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Older Persons’ Transitions in Care (OPTIC): a study protocol

Greta G Cummings18*, R Colin Reid2, Carole A Estabrooks1, Peter G Norton3, Garnet E Cummings4, Brian H Rowe4, Stephanie L Abel1, Laura Bissell2, Joan L Bottorff5, Carole A Robinson5, Adrian Wagg6, Jacques S Lee7, Susan L Lynch1 and Elmabrok Masaoud1

Author affiliations

1 Faculty of Nursing, University of Alberta, Edmonton, AB, Canada

2 School of Health and Exercise Sciences, University of British Columbia’s Okanagan campus, Kelowna, BC, Canada

3 Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada

4 Department of Emergency Medicine, Faculty of Medicine and Dentistry and School of Public Health, University of Alberta, Edmonton, AB, Canada

5 School of Nursing, University of British Columbia’s Okanagan campus, Kelowna, BC, Canada

6 Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada

7 Department of Emergency Services, Sunnybrook Health Sciences Center, Toronto, ON, Canada

8 Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, 11405-87 Ave, Edmonton, AB, T6G 0C1, Canada

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Citation and License

BMC Geriatrics 2012, 12:75  doi:10.1186/1471-2318-12-75

Published: 14 December 2012



Changes in health status, triggered by events such as infections, falls, and geriatric syndromes, are common among nursing home (NH) residents and necessitate transitions between NHs and Emergency Departments (EDs). During transitions, residents frequently experience care that is delayed, unnecessary, not evidence-based, potentially unsafe, and fragmented. Furthermore, a high proportion of residents and their family caregivers report substantial unmet needs during transitions. This study is part of a program of research whose overall aim is to improve quality of care for frail older adults who reside in NHs. The purpose of this study is to identify successful transitions from multiple perspectives and to identify organizational and individual factors related to transition success, in order to inform improvements in care for frail elderly NH residents during transitions to and from acute care. Specific objectives are to:

1. define successful and unsuccessful elements of transitions from multiple perspectives;

2. develop and test a practical tool to assess transition success;

3. assess transition processes in a discrete set of transfers in two study sites over a one year period;

4. assess the influence of organizational factors in key practice locations, e.g., NHs, emergency medical services (EMS), and EDs, on transition success; and

5. identify opportunities for evidence-informed management and quality improvement decisions related to the management of NH – ED transitions.


This is a mixed-methods observational study incorporating an integrated knowledge translation (IKT) approach. It uses data from multiple levels (facility, care unit, individual) and sources (healthcare providers, residents, health records, and administrative databases).


Key to study success is operationalizing the IKT approach by using a partnership model in which the OPTIC governance structure provides for team decision-makers and researchers to participate equally in developing study goals, design, data collection, analysis and implications of findings. As preliminary and ongoing study findings are developed, their implications for practice and policy in study settings will be discussed by the research team and shared with study site administrators and staff. The study is designed to investigate the complexities of transitions and to enhance the potential for successful and sustained improvement of these transitions.

Seniors; Elderly; Transitions; Quality of care; Handovers; Communications; Emergency Departments; Emergency Medical Services; Nursing homes; Measurement