Identifying Appropriate Nursing Home Resources to Reduce Fall-Related Emergency Department Transfers

Abstract

Objectives: To describe potentially avoidable fall-related transfers to the emergency department (ED), and to identify infrastructure, training needs, and resources deemed appropriate for implementation in nursing homes (NHs) to decrease fall-related transfers to EDs.

Design: A multi-method design, including (1) in-depth case review by an expert panel, (2) structured discussion with NH stakeholders, and (3) appropriateness rating.

Setting and participants: Fall-related transfers were identified from the prospective reporting of every unplanned hospital transfer occurring within 21 months, collected during the INTERCARE study in 11 Swiss NHs.

Methods: Eighty-one fall-related transfers were rated for avoidability by a 2-round expert panel. NH stakeholders were consulted to discuss key implementable resources for NHs to mitigate potentially avoidable fall-related transfers. A questionnaire composed of 21 contextually adapted resources was sent to a larger group of stakeholders, to rate the appropriateness for implementation in NHs. χ² tests were used to assess whether avoidability was associated with an ED visit and to describe transfers. The RAND/UCLA method for appropriateness was used to determine appropriate resources.

Results: One of 4 fall-related transfers were rated as potentially avoidable. A positive association was found between an ED visit and a rating of avoidability (χ² (1, N = 81) = 18.0, P < .001). Fourteen resources, including developing partnerships with outpatient clinics to access imaging services and strengthening geriatric expertise in nursing homes through clinical training and advanced nurse practitioners, were rated as appropriate by NH stakeholders for NH implementation to reduce potentially avoidable fall-related ED transfers.

Conclusions and implications: Access to diagnostic equipment, geriatric expertise, and clinical training is essential to reduce fall-related potentially avoidable transfers from NHs. Implementing and supporting advanced practice nurses or nurses in extended roles provides NH directors, policymakers, and health care institutions with the possibility of re-engineering resources to limit unnecessary transfers, which are detrimental for resident quality of care and costly for the health system.

Keywords: Emergency department transfers; falls; hospitalizations; long-term care; nursing homes; potentially avoidable transfers.