Life In The Slower Lane

Here is the structured PICO analysis for the fifty-eighth article you uploaded:

---

✅ 

Full Title (verbatim and exact):

“Decisions to Transfer Nursing Home Residents to Emergency Departments: A Scoping Review of Contributing Factors and Staff Perspectives”

Trahan LM, Spiers JA, Cummings GG

Journal of the American Medical Directors Association (JAMDA) (2016); 17(11):994–1005

DOI: 10.1016/j.jamda.2016.05.012

---

📄 

Type of Article:

Scoping review

---

🔍 

PICO Analysis:

Population:

• Nursing home (NH) residents in long-term care settings
• Includes perspectives from NH staff (nurses, physicians), residents, and family members across 19 included studies (qualitative and quantitative)
• Studies were conducted in the USA, Canada, Australia, Ireland, Norway, and Sweden 

---

Intervention (Phenomenon of Interest):

• Decision-making processes and contributing factors leading to the transfer of NH residents to emergency departments (EDs)
• Focused on identifying characteristics of “avoidable” or “unnecessary” transfers, and factors influencing these decisions 

---

Comparator:

• No formal comparator group (not interventional)
• Compares instances of transfer with and without established goals of care, clinical triggers, or sufficient NH resources
• Evaluates dimensions of decision-making (e.g., early detection vs. late crisis response) and perspectives from various stakeholders

---

Outcome:

1. Person-centred outcomes (inferred):

• NH residents are often transferred with the intent of:
  • Improving clinical outcomes
  • Preserving quality of life
• However, transfers were frequently associated with:
  • Disruption, distress, and decline in function post-transfer
  • Loss of autonomy if advance directives were absent or not followed
• Decision-making was improved when residents’ wishes were known and respected

2. Process outcomes:

• Identified five major categories of factors contributing to ED transfers (summarised in Table 5, page 10):
  • Nursing factors: limited skills, missed recognition of deterioration, liability concerns, communication gaps
  • Physician/NP factors: lack of on-site availability, defensive practice, absence of geriatric expertise
  • Facility/resource factors: limited diagnostics and treatment options, lack of care protocols, under-resourcing
  • Resident/family factors: preferences for hospital care, lack of trust in NH, insistence on transfer
  • Health system factors: bureaucratic limitations, regulatory pressures, poor NH–ED communication 
• Multiple studies reported structured tools (e.g., checklists) and clinical judgment as potential improvements
• Barriers included lack of point-of-care diagnostics, low confidence in in-house treatment, and variable adherence to ACPs

3. Health system outcomes:

• Transfers that might be “avoidable” were often:
  • Diagnoses that could be managed in NH with adequate support (e.g., UTI, dehydration, mild pneumonia)
  • ED visits that resulted in direct return without admission (suggesting over-triage)
• Ambulatory Care–Sensitive Indicators (ACSI) and Structured Implicit Review (SIR) tools were cited as promising evaluative frameworks
• The review calls for system-level investment in NH capacity, including:
  • Point-of-care testing
  • Geriatric-trained staff
  • Telemedicine and symptom-alert protocols 

---

Summary Conclusion:

This scoping review highlights the complex interplay of nursing, medical, family, facility, and system-level factorsinvolved in transferring NH residents to the ED. Despite the common use of terms like “avoidable” or “unnecessary” transfers, the review found no universal definition. Instead, avoidability is contextual—depending on resource availability, clinical competence, and the presence of ACPs. The authors advocate for a multifactorial approach to reform, including improved staff training, primary care access, diagnostics in NHs, and ACP integration to reduce potentially harmful and unnecessary ED transfers in frail populations.

---