Lessons Learned From Root Cause Analyses of Transfers of Skilled Nursing Facility (SNF) Patients to Acute Hospitals: Transfers Rated as Preventable Versus Nonpreventable by SNF Staff

Abstract

Background: Determining if a transfer of a skilled nursing facility (SNF) patient/resident to an acute hospital is potentially avoidable or preventable is challenging. Most previous research on potentially avoidable or preventable hospitalizations is based on diagnoses without in-depth root cause analysis (RCA), and few studies have examined SNF staff perspective on preventability of transfers.

Objectives: To examine factors associated with hospital transfers rated as potentially preventable versus nonpreventable by SNF staff.

Design: Trained staff from SNFs enrolled in a randomized controlled clinical trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program performed retrospective RCAs on hospital transfers during a 12-month implementation period.

Setting: SNFs from across the United States.

Participants: Sixty-four of 88 SNFs randomized to the intervention group submitted RCAs with a rating of whether the transfer was determined to be potentially preventable or nonpreventable.

Interventions: SNFs were implementing the INTERACT Quality Improvement (QI) program.

Measures: Data were abstracted from the INTERACT QI tool, a structured, retrospective RCA on hospital transfers.

Results: A total of 4527 RCAs with a rating of preventability were submitted during the 12-month implementation period, of which 1044 (23%) were rated as potentially preventable by SNF staff. In unadjusted univariate analyses, factors associated with ratings of potentially preventable included acute changes in condition of fever, decreased food or fluid intake, functional decline, shortness of breath, and new urinary incontinence; other factors included the clinician, resident, and/or family insisting on the transfer, transfers that occurred fewer than 30 days from SNF admission and that occurred on weekends, transfers ordered by a covering physician (as opposed to the primary physician), and transfers that resulted in an emergency department (ED) visit with return to the SNF. Factors associated with ratings of nonpreventable included on-site evaluation by a physician or other clinician, and transfers related to falls. Among factors precipitating the transfers, clinician and resident and/or family insistence on transfer, and transfers related to fever and falls remained significant in a multivariate analysis. There were no significant differences among characteristics of SNFs that rated a relatively high versus low proportion of transfers as potentially preventable.

Conclusion: SNF staff rated a substantial proportion of transfers as potentially preventable on retrospective RCAs. Factors associated with ratings of preventability, as well as illustrative case examples, provide important insights that can assist SNFs in focusing education and care process improvements in order to reduce unnecessary hospital transfers and their associated morbidity and costs.

Keywords: Skilled nursing facility; preventable hospitalizations; root cause analysis.