title: Root Cause Analyses of Transfers of Skilled Nursing Facility Patients to Acute Hospitals: Lessons Learned for Reducing Unnecessary Hospitalizations.
abstract: BACKGROUND
  Performing root cause analyses (RCA) on transfers of skilled nursing facility (SNF) patients to acute hospitals can help identify opportunities for care process improvements and education that may help prevent unnecessary emergency department (ED) visits, hospitalizations, and hospital readmissions.
  
  
  OBJECTIVE
  To describe the results of structured, retrospective RCAs performed by SNF staff on hospital transfers to identify lessons learned for reducing these transfers.
  
  
  METHODS
  SNFs enrolled in a randomized, controlled implementation trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program submitted RCAs on hospital transfers during a 12-month implementation period.
  
  
  METHODS
  SNFs from across the United States that volunteered and met the enrollment criteria for the implementation trial.
  
  
  METHODS
  Sixty-four of 88 SNFs randomized to the intervention group performed and submitted retrospective RCAs on hospital transfers.
  
  
  METHODS
  SNFs received education and technical assistance in INTERACT implementation.
  
  
  METHODS
  Data were summarized from the INTERACT Quality Improvement (QI) tool, a structured, retrospective RCA on hospital transfers.
  
  
  RESULTS
  A total of 4856 QI tools were submitted during the 12-month implementation period. Most transfers were precipitated by multiple symptoms and signs, many of them nonspecific. Patient and/or family preference or insistence was noted to have played a role in 16% of the transfers. Hospital transfers were relatively equally distributed among days of the week, and 29% occurred on the night or evening shift. Approximately 1 in 5 transfers occurred within 6 days of SNF admission from a hospital, and 1 in 10 occurred within 2 days of SNF admission. After completing the RCA, SNF staff identified 1044 (23%) of the transfers as potentially preventable. Common reasons for these ratings included recognition that the condition could have been detected earlier and/or could have been managed safely in the SNF, and that earlier advance care planning and discussions with patients and families about preferences for care may have prevented some transfers.
  
  
  CONCLUSIONS
  Summarizing findings from RCAs of transfers of SNF patients to acute hospitals can provide important insights into areas of focus for care process improvements and related education that may help prevent unnecessary ED visits, hospital admissions, and readmissions.
authors.affiliation: Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL; Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL. Electronic address: Joseph.Ouslander@fau.edu.
authors.forename: Joseph G
authors.initials: JG
authors.lastname: Ouslander
authors.affiliation: Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL; Gulhane School of Medicine, Ankara, Turkey.
authors.forename: Ilkin
authors.initials: I
authors.lastname: Naharci
authors.affiliation: Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL.
authors.forename: Gabriella
authors.initials: G
authors.lastname: Engstrom
authors.affiliation: Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL.
authors.forename: Jill
authors.initials: J
authors.lastname: Shutes
authors.affiliation: Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL; Barry University, Miami, FL.
authors.forename: David G
authors.initials: DG
authors.lastname: Wolf
authors.affiliation: Morsani College of Medicine, University of South Florida, Tampa, FL.
authors.forename: Graig
authors.initials: G
authors.lastname: Alpert
authors.affiliation: Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL; Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL.
authors.forename: Carolina
authors.initials: C
authors.lastname: Rojido
authors.affiliation: Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL.
authors.forename: Ruth
authors.initials: R
authors.lastname: Tappen
authors.affiliation: Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL.
authors.forename: David
authors.initials: D
authors.lastname: Newman
mesh_terms: D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D010359:Patient Readmission / Q000706:statistics & numerical data; D010360:Patient Transfer / Q000706:statistics & numerical data; D012189:Retrospective Studies; D060891:Root Cause Analysis; D012866:Skilled Nursing Facilities; D014481:United States
keywords: Skilled nursing facilities; root cause analysis; unnecessary hospitalizations