The frequency of and reasons for acute hospital transfers of older nursing home residents

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

“…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.…”

“…21,22 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. 11,17,21 Health System Factors Five studies described health system factors. The influence of government in terms of legislating the nature and scope of practice of Table 4 Descriptions of "Avoidable" or "Unnecessary" Transfers Definition of "Avoidable" or "Unnecessary"…”

“…Management of Early-Acute of Low-Acuity Symptoms and CDM in NH "potentially avoidable" / one that may have been avoided if optimal management of an existing condition was available in the NH at an earlier stage 1,2 "low-acuity" / not requiring inpatient management resulting in direct discharge from ED, CTAS 4e5 31 focus on strategies for early detection of acute health changes and prompt, timely care to address symptoms 10 becomes "unavoidable" if specialist care is required 13 end-of-life care, transfers made in contradiction to advanced care directives, or without clear clinical benefit to the NH resident 11 is a balance of issues including timeliness and availability of diagnostic and treatment resources with physician/NP expertise and accessibility, premorbid condition of the NH resident and respect for NH resident and family wishes 32 highly dependent on availability of and accessibility of primary care provider, diagnostic and therapeutic means 11,32 B. Ambulatory CareeSensitive Indicators based on medical diagnosis and ICD-9 codes, anemia, angina pectoris, asthma, bleeding ulcers, cellulitis, chronic obstructive pulmonary disease, congestive heart failure, dehydration, diabetes mellitus complications, gastroenteritis, seizure disorders, hypertension, kidney/ urinary tract infections, and pneumonia 11,12,14 new to Canadian inclusion criteria: injuries from falls/fractures and septicemia 14 C. Post Hoc Assessment of Factors Contributing to Avoidability 12,16 Use of the SIR: retrospective in nature, guiding research and clinical recommendations Considers the following:…”

“…The underlying premise was that an ED visit is not required to treat these ailments with good clinical outcomes if it is managed in a timely manner within the NH. 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.…”

“…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.…”