Appropriateness of the decision to transfer nursing facility residents to the hospital.
OBJECTIVE
To develop and test a standardized instrument, the purpose of which is to assess (1) whether skilled nursing facilities (SNFs) transfer residents to emergency departments (ED) inappropriately, (2) whether residents are admitted to hospitals inappropriately, (3) and factors associated with inappropriate transfers.


METHODS
A structured implicit review (SIR) of medical records.


METHODS
Using nested random sampling in eight community SNFs, we identified SNF and hospital records of 100 unscheduled transfers to one of 10 hospitals.


METHODS
Seven trained physician reviewers assessed appropriateness using a SIR form designed for this study (2 independent reviews per record, 200 total reviews). We measured interrater reliability with kappa statistics and used bivariate analysis to identify factors associated with assessment that transfer was inappropriate.


RESULTS
In 36% of ED transfers and 40% of hospital admissions, both reviewers agreed that transfer/admit was inappropriate, meaning the resident could have been cared for safely at a lower level of care. Agreement was high for both ED (percent agreement 84%, kappa .678) and hospital (percent agreement 89%, kappa .779). When advance directives were considered, both reviewers rated 44% of ED transfers and 45% of admissions inappropriate. Factors associated with inappropriateness included the perceptions that: (1) poor quality of care contributed to transfer need, (2) needed services would typically be available in outpatient settings, and (3) the chief complaint did not warrant hospitalization.


CONCLUSIONS
Inappropriate transfers are a potentially large problem. Some inappropriate transfers may be associated with poor quality of care in SNFs. This study demonstrates that structured implicit review meets criteria for reliable assessment of inappropriate transfer rates. Structured implicit review may be a valuable tool for identifying inappropriate transfers from SNFs to EDs and hospitals.
Saliba
D
D
Geriatric Research Education and Clinical Center, VA Greater Los Angeles Health Care System, USA.
Kington
R
R
Buchanan
J
J
Bell
R
R
Wang
M
M
Lee
M
M
Herbst
M
M
Lee
D
D
Sur
D
D
Rubenstein
L
L
D016223:Advance Directives; D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000706:statistics & numerical data; D003657:Decision Making; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D006301:Health Services Needs and Demand / Q000706:statistics & numerical data; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D015588:Observer Variation; D010343:Patient Admission / Q000706:statistics & numerical data; D010360:Patient Transfer / Q000706:statistics & numerical data; D011787:Quality of Health Care; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012866:Skilled Nursing Facilities / Q000706:statistics & numerical data