Interviews with Australian nursing home managers reveal that various factors are associated with the decision to transfer a resident to hospital, including two factors not identified in previous research: advance care planning and support from local health services
- 1Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island, USA
- 2Department of Medicine, Brown University, Providence, Providence, Rhode Island, USA
- Correspondence to David M Dosa
Department of Medicine, Brown University, Box G-S121, 121 South Main Street, Providence, RI 02806, USA;
Implication for practice and research
■ There are many different factors that contribute to the complexity of the decision to transfer a nursing home resident to the hospital.
■ This study suggests that strategies such as improving advance care planning (ACP) and collaboration between hospitals and nursing homes could reduce the number of residents who are transferred to the local hospital.
Numerous factors impact the decision to transfer a nursing home resident to the local hospital. Previous research has broadly defined these as residents' welfare, residents' preferences, providers' attitudes and the financial implications of hospitalisation.1 Shanley et al studied nursing home administrators at 41 facilities in Australia with the goal of understanding the dynamics that lead to hospital transfer and explored ways to reduce such transitions in care.
Semistructured qualitative interviews were conducted with managers of nursing homes in New South Wales, Australia. Letters were sent out to randomly selected nursing home managers in the province until a saturation point of answers to research questions was achieved. A total of 41 nursing home managers were ultimately interviewed with a series of questions geared towards determining their facility's current practice around decisions to transfer to hospital. Administrators were also queried for innovative approaches to reducing hospital transfers. All interviews were transcribed and underwent content/thematic coding by the investigators using qualitative methodologies.
The authors note that some transfers are unavoidable, but they also note that other transfers are potentially impacted by the availability of medical support, decisions made by the resident's family, the availability and expertise of staff, fear of criticism or litigation, the presence of ACP, and the availability and support of services from local hospitals. They suggest that the present findings reinforce findings from other previous research and illustrate the complexity of the decision-making process related to transfer. The authors identify several limitations to this study; (1) interviews were drawn only from nursing home administrators rather than a broader range of stakeholders, and (2) the lack of relative weighting of the importance of one factor versus another.
Shanley and colleagues' study of nursing home administrators raises some interesting questions; it is important to note that the decision to transfer a resident to the hospital is seldom made based solely on their input. More often, the decision to transfer a resident to the hospital occurs as a result of communication (or lack thereof) between a nurse, another healthcare provider, and the patient and/or their proxy.2 Although this was cited as a limitation by the authors, it is important for researchers, healthcare providers, and policy-makers to focus more directly on ways to measure and improve the communication exchange that occurs before the decision to transfer.
The present study identifies that there was perceived variation across the 41 Australian nursing homes in how each facility approached ACP. The authors suggest that homes that were more systematic and deliberate with their ACP processes had fewer unplanned transfers. Since this point is not supported by quantitative data on actual transitions, it suggests the importance of performing such studies in the future. It also points to the need to standardise ACP forms as suggested by the American Medical Director's Association to better ensure that their contents are immediately accessible to healthcare providers during the actual decision-making process.3
Finally, beyond this research, more evidence-based data is required to better understand the direct risks and benefits of hospitalisation for commonly encountered problems such as nursing home pneumonia, urinary tract infections, and delirium. Do the benefits of hospitalisation for a particular patient with one of these conditions outweigh the risks? Is treatment in the nursing home associated with similar outcomes? Until such research is conducted, the parties involved in the decision-making process will be left making an educated guess, one that has the potential to be influenced by the many factors addressed by the investigators in their research.