Referrals to Hospital Emergency Departments from Residential Aged Care Facilities: Stuck in a Time Warp

By O'Connell, Beverly; Hawkins, Mary et al. | Contemporary Nurse : a Journal for the Australian Nursing Profession, October 1, 2013 | Go to article overview

Referrals to Hospital Emergency Departments from Residential Aged Care Facilities: Stuck in a Time Warp


O'Connell, Beverly, Hawkins, Mary, Considine, Julie, Au, Catherine, Contemporary Nurse : a Journal for the Australian Nursing Profession


Individuals in residential aged care facilities (RACFs) are reported to be more likely to pres- ent to emergency departments (EDs) than those living in the community (Crilly, Chaboyer, Wallis, Thalib, & Green, 2008; Ingarfield et ah, 2009). This is not surprising given that many RACF resi- dents 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 ah, 2006; Ouslander et ah, 2009). Given that RACF residents are cared for by nursing staff and have access to attending general practitioners (CPs), 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 ah, 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, 2009). Older patients experience a higher num- ber of adverse outcomes after ED discharge than younger patients (Salvi et ah, 2007), almost one- quarter are readmitted within 3 months, two- fifths 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 opportuni- ties to up-skill in this area (Roethler, Adelman, & Parsons, 2011) and thereby prevent some admis- sions 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 informa- tion to CPs (Ouslander et ah, 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 and discharge (Beifrage, Chiminello, Cooper, & Douglas, 2009; Ouslander et al., 2010).

(4) RACF staff use clinical algorithms for com- mon conditions that assist with providing better care within RACF (Arendts & Howard, 2010; Gruineir et al., 2010; Ouslander et ah, 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 diag- nostic and treatment equipment in RACFs, for example, use of mobile services (Ouslander et ah, 2010; Young et al., 2010).

(8) EDs should be better designed to accommo- date older people in terms of environment and type of care and services provided (Considine et ah, 2010). Alternative triage and waiting processes could enhance the patient journey and be better suited to the needs of elderly patients (Considine et ah, 2010; Nolan, 2009). Additionally, commu- nication 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 consul- tants 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). …

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