William Osler Health System (Osler) has partnered with McMaster University (McMaster) on a system-level transformation project that helps decrease transfers from long-term care homes to Emergency Departments (ED) – the PoET Southwest Spread Project (PSSP). The first of its kind, this study evaluates the impact of an ethics-based intervention in long-term care and has now been proven to have reduced consent-related errors that can result in long-term residents receiving unwanted and/or non-beneficial treatment, and hospital transfers at end of life.

Long-term care transfers to acute care for aggressive interventions are sometimes unnecessary, can increase health care costs, and result in avoidable hospitalizations with associated complications and even mortality. Conditions like infection, changes in mental health status, injuries due to falls, as well as the false assumption that end-of-life services are available only in an acute care setting, have resulted in avoidable transfers to the ED over the last several decades. The absence of consent from a capable long-term care home resident was also identified as a cause for many transfers to hospital. The Prevention of Error-based Transfers (PoET) Project, an award-winning Ethics Quality Improvement Project developed at Osler, helps staff and physicians of Ontario long-term care homes address these causes for transfer by aligning their policies and practices with the Ontario Health Care Consent Act (HCCA) and with related professional
obligations. 

The results of the PSSP show that PoET has the potential to both benefit long-term care home residents and have a positive impact on the entire provincial health care system. The findings validate an association between PoET and decreases in patient transfers to the ED and hospital, especially at end-of-life stage:

• Residents in long-term care homes where PoET was executed were sent to an ED at a 27 per cent lower rate than residents in other long-term care homes; 

• The rate of transfers from long-term care residents to acute care hospitals at end-of-life was at a 45 per cent lower rate than those in other long-term care homes; and 

• Residents in long-term care homes where PoET was implemented experienced palliative care encounters at a 147 per cent greater rate than residents from other long-term care homes. 

“We believe that PoET is the first ethics quality improvement project worldwide to demonstrate an association between improvement in an ethics intervention and a decrease in transfers from long-term care homes to Emergency Departments,” said Dr. Paula Chidwick, Director, Ethics & Spiritual Care, Ethics Quality Improvement Lab, William Osler Health System. “PoET has not only proven to enhance the lives of long-term care home residents through more informed decision-making, but it is a collaborative approach to health care system transformation.”

The PSSP implementation is a four-week process. During the first week, PoET team members observe the processes, decisions and discussions relating to hospital and ED transfers in the long-term care home. Based on these observations, in week two, PoET team members present the long-term care home with recommendations aligned with HCCA-related goals such as obtaining resident consent whenever they are capable. PoET team members also work with the long-term care home to tailor recommendations to ensure they are actionable and to create accountability for these changes. In weeks three and four, PoET team members mentor and support the long-term care home to implement, test and refine the recommendations to ensure continued sustainability. Researchers from McMaster then work with individual homes and the Institute for Clinical Evaluative Sciences (ICES) to collect data that would allow a comparison of PoET homes to similarly matched control homes in Ontario.

A continuation of the initial PoET Project, PSSP is a collaboration between Osler’s Ethics Quality Improvement Lab and McMaster’s Department of Family Medicine. Through this collaboration, PoET was piloted in 54 long-term care homes in the Hamilton, Niagara, Haldimand, Brant, Mississauga and Halton regions in Ontario. The project and its evaluation ran between 2019 and 2022, through a financial contribution from Health Canada’s Health Care Policy Contribution Program.

“The PSSP project demonstrated that PoET makes a difference to both residents of Ontario’s long-term care homes, and the entire health care system,” said Dr. Jill Oliver, Ethicist, Ethics Quality Improvement Lab, William Osler Health System. This is a fundamental shift in thinking for long-term care home staff, and we are so proud to make the program available to all long-term care homes in Ontario.” 

Dr. Henry Siu, Associate Professor at McMaster University’s Department of Family Medicine and co-lead of the PoET Southwest Spread Project, agrees. “As an academic family physician and a long-term care attending physician, the PoET Project is a game-changer,” said Dr. Siu. “Our work in the PoET Southwest Spread Project has shown that a shift in practice culture that promotes true long-term care resident-centric care can have huge system-level impacts that reduce unnecessary transfers to acute care, while supporting more palliative care in the long-term care home.” 

Following these significant findings, the project team aims to develop measurable process and performance indicators to help long-term care homes demonstrate alignment with the Health Care Consent Act, as well as advocate for an accreditation standard that will positively benefit all long-term care home residents and their families.