Describing Avoidable Transfers and Decisions to Transfer Residents From Long-Term Care to Emergency Departments

Sunday, 30 July 2017: 1:40 AM

Judith Spiers, PhD1
Rowan El-Bialy, MSc1
Kaitlyn C. Tate, BScN2
Patrick B. McLane, PhD3
Greta G. Cummings, PhD2
(1)University of Alberta, Edmonton, AB, Canada
(2)Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
(3)Emergency Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada

Purpose:  Long term care residents (LTC) are typically frail elderly, who can suffer from iatrogenic effects of unnecessary or avoidable transitions to the emergency department (ED). Although most transfers of LTC residents via ambulance to the ED are necessary, our prior research shows that healthcare providers consider around 20% of transfers to be potentially avoidable. The purpose of this two-phase, mixed-methods study was to: define avoidable transitions, identify factors that influence decisions to transfer or not, and identify modifiable attributes of avoidable transitions.

Methods:  Phase 1 involved in-depth individual and focus group interviews in 6 LTC facilities in Alberta, Canada. The sample consisted of 71 Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Healthcare Aides, managers, and family members of LTC residents, in addition to 9 regional Emergency Medical Services (EMS) Personnel. Thematic analysis of 25 interviews and 19 focus groups followed. In Phase 2, an online survey was administered to staff and physicians in 18 LTC facilities and regional EMS personnel (N=351) to verify the findings of Phase 1. Descriptive analysis was undertaken of the survey data completed by the working sample: 50 RNs and physicians in an ED; 137 paramedics and EMTs; 142 RNs, LPNs, and administrators in LTCs; and 22 LTC Medical Directors.

Results:  The results led to an inductively developed conceptual definition of avoidable transfers. The identification of primary factors contributing to avoidable LTC-ED transfer decisions included: healthcare providers’ lack of familiarity with residents, a shortage of diagnostic and treatment resources in LTCs, limitations in the staff-family relationship, and varied interpretations of the Advance Care Planning policy. Emergent themes included: fear of liability; staff & family relationships; interpreting Goals of Care Designations; knowing the resident; healthcare provider’s critical thinking & response to ambiguity; limited diagnostic & treatment options in LTC; access to a second opinion.

Conclusion: The implications of these findings lead to recommendations for changes to policies and the development of decision-making guidelines regarding LTC-ED transitions.

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