In Canada, there were over 60,000 long-term care facility patient transfers to emergency departments (EDs) in 2014, with up to a quarter of them being potentially preventable. Each preventable transfer exposes the patient to transport- and hospital-related complications, contributes to ED crowding, and adds significant costs to the health care system. There have been many proposed and studied interventions aimed at alleviating the issue, but few attempts to assess and evaluate different interventions across institutions.

A systematic search of MEDLINE, CINAHL, and EMBASE for studies describing the impact of interventions aimed at reducing preventable transfers from long-term care facilities to EDs on ED transfer rate. Two independent reviewers screened the studies for inclusion and completed a quality assessment. A tabular and narrative synthesis was then completed. This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines.

A total of 26 studies were included (Cohen's k = 0.68). One was of low quality (Cohen's k = 0.58). Studies were summarized into five themes based on intervention type: Telemedicine, Outreach Teams, Interdisciplinary Care, Integrated Approaches, and Other. Effective interventions reported reductions in ED transfer rates post intervention ranging from 10 to 70%. Interdisciplinary health care teams staffed within long-term care facilities were the most effective interventions.

There are several promising interventions that have successfully reduced the number of preventable transfers from long-term care facilities to EDs in a variety of health care settings. Widespread implementation of these interventions has the potential to reduce ED crowding in Canada.

Little is known about how hospital organizational and cultural factors associated with implementation of quality initiatives such as the Institute for Healthcare Improvement's (IHI) 100,000 Lives Campaign differ among levels of healthcare staff.

Evaluation of a mixed qualitative and quantitative methodology (“trilogic evaluation model”).

Six hospitals that joined the campaign before June 2006.

Three strata of staff (executive leadership, midlevel, and frontline) at each hospital.

Surveys were completed in 2008 by 135 hospital personnel (midlevel, 43.7%; frontline, 38.5%; executive, 17.8%) who also participated in 20 focus groups. Overall, 93% of participants were aware of the IHI campaign in their hospital and perceived that 58% (standard deviation, 22.7%) of improvements in quality at their hospital were a direct result of the campaign. There were significant differences between staff levels on the organizational culture (OC) items, with executive-level staff having higher scores than midlevel and frontline staff. All 20 focus groups perceived that the campaign interventions were sustainable and that data feedback, buy-in, hardwiring (into daily activities), and leadership support were essential to sustainability.

The trilogic model demonstrated that the 3 levels of staff had markedly different perceptions regarding the IHI campaign and OC. A framework in which frontline, midlevel, and leadership staff are simultaneously assessed may be a useful tool for future evaluations of OC and quality initiatives such as the IHI campaign.

Infect Control Hosp Epidemiol 2012;33(2):135-143