Tuesday, June 20, 2017

Guest Commentary: Reducing avoidable resident transfers from long term care facilities to the emergency department

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By Jude Spiers, PhD, RN; Rowan El-Bialy, MSc; Greta Cummings, PhD, RN, FCAHS, FAAN

Approximately 20% of long term care (LTC) resident transfers to the emergency department (ED) are deemed unnecessary or avoidable. Often, the resident’s clinical situation is ambiguous and a range of factors influences the decision to transfer.[i] In our study, Examining Aged Care Transitions (EXACT)[ii], we explored how local LTC and EMS staff defined and characterized avoidable transfers. We interviewed 80 LTC staff, EMS and family, then surveyed 351 LTC staff, ED Registered Nurses and Physicians, and EMS staff. Our survey indicated ED/EMS participants evaluated approximately 65% of the resident transfers in the past 12 months as avoidable, whereas LTC nurses/managers and physicians thought that approximately 33% of their transfers were avoidable. While this discrepancy reflects contrasting beliefs about LTC capacity, it is clear that clinicians across settings believe that there is a portion of LTC-ED transfers that can be avoided. Our research points to some of the priority areas in policy and practice regarding transfer decision-making.

A major contributor to avoidable transfers is the interpretation of Goals of Care Designations (GCD) Policy across LTC staff, ED/EMS and families. When the GCD is deemed the “rule” rather than a guide to be considered with other factors, it may lead to decisions to send residents to the ED rather than seek other options. The role of Public Guardians in decision-making in the context of existing GCDs is an area that needs further exploration.

A priority area is supporting LTC staff in building relationships with family. Trust is a core component that affects decisions, including families’ trust in the nursing assessment and trust in the ability of the facility to keep a resident comfortable. Unrealistic expectations about the capacity, skills and resources of ED are a major influence for family decision-makers whose primary need may be to know what is going on, regardless of whether or not treatment intervention is desirable. Managing family expectations and providing reassurance that their loved one is being carefully monitored and kept comfortable can significantly reduce avoidable transfers.

Feedback mechanisms to track avoidable transfers are another priority. Feedback loops help evaluate key decision points and factors leading to a transfer decision, which may range from clinical assessment skills to family pressure. Family preferences can overshadow the clinical assessment and even the resident’s preferences. LTC staff can be reluctant to risk repercussions from families or management if they decide not to transfer. Constructive and timely feedback will help enhance nurses’ clinical assessment and collaboration skills, and may help alleviate staff concerns about the ramifications of their decision.

Lastly, improving communication between LTC and EMS at the point of handover is vital. LTC staff need to present a comprehensive clinical assessment supported by physician decisions and resident/family wishes when requesting an emergency transfer. Policies enhancing standards for inter-professional interaction and education for effective communication will substantially improve EMS/LTC collaboration. We are piloting a short LTC decision making guide to help nurses gather all clinical assessment data and support effective consultation with residents, families, and physicians before deciding to transfer.[iii] Increasing opportunities for EMS staff and students to visit the LTC context will help sensitize them to the resources and constraints of LTC care.

Reducing avoidable and unnecessary transfers is complex, as each decision is unique. Nonetheless, these system changes can cumulatively reduce the number of avoidable transfers – and that is in everyone’s best interest. Please see our YouTube video for more on the EXACT study and findings (https://goo.gl/cQMz9V).

[i] Trahan, L. M., Spiers, J. A., & Cummings, G. G. (2016). Decisions to Transfer Nursing Home Residents to Emergency Departments: 
A Scoping Review of Contributing Factors and Staff Perspectives. Journal of the American Medical Directors Association, 17(11), 994-1005.

[ii] Funded by the Covenant Health Network of Excellence in Seniors’ Health and Wellness, Alberta, Canada

[iii] Funded by a Covenant Health Research Centre Grant


Jude Spiers, PhD, RN is an Associate Professor, Faculty of Nursing at the University of Alberta

Rowan El Bialy, MSc is the Research Program Manager, CLEAR Outcomes, University of Alberta

Greta Cummings, PhD, RN, FCAHS, FAAN is a Professor, Faculty of Nursing, University of Alberta