Decision to transfer to an emergency department from residential aged care: A systematic review of qualitative research

Abstract

Aim:If developing policies to optimize quality acute care within residential aged care facilities (RACF) is a goal, understanding the factors that influence the decision to transfer a resident from RACF to hospital emergency departments is important. The aim of the present study was to review the published literature pertaining to transfer decisions. Methods:We carried out a systematic review of the qualitative literature to ascertain key influences on transfer decisions amongst three key stakeholder groups -residents, their family and carers.Results: From 11 papers we found two themes encompassing seven domains of influence. Transfers are influenced by an expectation or goal of improved resident clinical or quality of life outcomes -these are domains within the "resident dominant" theme. However, transfers also occur where there is no expectation of resident benefit. These domains, such as inadequate facility resourcing and care planning, are categorized within the "resident subordinate" theme. Conclusion:Transfer decisions are often influenced by considerations beyond expected benefit to the individual resident. Conceptualizing influences on transfer decisions within this framework might assist clinicians and policy makers in the design and delivery of services for RACF residents. Geriatr Gerontol Int 2013; 13: 825-833.

Decisions to Transfer Nursing Home Residents to Emergency Departments: A Scoping Review of Contributing Factors and Staff Perspectives

“…Our findings describe factors related to avoidable transfers and some common concepts in definitions (early detection and management in the NH, balance between need and resources, and professional judgment about ability to provide timely, safe, quality care within immediate context of resources, family/resident preferences, and professional competence) without specifically defining "avoidable." The lack of consensus in theoretical definitions reflects the complexity required to integrate various perspectives; those of NH clinicians, 11,12,15,17,19,21e23 administrators, family/residents, 7,15,17,21,22 political policy, 7,23 and economic views, 7,18,23 each of which present specific expectations, values, and assumptions about appropriateness, quality, and safety of care services within the NH. Acute changes in health status that require transfer to ED are contextually specific and must consider not only the acute condition for which the transfer is "necessary," 1,2,10,31 but also resources available to the NH, 20 and the resident's and family members' preferences for care.…”

“…7,19,20 This phenomenon triggered policies to not-treat and to transfer because the resident's acuity outweighed the NH's capacity to care for them. 7,8,10,11,15,17,23 Physician/NP Factors Physician/NP factors influencing resident transfer to EDs were explored in 8 studies. The most common finding was the relative absence of a primary care provider in the NH facility, 11,12,15e17,19 which suggests that 1 visit by a physician or NP could potentially prevent an unnecessary transfer.…”

“…NH residents were transferred with the expectation that transfer would provide better clinical outcomes and increased quality of life. 7 The decision to transfer ideally is based on the "knowing" the resident, the resident's preferences and goals of care. 21,22 Controversy was reported when NH residents and/or family members lacked confidence in the care provided in the NH, 7 or requested transfer when otherwise not indicated by primary care providers 12,15 or when advanced directives were not followed.…”

“…1e3,10e18 The concept of "avoidable" is complex and multifactorial, and the decisionmaking process includes dilemmas of resource availability and utilization, 7,19,20 NH resident and family member preferences of care, 7,17,21,22 and macro health system issues of scope of practice and accreditation standards. 18 The current standard of practice, based on the theoretical approach to "unavoidable" or "unnecessary" transfers, is to transfer NH residents to the ED when the care they require exceeds the resources of the NH facility.…”

The Institutional Practice

“…«Qualitative research» is a vague and wide-ranging term, as is the application of the term for research on hospitalization from nursing homes, most notably in two recent literature reviews (Arendts et al 2013, Laging et al 2015, including research using observation, interviews, focus groups and questionnaires as primary methodological approaches. This segment of the research literature is distinguishable from other segments not only by approach, but also by time of publication.…”