Life In The Slower Lane

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

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Full Title (verbatim and exact):

“Appropriateness of Patient Transfer from Nursing Home to an Acute-Care Hospital: A Study of Emergency Room Visits and Hospital Admissions”

Howard Bergman, MD, and A. Mark Clarfield, MD

Journal of the American Geriatrics Society, 1991; 39:1164–1168

DOI: 10.1111/j.1532-5415.1991.tb03568.x

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Type of Article:

Retrospective cohort study (record review over 3 years)

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PICO Analysis:

Population:

• 112 residents of an 80-bed public nursing home in Quebec, Canada
• Study period: 3 years (1981–1983)
• Mean age: 81.6 years (range: 65–100)
• Residents generally frail, long-stay, with varied care needs (over 60% required >2.5 hours of nursing care/day) 

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Intervention:

• Transfer to an acute care hospital (via Emergency Room or direct admission) for acute medical issues
• Types of care required included diagnostics, IV medications, advanced imaging, or acute treatment unavailable at the nursing home
• Transfers were examined for appropriateness based on outcome (admission, emergency procedures, or death in ED) 

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Comparator:

• Implicit comparator: Cases where the acute condition might have been managed within the nursing home
• Defined as “inappropriate transfers”—transfers that did not require services beyond what could be delivered in the NH (e.g. behavioural issues, minor trauma, mild infection, etc.)

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Outcome:

1. Person-centred outcomes:

• Not explicitly examined in this study (no patient experience or quality of life metrics recorded)

2. Process outcomes:

• 49% of residents were transferred at least once during the 3-year study
• 102 total transfers:
  • 17% direct admissions
  • 34% ER → admission
  • 45% ER → return to NH
  • 4% died in the ED
• Mean length of hospital stay: 18.8 days
• Most common diagnoses: cardiovascular disease (31%), infection (19%), trauma (12%) 

3. Health system outcomes:

• 93% of transfers considered appropriate (either admitted, required ER-exclusive procedures, or resulted in death)
• 7% judged inappropriate: could have been managed in the NH with existing or modestly extended resources
• Key conclusion: Most NH-to-hospital transfers were medically justified, but system strain, procedural limitations, and diagnostic gaps influenced transfer rates
• Recommendations for future evaluation: better onsite capabilities, staffing, and reconsideration of transfer protocols, especially for terminally ill/demented residents 

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