Analyzing Hospital Transfers Using INTERACT Acute Care Transfer Tools: Lessons from MOQI

Abstract

OBJECTIVES We explored the differences in potentially avoidable/unavoidable hospital transfers in a retrospective analysis of Interventions to Reduce Acute Care Transfers (INTERACT) Acute Transfer Tools (ACTs) completed by advanced practice registered nurses (APRNs) working in the Missouri Quality Improvement (QI) Initiative (MOQI). DESIGN Cross‐sectional descriptive study of 3996 ACTs for 32.5 calendar months from 2014 to 2016. Univariate analyses examined differences between potentially avoidable vs unavoidable transfers. Multivariate logistic regression analysis of candidate factors identified those contributing to avoidable transfers. Setting Sixteen nursing homes (NHs), ranging from 120 to 321 beds, in urban, metro, and rural communities within 80 miles of a large midwestern city. PARTICIPANTS A total of 5168 residents with a median age of 82 years. MEASUREMENTS Data from 3946 MOQI‐adapted ACTs. RESULTS A total of 54% of hospital transfers were identified as avoidable. QI opportunities related to avoidable transfers were earlier detection of new signs/symptoms (odds ratio [OR] = 2.35; 95% confidence interval [CI] = 1.61‐3.42; P < .001); discussions of resident/family preference (OR = 2.12; 95% CI = 1.38‐3.25; P < .001); advance directive/hospice care (OR = 2.25; 95% CI = 1.33‐3.82; P = .003); better communication about condition (OR = 4.93; 95% CI = 3.17‐7.68; P < .001); and condition could have been managed in the NH (OR = 16.63; 95% CI = 10.9‐25.37; P < .001). Three factors related to unavoidable transfers were bleeding (OR = .59; 95% CI = .46‐.77; P < .001), nausea/vomiting (OR = .7; 95% CI = .54‐.91; P = .007), and resident/family preference for hospitalization (OR = .79; 95% CI = .68‐.93; P = .003). CONCLUSION Reducing avoidable hospital transfers in NHs requires challenging assumptions about what is avoidable so QI efforts can be directed to improving NH capacity to manage ill residents. The APRNs served as the onsite coaches in the use and adoption of INTERACT. Changes in health policy would provide a revenue stream to support APRN presence in NH, a role that is critical to improving resident outcomes by increasing staff capacity to identify illness and guide system change. J Am Geriatr Soc 67:1953–1959, 2019

The Impact of Nurse Practitioners on Hospitalizations and Discharges from Long-term Nursing Facilities: A Systematic Review

“…Reduced healthcare costs were mentioned in 9 of 136 occurrences of facilitator themes, or 6.62% [ 7 , 8 , 9 , 12 , 14 , 23 , 30 ]. Unrestrictive or least restrictive scope of practice for NPs was mentioned in 10 of 136 occurrences of facilitator themes, 7.35% [ 10 , 14 , 16 , 17 , 31 , 32 , 33 , 34 , 35 , 36 ].…”

“…The negative barrier theme most often mentioned was the restrictive scope of practice for NPs, identified in 13 of 45 occurrences (28.89%) reviewed [ 9 , 14 , 16 , 20 , 23 , 24 , 31 , 32 , 34 , 35 , 36 ]. Lack of policy and funding, Medicare regulations, state regulatory constraints, prohibited billing for visits, and no authority to write or change orders were all contributors to restrictive scope of practice for NPs [ 9 , 23 , 24 , 32 , 34 , 35 ]. These restrictions required direct or indirect supervision from physicians for NPs, as well [ 31 ].…”

Financial and Work-flow Benefits of Reducing Avoidable Hospitalizations of Nursing Home Residents

“…Consistent staff education and role modeling help overcome common nursing staff reactions to resident illness and change in condition. For instance, staff reactions to a resident change in condition is often "ship to hospital"; however, more complete assessment often reveals actions that are more appropriate to manage the clinical situation and treat the resident in place at the NH (9,20). Another recommendation is for nursing home leadership to invest in staff with the clinical skills (RNs and an APRN) to role model how to detect changes in health status early, how to do more complete assessments, communicate information to healthcare providers clearly, and guide implementing clinical interventions that help residents recover quickly within the nursing home.…”

“…Another recommendation is for nursing home leadership to invest in staff with the clinical skills (RNs and an APRN) to role model how to detect changes in health status early, how to do more complete assessments, communicate information to healthcare providers clearly, and guide implementing clinical interventions that help residents recover quickly within the nursing home. We have found that most diagnostic workups can be completed readily within the nursing home so that the majority of changes in health status can be managed without hospitalization (9,20).…”

Repeat hospital transfers among long stay nursing home residents: a mixed methods analysis of age, race, code status and clinical complexity

“…As part of the MOQI project, APRNs documented retrospective details about every resident’s hospital transfer into an adapted INTERACT acute care transfer (ACT) tool using Qualtrics survey software [ 21 , 22 ]. The ACT tool contains open- and closed-ended questions about each acute care transfer.…”