The Older Persons' Transitions in Care (OPTIC) study: pilot testing of the transition tracking tool

The development and validation of a conceptual definition of avoidable transitions from long-term care to the emergency department: A mixed methods study

Background/Objectives

Transitions to and from Emergency Departments (EDs) can be detrimental to long-term care (LTC) residents and burden the healthcare system. While reducing avoidable transfers is imperative, various terms are used interchangeably including inappropriate, preventable, or unnecessary transitions. Our study objectives were to develop a conceptual definition of avoidable LTC-ED transitions and to verify the level of stakeholder agreement with this definition.

Methods

The EXamining Aged Care Transitions study adopted an exploratory sequential mixed-method design. The study was conducted in 2015-2016 in 16 LTC facilities, 1 ED, and 1 Emergency Medical Service (EMS) in a major urban center in western Canada. Phase 1 included 80 participants, (healthcare aides, licensed practical nurses, registered nurses, LTC managers, family members of residents, and EMS staff). We conducted semistructured interviews (n = 25) and focus groups (n = 19). In Phase 2, 327 ED staff, EMS staff, LTC staff, and medical directors responded to a survey based on the qualitative findings.

Results

Avoidable transitions were attributed to limited resources in LTC, insufficient preventive care, and resident or family wishes. The definition generated was: A transition of an LTC resident to the ED is considered avoidable if: (a) Diagnostic testing, medical assessment, and treatment can be accessed in a timely manner by other means; (b) the reasons for a transfer are unclear and the transition would increase the disorientation, pain, or discomfort of a resident, outweighing a clear benefit of a transfer; and (c) the transition is against the wishes expressed by the resident over time, including through informal and undocumented conversations. There was a high level of agreement with the definition across the four participant groups.

Conclusions and Implications

To effectively reduce LTC resident avoidable transitions, stakeholders must share a common definition. Our conceptual definition may significantly contribute to improved care for LTC residents.

Incidence of Pressure Injury Among Older Adults Transitioning from Long-term Care to the ED

OBJECTIVE

To identify sociodemographic, health condition, and organizational/process factors associated with pressure injury (PI) incidence during older adults' emergency transitions from long-term care (LTC) to the ED.

METHODS

Emergency transitions were tracked for older adults within included LTC facilities to participating EDs in two urban centers located in provinces in Canada. Binary logistic regression was used to examine the influence of sociodemographic, service use, and client health and function factors on the incidence of PIs during transitions from LTC facilities to EDs.

RESULTS

Having a mobility issue (odds ratio [OR], 4.318; 95% CI, 1.344-13.870), transitioning from a publicly owned versus a nonprofit volunteer LTC facility (OR, 4.886; 95% CI, 1.157-20.634), and time from ED arrival to return to LTC being 7 to 9 days (OR, 41.327; 95% CI, 2.691-634.574) or greater than 9 days (OR, 77.639; 95% CI, 5.727-1,052.485) significantly increased the odds of experiencing a new skin injury upon return to LTC. A higher number of reported reasons for emergency transition (up to 4) significantly decreased the odds of a new PI upon return to LTC (OR, 0.315; 95% CI, 0.113-0.880).

CONCLUSIONS

The study findings can be used to identify LTC residents at increased risk for developing new skin injuries during an emergency transition, namely, those with mobility impairment, those requiring inpatient care for 6 or more days, and those transitioning from publicly owned LTC facilities. Evaluating the uptake and effectiveness of single-pronged and multipronged interventions such as visual cues for patient turning through online monitoring, consistent risk assessments, and improved nutrition in all care settings are vital next steps in preventing skin injuries in this population.

A first look at consistency of documentation across care settings during emergency transitions of long-term care residents

BACKGROUND

Documentation during resident transitions from long-term care (LTC) to the emergency department (ED) can be inconsistent, leading to inappropriate care. Inconsistent documentation can lead to undertreatment, inefficiencies and adverse patient outcomes. Many individuals residing in LTC have some form of cognitive impairment and may not be able to advocate for themselves, making accurate and consistent documentation vital to ensuring they receive safe care. We examined documentation consistency related to reason for transfer across care settings during these transitions.

METHODS

We included residents of LTC aged 65 or over who experienced an emergency transition from LTC to the ED via emergency medical services. We used a standardized and pilot-tested tracking tool to collect resident chart/patient record data. We collected data from 38 participating LTC facilities to two participating EDs in Western Canadian provinces. Using qualitative directed content analysis, we categorized documentation from LTC to the ED by sufficiency and clinical consistency.

RESULTS

We included 591 eligible transitions in this analysis. Documentation was coded as consistent, inconsistent, or ambiguous. We identified the most common reasons for transition for consistent cases (falls), ambiguous cases (sudden change in condition) and inconsistent cases (falls). Among inconsistent cases, three subcategories were identified: insufficient reporting, potential progression of a condition during transition and unclear reasons for inconsistency.

CONCLUSIONS

Shared continuing education on documentation across care settings should result in documentation supports geriatric emergency care; on-the-job training needs to support reporting of specific signs and symptoms that warrant an emergent response, and discourage the use of vague descriptors.

Detecting Acute Deterioration in Older Adults Living in Residential Aged Care: A Scoping Review

OBJECTIVES

To explore models, processes, or tools implemented in residential aged care (RAC) to support registered nurses (RNs) to identify and respond to the acute deterioration of residents.

DESIGN

Scoping literature review of English Language articles published in peer reviewed journals.

SETTINGS AND PARTICIPANTS

Studies were conducted in RAC facilities providing long-term 24-hour medical, nursing, and social care for people age 65 years or older with age-related disability.

METHODS

We completed a MESH term and key word search of MEDLINE, Embase, CINAHL, PubMed, and Google Scholar. Included studies had (1) part of the intervention based in RAC; (2) had a direct impact on RAC day to day practice; and (3) contained or provided access to the detail of the intervention. Data was charted by author, date, country, study design and the components, genesis, and efficacy of the methods used to identify and respond to acute deterioration.

RESULTS

We found 46 studies detailing models of care, clinical patterns of acute deterioration, and deterioration detection tools. It was not possible to determine which element of the models care had the greatest impact on RN decision making. The clinical patterns of acute deterioration painted a picture of acute deterioration in the frail. There was limited evidence to support the use of existing deterioration detection tools in the RAC population.

CONCLUSION AND IMPLICATIONS

We found no straight forward systematic method to support RAC RNs to identify and respond to the acute deterioration of residents. This is an important practice gap. The clinical pattern of acute deterioration described in the literature has the potential to be used for the development of a tool to support RAC RNs to identify and respond to the acute deterioration of residents.

Assessing quality of older persons' emergency transitions between long-term and acute care settings: a proof-of-concept study

Background

Long-term care (LTC) residents frequently experience transitions in the location of more advanced care delivery, including receiving emergency department (ED) care. In this proof-of-concept study, we aimed to determine if we could identify measures in quality of care across transitions from LTC to the ED, via emergency medical services and back, by applying Institute of Medicine (IOM) Quality of Care Domains to an existing dataset.

Methods

In the Older Persons’ Transitions in Care (OPTIC) study, we collected information on residents’ transitions in two Western Canadian cities. We applied the IOM’s Quality of Care Domains to the OPTIC data to create binary measures of transition quality. We report the median (MED) per cent and IQR of measures met within each domain of quality.

Results

We tracked 637 transitions over a 12-month period, with data collected from each setting. We developed 19 safety measures, 20 measures of resident-centred care, 3 measures of timely care and 5 measures of effective care. We were unable to develop measures for equitable care at an individual transfer level. Domain scores varied across individual transitions, with the highest scores in safety (MED 79%, IQR: 63–95), efficiency (66%; IQR: 66–99), and resident-centred (45%; IQR: 25–65), followed by effectiveness (36%; IQR: 16–56), and timeliness (0%; IQR: 0–50).

Conclusions

Our results show variation in scores across the domains of quality suggesting that it is possible to track quality of transitions for individuals across all settings, and not only within settings. We recommend that future work in tracking quality of care be performed at several levels (LTC, region, health authority, province). Such tracking is necessary to evaluate and improve overall quality of care.

Quality Indicators for Older Persons' Transitions in Care: A Systematic Review and Delphi Process

We identified quality indicators (QIs) for care during transitions of older persons (≥ 65 years of age). Through systematic literature review, we catalogued QIs related to older persons' transitions in care among continuing care settings and between continuing care and acute care settings and back. Through two Delphi survey rounds, experts ranked relevance, feasibility, and scientific soundness of QIs. A steering committee reviewed QIs for their feasible capture in Canadian administrative databases. Our search yielded 326 QIs from 53 sources. A final set of 38 feasible indicators to measure in current practice was included. The highest proportions of indicators were for the emergency department (47%) and the Institute of Medicine (IOM) quality domain of effectiveness (39.5%). Most feasible indicators were outcome indicators. Our work highlights a lack of standardized transition QI development in practice, and the limitations of current free-text documentation systems in capturing relevant and consistent data.

Addressing Communication Breakdowns during Emergency Care Transitions of Older Adults: Evaluation of a Standardized Inter-Facility Health Care Communication Form

Transitions for older persons from long-term care (LTC) to the emergency department (ED) and back, can result in adverse events. Effective communication among care settings is required to ensure continuity of care. We implemented a standardized form for improving consistency of documentation during LTC to ED transitions of residents 65 years of age or older, via emergency medical services (EMS), and back. Data on form use and form completion were collected through chart review. Practitioners' perspectives were collected using surveys. The form was used in 90/244 (37%) LTC to ED transitions, with large variation in data element completion. EMS and ED reported improved identification of resident information. LTC personnel preferred usual practice to the new form and twice reported prioritizing form completion before calling 911. To minimize risk of harmful unintended consequences, communication forms should be implemented as part of broader quality improvement programs, rather than as stand-alone interventions.

Improving care for residents in long term care facilities experiencing an acute change in health status

Background

Long term care (LTC) facilities provide health services and assist residents with daily care. At times residents may require transfer to emergency departments (ED), depending on the severity of their change in health status, their goals of care, and the ability of the facility to care for medically unstable residents. However, many transfers from LTC to ED are unnecessary, and expose residents to discontinuity in care and iatrogenic harms. This knowledge translation project aims to implement a standardized LTC-ED care and referral pathway for LTC facilities seeking transfer to ED, which optimizes the use of resources both within the LTC facility and surrounding community.

Methods/design

We will use a quasi-experimental randomized stepped-wedge design in the implementation and evaluation of the pathway within the Calgary zone of Alberta Health Services (AHS), Canada. Specifically, the intervention will be implemented in 38 LTC facilities. The intervention will involve a standardized LTC-ED care and referral pathway, along with targeted INTERACT® tools. The implementation strategies will be adapted to the local context of each facility and to address potential implementation barriers identified through a staff completed barriers assessment tool. The evaluation will use a mixed-methods approach. The primary outcome will be any change in the rate of transfers to ED from LTC facilities adjusted by resident-days. Secondary outcomes will include a post-implementation qualitative assessment of the pathway. Comparative cost-analysis will be undertaken from the perspective of publicly funded health care.

Discussion

This study will integrate current resources in the LTC-ED pathway in a manner that will better coordinate and optimize the care for LTC residents experiencing an acute change in health status.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05919-7.

Who Doesn't Come Home? Factors Influencing Mortality Among Long-Term Care Residents Transitioning to and From Emergency Departments in Two Canadian Cities

Residents of long-term care (LTC) whose deaths are imminent are likely to trigger a transfer to the emergency department (ED), which may not be appropriate. Using data from an observational study, we employed structural equation modeling to examine relationships among organizational and resident variables and death during transitions between LTC and ED. We identified 524 residents involved in 637 transfers from 38 LTC facilities and 2 EDs. Our model fit the data, (χ² = 72.91, df = 56, p = .064), explaining 15% variance in resident death. Sustained shortness of breath (SOB), persistent decreased level of consciousness (LOC) and high triage acuity at ED presentation were direct and significant predictors of death. The estimated model can be used as a framework for future research. Standardized reporting of SOB and changes in LOC, scoring of resident acuity in LTC and timely palliative care consultation for families in the ED, when they are present, warrant further investigation.

Learning Integrated Health System to Mobilize Context-Adapted Knowledge With a Wiki Platform to Improve the Transitions of Frail Seniors From Hospitals and Emergency Departments to the Community (LEARNING WISDOM): Protocol for a Mixed-Methods Implementation Study

BACKGROUND

Elderly patients discharged from hospital experience fragmented care, repeated and lengthy emergency department (ED) visits, relapse into their earlier condition, and rapid cognitive and functional decline. The Acute Care for Elders (ACE) program at Mount Sinai Hospital in Toronto, Canada uses innovative strategies, such as transition coaches, to improve the care transition experiences of frail elderly patients. The ACE program reduced the lengths of hospital stay and readmission for elderly patients, increased patient satisfaction, and saved the health care system over Can $4.2 million (US $2.6 million) in 2014. In 2016, a context-adapted ACE program was implemented at one hospital in the Centre intégré de santé et de services sociaux de Chaudière-Appalaches (CISSS-CA) with a focus on improving transitions between hospitals and the community. The quality improvement project used an intervention strategy based on iterative user-centered design prototyping and a "Wiki-suite" (free web-based database containing evidence-based knowledge tools) to engage multiple stakeholders.

OBJECTIVE

The objectives of this study are to (1) implement a context-adapted CISSS-CA ACE program in four hospitals in the CISSS-CA and measure its impact on patient-, caregiver-, clinical-, and hospital-level outcomes; (2) identify underlying mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly; and (3) identify underlying mechanisms by which the Wiki-suite contributes to context-adaptation and local uptake of knowledge tools.

METHODS

Objective 1 will involve staggered implementation of the context-adapted CISSS-CA ACE program across the four CISSS-CA sites and interrupted time series to measure the impact on hospital-, patient-, and caregiver-level outcomes. Objectives 2 and 3 will involve a parallel mixed-methods process evaluation study to understand the mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly and by which our Wiki-suite contributes to adaptation, implementation, and scaling up of geriatric knowledge tools.

RESULTS

Data collection started in January 2019. As of January 2020, we enrolled 1635 patients and 529 caregivers from the four participating hospitals. Data collection is projected to be completed in January 2022. Data analysis has not yet begun. Results are expected to be published in 2022. Expected results will be presented to different key internal stakeholders to better support the effort and resources deployed in the transition of seniors. Through key interventions focused on seniors, we are expecting to increase patient satisfaction and quality of care and reduce readmission and ED revisit.

CONCLUSIONS

This study will provide evidence on effective knowledge translation strategies to adapt best practices to the local context in the transition of care for elderly people. The knowledge generated through this project will support future scale-up of the ACE program and our wiki methodology in other settings in Canada.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04093245; https://clinicaltrials.gov/ct2/show/NCT04093245.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17363.

Fractured Care: A Window Into Emergency Transitions in Care for LTC Residents With Complex Health Needs

Objective: For long-term care (LTC) residents, transfers to emergency departments (EDs) can be associated with poor health outcomes. We aimed to describe characteristics of residents transferred, factors related to decisions during transfer, care received in emergency medical services (EMS), ED settings, outcomes on return to LTC, and times of transfer segments along the transition. Method: We prospectively followed 637 transitions to an ED in British Columbia and Alberta, Canada, over a 12-month period. Data were captured through an electronic Transition Tracking Tool and interviews with health care professionals. Results: Common events triggering transfer were falls (26.8%), sudden change in condition (23.5%), and shortness of breath (19.8%). Discrepancies existed between reason for transfer, EMS reported chief complaint, and ED diagnosis. Many transfers resulted in resident return directly to LTC (42.7%). Discussion: Avoidable transfers may put residents at risk of receiving inappropriate care. Standardized communication strategies to highlight changes in resident condition are warranted.

Long-Term Care Health Care Aides' Perceptions of Decision-Making Processes in Transferring Residents to Acute Care Services

Most transfers of long-term care (LTC) facility residents to the emergency department (ED) via 911 calls are necessary. Avoidable transfers can have adverse effects including increased confusion and dehydration. Around 20% of transfers are perceived to be avoidable or unnecessary, yet decision making around transfers is complex and poorly understood. Using a qualitative-focused ethnographic approach, we examined 20 health care aides' (HCAs) perceptions of decision processes leading to transfer using experiential interview data. Inductive analysis throughout iterative data collection and analysis illuminated how HCAs' familiarity with residents make them vital in initiating care processes. Hierarchical reporting structures influenced HCAs' perceptions of nurse responsiveness to their concerns about resident condition, which influenced communications related to transfers. Communication processes in LTC facilities and the value placed on HCA concerns are inconsistent. There is an urgent need to improve conceptualization of HCA roles and communication structures in LTCs.

Factors affecting residents transition from long term care facilities to the community: a scoping review

BACKGROUND

Long-term care facilities (LTCFs) are often places where persons with complex health needs that cannot be met in a community setting, reside and are cared for until death. However, not all persons experience continuous declines in health and functioning. For some residents who experience improvement in personal abilities and increased independence, transition from the LTCF to the community may be an option. This scoping review aimed to synthetize the existing evidence regarding the transition process from discharge planning to intervention and evaluation of outcomes for residents transitioning from LTCFs to the community.

METHODS

This review followed a five-stage scoping review framework to describe the current knowledge base related to transition from LTCFs to community based private dwellings as the location of the discharge (example: Person's own home or shared private home with a family member, friend, or neighbour). Of the 4221 articles retrieved in the search of 6 databases, 36 articles met the criteria for inclusion in this review.

RESULTS

The majority of studies focussed on an older adult population (aged 65 years or greater), were conducted in the USA, and were limited to small geographic regions. There was a lack of consistency in terminology used to describe both the facilities as well as the transition process. Literature consisted of a broad array of study designs; sample sizes ranged from less than 10 to more than 500,000. Persons who were younger, married, female, received intense therapy, and who expressed a desire to transition to a community setting were more likely to transition out of a LTCF while those who exhibited cognitive impairment were less likely to transition out of a LTCF to the community.

CONCLUSIONS

Findings highlight the heterogeneity and paucity of research examining transition of persons from LTCFs to the community. Overall, it remains unclear what best practices support the discharge planning and transition process and whether or not discharge from a LTCF to the community promotes the health, wellbeing, and quality of life of the persons. More research is needed in this area before we can start to confidently answer the research questions.

Factors affecting residents transition from long term care facilities to the community: a scoping review

Background

Long-term care facilities (LTCFs) are often places where persons with complex health needs that cannot be met in a community setting, reside and are cared for until death. However, not all persons experience continuous declines in health and functioning. For some residents who experience improvement in personal abilities and increased independence, transition from the LTCF to the community may be an option. This scoping review aimed to synthetize the existing evidence regarding the transition process from discharge planning to intervention and evaluation of outcomes for residents transitioning from LTCFs to the community.

Methods

This review followed a five-stage scoping review framework to describe the current knowledge base related to transition from LTCFs to community based private dwellings as the location of the discharge (example: Person’s own home or shared private home with a family member, friend, or neighbour). Of the 4221 articles retrieved in the search of 6 databases, 36 articles met the criteria for inclusion in this review.

Results

The majority of studies focussed on an older adult population (aged 65 years or greater), were conducted in the USA, and were limited to small geographic regions. There was a lack of consistency in terminology used to describe both the facilities as well as the transition process. Literature consisted of a broad array of study designs; sample sizes ranged from less than 10 to more than 500,000. Persons who were younger, married, female, received intense therapy, and who expressed a desire to transition to a community setting were more likely to transition out of a LTCF while those who exhibited cognitive impairment were less likely to transition out of a LTCF to the community.

Conclusions

Findings highlight the heterogeneity and paucity of research examining transition of persons from LTCFs to the community. Overall, it remains unclear what best practices support the discharge planning and transition process and whether or not discharge from a LTCF to the community promotes the health, wellbeing, and quality of life of the persons. More research is needed in this area before we can start to confidently answer the research questions.

Insights Into Roles for Health-Care Professionals in Meeting the Needs of Older Adults and Unpaid Caregivers During Health-Care Transitions

We provided insights from older adults, their unpaid caregivers, and health-care professionals into specific roles for professionals within the health system to better meet the needs of community-dwelling older adults and their unpaid caregivers experiencing transitions between health services. We used a qualitative approach to collect data within one Canadian province from older adults and unpaid caregivers of older adults who participated in focus groups ( n = 98) and professionals working in the health system who participated in an online survey ( n = 52). Questions included experiences with health service transitions, strengths, challenges, and suggestions to improve transitions. Thematic analysis resulted in identifying seven specific roles for professionals in supporting health-care transitions: information and education, planning for future health needs, supporting the acceptance of necessary care, facilitating access to the right services at the right time, facilitating communication between services, facilitating the discharge planning process and advocacy for older adults and unpaid caregivers. Our results based on evidence from older adults, unpaid caregivers, and health-care professionals will inform future research and further development of the instrumental and relational roles for professionals supporting older adults and their caregivers experiencing health-care transitions.

The impact of transitional care programs on health services utilization among community-dwelling older adults and their caregivers: a systematic review protocol of quantitative evidence

What is the impact of transitional care programs on health services utilization among community-dwelling older adults and their caregivers?

Impact of a Novel Collaborative Long-Term Care -EMS Model: A Before-and-After Cohort Analysis of an Extended Care Paramedic Program

To compare system and clinical outcomes before and after an extended care paramedic (ECP) program was implemented to better address the emergency needs of long-term care (LTC) residents. Data were collected from emergency medical services (EMS), hospital, and ten LTC facility charts for two five-month time periods, before and after ECP implementation. Outcomes include: number of EMS patients transported to emergency department (ED) and several clinical, safety, and system secondary outcomes. Statistics included descriptive, chi-squared, t-tests, and ANOVA; α = <0.05. 413 cases were included (before: n = 136, 33%; after n = 277, 67%). Median patient age was 85 years (IQR 77-91 years) and 292/413 (70.7%) were female. The number of transports to ED before implementation was 129/136 (94.9%), with 147/224 (65.6%) after, p < 0.001. In the after period, fewer patients seen by ECP were transported: 58/128 (45.3%) vs. 89/96 (92.7%) of those not seen by ECP, p < 0.001. Hospital admissions were similar between phases: 39/120 (32.5%) vs. 56/213 (29.4%), p = NS, but in the after phase, fewer ECP patients were admitted vs. non-ECP: 21/125 (16.8%) vs. 35/88 (39.8%), p < 0.001. Mean EMS call time (dispatch to arrive ED or clear scene) was shorter before than after: 25 minutes vs. 57 minutes, p < 0.001. In the after period, calls with ECP were longer than without ECP: 1 hour, 35 minutes vs. 30 minutes, p < 0.001. The mean patient ED length-of-stay was similar before and after: 7 hours, 29 minutes compared to 8 hours, 11 minutes; p = NS. In the after phase, ED length-of-stay was somewhat shorter with ECPs vs. no ECPs: 7 hours, 5 minutes vs. 9 hours, p = NS. There were zero relapses after no-transport in the before phase and three relapses from 77 calls not transported in the after phase (3/77, 3.9%); two involved ECP (2/70, 2.8%). Reductions were observed in the number of LTC patients transported to the ED when the ECP program was introduced, with fewer patients admitted to the hospital. EMS calls take longer with ECP involved. The addition of ECP to the LTC model of care appears to be beneficial and safe, with few relapse calls identified.

Hospital discharge of the elderly--an observational case study of functions, variability and performance-shaping factors

Background

Understanding and improving hospital discharge has assumed major importance since it represents an error-prone transition in care. One barrier to improvement is the lack of detailed understanding of how hospital discharge is organized, including its interdependencies and influential performance-shaping factors (PSFs). This study examines the discharge of elderly patients using the Functional Resonance Analysis Method, developed to analyze performance variability in complex systems. Our main aim was to identify hospital discharge functions, variability, and PSFs that may explain the variability and different outcomes in discharge practices by incorporating multiple-stakeholder perceptions (health-care providers, patients, next of kin).

Methods

The data consisted of moderate participant observations of 20 elderly patients (>75) discharged from hospital to primary health care. The data comprised 90 hours’ observations at hospital wards, including 173 conversations with patients, next of kin, and health-care personnel involved in discharge.

Results

We identified 10 common functions in the discharge of elderly patients to primary health care. We found substantial variability in terms of timing, duration, and precision. Duration is a significant source of variability, primarily determined by the time of day the patient was determined medically fit for discharge. Precision issues related to (1) decision-making criteria concerning the medical fitness decision and appropriate level of care, (2) quality of discharge planning, (3) degree of patient involvement, and (4) quality of information transfer. PSFs were temporal conditions (degree of time pressure), individual and team characteristics, patient factors, organizational factors (unit, specialization, leadership, institutionalized routines), work environment factors (bed availability, availability in municipal services, quality of discharge planning, familiarity with the patient, pressure from next of kin, doctor’s specialization) and regulatory influences (financial incentives).

Conclusions

The study provides a detailed understanding of the discharge of elderly patients by describing common functions and variability in performance caused by multiple PSFs. Our findings indicate the necessity for studying multiple factors related to discharge, interdependencies, and their effects on a range of discharge outcomes incorporating a multiple-stakeholder perspective. We argue that the existing sequential approaches to the complexity surrounding hospital discharge are inadequate. Given the interdependencies among functions, there is a need for corresponding multi-factorial interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6963-14-365) contains supplementary material, which is available to authorized users.