Residential Aged Care Facilities Should Identify Modifiable Markers to Mitigate the Need for Transfer to Hospital

The number of frail, older adults who require care in residential aged care facilities (RACFs) is growing. Cognitive and functional impairment, as well as significant medical comorbidity, is common among this population and are, thus, vulnerable to sharp declines in health.

Annually, up to 75% of residents undergo an unexpected transfer to hospital emergency departments (ED) for treatment. The results of these transfers include many adverse consequences. During a hospital stay, older adult residents are highly at risk of potentially intrusive interventions and can experience delirium, bed sores, and hospital-acquired infections. The functional decline of residents is exacerbated post admission, and short-term mortality rates post-transfer are high, even following specialist inpatient care. A study has shown that the rate of these burdensome transfers near the end of life grew from 17% to 20% of RACF residents between 2000 and 2007.

Unplanned transfers to hospital occur due to a variety of factors such as diminished physical health, falls, complications involving indwelling devices or medications, and difficulty in managing complex behaviors. They often include transfers associated with ambulatory care sensitive (ACS) conditions and end-of-life care. Provided the potential for negative consequences, it is crucial to understand the individual patient and health system factors that increase a resident’s risk of emergency hospital transfer. This would allow modifiable risk factors to be addressed and inform development of appropriately targeted interventions to decrease the rate of burdensome transfers.

A recent review synthesized current evidence pertaining to clinical and organizational factors of unplanned emergency transfer to hospital for acute illness or injury among frail, older adults residing in RACFs. The review identified many factors, including patient and facility characteristics that influence risk of unplanned emergency hospital transfer. Some individual health factors, such as medication use and vaccination, are modifiable and can be evaluated on a regular basis through routine, structured primary healthcare. Although comorbidities and functional disability can be less modifiable, their presence can indicate the likelihood of future deterioration or falls, which can be anticipated and planned for to prevent need for acute, disruptive transfer to a hospital. Facilities should make strides to improve planning for these more predictable regressions with earlier intervention for their residents. This may include triggers to more frequent reviews by a patient’s primary treating physician, structured guidelines, protocols, and training programs for facility staff in the management of common acute medical conditions, improved infection control strategies such as vaccination, infection control practices, and antibiotic stewardship, and earlier implementation of appropriate outpatient and palliative care services, which may alleviate the need for transfer to hospital.