Aged care homes manage patients well despite poor resources for emergency procedures
Despite anecdotal evidence that a substantial number of nursing home or hostel residents are inappropriately transferred to hospital emergency departments (EDs), a recent study has shown that the proportion of inappropriate transfers is quite low.
The study, by Dr Judith Finn and colleagues from the University of Western Australia, the Royal Perth Hospital and the Catherine McAuley Nursing Home, is reported in the latest issue of the Medical Journal of Australia.
In a six-month study of 541 aged care residents presenting to the Royal Perth Hospital in 2002, the authors found that only 13.1 per cent of transfers to the ED were inappropriate.
Criteria for "appropriate" transfer included fractures, infections, the need for a procedure that could not be performed in a nursing home (eg, x-ray, plaster application), the need for intravenous antibiotics, or suspicion of a stroke.
Although the proportion of inappropriate ED presentations was reasonably low, the number could have been further reduced by greater involvement of GPs and extra training for nursing home staff.
Analysing the inappropriate presentations, the authors found that in about two-thirds of cases, a GP could have dealt with the problem.
In a further 24% of cases, a visit to the ED could have been avoided if nursing home staff had had the training and resources to do simple insertions of indwelling urinary catheters or gastrostomy tubes. Resource constraints often meant there was no other choice than transfer to the ED.
"It is hoped that the MedicarePlus initiatives and the formation of residential aged care panels may provide the mechanism for greater GP availability and training of all members of the health care team in residential care facilities," the authors said.
In an accompanying editorial, Dr Susan Kurrle, Director of Rehabilitation and Aged Care at Hornsby Kur-ring-gai Hospital, said the study by Finn and colleagues was particularly pertinent in view of the growing number of older people in nursing homes and hostels.
"The substantial majority of . . . presentations were considered to be appropriate," she said.
"These patients were acutely unwell and required the investigations and expertise available in the ED."
However, she said the number of inappropriate presentations could be further reduced by following the study's recommendations and by initiatives such as the Gold Coast Hospital's pilot "Hospital in the Nursing Home" program, which delivers acute care to nursing home residents using their own GP and nursing home staff, with medical and nursing input from hospital staff.
"The service has treated 400 patients, resulting in hospital bed-day savings of more than 1,500 days over two years and allowing residents to stay in familiar surrounding while receiving acute care," Dr Kurrle said.
"This would appear to be a positive outcome for all parties, but a randomised controlled trial would be needed to confirm the effectiveness of the intervention."
The Medical Journal of Australia is a publication of the Australian Medical Association.