Lessons Learned From Root Cause Analyses of Transfers of Skilled Nursing Facility (SNF) Patients to Acute Hospitals: Transfers Rated as Preventable Versus Nonpreventable by SNF Staff

Journal of the American Medical Directors Association

Volumn 17, Issue 7, 2016, Pages 596-601

  Ouslander, Joseph G ^a,b   Naharci, Ilkin ^a,c   Engstrom, Gabriella ^b   Shutes, Jill ^a   Wolf, David G ^a,d   Alpert, Graig ^e   Rojido, Carolina ^a,b   Tappen, Ruth ^b   Newman, David ^b  

^a FLORIDA ATLANTIC UNIVERSITY   (United States)

^b FLORIDA ATLANTIC UNIVERSITY   (United States)

^c GULHANE SCHOOL OF MEDICINE   (Turkey)

^d BARRY UNIVERSITY   (United States)

^e UNIVERSITY OF SOUTH FLORIDA   (United States)

Author keywords

preventable hospitalizations; root cause analysis; Skilled nursing facility

Indexed keywords

ARTICLE; COMPARATIVE STUDY; DYSPNEA; EMERGENCY WARD; FALLING; FEVER; FLUID INTAKE; FOOD INTAKE; FUNCTIONAL DISEASE; HEALTH CARE COST; HEALTH CARE FACILITY; HEALTH CARE QUALITY; HUMAN; MORBIDITY; NURSING STAFF; PATIENT TRANSPORT; RANDOMIZED CONTROLLED TRIAL (TOPIC); ROOT CAUSE ANALYSIS; SKILLED NURSING FACILITY; TOTAL QUALITY MANAGEMENT; UNITED STATES; URINE INCONTINENCE; HOSPITAL EMERGENCY SERVICE; HOSPITALIZATION; NURSING HOME; RETROSPECTIVE STUDY; STATISTICS AND NUMERICAL DATA; TRENDS; UTILIZATION;

EMERGENCY SERVICE, HOSPITAL; HOSPITALIZATION; HUMANS; PATIENT TRANSFER; RANDOMIZED CONTROLLED TRIALS AS TOPIC; RETROSPECTIVE STUDIES; ROOT CAUSE ANALYSIS; SKILLED NURSING FACILITIES;

EID: 84977119081     PISSN: 15258610     EISSN: 15389375     Source Type: Journal    
DOI: 10.1016/j.jamda.2016.02.014     Document Type: Article

References (36)

1. 1 Centers for Medicare and Medicaid Services. Welcome to the Partnership for Patients. Available at: https://partnershipforpatients.cms.gov/. Accessed November 4, 2015.
2. 2 Ouslander, J.G., Berenson, R.A., Reducing unnecessary hospitalizations of nursing home residents. N Engl J Med 365 (2011), 1165–1167.
3. 3 Ouslander, J.G., Maslow, K., Geriatrics and the triple aim: Defining preventable hospitalizations in the long term care population. J Am Geriatr Soc 60 (2012), 2313–2318.
4. 4 Ouslander, J.G., Diaz, S., Hain, D., Tappen, R., Frequency and diagnoses associated with 7- and 30-day readmission of skilled nursing facility patients to a non-teaching community hospital. J Am Med Dir Assoc 12 (2011), 195–203.
5. 5 Saliba, D., Kington, R., Buchanan, J., et al. Appropriateness of the decision to transfer nursing facility residents to hospital. J Am Geriatr Soc 48 (2000), 154–163.
6. 6 Ouslander, J.G., Lamb, G., Perloe, M., et al. Potentially avoidable hospitalizations of nursing home residents: Frequency, causes, and costs. J Am Geriatr Soc 58 (2010), 627–635.
7. 7 Grabowski, D.C., O'Malley, A.J., Barhydt, N.R., The costs and potential savings associated with nursing home hospitalizations. Health Aff (Millwood) 26 (2007), 1753–1761.
8. 8 Walsh, E.G., Wiener, J.M., Haber, S., et al. Potentially avoidable hospitalizations of dually eligible Medicare/Medicaid beneficiaries from nursing facility and home and community-based services waiver programs. J Am Geriatr Soc 60 (2012), 821–829.
9. 9 Spector, W.D., Limcangco, R., Williams, C., et al. Potentially avoidable hospitalizations for elderly long-stay residents of nursing homes. Med Care 51 (2013), 673–681.
10. 10 Burke, R.E., Rooks, S.P., Levy, C., et al. Identifying preventable emergency department visits by nursing home residents in the United States. J Am Med Dir Assoc 16 (2015), 395–399.
11. 11 Lamb, G., Tappen, R., Diaz, S., et al. Avoidability of hospital transfers of nursing home residents: Perspectives of frontline staff. J Am Geriatr Soc 59 (2011), 1665–1672.
12. 12 Ouslander, J.G., Naharci, I., Engstrom, G., et al. Root cause analyses of transfers of skilled nursing facility patients to acute hospitals: Lessons learned for reducing unnecessary hospitalizations. J Am Med Dir Assn 17 (2016), 256–262.
13. 13 Buchanan, J., Murkofsly, R.L., O'Malley, A.J., et al. Nursing home capabilities and decisions to hospitalize: A survey of medical directors and directors of nursing. J Am Geriatr Soc 54 (2006), 458–465.
14. 14 Dwyer, R., Stoelwinder, J., Gabbe, B., et al. Unplanned transfer to emergency departments for frail elderly residents of aged care facilities: A review of patient and organizational factors. J Am Med Dir Assoc 16 (2015), 551–562.
15. 15 Ouslander, J.G., Bonner, A., Herndon, L., Shutes, J., The INTERACT Quality Improvement Program: An overview for medical directors and primary care clinicians in long-term care. J Am Med Dir Assoc 15 (2014), 162–170.
16. 16 INTERACT. Interactions to Reduce Acute Care Transfers. https://interact.fau.edu. Accessed February 11, 2016.
17. 17 Ouslander, J.G., Schnelle, J.F., Han, J., Is this really an emergency? Reducing potentially preventable emergency department visits among nursing home residents. J Am Med Dir Assoc 16 (2015), 354–357.
18. 18 High, K.P., Bradley, S.F., Gravenstein, S., et al. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Disease Society of America. Clin Infect Dis 48 (2009), 149–171.
19. 19 Choi, M., Hector, M., Effectiveness of intervention programs in preventing falls: A systematic review of recent 10 years and meta-analysis. J Am Med Dir Assoc 13 (2012), 188.e13–188.e21.
20. 20 American Medical Directors Association. Falls and Fall Risk Clinical Practice Guideline. 2011, AMDA, Columbia, MD.
21. 21 Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older People. J Am Geriatr Soc 59 (2011), 148–157.
22. 22 Jo A Taylor Consulting. Available at: http://joataylor.com/resources. Accessed February 11, 2016.
23. 23 Reuben, D., Buchanan, J., Farley, D., et al. Primary care of long-stay nursing home residents: A comparison of 3 HMO programs with fee-for-service care. J Am Geriatr Soc 47 (1999), 131–138.
24. 24 Konetzka, R.T., Spector, W., Limcangco, M.R., Reducing hospitalizations from LTC settings. Med Care Res Rev 65 (2008), 40–66.
25. 25 Bakerjian, D., Care of nursing home residents by advance practice nurses: A review of the literature. Res Gerontol Nurs 1 (2008), 177–185.
26. 26 Kuo, Y.F., Raji, M.A., Goodwin, J.S., Association between proportion of provider clinical effort in nursing homes and potentially avoidable hospitalizations and medical costs of nursing home residents. J Am Geriatr Soc 61 (2013), 1750–1757.
27. 27 Grabowski, D.C., O'Malley, A.J., Use of telemedicine can reduce hospitalizations of nursing home residents and generate savings for Medicare. Health Aff (Millwood) 33 (2014), 244–250.
28. 28 Katz, P.R., Resnick, B., Ouslander, J.G., Requiring on-site evaluation in the nursing home before hospital transfer: Is this proposed CMS rule safe and feasible?. J Am Med Dir Assoc 16 (2015), 801–803.
29. 29 Molloy, D.W., Guyatt, G.H., Russo, R., et al. Systematic implementation of an advance directive program in nursing homes: A randomized controlled trial. JAMA 283 (2000), 1437–1444.
30. 30 Mitchell, S.L., Teno, J.M., Intrator, O., et al. Decisions to forgo hospitalization in advanced dementia: A nationwide study. J Am Geriatr Soc 55 (2007), 432–438.
31. 31 Tulsky, J.A., Beyond advance directives: Importance of communication skills at the end of life. JAMA 294 (2005), 359–365.
32. 32 National Hospice and Palliative Care Organization. Available at: http://www.nhpco.org/. Accessed November 4, 2015.
33. 33 Coalition of Compassionate Care of California. Available at: http://coalitionccc.org/. Accessed November 4, 2015.
34. 34 Physicial Orders for LifeSustaining Treatment Paradigm. POLST. Available at: http://www.polst.org/. Accessed November 4, 2015.
35. 35 The Conversation Project. Available at: http://theconversationproject.org/. Accessed November 4, 2015.
36. 36 Decision Guide. Available at: http://www.decisionguide.org/. Accessed November 15, 2015.