From the Care Home to the Hospital: Understanding hospital transfers through the experiences of care home staff

Problem

Care home residents are frequently transferred to hospital despite the potential that this will be of limited benefit to them and risk significant iatrogenic harm. Several initiatives to support care homes in avoiding transfer of their residents to hospital have been introduced, but robust evaluations of these are lacking. Particular gaps relate to understanding the role of care home staff in transfer decisions and the nuanced contexts in which transfer decisions are made. An enhanced understanding of decisions about hospital transfer could help to optimise the care that residents receive and reduce inappropriate transfers. The aim of the current project is to develop a model of escalation, based on the experiences of care home staff, that describes the decisions and processes that occur prior to the transfer to hospital of a care home resident.

Approach

Semi-structured interviews were carried out with 30 care home staff across a purposive sample of 6 nursing and residential homes in the Midlands. Participants were managers, deputy managers, registered nurses, senior care assistants and care assistants. Discussions covered personal experience of being involved in transfers and reflection on hypothetical vignettes which had been developed in collaboration with four care home managers to reflect situations that could occur in a care home. Interviews were audio recorded, transcribed verbatim and analysed using constant comparison.

Findings

Thematic analysis will contribute to a model of escalation that describes the events and process that precede a transfer. Preliminary analysis suggests that care staff recognise deterioration through non-specific features (e.g. change from usual behaviour) rather than a structured clinical assessment. This is shaped by carers’ tacit (rather than formal) knowledge of each resident. Once a deterioration is recognised, processes for escalation within the homes vary significantly, reflecting organisational structures. When deciding the most appropriate course of action staff consider multiple factors This includes clinical information, resident and family wishes and (perceived) legal responsibilities. Despite holding in depth knowledge of each resident, care staff believe the decision to transfer a resident (or not) should be made by a healthcare professional such as a GP or paramedic. Staff spoke extensively about the role of advance care plans (ACPs) in the transfer process. ACPs may be useful but vague and ambiguous ACPs are subject to interpretation at the time of deterioration, which can increase the likelihood that a hospital transfer will occur.

Consequences

This study approaches hospital transfers from care homes from a new perspective, by emphasising the experiences of care home staff. Understanding the processes and interactions that precede a transfer is an important first step to developing high quality alternatives to a hospital transfer. Our model of escalation can provide a theoretical basis for interventions and policies to support such alternatives.