Primary care physicians and advanced care plans can help reduce unplanned hospital admission among elderly patients in residential care

Dwyer R, Stoelwinder J, Gabbe B, et al.  Unplanned transfer to emergency departments for elderly residents of aged care facilities: A review of patient and organizational factors Journal of the American Medical Directors Association. 2015 Jul;16(7):551-62.

Review question

What clinical and organizational factors put elderly patients living in residential aged care facilities at risk for unplanned hospital admissions?

Background

The number of residents in residential aged care facilities is increasing. These residents frequently have substantial comorbidities, functional impairment, and are susceptible to infections and falls.

More than 70% of residents in aged care facilities experience unplanned transfers to hospital emergency departments after injury or acute illness, and many experience poor health outcomes afterwards.

Hospital transfers are a burden on health system resources, thus a better understanding is needed of the clinical and organizational factors that put people at risk of an unplanned hospital admission.

How the review was done

A detailed search of a number of electronic databases for studies published up until 2014 was conducted. Studies that included patients who were 65 or older and living in residential aged care facilities, and that looked at the factors associated with unplanned transfer to the emergency department, were included in the review.

A total of 2,743 studies were identified in searches and 78 were included in the review after assessment for eligibility.

This review was funded by the Monash University Postgraduate Research Scholarship, the National Health and Medical Research Council (NHMRC) Career Development Fellowship and the NHMRC Early Career Fellowship.

What the researchers found

There are several patient-related risk factors associated with unplanned transfers to hospitals, including: chronic disease; the use of permanent in-dwelling devices (e.g. catheter tubes); physical characteristics that are associated with ill-health such as low body weight; having large numbers of prescribed medications; and a recent admission to a hospital or residential aged care facility.

Organizational risk factors that were identified included private facility ownership, smaller facility size and low staff-to-patient ratios. Increased involvement of primary care providers and advance care planning (e.g. do not resuscitate orders), were found to reduce the risk for unplanned admissions.

Conclusion

While there are several unchangeable geographical and facility-related factors that influence the rate of hospital transfer, individual health variables are modifiable and may lower the number of elderly patients requiring transfers. This review found that advance care planning and advance directives were instrumental in maintaining quality of life for residents, and in reducing the frequency of unplanned admissions. More research is needed into the interplay of gender, race and culture, and the effect this may have on hospital transfer and admissions among the elderly.