By Lynn McVey
In England, care home residents are disproportionately likely to attend A&E departments compared to other older people. Attendance has risks, including hospital-acquired infections and deterioration in residents’ health. It also increases pressures on hospitals and demand for beds. Research suggests that as many as 41% of these emergency journeys to hospital could be avoided, with residents being treated at their homes or in the community. However, our understanding of how to do this in a UK-context is limited by the fact that there’s no universally agreed definition of these ‘avoidable emergency transfers of care’ that’s meaningful to all involved. In addition, much existing research has been carried out in the US or Australia. Given this background, we undertook this stakeholder consultation project to identify priorities for future research in this area in the UK.
What did we do?
We worked with residents, family members and staff from two residential care homes – a large charity-owned home and a smaller privately-owned home – as well as staff from other organisations involved with transfers, such as district nurses, GPs, telemedicine, ambulance service staff and hospital doctors. Overall, we talked to 31 stakeholders either one-to-one or in small groups.
What did we find?
Residents and their loved ones said that emergency transfers to hospital were often distressing and uncomfortable. Everyone we talked to wanted to avoid them when it was appropriate to do so.
If I can prevent any of ‘em [residents] going in hospital I will, only because this is their home […] so I think what can I do to prevent this person from going off in an ambulance? (Care home worker).
We found that a great deal is already happening to prevent such transfers, including services such as:
- telemedicine – where care home staff can video-call a nurse 24/7 if they’re worried about a resident; where appropriate, the nurse can organise care in the community for the resident;
- work by staff in and outside care homes to co-ordinate and follow-up services, making sure residents get the preventative treatment they need when they need it, so they don’t become acutely unwell and have to be taken to hospital.
However, there’s still a lot to do, especially around making sure risks to residents are managed appropriately and improving communication of care plans. For example, care home staff do not have access to residents’ GP and hospital electronic care records, which can make it difficult for them to ensure the care they offer residents aligns with these plans and that they are responding to risks in the most effective ways.
We asked stakeholders how they would define an ‘avoidable emergency transfer’ and what they thought was involved. There was widespread dislike of the word ‘avoidable’, with alternative terms such as ‘preventable’ or ‘unplanned’ suggested in its place. Some thought ‘avoidable’ was demotivating, dismissing the good work that already takes place. Stakeholders explained that while some emergency transfers are ‘one-off’ avoidable events, others happen after repeated attempts over time to avoid them, meaning that preventative care is not provided so residents become avoidably, acutely unwell and need hospital care. Taking all this into account, we suggest these transfers might be defined like this:
“A preventable emergency transfer takes place when problems -e.g. around service integration and availability, risk management and communication of care plans – stop residents who otherwise could have been cared for appropriately at home from receiving such care. Sometimes these transfers happen because of a one-off problem, and at other times they happen after many attempts to prevent them. Here, the transfer itself might not be preventable, but the events leading up to it were.”
What next?
We asked stakeholders what they thought priorities for future research should be. They suggested several key areas to look at, including:
- Improve communication about care plans between staff and services and with residents and their loved ones.
- Extend services that are already working to avoid transfers, including services in primary care and residential homes and community/telemedicineservices.
- Provide further training & awareness raising for staff and residents/families.
- Look at policies for falls management and monitoring residents after falls.
- Extend treatment and monitoring for frail residents.
- Further service integration to provide more joined up, systematic support to care homes.
- Improve advance care planning/risk management tosupport honest, sensitive conversations between care staff, clinicians, residents and families about hospital care.
They also thought research was needed into improving residents’ and families’ experiences in A&E. This could include looking at how to develop and operationalise dedicated spaces or services in A&E departments for older people and people living with dementia.
We will work with the urgent and emergency care theme in the YHARC and other groups to develop dissemination and action plans for these findings.
