Stakeholder perspectives on transitions of nursing home residents to hospital emergency departments and back in two Canadian provinces

Abstract

Major gaps exist in our understanding of transitions in care for older persons living in nursing homes. The purpose of the study was to identify key elements, from multiple stakeholder perspectives, that influence the success of transitions experienced by nursing home residents when they required transfer to a hospital emergency department. This interpretive descriptive study was conducted in two cities in the Canadian provinces of British Columbia and Alberta. Data were collected from 71 participants via focus groups and individual interviews with nursing home residents, family members, and professional healthcare providers working in nursing homes, emergency departments, and emergency medical services. Transcripts were analyzed using constant comparison. The elements contributing to the success of transitions reflected a patient- and family-centered approach to care. Transitions were influenced by the complex interplay of multiple elements that included: knowing the resident; critical geriatric knowledge and skilled assessment; positive relationships; effective communication; and timeliness. When one or more of the elements was absent or compromised, the success of the transition was also compromised. There was consistency about the importance of all the identified elements across all stakeholder groups whether they are residents, family members, or health professionals in nursing homes, emergency departments or emergency medical services. Aspects of many of these elements are modifiable and suggest viable targets for interventions aimed at improving the success of transitions for this vulnerable population.

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

“…11,14 Use of Post Hoc Evaluation Tool to Assess Avoidability Implicit reviews are considered the gold standard for rating comprehensive quality of care in other patient populations. 16 The Structured Implicit Review (SIR) 22 is a retrospective evaluation tool used to identify potential factors contributing to transfers of NH residents to ED, and has been validated by others. 8 Categories of "avoidable" versus "unavoidable" are based on baseline health status, advanced directives, acute illness signs and symptoms (including severity), known interventions, response to NH-based therapy, components of resource availability (including physician and NH staffebased services), and quality of care within the NH compared with services available and quality of care available in external services.…”

“…17 This included knowledge and skills that were inadequate to detect early-acute changes in the NH resident's status. 11,12,15,17,22 Nursing staff levels of competency 15 coupled with knowing the resident and having positive relationships with residents, families, and their primary care providers were associated with successful transfers. 21,22 Facility/Resource Factors Facility and resourceerelated factors were reported in 9 studies.…”

“…21 Presence of a physician or NP in the facility, with high level of geriatric expertise, improved NH clinical outcomes and limited risk of personal liability incurred when assessment was not possible. 1,12,19,22 …”

“…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.…”

A Randomized Trial Exploring the Effect of a Telephone Call Follow‐up on Care Plan Compliance Among Older Adults Discharged Home From the Emergency Department

“…3 Current ED care processes, and in particular ED discharge processes, are not optimized to meet the complex care needs of older adults or to ensure coordinated care beyond the ED. 4 When patients are discharged from the inpatient hospital setting, it is believed that the quality of their transitional care can be improved, in part, if expedited follow-up with a primary care physician and medication management services are provided. 5,6 Increased attention to these pillars of high-quality transitional care may help mitigate the risks experienced by older adults on discharge from the ED as well.…”