At a time when there is a widely held perception that older people, and particularly nursing home residents, are occupying acute care hospital beds at the expense of others,1 the article by Finn et al2 in this issue of the Journal is very pertinent. It describes the presentation, over a 6-month period, of a cohort of 541 patients from aged care facilities (nursing homes and hostels) to the emergency department of a large tertiary hospital, and notes that the substantial majority (87%) of these presentations were considered to be appropriate. These patients were acutely unwell (most having been so for less than 2 days) and required the investigations and expertise available in the emergency department for diagnosis and management. Sixty per cent of these patients required hospital admission and most (90%) survived to be discharged back to their aged care facility.

There are currently about 78 000 people in nursing homes across Australia and about 81 000 in hostel care.3 These numbers will continue to grow as the number of older people increases. Consequently, presentations to emergency departments and admissions to hospital are also likely to increase, placing further strain on already busy hospitals. Hospitals can be dangerous and unfriendly places for frail older people or people with dementia, who are most likely to be residents of aged care facilities. Polypharmacy, undernutrition, skin tears, pressure areas, fall-related injuries, nosocomial infections, and deconditioning are some of the hazards of hospitalisation.4 It is therefore now very appropriate to be looking at methods of reducing the need to hospitalise these patients by providing assessment and management of selected conditions within aged care facilities. Finn et al suggest some of the resources that would be required to prevent inappropriate hospital presentation (such as the ability to insert indwelling catheters and to replace percutaneous endoscopic gastrostomy tubes), but more than this will probably be necessary.

Recently, a number of hospitals around Australia have identified the need to work more closely with aged care facilities and general practitioners to provide acute care to patients in nursing homes. For example, Gold Coast Hospital in Queensland has piloted a “Hospital in the Nursing Home” program that delivers acute care to nursing home residents using their own GP and nursing home staff, with medical and nursing input from Gold Coast Hospital staff.5 This service also provides education and information to nursing home staff in areas such as wound care, continence management and intravenous fluid administration, enabling staff to improve their skills in these areas. Clinical pathways are used for management of pneumonia, urinary sepsis, dehydration, palliative care and wounds. The service has treated 400 patients, resulting in hospital bed-day savings of more than 1500 days over 2 years and allowing residents to stay in familiar surroundings while receiving acute care (Ms Kerry Robinson, Project Officer, Aged Care Early Intervention and Management, Gold Coast Hospital, personal communication). 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.

Finn and colleagues also raise a number of other issues that merit attention, and addressing these issues could potentially avoid some presentations and improve information sharing in others. Their study revealed that a GP had been consulted for only a quarter of patients presenting to the emergency department. Increased GP availability and involvement is clearly important, given that 126 out of the 136 presentations involving GP input were judged “appropriate”, whereas up to 45 of the 71 presentations considered “inappropriate” could have been avoided if GP review had occurred. With the increased use of Enhanced Primary Care Initiatives, in particular, comprehensive medical assessment for permanent residents of residential aged care facilities (Medicare Benefits Schedule item 712), and Aged Care GP Panels, it is hoped that there will be much greater direct involvement of GPs in the care of their patients in aged care facilities. Overseas experience indicates that increased availability of primary care (both medical and nursing) in nursing homes results in fewer hospital admissions.6

The lack of communication between aged care facilities and the emergency department in 61% of presentations is also of concern. Use of a common aged care facility transfer sheet may improve this, and as the use of technology increases (eg, electronic care plans for residents), the use of electronic referrals may assist the process of information transfer. Inadequate communication or documentation between aged care facilities and emergency departments has been shown to increase the likelihood of admission to hospital.7

The preparation and use of advance care directives was also suggested by Finn et al to guide response to acute events occurring in residential care. Advance care directives (also known as “health care directives” or “living wills”) allow residents to document their preferences for treatment and care. The directives may indicate a desire for hospital admission and full treatment or a preference for limited treatment in certain situations. Many aged care facilities already encourage their use and help residents and their families formulate such directives in the weeks following their admission. Advice in preparing these directives is available from a number of sources, such as NSW Health.8

Finn and colleagues have given us an understanding of current presentations of patients from residential care facilities to emergency departments that can assist us in developing different and better quality services for these people. Adequate training and resourcing of staff in aged care facilities, increasing involvement of GPs, and consultation with residents and their families are the first steps in developing these services.