Aim: If developing policies to optimize quality acute care within residential aged care facilities (RACF) is a goal, understanding the factors that influence the decision to transfer a resident from RACF to hospital emergency departments is important. The aim of the present study was to review the published literature pertaining to transfer decisions. Methods: We carried out a systematic review of the qualitative literature to ascertain key influences on transfer decisions amongst three key stakeholder groups - residents, their family and carers. Results: From 11 papers we found two themes encompassing seven domains of influence. Transfers are influenced by an expectation or goal of improved resident clinical or quality of life outcomes - these are domains within the "resident dominant" theme. However, transfers also occur where there is no expectation of resident benefit. These domains, such as inadequate facility resourcing and care planning, are categorized within the "resident subordinate" theme. Conclusion: Transfer decisions are often influenced by considerations beyond expected benefit to the individual resident. Conceptualizing influences on transfer decisions within this framework might assist clinicians and policy makers in the design and delivery of services for RACF residents. Geriatr Gerontol Int 2013; 13: 825-833.© 2013 Japan Geriatrics Society.