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Hospital or not: goals of care and hospital avoidance

Residents & families GPs & clinicians Facility leadership 7 min read

By Dr Josh Hatch, FRACGP

For an acutely unwell resident, hospital can offer tests and treatment the facility cannot, and it carries risks of its own 28. The right choice depends on what is wrong, what hospital could add, what the facility can provide, and above all what the resident wants. This page is about acute illness at any stage; transfer near the end of life has its own page in the palliative care section.

Numbers in the text link to the 9 sources listed at the foot of this page.

What happens to residents who go to hospital

A 2014 systematic review of residents transferred to emergency departments found that they often arrived severely unwell with several problems at once. Pressure injuries were reported in 19% and delirium in 38%, up to 80% had potentially invasive procedures, and up to 34% died in hospital 28. The authors concluded that it was not clear whether the benefits of hospital emergency care outweighed the harms of transfer 28. These were observational studies of residents who were often very sick, so they show what happens, not what would have happened had they stayed.

The national quality indicator

The national quality indicators include hospitalisation, reported each quarter as the percentage of residents with one or more emergency department presentations, and with one or more presentations or hospital admissions 6. The program’s guide says excessive transfers may indicate poor care quality and access, and that many presentations and admissions are avoidable with timely access to appropriate care 6.

In its trend analysis to October–December 2025, the national quarterly report found a statistically significant increase in both hospitalisation measures 7.

Treating in place and hospital avoidance: the evidence

Graded on randomised evidence for hospital transfer, with deaths and wellbeing as the balancing outcomes.

A structured pathway to treat chest infection in the nursing home

Promising, not yet proven

Fewer hospital admissions with no difference in deaths, in one Canadian trial.

The evidence

Admissions fell from 22% to 10% among 680 residents in 22 nursing homes; deaths were 8% against 9% 21.

In practice

The pathway used close monitoring by a research nurse 21.

Nurse-led emergency department outreach with video consultation (New South Wales)

Uncertain / conflicting

A 29% fall in emergency presentations that was not statistically significant.

The evidence

A stepped-wedge cluster randomised trial in 16 facilities added video consultation to a weekday telephone outreach service. Presentations during service hours fell by 29%, but the confidence interval included no effect. A post hoc analysis was significant 30.

Staff training in an acute-change toolkit (INTERACT)

Not supported

No change in hospital admissions or emergency visits in 85 US nursing homes.

The evidence

Training and implementation support had no significant effect on all-cause admissions or emergency visits 11.

Australian services and non-randomised evidence

In Sydney, a program combining advance care planning with hospital-level care delivered in the nursing home was compared with a separate area. Ambulance calls from intervention homes changed little (down 1%) while they rose 21% in control homes, and the use of hospital beds by residents fell by about a quarter 29. This was a controlled evaluation, not a randomised trial 29.

In Queensland, residential aged care acute support services (RaSS) give phone advice when a resident becomes unwell, can send specialist nurses or doctors to the facility to give care that would otherwise happen in an emergency department, and hand over to the emergency department if transfer is needed 31. The Queensland program that preceded RaSS estimated that 1,522 emergency presentations and 2,329 admissions were avoided; this was a service estimate, not a trial 31. Services and hours differ by region 32.

Questions that help the decision

  • What is the likely problem?. And how certain is that? Some diagnoses need a test only hospital can do.

  • What could hospital add?. A scan, surgery, a procedure or treatment that cannot be given in the facility.

  • What does the resident want?. What they have said, what their advance care plan says, and what their substitute decision-maker understands of their wishes.

  • Can the facility manage overnight?. Monitoring, fluids, oxygen, medicines, and a doctor or outreach service who can be reached.

  • What would change the plan?. Agreeing on this in advance makes a 3 am decision easier.

Related pages on this site

Sources cited on this page

  1. 6 Australian Government Department of Health, Disability and Ageing. National Aged Care Mandatory Quality Indicator Program: quick reference guide, hospitalisation. (Undated; published October 2025.) View source
  2. 7 Australian Institute of Health and Welfare, GEN Aged Care Data. Residential aged care quality indicators — October to December 2025 (released 23 April 2026; 2,575 homes; trend analysis over 18 quarters from July–September 2021). Reported quarterly; later quarters are published on the same page. View source
  3. 11 Kane RL, Huckfeldt P, Tappen R, et al. Effects of an intervention to reduce hospitalizations from nursing homes: a randomized implementation trial of the INTERACT program. JAMA Intern Med. 2017;177:1257–64. (85 US nursing homes, 36,717 residents.) View source
  4. 21 Loeb M, Carusone SC, Goeree R, et al. Effect of a clinical pathway to reduce hospitalizations in nursing home residents with pneumonia: a randomized controlled trial. JAMA. 2006;295:2503–10. (Cluster randomised; 680 residents in 22 nursing homes in Hamilton, Ontario.) View source
  5. 28 Dwyer R, Gabbe B, Stoelwinder JU, Lowthian J. A systematic review of outcomes following emergency transfer to hospital for residents of aged care facilities. Age Ageing. 2014;43:759–66. (Observational studies.) View source
  6. 29 Caplan GA, Meller A, Squires B, Chan S, Willett W. Advance care planning and hospital in the nursing home. Age Ageing. 2006;35:581–5. (Controlled, non-randomised evaluation; 21 intervention and 13 control nursing homes in Sydney.) View source
  7. 30 Sunner C, Giles M, Ball J, et al. Implementation and evaluation of a nurse-led intervention to augment an existing residential aged care facility outreach service with a visual telehealth consultation: stepped-wedge cluster randomised controlled trial. BMC Health Serv Res. 2023;23:1429. (16 facilities in two New South Wales local health districts.) View source
  8. 31 Clinical Excellence Queensland, Improvement Exchange. Residential aged care facility acute care support service (RaSS). (Published 9 August 2019; status listed as sustained.) View source
  9. 32 Queensland Health. RaSS telephone triage contacts for registered nurses, clinical managers and GPs. (Last updated 20 April 2022.) View source

See every source cited across the deteriorating resident section →

Written by Dr Josh Hatch, FRACGP. General information only, reflecting his reading of the published evidence as at November 2026. It is not individual medical advice, does not create a doctor–patient relationship, and must not be used to start, stop or change any treatment, and it does not set escalation rules for any facility. Antibiotic choices and doses follow current prescribing guidelines and local advice. Evidence, Australian regulatory requirements and local services change — always confirm current advice with the treating GP and the facility’s own procedures.

This is general education, not a clinical protocol. The doctors who practise with Umbrella Aged Care are independent general practitioners, and each makes their own clinical decisions with the resident and family. Your GP’s advice for an individual may differ from what is written here. If it does, please ask them to talk it through with you.

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