A recent study by Tappen and co-workers from the American aged care system has examined the issue of transferring a nursing home resident to hospital upon deterioration in their condition. The reason for this focus stems from a previous study that has shown as many as two thirds of transferrals from a nursing home to an acute care setting may be avoidable.
What are the factors that influence the decision on whether to transfer a patient? Those of the patient, their family, and care workers all come into play. Tappen cites that in quality improvement reports from 30 nursing homes in America two of the three most frequent reasons given by staff for avoidable or possibly avoidable transfer to hospital were: (1) insistence by nursing home residents and their families; and (2) communication gaps amongnursing staff, primary care providers and families.
It has been suggested that family members are often poorly informed about the resident’s condition and treatment options available within the nursing home. This leads to insistence on hospitalization based on a belief that the transfer is beneficial. However there is little published data that investigates this decision-making.
Tappen and co-workers have therefore conducted semi-structured interviews of nursing homeresidents, their families and staff in 19 nursing home in Florida. They investigated: (a) their preferences on whether the resident should receive hospital or nursing home treatment; (b) their preferred degree of involvement in the decision; and (c) how much prior thought had been given to the decision about whether to transfer. Responses were coded, and merged with sociodemographic data for analysis.
Whilst staff overwhelmingly preferred keeping residents in the nursing home, residents were evenly divided between the options of wishing to be transferred to hospital upon deterioration in their condition, preferring to stay in the nursing home, and an intermediate position to these two options. More African American residents preferred acute care transfer whereas European American residents were evenly distributed across these preferences. More Hispanic and Afro-Caribbean residents preferred remaining in the nursing home.
The majority of nursing home residents and a half of family members had not given thought to a potential future decision concerning transfer to hospital upon a change in their condition, but residents had strong opinions about the degree of involvement they should have in this decision.
These findings suggest there is scope for education to improve decision-making and reduceavoidable hospital admissions due to family and resident insistence. The authors’ recommendation is that conversations about what to do if an acute change occurs should be held in advance. A resident and family appreciation of the quality of care available within the home, and of the risks associated with acute care –such as hospital acquired infections, may improve both the patients quality of life, and prevent unnecessary health care expenditure.
RM Tappen, SM Worch, D Elkins, DJ Hain, CM Moffa, G Sullivan, Remaining in the nursing home versus transfer to acute care: resident, family and staff preferences. Journal of Gerontoligical Nursing, 2014;40:48-57.
Article taken from HITH Journal Club, Issue No. 20 April 2015