Search Strategy

Inclusion/ Exclusion Criteria

DataExtraction & Analysis

Key Findings

Recommendations &Implications

Laging, Ford, Bauer & Nay, 2015

Explore the role in nursing home staff in decisions to transfer to hospital

Systematic review; meta-synthesis; CINAHL, Embase, Medline, and PsycInfo databases were searched

Qualitative research papers published between January 1989-Ocotber 2012; transfers to hospital from the nursing home setting

Study categories were synthesized on the basis of similarity in meaning. The categories were then placed into five synthesized findings. Each study was reviewed and re-read. Author findings were extracted and findings supported using the JBI-QARI

Nursing home staff members play a key role in decision making at the time of a client’s deterioration. Multiple factors influence decisions to transfer to hospital including an unclear expectation of the nursing home role; limited staffing capacity; fear of working outside their scope of practice; poor access to multidisciplinary support and difficulties communicating with other decision makers

There is a lack of consensus regarding the role of the nursing home when a client’s condition deteriorates. Nursing home staff would benefit from a clear understanding of their expected clinical skill set; a staffing capacity that allows for the increased requirements to manage clients on-site, greater consistency in access to outside resources and further confidence and skills to optimize their role in client advocacy. All nursing home clients (with their families) should be encouraged to identify and document their end of life care wishes.

Low, Fletcher, Goodenough, Jeon, Etherton-Beer, McAndrew, & Beattie, 2015

What interventions have been attempted to change staff practice to improve long-term care resident outcomes?

Systematic review of interventions that attempted to change staff practice to improve long-term care resident outcomes

Randomized controlled trials and quasi-experimental controlled trials were included as recommended by the EPOC group.

Extracted using standard forms based on forms developed by the Cochrane Effective Practice and Organisation of Care Group. Extraction was conducted by one researcher and checked by a second researcher.

Results support that using theory to plan implementation strategies will increase the success of translating research into practice change. When staff behavior is not measured, it is not clear whether the program has been unsuccessful because of implementation error or because the staff behavior has changed, but has not brought about the desired improvement in clients.

Changing staff practice in nursing homes is possible but complex. Interventionists should consider barriers and feasibility of program components to impact on each intended outcome.

Nelson & Pulley, 2015

State the problem of readmission rates; compare transitional care models; discuss strategies for effective transitional care

Systematic literature search: not stated

25 long term care facilities that incorporated INTERACT quality improvement program (a transitional care model principle)

In 2014 meta-analysis of 26 RCTs one research group for 30-day readmissions were reduced only by high intensity transitional care model principles

Rates decreased an average of 17%; facilities with greater commitment and resources allocated to model implementation saw greater reductions than those SNFs with a minimal commitment

Transitional care models are recommended with high-risk older adults to prevent hospital readmission.

O’Neill, Parkinson, Dwyer, & Reid-Searl, 2015

Describe nursing home nurses’ perception around emergency transfers to hospital.

CINAHL, Health Source: Nursing Academic Edition, MEDLINE, JBI of Systematic Reviews; published studies between 2000 and 2014, English, peer-reviewed

Inclusion: 7 qualitative studies & mixed-method studies that focus on decision-making processes by nurses

Exclusion: poor nursing staff identification and perceptions beyond views on symptomology were not prominent

The findings from each study were summarized verbatim and organized in NVivo 10. A total of 92 findings were extracted and assigned a credibility rating of Unequivocal, Credible, and Unsupported.

Meta synthesis 1: Nursing home nurses require clinical knowledge, skills, and resources to assess and manage the deteriorating client.

Meta synthesis 2: Nursing home nurses use persuasive and targeted communication techniques to manage and direct possible transfer situations.

Metasynthesis 3: Nurses are more decisive and confident when a “plan” is in place; INTERACT is a quality improvement program designed to reduce hospitalizations

Targeted education for nursing; identify problems causing communication issues; nurses’ perceptions around perceptions of hospital transfer must be sought and considered

Graverholt, Forsetlund, &Jamtvedt, 2014

Summarize the effects of interventions to reduce acute hospitalizations from nursing homes

Systematic search performed in Cochrane Library, PubMed, MEDLINE, EMBASE and ISI Web of Science

Studies were included if they had a geriatric nursing home study population & were evaluating any type of intervention aimed at reducing acute hospital admissions. Systematic reviews, RCTs, controlled before-after studies and interrupted time series were eligible.

Process of selection studies, assessing them, extracting data and grading the total evidence was conducted by two researchers individually.

Eleven interventions to reduce hospital admissions from nursing homes were identified. Several of the interventions had effects on reducing hospital admissions and may represent important aspects of nursing home care to reduce hospital admissions.

For future studies evaluating interventions to reduce rehospitalizations, adherence to the framework of complex interventions is recommended.

Renom-Guiteras, Uhrenfeldt, Meyer, & Mann, 2014

The goal of the systematic review is 1) to provide an overview of the studies dealing with tools for assessing appropriateness of hospital admissions in long term care residents and 2) to describe the published assessment tools in detail, including information about their development and the aspects covered by the tools.

Systematic review of the literature using PubMed and CINAHL was conducted. The search covered 7 languages from January 2000 and December 2012.

All quantitative studies were included if any assessment tool for appropriateness of hospital and/or emergency department admission of long-term care residents was used.

Twenty-nine articles were included, covering study periods between 1991 and 2009. Two independent researchers extracted information on the study characteristics and the assessment tools. Inter-related reliability was not calculated because most information extracted was descriptive.

Assessment tools differed widely regarding the aspects considered as criteria for judgement of appropriateness of acute care admissions. All tools identified in the systematic review were developed based on expert opinion.

Further research is needed to develop a tool that is evidence-based, comprehensive, and generaliz able to different regions or countries in order to assess the appropriateness of hospital admission among skilled nursing facility residents.

Maslow &Ouslander, 2012

Search for quality measures that have been developed to identify potentially preventable hospitalizations was conducted.

Focused on U.S. sources

Inclusion: Population that is frail and chronically ill who receive long-term services and supports

Analysis of quality measures

Measures overlap and are highly detailed; failure of measures to account for medical comorbidities and clinical complexity; failure of measures to account for differences in the available resources for care in particular facilities and other care settings; lack of research to validate measures for use in the chronically ill adults who receive long-term care services; lack of attention to how and where decisions about hospitalization are made for the adult receiving long-term care and supports; the extent of current and future effort to reduce potentially preventable hospitalizations by government programs is growing

Long Term Quality Alliance (LTQA) should define measures in general; the LTQA should define as specifically as possible the population of frail and chronically ill adults who receive long-term care services to test validity of measures intended to reduce potentially preventable hospitalizations; the LTQA should identify ways to help clinicians understand current and new programs; several interventions for nursing staff at nursing homes described in this paper include training and structure procedures in determining potentially preventable hospitalizations

Ouslander, Naharci, &Engstrom, Shutes, Wolf, Alpert, Rojido, Tappen, & Newman, 2011

Data and lessons learned from more than 4800 hospital transfers from 64 skilled nursing facilities who trialed INTERACT QI program

SNFs were recruited via contacts from national organizations. A total of 613 SNFs were screened for eligibility via online and telephone surveys.

Inclusion criteria: Evidence of support from corporate and facility leadership; ability to manage acute changes in condition safely within the facility as evidenced by availability of lab, pharmacy, & medical care resources

Exclusion criteria: Hospital-based facilities; participating in another project design specifically to reduce acute care transfers or hospitalization rates that might influence the intervention or control conditions; conducting more than one other major quality improvement or research project during the project period

Interim analysis of approximately half of the QI tools was performed in the middle of the implementation period. The mean and median numbers were 76 and 49, with an interquartile range of 30 - 106. The results of the analysis of all the QI tools in the article are almost identical to the interim analysis.

More than one quarter of the transfers were recognized by the staff as potentially avoidable. INTERACT may help prevent unnecessary hospitalizations.

SNF staff should be trained in comprehensive acute changes more than disease specific. Templates for the evaluation of acute changes in SNF clients and related decision support tools should account for the common occurrence of multiple and nonspecific symptoms in the SNF population.

Boutwell & Hwu, 2009

Review the evidence for effective interventions to reduce hospitalizations across patient populations and settings of care

Survey of published literature in PubMed; search strategies narrowed by publication date (few than 10 years from September 2008); English, and U.S. based studies

Inclusion: epidemiology of avoidable hospitalizations and rehospitalizations from specific setting of care, specific service interventions, interventions for patients with specific diseases

158 articles were selected by the research team for further review, The Institute for Hospital Improvement conducted the analysis.

Researchers and institutions are attempting to identify strategies to reduce avoidable hospitalizations; improvement in reducing rehospitalizations is possible although the relative effect of any single intervention discussed in this document is not possible at this time; many of the interventions in literature to date have focused on heart failure populations; a variety of approaches seem to be promising

Nurse-led transition care that proved to be effective interventions include the following: communication tools, patient activation, nurse-led coaching, education sessions, telephone outreach, comprehensive discharge planning and home follow-up visits