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

https://doi.org/10.1016/j.jamda.2016.05.012Get rights and content

Abstract

Objectives

Nursing home (NH) residents are a frail and vulnerable population often faced with iatrogenic effects of hospital stays when transferred to emergency departments for acute changes in health status. Avoidable or unnecessary transfers of care need to be identified and defined to prevent unintended harm. The aim of this scoping review was to identify characteristics of avoidable or unnecessary transitions of NH residents to emergency departments, and examine factors influencing decision-making by NH staff, residents, and their family members to transfer nursing home residents to emergency departments.

Methods

The search strategy began with 5 electronic databases, and a hand search of gray literature. Published qualitative and quantitative studies were included that examined the definition of avoidable or unnecessary transfers, and/or reported factors associated with decision-making to transfer NH residents to emergency departments. Methods included quality assessments, data extraction, and synthesis using content analysis.

Results

A total of 783 titles and abstracts were retrieved and screened resulting in 19 included studies. Results describing “avoidable” or “unnecessary” transfers were grouped into 3 dimensions of factors: management of early-acute or low-acuity symptoms and chronic disease management in NHs, ambulatory care–sensitive indicators, and use of post hoc assessments. Five categories of factors contributing to decision-making to transfer were identified: nursing factors, physician factors, facility/resource factors, NH resident/family factors, and health system factors. A consensus on the definition of “avoidable” or “unnecessary” transfers was not found.

Conclusion

Findings suggest that transfers of NH residents to emergency departments may be avoided with increased care capacity within NHs. The decision-making process involved in the transfer is influenced by many factors, with intentions of both improving clinical outcomes and maintaining quality of life for the NH resident. Acute changes in health status are contextually specific and decisions must consider not only the resident's acute condition, but also resources available in the NH, and resident and family members' preferences for care. A definition of “avoidable” or “unnecessary” transfer must include reliable measurement, yet remain flexible enough to be generalizable to various care facilities to meet the needs of NH residents and manage required care safely within the NH. Robust research aimed at improving the primary care of NH residents is essential to informing health policy reform and education of those providing care in NHs.

Section snippets

Search Strategy, Data Sources, and Screening

The systematic search used 5 electronic health databases: CINAHL (1984–present), MEDLINE (1948–present), EMBASE (1974–present), SCOPUS, and Proquest Dissertations and Theses Full Test. In addition, a search through the gray literature via Google Scholar, and a hand search of selected bibliographies were completed. A health sciences librarian assisted in the development of the search strategy and database searches. The specific search strategy was based on the following; (“long term care” or

Search Results

Electronic health database searches yielded 850 titles and abstracts, and following removal of duplicates, 783 titles and abstracts were screened using inclusion criteria. Of these, 54 full-text articles met inclusion criteria and were retrieved for full review. Of these, 19 articles were included and underwent quality review and assessment. See Figure 1 for search results. No articles were excluded after quality review, as the purpose of the scoping review was to map the key concepts available

Interpretations of “Avoidable” or “Unnecessary” Transfers from NH to ED

Seven articles provided explicit theoretical definitions of “avoidable” and “unnecessary” transfer, where the terms were used interchangeably.2, 10, 11, 12, 13, 14, 31 The common concepts in these definitions centered on 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. No consensus on a

Factors Contributing to NH Residents' Transfer to EDs

Fourteen of the 19 included studies investigated factors that contribute to NH resident transfer to ED. Five categories of factors were identified: nursing, facility/resources, physician/nurse practitioner (NP), NH resident and family, and health system factors (Table 5).

Discussion

Integrated findings of the 19 studies in this scoping review provide a rich understanding of the complex interplay of factors and processes involved in decision-making to transfer a NH resident to an ED. However, a consensus on the definition of “avoidable” or “unnecessary” transfers was not found. 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

Conclusion

Reducing the use of acute care services, such as EDs, is essential in maintaining accountability and fiscal responsibility of the health care system, even for NH residents who are a highly vulnerable and frail population. The care needs of NH residents are supportive in nature, but can quickly escalate to encompass complex, multifactorial situations when acute health changes occur. Access to acute care remains an essential aspect of care; however, delivery of these care needs and the

Acknowledgments

We acknowledge L. Slater, a health sciences librarian, who assisted with the initial literature search strategy, and K. Tate, nursing student, who assisted with review calibration.

References (41)

  • R. Briggs et al.

    Nursing home residents attending the emergency department: Clinical characteristics and outcomes

    QJM

    (2013)
  • A. Grunier

    “Avoidable” emergency department transfers from long-term care homes: A brief review

    Healthc Q

    (2013)
  • Canada's population estimates: Age and sex, July 1, 2012

    (2012)
  • S.R. Finmore et al.

    Shortening the wait: A strategy to reduce waiting times in the Emergency Department

    J Emerg Nurs

    (2009)
  • G. Arendts et al.

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

    Geriatr Gerontol Int

    (2010)
  • J.G. Ouslander et al.

    Geriatrics and the triple aim: Defining preventable hospitalizations in the long-term care population

    J Am Geriatr Soc

    (2012)
  • M.J. Hodgins et al.

    Full house: The incidence and impact of boarding admitted patients in the emergency department

    Outlook

    (2010)
  • P.M. Jensen et al.

    Are long-term care residents referred appropriately to hospital emergency departments?

    Can Fam Physician

    (2009)
  • C.E. Vossius et al.

    Referrals from nursing home to hospital: Reasons, appropriateness and costs

    Scand J Public Health

    (2013)
  • J.D. Walker et al.

    Identifying potentially avoidable hospital admissions from Canadian long-term care facilities

    Med Care

    (2009)
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    The authors declare no conflicts of interest.

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