Comfort Measures Orders and Hospital Transfers: Insights From the OPTIMISTIC Demonstration Project

Abstract

Context: Nursing facility residents and their families may identify "comfort measures" as their overall goal of care, yet some hospital transfers still occur.

Objectives: Describe nursing facility residents with comfort measures and their hospital transfers.

Methods: Mixed methods, including root cause analyses of transfers by registered nurses and interviews with a subset of health care providers and family members involved in transfers. Participants were residents in 19 central Indiana facilities with comfort measures orders who experienced unplanned transfers to the hospital between January 1, 2015 and June 30, 2016. Project demographic and clinical characteristics of the residents were obtained from the Minimum Data Set 3.0. Interviews were conducted with stakeholders involved in transfer decisions. Participants were prompted to reflect on reasons for the transfer and outcomes. Interviews were transcribed and coded using qualitative descriptive methods.

Results: Residents with comfort measures orders (n = 177) experienced 204 transfers. Most events were assessed as unavoidable (77%). Communication among staff, or between staff and the resident/family, primary care provider, or hospital was the most frequently noted area needing improvement (59.5%). In interviews, participants (n = 11) highlighted multiple issues, including judgments about whether decisions were "good" or "bad," and factors that were important to decision-making, including communication, nursing facility capabilities, clinical situation, and goals of care.

Conclusion: Most transfers of residents with comfort measures orders were considered unavoidable. Nonetheless, we identified several opportunities for improving care processes, including communication and addressing acute changes in status.

Keywords: Comfort measures; advanced care planning; hospital transfers; nursing home.