Hospitalization of long-term care facility residents

person becomes more susceptible to infections, febrile episodes and eating problems (Mitchell et al. 2009). Other common conditions among LTCF residents such as chronic obstructive pulmonary disease and heart failure are also characterized by similar repeated occasions of decompensation/exacerbation (Decramer et al. 2012). Considering the above, it is not surprising that hospitalization of LTCF residents is very common.

Different approximations suggest that between two to six percent of residents experience a hospital transfer each month (Aaltonen et al. 2014; Connolly et al. 2015). Typical reasons for hospital or emergency department (ED) transfer include falls, fever, abnormal vital signs and difficulties with breathing and nutrient and fluid intake (Ouslander et al. 2016). A large proportion of hospitalizations are related to symptoms that are common in EOL and hospital transfers are indeed condensed to the last months of life. During the last month of life between five and 50% (suggested international median of one in three) of residents are hospitalized. This has been suggested to highlight deficiencies in ACP (Allers et al. 2019).

To a large degree, hospital transfers are considered to be avoidable.

Estimates of the proportion of avoidable transfers range from 28% (staff perspective in retrospect) to 60% (in external expert evaluation) (Spector et al. 2013; Ouslander et al. 2016). Non-avoidable transfers in these studies mainly constitute of acute traumas, other unexpected suffering and condition changes, when physician evaluation is not available on-site (Ouslander et al.

2016). The term potentially avoidable hospitalization (PAH) is mostly used in LTCF literature and a similar phenomenon is more widely referred to as ambulatory care-sensitive hospitalization (ACSH). ACSHs refer to events where indications of worsening condition could have been noted earlier and managed in outpatient care, but when left untreated eventually lead to

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hospitalization (Carter and Porell 2005). Most ACSHs are considered avoidable and their frequency is used as an indicator of preventive care and general healthcare service function (Carter and Porell 2005). Resident-related risk factors of PAHs include younger age and absence of cognitive decline, some studies also reporting men being hospitalized more frequently (Hoffmann et al. 2019). Similarly, in-hospital deaths of LTCF residents are common, with an estimated international median of 23%. Great variation in likelihood exists both across cultures and countries but also within similar facilities in a single country (Allers et al. 2019; Hoffmann et al. 2019). In general, the number of in-hospital deaths is commonly used as a negative care-quality indicator in palliative care, as the preferred place of death for older people very rarely is an ED or hospital (Teno et al. 1997). Place of death and care transitions probably affect QoL and QoD of LTCF residents, as hospitalizations are associated with many indicators of poor QoL and QoD (Mezey et al. 2002; Gozalo et al. 2011). Along with improving care and health, reducing the costs associated with PAHs is considered part of a proposed

“triple aim” of modern geriatrics (Ouslander and Maslow 2012).

In addition to being avoidable, hospitalizations are also considered burdensome for the residents. The concept of burdensomeness refers to the findings that ED and hospital visits can lead to iatrogenic harm and suffering that is prominent among older institutionalized people. Among these adverse outcomes are falls, infections, restraint use, delirium, pressure ulcers, sedative medication use and also increased mortality and fast functional decline (Dwyer et al. 2014; Ouslander et al. 2015). Hospitalizations may also result in care that is more aggressive compared with the persons’ initial preferences and at times conflicting with prior written documents. Considering that many typical acute conditions can be managed in the facility with more comfort, and with fewer adverse effects and, less mortality, the general principle of avoiding hospital transfers seems appropriate (Dosa 2006; Mitchell et al. 2009;

Lemoyne et al. 2019).

The processes leading to transfer decisions have been studied from several perspectives. Facilities with high registered nurse turnover may expect higher hospitalization rates (Kirsebom et al. 2017). Similarly, facilities with less experienced direct care staff are more likely to have high hospitalization rates as are for-profit facilities in some studies (Kirsebom et al. 2017). Some relationships between PAHs and common facility quality indicators such as psychotropic drug use, dependency on help with activities of daily living (ADL) and weight loss have been noted to exist (Xu et al. 2019). Studies on reducing readmission to hospitals suggest that motivation to change and adopt new methods, and financial incentives, are associated with diminishing readmissions, suggesting that motivational status and facility-wide attitudes might be more important than the exact methods used (Kane et al. 2003;

Bradley et al. 2015; Desai et al. 2016).

The perspectives of registered nurses and health care assistants towards hospitalizing their residents are complex and have cultural variation. In a

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review it was noted that LTCF personnel are often uncertain as to which acute scenarios they should manage and which scenarios are best managed in hospital (Laging et al. 2015). There were also doubts about the skill-mix and level of competence of staff members and the notion that fear of legal consequences always favored hospitalization. Poor availability of physician services and other multidisciplinary services was also considered to play a major role in the decision to hospitalize. In addition, the special role of the nurse as a liaison between resident, family and physician was viewed as important during considerations of hospitalization. While nurses often felt left out when they felt that they could have contributed essential information from the residents’ everyday perspectives, they, on the other hand were mostly reluctant to initiate the often difficult processes of EOL discussions with relatives and residents (Laging et al. 2015). Relatives and other proxies are involved in transfer decisions to varying degrees. Factors associated with proxies preferring hospitalization include: poor experiences of care quality in the facility, preference for medicalized treatment facilities in general, and denial as regards residents approaching death (Pulst et al. 2019). When proxies preferred treatment at a LTCF they referenced good comfort, familiarity with surroundings, hospitals’ confusing environment and recognition of symptoms being connected to approaching death (Pulst et al.

2019). Staff members tend to consider proxy participation in transfer decisions problematic, with proxies often considering all changes in a resident’s condition as crises. With mutual prejudice, timely and more extensive ACP has been proposed as a possible solution (Stephens et al. 2015).

In a previous systematic review, summarizing findings from various interventions to reduce hospitalizations, it was found that supporting ACP and hospice services, as well as improving ambulatory services by physicians or palliative specialists. have in some controlled studies reduced the rate of hospitalization of LTCF residents. However, the quality of evidence was graded low or very low (Graverholt et al. 2014).

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