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New article by Dr. Carole Estabrooks
Screening for Frailty in Canada’s Health Care System: A Time for Action 
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As Canada’s population ages, frailty – with its increased risk of functional decline, deterioration in health status, and death – will become increasingly common. The physiology of frailty reflects its multisystem, multi-organ origins. About a quarter of Canadians over age 65 are frail, increasing to over half in those older than 85. Our health care system is organized around single-organ systems, impairing our ability to effectively treat people having multiple disorders and functional limitations. To address frailty, we must recognize when it occurs, increase awareness of its significance, develop holistic models of care, and generate better evidence for its treatment. Recognizing how frailty impacts lifespan will allow for integration of care goals into treatment options. Different settings in the Canadian health care system will require different strategies and tools to assess frailty. Given the magnitude of challenges frailty poses for the health care system as currently organized, policy changes will be essential.
FREE Research Webinar by Dr. Greta Cummings
Development and testing of a standardized communication form to improve transitions for nursing home residents (CFN funded Catalyst Grant)
One of the key findings from the Older Persons’ Transitions in Care (OPTIC) study is the need to improve communication among healthcare providers involved in the handover of frail elderly residents during transfers to and from the emergency department. These transitions from long-term care to emergency departments and back are facilitated by personnel from emergency medical services, long-term care and the emergency department.
WHO Global Strategy and Plan of Action on Ageing and Health
Final Draft of WHO Global Strategy and Plan of Action on Ageing and Health
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The final draft of the Global Strategy made adjustments based on consultations with representatives of Member States, the United Nations and international partners. This has strengthened the plan which now provides clear objectives and actions for Member States and partners to create age-friendly environments, align health systems, develop long-term care systems and advance Healthy Ageing.
New articles by Dr. Greta Cummings
Informed consent comprehension and recollection in adult dental patients: A systematic review
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BACKGROUND: Patients’ ability to recollect and comprehend treatment information plays a fundamental role in their decision making. TYPES OF STUDIES REVIEWED: The authors considered original studies assessing recollection or comprehension of dental informed consent in adults. The authors searched 6 electronic databases and partial gray literature and hand searched and cross-checked reference lists published through April 2015. The authors assessed the risk of bias in the included studies via different validated tools according to the study design. RESULTS: Nineteen studies were included: 5 randomized clinical trials, 8 cross-sectional studies, 3 qualitative studies, 2 mixed-methods studies, and 1 case series. Conventional informed consent processes yielded comprehension results of 27% to 85% and recollection of 20% to 86%, whereas informed consent processes enhanced by additional media ranged from 44% to 93% for comprehension and from 30% to 94% for recollection. Patient self-reported understanding ranged positively, with most patients feeling that they understood all or almost all the information presented. Results of qualitative data analyses indicated that patients did not always understand explanations, although dentists thought they did. Some patients firmly stated that they did not receive any related information. Only a few patients were able to remember complications related to their treatment options. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Results of this systematic review should alert dentists that although patients in general report that they understand information given to them, they may have limited comprehension. Additional media may improve conventional informed consent processes in dentistry in a meaningful way.
Blinding in Physical Therapy Trials and Its Association with Treatment Effects: A Meta-epidemiological Study
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OBJECTIVE: The aim of this study was to examine whether blinding of participants, assessors, health providers, and statisticians have an effect on treatment effect estimates in physical therapy (PT) trials. DESIGN: This was a meta-epidemiological study. Randomized controlled trials in PT were identified by searching the Cochrane Database of Systematic Reviews for meta-analyses of PT interventions. Assessments of blinding in PT trials were conducted independently following established guidelines. RESULTS: Three hundred ninety-three trials and 43 meta-analyses that included 44,622 patients contributed to this study. Only a quarter of the trials were adequately blinded (n = 80; 20%). Most individual components of blinding as well as what they were blinded to were also poorly reported. Although trials with inappropriate blinding of assessors and participants tended to underestimate treatment effects when compared with trials with appropriate blinding of assessors and participants, the difference was not statistically significant (effect size, -0.07; 95% confidence interval, -0.22 to 0.08; effect size, -0.12; 95% confidence interval, -0.30 to 0.06, respectively). CONCLUSIONS: The lack of statistical significance between blinding and effect sizes should not be interpreted as meaning that an impact of blinding on effect size is not present in PT. More empirical evidence in a larger sample is needed to determine which biases are likely to influence reported effect sizes of PT trials and under which conditions.
New article by Dr. Cecilia Bukutu
N-of-1 trials are a tapestry of heterogeneity
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OBJECTIVES: To summarize the methods of design, analysis, and meta-analysis used in N-of-1 trials. STUDY DESIGN AND SETTING: Electronic search for English language articles published from 1950 to 2013. N-of-1 trials were selected if they followed an ABAB design and if they assessed a health intervention for a medical condition. Elements of design, analysis, and meta-analysis were extracted. RESULTS: We included 100 reports representing 1,995 participants. N-of-1 trials have been conducted in over 50 health conditions. Most reports incorporated the use of elements that maintain methodological rigor, including randomization, blinding, and formal outcome assessment; however, many failed to address trial registration, funding source, and adverse events. Most reports statistically analyzed individual N-of-1 trials; however, only a small proportion of included series meta-analyzed their results. CONCLUSIONS: N-of-1 trials have the ability to assess treatment response in individual participants and can be used for a variety of health interventions for a wide range of medical conditions in both clinical and research settings. Considerable heterogeneity exists in the methods used in N-of-1 trials.
Grants & Awards
Canadian Longitudinal Study on Aging (CLSA) data
Canadian researchers are invited to submit health research projects which make use of available CLSA data. The selected projects will help find ways to improve the health of Canadians by better understanding the aging process and the factors that shape the way we age.
CIHR: Challenge of Dementia in Indigenous Populations
Because the understanding of dementia is shifting, Indigenous peoples are exploring new models merging Indigenous and Western concepts of dementia care. As such, new research investments are needed to develop or adapt culturally appropriate diagnostic tools and care models for both urban and rural Indigenous people living in Canada. This funding opportunity intends to provide support for dementia care research that uses community-based participatory methods with rural and/or urban Indigenous populations. Funding will also work to iteratively build capacity among Indigenous scholars and students in dementia research.
Canadian Frailty Network Fellows and Summer Students
The CFN is reaching out to current and past supervisors of CFN Fellows and Summer Students for your assistance on calls for fellowships and summer student awards in our second funding cycle. A letter has been sent to your host institution’s head of research/research services, but we know that each organization has a different funding approval structure, so we wanted to make sure that you were aware of the opportunities available. They are offering the opportunity to co-fund a number of Fellows and Summer Students over the next five-year funding period, with matching CFN funding where letters of commitment are received. For more information, please contact Jackie at jackie@cfn-nce.ca or (613) 549-6666, x 6210, and Carol at executivedirector@cfn-nce.ca or (613) 549-6666, x 7689.
Publications
KT
Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Organizational Change
Research Practice and Methodology
Aging
KT
Mediating role of critical thinking disposition in the relationship between perceived barriers to research use and evidence-based practice
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BACKGROUND: Despite the importance of critical thinking in clinical and educational settings, little is known about its role in evidence-based practice (EBP). AIM: This study examined whether critical thinking disposition (CTD) mediates the relationship between perceived barriers to research use and EBP in clinical nurses (N=409). METHODS/DESIGN: A path diagram using structural equation modeling was used to estimate the direct and indirect effects of perceived barriers to research use on EBP, controlling for CTD as a mediator. RESULTS: CTD partially mediated the relationship between perceived barriers to research use and EBP. Furthermore, the hypothesized mediation model demonstrated an appropriate fit to the data. CONCLUSIONS: Individual and organizational efforts are needed to help nurses further improve their critical thinking skills. CTD is important as research barriers to engage effectively in EBP. Without the skills to evaluate evidence carefully, research utilization may be compromised.
End-of-life decision making for persons with dementia: Proxies’ perception of support
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Healthcare proxies need support in making end-of-life decisions for persons with dementia (PWD). This study explored perceptions of support in decision making among proxies of PWD through semi-structured interviews with 20 proxies. Thematic analysis identified three sources of support: family, doctors, and religiosity/spirituality. Family’s engagement in care discussions and support for proxies’ decisions were viewed helpful while disagreement or criticism, combined with lack of knowledge about PWD’s condition and needs, were not. Doctors were viewed supportive when proxies felt doctors respected their opinions and PWD’s wishes. Doctor-PWD rapport influenced proxies’ views of medical advice from doctors. Although religiosity/spirituality provided guidance and hope, it also presented conflicts when PWD’s wishes differed from proxies’ beliefs. Therefore, families of PWD should be provided with assistance in reconciling or mediating family conflicts and further education about the illness trajectory as well as risks/benefits of life-sustaining treatments. Assistance should also be provided to address religious/spiritual conflicts.
An evidence-based approach to the prevention and initial management of skin tears within the aged community setting: a best practice implementation project
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BACKGROUND: Maintaining skin integrity in a community setting is an ongoing issue, as research suggests that the prevalence of skin tears within the community is greater than that in an institutional setting. While skin tear prevention and management principles in these settings are similar to those in an acute care setting, consideration of the environmental and psychological factors of the client is pivotal to prevention in a community setting. Evidence suggests that home environment assessment, education for clients and care givers, and being proactive in improving activities of daily living in a community setting can significantly reduce the risk of sustaining skin tears. OBJECTIVES: The aim of this implementation project was to assess and review current skin tear prevention and management practices within the community setting, and from this, to implement an evidence-based approach in the education of clients and staff on the prevention of skin tears. As well. the project aims to implement evidence-based principles to guide clinical practice in relation to the initial management of skin tears, and to determine strategies to overcome barriers and non-compliance. METHODS: The project utilized the Joanna Brigg’s Institute Practical Application of Clinical Evidence System audit tool for promoting changes in the community health setting. The implementation of this particular project is based in a region within Anglicare Southern Queensland. A small team was established and a baseline audit carried out. From this, multiple strategies were implemented to address non-compliance which included education resources for clients and caregivers, staff education sessions, and creating skin integrity kits to enable staff members to tend to skin tears, and from this a follow-up audit undertaken. RESULTS: Baseline audit results were slightly varied, from good to low compliance. From this, the need for staff and client education was highlighted. There were many improvements in the audit criteria following client and staff education sessions and staff self-directed learning packages. Future strategies required to sustain improvements in practice and make further progress are to introduce a readily available Anglicare Skin Integrity Assessment Tool to the nursing staff for undertaking new client admissions over 65 years, and to provide ongoing education to staff members, clients and care givers in order to reduce the prevalence of skin tears in the community setting. CONCLUSIONS: This implementation project demonstrated the importance of education of personal care workers, clients and their caregivers for prevention of skin tears in the community setting. This in turn created autonomy and empowered clients to take control of their health.
Convergence of Implementation Science, Precision Medicine, and the Learning Health Care System: A New Model for Biomedical Research
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Since the start of the Human Genome Project 25 years ago, basic discoveries related to genomics and other “-omic” fields have continued to advance exponentially. This progress has facilitated the 2015 launch of the US Precision Medicine Initiative (PMI). The PMI is intended to merge genomic, biological, behavioral, environmental, and other data on individuals to identify drivers of health that might support personalized health care decision making. In the cancer domain, for example, recognition of both inherited genetic susceptibility (eg, Lynch syndrome for colorectal cancer, and BRCA1/2 for breast cancer) and cancer genome sequence alterations that can pinpoint therapeutic agents (eg, National Cancer Institute’s MATCH trials) has the potential to make clinical decisions more personalized both in prevention and treatment. The “National Cancer Moonshot Initiative” seeks to rapidly scale up these efforts.
Changing Practice: Frameworks From Implementation Science
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A critical time lag exists from the generation of new knowledge to integration into direct patient care. One effort to address this problem is through clinical initiatives to translate research findings into everyday practice at the unit, department, or institutional level. Such efforts can be particularly challenging when faced with the real-world conditions that healthcare professionals must confront in their day-to-day practice. These initiatives may be in response to an external requirement, a desire to improve practice, or to change care delivery to a more evidence-based model.
Bridging Research, Practice, and Policy: The “Evidence Academy” Conference Model
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Innovative models to facilitate more rapid uptake of research findings into practice are urgently needed. Community members who engage in research can accelerate this process by acting as adoption agents. We implemented an Evidence Academy conference model bringing together researchers, health care professionals, advocates, and policy makers across North Carolina to discuss high-impact, life-saving study results. The overall goal is to develop dissemination and implementation strategies for translating evidence into practice and policy. Each 1-day, single-theme, regional meeting focuses on a leading community-identified health priority. The model capitalizes on the power of diverse local networks to encourage broad, common awareness of new research findings. Furthermore, it emphasizes critical reflection and active group discussion on how to incorporate new evidence within and across organizations, health care systems, and communities. During the concluding session, participants are asked to articulate action plans relevant to their individual interests, work setting, or area of expertise.
Facilitators and Barriers to Evidence Based Practice: Perceptions of Nurse Educators, Clinical Coaches and Nurse Specialists from a descriptive study
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Background Implementation of evidence-based practice (EBP) is a major initiative within health care settings to ensure clinical and policy decisions incorporate best available evidence. Nurse educators, clinical coaches (clinical support nurses) and clinical nurse specialists are the key people to bring change by facilitating EBP within clinical settings. Aims In this paper the findings are reported from a descriptive study exploring nurse educators’, clinical coaches’ and nurse specialists’ perceptions of factors associated with using EBP. Methods A questionnaire containing quantitative and a small number of qualitative questions was employed. Data was collected from nurse educators, clinical coaches and clinical nurse specialists working in a tertiary health care network in Victoria, Australia. The questionnaire was distributed to a total of 435 people, of whom 135 responded. Data Analysis Data were analysed using SPSS (Statistical Package for Social Sciences version 17). Frequencies and percentages were calculated for demographic data and descriptive statistics for each questionnaire item were determined. Thematic analysis was performed for the qualitative part of the questionnaire. Results Findings revealed that nurse educators, clinical coaches and nurse specialists perceived organisational support (mean 3.53, median 4.00), sufficient resources (mean 3.62, median 4.00) and access to continuing education (mean 4.40, median 4.00) as factors promoting acceptance of EBP. Barriers to such acceptance in health care settings were identified as lack of knowledge and skills (mean 3.12 median 3.00), poor time allowance (median 3.79, median 4.00) limited support (mean 3.61, median 4.00) and insufficient resources (mean 3.42, median 4.00). Conclusion The reported findings and discussion in this study create evidence-based information for organisational strategic planning. Organisations need to develop educational programs to promote EBP in the clinical setting and employ strategies to overcome barriers to implementation.
Examining the quality of evidence to support the effectiveness of interventions: an analysis of systematic reviews
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OBJECTIVE: This analysis examines the quality of evidence (QOE) for 1472 outcomes linked to interventions where the QOE was rated in 42 systematic reviews of randomised clinical trials and/or observational studies across different topics. SETTING: Not applicable. PARTICIPANTS: 76 systematic reviews. PRIMARY AND SECONDARY OUTCOME MEASURES: Strength of evidence ratings by initial reviewers. RESULTS: Among 76 systematic reviews, QOE ratings were available for only 42, netting 1472 comparisons. Of these, 57% included observational studies; 4% were rated as high and 12% as moderate; the rest were low or insufficient. The ratings varied by topic: 74% of the surgical study pairs were rated as low or insufficient, compared with 82% of pharmaceuticals and 86% of device studies, 88% of organisational, 91% of lifestyle studies, and 94% of psychosocial interventions. CONCLUSIONS: We are some distance from being able to claim evidence-based practice. The press for individual-level data will make this challenge even harder.
Qualitative Interviews With Science Communication Trainers About Communication Objectives and Goals
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Qualitative interviews with science communication trainers (n = 24) on the role of objectives and goals in training efforts suggest that trainers believe that scientists come to training with a range of long-term goals in mind. However, trainers appear to focus on teaching communication skills and are relatively unlikely to focus on identifying specific communication objectives as a means of achieving scientists’ goals. The communication objective that trainers consistently report emphasizing is knowledge building. Other potential objectives such as fostering excitement, building trust, and reframing issues were rarely raised. Research aimed at helping trainers foster strategic communication capacity is proposed. ABSTRACT FROM AUTHOR]; Copyright of Science Communication is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract.
Recommendations for sexual expression management in long-term care: a qualitative needs assessment
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AIMS: To conduct a qualitative needs assessment of Directors of Nursing regarding challenges and recommendations for addressing sexual expression and consent. BACKGROUND: Sexual expression management among long-term care residents is a complex issue for nursing home staff. Little guidance is available for those wanting to follow a person-centred approach. Policies and procedures are needed, and must be usable across long-term care settings. DESIGN: Qualitative design for in-depth exploration. METHODS: Semi-structured interviews were conducted with 20 Directors of Nursing in the spring and summer of 2013, representing a range of regions, facility sizes and resident populations. Interview questions prompted them to identify recommendations that address challenges to improving sexual expression management in long-term care settings. RESULTS: Comparative thematic analysis resulted in several codes, which were grouped into eight overall categories. Recommendation categories that addressed key challenges included: address the issue, make environmental changes, identify staff expertise, provide education and training, assess sexuality initially and recurrently, establish policies/procedures for sexual expression management, develop assessment tools for sexual expression and consent, and clarify legal issues. The recommendation to develop national guidelines was observed across categories. DISCUSSION: Directors of Nursing report several challenges to sexual expression management in their facilities, and perceive their current methods to be ad hoc. A proactive approach to policy and procedure development is needed.
Significance of scientific evidence in organizing care processes
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Purpose The aim was to analyze how staff and managers in health and social care organizations use scientific evidence when making decisions about the organization of care practices. Design/methodology/approach Document analysis and repeated interviews (2008-2010) with staff (n=39) and managers (n=26) in health and social care organizations. The respondents were involved in a randomized controlled study about testing a continuum of care model for older people. Findings Scientific evidence had no practical function in the social care organization, while it was a prioritized source of information in the health care organization. This meant that the decision-making regarding care practices was different in these organizations. Social care tended to rely on ad hoc practice-based information and political decisions when organizing care, while health care to some extent also relied in an un-reflected manner on the scientific knowledge. Originality/value The study illustrates several difficulties that might occur when managers and staff try to consider scientific evidence when making complicated decisions about care practices.; Purpose The aim was to analyze how staff and managers in health and social care organizations use scientific evidence when making decisions about the organization of care practices. Design/methodology/approach Document analysis and repeated interviews (2008-2010) with staff (n=39) and managers (n=26) in health and social care organizations. The respondents were involved in a randomized controlled study about testing a continuum of care model for older people. Findings Scientific evidence had no practical function in the social care organization, while it was a prioritized source of information in the health care organization. This meant that the decision-making regarding care practices was different in these organizations. Social care tended to rely on ad hoc practice-based information and political decisions when organizing care, while health care to some extent also relied in an un-reflected manner on the scientific knowledge. Originality/value The study illustrates several difficulties that might occur when managers and staff try to consider scientific evidence when making complicated decisions about care practices.
An introduction to implementation science for the non-specialist
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BACKGROUND: The movement of evidence-based practices (EBPs) into routine clinical usage is not spontaneous, but requires focused efforts. The field of implementation science has developed to facilitate the spread of EBPs, including both psychosocial and medical interventions for mental and physical health concerns. DISCUSSION: The authors aim to introduce implementation science principles to non-specialist investigators, administrators, and policymakers seeking to become familiar with this emerging field. This introduction is based on published literature and the authors’ experience as researchers in the field, as well as extensive service as implementation science grant reviewers. Implementation science is “the scientific study of methods to promote the systematic uptake of research findings and other EBPs into routine practice, and, hence, to improve the quality and effectiveness of health services.” Implementation science is distinct from, but shares characteristics with, both quality improvement and dissemination methods. Implementation studies can be either assess naturalistic variability or measure change in response to planned intervention. Implementation studies typically employ mixed quantitative-qualitative designs, identifying factors that impact uptake across multiple levels, including patient, provider, clinic, facility, organization, and often the broader community and policy environment. Accordingly, implementation science requires a solid grounding in theory and the involvement of trans-disciplinary research teams. The business case for implementation science is clear: As healthcare systems work under increasingly dynamic and resource-constrained conditions, evidence-based strategies are essential in order to ensure that research investments maximize healthcare value and improve public health. Implementation science plays a critical role in supporting these efforts.
Moving towards a new vision: implementation of a public health policy intervention
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BACKGROUND: Public health systems in Canada have undergone significant policy renewal over the last decade in response to threats to the public’s health, such as severe acute respiratory syndrome. There is limited research on how public health policies have been implemented or what has influenced their implementation. This paper explores policy implementation in two exemplar public health programs -chronic disease prevention and sexually-transmitted infection prevention – in Ontario, Canada. It examines public health service providers’, managers’ and senior managements’ perspectives on the process of implementation of the Ontario Public Health Standards 2008 and factors influencing implementation. METHODS: Public health staff from six health units representing rural, remote, large and small urban settings were included. We conducted 21 focus groups and 18 interviews between 2010 (manager and staff focus groups) and 2011 (senior management interviews) involving 133 participants. Research assistants coded transcripts and researchers reviewed these; the research team discussed and resolved discrepancies. To facilitate a breadth of perspectives, several team members helped interpret the findings. An integrated knowledge translation approach was used, reflected by the inclusion of academics as well as decision-makers on the team and as co-authors. RESULTS: Front line service providers often were unaware of the new policies but managers and senior management incorporated them in operational and program planning. Some participants were involved in policy development or provided feedback prior to their launch. Implementation was influenced by many factors that aligned with Greenhalgh and colleagues’ empirically-based Diffusion of Innovations in Service Organizations Framework. Factors and related components that were most clearly linked to the OPHS policy implementation were: attributes of the innovation itself; adoption by individuals; diffusion and dissemination; the outer context – interorganizational networks and collaboration; the inner setting – implementation processes and routinization; and, linkage at the design and implementation stage. CONCLUSIONS: Multiple factors influenced public health policy implementation. Results provide empirical support for components of Greenhalgh et al’s framework and suggest two additional components – the role of external organizational collaborations and partnerships as well as planning processes in influencing implementation. These are important to consider by government and public health organizations when promoting new or revised public health policies as they evolve over time. A successful policy implementation process in Ontario has helped to move public health towards the new vision.
Promoting physical therapists’ use of research evidence to inform clinical practice: part 3 – long term feasibility assessment of the PEAK program
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BACKGROUND: Evidence is needed to develop effective educational programs for promoting evidence based practice (EBP) and knowledge translation (KT) in physical therapy. This study reports long-term outcomes from a feasibility assessment of an educational program designed to promote the integration of research evidence into physical therapist practice. METHODS: Eighteen physical therapists participated in the 6-month Physical therapist-driven Education for Actionable Knowledge translation (PEAK) program. The participant-driven active learning program consisted of four consecutive, interdependent components: 1) acquiring managerial leadership support and electronic resources in three clinical practices, 2) a 2-day learner-centered EBP training workshop, 3) 5 months of guided small group work synthesizing research evidence into a locally relevant list of, actionable, evidence-based clinical behaviors for therapists treating persons with musculoskeletal lumbar conditions–the Best Practices List, and 4) review and revision of the Best Practices List, culminating in participant agreement to implement the behaviors in practice. Therapists’ EBP learning was assessed with standardized measures of EBP-related attitudes, self-efficacy, knowledge and skills, and self-reported behavior at baseline, immediately-post, and 6 months following conclusion of the program (long-term follow-up). Therapist adherence to the Best Practice List before and after the PEAK program was assessed through chart review. RESULTS: Sixteen therapists completed the long-term follow-up assessment. EBP self-efficacy and self-reported behaviors increased from baseline to long-term follow-up (p < 0.001 and p = 0.002, respectively). EBP-related knowledge and skills showed a trend for improvement from baseline to long-term follow-up (p = 0.05) and a significant increase from immediate-post to long-term follow-up (p = 0.02). Positive attitudes at baseline were sustained throughout (p = 0.208). Eighty-nine charts were analyzed for therapist adherence to the Best Practices List. Six clinical behaviors had sufficient pre- and post-PEAK charts to justify analysis. Of those, one behavior showed a statistically significant increase in adherence, one had high pre- and post-PEAK adherence, and four were change resistant, starting with low adherence and showing no meaningful improvement. CONCLUSIONS: This study supports the feasibility of the PEAK program to produce long-term improvements in physical therapists’ EBP-related self-efficacy and self-reported behavior. EBP knowledge and skills showed improvement from post-intervention to long-term follow-up and a trend toward long-term improvements. However, chart review of therapists’ adherence to the participant generated Best Practices List in day-to-day patient care indicates a need for additional support to facilitate behavior change. Future versions of the PEAK program and comparable multi-faceted EBP and KT educational programs should provide ongoing monitoring, feedback, and problem-solving to successfully promote behavior change for knowledge translation.
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Health Care Administration and Organization
Recommendations for sexual expression management in long-term care: a qualitative needs assessment
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AIMS: To conduct a qualitative needs assessment of Directors of Nursing regarding challenges and recommendations for addressing sexual expression and consent. BACKGROUND: Sexual expression management among long-term care residents is a complex issue for nursing home staff. Little guidance is available for those wanting to follow a person-centred approach. Policies and procedures are needed, and must be usable across long-term care settings. DESIGN: Qualitative design for in-depth exploration. METHODS: Semi-structured interviews were conducted with 20 Directors of Nursing in the spring and summer of 2013, representing a range of regions, facility sizes and resident populations. Interview questions prompted them to identify recommendations that address challenges to improving sexual expression management in long-term care settings. RESULTS: Comparative thematic analysis resulted in several codes, which were grouped into eight overall categories. Recommendation categories that addressed key challenges included: address the issue, make environmental changes, identify staff expertise, provide education and training, assess sexuality initially and recurrently, establish policies/procedures for sexual expression management, develop assessment tools for sexual expression and consent, and clarify legal issues. The recommendation to develop national guidelines was observed across categories. DISCUSSION: Directors of Nursing report several challenges to sexual expression management in their facilities, and perceive their current methods to be ad hoc. A proactive approach to policy and procedure development is needed.
The Importance and Value of Professional Membership of Nursing Home Administrators
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This study examines the association between nursing home administrators (NHAs) professional membership, certification, and fellow status with quality indicators in nursing homes. Membership, certification, and fellow information (representing increasing levels of participation) originated from the American College of Health Care Administrators (ACHCA). ACHCA is a professional association which represents long-term care administrators. The Quality Measures reported on the Nursing Home Compare web-site, and facility information from the On-line Survey Certification of Automated Records (OSCAR) were used. The period of interest was 2010 and a total of 19 quality indicators were examined. Data were analyzed through multivariate analyses using negative binomial regression. The results indicate NHAs who are members of ACHCA are associated with better quality in 6 of the 19 quality indicators examined; ACHCA certified member fellows are associated with better quality in 7 of the 19 quality indicators examined; ACHCA fellows are associated with better quality in 10 of the 19 quality indicators examined; and, ACHCA members (excluding certified, certified fellows, and fellows) are associated with better quality in 13 of the 19 quality indicators examined. These findings support the value of professional membership, as well as voluntary certification or fellow credentialing of NHAs with respect to quality improvement.
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Health Care Innovation and Quality Assurance
A Quality Improvement Project to Assess Timing of Initial Investigations in Stroke Medicine
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There are several investigations that can be completed in the acute phase of admission for patients with suspected stroke.These include receiving a CT Head scan and also blood tests specific for stroke. The national guidelines regarding CT Head scans detail they should be completed within 12 hours of admission1 and the trust guidelines, local to where this quality improvement project was based, advise a CT Head should be completed within four hours of admission.2The current national guidelines do not specify exact stroke blood tests, however trust guidelines give a specific set of blood tests that would be appropriate to be taken when a patient presents to A&E with a suspected stroke. These included FBC, U&E, blood glucose, ESR, cholesterol, TFTs, and coagulation screen.2 The aim of this quality improvement project was to assess the timing of CT Head scans and blood tests and to implement a tool to ensure these are done in a timely fashion, within the emergency care setting. The project was completed through three PSDA cycles. The first was undertaken in an A&E department, which was soon to be closed and moved to a different site. The second cycle was then completed at the new site, to assess if there had been any change in timings of these interventions. In the previous site it was found that 97% of patients audited received a CT Head scan within four hours. At the new site it was found 94% patients received a CT Head within four hours, therefore both meeting trust targets on the whole. A full set of stroke blood tests were completed at the old site in 53% of patients and this decreased to 22% of patients at the new site. At this point it was decided an intervention should be implemented to ensure this did not continue. The intervention used was updating a stroke panel on the trust computer system (an easy to use, one-click button entitled “Stroke/TIA”) with the correct blood tests and the use of this was promoted throughout the trust.A post-intervention audit was completed three months after the tool was promoted and patients receiving the correct blood tests whilst in the A&E department increased to 75%. The amount of patients receiving a CT Head scan within four hours was 100% therefore meeting both trust and national guidelines. In conclusion, the stroke blood panel appears to have improved the amount of patients receiving the correct blood tests when admitted with suspected stroke and will continue to stay in place at the trust.
Survive On Call – A QI Project to Improve Access to Hospital Clinical Guidelines
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Accessing clinical guidelines and telephone numbers can be time consuming for junior doctors, particularly during a busy on-call shift. Smartphones allow instant access to this information, without leaving a patient’s bedside. This overcomes the relative paucity of fixed desktop computers available in most clinical areas. In this project, a trainee doctor developed a clinical smartphone app to improve the access of clinical and hospital-specific information.A representative sample of ten junior doctors were recruited to quantify the amount of time spent accessing guidelines using desktop computers, versus the App. The average time to access a common guideline (Hypokalaemia management) with the App was 12.4 seconds (95% CI 2.3), versus 76.8 seconds (95% CI 30.6) using a computer. A difference of 64.4 seconds (p < 0.001). The average time to access an Amiodarone prescribing guideline with the App was 25.9 seconds (95% CI 12.9), versus 142.0 seconds (95% CI 44.8) using a computer. A difference of 116.1 seconds (p < 0.001).User feedback was collected after each stage of release within the hospital. Following final release, users rated how much time they felt it saved them. 96.1% of respondents felt it either saved them time a ‘few times a week’ (53.85%) or ‘significantly saved time every day’ (42.31%).The project has significantly improved staff satisfaction with how easily they can access clinical guidelines and telephone numbers. They clearly feel it has improved their working efficiency. This has been supported by quantitative measures of actual time saved using the App. The ability to access such information in as little time as possible may be even more pertinent where decision-making is time-critical – for example in Anaesthesia and Emergency Medicine. Further study into these specialties is warranted to determine whether mobile information can impact upon patient safety and clinical outcomes.
Impact of a Videoconference Educational Intervention on Physical Restraint and Antipsychotic Use in Nursing Homes: Results From the ECHO-AGE Pilot Study
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OBJECTIVES: US nursing homes care for increasing numbers of residents with dementia and associated behavioral problems. They often lack access to specialized clinical expertise relevant to managing these problems. Project ECHO-AGE provides this expertise through videoconference sessions between frontline nursing home staff and clinical experts at an academic medical center. We hypothesized that ECHO-AGE would result in less use of physical and chemical restraints and other quality improvements in participating facilities. DESIGN: A 2:1 matched-cohort study comparing quality of care outcomes between ECHO-AGE facilities and matched controls for the period July 2012 to December 2013. SETTING: Eleven nursing homes in Massachusetts and Maine. PARTICIPANTS: Nursing home staff and a hospital-based team of geriatrician, geropsychiatrist, and neurologist discussed anonymized residents with dementia. INTERVENTION: Biweekly online video case discussions and brief didactic sessions focused on the management of dementia and behavior disorders. MEASUREMENTS: The primary outcome variables were percentage of residents receiving antipsychotic medications and the percentage of residents who were physically restrained. Secondary outcomes included 9 other quality of care metrics from MDS 3.0. RESULTS: Residents in ECHO-AGE facilities were 75% less likely to be physically restrained compared with residents in control facilities over the 18-month intervention period (OR = 0.25, P = .05). Residents in ECHO-AGE facilities were 17% less likely to be prescribed antipsychotic medication compared with residents in control facilities (OR = 0.83, P = .07). Other outcomes were not significantly different. CONCLUSION: Preliminary evidence suggests that participation in Project ECHO-AGE reduces rates of physical restraint use and may reduce rates of antipsychotic use among long-term nursing home residents.
Hospital Readmission Rates Following Skills Training for Nurses Employed in Long-term Care Facilities
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Reducing hospital readmissions is a priority for health care providers and affects Medicare reimbursement. The purpose of this study was to determine whether there is a significant difference in readmission rates from long-term care facilities to hospitals with the implementation of a training program for long-term care nurses. The main findings revealed that the training did not significantly affect hospital readmissions; however, the organization saw a significant decrease in hospital readmissions after 24 months of data collection.
Reducing Physical Restraints in Nursing Homes: A Report From Maria Wolff and Sanitas
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OBJECTIVE: Physical restraints are associated with severe side effects and suffering. A comprehensive, person-centered, methodology was implemented in 41 Spanish nursing homes to safely eliminate restraints. METHODS: Data were collected in 2 waves: September 2011 (at the beginning of the intervention, n = 4361) and September 2014 (n = 5051). Use of 10 different types of physical restraints was recorded, as well as frequency of psychotropic medication prescription, falls, and mortality. RESULTS: Mean age was 83.4 (SD 8.5) and 63.5% of the residents had dementia. Frequency (95% confidence interval) of people having at least 1 restraint was reduced from 18.1% (17.0-19.3) to 1.6% (1.3-2.0). Use of benzodiazepines was also reduced, with no significant changes in other psychotropic medications and mortality. The rate of total falls increased from 13.1% (12.1-14.1) to 16.1% (15.1-17.1), with no significant increase in injurious falls. CONCLUSION: Physical restraints can almost completely be eliminated with reasonable levels of safety.
From QASC to QASCIP: successful Australian translational scale-up and spread of a proven intervention in acute stroke using a prospective pre-test/post-test study design
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OBJECTIVES: To embed an evidence-based intervention to manage FEver, hyperglycaemia (Sugar) and Swallowing (the FeSS protocols) in stroke, previously demonstrated in the Quality in Acute Stroke Care (QASC) trial to decrease 90-day death and dependency, into all stroke services in New South Wales (NSW), Australia’s most populous state. DESIGN: Pre-test/post-test prospective study. SETTING: 36 NSW stroke services. METHODS: Our clinical translational initiative, the QASC Implementation Project (QASCIP), targeted stroke services to embed 3 nurse-led clinical protocols (the FeSS protocols) into routine practice. Clinical champions attended a 1-day multidisciplinary training workshop and received standardised educational resources and ongoing support. Using the National Stroke Foundation audit collection tool and processes, patient data from retrospective medical record self-reported audits for 40 consecutive patients with stroke per site pre-QASCIP (1 July 2012 to 31 December 2012) were compared with prospective self-reported data from 40 consecutive patients with stroke per site post-QASCIP (1 November 2013 to 28 February 2014). Inter-rater reliability was substantial for 10 of 12 variables. PRIMARY OUTCOME MEASURES: Proportion of patients receiving care according to the FeSS protocols pre-QASCIP to post-QASCIP. RESULTS: All 36 (100%) NSW stroke services participated, nominating 100 site champions who attended our educational workshops. The time from start of intervention to completion of post-QASCIP data collection was 8 months. All (n=36, 100%) sites provided medical record audit data for 2144 patients (n=1062 pre-QASCIP; n=1082 post-QASCIP). Pre-QASCIP to post-QASCIP, proportions of patients receiving the 3 targeted clinical behaviours increased significantly: management of fever (pre: 69%; post: 78%; p=0.003), hyperglycaemia (pre: 23%; post: 34%; p=0.0085) and swallowing (pre: 42%; post: 51%; p=0.033). CONCLUSIONS: We obtained unprecedented statewide scale-up and spread to all NSW stroke services of a nurse-led intervention previously proven to improve long-term patient outcomes. As clinical leaders search for strategies to improve quality of care, our initiative is replicable and feasible in other acute care settings.
Transitional care in skilled nursing facilities: a multiple case study
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BACKGROUND: Among hospitalized older adults who transfer to skilled nursing facilities (SNF) for short stays and subsequently transfer to home, twenty two percent require additional emergency department or hospital care within 30 days. Transitional care services, that provide continuity and coordination of care as older adults transition between settings of care, decrease complications during transitions in care, however, they have not been examined in SNFs. Thus, this study described how existing staff in SNFs delivered transitional care to identify opportunities for improvement. METHODS: In this prospective, multiple case study, a case was defined as an individual SNF. Using a sampling plan to assure maximum variation among SNFs, three SNFs were purposefully selected and 54 staff, patients and family caregivers participated in data collection activities, which included observations of care (N = 235), interviews (N = 66) and review of documents (N = 35). Thematic analysis was used to describe similarities and differences in transitional care provided in the SNFs as well as organizational structures and the quality of care-team interactions that supported staff who delivered transitional care services. RESULTS: Staff in Case 1 completed most key transitional care services. Staff in Cases 2 and 3, however, had incomplete and/or absent services. Staff in Case 1, but not in Cases 2 and 3, reported a clear understanding of the need for transitional care, used formal transitional care team meetings and tracking tools to plan care, and engaged in robust team interactions. CONCLUSIONS: Organizational structures in SNFs that support staff and interactions among patients, families and staff appeared to promote the ability of staff in SNFs to deliver evidence-based transitional care services. Findings suggest practical approaches to develop new care routines, tools, and staff training materials to enhance the ability of existing SNF staff to effectively deliver transitional care.
The effects of a life goal-setting technique in a preventive care program for frail community-dwelling older people: a cluster nonrandomized controlled trial
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BACKGROUND: Frailty among older people is associated with an increased risk of needing care. There have been many reports on preventive care programs for frail older people, but few have shown positive effects on disability prevention. Physical exercise programs for frail older people affect elements such as physical fitness and balance, but are less effective for disability outcomes and are not followed up in the longer term. We developed a life goal-setting technique (LGST). Our objective was to determine the effect of a LGST plus standard preventive care program for community-dwelling frail older people. METHODS: We used a cluster nonrandomized controlled trial with seven intervention and nine matched control groups, with baseline assessment and follow-up at 3, 6, and 9 months. Participants were 176 frail older people, aged 65 years or over, living in the community in Izumi, Osaka, Japan. All participants attended regular 120 min preventive care exercise classes each week, over 3 months. They also received oral care and nutrition education. The intervention groups alone received life goal-setting support. We assessed outcomes longitudinally, comparing pre-intervention with follow-up. The primary outcome measure was health improvement according to the Japanese Ministry of Health, Labour and Welfare’s “Kihon Checklist” for assessment of frailty and quality of life (QOL), analyzed with a two-way ANOVA and post-test comparison. Secondary outcomes included physical functions and assessment of life goals. RESULTS: The improvement on the Kihon Checklist for the intervention group was approximately 60 % from baseline to 9-months follow-up; the control group improved by approximately 40 %. The difference between groups was significant at 3-month (p = 0.043) and 6-month (p = 0.015) follow-ups but not at 9-month (p = 0.098) follow-up. Analysis of QOL yielded a significant time x group interaction effect (p = 0.022). The effect was significant at 3 months in the intervention group, but at no time in the control group. CONCLUSION: A 3-month exercise program helped to decrease frailty and improve QOL in frail older people, and the addition of LGST increased its effectiveness. The LGST is a feasible and promising intervention for reducing risk of needing care.
Developing palliative care practice guidelines and standards for nursing home-based palliative care teams: a Delphi study
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CONTEXT: Lack of nursing home (NH)-specific palliative care practice guidelines has been identified as a barrier to improving palliative and end-of-life (EOL) quality of care. OBJECTIVES: The objectives of this study were to (1) assess which of the guidelines developed by the National Consensus Project, and the corresponding preferred care practices endorsed by the National Quality Forum, are important and feasible to implement in NHs; and (2) identify the operational standards for palliative care teams in NHs. METHODS: Two-round mail Delphi study. Based on the existing literature, a set of 7 domains with associated 22 palliative practice guidelines was drafted. We invited 48 NH leaders, including clinicians, to review the importance (10-point Likert scale) and the feasibility (5-point Likert scale) of these guidelines. Participants were also asked about palliative care team composition rounding frequency. RESULTS: The response rate to both rounds was 85%. With regard to importance, the mean rating for all guidelines was 8 or higher (ie, highly important), but there was variability in agreement with regard to 5 of the guidelines. The same 5 guidelines were also considered more difficult to implement (eg, costly, unrealistic). Overall, 17 palliative care guidelines were identified for use by NH palliative care teams. Five disciplines (social work, certified nurse assistant, nurse, physician, and nurse practitioner or physician assistant) were identified as comprising a core team and 3 were proposed as extended or ad hoc members. CONCLUSION: The palliative care guidelines and team standards identified in this study may be helpful in providing practical direction to NH administrators and staff looking to improve palliative care practice for their residents.
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Aging
A multi-organisation aged care emergency service for acute care management of older residents in aged care facilities
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This case study describes a multi-organisation aged care emergency (ACE) service. The service was designed to enable point-of-care assessment and management for older people in residential aged care facilities (RACFs). Design of the ACE service involved consultation and engagement of multiple key stakeholders. The ACE service was implemented in a large geographical region of a single Medicare Local (ML) in New South Wales, Australia. The service was developed over several phases. A case control pilot evaluation of one emergency department (ED) and four RACFs revealed a 16% reduction in presentations to the ED as well as reductions in admission to the hospital following ED presentation. Following initial pilot work, the ACE service transitioned across another five EDs and 85 RACFs in the local health district. The service has now been implemented in a further 10 sites (six metropolitan and four rural EDs) across New South Wales. Ongoing evaluation of the implementation continues to show positive outcomes. The ACE service offers a model shown to reduce ED presentations and admissions from RACFs, and provide quality care with a focus on the needs of the older person.
Preliminary Data: An Adapted Hospital Elder Life Program to Prevent Delirium and Reduce Complications of Acute Illness in Long-Term Care Delivered by Certified Nursing Assistants
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Nursing home (NH) residents have a high prevalence of delirium risk factors, experience two to four acute medical conditions (e.g., infections) each year, and have an incidence of delirium during these conditions similar to that of hospitalized older adults. Many NH residents with delirium do not return to their prior level of cognitive function. They are more likely to die, be hospitalized, and less likely to be discharged home than those without delirium. Research on the prevention or treatment of delirium in NHs is limited. This article describes the development and pilot testing of a multicomponent delirium prevention intervention in the NH setting adapted from the Hospital Elder Life Program (HELP-LTC). Activities to reduce the risk of delirium that were appropriate for functionally impaired NH residents were developed and delivered during treatment for and recovery from acute illness, a novel resident-targeting approach. Expertly trained certified nursing assistants (CNAs – a total of 1.4 full-time equivalent (FTE) positions-) visited residents throughout the facility and delivered the activities. The current study reports on incident delirium, delirium remission, cognitive and physical function change, hospitalization, and death associated with acute medical conditions as ascertained by a program coordinator. The integration and acceptance of the CNAs’ activities by residents and staff are also reported on. Hospitalization and death were ascertained in a nonintervention comparison group. Findings support a test of the intervention in a controlled trial. The potential effect is great; there are approximately 1.4 million NH residents in the United States and an estimated 1 million with dementia or cognitive impairment, an important delirium risk factor. An intervention would be broadly adoptable if a reduction in healthcare costs through prevention of hospitalization offset the cost of the program’s CNAs.
Mortality Risk of Antipsychotic Dose and Duration in Nursing Home Residents with Chronic or Acute Indications
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OBJECTIVES: To examine disease-specific associations between antipsychotic dose and duration and all-cause mortality. DESIGN: Retrospective cohort study. SETTING: A 5% random sample of Medicare beneficiaries who had a Minimum Data Set 2.0 clinical assessment completed between 2007 and 2009. PARTICIPANTS: Three mutually exclusive cohorts of new antipsychotic users with evidence of severe mental illness (SMI, n = 5,621); dementia with behavioral symptoms (dementia + behavior) without SMI (n = 1,090); or delirium only without SMI or dementia + behavior (n = 2,100) were identified. MEASUREMENTS: Dose and duration of therapy with antipsychotics were assessed monthly with a 6-month look-back. Dose was measured as modified standardized daily dose (mSDD), with a mSDD of 1 or less considered below or at recommended maximum geriatric dose. Duration was categorized as 30 or fewer, 31 to 60, 61 to 90, and 91 to 184 days for SMI and dementia + behavior and 7 or fewer, 8 to 30, 31 to 90, and 91 to 184 days for delirium. Complementary log-log models with mSDD and duration as time-dependent variables were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for mortality. RESULTS: In all three groups, new antipsychotic users with a mSDD of 1 or less had significantly lower mortality risk (HRSMI = 0.77, 95% CI = 0.67-0.88; HRdementia+behavior = 0.52, 95% CI = 0.36-0.76; HRdelirium = 0.61, 95% CI = 0.44-0.85) than peers with a mSDD greater than 1. Individuals with longer duration of antipsychotic use (91-184 days for SMI and delirium) had significantly lower mortality than those with a short duration of use (</=30 days for SMI; </=7 days for delirium). The interaction between dose and duration was statistically significant in the SMI cohort (P < .001). CONCLUSION: Lower mortality was observed with within-recommended dose ranges for dementia + behavior, SMI, and delirium and with long duration of antipsychotic use for the latter two disease groups. Prescribers should monitor antipsychotic dosage throughout the course of antipsychotic treatment and customize dose and duration regimens to an individual’s indications.
Fecal incontinence among nursing home residents: Is it still a problem?
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BACKGROUND: Fecal incontinence (FI) is a significant health problem among the elderly, with a devastating effect on their quality of life. The aim of the present study was to describe the prevalence and severity of FI among nursing home residents, and to investigate factors associated with FI. METHODS: This was a cross-sectional study conducted in nursing homes in Ostrava, Czech Republic. Demographics and comorbidities were extracted from medical records of nursing homes. Data regarding incontinence were obtained via face-to-face interviews with residents or extracted from registered nurses’ accounts (regarding residents with severe cognitive impairment). RESULTS: In total, 588 nursing home residents were enrolled into the study. FI was noted in 336 (57.1%) participating residents. The majority of FI residents (57.8%) reported FI episodes several times a week; daily FI episodes were found in 22.9% of the FI residents. The mean Cleveland Clinic Incontinence Score in FI residents was 17.2+/-1.8 (mean+/-SD). Factors associated with FI (statistically significant) were poor general health status (>/=4 comorbidities), urinary incontinence, cognitive-function impairment (dementia), decreased mobility, and length of nursing home residency. There was no association between FI and age, sex, body mass index, or living with/without a partner. CONCLUSIONS: Our data indicate that FI is still a serious health problem-FI currently affects more than half of the nursing home residents in Ostrava, Czech Republic. The study outcomes (revealed high prevalence and seriousness of FI) emphasize the importance of close monitoring and appropriately managing FI in nursing home residents.
Adverse effects of pneumonia on physical functioning in nursing home residents: Results from the INCUR study
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BACKGROUND: Pneumonia is a very common infection in the nursing home, but little is known about its effects on levels of individual functioning. The aim of this study was to examine adverse effects of pneumonia events on physical functioning in nursing home residents. METHODS: Data were used from the INCUR study, a 1-year prospective cohort study of older residents from 13 nursing homes in France. The sample consisted of 716 residents, who were assessed at baseline, 6 and 12 months. Pneumonia diagnosis was based on clinical conditions documented in medical records. Physical functioning was measured by Activities of Daily Living (ADL). Longitudinal associations between pneumonia and physical functioning were explored using Generalized Estimating Equations (GEE). RESULTS: Of 716 participants, 145 (20%) had one or more pneumonia events during 12 months follow-up. Mean age of the participants was 86.0 (SD=7.4)years, and 76% of them were female. Overall, participants had relatively low levels of physical functioning at baseline (Mean ADL=2.4 out of 6, SD=1.8). The GEE analyses adjusted for age, gender, baseline physical functioning, and hospitalization during follow-up showed that pneumonia events had adverse effects on ADL functioning (B=-0.21, SE=0.08, p=0.008). Pneumonia events were mainly associated with loss of independence in transferring from bed to chair and bathing. CONCLUSIONS: In a population of nursing home residents where levels of physical functioning were already relatively low, pneumonia events were associated with loss of physical functioning. These results highlight the importance of preventive interventions aimed at reducing pneumonia in nursing home residents.
The association between the utilization of long-term care services and mortality in elderly Koreans
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It is necessary to confirm the effect of long-term care insurance (LTCI) by identifying changes in mortality, whether benefits are used or not, as well as the effects of in-home and institutional services on mortality. The goal of this study was to identify the association between service use and the mortality rate in elderly Koreans. We used Cox proportional hazard regression models and the Kaplan-Meier survival curve method to estimate the hazard ratio and survival probability for death while adjusting for covariates. We detected a 27.8% mortality rate at the 40-month follow-up period. Male gender, advanced age and activities of daily living were risk factors for mortality. In all models, the hazard ratio of participant death of those using long-term care services was significantly lower than for those who did not use these services. Among the service users, the hazard ratio for participant death of institutional service users was significantly higher than it was for in-home service users. This study also identified the impact of the transition from in-home services to institutional services. A primary goal of LTCI is to promote health and life stabilization in the elderly. To both delay and prevent institutionalization, it is necessary to develop assistive devices and effective in-home services and ensure access of these for elderly patients.
Modifiable risk factors for nursing home admission among individuals with high and low dementia risk
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BACKGROUND: Strategies to prevent or delay nursing home admission in individuals with cognitive impairment are urgently needed. We hypothesized that physical inactivity, not consuming alcohol (as opposed to moderate alcohol use), and having a history of smoking predict nursing home admission among individuals with normal cognitive function, but these behavioral factors would have attenuated associations with nursing home admission among individuals with impaired cognition. METHODS: We performed a prospective cohort study among 7631 Health and Retirement Study participants aged 65+ at baseline. Baseline dementia risk (high versus low, based on brief psychometric assessments and proxy reports) and modifiable risk factors (physical inactivity, ever smoking, and not consuming alcohol) were used to predict nursing home admission in pooled logistic regression models. We evaluated whether estimated effects of modifiable factors varied by dementia risk, comparing both relative and absolute effects using interaction terms between dementia risk and each modifiable risk factor. RESULTS: Low dementia probability was associated with lower nursing home admission risk (RR=0.49; 95% CI: 0.41, 0.59). Physical inactivity (RR=1.27; 95% CI: 1.15, 1.41), ever smoking (RR=1.12; 95% CI: 1.01, 1.25), and not consuming alcohol (RR=1.28; 95% CI: 1.13, 1.45) predicted increased relative risk of nursing home admission regardless of cognitive status. The relative effects of modifiable risk factors were similar for those with low and high dementia risk. CONCLUSION: Although cognitive impairment associated with incipient dementia strongly predicts nursing home admission, this risk can be partially ameliorated with modifiable risk factors such as physical activity.
Long-term care services and support systems for older adults: The role of technology
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The aging of the population, especially the increase in the “oldest old,” is a remarkable achievement that presents both opportunities and challenges for policymakers, researchers, and society. Although many older adults enjoy relatively good health into their later years, many have one or more chronic conditions or diseases and need help with disease management activities or activities important to independent living. Technology is playing an increasingly important role in the health care arena and is becoming ubiquitous in health management activities. There are a variety of technology applications that can be used to enhance the mobility and quality of life of people who have limitations and help to foster the ability of those with chronic conditions to remain at home. Technology applications can also provide a central role in providing support to family caregivers in terms of enhancing access to information and community resources and connections to formal and informal support services. Monitoring technologies may also allow caregivers to check on the status or activities of their loved one while they are at work or at a distant location. Furthermore, telemedicine applications can aid the ability of care providers to monitor patients and deliver health services. The objective of this article is to highlight the potential role that technology can play in the provision of long-term support for older adults and their families. Challenges and barriers that currently limit the full potential of technology to be realized for these populations will also be discussed. Finally the role of psychological science toward maximizing the potential of technology applications in enhancing long term care and support services will be highlighted.
Exploring nursing expertise in residential care for older people: a mixed method study
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AIMS: To explore the expertise of Registered Nurses in residential care for older people. BACKGROUND: As older people in residential care have many complex dependencies, nursing expertise is an essential component of care excellence. However, the work of these nurses can be invisible and, therefore, unrecognized. Thus, additional attention is required to illuminate such nursing expertise. DESIGN: A mixed method design was used in this study. METHODS: The research took place in 2012 in the Republic of Ireland. Twenty-three case study nurses were recruited from nursing homes. Each case study nurse involved five data collection methods: shadowing, interview with a colleague, interview with a resident, a demographic profile and a director of nursing survey. The study was also informed by a modified focus group. Qualitative data were analysed using directed content analysis using a conceptual framework generated from the literature on nursing expertise. Quantitative data were analysed using SPSS and presented in descriptive statistics. FINDINGS: The findings from the case studies and the modified focus group are presented in seven themes, which represent nursing expertise in residential care of older people: transitions, context of the nursing home, saliency, holistic practice knowledge, knowing the resident, moral agency and skilled know how. CONCLUSION: Nursing expertise in residential care of older people is a complex phenomenon which encompasses many aspects of care delivery in a person-centred framework. By rendering this expertise visible, the need for appropriate and adequate skill mix for a growing residential care population is presented.
Apathy and Its Response to Antipsychotic Review and Nonpharmacological Interventions in People With Dementia Living in Nursing Homes: WHELD, a Factorial Cluster Randomized Controlled Trial
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OBJECTIVES: Apathy is common, impactful, and difficult to manage in people with dementia. We evaluated the efficacy of nonpharmacological interventions, exercise, and social interaction, in combination with antipsychotic review, to reduce apathy in people with dementia living in nursing homes in a cluster randomized controlled trial (RCT). METHODS: Well-being and health for people with dementia (WHELD) program included a 2 x 2 x 2 factorial cluster RCT involving people with dementia living in 16 nursing homes in the United Kingdom. All homes received training in person-centered care, and were randomized to receive antipsychotic review, social interaction, and exercise, either alone or in combinations. Apathy was one of the secondary outcomes of the WHELD trial, and it was measured by the Neuropsychiatric Inventory-nursing home version at baseline and 9 months (n = 273). We used multilevel mixed effects linear regression models to assess the impact of the interventions on apathy. RESULTS: Prevalence of apathy was 44.0% (n = 120; 95% confidence interval [CI] 38.1%-49.9%) at baseline. Severity of apathy had significant positive correlations with dementia severity, neuropsychiatric symptoms, depressive symptoms, agitation, and the needs of the people with dementia (P < .001). Antipsychotic review reduced antipsychotic use, but it significantly increased apathy (beta = 5.37; SE = 0.91; P < .001). However, antipsychotic review in combination with either social interaction (beta = -5.84; SE = 1.15; P < .001) or exercise (beta = -7.54; SE = 0.93; P < .001) significantly reduced apathy. CONCLUSIONS: Antipsychotic review can play a significant role in improving apathy in people with dementia living in nursing homes, when combined with psychosocial interventions such as social interaction and exercise. Guidance must be adapted to reflect this subtlety in care.
Multisensory Stimulation as an Intervention Strategy for Elderly Patients With Severe Dementia: A Pilot Randomized Controlled Trial
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The objective of this study was to compare the effect of multisensory stimulation environment (MSSE) and one-to-one activity sessions in the symptomatology of elderly individuals with severe dementia. Thirty-two participants were randomly assigned to the following 3 groups: MSSE, activity, and control group. The MSSE and activity groups participated in two 30-minute weekly sessions over 16 weeks. Pre-, mid-, and posttrial; 8-week follow-up behavior; mood; cognitive status; and dementia severity were registered. Patients in the MSSE group demonstrated a significant improvement in the Neuropsychiatric Inventory and Bedford Alzheimer Nursing Severity Scale scores compared with the activity group. Both MSSE and activity groups showed an improvement during the intervention in the Cohen-Mansfield Agitation Inventory aggressive behavior factor and total score, with no significant differences between groups. The MSSE may have better effects on neuropsychiatric symptoms and dementia severity in comparison with one-to-one activity sessions in patients with severe dementia.
Do integrated care structures foster processes of integration? A quasi-experimental study in frail elderly care from the professional perspective
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OBJECTIVE: This study explores the processes of integration that are assumed to underlie integrated care delivery. DESIGN: A quasi-experimental design with a control group was used; a new instrument was developed to measure integration from the professional perspective. SETTING AND PARTICIPANTS: Professionals from primary care practices and home-care organizations delivering care to the frail elderly in the Walcheren region of the Netherlands. INTERVENTION: An integrated care intervention specifically targeting frail elderly patients was implemented. MAIN OUTCOME MEASURES: Structural, cultural, social and strategic integration and satisfaction with integration. RESULTS: The intervention significantly improved structural, cultural and social integration, agreement on goals, interests, power and resources and satisfaction with integration. CONCLUSIONS: This study confirms that integrated care structures foster processes of integration among professionals. TRIAL REGISTRATION: Current Controlled Trials ISRCTN05748494.
Transitions From Hospitals to Skilled Nursing Facilities for Persons With Dementia: A Challenging Convergence of Patient and System-Level Needs
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PURPOSE OF THE STUDY: To describe skilled nursing facility (SNF) nurses’ perspectives on the experiences and needs of persons with dementia (PwD) during hospital-to-SNF transitions and to identify factors related to the quality of these transitions. DESIGN AND METHODS: Grounded dimensional analysis study using individual and focus group interviews with nurses (N = 40) from 11 SNFs. RESULTS: Hospital-to-SNF transitions were largely described as distressing for PwD and their caregivers and dominated by dementia-related behavioral symptoms that were perceived as being purposely under-communicated by hospital personnel in discharge communications. SNF nurses described PwD as having unique transitional care needs, which primarily involved needing additional discharge preplanning to enable preparation of a tailored behavioral/social care plan and physical environment prior to transfer. SNF nurses identified inaccurate/limited hospital discharge communication regarding behavioral symptoms, short discharge timeframes, and limited nursing control over SNF admission decisions as factors that contributed to poorer-quality transitions producing increased risk for resident harm, rehospitalization, and negative resident/caregiver experiences. Engaged caregivers throughout the transition and the presence of high-quality discharge communication were identified as factors that improved the quality of transitions for PwD. IMPLICATIONS: Findings from this study provide important insight into factors that may influence transitional care quality during this highly vulnerable transition. Additional research is needed to explore the association between these factors and transitional care outcomes such as rehospitalization and caregiver stress. Future work should also explore strategies to improve inter-setting communication and care coordination for PwD exhibiting challenging behavioral symptoms.
Pain, delirium, and physical function in skilled nursing home patients with dementia
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OBJECTIVE: Skilled nursing facilities (SNFs) are major sites of postacute care for patients with dementia. A recent Office of the Inspector General report indicated that outcomes in SNFs are suboptimal because of poor-quality treatment, including the failure to provide needed care. Pain is frequently unrecognized and untreated in patients with dementia. The aim of this exploratory study was to examine the effect daily pain has on delirium and physical function in patients with dementia in SNFs. The association of daily pain with discharge disposition was also examined. DESIGN: Secondary analysis of data from an on-going randomized clinical trial. SETTING: Eight SNFs located in central and northeast Pennsylvania. PARTICIPANTS: A total of 103 SNF patients with adjudicated dementia and delirium diagnoses and a mean age of 86 (+/-6.8) years; most were women (66%) and white (98%). MEASUREMENTS: Measures of pain (Pain Assessment in Advanced Dementia), delirium (Confusion Assessment Method), and physical function (Barthel Index) were taken daily for 30 days or until discharge. RESULTS: On days when participants experienced greater than their average level of pain, they also experienced more delirium symptoms (P < .001) and lower physical function (P < .001). Participants with higher levels of average daily pain were more likely to die (odds ratio [OR] 6.306, 95% confidence interval [CI] 1.914-20.771, P = .003) or be placed in a nursing home (OR 4.77, 95% CI 1.7-13.2, P = .003) compared with returning to the community at 3-month follow-up. CONCLUSION: Greater attention to pain in patients with dementia may be a potential solution to some of the quality problems and high costs of care in SNFs.
Changes in Leisure Activities and Dimensions of Depressive Symptoms in Later Life: A 12-Year Follow-Up
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PURPOSE OF STUDY: Although leisure activities benefit the mental health of the elderly, the effect of changes in leisure activities on dimensions of depressive symptoms remains unclear. This investigation examined the influences of changes in intellectual, social, and physical activities between waves on four dimensions of depressive symptoms at follow-up. DESIGN AND METHODS: Random effects modeling was utilized with data from a nationwide longitudinal study conducted in Taiwan. The study data comprised 6,942 observations from 2,660 elders over a 12-year period. RESULTS: The results suggested that changes in physical activities contributed to depressive symptoms which reflected positive affect in the later wave. Increased social activities between waves predicted higher positive affect and lower interpersonal difficulties scores at follow-up. Increased intellectual activities between waves did not substantially affect any domain of depressive symptoms. In contrast, declines in intellectual activities between waves predicted higher scores in three depressive symptoms domains, including depressed mood, somatic symptoms, and interpersonal difficulties. IMPLICATIONS: Engagement in a varied range of activities benefits mental health among elders more than participation in any single type of activity among elders. Reducing physical activities can lower positive affect, while the adverse effect may be balanced by increasing social activities. Also, the impact of decreasing intellectual activities on the interpersonal difficulties domain of depressive symptoms may be offset by increasing social activities.
Health Reports – Alzheimer’s disease and other dementias in Canada
Using data from nationally representative self-report surveys, this study examines Canadians aged 45 or older living with Alzheimer’s disease or other dementia. Separate estimates are presented for resident of long-term health care facilities (Survey of Neurological Conditions in Institutions in Canada) and for those living in private households (Canadian Community Health Survey Neurological Conditions Prevalence File).
Dementia and Comorbidities: Ensuring Parity of Care
This report demonstrates that a failure to prevent, diagnose, and treat depression, diabetes and urinary tract infections in people with dementia could be costing the UK’s health and social care system up to nearly £1 billion per year.
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Events
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KT Canada Annual Scientific Meeting
Join the discussion on SCALING UP AND SUSTAINABILITY through attendance at the KT Canada Annual Scientific Meeting.
Symposium on Research Involving Persons with Dementia
This Symposium will bring together individuals with expertise, and lived experience for the purpose of: Exploring ways to engage people with dementia and care partners in dementia research; Networking with researchers, practitioners, policy makers and people with lived experience; Discussions and exchange of ideas on how people with lived experience can be more central to decision-making about research that is important to them.
Online
Robert TerSteege, CIRS & Valerie Borggard, Navigator for the MS Knowledge Network will provide an overview of how care partners can navigate different systems and share different resources that care partners can use to help support themselves and their loved ones living with chronic health conditions.
Fighting for Dignity: Prevention of Harmful Resident-to-Resident Interactions in Dementia in LTC
Based on an extensive review of practice and research literature and an observational study conducted by Dr. Caspi, this introductory presentation identifies: (1) Consequences of these behavioral expressions; (2) Common contributing factors, causes, and situational triggers; (3) Key psychosocial prevention and de-escalation strategies.
Courses
Realist Reviews and Realist Evaluation Short Course Department of Continuing Education @UNIOFOXFORD
This course will provide an understanding of realist review (or synthesis) and realist evaluation. Participants should then be able to apply their new knowledge and skills to their own realist research project, regardless of which field of research they come from. In health care and many other fields of research, interventions are often described as being complex and have outcomes that are dependent on context. When these complex interventions fail to achieve their desired outcomes, the explanation frequently provided is because they are both complex and context dependent. Realist research approaches (realist evaluation or realist review) can help make sense of these types of interventions or programmes. The approaches are theory driven – developing structurally coherent explanations of interventions and test these against empirical data.
News
AHRQ Leads Efforts to Prevent Nursing Home Pressure Ulcers
AHRQ’s Safety Program for Nursing Homes: On-Time Prevention has shown impressive potential to reduce pressure ulcers. The On-Time program supports prevention efforts by delivering timely, needed information to nursing home staff via specialized clinical reports that are pre-programmed into EMRs.
Why Nurses Were Meant to Be Improvers
Nurses know more about improvement than they often realize. The article provides a clinical example alongside a team-based example of a quality improvement project.
What is the potential of patient shadowing as a patient-centred method?
The potential of a specific observational method—that is, patient shadowing—is now being recognised as an important method of advance patient-centred care both conceptually and practically. Yet it is clear that patient shadowing is not a ‘quick and simple’ approach.
Over the last decade, nearly all countries for which we have data have seen an increase in the proportion of LTC users living at home, with particularly large shifts in France, Sweden and Korea.
A new learning network funded by AHRQ will explore with stakeholders how patient-centered outcomes research (PCOR) findings can be incorporated into clinical practice through health information technology–enabled clinical decision support (CDS).
Harnessing big data for health
The health sector should not be left to its own scrabbling to find funds to support big data research for public health benefit while industry is investing heavily in using big data for market research.
‘Hidden army’ of carers in their 80s, says Age UK
The number of people in their 80s or older who are relied on as carers has rocketed in the last seven years, according to a charity.
Alzheimer’s: Inside a Strangely Upbeat Story
In this podcast, Mr. Kleinfield explains and describes his reporting on a woman who talked about losing her ego as casually as she might mention having lost her keys, but who found herself feeling purposeful and alive to the beauty in all things.
Report offers solutions for B.C.’s aging population
B.C.’s health system is not prepared for the challenges of its aging population and changes are needed, according to a policy paper released today by the B.C. Care Providers Association.
Government still lets nursing homes improperly drug seniors
The good news from a study released this week is that it is possible for nursing homes to dramatically cut back on the practice of improperly doping elderly residents with dangerous anti psychotic drugs. The bad news is that government isn’t requiring them to do so, writes Thomas Walkom.
Why Pleasant Mealtimes Could Be Key to Alzheimer’s Care
Enhanced atmosphere reduces odds of malnutrition, dehydration, study suggests.
Should we Rethink Causes of Dementia?
University of Adelaide researchers have developed a new theory for the causes of dementia and other neurodegenerative diseases, involving an out-of-control immune system.
Too many delay seeking dementia diagnosis, charity says
More than half of those seeking a diagnosis for dementia have delayed going to their GP by at least a year, according to a survey carried out by the Alzheimer’s Society.
Nursing homes urged to rethink drugging people with dementia
Getting many residents off inappropriate antipsychotic prescriptions saved costs, while sharply reducing falls and abusive behaviour.
What’s the robust evidence of safe staffing levels and skill mix in a community care provider organisation? Nurse Carrie Jackson’s ran an economic assessment to consider the costs and the benefits of implementing a workload analysis tool from the perspective of a community care provider.
New study to assess safe staffing levels on hospital wards
Bangor University researchers will be working with the University of Southampton on a new study to assess the implementation, impact and costs of safe staffing policies for nursing in acute trusts. The study will be led by Jane Ball and Professor Peter Griffiths at the University of Southampton, with collaboration from Bangor University’s Professor Jo Rycroft-Malone, Pro Vice-chancellor and Professor Christopher Burton from the School of Healthcare Sciences.
Less waiting, more choices for residents at Grenfell Pioneer Home
Residents living at Grenfell Pioneer Home are getting their breakfast sooner and have more choices about what they can eat, thanks to recent process improvements at the long-term care facility in Regina Qu’Appelle Health Region.
The one-man crusader driven to improve lives with dementia
Spurred by his mother’s early-onset dementia, James Ashwell set up Unforgettable – advising on everything from lacy incontinence knickers to powers of attorney.
Have your say: Help set dementia research priorities in Canada
This study, the Canadian Dementia Priority Setting Partnership, aims to identify priority areas for Canadian dementia researchers and research funding organizations. Your responses to this questionnaire are extremely important. By participating in this study, you can help researchers address what matters most to Canadians like you who are affected by dementia.
New National Results: Taking seniors off antipsychotics shows dramatic improvement in care
The Canadian Foundation for Healthcare Improvement (CFHI) today released dramatic results from a bold pan-Canadian initiative reducing the inappropriate use of antipsychotic medication among seniors in long term care (LTC) – fewer falls, less aggressive behaviours and resistance to care, and an improved quality of life for residents and their families.
Atlantic premiers seek more health-care funding for seniors
Atlantic premiers want a new deal on health-care funding with the federal government that would see additional dollars go to jurisdictions, such as theirs, whose populations are disproportionately elderly.
Resources
What’s the Risk? Understanding Absolute and Relative Risk Reduction
Studies on the effectiveness of public health interventions can present the results in different ways. Knowing how to interpret these results will not only help you understand how effective an intervention is, but also how meaningful it will be to your population. In this eight-minute video, we look at how three statistics – baseline risk, relative risk and absolute risk – are connected and how using them together can help you make better informed public health decisions.
This is the current release of the guideline. This guideline updates a previous version: American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012 Apr;60(4):616-31.
Government of Canada Supports Seniors: Taking Action to Reduce Social Isolation
A new plan to address social isolation among older adults is being implemented by the Pan-Edmonton Group Addressing Social Isolation (PEGASIS) to increase community participation and provide connections to essential social services and support.
40 Things Editors Won’t Tell You (But You Need to Know)
These nurse editors have also walked in the shoes of writers, peer reviewers, and editorial advisory board members. You can use their advice to enhance your own publishing experience.
AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing
The Agency for Healthcare Research and Quality (AHRQ) created On-Time Pressure Ulcer Healing to help nursing homes with electronic medical records address pressure ulcers that are slow to heal.
Opportunities
CIHR is looking to fill a dedicated College Chair position with expertise in patient and citizen engagement, and experience with peer review processes. This Chair will ensure patient and citizen perspectives are integrated throughout the implementation of the College of Reviewers. The selected individual will join the other College Chairs who will work in collaboration with CIHR’s Chief Scientific Officer to recruit and oversee the peer reviewer membership base and provide the strategic guidance needed to build the College of Reviewers into a national resource.
NIHR CLAHRC South West Peninsula (PenCLAHRC) are looking to appoint an Associate Professor with demonstrable expertise in health services research. The successful candidate will be expected to develop and support research projects adopted by PenCLAHRC and to identify research and implementation ideas in their own field and develop these into funding proposals and a programme of research.
