Life In The Slower Lane

Here is the structured PICO analysis for the fortieth article you uploaded:

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Full Title (verbatim and exact):

“Analyzing Hospital Transfers Using INTERACT Acute Care Transfer Tools: Lessons from MOQI”

Popejoy LL, Vogelsmeier AA, Alexander GL, et al.

Journal of the American Geriatrics Society (2019); 67(9):1953–1959

DOI: https://doi.org/10.1111/jgs.15996

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📄 

Type of Article:

Cross-sectional descriptive study of quality improvement (QI) data

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🔍 

PICO Analysis:

Population:

• 5168 residents (median age 82) from 16 Missouri nursing homes (NHs)
• Facilities ranged from 120–321 beds, in urban, metro, and rural areas
• Residents were enrolled in Medicare and/or Medicaid, and had lived in the NH >100 days
• Data collected as part of the Missouri Quality Improvement Initiative (MOQI)

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Intervention:

• Use of INTERACT v3.0 QI Acute Care Transfer (ACT) tools, supported by full-time embedded Advanced Practice Registered Nurses (APRNs)
• APRNs conducted root cause analyses of all hospital transfers using adapted INTERACT ACT forms
• QI processes included monthly ACT reviews, identification of system-level issues, and NH team discussions
• Supported by a multi-disciplinary team including a medical director, QI coach, HIT coach, and social worker 

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Comparator:

• No external control group
• Analysis focused on comparison between avoidable vs unavoidable transfers within the same cohort over time

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Outcome:

1. Person-centred outcomes:

• Not directly assessed, but indirectly linked to:
  • ED visits without admission (701 avoidable vs 239 unavoidable; P < .001)
  • Likelihood of hospital death (greater among unavoidable transfers)
• Advance directive/hospice documentation was associated with avoidable transfers and earlier preference discussions 

2. Process outcomes:

• Hospital transfers (n = 3946):
  • 54% (2111) were classified as avoidable
  • Avoidable transfers were associated with:
    • Missed opportunities for early symptom recognition (OR = 2.34)
    • Inadequate communication about resident condition (OR = 4.93)
    • No advance directive or preference discussions (OR = 2.12–2.25)
    • Condition could have been managed in the NH (OR = 16.6) 
• Unavoidable transfers were linked to:
  • Acute clinical events like bleeding (OR = 0.59), nausea/vomiting (OR = 0.70)
  • Resident/family request for hospitalization (OR = 0.79)
  • Morning transfers and full resuscitation orders 
• Use of INTERACT tools and QI efforts over 3 years:
  • Avoidable transfer percentage rose from 47% to 58%, suggesting shifting staff perception of what is avoidable with APRN coaching 

3. Health system outcomes:

• Overall reduction in hospital transfers
• Increased capacity for NHs to manage residents in place:
  • 43% of transfers were deemed manageable in-house
  • Substantial increase in advance directive use (72%) vs other studies (30%)
• APRNs provided non-billable services under current Medicare rules, limiting generalisability and scalability without policy reform

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Summary Conclusion:

This large retrospective QI study found that more than half of hospital transfers in Missouri nursing homes were avoidable, particularly when robust INTERACT processes and APRN-led QI methods were implemented. Key modifiable contributors included poor communication, lack of symptom detection, and unclear care preferences. The study highlights the transformative role of APRNs in challenging assumptions about avoidability, building NH capability, and guiding systems-level change. The findings support policy advocacy for sustained APRN fundingand widespread adoption of INTERACT tools as part of comprehensive hospital avoidance strategies.

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