The role of advance care planning in reducing ED presentations

Newly published Australian research describes the patterns of emergency department (ED) presentations for patients referred from residential aged care facilities (RACF) and the predictors of 30-day mortality (death) in the same patient cohort.

The findings of the study¹, said to be the largest of its kind undertaken to date, indicate two key areas that need to be addressed to help reduce hospital re-admissions and ED admissions for RACF residents:

1. The need to improve access to clinical care within RACFs.
2. A need to improve coordination between care providers.

The paper by Chiswell et al. (2022), published in the Australian Heath Review, presents an analysis of linked state-wide emergency, inpatient and death data from 136 public ED hospitals in New South Wales, Australia. Specifically, linked data from the NSW Emergency Department Data Collection database, the NSW Admitted Patient Data Collection database and the NSW Registry of Births, Deaths and Marriages allowed the authors to analyse 43,248 ED presentations between January 2017 and July 2018, aged 65 and above, and who had come to hospital from an RACF. Analysis considered ED diagnosis categories, readmission rates within 30 days and 30-day all-cause mortality.

The research found that the most common reasons for ED presentations were injury (26.48%), most commonly due to falls, respiratory conditions (14.12%) and cardiovascular conditions (10.74%). It also found that 30-day mortality and readmission rates were high for this cohort at approximately 15% and 21% respectively. Prolonged length of stay in the ED and re-admission within 30 days were found to be a predictor of increased mortality.

Data also showed that there was a range of both high- and low-urgency presentations. Of patients in the ED, 68% were admitted to hospital and 32% were discharged from the ED. A total of 34% of patients were admitted or discharged from the ED within four hours of arrival.

Improving access to clinical care within RACFs

The authors have suggested that the high re-admission rate seen for patients readmitted within 30 days, compared to the same age group in general ED presentations (21% compared to approx. 5%) provides an opportunity for improving access to clinical care within RACFs.

They have also suggested that one way to enable greater access to clinical care within an RACF is the earlier identification of a resident’s deterioration and a focus on those with risk factors for ED presentations (increased age, complex care needs, polypharmacy and delirium history).

However, improving access to clinical care in RACFs faces major barriers, as set out in the findings of the Royal Commission into Aged Care Quality and Safety. One of the main and most significant barriers includes workforce issues in aged care and general practice.

Improving coordination between care providers

In addition to the high re-admission and mortality rates, the research also found that a large number of RACF residents were non-urgent presentations and that many were staying longer in the ED than the emergency treatment performance target of discharge or admission (within four hours).

The authors suggest that better coordination and communication between hospitals, RACFs and other care providers (such as Geriatrics Outreach Services, Hospital in the Home and allied health providers) might help to avoid non-urgent ED presentations and improve outpatient services to reduce re-admission.

A major barrier to care coordination is the systematic fragmentation of the Australian health care and aged care systems.

Advance care planning, a partial solution

Advance care planning enables the provision of palliative care at the RACF, particularly when appropriate and preferred by the patient, and provides an achievable solution to reducing ED presentations from RACFs.

This is not, however, an easy solution, nor is it a magic bullet. The authors point to a recent audit² which demonstrated that: “Many patients from RACFs do not have advance care planning documentation or an Advance Care Directive and, when they do, it often lacked adequate information required to provide care in full accordance with the patient’s wishes.^”1

Yet Advance Care Planning should be embedded as part of a resident’s health care. It is person-centred and addresses the challenges that an aging population face — that is, loss of the ability to make decisions about one’s own care³.

End of Life Directions for Aged Care (ELDAC), a national specialist palliative care and advance care planning advisory service funded by the Australian Government Department of Health and Aged Care, can help support efforts to address the access and coordination needs identified in this research. The ELDAC Primary Care Toolkit can guide primary care providers and teams through the steps in providing palliative care and supporting advance care planning with patients and their families. In addition, the toolkit also supports general practices to develop capabilities in the provision of continuous and comprehensive care relating to palliative care (aligning with Criterion GP2.1 of the RACGP standards for general practice).

The ELDAC Residential Aged Care Toolkit is designed for health professionals and care staff providing palliative care and supporting advance care planning for older Australians living with advanced life limiting illnesses, their families and carers.

^References

<sup>1. Chiswell K, Bein K, Simpkins D, Latt M, Dinh M. Emergency department presentations and 30-day mortality in patients from residential aged care facilities. Aust Health Rev. 2022 Aug;46(4):414-420.
2. Chua TH, Foong JR, Tan RR, Rukasha PN, Hullick C. Assessment of advance care planning documentation for residents of residential aged care facilities presenting to the emergency department. Aust Health Rev. 2020 Dec;44(6):847-852.
3. Rhee JJ, Zwar NA, Kemp LA. Uptake and implementation of Advance Care Planning in Australia: findings of key informant interviews. Aust Health Rev. 2012 Feb;36(1):98-104.</sup>

^{Originally published here.}

*Adjunct Assoc Prof Rebecca Haddock, Executive Director, Knowledge Exchange, Deeble Institute for Health Policy Research, Australian Healthcare and Hospitals Association.
**Naomi Sheridan, Policy Officer, Australian Healthcare and Hospitals Association.

Image credit: iStock.com/Mladen Zivkovic

Originally published here.