Experiences and involvement of family members in transfer decisions from nursing home to hospital: a systematic review of qualitative research

Suffering while resigning to an unacceptable violation of dignity

BACKGROUND

The interaction of health personnel with relatives is linked to the quality of care results in nursing homes. However, there is limited knowledge of how relatives perceive being an integral part of the nursing home context. This secondary analysis has its starting point in an ethical concern about relatives' experiences in a previous study.

AIM

To critically discuss relatives' experiences of suffering when their next of kin live in a nursing home in a rural arctic context.

RESEARCH DESIGN, PARTICIPANTS AND CONTEXT

The critical hermeneutic stance is informed by Habermas. The secondary analysis is conducted on original data from five semi-structured focus groups with 18 relatives of residents of two nursing homes in a rural part of Norway. The theoretical framework concerning dignity, well-being, and suffering, as developed by Galvin and Todres, contrasts the analysis.

ETHICAL CONSIDERATIONS

The study followed the principles of the Helsinki Declaration. It was approved by the Norwegian Center for Research Data (NSD) (reg. no. 993360).

FINDINGS

The main theme of this study is: suffering while resigning to an unacceptable violation of dignity. This theme is deepened by two subthemes: (a) suffering while adapting to a relationship of dependence and (b) suffering while accepting the unacceptable.

CONCLUSIONS

Relatives experience suffering as a cross-pressure in their struggle to interact responsibly with health personnel in nursing homes. This may have a negative outcome, where relatives end up adapting to being silent witnesses to missed care and a violation of dignity.

Emergency physicians' and nurses' perception on the adequacy of emergency calls for nursing home residents: a non-interventional prospective study

Introduction

A considerable percentage of daily emergency calls are for nursing home residents. With the ageing of the overall European population, an increase in emergency calls and interventions in nursing homes (NH) is to be expected. A proportion of these interventions and hospital transfers may be preventable and could be considered as inappropriate by prehospital emergency medical personnel. The study aimed to understand Belgian emergency physicians' and emergency nurses' perspectives on emergency calls and interventions in NHs and investigate factors contributing to their perception of inappropriateness.

Methods

An exploratory non-interventional prospective study was conducted in Belgium among emergency physicians and emergency nurses, currently working in prehospital emergency medicine. Electronic questionnaires were sent out in September, October and November 2023. Descriptive statistics were used to analyze the overall results, as well as to compare the answers between emergency physicians and emergency nurses about certain topics.

Results

A total of 114 emergency physicians and 78 nurses responded to the survey. The mean age was 38 years with a mean working experience of 10 years in prehospital healthcare. Nursing home staff were perceived as understaffed and lacking in competence, with an impact on patient care especially during nights and weekends. General practitioners were perceived as insufficiently involved in the patient's care, as well as often unavailable in times of need, leading to activation of Emergency Medical Services (EMS) and transfers of nursing home residents to the Emergency Department (ED). Advance directives were almost never available at EMS interventions and transfers were often not in accordance with the patient's wishes. Palliative care and pain treatment were perceived as insufficient. Emergency physicians and nurses felt mostly disappointed and frustrated. Additionally, differences in perception were noted between emergency physicians and nurses regarding certain topics. Emergency nurses were more convinced that the nursing home physician should be available 24/7 and that transfers could be avoided if nursing home staff had more authority regarding medical interventions. Emergency nurses were also more under the impression that pain management was inadequate, and emergency physicians were more afraid of the medical implications of doing too little during interventions than emergency nurses. Suggestions to reduce the number of EMS interventions were more general practitioner involvement (82%), better nursing home staff education/competences (77%), more nursing home staff (67%), mobile palliative care support teams (65%) and mobile geriatric nursing intervention teams (52%).

Discussion and conclusion

EMS interventions in nursing homes were almost never seen as necessary or indicated by emergency physicians and nurses, with the appropriate EMS level almost never being activated. The following key issues were found: shortages in numbers and competence of nursing home staff, insufficient primary care due to the unavailability of the general practitioner as well as a lack of involvement in patient care, and an absence of readily available advance directives. General practitioners should be more involved in the decision to call the Emergency Medical Services (EMS) and to transfer nursing home residents to the Emergency Department. Healthcare workers should strive for vigilance regarding the patients' wishes. The emotional burden of deciding on an avoidable hospital admission of nursing home residents, perhaps out of fear for medico-legal consequences if doing too little, leaves the emergency physicians and nurses frustrated and disappointed. Improvements in nursing home staffing, more acute and chronic general practitioner consultations, and mobile geriatric and palliative care support teams are potential solutions. Further research should focus on the structural improvement of the above-mentioned shortcomings.

Impact of family involvement and an advance directive to not hospitalize on hospital transfers of residents in long-term care facilities

OBJECTIVE

With the rapidly aging population, the number of residents transferred to hospitals from long-term care facilities (LTCFs) is increasing globally. The objective of this study was to investigate the association between family involvement and an advance directive (AD) for not hospitalizing and hospital transfers among LTCF residents with dementia.

METHOD

Using the InterRAI assessment database from September 2014 to June 2019, we included 874 residents from 16 LTCFs in Japan.

RESULTS

Of the 874 participants, 19.0% had an AD for not hospitalizing, and 20.5% were transferred to hospitals. An AD for not hospitalizing decreased the likelihood of hospital transfers (p = 0.005). Multilevel logistic regression analysis showed that family involvement was not associated with hospital transfers (odds ratio [OR]: 1.18; 95% confidence interval [CI]: 0.77-1.80), while an AD for not hospitalizing was significantly associated with decreased hospital transfers (OR: 0.50; 95% CI: 0.28-0.89) among the LTCF residents.

CONCLUSIONS

Although ADs are not legally defined in Japan, we found that an AD for not hospitalizing decreased hospital transfers. Given that many older people tend to hesitate to express their wishes in clinical decision-making situations in Japan, regular discussions are necessary to help them express their care preferences while also documenting the discussions to ensure the residents receive high-quality care.

Reducing risks in complex care transitions in rural areas: a grounded theory

PURPOSE

Although previous research indicates that care transitions differ between rural and urban areas, the knowledge of challenges related to care transitions in rural areas appears limited. This study aimed to provide a deeper understanding of what registered nurses' perceive as the main concerns in care transitions from hospital care to home healthcare in rural areas, and how they handle these during the care transition process.

METHODS

A Constructivist Grounded Theory method based on individual interviews with 21 registered nurses.

RESULTS

The main concern in the transition process was "Care coordination in a complex context". The complexity stemmed from several environmental and organizational factors, creating a messy and fragmented context for registered nurses to navigate. The core category "Actively communicating to reduce patient safety risks" was explained by the three categories- "Collaborating on expected care needs", "Anticipating obstacles" and "Timing the departure".

CONCLUSIONS

The study shows a very complex and stressed process that includes several organizations and actors. Reducing risks during the transition process can be facilitated by clear guidelines, tools for communication across organizations and sufficient staffing.

Factors associated with avoidable hospital transfers among residents in Swiss nursing homes

Unplanned hospitalizations from nursing homes (NHs) may be considered potentially avoidable and can result in adverse resident outcomes. There is little information about the relationship between a clinical assessment conducted by a physician or geriatric nurse expert before hospitalization and an ensuing rating of avoidability. This study aimed to describe characteristics of unplanned hospitalizations (admitted residents with at least one night stay, emergency department visits were excluded) and to examine this relationship. We conducted a cohort study in 11 Swiss NHs and retrospectively evaluated data from the root cause analysis of 230 unplanned hospitalizations. A telephone assessment by a physician (p=.043) and the need for further medical clarification and treatment (p=<0.001) were the principal factors related to ratings of avoidability. Geriatric nurse experts can support NH teams in acute situations and assess residents while adjudicating unplanned hospitalizations. Constant support for nurses expanding their clinical role is still warranted.

Mobile X-ray services in nursing homes as an enabler to healthcare-in-place for residents: informal carers' views

BACKGROUND

Informal carers (ICs) of residents living in nursing homes (NH) have a key role in the care of residents, including making decisions about and providing care. As radiology has a role in decision making about care, it is important to understand IC's perspectives about resident's use of mobile X-ray services (MXS). The aim was to explore the perspectives of ICs of residents living in nursing homes about the use of MXS.

METHODS

From November 2020 to February 2021, twenty ICs of residents living in four nursing homes in different areas of one Australian city participated. Their perspectives of MXS, including benefits and barriers, were explored in semi-structured interviews. Data were analysed using thematic analysis.

RESULTS

ICs were resident's children (80%) and spouses (20%). One resident had received a MXS. Four themes were developed: (1) a priority for resident well-being, where ICs were positive about using MXS, because residents could receive healthcare without transfer; (2) MXS could reduce carer burden; (3) economic considerations, where MXS could reduce health system burden but the MXS call-out fee could result in health inequities; and (4) pathways to translation, including the need to improve consumer awareness of MXS, ensure effective processes to using MXS,, consider nursing home staff levels to manage MXS and ICs expectations about quality and availability of MXS.

CONCLUSIONS

ICs consider MXS can benefit resident well-being by potentially reducing transfers to hospital or radiology facilities and advocated equitable access. ICs cautioned that the quality and safety of healthcare delivered in nursing homes should equal what they would receive in hospitals.

Dignity at stake - relatives' experiences of influencing dignified care in nursing homes

BACKGROUND

Dignity, in the care of older nursing home residents, has been an increasingly part of the public discourse the recent years. Despite a growing body of knowledge about dignity and indignity in nursing homes, we have less knowledge of how relatives experience their role in this context. This study is a follow-up to a previous study in nursing homes, which gave rise to concern about the relatives' descriptions of residents' dignity. The aim of this current study is to critically discuss relatives' experiences of influencing the dignified care of residents of nursing homes.

METHODS

Methodologically, the study is informed by a critical hermeneutic stance, where the analysis is guided by a qualitative interpretive approach and a humanizing framework. This is a secondary analysis that includes data from five semi-structured focus groups from a previous study. The participants were 18 relatives of 16 residents living in two nursing homes in rural northern Norway.

RESULTS

The main theme in this study, preventing missed care when dignity is at stake, is identified when relatives of nursing homes experience that they are able to influence dignified care by (a) pinpointing to prevent missed care and (b) compensating when dignity is threatened.

CONCLUSIONS

Despite their stated good intentions to safeguard dignity, relatives of nursing homes experience being alienated in their attempts to change what they describe as undignified and unacceptable practice into dignified care. The relatives' observations of dignity and indignity are, contrary to what national and international regulations require, not mapped and/or used in any form of systematic quality improvement work. This indicates that knowledge-based practice in nursing homes, including the active application of user and relative knowledge, has untapped potential to contribute to quality improvement towards dignified care.

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.

Online public information about advance care planning: An evaluation of UK and international websites

Introduction

Healthcare information is increasingly internet-based. Standards require websites to be 'perceivable, operable, understandable and robust' with relevant content for citizens in appropriate language. This study examined UK and international websites offering public healthcare information on advance care planning (ACP) using current recommendations for website accessibility and content and informed by a public engagement exercise.

Methods

Google searches identified websites in English from health service providers, governmental or third sector organisations based in the UK and internationally. Target keywords that would be used by a member of the public informed the search terms. Data extraction used criterion-based assessment and web content analysis of the first two pages of each search result. Public patient representatives as key members of the multidisciplinary research team guided the development of the evaluation criteria.

Results

A total of 1158 online searches identified 89 websites, reduced to 29 by inclusion/exclusion criteria. Most sites met international recommendations for knowledge/understanding about ACP. Differences in terminology, lack of information about ACP limitations and non-adherence to recommended reading levels, accessibility standards and translation options were apparent. Sites targeting members of the public used more positive, non-technical language than those for both professional and lay users.

Conclusions

Some websites met accepted standards required to facilitate understanding and public engagement in ACP. Others could be improved significantly. Website providers have important roles and responsibilities in increasing people's understanding of their health conditions, future care options and ability to take an active role in planning for their health and care.

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.

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

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

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

BACKGROUND

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

The influence of sociodemographic factors and close relatives at hospital discharge and post hospital care of older people with complex care needs: nurses’ perceptions on health inequity in three Nordic cities

Hospital discharge of older people in need of both medical and social care following their hospital stay requires extensive coordination. This study aims to examine and compare the views of nurses in three Nordic cities on the influence of sociodemographic factors and having close relatives, for the hospital discharge and post hospital care of older people with complex health and social care needs. Thirty-five semi-structured interviews (Copenhagen n = 11, Tampere n = 8, Stockholm n = 16) with nurses were conducted. The nurses were identified through the researchers’ networks, invitation and snowball sampling, and recruited from hospitals, primary care practices, home care units, home nursing units, and geriatric departments. The interviews were transcribed and analysed using thematic analysis. Interpretations were discussed and agreed within the team. Four main themes and 13 sub-themes were identified. Across the cities, informants reported that the patient’s health status, rather than their gender or ethnicity, steered the discharge date and further care. Care costs, commonly reported in Tampere but also in Copenhagen and Stockholm including costs for medications and home help, were considered barriers for disadvantaged older people. Home situation, local arrangements and differences in collaboration between healthcare professionals at different sites also influenced the hospital discharge. Generally, the patient’s health status steered the hospital discharge and post-hospital care. Close relatives were regarded important and a potential advantage. Some informants tried to compensate for the absence of close relatives, highlighting the importance of care systems that can compensate for this to minimise avoidable inequity.

Nurses' perspectives on the role of relatives in emergency situations in nursing homes: a qualitative study from Germany

BACKGROUND

In nursing homes, emergencies often result in unnecessary hospital transfers, which may negatively affect residents' health. Emergency management in nursing homes is complicated by structural conditions, uncertainties and difficulties communicating with the treating healthcare professionals. The present study investigated the role played by relatives in this emergency management, as perceived by nursing staff.

METHODS

Within the context of a larger multi-method, interdisciplinary research project, we conducted six focus group discussions and 33 semi-structured interviews with nurses at nursing homes in northern Germany between September 2020 and April 2021. Discussions and interviews focused on emergency management in nursing homes, and were recorded, transcribed and analysed using qualitative content analysis, according to Mayring.

RESULTS

Nurses reported that relatives were actively involved in emergency management in the nursing homes. Relatives were informed when there was an emergency situation, and they participated in decision making around the resident's care. Nurses sometimes perceived the involvement of relatives as challenging, due to a lack of time or staff, the opposing views of relatives and/or uncertain communication structures; however, they were willing to involve relatives according to the relatives' preferences. The role played by relatives was seen to range from that of an active supporter to that of a troublemaker. On the one hand, relatives were reported to support nurses in emergency management (i.e. by identifying residents' preferences and advocating for residents' interests). On the other hand, relatives were often perceived by the nurses as overstrained and unprepared in emergency situations, leading them to override residents' wishes, question the emergency plan and put pressure on the nurses' decision making.

CONCLUSIONS

Nurses perceive the roles played by relatives in emergency situations in nursing homes as relatively supportive or, alternatively, demanding and troublesome. The timely involvement of relatives in emergency planning, the establishment of clear agreements with general practitioners and the development of trusting relationships between nursing staff and relatives may improve emergency management for nurses.

Reimagining Family Involvement in Residential Long-Term Care

Although descriptions of family involvement in residential long-term care (RLTC) are available in the scientific literature, how family involvement is optimized in nursing homes or assisted living settings remains underexplored. During the facility lockdowns and visitor restrictions of the COVID-19 pandemic, residents experienced social deprivation that may have resulted in significant and adverse health outcomes. As with so many other critical issues in RLTC, the COVID-19 pandemic has magnified the need to determine how families can remain most effectively involved in the lives of residents. This article seeks to better understand the state of the science of family involvement in RTLC and how the COVID-19 pandemic has expedited the need to revisit, and reimagine, family involvement in RLTC.

Supporting residential aged care through a Community of Practice

Transfers to Emergency Departments and hospitalizations are common for older people living in residential aged care who experience acute deterioration. This paper shares reflections from 10 years of work across a region in New South Wales, Australia, to develop a new model of care in141 residential aged care homes. The model successfully reduced Emergency Department transfers and admissions to hospital. Using an exemplar patient case, the paper describes the Aged Care Emergency Program and associated research outputs. An interprofessional, multi-agency Community of Practice supported this work. The authors reflect on the successes and challenges of using a Community of Practice to implement the model of care. We conclude that the Community of Practice, with its iterative evaluation, facilitated change and provided a mechanism for interprofessional practice. Broader systemic change requires clarity in goals of care, shared decision-making, working across sectors, and appropriate resource allocation. This article is protected by copyright. All rights reserved.

Advance Care Planning in Dutch Nursing Homes During the First Wave of the COVID-19 Pandemic

Objectives

To explore how physicians in Dutch nursing homes practiced advance care planning (ACP) during the first wave of the COVID-19 pandemic, and to explore whether and how ACP changed during the first wave of the pandemic.

Design

Qualitative analysis of an online, mainly open-ended questionnaire on ACP among physicians working in nursing homes in the Netherlands during the first wave of the COVID-19 pandemic.

Setting and Participants

Physicians in Dutch nursing homes.

Methods

Respondents were asked to describe a recent case in which they had a discussion on anticipatory medical care decisions and to indicate whether ACP was influenced by the COVID-19 pandemic in that specific case and in general. Answers were independently coded and a codebook was compiled in which the codes were ordered by themes that emerged from the data.

Results

A total of 129 questionnaires were filled out. Saturation was reached after analyzing 60 questionnaires. Four main themes evolved after coding the questionnaires: reasons for ACP discussion, discussing ACP, topics discussed in ACP, and decision making in ACP. COVID-19–specific changes in ACP indicated by respondents included (1) COVID-19 infection as a reason for initiating ACP, (2) a higher frequency of ACP discussions, (3) less face-to-face contact with surrogate decision makers, and (4) intensive care unit admission as an additional topic in anticipatory medical decision making.

Conclusions and Implications

ACP in Dutch nursing homes has changed because of the COVID-19 pandemic. Maintaining frequent and informal contact with surrogate decision makers fosters mutual understanding and aids the decision-making process in ACP.

Perceptions and experiences of residents and relatives of emergencies in care homes: a systematic review and metasynthesis of qualitative research

Background

the perceptions and experiences of care home residents and their families are important for understanding and improving the quality of emergency care.

Methods

we conducted a systematic review and metasynthesis to understand the perceptions and experiences of care home residents and their family members who experienced medical emergencies in a care home setting. The review protocol was registered in PROSPERO (CRD42020167018). We searched five electronic databases, MEDLINE, CINAHL, PubMed, Cochrane Library and PsycINFO, supplemented with internet searches and forward and backward citation tracking from included studies and review articles. Data were synthesised thematically following the Thomas and Harden approach. The Critical Appraisal Skills Programme qualitative checklist was used to assess the quality of studies included in this review.

Results

of the 6,140 references retrieved, 10 studies from four countries (Australia, Canada, UK and USA) were included in the review and metasynthesis. All the included studies were assessed as being of good quality. Through an iterative approach, we developed six analytical themes: (i) infrastructure and process requirements in care homes to prevent and address emergencies; (ii) the decision to transfer to hospital; (iii) experiences of transfer and hospitalisation for older patients; (iv) good communication is vital for desirable outcomes; (v) legal, regulatory and ethical concerns and (vi) trusting relationships enabled residents to feel safe.

Conclusions

the emergency care experience for care home residents can be enhanced by ensuring resources, staff capacity and processes for high quality care and trusting relationships between staff, patients and relatives, underpinned by good communication and attention to ethical practice.

Unplanned hospital transfers from nursing homes: who is involved in the transfer decision? Results from the HOMERN study

Background

Emergency department visits and hospital admissions are common among nursing home residents (NHRs) and seem to be higher in Germany than in other countries. Yet, research on characteristics of transfers and involved persons in the transfer decision is scarce.

Aims

The aim of this study was to analyze the characteristics of hospital transfers from nursing homes (NHs) focused on contacts to physicians, family members and legal guardians prior to a transfer.

Methods

We conducted a multi-center study in 14 NHs in the regions Bremen and Lower Saxony (Northwestern Germany) between March 2018 and July 2019. Hospital transfers were documented for 12 months by nursing staff using a standardized questionnaire. Data were derived from care records and perspectives of nursing staff and were analyzed descriptively.

Results

Among 802 included NHRs, n = 535 unplanned hospital transfers occurred of which 63.1% resulted in an admission. Main reasons were deterioration of health status (e.g. fever, infections, dyspnea and exsiccosis) (35.1%) and falls/accidents/injuries (33.5%). Within 48 h prior to transfer, contact to at least one general practitioner (GP)/specialist/out-of-hour-care physician was 46.2% and varied between the NHs (range: 32.3–83.3%). GPs were involved in only 34.8% of transfer decisions. Relatives and legal guardians were more often informed about transfer (62.3% and 66.8%) than involved in the decision (21.8% and 15.1%).

Discussion

Contacts to physicians and involvement of the GP were low prior to unplanned transfers. The ranges between the NHs may be explained by organizational differences.

Conclusion

Improvements in communication between nursing staff, physicians and others are required to reduce potentially avoidable transfers.

Electronic supplementary material

The online version of this article (10.1007/s40520-020-01751-5) contains supplementary material, which is available to authorized users.

Resident and family engagement in medication management in aged care facilities: a systematic review

Introduction: Medication-related harms may occur if residents and families are not involved when important medication decisions are made. We examined how residents and families engage in the management of residents' medications in aged care facilities.Areas covered: A systematic review was undertaken, which was registered with PROSPERO (CRD42020152700). Electronic databases were searched from inception until 27 August 2020 using MEDLINE/PubMed, CINAHL, PsycINFO and EMBASE. Data synthesis was undertaken using thematic analysis.Expert opinion: Forty studies were included. Communication tended to be unidirectional comprising consultations where residents and families provided medication information to health care providers or where health care providers provided medication information to residents and families. Many challenges prevailed that prevented effective engagement, including families' hesitation about making decisions, and the lack of adequately-trained health care providers. Testing of interventions often did not include residents or families in developing these interventions or in examining how they participated in medication decisions following implementation of interventions. Areas for improvement comprise actively involving residents and families in planning interventions for resident-centered care. Health care providers need to have greater appreciation of families' ability to detect dynamic changes in residents' behavior, which can be used to enable optimal alterations in medication therapy.

Decision difficulties of long-term-care facility nurses in transferring residents to the emergency department: A cross-sectional nationwide study

AIMS

To examine the level of decision difficulties of long-term-care facility (LTCF) nurses when transferring residents to the emergency department (ED) and associated influencing factors.

DESIGN

A cross-sectional nationwide study.

METHODS

The LTCFs were selected through random stratified sampling across the whole Taiwan during February 2018 to January 2019. LTCF nurses who met the selection criteria were invited to participate with two or three nurses selected from each LTCF. The Patient Transfer Decision Difficulty Scale (PTDDS) was used to measure the level of difficulty in making decisions related to the transfer of residents to the ED. Data were collected by mailing the questionnaires and asking the nurses to return the completed form in 2 weeks. Data were analysed using simple linear regression and multiple regression with stepwise methods.

RESULTS

In total, 618 valid questionnaires with an 85.32% response rate from 319 LTCFs were used for the data analysis. Decision difficulties that LTCF nurses experienced were moderate, the nursing personnel-bed ratio, LTCF professional training and basic life support training were predictive factors of the level of difficulty experience (scores of PTDDS) for the LTCF nurse (F = 6.81, p < .001).

CONCLUSIONS

Enhancing emergency training in LTCF can improve nurses' decision-making ability to refer LTCF residents to emergency treatment.

IMPACT

What problem did the study address? The study addressed the difficult decision LTCF nurses may experience when transferring a resident to the emergency department. What were the main findings? All LTCF nurses faced a moderate level of difficulty in decision-making. 'Transfer timing' was most often considered in the decision-making process when a resident was transferred to the ED. Where and on whom will the research have impact? Results of this study have considerable reference value for LTCF managers and nurses in the decision-making ability and suitability of transferring residents for emergency treatment.

Applying the Knowledge-to-Action Framework to Engage Stakeholders and Solve Shared Challenges with Person-Centered Advance Care Planning in Long-Term Care Homes

As they near the end of life, long term care (LTC) residents often experience unmet needs and unnecessary hospital transfers, a reflection of suboptimal advance care planning (ACP). We applied the knowledge-to-action framework to identify shared barriers and solutions to ultimately improve the process of ACP and improve end-of-life care for LTC residents. We held a 1-day workshop for LTC residents, families, directors/administrators, ethicists, and clinicians from Manitoba, Alberta, and Ontario. The workshop aimed to identify: (1) shared understandings of ACP, (2) barriers to respecting resident wishes, and (3) solutions to better respect resident wishes. Plenary and group sessions were recorded and thematic analysis was performed. We identified four themes: (1) differing provincial frameworks, (2) shared challenges, (3) knowledge products, and 4) ongoing ACP. Theme 2 had four subthemes: (i) lacking clarity on substitute decision maker (SDM) identity, (ii) lacking clarity on the SDM role, (iii) failing to share sufficient information when residents formulate care wishes, and (iv) failing to communicate during a health crisis. These results have informed the development of a standardized ACP intervention currently being evaluated in a randomized trial in three Canadian provinces.

Evaluation of a Novel Decision Guide "Go to the Hospital or Stay Here?" for Nursing Home Residents and Families: A Randomized Trial

Initiatives to reduce potentially preventable hospitalizations of nursing home residents have focused on staff response to changes in condition and advance care planning. Yet, resident and family insistence on transfer has been one of the most intractable sources of these hospitalizations, although not the target of active intervention until now. Consented residents and family members in the intervention group received a newly developed decision aid entitled, "Go to the Hospital or Stay Here?," providing information on the risks and benefits of transfer versus remaining in the nursing home. This person-centered decision aid was developed from the results of 271 interviews of residents, families, and providers to identify what they wanted to know and any misunderstandings surrounding the transfer process. Engaging residents in the decision respects their right to participate and provides the information they need to make a deliberative decision. The intervention group showed a gain in knowledge and reduction in decisional conflict but reported decreased decisional preparation. There was no decrease in transfers compared to the control group. Evaluation of the decision guide by residents and families was positive.

TARGETS

Nursing home residents and their family members.

INTERVENTION

To provide information regarding the decision to stay in the nursing home or transfer to acute care due to a change in condition.

MECHANISMS OF ACTION

Decision aid "Go the "Hospital or Stay Here?" to impart knowledge regarding the decision to remain in the nursing home or transfer to acute care.

OUTCOMES

Use of the Guide was found to increase residents' and family members' knowledge and decrease decisional conflict, but it did not increase decisional preparation. No reduction in transfers was found. Residents and families rated the Guide as very helpful. [Research in Gerontological Nursing, 13(6), 309-319.].

Emergency transfers of home care patients in Fukui Prefecture, Japan: A retrospective observational study

Little is known about how emergency transfers take place and what outcomes they lead to in the patients who receive home care in Japan. We aimed to assess outcomes of emergency transfers and factors associated with such outcomes in the Japanese home care setting.A retrospective analysis of patient data from a home care clinic in Fukui, Japan, included all patients who experienced emergency transfers which were reported to the clinic during 2018 and 2019. We collected data on patients' sociodemographic and clinical characteristics, as well as the transfer process and its outcome, using patient charts and other administrative records. We first analyzed the overall outcome and then evaluated whether transfer outcomes would differ according to by whom and from where the emergency medical service (EMS) was called, by univariate and multivariate analyses.We considered 63 patients who experienced emergency transfers during the study period. Of the total, 10 (15.9%) returned to their residences without being admitted or being dead on arrival. Although only 2.6% (1/39) of patients whose transfers were determined by health care professionals (HCPs) returned home without being admitted, a direct return was observed for 37.5% (9/24) of patients whose transfer was determined by those other than HCPs (odds ratio of direct return to residences 22.80, 95% confidence interval 2.65-195.87). There was no other variable which was significantly associated with the outcomes after the emergency transfers, although all the patients who have no available caregivers resulted in hospitalization.In this preliminary analysis in the Japanese home care setting, only a small proportion of patients returned to their residences without being admitted following emergency transfers. Patients whose EMS transfer was requested by an HCP usually resulted in an admission to the clinic, whereas transfers requested by non-HCPs frequently did not.

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

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Does the institutionalization influence elderly's quality of life? A systematic review and meta-analysis

Background

Institutionalization is a global phenomenon and its impact on elderly’s quality of life (QoL) is under discussion. This systematic review and meta-analysis evaluated the influence of the institutionalization on elderly’s QoL.

Methods

Searches were performed in Medline, Scopus, Web of Science, Lilacs, Cochrane Library and SIGLE by two independent reviewers up to May 2019. The eligibility criteria were based on PECO strategy, considering observational studies in elderly (P), which were (E) or not (C) institutionalized to identify differences in their QoL (O). For qualitative synthesis, data were extracted and risk of bias was evaluated through a validated guideline. Meta-analysis was based on Mean Difference (MD) and Standard Mean Difference (SMD) calculation (p ≤ 0.05). The evidence was quality-tested using Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Results

The initial search identified 3841 articles. Duplicates were removed, titles and abstracts were read and eligibility criteria were applied, remaining 16 sixteen cross-sectional studies that were included for data extraction and qualitative synthesis. Out of 16 articles, 14 evaluated the Health-Related Quality of Life, using Leipad (n = 2), WHOQOL-BREF and/or OLD (n = 8), SF-36 or RAND-36 (n = 4) questionnaires, and two assessed the Oral Health–Related Quality of Life, through GOHAI questionnaire. One eligible article was considered as low risk of bias. In the meta-analysis, 12 studies were included. Leipad questionnaire did not show differences on elderly’s QoL (MD 0.11 [− 0.10, 0.32] I² = 76%). Differences on elderly’s QoL were detected through WHOQOL-BREF (SMD -0.70 [CI95%: − 0.94, − 0.47] I² = 93%), WHOQOL-OLD (SMD -1.13 [− 1.47, − 0.80] I² = 91%) and SF-36/RAND-36 (MD -5.97 [CI95%: − 11.29, − 0.64] I² = 90%). All studies had very low or low certainty of evidence, since the study design influenced evidence classification, and show high heterogeneity.

Conclusion

Although the institutionalization influences negatively the elderly’s QoL, further well-designed studies are needed to confirm this evidence.