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Predicting avoidable transfers from nursing homes is ‘complex’

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Predicting ahead of time which resident nursing home transfers to hospital could potentially be avoided is “difficult”, according to a new US study.

Researchers found that both symptoms and patient risk conditions were only “weakly predictive” of whether hospital admission would be considered potentially avoidable.

“Symptoms and risk conditions were only weakly predictive of hospital diagnoses”

Study authors

They highlighted that treating acutely ill nursing home residents “in place” and, therefore, avoiding admissions when possible is better for their health and for the healthcare system.

They noted that common diagnoses, such as heart failure or urinary tract infection, were often used to classify whether a hospitalisation of a nursing home resident was “potentially avoidable”.

The same team of researchers have previously found almost half of long-stay nursing home residents experience at least one transfer to an accident and emergency department over the course of a year, regardless of cognitive status.

Part of a longer-term project, the new research saw clinical staff collect data on long-stay residents who were transferred from 19 nursing homes to the emergency department or hospital.

The study by the Indiana University Center for Aging Research and the Regenstrief Institute involved 1,174 nursing home residents, who experienced 1,931 acute transfers during just over 18 months.

The study authors said they found that 44% of acute transfers were associated with one of six potentially avoidable diagnoses. However, they said symptoms before transfer “did not discriminate well among hospital diagnoses”.

“Continued work is needed to understand and recognise true avoidability of these events”

Kathleen Unroe

The symptoms “mapped into multiple diagnoses and most hospital diagnoses had multiple associated symptoms”, they said.

“For example, more than two-thirds of acute transfers of residents with a history of chronic heart failure and chronic obstructive pulmonary disease were for reasons other than exacerbations of those two conditions,” they noted.

They stated: “Although it is widely recognised that many transfers of nursing facility residents are potentially avoidable, determining ‘avoidability’ at time of transfer is complex.

“Symptoms and risk conditions were only weakly predictive of hospital diagnoses,” they said in the Journal of the American Geriatrics Society.

Lead study author Dr Kathleen Unroe said: “We need to be asking and answering a lot of questions in order to determine if a nursing home resident should have been transported to the hospital.

For example, she highlighted questions about the patient in the hours leading up to possible transfer and association between current symptoms and the patient’s underlying risk conditions.

“Our findings of the difficulty of predicting the avoidability of hospital transfers with information available at the time of transfer, highlights the challenge of designing targeted strategies to reduce potentially avoidable transfers from the nursing home to the hospital,” she said.

Indiana University Center for Aging Research

Half of nursing home residents visit A&E each year

Source: Regenstrief Institute

Kathleen Unroe

The study formed the part of the Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project.

Its ultimate goal was to test out a care model that embedded a clinical team in nursing homes with the aim of optimising chronic disease management and reducing unnecessary admissions.

During the four-year initial phase of the project, the researchers said avoidable hospitalisations among long-stay nursing home residents were reduced by a “striking” 33%.

Dr Unroe said: “Multi-component, comprehensive quality improvement efforts like OPTIMISTIC, which embeds specially trained nurses in the facilities have been successful in reducing these transfers.

“But continued work is needed to understand and recognise true avoidability of these events,” she added.

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