Avoidability of hospital transfers of nursing home residents: Perspectives of frontline staff

OBJECTIVES: To describe nursing home (NH) staff perceptions of avoidability of hospital transfers of NH residents. DESIGN: Mixed methods qualitative and quantitative analysis of 1,347 quality improvement (QI) review tools completed by staff at 26 NHs and transcripts of conference calls. SETTING: Twenty-six NHs in three states participating in the Interventions to Reduce Acute Care Transfers (INTER-ACT II) QI project. PARTICIPANTS: Site coordinators and staff who participated in project orientation and conference calls and completed QI tools. MEASUREMENTS: NH and hospitalization data collected for the INTERACT II project. An interprofessional team coded and quantified reasons for hospital transfer on 1,347 QI review tools. RESULTS: Staff rated 76% of the transfers in the QI review tools as not avoidable. Common reasons for transfers rated as unavoidable were acute change in resident status, family insistence, and physician order for transfer. These same reasons were given for transfers rated as avoidable. Avoidable ratings were associated with a broader set of reasons and recommendations for improvement, including earlier identification and management of changes in clinical status, earlier discussion with family members about advance directives, and more-comprehensive communication with physicians. NHs that were more actively engaged in the INTERACT II interventions rated more transfers as avoidable. Percentage of transfers rated avoidable was not correlated with change in hospitalization rates. CONCLUSION: NH staff rated fewer hospital transfers as avoidable than published estimates. Greater attention to the complex array of reasons that staff provide for hospital transfer should be considered in strategies to reduce avoidable hospitalizations of NH residents.