Older people over-represented in emergency departments

The Australian Health Review recently published a research paper that found older people are over-represented in emergency departments (EDs) in Victoria.
 
The paper, Emergency department utilisation by older people in metropolitan Melbourne, 2008–12: Findings from the Reducing Older Patient’s Avoidable Presentations for Emergency Care Treatment (REDIRECT) study, was based on routinely collected data from 22 public hospital ED presentations of patients aged 70 or older across metropolitan Melbourne between 2008–12.
 
Of 744,519 ED presentations by older people, 103,471 (13.9%) were classified as potentially avoidable – where the patient could have instead gone to their GP. These presentations are known as PAGP-type (potentially avoidable general practitioner) presentations.
 
Over half (58.7%) of these patients were referred back to a medical officer, including a GP. The most common PAGP-type ED presentations were related to external injuries. The majority (39%) of non-PAGP-type presentations by frequent ED attendees were due to cardiovascular or respiratory problems.
 
So what does this means for GPs and the broader health system? And what are the possible solutions?
 
The research team identified a number of factors contributing to PAGP-type ED presentations.
 
Professor Danielle Mazza was lead research author of the paper, and is Head of the Department of General Practice, Monash University and member of the RACGP Expert Committee – Quality Care. She told newsGP there is a need to focus on chronic disease management in general practice and to use ED attendance as a marker that additional care may be required, particularly in older patients and frequent ED attendees.
 
Data from the study indicated some varied results relating to older people presenting to EDs during the data collection period.
 
‘The volume of PAGP-type presentations decreased by 2.6%, with declining rates per 1000 population for patients aged 70 or older,’ Professor Mazza said.
 
‘In contrast, the volume of non-PAGP-type presentations grew by 15.4%, with increasing repeat and frequent presentation rates per 1000 population for patients aged 70 or older.’
 
Dr Jamie Hendrie, who has been an ED doctor at the Austin Hospital in Melbourne for almost 30 years, said he has seen an overall rise of ED presentations.
 
‘More people are presenting to ED overall, earlier in their health situation than they used to,’ he told newsGP.
 
‘At the Austin [Hospital] for example, we get an increase of about 3000 patients a year, but the population of Melbourne only goes up 1% per year, so there’s a disproportionate increase.
 
‘But with older patients presenting to EDs, you can usually guarantee they are sicker and have more acute issues.’
 
According to Dr Hendrie, one of the challenges working at an ED is that issue of under-staffing can make it difficult to stay on top of the annual increase in presentations.
 
‘We have trouble keeping up with the increasing demand,’ he said.
 
‘Over the years we have improved the system, then the demand ramps up to consume any improvement that you make, so you’re always back where you started.’
 
Dr Hendrie believes older patients being encouraged to maintain a stable relationship with their GP may help to address issues of over representation in EDs.
 
Professor Mazza said a large part of the solution to continuing the decrease of PAGP-type ED presentations is to provide additional care for older patients, as well as education to healthcare professionals involved in their ongoing care.
 
‘We need to come up with innovative solutions like aged care nurses and paramedics who can provide additional services to this group of patients,’ she said.
 
‘We also need to educate these aged care nurses and paramedics about how general practice works and re-educate general practice to care for the needs of older patients better.’

after-hours emergency-departments emergency-rooms older older-people patients