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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