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      Appropriateness of transferring nursing home residents to emergency departments: a systematic review

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          Abstract

          Background

          Elderly living in a Nursing Home (NH) are frequently transferred to an Emergency Department when they need acute medical care. A proportion of these transfers may be considered inappropriate and may be avoidable.

          Methods

          Systematic review. Literature search performed in September 2018 using PubMed, Web of Science, the Cochrane Library and the Cumulative Index to Nursing and Allied Health Literature database. Titles and abstracts were screened against inclusion and exclusion criteria. Full-texts of the selected abstracts were read and checked for relevance. All years and all languages were included provided there was an English, French, Dutch or German abstract.

          Results

          Seventy-seven articles were included in the systematic review: 1 randomised control trial (RCT), 6 narrative reviews, 9 systematic reviews, 7 experimental studies, 10 qualitative studies and 44 observational studies. Of all acute transfers of NH residents to an ED, 4 to 55% were classified as inappropriate. The most common reasons for transfer were trauma after falling, altered mental status and infection. Transfers were associated with a high risk of complications and mortality, especially during out-of-hours. Advance directives (ADs) were usually not available and relatives often urge NH staff to transfer patients to an ED. The lack of availability of GPs was a barrier to organise acute care in the NH in order to prevent admission to the hospital.

          Conclusions

          The definition of appropriateness is not uniform across studies and needs further investigation. To avoid inappropriate transfer to EDs, we recommend to respect the patient’s autonomy, to provide sufficient nursing staff and to invest in their education, to increase the role of GPs in the care of NH residents both in standard and in acute situations, and to promote interprofessional communication and collaboration between GPs, NH staff and EDs.

          Electronic supplementary material

          The online version of this article (10.1186/s12877-019-1028-z) contains supplementary material, which is available to authorized users.

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          Most cited references85

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          Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups.

          Qualitative research explores complex phenomena encountered by clinicians, health care providers, policy makers and consumers. Although partial checklists are available, no consolidated reporting framework exists for any type of qualitative design. To develop a checklist for explicit and comprehensive reporting of qualitative studies (in depth interviews and focus groups). We performed a comprehensive search in Cochrane and Campbell Protocols, Medline, CINAHL, systematic reviews of qualitative studies, author or reviewer guidelines of major medical journals and reference lists of relevant publications for existing checklists used to assess qualitative studies. Seventy-six items from 22 checklists were compiled into a comprehensive list. All items were grouped into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and reporting. Duplicate items and those that were ambiguous, too broadly defined and impractical to assess were removed. Items most frequently included in the checklists related to sampling method, setting for data collection, method of data collection, respondent validation of findings, method of recording data, description of the derivation of themes and inclusion of supporting quotations. We grouped all items into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and reporting. The criteria included in COREQ, a 32-item checklist, can help researchers to report important aspects of the research team, study methods, context of the study, findings, analysis and interpretations.
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            Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.

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              Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews

              Background Our objective was to develop an instrument to assess the methodological quality of systematic reviews, building upon previous tools, empirical evidence and expert consensus. Methods A 37-item assessment tool was formed by combining 1) the enhanced Overview Quality Assessment Questionnaire (OQAQ), 2) a checklist created by Sacks, and 3) three additional items recently judged to be of methodological importance. This tool was applied to 99 paper-based and 52 electronic systematic reviews. Exploratory factor analysis was used to identify underlying components. The results were considered by methodological experts using a nominal group technique aimed at item reduction and design of an assessment tool with face and content validity. Results The factor analysis identified 11 components. From each component, one item was selected by the nominal group. The resulting instrument was judged to have face and content validity. Conclusion A measurement tool for the 'assessment of multiple systematic reviews' (AMSTAR) was developed. The tool consists of 11 items and has good face and content validity for measuring the methodological quality of systematic reviews. Additional studies are needed with a focus on the reproducibility and construct validity of AMSTAR, before strong recommendations can be made on its use.
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                Author and article information

                Contributors
                +32 3 821 56 41 , sabine.lemoyne@uza.be
                Hanne.herbots@student.uantwerpen.be
                Dennis.deblick@student.uantwerpen.be
                Roy.remmen@uantwerpen.be
                Koen.monsieurs@uza.be
                Peter.vanbogaert@uantwerpen.be
                Journal
                BMC Geriatr
                BMC Geriatr
                BMC Geriatrics
                BioMed Central (London )
                1471-2318
                21 January 2019
                21 January 2019
                2019
                : 19
                : 17
                Affiliations
                [1 ]ISNI 0000 0004 0626 3418, GRID grid.411414.5, Emergency Department, , Antwerp University Hospital, ; Wilrijkstraat 10, 2650 Edegem, Belgium
                [2 ]ISNI 0000 0001 0790 3681, GRID grid.5284.b, Faculty of Medicine and Health Sciences, , University of Antwerp, ; Universiteitsplein 1, 2610 Wilrijk, Belgium
                [3 ]Department of Primary and Interdisciplinary Care, Universiteitsplein 1, 2610 Wilrijk, Belgium
                [4 ]Center for Research and Innovation in Care, Universiteitsplein 1, 2610 Wilrijk, Belgium
                Author information
                http://orcid.org/0000-0003-4477-7105
                Article
                1028
                10.1186/s12877-019-1028-z
                6341611
                30665362
                cf7646a3-8908-451d-a658-b01eddd05d22
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 5 July 2018
                : 4 January 2019
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2019

                Geriatric medicine
                appropriateness,emergency medical service,emergency department,general practitioner,nursing home,nursing staff,patient transfer

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