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A MAJOR aged care provider has warned of dire “unintended consequences” if regulations are tightened around the sector to reduce preventable nursing home deaths.
Dr Stephen Judd, chief executive of HammondCare, told MJA InSight that recent calls to increase nursing home regulation would produce “nursing staff who are fixated on compliance rather than fostering a good quality of life for the people they are caring for”.
“If staff think they are going to get rapped over the knuckles if Mary falls over when she goes outside, they’ll lock the door so she can’t get out,” he said.
“All life is about risk; we have to encourage people to enjoy life, not just keep themselves hermetically sealed in a life of boredom,” he said. “Rather than trying to eliminate risks, we must manage risks intelligently.”
Dr Judd was responding to a study published in the MJA which used coronial records to identify 3289 nursing home deaths due to external causes between 1 July 2000 and 30 June 2013.
The majority of those deaths related to falls (81.5%), followed by choking incidents (7.9%) and suicides (4.4%). There were 38 deaths due to transport crashes (1.2%), 39 due to complications of clinical care (1.2%) and 34 due to resident-to-resident assault (1%).
Most of the deaths occurred in hospital after the initial incident in the nursing home.
The incidence of premature and potentially preventable deaths increased over the 12 years, the study found, from 1.2 per 1000 residential aged care services admissions in 2001–02 to 5.3 per 1000 admissions in 2011–12.
Professor Joseph Ibrahim and colleagues from the University of Melbourne said that this finding was consistent with trends in other developed countries.
“Disturbingly, there has been no reduction in the prevalence of these types of external cause deaths over the past 12 years,” they wrote. “This raises an important question about governance structures for the care and safety of nursing home residents.”
“A national policy framework is needed to reduce the incidence of premature deaths among Australians living in nursing homes,” they concluded.
However, Dr Judd said it was troubling that the study did not consider deaths from all causes, making it easy to wrongly infer that falls and choking were major causes of all nursing home deaths.
He queried the finding that rates of external-cause deaths rose over the past decade, saying that this was more likely to reflect increased reporting to the coroner – a limitation the study authors also noted was possible.
Dr Judd commented: “Our experience is that we are reporting far more to the coroner than a decade ago, at the request of the coroner.”
Dr Judd said that the quality of care in Australian nursing homes in general had “increased incredibly in the past 15 years”.
“Does it need to improve? I do believe that,” he said.
However, he said, better care would not come through greater regulation but through market competition. He urged the federal government to uncap supply of nursing homes by scrapping current licensing arrangements so operators could set up anywhere they wanted, as had been done in the home care market.
“This would enable greater true choice for prospective residents and ultimately lift the standard for residential services,” he said.
Dr Catherine Yelland, Director of Medicine at Brisbane’s Redcliffe Hospital, wrote an MJA editorial, to be published on 5 June, arguing that the study showed Australia “could be doing better” at caring for the, often vulnerable, residents of aged care facilities.
The rate of choking deaths was particularly worrying, she said, and underscored the need for expert swallowing assessment, modified diets and sufficient staff to supervise meals or to feed patients as required.
On this issue, Dr Judd said that residents’ individual likes and dislikes should also be taken into account. “If a resident loves sandwiches, we can make sandwiches with xanthan gum so they melt in the mouth, rather than feeding people mush,” he said.
On the topic of reducing falls, Dr Yelland said that there was “always a balance between acceptable risks”.
“If we stop people walking, we can prevent a lot of falls … But if we do that we decondition them; they get weaker, lose more muscle strength and are at an even higher risk of falls. We reduce their quality of life if they’re not able to move around,” Dr Yelland said in an exclusive MJA InSight podcast.
Risk reduction strategies should include reducing the use of medications associated with falls, particularly sedatives; creating safe environments without trip hazards; providing adequate supervision of people at high risk; and increasing use of walking aids, she said.
Professor Jacqueline Close, consultant geriatrician at Sydney’s Prince of Wales Hospital, said that vitamin D supplementation should be added to this list.
“There is evidence to support the use of vitamin D as a cheap and effective approach to falls prevention in residential aged care facilities,” she told MJA InSight.
Professor Close suggested that the increasing rate of unnatural cause deaths seen in the latest study may relate to the change in the status of people being admitted to residential aged care facilities over the past decade.
“On the whole, people are older and frailer when they are admitted now than in 2000,” she said. “However, if they are older and frailer, then the skill set and staff ratios need to reflect the potentially higher care needs.”
She said that all staff working with older people should be trained in working with people with dementia, and suggested that this could be a mandated requirement or performance indicator for residential aged care facilities.
A spokeswoman for the federal Department of Health noted that the number of deaths identified in the study was “very small” compared with the total number of residents in aged care over that period. In 2015–16, 234 931 people received permanent residential aged care.
Federal Minister for Aged Care Ken Wyatt announced an independent review of the Commonwealth’s aged care quality regulatory processes on 1 May 2017.
The review is in response to a report by the Australian Chief Psychiatrist, Dr Aaron Groves, which uncovered abuse, excessive use of restraint and overmedication of residents at the Oakden Older Persons Mental Health Service in South Australia.
At present, the Australian Aged Care Quality Agency assesses nursing homes, with unannounced site visits at least once a year.
However, Professor Hal Swerissen, a health policy academic at Melbourne’s Grattan Institute, suggested that current procedures to safeguard quality in residential care may be inadequate.
“There are still many individual reports of poor quality care,” he told MJA InSight. “It is no surprise that few people are happy to go to residential care.
“Comprehensive data collection, reporting and analysis of all deaths of residents in aged care facilities is needed for better policy formulation,” he said. “With better data, incentives and sanctions for appropriately adjusted performance against agreed outcome standards can be introduced to drive better performance.”
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The laws need to change to reflect peoples wishes when they can no longer care for themselves. Able body and minded people should have the choice to document there wishes about life choices when and if they develop Dementia, Alzheimers or stroke. People when able bodied need to be able to choose assisted dying, rather than the slow painful death imposed through falls and choking when in “nursing” homes
I am the General Manager of a for profit, large Residential Aged Care Facility. Working at the coal face we are confronted with the reality every day of the complexity of aged care. It was very refreshing to see informed commentary that looks beyond simplistic quick fix options. Higher staffing levels will obviously have some beneficial impact but is not the magical panacea being sought. Putting cost aside (and who will pay as Dr Geffen accurately describes) a more pressing issue becomes ‘who will undertake these duties’. The sector is already struggling in finding suitably qualified and psychologically capable of working in the industry let alone for around $20 p.h and predominantly offered only part time/casual hours.
Before rushing to judgement on the reliance of overseas qualified staff on 457 visa it is worth noting this is predominantly available to highly skilled doctors and registered nurses – the visa conditions require paying at the prevailing local scale and predominantly sourced by agencies due to the high costs of relocation resulting in high charge out rates. Now what employer in their right mind would take this option over a local skilled practitioner – well there is no choice since few want to take up employment in such a difficult, over regulated and often thankless environment.
I love aged care, but the system is broken and I hope the reviews currently being undertaken will go some way to assisting the sector – I am pessimistic. My treasured moments are with those residents and staff where the intentions are clear, the care is as good as it can be, flaws are acknowledged and we worked together to make the final journey a positive experience. Thank you for this enaging article.
Higher nurse/carer ratios is urgently needed the more staff to patient care the closer scrutiny of the patient will help stop the falls and dehydration which is so common in facilities .This along with abuse by other patients and staff who have no patience or empathy towards the elderly. There should be no need for restraints if there were more staff on the floor you cannot expect people of any age to sit for hours on end in the one place and in most cases being supervised by a TV.
I completely agree with 5, 6 & 7 above. My mother died in 2007 in a nursing home. She had Parkinsons and Lewy Body Dementia. She had always been a great “walker”. Staff were concerned that she may injure herself as she mobilised at will with a 4WF. Staff asked me if I would like them to remove her 4WF. I said ‘no way’ She loves walking and if she dies doing something she has always loved there is no problem’. I would prefer that for her than restraint. I frequently found her on the floor in a corridor – but she never had any injuries. I would help her up and keep walking with her. Quality (of life) is more important than quantity (of years). Then again – I always took her outside for a cigarette too – a lifetime habit she enjoyed!! I also totally agree with the comments on thickened fluids. If it is choice between someone enjoying a cup of tea with the possibility of aspirating to becoming dehydrated because of a refusal to drink thickened fluids, I would support giving a relative unthickened tea. All of life is definitely about choices and taking risks.
Very interesting, thank you Sarah and Cate.
I note with interest that “Dr Judd said it was troubling that the study did not consider deaths from all causes, making it easy to wrongly infer that falls and choking were major causes of all nursing home deaths”. However, Joe Ibrahim’s paper in MJA does mention the incidence of ‘natural’ as well as injurious ‘external’ deaths – in fact, it specifically notes that, in 2011-12, death rates from natural causes were double those caused by falls (10.7 versus 5.3 deaths per 100,000 RACF admissions).
It is also worth pointing out that Prof Ibrahim, despite the rise in coroner-reported nursing home deaths from falls and accidents since the turn of the century, has not gone on to say that we should consign people to bed and wrap them in proverbial cotton wool – in fact, quite the opposite. He has written and spoken eloquently on the important topic of ‘dignity of risk’, and has challenged the status quo around ‘safety first’ for older people, arguing that quality of life and autonomy are precious but under-represented variables.
http://www.profjoe.com.au/all-cases-list/dignity-of-risk/
http://www.abc.net.au/news/2015-11-22/risky-activities-could-improve-quality-of-life-for-elderly/6939166
http://onlinelibrary.wiley.com/doi/10.1111/ajag.12014/abstract
In terms of falls as described above, yes in some cases they do signal ‘failure’ of a system biologically. I guess the key philosophy, though, is that we ought to minimise those obvious, transparent, easily-reversed contributory risks, so that (at least) we are not virtually ‘guaranteeing’ a fall. For example, sedatives with questionable indications, bifocal glasses, unlit corridors, or under-treated motor parkinsonism are almost ‘certainly’ going to trigger falls in a foreseeable way if they remain unchecked. Falls prevention is essentially ‘doing the few simple things you realistically can’. I often teach students that, if one imagines a group of people sitting around a small camp-fire, and they all throw a small amount of petrol onto the flame, a big fire will emerge; the principle then becomes remove whichever factors are ‘fuelling’ the problem and are actually removable. Not all falls risk factors, naturally, can be ‘reversed’, but it is better to ameliorate, say, ‘two out of ten’, rather than ‘zero out of ten’. The notion of ‘falls prevention’ doesn’t mean punitive beneficence should prevail, making us restrain or constrain older people so they ‘can’t’ fall – in fact, taking away the small, obvious falls risk factors may foster a greater chance that older people may take some risks and ‘get away with them’, in the name of quality of life.
I agree wholeheartedly with 5 above, but also raise the matter of the serious deterioration in staffing levels following the new Aged Care Standards promulgated last year. This has resulted in a marked increase in the use of agency or 457 visa-holding staff, employed at seemingly rock bottom wages, on rosters that rapidly exhaust staff, lead to medication and other errors, and in some cases, actual patient neglect. Staff have little time to spend with individual patients, are unable to adequately monitor food or fluid intake, and certainly appear, to my trained eye, to have little real timd to spend in active patient care. These aspects are at their worst in the high dependency and dementia-specific areas, so continence management becomes reactive, not proactive, perineal irritation and even breakdown are seen often, and behaviour management relies far too heavily on medication because there is insufficient time for the non-pharmacological measures to be employed, and the lack of continuity of care that seems to be increasing. I was initially unaware that there was no longer a need to have any RN on site for every shift, but that one must be “contactable” should staff (EN, PCAs) feel the need for advice. I have been reliably informed that some remote RNs are not even located onshore! Long-term staff, including fully trained aged care RNs, have been made redundant, hounded into early retirement, or forced by workplace stress onto Workcover support so that large corporate, largely for-profit service providers can re-arrange the composition of their staff to maximise their profits, seemingly at the expense of the residents, the very people whose families and loved ones have trusted to care for them!
As a GP with a very frail elderly mother in care for the last 2 years, and one who has been involved in assisting with the care of well over 100 ACF residents in my role as a locum in my home town, my observations are soundly based in reality. Pretty buildings they may be, but places of loving care they are fast failing to br. Committed caring staff are becoming burnt out, stressed and depressed, then leaving the arena because they have lost the joy of work they once had.
If the reguations on staffing, and the funding to support these levels, are not returned, it is those who must use these facilities for their last days who will suffer.
Editor’s note to Anonymous re conflict of interest:
Dr Judd’s affiliation with HammondCare is clearly stated, so I do not understand your objection. This isn’t an academic paper presented in the MJA, it is a news story published in an open forum website, and therefore we present a balance of opinions, to the best of our ability.
The comment (number 5 above) is the most sensible that I have read on the topic for some time.
Everyone is going to die of something eventually, so there will always be conditions which statistically are common causes of death. This does not necessarily imply that health care is deficient. As modern medicine manages to better treat previously life threatening conditions (such as cardiac causes) then people will die as a result of other physiological changes of ageing.
I have come across people in residential aged care, perfectly competent to give informed consent, who longed for a normal cup of tea. However they were forced to drink thickened beverages because of a high risk choking assessment. Surely if such a person (or their legally responsible relative) accepts the risk of choking/aspiration (leading to a relatively quick death) then they should be allowed to drink whatever they like! What right do we have to impose our wishes just because of medicolegal concerns?
If someone of great age is anorexic and losing weight, this is not necessarily a reason to blame to carers.
Currently when a person enters residential care, they surrender autonomy- they can’t even self administer paracetamol when they wish!
This seems particularly odd given society’s increasing wish to legalise euthanasia. Maybe there should be an option somewhere between overly protective, restrictive risk avoidance and euthanasia: the choice to eat and drink and move around as one wishes, and to live or die with the consequences.
The comment (number 5 above) is the most sensible that I have read on the topic for some time.
Everyone is going to die of something eventually, and there will always be conditions which statistically are common causes of death. This does not necessarily imply that health care is deficient. As modern medicine manages to better treat previously life threatening conditions (such as cardiac causes) then people will die as a result of other physiological changes of ageing.
I have come across people in residential aged care, perfectly competent to give informed consent, who longed for a normal cup of tea. However they were forced to drink thickened beverages because of a high risk choking assessment. Surely if such a person (or their legally responsible relative) accepts the risk of choking/aspiration (leading to a relatively quick death) then they should be allowed to drink whatever they like! What right do we have to impose our wishes just because of medicolegal concerns?
If someone of great age is anorexic and losing weight, this is not necessarily a reason to blame to carers.
Currently when a person enters residential care, they surrender autonomy- they can’t even self administer paracetamol when they wish!
This seems particularly odd given society’s increasing wish to legalise euthanasia. Maybe there should be an option somewhere between overly protective, restrictive risk avoidance and euthanasia: the choice to eat and drink and move around as one wishes, and to live or die with the consequences.
My 95 year old mother spent her last 6 months in an excellent aged care facility. The nursing staff recognised that she was frail and at high risk of falling when getting out of bed alone to go to the ensuite toilet. So they placed a special mat at her bedside which would alert the duty staff when she got out of bed. She hated the intrusion into her life and privacy so would crawl down to the end of the bed and struggle out over the end of the bed. When she explained this to me, I asked the staff not to use the mat. They insisted that it was policy and refused to accede to her request and remove the mat. So she continued to struggle to avoid the mat. She was fully aware of her situation, had an advanced directive and was on the books of the palliative care service. Had she sustained a fractured neck of femur she would have refused active treatment.
The most fundamental problem underpinning the management of people of great age who are in “high care” is that we have never really investigated and described the physical, psychological and spiritual history of dying at a great age. Death at a great age is a normal physiological process, not something pathological. We thus have no coherent and agreed framework for defining good care. It is equivalent to trying to manage childbirth without understanding the natural history of this entirely normal process at the other end of the life cycle.
Falls are a part of the natural biological process of many people of great age; in some cases, they mark the beginning of the end of life’s biological journey. If a fall is described as an “accident”, then by definition the fall was “preventable”. Then the person “responsible” for not preventing the accident is blamed. So we create the cycle of restraint and other “preventative” activities to protect the staff.
We need to recognise that a failing musculoskeletal system is conceptually no different from cardiac, respiratory or cerebral failure or failure of any other organ system. The great aged and their caring family members must be involved in a comprehensive rational discussion of these issues so an appropriate individualised care plan can be developed with the care staff. This might well involve discussion of the possibility and serious consequences of a fall and how this might be a rather gentle final pathway to death. Personally, I think that a fractured neck of femur followed by immobilisation and good palliative care leading to death by DVT, PE and bronchopneumonia over a few days would be a far preferable way to leave this life than to be kept alive by endless poorly conceived “preventable” measures.
Some years ago, I attended a national RACGP conference. A session on caring for the advanced aged was opened by a leader from the residential aged care sector who stated “We do not want our facilities to be seen as places where people come to die.” This is about as illogical as the director of a palliative care hospice saying the same thing. Dying at the end of very long life is only different from dying earlier from cancer in that the process is often more protracted and less predictable. The principles of good management should be the same.
We must recognise that these facilities are places where residents eventually die. We need them to operate from a model of palliative care designed for the great aged that provides excellent quality care with fully informed collaboration with the patient and family.
Catherine Sharp it costs $20.90 average? Does that include overnights? Second staff member for toilet breaks? Workcover, super, leave loading, sundays? Your suggestion even at the ludicrously low rates you claim equates to $183 960 per annum per patient. Indeed if your plan was applied to just 3000 residents Australia wide it would cost 5.5 billion. Who is going to pay? Basically you are suggesting ICU 1 to 1 nursing care. I do wish the editors would review these suggestions.
“However, he said, better care would not come through greater regulation but through market competition.”
The guy is conflicted to his eyeballs, and shouldn’t therefore be given airtime to comment. How could MJA InSight not see the conflict of interest?
Consider using a volunteer sitter program for patients who have a high risk of falling. High risk patients should have somebody with them 24 / 7… they should never be left alone.
See ”Preventing Falls and Harm from Falls in Older People: Best Practice Guidelines for Australian Hospitals 2009 Australian Commission on Safety and Quality in Health Care (ACSQHC).”
The average wage for an Aged Care Worker in New South Wales is AU$20.90 per hour. It would cost about $504 for 24 hours of care (much cheaper than a # femur, brain bleed, surgery, death etc etc).
I have a family member in an Aged Care Facility who has had several falls and fractures.
The use of restraints is not the answer because the problem is multifactorial.
The data may be flawed due to greater reporting to the coroner compared to earlier etc.
The posed question is in the negative – this may be a problem and produce an invalid response.