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Teggi D, Woodthorpe K. Anticipatory prescribing of injectable controlled drugs (ICDs) in care homes: a qualitative observational study of staff role, uncertain dying and hospital transfer at the end-of-life. BMC Geriatr 2024; 24:310. [PMID: 38570758 PMCID: PMC10988888 DOI: 10.1186/s12877-024-04801-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 02/10/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND The anticipatory prescribing of injectable controlled drugs (ICDs) by general practitioners (GPs) to care home residents is common practice and is believed to reduce emergency hospital transfers at the end-of-life. However, evidence about the process of ICD prescribing and how it affects residents' hospital transfer is limited. The study examined how care home nurses and senior carers (senior staff) describe their role in ICDs prescribing and identify that role to affect residents' hospital transfers at the end-of-life. METHODS 1,440 h of participant observation in five care homes in England between May 2019 and March 2020. Semi-structured interviews with a range of staff. Interviews (n = 25) and fieldnotes (2,761 handwritten A5 pages) were analysed thematically. RESULTS Senior staff request GPs to prescribe ICDs ahead of residents' expected death and review prescribed ICDs for as long as residents survive. Senior staff use this mechanism to ascertain the clinical appropriateness of withholding potentially life-extending emergency care (which usually led to hospital transfer) and demonstrate safe care provision to GPs certifying the medical cause of death. This enables senior staff to facilitate a care home death for residents experiencing uncertain dying trajectories. CONCLUSION Senior staff use GPs' prescriptions and reviews of ICDs to pre-empt hospital transfers at the end-of-life. Policy should indicate a clear timeframe for ICD review to make hospital transfer avoidance less reliant on trust between senior staff and GPs. The timeframe should match the period before death allowing GPs to certify death without triggering a Coroner's referral.
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Affiliation(s)
- Diana Teggi
- Department of Social and Policy Sciences, Centre for Death and Society (CDAS), University of Bath, Bath, UK.
| | - Kate Woodthorpe
- Department of Social and Policy Sciences, Centre for Death and Society (CDAS), University of Bath, Bath, UK.
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Chambers D, Cantrell A, Preston L, Marincowitz C, Wright L, Conroy S, Lee Gordon A. Reducing unplanned hospital admissions from care homes: a systematic review. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-130. [PMID: 37916580 DOI: 10.3310/klpw6338] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Background Care homes predominantly care for older people with complex health and care needs, who are at high risk of unplanned hospital admissions. While often necessary, such admissions can be distressing and provide an opportunity cost as well as a financial cost. Objectives Our objective was to update a 2014 evidence review of interventions to reduce unplanned admissions of care home residents. We carried out a systematic review of interventions used in the UK and other high-income countries by synthesising evidence of effects of these interventions on hospital admissions; feasibility and acceptability; costs and value for money; and factors affecting applicability of international evidence to UK settings. Data sources We searched the following databases in December 2021 for studies published since 2014: Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews; Cumulative Index to Nursing and Allied Health Literature; Health Management Information Consortium; Medline; PsycINFO; Science and Social Sciences Citation Indexes; Social Care Online; and Social Service Abstracts. 'Grey' literature (January 2022) and citations were searched and reference lists were checked. Methods We included studies of any design reporting interventions delivered in care homes (with or without nursing) or hospitals to reduce unplanned hospital admissions. A taxonomy of interventions was developed from an initial scoping search. Outcomes of interest included measures of effect on unplanned admissions among care home residents; barriers/facilitators to implementation in a UK setting and acceptability to care home residents, their families and staff. Study selection, data extraction and risk of bias assessment were performed by two independent reviewers. We used published frameworks to extract data on intervention characteristics, implementation barriers/facilitators and applicability of international evidence. We performed a narrative synthesis grouped by intervention type and setting. Overall strength of evidence for admission reduction was assessed using a framework based on study design, study numbers and direction of effect. Results We included 124 publications/reports (30 from the UK). Integrated care and quality improvement programmes providing additional support to care homes (e.g. the English Care Homes Vanguard initiatives and hospital-based services in Australia) appeared to reduce unplanned admissions relative to usual care. Simpler training and staff development initiatives showed mixed results, as did interventions aimed at tackling specific problems (e.g. medication review). Advance care planning was key to the success of most quality improvement programmes but do-not-hospitalise orders were problematic. Qualitative research identified tensions affecting decision-making involving paramedics, care home staff and residents/family carers. The best way to reduce end-of-life admissions through access to palliative care was unclear in the face of inconsistent and generally low-quality evidence. Conclusions Effective implementation of interventions at various stages of residents' care pathways may reduce unplanned admissions. Most interventions are complex and require adaptation to local contexts. Work at the interface between health and social care is key to successful implementation. Limitations Much of the evidence identified was of low quality because of factors such as uncontrolled study designs and small sample size. Meta-analysis was not possible. Future work We identified a need for improved economic evidence and the evaluation of integrated care models of the type delivered by hospital-based teams. Researchers should carefully consider what is realistic in terms of study design and data collection given the current context of extreme pressure on care homes. Study registration This study is registered as PROSPERO database CRD42021289418. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (award number NIHR133884) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 18. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Louise Preston
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Carl Marincowitz
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Simon Conroy
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Adam Lee Gordon
- Academic Unit of Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, University of Nottingham, Nottingham, UK
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Højbjerg K, Poulsen I, Egerod I. Facilitators and inhibitors of traumatic brain injury transfers: A fieldwork investigation. Nurs Open 2023; 10:6282-6290. [PMID: 37317011 PMCID: PMC10416057 DOI: 10.1002/nop2.1874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 01/30/2023] [Accepted: 05/25/2023] [Indexed: 06/16/2023] Open
Abstract
AIM Intensified healthcare specialization has increased the need for patient transfers. We aimed to describe in-hospital and interhospital patient transfer decisions during the traumatic brain injury (TBI) trajectory from a nursing perspective. DESIGN Ethnographic fieldwork. METHODS We used participant observation and interviews at three sites representing the acute, subacute and stable stages of the TBI trajectory. Deductive analysis was applied supported by transition theory. RESULTS During the acute stage (neurointensive care), transfer decisions were facilitated by physicians assisted by critical care nurses, in the subacute stage (highly specialized rehabilitation), transfer decisions were collaborative among in-house healthcare professionals, community staff and family, and during the stable stage (municipal rehabilitation), transfer decisions were made by non-clinical staff. Most of the resources allocated during the trajectory went towards highly specialized rehabilitation, whereas more resources are needed during the end of the trajectory. NO PATIENT OR PUBLIC CONTRIBUTION Patients and the public were not involved in this study .
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Affiliation(s)
- Karin Højbjerg
- Department of Learning and PhilosophyAalborg University CopenhagenCopenhagenDenmark
- Present address:
Department of Nursing and Nutrition, Faculty of HealthCopenhagen University CollegeCopenhagen NDenmark
| | - Ingrid Poulsen
- Department of Brain Injury, Copenhagen University HospitalRigshospitaletCopenhagenDenmark
- Department of Nursing Science, HealthAarhus UniversityAarhusDenmark
- Present address:
Department of Clinical ResearchCopenhagen University Hospital, Amager and HvidovreHvidovreDenmark
| | - Ingrid Egerod
- Department of Intensive Care, Copenhagen University HospitalRigshospitaletCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
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Hodge SY, Ali MR, Hui A, Logan P, Gordon AL. Recognising and responding to acute deterioration in care home residents: a scoping review. BMC Geriatr 2023; 23:399. [PMID: 37386360 PMCID: PMC10308707 DOI: 10.1186/s12877-023-04082-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 05/31/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Acute deterioration describes a rapid change in physical and/or mental health resulting from an acute illness - e.g., heart attack or infection. Older people in care homes are some of the frailest and vulnerable in society. They have complex health needs, experience multiple long-term conditions (MLTC) and have weakened immune systems due to the ageing process. They are more susceptible to acute deterioration and delayed recognition and response, is linked to poorer health outcomes, adverse events and death. Over the past five years, the need to manage acute deterioration in care homes and prevent hospital admissions has led to development and implementation of improvement projects, including the use of hospital derived practices and tools to identify and manage this condition. This is potentially problematic as care homes are different from hospitals-options to escalate care vary throughout the UK. Further, hospital tools have not been validated for use in care homes and have shown to be less sensitive in older adults living with frailty. OBJECTIVES To collate the available evidence on how care home workers recognise and respond to acute deterioration in residents using published primary research, non-indexed and grey literature, policies, guidelines and protocols. METHODS A systematic scoping review was conducted following Joanna Briggs Institute (JBI) scoping review methodology. Searches were conducted using: CINAHL (EBSCOhost), EMCARE (OVID), MEDLINE (OVID) and HMIC (OVID). Snowball searches of included studies' reference lists were conducted. Studies that featured care homes with or without nursing and provided 24/7 care to residents were included. RESULTS Three hundred and ninety-nine studies were identified. After reviewing all studies against inclusion criteria, n = 11 were included in the review. All studies used qualitative methods and were conducted in Australia, UK, South Korea, USA and Singapore. Four themes were generated from the review: identifying residents with acute deterioration; managing acute deterioration, care home policies and procedures, and factors affecting recognition and response to acute deterioration. FINDINGS Recognition and response to acute deterioration in residents is determined by multiple factors and is context sensitive. There are several interrelated factors within and external to the care home that contribute to how acute deterioration is recognised and managed. CONCLUSIONS AND IMPLICATIONS The available literature on how care home workers recognise and respond to acute deterioration is limited and often subtends other areas of interest. Recognising and responding to acute deterioration in care home residents is reliant on a complex and open system encompassing multiple interrelated components. The phenomenon of acute deterioration remains underexplored and further research is required to examine contextual factors that accompany identification and management of this condition in care home residents.
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Affiliation(s)
- Sevim Y Hodge
- School of Medicine, Centre for Rehabilitation and Ageing Research, University of Nottingham, Nottingham, UK.
| | - Mohammad R Ali
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Ada Hui
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Pip Logan
- School of Medicine, Centre for Rehabilitation and Ageing Research, University of Nottingham, Nottingham, UK
| | - Adam L Gordon
- Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
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Marincowitz C, Preston L, Cantrell A, Tonkins M, Sabir L, Mason S. What influences decisions to transfer older care-home residents to the emergency department? A synthesis of qualitative reviews. Age Ageing 2022; 51:6834152. [PMID: 36413591 PMCID: PMC9681131 DOI: 10.1093/ageing/afac257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Carl Marincowitz
- Address correspondence to: Carl Marincowitz, Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK.
| | - Louise Preston
- Health Economics and Decision Science, Health Services Research School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Anna Cantrell
- Health Economics and Decision Science, Health Services Research School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Michael Tonkins
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
| | - Lisa Sabir
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
| | - Suzanne Mason
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
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Harrad-Hyde F, Williams C, Armstrong N. Hospital transfers from care homes: conceptualising staff decision-making as a form of risk work. HEALTH, RISK & SOCIETY 2022. [DOI: 10.1080/13698575.2022.2133094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Fawn Harrad-Hyde
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Chris Williams
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Natalie Armstrong
- Department of Health Sciences, University of Leicester, Leicester, UK
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Kesten JM, Redwood S, Pullyblank A, Tavare A, Pocock L, Brant H, Hill EM, Tutaev M, Shum RZ, Banks J. Using the recommended summary plan for emergency care and treatment (ReSPECT) in care homes: a qualitative interview study. Age Ageing 2022; 51:6770071. [PMID: 36273344 PMCID: PMC9588387 DOI: 10.1093/ageing/afac226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is an advance care planning process designed to facilitate discussion and documentation of preferences for care in a medical emergency. Advance care planning is important in residential and nursing homes. AIM To explore the views and experiences of GPs and care home staff of the role of ReSPECT in: (i) supporting, and documenting, conversations about care home residents' preferences for emergency care situations, and (ii) supporting decision-making in clinical emergencies. SETTING/PARTICIPANTS Sixteen GPs providing clinical care for care home residents and 11 care home staff in the West of England. METHODS A qualitative research design using semi-structured interviews. RESULTS Participants' accounts described the ReSPECT process as facilitating person-centred conversations about residents' preferences for care in emergency situations. The creation of personalised scenarios supported residents to consider their preferences. However, using ReSPECT was complex, requiring interactional work to identify and incorporate resident or relative preferences. Subsequent translation of preferences into action during emergency situations also proved difficult in some cases. Care staff played an important role in facilitating and supporting ReSPECT conversations and in translating it into action. CONCLUSIONS The ReSPECT process in care homes was positive for GPs and care home staff. We highlight challenges with the process, communication of preferences in emergency situations and the importance of balancing detail with clarity. This study highlights the potential for a multi-disciplinary approach engaging care staff more in the process.
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Affiliation(s)
- Joanna May Kesten
- Address correspondence to: Joanna May Kesten, NIHR ARC West at University Hospitals Bristol and Weston NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol BS1 2NT, UK.
| | - Sabi Redwood
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
| | - Anne Pullyblank
- West of England Academic Health Science Network (West of England AHSN), Bristol, UK,North Bristol NHS Trust, Bristol, UK
| | - Alison Tavare
- West of England Academic Health Science Network (West of England AHSN), Bristol, UK
| | - Lucy Pocock
- Population Health Sciences, Bristol Medical School, University of Bristol
| | - Heather Brant
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
| | - Elizabeth M Hill
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
| | | | - Rui Zhi Shum
- Population Health Sciences, Bristol Medical School, University of Bristol
| | - Jon Banks
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
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Harrad-Hyde F, Armstrong N, Williams CD. 'Weighing up risks': a model of care home staff decision-making about potential resident hospital transfers. Age Ageing 2022; 51:6649130. [PMID: 35871419 PMCID: PMC9308989 DOI: 10.1093/ageing/afac171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 05/16/2022] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Fawn Harrad-Hyde
- Department of Health Sciences, George Davies Centre, University of Leicester, University Road, Leicester, LE1 7RH, UK
| | - Natalie Armstrong
- Department of Health Sciences, George Davies Centre, University of Leicester, University Road, Leicester, LE1 7RH, UK
| | - Christopher D Williams
- Department of Health Sciences, George Davies Centre, University of Leicester, University Road, Leicester, LE1 7RH, UK
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