Patients on trolleys in emergency departments represent the most cited example of failure of the health services in Ireland. Most of these patients are elderly and a significant number are brought in by ambulance from nursing homes. Sometimes a short hospital visit may be in a care home resident’s interests, but often it is not. 

The disorientation and distress caused by hospitalisation of an older person may be significant. A recent systematic review showed common avoidable harms associated with residents’ hospitalisation¹ and an analysis of hospital admissions in Ireland² showed little added value for many residents.

There are about 20,000 nursing and residential homes in the UK, which have and in the region of 430,000 residents, almost all of whom have age related disability, frailty, multimorbidity or cognitive impairment. Median life expectancy in a nursing home is 15 months, with one in four residents dying within the first year. Therefore, planning and support for end of life care should be the norm.

One third of care home residents who are admitted acutely to hospital die during that admission¹ and it is often apparent when they first arrive at hospital that they are close to the end of life. On arrival at hospital, many more receive only very short term treatment with fluids, oxygen or antibiotics, or an x-ray to exclude injury. Yet care home residents aged over 75 are three times more likely to be admitted as emergencies than those over the age of 75 living in their own home/with relatives.

Nursing homes need proactive care planning and equitable access to medical and other healthcare. These should include palliative care and support for dementia and other mental health problems. The plans should allow for rapid ‘hospital at home’ style interventions in a crisis, or collaboration with ambulance staff and emergency GPs to make conveyance a last resort. Outreach programmes from specialists in elderly care and specialist nurse practitioners can work with nursing homes to support them.

Nursing home staff, who are already undervalued and in scarce supply, need to feel trained, supported and empowered to do the right thing for residents rather than feel obliged to use acute admission to hospital as the default option. Residents’ families also need to understand how the best interests of their relatives can be served in the event of an acute medical problem. Health professionals, including HIQA, need to accept that mortality among nursing home residents is high and that death in a nursing home is not a measure of lack of quality of care.

Simple planning and interventions, such as those outlined above, can achieve drastic reductions in ambulance conveyance or hospital admission and in attendant morbidity and distress.

References

1. Dwyer R, Gabbe B, Stoelwinder JU, Lowthian J. A systematic review of outcomes following emergency transfer to hospital for residents of aged care facilities. Age Ageing 2014; 43:759-766
2. Delos Reyes J, O’Keefe J, Cooney MT, O’Shea D, Hughes G, O’Callaghan S. Multiple hospital admissions do not improve older nursing home residents’ survival: a trigger for advance care planning. Presentation to British Geriatrics Society scientific meeting. May 2015. www.bgs.org.uk/pdf_cms/admin_archive/2015_spring_abstracts.pdf (p56)