Decision to transfer to an emergency department from residential aged care: A systematic review of qualitative research

Authors

  • Glenn Arendts,

    Corresponding author
    1. Center for Clinical Research in Emergency Medicine, Western Australian Institute for Medical Research, Perth, Western Australia, Australia
    2. School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Western Australia, Australia
    3. School of Public Health, University of Sydney, Sydney, New South Wales, Australia
    • Correspondence: Dr Glenn Arendts MBBS, Emergency Medicine, Royal Perth Hospital, GPO Box X2213, Perth, WA 6847, Australia. Email: glenn.arendts@uwa.edu.au

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  • Susan Quine,

    1. School of Public Health, University of Sydney, Sydney, New South Wales, Australia
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  • Kirsten Howard

    1. School of Public Health, University of Sydney, Sydney, New South Wales, Australia
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Abstract

Aim

If developing policies to optimize quality acute care within residential aged care facilities (RACF) is a goal, understanding the factors that influence the decision to transfer a resident from RACF to hospital emergency departments is important. The aim of the present study was to review the published literature pertaining to transfer decisions.

Methods

We carried out a systematic review of the qualitative literature to ascertain key influences on transfer decisions amongst three key stakeholder groups – residents, their family and carers.

Results

From 11 papers we found two themes encompassing seven domains of influence. Transfers are influenced by an expectation or goal of improved resident clinical or quality of life outcomes – these are domains within the “resident dominant” theme. However, transfers also occur where there is no expectation of resident benefit. These domains, such as inadequate facility resourcing and care planning, are categorized within the “resident subordinate” theme.

Conclusion

Transfer decisions are often influenced by considerations beyond expected benefit to the individual resident. Conceptualizing influences on transfer decisions within this framework might assist clinicians and policy makers in the design and delivery of services for RACF residents. Geriatr Gerontol Int 2013; 13: 825–833.

Introduction

People living in residential aged care facilities (RACF) are one of the most vulnerable groups in society. By definition, a RACF resident has chronic incurable illness and disability rendering them unable to live independently.[1] Up to 70% of people in RACF have major cognitive impairment, with a median life expectancy of less than 18 months.[2]

Exacerbations of chronic illness, and predisposition to new illness and injury as a result of frailty, mean that people in RACF often require acute health care. To access such care, transfer to hospital emergency departments (ED) from RACF is frequent.[3] Such transfers occur despite evidence that providing some acute care within RACF as an alternative to hospital transfer is more effective in terms of clinical outcome and cost,[4] and that many cases that are transferred could be effectively managed in the RACF environment.[5] There is considerable policy emphasis on minimizing transfer to the acute hospital setting from RACF, although some criticize this approach for having a hospital-centric view of transfer, and ignoring the perspectives of residents and other stakeholders, such as RACF staff and residents' families.[6] As care within the facility can be seen as “competing” with ED transfer, there is disquiet amongst some clinicians when programs that have been shown in the peer reviewed literature to favor RACF care over transfer are either not adopted, or ignored.

This somewhat simplistic view ignores the complexity of decisions regarding care for older people in RACF. In many circumstances, an older person living in aged care is not empowered or capable of making decisions regarding his/her own health care. Difficult choices regarding how much care should be provided, where and by whom, are influenced by many factors never encountered in the everyday autonomous decision making by individuals. These factors can include financial[7] and staffing[8] arrangements of the RACF; the lack of a dominant decision maker or decision making structure when staff preferences do not align with those of residents;[9] statutory requirements;[10] and so on. If developing optimal processes to minimize RACF to ED transfer is an aim, policy makers need to incorporate a good understanding of the complex factors beyond clinical outcomes that influence decisions to transfer. Such an understanding can be informed through a synthesis of the findings from the qualitative peer reviewed literature.

In the present study, we aimed to systematically review the qualitative literature regarding decisions to transfer people from RACF to ED, and examined the major influences on that decision and how the decision is made.

Methods

A literature search was carried out in 2011 across four electronic databases (MEDLINE [1950–], EMBASE [1988–], PsycInfo [1950–] and CINAHL [1982–]). We used validated search strategies to optimize accuracy for identifying qualitative studies, tailored to the database being interrogated.[11-14] The MEDLINE search strategy is shown in the appendix, and searches in other databases were similarly broad. Abstracts were assessed for relevance and full text articles reviewed where relevance was established or in doubt. Reference lists from papers were manually searched for additional material. We included papers that appeared only in electronic “pre-publication” form on journal websites providing they had been approved for publication after peer review. Papers published in languages other than English were translated for analysis.

There is no international definition of RACF, and many common terms, such as “home for the aged”, refer to services that are configured differently in different countries, making comparisons potentially problematic. For the present study, we defined RACF as facilities that coupled permanent accommodation with the provision of facility-specific nursing services in addition to personal care services. Studies referring to nursing homes were accepted as RACF unless it was clear they did not meet this definition. Studies using other description (e.g. low care facilities, assisted living facilities, restorative units) were excluded unless we could establish they met the aforementioned definition.

ED was defined as any hospital-based department to which a resident was transferred that was separate from their current facility. Terms such as “A&E” and “casualty” were accepted to mean ED. We included papers where data on the transfer to ED were part or whole of the data within the paper. We excluded studies where data pertained only to life within the facility, or to the use of services outside the facility that were not ED based; for example, palliative hospice care.

We included papers that contained qualitative data from interviews (structured, semi-structured or unstructured) or focus groups. Scaled questionnaire studies were included only where “open” questions formed at least part of the questionnaire and data were available to enable contextual evaluation of responses; studies with only “closed” questions or where results were presented in terms of summary statistics alone (for example, mean or median results from Likert scale questions) were not included. We excluded purely observational studies, opinion pieces or studies with entirely quantitative or yes/no questionnaire data.

There is no universally accepted way of accurately assessing methodological quality primary studies in a systematic review of qualitative literature. Comprehensiveness of detail in the methods section of primary studies can be used as one indication of the methodological rigor of the research. As such, we used a checklist that has been used in other systematic reviews of qualitative literature[15] to describe the methodological features of included primary studies. For each primary study, we coded the text to identify key domains and the authors' interpretation of these. As common themes emerged from the analysis, domains were then grouped under these common themes and each included paper was re-read to ensure all domains could be subsumed within a major theme for analysis.

Results

Literature search and included study characteristics

Our search yielded 1631 articles (Fig. 1). Of these, 1484 were excluded on the basis of abstract review only, and another 120 excluded after the first read through of the full text, predominantly because they examined other aspects of RACF life or care rather than hospital transfer. This left 27 studies that underwent coding and assessment, from which we excluded a further 16 studies because they: (i) contained data almost exclusively from non-RACF settings;[16, 17] (ii) contained questionnaire data from which no contextual information could be extracted;[18-23] (iii) predominantly addressed other aspects of transfer and care unrelated to the decision to transfer and the influences thereof;[24-26] (iv) contained duplicate data from other studies;[27, 28] (v) were predominantly observational or descriptive;[29, 30] or (vi) were review articles with no primary data.[31] Ultimately, 11 studies containing data relevant to the research question of what influences the decision to transfer were included.[32-42] These studies are summarized in Table 1. The informants were exclusively professional staff in seven papers; a mixture of staff and residents with relatives (two papers) and without relatives (one paper); and relatives and residents alone in one paper.

Figure 1.

Summary of literature search.

Table 1. Characteristics of included studies
Primary authorPublication yearCountryMethodologyRespondentsComments
  1. DON, Directors of Nursing; ED, emergency department; RACF, residential aged care facilities.
Arendts2010AustraliaIndividual interviews and focus groups33 RACF/ED staff and family, 9 residentsResidents interviewed one on one, remainder in focus groups
Bottrell2001USAFocus groupsRACF DONParticipant numbers unclear, possibly 13 DON
Carusone2006CanadaSmall group or individual interview25 RACF nurses in 8 interviewsThree separate publications with different stakeholders all exploring attitudes to care within RACF in preference to hospital as part of a single clinical trial
Carusone2006CanadaSmall group or individual interview9 RACF administrators and 2 medical directors
Carusone2006CanadaIndividual interviews6 residents and 8 family members
Cohen-Mansfield2006USAQuestionnaire6 primary care physicians, one nurse practitioner 
Jablonski2007USAIndividual interviews42 respondents (residents, RACF staff, family) around 16 transfersParticularly explores group decision making
Kihlgren2003SwedenIndividual interviews10 RACF nurses and 4 physicians 
McCloskey2011CanadaObservation augmented with interviews24 transfers observed, interviews with 9 residents and staffOnly interview data analysed
Read1999UKQuestionnaire40 RACF nurses 
Shanley2011AustraliaIndividual interviews41 RACF nurse managers 

Methodological evaluation of included studies

Amongst our included studies there was variable reporting of methodological standards (Table 2). No studies reported or met all of the standards. Where it has been indicated in Table 2 that standards are not met, this might be because there was insufficient detail in the manuscript to determine this. The majority of the standards in Table 2 are not applicable to questionnaire studies and so were not used to evaluate two of the included papers.[40, 41]

Table 2. Assessment of methodological descriptions within papers
 ArendtsJablonskiCarusoneCarusoneCarusoneKihlgrenBottrellShanleyMcCloskey
1. Personal characteristics of interviewer 
Interviewer identified   
Credentials    
Occupation       
Sex    
Experience and training      
2. Relationship of interviewer with participants 
Relationship established before study commencement       
Participant knowledge of reasons for research     
3. Participant selection 
Sampling (e.g. purposive, snowball)  
Method of approach  
Sample size
Number and reason for non-participation      
4. Setting 
Setting of data collection   
Presence of non-participants         
5. Data collection 
Interview guide   
Repeat interviews        
Audio/visual recording 
Field notes     
Duration    
Data or theoretical saturation      
Transcripts returned to participants      
6. Data analysis 
No. data coders   
Description of coding tree     
Derivation of themes 
Protocol for data transcription      
Use of software      
7. Reporting 
Respondent quotations provided

Analysis

Our analysis and coding of the results and authors' interpretation from each included primary study yielded seven domains that influence decisions to transfer to ED. These are: (i) supporting clinical outcomes; (ii) supporting quality of life; (iii) lack of facility resources; (iv) lack of confidence in care provided in the facility; (v) inadequate planning and communication; (vi) bureaucratic and legal; and (vii) conflicting stakeholder preferences. Further analysis of these seven domains showed that they could be grouped under two overarching themes: (a) transfers occur because of an expectation of decision makers that they will yield better resident outcomes or support resident quality of life, which we term the “resident dominant” domains; or (b) transfers occur because of external influences to which decision makers yield, with little expectation of better resident outcomes or quality of life, which we term the “resident subordinate” domains. The two themes, and the seven domains within these themes, are described below and illustrated with quotations from the included papers. Informant quotations are provided in italics, quotations from the text of the papers are not italicized.

a. Transfer with an expectation of better outcomes for the resident – “resident dominant” theme and its domains

Two domains were identified under this theme. Generally, decision makers represent their transfer decision in a positive light with the best interests of the resident at the center of the decision.

Supporting clinical outcomes

Nine studies described an expectation that clinical care in the ED was superior to clinical care within the RACF in some circumstances. This might not necessarily reflect that clinical care in ED was perceived as high quality in absolute terms, only that it was superior to RACF care in relative terms. Some studies noted that informants expressed a view that ED transfer was undesirable for other reasons, but, at the same time, necessary to obtain maximum clinical benefit for the resident. For example, Shanley et al. noted that “participants suggested they would always transfer a resident who needed immediate, acute care that was only available in a hospital setting” [pg 4].[42]

Additional commentary in this domain is relevant in relation to the series of papers by Carusone et al.[33-35] The emphasis of these papers is an evaluation from different stakeholder perspectives of a clinical pathway for the management of nursing home-acquired pneumonia. Predominantly the findings from these series of papers support management within RACF and avoiding transfer where possible. Nonetheless, respondents in these series of studies did support transfer when it was felt this would be in the interests of the resident “Definitely … the hospital would provide better care”[pg 5].[35]

Supporting quality of life

Two studies described some transfers as influenced by a philosophy of improving quality of life and choice of residents. In a study by Cohen-Mansfield and Lipson, quality of life determinations were used in decisions to both transfer and not transfer.[41] McCloskey describes a number of residents who were grateful for being transferred, as it reflected that staff were taking their concerns seriously and they were being listened to as in “residents spoke positively of practitioners who ‘were willing’ to send them to the ED whenever they requested a transfer”[pg 720].[39]

b. Transfer with no expectation of better outcomes for the resident – “resident subordinate” theme and its domains

Five domains were identified under this theme. In discussing these domains, the framing of language around transfers was often driven by at least some level of apparent dissatisfaction with the transfer decision. Frequently within these domains, the decision to transfer is presented as yielding to some external influence, as distinct from the primary concern of maximizing benefit for the resident. Reference to the philosophy that it is “best” for the residents to be cared for in the facility where they live is often discussed, with the transfer decision being described in terms of why that was not possible. In essence, these decisions are taken with the understanding that there is a risk to an individual resident of transfer, but that this risk is outweighed by more global concerns, such as use of facility resources to care for the other residents, or avoidance of conflict with other parties, such as relatives of the resident.

Lack of resources for the facility

Eight papers describe resource constraints inhibiting the ability of respondents to care for residents as they would wish, necessitating transfer. This includes staffing levels and availability of necessary equipment or supplies, as exemplified by this quotation from a facility manager “I can see the workload is going to be not manageable either … so I have sent a couple [of residents] to hospital”[pg 5].[42] Within this realm of resourcing also sits consideration of timely access to alternatives to ED transfer. For example one nurse, when discussing trying to get a primary care physician to visit the facility for a resident, states “We would ring … but it might take 7–8 hours, so common sense prevails and we would ring an ambulance”[pg 62].[32]

Lack of confidence in care that can be provided in the facility

This has some relationship with other domains, but from nine papers emerges the sense that care in the facility is compromised, such that managing eligible cases in the facility appears unsafe. Sometimes this lack of confidence comes from staff assessing their own facility, as illustrated by “… when the nurses felt lacking in competence, other staff's mistakes frightened them. This created uncertainty and contributed to hasty decisions to refer patients to the ED”[pg 31].[38]

Inadequate care planning and communication

Nine papers discuss the decision to transfer as being influenced by uncertainty surrounding aspirations for care of the resident, lack of communication between decision makers, or both. “Nurses' lack of knowledge of resident and family wishes”[36] is commonly cited as a reason for transfer as seen in this response “Sometimes … in an acute situation you are given conflicting messages”[pg 32].[38] Similarly “physicians were more likely to hospitalize a resident when they … did not know whether directives were present”[pg 68].[41] The transfer decision might be seen as a path of least resistance in these situations.

Bureaucratic and legal concerns

In seven papers, the influence of government accrediting bodies, the perceived threat of litigation, or both, were seen to be associated with an increased likelihood of transfer. “The facilities are being constrained by their accreditors … and they don't allow the facilities the flexibility to care for people”[pg 63].[32]

Conflicting “stakeholder” preference

This domain was the most difficult to classify, as it is invariably described as occurring where one stakeholder believes it is in the resident's interest to transfer to hospital, and another does not. Because the literature predominantly seeks the perspectives of those stakeholders explaining the reason behind transfer, the conflict is mostly portrayed in terms of another party “forcing the hand” of the informant to transfer against their instincts or inclination. For example, in this scenario describing a resident with pneumonia “staff … did not feel an acute care setting could improve the client's quality of life. However his family… . requested admission to hospital”[pg 34].[40]

Discussion

We have identified two overarching, but conflicting, themes representing the differing principles on which the decision to transfer aged care residents to hospital is made. Stakeholders (staff, relatives and residents themselves) were committed to maximizing resident well-being. However, informants (particularly staff informants) often felt constrained by other influences that led them to transfer residents to hospital with no expectation that the individual resident would have improved health outcomes as a result of the transfer.

The importance of the present systematic review of the peer reviewed qualitative literature on this issue is to clarify the complexity associated with the decision to transfer aged care residents to ED. Until the complexity is understood and unravelled, a systematic approach to designing services that seek to minimize unnecessary or undesired resident transfer cannot occur. There are myriad reasons to believe that minimizing unnecessary transfer to ED from RACF is a supportable policy objective.[43, 44] However, particularly from the perspective of nursing staff working at the coalface of a stressed aged care system, the acknowledged benefits of maintaining within the RACF a person in need of acute health care might be overwhelmed by other competing interests.

There is some degree of artificiality to the thematic summation we have employed in this paper. For example, even in each of the domains within the “resident subordinate” theme, it can be argued that the principle behind the domain is to support the care of residents. For instance, bureaucratic standards have been established in response to suboptimal care. Nurses making decisions to transfer residents that do not clinically require ED care because of a lack of nursing resources in their facility are making utilitarian judgements on the care not only of the single resident in need of care, but the other residents within the facility. Nonetheless, because the published data is exploring the views of informants as to factors influencing their decisions, it makes little difference whether these external factors are well meaning or supportable. What really matters is how informants perceive these factors and how they influence decision-making, particularly if they influence decisions that they feel are not in the interests of residents.

Of interest is that there is less qualitative data exploring the research question of what, if any, enablers allow staff to confidently maintain residents within the facility instead of transferring to hospital. One series of papers contains substantial data in this area.[33-35] It is also explored, but to a lesser extent, in other included studies.[41, 42] This limited coverage of enablers most likely reflects the paradigm of viewing hospital transfer as a negative, and seeking explanations for why hospitalization occurred. It would be worthy of further research for qualitative studies to be undertaken that more comprehensively look at what factors assist staff, particularly nurses, to have confidence in decisions to not transfer.

The present study has used methods to rigorously evaluate and systematically review qualitative data using predetermined inclusion and exclusion criteria. We have provided comprehensive details about the studies cross-tabulated against a recognized methodological evaluation of such studies.

As with all similar review articles, our findings largely reflect the evidence from primary papers, but we have provided our own analysis of the published data to reach the conclusions we have drawn in this paper. This is an important step in synthesising data from diverse sources; however, qualitative systematic reviews can dilute the richness of data available in the primary studies.

Conclusion

Transfer of aged care residents to ED remains a highly complex area of health policy. In complex realms such as this, qualitative data can help guide a rigorous evaluation of policy alternatives and add to the evidence from quantitative sources.[45] This work adds an important dimension to the current debate by providing a framework for understanding stakeholder preferences for how care is delivered and why decisions are made. Policy designed without reference to this data will most likely be skewed to meet the needs of large bodies, such as hospitals, rather than facilities and their residents.

Acknowledgments

This research is partly funded by an Australian Research Council (ARC) Discovery Project Grant (DP120100770). The funders did not have any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; and preparation, review or approval of the manuscript.

Disclosure statement

No potential conflicts of interest were disclosed.

Appendix: Appendix

MEDLINE Search Strategy

  1. homes for the aged/ or nursing homes/
  2. Housing for the Elderly/
  3. (nursing and home$).tw.
  4. (residential and aged).tw.
  5. (nursing adj1 home$).tw.
  6. (residential adj1 aged).tw.
  7. or/1–6
  8. exp emergency medical services/ or exp emergency service, hospital/
  9. exp Emergencies/
  10. exp Emergency Medicine/
  11. ED.tw.
  12. (emergency and department).tw.
  13. A&E.tw.
  14. (accident and emergency).tw.
  15. (accident adj1 emergency).tw.
  16. exp Hospitalization/
  17. or/8–16
  18. 7 and 17
  19. interview.mp.
  20. px.fs.
  21. qualitative.tw.
  22. 19 or 20 or 21
  23. 18 and 22

Ancillary