May 19, 2020



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TREC in the News
After decades of systemic issues, time to finally overhaul Alberta long-term care, experts say

Pandemic has exposed impact of years of ‘benign neglect’: researcher.

New TREC Article
Prefrailty in Older Adults: A Concept Analysis
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Jananee Rasiah, Greta G. Cummings, Andrea Gruneir, Nelly D. Oelke, Carole Estabrooks and Jayna Holroyd-Leduc.
Int J Nurs Stud 2020 05/08:103618
The concept of prefrailty lacks clarity. Often, prefrailty is defined in relation to frailty and less often as a distinct concept. Theoretical evidence for prefrailty is minimal unlike frailty, which has been examined for decades although consensus about how to measure frailty has not been achieved. Objective The aim of this study was to conduct a concept analysis of prefrailty to provide greater understanding of this phenomenon in the context of older adults. Design Rodgers’ and Knafl’s evolutionary concept analysis approach. Data sources The literature search for the concept analysis was conducted as follows: three databases (MEDLINE, CINAHL, and Abstracts in Social Gerontology databases) were searched using carefully selected search terms; and grey literature was not included. Review methods In phase one, we used the search strategy and search terms to narrow the search for relevant articles. We selected articles that met the following inclusion criteria: (1) how prefrailty was conceptualized; (2) how prefrailty was measured; and (3) interventions targeted towards prefrailty. In phase two, we extracted data from included articles. In phase three, we analyzed data using thematic analysis and findings were presented as attributes, antecedents, consequences, and related concepts of prefrailty. One example of prefrailty in older adults was presented to highlight the concept in praxis. In phase four, methodological and substantive area experts reviewed and contributed to discussion and interpretation of findings including disciplinary perspectives of prefrailty. Results A total of 41 articles were included for synthesis. The attributes of prefrailty were predisposing in nature, non-specific, multidimensional, and cumulative in effects. Antecedents of prefrailty were categorized into the following domains: sociodemographic characteristics, comorbidity, behaviours, and laboratory/clinical markers. Consequences of prefrailty were separated into two themes: increased risk of adverse outcomes and advancing levels of frailty. Surrogate and related terms (noted in the literature) that had shared attributes with prefrailty were increased vulnerability, transitional stage, dynamic process, progressive process with latent phase, and physical frailty. Conclusions As a result of conducting this concept analysis, we found that prefrailty was defined as a clinically silent process that predisposes individuals to frailty. Prefrailty, as a concept, was derived from the Fried’s operational definition for frailty. Attributes, antecedents, consequences, and related terms will help clinicians consider how prefrailty presents in older adults separate from frailty. Further research is needed to build upon our understanding from this concept analysis. Tweetable Abstract: Prefrailty is unclear as a concept – Research on sociodemographic characteristics of older adults living with frailty will help clarify.

New article by Greta Cummings
Does Type of Sponsorship of Randomized Controlled Trials Influence Treatment Effect Size Estimates in Rehabilitation A Meta-epidemiological Study
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Jorge Fuentes, Susan Armijo-Olivo, Bruno R. da Costa, et al.
American Journal of Physical Medicine & Rehabilitation 9000;Publish Ahead of Print
Sponsorship bias could affect research results to inform decision makers when using the results of these trials. The extent to which sponsoship bias affect results in the field of physical therapy (PT) has been unexplored in the literature. Therefore, the main aim of this study was to evaluate the influence of sponsorship bias on the treatment effects of RCTs in PT area. Methods This was a meta-epidemiological study. A random sample of RCTs included in meta-analyses of physical therapy (PT) area were identified. Data extraction including assessments of appropriate influence of funders was conducted independently by 2 reviewers. To determine the association between biases related to sponsorship biases and effect sizes, a 2-level analysis was conducted using a meta-meta-analytic approach. Results We analyzed 393 trials included in 43 meta-analyses. The most common sources of sponsorship for this sample of PT trials were government (n=205, 52%) followed by academic (n=44, 11%), and industry (n=39, 10%). The funding was not declared in a high percentage of the trials (n=85, 22%). The influence of the trial sponsor was assessed as being appropriate in 246 trials (63%) and considered inappropriate/unclear in 147 (37%) of them. We have moderate evidence to say that trials with inappropriate/unclear influence of funders tended to have on average a larger effect size than those with appropriate influence of funding (ES= 0.15; 95% CI -0.03; 0.33). Conclusion Based on our sample of PT trials, it seems that most of the trials are funded by either government and academia and a small percentage are funded by the industry. Treatment effect size estimates were on average 0.15 larger in trials with lack of appropriate influence of funders as compared to trials with appropriate influence of funding. Contrarily to other fields, industry funding was relatively small and their influence perhaps less marked. All these results could be explained by the relative youth of the field and/or the absence of clear industry interests. In front of the call for action by the World Health Organization to strengthen rehabilitation in health systems, these results raise the issue of the need of public funding in the field. Jorge Fuentes and Susan Armijo-Olivo contributed equally to the project and share first authorship Corresponding author: Susan Armijo-Olivo, BScPT, MScPT, PhD, University of Applied Sciences Osnabrück/University of Alberta, Edmonton, AB, Canada T6G 2G4, Caprivistraße 30A, 49076 OsnabrückOsnabrück-Germany, s.armijo-olivo@hs-osnabrueck.de or susanarmijo@gmail.com Funding: This study was supported by the Canadian Institutes of Health Research (CIHR), Alberta Innovates through a knowledge translation initiative grant, the Knowledge Translation (KT) Canada research Stipend program, and the Physiotherapy Foundation of Canada (PFC) through a B.E. Schnurr Memorial Fund Award. In addition, The Government of Alberta, and internal funds from the Institute of Health Economics (IHE) were provided to carry out this study. The funding bodies had no input in the design, collection, analysis, and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Calls for Abstracts

CALL FOR PAPERS:
Special Issue on COVID-19 and Novel Mixed Methods Methodological Approaches During Catastrophic Social Changes

Journal of Mixed Methods Research
DEADLINE 30 September 2020
Articles for the Special Issue should focus on relevant theoretical and methodological topics relevant to mixed methods research rather than substantive/disciplinary topics. Papers about specific substantive/disciplinary topics that illustrate particularly salient and important innovations in methodology are welcome. As JMMR is a methodological journal that focuses on mixed methods research, the key criterion for papers to be published in general and for this Special Issue is to add value by contributing to the methodological and theoretical mixed methods literature. Manuscript types eligible for this Special Issue include commentaries, research notes, empirical papers, and methodological/theoretical papers. To illustrate the highest commitment at JMMR to this Special Issue, it will be led and managed by the Co-Editors in Chief. The special issue will be free to read upon publication and COVID-19 articles will be published open access under CC-BY licenses.

CALL FOR ABSTRACTS:
Evidence and Implementation Summit 2021

Sydney Australia 30-31 August
DEADLINE: 23 August

The Summit will bring together experts from across the world to talk about their experiences in generating and implementing evidence for better policy and practice. We are currently working on creative ways to ensure this happens in case of ongoing travel restrictions. Our need to come together to learn and share ideas is more important than ever.

 

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Publications

 

COVID-19 and Long Term Care
KT
Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Organizational Culture and Change
Research Practice and Methodology
Aging


Collection of articles on COVID and LTC is available here

COVID-19 and Long Term Care

COVID‐19 in The Long‐term Care Setting: The CMS Perspective
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A. F. Levitt and S. M. Ling.
J Am Geriatr Soc 2020 May 13
Safeguarding the health and promoting the wellbeing and quality of life of the most vulnerable and fragile citizens is a top priority for the Centers for Medicare & Medicaid Services (CMS). In response to the COVID-19 pandemic, numerous regulatory policies and 1135 waivers of federal requirements have been implemented by CMS to give long-term care providers and professionals flexibilities to meet to the demands of resident and patient care needs during this public health emergency. Goals for these policies and waivers include to increase capacity, enhance workforce and capability, improve oversight and transparency, prevent COVID-19 transmission and reduce provider burden. This article is protected by copyright. All rights reserved.

Guidelines for preventing respiratory illness in older adults aged 60 years and above living in long-term care: A rapid review of clinical practice guidelines

Patricia Rios, Amruta Radhakrishnan, Sonia M. Thomas, Nazia Darvesh, Sharon E. Straus and Andrea C. Tricco.
medRxiv 2020 01/01:2020.03.19.20039180
The overall objective of this rapid review was to identify infection protection and control recommendations from published clinical practice guidelines (CPGs) for adults aged 60 years and older in long-term care settings Methods: Comprehensive searches in MEDLINE, EMBASE, the Cochrane Library, and relevant CPG publishers/repositories were carried out in early March 2020. Title/abstract and full-text screening, data abstraction, and quality appraisal (AGREE-II) were carried out by single reviewers. Results: A total of 17 relevant CPGs were identified, published in the USA (n=8), Canada (n=6), Australia (n=2), and the United Kingdom (n=1). All of the CPGs dealt with infection control in long-term care facilities (LTCF) and addressed various types of viral respiratory infections (e.g., influenza, COVID-19, severe acute respiratory syndrome). Ten or more CPGs recommended the following infection control measures in LTCF: hand hygiene (n=13), wearing personal protective equipment (n=13), social distancing or isolation (n=13), disinfecting surfaces (n=12), droplet precautions (n=12), surveillance and evaluation (n=11), and using diagnostic testing to confirm illness (n=10). While only two or more CPGs recommended these infection control measures: policies and procedures for visitors, staff and/or residents (n=9), respiratory hygiene/cough etiquette (n=9), providing supplies (n=9), staff and/or residents education (n=8), increasing communication (n=6), consulting or notifying health professionals (n=6), appropriate ventilation practices (n=2), and cohorting equipment (n=2). Ten CPGs also addressed management of viral respiratory infections in LTCF and recommended antiviral chemoprophylaxis (n=10) and one CPG recommended early mobilization of residents. Conclusion: The recommendations from current guidelines overall seem to support environmental measures for infection prevention and antiviral chemoprophylaxis for infection management as the most appropriate first-line response to viral respiratory illness in long-term care.Competing Interest StatementThe authors have declared no competing interest.Funding StatementThis work was funded by the Canadian Institutes of Health Research (CIHR) through the Strategy for Patient Oriented-Research (SPOR) Evidence AllianceAuthor DeclarationsAll relevant ethical guidelines have been followed; any necessary IRB and/or ethics committee approvals have been obtained and details of the IRB/oversight body are included in the manuscript.YesAll necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesAll datasets supporting the conclusions of this article are included within the article.

Research Brief Preventing the transmission of Coronavirus (COVID-19) in older adults aged 60 years and above living in long term care: A rapid review

Andrea Tricco
A comprehensive literature search of both electronic databases and grey literature sources as well as references leveraged from a prior review resulted in one ongoing trial, one primary study and 5 clinical practice guidelines (CPG) addressing infection control and prevention for COVID-19 or SARS in long-term care facilities. Results of the primary study suggested preventing entry of COVID-19 into facilities and screening/testing all staff, residents, and visitors is the best first-line approach. The 5 CPGs most commonly recommended strategies such as establishing surveillance monitoring and evaluation systems, consulting with health professionals, regular or increased disinfection of surfaces, educating individuals on infection control and hand or respiratory hygiene, mandating use of personal protective equipment (PPE), ensuring adequate supplies for facilities, and employing social distancing/isolation or cohorting for residents.

Infection prevention and control for COVID-19: Interim guidance for long term care homes

Government of Canada, 8 April 2020
This document provides guidance specific to the COVID-19 pandemic in long term care homes (LTCHs).

Loneliness and Isolation in Long-term Care and the Covid-19 pandemic
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Joyce Simard and Ladislav Volicer.
Journal of the American Medical Directors Association 2020/05.
In all countries impacted by Covid-19 the message that is being sent by government officials and medical experts is “stay at home” and “isolate in place”. The isolation is especially difficult for people living in nursing homes and assisted living communities. Most facilities have asked that no one enters the facilities unless they work there because there is a high risk that COVID-19 would spread rapidly once it is introduced. Group activities have been canceled and, in many facilities, residents are eating in their rooms as all communal dining has been stopped. Although prohibiting group activities will decrease the risk of spreading the Covid-19 infection in nursing homes it significantly increases the isolation and resulting loneness of residents.

SARS-cov-2 related deaths in French long-term care facilities: the “confinement disease” is probably more deleterious than the COVID-19 itself
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Sylvain Diamantis, Coralie Noel, Nicolas Vignier and S Gallien.
Journal of the American Medical Directors Association 2020 05/03.
To date coronavirus SARS-cov-2 has infected 2.2 million people and has killed more than 150,000. The population groups most susceptible to severe and fatal COVID-19 are older adults and those with chronic underlying chronic medical disorders. The residents of long term care facilities (LTCFs) typically combine those two features and are thus particularly at risk. In France, 9.4% of the population is over 75, and nearly 600,000 people currently reside in LTCFs for elderly dependent individuals. To date, more than 60% of the French LTCFs have reported at least one case of COVID-19 among their residents. Estimated overall mortality among COVID-19 patients is 10% in France, but reaches up to 30% in LTCFs. There are however substantial differences in mortality rates between the different LTCFs. What explains these differences?

Social preparedness in response to spatial distancing measures for aged care during COVID-19
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Joyce Siette, Viviana Wuthrich and Lee-Fay Low.
Journal of the American Medical Directors Association 2020/05.
To tackle the pandemic and bring forth the next era of digital inclusion, governments should apply a Digital Education Revolution to support e-connections within aged care.

Israel ad hoc COVID 19 committee. Guidelines for care of older persons during a pandemic
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A. M. Clarfield, T. Dwolatzky, S. Brill, et al.
J Am Geriatr Soc 2020 May 11
Early on, geriatricians in Israel viewed with increasing alarm the spread of COVID-19. It was clear that this viral disease exhibited a clear predilection for and danger to older persons. Informal contacts began with senior officials from the country’s Ministry of Health, the Israel Medical Association and the country’s largest Health Fund; this in order to plan an approach to the possible coming storm. A group was formed, comprising three senior geriatricians, a former dean, palliative care specialist and a lawyer/ethicist. The members made every effort to ensure that its recommendations would be practical while at the same time taking into account the tenets of medical ethics. The committee’s main task was to think through a workable approach were ICU/ventilator resources be far outstripped by those requiring such care. Recommendations included the approach to older persons both in the community and long term care institutions, a triage instrument and palliative care. Patient autonomy was emphasized with a strong recommendation for people of all ages to update their advance directives or if they did not have any, to quickly draw them up. Considering the value of distributive justice, with respect to triage, a “soft utilitarian” approach was advocated with the main criteria being function and co-morbidity. While chronological age was rejected as a sole criterion, in the case of an overwhelming crisis, “biological age” would enter into the triage considerations; but only in the case of distinguishing between people with equal non-age related deficits. The guideline emphasized that no matter what, in the spirit of beneficence, anyone who fell ill must receive active palliative care throughout the course of a COVD-19 infection but especially at the end of life. Furthermore, in the spirit of non-maleficence, the very frail, old-old and severely demented would be actively protected from dying on ventilation. This article is protected by copyright. All rights reserved.

First impressions of performing bedside cognitive assessment of COVID-19 inpatients.
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R. Coetzer.
J Am Geriatr Soc 2020 May 12
Below I outline some of the challenges encountered when performing bedside cognitive assessment of COVID-19 inpatients with acquired brain injury, degenerative conditions or other neurological diagnoses.

COVID-19: It is time to balance infection management and person-centered care to maintain mental health of people living in German nursing homes.
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M. N. Dichter, M. Sander, S. Seismann-Petersen and S. Kopke.
Int Psychogeriatr 2020 May 12:1-11
There are risk factors at the institutional level that favor infectious diseases in nursing homes. These factors are staff shortage, sharing bathroom facilities, mutual social activities, and low preparedness for infection control. In addition, in Germany as in many other countries, there is a shortage of urgently needed personal protective equipment for nursing home staff, including masks and gowns.

Palliative Care Pandemic Support for Long-Term Care.
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L. E. Dingfield, M. K. Brooks, D. O’Keefe, J. Uy, V. J. Vanston and N. O’Connor.
J Palliat Med 2020 May 11
Residents of LTC facilities have many palliative care needs, including need for communication about preferences for medical interventions and management of symptoms related to chronic disease and its treatment. In the midst of the COVID-19 pandemic, addressing these needs is critically important. Residents whose preferences are to forgo hospitalization or aggressive life-sustaining care likely have high symptom burdens needing to be managed at LTC facilities. In addition, residents, families, and facility staff could all benefit from additional psychosocial support during times of high stress and isolation, and specialist bereavement services may be needed in some instances. However, many facilities have significantly curtailed physical access to their buildings to limit virus transmission to vulnerable residents and staff, creating challenges to the delivery of palliative care in the LTC setting.

AGS Position Statement: Resource Allocation Strategies and Age-Related Considerations in the COVID-19 Era and Beyond.
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T. W. Farrell, L. E. Ferrante, T. Brown, et al.
J Am Geriatr Soc 2020 May 6
COVID-19 continues to impact older adults disproportionately, from severe illness and hospitalization to increased mortality risk. Concurrently, concerns about potential shortages of healthcare professionals and health supplies to address these needs have focused attention on how resources are ultimately allocated and used. Some strategies misguidedly use age as an arbitrary criterion, which inappropriately disfavors older adults. This statement represents the official policy position of the American Geriatrics Society (AGS). It is intended to inform stakeholders including hospitals, health systems, and policymakers about ethical considerations to consider when developing strategies for allocating scarce resources during an emergency involving older adults. Members of the AGS Ethics Committee collaborated with interprofessional experts in ethics, law, nursing, and medicine (including geriatrics, palliative care, emergency medicine, and pulmonology/critical care) to conduct a structured literature review and examine relevant reports. The resulting recommendations defend a particular view of distributive justice that maximizes relevant clinical factors and de-emphasizes or eliminates factors placing arbitrary, disproportionate weight on advanced age. The AGS positions include: (1) avoiding age per se as a means for excluding anyone from care; (2) assessing comorbidities and considering the disparate impact of social determinants of health; (3) encouraging decision makers to focus primarily on potential short-term (not long-term) outcomes; (4) avoiding ancillary criteria such as “life-years saved” and “long-term predicted life expectancy” that might disadvantage older people; (5) forming and staffing triage committees tasked with allocating scarce resources; (6) developing institutional resource allocation strategies that are transparent and applied uniformly; and (7) facilitating appropriate advance care planning. The statement includes recommendations that should be immediately implemented to address resource allocation strategies during COVID-19, aligning with AGS positions. The statement also includes recommendations for post-pandemic review. Such review would support revised strategies to ensure that governments and institutions have equitable emergency resource allocation strategies, avoid future discriminatory language and practice, and have appropriate guidance to develop national frameworks for emergent resource allocation decisions.

Rationing Limited Health Care Resources in the COVID-19 Era and Beyond: Ethical Considerations Regarding Older Adults.
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T. W. Farrell, L. Francis, T. Brown, et al.
J Am Geriatr Soc 2020 May 6
COVID-19 continues to impact older adults disproportionately with respect to serious consequences ranging from severe illness and hospitalization to increased mortality risk. Concurrently, concerns about potential shortages of healthcare professionals and health supplies to address these issues have focused attention on how these resources are ultimately allocated and used. Some strategies, for example, misguidedly use age as an arbitrary criterion, which disfavors older adults in resource allocation decisions. This is a companion manuscript to the American Geriatrics Society (AGS) position statement, “Resource Allocation Strategies and Age-Related Considerations in the COVID-19 Era and Beyond.” It is intended to inform stakeholders including hospitals, health systems, and policymakers about ethical considerations that should be considered when developing strategies for allocation of scarce resources during an emergency involving older adults. This review presents the legal and ethical background for the position statement and discusses the following issues that informed the development of the AGS positions: (1) age as a determining factor; (2) age as a tiebreaker; (3) criteria with a differential impact on older adults; (4) individual choices and advance directives; (5) racial/ethnic disparities and resource allocation; and (6) scoring systems and their impact on older adults. It also considers the role of advance directives as expressions of individual preferences in pandemics.

Ageism and COVID-19: What does our society’s response say about us?
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S. Fraser, M. Lagace, B. Bongue, et al.
Age Ageing 2020 May 6
The goal of this commentary is to highlight the ageism that has emerged during the COVID-19 pandemic. Over 20 international researchers in the field of aging have contributed to this document. This commentary discusses how older people are misrepresented and undervalued in the current public discourse surrounding the pandemic. It points to issues in documenting the deaths of older adults, the lack of preparation for such a crisis in long term care homes, how some “protective” policies can be considered patronizing and how the initial perception of the public was that the virus was really an older adult problem. This commentary also calls attention to important intergenerational solidarity that has occurred during this crisis to ensure support and social-inclusion of older adults, even at a distance. Our hope is that with this commentary we can contribute to the discourse on older adults during this pandemic and diminish the ageist attitudes that have circulated.

Commentary: COVID in Care Homes-Challenges and Dilemmas in Healthcare Delivery.
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A. L. Gordon, C. Goodman, W. Achterberg, et al.
Age Ageing 2020 May 13
The COVID-19 pandemic has disproportionately affected care home residents internationally, with 19-72% of COVID-19 deaths occurring in care homes. COVID-19 presents atypically in care home residents and up to 56% of residents may test positive whilst pre-symptomatic. In this article, we provide a commentary on challenges and dilemmas identified in the response to COVID-19 for care homes and their residents. We highlight the low sensitivity of PCR testing and the difficulties this poses for blanket screening and isolation of residents. We discuss quarantine of residents and the potential harms associated with this. Personal Protective Equipment (PPE) supply for care homes during the pandemic has been suboptimal and we suggest that better integration of procurement and supply is required. Advance care planning has been challenged by the pandemic and there is a need to for healthcare staff to provide support to care homes with this. Finally, we discuss measures to implement augmented care in care homes, including treatment with oxygen and subcutaneous fluids, and the frameworks which will be required if these are to be sustainable. All of these challenges must be met by healthcare, social care and government agencies if care home residents and staff are to be physically and psychologically supported during this time of crisis for care homes.

Continuing care and COVID-19: a Canadian tragedy that must not be allowed to happen again.
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J. M. Holroyd-Leduc and A. Laupacis.
CMAJ 2020 May 14
By any measure, what has happened in continuing care is a national tragedy. Although a high death rate from COVID-19 among residents of continuing care homes might be expected given their age, frailty and comorbidities, a death rate of such magnitude need not have occurred. As we address the current impact of COVID-19 in continuing care, we must ensure that we also address the underlying problems that COVID-19 has exposed within the sector

ResearchCOVID‐19 Preparedness in Michigan Nursing Homes
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K. M. Jones, J. Mantey, J. P. Mills, et al.
J Am Geriatr Soc 2020 May;68(5):937-939
The objectives of this study were (1) to understand preparedness among Michigan NHs in the midst of an ongoing pandemic and (2) to compare with a 2007 survey on pandemic influenza preparedness in Michigan NHs.

COMMENT: Coronavirus 2019 in Geriatrics and Long-term Care: The ABCDs of COVID-19.
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R. P. Lopez.
J Am Geriatr Soc 2020 May 13
I am especially concerned for those residents with advanced dementia, who likely will not benefit from hospital transfers. Simply obtaining a code status and writing DNRs (do not resuscitate orders), are not enough because it only addresses the care that is not going to be provided. Instead, proxy decision makers should be offered a meaningful alternative which I call Intensive Individualized Comfort Care (IICC).

Practical Steps to Improve Air Flow in Long-Term Care Resident Rooms to Reduce COVID-19 Infection Risk.
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R. M. Lynch and R. Goring.
J Am Med Dir Assoc 2020 Apr 10
The potential for spread of COVID-19 infections in skilled nursing facilities and other long-term care sites poses new challenges for nursing home administrators to protect patients and staff. It is anticipated that as acute care hospitals reach capacity, nursing homes may retain COVID-19 infected residents longer prior to transferring to an acute care hospital. This article outlines 5 pragmatic steps that long-term care facilities can take to manage airflow within resident rooms to reduce the potential for spread of infectious airborne droplets into surrounding areas, including hallways and adjacent rooms, using strategies adapted from negative-pressure isolation rooms in acute care facilities.

Clinical judgement is paramount when performing cognitive screening during COVID-19.
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N. A. Phillips, M. Andrews, H. Chertkow, M. K. Pichora-Fuller, K. Rockwood and W. Wittich.
J Am Geriatr Soc 2020 May 12
Our goal is to continue a dialogue on how to engage in best practices for bedside and/or emergency room cognitive screening under these challenging conditions. Our take-home message is that cognitive assessment is as much a process as an outcome.

Guidelines for the management of diabetes in care homes during the Covid-19 pandemic.
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A. Sinclair, K. Dhatariya, O. Burr, et al.
Diabet Med 2020 May 5
The National Diabetes Stakeholders Covid-19 Response Group was formed in early April 2020 as a rapid action by the Joint British Diabetes Societies for Inpatient Care, Diabetes UK, the Association of British Clinical Diabetologists, and Diabetes Frail to address and support the special needs of residents with diabetes in UK care homes during Covid-19. It was becoming obvious that the care home sector was becoming a second wave of Covid-19 infection and that those with diabetes residing in care homes were at increased risk not only of susceptibility to infection but also to poorer outcomes. Its key purposes included minimising the morbidity and mortality associated with Covid-19 and assisting care staff to identify those residents with diabetes at highest risk of Covid-19 infection. The guidance was particularly created for care home managers, other care home staff, and specialist and non-specialist community nursing teams. The guidance covers the management of hyperglycaemia by discussion of various clinical scenarios that could arise, the management of hypoglycaemia, foot care and end of life care. In addition, it outlines the conditions where hospital admission is required. The guidance should be regarded as interim and will be updated as further medical and scientific evidence becomes available.

COVID-19 in Older Adults: Transfers Between Nursing Homes and Hospitals

Stacie Levine, Alice Bonner, Adam Perry, Donald Melady, Kathleen T Unroe,
Journal of Geriatric Emergency Medicine March 27, 2020
This article describes the impact of COVID-19 on this diverse, vulnerable population living in communal facilities. We outline key issues that will predictably arise between nursing homes and EDs in the COVID-19 era. Recommendations including reengineering nursing home-ED communication, coordinating hospital and non-hospital-based emergency care, and considerations in acute resource limitation, are discussed. Though these issues are universal, evolving solutions are necessarily local. This manuscript may guide conversations and planning now between nursing homes, health care systems, EDs, and state agencies

Optimizing Medication Management during the COVID-19 Pandemic: Implementation Guide for Post-Acute and Long-Term Care

University of Maryland School of Pharmacy, 2020
Welcome to this implementation guide for improving medication management in post-acute and long-term care settings during the COVID-19 pandemic. Its goal is to improve resident-centered health and well-being by reducing use of unnecessary medications, simplifying medication management, and reducing opportunities for transmission of COVID-19 between residents and staff. By streamlining medication administration, these changes may also increase the time that staff have available for other direct care activities.

 

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KT

Improving KT tools and products: development and evaluation of a framework for creating optimized, Knowledge-activated Tools (KaT)

Monika Kastner, Julie Makarski, Leigh Hayden, et al.
Implementation Science Communications 2020 05/08;1(1):47
Positive impacts of quality improvement initiatives on health care and services have not been substantial. Knowledge translation (KT) strategies (tools, products and interventions) strive to facilitate the uptake of knowledge thereby the potential to improve care, but there is little guidance on how to develop them. Existing KT guidance or planning tools fall short in operationalizing all aspects of KT practice activities conducted by knowledge users (researchers, clinicians, patients, decision-makers), and most do not consider their variable needs or to deliver recommendations that are most relevant and useful for them.

Scaling-up an evidence-based intervention for osteoarthritis in real-world settings: a pragmatic evaluation using the RE-AIM framework

Andrew Walker, Annette Boaz, Amber Gibney, Zoe Zambelli and Michael V. Hurley.
Implementation Science Communications 2020 04/28;1(1):40
Scaling-up and sustaining effective healthcare interventions is essential for improving healthcare; however, relatively little is known about these processes. In addition to quantitative experimental designs, we need approaches that use embedded, observational studies on practice-led, naturally occurring scale-up processes. There are also tensions between having adequately rigorous systems to monitor and evaluate scale-up well that are proportionate and pragmatic in practice. The study investigated the scale-up of an evidence-based complex intervention for knee and hip osteoarthritis (ESCAPE-pain) within “real-world” settings by England’s 15 Academic Health Science Networks (AHSNs)

Implementation science as a leadership capability to improve patient outcomes and value in healthcare.
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K. Votova, A. M. Laberge, J. M. Grimshaw and B. Wilson.
Healthc Manage Forum 2019 Nov;32(6):307-312
When evidence thresholds are met, adopting healthcare innovations should add value, and this is forgone when evidence is not translated into practice. Activities that are not supported by evidence lead to ineffective or unnecessary care, or harm, poor outcomes, and low-value healthcare. This article provides an overview of implementation science, which is the scientific study of why implementation succeeds or fails. We draw parallels between the LEADS in a Caring Environment leadership framework and implementation science process models and frameworks. Taken together, the principles and practices in LEADS and the aims of implementation science are effectively quite similar and can be useful for healthcare management looking to optimize resources when implementing evidence-based practice and innovation into routine clinical care.

 

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Health Care Administration and Organization

Nursing Role for Medication Stewardship Within Long-Term Care Facilities.
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T. Chaaban, M. Ahouah, P. Lombrail, J. M. Morvillers, M. Rothan-Tondeur and K. Carroll.
Nurs Sci Q 2019 Apr;32(2):113-11
Elderly residents in long-term care facilities (LTCFs) constitute a population noted to have a large number of medications prescribed and administered. The aim of this article is to explore the nursing role for medication management, with an emphasis on antimicrobial stewardship, guided by disciplinary knowledge of King’s theory of goal attainment and skill-based medication knowledge. The outcome is a nursing workforce truly engaged in working with interdisciplinary colleagues and focusing on care planning that includes medication management to improve the health status of residents in long-term care facilities.

Effects of registered nurse staffing on quality of care and resident outcomes in nursing homes.
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E. Cho, I. S. Kim, T. W. Lee, G. S. Kim, H. Lee and D. Min.
Geriatr Nurs 2020 May 6
Few studies focus on Registered Nurse (RN) staffing and resident health outcomes in Korean nursing homes. This study aimed to investigate the effects of RN staffing on quality of care and resident outcomes in South Korean nursing homes. The study was a secondary data analysis of 5679 participants from the National Health Insurance Service. A mixed-effect linear model and multinomial logistic regression model assessed resident outcomes and quality of care, respectively. The number of RNs significantly affected patient mortality. The overall evaluation rating for quality of care in nursing homes increased as the number of RNs increased. Level of RN staffing in nursing homes influenced health management and quality of care for residents. A variety of efforts are needed to strengthen the workforce of RNs in nursing homes, including enacting a law for safe RN staffing and converting the evaluation of nursing home quality into health outcomes.

The Feasibility of Using Electronic Consultation in Long-Term Care Homes.
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M. Helmer-Smith, C. Fung, A. Afkham, et al.
J Am Med Dir Assoc 2020 Apr 29
Patients in long-term care (LTC) homes face barriers to accessing specialist advice. Electronic consultation (eConsult) has the potential to improve access for these patients. We used a multi-method approach to evaluate adoption of the Champlain BASE eConsult service in LTC homes across Eastern Ontario, Canada. We conducted a cross-sectional study of all eConsults submitted by primary care providers (PCPs) working at LTC homes between January 1, 2018 and December 31, 2018. Service use data were collected and descriptive statistics were calculated. We completed a thematic analysis of 4 focus groups with PCPs, senior leadership, and a nurse champion working in LTC homes where eConsult is used. Sixty-four cases were submitted to 23 specialty and subspecialty groups by LTC PCPs, most frequently dermatology (19%), geriatric medicine (11%), and infectious disease (9%). Specialists responded in a median of 0.6 days, and 70% of cases were resolved without the resident needing a face-to-face specialist visit. In 60% of cases, PCPs received advice for a new or additional course of action. Participants described complexities in the LTC context, the value of eConsult in LTC, and considerations for implementation. PCPs with experience using the service described increased access to specialist advice, ease of use, and benefits to themselves, residents, and families. eConsult is feasible in LTC and should continue to be used in this region and beyond to improve equity of access to specialist advice. Resolving the identified limitations in LTC, which hinder access to specialists and adoption of eConsult and similar innovations, should be of high priority to researchers and policy makers.

Using touchscreen tablets to support social connections and reduce responsive behaviours among people with dementia in care settings: A scoping review.
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L. Hung, B. Chow, J. Shadarevian, et al.
Dementia (London) 2020 May 7:1471301220922745
The use of touchscreen tablets, such as the iPad, offers potential to support the person with dementia staying in a care setting, ranging from a long-term care home to an adult day programme. Although electronic devices are used among people with dementia, a comprehensive review of studies focusing on their impact and how they may be used effectively in care settings is lacking. We conducted a scoping review to summarize existing knowledge about the impact of touchscreen tablets in supporting social connections and reducing responsive behaviours of people with dementia in care settings. Our research team consists of patient partners and family partners, physicians, nurses, a medical student and an academic professor. A total of 17 articles were included in the review. Our analysis identified three ways in which touchscreen tablets support dementia care: (1) increased the person’s engagement, (2) decreased responsive behaviours and (3) positive effect on enjoyment/quality of life for people with dementia. Lessons learned and barriers to the use of touchscreen tablets in the care of people with dementia are described. Overall, only a few studies delineated strategies that helped to overcome barriers to technology adoption in care settings. Knowledge translation studies are needed to identify effective processes and practical tips to overcome barriers and realize the potential of assistive technology in dementia care.

Multiple brief training sessions to improve nurses’ knowledge, attitudes, and confidence regarding nursing care of older adults with depression in long-term care facilities.
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C. C. Lee, H. C. Tseng, L. P. Wu and Y. H. Chuang.
Res Nurs Health 2020 Jan;43(1):114-12
In long-term care facilities (LTCFs), nurses are key healthcare providers for older residents who have depressive symptoms or depression; therefore, they need accurate knowledge of late-life depression, positive attitudes towards depression, and confidence in providing depression care. This cluster-randomized trial was designed to examine the effectiveness of multiple, face-to-face, brief training sessions in improving nurses’ knowledge, attitudes, and confidence in providing late-life depression care in LTCFs. Nine LTCFs were included in the study. In total, 30 nurses from the four LTCFs assigned to the intervention group received three 30-min training sessions and 36 nurses in the five comparison group LTCFs did not. A self-report questionnaire was administered before and after the intervention. There were significant differences between groups concerning improvement in nurses’ knowledge of late-life depression, attitudes towards depression, and confidence in providing depression care. The effect size (Cohen’s d) was 1.55 for knowledge, 1.38 for attitudes, and 0.89 for confidence. This training program was effective in improving LTCF nurses’ knowledge, attitudes, and confidence in providing depression care. On the basis of these findings, we recommend that nurse managers and directors implement similar training programs for nurses in LTCFs to enhance the care quality for older residents.

Effect of Weekly Specialized Surgeon-led Bedside Wound Care Teams on Pressure Ulcer Time-to-heal Outcomes: Results From a National Dataset of Long-term Care Facilities.
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A. W. Levinson, H. J. Lavery, A. P. Santos, F. S. Ciminello and R. J. Marriott.
Wounds 2019 Oct;31(10):257-261
Delayed healing of pressure ulcers (PUs) in long-term care facilities (LTCFs) is associated with increased morbidity and expense. OBJECTIVE: The authors hypothesize that guideline-based, weekly coordinated care using specialized wound care surgeon-led bedside teams (SLBTs) may improve PU time-to-heal (TTH) outcomes when compared with usual care (UC). MATERIALS AND METHODS: Using a deidentified United States nationwide database, the authors retrospectively compared TTH outcomes of PUs diagnosed in LTCFs treated by either weekly SLBTs or UC. The SLBTs included an external specialized wound care surgeon (with or without a physician assistant and nurse practitioner) collaborating with facility nurses. Usual care was defined as all patient encounters not known to incorporate this team process. Variables assessed included patient age, gender, and comorbidities. The primary outcome measure was TTH; the TTH outcomes then were compared graphically and statistically between groups. Statistical significance was double-sided P .05. RESULTS: In 2014, there were 39 459 consecutive PUs treated by UC and 5985 by SLBTs. The 5985 SLBT wounds originated from 3435 patients in 10 states and all geographic regions (mean age, 76.6 years; 55.9% female; 42.8% with hypertension; 23.7% with diabetes). The mean TTH for wounds managed by SLBTs was 47.5 days (median, 21 days) versus 69.0 days (median, 28 days) for wounds managed by UC, corresponding to an absolute TTH decrease of 21.5 days in wounds managed by SLBTs versus UC. Wounds managed by SLBTs also were significantly more likely to heal in less than 28 days (P .0001). CONCLUSIONS: Pressure ulcers managed by coordinated nursing and weekly SLBTs appear to heal significantly faster than wounds managed by UC. Further studies are required to confirm these hypothesis-generating results.

Comparing residential long-term care regulations between nursing homes and assisted living facilities.
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A. M. Trinkoff, J. M. Yoon, C. L. Storr, N. B. Lerner, B. K. Yang and K. Han.
Nurs Outlook 2020 Jan – Feb;68(1):114-122
Nursing homes (NHs) are federally regulated under uniform standards, whereas assisted living facilities (ALFs) use individual state regulations for staffing, training, and oversight of care quality and safety. PURPOSE: To describe ALF staffing, training, inspection, and enforcement regulations for 50 U.S. states and the District of Columbia, and compare them to NH regulations. Publication of ALF quality and safety outcomes data also was assessed and compared to NHs. METHODS: Regulatory data were compiled from administrative and regulatory data sources, state websites, and regulatory compendia. FINDINGS: NHs followed a standard set of regulations, whereas ALF regulations varied widely. Overall, state ALF regulations were less stringent than NH in all categories. DISCUSSION: As ALF populations and acuity levels increase, staffing, training, nursing presence, and outcomes data requirements are warranted, and could be tailored from NH regulations to protect ALF quality and safety.

Construction and Validation of Risk-adjusted Rates of Emergency Department Visits for Long-stay Nursing Home Residents.
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H. Xu, J. R. Bowblis, Y. Li, T. V. Caprio and O. Intrator.
Med Care 2020 Feb;58(2):174-182
Long-stay nursing home (NH) residents are at high risk of having emergency department (ED) visits, but current knowledge regarding risk-adjusted ED rates is limited. OBJECTIVES: To construct and validate 3 quarterly risk-adjusted rates of long-stay residents’ ED use: any ED visit, ED visits without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED). RESEARCH DESIGN: The authors calculated quarterly NH risk-adjusted ED rates from 2011 Q2 to 2013 Q3 national Medicare claims and Minimum Data Set data. Using random-effect linear regressions, the authors validated these rates against Nursing Home Compare overall 5-star quality ratings and examined their associations with hospitalization rates to provide a quality context. SUBJECTS: Resident-quarter observations (7.3 million) from 15,235 unique NHs. RESULTS: Risk-adjusted rates of any ED, outpatient ED, and PAED averaged 9.7%, 3.4%, and 3.2%, respectively. Compared with NHs with 1 or 2 stars overall rating, NHs with >/=3 stars were significantly associated with lower rates of any ED visit, outpatient ED, and PAED (beta, -0.23%, -0.16%, and -0.11%, respectively; all P<0.01). Pearson Correlation coefficients between hospitalization rates and rates of any ED visit, outpatient ED, and PAED were 0.74, 0.31, and 0.46, respectively. CONCLUSIONS: The moderately negative associations of 5-star ratings with ED rates provide supportive evidence to their validity. Outpatient ED and PAED were moderately correlated to hospitalizations suggesting they provided more information about quality than any ED.

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Health Care Innovation and Quality Assurance

Code Work: RAI-MDS, Measurement, Quality, and Work Organization in Long-Term Care Facilities in Ontario

Tamara Daly, Jacqueline Choiniere And Hugh Armstrong.
Health Matters: Evidence, Critical Social Science, and Health Care in Canada; Eric Mykhalovskiy, Jacqueline A. Choiniere, Pat Armstrong, and Hugh Armstrong (eds); 75-93.
Reflecting on the notion of measurement as a human act, informed by the observer’s viewpoint–in terms of what is measured, by whom, and to what ends–raises important questions for health, health services, health outcomes, and care work organization. What conditions and care are measured, what health care data are collected, by whom, in what way and for what ends affects who gets care with public funds, the quantity and quality of that care, the way care work is organized, and the quality of working conditions for those …

The construction of a conceptual framework explaining the relation between barriers to change of management of neuropsychiatric symptoms in nursing homes: a qualitative study using focus groups.
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C. F. van Teunenbroek, K. Verhagen, M. Smalbrugge, A. Persoon, S. U. Zuidema and D. L. Gerritsen.
BMC Geriatr 2020 May 6;20(1):163-020-01569-w
Several efforts have been made to change management of neuropsychiatric symptoms (NPS) in nursing homes, however only few were successful. Numerous barriers to change in healthcare were identified, yet only one conceptual model is known to study their interrelationships. Unfortunately, this model does not discuss specific barriers encountered in nursing home practice. The aim of this study is to explore perceived barriers to change in the management of NPS in nursing homes and to construct a conceptual framework providing insight into the relative importance and interrelationships of these barriers when improving quality of care. METHODS: Four focus groups were conducted in different dementia special care units of one Dutch nursing home. Participants were either nursing staff, treatment staff or relatives of residents. Qualitative thematic analysis was conducted according to the five phases defined by Braun & Clarke. Finally, a conceptual framework showing the interrelations of barrier-themes was constructed using text fragments of the focus groups. RESULTS: We constructed a conceptual framework consisting of eight themes of barriers explaining the extent to which change in NPS-management can be achieved: ‘organizational barriers’, ‘personal barriers’, ‘deficiency of staff knowledge’, ‘suboptimal communication’, ‘inadequate (multidisciplinary) collaboration’, ‘disorganization of processes’, ‘reactive coping’ and ‘differences in perception’. Addressing ‘organizational barriers’ and ‘deficiency of staff knowledge’ is a precondition for change. ‘Suboptimal communication’ and ‘inadequate (multidisciplinary) collaboration’ play a key role in the extent of change achieved via the themes ‘differences in perception’ and ‘disorganization of processes’. Furthermore, ‘personal barriers’ influence all themes – except ‘organizational barriers’ – and may cause ‘reactive coping’, which in turn may lead to ‘difficulties to structure processes’. CONCLUSIONS: A conceptual framework was created explaining the relationships between barriers towards achieving change focused on improving management of NPS in nursing homes. After this framework has been confirmed and refined in additional research, it can be used to study the interrelatedness of barriers to change, and to determine the importance of addressing them for achieving change in the provided care.

Defining and conceptualizing outcomes for de-implementation: key distinctions from implementation outcomes

Beth Prusaczyk, Taren Swindle and Geoffrey Curran.
Implementation Science Communications 2020 04/30;1(1):43
Increasingly, scholars argue that de-implementation is a distinct concept from implementation; factors contributing to stopping a current practice might be distinct from those that encourage adoption of a new one. One such distinction is related to de-implementation outcomes. We offer preliminary analysis and guidance on de-implementation outcomes, including how they may differ from or overlap with implementation outcomes, how they may be conceptualized and measured, and how they could be measured in different settings such as clinical care vs. community programs.

Implementation support practitioners – a proposal for consolidating a diverse evidence base.
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B. Albers, A. Metz and K. Burke.
BMC Health Serv Res 2020 May 1;20(1):368-020-05145-1
Workforce development for implementation practice has been identified as a grand challenge in health services. This is due to the embryonic nature of the existing research in this area, few available training programs and a general shortage of frontline service staff trained and prepared for practicing implementation in the field. The interest in the role of “implementation support” as a way to effectively build the implementation capacities of the human service sector has therefore increased. However, while frequently used, little is known about the skills and competencies required to effectively provide such support. MAIN BODY: To progress the debate and the research agenda on implementation support competencies, we propose the role of the “implementation support practitioner” as a concept unifying the multiple streams of research focused on e.g. consultation, facilitation, or knowledge brokering. Implementation support practitioners are professionals supporting others in implementing evidence-informed practices, policies and programs, and in sustaining and scaling evidence for population impact. They are not involved in direct service delivery or management and work closely with the leadership and staff needed to effectively deliver direct clinical, therapeutic or educational services to individuals, families and communities. They may be specialists or generalists and be located within and/or outside the delivery system they serve. To effectively support the implementation practice of others, implementation support practitioners require an ability to activate implementation-relevant knowledge, skills and attitudes, and to operationalize and apply these in the context of their support activities. In doing so, they aim to trigger both relational and behavioral outcomes. This thinking is reflected in an overarching logic outlined in this article. CONCLUSION: The development of implementation support practitioners as a profession necessitates improved conceptual thinking about their role and work and how they enable the uptake and integration of evidence in real world settings. This article introduces a preliminary logic conceptualizing the role of implementation support practitioners informing research in progress aimed at increasing our knowledge about implementation support and the competencies needed to provide this support.

Ten recommendations for using implementation frameworks in research and practice.

Joanna C. Moullin, Kelsey S. Dickson, Nicole A. Stadnick, et al.
Implementation Science Communications 2020 04/30;1(1):42
Recent reviews of the use and application of implementation frameworks in implementation efforts highlight the limited use of frameworks, despite the value in doing so. As such, this article aims to provide recommendations to enhance the application of implementation frameworks, for implementation researchers, intermediaries, and practitioners.

 

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Organizational Culture and Change

Organizational Readiness Assessment in Acute and Long-Term Care has Important Implications for Antibiotic Stewardship for Asymptomatic Bacteriuria
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Melanie C. Goebel, Barbara W. Trautner, Yiqun Wang, et al.
Am J Infect Control 2020 05/08
Prior to implementing an antibiotic stewardship intervention for asymptomatic bacteriuria (ASB), we assessed institutional barriers to change using the Organizational Readiness to Change Assessment (ORCA). Methods Surveys were self-administered on paper in inpatient medicine and long-term care units at 4 Veterans Affairs facilities. Participants included providers, nurses, and pharmacists. The survey included seven subscales: evidence (perceived strength of evidence) and six context subscales (favorability of organizational context). Responses were scored on a 5-point Likert-type scale. Results 104 surveys were completed (response rate =69.3%). Overall, the evidence subscale had the highest score; the resources subscale (mean 2.8) was significantly lower than other subscales (P < 0.001). Scores for budget and staffing resources were lower than scores for training and facility resources (P < 0.001 for both). Pharmacists had lower scores than providers for the staff culture subscale (P = 0.04). The site with the lowest scores for resources (mean 2.4) also had lower scores for leadership and lower pharmacist effort devoted to stewardship. Conclusions Although healthcare professionals endorsed the evidence about non-treatment of ASB, perceived barriers to antibiotic stewardship included inadequate resources and leadership support. These findings provide targets for tailoring the stewardship intervention to maximize success.

Supporting adoption of the palliative approach toolkit in residential aged care: an exemplar of organisational facilitation for sustainable quality improvement.
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J. Davis, A. Morgans and M. Dunne.
Contemp Nurse 2019 Aug – Oct;55(4-5):369-379
National guidelines and resources to support a palliative approach in residential aged care were designed to improve the provision of palliative and end-of-life care; however, implementation has been sporadic.Objective: To support implementation of a palliative approach in aged care using a facilitation training model and existing palliative approach toolkit resources.Methods: Organisation-wide educational intervention delivered by a specialised Palliative Approach Facilitator for 6 months. Training included palliative approach principles, advance care planning, clinical management, equipment use, case conferencing, care planning and self-care.Results: The intervention included 197 internal and external staff and reviewed advanced care plans for 484 clients. Increased staff knowledge and confidence with discussions involving advance care planning, end-of-life care and supporting bereaving families resulted.Conclusion: This targeted intervention addressed barriers to adoption of a palliative approach, representing a flexible training model for building workforce capacity, promoting quality improvement and sustaining best practice in aged care settings.

Integrating People, Context, and Technology in the Implementation of a Web-Based Intervention in Forensic Mental Health Care: Mixed-Methods Study.
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H. Kip, F. Sieverink, L. J. van Gemert-Pijnen, Y. H. Bouman and S. M. Kelders.
J Med Internet Res 2020 Feb 1
While eMental health interventions can have many potential benefits for mental health care, implementation outcomes are often disappointing. In order to improve these outcomes, there is a need for a better understanding of complex, dynamic interactions between a broad range of implementation-related factors. These interactions and processes should be studied holistically, paying attention to factors related to context, technology, and people. OBJECTIVE: The main objective of this mixed-method study was to holistically evaluate the implementation strategies and outcomes of an eMental health intervention in an organization for forensic mental health care. METHODS: First, desk research was performed on 18 documents on the implementation process. Second, the intervention’s use by 721 patients and 172 therapists was analyzed via log data. Third, semistructured interviews were conducted with all 18 therapists of one outpatient clinic to identify broad factors that influence implementation outcomes. The interviews were analyzed via a combination of deductive analysis using the nonadoption, abandonment, scale-up, spread, and sustainability framework and inductive, open coding. RESULTS: The timeline generated via desk research showed that implementation strategies focused on technical skills training of therapists. Log data analyses demonstrated that 1019 modules were started, and 18.65% (721/3865) of patients of the forensic hospital started at least one module. Of these patients, 18.0% (130/721) completed at least one module. Of the therapists using the module, 54.1% (93/172 sent at least one feedback message to a patient. The median number of feedback messages sent per therapist was 1, with a minimum of 0 and a maximum of 460. Interviews showed that therapists did not always introduce the intervention to patients and using the intervention was not part of their daily routine. Also, therapists indicated patients often did not have the required conscientiousness and literacy levels. Furthermore, they had mixed opinions about the design of the intervention. Important organization-related factors were the need for more support and better integration in organizational structures. Finally, therapists stated that despite its current low use, the intervention had the potential to improve the quality of treatment. CONCLUSIONS: Synthesis of different types of data showed that implementation outcomes were mostly disappointing. Implementation strategies focused on technical training of therapists, while little attention was paid to changes in the organization, design of the technology, and patient awareness. A more holistic approach toward implementation strategies-with more attention to the organization, patients, technology, and training therapists-might have resulted in better implementation outcomes. Overall, adaptivity appears to be an important concept in eHealth implementation: a technology should be easily adaptable to an individual patient, therapists should be trained to deal flexibly with an eMental health intervention in their treatment, and organizations should adapt their implementation strategies and structures to embed a new eHealth intervention.

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Research Practice and Methodology

Participant and Caregiver Perspectives on Clinical Research During Covid-19 Pandemic.
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P. R. Padala, A. M. Jendro, C. H. Gauss, et al.
J Am Geriatr Soc 2020 Apr 21
The COVID-19 pandemic has massively disrupted essential clinical research. Many regulatory organizations have rightfully advocated to temporarily halt enrollment and curtail all face-to-face interactions. Views and opinions of patients and their caregivers are seldom considered while making such decisions. The objective was to study older participants’ and their caregivers’ perspectives to participate in ongoing clinical research during the COVID-19 pandemic. DESIGN: Cross-sectional. SETTING: VISN-16/Geriatric Research, Education and Clinical Center (GRECC), Department of Veterans Affairs. PARTICIPANTS: Older participants and their caregivers (N = 51) enrolled in ongoing clinical research studies. MEASUREMENTS: Questions about perceptions of safety to attend research visit, the level of panic among the general public, and medical center’s preparedness in handling the pandemic. Other questions identified the source of pandemic information and the preference of a phone or in-person visit. RESULTS: Mean age was 69.3 (+/-9.4) years, 53% were male, 39% were caregivers, and 65% were Caucasian. Majority (78%) of the participants felt safe/very safe attending the scheduled research appointment; 63% felt that the extra screening made them feel safe/very safe; 82% felt that the medical center was prepared/very prepared for the pandemic. Participants split evenly on their preference for phone versus in-person visits. Family members and television news media were the commonly used sources of pandemic information irrespective of their education. Perceptions were influenced by gender and source of information, not by age or education. Females perceived higher level of panic compared to males (P = .02). Those relying on news media felt safer compared to those that relied on family members (P = .008). CONCLUSION: Even though informants felt that the medical center was prepared to handle the pandemic, only half the participants preferred the in-person visit. Pandemic information was obtained from family members or the television news media. Knowing patients’ perspectives may help researchers be better prepared for future pandemics.

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Aging

Potentially Inappropriate Medication Use and Related Hospital Admissions in Aged Care Residents: the Impact of Dementia.
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T. C. Eshetie, G. Roberts, T. A. Nguyen, M. H. Gillam, D. Maher and L. M. Kalisch Ellett.
Br J Clin Pharmacol 2020 May 6
To determine the prevalence of potentially inappropriate medication (PIM) use at hospital admission and discharge, and the contribution to hospital admission among residential aged care facility (RACF) residents with and without dementia. METHODS: We conducted a secondary analysis using data from a multi-hospital prospective cohort study involving consecutively admitted older adults, aged 75 years or older, who were taking five or more medications prior to hospital admission and discharged to a RACF in South Australia. PIM use was identified using the 2015 Screening Tool for Older Persons’ Prescription (STOPP) and 2019 Beers Criteria. An expert panel of clinicians with geriatric medicine expertise evaluated the contribution of PIM to hospital admission. RESULTS: In total, 181 participants were included, the median age was 87.5 years and 54.7% were female. Ninety-one (50.3%) had a diagnosis of dementia. Participants with dementia had less PIMs, according to at least one of the two screening criteria, than those without dementia, at admission (dementia: 76 (83.5%) vs no dementia: 84 (93.3%), p=0.04) and discharge (78 (85.7%) vs 83(92.2%), p=0.16). PIM use was causal or contributory to the admission in 28.1% of study participants (n=45) who were taking at least one PIM at admission. CONCLUSIONS: Over 80% of acutely admitted older adults took PIMs at hospital admission and discharge and for over a quarter of these people the admissions were attributable to PIM use. Hospitalisation presents an opportunity for comprehensive medication reviews, and targeted interventions that enhance such a process could reduce PIM use and related harm.

What is the prevalence of loneliness amongst older people living in residential and nursing care homes? A systematic review and meta-analysis.
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C. Gardiner, P. Laud, T. Heaton and M. Gott.
Age Ageing 2020 May 12
The number of older people living in residential and nursing care homes is rising. Loneliness is a major problem for older people, but little is known about the prevalence of loneliness amongst older people living in care homes. AIM: to undertake a systematic review of literature on the prevalence of moderate and severe loneliness amongst older people living in residential and nursing care homes. DESIGN: we systematically reviewed the databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PsycINFO, Embase, Scopus, Cochrane and Allied and Complementary Medicine Database (AMED) from inception to January 2019. We included all studies reporting data on the prevalence of loneliness amongst older people living in care homes. A random-effects meta-analysis was conducted on all eligible data. RESULTS: a total of 13 articles were included, representing 5,115 participants (age range of 55-102 years, mean age 83.5 years, 68% female). There was a significant variation between studies in estimates of prevalence. The prevalence of moderate loneliness ranged from 31 to 100%, and the prevalence of severe loneliness ranged from 9 to 81%. The estimated mean prevalence of ‘moderate loneliness’ was 61% (95% confidence interval (CI): 0.41, 0.80). The estimated mean prevalence of ‘severe loneliness’ was 35% (95% CI: 0.14, 0.60). CONCLUSION: the prevalence of both moderate loneliness and severe loneliness amongst care home residents is high enough to warrant concern. However, the significant variation in prevalence estimates warrants further research. Future studies should identify which interventions can address loneliness and promote meaningful social engagement to enhance quality of life in care homes.

Dog-assisted interventions and outcomes for older adults in residential long-term care facilities: A systematic review and meta-analysis
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B. Jain, S. Syed, T. Hafford-Letchfield and S. O’Farrell-Pearce.
Int J Older People Nurs 2020 May 11:e12320
To comprehensively review studies on dog-assisted interventions (DAIs) among older people in residential long-term care facilities (RLTCFs) and to provide an overview of their interventions, outcomes and methodological quality. METHOD: We searched 18 electronic databases to identify English articles (published January 2000-December 2019) reporting on well-defined DAIs targeting older adults (>/=65 years) in RLTCF. Data were extracted by two independent reviewers. Descriptive statistics were produced for quantitative studies, with key themes identified among qualitative studies. Where possible, estimates were pooled from randomised controlled trials using random effects meta-analyses. RESULTS: Forty-three relevant studies (39 quantitative; 4 qualitative) were identified. The majority of quantitative studies were assessed as low-quality according to the MMAT criteria (n = 26, 67%). Almost half of the quantitative studies (n = 18, 46%) found no significant changes over time or between groups across outcomes measured. The most salient intervention effects included improved social functioning (n = 10), reduced depressive symptoms (n = 6) and loneliness (n = 5). A random-effects meta-analysis revealed a medium effect in favour of DAT on reducing depressive or loneliness symptoms (pooled SMD: 0.66, 95%CI 0.21-1.11; I(2) = 50.5; five trials), relative to treatment as usual. However, compared to treatment as usual, no overall effect of DAI on activities of daily living was detected (p = .737). Key themes from qualitative studies included (a) animals as effective transitional objects, (b) the therapeutic value of pets and (c) the significance of the care environment and stakeholders in facilitating DAI. IMPLICATIONS FOR PRACTICE: The findings of this review indicate that while DAI has value for older people in RLTCF, challenges remain in accurately measuring its impact to provide a stronger evidence-base. Standardisation of DAI service design, delivery and evaluation is required for future research and practice in providing holistic care for older adults.

Acceptability and use of a patient-held communication tool for people living with dementia: a longitudinal qualitative study.
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G. Leavey, D. S. Corry, B. Waterhouse-Bradley, et al.
BMJ Open 2020 May 5;10(5):e036249-2019-036249
To assess the acceptability and use of a low-cost patient-held communication tool. DESIGN: Longitudinal qualitative interviews at three time points over 18 months and document content analysis. SETTING: Primary and community services. PARTICIPANTS: Twenty-eight dyads: People living with dementia in Northern Ireland and their informal carers. INTERVENTIONS: A patient-held healthcare ‘passport’ for people living with dementia. PRIMARY AND SECONDARY OUTCOMES: Acceptability and use of the passport-barriers and facilitators to successful engagement. RESULTS: There was a qualified appreciation of the healthcare passport and a much more nuanced, individualistic or personalised approach to its desirability and use. How people perceive it and what they actually do with it are strongly determined by individual contexts, dementia stage and other health problems, social and family needs and capacities. We noted concerns about privacy and ambivalence about engaging with health professionals. CONCLUSION: Such tools may be of use but there is a need for demanding, thoughtful and nuanced programme delivery for future implementation in dementia care. The incentivisation and commitment of general practitioners is crucial. Altering the asymmetrical relationship between professionals and patients requires more extensive attention.

Nursing home residents with advanced dementia and persistent vocalisations: Observations of surrounding context.
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J. S. Sefcik, M. Ersek and P. Z. Cacchione.
Int J Older People Nurs 2020 May 8:e12322
Persistent vocalisations are commonly exhibited by persons with dementia and are often characterised as agitation or aggression. There has been little focus on persistent vocalisations independent from other behavioural and psychological symptoms of dementia making it difficult to differentiate information about the context that surrounds the person with dementia, including the circumstances and events that precede and accompany the expression. Therefore, the aim of this study was to describe the context surrounding persistent vocalisations expressed by older adults residing in nursing homes (NH) with advanced dementia. DESIGN AND METHODS: The need-driven dementia-compromised behaviour model informed this qualitative descriptive study. This naturalistic qualitative observational study involved direct observations of nine older adults diagnosed with dementia residing in four NHs and included informal interviews with formal caregivers. Field notes were taken and analysed using conventional content analysis. RESULTS: Variability of exhibited persistent vocalisations was both observed by the investigator and explained by NH staff. Two themes emerged from the field notes; Routine of Staying in Room was identified for participants considered ‘disruptive’ to others, and Providing Care Without Communicating triggered persistent vocalisations. IMPLICATIONS: The findings provide insight into the lack of therapeutic interactions between NH staff and persons with advanced dementia and persistent vocalisations residing in NHs. Ongoing, mandatory, evidence-based training on person-centred interventions and dementia care communication for all NH staff globally could have a significant impact on the delivery of holistic quality care for persons with dementia and persistent vocalisations.

 

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Events & Training Opportunities

IFA Virtual Town Hall COVID-19 and Older People: Facts and Fiction in Communication

Friday 22 May 05:00 MT
COVID-19 has brought with it many unprecedented challenges, particularly regarding the impacts on older people. As many of us remain under lockdown we rely on media – whether digital or print – to almost validate what is happening in the world, to gain the most up-to-date public health information but also to maintain a sense of connection to the “outside” world.

However, perspective is paramount. Join experts in the digital media space, Mr. Peter Evans and Mr. Eli Singer, as they masterfully explore innovative solutions that have connected us to reliable facts and separated us from the fiction of the COVID-19 pandemic.

Keeping Nursing Home Residents and Staff Safe in the Era of COVID-19

Available on demand
NASEM
States and localities across the U.S. are seeking effective ways to provide high-quality care to as many nursing home patients as is possible without transporting them to the hospital. Our webinar highlighted innovative approaches to address complex challenges that are currently being implemented in the state of Maryland.

Implementation, Spread, and Scale

Open for Enrollment until June 30, 2020
The Center for Implementation
Our comprehensive 8-module online course on planning for implementation, spread, and scale – informed by the science of implementation.

If you are a professional tasked with implementing a program, policy, or innovation, this course is for you. We welcome participants from a range of settings and topic areas.

An update on Lewy body spectrum disorders

Wednesday 20 May 10:00-11:00 MT
Presenter: Mario Masellis
Using a case-based approach, we will review the following:
To compare the clinical features of dementia with Lewy bodies (DLB) and Parkinson’s disease dementia (PDD), with a focus on diagnostic issues
To compare the cognitive profile of DLB, PDD and Alzheimer’s disease
To understand the underlying brain changes of DLB and PDD
To understand the multi-factorial approach to management of DLB and PDD

Maintaining and Strengthening Patient/Family/Caregiver Partnerships

Tuesday 26 May 09:30–10:30 MT
CFHI
What does patient engagement look like in a time of COVID-19 from a patient, family or caregiver perspective and from an organizational and healthcare leader perspective? Participants on this webinar will discuss ways organizations have maintained their engagement and partnership activities and, in many cases, strengthened and accelerated their efforts. Participants will also share expectations and priorities for patients, families and caregivers.

Integrated Knowledge Translation (iKT) 101: The Essentials

Wednesday 3 June 13:00–14:00 MT
Presenters: Sarah Donkers and Sarah Oosman
This Webinar will Discuss:
Who is a knowledge user?
What are the benefits of engaging knowledge users in research projects?
Where does Patient-Oriented Research fit into iKT?
What are some strategies for sustaining meaningful engagement of knowledge users throughout the research process?
How can researchers build meaningful relationships with knowledge users living in rural and remote communities?
How has iKT influenced research projects?

Implementation science: the third decade

Wednesday 27 May 2020 01:00-02:00 MT
Presenters: Robyn Mildon, Aron Shlonsky and Bianca Albers
Robyn Mildon, Aron Shlonsky and Bianca Albers, implementation science experts and co-editors of the recently published book Implementation Science 3.0 (Springer International Publishing, 2020) will use this motto to frame their exploration of the current state of the discipline known as implementation science, a field that has experienced substantial growth over the last two decades. Some of the questions they will address include:

What are the key criteria of high-quality implementation practice?
What types of measures and designs are needed to reliably generate the kind of high-quality implementation research that pushes the field forward?
What do the impressive number of empirical studies that have been published tell us?

How to Do Knowledge Translation in a Pandemic

Friday 29 May 13:00-14:00 MT
Presenter: Sarah Munro
The COVID-19 pandemic has led to disruption in the health research community through curtailment of research activities and social distancing practices. Knowledge translation (KT) of health research may need to pivot during this time, but health experts are on centre stage, and the public and policy makers are a captive audience. The need for effective communication, dissemination, and behaviour change remains critical. This presentation will provide guidance on methods for integrated and end-of-grant KT during the COVID-19 pandemic and similar periods of social disruption, as well as what to do for research that has been curtailed.

Virtually CAHSPR: A COVID Informed Vision for the Future of Healthcare and Health Services and Policy Research.

Wednesday 27- Thursday 28 May
Virtually CAHSPR will focus on the impacts of COVID19 on Canada’s health system, as we explore A COVID Informed Vision for the Future of Healthcare and Health Services and Policy Research. We have a group of spectacular speakers and panelists lined up to discuss their views and observations on what the COVID pandemic has taught us about the delivery of healthcare in Canada, and the impacts of these lessons on health services and policy as the system evolves in response to the pandemic. The agenda for our first virtual conference is an exciting one with thought leaders from primary care, health economics, acute care, home and community care, patient experience, health informatics and policy.

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Resources

Facilitating Virtual Collaboration: Tips and Tricks for Being Creative Virtually

Coronavirus in Long-Term Care Facilities: Information for Advocates

The WHO Academy’s COVID-19 mobile learning app for health workers

Available for iPhone OR android devices

How to work with a multigenerational team

Graduate Advising in the Time of Covid-19

Why Working From Home Is So Exhausting—And How To Reinvigorate

Stop Zoning Out in Zoom Meetings

Toolkit: How to work in science communication

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News

Implementation during a time of crisis: The critical role of trusting relationships

The Plight of Personal Support Workers during COVID-19 [podcast]

How coronavirus is changing research practices and publishing

5 soldiers serving in Quebec, Ontario nursing homes test positive for COVID-19

COVID-19 could change long-term care forever — at the site of Canada’s first outbreak, the shift is already underway

Canada’s pandemic record is good, but we failed when it came to protecting seniors homes

What Happened to Residents’ Rights? How Blanket Family Bans Violate Ontario’s Long-Term Care Homes Act

Male researchers’ ‘vague’ language more likely to win grants

How a nursing home in France stopped coronavirus from killing elderly in its care

Want to slash coronavirus deaths? Start (really) caring about long term care

For-profit nursing homes have four times as many COVID-19 deaths as city-run homes, Star analysis finds

Waste in covid-19 research

Long-term care work is essential, but has not been properly valued.

Continuing care and COVID-19: a Canadian tragedy that must not be allowed to happen again

COVID-19–Inspired Health Provider Innovation and Collaboration Should Continue

Which Covid-19 Data Can You Trust?

Florence Nightingale understood the power of visualizing science

The COVID Grim Reaper

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Opportunities

Policy and research manager

Sense about Science
DEADLINE: 26 May
The role will deliver Sense about Science’s policy activity including Transparency of Evidence, Evidence Week in the UK parliament, and our responsive work, eg on Covid-19, standards of evidence, scientific advice, applications of AI and AllTrials. Specific duties include:
-Planning and delivering our annual Evidence Week, including main point of contact within parliament and among the research and evidence community
-Promoting government awareness of our Transparency of Evidence framework and following its applications by different agencies in the UK and internationally
-Monitoring policy issues related to our work, particularly on the use of evidence and its reliability
-Preparing responses to formal consultations and to emerging policy issues in the UK and internationally
-Organising research, briefing and preparing material for the director
-Fundraising, and sourcing and securing policy partnerships
-Line managing our research and campaigns officer and the work of other staff as required
-Giving talks, writing articles, and representing Sense about Science at meetings.

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