Life In The Slower Lane

Here is the PICO analysis for the fourteenth uploaded article:

---

✅ PICO Analysis

Full Article Title:

Root Cause Analyses of Transfers of Skilled Nursing Facility Patients to Acute Hospitals: Lessons Learned for Reducing Unnecessary Hospitalizations

Type of Study:

Retrospective observational study using structured root cause analysis (RCA)

Journal and Year:

Journal of the American Medical Directors Association (JAMDA), 2016; 17(4):256–262

DOI: 10.1016/j.jamda.2015.11.018

---

P – Population

• Setting: 64 skilled nursing facilities (SNFs) across the United States
• Participants:
  • Over 4800 hospital transfers of SNF residents were analysed using the INTERACT Quality Improvement (QI) tool
  • Residents included both short- and long-stay populations; average SNF size was 139 beds 

---

I – Intervention

• Nature of Intervention:
  • Implementation of the INTERACT (Interventions to Reduce Acute Care Transfers) Quality Improvement Program
  • SNF staff conducted structured, retrospective RCAs of hospital transfers using the INTERACT QI tool
  • The intervention included training webinars and feedback based on graphical summaries of the QI data 

---

C – Comparison

• Comparator:
  • No direct control group for the RCA findings in this publication, though the broader study was a randomised controlled implementation trial
  • Internal comparisons included identifying characteristics of transfers deemed preventable vs non-preventable
  • Analysis also stratified by timing of transfer, clinician involvement, diagnostic tests performed, and advance care planning status 

---

O – Outcomes

1. Characteristics of Transfers:

• 23% (1 in 4) of all transfers were considered potentially preventable by SNF staff
• Common preventable factors included:
  • Delay in recognising or managing symptoms onsite (36%)
  • Lack of advance care planning or directives (27%)
  • Insufficient communication or staff education (18–25%) 

2. Clinical Indicators at Time of Transfer:

• Most transfers were prompted by multiple nonspecific symptoms:
  • Abnormal vital signs (33%)
  • Altered mental status (28%)
  • Shortness of breath (23%)
• Only 13% were evaluated in-person by a physician before transfer; 65% had only phone-based consultation 

3. Timing and Setting of Transfers:

• 22% of transfers occurred within 6 days of SNF admission
• 29% of transfers occurred during evening or night shifts
• 78% of transfers led to hospital admission; 19% were emergency department only 

4. Role of Preferences and Planning:

• Patient/family preference influenced 16% of transfers
• Only 32% had advance care planning noted; new directives were placed in just 2% before transfer
• Absence of a directive was flagged as a contributing factor in 6% of transfers 

---

Outcome Classification

• Person-centred outcomes: Improved advance care planning and preference-concordant care may reduce unnecessary transfers
• Process outcomes: Early recognition of symptoms, timely clinician access, communication improvement, and staff education were key areas of focus
• Health system outcomes: Reducing preventable transfers could lower hospital admissions, readmissions, and healthcare costs 

---

Summary Conclusion

This large-scale retrospective review of hospital transfers using the INTERACT QI tool identified that nearly 1 in 4 SNF-to-hospital transfers could have been prevented with earlier symptom recognition, better communication, more robust onsite clinical management, and improved advance care planning. The findings highlight specific targets for educational and systemic quality improvements in SNFs. Moreover, they reinforce the value of structured RCA as part of a continuous quality improvement framework in long-term care .

---