The initial search yielded 347 articles after deduplication. After title and abstract screening, 341 were excluded. The full texts of six studies were retrieved and a further two were excluded at this stage. This left four studies meeting inclusion criteria which were included in the review. Snowball searches did not yield further relevant articles and no relevant national policy or guidelines searches were identified. A PRISMA diagram is shown in Fig. 1.
Characteristics and key findings of included studies are summarised in Table 2. All were qualitative studies conducted in Australia. They comprised: a meta-synthesis of factors influencing nursing home staff’s decision to transfer residents to hospital 22; a critical ethnography using observations and qualitative interviews to examine how deterioration in residents is recognised 23; interviews and focus groups to examine factors influencing decisions surrounding unwell residents 24; qualitative interviews to examine how resident deterioration is managed following introduction of a hospital avoidance programme 25.
<insert Table 2. Charted data of study characteristics and key findings>
Thematic Analysis Results
Three main themes, comprising 32 codes (Table 3), were identified: identifying residents with acute deterioration; managing acute deterioration; and factors affecting recognition and response to acute deterioration.
Table 3
Review questions & associated codes
Theme topic | Associated codes |
Identifying residents with acute deterioration | Recognition, see, identify, suspect, gut feeling, know/knowing |
Managing acute deterioration | Act, behave, action, inaction, watch, escalate care, report, follow care home procedure, ask for help, respond, |
Factors affecting recognition and response to acute deterioration | Protocols, tools, policies, guidelines, care home directed, organisational process, culture, staffing ratios, skill mix, size of care home |
Identifying residents with acute deterioration
Reports on how care home staff recognised AD in residents was varied. Central to this theme were descriptions of care home staff relying more on instinct rather than structured tools or guidelines to recognise AD. Laging et al.’s (2015) qualitative review 22 summarised multiple studies where care home staff described having an ‘intuition’ or ‘gut feeling’ when there was a change in a resident’s health status. Furthermore, identification of AD was reported as care home staff relying on tacit knowledge and their relationship with residents as opposed to conscious logical rationale 22,23.
O’Neill et al’s., (2017) study examining nursing home staff’s perceptions of managing AD following the introduction of a ‘sub-acute program’ reported on a hospital style approach to identifying and managing AD 25. The sub-acute program included training on signs and symptoms of AD, associated illnesses/diagnoses, and use of equipment to manage AD in residents. Even with this additional knowledge and training, participants still reported a ‘sense of knowing’ when a resident was unwell. Explicit examples of how AD was identified following the implementation of the sub-acute program were not provided and it remains unclear how/if the intervention improved identification of residents with AD or if care home staff relied on their knowledge of the resident to detect changes in their health. The study also claimed that detection of AD was increased because of raised awareness of signs and symptoms and increased confidence in clinical intuition. However, staff reported being competent at recognising when a resident was unwell prior to the programme being implemented. The assertion that the subacute programme increased recognition is not grounded in evidence and it unclear how the authors knew this or whether the fact they were “good” was objectively established 25.
A recurrent pattern within the data was the reliance on unregistered care staff to identify AD. Registered Nurses (RNs) were reported as having limited interactions with residents, with most day-to-day contact from Enrolled Nurses (ENs) and Personal Care Assistants (PCAs). RNs had less opportunity to identify AD because of limited resident contact and the need to work through intermediaries with varying skills and experience. RNs expressed concerns about relying on unregistered staff to identify AD as early clinical indicators might be missed due to lack of clinical acumen or training 23,24.
“PCAs will pass general comments – “room number 53, she looks pale”. They mention it in passing without realising this could be something happening” (24: p.1456).
There was a tension from RNs recognising that PCAs had frequent contact with residents but could miss signs of AD or not be able to assess the acuity or severity of an observation/situation. Overall, these concerns reflected a lack of confidence amongst RNs about delegating and/or relying on unregistered staff to identify AD in residents.
Managing acute deterioration
This theme reports how care home staff responded to AD. Central to this theme were the common listed actions undertaken by care home staff to manage AD and external healthcare providers (Table 4). Responses within the care home were reported as isolated actions or a series of tasks that were influenced by staff hierarchies, individual job roles and duties 22–24.
Two of the studies featured additional approaches to managing AD with the aim of avoiding hospitalisation of residents. O’Neill et al., (2017) study reported that the sub-acute program provided structure for care home staff to assess and provide care for residents in the home25. Participants stated that their responsibilities had increased however, their time was used differently – focus was directed on providing care to a resident that had deteriorated instead of organising a hospital transfer, for example. It was not reported whether the sub-acute programme made it more likely that staff would ask for help and escalate care or, whether it prevented hospital admissions.
Amadoru et al., (2018) reported care homes having access to a purpose-designed ‘rapid-in-reach service’ that could provide assistance for residents with AD24. The RiR service comprised nurse specialists and geriatricians and provided ‘sub-acute care’ to residents in the care home. The study reported RNs/ENs frequent use of the services, especially when access to usual GPs or other health professionals was limited. Not only did this help care home staff, the RiR reduced GP workload, and helped residents who might not be able to access GPs during busy times when they had competing clinical priorities. Outside of the RiR service hours, the study reported problems with accessing timely care for residents and this increased likelihood of residents being sent to hospital.
Registered nurses were considered the highest-ranking figure when managing a resident with AD within the care home. RNs were described as having overall responsibility and decision-making authority in these scenarios despite having infrequent interactions with residents 22–25.
A recurrent theme was around RN and PCA role boundaries and how this interfered with managing AD. This was considered to have a negative impact on resident care and potentially contributed to delayed responses to AD.
“I see this dressing full of blood and smelling. I said to the PCA – didn’t you see this? And the other PCA said “Yes, but what am I supposed to do about it? That’s the nurse’s job…”” (24: p.1457).
O’Neill et al., (2017) alluded to similar hierarchies existing prior to the implementation of their sub-acute program 25. They reported that the sub-acute program established more collaborative working between RNs and PCAs and thus better management of AD.
“Statements from a few nursing assistants who felt they were now working more closely with the nurses as a resident’s health was being monitored…one nursing assistant described her role as being more integrated into the process” (27: p.317).
The studies collectively demonstrated a shift in hierarchy when care home workers requested services from external healthcare providers. The ‘handing over’ of authority and decision making from RNs/ENs/PCAs to attending external healthcare professionals was evident in all studies. This passing of responsibility was not explicit or even conscious. Staff appeared to assume this position when they lacked confidence to lead and manage care of the residents, because of litigation concerns, pressure from residents or relatives, and external healthcare professionals undervaluing care home staff’s assessments 22–25.
Table 4
Responses to acute deterioration reported in included studies
STEP 1 – response to AD initiated by care home staff | STEP 2 – response to AD by external healthcare visitor |
Personal care assistants/enrolled nurses reporting concerns to RN | Care home staff advised to call for ambulance services (out of hours) |
Clinical observations taken – vital signs (BP, HR, RR, O2 etc) | Direct call to ambulance services |
Request/referral for GP review | Decision to transfer resident to hospital |
Call for ambulance services | Review/follow ACP directive |
Decision to transfer resident to hospital (out of hours) | Prescribe/administer sub-acute care (antibiotics, IV fluids) |
Follow in-house care home policy | Decision to initiate palliative treatments |
Follow ACP directive | GP review of unwell resident |
Request for RiR team review | |
Discussion/concerns raised regarding palliative care | |
Monitor resident – watch & wait | |
In-action – concerns not escalated | |
Acknowledgement of resident/relative requests | |
Use of SBAR communication tool to escalate concerns | |
Response to AD influenced through fear of litigation | |
Factors affecting recognition and response to acute deterioration
Central to this theme were multiple interrelated factors influencing identification, escalation and management of acutely unwell residents: organisational factors, access to resources and equipment, staffing levels and care home culture (Table 5). Whilst staff ratios and care home culture were not part of the initial review objectives, these factors were prominent in all studies and provided essential context to understanding the management of AD in care home residents.
The ratio of registered nurses to care home residents had a detrimental impact on early identification and management of AD. Studies reported RN to resident ratio ranging from 1:30 and 1:150 23,24. Two studies reported that responses from healthcare professionals was delayed because of low RN to high resident ratios 22,23. RNs were unable to review the resident promptly due to competing responsibility for other residents both well and unwell 22,23,25.
Studies collectively reported RNs felt they worked in isolation from other healthcare professionals when a resident deteriorated. Access to additional support and/or external healthcare providers was described as variable, disjointed and dependent on local service configuration. The lack of timely multi-disciplinary support appeared to increase the likelihood of residents being admitted to hospital as RNs redirected their focus/care to arranging resident transfer to hospital rather than trying to manage the resident in situ 23,24.
“It’s hard sometimes, you’re trying to really hold out for the inReach [RiR] service. You can’t get hold of the GP and you get a locum in the middle of the night saying, ‘send to hospital’” (25: p.65).
Key to this theme was the recurring pattern of how staff adhered to organisational polices regarding care and how this created a conflict between following mandated rules and clinical judgement. Conditions such haemorrhage, head injuries, fractures, respiratory distress and falls were specified as needing to be treated in hospital 22–25. However, care home staff reported feeling obligated to send residents to hospital regardless of whether this was deemed clinically appropriate as they felt it was easier not to resist protocols as a way of managing other care home pressures and/or to avoid possible disciplinary repercussions or litigation 22,23.
Table 5
Factors influencing the care of residents with AD
Organisational factors (care home directives/policies) | Study |
Polices/directives (includes major conditions, litigation, performance management). | 22–25 |
Advanced care planning (ACP) – record of residents’ treatment and care wishes. | 23,24 |
Resident/family requests – influenced care of resident with AD. Overruled ACP/clinical assessments, enables requests for hospitalisation. | 23,24 |
Staffing levels and skill mix – care homes mandate number of staff per shift and manage allocation of staff based on skill levels. | 23–25 |
Implementation of interventions – provided structure for AD to be managed. | 24,25 |
Organisational processes – workload/time allocation tasks hindered identification of AD. | 23,25 |
Resource allocation and access to equipment | |
Access to diagnostic equipment (bladder scanner, ECG). | 23 |
Access to clinical assessment/observation equipment (vital sign monitor, thermometer, oxygen saturation probe, stethoscope). | 23 |
Upskilling staff - programme to manage AD or access to relevant training to support the needs of AD resident. | 25 |
Access/relationships with GPs affiliated with care homes. | 24,25 |
Access to additional support services in the area. | 24 |
Lack of timely access/support from multi-disciplinary team/treatments. Care home staff felt they had to make decisions to transfer residents to hospital. | 22–25 |
AD programmes – opportunity cost. Care redirected to support the unwell resident(s). Not enough resource to manage multiple unwell residents or cover routine care whilst staff are prioritising sick residents. | 25 |
High turnover of staff - requires regular ‘upskilling’ and training of staff. | 22–25 |
Care home culture | |
Staff’s relationships with residents are critical to identifying signs of AD. Developed over time, continuous care and frequent interactions. | 22,23,25 |
Resident and/or family requests influenced care decisions. | 22,24 |
Fear of litigation – care decisions being made through fear of legal repercussions as opposed to using clinical judgement/assessments to determine care. | 22–25 |
Low confidence – care home staff lacked confidence in managing AD. Reinforced by feelings of working in isolation and external healthcare providers undervaluing their clinical assessments. | 22–25 |
Lack of autonomy to manage AD in residents – care staff felt they had little decision-making authority. Handed over ‘authority’ to external healthcare agencies. | 22–25 |
Hierarchies and role boundaries – existed between different staff groups. Overstretched staff were reluctant to report AD in residents as they felt it was not part of their role or through concerns it would increase their workload. | 23 |