Appropriateness of transferring nursing home residents to emergency departments: a systematic review

Bridging Hospital and Nursing Home: Collaboration for Smoother Transitions and Reduced Hospitalizations

The exigencies of managing acutely ill residents within nursing homes have led to an increase in ambulance conveyances to the emergency department. This is further compounded by a shortage of adequately trained nursing staff and on-site physicians available around the clock. An acute regional hospital, strategically located in the epicenter of nursing home facilities in Singapore, encountered this challenge on its inception in 2018 within the northeast region. In response, the institution initiated a collaboration, EAGLEcareACT (Enhancing Advance Care Planning, Geriatrics, and End-of-Life Care Acute Care Team), aimed at rectifying the prevailing care disparities between neighboring nursing homes and the hospital. Within the EAGLEcareACT, a systematic and comprehensive approach was undertaken to engage diverse nursing homes, delineate precise needs, and establish mutually shared objectives. This encompassed the provisioning of monitoring of patients treated for acute medical conditions, structured training programs for nursing staff and aids in advance care planning. Teleconsultations with EAGLEcareACT team obviate the immediate necessity for conveyance to the emergency department.

Analysis of traumatic event emergency department visits among care home residents aged 65 + years in Southern Jutland, Denmark: implications for comprehensive care and subsequent hospital admissions - a register-based cohort study

BACKGROUND

Care home residents aged 65 + years frequently experience acute health issues, leading to emergency department visits. Falls and associated injuries are a common cause of these visits and falls in a geriatric population can be a symptom of an incipient acute illness such as infection. Conversely, the traumatic event can cause illnesses to arise due to consequences of the fall, e.g. delirium or constipation due to opioid use. We hypothesised that a traumatic event treat-and-release emergency department visit serves as an indicator for an upcoming acute hospital admission due to non-trauma-related conditions.

METHODS

We studied emergency department visits for traumatic events among all care home residents aged 65+ (n = 2601) living in Southern Jutland, Denmark, from 2018 to 2019. Data from highly valid national registers were used to evaluate diagnoses, mortality, and admissions. Cox Regression was used to analyse the hazard of acute hospital admission following an emergency department treat-and-release visit.

RESULTS

Most visits occurred on weekdays and during day shifts, and 72.0% were treated and released within 6 h. Contusions, open wounds, and femur fractures were the most common discharge diagnoses, accounting for 53.3% of all cases (n = 703). In-hospital mortality was 2.3%, and 30-day mortality was 10.4%. Among treat-and-release visits (n = 506), 25% resulted in a new hospital referral within 30 days, hereof 13% treat-and-release revisits (duration ≤ 6 h), and 12% hospital admissions (duration > 6 h). Over half (56%) of new hospital referrals were initiated within the first seven days of discharge. Almost three-fourths of subsequent admissions were caused by various diseases. The hazard ratio of acute hospital admissions was 2.20 (95% CI: 1.52-3.17) among residents with a recent traumatic event treat-and-release visit compared to residents with no recent traumatic event treat-and-release visit.

CONCLUSION

Traumatic event treat-and-release visits among care home residents serve as an indicator for subsequent hospitalisations, highlighting the need for a more comprehensive evaluation, even for minor injuries. These findings have implications for improving care, continuity, and resource utilisation.

TRIAL REGISTRATION

Not relevant.

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.

Emergency department visits by nursing home residents. A retrospective Italian study of administrative databases from 2015 to 2019

BACKGROUND

Visits to Emergency Departments (ED) can be traumatic for Nursing Home (NH) residents. In Italy, the rate of ED visits by NH residents was recently calculated as 3.3%. The reduction of inappropriate ED visits represents a priority for National Healthcare Systems worldwide. Nevertheless, research on factors associated with ED visits is still under-studied in the Italian setting. This study has two main aims: (i) to describe the baseline characteristics of NH residents visiting ED at regional level; (ii) to assess the characteristics, trends, and factors associated with these visits.

METHODS

A retrospective study of administrative data for five years was performed in the Piedmont Region. Data from 24,208 NH residents were analysed. Data were obtained by merging two ministerial databases of residential care and ED use. Sociodemographic and clinical characteristics of the residents, trends, and rates of ED visits were collected. A Generalized Linear Model (GLM) regression was used to evaluate the factors associated with ED visits.

RESULTS

In 5 years, 12,672 residents made 24,609 ED visits. Aspecific symptoms (45%), dyspnea (17%) and trauma (16%) were the most frequent problems reported at ED. 51% of these visits were coded as non-critical, and 58% were discharged to the NH. The regression analysis showed an increased risk of ED visits for men (OR = 1.61, 95% CI 1.51-1.70) and for residents with a stay in NH longer than 400 days (OR = 2.19, 95% CI 2.08-2.31).

CONCLUSIONS

Our study indicates that more than half of NH residents' ED visits could potentially be prevented by treating residents in NH. Investments in the creation of a structured and effective network within primary care services, promoting the use of health technology and palliative care approaches, could reduce ED visits and help clinicians manage residents on-site and remotely.

Areas of consensus on unwarranted and warranted transfers between nursing homes and emergency care facilities in Norway: a Delphi study

BACKGROUND

Transferring residents from nursing homes (NHs) to emergency care facilities (ECFs) is often questioned as many are terminally ill and have access to onsite care. While some NH to ECF transfers have merit, avoiding other transfers may benefit residents and reduce healthcare system costs and provider burden. Despite many years of research in this area, differentiating warranted (i.e., appropriate) from unwarranted NH to ECF transfers remains challenging. In this article, we report consensus on warranted and unwarranted NH to ECF transfers scenarios.

METHODS

A Delphi study was used to identify consensus regarding warranted and unwarranted NH to ECF transfers. Delphi participants included nurses (RNs) and medical doctors (MDs) from NHs, out-of-hours primary care clinics (OOHs), and hospital-based emergency departments. A list of 12 scenarios and 11 medical conditions was generated from the existing literature on causes and medical conditions leading to transfers, and pilot tested and refined prior to conducting the study. Three Delphi rounds were conducted, and data were analyzed using descriptive and comparative statistics.

RESULTS

Seventy-nine experts consented to participate, of whom 56 (71%) completed all three Delphi rounds. Participants reached high or very high consensus on when to not transfer residents, except for scenarios regarding delirium, where only moderate consensus was attained. Conversely, except when pain relieving surgery was required, participants reached low agreement on scenarios depicting warranted NH to ECF transfers. Consensus opinions differ significantly between health professionals, participant gender, and rurality, for seven of the 23 transfer scenarios and medical conditions.

CONCLUSIONS

Transfers from nursing homes to emergency care facilities can be defined as warranted, discretionary, and unwarranted. These categories are based on the areas of consensus found in this Delphi study and are intended to operationalize the terms warranted and unwarranted transfers between nursing homes and emergency care facilities.

Models for delivery and co-ordination of primary or secondary health care (or both) to older adults living in aged care facilities

BACKGROUND

The number of older people is increasing worldwide and public expenditure on residential aged care facilities (ACFs) is expected to at least double, and possibly triple, by 2050. Co-ordinated and timely care in residential ACFs that reduces unnecessary hospital transfers may improve residents' health outcomes and increase satisfaction with care among ACF residents, their families and staff. These benefits may outweigh the resources needed to sustain the changes in care delivery and potentially lead to cost savings. Our systematic review comprehensively and systematically presents the available evidence of the effectiveness, safety and cost-effectiveness of alternative models of providing health care to ACF residents.

OBJECTIVES

Main objective To assess the effectiveness and safety of alternative models of delivering primary or secondary health care (or both) to older adults living in ACFs. Secondary objective To assess the cost-effectiveness of the alternative models.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers (WHO ICTRP, ClinicalTrials.gov) on 26 October 2022, together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included individual and cluster-randomised trials, and cost/cost-effectiveness data collected alongside eligible effectiveness studies. Eligible study participants included older people who reside in an ACF as their place of permanent abode and healthcare professionals delivering or co-ordinating the delivery of healthcare at ACFs. Eligible interventions focused on either ways of delivering primary or secondary health care (or both) or ways of co-ordinating the delivery of this care. Eligible comparators included usual care or another model of care. Primary outcomes were emergency department visits, unplanned hospital admissions and adverse effects (defined as infections, falls and pressure ulcers). Secondary outcomes included adherence to clinical guideline-recommended care, health-related quality of life of residents, mortality, resource use, access to primary or specialist healthcare services, any hospital admissions, length of hospital stay, satisfaction with the health care by residents and their families, work-related satisfaction and work-related stress of ACF staff.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any alternative model of care versus usual care.

MAIN RESULTS

We included 40 randomised trials (21,787 participants; three studies only reported number of beds) in this review. Included trials evaluated alternative models of care aimed at either all residents of the ACF (i.e. no specific health condition; 11 studies), ACF residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers, 13 studies) or residents requiring a specific type of care (e.g. residents after hospital discharge, four studies). Most alternative models of care focused on 'co-ordination of care' (n = 31). Three alternative models of care focused on 'who provides care' and two focused on 'where care is provided' (i.e. care provided within ACF versus outside of ACF). Four models focused on the use of information and communication technology. Usual care, the comparator in all studies, was highly heterogeneous across studies and, in most cases, was poorly reported. Most of the included trials were susceptible to some form of bias; in particular, performance (89%), reporting (66%) and detection (42%) bias. Compared to usual care, alternative models of care may make little or no difference to the proportion of residents with at least one emergency department visit (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.84 to 1.20; 7 trials, 1276 participants; low-certainty evidence), but may reduce the proportion of residents with at least one unplanned hospital admission (RR 0.74, 95% CI 0.56 to 0.99, I2 = 53%; 8 trials, 1263 participants; low-certainty evidence). We are uncertain of the effect of alternative models of care on adverse events (proportion of residents with a fall: RR 1.15, 95% CI 0.83 to 1.60, I² = 74%; 3 trials, 1061 participants; very low-certainty evidence) and adherence to guideline-recommended care (proportion of residents receiving adequate antidepressant medication: RR 5.29, 95% CI 1.08 to 26.00; 1 study, 65 participants) as the certainty of the evidence is very low. Compared to usual care, alternative models of care may have little or no effect on the health-related quality of life of ACF residents (MD -0.016, 95% CI -0.036 to 0.004; I² = 23%; 12 studies, 4016 participants; low-certainty evidence) and probably make little or no difference to the number of deaths in residents of ACFs (RR 1.03, 95% CI 0.92 to 1.16, 24 trials, 3881 participants, moderate-certainty evidence). We did not pool the cost-effectiveness or cost data as the specific costs associated with the various alternative models of care were incomparable, both across models of care as well as across settings. Based on the findings of five economic evaluations (all interventions focused on co-ordination of care), we are uncertain of the cost-effectiveness of alternative models of care compared to usual care as the certainty of the evidence is very low.

AUTHORS' CONCLUSIONS

Compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits but may reduce unplanned hospital admissions. We are uncertain of the effect of alternative care models on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guidelines compared to usual care, as the certainty of the evidence is very low. Alternative models of care may have little or no effect on health-related quality of life and probably have no effect on mortality of ACF residents compared to usual care. Importantly, we are uncertain of the cost-effectiveness of alternative models of care due to the limited, disparate data available.

Internal Medicine Virtual Specialist Assessment Program Reduces Emergency Department Transfers from Long-Term Care

BACKGROUND

Transfers to emergency departments (EDs) from long-term care (LTC) can expose residents to care discontinuities and risks. Virtual platforms can increase the breadth of care available for residents within their facility, thus replacing transfers to EDs when safe and appropriate. The authors aimed to assess whether leveraging a virtual care platform at an LTC facility would reduce the number of transfers to EDs.

METHODS

Data on the number of transfers to EDs were collected from January 2019 to October 2021 at an LTC facility. In June 2020 the home began using a virtual care platform that allowed residents to speak with specialist physicians through video and receive management plans remotely. The authors evaluated the Internal Medicine Virtual Specialist Program (IMVSP) using a pre-post study design by comparing the number of transfers to EDs and the proportion of transfers resulting in hospital admission before and after program implementation. Unstructured phone interviews were conducted with employees at the home to understand their experiences.

RESULTS

The median number of transfers to EDs per month after program implementation showed a 13.0% reduction. The median proportion of these transfers resulting in hospital admission per month increased by 26.1%. Employees at the LTC home were satisfied with the program.

CONCLUSION

The IMVSP reduced transfers to EDs and allowed for a higher proportion of transfers that resulted in hospital admission. Early access to specialist care via virtual platforms has important implications for improving accessibility to high-quality care for LTC residents and reducing risks associated with transfers.

Development and validation of the resident safety activity questionnaire for long-term care facility staff

This study developed and tested a questionnaire to evaluate the safety activities supporting older adult residents' quality of care among long-term care facility staff. The process included item construction, expert review and pilot testing, testing of reliability and validation with 268 staff from 12 targeted facilities in South Korea. The final questionnaire yielded 28 items across six domains: proactive activities for emergency situations, comfort management, prevention of infections, staff training and communication, sufficient goods and equipment, and adequate personnel. These factors explained 73.48 % of the total variance. The fit indices in the confirmatory factor analysis were acceptable, and the total Cronbach's ⍺ was 0.952 (sub-domains: 0.823 - .895), indicating high reliability. The findings suggest the reliability and validity of the newly-developed Resident Safety Activity Questionnaire, enabling an accurate evaluation of the safety of long-term care facility residents and serving as an indicator for improving care quality in such establishments.

Identifying key items to be addressed by non-clinical operators to manage out-of-hours telephone triage services for older adults seeking non-urgent unplanned care in Belgium: an e-Delphi study

BACKGROUND

This study aimed to achieve expert consensus regarding key items to be addressed by non-clinical operators using computer-software integrated medical dispatch protocols to manage out-of-hours telephone triage (OOH-TT) services for calls involving older adults seeking non-urgent unplanned care across Belgium.

METHODS

A three-part classic e-Delphi study was conducted. A purposive sample of experts specialized in out-of-hours unplanned care and/or older persons across Belgium were recruited as panelists. Eligibility criteria included experts with at least 2 years of relevant experience. Level of consensus was defined to be reached when at least 70% of the panelists agreed or disagreed regarding the value of each item proposed within a survey for the top 10 most frequently used protocols for triaging older adults. Responses were analyzed over several rounds until expert consensus was found. Descriptive and thematic analyses were used to aggregate responses.

RESULTS

N = 12 panelists agreed that several important missing protocol topics were not covered by the existing OOH-TT service. They also agreed about the nature of use (for the top 10 most frequently used protocols) but justified that some modifications should be made to keywords, interrogation questions, degree of urgency and/or flowcharts used for the algorithms to help operators gain better comprehensive understanding patient profiles, medical habits and history, level of support from informal caregivers, known comorbidities and frailty status. Furthermore, panelists also stressed the importance of considering feasibility in implementing protocols within the real-world setting and prioritizing the right type of training for operators which can facilitate the delivery of high-quality triage. Overall, consensus was found for nine of the top 10 most frequently used protocols for triaging older adults with no consensus found for the protocol on triaging patients unwell for no apparent reason.

CONCLUSION

Our findings show that overall, a combination of patient related factors must be addressed to provide high quality triage for adults seeking non-urgent unplanned care over the telephone (in addition to age). However, further elements such as appropriate operator training and feasibility of implementing more population-specific protocols must also be considered. This study presents a useful step towards identifying key items which must be targeted within the larger scope of providing non-urgent out-of-hours telephone triage services for older adults seeking non-urgent unplanned care.

Comparison of medical care needs and actual care in German and Dutch nursing home residents: A cross-sectional study conducted in neighboring European countries

OBJECTIVE

Assessing and comparing characteristics of German and Dutch nursing homes, their residents as well as residents' medical care needs and the actual provision of care.

METHODS

Two surveys were conducted among 600 randomly selected nursing homes each from Germany and the Netherlands. Questionnaires were mailed in May 2022. Responses were compared between German and Dutch respondents.

RESULTS

We received 199 German (response: 33.2%) and 102 Dutch questionnaires (response: 17.0%). Residents' characteristics were comparable in both countries. While German nursing homes rated residents' general medical care needs higher than Dutch facilities (87.9% vs. 78.4%), the reverse was true for dental care needs (81.4% vs. 71.1%). For all 4 medical specialties surveyed, German nursing homes saw a need for treatment more frequently than Dutch facilities, e.g., 48.3% vs. 11.7% for neurology. In addition, Dutch nursing homes significantly more often considered general practitioners/elder care physicians (GPs/ECPs) to be able to cover these needs. The number of GP/ECP contacts per resident per year was similar in both countries (Germany: 26.5; Netherlands: 28.7). Almost all Dutch facilities had permanently employed allied health professionals (e.g. physiotherapists), whereas this was rarely the case in Germany.

CONCLUSIONS

We observed large differences in nursing home residents' medical care. It appears that GPs/ECPs in the Netherlands cover needs deemed to require specialist consultations in Germany. Some differences between countries can possibly be explained by system-cultural differences. Future studies should therefore look closely at the process of medical care provision and its quality in nursing homes in both countries.

Emergency department admissions and economic costs burden related to ambulatory care sensitive conditions in older adults living in care homes

OBJECTIVES

To assess the frequency of emergency department admissions (EDA) for ambulatory care sensitive conditions (ACSC) and non-ACSC among older adults living in care homes (CH), to describe and compare their demographic and clinical characteristics, the outcomes of the hospitalisation process and the associated costs.

METHOD

This multicenter, retrospective and observational study evaluated 2444 EDAs of older adults ≥ 65 years old living in care homes in 5 emergency departments in Catalonia (Spain) by ACSC and non-ACSC, in 2017. Sociodemographic variables, prior functional and cognitive status, and information on diagnosis and hospitalisation were collected. Additionally, the costs related with the EDAs were calculated, as well as a sensitivity analysis using different assumptions of decreased admissions due to ACSC.

RESULTS

A total of 2444 ED admissions were analysed. The patients' mean (SD) age was 85.9 (7.2) years. The frequency of ACSC-EDA and non-ACSC-EDA was 56.6% and 43.4%, respectively. Severe dependency and cognitive impairment were present in 56.6% and 78%, respectively, with no differences between the two groups. The three most frequent ACSC were falls/trauma (13.8%), chronic obstructive pulmonary disease/asthma (11.4%) and urinary tract infection (7.4%). The average cost per ACSC-EDA was є1,408.24. Assuming a 60% reduction of ACSC-EDA, the estimated cost savings would be є1.2 million.

CONCLUSIONS

Emergency admissions for ACSC from care homes have a significant impact on both frequency and costs. Reducing these conditions through targeted interventions could redirect the avoided costs towards improving care support in residential settings.

Epidemiology and clinical characteristics of trauma in older patients transferred from long-term care hospitals to emergency departments: A nationwide retrospective study in South Korea

BACKGROUND

South Korea's aging population had leg to an increased number of long-term care hospitals (LTCHs), and increased transfer of older patients to emergency departments (EDs). This study investigated the epidemiological and injury profiles of LTCH patients aged ≥65 who were transferred from LTCHs to EDs due to trauma.

METHOD

This retrospective study conducted between January 2014 and December 2019 in South Korea utilized data from the National Emergency Department Information System. The requirement for informed consent was waived by the IRB due to the retrospective nature of the study. Patient information was anonymized prior to analysis.

RESULTS

Of the 1,472,006 trauma cases aged ≥65, 14,469 came from LTCHs. Outcomes varied: 44.1% were discharged, 40.6% were admitted to general wards (GW), 5.9% to intensive care units (ICU), 2.4% to other hospitals, and 6.5% returned to LTCHs. ED length of stay (LOS) was longest in the death (410.28 ± 559.73 min) and GW admission (390.12 ± 621.71 min) groups. Falls were the main cause of injury (50.1%), and the most common fracture was femoral (71.6%). Femoral and shoulder/upper extremity fractures increased hospitalization risk only, whereas self-harm increased both hospitalization and mortality risk.

CONCLUSION

Visits to the ED by older patients from LTCH for trauma were avoidable in 50.6% of cases. Additionally, these patients had longer ED LOS and higher hospitalization rates than non-LTCH patients. Falls were the predominant mode of presentation, femoral fracture was the most common fracture among patients from LTCH.

Evaluating the Association between the Implementation of the PoET Southwest Spread Project and Reductions in Acute Care Transfers from Long-Term Care: A Quasi-Experimental Matched Cohort Study Using Population-Level Health Administrative Data

OBJECTIVES

To measure changes in resident-level acute care transfer rates after the PoET Southwest Spread Project (PSSP), and to identify patient and long-term care (LTC) home characteristics associated with acute care transfers after program launch.

DESIGN

Quasi-experimental matched (1:1 ratio) cohort study design using linked population-based health administrative data.

SETTING

Sixty publicly funded LTC homes (PSSP = 30; control = 30) in Ontario, Canada, from November 2019 to December 2021.

METHODS

We matched 30 PSSP homes to 30 control homes with similar characteristics and described incidence rates for resident-level acute care transfers during the 7-month post-implementation period. We used generalized linear mixed models to evaluate the association between PSSP implementation and acute care transfers during the post-implementation period. We adjusted resident-level characteristics (ie, age, sex, comorbidity status) and home-level characteristics (ie, rurality status, profit model, COVID-19 impact). We identified a decedent sub-cohort to measure transfer patterns during the last 2 months of life.

RESULTS

A matched cohort of 8894 residents (PSSP = 4103; control = 4791) was captured. Incidence rates of transfers increased during the post-implementation period for both PSSP (78.8 to 80.9 transfers per 1000 person-months) and control residents (66.9 to 67.9 transfers per 1000 person-months). After adjusting for covariates of interest, PSSP exposure was associated with a reduction in acute care transfers during the post-implementation period after adjusting for covariates (incidence rate ratio, 0.73; 95% CI, 0.62-0.87; P = .0002). Older age and select health regions were associated with reduced transfers, whereas higher comorbidity status and higher COVID-19 outbreak days were associated with increases. Similar patterns persisted for transfers during the last 2 months of life.

CONCLUSIONS AND IMPLICATIONS

This study systematically evaluated the impact of an ethics-based health care intervention in LTC using health care utilization databases. PoET implementation is associated with reduced acute care transfer rates, especially in the last 2 months of life in LTC.

A pilot observational study of gait changes over time before and after an unplanned hospital visit in long-term care residents with dementia

BACKGROUND

Older adults with dementia living in long-term care (LTC) have high rates of hospitalization. Two common causes of unplanned hospital visits for LTC residents are deterioration in health status and falls. Early detection of health deterioration or increasing falls risk may present an opportunity to intervene and prevent hospitalization. There is some evidence that impairments in older adults' gait, such as reduced gait speed, increased variability, and poor balance may be associated with hospitalization. However, it is not clear whether changes in gait are observable and measurable before an unplanned hospital visit and whether these changes persist after the acute medical issue has been resolved. The objective of this study was to examine gait changes before and after an unplanned acute care hospital visit in people with dementia.

METHODS

We performed a secondary analysis of quantitative gait measures extracted from videos of natural gait captured over time on a dementia care unit and collected information about unplanned hospitalization from health records.

RESULTS

Gait changes in study participants before hospital visits were characterized by decreasing stability and step length, and increasing step variability, although these changes were also observed in participants without hospital visits. In an age and sex-adjusted mixed effects model, gait speed and step length declined more quickly in those with a hospital visit compared to those without.

CONCLUSIONS

These results provide preliminary evidence that clinically meaningful longitudinal gait changes may be captured by repeated non-invasive gait monitoring, although a larger study is needed to identify changes specific to future medical events.

A Qualitative Study of Nursing Home Staff Lived Experience With Advance Care Planning

OBJECTIVE

Advance care planning (ACP) within nursing homes (NHs) is an integral component of resident-centered care yet remains an ongoing area for improvement. This study explored health care providers' experiences when facilitating ACP discussions with residents and their families.

DESIGN

Interpretive description was used to explore meanings and generate knowledge that is applicable for clinical contexts.

SETTING AND PARTICIPANTS

A purposive sample of 27 staff members (2 directors of care, 3 assistant directors of care, 1 nurse practitioner, 11 registered nurses, 3 registered practical nurses, and 7 social workers) from 29 NHs located across 3 Canadian provinces that participated in cluster-randomized intervention study to improve ACP.

METHODS

Semistructured interviews were conducted between January and July 2020. Interpretive description methods were used for analysis.

RESULTS

Three themes were identified. "Navigating Relational Tensions During ACP with Families" captures the relational tensions that participants experienced while navigating ACP processes with residents and their families. The second theme, "Where's the Doctor?" highlights the general lack of physician involvement in ACP discussions and the subsequent pressures faced by participants when supporting residents and families. The last theme, "Crises Change the Best Laid Plans," illustrates the challenges participants face when trying to adhere to existing care plans during residents' medical crises.

CONCLUSION AND IMPLICATIONS

Participants' experiences indicate that current ACP processes in NHs do not meet the needs of residents, families, or care teams. Additional support from physicians and changes to structural processes are needed to support resident-centered end-of-life planning within this care context.

Cost-benefit analysis of the CoCare intervention to improve medical care in long-term care nursing homes: an analysis based on claims data

BACKGROUND

Providing adequate medical care to nursing home residents is challenging. Transfers to emergency departments are frequent, although often avoidable. We conducted the complex CoCare intervention with the aim to optimize nursing staff-physician collaboration to reduce avoidable hospital admissions and ambulance transportations, thereby reducing costs.

METHODS

This prospective, non-randomized study, based on German insurance data, includes residents in nursing homes. Health care cost from a payer perspective and cost-savings of such a complex intervention were investigated. The utilisation of services after implementation of the intervention was compared with services in previous quarters as well as services in the control group. To compensate for remaining differences in resident characteristics between intervention and control group, a propensity score was determined and adjusted for in the regression analyses.

RESULTS

The study population included 1240 residents in the intervention and 7552 in the control group. Total costs of medical services utilisation were reduced by €468.56 (p < 0.001) per resident and quarter in the intervention group. Hospital stays were reduced by 0.08 (p = 0.001) and patient transports by 0.19 (p = 0.049). This led to 1.66 (p < 0.001) avoided hospital days or €621.37 (p < 0.001) in costs-savings of inpatient services. More services were billed by general practitioners in the intervention group, which led to additional costs of €97.89 (p < 0.001).

CONCLUSION

The benefits of our intervention clearly exceed its costs. In the intervention group, avoided hospital admissions led to additional outpatient billing. This indicates that such a multifactorial intervention program can be cost-saving and improve medical care in long-term care homes.

Factors Influencing Decision Making in Terminal Hospitalization of Nursing Home Residents: A Qualitative Study of the Perspective of Nurses, Social Workers, and General Practitioners

A significant percentage of nursing home residents die in hospitals. The objective of this study is to explore the factors that influence decision-making about hospitalizations of nursing home residents in the Czech Republic that become terminal. A total of 27 semi-structured interviews with nurses and social workers registered with nursing homes, as well as general practitioners cooperating with nursing homes, were conducted. Data were analyzed using thematic analysis. Six themes of the factors influencing decision-making about hospitalizations were made: the options of the nursing home, the accessibility of medical decision-making, inadequate care planning, the age of the resident, fear of legal action, and making the decision to hospitalize. Terminality of life seems to have no impact on the decision of nurses about hospitalization. Terminal hospitalization seems to be the result of the limited options that nurses have in different nursing homes in terms of how to organize end-of-life care.

[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.

Telemedicine vs Face-to-Face for Nursing Home Residents With Acute Presentations: A Noninferiority Study

OBJECTIVES

Telemedicine and face-to-face outreach services to nursing homes (NHs) have been used to reduce hospital utilization rates for acute presentations. However, how these modalities compare against each other is unclear. This article examines if the management of acute presentations in NHs with care involving telemedicine is noninferior to care delivered face-to-face.

DESIGN

A noninferiority study was conducted on a prospective cohort. Face-to-face intervention involved on-site assessment by a geriatrician and aged care clinical nurse specialist (CNS). Telemedicine intervention involved on-site assessment by an aged care CNS with telemedicine input by a geriatrician.

SETTING AND PARTICIPANTS

A total of 438 NH residents with acute presentations from 17 NHs between November 2021 and June 2022.

METHODS

Between-group differences in proportion of residents successfully managed on-site and mean number of encounters were evaluated using bootstrapped multiple linear regression; 95% CIs were compared against predefined noninferiority margins with noninferiority P values calculated.

RESULTS

In the adjusted models, care involving telemedicine demonstrated noninferiority in the difference in proportion of residents successfully managed on-site (95% CI lower limit -6.2% to -1.4% vs -10% noninferiority margin; P < .001 for noninferiority) but not in the difference in mean number of encounters (95% CI upper limit 1.42 to 1.50 encounters vs 1 encounter noninferiority margin; P = .7 for noninferiority).

CONCLUSIONS AND IMPLICATIONS

In our model of care, care that involved telemedicine was noninferior to care delivered face-to-face in managing NH residents with acute presentations on-site. However, additional encounters may be required. Application of telemedicine ought to be tailored to fit the needs and preferences of stakeholders.

Quality improvement interventions to prevent the use of hospital services among nursing home residents: protocol for a systematic review and meta-analysis

INTRODUCTION

Quality improvement interventions are a promising strategy for reducing hospital services use among nursing home residents. However, evidence for their effectiveness is limited. It is unclear which characteristics of the quality improvement intervention and activities planned to facilitate implementation may promote fidelity to organisational and system changes. This systematic review and meta-analysis will assess the effectiveness of quality improvement interventions and implementation strategies aimed at reducing hospital services use among nursing home residents.

METHODS AND ANALYSIS

The MEDLINE, CINAHL, Cochrane Library, Embase and Web of Science databases will be comprehensively searched in September 2023. The eligible studies should focus on the implementation of a quality improvement intervention defined as the systematic, continuous approach that designs, tests and implements changes using real-time measurement to reduce hospitalisations or emergency department visits among long-stay nursing home residents. Quality improvement details and implementation strategies will be deductively categorised into effective practice and organisation of care taxonomy domains for delivery arrangements and implementation strategies. Quality and bias assessments will be completed using the Quality Improvement Minimum Quality Criteria Set and the Joanna Briggs Institute Critical Appraisal Tools.The results will be pooled in a meta-analysis, by combining the natural logarithms of the rate ratios across the studies or by calculating the rate ratio using the generic inverse-variance method. Heterogeneity will be assessed using the I2 or H2 statistics if the number of included studies will be less than 10. Raw data will be requested from the authors, as required.

ETHICS AND DISSEMINATION

Ethical approval is not required. The results will be published in a peer-review journal and presented at (inter)national conferences.

PROSPERO REGISTRATION NUMBER

CRD42022364195.

The value of fever assessment in addition to the Early Detection Infection Scale (EDIS). A validation study in nursing home residents in Sweden

BACKGROUND

In order to improve detection of suspected infections in frail elderly there is an urgent need for development of decision support tools, that can be used in the daily work of all healthcare professionals for assessing non-specific and specific changes. The aim was to study non-specific signs and symptoms and fever temperature for early detection of ongoing infection in frail elderly, and how these correlates to provide the instrument, the Early Detection Infection Scale (EDIS), which is used to assess changes in health condition in frail elderly.

METHODS

This was an explorative, prospective cohort study, including 45 nursing home residents, 76 to 99 years, in Sweden. Nursing assistants measured morning ear body temperature twice a week and used the EDIS to assess individual health condition daily for six months. The outcome comprised events of suspected infection, compiled from nursing and medical patient records. Factor analysis and multivariate logistic regression analysis were performed to analyse data.

RESULTS

Fifteen residents were diagnosed with at least one infection during the six-month follow-up and 189 observations related to 72 events of suspected infection were recorded. The first factor analysis revealed that the components, change in cognitive and physical function, general signs and symptoms of illness, increased tenderness, change in eye expression and food intake and change in emotions explained 61% of the variance. The second factor analysis, adding temperature assessed as fever to > 1.0 °C from individual normal, resulted in change in physical function and food intake, confusion and signs and symptoms from respiratory and urinary tract, general signs and symptoms of illness and fever and increased tenderness, explaining 59% of the variance. In the first regression analysis, increased tenderness and change in eye expression and food intake, and in the second change in physical function and food intake, general signs and symptoms of illness and fever (> 1.0 °C from individual normal) and increased tenderness were significantly associated with increased risk for ongoing infection.

CONCLUSION

No items in the EDIS should be removed at present, and assessment of fever as > 1.0 °C from individual normal is a valuable addition. The EDIS has the potential to make it easier for first line caregivers to systematically assess changes in health condition in fragile elderly people and helps observations to be communicated in a standardised way throughout the care process. The EDIS thus contributes to ensuring that the decisions not being taken at the wrong level of care.

Avoidable Care Transitions: A Consensus-Based Definition Using a Delphi Technique

Background and Objectives

Older adults are at increased risk of frequent transitions between care settings, even though some care transitions are avoidable. The term "avoidable care transitions" is not clearly defined in the research literature. This study aimed to find a consensus-based definition for "avoidable care transitions."

Research Design and Methods

This study was conducted as part of the TRANS-SENIOR research network. A 4-round Delphi survey was based on a literature review that identified existing definitions of "avoidable care transitions." Articles in MEDLINE via PubMed and CINAHL were searched. In total 95 references were included, and 106 definitions were identified. Definitions were coded to find themes, resulting in 3 themes with 2 codes for each.

Results

In total, 99 experts from 9 countries were invited, and the response rates in Delphi Rounds 1, 2, 3, and 4 were 37.5%, 19.1%, 33.3%, and 23.3%, respectively. Upon reaching the predefined minimum of 90% agreement, the following definition was declared as final: "Avoidable care transitions (a) are without significant patient-relevant benefits or with a risk of harm outweighing patient-relevant benefits and/or (b) are when a comparable health outcome could be achieved in lower resource settings using the resources available in that place/health care system, and/or (c) violate a patient's/informal caregiver's preference or an agreed care plan."

Discussion and Implications

Consensus on a definition for "avoidable care transitions" was reached by a multidisciplinary and international panel of experts comprising researchers and providers. The resulting definition consists of 3 distinct dimensions relating to the balance of benefit and harm to a patient, resource consumption, and a patient's or informal caregiver's preferences. The new definition might enhance the common understanding of avoidable care transitions and is now ready for application in research and quality and safety management in health care.

Measuring Potentially Avoidable Acute Care Transfers From Long-Term Care Homes in Quebec: a Cross Sectional Study

Background

Potentially avoidable emergency department transfers (PAEDTs) and hospitalizations (PAHs) from long-term care (LTC) homes are two key quality improvement metrics. We aimed to: 1) Measure proportions of PAEDTs and PAHs in a Quebec sample; and 2) Compare them with those reported for the rest of Canada.

Methods

We conducted a repeated cross-sectional study of residents who were received at one tertiary hospital between April 2017 and March 2019 from seven LTC homes in Quebec, Canada. The MedUrge emergency department database was used to extract transfers and resident characteristics. Using published definitions, PAEDTs and PAHs were identified from principal emergency department and hospitalization diagnoses, respectively. PAEDT and PAH proportions were compared to those reported by the Canadian Institute for Health Information.

Results

A total of 1,233 transfers by 692 residents were recorded, among which 36.3% were classified as being potentially avoidable: 22.8% 'PAEDT only', 11.6% 'both PAEDT & PAH', and 1.9% 'PAH only'. Shortness of breath was the most common reason for transfer. Pneumonia was the most common diagnosis from the 'both PAEDT & PAH' category. PAEDTs and PAHs accounted for 95% and 37% of potentially avoidable transfers, respectively. Among 533 hospitalizations, 31.3% were PAHs. These proportions were comparable to the rest of Canada, with some differences in proportions of transfers due to congestive heart failure, urinary tract infection, and implanted device management.

Conclusions

PAEDTs far outweigh PAHs in terms of frequency, and their monitoring is important for quality assurance as they may inform LTC-level interventions aimed at their reduction.

Developing a Machine Learning Risk-adjustment Method for Hospitalizations and Emergency Department Visits of Nursing Home Residents With Dementia

BACKGROUND

Long-stay nursing home (NH) residents with Alzheimer disease and related dementias (ADRD) are at high risk of hospital transfers. Machine learning might improve risk-adjustment methods for NHs.

OBJECTIVES

The objective of this study was to develop and compare NH risk-adjusted rates of hospitalizations and emergency department (ED) visits among long-stay residents with ADRD using Extreme Gradient Boosting (XGBoost) and logistic regression.

RESEARCH DESIGN

Secondary analysis of national Medicare claims and NH assessment data in 2012 Q3. Data were equally split into the training and test sets. Both XGBoost and logistic regression predicted any hospitalization and ED visit using 58 predictors. NH-level risk-adjusted rates from XGBoost and logistic regression were constructed and compared. Multivariate regressions examined NH and market factors associated with rates of hospitalization and ED visits.

SUBJECTS

Long-stay Medicare residents with ADRD (N=413,557) from 14,057 NHs.

RESULTS

A total of 8.1% and 8.9% residents experienced any hospitalization and ED visit in a quarter, respectively. XGBoost slightly outperformed logistic regression in area under the curve (0.88 vs. 0.86 for hospitalization; 0.85 vs. 0.83 for ED visit). NH-level risk-adjusted rates from XGBoost were slightly lower than logistic regression (hospitalization=8.3% and 8.4%; ED=8.9% and 9.0%, respectively), but were highly correlated. Facility and market factors associated with the XGBoost and logistic regression-adjusted hospitalization and ED rates were similar. NHs serving more residents with ADRD and having a higher registered nurse-to-total nursing staff ratio had lower rates.

CONCLUSIONS

XGBoost and logistic regression provide comparable estimates of risk-adjusted hospitalization and ED rates.

[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.

Expanded nursing competencies to improve person-centred care for nursing home residents with complex health needs (Expand-Care): study protocol for an exploratory cluster-randomised trial

INTRODUCTION

Older age is associated with multimorbidity, chronic diseases and acute deteriorations and leads to complex care needs. Nursing home residents are more often unnecessarily transferred to emergency departments or hospitals than community dwellers-largely due to a lack of qualified staff and diffusion of responsibility in the institutions. In Germany, only few academically trained nurses work in nursing homes, and their potential roles are unclear. Therefore, we aim to explore feasibility and potential effects of a newly defined role profile for nurses with bachelors' degree or equivalent qualification in nursing homes.

METHODS AND ANALYSIS

A pilot study (Expand-Care) with a cluster-randomised controlled design will be conducted in 11 nursing homes (cluster) in Germany, with an allocation ratio of 5:6 to the intervention or control group, aiming to include 15 residents per cluster (165 participants in total). Nurses in the intervention group will receive training to perform role-related tasks such as case reviews and complex geriatric assessments. We will collect data at three time points (t0 baseline, t1 3 months and t2 6 months after randomisation). We will measure on residents' level: hospital admissions, further health services use and quality of life; clinical outcomes (eg, symptom burden), physical functioning and delivery of care; mortality, adverse clinical incidents and changes in care level. On nurses' level, we will measure perception of the new role profile, competencies and implementation of role-related tasks as part of the process evaluation (mixed methods). An economic evaluation will explore resource use on residents' (healthcare utilisation) and on nurses' level (costs and time expenditure).

ETHICS AND DISSEMINATION

The ethics committees of the University of Lübeck (Nr. 22-162) and the University Clinic Hamburg-Eppendorf (Nr. 2022-200452-BO-bet) approved the Expand-Care study. Informed consent is a prerequisite for participation. Study results will be published in open-access, peer-reviewed journals and reported at conferences and in local healthcare providers' networks.

TRIAL REGISTRATION NUMBER

DRKS00028708.

Care coordination across healthcare systems: development of a research agenda, implications for practice, and recommendations for policy based on a modified Delphi panel

OBJECTIVE

For large, integrated healthcare delivery systems, coordinating patient care across delivery systems with providers external to the system presents challenges. We explored the domains and requirements for care coordination by professionals across healthcare systems and developed an agenda for research, practice and policy.

DESIGN

The modified Delphi approach convened a 2-day stakeholder panel with moderated virtual discussions, preceded and followed by online surveys.

SETTING

The work addresses care coordination across healthcare systems. We introduced common care scenarios and differentiated recommendations for a large (main) healthcare organisation and external healthcare professionals that contribute additional care.

PARTICIPANTS

The panel composition included health service providers, decision makers, patients and care community, and researchers. Discussions were informed by a rapid review of tested approaches to fostering collaboration, facilitating care coordination and improving communication across healthcare systems.

OUTCOME MEASURES

The study planned to formulate a research agenda, implications for practice and recommendations for policy.

RESULTS

For research recommendations, we found consensus for developing measures of shared care, exploring healthcare professionals' needs in different care scenarios and evaluating patient experiences. Agreed practice recommendations included educating external professionals about issues specific to the patients in the main healthcare system, educating professionals within the main healthcare system about the roles and responsibilities of all involved parties, and helping patients better understand the pros and cons of within-system and out-of-system care. Policy recommendations included supporting time for professionals with high overlap in patients to engage regularly and sustaining support for care coordination for high-need patients.

CONCLUSIONS

Recommendations from the stakeholder panel created an agenda to foster further research, practice and policy innovations in cross-system care coordination.

Regional Workshops to Disseminate Decision Guide to Reduce Potentially Preventable Hospital Transfers: Application of the Diffusion of Innovation Model

INTRODUCTION

Medically unnecessary, potentially preventable transfers of nursing home (NH) residents to acute care poses multiple risks for residents. Family and resident insistence on these preventable transfers has not been thoroughly addressed in transfer reduction programs.

METHODS

The Diffusion of Innovation model guided dissemination of an evidence-based patient decision guide that addressed resident and family insistence on hospital transfer. Twenty workshops were held across eight states of Centers for Medicare and Medicaid Services Region IV. All Medicare-certified NHs in Region IV received emailed invitations to the workshops in their states. Quantitative and qualitative data were collected on workshop attendees, the facilities they represented, and response to the workshop including adoption of the Guide and its effect on hospital readmissions.

RESULTS

Altogether, 1124 facility representatives and affiliated professionals attended the workshops. NH administrators rated the program 4.4 out of 5. Of those who responded, 71% said that they were using the Guide as a result of the workshop; 89% of these said that it was helpful, especially to initiate difficult conversations about end-of-life care and to discuss the care a contemporary NH can provide. Readmission rates dropped 30% in the NHs that reported their results.

DISCUSSION

The use of the Diffusion of Innovation model was effective in delivering information to a large number of facilities in sufficient detail to implement the Decision Guide. However, the workshop format provided little opportunity to respond to concerns that arose after the workshops, to diffuse the innovation further, or to build sustainability.

Associations between care home residents' characteristics and acute hospital admissions - a retrospective, register-based cross-sectional study

BACKGROUND

Care home residents are frail, multi-morbid, and have an increased risk of experiencing acute hospitalisations and adverse events. This study contributes to the discussion on preventing acute admissions from care homes. We aim to describe the residents' health characteristics, survival after care home admission, contacts with the secondary health care system, patterns of admissions, and factors associated with acute hospital admissions.

METHOD

Data on all care home residents aged 65 + years living in Southern Jutland in 2018-2019 (n = 2601) was enriched with data from highly valid Danish national health registries to obtain information on characteristics and hospitalisations. Characteristics of care home residents were assessed by sex and age group. Factors associated with acute admissions were analysed using Cox Regression.

RESULTS

Most care home residents were women (65.6%). Male residents were younger at the time of care home admission (mean 80.6 vs. 83.7 years), had a higher prevalence of morbidities, and shorter survival after care home admission. The 1-year survival was 60.8% and 72.3% for males and females, respectively. Median survival was 17.9 months and 25.9 months for males and females, respectively. The mean rate of acute hospitalisations was 0.56 per resident-year. One in four (24.4%) care home residents were discharged from the hospital within 24 h. The same proportion was readmitted within 30 days of discharge (24.6%). Admission-related mortality was 10.9% in-hospital and 13.0% 30 days post-discharge. Male sex was associated with acute hospital admissions, as was a medical history of various cardiovascular diseases, cancer, chronic obstructive pulmonary disease, and osteoporosis. In contrast, a medical history of dementia was associated with fewer acute admissions.

CONCLUSION

This study highlights some of the major characteristics of care home residents and their acute hospitalisations and contributes to the ongoing discussion on improving or preventing acute admissions from care homes.

TRIAL REGISTRATION

Not relevant.

Mobile emergency department care to nursing home residents: a novel outreach service

BACKGROUND

Every month, 6% of Danish nursing home residents are admitted to hospital. However, these admissions might have limited benefits and are associated with an increased risk of complications. We initiated a new mobile service comprising consultants performing emergency care in nursing homes.

OBJECTIVE

Describe the new service, the recipients of this service, hospital admission patterns and 90-day mortality.

DESIGN

A descriptive observational study.

MODEL

When an ambulance is requested to a nursing home, the emergency medical dispatch centre simultaneously dispatches a consultant from the emergency department who will provide an emergency evaluation and decisions regarding treatment at the scene in collaboration with municipal acute care nurses.

METHOD

We describe the characteristics of all nursing home contacts from 1st November 2020 to 31st December 2021. The outcome measures were hospital admissions and 90-day mortality. Data were extracted from the patients' electronic hospital records and prospectively registered data.

RESULTS

We identified 638 contacts (495 individuals). The new service had a median of two (interquartile range: 2-3) new contacts per day. The most frequent diagnoses were related to infections, unspecific symptoms, falls, trauma and neurologic disease. Seven out of eight residents remained at home following treatment, 20% had an unplanned hospital admission within 30 days and 90-day mortality was 36.4%.

CONCLUSION

Transitioning emergency care from hospitals to nursing homes could present an opportunity for providing optimised care to a vulnerable population and limiting unnecessary transfers and admissions to hospitals.

Cluster randomised trial of a complex interprofessional intervention (interprof ACT) to reduce hospital admission of nursing home residents

BACKGROUND

Some hospital admissions of nursing home residents (NHRs) might be attributed to inadequate interprofessional collaboration. To improve general practitioner-nurse collaboration in nursing homes (NHs), we developed an intervention package (interprof ACT) in a previous study.

OBJECTIVE

To assess the impact of interprof ACT on the proportion of hospitalisation and other clinical parameters within 12 months from randomisation among NHRs.

METHODS

Multicentre, cluster randomised controlled trial in 34 German NHs. NHRs of the control group received usual care, whereas NHRs in the intervention group received interprof ACT. Eligible NHs had at least 40 long-term care residents. NHs were randomised 1:1 pairwise. Blinded assessors collected primary outcome data.

RESULTS

Seventeen NHs (320 NHRs) were assigned to interprof ACT and 17 NHs (323 NHRs) to usual care. In the intervention group, 136 (42.5%) NHRs were hospitalised at least once within 12 months from randomisation and 151 (46.7%) in the control group (odds ratio (OR): 0.82, 95% confidence interval (CI): [0.55; 1.22], P = 0.33). No differences were found for the average number of hospitalisations: 0.8 hospitalisations per NHR (rate ratio (RR) 0.90, 95% CI: [0.66, 1.25], P = 0.54). Average length of stay was 5.7 days for NHRs in the intervention group and 6.5 days in the control group (RR: 0.70, 95% CI: [0.45, 1.11], P = 0.13). Falls were the most common adverse event, but none was related to the study intervention.

CONCLUSIONS

The implementation of interprof ACT did not show a statistically significant and clinically relevant effect on hospital admission of NHRs.

Nursing Home Resident, Family, and Staff Perspectives on Hospital Transfers for End-of-Life Care

Residents who are terminally ill often experience transfers to the emergency department resulting in hospitalizations, which may be potentially avoidable with treatment in the nursing home. This qualitative study explored the perspectives of 15 residents, 10 family members, and 20 nursing home staff regarding end-of-life care and the circumstances prompting resident transfers. Data analysis of participant interviews conducted January to May 2019 in a South Florida nursing home identified four themes related to transfer to the hospital: time left to live, when aggressive treatments would be unavailing, not knowing what the nursing home can do, and transfer decisions are situation-dependent. Study findings underscore the importance of increasing resident and family awareness of treatments available in the nursing home and person-centered advance care planning discussions. Further research should explore the reasons for residents' and family members' choice of aggressive therapies and their goals for care at the end of life.

Potentially avoidable emergency department transfers from residential aged care facilities for possible post-fall intracranial injury

OBJECTIVES

To determine the percentage of potentially preventable residential aged care facility (RACF) to ED transfers for potential intracranial injury post-fall. To describe rates of CT brain (CTB) performance, intracranial trauma-related findings, neurosurgical intervention, and patient outcome.

METHODS

Patient lists were obtained from the hospital electronic medical record, screened for eligibility and data abstracted. Potentially preventable was defined as: (1) RACF return from ED within 24 h, regardless of CTB performance or finding; (2) ED management could reasonably have been provided at the RACF. Comparisons between those with CTB performed or not, including external signs of craniofacial trauma, anticoagulant medication use, baseline cognitive impairment and presence of an advanced care directive (ACD) were made.

RESULTS

Of 784 patients, 415 (53%) were classified as potentially avoidable. Of these, 314 (76%) had a CTB. Of all 784 patients, 538 (69%) had a CTB performed. CTB was more likely with presence of external signs of craniofacial trauma (26% [95% CI 23-30] vs 20% [95% CI 15-25], P < 0.001) and anticoagulant use (59% [95% CI 55-63] vs 42% [95% CI 37-49], P < 0.001) but not for presence of cognitive impairment or ACD. From the 538 CTBs, 31 (6%) patients had acute intracranial trauma-related findings with all having conservative management. None of the 11 (1%) deaths were in the potentially preventable subgroup.

CONCLUSION

Just over half of the RACF to ED transfers were classified as 'potentially avoidable'.

Transferring nursing home residents to emergency departments by emergency physician-staffed emergency medical services: missed opportunities to avoid inappropriate care?

BACKGROUND

The decision to transfer a nursing home (NH) resident to an emergency department (ED) is multifactorial and challenging but many of the emergency physician-staffed emergency medical service (EP-EMS) interventions and ED transfers are probably inappropriate.

METHODS

We conducted a retrospective, cross-sectional study in three EP-EMSs in Belgium over a period of three years. We registered indicators that are potentially associated with inappropriate transfers: patient characteristics, availability of written do not resuscitate (DNR) orders or treatment restrictions, involvement of a general practitioner (GP) and availability of transfer notes. We also explored the association between age, the Charlson Comordity Index (CCI), polypharmacy, dementia, and the availability of DNR documents.

RESULTS

We registered 308 EP-EMS interventions in NH residents. In 98% the caller was a health-care professional. In 75% there was no GP present and 40% had no transfer note. Thirty-two percentage of the patients had dementia, 45% had more than two comorbidities and 68% took five medications or more. In 6% cardiopulmonary resuscitation was performed. DNR orders were available in 25%. Eighty-eight percentage of the NH residents were transferred to the ED. Forty-four percent had a CCI >5. In patients of ≥90 years, with a CCI >5, with dementia and with polypharmacy, DNR orders were not available in 81%, 67%%,and 69%, respectively.

CONCLUSIONS

Improved EMS dispatch centre-NH caller interaction, more involvement of GP's, higher availability of DNR orders and better communication between GPs/NHs and EP-EMS could prevent inappropriate interventions, futile prehospital aactions,and ED transfers.

Medication-Related Acute Care Admission and Inappropriate Polypharmacy of Nursing Home Residents

OBJECTIVES

To evaluate the prevalence of medication-related admissions (MRAs) and their association with potentially inappropriate medications (PIMs) used by nursing home residents admitted to the geriatric center of a tertiary hospital.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Older patients admitted from nursing homes to the geriatric center of the Seoul National University Bundang Hospital who had undergone comprehensive geriatric assessment from January 1, 2016, to December 31, 2020.

METHODS

MRAs were determined and verified using a previously described MRA adjudication guide. The PIMs in the preadmission medication lists were identified according to each of the following criteria (as well as the combined criteria), the Beers, NORGEP-NH, STOPP/START-NH, and STOPPFrail criteria. Medication use factors associated with MRAs were analyzed using multivariate logistic regression.

RESULTS

Among the 304 acute care admissions, 32.2% were MRAs. The main cause of MRAs was acute kidney injury related with use of renin-angiotensin system inhibitors. Approximately 81% of the patients used at least 1 PIM according to the combined criteria. The use of 1 or more PIMs, renin-angiotensin system inhibitors, diuretics, nonsteroidal anti-inflammatory drugs, and benzodiazepines was significantly associated with MRAs. The combined criteria were able to predict MRAs better than the individual criteria.

CONCLUSIONS AND IMPLICATIONS

Approximately one-third of acute admissions of nursing home residents may be MRAs. Interventions for the optimal use of medication among nursing home residents are needed.

Nursing Home Residents' Use of Radiography in New Brunswick: A Case for Mobile Radiography?

Introduction

Identifying ways to eliminate unnecessary transfer of nursing home (NH) residents to hospitals provides an opportunity to improve outcomes and use scarce healthcare resources more efficiently. This study's goal was to better understand where NH residents access X-ray (XR) and computed tomography (CT) scans and to determine if there was a case for mobile radiography policies in New Brunswick.

Methods

A retrospective analysis of all the visits to the emergency department (ED) and outpatient imaging departments in two hospitals in Saint John, New Brunswick, in 2020, that involved XR or CT investigations was conducted.

Results

There were 521 visits by 311 unique NH residents and 920 investigations (688 XR and 232 CT scans). Most investigations were ordered in the ED (696 of 920; 75.6%; confidence interval: 72.8-78.3%). Of the NH residents who visited the ED and received either an XR or a CT scan, 33.2% received only XR imaging and were discharged back to the NH after a mean ED stay of 5.15 hours.

Discussion

The pattern of NH residents' use of the ED for their imaging needs supports the creation of mobile XR policies to deliver more safe and efficient care in a Canadian medium population urban centre.

Potentially avoidable hospitalizations for older patients transferred from long-term care hospitals: a nationwide cross-sectional analysis of potential healthcare consequences

Multiple chronic disorders and disabilities among older patients in long term care hospitals (LTCH) tends to increase the healthcare burden by causing overcrowding, particularly in emergency departments. Therefore, access to timely and adequate healthcare for LTCH patients is an increasingly important issue, and potentially avoidable hospitalizations (PAHs) and hospitalizations during non-office hours can result as indicators of emergency department overcrowding. The study aimed to evaluate PAHs and hospitalizations during non-office hours in emergency departments for older patients transferred from LTCH compared to patients living at home. We performed a cross-sectional study using the National Emergency Department Information System database from January 2018 to December 2019, in South Korea, with older patients (≥ 65 years) who visited nationwide emergency departments. Adjusted odds ratio (aOR) and 95% confidence interval (CI) for indicators of overcrowding as PAHs and hospitalizations during non-office hours were calculated by logistic regression. Among the 2,177,663 older patients who visited the emergency departments, 98,434 patients were living in LTCH and 2,079,229 patients were living at home. The older patients living in LTCH was associated with PAHs (aOR: 1.90, 95% CI 1.87-1.94) and hospitalizations during non-office hours (aOR: 1.76, 95% CI 1.73-1.78). LTCH patients showed more hospital visits, extended stay in the emergency department, greater prevalence of chronic diseases, greater rates of transfer as well as higher admission rates and mortality as compared to the patients living at home. The LTCH older patients were associated with the indicators of emergency department overcrowding, which impacts health care quality in hospitals. Introduction of policy and training programs for LTCH staff are recommended to manage vulnerable groups in advance.

What influences decisions to transfer older care-home residents to the emergency department? A synthesis of qualitative reviews

BACKGROUND

care home residents aged over 65 have disproportionate rates of emergency department (ED) attendance and hospitalisation. Around 40% attendances may be avoidable, and hospitalisation is associated with harms. We synthesised the evidence available in qualitative systematic reviews of different stakeholders' experiences of decisions to transfer residents to the ED.

METHODS

six electronic databases, references and citations of included reviews and relevant policy documents were searched. Reviews of qualitative studies exploring factors that influenced care home staff, medical practitioners, residents' family or residents' experiences and factors influencing decisions to transfer residents to the ED were included. Thematic analysis was used to synthesise findings.

RESULTS

six previous reviews were included, which synthesised the findings of 34 primary studies encompassing 152 care home residents, 283 resident family members or carers and 447 care home staff. Of the primary studies, 19 were conducted in the North America, seven in Australia, five were conducted in Scandinavia, two in the United Kingdom and one in Holland. Three themes were identified: (i) power dynamics between residents, family members, care home staff and health care professionals (external to the care home) influence decisions; (ii) admission can be necessary; however, (iii) some decisions may be driven by factors other than clinical need.

CONCLUSION

transfer decisions are complex and are determined not just by changes in health status interventions aimed at reducing avoidable transfers need to address the key role family members have in transfer decisions, the medical legal fears of care home staff and barriers to accessing community services.

English language proficiency and hospital admissions via the emergency department by aged care residents in Australia: A mixed-methods investigation

Residents of Residential Age Care Facilities (RACFs) have particularly high rates of Emergency Department (ED) visits, with up to 55% being potentially avoidable (e.g. not resulting in a hospital admission). This is concerning as ED visits by RACF residents are associated with negative outcomes including longer hospital stays, iatrogenic illness, complications and mortality. Limited English proficiency (LEP) has significant negative impacts on the healthcare quality and outcomes for older people but has not been studied as a factor in ED visits from RACFs. This study aimed to examine if RACF residents with LEP have a lower rate of hospital admission via the ED compared to non-LEP controls and identify any associated factors. We hypothesised that LEP-related communication difficulties would reduce the ability to manage minor health issues in the RACF, leading to a lower proportion of LEP ED transfers being admitted. We used a parallel mixed-methods design, comprising a quantitative matched cohort study of ED visit data from two Local Hospital Networks (LHNs) in South-East Melbourne, Australia and secondary thematic analysis of 25 interviews with LEP residents, family carers and staff from two RACFs in the same region. We found no differences in the proportion of hospital ED transfers that led to admission (LHN1, 87.1% LEP, 85.6% non-LEP controls, p = 0.57; LHN2, 76.0% LEP, 76.9% non-LEP controls, p = 0.41) and no direct qualitative evidence suggesting that resident LEP affected decisions to transfer residents to ED, despite communication difficulties being reported during the transfer process. These results may be due to the high level of family carer involvement in residents' care identified in the qualitative study. However, additional research using different measures of LEP is recommended to further explore a broader range of cultural and linguistic factors in both rates of ED presentations and the decision-making processes underpinning resident transfers to ED.

The Causes and Control Measures of Extended Spectrum Beta-Lactamase Producing Enterobacteriaceae in Long-Term Care Facilities: A Systematic Review and Meta-Analysis

Background

Due to extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE), infections among residents are increasing in long-term care facilities (LTCFs), resulting in a high rate of morbidity and healthcare costs. A designated infection control team is unavailable to control the disease.

Methods

A systematic review and meta-analysis were conducted to characterize the causes of ESBL-PE and evaluate the infection control strategies within LTCFs. Multiple regression analysis (MRA) was included as supplementary statistical analysis to identify relationships between LTCFs, geographical locations, infection control measures (ICMs), and ESBL-PE. A systematic search was conducted for studies from January 2008 to December 2018. Twenty-two of the 3106 studies met the inclusion criteria.

Results

The pooled prevalence for ESBL-PE among LTCFs residents was a mean difference (MD) of 15.78 (95% CI: 0.04, 31.53). Risk factors included the influence of regional areas was a standardized mean difference (SMD) of 0.61(95% CI: 0.32, 0.91) in Europe, SMD was 14.92 (95% CI: 9.17, 20.68) in Asia, and SMD was 0.51(95% CI: 0.35, 0.67) in other regions (North America and Australia). Nine of 22 studies reported ICMs were MD of 13.59 (95% CI: 5.32, 21.86).

Conclusions

Meta-analysis and MRA revealed a statistically significant association between LTCF and ESBL-PE among residents (p = .05). Strict adherence to infection control measures in LTCFs is needed to address this ESBL-PE prevalence among residents. The potential positive social change is promoting knowledge about vulnerable residents in LTCFs and the community factors responsible for ESBL infection.

Emergency department transfers from residential aged care: what can we learn from secondary qualitative analysis of Australian Royal Commission data?

OBJECTIVES

To use publicly available submissions and evidence from the Australian Royal Commission into Aged Care Quality and Safety as data for secondary qualitative analysis. By investigating the topic of emergency department transfer from the perspective of residents, family members and healthcare professionals, we aimed to identify modifiable factors to reduce transfer rates and improve quality of care.

DESIGN

The Australian Royal Commission into Aged Care Quality and Safety has made over 7000 documents publicly available. We used the documents as a large data corpus from which we extracted a data set specific to our topic using keywords. The analysis focused on submissions and hearing transcripts (including exhibits). Qualitative thematic analysis was used to interrogate the text to determine what could be learnt about transfer events from a scholarly perspective.

RESULTS

Three overarching themes were identified: shortfalls and failings, reluctance and misunderstanding, and discovery and exposure.

CONCLUSIONS

The results speak to workforce inadequacies that have been central to problems in the Australian aged care sector to date. We identified issues around clinical and pain assessment, lack of consideration to advance care directives and poor communication among all parties. We also highlighted the role that emergency departments play in identifying unmet clinical needs, substandard care and neglect. Given the inadequate clinical care available in some residential aged care facilities, transferring residents to a hospital emergency department may be making the best of a bad situation. If the objective of reducing unnecessary transfers to emergency departments is to be achieved, then access to appropriate clinical care is the first step.

Healthcare professionals' experience with emergency department-based acute care performed within nursing homes

BACKGROUND

hospital admissions of residents from nursing homes often lead to delirium, infections, mortality and reduced functional capacity. We initiated a new service, 'emergency department-based acute care service', maintained by consultants from an emergency department (ED) moving emergency care from the hospitals into nursing homes.

OBJECTIVE

this study explored healthcare professionals' experiences with this service.

DESIGN

qualitative semi-structured focus group discussions.

INTERVENTION/SETTING

the new service provides acute on-site evaluation and treatment to nursing home residents following calls to the emergency dispatch centre.

METHODS

we conducted focus groups with general practitioners, prehospital personnel, municipal acute care nurses, ED staff and nursing home staff. The analysis was performed using the iterative and explorative approach, 'systematic text condensation'.

RESULTS

the participants considered the service as a meaningful and appropriate alternative to hospital admission, as the treatment can be tailored to meet the residents' wishes and daily capabilities. This was experienced to promote dignity for the residents by reducing unnecessary transfers to the ED and the residents could remain in familiar surroundings with staff who knew their habitual behaviour and history. The nursing home staff contributed valuable information to the ED consultants' decision-making. The service made it possible to base the decision-making on complete patient pictures, as the ED consultants had the time to get to understand the residents.

CONCLUSION

acute care at nursing homes provides an alternative to routine admissions to hospitals and enables healthcare professionals to provide more dignity in the care of nursing home residents.

Inappropriate and potentially avoidable emergency department visits of Swiss nursing home residents and their resource use: a retrospective chart-review

Background

Emergency department (ED) visits for nursing home residents lead to higher morbidity and mortality. Therefore, inappropriate visits (for conditions treatable elsewhere) or potentially avoidable visits (those avoidable through adequate chronic care management) must be minimized. This study aimed to investigate factors and resource consumption patterns associated with inappropriate and potentially avoidable visits in a Swiss tertiary hospital.

Methods

This is a single-center retrospective chart review in an urban Swiss university hospital ED. A consecutive sample of 1276 visits by nursing home residents (≥ 65 years old), recorded between January 1, 2015 and December 31, 2017 (three calendar years) were included. Case characteristics were extracted from ED electronic documentation. Appropriateness was assessed via a structured Appropriateness Evaluation Protocol; potentially avoidable visits—measured as ambulatory-care sensitive conditions (ACSCs)—were analyzed separately. Inter-group differences concerning ED resource use were tested respectively with chi-square or Wilcoxon rank sum tests. To identify predictors of inappropriate or potentially-avoidable visits, we used multivariable logistic regression analysis.

Results

Six percent of visits were rated as inappropriate: they had lower triage levels (OR 0.55 [95%-CI 0.33-0.92], p=0.024) and, compared to ambulance calls, they had higher odds of initiation via either patient-initiated walk-in (OR 3.42 [95%-CI 1.79-6.55], p≤0.001) or GP referrals (OR 2.13 [95%-CI 1.16-3.90], p=0.015). For inappropriate visits, overall ED resource use was significantly lower (median 568 vs. 1403 tax points, p≤0.001). Of all visits included, 29% were due to (often potentially-avoidable) ACSCs. In those cases, compared to ambulance initiation, odds of being potentially-avoidable were considerably lower for walk-in patients (OR 0.46 [95%-CI 0.27-0.77], p=0.004) but higher for GP referrals (OR 1.40 [95%-CI 1.00-1.94], p=0.048). Nurse work (93 tax points vs. 64, p≤0.001) and laboratory resource use (334 tax points vs. 214, p≤0.001) were higher for potentially-avoidable ED visits.

Conclusions

We revealed substantial differences between the investigated groups. While nearly one third of ED visits from nursing homes were potentially avoidable, inappropriate visits were lower in numbers and not resource-intensive. Further research is required to differentiate potentially avoidable visits from inappropriate ones and to determine these findings’ public health implications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03308-9.

Epidemiology and Clinical Characteristics of Older Patients Transferred from Long-Term-Care Hospitals (LTCHs) to Emergency Departments by a Comparison with Non-LTCHs in South Korea: A Cross-Sectional Observational Study

The South Korean population is rapidly aging, and the number of older patients in long-term-care hospitals (LTCHs) continues to increase. This study aims to investigate the epidemiologic data, characteristics, and clinical outcomes of patients aged 65 years and older transferred from LTCHs to emergency departments (EDs). This is a retrospective study based on National Emergency Department Information System data from 2014 to 2019. Of the 6,209,695 older patients visiting EDs for disease treatment, 211,141 (3.4%) were transferred from LTCHs. Among patients from LTCHs (211,141), 24.2% were discharged from EDs, 43.0% were admitted to general wards, 20.7% were hospitalized in intensive care units, 3.1% were transferred to another hospital, 6.1% returned to LTCHs, and 2.1% died in EDs. ED stays were the longest for those returning to LTCHs (710.49 ± 1127.43 min). Foley catheterization (40.3%) was most frequently performed in preventable ED visits. In South Korea, older patients being discharged from the ED or returning to LTCHs, after being transferred from LTCHs to EDs, increased. ED stays among older LTCH patients were longer than among non-LTCH older patients, contributing to congestion. To reduce avoidable transfer to EDs from LTCHs, it is necessary to discuss policies, such as expanding appropriate medical personnel and transitional treatment.

Characteristics of Patients Who Visited Emergency Department: A Nationwide Population-Based Study in South Korea (2016-2018)

The utilization of the emergency department (ED) has been continuously increasing and has become a burden for ED resources. The aim of this study was to describe the characteristics, outcomes, common diagnoses, and disease classifications of patients who were referred to the ED. This nationwide epidemiologic study examined the data from adult patients (>18 years) who visited EDs from 1 January 2016 to 31 December 2018. Most EDs in Korea provide data from ED patients to the National Emergency Medical Center (NEMC). The disposition of ED patients was classified as discharge, admission, death, and re-transfer. From 2016 to 2018, the proportion of referred patients out of the total ED visits increased from 7.3% to 7.8%. The referred patients were older (61.1 vs. 50.5 years), had worse vital signs, longer ED lengths of stay (409.1 vs. 153.3 min), and higher admission (62.3 vs. 16.9%) and re-transfer rates (4.4 vs. 1.9%) than the direct-visit patients. Among the referred patients in the 3 years, 62.3% were hospitalized, and the most common disease classification was “disease of the digestive system” (19.8%). The most common diagnosis was pneumonia (6.0%), followed by urinary tract infection, gastrointestinal bleeding, and hepatobiliary infection. The number of patients referred to EDs is increasing, and more than 60% of referred patients are hospitalized. Detailed characteristics of these patients will be helpful for improving ED management and the distribution of medical resources.

Decision support-tools for early detection of infection in older people (aged> 65 years): a scoping review

Background

Infection is more frequent, and serious in people aged > 65 as they experience non-specific signs and symptoms delaying diagnosis and prompt treatment. Monitoring signs and symptoms using decision support tools (DST) is one approach that could help improve early detection ensuring timely treatment and effective care.

Objective

To identify and analyse decision support tools available to support detection of infection in older people (> 65 years).

Methods

A scoping review of the literature 2010–2021 following Arksey and O’Malley (2005) framework and PRISMA-ScR guidelines. A search of MEDLINE, Cochrane, EMBASE, PubMed, CINAHL, Scopus and PsycINFO using terms to identify decision support tools for detection of infection in people > 65 years was conducted, supplemented with manual searches.

Results

Seventeen papers, reporting varying stages of development of different DSTs were analysed. DSTs largely focussed on specific types of infection i.e. urine, respiratory, sepsis and were frequently hospital based (n = 9) for use by physicians. Four DSTs had been developed in nursing homes and one a care home, two of which explored detection of non- specific infection.

Conclusions

DSTs provide an opportunity to ensure a consistent approach to early detection of infection supporting prompt action and treatment, thus avoiding emergency hospital admissions. A lack of consideration regarding their implementation in practice means that any attempt to create an optimal validated and tested DST for infection detection will be impeded. This absence may ultimately affect the ability of the workforce to provide more effective and timely care, particularly during the current covid-19 pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03218-w.

'Weighing up risks': a model of care home staff decision-making about potential resident hospital transfers

Background

care home staff play a crucial role in managing residents’ health and responding to deteriorations. When deciding whether to transfer a resident to hospital, a careful consideration of the potential benefits and risks is required. Previous studies have identified factors that influence staff decision-making, yet few have moved beyond description to produce a conceptual model of the decision-making process.

Objectives

to develop a conceptual model to describe care home staff’s decision-making when faced with a resident who potentially requires a transfer to the hospital.

Methods

data collection occurred in England between May 2018 and November 2019, consisting of 28 semi-structured interviews with 30 members of care home staff across six care home sites and 113 hours of ethnographic observations, documentary analysis and informal conversations (with staff, residents, visiting families, friends and healthcare professionals) at three of these sites.

Results

a conceptual model of care home staff’s decision-making is presented. Except in situations that staff perceived to be urgent enough to require an immediate transfer, resident transfers tended to occur following a series of escalations. Care home staff made complex decisions in which they sought to balance a number of potential benefits and risks to: residents; staff (as decision-makers); social relationships; care home organisations and wider health and social care services.

Conclusions

during transfer decisions, care home staff make complex decisions in which they weigh up several forms of risk. The model presented offers a theoretical basis for interventions to support deteriorating care home residents and the staff responsible for their care.