Root causes and fields of action to address unplanned hospitalisation in long-term care: a multiple case study with root-cause analysis

BACKGROUND: Being of older age is associated with chronic conditions and multimorbidity, which may lead to complex care needs of the persons affected. Residents in care homes are more often hospitalised than older adults living at home, and hospitalisations are often unplanned. It not sufficiently clear, how processes preceding unplanned hospitalisations are characterised, who is involved, what their decisions and competencies are, and what is needed to prevent such situations. We aimed to identify major causal factors for unplanned hospitalisations, potential fields of actions and goals for care.

METHODS: We conducted a multiple case study including a root-cause analysis based on cases of residents in care homes with unplanned acute care incidents as key events. We extracted data from 5 care home residents' records and interviewed 18 involved parties (health professionals, residents, relatives) in two facilities. We analysed data from 8 weeks preceding the key event on case base with event flow diagrams and qualitative content analysis of case-related interviews. Based on causal factors for gaps in care we derived fields of action and goals for care.

RESULTS: Across cases, major causal factors were insufficient management of chronic diseases, disrupted interprofessional collaboration processes, and lack of individualised protocol application. We developed 31 fields of action with goals for care and clustered these into 7 overarching meta-themes: geriatric nursing processes; interprofessional collaboration; empowerment of residents; health promotion and prevention; communication processes; management; values, standards and guidelines.

CONCLUSIONS: Caring for residents with complex care needs in long-term care requires nurses with expanded skills in clinical nursing, cooperation and communication. The results of this study contribute to the development of a new role profile for these nurses in German long-term care homes and specify relevant fields of action and goals for care.

PATIENT OR PUBLIC CONTRIBUTION: An advisory board including resident representatives discussed and supported the project in repeated consultation meetings throughout the research process.

TRIAL REGISTRATION: The study was positively evaluated by the ethics committee of the University of Lübeck (file number 21-301) and registered prospectively at the German register for clinical trials (DRKS00025773).

CLINICAL TRIAL REGISTRATION: German Register for clinical trials: DRKS00025773. Registered prospectively on 20th of August 2021.