Avoiding Unnecessary Hospitalizations
Unnecessary hospitalizations of nursing home residents are common, with research suggesting that 40% to 67% of hospitalizations of residents may be avoidable. The costs and risks of unnecessary hospitalizations are high. Transfers from nursing homes to hospital are often accompanied by complications such as delirium and functional decline. Residents taking medications before hospitalization have the added risk of adverse drug interactions if prescribed new medications at the hospital.
Many complex and interrelated factors appear to influence decisions to hospitalize nursing home residents; however, until recently, there was little research examining how a key factor affects hospitalization rates: frontline nursing home staffers’ views of when transfers are, and are not, avoidable. A study published in the August 2011 issue of the Journal of the American Geriatrics Society sheds light on this important matter (www.ncbi.nlm.nih.gov/pubmed/21883105).
The study was part of the multicomponent Interventions to Reduce Acute Care Transfers (INTERACT) II quality improvement project, which included 26 US nursing homes in three states and implemented and evaluated strategies aimed at reducing unnecessary hospital transfers. Among other things, frontline nursing staff in each home reported the reasons transfers occurred in their facilities during the 6-month intervention. They then retrospectively evaluated these reasons by using an assessment tool developed as part of the intervention to decide whether transfers at their facility had been unavoidable, offering commentary when appropriate.
Staff at the nursing homes participating in the study retrospectively reported that 76% of hospitalizations at their facilities had been unavoidable, even though many were for problems that are widely considered avoidable or potentially avoidable, such as an acute change in the resident’s status, family insistence, and physician-ordered transfer. Respondents were more likely to classify these as “unavoidable” than as “avoidable” or “possibly avoidable,” reported lead author Gerri Lamb, PhD, Arizona State University’s College of Nursing and Health Innovation, and colleagues. The staffers’ retrospective comments regarding patient transfers suggest a degree of confusion regarding the preventability of hospitalizations at their facilities, the researchers noted. Comments about transfers that had been rated as unavoidable “also included suggestions for how the transfer might have been prevented—suggesting a lack of clarity and consistency in how staff may define and think about avoidability,” Lamb and associates wrote.
Some variation among facilities, however, was observed. Nursing homes that Lamb and coauthors characterized as “engaged”—those that were proactively involved in a variety of efforts to lower the incidence of unnecessary hospitalizations—retrospectively rated a greater proportion of hospitalizations as “avoidable” and “possibly avoidable” than did nursing homes that were not categorized as “engaged.” Staff at engaged homes repeatedly asked themselves questions, such as “Could we have recognized changes in this patient’s status earlier?”; “Would it have helped to talk with family members earlier about advance directives?”; “Is our falls prevention program as effective as it should be?”; and “Are we sending residents to the hospital for treatments and procedures we can safely offer in our facility?”
“There may be important factors associated with the process of becoming engaged in quality improvement efforts that contribute to changes in thinking about avoidability and, subsequently, to reductions in hospitalization rates,” Lamb and colleagues concluded. “In a previous analysis of INTERACT II results, facility engagement was significantly correlated with greater reductions in hospitalization rates, ” they noted.
Given the many benefits of preventing unnecessary hospitalizations of nursing home residents, further research in this area is clearly warranted. In light of Lamb and colleagues’ findings, additional research to identify strategies for engaging facilities in this effort should be a priority.
