January 24, 2023

Announcements

New TREC article
Pre-COVID-19 work-life quality of regulated nurses in Canadian nursing homes.
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Song Y, Thorne TE, Duan Y, Cummings G, Norton PG, Squires J, et al.
Geriatr Gerontol Int. 2023 Jan 10.
COVID-19 has disproportionately affected nursing homes, where up to 90% of residents live with cognitive impariment. Researchers have reported worsening mental health among frontline nurses (registered nurses [RNs] and licensed practical nurses [LPNs]) working in nursing homes during the pandemic. This workforce influences care quality both directly through providing vital care for nursing home residents and indirectly through supervising care aides who provide most direct resident care. While knowledge of pre-pandemic work-related outcomes is essential to interpreting peri- or post-pandemic reports, few studies have reported pre-pandemic data. Additionally, these reports focused on selected work-related outcomes, such as burnout or job satisfaction. It is crucial to have a more comprehensive understanding of these and other interrelated outcomes (e.g., work engagement, psychological empowerment) assessed in a single sample of nurses. In addition, while RNs and LPNs work closely in care teams, these two workforces have different training backgrounds and work within different scopes of practice,4 possibly leading to differences in the quality of their work life and indicating support interventions targeting each workforce. We aimed to address the gaps by describing a more comprehensive set of nurses’ work-related outcomes in nursing homes in western Canada immediately preceding the COVID-19 pandemic.

How did Canada’s Dementia Strategy do in 2022?
A Dementia Strategy for Canada: Together We Achieve – 2022 Annual Report

Public Health Agency of Canada, January 2023
Action to pursue the national objectives requires high-quality data and evidence and needs to be informed by lived experience to ensure it responds to notable gaps and reflects Canadians’ priorities. This report shares the results of public opinion research that have deepened knowledge about dementia in Canada, including about quality of life when living with dementia, dementia guidance and Indigenous peoples, and the perspectives and experiences of health care providers who work with people living with dementia. The report also provides results from a 2022 dementia prevention study and includes key findings from analytical work on dementia guidance. A focus on populations identified as being likely to be at higher risk of developing dementia and/or to face barriers to dementia care continues this year, which includes information about Indigenous peoples and dementia guidance.

This year’s report also provides an overview of the impact of the COVID-19 pandemic on people living with dementia as well as on the ability to maintain healthy behaviours associated with a reduced risk of developing dementia. It notes the need to improve the capacity to support people living with dementia during times of climate-change related emergencies such as extreme weather events. People living with dementia are likely to be at higher risk of adverse outcomes in both pandemic situations and climate change-related emergencies and efforts are underway to better understand how to mitigate these impacts and develop necessary resources.

New article on staff retention in Alberta Continuing Care Facilities
Perceived strategies for reducing staff-turnover and improving well-being and retention among professional caregivers in Alberta’s continuing-care facilities: A qualitative study.
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Awosoga OA, Odole AC, Onyeso OK, Ojo JO, Ekediegwu EC, Nwosu IB, et al.
Home Health Care Serv Q. 2023 Jan 16;1–23.
This qualitative study explored potential factors that lead to turnover and absenteeism and how to improve well-being and retention among professional older-adult-caregivers in Alberta’s assisted living (AL) and long-term care (LTC) facilities. Four hundred and forty-seven participants aged 45-54 years were interviewed through a five-item, content-validated open-ended questionnaire. The questionnaire was self-administered in the English language and the soft copy of their responses was transferred into NVIVO version 12 software for coding. A thematic narrative analysis grounded in the “happy productive worker” theory was completed. The main themes were caregivers’ perception of the factors affecting their well-being, absenteeism, and turnover, and caregivers’ suggestions on ways to improve their well-being and retention. Participants reported that their professional well-being was suboptimal. They suggested that their employers should provide them with the needed social, psychological, and professional support, improve wages and hire more staff to ameliorate absenteeism and turnover rates.

New article on how funding resources impact working conditions for LTC workers
The costs of care: An ethnography of care work in residential homes for older people.
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Johnson EK.
Sociol Health Illn. 2023 Jan;45(1):54–69.
The cost of social care, the work conditions experienced by care workers and the quality of care provided by residential homes for older people are all linked, yet we know very little about how this relationship works in practice. Drawing upon an ethnography of two differently priced residential care homes for older people in Southern England, I examine the implications of different financial regimes for care-giving practices. I show how the scheduling and allocation of resources-conveyed, for example, in formal routines and staffing levels-structure the care workers’ time, tasks and activities in each setting. This acts to symbolically demarcate what, or who, is valued. I argue that the availability of resources facilitates and impedes the symbolic culture of care work, shapes care workers’ ability to afford dignity to the individuals in their care and affects how care workers experience, and relate to, their labour. I conclude by discussing how current practices of funding and pricing social care have effects seeping beyond the practical and measurable, and into the realm of the symbolic.

New article on NH care quality and staffing levels
Association of Staffing Instability With Quality of Nursing Home Care.
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Mukamel DB, Saliba D, Ladd H, Konetzka RT.
JAMA Netw Open. 2023 Jan 3;6(1):e2250389.

IMPORTANCE: Recent work suggests that instability in nursing home staffing levels may be an important marker of nursing home quality. Whether that association holds when controlling for average staffing levels is unknown. OBJECTIVE: To examine whether staffing instability, defined as the percentage of days below average staffing levels, is associated with nursing home quality when controlling for average staffing levels. DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study of 14 717 nursing homes used the merged Centers for Medicare & Medicaid Services Payroll Based Journal, Minimum Data Set, Nursing Home Care Compare, and Long-Term-Care Focus data for fiscal years 2017 to 2019. Statistical analysis was performed from February 8 to November 14, 2022. MAIN OUTCOMES AND MEASURES: Linear, random-effect models with state fixed effects and robust SEs were estimated for 12 quality indicators as dependent variables, percentage of below-average staffing days as independent variables, controlling for average staffing hours per resident-day for registered nurses, licensed practical nurses, and certified nurse aides. Below-average staffing days were defined as those 20% below the facility average, by staffing type. Quality indicators included deficiency citations; long-stay residents receiving an antipsychotic; percentage of high-risk long-stay residents with pressure ulcers (2 different measures for pressure ulcers were used); and percentage of long-stay residents with activities of daily living decline, mobility decline, emergency department visits, and hospitalizations; and short-stay residents with new antipsychotic medication, mobility decline, emergency department visits, and rehospitalizations. RESULTS: For the 14 717 nursing homes in this study, the mean (SD) percentage of days with below-average staffing was 30.2% (12.0%) for registered nurses, 16.4% (11.3%) for licensed practical nurses, and 5.1% (5.3%) for certified nurse aides. Mean (SD) staffing hours per resident-day were 0.44 (0.40) for registered nurses, 0.80 (0.32) for licensed practical nurses, and 2.20 (0.50) for certified nurse aides. In regression models that included average staffing, a higher percentage of below-average staffing days was significantly associated with worse quality for licensed practical nurses in 10 of 12 models, with the largest association for decline of activities of daily living among long-stay residents (regression coefficient, 0.020; P < .001). A higher percentage of below-average staffing days was significantly associated with worse quality for certified nurse aides in 9 of 12 models, with the largest association for short-stay functioning (regression coefficient, 0.030; P = .01). CONCLUSIONS AND RELEVANCE: This study suggests that holding average staffing levels constant, day-to-day staffing stability, especially avoiding days with low staffing of licensed practical nurses and certified nurse aides, is a marker of better quality of nursing homes. Future research should investigate the causes and potential solutions for instability in staffing in all facilities, including those that may appear well-staffed on average.

 

Recommendations from the National Academies of Sciences, Engineering, and Medicine to improve the quality of care in nursing homes.
The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff
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National Academies of Sciences Engineering, Medicine.
Washington, DC: The National Academies Press; 2022.
Nursing homes play a unique dual role in the long-term care continuum, serving as a place where people receive needed health care and a place they call home. Ineffective responses to the complex challenges of nursing home care have resulted in a system that often fails to ensure the well-being and safety of nursing home residents. The devastating impact of the COVID-19 pandemic on nursing home residents and staff has renewed attention to the long-standing weaknesses that impede the provision of high-quality nursing home care.\nWith support from a coalition of sponsors, the National Academies of Sciences, Engineering, and Medicine formed the Committee on the Quality of Care in Nursing Homes to examine how the United States delivers, finances, regulates, and measures the quality of nursing home care. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff identifies seven broad goals and supporting recommendations which provide the overarching framework for a comprehensive approach to improving the quality of care in nursing homes.

Canadian scoping review on family interventions for persons with dementia
A scoping review of family-centered interventions in dementia care.
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Ramachandran M, Bangera K, Anita Dsouza S, Belchior P.
Dementia (London). 2022 Dec 10;14713012221144484.
Families of persons living with dementia provide varying levels and forms of support to their loved ones and experience changes in familial dynamics, roles, and responsibilities over time. Family-centered care can enable their successful adaptation and participation in meaningful occupations. This scoping review aimed to explore available familycentered interventions for persons living with dementia, with a focus on occupational therapy. Three databases were searched and 31 eligible studies were found. Thirteen family-centered interventions were identified that were mostly multicomponent in nature, of which three involved occupational therapy. These interventions were investigated using a range of study designs and addressed outcomes related to the person with dementia, primary caregiver, and extended social network. With respect to study context, most interventions were developed in the United States and other Western countries with a limited number located in other contexts. The review findings underline the need for developing more family-centered interventions within occupational therapy, particularly for different contexts and cultures, and for translating available interventions to practice.

Article on doing research in LTC homes
Stop and Go: Barriers and Facilitators to Care Home Research.
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Ritchie LA, Gordon AL, Penson PE, Lane DA, Akpan A.
J Frailty Aging. 2023;12(1):63–6.
Barriers to care home research have always existed, but have been thrown into sharp relief by the COVID-19 pandemic. Existing infrastructure failed to deliver the research, or outcomes, which care home residents deserved and we need to look, again, at how these barriers can be taken down. Barriers can be categorised as procedural (encountered before research starts), system (encountered during research) or resident-specific. To tackle these, research regulatory bodies need to adopt a standardised approach to how care home research is developed and designed, reviewed and regulated, and how such approaches can enable recruitment of as wide a range of residents and their representatives as possible, including those without the mental capacity to consent for research. Establishment of local, inter-disciplinary collaborations between universities, general practices, health and social care providers and care homes is another priority. This should be based on pre-existing models such as the ‘Living lab’ model developed in The Netherlands and now being implemented in the UK and Austria. These changes are critical to develop a sustainable research model. If well designed this will deliver better outcomes for residents and align with the individual and organisational priorities of those who care for them.

Assessment of a tool that can be used to assess context in quality improvement
A pragmatic context assessment tool (pCAT): using a Think Aloud method to develop an assessment of contextual barriers to change.
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Robinson CH, Damschroder LJ.
Implement Sci Commun. 2023 Jan 11;4(1):3.
BACKGROUND: The Consolidated Framework for Implementation Research (CFIR) is a determinant framework that can be used to guide context assessment prior to implementing change. Though a few quantitative measurement instruments have been developed based on the CFIR, most assessments using the CFIR have relied on qualitative methods. One challenge to measurement is to translate conceptual constructs which are often described using highly abstract, technical language into lay language that is clear, concise, and meaningful. The purpose of this paper is to document methods to develop a freely available pragmatic context assessment tool (pCAT). The pCAT is based on the CFIR and designed for frontline quality improvement teams as an abbreviated assessment of local facilitators and barriers in a clinical setting. METHODS: Twenty-seven interviews using the Think Aloud method (asking participants to verbalize thoughts as they respond to assessment questions) were conducted with frontline employees to improve a pilot version of the pCAT. Interviews were recorded and transcribed verbatim; the CFIR guided coding and analyses. RESULTS: Participants identified several areas where language in the pCAT needed to be modified, clarified, or allow more nuance to increase usefulness for frontline employees. Participants found it easier to respond to questions when they had a recent, specific project in mind. Potential barriers and facilitators tend to be unique to each specific improvement. Participants also identified missing concepts or that were conflated, leading to refinements that made the pCAT more understandable, accurate, and useful. CONCLUSIONS: The pCAT is designed to be practical, using everyday language familiar to frontline employees. The pCAT is short (14 items), freely available, does not require research expertise or experience. It is designed to draw on the knowledge of individuals most familiar with their own clinical context. The pCAT has been available online for approximately two years and has generated a relatively high level of interest indicating potential usefulness of the tool.

New article on the stress experienced by HCAs working during times of financial austerity
Utilization of Job Demands-Resources (JD-R) Theory to Evaluate Workplace Stress Experienced by Health Care Assistants in a UK In-Patient Dementia Unit after 10 Years of National Financial Austerity (2008-2018).
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Udushirinwa CC, McVicar A, Teatheredge J.
Int J Environ Res Public Health. 2022 Dec 21;20(1).
AIMS: Workplace stress for support workers in UK hospitals (Health Care Assistants; HCAs) is poorly understood. This study explores experiences of HCAs working in a National Health Service in-patient dementia unit after 10 years of national financial austerity (2008-2018). DESIGN: Qualitative evaluation. METHODS: 15 HCAs (42%) from a specialist dementia care Unit were interviewed. Interviews were guided by UK Health & Safety Executive published dimensions of work stress. Framework analysis was applied to interview transcriptions, corroborated by a follow-up focus group (6 HCAs). Post hoc interviews with 10 nurses were later introduced to obtain a balanced view of teamwork on the Unit. RESULTS: Health care assistants were altruistic regarding demands of dementia care but otherwise negative of most aspects of their work environment. Staff shortages had increased job demands: workload, poor shift rotas, and excessive reliance on inexperienced agency staff. According to HCAs, job resources of the care team were in significant deficit: nurses in charge were perceived as poor team leaders, had poor interpersonal skills, lacked respect for experienced HCAs, and deemed to be frequently absent from the ward so failing to support carers. HCAs’ lack of decision-latitude exacerbated the situation. In contrast, nurses interviewed did not recognise the teamwork issues raised by HCAs, who were considered obstructive, unsupportive, lacked awareness of nurses’ responsibilities, and of insights how understaffing meant excessive administration and time required to support patients’ relatives. Such dissonant inter-group views caused considerable friction and exacerbated the work pressure. CONCLUSION: Study outcomes spotlighted impacts of socioeconomic issues for HCAs. Staff shortage, exacerbated by financial austerity measures (pre-COVID pandemic), increased job demands for HCAs but their psychosocial job resources were in serious deficit, so putting them at risk of burnout. Inter-group relations are key for a collaborative ethos, and are amenable to interventions. Such difficulties should not be allowed to fester.

New article on the impact of the COVID pandemic on LTC workers
Determination of Workload, Work Stress and Related Factors in Nursing Home Workers during the COVID-19 Pandemic in Turkey.
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Akdeniz Ş, Çoban M, Koç O, Pekesen M, Korkmaz Yaylagul N, Sönmez S, et al.
Int J Environ Res Public Health. 2022 Dec 22;20(1).
COVID-19 has caused a major crisis all over the world. To manage this crisis, a fixed shift system was applied to nursing home staff in Turkey to protect nursing home residents from the COVID-19 pandemic. Staff were not allowed to leave the institution during fixed shifts. It is thought that this practice for the COVID-19 outbreak, while protecting nursing home residents on the one hand, increased the workload and related stress of nursing home staff on the other hand. To the best of our knowledge, there is no study examining the workload and stress caused by the COVID-19 pandemic for nursing home staff in Turkey. The aim of this study was to examine the level of workload and work stress experienced by staff working in nursing homes during the COVID-19 pandemic in Turkey. METHODS: A cross-sectional research design was used in the study. The sample of the study consisted of nursing home personnel working in nursing homes in the provinces of Istanbul, Ankara, Izmir and Antalya between October 2021 and January 2022. A personal information form and a workload and stress scale were used for collecting the data. Cluster analysis was performed with SPSS software. RESULTS: In total, 154 nursing home personnel participated in the study. A statistically significant difference was found between the mean age of the two clusters. The first cluster was described as “old” and the second as “young”. Statistically significant and high values were found in the quantitative workload, qualitative workload, job organization, social work area and fatigue factors in the nursing home staff in the older participant cluster. CONCLUSION: The results of this study provide new information about the concepts of workload and work stress experienced during the COVID-19 pandemic in Turkey, which will serve as a guide for the management of future pandemics. Therefore, this study will contribute to the strategies to be followed in future pandemics in Turkey.

New article by Matthias Hoben, Jennifer Baumbusch, Andrea Gruneir, and Stephanie Chamberlain
Caregivers’ Concerns About Assisted Living Residents’ Mental Health During the COVID-19 Pandemic: A Cross-Sectional Survey Study.
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Hoben M, Baumbusch J, B Hogan D, Gruneir A, A Chamberlain S, Corbett K, et al.
J Fam Nurs. 2023 Feb;29(1):28–42.
Family or friend caregivers’ concerns about assisted living (AL) residents’ mental health are reflective of poor resident and caregiver mental health. COVID-19-related visiting restrictions increased caregiver concerns, but research on these issues in AL is limited. Using web-based surveys with 673 caregivers of AL residents in Western Canada, we assessed the prevalence and correlates of moderate to severe caregiver concerns about residents’ depressed mood, loneliness, and anxiety in the 3 months before and after the start of the COVID-19 pandemic. Caregiver concerns doubled after the start of the pandemic (resident depressed mood: 23%-50%, loneliness: 29%-62%, anxiety: 24%-47%). Generalized linear mixed models identified various modifiable risk factors for caregiver concerns (e.g., caregivers’ perception that residents lacked access to counseling services or not feeling well informed about and involved in resident care). These modifiable factors can be targeted in efforts to prevent or mitigate caregiver concerns and resident mental health issues.

New article by Alison Kitson
Mobilising Implementation of i-PARIHS (Mi-PARIHS): development of a facilitation planning tool to accompany the Integrated Promoting Action on Research Implementation in Health Services framework.
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Hunter SC, Kim B, Kitson AL.
Implement Sci Commun. 2023 Jan 9;4(1):2.
BACKGROUND: Facilitation makes the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework a popular framework in the field of implementation science. Facilitation allows for flexible application of the i-PARIHS framework by encouraging the iterative tailoring of implementation strategies to a dynamic context. However, successfully harnessing this flexibility can be challenging to navigate, particularly for novice facilitators. Therefore, to support and promote more widespread use of the i-PARIHS framework, and to make it easier for people who are already using i-PARIHS, we have undertaken the Mi-PARIHS Project-Mobilising Implementation of i-PARIHS, focused on developing a suite of practical and pragmatic i-PARIHS resources. METHODS: Through a co-design approach drawing on end-users’ experiences, we developed the Mi-PARIHS Facilitation Planning Tool, and this article reports on the final end-user feedback via an online survey. RESULTS: A total of 58 participants completed the online survey. The survey focused on participants’ previous experiences with i-PARIHS, their feedback on the background information provided with the Mi-PARIHS Tool, and their feedback on the tool itself (e.g. clarity, use, satisfaction, improvements). This feedback resulted in the development of a comprehensive 34-item Mi-PARIHS Facilitation Planning Tool that supports i-PARIHS users in their (1) assessment of the i-PARIHS framework’s innovation, context, and recipient constructs; (2) development of a tailored facilitation plan; and (3) repeated use over time to evaluate the effectiveness of facilitation strategies. CONCLUSIONS: The Mi-PARIHS Facilitation Planning Tool makes framework-guided implementation more accessible and reliable to a wider range of systems and stakeholders, thereby contributing to more consistent implementation of evidence-based practices and other innovations. It addresses the challenge of systematically assessing core constructs of the i-PARIHS framework to develop tailored facilitation strategies. The Mi-PARIHS Facilitation Planning Tool is freely available for use at the website https://www.flinders.edu.au/caring-futures-institute/Mi-PARIHS-tool .

New article by Lori Weeks
Effectiveness of physical rehabilitation in improving physical functioning and quality of life for long-term-care residents with dementia: a systematic review protocol.
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McArthur C, Alizadehsaravi N, Affoo R, Cooke K, Douglas N, Earl M, et al.
JBI Evid Synth. 2023 Jan 1;21(1):207–13.
OBJECTIVE: The objective of this review is to evaluate the effectiveness of physical rehabilitation versus non-rehabilitation control in improving physical functioning and quality of life in long-term care residents with dementia. INTRODUCTION: Many long-term-care residents live with dementia and have impaired physical function and poor quality of life. Physical rehabilitation can improve physical function and quality of life for people living with dementia, yet many long-term-care residents with dementia do not receive this intervention, and health care providers are unsure of which rehabilitation interventions are effective. Studies synthesizing effective rehabilitation programs are needed to guide practice in the long-term-care sector where many residents live with dementia. Previous studies have focused broadly on long-term care, specific professions, interventions or outcomes, or people with dementia in the community. Our review will focus on long-term-care residents living with dementia and a broader definition of physical rehabilitation. INCLUSION CRITERIA: This review will include studies that evaluate physical rehabilitation in comparison with non-rehabilitation controls among long-term-care residents with any severity of dementia. We will include studies that measure the effect on performance-based physical functioning and self- or proxy-reported quality of life. METHODS: Searches will be conducted in APA PsycINFO (EBSCO), CINAHL (EBSCO), MEDLINE (Ovid), Embase, Scopus, and the Cochrane CENTRAL database with no date or language limitations. Two independent reviewers will conduct a critical appraisal of eligible studies, assess methodological quality, and extract the data. Where possible, studies will be pooled in a statistical meta-analysis. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42022308444.

New article by Adrian Wagg
Effectiveness of a Smart Urinary Continence Care Assessment System for Nursing Home Residents: A Quasi-Experimental, Sequential Quantitative-Qualitative Methods Trial.
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Rajabali SN, Hunter KF, Asaana P, McCreary ML, Nazari S, Wagg AS.
J Wound Ostomy Continence Nurs. 2023 Feb 1;50(1):48–56.
PURPOSE: The purpose of this study was to compare the effect of use of an electronic urinary continence assessment system versus usual care on construction of care plans, resource use, and continence care for nursing home (NH) residents. DESIGN: Convergent mixed-methods study comprising a prospective, parallel arm-controlled phase, and concurrent qualitative component. SUBJECTS AND SETTING: The study setting was Alberta, a province in Western Canada. Residents requiring a continence assessment or reassessment in an NH with 2 units assigned to intervention (I) and 2 units to usual care (UC). One hundred one residents (I: n = 49; UC: n = 52) participated; 89 (I: n = 43; UC: n = 46) completed the study. The mean age of the UC group was 88.5 (SD = 6.9) years, whereas the mean age of the intervention group was 85.6 (SD = 7.5) years. METHODS: Quantitative data on assessment, resource use, resident quality of life, and continence care outcomes were collected at weeks 0, 2, and 8; plan adherence was assessed at week 16. Qualitative data were collected via interviews. RESULTS: Analysis revealed a significant change in the proportion of residents achieving a reduction in 24-hour pad absorbency (50.6% vs 39.1%, P = .034) at week 8. There were significant differences in between-group changes (total absorbency of pads used in 24 hours and total cost of night pads used). Both groups reported improved health-related quality of life. Analysis of qualitative data revealed 3 themes: resource use; quality of continence care; and system utility and limitations. CONCLUSIONS: A technological solution offering a standardized system of continence assessment provided benefit in terms of quality of care for residents and use of continence containment products; utility was validated by staff.

New article by Greta Cummings
A first look at consistency of documentation across care settings during emergency transitions of long-term care residents.
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Tate K, Ma R, Reid RC, McLane P, Waywitka J, Cummings GE, et al.
BMC Geriatr. 2023 Jan 11;23(1):17.
BACKGROUND: Documentation during resident transitions from long-term care (LTC) to the emergency department (ED) can be inconsistent, leading to inappropriate care. Inconsistent documentation can lead to undertreatment, inefficiencies and adverse patient outcomes. Many individuals residing in LTC have some form of cognitive impairment and may not be able to advocate for themselves, making accurate and consistent documentation vital to ensuring they receive safe care. We examined documentation consistency related to reason for transfer across care settings during these transitions. METHODS: We included residents of LTC aged 65 or over who experienced an emergency transition from LTC to the ED via emergency medical services. We used a standardized and pilot-tested tracking tool to collect resident chart/patient record data. We collected data from 38 participating LTC facilities to two participating EDs in Western Canadian provinces. Using qualitative directed content analysis, we categorized documentation from LTC to the ED by sufficiency and clinical consistency. RESULTS: We included 591 eligible transitions in this analysis. Documentation was coded as consistent, inconsistent, or ambiguous. We identified the most common reasons for transition for consistent cases (falls), ambiguous cases (sudden change in condition) and inconsistent cases (falls). Among inconsistent cases, three subcategories were identified: insufficient reporting, potential progression of a condition during transition and unclear reasons for inconsistency. CONCLUSIONS: Shared continuing education on documentation across care settings should result in documentation supports geriatric emergency care; on-the-job training needs to support reporting of specific signs and symptoms that warrant an emergent response, and discourage the use of vague descriptors.

 

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