Paramedics's perspectives on hospital transfers of nursing home residents - a qualitative focus group study

Abstract Background: Emergency department (ED) visits and hospital admissions are common among nursing home residents (NHRs). These transfers are often considered avoidable and can have negative effects on residents’ health status. Emergency medical services (EMS) are an important linking profession between nursing homes (NHs) and hospitals and responsible for transports. So far, little is known about the perspectives of paramedics in this context. The aim of this qualitative study is to explore how paramedics experience hospital transfer process of NHRs and how hospitalizations could be avoided from their point of view. Methods: A qualitative study with three focus groups was conducted with paramedics. The focus groups followed a semi-structured question guide focusing on issues during transfer process, avoidable hospital transfers and potential interventions which might reduce transfers from NHs. Discussions were audio recorded and transcribed verbatim. Data were analyzed by content analysis using the software MAXQDA. Results: In total, 18 paramedics (mean age: 33 years, male n=14) participated in the focus groups. Paramedics mainly reported about perceived structural reasons (e.g. understaffing or lack of time) in NHs which led to initiation of an emergency call. Paramedics were often faced with poorly organized handovers because of lacking or incomplete information. In many cases, nursing staff was perceived as insufficiently qualified and not well-prepared regarding health status of NHRs. Throughout transfer process, the behavior of all involved professional groups (dispatcher/ambulance control center, nurses, physicians and paramedics) was influenced by legal uncertainties. Paramedics rated hospital transfers as avoidable in case of urinary catheter complications, exsiccosis/infections and partially in case of falls. Emergency standards in NHs, trainings for nursing staff, improvement of working conditions and legal conditions were discussed as potential interventions which could reduce hospital transfers of NHRs. Conclusion: Paramedics are faced with complex issues when transporting a NHR to hospital. According to their point of view staff shortage and legal uncertainties play a relevant role in transfer decisions. Interventions reducing (avoidable) hospital transfers of NHRs have to take these factors into account. Keywords: nursing home residents, hospitalization, hospital admission, patient transfer, referral, transition, emergency department, emergency medical services, decision making, advance care planning