Appropriateness of transferring nursing home residents to emergency departments: a systematic review

Abstract

BackgroundElderly living in a Nursing Home (NH) are frequently transferred to an Emergency Department when they need acute medical care. A proportion of these transfers may be considered inappropriate and may be avoidable.MethodsSystematic review. Literature search performed in September 2018 using PubMed, Web of Science, the Cochrane Library and the Cumulative Index to Nursing and Allied Health Literature database. Titles and abstracts were screened against inclusion and exclusion criteria. Full-texts of the selected abstracts were read and checked for relevance. All years and all languages were included provided there was an English, French, Dutch or German abstract.ResultsSeventy-seven articles were included in the systematic review: 1 randomised control trial (RCT), 6 narrative reviews, 9 systematic reviews, 7 experimental studies, 10 qualitative studies and 44 observational studies. Of all acute transfers of NH residents to an ED, 4 to 55% were classified as inappropriate. The most common reasons for transfer were trauma after falling, altered mental status and infection. Transfers were associated with a high risk of complications and mortality, especially during out-of-hours. Advance directives (ADs) were usually not available and relatives often urge NH staff to transfer patients to an ED. The lack of availability of GPs was a barrier to organise acute care in the NH in order to prevent admission to the hospital.ConclusionsThe definition of appropriateness is not uniform across studies and needs further investigation. To avoid inappropriate transfer to EDs, we recommend to respect the patient’s autonomy, to provide sufficient nursing staff and to invest in their education, to increase the role of GPs in the care of NH residents both in standard and in acute situations, and to promote interprofessional communication and collaboration between GPs, NH staff and EDs.Electronic supplementary materialThe online version of this article (10.1186/s12877-019-1028-z) contains supplementary material, which is available to authorized users.

Perspectives of general practitioners and nursing staff on acute hospital transfers of nursing home residents in Germany: results of two cross-sectional studies

“…Some of the findings of this study, especially the stated proportions of inappropriate hospital transfers have to be interpreted with caution as they are attributed to personal impressions of the responding GPs and NH staff. There exists a broad range of ways to define appropriateness of transfers [24,25] but this study aimed to illustrate the perception of GPs and NH staff in Germany. Another limitation applies to the generalizability of the findings.…”

“…Thus, the existing evidence considers many of these transfers inappropriate or potentially avoidable [21][22][23][24]. However, there are numerous instruments judging the appropriateness of hospital transfers [24,25], and the according proportions of inappropriate transfers vary substantially between 2 and 77% [26,27]. In many cases solely specific medical diagnoses belonging to the so called ambulatory care sensitive conditions (ACSCs) were used, for instance, heart failure and pneumonia [18,[28][29][30][31][32].…”

“…In Germany, NH residents can be admitted to a hospital with a physician's (e.g., GP's) referral, however, the transfer process can also be initiated by the NH staff calling the emergency medical service without involvement of a physician which is common practice in German speaking countries [23,47]. Several approaches discussed for reducing inappropriate hospital transfers include better interprofessional collaboration [25,33,37,41,48]. However, most of the existing literature on reasons for hospital transfers of NH residents and areas for improvement only focussed on just one of these healthcare professionals [35,37,40,43,48], or had small sample sizes [39,49,50].…”

Perspectives of General Practitioners and Nursing Staff on Acute Hospital Transfers of Nursing Home Residents in Germany: Results of two cross-sectional Studies

“…However, there are numerous instruments judging the appropriateness of hospital transfers [24,25], and the according proportions of inappropriate transfers vary substantially between 2-77% [26,27]. In many cases solely specific medical diagnoses belonging to the so called ambulatory care sensitive conditions (ACSCs) were used, for instance, heart failure and pneumonia [18,[28][29][30][31][32].…”

“…further functional and mental decline or nosocomial infections [19,20], and lead to a high use of healthcare resources [19,21]. Thus, the existing evidence considers many of these transfers inappropriate or potentially avoidable [21][22][23][24].However, there are numerous instruments judging the appropriateness of hospital transfers [24,25], and the according proportions of inappropriate transfers vary substantially between 2-77% [26,27]. In many cases solely specific medical diagnoses belonging to the so called ambulatory care sensitive conditions (ACSCs) were used, for instance, heart failure and pneumonia [18,[28][29][30][31][32].…”