Emergency department transfers and hospital admissions from residential aged care facilities: a controlled pre-post design study

Abstract

BackgroundOlder people living in Residential Aged Care Facilities (RACF) are a vulnerable, frail and complex population. They are more likely than people who reside in the community to become acutely unwell, present to the Emergency Department (ED) and require admission to hospital. For many, hospitalisation carries with it risks. Importantly, evidence suggests that some admissions are avoidable. A new collaborative model of care, the Aged Care Emergency Service (ACE), was developed to provide clinical support to nurses in the RACFs, allowing residents to be managed in place and avoid transfer to the ED. This paper examines the effects of the ACE service on RACF residents’ transfer to hospital using a controlled pre-post design.MethodsFour intervention RACFs were matched with eight control RACFs based on number of total beds, dementia specific beds, and ratio of high to low care beds in Newcastle, Australia, between March and November 2011. The intervention consisted of a clinical care manual to support care along with a nurse led telephone triage line, education, establishing goals of care prior to ED transfer, case management when in the ED, along with the development of collaborative relationships between stakeholders. Outcomes included ED presentations, length of stay, hospital admission and 28-day readmission pre- and post-intervention. Generalised estimating equations were used to estimate mean differences in outcomes between intervention and controls RACFs, pre- and post-intervention means, and their interaction, accounting for repeated measures and adjusting for matching factors.ResultsResidents had a mean age of 86 years. ED presentations ranged between 16 and 211 visits/100 RACF beds/year across all RACFs. There was no overall reduction in ED presentations (OR = 1.17, p = 0.56) with the ACE intervention. However, when compared to the controls, the intervention group reduced their ED length of stay by 45 min (p = 0.0575), and was 40 % less likely to be admitted to hospital, . The latter was highly significant (p = 0.0012).ConclusionsTransfers to ED and admission to hospital are common for residents of RACFs. This study has demonstrated that a complex multi-strategy intervention led by nursing staff can successfully reduce hospital admissions for older people living in Residential Aged Care Facilities. By defining goals of care prior to transfer to the ED, clinicians have the opportunity to better deliver care that patients require. Integrated care requires accountability from multiple stakeholders.Trial registrationThe Australian New Zealand Clinical Trials Registration number is ACTRN12616000588493 It was registered on 6th May 2016.

Emergency Department presentation of frail older people and interventions for management: Geriatric Emergency Department Intervention

“…Further to these models, the Aged Care Emergency (ACE) service provides evidence based resources, telephone support by an ED advanced practice nurse, education and proactive case management aligned with pre-established goals of care [42]. Similarly, GEDI have a dedicated telephone line that staff from RACFs, or primary care areas such as PHPs, can use to contact the GEDI team.…”

“…GEDI does not provide mobile assessment and treatment resources as the current focus is on admission avoidance. Interestingly, in the review of the ACE model, only hospital admission avoidance could be demonstrated [42].…”

Abuse of the older person: Is this the case you missed last shift?

“…A total of 270 559 people lived in Australian RACFs at some point during 2013–2014, representing 7.8% of the population aged over 65 years . As at least 30 transfers from RACF to the ED occur per 100 RACF beds annually, aged care residents represent a substantial fraction of older adult ED presentations . These are the most vulnerable older adults in society and may become victims of mistreatment .…”

“…• 30 As at least 30 transfers from RACF to the ED occur per 100 RACF beds annually, [31][32][33] aged care residents represent a substantial fraction of older adult ED presentations. 34 These are the most vulnerable older adults in society 32,35 and may become victims of mistreatment.…”

Distinguishing characteristics of delirium in a skilled nursing facility in Spain: Influence of baseline cognitive status

“…The prevalence of delirium in elderly patients transferred from hospitals to SNF is 8.2% and of well-established cognitive impairment is 25.5%. 4,5 Unfortunately, delirium is underdiagnosed in SNF patients. 3 Patients transferred from SNFs to emergency rooms have a high rate of delirium and admission to the hospital.…”