Aged care providers shift burden to public hospitals 

Avoidable hospitalisations and unnecessary delays in transferring patients back to residential homes are putting significant pressure on our public health system, a new survey confirms.

Understaffing and a lack of qualified nursing staff in NSW residential aged care facilities is responsible for a deluge of costly and distressing transfers of residents to hospitals, a new report has found. The report, from the NSW Aged Care Roundtable, found that half of hospital doctors surveyed witnessed avoidable hospitalisations on a daily basis.

A lack of national data about the problem prompted 11 clinical, medical and advocacy groups from the Roundtable, including the NSWNMA, to survey their members about the issue.

The report authors write that avoidable hospitalisations are occurring because of both “systemic” and “incidental” problems in residential aged care facilities.

More than 1600 NSWNMA members responded to the survey, with 42 per cent saying there were employed on a ratio of one registered nurse to between 50 to 100 residents on each shift. Nearly one in ten (9 per cent) had a ratio of one registered nurse to between 100 and 150, and 3 per cent worked in facilities with one registered nurse to over 150 residents/patients.

One respondent wrote: “If RN coverage couldn’t be found for night shift in one facility, there was one RN to two facilities with approximately 260 residents.”

Those surveyed cited falls, palliative care, behaviour management of people living with dementia, catheterisation and pain management as the main reasons why people are transferred to hospital. Other causes of avoidable hospitalisations included simple wound care, medication errors and pain relief.

Doctors diagnose transfer problem

Just over half (54 per cent) of hospital doctors surveyed by the Australian Salaried Medical Officers Federation (ASMOF)said they witnessed avoidable hospitalisations from aged care facilities daily. 44 per cent of ASMOF doctors cited insufficient staffing at aged care facilities and 35 per cent nominated registered nurse workload as factors in avoidable hospitalisations.

Members of the Australia & New Zealand Society for Geriatric Medicine identified the most common reasons for avoidable hospitalisations as: behaviour management (78 per cent); falls (62 per cent); urinary tract infections (62 per cent); dehydration and/or poor nutrition (53 per cent); upper respiratory infections (50 per cent); simple wound care (including pressure sores) (47 per cent); and pain relief (47 per cent). Elder abuse – including neglect and/or attack by another resident – was also identified as a cause of avoidable hospitalisations.

ASMOF members also reported unnecessary delays in residents being transferred back to residential homes, with 92 per cent experiencing delays in discharging a person back to an aged care facility. The length of delay ranged from between several hours to several weeks. Some 46 per cent of ASMOF members surveyed said delays were caused by relatives refusing to have a resident returned to a facility with insufficient staffing levels, while 43 per cent attributed the delay to the absence of a registered nurse at the facility and 31 per cent to lack of staff knowledge at the facility.

 One member of The Australia & New Zealand Society for Geriatric Medicine noted that: “Certain facilities in our area will not accept residents back on Friday or over the weekend.”

Another wrote that residential care facilities were often unwilling to accept patients with complex needs. Over 90 per cent had experienced delayed discharges to RACFs ranging from a day or two up to 120 days.

GPs abandoning facilities

General practitioners surveyed said they were increasingly unlikely to visit residential care facilities in the future because they are poorly remunerated 
and there is a lack of qualified staff for them to liaise with.

An enrolled nurse at a not-for-profit RACF noted that: “Quite often residents are transferred to hospital (on family request and staff request) when doctors are unavailable to give orders for treatment to commence e.g. (for) antibiotics.”

One GP noted the crucial role of RNs in aged care facilities: “RNs are able to recognise and ensure early intervention and management in response to changes in an individual’s health, thus reducing the risk of deterioration and potentially reducing the need for unplanned admissions to acute facilities or transfer to emergency departments. This not only assists in maintaining quality of life for care recipients but also reduces overall costs to the health system.”

NSWNMA General Secretary, Brett Holmes, said: “Improved staffing in residential aged care is paramount, with 74 per cent of our members stating hospital transfers could have been prevented if more nursing staff were rostered on, while 49 per cent said a lack of GP availability was a contributing factor.”

Read the report

The report, Joint report on avoidable hospitalisations from residential aged care facilities in NSW and delayed discharge, is available on the NSWNMA website:

The Roundtable’s recommendations

The Aged Care Roundtable member groups called for the following improvements to the residential aged care sector:

  • improvements to staffing levels and the qualifications and training of RACF staff
  • access to specialist nursing services and other health professionals needs to be improved
  • medication management needs improvement
  • national clinical care benchmarking for residential aged care is needed to reduce avoidable hospital presentations
  • clinical care benchmarking needs to be supported by the national collection of data on hospital admission and discharges of RACF residents
  • RACFs should be considered healthcare providers and better integrated within primary care services
  • cultural competency should be part of an ongoing development plan across all staffing levels within RACF.