et al., 2006) using proportionally more ED resources than younger patients (Chu, Yung, Leung, Chan, & Leung, 2001). Several factors complicate the assessment of older patients in ED including the extra time and resources required, reduced cognitive function, functional impairment and age-related deficits in hearing and vision (Nolan,
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2009). Older patients experience a higher number of adverse outcomes after ED discharge than younger patients (Salvi et al., 2007), almost onequarter are readmitted within 3 months, twofifths within 6 months, and they experience an increased risk of death within 3 months of ED presentation (Aminzadeh, Dalziel, Molnar, & Alie, 2004). A multiplicity of factors has been identified in the literature and provides guidance on to how to minimise RACF residents’ referrals to EDs and how to better manage older patients in EDs. These factors include that: (1) RACF staff should be offered opportunities to up-skill in this area (Roethler, Adelman, & Parsons, 2011) and thereby prevent some admissions to EDs (Friedman, Mendelson, Bingham, & McCann, 2008). (2) RACF staff should also be educated on acronym-based handover techniques so that they can communicate pertinent handover information to GPs (Ouslander et al., 2010; Terrell & Miller, 2006; Young, Barhydt, Broderick, Colello, & Hannan, 2010). (3) ED and RACF staff make better use of communication tools that provide clear resident information and instructions to on admission
Aged care referrals to emergency departments and discharge (Belfrage, Chiminello, Cooper, & Douglas, 2009; Ouslander et al., 2010). (4) RACF staff use clinical algorithms for common conditions that assist with providing better care within RACF (Arendts & Howard, 2010; Gruineir et al., 2010; Ouslander et al., 2009, 2010). (5) Primary care and GP services and the employment of paramedics or nurse practitioners to provide care for residents in RACF be expanded (Arendts & Howard, 2010; Codde et al., 2010; Gulland, 2007; Young et al., 2010). (6) Better use is made of advanced care planning so that residents are not inappropriately referred to ED (Arendts & Howard, 2010; Ouslander et al., 2010; Shanley et al., 2011). (7) Better access is made to pathology and diagnostic and treatment equipment in RACFs, for example, use of mobile services (Ouslander et al., 2010; Young et al., 2010). (8) EDs should be better designed to accommodate older people in terms of environment and type of care and services provided (Considine et al., 2010). Alternative triage and waiting processes could enhance the patient journey and be better suited to the needs of elderly patients (Considine et al., 2010; Nolan, 2009). Additionally, communication aids should be provided to older people when they are in ED (Nolan, 2009). (9) Interdisciplinary teams with geriatricians and aged care nurse practitioners/nurse consultants should be deployed in ED for assessments/ evaluations (Nolan, 2009). Alternatively it may be useful to enhance the geriatric knowledge of existing ED nurses (Robinson & Mercer, 2007). (10) Some large-scale arrangements for residents that have been found successful in improving their care are the provision of a geriatric-specific ED service (Salvi et al., 2008), providing a hospital in RACFs (with ED outreach) for residents to go to following early discharge from ED (Crilly, Chaboyer, Wallis, Thalib, & Polit, 2011), and ED observational units specifically for elders (Salvi et al., 2008). Others suggest that alternatives for low acuity residents that reduce the need to send residents to EDs are needed (Gruineir et al., 2010).
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Although this literature highlights a number of factors that could reduce transfers from RACFs to EDs or improve residents’ experiences of EDs, the presentation of large numbers of residents at EDs continues to be an on-going problem. There is a need for further investigation to see if further issues can be identified to reduce transfers from RACFs to EDs and improve residents’ experiences of EDs. Such improvements need to be given some priority due to the demographic changes and the increasing number of elderly patients in hospitals. The aim of this study was to: (1) describe the number and type of residents admitted to EDs in a large health care service over a 2 year period from May 2007–June 2009; and (2) to explore nurses’ perceptions of the reasons why RACF residents are referred to EDs. An understanding of the reasons why individuals from RACFs are referred to EDs will provide information on which to develop guidelines and interventions to reduce such referrals. Moreover, this information may improve outcomes for the RACF residents concerned. Reducing the hospitalisations of RACF residents provides an opportunity to improve care quality and avoid unnecessary healthcare expenditures (Ouslander et al., 2010). METHODS The research objective was addressed in a retrospective exploratory study using both quantitative data and qualitative data. Quantitative data were gathered to provide objective information on the number and types of admissions to EDs from RACFs at the participating organisation, and qualitative data were gathered to provide information on nurses’ perceptions of the issues involved. This study was approved by the human research ethics committees of the participating organisations. Data from 3,094 referrals of RACF residents aged 65 years and over to three metropolitan public hospital EDs from 31 May, 2007 to 1 June, 2009 were included in the analyses. This quantitative data was accessed from information management records and analysed using descriptive and comparative analyses using SPSS Version 18.
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Semi-structured interviews were conducted to ascertain nurses’ perceptions of the issues associated with RACF residents’ referrals to EDs. Participants were seven RACF nurses (either nursesin-charge or nursing supervisors) who had sent residents to EDs, and four ED nurses with experience and management of RACF residents in EDs. These staff had from 6–15 years working experience. Interviews were transcribed verbatim and analysed using thematic analysis procedures recommended by Grbich (2007). The data were reduced into meaningful themes and further certified and grouped.
TABLE 1: FREQUENCY
EMERGENCY DEPARTMENTS
CN
(ED)
Admissions from aged care to emergency departments Gender Female Male Patient status Public patients Private patients , Veterans affairs Information not provided Transport Ambulance, road service Ambulance, private Undertaker Other, unspecified Triage category Resuscitation Emergency Urgent Semi-urgent Non-urgent Dead on arrival
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(RACF)
TO
BY DEPARTURE DESTINATION
Admitted to ward Returned or died in ED to RACF
RESULTS Clinical information management data on ED admissions from RACF Analysis of the demographic data revealed that a greater proportion of admissions were for females than males and ages ranged from 65–105 years (M = 84.65, SD = 7.47) as shown in Table 1. Females admitted to EDs tended to be older than males (M = 85.59, SD = 7.26; and M = 82.86, SD = 7.54; respectively). Only 7.4% of residents (n = 228) were reported as requiring an interpreter although 11.3% preferred to speak a language other than English. Most residents were admitted as public patients. Less than one-quarter of residents were discharged back to their RACFs (23.2%, N = 718), the majority were admitted to a hospital ward (n = 2,339, 75.6%), and some were dead on arrival or died in EDs (n = 37, 1.2%). Those residents admitted to hospital had an average length of stay of 4.47 days (SD = 6.95; range = 0–99 days). These residents were significantly more likely to be in higher triage categories (more urgent) than those who returned directly to RACFs (chi-square = 214.77[4], p < 0.001, Cramer’s V = 0.26) from the EDs. Most of the residents in the sample (55.4%, N = 1,702) had four encounters or less with any of the
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AND PERCENTAGE OF DEMOGRAPHICS FOR
ADMISSIONS BY RESIDENTS FROM AGED CARE FACILITIES
f
%
2,376
76.8
718 23.2 3,094 100.0
1,557 819
65.5 34.5
474 66.0 2,031 65.6 244 34.0 1,063 34.4
1,935 88 241 112
81.4 3.7 7.8 4.7
255 35.5 2,190 70.8 1 0.1 89 2.9 41 5.7 282 9.1 421 58.6 533 17.3
1,827
76.9
477 66.4 2,304 74.5
400 2 147
16.8 0.1 6.2
173 24.1
53 340 1,090 839 51 3
2.2 14.3 45.9 35.4 2.1 0.1
3 0.4 56 1.8 38 5.3 378 12.2 210 29.2 1,300 42.1 400 55.7 1,239 40.0 67 9.3 118 3.8 – – 3 0.1
f
68
%
Total
9.5
f
573 2 215
%
18.5 0.1 6.9
three participating hospitals over their lifetimes (M = 7.13, SD = 22.21, range = 1–903). For the total sample, the average number of diagnoses was 4.86 (SD = 4.27; range = 1–40). Those residents admitted to a hospital ward had significantly more diagnoses (M = 5.76, SD = 4.41) than those who returned to RACFs (M = 1.88, SD = 1.67; t = 35.34, df = 2,959, p < 0.001, equal variance not assumed). On average, the number of procedures performed on residents was 3.91 (SD = 2.86; range = 0–15). Those admitted to a hospital ward had significantly more procedures (M = 4.40, SD = 2.82) than those who returned to RACFs (M = 2.30, SD = 2.36; t = 18.89, df = 1,391, p < 0.001, equal variance not assumed).
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Aged care referrals to emergency departments Qualitative analysis of interview data The nurses from RACFs and EDs identified a number of issues related to residents from RACFs being referred to EDs for assessment and treatment. Major themes identified included: Staff level of competency Nurses stated that some staff members who were employed in the aged care sector over a period of time no longer had the necessary skills to assess and manage residents’ deteriorating conditions. Additionally, RACFs may be staffed by PCAs who were not clinically skilled in managing residents’ deteriorating conditions. At times, casual nurses and agency nurses not usually employed by the RACFs had limited knowledge of residents’ usual health status and so were unable to make judgements about their clinical status or care requirements. Availability of GPs GPs were often difficult to contact and not ‘on call’ or available at all times. If a GP was unavailable and medical review or investigations were needed, the staff would refer the resident to EDs for investigation. Lack of equipment in RACFs RACFs lacked diagnostic equipment such as x-ray equipment, resuscitation trolleys and ECG machines. They also lacked access to pathology services on weekends. Consequently residents were referred to EDs for further investigations. Resident and family member requests Some residents and family members requested that the staff refer residents to EDs for assessment and treatment. Family members considered that residents would receive the best possible care in EDs. Communication difficulties Both groups of nurses reported experiencing communication difficulties between RACFs and EDs. These difficulties related to poor documentation, lack of telephone access and person-to-person handover. RACF staff noted that ED staff sometimes sent residents back to
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RACFs during the night with no warning or follow-up. Poor attitudes towards RACF staff RACF staff believed that ED and ambulance staff made unfounded assumptions about them and lacked respect for their positions. One person stated that an ambulance officer had refused to take a resident to hospital. In general, both groups of nurses stated that with up-skilling of RACF staff and purchasing of equipment, some residents may be able to be assessed and treated in RACFs rather than referred to EDs. DISCUSSION The findings of this study revealed that threequarters of residents transferred from RACFs to EDs were admitted to hospital, indicating that these residents required medical attention. This is further supported by residents’ average length of stay in hospital which was more than four days. Consistent with this finding, residents who were admitted were significantly more likely to be rated in a higher triage category and had significantly more procedures than those who were discharged back to RACFs. Therefore there is a need to focus on strategies that detect deteriorating residents promptly so that their conditions can be managed in the facility. It may be useful to put in place a mobile emergency response team who can attend to the needs of deteriorating residents in RACFs and prevent them being transferred to EDs. The development and use of a resident risk assessment and management system (like the acute care medical emergency team call system) may provide a more proactive strategy to address this problem. Some attention needs to be given to developing mobile diagnostic and blood testing services that can be used in RACFs. Interview data revealed that it may be beneficial to look at the RACF staff levels of competency to ensure that they can manage non-acute deteriorating conditions. The finding that residents’ families can sometimes exert pressure on RACF staff to transfer the resident for treatment in EDs deserves some
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attention. Information and education should be provided to residents and their families highlighting alternatives to being transferred to EDs and about advanced care planning options. The findings indicate that communication between all health care professionals involved in the care of residents needs to be improved. It is supported by previous research indicating that relationships between ED and RACF staff could be improved by providing information on each others’ perspectives (McCloskey, Campo, Savage, & Mandville-Anstey, 2009). For example, ED staff sometimes don’t realise that RACF staff do not always have control over referrals and that families exert considerable pressure to have residents transferred to EDs. In this study, 23% of residents referred to the EDs were sent back to their facility, thus raising the question as to whether these referrals to EDs were necessary. This finding is supported by Victorian Emergency Minimum Dataset statistics on the departure status from Victorian EDs of patients referred from RACFs during the financial year 2010/11 that provided a slightly higher figure of almost 30% in their report. Further research is therefore necessary to analyse the information on the group of residents who were discharged back to RACFs to determine if their presentations could be avoided. CONCLUSIONS The current system for managing deteriorating residents in RACFs needs to be improved. These improvements need to be given some priority due to the acuity changes in the RAC sector and the increasing admissions of frail, high dependent residents with cognitive impairment. The current study suggests that most residents presenting at EDs require urgent medical attention. One must question whether this situation is avoidable with the implementation of services that better manage residents’ deteriorating conditions in RACFs. Although recommendations have been made on strategies that would improve the current situation, very few of these changes have been implemented in RACFs. The RAC sector needs to be cognisant that their
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services should be broader based, focussing not only on well residents but also on the management of frail residents whose conditions can deteriorate. It will take much will and effort to change the types of services provided in aged care, however, the need to embrace this change is essential if we are to improve the care of residents in the aged care sector and prevent avoidable transfers to EDs. ACKNOWLEDGEMENTS This research was funded by a grant from the Deakin University, Faculty of Health, Victoria. The authors would like to acknowledge the work of Ms. Vibeke Russell in obtaining the hospital data. REFERENCES Aminzadeh, F., Dalziel, W. B., Molnar, F. J., & Alie, J. (2004). An examination of the health profile, service use and care needs of older adults in residential care facilities. Canadian Journal on Aging, 23(3), 281–294. doi:10.1353/cja.2004.0029 Arendts, G., & Howard, K. (2010). The interface between residential aged care and the emergency department: A systematic review. Age and Ageing, 39(3), 306–312. doi:10.1093/ageing/afq008 Australian Institute of Health and Welfare. (2009). Residential aged care in Australia 2007-08: A statistical overview. Aged care statistics series 28 (Cat. no. AGE 58). Canberra, ACT: Author. Belfrage, M. K., Chiminello, C., Cooper, D., & Douglas, S. (2009). Pushing the envelope: Clinical handover from the aged-care home to the emergency department. Medical Journal of Australia, 190(Suppl. 11), S117–S120. Chu, N. M., Yung, C. Y., Leung, W. S., Chan, V. L., & Leung, E. M. F. (2001). Early unplanned readmission of patients with newly diagnosed tuberculosis discharged from acute hospital to ambulatory treatment. Respirology, 6(2), 145–149. Codde, J., Arendts, G., Frankel, J., Ivey, M., Reibel, T., Bowen, S., & Babich, P. (2010). Transfers from residential aged care facilities to the emergency department are reduced through improved primary care services: An intervention study. Australasian Journal on Ageing, 29(4), 150–154. doi:10.1111/j.1741-6612.2010.00418.x Considine, J., Smith, R., Hill, K., Weiland, T., Gannon, J., Behm, C., & McCarthy, S. (2010).
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Aged care referrals to emergency departments Older peoples’ experience of accessing emergency care. Australasian Emergency Nursing Journal, 13(3), 61–69. doi:10.1016/j.aenj.2010.05.001 Crilly, J., Chaboyer, W., Wallis, M., Thalib, L., & Green, D. (2008). Predictive outcomes for older people who present to the emergency department. Australasian Emergency Nursing Journal, 11(4), 178–183. doi:10.1016/j.aenj.2008.07.002 Crilly, J., Chaboyer, W., Wallis, M., Thalib, L., & Polit, D. (2011). An outcomes evaluation of an Australian hospital in the nursing home admission avoidance programme. Journal of Clinical Nursing, 20(7/8), 1178–1187. doi:10.1111/j.1365-2702.2010.03371.x Finn, J. C., Flicker, L., Mackenzie, E., Jacobs, I. G., Fatovich, D. M., Drummond, S., & Sprivulis, P. (2006). Interface between residential aged care facilities and a teaching hospital emergency department in Western Australia. Medical Journal of Australia, 184(9), 432–435. Friedman, S. M., Mendelson, D. A., Bingham, K. W., & McCann, R. M. (2008). Hazards of hospitalization: Residence prior to admission predicts outcomes. The Gerontologist, 48(4), 537–541. doi:10.1093/ geront/48.4.537 Grbich, C. (2007). Qualitative data analysis: An introduction. London, England: Sage. Gruineir, A., Bell, C. M., Bronskill, S. E., Schull, M., Anderson, G. M., & Rochon, P. A. (2010). Frequency and pattern of emergency department visits by long-term care residents – A population based study. Journal of the American Geriatrics Society, 58, 510–517. doi:10.1111/j.1532-5415.2010.02736.x Gulland, A. (2007). Improving care to avoid A&E. Nursing Times, 103(41), 6–8. Ingarfield, S. L., Finn, J. C., Jacobs, I. G., Gibson, N. P., Holman, C. D., Jelinek, G. A., & Flicker, L. (2009). Use of emergency departments by older people from residential care: A population based study. Age and Ageing, 38(3), 314–318. doi:10.1093/ageing/afp022 McCloskey, R., Campo, M., Savage, R., & MandvilleAnstey, S. (2009). A conceptual framework for understanding interorganizational relationships between nursing homes and emergency departments: Examples from the Canadian setting. Policy, Politics & Nursing Practice, 10(4), 285–294. doi:10.1177/1527154409357795 Nolan, M. R. (2009). Older patients in the emergency department. Journal of Gerontological Nursing, 35(12), 14–18. doi:10.3928/00989134-20091103-01 Ouslander, J. G., Lamb, G., Perloe, M., Givens, J. H., Kluge, L., Rutland, T., & Saliba, D. (2010). Potentially avoidable hospitalizations of nursing
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home residents: Frequency, causes, and costs. Journal of the American Geriatrics Society, 58(4), 627–635. doi:10.1111/j.1532-5415.2010.02768.x Ouslander, J. G., Perloe, M., Givens, J. H., Kluge, L., Rutland, T., & Lamb, G. (2009). Reducing potentially avoidable hospitalizations of nursing home residents: Results of a pilot quality improvement project. Journal of the American Medical Directors Association, 10(9), 644–652. doi:10.1016/j.jamda.2009.07.001 Robinson, S., & Mercer, S. (2007). Older adult care in the emergency department: Identifying strategies that foster best practice. Journal of Gerontological Nursing, 33(7), 40–47. Roethler, C., Adelman, T., & Parsons, V. (2011). Assessing emergency nurses’ geriatric knowledge and perceptions of their geriatric care. Journal of Emergency Nursing: JEN: Official Publication of the Emergency Department Nurses Association, 37(2), 132–137. doi:10.1016/j.jen.2009.11.020 Salvi, F., Morichi, V., Grilli, A., Giorgi, R., De Tommaso, G., & Dessì-Fulgheri, P. (2007). The elderly in the emergency department: A critical review of problems and solutions. Internal and Emergency Medicine, 2(4), 292–301. doi:10.1007/s11739-007-0081-3 Salvi, F., Morichi, V., Grilli, A., Giorgi, R., Spazzafumo, L., Polonara, S., & DessÃ-Fulgheri, P. (2008). A geriatric emergency service for acutely ill elderly patients: Pattern of use and comparison with a conventional emergency department in Italy. Journal of the American Geriatrics Society, 56(11), 2131–2138. doi:10.1111/j.1532-5415.2008.01991.x Shanley, C., Whitmore, E., Conforti, D., Masso, J., Jayasinghe, S., & Griffiths, R. (2011). Decisions about transferring nursing home residents to hospital: Highlighting the roles of advance care planning and support from local hospital and community health services. Journal of Clinical Nursing, 20, 1–10. doi:10.1111/j.1365-2702.2010.03635.x Terrell, K. M., & Miller, D. K. (2006). Challenges in transitional care between nursing homes and emergency departments. Journal of the American Medical Directors Association, 7(8), 499–505. doi:10.1016/j. jamda.2006.03.004 Young, Y., Barhydt, N. R., Broderick, S., Colello, A. D., & Hannan, E. L. (2010). Factors associated with potentially preventable hospitalization in nursing home residents in New York State: A survey of directors of nursing. Journal of the American Geriatrics Society, 58(5), 901–907. doi:10.1111/j.1532-5415.2010.02804.x Received 08 November 2012
Accepted 09 May 2013
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Referrals to hospital emergency departments from residential aged care facilities: Stuck in a time warp BEVERLY O’CONNELL*,+, MARY HAWKINS!, JULIE CONSIDINE# AND CATHERINE AU! *Deakin University, Melbourne, VIC, Australia; +Faculty of Nursing, University of Manitoba, Winnipeg, MB, Canada; !Deakin University – Southern Health Nursing Research Centre, Deakin University, Melbourne, VIC, Australia; #Eastern Health – Deakin University Nursing and Midwifery Research Centre, School of Nursing and Midwifery, Deakin University, Melbourne, VIC, Australia
Abstract: This research aimed to describe the number and type of residents admitted to emergency departments (EDs) over 2 years; and to explore nurses’ perceptions of the reasons why residential aged care facility (RACF) residents are referred to EDs. The research objective was addressed in a retrospective exploratory study using data on admissions to EDs from RACFs (N = 3,094) at the participating organisation over a 2-year period, and interview data on seven RACF and four ED nurses’ perceptions of the issues involved. Most residents presenting at EDs required urgent medical attention. Major themes identified by RACF and ED nurses included issues related to staff competency, availability of general practitioners, lack of equipment in RACFs, residents and family members requesting referrals, communication difficulties, and poor attitudes towards RACF staff. There is a need to use strategies to detect residents whose conditions are deteriorating and treat them promptly in RACFs.
Keywords: residential aged care, nursing home, emergency department, transfer, aged
I
ndividuals in residential aged care facilities (RACFs) are reported to be more likely to present to emergency departments (EDs) than those living in the community (Crilly, Chaboyer, Wallis, Thalib, & Green, 2008; Ingarfield et al., 2009). This is not surprising given that many RACF residents are frail, vulnerable elderly people; 55% are 85 years or older (Australian Institute of Health and Welfare, 2009). However, approximately 15% of presentations to EDs from RACFs are classified as potentially preventable (Finn et al., 2006; Ouslander et al., 2009). Given that RACF residents are cared for by nursing staff and have access to attending general practitioners (GPs), the reasons for their repeated referrals to EDs needs further examination. EDs are extremely busy settings in Australian hospitals and people aged over 65 years make up an increasing proportion of those presenting for health care (up to 18%) (Finn et al., 2006) using proportionally more ED resources than younger patients (Chu, Yung, Leung, Chan, & Leung, 2001). Several factors complicate the assessment of older patients in ED including the extra time and resources required, reduced cognitive function, functional impairment and age-related deficits in hearing and vision (Nolan,
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2009). Older patients experience a higher number of adverse outcomes after ED discharge than younger patients (Salvi et al., 2007), almost onequarter are readmitted within 3 months, twofifths within 6 months, and they experience an increased risk of death within 3 months of ED presentation (Aminzadeh, Dalziel, Molnar, & Alie, 2004). A multiplicity of factors has been identified in the literature and provides guidance on to how to minimise RACF residents’ referrals to EDs and how to better manage older patients in EDs. These factors include that: (1) RACF staff should be offered opportunities to up-skill in this area (Roethler, Adelman, & Parsons, 2011) and thereby prevent some admissions to EDs (Friedman, Mendelson, Bingham, & McCann, 2008). (2) RACF staff should also be educated on acronym-based handover techniques so that they can communicate pertinent handover information to GPs (Ouslander et al., 2010; Terrell & Miller, 2006; Young, Barhydt, Broderick, Colello, & Hannan, 2010). (3) ED and RACF staff make better use of communication tools that provide clear resident information and instructions to on admission
Aged care referrals to emergency departments and discharge (Belfrage, Chiminello, Cooper, & Douglas, 2009; Ouslander et al., 2010). (4) RACF staff use clinical algorithms for common conditions that assist with providing better care within RACF (Arendts & Howard, 2010; Gruineir et al., 2010; Ouslander et al., 2009, 2010). (5) Primary care and GP services and the employment of paramedics or nurse practitioners to provide care for residents in RACF be expanded (Arendts & Howard, 2010; Codde et al., 2010; Gulland, 2007; Young et al., 2010). (6) Better use is made of advanced care planning so that residents are not inappropriately referred to ED (Arendts & Howard, 2010; Ouslander et al., 2010; Shanley et al., 2011). (7) Better access is made to pathology and diagnostic and treatment equipment in RACFs, for example, use of mobile services (Ouslander et al., 2010; Young et al., 2010). (8) EDs should be better designed to accommodate older people in terms of environment and type of care and services provided (Considine et al., 2010). Alternative triage and waiting processes could enhance the patient journey and be better suited to the needs of elderly patients (Considine et al., 2010; Nolan, 2009). Additionally, communication aids should be provided to older people when they are in ED (Nolan, 2009). (9) Interdisciplinary teams with geriatricians and aged care nurse practitioners/nurse consultants should be deployed in ED for assessments/ evaluations (Nolan, 2009). Alternatively it may be useful to enhance the geriatric knowledge of existing ED nurses (Robinson & Mercer, 2007). (10) Some large-scale arrangements for residents that have been found successful in improving their care are the provision of a geriatric-specific ED service (Salvi et al., 2008), providing a hospital in RACFs (with ED outreach) for residents to go to following early discharge from ED (Crilly, Chaboyer, Wallis, Thalib, & Polit, 2011), and ED observational units specifically for elders (Salvi et al., 2008). Others suggest that alternatives for low acuity residents that reduce the need to send residents to EDs are needed (Gruineir et al., 2010).
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Although this literature highlights a number of factors that could reduce transfers from RACFs to EDs or improve residents’ experiences of EDs, the presentation of large numbers of residents at EDs continues to be an on-going problem. There is a need for further investigation to see if further issues can be identified to reduce transfers from RACFs to EDs and improve residents’ experiences of EDs. Such improvements need to be given some priority due to the demographic changes and the increasing number of elderly patients in hospitals. The aim of this study was to: (1) describe the number and type of residents admitted to EDs in a large health care service over a 2 year period from May 2007–June 2009; and (2) to explore nurses’ perceptions of the reasons why RACF residents are referred to EDs. An understanding of the reasons why individuals from RACFs are referred to EDs will provide information on which to develop guidelines and interventions to reduce such referrals. Moreover, this information may improve outcomes for the RACF residents concerned. Reducing the hospitalisations of RACF residents provides an opportunity to improve care quality and avoid unnecessary healthcare expenditures (Ouslander et al., 2010). METHODS The research objective was addressed in a retrospective exploratory study using both quantitative data and qualitative data. Quantitative data were gathered to provide objective information on the number and types of admissions to EDs from RACFs at the participating organisation, and qualitative data were gathered to provide information on nurses’ perceptions of the issues involved. This study was approved by the human research ethics committees of the participating organisations. Data from 3,094 referrals of RACF residents aged 65 years and over to three metropolitan public hospital EDs from 31 May, 2007 to 1 June, 2009 were included in the analyses. This quantitative data was accessed from information management records and analysed using descriptive and comparative analyses using SPSS Version 18.
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Semi-structured interviews were conducted to ascertain nurses’ perceptions of the issues associated with RACF residents’ referrals to EDs. Participants were seven RACF nurses (either nursesin-charge or nursing supervisors) who had sent residents to EDs, and four ED nurses with experience and management of RACF residents in EDs. These staff had from 6–15 years working experience. Interviews were transcribed verbatim and analysed using thematic analysis procedures recommended by Grbich (2007). The data were reduced into meaningful themes and further certified and grouped.
TABLE 1: FREQUENCY
EMERGENCY DEPARTMENTS
CN
(ED)
Admissions from aged care to emergency departments Gender Female Male Patient status Public patients Private patients , Veterans affairs Information not provided Transport Ambulance, road service Ambulance, private Undertaker Other, unspecified Triage category Resuscitation Emergency Urgent Semi-urgent Non-urgent Dead on arrival
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(RACF)
TO
BY DEPARTURE DESTINATION
Admitted to ward Returned or died in ED to RACF
RESULTS Clinical information management data on ED admissions from RACF Analysis of the demographic data revealed that a greater proportion of admissions were for females than males and ages ranged from 65–105 years (M = 84.65, SD = 7.47) as shown in Table 1. Females admitted to EDs tended to be older than males (M = 85.59, SD = 7.26; and M = 82.86, SD = 7.54; respectively). Only 7.4% of residents (n = 228) were reported as requiring an interpreter although 11.3% preferred to speak a language other than English. Most residents were admitted as public patients. Less than one-quarter of residents were discharged back to their RACFs (23.2%, N = 718), the majority were admitted to a hospital ward (n = 2,339, 75.6%), and some were dead on arrival or died in EDs (n = 37, 1.2%). Those residents admitted to hospital had an average length of stay of 4.47 days (SD = 6.95; range = 0–99 days). These residents were significantly more likely to be in higher triage categories (more urgent) than those who returned directly to RACFs (chi-square = 214.77[4], p < 0.001, Cramer’s V = 0.26) from the EDs. Most of the residents in the sample (55.4%, N = 1,702) had four encounters or less with any of the
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AND PERCENTAGE OF DEMOGRAPHICS FOR
ADMISSIONS BY RESIDENTS FROM AGED CARE FACILITIES
f
%
2,376
76.8
718 23.2 3,094 100.0
1,557 819
65.5 34.5
474 66.0 2,031 65.6 244 34.0 1,063 34.4
1,935 88 241 112
81.4 3.7 7.8 4.7
255 35.5 2,190 70.8 1 0.1 89 2.9 41 5.7 282 9.1 421 58.6 533 17.3
1,827
76.9
477 66.4 2,304 74.5
400 2 147
16.8 0.1 6.2
173 24.1
53 340 1,090 839 51 3
2.2 14.3 45.9 35.4 2.1 0.1
3 0.4 56 1.8 38 5.3 378 12.2 210 29.2 1,300 42.1 400 55.7 1,239 40.0 67 9.3 118 3.8 – – 3 0.1
f
68
%
Total
9.5
f
573 2 215
%
18.5 0.1 6.9
three participating hospitals over their lifetimes (M = 7.13, SD = 22.21, range = 1–903). For the total sample, the average number of diagnoses was 4.86 (SD = 4.27; range = 1–40). Those residents admitted to a hospital ward had significantly more diagnoses (M = 5.76, SD = 4.41) than those who returned to RACFs (M = 1.88, SD = 1.67; t = 35.34, df = 2,959, p < 0.001, equal variance not assumed). On average, the number of procedures performed on residents was 3.91 (SD = 2.86; range = 0–15). Those admitted to a hospital ward had significantly more procedures (M = 4.40, SD = 2.82) than those who returned to RACFs (M = 2.30, SD = 2.36; t = 18.89, df = 1,391, p < 0.001, equal variance not assumed).
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Aged care referrals to emergency departments Qualitative analysis of interview data The nurses from RACFs and EDs identified a number of issues related to residents from RACFs being referred to EDs for assessment and treatment. Major themes identified included: Staff level of competency Nurses stated that some staff members who were employed in the aged care sector over a period of time no longer had the necessary skills to assess and manage residents’ deteriorating conditions. Additionally, RACFs may be staffed by PCAs who were not clinically skilled in managing residents’ deteriorating conditions. At times, casual nurses and agency nurses not usually employed by the RACFs had limited knowledge of residents’ usual health status and so were unable to make judgements about their clinical status or care requirements. Availability of GPs GPs were often difficult to contact and not ‘on call’ or available at all times. If a GP was unavailable and medical review or investigations were needed, the staff would refer the resident to EDs for investigation. Lack of equipment in RACFs RACFs lacked diagnostic equipment such as x-ray equipment, resuscitation trolleys and ECG machines. They also lacked access to pathology services on weekends. Consequently residents were referred to EDs for further investigations. Resident and family member requests Some residents and family members requested that the staff refer residents to EDs for assessment and treatment. Family members considered that residents would receive the best possible care in EDs. Communication difficulties Both groups of nurses reported experiencing communication difficulties between RACFs and EDs. These difficulties related to poor documentation, lack of telephone access and person-to-person handover. RACF staff noted that ED staff sometimes sent residents back to
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RACFs during the night with no warning or follow-up. Poor attitudes towards RACF staff RACF staff believed that ED and ambulance staff made unfounded assumptions about them and lacked respect for their positions. One person stated that an ambulance officer had refused to take a resident to hospital. In general, both groups of nurses stated that with up-skilling of RACF staff and purchasing of equipment, some residents may be able to be assessed and treated in RACFs rather than referred to EDs. DISCUSSION The findings of this study revealed that threequarters of residents transferred from RACFs to EDs were admitted to hospital, indicating that these residents required medical attention. This is further supported by residents’ average length of stay in hospital which was more than four days. Consistent with this finding, residents who were admitted were significantly more likely to be rated in a higher triage category and had significantly more procedures than those who were discharged back to RACFs. Therefore there is a need to focus on strategies that detect deteriorating residents promptly so that their conditions can be managed in the facility. It may be useful to put in place a mobile emergency response team who can attend to the needs of deteriorating residents in RACFs and prevent them being transferred to EDs. The development and use of a resident risk assessment and management system (like the acute care medical emergency team call system) may provide a more proactive strategy to address this problem. Some attention needs to be given to developing mobile diagnostic and blood testing services that can be used in RACFs. Interview data revealed that it may be beneficial to look at the RACF staff levels of competency to ensure that they can manage non-acute deteriorating conditions. The finding that residents’ families can sometimes exert pressure on RACF staff to transfer the resident for treatment in EDs deserves some
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attention. Information and education should be provided to residents and their families highlighting alternatives to being transferred to EDs and about advanced care planning options. The findings indicate that communication between all health care professionals involved in the care of residents needs to be improved. It is supported by previous research indicating that relationships between ED and RACF staff could be improved by providing information on each others’ perspectives (McCloskey, Campo, Savage, & Mandville-Anstey, 2009). For example, ED staff sometimes don’t realise that RACF staff do not always have control over referrals and that families exert considerable pressure to have residents transferred to EDs. In this study, 23% of residents referred to the EDs were sent back to their facility, thus raising the question as to whether these referrals to EDs were necessary. This finding is supported by Victorian Emergency Minimum Dataset statistics on the departure status from Victorian EDs of patients referred from RACFs during the financial year 2010/11 that provided a slightly higher figure of almost 30% in their report. Further research is therefore necessary to analyse the information on the group of residents who were discharged back to RACFs to determine if their presentations could be avoided. CONCLUSIONS The current system for managing deteriorating residents in RACFs needs to be improved. These improvements need to be given some priority due to the acuity changes in the RAC sector and the increasing admissions of frail, high dependent residents with cognitive impairment. The current study suggests that most residents presenting at EDs require urgent medical attention. One must question whether this situation is avoidable with the implementation of services that better manage residents’ deteriorating conditions in RACFs. Although recommendations have been made on strategies that would improve the current situation, very few of these changes have been implemented in RACFs. The RAC sector needs to be cognisant that their
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services should be broader based, focussing not only on well residents but also on the management of frail residents whose conditions can deteriorate. It will take much will and effort to change the types of services provided in aged care, however, the need to embrace this change is essential if we are to improve the care of residents in the aged care sector and prevent avoidable transfers to EDs. ACKNOWLEDGEMENTS This research was funded by a grant from the Deakin University, Faculty of Health, Victoria. The authors would like to acknowledge the work of Ms. Vibeke Russell in obtaining the hospital data. REFERENCES Aminzadeh, F., Dalziel, W. B., Molnar, F. J., & Alie, J. (2004). An examination of the health profile, service use and care needs of older adults in residential care facilities. Canadian Journal on Aging, 23(3), 281–294. doi:10.1353/cja.2004.0029 Arendts, G., & Howard, K. (2010). The interface between residential aged care and the emergency department: A systematic review. Age and Ageing, 39(3), 306–312. doi:10.1093/ageing/afq008 Australian Institute of Health and Welfare. (2009). Residential aged care in Australia 2007-08: A statistical overview. Aged care statistics series 28 (Cat. no. AGE 58). Canberra, ACT: Author. Belfrage, M. K., Chiminello, C., Cooper, D., & Douglas, S. (2009). Pushing the envelope: Clinical handover from the aged-care home to the emergency department. Medical Journal of Australia, 190(Suppl. 11), S117–S120. Chu, N. M., Yung, C. Y., Leung, W. S., Chan, V. L., & Leung, E. M. F. (2001). Early unplanned readmission of patients with newly diagnosed tuberculosis discharged from acute hospital to ambulatory treatment. Respirology, 6(2), 145–149. Codde, J., Arendts, G., Frankel, J., Ivey, M., Reibel, T., Bowen, S., & Babich, P. (2010). Transfers from residential aged care facilities to the emergency department are reduced through improved primary care services: An intervention study. Australasian Journal on Ageing, 29(4), 150–154. doi:10.1111/j.1741-6612.2010.00418.x Considine, J., Smith, R., Hill, K., Weiland, T., Gannon, J., Behm, C., & McCarthy, S. (2010).
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Aged care referrals to emergency departments Older peoples’ experience of accessing emergency care. Australasian Emergency Nursing Journal, 13(3), 61–69. doi:10.1016/j.aenj.2010.05.001 Crilly, J., Chaboyer, W., Wallis, M., Thalib, L., & Green, D. (2008). Predictive outcomes for older people who present to the emergency department. Australasian Emergency Nursing Journal, 11(4), 178–183. doi:10.1016/j.aenj.2008.07.002 Crilly, J., Chaboyer, W., Wallis, M., Thalib, L., & Polit, D. (2011). An outcomes evaluation of an Australian hospital in the nursing home admission avoidance programme. Journal of Clinical Nursing, 20(7/8), 1178–1187. doi:10.1111/j.1365-2702.2010.03371.x Finn, J. C., Flicker, L., Mackenzie, E., Jacobs, I. G., Fatovich, D. M., Drummond, S., & Sprivulis, P. (2006). Interface between residential aged care facilities and a teaching hospital emergency department in Western Australia. Medical Journal of Australia, 184(9), 432–435. Friedman, S. M., Mendelson, D. A., Bingham, K. W., & McCann, R. M. (2008). Hazards of hospitalization: Residence prior to admission predicts outcomes. The Gerontologist, 48(4), 537–541. doi:10.1093/ geront/48.4.537 Grbich, C. (2007). Qualitative data analysis: An introduction. London, England: Sage. Gruineir, A., Bell, C. M., Bronskill, S. E., Schull, M., Anderson, G. M., & Rochon, P. A. (2010). Frequency and pattern of emergency department visits by long-term care residents – A population based study. Journal of the American Geriatrics Society, 58, 510–517. doi:10.1111/j.1532-5415.2010.02736.x Gulland, A. (2007). Improving care to avoid A&E. Nursing Times, 103(41), 6–8. Ingarfield, S. L., Finn, J. C., Jacobs, I. G., Gibson, N. P., Holman, C. D., Jelinek, G. A., & Flicker, L. (2009). Use of emergency departments by older people from residential care: A population based study. Age and Ageing, 38(3), 314–318. doi:10.1093/ageing/afp022 McCloskey, R., Campo, M., Savage, R., & MandvilleAnstey, S. (2009). A conceptual framework for understanding interorganizational relationships between nursing homes and emergency departments: Examples from the Canadian setting. Policy, Politics & Nursing Practice, 10(4), 285–294. doi:10.1177/1527154409357795 Nolan, M. R. (2009). Older patients in the emergency department. Journal of Gerontological Nursing, 35(12), 14–18. doi:10.3928/00989134-20091103-01 Ouslander, J. G., Lamb, G., Perloe, M., Givens, J. H., Kluge, L., Rutland, T., & Saliba, D. (2010). Potentially avoidable hospitalizations of nursing
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home residents: Frequency, causes, and costs. Journal of the American Geriatrics Society, 58(4), 627–635. doi:10.1111/j.1532-5415.2010.02768.x Ouslander, J. G., Perloe, M., Givens, J. H., Kluge, L., Rutland, T., & Lamb, G. (2009). Reducing potentially avoidable hospitalizations of nursing home residents: Results of a pilot quality improvement project. Journal of the American Medical Directors Association, 10(9), 644–652. doi:10.1016/j.jamda.2009.07.001 Robinson, S., & Mercer, S. (2007). Older adult care in the emergency department: Identifying strategies that foster best practice. Journal of Gerontological Nursing, 33(7), 40–47. Roethler, C., Adelman, T., & Parsons, V. (2011). Assessing emergency nurses’ geriatric knowledge and perceptions of their geriatric care. Journal of Emergency Nursing: JEN: Official Publication of the Emergency Department Nurses Association, 37(2), 132–137. doi:10.1016/j.jen.2009.11.020 Salvi, F., Morichi, V., Grilli, A., Giorgi, R., De Tommaso, G., & Dessì-Fulgheri, P. (2007). The elderly in the emergency department: A critical review of problems and solutions. Internal and Emergency Medicine, 2(4), 292–301. doi:10.1007/s11739-007-0081-3 Salvi, F., Morichi, V., Grilli, A., Giorgi, R., Spazzafumo, L., Polonara, S., & DessÃ-Fulgheri, P. (2008). A geriatric emergency service for acutely ill elderly patients: Pattern of use and comparison with a conventional emergency department in Italy. Journal of the American Geriatrics Society, 56(11), 2131–2138. doi:10.1111/j.1532-5415.2008.01991.x Shanley, C., Whitmore, E., Conforti, D., Masso, J., Jayasinghe, S., & Griffiths, R. (2011). Decisions about transferring nursing home residents to hospital: Highlighting the roles of advance care planning and support from local hospital and community health services. Journal of Clinical Nursing, 20, 1–10. doi:10.1111/j.1365-2702.2010.03635.x Terrell, K. M., & Miller, D. K. (2006). Challenges in transitional care between nursing homes and emergency departments. Journal of the American Medical Directors Association, 7(8), 499–505. doi:10.1016/j. jamda.2006.03.004 Young, Y., Barhydt, N. R., Broderick, S., Colello, A. D., & Hannan, E. L. (2010). Factors associated with potentially preventable hospitalization in nursing home residents in New York State: A survey of directors of nursing. Journal of the American Geriatrics Society, 58(5), 901–907. doi:10.1111/j.1532-5415.2010.02804.x Received 08 November 2012
Accepted 09 May 2013
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