Despite comprising under 17% of the population, older people accounted for a quarter of all public hospital ED presentations in 2023-24, with more than half admitted to hospital.
Emergency departments across Australia are managing older patients with rising acuity and complexity of emergency care needs – but rural communities are the hardest hit, research finds.
The Australasian College for Emergency Medicine’s (ACEM) State of Emergency: Australia’s Ageing Population report, released yesterday, affirmed “access block is the single most pressing patient safety issue facing EDs across Australia”.
RACGP president Dr Michael Wright told The Medical Republic a 400% increase in people aged over 85 presenting to EDs since 2010 meant older people were having to wait “far longer than what’s acceptable”.
“The report really highlights a lot of the issues that we’re seeing as our population ages, as well as what the college has been calling for,” he said.
“We need to provide more preventive and comprehensive care in the community to take the pressure off the overburdened hospital system.”
But Dr Wright said this required adequate funding and less administrative burden in aged care.
Between 2018-19 and 2023-34, presentations to rural and remote EDs increased by 27% and 33%, respectively – three times the increase in metropolitan EDs.
Nearly seven in 10 older people who presented to an ED were triaged to the higher-urgency categories (ATS 1-3).
According to ACEM, ramping delays increase patients’ seven-day risk of death following presentation and the likelihood of leaving before treatment has commenced or been completed.
While 87% of older people were discharged from the ED within the eight-hour target in 2023-24, only 54% of patients admitted to an inpatient bed left the ED within that time – well below the college’s 90% target.
Despite ACEM’s strong belief that 24-hour stays in the ED should be a “never event”, more than 53,000 older patients spent more than 24 hours in the ED before admission.
“For someone living with frailty or dementia, that is not merely an inconvenient wait. The report describes risks including delirium, immobility and loss of function,” Dr Anthony Marinucci, chair of the RACGP aged care specific interest group, told TMR.
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ED treatment delays could also worsen existing conditions or cause hospital-acquired complications (HAC), prolonging hospital stays, the report read.
For patients with at least one HAC, the average length of stay was 18 days, compared with 4.1 days for those without any HAC.
Dr Marinucci said early recognition of deterioration and prompt escalation were necessary, but he warned that the triage data did not indicate whether patients’ presentations could have been prevented or whether a GP had missed a diagnosis.
“In older people, illness can present subtly. An infection may first appear as new confusion or a sudden loss of function, rather than an obvious fever,” he said.
“Knowing the person’s baseline, listening to family and care staff, and taking changes seriously are important parts of [a patient’s] assessment.”
“We should examine missed opportunities rather than assume every problem is about funding. But clinicians also need a [multidisciplinary] service around them that makes timely care possible.”
Older people who regularly see a GP are up to 28% less likely to go to an ED or be hospitalised than those who see new doctors; however, many people who move into residential aged care are required to change GPs, the report read.
“Moving into residential aged care should not automatically mean losing a trusted GP,” Dr Marinucci said.
“[But] where a change is necessary, we need a proper clinical handover and a consistent ongoing team.”
However, fragmented IT across hospitals, general practice, and aged-care software remained a major barrier to accessing a patient’s clinical information.
As a result, outstanding investigations, follow-up responsibilities and goals of care are not always communicated during transitions of care, Dr Marinucci told TMR.
Among ACEM’s recommendations was the need for further investment in preventive health, as Australia lags behind other OECD countries.
Currently, Australia spends 3% of its healthcare budget on preventive health. While the government committed to increasing this to 5% by 2030, that is still less than Canada’s 7% and the United Kingdom’s 6%, according to the report.
The college also urged the federal government to fund sustainable care models and to adequately remunerate GPs for the ongoing care of older people with complex needs.
Dr Anthony Marinucci said he welcomed emergency physicians’ call for adequately funded, longitudinal general practice – “that is important common ground”.
“The next step is to translate that into a funded delivery plan,” he said.
Redesigning the General Practice in Aged Care Incentive (GPACI) to ensure equitable incentives for all practices serving residential aged care also featured on the list.
“The current incentive payments are insufficient to cover smaller GP practices’ expenses, and thus the program tends to favour larger practices,” the report read.
Without reform, the college warned that many older Australians in regional and rural areas served by smaller practices would lose access to GPACI care.
“A GP caring for only a few residents still has to organise visits, complete registration requirements and track eligibility. Those costs can make participation difficult,” Dr Marinucci said.
“Equally, a practice caring for many residents is providing more clinical care, and that workload still needs to be funded. Supporting one group should not mean overlooking the other.”
But this also meant payment rules accommodating “real clinical circumstances”, he told TMR.
To receive GPACI quarterly payments, GPs must deliver at least two regular services per quarter, each in a different month.
However, this requirement did not accommodate older patients entering permanent care late in a quarter, who may need several reviews on admission, Dr Marinucci said.
The ACEM called for at least 10,000 additional aged care beds each year by 2028.
“Alongside that target, I would like to see an explicit plan for the clinical workforce and ongoing medical care those residents will need, including GP availability, nursing support and access to specialist advice,” the RACGP aged care chair said.
Overall, there were almost 9 million ED presentations across 293 public hospitals in Australia in 2023-24 – an increase of nearly 600,000 from 2018-19.
Read the full ACEM report here.
