Hospital transfers from care homes: conceptualising staff decision-making as a form of risk work

Harrad-Hyde, Fawn; Williams, Chris; Armstrong, Natalie

doi:10.1080/13698575.2022.2133094

Cited by 3 publications

(5 citation statements)

References 30 publications

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“…The weight given to social care staff (carers and senior cares), nursing staff (nurses) and managerial staff (managers) reflects the composition of care home staff’s roles in England [ 32 ]. Senior staff roles (nurses in nursing settings and senior carers in residential settings) were oversampled with respect to ancillary roles (carers) because senior staff are responsible for liaising with GPs, district nurses and emergency services [ 21 ]. In the UK, any doctor or nurse prescriber can prescribe ICDs to a patient expected to die out of hospital.…”

Section: Methodsmentioning

confidence: 99%

“…The few studies linking anticipatory prescribing to a reduction in care home residents’ hospital transfers evaluate the outcome of single interventions [ 17 , 18 ], failing to investigate the care home staff’s common practices which may hinder or facilitate this reduction. This is a key gap in knowledge considering that care home senior staff are responsible for triggering residents’ hospital transfers through emergency services [ 21 ], residents’ dying is extremely difficult to predict [ 22 ], and most hospital admissions of care home residents are inappropriate at the end-of-life, leading to traumatic transfers and poor symptom control [ 16 , 23 – 25 ].…”

Section: Introductionmentioning

confidence: 99%

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Anticipatory prescribing of injectable controlled drugs (ICDs) in care homes: a qualitative observational study of staff role, uncertain dying and hospital transfer at the end-of-life

Teggi,

Woodthorpe

2024

BMC Geriatr

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Background The anticipatory prescribing of injectable controlled drugs (ICDs) by general practitioners (GPs) to care home residents is common practice and is believed to reduce emergency hospital transfers at the end-of-life. However, evidence about the process of ICD prescribing and how it affects residents’ hospital transfer is limited. The study examined how care home nurses and senior carers (senior staff) describe their role in ICDs prescribing and identify that role to affect residents’ hospital transfers at the end-of-life. Methods 1,440 h of participant observation in five care homes in England between May 2019 and March 2020. Semi-structured interviews with a range of staff. Interviews (n = 25) and fieldnotes (2,761 handwritten A5 pages) were analysed thematically. Results Senior staff request GPs to prescribe ICDs ahead of residents’ expected death and review prescribed ICDs for as long as residents survive. Senior staff use this mechanism to ascertain the clinical appropriateness of withholding potentially life-extending emergency care (which usually led to hospital transfer) and demonstrate safe care provision to GPs certifying the medical cause of death. This enables senior staff to facilitate a care home death for residents experiencing uncertain dying trajectories. Conclusion Senior staff use GPs’ prescriptions and reviews of ICDs to pre-empt hospital transfers at the end-of-life. Policy should indicate a clear timeframe for ICD review to make hospital transfer avoidance less reliant on trust between senior staff and GPs. The timeframe should match the period before death allowing GPs to certify death without triggering a Coroner’s referral.

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Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Anticipatory prescribing of injectable controlled drugs (ICDs) in care homes: a qualitative observational study of staff role, uncertain dying and hospital transfer at the end-of-life

Teggi,

Woodthorpe

2024

BMC Geriatr

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“…The weight given to social care staff (carers and senior cares), nursing staff (nurses) and managerial staff (managers) re ects the composition of care home staff's roles in England 32 . Senior staff roles (nurses in nursing settings and senior carers in residential settings) were oversampled with respect to ancillary roles (carers) because senior staff are responsible for liaising with GPs and emergency services 21 .…”

Section: Recruitment and Participantsmentioning

confidence: 99%

“…The few studies linking anticipatory prescribing to a reduction in care home residents' hospital transfers evaluate the outcome of single interventions 17,18 , failing to investigate the care home staff's common practices which may hinder or facilitate this reduction. This is a key gap in knowledge considering that care home senior staff are responsible for triggering residents' hospital transfers through emergency services 21 , residents' dying is extremely di cult to predict 22 , and most hospital admissions of care home residents are inappropriate at the endof-life, leading to traumatic transfers and poor symptom control 16,[23][24][25] .…”

Section: Introductionmentioning

confidence: 99%

Anticipatory Prescribing of Injectable Controlled Drugs (ICDs) in Care Homes: a qualitative observational study of Staff Role, Uncertain Dying and Hospital Transfer at the End-of-Life

Teggi,

Woodthorpe

2023

Preprint

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Background: The anticipatory prescribing of injectable controlled drugs (ICDs) by general practitioners (GPs) to care home residents is common practice and is believed to reduce emergency hospital transfers at the end-of-life. However, evidence about the process of ICD prescribing and how it affects residents’ hospital transfer is limited. The study examined how care home nurses and senior carers (senior staff) describe their role in ICDs prescribing and identify that role to affect residents’ hospital transfers at the end-of-life. Methods: 1,440 hours of participant observation in five care homes in England between May 2019 and March 2020. Semi-structured interviews with a range of staff. Interviews (n = 25) and fieldnotes (2,761 handwritten A5 pages) were analysed thematically. Results: Senior staff request GPs to prescribe ICDs ahead of residents’ expected death and review prescribed ICDs for as long as residents survive. Senior staff use this mechanism to ascertain the clinical appropriateness of withholding potentially life-extending emergency care (which usually led to hospital transfer) and demonstrate safe care provision to GPs certifying the medical cause of death. This enables senior staff to facilitate a care home death for residents experiencing uncertain dying trajectories. Conclusion: Senior staff use GPs’ prescriptions and reviews of ICDs to pre-empt hospital transfers at the end-of-life. Policy should indicate a clear timeframe for ICD review to make hospital transfer avoidance less reliant on trust between senior staff and GPs. The timeframe should match the period before death allowing GPs to certify death without triggering a Coroner’s referral.

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“…Peer-support is benefcial for people who support a family member living with dementia at home [25,[30][31][32]. To date, research has neglected to consider whether diferent forms of peer-support may be benefcial for people who support a person living in a care home, where decisions about deterioration and dying can be complex and infuenced by numerous actors and the care home's policies and informal norms [33,34]. Furthermore, little is known about whether more formal peer-mentors might be useful in helping families to prepare for discussion and decisions about end-of-life care.…”

Section: Introductionmentioning

confidence: 99%

Could Peer-Mentors Support Families of Care Home Residents to Prepare for Deterioration and End-of-Life? An Interview Study with Families and Care Home Staff

Harrad-Hyde,

Jones,

Agarwal

et al. 2024

Health & Social Care in the Community

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When older people move into a care home, family members often continue to be involved in caregiving. This can include contributing to discussion and decisions about care and treatment, especially when the resident lacks capacity. However, families may not know what to expect as their relative’s condition progresses and may not have a good understanding of their relative’s end-of-life care and treatment wishes. Therefore, although often willing, families may feel unprepared for making decisions in advance of or at the time of deterioration and end-of-life. The study aimed to explore the potential role that peer-mentors might have in supporting families to prepare for discussion and decisions about care and treatment and to understand what participants would consider to be important characteristics of an effective peer-mentor and peer-mentoring program. The study was guided by the philosophical assumptions of social constructionism. Data from semistructured interviews with 14 current and 15 bereaved family members and 11 senior members of care were analysed thematically. Findings suggest that peer-mentors could help to empower families to prepare to be involved in discussions and decisions about the types of care their relatives might receive as their health deteriorates and they reach the end-of-life. However, it was seen as important that peer-mentors have lived experience of supporting a relative in a care home, strong interpersonal and communication skills, and the ability to discuss deterioration and end-of-life in a compassionate but factual manner. Although peer-mentoring is often time-limited, introducing mentors to families earlier in the care journey, for example, before admission into a care home, could enable a trusting relationship to develop. This, in turn, could facilitate open discussions about what to expect and different care choices as the person’s health changes.

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Hospital transfers from care homes: conceptualising staff decision-making as a form of risk work

Cited by 3 publications

References 30 publications

Anticipatory prescribing of injectable controlled drugs (ICDs) in care homes: a qualitative observational study of staff role, uncertain dying and hospital transfer at the end-of-life

Anticipatory prescribing of injectable controlled drugs (ICDs) in care homes: a qualitative observational study of staff role, uncertain dying and hospital transfer at the end-of-life

Anticipatory Prescribing of Injectable Controlled Drugs (ICDs) in Care Homes: a qualitative observational study of Staff Role, Uncertain Dying and Hospital Transfer at the End-of-Life

Could Peer-Mentors Support Families of Care Home Residents to Prepare for Deterioration and End-of-Life? An Interview Study with Families and Care Home Staff

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