Reconsidering Hospital Transfers from Residential Aged Care: A Scoping Review of Determinants, Prevalence, and System-Level Solutions in Australia

Murphy, Emma-Kaitlin; Cardona, Magnolia; Dixon, Caitlin; Fien, Samantha; Ní Chróinín, Danielle; Lewis, Ebony T.

doi:10.3390/hospitals3020013

Abstract

To identify the determinants, prevalence, and proposed solutions for potentially avoidable hospital transfers (PAHT) of residential aged care facility (RACF) residents in Australia, a scoping review was conducted using PubMed, CINAHL, Cochrane Library and Google Scholar, covering the period from 2015 to 2025. The database search identified 1350 articles, of which 43 studies met inclusion criteria. Prevalence of PAHT ranged from of 8.5% to 95.2% when defined as specific conditions manageable by an outreach service; from 2.2% to 55.6% when defined as potentially manageable with primary care; and from 11.6% to 53% when defined as an Emergency Department (ED) presentation not requiring a hospital admission. The most frequently reported determinant of PAHT pertained to the overarching theme of RACF clinical decision-making and systemic RACF practice-based factors. Establishment of, and access to, outreach services was the main proposed solution, alongside onsite General Practitioners (GP), Advance Care Planning (ACP), and capacity building for RACF nurses. Despite Australia’s diversity, our findings demonstrate patterns and similarities in prevalence, determinants and solutions. Consensus or standardisation of denominators would enhance comparability of outcomes across studies. These findings offer opportunities to reconsider solutions in response to the chronic challenge of avoidable nursing home patient transfers.

Keywords:

hospital; patient transfer; aged care; nursing homes

1. Introduction

As life expectancy increases, the proportion of older adults is rapidly growing worldwide, and this demographic shift is intrinsically linked to multimorbidity, functional and cognitive decline, and increasingly complex healthcare needs [1]. Residential Aged Care Facilities (RACFs) provide an essential environment where supported living is achieved outside of hospital.

RACFs offer homelike comforts with personal touches, shared living, and dining spaces, unlike a clinical environment which can be sterile and impersonal. However, in the event of a RACF resident’s acute deterioration of health, the residential-style living environment means RACFs are often ill-equipped in terms of staffing ratios or expertise and equipment [2] to respond to such situations, often resulting in a hospital transfer. Hospital transfers can be planned and unavoidable. However, there are many occasions where a change in a resident’s health status results in a hospital transfer that could potentially be managed within the RACF [1], which we term potentially avoidable hospital transfers (PAHTs). Examples may include a blocked indwelling catheter, post-fall assessment without critical injury, urinary tract infections without severe sepsis or delirium, or uncomplicated hyperglycaemia [3,4]. The Australian Institute of Health and Welfare [3] defines potentially preventable hospitalisations as conditions that are manageable through the provision of early chronic condition management and robust primary healthcare.

However, defining what constitutes a PAHT is challenging, as it can depend on clinical judgement, available equipment, medical support, and individual resident/family preferences. Terms like “preventable,” “avoidable,” and “unnecessary” are used interchangeably throughout studies, complicating efforts to measure and reduce such transfers [1]. Central to discussions of PAHTs is ensuring older adults are not deprived of appropriate, timely, and optimal care. This requires the availability of goal-concordant and accessible alternatives to hospital care if transfer is to be avoided.

Older adults living in RACFs experience higher levels of dementia, frailty, and medical complexity compared to the wider community [5]. Hospital environments are known to present higher risk of consequential health outcomes for this population, including exacerbated risk of falls, delirium, emotional/physical distress, and other iatrogenic harm [5]. Impaired cognition and poorly defined or low-uptake of goals of care (GOC) documentation contribute to the persistence of hospital transfers for RACF residents, which can result in aggressive investigation and management that may be incongruent with individual wishes [6]. In Australia, this is particularly relevant in light of the new Aged Care Act 2024 which commenced 1 November 2025 [7]. This Act takes a rights-based approach to individualised care emphasising resident’s right to exercise choice and control in the planning and delivery of their healthcare services. Embedded in the Act are the Statement of Rights which recognises the RACF residents’ rights to independence, informed decision -making, and equitable access to services. This is highly relevant to PAHTs among RACF residents, as many transfers are associated with gaps in care and communication.

The associated risk of hospital transfers for RACF residents has led to international exploration of alternatives, including but not limited to investment in early identification and management of acute changes in residents’ health, greater utilisation of primary healthcare, robust Advance Care Planning (ACP), and acute outreach services (a broad model of care in which clinicians assess and treat residents within the RACF, often described interchangeably as in-reach or hospital-avoidance services) [1,5,6]. Despite the international evidence supporting effective solutions, synthesis of the extent of the problem and of interventions designed to respond to and reduce PAHT in Australia remain a gap in the literature. This gap underscores the significance of understanding the Australian context, where the scale of hospital transfers is considerable. In 2018–2019, 36.9% of older Australians living in RACFs experienced at least one Emergency Department (ED) transfer [8]. However, prevalence and determinants of avoidable transfers remain unclear. Therefore, the objective of this study is to fill this gap by interrogating and synthesising studies across Australia to (1) identify and describe the prevalence and determinants of PAHT, and (2) identify and describe solutions to optimise health outcomes of Australian RACF residents requiring unplanned care. The overarching aim is to stimulate discussion on whether recent interventions are effectively addressing avoidable transfers, or whether strategic reconsideration is warranted to achieve meaningful outcomes for residents.

2. Materials and Methods

A scoping review of the available literature was deemed appropriate, as it enables the identification of knowledge gaps and recommendations for future practice and research [9]. Our protocol was registered in Open Science Framework (OSF) on https://osf.io/vzt93/overview?view_only=c453b362f7914154b5b9e4b69bf929ce (accessed on 12 March 2025).

2.1. Eligibility Criteria

A publication date range of 2015 to 2025 was chosen to ensure a contemporary overview of data and patterns. Included studies were required to be published in the English language and within the Australian context. In brief, Australia comprises six states and two territories and is a mix of urban, regional, and remote areas with most people living in coastal urban regions. New South Wales (NSW) accounts for 31.8% of the national population followed by Victoria (VIC) and Queensland (QLD), while the Northern Territory (NT) has the smallest population and greatest pockets of remoteness [10].

All qualitative, quantitative, and mixed-methods studies were included, if they provided quantification or description of either (a) determinants of PAHT, (b) prevalence of PAHT, or (c) solutions proposed by the study participants and/or the authors of the included studies. In the context of our study, the population had to focus on older adults living in RACFs or titular equivalents (e.g., nursing home). “Older” was defined as per descriptors used by the authors of eligible studies, and this could be an age range, e.g., 60 years or above, or termed elderly, older, aged.

Opinion pieces, editorials, and studies without information on outcomes of interest were excluded. In addition to modelling exercises, conference abstracts, study protocols without results, research letters, and letters to editors were excluded. For more details of the inclusion criteria, see OSF for the protocol. We deviated from the original protocol by including two additional data sources, Cochrane Library and Google Scholar, which enhanced the breadth and depth of the evidence base. Cochrane Library returned no eligible records, and Google Scholar returned 100 records; all were either duplicates of records already identified or did not meet the eligibility criteria. No additional studies were included following the addition of these sources to the search strategy. Their inclusion therefore served as a confirmatory check, supporting the comprehensiveness of the primary database search. Consistent with scoping review methodology [9], a formal critical appraisal of individual studies was not undertaken. The included studies nonetheless varied considerably in design, data sources, and operational definitions of avoidability. This methodological variability means the strength of the evidence base is uneven, and findings, particularly prevalence estimates, should be interpreted with this in mind.

2.2. Databases and Search Strategy

An advanced keyword search of Pubmed, CINAHL, Cochrane Library and Google Scholar was conducted in June 2025, covering the period from 2015 to 2025. The search strategy was developed by (EKM) and subsequently validated by University of New South Wales librarian (HJ). Key search terms and MeSH terms were utilised based on four domains: “potentially avoidable hospital transfer”, “residential aged care”, “determinant”, and “Australia” (see Appendix A for full search strategy).

2.3. Screening Process and Study Selection

Following the search, all identified citations were uploaded to EndNote v21.5 for duplicate removal, then uploaded to Covidence (Veritas Health Innovation 2024) for independent title and abstract screening by paired reviewers (EKM, CD, MC, ETL) against our predefined eligibility criteria. During the second stage, (EKM) independently reviewed full-text articles and reasons for exclusion were recorded. Any discrepancies throughout the screening stages were reconciled by a third reviewer.

2.4. Data Extraction Process

Data extraction was conducted by two authors (EKM, CD). The creation of three purpose-built tables allowed for the capture of study characteristics, prevalence of PAHT, and drivers and solutions of PAHT. Prior to commencing data extraction, a small sample (n = 5) of test papers were used to pilot the extraction forms. Study characteristic data extracted included location, setting, sample size, and hospital avoidability criteria (as defined by the authors of the study). The prevalence table captured data on study numerator, denominator, and actual estimate of PAHT, accompanied by the author’s adopted definition or criteria of avoidability. The third table comprised a two-column narrative table that identified drivers and proposed solutions of PAHT.

There was no use of generative artificial intelligence at any stage of this paper.

3. Results

Our database search produced 1350 articles including 345 duplicates; 99 underwent full-text review, including 3 articles that were found through hand searching. A total of 43 studies met the inclusion criteria and are the subject of this review (see Figure 1). The included studies were conducted in six states and territories (from a total possible eight) covering a combined population of 344,583 Australian RACF residents, clinicians, and family members.

Figure 1. Search results, screening process, and reasons for exclusion (PRISMA diagram).

3.1. Study Characteristics

Of the 43 included studies, 23 were quantitative, 13 qualitative, and seven mixed-methods. The majority of studies were conducted in NSW [11,12,13,14,15,16,17,18,19,20,21,22,23] (n = 13) and VIC [24,25,26,27,28,29,30,31,32,33,34,35] (n = 12), while five studies were conducted across multiple states (NSW, QLD, VIC, South Australia (SA), and Western Australia (WA)) [36,37,38,39,40,41,42]. Every multistate study included NSW; therefore, NSW was represented in 46.5% (n = 20) of all studies. Most studies were conducted exclusively in metropolitan or urban settings (n = 22, 54%), with only 9% focusing exclusively on regional or rural areas. A further 23% included both metropolitan and rural settings, while 14% did not report study setting.

Each study’s outcome/s of interest were categorised into three domains, with some studies reporting on more than one domain:

Determinants: 25 studies (n = 12 quantitative, n = 9 qualitative, n = 4 mixed methods) identified driving factors contributing to PAHT.
Prevalence: 24 studies (n = 19 quantitative, n = 5 mixed methods) quantified the prevalence of PAHT based on the authors’ operational definition.
Solutions: 31 studies (n = 16 quantitative, n = 10 qualitative, n = 5 mixed methods) proposed solutions and services aimed at reducing PAHT.

A more detailed overview of study characteristics can be seen in Table 1.

Table 1. Study characteristics of potentially avoidable hospital transfers in Australia (n = 43).

3.2. Definition of Potentially Avoidable Hospital Transfers

Although all studies reported some form of preventable, avoidable, or unnecessary hospital transfer, only 25 explicitly defined avoidability. Most defined avoidability as (1) clinical situations or conditions manageable within RACFs with outreach services or interventions (n = 15) [11,12,13,17,20,22,25,26,30,31,38,40,43,46,47]; six [15,16,33,34,39,53] as (2) conditions manageable within RACFs with robust support and continuity of primary care delivered by a GP or Nurse Practitioner (NP); or (3) presentations to ED not requiring hospital admission [28,29,32]. One study defined avoidability as ambulance attendance without ED transfer [49]. See Appendix B for detailed operational definitions.

3.3. Prevalence of Potentially Avoidable Hospital Transfers

PAHT prevalence was synthesised using each study’s operational definition of avoidability, with state-based comparisons when feasible (Appendix C).

Data sources to quantify PAHT prevalence differed. Most [15,28,29,30,31,32,33,34,43,46] solely utilised hospital/ED data (n = 10), or a combination hospital/ED and the hospital-avoidance or outreach service of interest (n = 6) [11,12,13,20,25,26]. Other data sources included RACF databases (n = 4) [38,40,49,53], ambulance service data and Registry of Senior Australians data (n = 2) [39,42]. Single studies used a combination of hospital/ED and RACF data [37], state mortality data with hospital/ED (n = 1) [16], administrative data (n = 1) [47], hospital-avoidance service data only (n = 1) [17], and one study [22] did not report its data source.

Prevalence of PAHT ranged from 8.5% to 95.2% when defined as specific conditions manageable by outreach services; 2.2% to 55.6% when defined as manageable within RACF with primary care; and 11.6% to 53% when defined as ED presentation not requiring a hospital admission. A summary of definitions, denominators, and prevalence estimates is presented in Table 2 to facilitate cross-study comparison.

Table 2. Summary of avoidability definitions, denominators and prevalence of PAHT (n = 25).

3.3.1. Manageable by Outreach Service/Programme/Intervention

Fifteen studies (NSW, VIC, QLD, SA) quantified prevalence by evaluating interventions to reduce RACF to hospital transfers. Two studies [43,46] analysed the same intervention study of Hospital in the Nursing Home (HiNH) over the same study period, reporting the same results, and are therefore reported together (see Appendix C).

Avoidability varied widely across these fifteen studies (range 8.5–95.2%). The largest sample size (n = 4329) in this category was a quantitative study in Victoria by Street et al. [31], which examined hospital transfer rates pre- and post-implementation of an outreach service, reporting an 11% reduction in transfers. The highest reduction in PAHTs was reported in a NSW study by Huang et al. [17] with a total sample size of n = 438 episodes of care (n = 270 face-to-face care and n = 168 telemedicine) delivered by the Acute Geriatric Outreach Service, which successfully managed n = 248 residents (91.9%) face-to-face and n = 160 (95.2%) via telemedicine.

Only two interventional studies found no effect on PAHT rates. One NSW study [13] (n = 1289) reported that the Clinical Nurse Consultant-led Aged Care Emergency Service (ACE) resulted in no significant change (p = 0.56) on RACF residents presenting to ED. Similarly, the IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) [40] study with a sample size of n = 1304 RACF residents across NSW, QLD, and SA found no effect on the rate of unplanned ED transfers.

3.3.2. Manageable in RACF with Primary Care

Of the six studies defining PAHT as a condition manageable within RACFs with primary care, only one study (VIC) [34] reported more than 50% of presentations as avoidable. The largest sample size (n = 146, 963) in this category, a multistate (NSW, VIC, QLD, SA) study by Harrison et al. [39], found 14.5% of presentations to be potentially preventable through primary care provision within RACFs.

3.3.3. Not Requiring Hospital Admission

Three Victorian studies defined avoidability as ED presentations not requiring hospital admission [28,29,32]. One study [29] found greater than 50% of all presentations not requiring admission to be PAHT, while the other two studies reported PAHT prevalence below 40%.

3.4. Drivers of Avoidable Transfers and Proposed Solutions

As seen in Table 3, 25 studies from across NSW, VIC, QLD, Australian Capital Territory (ACT), and WA identified 35 individual drivers or determinants. A total of 31 studies across NSW, VIC, QLD, ACT, WA, and SA identified 33 individual solutions to reduce PAHT. Across studies, drivers were not equally represented with most categorised into the domain of clinical decision-making complexity and systemic RACF practice-based factors, while the most frequently reported solutions were in response to limited access to ongoing support.

Table 3. Drivers (n = 25) * and proposed solutions (n = 31) * of potentially avoidable hospital transfers.

The identified drivers and solutions of PAHT were categorised into seven main domains: clinical decision-making complexity, low clinical confidence, RACF policy-based factors, systemic RACF practice-based factors, limited access to ongoing support, health system attitudes, and family expectations (see Figure 2).

Figure 2. Overarching domains of potentially avoidable hospital transfers.

3.4.1. Clinical Decision-Making Complexity

Mentioned in 18 studies across NSW, VIC, QLD, WA, SA and the ACT, the evidence for these findings was drawn from a combination of author interpretations supported by quantitative data and qualitative interviews or surveys with RACF staff and residents’ families. The inherent complexity of the clinical decision-making process faced by RACF staff [24,27,42,49] was the main driver within this domain, identified by 25% (n = 4/16) of studies, followed by the fear of consequences arising from incorrect intervention decisions (n = 3) [23,44,49]. Other drivers identified within individual studies included inexperience among RACF Registered Nurses (RN) [21], poor recognition of resident deterioration [44], delayed identification of end of life (EOL) [21], lack of formal ACP [24,34], and poor differentiation between conditions requiring hospital-level care and those manageable within the RACF [30].

The most commonly proposed solution for this domain was the utilisation and availability of acute outreach services, proposed by RACF and outreach service staff in addition to residents’ families and supported by quantitative data of existing outreach services. This solution was suggested in eight studies [17,19,21,24,30,31,43,49] and included both onsite and telehealth support from GPs, NPs, Geriatricians, and ED nurses. The second most common solution was the implementation of robust and up-to-date ACPs [11,24,26,36,37,51] to support individualised decision-making in management of acute illness and injury (NSW, VIC, QLD, WA, SA, ACT).

3.4.2. Low Clinical Confidence

The most consistently reported driver in this domain (by three studies) [11,27,36] representing five states (VIC, NSW, QLD, WA and SA) identified low clinical confidence in assessment and management skills as a contributing factor to PAHT. In a mixed-methods study by Conway et al. [11], interviews and focus groups with RACF and ED staff identified lack of confidence among RACF RNs in performing clinical skills as a contributor to PAHT. Additional determinants identified by RACF, ED and outreach service staff and GPs included minimal support for RACF RNs in clinical decision-making [44,45] and RACF staff feeling out of their depth caring for acutely unwell residents [23].

The most commonly proposed solution to enhance clinical confidence, supported not only by participants in the primary studies but also by quantitative evidence, was the use of outreach services. These services provided clinical advice [11,17,31,37], onsite support and management of deteriorating residents [19,24,44], clinical education [11,44], and capacity-building for RACF staff [21,30,43]. Several studies also proposed evidence-based clinical care protocols, decision guides and escalation pathways to support clinical decision-making [11,37,44,53].

3.4.3. RACF Policy-Based Factors

Six studies identified specific policy as a driver of PAHT. RACF RNs and GPs in NSW identified local RACF policy that preclude nurse-initiated medications and does not support onsite management of acutely unwell residents [23] as a determinant of PAHT. Similarly, in VIC RACF staff reported that local policy inhibits many RN-level skills, such as troubleshooting indwelling catheters and administering nurse-initiated medications [27]. Qualitative interviews with RACF staff indicated that specific policies governed their decision-making, often resulting in hospital transfer irrespective of resident wishes or staff capability to provide care [27]. In addition, RACF, ED and outreach staff, along with local GPs, identified inconsistently completed and often contradictory GOC documentation as a determinant of PAHT [11,24,27,53]. For example, family requests for hospital transfer sometimes conflict with residents predefined wishes to remain in the RACF [11].

RACF managers, RNs and care staff in the ACT also reported inadequate policy guidance for identifying and managing the palliative care requirements of residents [50]. Proposed policy-based solutions included consulting evidence-based protocols and resident-informed GOC when considering hospital transfer [11,13,53], as well as engaging outreach services to provide support and equipment that enable the management of acutely unwell residents within the RACF environment [12,25].

3.4.4. Systemic RACF Practice-Based Factors

Of the ten studies reporting on determinants in this domain, 60% (30% qualitative, 20% quantitative and 10% mixed-methods) [11,23,27,28,36,49] reported RACF workforce issues, including poor skill mix, inadequate staffing levels, and a lack of specialised RACF RNs to initiate and manage acute clinical changes. Three studies [27,28,36] identified RACF RNs working in isolation as a determinant of avoidable transfers, limiting collaborative decision-making and confidence. Lack of anticipatory EOL medications or ward-stock availability during sudden deterioration [35] was identified as another contributor of PAHT, in addition to polypharmacy [36,42]. Two quantitative NSW studies identified the absence of follow-up after hospital discharge [22] and lack of physiotherapists in RACFs [16] as contributing factors.

The most frequently proposed solution to address these systemic challenges was increased availability of medical support and outreach services, particularly after hours, as reported in eight studies (NSW, VIC, QLD, WA, and SA) [13,17,24,25,28,31,37,45].

3.4.5. Limited Access to Ongoing Support

A multifaceted lack of support for RACF RNs was identified across ten studies (50% qualitative, 40% quantitative and 10% mixed-methods). This included delayed access to GPs, NPs, geriatricians and palliative care teams in NSW and VIC [15,24,28]; poor continuity of, and access to, primary care services in VIC and QLD [33,34,45]; inadequate inter-sector information sharing between RACFs, ambulance services and ED across NSW, VIC, QLD, WA and SA [14,25,36,45]; and limited availability of outreach services during after-hours and weekends, identified in one study from NSW [21].

The most commonly proposed solution (n = 4) to address this lack of support was the implementation of an onsite RACF GP. One qualitative study [45] described QLD RACF RNs’ experiences including a reduction in unnecessary hospital transfers that occurred when GP support increased, while three quantitative studies supported this solution [33,34,38]. One multistate study (VIC, QLD, NSW) [38] demonstrated the impact of a new RACF model of care employing GPs as staff members; another (VIC) [33] found that a large proportion of ED presentations involved issues that could be managed within the RACF with primary care; and a third (VIC) [34] study found that RACF residents not assessed by a GP were more likely to present to ED than those who were. Another commonly suggested solution was improved access to comprehensive outreach services, including extending operation hours [21], hospital-in-the-home style interventions such as intravenous treatments [12,25], and increased clinical support for RACF staff [25,28].

3.4.6. Health System Attitudes

The most reported driver was noted by four studies (n = 2 quantitative, n = 1 mixed methods, n = 1 qualitative) and identified poor inter-sector recognition and understanding of the unique care context and barriers faced across the RACF setting [11,13,14,25]. For example, a qualitative study of QLD RACF staff perceptions highlighted poor recognition of RACF RNs as professionals, with some feeling they were labelled as incompetent [45], while in NSW, RACF staff reported feeling a lack of respect from ambulance and ED staff [23].

Four qualitative studies using interviews and focus groups with RACF RNs, GPs, and ED RNs across NSW and QLD proposed solutions to address health system attitudes. These included utilising outreach services to bridge gaps between RACF and ambulance/ED staff through clinical support [44,45] and enhancing communication and positive working relationships [23,45]. Additionally, a NSW-based study found that ED-led virtual telehealth support for RACF staff during acute situations helped build inter-sector trust and relationships [19].

3.4.7. Family Expectations

Family pressure on RACF RNs to initiate hospital transfers was identified as the main contributing factor to PAHT reported by five studies (n = 3 quantitative, n = 2 qualitative) [24,26,36,49,53]. In the context of palliative care, a mixed-methods study conducted in NSW [15] observed families’ poor understanding of EOL trajectories and overruling of ACPs during the terminal phase of a resident’s life. In VIC, the absence of predefined individual wishes, often due to incomplete ACP documentation, was identified as a determinant of PAHT [35]. Conversely, a discrete choice experiment found that RACF residents, families, and staff share an underlying preference for hospital transfer in certain situations, such as pneumonia [41].

Proposed solutions included early and robust GOC discussions with residents and families, alongside completion of ACP documentation, as recommended by two mixed-methods studies involving RACF RNs, assistants in nursing, NPs and GPs [15,26]. Outreach services capable of providing ED-equivalent investigations and treatments within the RACF were also recommended in two studies [41,44].

4. Discussion

In this scoping review synthesis of 43 studies reporting on determinants, prevalence, and proposed solutions of PAHT among RACF residents in Australia, we identified three main sources of avoidable hospital transfers: those amenable to management by outreach services, those manageable onsite with primary care, and those not warranting hospital admission.

Multi-level interventions demonstrated effectiveness in reducing PAHT. Consistent evidence across five states and one territory, spanning both metropolitan and rural healthcare settings, supports the role of acute outreach services as a key mechanism for reducing avoidable transfers, with similar findings reported internationally [6]. The proposed solutions in this study align with the Australian Medical Association’s 2021 [2] recommendations to strengthen healthcare provision within aged care, including improved primary care access, telehealth utilisation and better interoperability between acute service, GPs and RACFs [2,54]. Given the demonstrated impact of outreach services, a national policy position is needed on whether RACFs should remain a non-acute care environment or evolve to incorporate aspects of acute care.

The provision of acute care in RACFs, supported by onsite GPs, Geriatricians, and/or continuity and expansion of outreach services, would ensure equitable access to acute care services for RACF residents. In Australia, aged care funding is divided between the Commonwealth contributing to the funding of RACFs and local State government funding the majority of outreach services. This funding arrangement creates fragmented programme delivery and gaps in continuity of care.

Our study reported an overall avoidability prevalence as a range from 8.5% to 95.2%, a variation driven largely by study methods and definitions of avoidability rather than true practice variation. In keeping with the global literature, our review found no consensus of definition for avoidability of hospital transfers from RACF [1,55]. Two dominant operational definitions emerged from our included studies: (1) conditions manageable in RACFs through robust primary care and early intervention, and (2) acute changes manageable in RACFs with support from acute outreach services. Although no consensus of a definition has been reached, similar concepts were identified in a 2016 review finding early detection and management within RACF to be one of the most common criteria for avoidability [56]. Heterogeneous definitions remain a major barrier to consistent measurement, complicating efforts to ascertain true prevalence and compare outcomes across facilities and jurisdictions. This lack of clarity is particularly salient, regarding significant investments in initiatives aiming to reduce hospital transfers, such as NSW Health’s HITH [54]. Without standardised definitions, comparing outcomes and measuring success across programmes will remain challenging.

On a larger scale, a 2019 systematic review of 77 studies [1] supports this view, reporting a wide PAHT prevalence (range 4–55%), attributed partly to the subjective nature of what is referred to as appropriateness of transfers. Conversely, in Australia, a study conducted in the ACT reported similar state-level prevalence, with Codde et al. [57] quantifying PAHT at 31% of RACF resident hospital presentations.

In attempt to consolidate our PAHT prevalence results and address definitional subjectivity, we reported our findings by avoidability criteria. However, even with this approach, we reported a wide prevalence range of PAHT, from 2.2% to 95.2% (across all avoidability criteria), suggesting that the complexity of PAHT extends beyond definitional subjectivity and reflects fundamental differences in system capacity, workforce skill mix and staffing, and integration of external services and support. This finding implies that PAHT is not solely a measurement challenge but an indicator of variation in the delivery of care. The wide range is likely to also be explained by the difference in study design (interventions, observational audits, pre/post comparisons), data sources (hospital records, RACF databases, outreach service data), studies focusing on specific conditions (e.g., falls or infections) rather than all cause transfers, and populations sampled (single-facility, multi-state, urban/rural).

Determinants and solutions were categorised into seven overarching themes, identifying 35 individual drivers and more than 30 solutions, and clearly demonstrating the complex multifaceted nature of PAHT. Most determinants reflect system-level barriers that preclude RACF staff from providing acute care within the RACF environment. Six studies explicitly identified RACF policy as a driver of PAHT, indicating that care could reasonably have been delivered within the RACF. These broad systemic drivers of PAHT, including insufficient equipment and clinical support to manage acute care needs of residents, are likely to have a causative effect on the low clinical confidence of RACF staff. This thematic approach offers a novel conceptualisation of PAHT drivers and solutions, contrasting with previous studies that utilised a single lens discussion of drivers, for example, falls as a specific clinical condition resulting in high prevalence of ED presentation [4]. Our approach captures the comprehensive interplay of system pressure, workforce capability and clinical complexity. Importantly, this synthesis shifts the framing of PAHT from being primarily condition-specific to a broader systems-level approach shaped by workforce capability, timely access of medical support, and organisational policy constraints. This conceptualisation highlights that the solution to PAHT requires coordinated system redesign in favour of isolated clinical interventions.

Many determinants speak to low clinical confidence and skill levels among RACF nurse. In hospitals, nurses respond to acute changes with immediate access to medical practitioners, providing direct consultation, coordination, and continuous clinical governance. In contrast, Australian RACF nurses operate without direct, ongoing medical oversight, with GP involvement often being episodic and delayed during acute deterioration [58]. Consequently, RACF nurses are often required to make complex clinical decisions without timely medical input. Our review found that improved GP continuity and timely medical support are proven solutions to PAHT, yet limited access remains due to GP availability and inconsistency of after-hours services [59]. While acute outreach services can mitigate these gaps, they do not address the underlying cause. This instead calls for supportive policy, robust education, and clinical support for RACF nurses to build capacity and uplift clinical capability and confidence of the RACF workforce. This is further supported by the Australian Medical Association’s 2021 [2] recommendations for stronger investment in RACF primary care and the Aged Care Royal Commission’s mandate for increased RACF workforce through care minutes [60].

Notably, no determinants explicitly identified resident choice as a driver of PAHT, although qualitative findings from Arendts et al. [41] indicated residents and families often preferred hospital transfer in certain clinical scenarios. Ten studies identified lack of ACP documentation as a contributor to PAHT, with three identifying that an absence of ACP can result in care misaligned with patient goals and wishes. These findings are particularly relevant in the context of Australia’s Aged Care Act 2024, the rights-based framework emphasising autonomy, informed decision-making, dignity, and person-centred care. The Act’s Statement of Rights reinforces older persons’ rights to participate in decisions regarding their care, including the choice of care that aligns with their preferences and values. In this context, inadequate ACP processes may compromise residents’ ability to exercise these rights, particularly during acute clinical deterioration. More broadly, the rights-based Act is highly relevant to PAHT among RACF residents, as avoidable transfers are frequently associated with gaps in timely clinical assessment, chronic disease management, communication, workforce capability, continuity of care, and access to appropriate onsite management. By positioning safe, high-quality, and person-centred care as a legal and regulatory obligation, the Act may influence clinical decision-making and hospital referral practices within RACFs by increasing expectations for comprehensive assessment, proactive care planning, and delivery of appropriate care within the residential setting where clinically feasible. However, these health reforms may currently fall short of associated funding to support aged care practice and policy but highlight the need for strengthened clinical governance, workforce capability, multidisciplinary collaboration, and ACP implementation to support residents’ preferences while reducing avoidable hospital transfers.

4.1. Future Research

The new Aged Care Act 2024, which commenced in November 2025, introduces a rights-based approach to individualised care. A key change is that RACF policy can no longer apply blanket rules and must instead support individualised care informed by good clinical judgement [7]. This reform is expected to influence clinical practice, while future research evaluating the outcome of this change would be valuable.

Beyond legislative reform, further research is needed to examine the practical realities of delivering acute care within RACFs. Significant gaps remain in understanding the long-term effectiveness and sustainability of outreach services, particularly in geographically diverse and rural and remote areas, and whether such services can complement or serve as a substitute for onsite medical practitioners. While outreach services are consistently identified as an effective strategy to reduce PAHT, their practicality and scalability are context-dependent. These services can be resource-intensive, requiring specialised clinicians, extended operating hours, access to diagnostic technology, and strong integration of primary and acute care. Such requirements may be feasible in metropolitan regions with established workforce capacity and infrastructure but pose significant challenges in rural and remote areas where workforce shortages, geographic reach, and limited after-hours coverage would constrain implementation. Sustainability and equity of access is further influenced by fragmented funding arrangements between aged care and health systems. Without careful consideration of workforce supply, funding models, and regional context, widespread scaling of outreach services might not be achievable at large scale despite demonstrated effectiveness.

The establishment of a national consensus or a set of clearly defined categories with associated indicators on what constitutes a PAHT in RACF would greatly enhance the accuracy of prevalence estimates and the evaluation of intervention effectiveness and cost-efficiency. A consensus would support the development of clinical protocols and resident-centred care, improve data quality across the healthcare sector, and reduce unwarranted variation. Finally, a public education campaign to inform families about the benefits and harms of burdensome transfers may reduce demand for acute services and improve trust in onsite nursing care for conditions that can be safely managed within RACFs.

4.2. Study Limitations

Notably, NSW and VIC are populous states with large metropolitan areas and were over-represented, while representation of WA, SA and ACT was poor, and there was no representation in Northen Territory or Tasmania. As a result, findings may not fully reflect healthcare landscapes across all Australia jurisdictions or internationally, given differing geographical and sociocultural environments. The lack of standardised avoidability criteria is likely to have reduced the accuracy of PAHT estimates. Along these lines, a major limitation of this evidence synthesis is heterogeneity across the included studies, arising from variation in definitions of avoidability, study design, data sources, and population profiles, which shaped how determinants of PAHT were identified and interpreted. Drivers such as clinical confidence, inter-sector relationships, and family expectations were found predominantly in qualitative studies, while quantitative studies more often highlighted structural contributors, including staffing levels and access to primary care, differences in state-based RACF policies, funding models, and availability of outreach services which also produced variations in results. Variation in participant groups (RNs, care staff, GPs, ED clinicians, families) further influenced the emphasis placed on certain determinants, especially regarding clinical decision-making complexity. All these contextual and workforce-related differences point to the need for nationally consistent data and policy frameworks to better understand and address PAHT.

Further, the voices of cognitively impaired residents were absent, and culturally and linguistically diverse (CALD) residents and families were represented in only one study. This gap warrants further exploration to ensure future interventions and policies are inclusive and address the needs of these underrepresented groups. As this review focused exclusively on the Australian context, the practical impact of the English-language restriction is likely to be minimal. However, we acknowledge that any non-English literature published in other languages relevant to CALD residents would not have been captured.

5. Conclusions

Across studies, consistent patterns emerged, particularly regarding the effectiveness of acute outreach services in supporting RACF staff to manage acute deterioration and reduce PAHTs. Key policy priorities should be supported with funding to support strengthening continuity of primary care in RACFs, innovative funding models, enhanced workforce capacity, interprofessional integration of health service tiers, and shared infrastructure, which might be needed to secure equitable access to outreach assessment and management services more widely in Australia. These efforts should be complemented by data collection, including capture of patient and carer experience measures, to enable accurate analysis of drivers, outcomes and associated costs. Standardisation of avoidability definitions and monitoring indicators may assist in ascertainment of unwarranted practice variation.

Author Contributions

Conceptualization, E.-K.M., M.C. and E.T.L.; methodology, E.-K.M., M.C. and E.T.L.; software, E.-K.M., M.C. and E.T.L.; validation, E.-K.M., M.C. and E.T.L.; formal analysis, E.-K.M., M.C. and E.T.L.; investigation, E.-K.M., M.C. and E.T.L.; resources, E.-K.M., M.C. and E.T.L.; data curation, E.-K.M., M.C., E.T.L. and C.D.; writing—original draft preparation, E.-K.M., M.C. and E.T.L.; writing—review and editing, S.F. and D.N.C.; visualization, E.-K.M., C.D. and S.F.; supervision, M.C. and E.T.L. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Data Availability Statement

The data supporting the findings of this study are presented in the appendices of this article.

Acknowledgments

We thank the University of New South Wales librarian Helen Jones for assistance with refinement of the search strategy. We also thank nurse JK for her contribution to the screening process.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:

PAHT	Potentially Avoidable Hospital Transfer
RACF	Residential Aged Care Facility
EOL	End of Life
ED	Emergency Department
GP	General Practitioner
NP	Nurse Practitioner
RN	Registered Nurse
NSW	New South Wales
QLD	Queensland
VIC	Victoria
SA	South Australia
WA	Western Australia
ACT	Australian Capital Territory
ACP	Advanced Care Planning
IV	Intravenous
GoC	Goals of Care
CALD	Culturally and Linguistical Diverse
UTI	Urinary Tract Infection
HITH	Hospital in the Home

Appendix A

Proposed Full Search Strategy

PubMed

(“emergency department*”[Title/Abstract] OR “hospital*”[Title/Abstract] OR “ED”[Title/Abstract] OR “emergency room*”[Title/Abstract] OR “emergency care”[Title/Abstract] OR “emergency presentation*”[Title/Abstract] OR “hospital transfer*”[Title/Abstract] OR “hospital admission*”[Title/Abstract] OR “hospitali*ation”[Title/Abstract] OR “hospital stay*”[Title/Abstract] OR “patient transfer*”[Title/Abstract] OR “hospital presentation*”[Title/Abstract] OR “resident transfer*”[Title/Abstract] OR “nursing home resident transfer”[Title/Abstract:~4] OR “potential resident hospital transfer”[Title/Abstract:~4] OR “potential resident hospital transfers”[Title/Abstract:~4])

OR

(“avoidable hospital transfer”[Title/Abstract:~4] OR “avoidable hospital transfers”[Title/Abstract:~4] OR “avoidable hospital admission”[Title/Abstract:~4] OR “avoidable hospital admissions”[Title/Abstract:~4] OR “avoidable patient transfer”[Title/Abstract:~4] OR “avoidable transfer”[Title/Abstract:~4] OR “avoidable transfers”[Title/Abstract:~4] OR “avoidable patient transfers”[Title/Abstract:~4] OR “potentially avoidable hospital transfer”[Title/Abstract:~4] OR “potentially avoidable hospital admissions”[Title/Abstract:~4] OR “potentially avoidable emergency department transfer”[Title/Abstract:~4] OR “potentially avoidable emergency department transfers”[Title/Abstract:~4] OR “potentially avoidable hospital presentations”[Title/Abstract:~4] OR “inappropriate hospital presentation”[Title/Abstract:~4] OR “potentially inappropriate hospital transfer”[Title/Abstract:~4] OR “unnecessary hospital transfer”[Title/Abstract:~4] OR “preventable hospital transfer”[Title/Abstract:~4] OR “non-beneficial hospital transfer”[Title/Abstract:~4] OR “burdensome hospital transfer”[Title/Abstract:~4] OR “unwarranted hospital transfer”[Title/Abstract:~4] OR “ambulatory care-sensitive conditions”[Title/Abstract:~4])

OR

(“Hospitalization”[MeSH Terms] OR “Patient Transfer”[MeSH Terms])

AND

(“RACH”[Title/Abstract] OR “RACF”[Title/Abstract] OR “aged residential care”[Title/Abstract] OR “care home*”[Title/Abstract] OR “aged care”[Title/Abstract] OR “aged care resident*”[Title/Abstract] OR “aged care home*”[Title/Abstract] OR “aged care facilit*”[Title/Abstract] OR “nursing home*”[Title/Abstract] OR “residential aged care”[Title/Abstract] OR “residential aged care facility resident”[Title/Abstract:~6] OR “aged care resident”[Title/Abstract:~6] OR “aged care facility resident”[Title/Abstract:~6] OR “nursing home resident”[Title/Abstract:~6] OR “residential aged care facility residents”[Title/Abstract:~6] OR “aged care residents”[Title/Abstract:~6] OR “aged care facility residents”[Title/Abstract:~6] OR “nursing home residents”[Title/Abstract:~6])

OR

(“Homes for the Aged”[MeSH Terms] OR “Nursing Homes”[MeSH Terms])

AND

(“determin*”[Title/Abstract] OR “prevalence*”[Title/Abstract] OR “incidence”[Title/Abstract] OR “occurrence”[Title/Abstract] OR “factor*”[Title/Abstract] OR “caus*”[Title/Abstract] OR “predisposing factor*”[Title/Abstract] OR “precipitating factor*”[Title/Abstract] OR “perspective*”[Title/Abstract] OR “appropriate*”[Title/Abstract] OR “proportion”[Title/Abstract] OR “perception*” [Title/Abstract] OR “impact of intervention”[Title/Abstract:~6])

OR

(“Causality”[MeSH Terms])

AND

(“Austral*”[Title/Abstract] OR “Queensland”[Title/Abstract] OR “Brisbane”[Title/Abstract] OR “Victoria”[Title/Abstract] OR “Melbourne”[Title/Abstract] OR “New South Wales”[Title/Abstract] OR “NSW”[Title/Abstract] OR “Sydney”[Title/Abstract] OR “South Australia”[Title/Abstract] OR “Adelaide”[Title/Abstract] OR “Western Australia”[Title/Abstract] OR “Perth”[Title/Abstract] OR “Northern Territory”[Title/Abstract] OR “Darwin”[Title/Abstract] OR “Australian Capital Territory”[Title/Abstract] OR “ACT”[Title/Abstract] OR “Canberra”[Title/Abstract] OR “Tasmania”[Title/Abstract] OR “Hobart”[Title/Abstract])

OR

(“AUSTRALIA”[MeSH Terms] OR “Australasian People”[MeSH Terms])

Appendix B

Table A1. Operational Definitions of Avoidability for Each Included Study by State (n = 25).

Reference and State/s	Avoidability—Defined by:
	Hospital avoidance service or intervention
[40]; NSW, QLD, SA	Providing IMPETUS-D training to RACF staff to reduce hospital transfers.
[38];NSW, VIC, QLD, SA	Implementation of in-house GPs, to reduce hospital transfers.
[11]; NSW	“The ACE APN provided telephone support to RACF staff concerned about residents with acute care needs. When telephoned from the RACF, the ACE APN, in consultation with the RACF staff and using the guidelines, helped to determine whether transfer was necessary. The guidelines included algorithms for managing events such as chest pain, diabetes, falls, gastroenteritis, pain, wounds and urinary symptoms which were collated into a manual for use by RACF staff.”
[12]; NSW	ED presentations and hospital admissions that can potentially be avoided by treating patients safely in the RACF with support of AGOS (geriatrician and nurse “hospital in the home” interventions). AGOS saw clinical presentations including urinary infections, dehydration, skin infections, urinary catheter issues, exacerbation of heart failure, exacerbation of COPD, abdominal pain, infections and BPSD.
[13]; NSW	Transfers of residents to ED are considered avoidable when resident healthcare needs and goals of care can be met through delivery of quality clinical care in RACF, through the ACE Program “an integrated nurse-led intervention underpinned by a community of practice designed to improve the capability of RACFs managing acutely unwell residents. It includes telephone support, evidence-based algorithms, defining goals of care for ED transfer, case management in the ED, and an education program.”
[17]; NSW	Successful management of conditions in RACF with geriatrician-led telehealth and outreach services. “AGOS delivered interventions such as intravenous cannulation, intravenous drugs, and subcutaneous hydration. AGOS relies on private pathology and radiology providers for investigations and collaborates with private wound nurse practitioners and community nursing services.”
[22]; NSW	REAP protocol of coordinated specialist geriatrician and nurse practitioner visits conducted that prevented rehospitalisation.
[21]; NSW	RACF residents who were seen by ARRT service and had care needs that could be safely managed within RACF. Services provided by ARRT include Comprehensive Geriatric Assessment, treatment of acute infections, liaison with other services, e.g., NSW ambulance, mobile x-ray and ultrasound, falls assessment, pain management and medication review.
[25]; VIC	RIR can “treat acute health conditions not able to be managed by primary care, in lieu of hospital presentation. Common services provided include rapid access to pathology investigations, acute care interventions including intravenous or intramuscular antibiotics, sub cutaneous hydration, targeted goals of patient care discussions, prescription of palliative care medications (including anticipatory prescribing), suturing and wound review, emergency indwelling or suprapubic catheter replacement or percutaneous gastrostomy replacement, and urgent workup for new or worsening falls, changed behaviour or delirium.”
[30]; VIC	This study demonstrated hospital transfer of RACF residents post-falls are avoidable unless clinical features are suggestive of a long bone fracture, new neck pain post-fall, wound closure requiring sedation or first seizure, if they had active and ongoing resuscitation requirements, or if the family requested transfer.
[31]; VIC	Residential In-Reach coordinator would provide clinical advice and telephone triage of the RACF residents and be available to attend the patient at the RACF rather than require transfer to the ED… “providing timely, skilled assessment and diagnostic support to residential aged care facilities when residents become clinically unwell.”
[26]; VIC	GOPC intervention aimed to reduce hospital transfers.
[43]; QLD	Providing outreach services RACF residents that were able to be seen by outreach service, HiNH, e.g., urinary catheter change, parenteral antibiotic administration, wound care, etc., that could be alternatively provided within patients’ own facilities instead of at EDs.
[46]; QLD	RACF residents who can be seen in the RACF by HiNH outreach service.
[47]; QLD	In the context of this study, a sub-acute episode (as seen by EDDIE intervention) was defined as a scenario where a resident required more intensive treatments, interventions and frequent assessments for a complex condition that did not require immediate hospitalisation. This included conditions such as kidney infections, pneumonia and urinary tract infections where residents could be monitored using appropriate diagnostic equipment and treated with intra-venous antibiotics within the RACF.
	Primary Care
[39]; NSW, VIC, QLD, SA	“Admission to hospital for a condition where the hospitalisation could have potentially been prevented through the provision of appropriate individualised preventative health interventions and early disease management usually delivered in primary care and community-based care settings (including by General Practitioners, medical specialists, dentists, nurses and allied health professionals).”
[15]; NSW	“Avoidable presentations were defined as those with clear symptomatology which could be reasonably diagnosed and managed within a non-hospital facility staffed at the level of a registered nurse with General Practitioner/nurse practitioner availability for direct or indirect clinical assessment and prescribing.”
[33]; VIC	“We defined primary care type ED presentations in this study as those assessed as triage category 4 or 5” Referred to primary care presentations rather than using language of avoidable, preventable, unnecessary, etc.
[34]; VIC	Potentially avoidable ED transfers: “Ambulatory care-sensitive conditions (ACSC); this includes conditions that could be prevented through access to primary care such as preventative management Assessment and simple wound dressing or closure required Assessment and simple suturing required—no significant nerve, tendon or vessel damage Uncomplicated urinary tract infection (UTI), not systemically unwell Soft tissue injury—nil radiology required, or radiology required in hours Replacement of IDC Noncritical diagnosis—assessment in RACF would be appropriate (including ACSC conditions) Palliative at the time of transfer.”
[16]; NSW	“30-day PPR was defined as a hospitalization due to 22 medical conditions usually treated in primary care and community- based healthcare settings according to classifications within the Australian National Health Care Agreement (Australian Institute of Health Welfare, 2022). Moreover, three additional medical conditions (i.e., pressure injury, dehydration, and sepsis) were included because these conditions were considered as potentially preventable conditions causing hospitalizations for residents living in RACFs in previous studies….”
[53]; WA	Does not define avoidability; assesses the demographic and clinical factors of residents with UTI that were treating in the RACF vs. in hospital.
	Clinical condition
[42]; NSW, VIC, SA	“We also identified 27 factors, including potentially modifiable ones such as exposure to high medication sedative load, that are common predictors of both unplanned hospitalisations and ED presentation and an additional 7 that are unique to each of the outcomes examined.”
	Not requiring hospital admission
[32]; VIC	“We adopted the broader definition of a potentially avoidable ED visit as one that does not result in a hospital admission.”
[28]; VIC	“Residents returned to RACFs having received simple interventions, such as minor wound dressings, requiring simple investigations during office hours or with uncomplicated non-critical diagnoses such as urinary tract infections…” “potentially avoidable transfers = could have been managed in primary care setting e.g., pathology and X-ray (during “office hours”).”
[29]; VIC	“Defined as presence of both the following: (i) RACF return from ED within 24 h, regardless of CTB performance or finding; (ii) ED management could reasonably have been provided at the RACF (e.g., superficial wound repair or dressing as opposed to distal radial fracture or dislocated prosthetic hip reduction).”
	Ambulance attendance not requiring transfer
[49]; ACT	Ambulance attendance and assessment, that did not result in ED transfer.

Abbreviations: Residential Aged Care Facilities (RACF); Aged Care Emergency Advanced Practice Nurse (ACE APN); Potentially Preventable Readmissions (PPR); Acute Geriatric Outreach Service (AGOS); Aged Care Emergency (ACE); Residential In-Reach (RIR); Hospital in The Nursing Home (HiNH); Regular Early Assessment Post-Discharge (REAP); Early Detection of Deterioration In Elderly residents (EDDIE); ambulatory care-sensitive conditions (ACSC); Aged Care Rapid Response Team (ARRT); General Practitioners (GP); Emergency Department (ED); IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D); Urinary Tract Infection (UTI); FORMAT; indwelling catheter (IDC); Computed Tomography of the Brain (CTB); Queensland (QLD); New South Wales (NSW); Victoria (VIC); South Australia (SA); Western Australia (WA); Australian Capital Territory (ACT).

Appendix C

Table A2. Prevalence by Avoidability Criteria and Total Sample Size n = 25.

Avoidability Criteria	Reference & State	Numerator	Denominator	Actual Estimate	Avoidability Prevalence
(1) Outreach service/programme or intervention
Hospital in the Nursing Home (HiNH)	[31] VIC	ED presentations pre and post implementation of in-reach services for RACF residents.	Total of n = 4329 ED presentations by RACF residents.	n = 2278 RACF presentations to ED in 2009 (pre-implementation) vs. n = 2051 presentations in 2011.	11%
Residential In-Reach (RIR) services	[25] VIC	ED presentations 12 months prior to, and post- RIR service restructure.	Total RACF resident ED presentations n = 3094.	ED presentations prior to restructure n = 1616 and post restructure n = 1478 (41.9 vs. 37.2 presentations/100 RACF beds, p < 0.001).	8.5%
Subacute/Acute Geriatric Outreach Service (S/AGOS)	[12] NSW	RACF resident admissions post implementation of SGOS and AGOS vs. pre-intervention.	Total number of beds in the 12 study RACF (n = 2912). n = 1421 (2012) and n = 1491 (2019).	Pre-intervention n = 1496. SGOS period n = 812. AGOS period n = 1302.	36.1%
Aged Care Emergency Advanced Practice Nurse (ACE APN)	[11] NSW	Hospital transfers of intervention (ACE APN) vs. control group between 2010 and 2011.	Total RACF residents n = 1596. Intervention group n = 774 control group n = 822.	Hospital transfers: Intervention group decreased 16% (n = 68). Control group increased by 4% (n = 16).	16%
Recruiting GPs to work directly in RACFs	[38] NSW, QLD, VIC	Unplanned hospital transfers pre and post intervention of onsite GPs.	Mean (SD) Total mean beds n = 1470 across 15 RACF. 98(31) per RACF.	Pre-intervention 18(7). Post-intervention: control 19(10) vs. intervention 14(9).	50%
Aged Care Rapid Response Team (ARRT)	[20] NSW	Hospital transfers post ARRT review in RACF.	n = 1437 RACF residents reviewed by ARRT over 3-year study period. Total of n = 5898 occasions of service.	85% of ARRT occasions of service concluded with the resident remaining within the RACF.	48.1%
Hospital in the Nursing Home (HiNH)	[43,46] * QLD	ED presentations pre and post HiNH implementation between RBWH (case) and LH (control).	Total ED presentations (n = 1314). Pre-RBWH n = 449 from 2127 RACF beds, LH n = 207 from 921 beds and post- RBWH n = 393 from 2485 beds, LH n = 265 from 1313 beds.	Pre-RBWH n = 211 ED presentations per 1000 beds vs. LH n = 225. Post-RBWH n = 158 ED presentations per 1000 beds vs. LH n = 202.	ED presentations per 1000 beds decreased by 25.1% in RBWH (case) vs. 10.2% in LH (control).
Acute Geriatric Outreach Service (AGOS)	[17] NSW	Successful management (no hospital transfer) of acutely unwell RACF resident by AGOS.	Total 438 episodes of care n = 270 face-to-face care and n = 168 telemedicine.	AGOS successfully managed n = 248 (91.9%) residents with face-to-face care and n = 160 (95.2%) with telemedicine.	Potentially prevented 408 hospital transfers.
Goals of Patient Care (GOPC)	[26] VIC	ED presentations 12 months post-GOPC implementation.	Total ED presentations from study cohort of n = 326.	12-month Incident Rate Ratio 0.63 (95%CI 0.41–0.99, p = 0.044).	40% reduction in ED visits compared to usual care.
IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D)	[40] NSW, QLD, SA	Proportion of unplanned hospital transfers for residents with dementia. Control vs. intervention (IMPETUS-D).	Total RACF residents with dementia n = 1304 intervention n = 608 control n = 696.	At least one unplanned transfer in 6-month follow-up; n = 260 (19.9%) intervention n = 128 (21.1%) and control n = 132 (19.0%). At least one unplanned in 12-month follow-up; n = 407 (31.2%) intervention n = 201 (33.1%) and control n = 206 (29.6%).	The IMPETUS-D training had no effect on hospital transfers.
Aged Care Emergency Service (ACE)	[13] NSW	ED presentations by RACF residents aged >75 years pre and post ACE programme.	Total RACF residents n = 1289 Residents in 4 intervention RACF (n = 453) and 8 control RACF (n = 836).	Pre-intervention: control n = 653, intervention n = 604. Post-intervention: control n = 468, intervention n = 525.	ED presentations did not significantly change, (p = 0.56).
Falls Outreach and Residential Mobile Assessment Team (FORMAT)	[30] VIC	Hospitalisations post implementation of a specialised fall assessment team (FORMAT) between May–September 2022.	Total of n = 123 RACF residents had a fall and were reviewed by in-reach team at RACF.	n = 116 (94%) of residents were managed onsite and therefore avoided hospital transfer. n = 7 required hospital transfer.	94% of falls avoided hospital due to FORMAT.
Early Detection of Deterioration In Elderly residents (EDDIE) programme	[47] QLD	Hospital admissions pre and post implementation of EDDIE.	n = 112 episodes of care over pre-post implementation.	Intervention group n = 34 transfers Control group n = 47 hospital transfers.	19% reduction in hospital transfers.
Regular Early Assessment Post-Discharge (REAP)” Intervention	[22] NSW	ED presentations REAP protocol (intervention) vs. control.	Total RACF residents n = 43. REAP intervention n = 22 Control n = 21	Episodes of care in ED: Intervention n = 13 Control n = 26.	REAP (intervention) accrued half as many ED episodes of care compared with controls.
(2) Manageable in RACF with primary care
	[39] NSW, QLD, VIC, SA	PPH of RACF residents across NSW, QLD, VIC, SA during 2019.	Total RACF resident presentations to ED in 2019 n = 146,964.	PPH n = 21,329 (14.5%).	<20% avoidable
	[33] VIC	RACF residents presenting to ED with triage category 4 or 5.	Total RACF ED presentations in 2012–2013 n = 24,914.	Proportion of RACF residents with triage category 4 or 5 n = 39.2%.	<40% avoidable
	[34] VIC	ED presentations by RACF residents that met the predefined criteria of potentially avoidable presentations.	n = 448 ED presentations by RACF residents in 6-month period of July–December 2021.	n = 249 (55.6%) met potentially avoidable criteria.	>50% avoidable
	[15] NSW	Number of avoidable hospitalisations.	n = 317 public ED presentations between 2017 and 2018.	n = 120 (38%) presentations from 6 RACF were determined avoidable.	<40% avoidable
	[16] NSW	PPR 30-day post hip fracture (index admission).	n = 12,355 RACF residents were admitted with a hip fracture across NSW between 2013 and 2023.	n = 266 residents (2.2%) experienced 30-day PPR.	<5% avoidable
	[53] WA	RACF residents transferred to hospital following Urinary Tract Infection episode in study period (January 2018–June 2019).	n = 234 resident cases of UTI in four RACF.	Referred to hospital by RN following Urinary Tract Infection episode: n = 56 (23.9%).	<30% avoidable
(3) Not requiring hospital admission
	[32] VIC	Potentially avoidable ED presentations from January 2014 to December 2018; by condition.	Fall related ED presentations of n = 894. All other injury/illness ED presentations n = 1758.	n = 104 (11.6%). n = 218 (12.4%).	<15% avoidable
Returned from ED only requiring simple intervention	[28] VIC	Avoidable hospital transfers to two EDs between January–December 2012.	n = 2880 RACF presentations to ED between January–December 2012. A random sample of n = 408 chosen for further analysis.	n = 144 (35.3%) were deemed avoidable based on the avoidability criteria and operational definition.	<40% avoidable
Returned to RACF from ED < 24 h	[29] VIC	Percentage of potentially avoidable RACF to ED transfers.	n = 784 RACF patients presented to the three Monash EDs with a fall.	n = 415 (53.0%) were classified as potentially avoid able.	>50% avoidable
Ambulance attendance not requiring transfer
	[49] ACT	Ambulance attendances that did not result in ED transfer	n = 669 ambulance attendances	Remain in RACF post ambulance attendance: n = 87 (87.0%)	13% of ambulance call outs were potentially preventable.

* Fan [46] (2016) and Lukin [43] (2016) are counted as one (but both references included) as studies report on same results. While all studies reported some form of avoidable/unnecessary/unwarranted transition, the concept of avoidability is only explicitly defined in 25 studies. Abbreviations: Aged Care Emergency Advanced Practice Nurse (ACE APN); Emergency Department (ED); Residential Aged Care Facility (RACF); Acute Geriatric Outreach Service (AGOS); Subacute Geriatric Outreach Service (SGOS); Aged Care Emergency programme (ACE programme); Residential In-Reach services (RIR); Goals of Patient Care (GOPC); Falls Outreach and Residential Mobile Assessment Team (FORMAT); Regular Early Assessment Post-Discharge (REAP); Early Detection of Deterioration In Elderly residents (EDDIE); Aged Care Rapid Response Team (ARRT); Hospital in Nursing Home (HiNH); Royal Brisbane Woman’s Hospital (RBWH); Logan Hospital (LH); Potentially Preventable Hospitalisations (PPH); Potentially Preventable Readmissions (PPR).

Appendix D

Table A3. Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) Checklist.

SECTION	ITEM	PRISMA-ScR CHECKLIST ITEM	REPORTED ON PAGE #
Title
Title	1	Identify the report as a scoping review.	1
Absract
Structured summary	2	Provide a structured summary that includes (as applicable): background, objectives, eligibility criteria, sources of evidence, charting methods, results, and conclusions that relate to the review questions and objectives.	1
Introduction
Rationale	3	Describe the rationale for the review in the context of what is already known. Explain why the review questions/objectives lend themselves to a scoping review approach.	2
Objectives	4	Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.	2, 3
Methods
Protocol and registration	5	Indicate whether a review protocol exists; state if and where it can be accessed (e.g., a Web address); and if available, provide registration information, including the registration number.	3
Eligibility criteria	6	Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status) and provide a rationale.	3
Information sources	7	Describe all information sources in the search (e.g., databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.	3, 4
Search	8	Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated.	16, 17
Selection of sources of evidence	9	State the process for selecting sources of evidence (i.e., screening and eligibility) included in the scoping review.	3, 4
Data charting process	10	Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators.	4
Data items	11	List and define all variables for which data were sought and any assumptions and simplifications made.	4
Critical appraisal of individual sources of evidence	12	If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate).	n/a
Synthesis of results	13	Describe the methods of handling and summarizing the data that were charted.	4, 5
Results
Selection of sources of evidence	14	Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram.	4
Characteristics of sources of evidence	15	For each source of evidence, present characteristics for which data were charted and provide the citations.	5, 6
Critical appraisal within sources of evidence	16	If done, present data on critical appraisal of included sources of evidence (see item 12).	n/a
Results of individual sources of evidence	17	For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives.	6–12
Synthesis of results	18	Summarize and/or present the charting results as they relate to the review questions and objectives.	6–12
Discussion
Summary of evidence	19	Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups.	12–14
Limitations	20	Discuss the limitations of the scoping review process.	14, 15
Conclusions	21	Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps.	15
Funding
Funding	22	Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review. Describe the role of the funders of the scoping review.	n/a

PRISMA-ScR = Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.

References

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Figure 1. Search results, screening process, and reasons for exclusion (PRISMA diagram).

Figure 2. Overarching domains of potentially avoidable hospital transfers.

Table 1. Study characteristics of potentially avoidable hospital transfers in Australia (n = 43).

Study Characteristics		Number of Studies	References
Study location
	New South Wales	13	[11,12,13,14,15,16,17,18,19,20,21,22,23]
	Victoria	12	[24,25,26,27,28,29,30,31,32,33,34,35]
	Multi-State (NSW, QLD, VIC, SA, WA)	5	[37,38,39,40,42]
	Queensland	5 *	[43,44,45,46,47,48]
	Australian Capital Territory	3	[49,50,51]
	South Australia	1	[52]
	Western Australia	1	[53]
	Australian (does not specify States)	2	[36,41]
Study setting
	Urban/Metropolitan	22 *	[11,12,14,15,17,22,24,25,26,27,28,29,30,31,32,35,40,43,44,45,46,49,53]
	Regional or Rural	4	[13,34,47,48]
	Both urban & rural	10	[16,18,19,21,33,36,37,38,39,42]
	Not reported	6	[20,23,41,50,51,52]
Sample size
	≥100,000	2	[39,42]
	10,000 to 100,000	2	[16,33]
	1000 to 9999	13 *	[11,12,13,20,25,31,32,36,38,40,43,46,49,50]
	≥100 to 999	16	[14,15,17,18,23,26,27,28,29,30,34,35,37,41,46,47,53]
	<100	9	[19,21,22,24,44,45,48,51,52]
Study Type
	Quantitative	22 *	[12,13,16,17,18,20,22,25,26,28,29,31,33,34,35,38,39,42,43,46,47,49,53]
	Qualitative	13	[14,19,21,23,24,27,36,44,45,48,50,51,52]
	Mixed Methods	7	[11,15,30,32,37,40,41]
Driver **
	Medical	40 *	[11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,33,34,35,36,37,38,39,40,41,42,43,45,46,47,48,49,50,51,52,53]
	Social	13	[15,21,23,24,25,27,32,36,37,41,42,44,49]
Focus **
	Prevalence	24 *	[11,12,13,15,16,17,20,22,25,26,28,29,30,31,32,33,34,38,39,40,43,46,47,49,53]
	Determinants	25	[11,13,14,15,16,21,22,23,24,25,26,27,28,30,33,34,35,36,41,42,44,45,49,50,53]
	Proposed Solutions	31	[11,12,13,14,15,16,17,19,21,22,23,24,25,26,28,30,31,33,34,36,37,38,41,42,43,44,45,49,50,51,53]
Avoidability Criteria
	Illness Severity	19	[11,12,13,14,16,20,23,24,25,26,27,34,35,36,42,47,49,53]
	Clinical Judgement	31 *	[11,12,13,14,15,18,19,20,21,22,24,25,26,27,28,30,31,33,36,40,42,43,45,46,47,48,49,50,51,52,53]
	Requires Investigations	4	[21,29,47,52]
	Family/Resident request	8	[15,21,24,32,36,41,49,51]
	Staff shortages/skills	13	[17,19,23,24,25,27,28,36,39,43,45,48,49]

* Fan [46] (2016) and Lukin [43] (2016) are counted as one (but both references included) as studies report on same results. ** Total number higher than 43 as same studies are represented in multiple categories.

Table 2. Summary of avoidability definitions, denominators and prevalence of PAHT (n = 25).

Table 3. Drivers (n = 25) * and proposed solutions (n = 31) * of potentially avoidable hospital transfers.

Clinical Decision-Making Complexity
Drivers:	Solutions:
- Complexity of decision-making process [24,27,42,49]	- Outreach services [19,30,43], specialised falls team [30], and telehealth support [21,31]
- Poor/delayed recognition of resident deterioration [44]	- Advance Care Planning and goals of care for all RACF residents [11,24,26,36,37,51]
- Poor differentiation of what is manageable in RACF vs. what requires hospital management [30]	- Training and education including traffic light system, tools, and pathways [44]
- Delayed identification and intervention of end-of-life pathway [21]	- Risk profile and prevention strategies [42,53]
- Lack of RACF RN experience [21]
- Fear of consequence (e.g., litigation) if intervention is “incorrect” [23,44,49]
- Lack of Advance Care Planning informed decisions [24,34]
Low Clinical Confidence
Drivers:	Solutions:
- Low confidence in assessment + management of acutely unwell residents [11,27,36]	- Access to telephone advice from geriatric acute care specialists [11,17,31,37]
- Minimal support for RNs in decision-making [44,45]	- Evidence-based protocols and decision guides [11,14,23,44,53]
- Feeling out of depth managing with acutely unwell residents [23]	- Upskilling, education, peer-to-peer teaching [11,44]
- Lack of confidence performing specific clinical skills [24]	- Subacute outreach programmes [24,44] and telehealth [19]
	- Building capacity and confidence via outreach support [21,30,43]
RACF Policy-Based Factors
Drivers:	Solutions:
- Policy that contradicts individualised care plans [11,24,27,53]	- Consult evidence-based protocols and individual GoC before transfer [11,13,53]
- Inadequate policy on identification and management of palliative care [50]	- ACP discussions to include location of care [50]
- Policy precluding the provision of emergency care to acutely ill older people [23] - Policies prohibiting nurse-initiated medication [23,27]	- Outreach services with equipment/interventions [12,25]
Systemic RACF Practice-Based Factors
Drivers:	Solutions:
- Poor charting and ward stock availability of anticipatory medications [35] - Polypharmacy and lack of routine medication reviews/deprescribing [36,42] - Poor continuity of physiotherapy, especially post-hip fracture [16] - Inadequate staffing, skill mix, and GPs with competing priorities [23] - No follow-up post discharge [22] - Limited number of specialised staff to initiate and manage acute care [11,27,28,36,49] - Decision-making delegated to single RN, exacerbated by a lack of after-hours and weekend support [27,28,36]	- After-hours access to GP/NP/geriatrician/outreach services [13,17,24,25,28,31,37,45] - Follow-up after hospital discharge [22] - Regular medication review [42] - Adequately skilled workforce, working to full scope [11,24,53] - Training, guidelines, and educational opportunities [11,24,36,49] - Hospital-based rehabilitation and allied health support [16]
Limited Access to Ongoing Support
Drivers:	Solutions:
- Limited access to timely GP/primary care support [15,24,28,33,34,45]	- Outreach services providing hospital in the home-style interventions [12,25]
- Minimal outreach services after hours [21] - Poor inter-sector info sharing RACF-ambulance-ED [14,25,36,45]	- Specialist palliative care services and medication access [15] - Extend outreach service hours [21] and increased support [25,28] - RACF access to electronic hospitals records for residents [36] - Standardised ACP & treatment strategies [36] - Formalised inter-sector handover and clinical communication tools [14] - Onsite GPs (or greater access to) [33,34,38,45]
Health System Attitudes
Drivers:	Solutions:
- Negative perception of RACF RNs by ambulance and ED staff [45] - RACF staff made to feel incompetent and undermined by inter-sector colleagues [45] - Lack of inter-sector recognition of RACF barriers to acute care [11,13,14,25] - Disrespect from ED/ambulance staff [23]	- Outreach services and inter-sector support [44,45] - Structured partnerships and integrated care pathways [11,25] - Communities of practice across services [13] - Recognition of RACF RNs’ capability by building positive inter-sector relationships [23,45] - Virtual telehealth to build trust and relationships between ED and RACF [19]
Family expectations
Drivers:	Solutions:
- Family pressure for hospital transfer [24,26,36,49,53] - Poor family understanding of dying process [15] - Family overriding goals of care [15] - Preference for ED care [41] - ACP scarcely completed [35] - Pressure on RACF RNs to avoid hospital transfer [44]	- Cultural competency training for RACF staff [36] - GoC/ACP discussions and documentation [15,26] - Outreach services as an alternative to ED [41,44] - Early referral to palliative care teams [15]

* Some studies identified drivers but not solutions, therefore the total count of studies are separated into drivers and solutions.

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Avoidability Definition	Typical Denominator	Prevalence Range
Condition manageable within RACFs with outreach services or interventions [11,12,13,17,20,22,25,26,30,31,38,40,43,46,47].	Varied—RACF resident ED presentations, RACH resident reviewed by outreach service, total RACF residents or beds, episodes of care pre- and post-programme implementation.	8.5–95.2%
Condition manageable in RACF with primary care [15,16,33,34,39,53].	Predominantly RACF resident ED presentations; some studies used condition specific denominators (i.e., hip fracture and UTI cases).	2.2–55.6%
Presentation to ED not requiring hospital admission [28,29,32].	RACF resident ED presentations; some studies further grouped by presenting conditions.	11.6–53.0%