OBJECTIVES Many older adults in long-term care (LTC) experience acute health crises but are at high risk of transfer distress and in-hospital morbidity and mortality. Residents often complete advance directives (ADs) regarding future care wishes, including directives for hospital transfers. This study aims to estimate the prevalence of, and adherence to, "no transfer to hospital" ADs in LTC, and to explore the circumstances leading to transfers against previously expressed directives. DESIGN We conducted a mixed methods study in 10 nursing homes in Nova Scotia, Canada. A total of 748 resident charts and Emergency Health Services (EHS) database notes were reviewed from 3 time periods spanning implementation of a new primary care model, Care by Design (CBD). MEASURES ADs were divided into those requesting transfer to hospital vs on-site management only, which were then analyzed in relation to actual hospital transfers. Reasons for EHS calls, management, and qualitative data were derived from the EHS database. Resident variables were obtained from LTC charts. Measures were compared between time periods. RESULTS ADs were complete in 92.4% of charts. Paramedics were called for 80.5% of residents, and 73.6% were transferred to hospital, 51.3% of whom had explicit ADs to the contrary. The majority of those were transferred for fall-related injuries, followed by medical illness. Unclear care plans, symptom control, and perceived need for investigations and procedures all influenced transfer decisions. CONCLUSIONS/IMPLICATIONS The use of "no transfer to hospital" directives did not appear to impact the number of residents being transferred to acute care. Half of those transferred to hospital had explicit ADs to the contrary, largely driven by fall-related injury. The high incidence of injury-related transfers highlights an important gap in advance care planning. Clarifying transfer preferences for injury management in advance directives may lead to better end-of-life experiences for residents and improve effective resource utilization.

中文翻译：

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在疗养院居民中遵守“不得转移到医院”的预先指示

目标 长期护理 (LTC) 中的许多老年人经历了严重的健康危机，但处于转移困境和院内发病率和死亡率的高风险中。居民通常会完成关于未来护理愿望的预先指示 (AD)，包括转院指示。本研究旨在估计 LTC 中“不转移到医院”AD 的流行率和依从性，并探讨导致违背先前表达的指令转移的情况。设计 我们在加拿大新斯科舍省的 10 家疗养院进行了一项混合方法研究。总共 748 份居民图表和紧急医疗服务 (EHS) 数据库注释来自 3 个时间段，跨越了新的初级保健模式的实施，即设计关怀 (CBD)。措施广告分为要求转移到医院和仅现场管理的那些，然后结合实际的医院转移进行分析。EHS 电话、管理和定性数据的原因来自 EHS 数据库。常驻变量是从 LTC 图表中获得的。在时间段之间比较措施。结果广告在 92.4% 的图表中完成。80.5% 的居民被叫来了护理人员，73.6% 的居民被转移到医院，其中 51.3% 的居民有明确的 AD。大多数人因跌倒受伤而被转移，其次是医疗疾病。不明确的护理计划、症状控制以及对调查和程序的感知需求都会影响转移决策。结论/影响 “不转院”的使用 指令似乎没有影响被转移到急症护理的居民人数。一半被转移到医院的人有明显的 AD 与此相反，主要是由跌倒相关的伤害引起的。与伤害相关的转移发生率高，突显了预先护理计划中的一个重要差距。在预先指示中明确伤害管理的转移偏好可能会为居民带来更好的临终体验并提高资源的有效利用。