Acute health care services use among nursing home residents in Germany: a comparative analysis of out-of-hours medical care, emergency department visits and acute hospital admissions

Effects of an interprofessional care concept in nursing homes evaluated in the SaarPHIR project: A cluster-randomized controlled trial

INTRODUCTION

Deficits in interprofessional collaboration can lead to insufficient medical care for nursing home residents, particularly inappropriate hospitalizations. Transfers are stressful for residents, and hospital stays can lead to infections and functional decline. Increasing the role of general practitioners and improving collaboration between professionals may reduce hospitalizations. In an effort to reduce hospitalizations and improve quality of care for nursing home residents, the SaarPHIR project implemented and evaluated a complex intervention which aimed at improving cooperation between general practitioners and nurses. This paper evaluates the effectiveness of an interprofessional care concept in nursing homes.

METHODS

A prospective, cluster-randomized controlled trial was conducted in Saarland, Germany, from May 2019 until July 2020 with a 15-months of follow-up, with two parallel groups and a 1:1 randomization at district level to evaluate the effectiveness of the intervention. The six administrative districts of the German federal state of Saarland were selected as randomization clusters to avoid spillover effects. The primary outcome, hospitalization, was assessed using claims data from six health insurers. Analyses were performed using generalized linear mixed models assuming both a Poisson and, for sensitivity analyses, a negative binomial distribution allowing for clustering at the nursing home level. Considering the randomized cluster level in the primary analysis would be the proper approach. However, after careful consideration, an unconventional approach was adopted to ensure the evaluation of the intervention within the complex healthcare system with a pragmatic design. The randomized cluster level was considered in sensitivity analyses. Secondary outcomes included ambulatory care-sensitive and nursing home care-sensitive admissions, mortality and hospital days. Furthermore, health economic aspects were explored by comparing costs between groups descriptively and exploratively using a generalized linear mixed model with a log-link and a gamma distribution.

RESULTS

Twenty-eight nursing homes received the intervention (1,053 residents), and 16 nursing homes (680 residents) were assigned to usual care. Hospitalization rates did not differ significantly between groups (incidence rate ratio [IRR] = 0.94; 95% CI: 0.78-1.14). Nursing home care-sensitive admissions could be reduced in residents treated with the interprofessional care concept (IRR: 0.73, 95% CI: 0.59-0.96). No differences in mortality, number of days spent in hospital and healthcare costs were found between groups. Mean drug costs (€82.53; 95% CI: 11.79-165.06) were higher and costs for ambulatory hospital stays lower (-€40.80; 95% CI: -76.50-0.00) in the intervention group.

CONCLUSION

All-cause hospitalization was not significantly affected in the relatively short duration of the intervention. Nevertheless, secondary outcomes suggest some positive effects for the intervention group. However, participation in the intervention group was lower than expected at both the nursing home and resident levels, limiting the validity of the results.

Hospitalizations, emergency medical care utilization, and contacts with the regional on-call medical services among nursing home residents in Germany: a cross-sectional study in 44 nursing homes

BACKGROUND

Nursing home residents frequently utilize medical care, but there lacks a complete picture of their acute medical care utilization. We quantified hospitalizations, emergency medical care utilization, and contacts with the regional on-call medical services among nursing home residents, and investigated individual characteristics that may be associated with the utilization of these medical care types.

METHODS

Cross-sectional data from the "Needs-based provision of medical care to nursing home residents" (MVP-STAT) study were analyzed, which were collected in 44 German nursing homes from 442 residents in 2018/2019. Proportions of residents with at least one hospitalization, emergency medical care utilization (via the nationwide phone number 112), and contact with an on-call medical service (nationwide via 116117) over the previous 12 months were determined. Associations between individual characteristics and the utilization of the three medical care types were examined using multivariable logistic regressions.

RESULTS

Of the analyzed residents, 45.8% were hospitalized, 23.2% utilized emergency medical care, and 12.1% had contact with an on-call medical service at least once in the previous 12 months. Hospitalizations were positively associated with male vs. female sex (adjusted odds ratio 1.99 [95% confidence interval 1.22-3.26]), age group 85 + vs. 60-74 years (2.15 [1.12-4.13]), long-term care grades 4/5 vs. 1/2 (2.78 [1.48-5.21]), 6 + vs. 0-1 Elixhauser diseases (2.58 [1.01-6.62]), and the risk or presence of vs. no malnutrition (3.10 [1.52-6.35] and 2.01 [1.26-3.21]); and not associated with years of residence in the respective nursing home. Emergency medical care utilization was positively associated with age group 85 + vs. 60-74 years (2.58 [1.14-5.84]) and long-term care grades 3 and 4/5 vs. 1/2 (2.65 [1.07-6.55], 6.31 [2.60-15.35]); negatively associated with 5 + vs. 1- < 3 years of residence (0.46 [0.24-0.86]); and not associated with sex, the number of Elixhauser diseases, and nutritional status. No associations were found with on-call medical services.

CONCLUSIONS

Hospitalizations and emergency medical care utilization were more frequent among nursing home residents than contacts with on-call medical services. Future studies should investigate whether the frequent hospitalizations and emergency medical care utilization among nursing home residents are justified, or whether they can be reduced by strengthening medical care provision by on-call doctors and other professionals.

TRIAL REGISTRATION

DRKS00012383 [2017/12/06].

Predictors of care home resident conveyance to hospital or referral to community pathways by a regional ambulance service attending medical emergencies: a retrospective cross sectional study

BACKGROUND

Care home residents are at higher risk compared with community dwelling elders for medical emergencies, often resulting in ambulance attendance and conveyance to hospital. We aimed to determine the factors predicting care home resident conveyance to hospital or referral to community pathways by an ambulance service.

METHODS

We used a retrospective cross-sectional study design analysing routine data from electronic clinical records from East Midlands Ambulance Service NHS Trust (EMAS). Data comprised all patients including care home residents attended by ambulance from 2018 to 2021. A multivariable logistic regression model was used to identify the main predictors of conveyance to hospital or referral to community services.

RESULTS

Data included 170,612 attendances to care homes representing 7.5% of the total number of EMAS attendances between 2018 and 2021. The main predictors of conveyance to hospital were being male (Relative Risk Ratio [RRR] 1.07, 95% Confidence Interval [CI] 1.03-1.10, p < 0.001), aged 70-79 years (RRR 1.09, 95%CI 1.03-1.17, p < 0.001) or 80-89 years (RRR 1.10, 95%CI 1.03-1.17, p < 0.001), situated in an area of higher deprivation (RRR 1.06, 95%CI 1.03-1.09, p < 0.001), or having dispatch categories which included cardiovascular (RRR 11.29, 95%CI 10.43-12.22, p < 0,001), trauma such as falls (RRR 9.50, 95%CI 8.97-10.05, p < 0,001) or neurological conditions (RRR 9.06, 95%CI 8.42-9.75, p < 0,001). Calls made by health care professionals (HCPs) (RRR 15.37, 95%CI 13.41-17.62, p < 0,001) or where patients had a higher National Early Warning Score (NEWS2) (RRR 1.23, 95%CI 1.22-1.24, p < 0,001) resulted in significantly increased conveyance.

CONCLUSIONS

Various factors significantly predicted conveyance of care home residents to hospital by ambulance. These included HCP referral and a higher NEWS2 score confirming that severity of clinical condition of the patient significantly increased conveyance. Future interventions to prevent or address certain conditions such as falls or provide enhanced care in care homes may prevent some emergencies or reduce the likelihood of conveyance to hospital.

Implementing telemedicine with 5G technologies in a nursing home for reducing emergency admissions- study protocol of a mixed-methods study

BACKGROUND

By transmitting various types of data, telemedical care enables the provision of care where physicians and patients are physically separated. In nursing homes, telemedicine has the potential to reduce hospital admissions in nonemergency situations. In this study, telemedicine devices were implemented with the new 5G mobile communications standard in selected wards of a large nursing home in Northwest Germany. The main aim of this study is to investigate which individual and organizational factors are associated with the use of telemedicine devices and how users perceive the feasibility and implementation of such devices. Moreover, it is investigated whether the telemedical devices help to reduce the number of emergency admissions.

METHODS

Telemedicine devices are implemented over an 18-month period using a private 5G network, and all users receive training. This study uses qualitative and quantitative methods: To assess the individual and organizational factors associated with the use of telemedicine devices, survey data from employees before and after the implementation of these devices are compared. To assess the perception of the implementation process as well as the feasibility and usability of the telemedical devices, the nursing staff, physicians, medical assistants and residents are interviewed individually. Moreover, every telemedicine consultation is evaluated with a short survey. To assess whether the number of emergency admissions decreased, data from one year before implementation and one year after implementation are compared. The data are provided by the integrated dispatch centre and emergency medical services (EMS) protocols. The interview data are analysed via structured qualitative content analysis according to Kuckartz. Survey data are analysed using multivariable regression analysis.

DISCUSSION

Learnings from the implementation process will be used to inform future projects implementing telemedicine in care organizations, making the final telemedicine implementation and care concept available to more nursing homes and hospitals. Moreover, the study results can be used to provide use cases for appropriate and targeted application of telemedicine in nursing homes and to define the role of 5G technologies in these use cases. If the intervention is proven successful, the results will be used to promote 5G network rollout.

TRIAL REGISTRATION

German Clinical Trials Register - trial registration number: DRKS00030598.

Differences in emergency department visits and hospitalization between German and Dutch nursing home residents: a cross-national survey

PURPOSE

Assessing and comparing German and Dutch nursing home perspectives on residents' hospital transfers.

METHODS

Cross-sectional study among German and Dutch nursing homes. Two surveys were conducted in May 2022, each among 600 randomly selected nursing homes in Germany and the Netherlands. The questionnaires were identical for both countries. The responses were compared between the German and Dutch participants.

RESULTS

We received 199 German (response: 33.2%) and 102 Dutch questionnaires (response: 17.0%). German nursing homes estimated the proportion of transfers to hospital during 1 year to be higher than in Dutch facilities (emergency department visits: 26.5% vs. 7.9%, p < 0.0001; hospital admissions: 29.5% vs. 10.5%, p < 0.0001). In German nursing homes, the proportion of transfers to hospital where the decision was made by the referring physician was lower than in the Dutch facilities (58.8% vs. 88.8%, p < 0.0001). More German nursing homes agreed that nursing home residents are transferred to the hospital too frequently (24.5% vs. 10.8%, p = 0.0069). German nursing homes were much more likely than Dutch facilities to believe that there was no alternative to transfer to a hospital when a nursing home resident had a fall (66.3% vs. 12.8%, p < 0.0001).

CONCLUSION

German nursing home residents are transferred to hospital more frequently than Dutch residents. This can probably be explained by differences in the care provided in the facilities. Future studies should, therefore, look more closely at these two systems and examine the extent to which more intensive outpatient care can avoid transfers to hospital.

Variations in older people's emergency care use by social care setting: a systematic review of international evidence

BACKGROUND

Older adults' use of social care and their healthcare utilization are closely related. Residents of care homes access emergency care more often than the wider older population; however, less is known about emergency care use across other social care settings.

SOURCES OF DATA

A systematic review was conducted, searching six electronic databases between January 2012 and February 2022.

AREAS OF AGREEMENT

Older people access emergency care from a variety of community settings.

AREAS OF CONTROVERSY

Differences in study design contributed to high variation observed between studies.

GROWING POINTS

Although data were limited, findings suggest that emergency hospital attendance is lowest from nursing homes and highest from assisted living facilities, whilst emergency admissions varied little by social care setting.

AREAS TIMELY FOR DEVELOPING RESEARCH

There is a paucity of published research on emergency hospital use from social care settings, particularly home care and assisted living facilities. More attention is needed on this area, with standardized definitions to enable comparisons between studies.

[Emergency department visits by nursing home residents: analysis of routine data from an urban hospital]

BACKGROUND

The number of emergency department (ED) visits in Germany continues to increase, especially by older people and persons receiving care.

OBJECTIVES

We aimed to characterize ED visits by nursing home residents (NHR) in Germany.

MATERIALS AND METHODS

We analyzed routine data of a hospital without trauma surgery (Pius-Hospital Oldenburg). All ED visits by NHR in the period 06/2014-05/2017 were selected from the hospital information system.

RESULTS

Of 47,270 ED visits, 1676 (3.6%) were NHR (mean age: 78.8 years; 62.9% women; 40.3% were referred). Of them, 20.1% were on weekends and 80.6% occurred between 8 am-8 pm. A total of 84.2% visits led to hospitalization; the length of stay was 1 day for 21.1% and 2-3 days for another 14.6%. With longer length of stay, the proportion of admissions by referring physicians increased. Of those admitted, 10.3% died during hospitalization (28.2% on the day of admission; 47.9% within the first 3 days). People who died were older, their visits were more frequently on weekends, and they were less often referred.

CONCLUSION

Our study reveals problems in several areas. Improved interprofessional cooperation with general practitioners and strengthened palliative structures should be implemented in nursing homes. Furthermore, there is a need for establishing processes in EDs to realize continued outpatient care for these patients.

Acute Health Care Provision in Rural Long-Term Care Facilities: A Scoping Review of Integrated Care Models

OBJECTIVES

We aimed to map integrated care models for acute health care in rural long-term care facilities (LTCFs) for future investigation.

DESIGN

Systematic scoping review.

SETTING AND PARTICIPANTS

Residential LTCFs in rural areas worldwide.

METHODS

The common health-related online databases were systematically searched complemented by a manual search of gray literature. Following the 5-stage framework of Arksey and O'Malley, the extent of included literature was identified and findings were summarized using qualitative meta-summary.

RESULTS

A total of 35 references were included for synthesis, predominantly primary research on completed and ongoing projects reporting on integrated health care services in rural LTCFs. Incorporating previous research, we extracted 5 approaches of integrated acute-health care models: (1) Availability of Specialists, (2) Networks, (3) Quality Management (QM) and Organization, (4) Telemedicine, and (5) Telehealth.

CONCLUSIONS AND IMPLICATIONS

This research presents the result of a literature review examining integrated care models as a way to improve acute health care in LTCFs in rural areas. Integrated care models in rural settings can help face the challenging situation and fulfil the complex health care needs of LTCF residents by reducing fragmentation and thereby improve continuity and coordination of acute health care services. These results can guide policy making in creating interventions and support adequate implementation of care models by knowledge translation in health care.

[Impact of CoCare, a Complex Model Intervention, on medical care in long-term care nursing homes in Germany: An overview of the outcome and process evaluation]

INTRODUCTION

More and more people are being cared for in nursing homes these days. Multimorbidity results in frequent but sometimes unnecessary patient transports and hospitalisations. The CoCare intervention was developed as a nursing home-based intervention to improve coordination of medical care and GP and specialist care in long-term care homes. The project aimed to reduce avoidable hospital admissions and ambulance transportation, minimise costs through the resulting better collaboration and improving the quality of life of nursing home residents. This article presents the results of the process and outcome evaluation of the intervention in an integrated way and assesses them against the background of the project objectives.

METHODS

Intervention and data collection started in January 2018 and ended in September 2020. A mixed-methods design was chosen for the evaluation. The (cost) effectiveness of the intervention was tested by a controlled observational study, comparing intervention (IG) and control group (CG). As part of the evaluation of the results, claims data from health insurance funds and a questionnaire-based survey among nursing staff, physicians and nursing home residents were analysed. As part of the process evaluation, subjectively perceived changes in care and implementation difficulties were recorded with the help of focus groups and telephone interviews conducted quarterly.

RESULTS

From the point of view of the health economic evaluation, with a decrease in total costs of € 468.56 (p<.001) per nursing home resident and quarter, an advantageous cost-benefit ratio can be assumed. Thus, the significant increase in outpatient care for nursing home residents goes along with a reduction of ambulance transportation by 0.19 (p=.049) and hospitalization rates by 0.08 (p=.001). In the nursing staff sample, a significant positive difference between IG (T1) and CG was observed with regard to communication and cooperation. In addition, pre-post comparison showed a significant improvement in the nursing staff's assessment of interprofessional cooperation in IG at T1 compared to T0. Both nursing staff and physicians perceived positive changes in care and positively assessed the benefit of the intervention. While practitioners experienced an intensification and improvement of communication and cooperation through the implementation of the CoCare measures, these changes were not perceived by residents.

DISCUSSION

The CoCare intervention lowered the barriers for nursing homes to contact general practitioners, specifically in unclear situations and can thus be seen as an effective tool to reduce potentially avoidable hospital admissions and costs. It is conceivable that results can be transferred to other regions in Germany and to similar care scenarios. It should be examined to what extent approaches of this new form of care can be transferred to standard care and whether adjustments to facilitate the implementation of coordinated care approaches across occupational groups in inpatient care facilities can be proposed within the framework of legislative procedures.

[Advance Directives and Palliative Medical Care in Nursing Homes: A Study on Everyday Life and Relevance in Out-of-Hours Medical Care]

BACKGROUND

The percentage of nursing home residents that have documented advance directives (AD) is increasing. However, there are no studies concerning the consideration of these directives within the out-of-hours primary care or the emergency service. There is also a lack of information on the differences in the attitudes of doctors on duty in various disciplines towards therapeutic options in palliative situations.

METHODS

In the context of research about the medical care of nursing home residents outside regular practice hours, the existence of AD and their consideration by the doctors on duty or emergency doctors was investigated (n=101). Furthermore, the attitudes of the doctors on duty (n=60) and of a reference group of palliative doctors (n=19) towards experience in palliative medicine, asking for AD of the patients and the approach in a fictive palliative case were recorded.

RESULTS

71% of the 82 residents had documented a living will. In 54% of the 101 cases, the doctors on duty and emergency doctorsmade enquiries about AD. In 92% of cases, the doctors followed the given directives. Significant differences between doctors on duty and emergency doctors could not be confirmed. Given a fictive palliative case, 92% of the doctors on duty and 95% of the reference group stated they would enquire about an AD. In acute palliative situations, general practitioners, internists and palliative physicians were more likely to use rapid-acting opioids and anxiolytics, were less likely to call the emergency doctor and were less likely to admit patients to hospital. This distinguishes them from other disciplines.

CONCLUSIONS

In only 54% of all contacts between patient and doctors on duty or emergency doctors, enquiries were about an AD. That is why doctors need to be further sensitized on the issue of making enquiries about AD from unknown. Additionally, the patient's will should be visible in short form in the respective patient file. Arrangements made with foresight, early involvement of doctors with palliative experience (AAPV, SAPV) as well as increased palliative medical training could improve the care of nursing home residents.

Factors associated with increased Emergency Department transfer in older long-term care residents: a systematic review

The proportion of adults older than 65 years is rapidly increasing. Care home residents in this age group have disproportionate rates of transfer to the Emergency Department (ED) and around 40% of attendances might be avoidable. We did a systematic review to identify factors that predict ED transfer from care homes. Six electronic databases were searched. Observational studies that provided estimates of association between ED attendance and variables at a resident or care home level were included. 26 primary studies met the inclusion criteria. Seven common domains of factors assessed for association with ED transfer were identified and within these domains, male sex, age, presence of specific comorbidities, polypharmacy, rural location, and care home quality rating were associated with likelihood of ED transfer. The identification of these factors provides useful information for policy makers and researchers intending to either develop interventions to reduce hospitalisations or use adjusted rates of hospitalisation as a care home quality indicator.

[Emergency situations and emergency department visits in nursing homes-a scoping review about circumstances and healthcare interventions]

BACKGROUND

Nursing home residents are more likely to be hospitalized as non-institutionalized peers. A large number of emergency medical services (EMS) and emergency department visits are classified as potentially avoidable.

OBJECTIVES

To identify circumstances that increase the number of emergency situations in nursing homes and approaches to reduce hospital admissions in order to illustrate the complexity and opportunities for action.

MATERIALS AND METHODS

Scoping review with analysis of current original and peer-reviewed papers (2015-2020) in PubMed, CINAHL, and hand-search databases.

RESULTS

From 2486 identified studies, 302 studies were included. Injuries, fractures, cardiovascular, respiratory, and infectious diseases are the most frequent diagnostic groups that have been retrospectively recorded. Different aspects could be identified as circumstances inducing emergency department visits: resident-related (e.g., multimorbidity, lack of volition, and advance directives), facility-related (e.g., staff turnover, uncertainties), physician-related (lack of accessibility, challenging access to specialists), and system-related circumstances (e.g., limited possibilities for diagnostics and treatment in facilities). Multiple approaches to reduce emergency department visits are being explored.

CONCLUSIONS

A variety of circumstances influence the course of action in emergency situations in nursing facilities. Therefore, interventions to reduce emergency department visits address, among other things, strengthening the competence of nursing staff, interprofessional communication, and systemic approaches. A comprehensive understanding of the complex processes of care is essential for developing and implementing effective interventions.

[Support of treatment safety by nursing personnel when dealing with emergency situations in long-term care facilities : Results of a qualitative empirical study]

A significant number of emergency responses and hospitalizations of nursing home residents are considered avoidable and result in an unnecessary burden or health risk for residents. One cause of these unnecessary emergency responses lies in the lack of confidence of nursing personnel in their own actions and decisions. The goal of the NOVELLE project is to develop recommendations for action for certain emergency situations that enable nursing personnel to make operationalized decisions and empower them to take confident action. The challenges for nursing professionals to act with confidence in emergency situations were collated and assessed through a qualitative interview study. The results of this study are presented.

[Care of older patients by community emergency paramedics : Comparison of community-dwellers and nursing home residents]

Hintergrund

Notaufnahmen und Rettungsdienste werden zunehmend durch nicht vital bedrohlich erkrankte Patienten belastet. Ein großer Anteil der Rettungsdiensteinsätze entfällt auf ältere Menschen. Um eine unnötige Disponierung höherwertiger Rettungsmittel zu reduzieren, wurde das Modellprojekt Gemeindenotfallsanitäter (G-NFS) entwickelt.

Ziel der Arbeit

Ziel dieser Arbeit war es herauszufinden, ob sich spezifische Einsatzschwerpunkte des G‑NFS in der Versorgung älterer Menschen in häuslicher Umgebung und im Pflegeheim zeigen.

Material und Methoden

Es handelt sich um eine retrospektive Beobachtungsstudie auf Basis der Einsatzdokumentation vom 01.07.2019 bis zum 30.06.2020. Es wurden G‑NFS Einsätze bei älteren Menschen (≥ 65 Jahre) analysiert, unterteilt nach den Einsatzorten Pflegeheim oder Häuslichkeit.

Ergebnisse

Es wurden 2358 Protokolle ausgewertet (Durchschnittsalter: 80,8 Jahre; 52,9 % weiblich). Vor Ort wurden 55 % der Patienten versorgt. Die durchgeführten Maßnahmen umfassten Beratungsgespräche (79,4 %), Hilfe bei Selbstmedikation (16,7 %) und Medikamentengabe (23,2 %). Auf Pflegeheimbewohner entfielen 329 (14,0 %) Einsätze. Maßnahmen in Bezug auf Urindauerkatheter wurden häufiger bei Pflegeheimbewohnern als in der Häuslichkeit durchgeführt (32,2 % bzw. 5,7 % aller Einsätze). Bei Patienten mit Katheterproblemen erfolgte im Vergleich zu anderen Einsätzen nahezu immer eine Versorgung vor Ort (84,3 % bzw. 52,2 %).

Diskussion

Durch G‑NFS können die Mehrzahl der älteren Patienten ambulant versorgt und andere Ressourcen entlastet werden. Allerdings führen G‑NFS auch Maßnahmen durch, die im Verantwortungsbereich der hausärztlichen Versorgung liegen, und gleichen somit strukturelle Defizite in der medizinisch-pflegerischen Versorgung aus.

Zusatzmaterial online

Die Onlineversion dieses Beitrags (10.1007/s00063-021-00863-8) enthält die Tabellen S1–S3.

Effects of strategies to improve general practitioner-nurse collaboration and communication in regard to hospital admissions of nursing home residents (interprof ACT): study protocol for a cluster randomised controlled trial

BACKGROUND

In Germany, up to 50% of nursing home residents are admitted to a hospital at least once a year. It is often unclear whether this is beneficial or even harmful. Successful interprofessional collaboration and communication involving general practitioners (GPs) and nurses may improve medical care of nursing home residents. In the previous interprof study, the six-component intervention package interprof ACT was developed to facilitate collaboration of GPs and nurses in nursing homes. The aim of this study is to evaluate the effectiveness of the interprof ACT intervention.

METHODS

This multicentre, cluster randomised controlled trial compares nursing homes receiving the interprof ACT intervention package for a duration of 12 months (e.g. comprising appointment of mutual contact persons, shared goal setting, standardised GPs' home visits) with a control group (care as usual). A total of 34 nursing homes are randomised, and overall 680 residents recruited. The intervention package is presented in a kick-off meeting to GPs, nurses, residents/relatives or their representatives. Nursing home nurses act as change agents to support local adaption and implementation of the intervention measures. Primary outcome is the cumulative incidence of hospitalisation within 12 months. Secondary outcomes include admissions to hospital, days admitted to hospital, use of other medical services, prevalence of potentially inappropriate medication and quality of life. Additionally, health economic and a mixed methods process evaluation will be performed.

DISCUSSION

This study investigates a complex intervention tailored to local needs of nursing homes. Outcomes reflect the healthcare and health of nursing home residents, as well as the feasibility of the intervention package and its impact on interprofessional communication and collaboration. Because of its systematic development and its flexible nature, interprof ACT is expected to be viable for large-scale implementation in routine care services regardless of local organisational conditions and resources available for medical care for nursing home residents on a regular basis. Recommendations will be made for an improved organisation of primary care for nursing home residents. In addition, the results may provide important knowledge and data for the development and evaluation of further strategies to improve outpatient care for elderly care-receivers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03426475 . Initially registered on 7 February 2018.

Sex-Specific Differences in Hospital Transfers of Nursing Home Residents: Results from the HOspitalizations and eMERgency Department Visits of Nursing Home Residents (HOMERN) Project

Nursing home (NH) residents are often transferred to hospital (emergency department (ED) visits or hospital admissions) and this occurs more frequently in males. However, respective reasons are rather unclear. We conducted a multicenter prospective study in 14 northwest German NHs with 802 residents in which NH staff recorded anonymized data between March 2018 and July 2019 for each hospital transfer. Measures were analyzed using descriptive statistics and compared between sexes via univariate logistic regression analyses using mixed models with random effects. Eighty-eight planned transfers (53.5% hospital admissions, 46.5% ED visits) occurred as well as 535 unplanned transfers (63.1% hospital admissions, 36.9% ED visits). The two most common causes for unplanned transfers were deteriorations of health status (35.1%) and falls/accidents/injuries (33.5%). Male transferred residents were younger, more often married; their advance directives were more commonly not considered correctly and the NH staff identified more males nearing the end of life than females (52.9% vs. 38.2%). Only 9.2% of transfers were rated avoidable. For advance directive availability and NH staff’s perceptions on transfer conditions, we found marked inter-facility differences. There might be sociocultural factors influencing hospital transfer decisions of male and female nursing home residents and facility characteristics that may affect transfer policy.

Paramedics' Perspectives on the Hospital Transfers of Nursing Home Residents-A Qualitative Focus Group Study

Emergency department (ED) visits and hospital admissions are common among nursing home residents (NHRs). Little is known about the perspectives of emergency medical services (EMS) which are responsible for hospital transports. The aim of this study was to explore paramedics’ experiences with transfers from nursing homes (NHs) and their ideas for possible interventions that can reduce transfers. We conducted three focus groups following a semi-structured question guide. The data were analyzed by content analysis using the software MAXQDA. In total, 18 paramedics (mean age: 33 years, male n = 14) participated in the study. Paramedics are faced with complex issues when transporting NHRs to hospital. They mainly reported on structural reasons (e.g., understaffing or lacking availability of physicians), which led to the initiation of an emergency call. Handovers were perceived as poorly organized because required transfer information (e.g., medication lists, advance directives (ADs)) were incomplete or nursing staff was insufficiently prepared. Hospital transfers were considered as (potentially) avoidable in case of urinary catheter complications, exsiccosis/infections and falls. Legal uncertainties among all involved professional groups (nurses, physicians, dispatchers, and paramedics) seemed to be a relevant trigger for hospital transfers. In paramedics’ point of view, emergency standards in NHs, trainings for nursing staff, the improvement of working conditions and legal conditions can reduce potentially avoidable hospital transfers from NHs.

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

Background

Visits in emergency departments and hospital admissions are common among nursing home (NH) residents and they are associated with significant complications. Many of these transfers are considered inappropriate. This study aimed to compare the perceptions of general practitioners (GPs) and NH staff on hospital transfers among residents and to illustrate measures for improvement.

Methods

Two cross-sectional studies were conducted as surveys among 1121 GPs in the German federal states Bremen and Lower Saxony and staff from 1069 NHs (preferably nursing staff managers) from all over Germany, each randomly selected. Questionnaires were sent in August 2018 and January 2019, respectively. The answers were compared between GPs and NH staff using descriptive statistics, Mann-Whitney U tests and χ2-tests.

Results

We received 375 GP questionnaires (response: 34%) and 486 NH questionnaires (response: 45%). GPs estimated the proportion of inappropriate transfers higher than NH staff (hospital admissions: 35.0% vs. 25.6%, p < 0.0001; emergency department visits: 39.9% vs. 20.9%, p < 0.0001). The majority of NH staff and nearly half of the GPs agreed that NH residents do often not benefit from hospital admissions (NHs: 61.4% vs. GPs: 48.8%; p = 0.0009). Both groups rated almost all potential measures for improvement differently (p < 0.0001), however, GPs and NH staff considered most areas to reduce hospital transfers importantly. The two most important measures for GPs were more nursing staff (91.6%) and better communication between nursing staff and GP (90.9%). NH staff considered better care / availability of GP (82.8%) and medical specialists (81.3%) as most important. Both groups rated similarly the importance of explicit advance directives (GPs: 77.2%, NHs: 72.4%; p = 0.1492).

Conclusions

A substantial proportion of hospital transfers from NHs were considered inappropriate. Partly, the ratings of possible areas for improvement differed between GPs and NH staff indicating that both groups seem to pass the responsibility to each other. These findings, however, support the need for interprofessional collaboration.