July 15, 2020

Grants & Awards
Events & Training Opportunities


Canada’s Senate interim report on COVID-19: Possible second wave threatens vulnerable Canadians
The Federal Response to COVID-19: Our Interim Observations

The Senate Committee on Social Affairs, Science and Technology has been studying the federal government’s response to the COVID-19 pandemic with respect to vulnerable population groups, including seniors, health care workers, essential frontline workers, young people and people with mental health conditions. The committee’s work is far from complete; the committee released this interim report to provide preliminary observations on areas of the government’s response that would benefit from more attention.

Carole Estabrooks in the news
Experts urge federal standards, investment to fix long-term care system

Report calls on Ottawa to overhaul long-term care system

Regarding this pandemic, how do Canadian LTC facilities compare internationally? Quick answer, poorly]
Pandemic Experience in the Long-Term Care Sector How Does Canada Compare with Other Countries?

This short analysis examines the similarities and differences between Canada’s pandemic experience in LTC and that of other countries in the Organisation for Economic Co-operation and Development (OECD). Specifically, it focuses on 3 areas of comparison:
• COVID-19 outcomes in LTC (cases and deaths);
• Baseline sector characteristics; and
• Policy responses to address the pandemic.
Comparisons must be interpreted with extreme caution due to rapidly evolving infection case numbers, different definitions of LTC and variations across countries in COVID-19 testing and reporting practices.

Royal Society of Canada Report on COVID-19 and LTC
Restoring Trust:
COVID-19 and The Future of Long-Term Care

Pat Armstrong, Véronique Boscart, Gail Donner, Francine Ducharme, Carole Estabrooks (Chair), Colleen Flood, Janice Keefe, James Silvius, Sharon Straus, Michael Wolfson
Established by the President of the Royal Society of Canada in April 2020, the RSC Task Force on COVID-19 was mandated to provide evidence-informed perspectives on major societal challenges in response to and recovery from COVID-19.

The Task Force established a series of Working Groups to rapidly develop Policy Briefings, with the objective of supporting policy makers with evidence to inform their decisions.

Policy Briefings have three sections:

Context and policy status before COVID-19
Vulnerabilities exposed as a result of COVID-19
Principles for action and leading options.

New article by Susan Slaughter, Carole Estabrooks, and Adrian Wagg
Effectiveness of reminders to sustain practice change among direct care providers in residential care facilities: a cluster randomized controlled trial.
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S. E. Slaughter, M. Eliasziw, C. Ickert, C. A. Jones, C. A. Estabrooks and A. S. Wagg.
Implement Sci 2020 Jul 1;15(1):51-020-01012-z
The study purpose was to compare the effectiveness of monthly or quarterly peer reminder knowledge translation interventions, with monthly or quarterly paper-based reminders, to sustain a mobility innovation, the sit-to-stand activity. METHOD: A cluster RCT using a stratified 2 × 2 factorial design was conducted in 24 Canadian residential care facilities with 416 residents and 54 peer reminder care aides. The 1-year intervention included two intensities of reminders (high: socially based peer reminders delivered by volunteer care aides to other care aides; low: paper-based reminders posted in residents’ rooms), at two frequencies (monthly; every 3 months). Intervention fidelity was assessed using questionnaires and observations. Monthly sustainability rate of the sit-to-stand activity was calculated as the percentage of opportunities that residents successfully completed the activity in 30 days. Residents’ sustainability rates were analyzed using a linear mixed model that mirrored the clustered repeated-measures factorial trial design. The model included a random intercept to account for clustering within sites. An unstructured covariance structure characterized the interdependence of repeated measures over time. RESULTS: Twenty-four sites were randomized. One site was excluded because of falsifying data, leaving 23 sites and 349 residents for intention-to-treat analysis. Paper reminders were implemented with high fidelity across all arms (91.5% per protocol), while the peer reminders were implemented with moderate fidelity in the monthly group (81.0% per protocol) and poor fidelity in the quarterly group (51.7% per protocol). At month 1, mean sustainability ranged from 40.7 to 47.2 per 100 opportunities, across the four intervention arms (p = 0.43). Mean rate of sustainability in the high intensity, high frequency group diverged after randomization, yielding statistically significant differences among the groups at 4 months which persisted for the remainder of the trial. After 12 months, the mean sustainability in the high intensity, high frequency group was approximately twice that of the other three groups combined (64.1 versus 37.8 per 100 opportunities, p < 0.001). CONCLUSIONS: A monthly peer reminder intervention was more effective than a quarterly peer reminder intervention, a monthly paper-based reminder intervention, and a quarterly paper-based reminder intervention, in supporting care aides to sustain a mobility innovation in residential care facilities over 1 year. TRIAL REGISTRATION: ClinicalTrials.gov , NCT01746459. Registered 11 December 2012: https://clinicaltrials.gov/ct2/show/NCT01746459.

Handbook on Implementation Science now available via University of Alberta libraries
Handbook on Implementation Science

Per Nilsen and Sarah A. Birken (editors)
The Handbook on Implementation Science provides an overview of the field’s multidisciplinary history, theoretical approaches, key concepts, perspectives, and methods. By drawing on knowledge concerning learning, habits, organizational theory, improvement science, and policy research, the Handbook offers novel perspectives from a broad group of international experts in the field representing diverse disciplines. The editors seek to advance implementation science through careful consideration of current thinking and recommendations for future directions.

New article by Anita Kothri
Exploring the knowledge translation of domestic violence research: A literature review.
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J. Cameron, C. Humphreys, A. Kothari and K. Hegarty.
Health Soc Care Community 2020 Jul 2
There is growing recognition of the links between knowledge translation, policy and practice, particularly in the domestic violence research area. A literature review applying a systematic approach with a realist lens was the preferred methodology. The review answered the following question: What are the mechanisms of change in research networks which ‘work’ to support knowledge translation? A search of eight electronic databases for articles published between 1960 and 2018 was completed, with 2,999 records retrieved, 2,869 records excluded and 130 full-text articles screened for final inclusion in the review. The inclusion criteria were purposefully broad, including any study design or data source (including grey literature) with a focus on domestic violence knowledge translation. The analysis of included studies using a realist lens identified the mechanisms of change to support knowledge translation. A disaggregation of the included studies identified five theories focused on the following outcomes: (1) develop key messages, (2) flexible evidence use, (3) strengthen partnerships, (4) capacity building and (5) research utilisation. This review adds to our understanding of knowledge translation of domestic violence research. The mechanisms of change identified may support knowledge translation of research networks. Further research will focus on exploring the potential application of these program theories with a research network.

New article by Alison Kitson
Experiences of using the i-PARIHS framework: a co-designed case study of four multi-site implementation projects
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S. C. Hunter, B. Kim, A. Mudge, et al.
BMC Health Serv Res 2020 Jun 23;20(1):573-020-05354-8
The integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework is an implementation framework that has been developed and refined over the last 20 years. Its underlying philosophy is that implementing research into healthcare practice is complex, unpredictable and non-linear which therefore requires a flexible and responsive approach to implementation. Facilitation is recognized as the central ingredient of this approach, and i-PARIHS now provides a Facilitation Guide with associated tools. This multiple case study of four implementation projects explored how the i-PARIHS framework has been practically operationalized by diverse implementation project teams. METHODS: A co-design approach was used to elicit the experiences of four implementation project teams who used the i-PARIHS framework to guide their implementation approach. We conducted the established co-design steps of (i) setting up for success, (ii) gathering the experience, and (iii) understanding the experience. In particular we explored teams’ approaches to setting up their projects; why and how they used the i-PARIHS framework and what they learnt from the experience. RESULTS: We found both commonalities and differences in the use of i-PARIHS across the four implementation projects: (i) all the projects used the Facilitation Checklist that accompanies i-PARIHS as a starting point, (ii) the projects differed in how facilitation was carried out, (iii) existing tools were adapted for distinct phases: pre-implementation, during implementation, and post-implementation stages; and (iv) project-specific tools were often developed for monitoring implementation activities and fidelity. CONCLUSIONS: We have provided a detailed overview of how current users of i-PARIHS are operationalising the framework, which existing tools they are using or adapting to use, and where they have needed to develop new tools to best utilise the framework. Importantly, this study highlights the value of existing tools from the published i-PARIHS Facilitation Guide and provides a starting point to further refine and add to these tools within a future Mobilising Implementation of i-PARIHS (or “Mi-PARIHS”) suite of resources. Specifically, Mi-PARIHS might include more explicit guidance and/or tools for developing a structured implementation plan and monitoring fidelity to the implementation plan, including recording how strategies are tailored to an evolving context.


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Grants & Awards

SPOR 2020 Seed Grant: Advancing the Science of Guideline Development in a Patient-Oriented Research Setting

DEADLINE 4 October
The SPOR Evidence Alliance Seed Grant aims to encourage a culture of learning, innovation, and advancement of science in the areas of knowledge synthesis, guideline development, knowledge translation, and patient-oriented research by funding methods projects at the conceptual stage.

Only projects studying methodological advancements of guideline development in a patient-oriented research setting will be considered; guideline projects themselves are not eligible for inclusion. Successful projects must have a strong focus on patient-oriented research.

WCHRI Clinical/community Research Integration Support Program CRISP

DEADLINE 4 September
The Clinical/Community Research Integration Support Program (CRISP) funds clinical and/or community research that has the potential to improve health outcomes and/or influence clinical practice at the point of care for women and/or children.


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

COVID-19 and Long Term Care

Collection of articles on COVID and LTC is available here

COVID-19 and Resident Care

Impact of COVID-19 on residents of Canada’s long-term care homes – ongoing challenges and policy response

Amy T. Hsu and Natasha Lane
International Long Term Care Policy Network
Key findings
• While there are many sources of data on the impact of COVID-19 on the Canadian population in general, timely information on the number of confirmed cases of COVID-19 in Canadian long-term care homes is less accessible.
• As new information becomes available and cases evolved or resolved, we have observed changes to previously estimated prevalence and case fatality of residents in Canadian longterm care homes.
• Case fatality rate among residents in Canadian long-term care homes is approximately 20%. This is roughly 5% higher than the global case fatality rate among people over the age of 80.
• Based on publicly available information, we estimate that deaths in long-term care residents represent approximately 63% of all COVID-19 deaths in Canada.
• Between-province differences in the proportion of adults aged 80+ years living in long-term care explains why long-term care residents constitute >50% of COVID-19 deaths in some provinces, but not others.
• Given the vulnerability of residents in long-term care homes, infection prevention is the most effective strategy to reduce overall fatality in this population.
• Policy measures to ensure adequate staffing and limit movement of healthcare workers between multiple sites is key in helping to prevent continued spread of COVID-19 and associated mortality in Canadian long-term care home residents.

The COVID-19 pandemic in UK care homes – revealing the cracks in the system

R. Devi ; K. Hinsliff-Smith ; C. Goodman ; A.L Gordon
The Journal of Nursing Home Research Science (JNHRS). http://dx.doi.org/10.14283/jnhrs.2020.17
It was clear from the experiences of Italy and Spain that the already compromised care home sector in the UK would struggle when faced with the COVID-19 pandemic. The pandemic has, though, been catastrophic for many care homes. In England and Wales, 29,393 excess deaths were reported for the care home sector between 28th December 2019 and 12th June 2020 (9). 19,394 deaths were directly attributable to COVID-19. As of 12th June, care home deaths caused by COVID-19 comprised 47% of all deaths attributable to COVID-19 in England and Wales.
The makings of this catastrophic death toll lie in the ways in which successive administrations have refused to plan proactively for care in care homes. These long-term deficiencies have manifested in important systematic failures during the pandemic.

COVID-19 Epidemic in the Nursing Home – the German Experience

S. Grund ; M. Gosch ; T. Laurentius ; C. Bollheimer ; C. Becker ; J.M. Bauer
The Journal of Nursing Home Research Science (JNHRS). http://dx.doi.org/10.14283/jnhrs.2020.16
Until mid of June 2020 186.269 Covid-19 infections were confirmed across Germany and 8.787 infected persons had died with a mortality rate around 4.2%. 172.000 persons had recovered then. Based on the report provided by the Robert-Koch-Institut (RKI) more than 85% of the deceased persons were beyond age 70.
In Germany 14.500 nursing homes with more than 800.000 residents have been registered. German nursing home residents show a wide range of pre-existing conditions their functionality usually being seriously impaired. As a consequence they must be regarded as highly vulnerable.
Based on the latest report 17.278 residents and 9.654 staff member of collective living quarters were infected by Covid-19. The term collective living quarters refers to nursing homes and to refugee centers and homeless shelters as well. However, the vast majority of infected persons in this category were nursing home residents and specific recommendations for their protection were drawn up (3). Among the infected residents 22.9% were treated in hospitals and 4.2 of the staff members. 19,9% of infected residents had died, but only 0.5% of infected staff members.

Strategy for Residents of Nursing Homes Facing the SARS-COV2 Epidemic in France

S. Vienne-Noyes ; L. Andre ; Y. Rolland
The Journal of Nursing Home Research Science (JNHRS). http://dx.doi.org/10.14283/jnhrs.2020.15
In December 2019, a new virus – SARS-Cov 19 – appeared, which rapidly evolved from local spread in China to a pandemic. In France, the first clusters were identified at the beginning of February, mainly in the North-East, causing a massive influx of infected patients in hospitals. Significant disparities have been observed between the 8 regions of France. On March 17, during the national confinement order for the general population in France, nearly 1,000 cases were already confirmed in some parts of the Northeast, while other parts in the south recorded fewer than 50 cases.
The elderly are not only more easily affected by SARS-Cov 19, but are also more at risk of reporting serious forms and complications due to physiological aging, impaired immune function and multi-morbidities. The mortality rate from covid-19 infection has been reported to be as high as 30% in this population. Preventing the entry of the virus into Nursing Homes (NHs) and avoiding the chain of contamination within the NHs quickly emerged as a priority in the strategy to combat the epidemic in France.

Nursing Home Care In Austria During SARS-COVID 19 Pandemic 2020

R. Roller-Wirnsberger ; S. Lindner ; A. Matijevic ; E. Stolz ; G. Wirnsberger
The Journal of Nursing Home Research Science (JNHRS). http://dx.doi.org/10.14283/jnhrs.2020.14
In Austria, the first confirmed case of COVID-19 disease was diagnosed in Tyrol on February 25th, 2020. Given the highly contagious nature of the virus, SARS-CoV-2 spread within days, particularly affecting older and frail people in the country. Up to June 12th, 2020 16,868 confirmed cases of COVID-19 are documented in Austria, 22% of which were aged 65 years and over. 94% of the deceased COVID-19 patients were over the age of 65 years. Over the past 3 months, the Austrian public health body detected 355 clusters of disease accumulation, 61 in one of the total 900 Austrian nursing home institutions (22.8% share of total cluster detection). In total, 833 nursing home residents have been tested positive for SARS-CoV-2 infection by real time Polymerase Chain Reaction (rt-PCR) up to this date. 222 of those residents died from COVID-19 in the last weeks.
The Austrian government, together with the Austrian National Institute for Public Health, therefore released recommendations how to best manage prevention, diagnostics and therapy of suspected SARS-Cov-2 positive nursing home residents in Austrian care facilities mid of March 2020. These “Austrian recommendations” were based on advice from the World Health Organization (WHO) as well as the CDC.

The Experience of Managing Covid-19 In Irish Nursing Homes In 2020

D.W. Molloy ; C. O’Sullivan ; R. O’Caoimh ; E. Duggan ; K. Mcgrath ; M. Nolan ; J. Hennessy ; G. O’Keeffe ; K. O’Connor
The Journal of Nursing Home Research Science (JNHRS). http://dx.doi.org/10.14283/jnhrs.2020.13
By 20th May, the Department of Health had confirmed 24,315 cases and 1,571 deaths, a rate of 4,931 cases per million and 319 deaths per million population. Over 90% of those who died were aged 65 or older, and most had underlying illnesses. The median age of those who died was 83 years, compared to the median age of 48 for all confirmed cases. This older age group accounted for more than 26% of all confirmed cases and 14% were aged 80 or more, despite only making up 3% of the population. Some 83% of patients in ICU had underlying conditions, whose median age was 60. By April 30th there were 369 clusters of the disease in residential care settings, including 219 in nursing homes

COVID-19 in LTC – Reflections from Ontario Canada

A. Moser ; P. Pariser ; A. Verma ; F. Razak ; B. Wong ; L. Pus ; S. Feldman
The Journal of Nursing Home Research Science (JNHRS). http://dx.doi.org/10.14283/jnhrs.2020.12
The Novel Coronavirus, COVID-19 began circulating among humans in late December 2019. The first cases in Canada were identified in February, with the majority of initial cases linked to travel. By June 5, 2020, there were over 94,000 cases of COVID-19 in Canada with 7652 deaths, with over 75% of deaths being individuals who resided in nursing homes. This deadly virus has exposed many opportunities for improvement in the nursing home sector in Canada. We will focus on our experience in the Province of Ontario, Canada.

Struggling with COVID 19 Pandemic in Nursing Homes: the Case of Spain

L. Rodríguez-Mañas
The Journal of Nursing Home Research Science (JNHRS). http://dx.doi.org/10.14283/jnhrs.2020.11
According the official figures released by the Spanish Ministry of Health about covid19 in Spain, dated on 10th May, in Spain there was 31,899 causalities due to coronavirus. 9,642, that is 30.2% of the total, took place in Nursing Homes (1). A figure lower than the one recorded in Belgium, France, Ireland, Canada or Norway, where the percentage of people dying in Nursing Homes exceeded 50% of total deaths, but high enough to be consider a true tragedy.
The first case officially recognized in Spain occurred in January but until 5th of March the health authority did not release its first report containing any rules for the Nursing Homes.

COVID-19 epidemic in the Nursing Homes in Belgium.

S. Gillain ; J.-L. Belche ; J.-F. Moreau
The Journal of Nursing Home Research Science (JNHRS). http://dx.doi.org/10.14283/jnhrs.2020.10
The objective of this report is to describe the characteristics of the COVID-19 pandemic in nursing homes (NH) in Belgium, particularly in the Walloon (or French-speaking) part, and the local measures initiated to meet the urgent needs of this sanitary crisis (1). This narrative review, including an author’s critical approach, does not show an exhaustive list of all situations and initiatives.

New Zealand Nursing Homes (Aged Residential Care Facilities) and COVID-19 Pandemic

X.J. Walker ; D.L. Waters ; N. Millar
The Journal of Nursing Home Research Science (JNHRS). http://dx.doi.org/10.14283/jnhrs.2020.9
The first confirmed case of COVID-19 in New Zealand was 28 February 2020. New Zealand applied initial country entry restrictions from February 3rd then on March 16th applied border restrictions, compulsory self-isolation following travel and cruise ship restrictions. Progressive lockdown from Alert level 2 on March 21 to Alert level 4 (lockdown and greatest restriction) occurred March 25, 2020, which has seen a dramatic reduction to near zero new cases and essentially no community transmission. New Zealand is currently at Alert level 2. As of May 15, 2020, there were 1148 confirmed and 350 probable cases of COVID-19. There have been 290 cases over the age of 60 and 39 cases over the age of 80 years old. Overall there have been 21 deaths, all of which have been for patients over the age of 60 years old. There have been 16 COVID-19 significant case clusters, with 5 of them occurring in ARC facilities. The deadliest cluster has occurred at an ARC in Christchurch where 55 people were infected and 10 patients died, eight from Dementia level care and additional two from the hospital-wing.

Dealing with COVID-19 in Dutch nursing homes

J.M.G.A. Schols ; E.P. Poot ; N.M. Nieuwenhuizen ; W.P. Achterberg
The Journal of Nursing Home Research Science (JNHRS). http://dx.doi.org/10.14283/jnhrs.2020.7
It is absolutely no surprise that the Dutch nursing home sector with a total of 125.000 residents would be affected by the COVID-19. Before the first case in the Netherlands was registered, alarming signals had already arrived from other countries, indicating that the frail and disabled, multimorbid nursing home population is an easy prey for this virus. In the meantime, despite a visitor lockdown since mid-March, a considerable amount of residents and staff have been infected and around 1700 residents have died from COVID-19 (mid-May). The future will learn what the long-term consequences of this crisis will be for residents and staff and what finally will be the main lessons learnt. This article shows that it is clear that we have some way to go, to ensure that the Dutch nursing home sector, despite its good infrastructure, will be sustainably and proactively recognized, resourced and equipped to fulfil its unique role in long-term care. Moreover the sector has to find its way in preparing itself for the temporary future 1,5 meter society.

An Aspirational Approach to Nursing Home Operations During the COVID-19 Pandemic.

M. Wasserman ; A.G. Wolk ; A. Lam
The Journal of Nursing Home Research Science (JNHRS). http://dx.doi.org/10.14283/jnhrs.2020.6
COVID-19 has infected nearly half of all nursing homes in the United States. Tens of thousands of residents have lost their lives, and many more have been hospitalized. Emerging data suggest that few nursing facilities have the organizational structure, training, resources, physical plant, and operational capability to keep the COVID-19 infection completely out of a facility. Key infection prevention strategies (such as cohorting, universal masking of patients/staff, focused ventilation, point-prevalence testing, and preventing movement of healthcare workers between facilities) have been inconsistently and haphazardly applied. With these challenges in mind, the California Association of Long Term Care Medicine (CALTCM) proposed a model for a virtual centralized Support and Guidance Center that develops and disseminates real-time expert-driven recommendations to the traditional organizational structure of a nursing facility. We recommended that all senior congregate facilities transition to an incident command management structure. This would allow local leadership teams to focus on day to day management, transferring the responsibility of training, PPE procurement, engineering, testing, and real-time expert-driven recommendations to a centralized entity. Clinical and operational aspects of this model are based on emergency preparedness principles. While this approach is aspirational, the principles delineated in this document can be used to guide policy decisions as we work to mitigate the impact of this virus.

COVID-19 in Italian Nursing Homes: from guidelines to practice.

G. Pezzoni ; C. Luchetti ; M. Cesari
Journal of Nursing Home Research Science (JNHRS). http://dx.doi.org/10.14283/jnhrs.2020.5
The COVID-19 pandemic has pushed the world at urgently elaborating new strategies to cope with the many healthcare issues raising from such unprecedent and complex situation. This article is focused on the many problems faced by Italian nursing homes. In particular, it is described which countermeasures were suggested in the guidelines, and the obstacles encountered in their implementation. It is then explained the importance of reshaping the current “hospital-centered” healthcare system into a more modern model, giving more value to the centrality of the person.

Covid 19 and Residential Care Homes in Hong Kong

J. Woo
The Journal of Nursing Home Research Science (JNHRS). http://dx.doi.org/10.14283/jnhrs.2020.4
It is known from the first outbreak in Wuhan China that serious illness and fatality occur with increasing age and co-morbidity. Therefore it is not surprising that outbreaks with high fatality rate occur in nursing homes or residential care settings, as is reported in many European countries and the United States (1, 2), where healthcare expertise and resource may be achievable. For middle and low income countries the situation may be worse. Hong Kong is a city of just over seven million people in China, 17.6% aged 65 and over, with 7% living in long term institutional care settings. Although it is a Special Administrative Region of China responsible for its own administration separate from that of China, the physical border with China is essentially porous, with many land, sea and air routes where high volumes of people move each day, many commuting to work or school across these points. The economy of Hong Kong is inseparable from that of China. Therefore it is surprising that not only is there no Covid 19 outbreak among residential care homes, but that no case has been reported among the residents.

Geriatric Syndromes and SARS-Cov-2: More than Just Being Old.
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I. Aprahamian and M. Cesari.
J Frailty Aging 2020;9(3):127-129
Older patients are surely at increased risk for severe SARS-CoV-2, but age per se may not be the main contributor to this evidence. The older population is characterized by high prevalence of multimorbidity, frailty, and alterations of the biological background (e.g., the so-called phenomenon of inflamm-aging); all aspects that can complicate the course of disease, much more than the mere number of years lived.

Long term care settings in the times of the COVID-19: Challenges and future directions.
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L. Ayalon, A. Zisberg, E. Cohn-Schwartz, J. Cohen-Mansfield, S. Perel-Levin and E. Bar Asher-Sigal.
Int Psychogeriatr 2020 Jul 1:1-14
The term ‘long term care settings’ (LTCS) encompasses settings that provide a range of services to meet older persons’ needs for social, personal and/or health care. These settings may include nursing homes or assisted living facilities, which are designed for people who require assistance in performing activities of daily living, such as bathing or transferring; meals, cleaning services and social activities are also provided.

The Another Side of COVID-19 in Alzheimer’s Disease Patients: Drug-Drug Interactions.
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N. Balli, E. Kara and K. Demirkan.
Int J Clin Pract 2020 Jun 27:e13596
Coronavirus Disease 2019 (COVID-19) outbreak caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a major public health problem. The elderly people are the most affected population by the COVID-19 outbreak in terms of mortality and morbidity. Delirium caused by hypoxia, a prominent clinical feature of COVID-19, may increase the need for treatment of Alzheimer’s disease (AD) patients (1). Therefore, drug-drug interactions should be considered in AD patients while receiving COVID-19 treatment.

Improving the care of older patients during the COVID-19 pandemic.
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A. Bianchetti, G. Bellelli, F. Guerini, et al.
Aging Clin Exp Res 2020 Jul 11
The SARS-CoV-2 pandemic has led to a dramatic crisis of Health Care Systems worldwide, and older people have been among the most disadvantaged. Specific recommendations and reports have been released both at International and National level, regarding the diagnosis and management of COVID-19 in the elderly. However, little has been proposed for an appropriate response to older, frail and multimorbid patients in different settings of care (acute care units, long term care facilities, nursing homes and primary care) and for the management of geriatric syndromes (i.e. delirium, sarcopenia, falls). We presume that the current pandemic of will leads to substantial changes in health care systems, and we suggest some key guide principles that could inspire the provision of healthcare services to older people and their families. These principles are primarily directed to physicians and nurses working in the geriatric field but could also be useful for other specialists.

COVID-19 in Nursing Homes: The Problematic Management of Residents Without Positive COVID-19 RT-PCR
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F. Bloch.
Int J Health Policy Manag 2020 Jun 10
Creating a ‘confirmed COVID-19’ sector requires relocating other residents, interchanging them in order to have confirmed or probable COVID-19 residents on one wing and others residents in another in an attempt to keep non-COVID-19 residents in separate areas. But it is not that simple. Indeed, a resident without positive COVID-19 RTPCR is not a non-COVID-19 resident.

Providing Simultaneous COVID-19–sensitive and Dementia-Sensitive Care as We Transition from Crisis Care to Ongoing Care.

Marco Canevelli, Giuseppe Bruno and Matteo Cesari.
Journal of the American Medical Directors Association 2020 07/01;21(7):968-969.
From a public health perspective, one of the main challenges that health care systems will probably face is how to progressively move from a COVID-19–centric organization (built up for combating the emergency) to models of care that reflect the “ordinary” health needs of the population.

Competing Crises: COVID-19 Countermeasures and Social Isolation among Older Adults in Long Term Care
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C. H. Chu, S. Donato-Woodger and C. J. Dainton.
J Adv Nurs 2020 Jul 9
While debate over the appropriate scope and goals of COVID-19 lockdowns has raged, all public health agencies have been clear on one matter: older adults have the highest rates of mortality (Comas-Herrera et al., 2020) and should be isolated (Public Health Agency of Canada, 2020). Older adults and individuals with complex health conditions are most vulnerable to the virus. Yet, social isolation contributes to the onset and intensifies depression, feelings of despair and, in older adults with dementia, further cognitive decline.

Rapid Telehealth-Centered Response to COVID-19 Outbreaks in Postacute and Long-Term Care Facilities.
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D. A. Harris, L. Archbald-Pannone, J. Kaur, et al.
Telemed J E Health 2020 Jul 9
The vulnerability of postacute and long-term care (PA/LTC) facility residents to COVID-19 has manifested across the world with increasing facility outbreaks associated with high hospitalization and mortality rates. Systematic protocols to guide telehealth-centered interventions in response to COVID-19 outbreaks have yet to be delineated. This article is intended to inform PA/LTC facilities and neighboring health care partners how to collaboratively utilize telehealth-centered strategies to improve outcomes in facility outbreaks. Methods: The University of Virginia rapidly developed a multidisciplinary telehealth-centered COVID-19 facility outbreak strategy in response to a LTC facility outbreak in which 41 (out of 48) facility residents and 7 staff members tested positive. This strategy focused on supporting the facility team remotely using rapidly deployed technologic solutions. Goals included (1) early identification of patients who need their care escalated, (2) monitoring and treating patients deemed safe to remain in the facility, (3) care coordination to facilitate bidirectional transfers between the skilled nursing facility (SNF) and hospital, and (4) daily facility needs assessment related to technology, infection control, and staff well-being. To achieve these goals, a standardized approach centered on daily multidisciplinary virtual rounds and telemedicine consultation was provided. Results: Over a month since the outbreak began, 18 out of 48 (38%) facility residents required hospitalization and 6 (12.5%) died. Eleven facility residents have since returned back to the SNF after recovering from their hospitalization. No staff required hospitalization. Conclusions: Interventions that reduce hospitalizations and mortality are a critical need during the COVID-19 pandemic. The mortality and hospitalization rates seen in this PA/LTC facility outbreak are significantly lower than has been documented in other facility outbreaks. Our multidisciplinary approach centered on telemedicine should be considered as other PA/LTC facilities partner with neighboring health care systems in responding to COVID-19 outbreaks. We have begun replicating these services to additional PA/LTC facilities facing COVID-19 outbreaks.

Nursing Home in the COVID-19 Outbreak:Challenge,Recovery, and Resiliency.
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H. Huang, Y. Xie, Z. Chen, et al.
J Gerontol Soc Work 2020 Jul 2:1-5
It is generally believed that when an emergency occurs, a resilient organization can feed back useful information and urge the government to make decisions, so as to cooperate or partner with the government. Qinggang nursing home, China’s first nursing home approved by the national development and reform commission, was set up by a first-class tertiary hospital, as the vanguard and pilot base of a nursing care institution in China, becoming famous throughout the country for its integration of medical care and nursing. We declared a “state of alert” and adopted a series of resilient strategies when the COVID-19 pandemic was first declared and achieved “zero infection” among 335 residents and 276 health-care personnel.

Clinical observations in the very elderly patients with COVID-19 in Wuhan.
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L. Rui, L. Sirui, D. Xuebei, Y. Xujun and W. Yanggan.
Geriatr Gerontol Int 2020 Jul 7
In December 2019, the outbreak of coronavirus disease 2019 (COVID-19) was initiated in Wuhan, now causing a worldwide pandemic. However, the experience in the very elderly patients is very limited, which has important implications for the surveillances of hospital infection in medical and health institutions. METHODS: Seven patients with confirmed COVID-19 infection in the Department of Geriatrics at Zhongnan Hospital of Wuhan University were included. Clinical data were retrospectively collected and analyzed. The laboratory test and chest CT images from the patients before and after the COVID-19 infection were compared. RESULTS: The median age of patients was 91 years old (from 87 to 96). Six patients had pneumonia in the last six months. Dyspnea occurred in one patient 64 hours after the onset of the disease. The rest six patients only manifested minor fatigue with low fever. Lymphopenia and a significant reduction in plasma globulin level has been observed compared to the levels before the onset of the disease. None had typical chest CT phenotypes at the early stage, except the mentioned critically ill patient who had a “white lung” development and died. One even showed an absorption of inflammation compared with previous hypostatic pneumonia. CONCLUSIONS: The ratio of fatal cases in the very elderly COVID-19 infected patients is not higher to that reported in the non-elderly patients, probably due to low immune response. The elderly patients, however, manifested minor clinical symptoms and atypical changes in chest CT images, which usually lead to misdiagnosis or delayed diagnosis.

COVID-19 pandemic: urgent need for action in care homes and senior citizens’ homes from a medical-ethics perspective.
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B. Schöne-Seifert and H. K. Van Aken.
Curr Opin Anaesthesiol 2020 Aug;33(4):481-482
The latest news has been providing us with horrifying pictures of the way in which the coronavirus pandemic is leading to catastrophic mortality and care conditions in senior citizens’ homes in other countries — in Spain, for example. Here in Germany, too, however, the residents of the country’s 14 000 or so senior citizens’ homes are at high risk, as protective measures are particularly difficult to implement there. In addition, the infection is particularly dangerous for the residents, who are already often ill and frail.

Dementia Care in the Time of COVID-19 Pandemic.
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B. Tousi.
J Alzheimers Dis 2020 Jul 7
Patients with dementia are particularly vulnerable during the COVID-19 pandemic. The initial response to COVID-19 promoted behavioral changes in both society and healthcare, while a long-term solution is sought by prioritizing societal values. In addition, there has been disruption to clinical care and clinical research. This pandemic might have significantly changed the care for our patients with dementia toward increased acceptance of telemedicine by the patients and providers, and its utilization in both clinical care and research.

Coordinated outreach for Veterans in long-term care facilities by an integrated Veterans Affairs healthcare system during the COVID-19 pandemic.
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A. Winnett, L. P. Jatt, L. Sohn, et al.
Infect Control Hosp Epidemiol 2020 Jul 3:1-5
We offer a brief description of unprecedented measures by a large integrated Veterans Affairs(VA) healthcare system to support community LTC facilities facing resource limitations during the COVID-19 pandemic.

COVID-19 in Care Home Settings.
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A. S. Yahya and S. Khawaja.
Prim Care Companion CNS Disord 2020 Jun 11;22(3):20com02652. doi: 10.4088/PCC.20com02652
The pathophysiology of coronavirus disease 2019 (COVID-19) and related government policy have had notable impact on the elderly population. Care homes support the most vulnerable group, with approximately 400,000 older adults in the United Kingdom residing in these facilities

COVID-19 Prevalence and Spread

Almost two-thirds of the elderly with Covid-19 surviving in nursing homes.
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S. Amér, C. Molnar, M. Tuutma, et al.
Lakartidningen 2020 Jun 26;117:20104
A large proportion of deaths worldwide have occurred among elderly living in nursing homes. Sweden is no exception with a comparable proportion making up around half of all deaths. The elderly, frail individuals living in nursing homes are among the most vulnerable and with the highest risk to die of covid-19. In spite of that we see almost two-thirds of the infected are still alive with a majority recovering fully after receiving treatment at the nursing home. Of 8 057 residents living in nursing homes in Stockholm, 1 464 (18 %) individuals have so far been diagnosed with covid-19 and 532 have died (6 % of all residents). Importantly, this means that a great majority of the residents are still alive including almost two-thirds (932/1 464) of the infected individuals.

Outbreak of COVID-19 in a nursing home in Madrid
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E. Bouza, M. J. Pérez-Granda, P. Escribano, et al.
J Infect 2020 Jun 25
We evaluated the status against SARS-CoV-2 of people either residing or working at a privately run nursing home located at Madrid area (Spain) that was severely affected by an outbreak of COVID-19.

Distribution in Place of Death for Coronavirus 2019 (COVID-19)-Related Mortality in the United States
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S. Chuzi, R. Molsberry, M. E. McCabe, et al.
J Am Geriatr Soc 2020 Jul 9
Place of death is an important determinant of quality of care and patient and caregiver experience. Therefore, we sought to examine the distribution of place of COVID-19-related deaths in the US.

Elderly people and responses to COVID-19 in 27 Countries.
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J. F. Daoust.
PLoS One 2020 Jul 2;15(7):e0235590
Amongst the most robust consensus related to the COVID-19 disease is that the elderly are by far the most vulnerable population group. Hence, public authorities target older people in order to convince them to comply with preventive measures. However, we still know little about older people’s attitudes and compliance toward these measures. In this research, I aim to improve our understanding of elderly people’s responses to the pandemic using data from 27 countries. Results are surprising and quite troubling. Elderly people’s response is substantially similar to their fellow citizens in their 50’s and 60’s. This research (i) provides the first thorough description of the most vulnerable population’s attitudes and compliance in a comparative perspective (ii) suggest that governments’ strategies toward elderly people are far from successful and (iii) shows that methodologically, we should be more cautious in treating age as having a linear effect on COVID-19 related outcomes.

High Proportion of Asymptomatic SARS-CoV-2 Infections in 9 Long-Term Care Facilities, Pasadena, California, USA, April 2020.
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M. Feaster and Y. Y. Goh.
Emerg Infect Dis 2020 Jul 2;26(10):10.3201/eid2610.202694
Our analysis of coronavirus disease prevalence in 9 long-term care facilities demonstrated a high proportion (40.7%) of asymptomatic infections among residents and staff members. Infection control measures in congregate settings should include mass testing-based strategies in concert with symptom screening for greater effectiveness in preventing the spread of severe acute respiratory syndrome coronavirus 2.

Asymptomatic SARS-CoV-2 infection in Belgian long-term care facilities.
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A. Hoxha, C. Wyndham-Thomas, S. Klamer, et al.
Lancet Infect Dis 2020 Jul 3
This analysis of a large number of tests done in LTCFs shows a high proportion of asymptomatic cases.

Clusters of COVID-19 in long-term care hospitals and facilities – Japan, Jan 15-May 9, 2020.
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O. Iritani, T. Okuno, D. Hama, et al.
Geriatr Gerontol Int 2020 Jul 7
To clarify the association of cluster number and size of coronavirus disease 2019 (COVID-19) in long-term care (LTC) hospitals/facilities, general medical/welfare facilities, and non-medical/welfare facilities, with morbidity and mortality in 47 prefectures during Jan 15 – May 9, 2020 in Japan. METHODS: Information on COVID-19 clusters (n >2) and morbidity and mortality of COVID-19 was collected. RESULTS: A total of 381 clusters with 3,786 infected cases were collected, accounting for 23.9% of 15,852 cumulated cases on May 9, 2020. Although the cluster number (/10(7) subjects) in LTC hospitals/facilities was significantly smaller compared to those in the other two groups, the cluster size in LTC hospitals/facilities was significantly larger than that in non-medical/welfare facilities. Cluster numbers in general medical/welfare facilities and in non-medical/welfare facilities were significantly positively correlated with morbidity (/10(5) ), indicating relatively early identification of clusters in these facilities. Unlike in these facilities, cluster size in LTC hospitals/facilities was significantly positively correlated with morbidity, indicating that clusters in LCT hospitals/facilities were finally identified after already having grown to a large size in areas where infection was prevalent. Multivariate logistic regression analysis revealed that both cluster number and cluster size only in LTC hospitals/facilities were independently associated with higher mortality (> median: 0.64/10(5) subjects) after adjustment. CONCLUSIONS: Preventive efforts against COVID-19 outbreaks even at the early phase of the epidemic are critically important in LTC hospitals/facilities, since both larger number and size of cluster only in LTC hospitals/facilities were independently linked to higher mortality in prefectures in Japan.

Recurrence or Relapse of COVID-19 in Older Patients: A Description of Three Cases.
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L. Lafaie, T. Célarier, L. Goethals, et al.
J Am Geriatr Soc 2020 Jul 7
The coronavirus disease 2019 (COVID-19) has infected millions of people worldwide, particularly in older adults. The first cases of possible re-infection by SARS-CoV-2 were reported in April 2020 among older adults. DESIGN/SETTING: In this brief report, we present three geriatric cases with two episodes of SARS-CoV-2 infection separated by a symptom-free interval.

Environmental Detection of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) from Medical Equipment in Long-Term Care Facilities undergoing COVID-19 Outbreaks.
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A. Nelson, J. Kassimatis, J. Estoque, et al.
Am J Infect Control 2020 Jul 6
We conducted environmental sampling at long-term care facilities to determine the extent of surface contamination with SARS-CoV-2 virus. Medical equipment used throughout the facility was determined to be contaminated.

Older Adults and Covid-19: The Most Vulnerable, the Hardest Hit.
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T. Powell, E. Bellin and A. R. Ehrlich.
Hastings Cent Rep 2020 May;50(3):61-63
Older adults in the United States have been the age group hardest hit by the Covid pandemic. They have suffered a disproportionate number of deaths; Covid patients eighty years or older on ventilators had fatality rates higher than 90 percent. How could we have better protected older adults? Both the popular press and government entities blamed nursing homes, labeling them “snake pits” and imposing harsh fines and arduous new regulations. We argue that this approach is unlikely to improve protections for older adults. Rather than focusing exclusively on acute and critical resources, including ventilators, a plan that respected the best interests of older adults would have also supported nursing homes, a critical part of the health care system. Better access to protective equipment for staff members, early testing of staff members and patients, and enhanced means of communication with families were what was needed. These preventive measures would have offered greater benefit to the oldest members of our population than the exclusive focus on acute care.

Initial and Repeated Point Prevalence Surveys to Inform SARS-CoV-2 Infection Prevention in 26 Skilled Nursing Facilities – Detroit, Michigan, March-May 2020.
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G. V. Sanchez, C. Biedron, L. R. Fink, et al.
MMWR Morb Mortal Wkly Rep 2020 Jul 10;69(27):882-886
Skilled nursing facilities (SNFs) are focal points of the coronavirus disease 2019 (COVID-19) pandemic, and asymptomatic infections with SARS-CoV-2, the virus that causes COVID-19, among SNF residents and health care personnel have been described (1-3). Repeated point prevalence surveys (serial testing of all residents and health care personnel at a health care facility irrespective of symptoms) have been used to identify asymptomatic infections and have reduced SARS-CoV-2 transmission during SNF outbreaks (1,3). During March 2020, the Detroit Health Department and area hospitals detected a sharp increase in COVID-19 diagnoses, hospitalizations, and associated deaths among SNF residents. The Detroit Health Department collaborated with local government, academic, and health care system partners and a CDC field team to rapidly expand SARS-CoV-2 testing and implement infection prevention and control (IPC) activities in all Detroit-area SNFs. During March 7-May 8, among 2,773 residents of 26 Detroit SNFs, 1,207 laboratory-confirmed cases of COVID-19 were identified during three periods: before (March 7-April 7) and after two point prevalence surveys (April 8-25 and April 30-May 8): the overall attack rate was 44%. Within 21 days of receiving their first positive test results, 446 (37%) of 1,207 COVID-19 patients were hospitalized, and 287 (24%) died. Among facilities participating in both surveys (n = 12), the percentage of positive test results declined from 35% to 18%. Repeated point prevalence surveys in SNFs identified asymptomatic COVID-19 cases, informed cohorting and IPC practices aimed at reducing transmission, and guided prioritization of health department resources for facilities experiencing high levels of SARS-CoV-2 transmission. With the increased availability of SARS-CoV-2 testing, repeated point prevalence surveys and enhanced and expanded IPC support should be standard tools for interrupting and preventing COVID-19 outbreaks in SNFs.

Prevention and control of COVID-19 in nursing homes, orphanages, and prisons.
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J. Wang, W. Yang, L. Pan, et al.
Environ Pollut 2020 Jul 2;266(Pt 1):115161
As the number of Coronavirus Disease (2019) (COVID-19) cases increase globally, countries are taking more aggressive preventive measures against this pandemic. Transmission routes of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) include droplet and contact transmissions. There are also evidence of transmission through aerosol generating procedures (AGP) in specific circumstances and settings. Institutionalized populations without mobility and living in close proximity with unavoidable contact are especially vulnerable to higher risks of COVID-19 infection, such as the elderly in nursing homes, children in orphanages, and inmates in prisons. In these places, higher prevention and control measures are needed. In this study, we proposed prevention and control strategies for these facilities and provided practical guidance for general measures, health management, personal protection measures, and prevention measures in nursing homes, orphanages, and prisons, respectively.

Prevention and infection control of COVID-19 in Nursing Homes: experience from China.
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L. Wang, N. Qi, Y. Zhou and H. Zhang.
Age Ageing 2020 Jun 25
Many older people in Asia live in Nursing Homes. In order to prevent and control the outbreak in nursing homes in China, the Ministry of Civil Affairs formulated “Guidelines on the Prevention and Control of the Pneumonia Epidemic caused by a Novel Coronavirus in Eldercare Institutions”. These guidelines were based on early experience of what worked in nursing homes across the country. This article summarises the main learning points.

Administrative & Organizational Issues

The Demographics and Economics of Direct Care Staff Highlight Their Vulnerabilities Amidst the COVID-19 Pandemic.
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B. Almeida, M. A. Cohen, R. I. Stone and C. E. Weller.
J Aging Soc Policy 2020 Jul-Oct;32(4-5):403-409
An estimated 3.5 million direct care staff working in facilities and people’s homes play a critical role during the COVID-19 pandemic. They allow vulnerable care recipients to stay at home and they provide necessary help in facilities. Direct care staff, on average, have decades of experience, often have certifications and licenses, and many have at least some college education to help them perform the myriad of responsibilities to properly care for care recipients. Yet, they are at heightened health and financial risks. They often receive low wages, limited benefits, and have few financial resources to fall back on when they get sick themselves and can no longer work. Furthermore, most direct care staff are parents with children in the house and almost one-fourth are single parents. If they fall ill, both they and their families are put into physical and financial risk.

Long-Term Care, Residential Facilities, and COVID-19: An Overview of Federal and State Policy Responses.

Angela T. Chen, Kira L. Ryskina and Hye-Young Jung.
Journal of the American Medical Directors Association 2020/07
The COVID-19 pandemic has disproportionately affected residents and staff at long-term care (LTC) and other residential facilities in the US. The high morbidity and mortality at these facilities has been attributed to a combination of a particularly vulnerable population and a lack of resources to mitigate the risk. During the first wave of the pandemic, the federal and state governments received urgent calls for help from LTC and residential care facilities; between March and early June of 2020, policymakers responded with dozens of regulatory and policy changes. In this article, we provide an overview of these responses by first summarizing federal regulatory changes, and then reviewing state-level executive orders. The policy and regulatory changes implemented at the federal and state levels can be categorized into the following four classes: 1) preventing virus transmission, which includes policies relating to visitation restrictions, personal protective equipment (PPE) guidance, and testing requirements; 2) expanding facilities? capacities, which includes both the expansion of physical space for isolation purposes and the expansion of workforce to combat COVID-19; 3) relaxing administrative requirements, which includes measures enacted to shift the attention of caretakers and administrators from administrative requirements to residents? care; and 4) reporting COVID-19 data, which includes the reporting of cases and deaths to residents, families, and administrative bodies (such as state health departments). These policies represent a snapshot of the initial efforts to mitigate damage inflicted by the pandemic. Looking ahead, empirical evaluation of the consequences of these policies ? including potential unintended effects ? is urgently needed. The recent availability of publicly reported COVID-19 LTC data can be used to inform the development of evidence-based regulations, though there are concerns of reporting inaccuracies. Importantly, these data should also be used to systematically identify hot spots and help direct resources to struggling facilities.; The COVID-19 pandemic has disproportionately affected residents and staff at long-term care (LTC) and other residential facilities in the US. The high morbidity and mortality at these facilities has been attributed to a combination of a particularly vulnerable population and a lack of resources to mitigate the risk. During the first wave of the pandemic, the federal and state governments received urgent calls for help from LTC and residential care facilities; between March and early June of 2020, policymakers responded with dozens of regulatory and policy changes. In this article, we provide an overview of these responses by first summarizing federal regulatory changes, and then reviewing state-level executive orders. The policy and regulatory changes implemented at the federal and state levels can be categorized into the following four classes: 1) preventing virus transmission, which includes policies relating to visitation restrictions, personal protective equipment (PPE) guidance, and testing requirements; 2) expanding facilities? capacities, which includes both the expansion of physical space for isolation purposes and the expansion of workforce to combat COVID-19; 3) relaxing administrative requirements, which includes measures enacted to shift the attention of caretakers and administrators from administrative requirements to residents? care; and 4) reporting COVID-19 data, which includes the reporting of cases and deaths to residents, families, and administrative bodies (such as state health departments). These policies represent a snapshot of the initial efforts to mitigate damage inflicted by the pandemic. Looking ahead, empirical evaluation of the consequences of these policies ? including potential unintended effects ? is urgently needed. The recent availability of publicly reported COVID-19 LTC data can be used to inform the development of evidence-based regulations, though there are concerns of reporting inaccuracies. Importantly, these data should also be used to systematically identify hot spots and help direct resources to struggling facilities.

Covid-19 and lack of linked datasets for care homes
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B. Hanratty, J. K. Burton, C. Goodman, A. L. Gordon and K. Spilsbury.
BMJ 2020 Jun 24;369:m2463
The covid-19 pandemic has placed a spotlight on how little is known about this sector, and the lack of easily accessible, aggregated data on the UK care home population. Basic information that could be used to inform service responses, such as the number of residents in homes with and without nursing care, and hospital admissions and deaths among them, is difficult to locate. It is not simply lack of data that is the problem, it is the number of different bodies that are collecting information, and the absence of standardisation and cross sector cooperation in how data are collated, shared, and used.

Nurse Staffing and Coronavirus Infections in California Nursing Homes.
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C. Harrington, L. Ross, S. Chapman, E. Halifax, B. Spurlock and D. Bakerjian.
Policy Polit Nurs Pract 2020 Jul 7:1527154420938707
In the United States, 1.4 million nursing home residents have been severely impacted by the COVID-19 pandemic with at least 25,923 resident and 449 staff deaths reported from the virus by June 1, 2020. The majority of residents have chronic illnesses and conditions and are vulnerable to infections and many share rooms and have congregate meals. There was evidence of inadequate registered nurse (RN) staffing levels and infection control procedures in many nursing homes prior to the outbreak of the virus. The aim of this study was to examine the relationship of nurse staffing in California nursing homes and compare homes with and without COVID-19 residents. Study data were from both the California and Los Angeles Departments of Public Health and as well as news organizations on nursing homes reporting COVID-19 infections between March and May 4, 2020. Results indicate that nursing homes with total RN staffing levels under the recommended minimum standard (0.75 hours per resident day) had a two times greater probability of having COVID-19 resident infections. Nursing homes with lower Medicare five-star ratings on total nurse and RN staffing levels (adjusted for acuity), higher total health deficiencies, and more beds had a higher probability of having COVID-19 residents. Nursing homes with low RN and total staffing levels appear to leave residents vulnerable to COVID-19 infections. Establishing minimum staffing standards at the federal and state levels could prevent this in the future.

COVID-19 and Quality Improvement

Providing care for the 99.9% during the COVID-19 pandemic: How ethics, equity, epidemiology, and cost per QALY inform healthcare policy.
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S. L. Archer.
Healthc Manage Forum 2020 Jul 8:840470420939854
Managing healthcare in the Coronavirus Disease 2019 (COVID-19) era should be guided by ethics, epidemiology, equity, and economics, not emotion. Ethical healthcare policies ensure equitable access to care for patients regardless of whether they have COVID-19 or another disease. Because healthcare resources are limited, a cost per Quality Life Year (QALY) approach to COVID-19 policy should also be considered. Policies that focus solely on mitigating COVID-19 are likely to be ethically or financially unsustainable. A cost/QALY approach could target resources to optimally improve QALYs. For example, most COVID-19 deaths occur in long-term care facilities, and this problem is likely better addressed by a focused long-term care reform than by a society-wide non-pharmacological intervention. Likewise, ramping up elective, non-COVID-19 care in low prevalence regions while expanding testing and case tracking in hot spots could reduce excess mortality from non-COVID-19 diseases and decrease adverse financial impacts while controlling the epidemic. Globally, only approximately 0.1% of people have had a COVID-19 infection. Thus, ethical healthcare policy must address the needs of the 99.9%.

COVIDApp: A Health Application as an Innovative Strategy for the Management and Follow-Up of the COVID-19 Pandemic in Long-Term Care Facilities in Catalonia.
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P. Echeverría, M. A. Mas-Bergas, J. Puig, et al.
JMIR Public Health Surveill 2020 Jul 6
The COVID-19 pandemic has caused an unprecedented worldwide public health crisis that requires new approaches. COVIDApp is a mobile application for the management of institutionalized individuals in long-term care facilities (LTCF). OBJECTIVE: Report the use of this innovative tool for the management of LTCF residents as a high-risk population, specifically for the early identification and self-isolation of suspected cases, the remote monitoring of mild cases and the real-time monitoring of the progression of the infection. METHODS: COVIDApp was implemented in 196 care centers in collaboration with 64 primary care teams. Objectives: early detection; self-isolation of suspected cases and rapid diagnosis; remote treatment and monitoring of mild cases; and real-time monitoring of the progression of the infection. The following parameters of COVID-19 were reported daily: signs/symptoms; diagnosis by polymerase chain reaction; absence of symptoms for ≥14 days; total deaths; and healthcare workers isolated with suspected COVID-19. The number of centers at risk was also described. RESULTS: Data were recorded from ≥10,000 institutionalized individuals and up to 4,000 healthcare workers between April 1st and 30th, 2020. A rapid increase in suspected cases was seen until day 6 but decreased during the 2 last weeks (from 1,084 to 282 cases). Confirmed cases increased from 419 cases (day 6) to 1,293 cases (day 22), remaining stable during the last week. Around 50% remained asymptomatic ≥14 days. A total of 854 (8%) deaths were reported (383 in suspected/confirmed cases). The number of isolated healthcare workers remained high over the 30 days; suspected cases decreased during the last 2 weeks. The number of high-risk LTCF decreased from 9.5% to 1.5%. CONCLUSIONS: COVIDApp could help clinicians to rapidly detect and remotely monitor suspected and confirmed cases of COVID-19 among institutionalized individuals, thus limiting the risk of spreading the virus. The platform shows the progression of infection in real time and can help us to design new strategies.

Policy Recommendations Regarding Skilled Nursing Facility Management of Coronavirus 19 (COVID-19): Lessons from New York State.

Paula E. Lester, Timothy Holahan, David Siskind and Elaine Healy.
Journal of the American Medical Directors Association 2020 07/01;21(7):888-892
To provide policy recommendations for managing Coronavirus 19 (COVID-19) in skilled nursing facilities, a group of certified medical directors from several facilities in New York state with experience managing the disease used e-mail, phone, and video conferencing to develop consensus recommendations. The resulting document provides recommendations on screening, protection of staff, screening of residents, management of Coronavirus 19 positive and presumed positive cases, communication during an outbreak, management of admissions and readmissions, and providing emotional support for staff. These consensus guidelines have been endorsed by the Executive Board of the New York Medical Directors Association and the Board of the Metropolitan Area Geriatrics Society.

Combating Heightened Social Isolation of Nursing Home Elders: The Telephone Outreach in the COVID-19 Outbreak Program.
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L. I. van Dyck, K. M. Wilkins, J. Ouellet, G. M. Ouellet and M. L. Conroy.
Am J Geriatr Psychiatry 2020 Jun 5
Social isolation and loneliness-common concerns in older adults-are exacerbated by the COVID-19 pandemic. To address social isolation in nursing home residents, the Yale School of Medicine Geriatrics Student Interest Group initiated a Telephone Outreach in the COVID-19 Outbreak (TOCO) Program that implements weekly phone calls with student volunteers. METHODS: Local nursing homes were contacted; recreation directors identified appropriate and interested elderly residents. Student volunteers were paired with elderly residents and provided phone call instructions. RESULTS: Three nursing homes opted to participate in the program. Thirty elderly residents were paired with student volunteers. Initial reports from recreation directors and student volunteers were positive: elderly residents look forward to weekly phone calls and express gratitude for social connectedness. CONCLUSIONS: The TOCO program achieved initial success and promotes the social wellbeing of nursing home residents. We hope to continue this program beyond the COVID-19 pandemic in order to address this persistent need in a notably vulnerable patient population.


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Characterizing evolving frameworks: issues from Esmail et al. (2020) review.
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R. E. Glasgow, P. A. Estabrooks and M. G. Ory.
Implement Sci 2020 Jul 2;15(1):53-020-01009-8
There are complex issues in understanding and categorizing implementation science theories, models, and frameworks. Systematic reviews of these models are important undertakings for synthesizing current knowledge. The issues involved are even more challenging when reviewing a large number of frameworks and when some of the frameworks have evolved significantly over time. This paper addresses how the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework was described in the recent Esmail (2020) review and identifies four mischaracterizations. This is followed by a more general discussion of how advances or extensions of frameworks after an original source publication or influential review tend to be overlooked. We discuss why inadvertent mischaracterization of what a framework is and is not, and what it can and cannot be used for, can have deleterious consequences. Finally, we suggest initial ideas about what could be done to prevent or alleviate some of these problems by reviewers, framework developers, and scholars at large.

Esmail et al’s response to letter to the editor.
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R. Esmail, H. M. Hanson, J. Holroyd-Leduc, et al.
Implement Sci 2020 Jul 2;15(1):52-020-01010-1
We would like to thank you for the opportunity to respond to Dr. Glasgow’s letter and clarify issues regarding our scoping review. We also want to thank Dr. Glasgow and his colleagues for taking an interest in our publication and expressing their concerns

Building knowledge translation competency in a community-based hospital: a practice-informed curriculum for healthcare providers, researchers, and leadership.
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C. Provvidenza, A. Townley, J. Wincentak, S. Peacocke and S. Kingsnorth.
Implement Sci 2020 Jul 3;15(1):54-020-01013-y
Enacting knowledge translation (KT) in healthcare settings is a complex process that requires organizational facilitation. In addition to addressing organizational-level barriers, targeting individual-level factors such as KT competencies are a necessary component of this aim. While literature on KT competency training is rapidly growing, there has been little exploration of the potential benefits of training initiatives delivered from an intra-organizational perspective. Addressing this gap, we developed the Knowledge Translation Facilitator Network (KTFN) to meet the KT needs of individuals expected to use and produce knowledge (e.g., healthcare providers, research staff, managers, family advisors) within an academic health sciences center. The aim of this study is to describe the development, implementation, and evaluation of the KTFN curriculum. METHODS: An educational framework was used to guide creation of the KTFN curriculum. Stakeholder interviews, a literature review of KT competency, and environmental scan of capacity building initiatives plus adult learning principles were combined with in-house experience of KT practitioners to inform content and delivery. An evaluation strategy consisting of pre/post-test curriculum and post-session satisfaction surveys, as well as post-curriculum interviews assessed impact on participant knowledge and skills and captured perceived value of KFTN. RESULTS: The curriculum has been delivered three times over 3 years, with 30 individuals trained, representing healthcare providers, graduate level research trainees, managers, and family advisors. Using the New World Kirkpatrick Model as an analysis framework, we found that the KTFN curriculum was highly valued and shifted learners’ perceptions of KT. Participants identified enhanced knowledge and skills that could be applied to different facets of their work; increased confidence in their ability to execute KT tasks; and intention to use the content in future projects. Barriers to future use included time to plan and conduct KT activities. CONCLUSION: KTFN was developed to enhance KT competency among organizational members. This initiative shows promise as a highly valued training program that meets both individual and organizational KT needs and speaks to the importance of investing in tailored KT competency initiatives as an essential building block to support moving evidence into practice.

How to translate scientific knowledge into practice? Concepts, models and application.
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A. C. G. Vieira, D. Gastaldo and D. Harrison.
Rev Bras Enferm 2020 Jul 1;73(5):e20190179-7167-2019-0179. eCollection 2020
To present the concept of Knowledge Translation and Exchange as it has been used in the international literature and in Canada, particularly. Next, to describe a renowned conceptual model to guide its implementation, entitled Knowledge-to-Action Cycle. RESULTS: we described the use of the model in the context of the municipal primary health care system in southern Brazil for the implementation of pain management strategies during vaccination. CONCLUSIONS: in this theoretical reflection, we argue that in order to promote health equity and quality of care in the Unified Health System (Brazilian SUS) it is important to translate scientific knowledge to various practice settings and create opportunities for exchange with users of this knowledge, such as health professionals, managers, policy makers, patients, family members and other stakeholders.

Nudge strategies to improve healthcare providers’ implementation of evidence-based guidelines, policies and practices: a systematic review of trials included within Cochrane systematic reviews.
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S. L. Yoong, A. Hall, F. Stacey, et al.
Implement Sci 2020 Jul 1;15(1):50-020-01011-0
Nudge interventions are those that seek to modify the social and physical environment to enhance capacity for subconscious behaviours that align with the intrinsic values of an individual, without actively restricting options. This study sought to describe the application and effects of nudge strategies on clinician implementation of health-related guidelines, policies and practices within studies included in relevant Cochrane systematic reviews. METHODS: As there is varied terminology used to describe nudge, this study examined studies within relevant systematic reviews. A two-stage screening process was undertaken where, firstly, all systematic reviews published in the Cochrane Library between 2016 and 2018 were screened to identify reviews that included quantitative studies to improve implementation of guidelines among healthcare providers. Secondly, individual studies within relevant systematic reviews were included if they were (i) randomised controlled trials (RCTs), (ii) included a nudge strategy in at least one intervention arm, and (iii) explicitly aimed to improve clinician implementation behaviour. We categorised nudge strategies into priming, salience and affect, default, incentives, commitment and ego, and norms and messenger based on the Mindspace framework. SYNTHESIS: The number and percentage of trials using each nudge strategy was calculated. Due to substantial heterogeneity, we did not undertake a meta-analysis. Instead, we calculated within-study point estimates and 95% confidence intervals, and used a vote-counting approach to explore effects. RESULTS: Seven reviews including 42 trials reporting on 57 outcomes were included. The most common nudge strategy was priming (69%), then norms and messenger (40%). Of the 57 outcomes, 86% had an effect on clinician behaviour in the hypothesised direction, and 53% of those were statistically significant. For continuous outcomes, the median effect size was 0.39 (0.22, 0.45), while for dichotomous outcomes the median Odds Ratio was 1.62 (1.13, 2.76). CONCLUSIONS: This review of 42 RCTs included in Cochrane systematic reviews found that the impact of nudge strategies on clinician behaviour was at least comparable to other interventions targeting implementation of evidence-based guidelines. While uncertainty remains, the review provides justification for ongoing investigation of the evaluation and application of nudge interventions to support provider behaviour change. TRIAL REGISTRATION: This review was not prospectively registered.


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Health Care Administration and Organization

Factors Influencing the Self-Perceived Competencies in Spiritual Care of Nurses in Long-term Care Facilities.
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M. L. Chen, Y. H. Chen, L. C. Lin and L. L. Chuang.
J Nurs Manag 2020 Jun 26
To identify key factors influencing institutional nurses’ self-perceived competencies in spiritual care. BACKGROUND: In the past decade, interest in spiritual care has been increasing; however, in long-term care facilities, limited knowledge is available about nurses’ competencies in spiritual care. METHODS: The cross-sectional study was conducted with 202 nurses in 11 long-term care facilities. Data were collected in a survey using the Spirituality and Spiritual Care Rating Scale, the Nurse Spiritual Care Therapeutics Scale, the Spiritual Care Competence Scale and demographic questions. Data were analyzed using stepwise linear regression. RESULTS: Study findings revealed that nurses’ perceptions of spirituality and spiritual care, frequency of spiritual care provision and self-satisfaction with the spiritual care given all significantly predicted overall spiritual care competence, which together explain 58% of the total variance. CONCLUSIONS: Improving nurses’ perceptions of spirituality and spiritual care and encouraging the performance of spiritual care may be an effective pathway to enhance the spiritual care competence of institutional nurses. IMPLICATIONS FOR NURSING MANAGEMENT: Additional continuing education on spiritual care topics, and the establishment of clear guidance and support from institutional administrators are required to enable nurses to deal with spiritual issues as they arise and improve the quality of holistic care.

Opioid Use in Long-Term Care: Guidelines and Policy Recommendations.
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L. S. Edelman and R. Hemmert.
J Gerontol Nurs 2019 Sep 1;45(9):5-10
Older adults living in long-term care (LTC) settings experience a higher incidence of chronic pain than those living in the community and are prescribed opioids at approximately twice the rate. Opioids are effective in managing pain in LTC residents, who are often not candidates for nonopioid pharmacological or nonpharmacological therapies. The recent Centers for Disease Control and Prevention guideline for opioid stewardship recommends conservative opioid prescribing and discourages long-term opioid use for chronic pain management, raising concern that pain may not be adequately treated for LTC residents. The Society for Post-Acute and Long-Term Care Medicine recently published a policy statement that addresses responsible opioid stewardship in LTC. The current article describes clinical guidelines and standards that can guide LTC nurses in assessing, treating, and monitoring opioid use so that residents have diminished pain without significant adverse events. [Journal of Gerontological Nursing, 45(9), 5-10.].

Nursing Management of Hearing Impairment in Nursing Facility Residents.
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C. Meyer and L. Hickson.
J Gerontol Nurs 2020 Jul 1;46(7):15-25
Hearing impairment (also known as hearing loss) is highly prevalent in residents of nursing facilities and its impacts are far-reaching. Hearing impairment has negative consequences for an individual’s quality of life, psychosocial health, physical health, and mortality; these impacts are also exacerbated when hearing impairment cooccurs with other conditions, such as visual or cognitive impairment. These guidelines summarize the extensive evidence about the impacts of hearing impairment, the factors that are associated with increased risk of hearing impairment, assessment criteria for measuring impairment, and the management of residents’ hearing impairment. Nursing interventions should focus on (a) cerumen management to reduce hearing impairment and allow for the use of hearing devices; (b) hearing device support so that residents can use hearing aids and/or other assistive listening devices; and (c) communication strategies so that conversations with residents can be facilitated. [Journal of Gerontological Nursing, 46(7), 15-25.].

Long-Term Care Facility Ownership and Acute Hospital Service Use in British Columbia, Canada: A Retrospective Cohort Study.
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J. Poss, K. McGrail, M. J. McGregor and L. A. Ronald.
J Am Med Dir Assoc 2020 Jul 6
Previous studies report higher hospitalization rates in for-profit compared with nonprofit long-term care facilities (LTCFs), but have not included staffing data, a major potential confounder. Our objective was to examine the effect of ownership on hospital admission rates, after adjusting for facility staffing levels and other facility and resident characteristics, in a large Canadian province (British Columbia). DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Our cohort included individuals resident in a publicly funded LTCF in British Columbia at any time between April 1, 2012 and March 31, 2016. MEASURES: Health administrative data were extracted from multiple databases, including continuing care, hospital discharge, and Minimum Data Set (MDS 2.0) assessment records. Cox extended hazards regression was used to estimate hospitalization risk associated with facility- and resident-level factors. RESULTS: The cohort included 49,799 residents in 304 LTCF facilities (116 publicly owned and operated, 99 for-profit, and 89 nonprofit) over the study period. Hospitalization risk was higher for residents in for-profit (adjusted hazard ratio [adjHR] 1.34; 95% confidence interval [CI] 1.29-1.38) and nonprofit (adjHR 1.37; 95% CI 1.32-1.41) facilities compared with publicly owned and operated facilities, after adjustment for staffing, facility size, urban location, resident demographics, and case mix. Within subtypes, risk was highest in single-site facilities: for-profit (adjHR 1.42; 95% CI 1.36-1.48) and nonprofit (adjHR 1.38, 95% CI 1.33-1.44). CONCLUSIONS AND IMPLICATIONS: This is the first Canadian study using linked health data from hospital discharge records, MDS 2.0, facility staffing, and ownership records to examine the adjusted effect of facility ownership characteristics on hospital use of LTCF residents. We found significantly lower adjHRs for hospital admission in publicly owned facilities compared with both for-profit and nonprofit facilities. Our finding that publicly owned facilities have lower hospital admission rates compared with for-profit and nonprofit facilities can help inform decision-makers faced with the challenge of optimizing care models in both nursing homes and hospitals as they build capacity to care for aging populations.

Advance care planning in Norwegian nursing homes – limited awareness of the residents’ preferences and values? A qualitative study.
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L. Thoresen, R. Pedersen, L. Lillemoen, E. Gjerberg and R. Forde.
BMC Geriatr 2019 Dec 23;19(1):363-019-1378-6
52% of all deaths in Norway occur in nursing homes. Still advance care planning (ACP) is scarce and heterogeneous. To improve the implementation and practice of ACP in nursing homes, knowledge about health care professionals’ views on ACP is vital. The objective of this study is to explore nurses and physicians’ aims and experiences with carrying out ACP in nursing homes. METHODS: Semi-structured group interviews were conducted with 20 health care professionals, recruited from nursing homes where ACP was performed regularly. Qualitative content analysis was used to analyse the data. RESULTS: The primary aim of the nursing home professionals when doing ACP in nursing homes were to build alliances with next of kin to avoid misunderstandings and future conflicts. Two main experiences with ACP were described: i) due to the sensitivity of ACP issues, it was important to balance directness with being sensitive, and ii) when the physicians raised questions concerning future medical treatment, the answers from residents as well as next of kin were often hesitant and unclear. CONCLUSION: Our study add insights into how ACP is practiced in nursing homes and the professionals’ agenda. A focus on medical issues and achieving consensus with next of kin may result in lack of involvement of the residents and limited awareness of the residents’ needs. Interdisciplinary approaches, ACP-training and tailored guidelines may improve the implementation and practice of ACP.

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Health Care Innovation and Quality Assurance

Development of a Tailored, Complex Intervention for Clinical Reflection and Communication about Suspected Urinary Tract Infections in Nursing Home Residents.
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S. H. Arnold, J. A. Olesen, J. N. Jensen, L. Bjerrum, A. Holm and M. B. Kousgaard.
Antibiotics (Basel) 2020 Jun 25;9(6):10.3390/antibiotics9060360
Inappropriate antibiotic treatments for urinary tract infections (UTIs) in nursing homes cause the development of resistant bacteria. Nonspecific symptoms and asymptomatic bacteriuria are drivers of overtreatment. Nursing home staff provide general practice with information about ailing residents; therefore, their knowledge and communication skills influence prescribing. This paper describes the development of a tailored, complex intervention for a cluster-randomised trial that targets the knowledge of UTI and communication skills in nursing home staff to reduce antibiotic prescriptions. METHODS: A dialogue tool was drafted, drawing on participatory observations in nursing homes, interviews with stakeholders, and a survey in general practice. The tool was tailored through a five-phase process that included stakeholders. Finally, the tool and a case-based educational session were tested in a pilot study. RESULTS: The main barriers were that complex patients were evaluated by healthcare staff with limited knowledge about disease and clinical reasoning; findings reported to general practice were insignificant and included vague descriptions; there was evidence of previous opinion bias; nonspecific symptoms were interpreted as UTI; intuitive reasoning led to the inappropriate suspicion of UTI. CONCLUSION: Sustainable change in antibiotic-prescribing behaviour in nursing homes requires a change in nursing home staff’s beliefs about and management of UTIs.

Empirical development of a typology on residential long-term care units in Germany – results of an exploratory multivariate data analysis.
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J. M. Bergmann, A. M. Ströbel, B. Holle and R. Palm.
BMC Health Serv Res 2020 Jul 11;20(1):646-020-05401-4
Organizational health care research focuses on describing structures and processes in organizations and investigating their impact on the quality of health care. In the setting of residential long-term care, this effort includes the examination and description of structural differences among the organizations (e.g., nursing homes). The objective of the analysis is to develop an empirical typology of living units in nursing homes that differ in their structural characteristics. METHODS: Data from the DemenzMonitor Study were used. The DemenzMonitor is an observational study carried out in a convenience sample of 103 living units in 51 nursing homes spread over 11 German federal states. Characteristics of living units were measured by 19 variables related to staffing, work organization, building characteristics and meal preparation. Multiple correspondence analysis (MCA) and agglomerative hierarchical cluster analysis (AHC) are suitable to create a typology of living units. Both methods are multivariate and explorative. We present a comparison with a previous typology (created by a nonexplorative and nonmultivariate process) of the living units derived from the same data set. RESULTS: The MCA revealed differences among the living units, which are defined in particular by the size of the living unit (number of beds), the additional qualifications of the head nurse, the living concept and the presence of additional financing through a separate benefit agreement. We identified three types of living units; these clusters occur significantly with a certain combination of characteristics. In terms of content, the three clusters can be defined as: “house community”, “dementia special care units” and “usual care”. CONCLUSION: A typology is useful to gain a deeper understanding of the differences in the care structures of residential long-term care organizations. In addition, the study provides a practical recommendation on how to apply the results, enabling living units to be assigned to a certain type. The typology can be used as a reference for definitions.

Interventions to improve appropriate antibiotic prescribing in long-term care facilities: a systematic review.
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E. Crayton, M. Richardson, C. Fuller, et al.
BMC Geriatr 2020 Jul 9;20(1):237-020-01564-1
Overuse of antibiotics has contributed to antimicrobial resistance; a growing public health threat. In long-term care facilities, levels of inappropriate prescribing are as high as 75%. Numerous interventions targeting long-term care facilities’ antimicrobial stewardship have been reported with varying, and largely unexplained, effects. Therefore, this review aimed to apply behavioural science frameworks to specify the component behaviour change techniques of stewardship interventions in long-term care facilities and identify those components associated with improved outcomes. METHOD: A systematic review (CRD42018103803) was conducted through electronic database searches. Two behavioural science frameworks, the Behaviour Change Wheel and Behaviour Change Technique Taxonomy were used to classify intervention descriptions into intervention types and component behaviour change techniques used. Study design and outcome heterogeneity prevented meta-analysis and meta-regression. Interventions were categorised as ‘very promising’ (all outcomes statistically significant), ‘quite promising’ (some outcomes statistically significant), or ‘not promising’ (no outcomes statistically significant). ‘Promise ratios’ (PR) were calculated for identified intervention types and behaviour change techniques by dividing the number of (very or quite) promising interventions featuring the intervention type or behaviour change technique by the number of interventions featuring the intervention type or behaviour change technique that were not promising. Promising intervention types and behaviour change techniques were defined as those with a PR ≥ 2. RESULTS: Twenty studies (of19 interventions) were included. Seven interventions (37%) were ‘very promising’, eight ‘quite promising’ (42%) and four ‘not promising’ (21%). Most promising intervention types were ‘persuasion’ (n = 12; promise ratio (PR) = 5.0), ‘enablement’ (n = 16; PR = 4.33) and ‘education’ (n = 19; PR = 3.75). Most promising behaviour change techniques were ‘feedback on behaviour’ (n = 9; PR = 8.0) and ‘restructuring the social environment’ (e.g. staff role changes; n = 8; PR = 7.0). CONCLUSION: Systematic identification of the active ingredients of antimicrobial stewardship in long-term care facilities was facilitated through the application of behavioural science frameworks. Incorporating environmental restructuring and performance feedback may be promising intervention strategies for antimicrobial stewardship interventions within long-term care facilities.

Dutch guideline for preventing nosocomial transmission of highly-resistant micro-organisms (HRMO) in long-term care facilities (LTCFs).
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A. Eikelenboom-Boskamp, J. Haaijman, M. Bos, et al.
Antimicrob Resist Infect Control 2019 Aug 27;8:146-019-0586-3. eCollection 2019
In 2012, the Dutch Working Party for Infection Control (WIP) issued the first Guideline for prevention of transmission of highly-resistant micro-organisms (HRMO) in Hospitals. The next step was to focus on long-term care facilities (LTCFs) both for nursing homes as for small-scale living facilities with nursing home care. These facilities providing care for residents with functional disabilities, chronical illnesses and cognitive disorders, such as dementia. The objective was to adapt the Guideline for prevention of transmission of HRMO in hospitals to LTCFs with a strong accent on living conditions and social interactions. Residents of LTCFs may be carriers of HRMO over a long period of time and most of the residents of the LTCF stay for extended periods of time. To respect individual living circumstances and to prevent unnecessary limitations in the social life of the residents due to the use of isolation measures, the WIP has chosen to describe infection control precautions per individual micro-organism instead of a ‘one size fits all’ method. The term “isolation” was therefore replaced by the term “additional” precautions. This guideline describes the screening policies for residents in LTCFs, definition and detection of HRMO carriage, standard and additional infection control precautions for HRMO positive residents, documentation and communication of HRMO carriage and discontinuation of additional infection control precautions. It also describes contact tracing of HRMO, environmental control/investigation, surveillance of HRMO and what is important when there is an outbreak.

The Influence of Transformational Leadership and Leader Attitudes on Subordinate Attitudes and Implementation Success.
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Lauren R. Farahnak, Mark G. Ehrhart, Elisa M. Torres and Gregory A. Aarons.
Journal of Leadership & Organizational Studies 2020 02/01; 2020/07;27(1):98-111
Recent literature has focused on identifying factors that facilitate or impede the implementation of innovation in organizations. Attitudes toward change and transformational leadership are regarded as important determinants of implementation success. This study tested a multilevel model of transformational leadership and leaders? attitudes toward the innovation being implemented as predictors of staff attitudes and implementation success. Participants were 565 service providers (n = 478) and their supervisors (n = 87) working in mental health organizations currently implementing an evidence-based practice (EBP). Results provided support for positive relationships between transformational leadership and staff attitudes toward EBP, as well as staff attitudes toward EBP and implementation success. Moreover, results supported an indirect relationship between transformational leadership and implementation success through employees? attitudes toward EBP. The results suggest that the leader?s behaviors are likely more critical to innovation implementation than the leader?s attitudes.

Clinical impact of antipsychotic and benzodiazepine reduction: findings from a multicomponent psychotropic reduction program within long-term aged care.
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D. J. Hoyle, G. M. Peterson, I. K. Bindoff, L. M. Clinnick, A. D. Bindoff and J. L. Breen.
Int Psychogeriatr 2020 Jun 18:1-13
To explore the relationships between dose changes to antipsychotic and/or benzodiazepine medications and resident outcomes, including variations in neuropsychiatric symptoms, quality of life (QoL), and social withdrawal, within a multicomponent, interdisciplinary antipsychotic and benzodiazepine dose reduction program. DESIGN: Prospective, observational, longitudinal study. INTERVENTION: The Reducing Use of Sedatives (RedUSe) project involved 150 Australian Long-Term Care Facilities (LTCFs) incorporating auditing and benchmarking of prescribing, education, and multidisciplinary sedative reviews. SETTING: A convenience sample of LTCFs (n = 28) involved in RedUSe between January 2015 and March 2016. PARTICIPANTS: Permanent residents (n = 206) of LTCFs involved in RedUSe taking an antipsychotic and/or benzodiazepine daily. Residents were excluded if they had a severe psychiatric condition where antipsychotic therapy should generally be maintained long-term (e.g., bipolar disorder, schizophrenia) or were considered end-stage palliative. MEASUREMENTS: Neuropsychiatric symptoms (Neuropsychiatric Inventory, Cohen-Mansfield Agitation Inventory (CMAI)), QoL (Assessment of Quality of Life-4D), and social withdrawal (Multidimensional Observation Scale for Elderly Subjects-withdrawal subscale) were measured at baseline and 4 months where nursing staff completed psychometric tests as proxy raters. RESULTS: There was no evidence that psychometric measures were worsened following dose reductions. In fact, dose reduction was associated with small, albeit non-statistically significant, improvements in behavior, particularly less physically non-aggressive behavior with both drug groups (-0.36 points per 10% reduction in antipsychotic dose, -0.17 per 10% reduction in benzodiazepine dose) and verbally agitated behavior with benzodiazepine reduction (-0.16 per 10% dose reduction), as measured with the CMAI. Furthermore, antipsychotic reduction was associated with non-statistically significant improvements in QoL and social withdrawal. CONCLUSIONS: Antipsychotic and benzodiazepine dose reduction in LTCFs was not associated with deterioration in neuropsychiatric symptoms, QoL, or social withdrawal. Trends toward improved agitation with antipsychotic and benzodiazepine dose reduction require further evaluation in larger, prospective, controlled studies.

Evaluating and prioritizing antimicrobial stewardship programs for nursing homes: A modified Delphi panel.
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S. Z. Kruger, S. E. Bronskill, L. Jeffs, M. Steinberg, A. M. Morris and C. M. Bell.
Infect Control Hosp Epidemiol 2020 Jun 22:1-7
Antibiotic use in nursing homes is often inappropriate, in terms of overuse and misuse, and it can be linked to adverse events and antimicrobial resistance. Antimicrobial stewardship programs (ASPs) can optimize antibiotic use by minimizing unnecessary prescriptions, treatment cost, and the overall spread of antimicrobial resistance. Nursing home providers and residents are candidates for ASP implementation, yet guidelines for implementation are limited. OBJECTIVE: To support nursing home providers with the selection and adoption of ASP interventions. DESIGN AND SETTING: A multiphase modified Delphi method to assess 15 ASP interventions across criteria addressing scientific merit, feasibility, impact, accountability, and importance. This study included surveys supplemented with a 1-day consensus meeting. PARTICIPANTS: A 16-member multidisciplinary panel of experts and resident representatives. RESULTS: From highest to lowest, 6 interventions were prioritized by the panel: (1) guidelines for empiric prescribing, (2) audit and feedback, (3) communication tools, (4) short-course antibiotic therapy, (5) scheduled antibiotic reassessment, and (6) clinical decision support systems. Several interventions were not endorsed: antibiograms, educational interventions, formulary review, and automatic substitution. A lack of nursing home resources was noted, which could impede multifaceted interventions. CONCLUSIONS: Nursing home providers should consider 6 key interventions for ASPs. Such interventions may be feasible for nursing home settings and impactful for improving antibiotic use; however, scientific merit supporting each is variable. A multifaceted approach may be necessary for long-term improvement but difficult to implement.

Advance Care Planning Video Intervention Among Long-Stay Nursing Home Residents: A Pragmatic Cluster Randomized Clinical Trial.
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S. L. Mitchell, A. E. Volandes, R. Gutman, et al.
JAMA Intern Med 2020 Jul 6
Standardized, evidenced-based approaches to conducting advance care planning (ACP) in nursing homes are lacking. Objective: To test the effect of an ACP video program on hospital transfers, burdensome treatments, and hospice enrollment among long-stay nursing home residents with and without advanced illness. Design, Setting, and Participants: The Pragmatic Trial of Video Education in Nursing Homes was a pragmatic cluster randomized clinical trial conducted between February 1, 2016, and May 31, 2019, at 360 nursing homes (119 intervention and 241 control) in 32 states owned by 2 for-profit corporations. Participants included 4171 long-stay residents with advanced dementia or cardiopulmonary disease (hereafter referred to as advanced illness) in the intervention group and 8308 long-stay residents with advanced illness in the control group, 5764 long-stay residents without advanced illness in the intervention group, and 11773 long-stay residents without advanced illness in the control group. Analyses followed the intention-to-treat principle. Interventions: Five 6- to 10-minute ACP videos were made available on tablet computers or online. Designated champions (mostly social workers) in intervention facilities were instructed to offer residents (or their proxies) the opportunity to view a video(s) on admission and every 6 months. Control facilities used usual ACP practices. Main Outcomes and Measures: Twelve-month outcomes were measured for each resident. The primary outcome was hospital transfers per 1000 person-days alive in the advanced illness cohort. Secondary outcomes included the proportion of residents with or without advanced illness experiencing 1 or more hospital transfer, 1 or more burdensome treatment, and hospice enrollment. To monitor fidelity, champions completed reports in the electronic record whenever they offered to show residents a video. Results: The study included 4171 long-stay residents with advanced illness in the intervention group (2970 women [71.2%]; mean [SD] age, 83.6 [9.1] years), and 8308 long-stay residents with advanced illness in the control group (5857 women [70.5%]; mean [SD] age, 83.6 [8.9] years), 5764 long-stay residents without advanced illness in the intervention group (3692 women [64.1%]; mean [SD] age, 81.5 [9.2] years), and 11773 long-stay residents without advanced illness in the control group (7467 women [63.4%]; mean [SD] age, 81.3 [9.2] years). There was no significant reduction in hospital transfers per 1000 person-days alive in the intervention vs control groups (rate [SE], 3.7 [0.2]; 95% CI, 3.4-4.0 vs 3.9 [0.3]; 95% CI, 3.6-4.1; rate difference [SE], -0.2 [0.3]; 95% CI, -0.5 to 0.2). Secondary outcomes did not significantly differ between trial groups among residents with and without advanced illness. Based on champions’ reports, 912 of 4171 residents with advanced illness (21.9%) viewed ACP videos. Facility-level rates of showing ACP videos ranged from 0% (14 of 119 facilities [11.8%]) to more than 40% (22 facilities [18.5%]). Conclusions and Relevance: This study found that an ACP video program was not effective in reducing hospital transfers, decreasing burdensome treatment use, or increasing hospice enrollment among long-stay residents with or without advanced illness. Intervention fidelity was low, highlighting the challenges of implementing new programs in nursing homes. Trial Registration: ClinicalTrials.gov Identifier: NCT02612688.

Implementation and sustainment of diverse practices in a large integrated health system: a mixed methods study.

Andrea L. Nevedal, Caitlin M. Reardon, George L. Jackson, et al.
Implementation Science Communications 2020 07/03;1(1):61
One goal of health systems seeking to evolve into learning health systems is to accelerate the implementation and sustainment of evidence-based practices (EBPs). As part of this evolution, the Veterans Health Administration (VHA) developed the Innovation Ecosystem, which includes the Diffusion of Excellence (DoE), a program that identifies and diffuses Gold Status Practices (GSPs) across facilities. The DoE hosts an annual “Shark Tank” competition in which leaders bid on the opportunity to implement a GSP with 6 months of implementation support. Over 750 diverse practices were submitted in cohorts 2 and 3 of Shark Tank; 23 were designated GSPs and were implemented in 31 VA networks or facilities. As part of a national evaluation of the DoE, we identified factors contributing to GSP implementation and sustainment.

Enhancing the Impact of Implementation Strategies in Healthcare: A Research Agenda.
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B. J. Powell, M. E. Fernandez, N. J. Williams, et al.
Front Public Health 2019 Jan 22;7:3
The field of implementation science was developed to better understand the factors that facilitate or impede implementation and generate evidence for implementation strategies. In this article, we briefly review progress in implementation science, and suggest five priorities for enhancing the impact of implementation strategies. Specifically, we suggest the need to: (1) enhance methods for designing and tailoring implementation strategies; (2) specify and test mechanisms of change; (3) conduct more effectiveness research on discrete, multi-faceted, and tailored implementation strategies; (4) increase economic evaluations of implementation strategies; and (5) improve the tracking and reporting of implementation strategies. We believe that pursuing these priorities will advance implementation science by helping us to understand when, where, why, and how implementation strategies improve implementation effectiveness and subsequent health outcomes.

Themes Related to Experienced Quality of Care in Nursing Homes From the Resident’s Perspective: A Systematic Literature Review and Thematic Synthesis.
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K. Y. J. Sion, H. Verbeek, S. M. G. Zwakhalen, G. Odekerken-Schroder, J. M. G. A. Schols and J. P. H. Hamers.
Gerontol Geriatr Med 2020 Jun 25;6:2333721420931964-Dec
The culture change from task-centered care to person- and relationship-centered care has resulted in the resident’s voice gaining importance when assessing experienced quality of care in nursing homes. This review aimed to identify which factors contribute to experienced quality of care in nursing homes worldwide from the resident’s perspective. Method: A systematic literature review and thematic data synthesis were performed. The databases PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, and Business Source Complete were searched to identify qualitative studies aimed at retrieving factors related to residents’ experienced quality of care in nursing homes. Only studies in which residents themselves were interviewed were included. Results: This literature review included 27 publications covering 14 countries. Thematic analysis revealed three overarching themes related to residents’ care experiences: (a) The nursing home environment consisted of the physical environment and caring environment, (b) individual aspects of living in the nursing home consisted of personhood and coping with change, and (c) social engagement consisted of meaningful relationships and care provision. Discussion: To achieve high experienced quality of care in nursing homes, residents’ care experiences need to be assessed and used in quality management.

Whole Person, Whole Journey: Developing a Person-Centred Regional Dementia Strategy.
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P. Stolee, J. Ashbourne, J. Elliott, et al.
Can J Aging 2020 Jul 7:1-15
We present the development of a regional dementia strategy in Southwestern Ontario, Canada. We worked with stakeholders in a regional health authority to develop a dementia strategy. We conducted interviews with persons with dementia and their care partners (n = 26) and health care administrators and policy makers (n = 33); and administered a priority-setting survey (n = 64). Both participant groups identified provider compassion, professionalism, and care in the early stages of dementia as system strengths. Both groups also highlighted a need for more integration and coordination, a need for more person-centred care, support for care partners, and more flexibility in the provision and receipt of services. The highest-ranked priorities were improving care partner support, improving access to care, and improving system-wide quality. We integrate these strengths, needs, and priorities in a strategic framework, “Whole Person, Whole Journey”. Organizations developing a dementia strategy may use this framework as a springboard for their own work.

Fidelity and sustainability of Mouth Care Without a Battle and lessons for other innovations in care.
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S. Zimmerman, C. J. Wretman, K. Ward, M. Tandan, P. D. Sloane and J. S. Preisser.
Geriatr Nurs 2020 Jun 24
There are countless efficacious interventions that improve outcomes when conducted in controlled situations. Many fewer are effective when implemented in real-world situations, largely because they are not implemented with fidelity. Still fewer are sustained over time, for reasons including lack of institutional support and fit with existing values, among others. It is especially important to examine fidelity and sustainability when efficacious interventions are being implemented, because these interventions are the ones that hold the most promise. This project examined the fidelity and sustainability of Mouth Care Without a Battle (MCWB), an evidence-based program conducted in a two-year cluster randomized trial in 14 nursing homes. Results that triangulated two sources of data indicated that fidelity decreased after the first year; they provide guidance to promote fidelity and sustainability of this and other new care practices in nursing homes, including ongoing education, coaching, evaluation, feedback, and sufficient resources.


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Organizational Culture and Change

Human Resource Management and Innovative Performance in Non-profit Hospitals: The Mediating Effect of Organizational Culture.
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J. C. Acosta-Prado, O. H. López-Montoya, C. Sanchís-Pedregosa and R. A. Zárate-Torres.
Front Psychol 2020 Jun 19;11:1422
Literature suggests that human resources of non-profit hospitals (NPHs) present features that could potentially reach any expected organizational performance even when the attention to human resource management (HRM) are often low in non-profit organizations. Nowadays ambitious organizations strive to obtain a profitable performance that is also innovate and do it through building an organizational culture (OC), while for NPHs a positive culture is given by their human resources traits. However, there is not enough literature to understand how these three variables behave together. This study aims to explain the influence of HRM on IP mediated by OC. The research model was assessed through Partial Least Squares Structural Equation Modeling (PLS-SEM). The results support all the stated hypotheses. Both, HRM and OC are moderately strong predictors of IP, and OC mediates partially and in a complementary way the relationship between HRM on IP. An importance-performance map analysis (IPMA) was performed to expand the PLS-SEM results. The OC indicators show greater importance to explain IP, consequently, they are the most relevant indicators to initiate management actions by NPHs. The influence of HRM on IP represent an opportunity for NPH as it implies an affordable investment in comparison to the cost of technological solutions for enterprises.

Individual, health system, and contextual barriers and facilitators for the implementation of clinical practice guidelines: a systematic metareview.
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V. C. Correa, L. H. Lugo-Agudelo, D. C. Aguirre-Acevedo, et al.
Health Res Policy Syst 2020 Jun 29;18(1):74-020-00588-8
Clinical practice guidelines (CPGs) are designed to improve the quality of care and reduce unjustified individual variation in clinical practice. Knowledge of the barriers and facilitators that influence the implementation of the CPG recommendations is the first step in creating strategies to improve health outcomes. The present systematic meta-review sought to explore the barriers and facilitators for the implementation of CPGs. METHODS: A search was conducted in the PubMed, Embase, Cochrane, Health System Evidence and International Guideline Library (G-I-N) databases. Systematic reviews of qualitative, quantitative or mixed-methods studies that identified barriers or facilitators for the implementation of CPGs were included. The selection of the title and abstract, the evaluation of the full text, extraction of the data and the quality assessment were carried out by two independent reviewers. To summarise the evidence, we grouped the barriers and facilitators according to the following contexts: political and social, health organisational system, guidelines, health professionals and patients. RESULTS: Overall, 25 systematic reviews were selected. The relevant barriers in the social-political context were the absence of a leader, difficulties with teamwork and a lack of agreement with colleagues. Relevant barriers in the health system were a lack of time, financial problems and a lack of specialised personnel. Barriers of the CPGs included a lack of clarity and a lack of credibility in the evidence. Regarding the health professional, a lack of knowledge about the CPG and confidence in oneself were relevant. Regarding patients, a negative attitude towards implementation, a lack of knowledge about the CPG and sociocultural beliefs played a role. Some of the most frequent facilitators were consistent leadership, commitment of the members of the team, administrative support of the institution, existence of multidisciplinary teams, application of technology to improve the practice and education regarding the guidelines. CONCLUSIONS: The barriers and facilitators described in this review are factors that influence the implementation of evidence in clinical practice. Knowledge of these factors should contribute to the development of a theoretical basis for the creation of CPG implementation strategies to improve professional practice and health outcomes for patients.

Defining and assessing context in healthcare implementation studies: a systematic review.
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L. Rogers, A. De Brún and E. McAuliffe.
BMC Health Serv Res 2020 Jun 29;20(1):591-020-05212-7
The implementation of evidence-based healthcare interventions is challenging, with a 17-year gap identified between the generation of evidence and its implementation in routine practice. Although contextual factors such as culture and leadership are strong influences for successful implementation, context remains poorly understood, with a lack of consensus regarding how it should be defined and captured within research. This study addresses this issue by providing insight into how context is defined and assessed within healthcare implementation science literature and develops a definition to enable effective measurement of context. METHODS: Medline, PsychInfo, CINAHL and EMBASE were searched. Articles were included if studies were empirical and evaluated context during the implementation of a healthcare initiative. These English language articles were published in the previous 10 years and included a definition and assessment of context. Results were synthesised using a narrative approach. RESULTS: Three thousand and twenty-one search records were obtained of which 64 met the eligibility criteria and were included in the review. Studies used a variety of definitions in terms of the level of detail and explanation provided. Some listed contextual factors (n = 19) while others documented sub-elements of a framework that included context (n = 19). The remaining studies provide a rich definition of general context (n = 11) or aspects of context (n = 15). The Alberta Context Tool was the most frequently used quantitative measure (n = 4), while qualitative papers used a range of frameworks to evaluate context. Mixed methods studies used diverse approaches; some used frameworks to inform the methods chosen while others used quantitative measures to inform qualitative data collection. Most studies (n = 50) applied the chosen measure to all aspects of study design with a majority analysing context at an individual level (n = 29). CONCLUSIONS: This review highlighted inconsistencies in defining and measuring context which emphasised the need to develop an operational definition. By providing this consensus, improvements in implementation processes may result, as a common understanding will help researchers to appropriately account for context in research.

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Research Practice and Methodology

Statistical Considerations for Embedded Pragmatic Clinical Trials in People Living with Dementia.
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H. G. Allore, K. S. Goldfeld, R. Gutman, et al.
J Am Geriatr Soc 2020 Jul;68 Suppl 2:S68-S73
There is overwhelming need for nonpharmacological interventions to improve the health and well-being of people living with dementia (PLWD). The National Institute on Aging Imbedded Pragmatic Alzheimer’s Disease (AD) and AD-Related Dementias Clinical Trials (IMPACT) Collaboratory supports clinical trials of such interventions embedded in healthcare systems. The embedded pragmatic clinical trial (ePCT) is ideally suited to testing the effectiveness of complex interventions in vulnerable populations at the point of care. These trials, however, are complex to conduct and interpret, and face challenges in efficiency (i.e., statistical power) and reproducibility. In addition, trials conducted among PLWD present specific statistical challenges, including difficulty in outcomes ascertainment from PLWD, necessitating reliance on reports by caregivers, and heterogeneity in measurements across different settings or populations. These and other challenges undercut the reliability of measurement, the feasibility of capturing outcomes using pragmatic designs, and the ability to validly estimate interventions’ effectiveness in real-world settings. To address these challenges, the IMPACT Collaboratory has convened a Design and Statistics Core, the goals of which are: to support the design and conduct of ePCTs directed toward PLWD and their caregivers; to develop guidance for conducting embedded trials in this population; and to educate quantitative and clinical scientists in the design, conduct, and analysis of these trials. In this article, we discuss some of the contemporary methodological challenges in this area and develop a set of research priorities the Design and Statistics Core will undertake to meet these goals. J Am Geriatr Soc 68:S68-S73, 2020.

A Systematic Methodological Review of Hierarchical Linear Modeling in Mixed Methods Research.
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Kirstie L. Bash, Michelle C. Howell Smith and Pam S. Trantham.
Journal of Mixed Methods Research 2020 07/02; 2020/07:1558689820937882
The use of advanced quantitative methods within mixed methods research has been investigated in a limited capacity. In particular, hierarchical linear models are a popular approach to account for multilevel data, such as students within schools, but its use and value as the quantitative strand in a mixed methods study remains unknown. This article examines the role of hierarchical linear modeling in mixed methods research with emphasis on design choice, priority, and rationales. The results from this systematic methodological review suggest that hierarchical linear modeling does not overshadow the contributions of the qualitative strand. Our study contributes to the field of mixed methods research by offering recommendations for the use of hierarchical linear modeling as the quantitative strand in mixed methods studies.

Building a National Program for Pilot Studies of Embedded Pragmatic Clinical Trials in Dementia Care.
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A. A. Brody, D. E. Barnes, J. Chodosh, et al.
J Am Geriatr Soc 2020 Jul;68 Suppl 2:S14-S20
Sixteen million caregivers currently provide care to more than 5 million persons living with dementia (PLWD) in the United States. Although this population is growing and highly complex, evidence-based management remains poorly integrated within healthcare systems. Therefore, the National Institute on Aging IMPACT Collaboratory was formed to build the nation’s ability to conduct embedded pragmatic clinical trials (ePCTs) for PLWD and their caregivers. The pilot core of the IMPACT Collaboratory seeks to provide funds for upward of 40 pilots for ePCTs to accelerate the testing of nonpharmacologic interventions with the goal that these pilots lead to full-scale ePCTs and eventually the embedding of evidence-based care into healthcare systems. The first two challenges for the pilot core in building the pilot study program were (1) to develop a transparent, ethical, and open nationwide process for soliciting, reviewing, and selecting pilot studies; and (2) to begin the process of describing the necessary components of a pilot study for an ePCT. During our initial funding cycle, we received 35 letters of intent, of which 17 were accepted for a full proposal and 14 were submitted. From this process we learned that investigators lack knowledge in ePCTs, many interventions lack readiness for an ePCT pilot study, and many proposed studies lack key pragmatic design elements. We therefore have set three key criteria that future pilot studies must meet at a minimum to be considered viable. We additionally discuss key design decisions investigators should consider in designing a pilot study for an ePCT. J Am Geriatr Soc 68:S14-S20, 2020.

Using Healthcare Data in Embedded Pragmatic Clinical Trials among People Living with Dementia and Their Caregivers: State of the Art.
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J. P. W. Bynum, D. A. Dorr, J. Lima, et al.
J Am Geriatr Soc 2020 Jul;68 Suppl 2:S49-S54
Embedded pragmatic clinical trials (ePCTs) are embedded in healthcare systems as well as their data environments. For people living with dementia (PLWD), settings of care can be different from the general population and involve additional people whose information is also important. The ePCT designs have the opportunity to leverage data that becomes available through the normal delivery of care. They may be particularly valuable in Alzheimer’s disease and Alzheimer’s disease-related dementia (AD/ADRD), given the complexity of case identification and the diversity of care settings. Grounded in the objectives of the Data and Technical Core of the newly established National Institute on Aging Imbedded Pragmatic Alzheimer’s Disease and AD-Related Dementias Clinical Trials Collaboratory (IMPACT Collaboratory), this article summarizes the state of the art in using existing data sources (eg, Medicare claims, electronic health records) in AD/ADRD ePCTs and approaches to integrating them in real-world settings. J Am Geriatr Soc 68:S49-S54, 2020.

Training the Workforce to Conduct Embedded Pragmatic Clinical Trials to Improve Care for People Living with Dementia and Their Caregivers.
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C. M. Callahan, A. M. Torke, C. A. Alder, J. A. Broughton and S. L. Mitchell.
J Am Geriatr Soc 2020 Jul;68 Suppl 2:S21-S27
The National Institute on Aging IMbedded Pragmatic Alzheimer’s Disease and Alzheimer’s Disease-Related Dementias Clinical Trials (IMPACT) Collaboratory serves as a national resource for the conduct of embedded pragmatic clinical trials to improve the care of people living with dementia (PLWD) in partnership with the healthcare systems that serve them. Inherent in this objective is the need to train and support a cadre of investigators prepared to conduct this work now and in the future. The Training Core of the IMPACT Collaboratory supports the training of investigators to become experts in this field through three objectives: (1) curricula development and dissemination; (2) network generation and navigation; and (3) a career development award program. The innovative approach of the Training Core will require developing content and providing training experiences that recognize the unique challenges of research at the intersection of health systems, pragmatic trials, and PLWD and their caregivers. Ultimately, we seek to build the nation’s capacity to conduct research that bridges the gaps between efficacy studies to effectiveness research to implementation science. Although foundational resources in the methods of each of these areas are already available, few actually focus on pragmatic trials embedded within healthcare systems that focus on PLWD. To bring new interventions for PLWD from efficacy to widespread implementation, researchers must build diffusability, adaptability, heterogeneity, and scalability into the design of the intervention. In achieving these objectives, the Training Core will utilize the network of investigators, institutions, and stakeholders represented in the IMPACT Collaboratory. J Am Geriatr Soc 68:S21-S27, 2020.

Dissemination and Implementation of Evidence-Based Dementia Care Using Embedded Pragmatic Trials.
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L. N. Gitlin, R. R. Baier, E. Jutkowitz, et al.
J Am Geriatr Soc 2020 Jul;68 Suppl 2:S28-S36
There are many nonpharmacologic interventions tested in randomized clinical trials that demonstrate significant benefits for people living with Alzheimer’s disease (AD) and AD-related dementia, their care partners, or professional care providers. Nevertheless, with few exceptions, proven interventions have not been translated for delivery in real-world settings, such as home care, primary care, hospitals, community-based services, adult day services, assisted living, nursing homes, or other healthcare systems (HCSs). Using embedded pragmatic clinical trial (ePCT) methods is one approach that can facilitate dissemination and implementation (D&I) of dementia care interventions. The science of D&I can inform the integration of evidence-based dementia care in HCSs by offering theoretical frameworks that capture field complexities and guiding evaluation of implementation processes. Also, D&I science can suggest evidence-based strategies for implementing dementia care in HCSs. Although D&I considerations can inform each stage of dementia care intervention development, it is particularly critical when designing ePCTs. This article examines fundamental considerations for implementing dementia-specific interventions in HCSs and how best to prepare for successful dissemination upstream in the context of ePCTs, thereby illustrating the critical role of the D&I Core of the National Institute on Aging Imbedded Pragmatic Alzheimer’s Disease and AD-Related Dementias Clinical Trials Collaboratory. The scientific premise of the D&I Core is that having the “end” in mind, upfront in the design and testing of dementia care programs, can lead to decision-making that optimizes the ultimate goal of wide-scale D&I of evidence-based dementia care programs in HCSs. J Am Geriatr Soc 68:S28-S36, 2020.

Evidence Synthesis International (ESI): Position Statement.
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D. Gough, P. Davies, G. Jamtvedt, et al.
Syst Rev 2020 Jul 10;9(1):155-020-01415-5
This paper is the initial Position Statement of Evidence Synthesis International, a new partnership of organizations that produce, support and use evidence synthesis around the world. The paper (i) argues for the importance of synthesis as a research exercise to clarify what is known from research evidence to inform policy, practice and personal decision making; (ii) discusses core issues for research synthesis such as the role of research evidence in decision making, the role of perspectives, participation and democracy in research and synthesis as a core component of evidence ecosystems; (iii) argues for 9 core principles for ESI on the nature and role of research synthesis; and (iv) lists the 5 main goals of ESI as a coordinating partnership for promoting and enabling the production and use of research synthesis.

Developing pathways for community-led research with big data: a content analysis of stakeholder interviews.
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S. Grayson, M. Doerr and J. H. Yu.
Health Res Policy Syst 2020 Jul 8;18(1):76-020-00589-7
Big data (BD) informs nearly every aspect of our lives and, in health research, is the foundation for basic discovery and its tailored translation into healthcare. Yet, as new data resources and citizen/patient-led science movements offer sites of innovation, segments of the population with the lowest health status are least likely to engage in BD research either as intentional data contributors or as ‘citizen/community scientists’. Progress is being made to include a more diverse spectrum of research participants in datasets and to encourage inclusive and collaborative engagement in research through community-based participatory research approaches, citizen/patient-led research pilots and incremental research policy changes. However, additional evidence-based policies are needed at the organisational, community and national levels to strengthen capacity-building and widespread adoption of these approaches to ensure that the translation of research is effectively used to improve health and health equity. The aims of this study are to capture uses of BD (‘use cases’) from the perspectives of community leaders and to identify needs and barriers for enabling community-led BD science. METHODS: We conducted a qualitative content analysis of semi-structured key informant interviews with 16 community leaders. RESULTS: Based on our analysis findings, we developed a BD Engagement Model illustrating the pathways and various forces for and against community engagement in BD research. CONCLUSIONS: The goal of our Model is to promote concrete, transparent dialogue between communities and researchers about barriers and facilitators of authentic community-engaged BD research. Findings from this study will inform the subsequent phases of a multi-phased project with the ultimate aims of organising fundable frameworks and identifying policy options to support BD projects within community settings.

Selecting Outcomes to Ensure Pragmatic Trials Are Relevant to People Living with Dementia.
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L. C. Hanson, A. V. Bennett, M. Jonsson, et al.
J Am Geriatr Soc 2020 Jul;68 Suppl 2:S55-S61
Outcome measures for embedded pragmatic clinical trials (ePCTs) should reflect the lived experience of people living with dementia (PLWD) and their caregivers, yet patient- and caregiver-reported outcomes (PCROs) are rarely available in large clinical and administrative data sources. Although pragmatic methods may lead to use of existing administrative data rather than new data collected directly from PLWD, interventions are truly impactful only when they change outcomes prioritized by PLWD and their caregivers. The Patient- and Caregiver-Reported Outcomes Core (PCRO Core) of the IMbedded Pragmatic Alzheimer’s Disease (AD) and AD-Related Dementias Clinical Trials (IMPACT) Collaboratory aims to promote optimal use of outcomes relevant to PLWD and their caregivers in pragmatic trials. The PCRO Core will address key scientific challenges limiting outcome measurement, such as gaps in existing measures, methodologic constraints, and burdensome data capture. PCRO Core investigators will create a searchable library of AD/AD-related dementias (ADRD) clinical outcome measures, including measures in existing data sources with potential for AD/ADRD ePCTs, and will support best practices in measure development, including pragmatic adaptation of PCROs. Working together with other Cores and Teams within the IMPACT Collaboratory, the PCRO Core will support investigators to select from existing outcome measures, and to innovate in methods for measurement and data capture. In the future, the work of the IMPACT Collaboratory may galvanize broader embedded use of outcomes that matter to PLWD and their care partners in large health systems. J Am Geriatr Soc 68:S55-S61, 2020.

Engaging Stakeholders in the Design and Conduct of Embedded Pragmatic Clinical Trials for Alzheimer’s Disease and Alzheimer’s Disease-Related Dementias.
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J. Harrison, K. Maslow, E. Tambor, et al.
J Am Geriatr Soc 2020 Jul;68 Suppl 2:S62-S67
Embedded pragmatic clinical trials (ePCTs) of nondrug interventions for Alzheimer’s disease and Alzheimer’s disease-related dementias (AD/ADRD) are conducted in real-world clinical settings and designed to generate an evidence base to inform clinical and policy decisions about care for this vulnerable population. The ePCTs exist within a complex ecosystem of relationships between researchers, payors, policymakers, healthcare systems, direct care staff, advocacy groups, families, caregivers, and people living with dementia (PLWD). Because the rapid increase of the number of Americans with AD/ADRD outpaces curative treatments, there is an urgent need to mobilize the power of these relationships to improve dementia care and address a mounting public health crisis. Stakeholder engagement in ePCTs is essential to generate research questions, establish the relevancy of trials to the intended end users, and understand the factors that influence dissemination and implementation in real-world clinical settings. The process of including stakeholders in ePCTs for dementia is similar to stakeholder engagement in ePCTs for other diseases and conditions; however, the unique nature of embedded research, prevalence of caregiver and provider burden, and the progressive worsening of cognitive impairment in PLWD must be approached with additional strategies. This article presents key considerations of stakeholder engagement for ePCTs in AD/ADRD and main activities of the stakeholder engagement team in the National Institute on Aging IMPACT Collaboratory to move the field forward. J Am Geriatr Soc 68:S62-S67, 2020.

Ethical and Regulatory Issues for Embedded Pragmatic Trials Involving People Living with Dementia.
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E. A. Largent, S. P. Hey, K. Harkins, et al.
J Am Geriatr Soc 2020 Jul;68 Suppl 2(Suppl 2):S37-S42
Embedded pragmatic clinical trials (ePCTs) present an opportunity to improve care for people living with dementia (PLWD) and their care partners, but they also generate a complex constellation of ethical and regulatory challenges. These challenges begin with participant identification. Interventions may be delivered in ways that make it difficult to identify who is a human subject and therefore who needs ethical and regulatory protections. The need for informed consent, a core human subjects protection, must be considered but can be in tension with the goals of pragmatic research design. Thus it is essential to consider whether a waiver or alteration of informed consent is justifiable. If informed consent is needed, the question arises of how it should be obtained because researchers must acknowledge the vulnerability of PLWD due in part to diminished capacity and also to increased dependence on others. Further, researchers should recognize that many sites where ePCTs are conducted will be unfamiliar with human subjects research regulations and ethics. In this report, the Regulation and Ethics Core of the National Institute on Aging Imbedded Pragmatic Alzheimer’s disease (AD) and AD-related dementias (AD/ADRD) Clinical Trials (IMPACT) Collaboratory discusses key ethical and regulatory challenges for ePCTs in PLWD. A central thesis is that researchers should strive to anticipate and address these challenges early in the design of their ePCTs as a means of both ensuring compliance and advancing science. J Am Geriatr Soc 68:S37-S42, 2020.

Embedded Pragmatic Trials in Dementia Care: Realizing the Vision of the NIA IMPACT Collaboratory.
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S. L. Mitchell, V. Mor, J. Harrison and E. P. McCarthy.
J Am Geriatr Soc 2020 Jul;68 Suppl 2:S1-S7
Close to 6 million Americans have Alzheimer’s disease (AD) or Alzheimer’s disease and related dementia (AD/ADRD). These high-need, high-cost patients are vulnerable to receiving poor quality uncoordinated care, ultimately leading to adverse health outcomes, poor quality of life, and misuse of resources. Improving the care of persons living with dementia (PLWD) and their caregivers is an urgent public health challenge that must be informed by high-quality evidence. Although prior research has elucidated opportunities to improve AD/ADRD care, the adoption of promising interventions has been stymied by the lack of research evaluating their effectiveness when implemented under real-world conditions. Embedded pragmatic clinical trials (ePCTs) in healthcare systems have the potential to accelerate the translation of evidence-based interventions into clinical practice. Building from the foundation of the National Institutes of Healthcare Systems Collaboratory, in September 2019 the National Institute on Aging Imbedded Pragmatic AD/ADRD Clinical Trials (IMPACT) Collaboratory was launched. Its mission is to build the nation’s capacity to conduct ePCTs within healthcare systems for PLWD and their caregivers by (1) developing and disseminating best practice research methods, (2) supporting the design and conduct of ePCTs including pilot studies, (3) building investigator capacity through training and knowledge generation, (4) catalyzing collaboration among stakeholders, and (5) ensuring the research includes culturally tailored interventions for people from diverse backgrounds. This report presents the rationale, structure, key activities, and markers of success for the overall NIA IMPACT Collaboratory. The articles that follow in this special Issue describe the specific work of its 10 core working groups and teams. J Am Geriatr Soc 68:S1-S7, 2020.

Guidance on authorship with and acknowledgement of patient partners in patient-oriented research.
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D. P. Richards, K. A. Birnie, K. Eubanks, et al.
Res Involv Engagem 2020 Jul 2;6:38-020-00213-6. eCollection 2020
The Strategy for Patient-Oriented Research Chronic Pain Network was founded in 2016 and is a patient-oriented research network funded by the Canadian Institutes of Health Research. The Network incorporates patient partners throughout its governance and operations meaning that patient partners may contribute to research projects in ways that warrant scientific authorship as defined by the International Committee of Medical Journal Editors. The Network did a brief informal review of guidance on patient authorship in 2019, but could not find any practical documentation to guide its members on this topic. Note the term patient partner here refers to a patient (or caregiver or other person with lived experience) who is a partner or collaborator on a research team. This guidance does not address patients as participants in a research study. This guidance has been co-written by a group of researchers and patient partners of the Chronic Pain Network in an effort to address this gap. It is intended for both researchers and patient partner audiences. This guidance is meant to facilitate conversations between researchers and patient partners about authorship and/or acknowledgement regarding research projects on which they collaborate. While the overall principles of academic authorship and acknowledgement remain unchanged, nuances for interpreting these principles through the lens of patient engagement or patient-oriented research is provided. Teams that carry out patient-oriented research projects will require different preparation to empower all team members (researchers and patient partners) to discuss authorship and acknowledgement. To facilitate these conversations, we have included an overview of the scientific publishing process, explanation of some common terms, and sets of considerations are provided for both patient partners and researchers in determining the range of team member contribution from acknowledgement to authorship. Conversations about authorship can be difficult, even for established research teams. This guidance, and the resources discussed within it, are provided with the intention of making these conversations easier and more thoughtful.

Research with older people in a world with COVID-19: identification of current and future priorities, challenges and opportunities.
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S. J. Richardson, C. B. Carroll, J. Close, et al.
Age Ageing 2020 Jun 25
Older people are disproportionately affected by the COVID-19 pandemic, which has had a profound impact on research as well as clinical service delivery. This commentary identifies key challenges and opportunities in continuing to conduct research with and for older people, both during and after the current pandemic. It shares opinions from responders to an international survey, a range of academic authors and opinions from specialist societies. Priorities in COVID-19 research include its specific presentation in older people, consequences for physical, cognitive and psychological health, treatments and vaccines, rehabilitation, supporting care homes more effectively, the impact of social distancing, lockdown policies and system reconfiguration to provide best health and social care for older people. COVID-19 research needs to be inclusive, particularly involving older people living with frailty, cognitive impairment or multimorbidity, and those living in care homes. Non-COVID-19 related research for older people remains of critical importance and must not be neglected in the rush to study the pandemic. Profound changes are required in the way that we design and deliver research for older people in a world where movement and face-to-face contact are restricted, but we also highlight new opportunities such as the ability to collaborate more widely and to design and deliver research efficiently at scale and speed.

Investigation of Longitudinal Data Analysis: Hierarchical Linear Model and Latent Growth Model Using a Longitudinal Nursing Home Dataset.
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J. H. Shin and I. S. Shin.
Res Gerontol Nurs 2019 Nov 1;12(6):275-283
The appropriate use of the data analysis method in a longitudinal design remains controversial in gerontological nursing research. The objective of the current study is to compare statistical approaches between a hierarchical-linear model (HLM) and a latent-growth model (LGM) in random effects, variance explained, growth trajectory, and model fitness. Secondary analysis of longitudinal data was used. Two variables were chosen to demonstrate the comparison between statistical methods. The HLM was superior in addressing unbalanced data in repeated-measures analysis of variance (ANOVA) and multivariate ANOVA because its nested data structure and random effects could be estimated. The LGM had advantages in modeling growth trajectories and model-fit comparisons. Superior to the HLM, the LGM reported more acceptable data fit, reporting a quadratic model, and successfully differentiated between and within components. The current research provides some evidence for applying appropriate statistical methods when addressing longitudinal datasets in gerontological nursing research. [Research in Gerontological Nursing, 12(6), 275-283.].

Rapid review methods more challenging during COVID-19: Commentary with a focus on 8 knowledge synthesis steps.
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A. C. Tricco, C. M. Garritty, L. Boulos, et al.
J Clin Epidemiol 2020 Jun 29
In this paper, we outline several challenges based on our collective experience conducting COVID-19 rapid reviews predominantly for healthcare provider and policy decision-makers.

Transforming Dementia Care Through Pragmatic Clinical Trials Embedded in Learning Healthcare Systems.
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L. Tuzzio, L. R. Hanson, D. B. Reuben, et al.
J Am Geriatr Soc 2020 Jul;68 Suppl 2:S43-S48
The current evidence base for testing nonpharmacological interventions for people living with dementia (PLWD) and their caregivers is limited, especially within care settings such as ambulatory care, assisted living communities, nursing homes, hospitals, and hospices. There has been even less attention to translation of effective interventions for PLWD into delivery of care. Thus, there is an urgent need for researchers to partner with these care settings, especially those that follow a learning healthcare systems (LHSs) model, and vice versa to conduct embedded pragmatic clinical trials (ePCTs). These trials are conducted within sites that offer routine care and are designed to answer important, relevant clinical questions and leverage existing electronic health and administrative data. ePCTs set in LHSs create a unique opportunity for researchers, healthcare providers, and PLWD and their families to work and learn together as potentially effective interventions are studied and stress tested in real-world situations. Healthcare settings that embrace research or quality improvement as part of a culture of continuous learning are ideal settings for ePCTs. In this article, we summarize what we have learned from the National Institutes of Health’s Health Care Systems Research Collaboratory-funded ePCTs, discuss challenges of ePCTs within settings that serve PLWD, and describe the work of the Health Care Systems Core within the National Institute on Aging’s IMbedded Alzheimer’s Disease and Related Dementias Clinical Trials Collaboratory that will occur over the next 5 years. J Am Geriatr Soc 68:S43-S48, 2020.

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Optimisation of medications used in residential aged care facilities: a systematic review and meta-analysis of randomised controlled trials.
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H. Almutairi, A. Stafford, C. Etherton-Beer and L. Flicker.
BMC Geriatr 2020 Jul 8;20(1):236-020-01634-4
Frail older adults living in residential aged care facilities (RACFs) usually experience comorbidities and are frequently prescribed multiple medications. This increases the potential risk of inappropriate prescribing and its negative consequences. Thus, optimising prescribed medications in RACFs is a challenge for healthcare providers. OBJECTIVE: Our aim was to systematically review interventions that increase the appropriateness of medications used in RACFs and the outcomes of these interventions. METHODS: Systematic review and meta-analysis of randomised control trials (RCTs) and cluster randomised control trials (cRCTs) were performed by searching specified databases (MEDLINE, PubMed, Google scholar, PsycINFO) for publications from inception to May 2019 based on defined inclusion criteria. Data were extracted, study quality was assessed and statistically analysed using RevMan v5.3. Medication appropriateness, hospital admissions, mortality, falls, quality of life (QoL), Behavioural and Psychological Symptoms of Dementia (BPSD), adverse drug events (ADEs) and cognitive function could be meta-analysed. RESULTS: A total of 25 RCTs and cRCTs comprising 19,576 participants met the inclusion criteria. The studies tested various interventions including medication review (n = 13), staff education (n = 9), multi-disciplinary case conferencing (n = 4) and computerised clinical decision support systems (n = 2). There was an effect of interventions on medication appropriateness (RR 0.71; 95% confidence interval (CI): 0.60,0.84) (10 studies), and on medication appropriateness scales (standardised mean difference = - 0.67; 95% CI: - 0.97, - 0.36) (2 studies). There were no apparent effects on hospital admission (RR 1.00; 95% CI: 0.93, 1.06), mortality (RR 0.98; 95% CI: 0.86, 1.11), falls (RR 1.06; 95% CI: 0.89,1.26), ADEs (RR 1.04; 95% CI: 0.96,1.13), QoL (standardised mean difference = 0.16; 95% CI:-0.13, 0.45), cognitive function (weighted mean difference = 0.69; 95% CI: - 1.25, 2.64) and BPSD (RR 0.68; 95% CI: 0.44,1.06) (2 studies). CONCLUSION: Modest improvements in medication appropriateness were observed in the studies included in this systematic review. However, the effect on clinical measures was limited to drive strong conclusions.

An appreciative inquiry into older adults’ pain experience in long term care facilities: a pain education initiative.

Jennifer N. Auxier, Sian Roberts, Lauren Laing, Lee Finch, Sara Tung and Lillian Hung.
International Practice Development Journal 2020;10(1).
The prevalence of pain in older adults living in long-term care homes is as high as 80% in developed countries. A Pain Initiative was implemented to improve the pain experience of older adults in two care homes in Vancouver, Canada. This initiative consisted of education and coaching to strengthen the staff teams’ competence and confidence in pain management, although it was not evaluated for effectiveness. Aim: A clinical research team explored the lived experiences of older adults and professional caregivers participating in the Pain Initiative. The two research questions were: what were the experiences of participating in the Pain Initiative of older adults, professional caregivers and nurse supervisors? and what are enabling factors for positive changes in older adults’ pain experiences? Methods: We used appreciative inquiry to identify enabling factors for effective pain management, staying consistent with the tradition of this method to focus on the strengths within an organisation. Older adults and nurse supervisors participated in one-to-one interviews, and professional caregivers participated in focus groups. Inductive thematic analysis was used to analyse the data. Findings: Enhanced awareness of older adults’ pain led to increased empathy in professional caregivers. Ongoing coaching, education and resources were enabling factors for effective pain management. The findings illustrate that person-centred practices for pain management in long-term care homes were enhanced through getting to know the older adult, teamwork, non-pharmacological solutions and effective clinical and team processes. Conclusions and implications for practice: • Pain management is enhanced with ongoing multidisciplinary education, and coaching • Older adults’ life stories affect their experiences of pain. Care teams should seek personal knowledge about the older adults as a priority of care • Increased frequency of pain discussions results in changing assumptions about pain as a normal part of ageing and encourages empathic practice.

Using point-of-care C-reactive protein to guide antibiotic prescribing for lower respiratory tract infections in elderly nursing home residents (UPCARE): study design of a cluster randomized controlled trial.
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T. M. Boere, L. W. van Buul, R. M. Hopstaken, et al.
BMC Health Serv Res 2020 Feb 27;20(1):149-020-5006-0
Antibiotics are over-prescribed for lower respiratory tract infections (LRTI) in nursing home residents due to diagnostic uncertainty. Inappropriate antibiotic use is undesirable both on patient level, considering their exposure to side effects and drug interactions, and on societal level, given the development of antibiotic resistance. C-reactive protein (CRP) point-of-care testing (POCT) may be a promising diagnostic tool to reduce antibiotic prescribing for LRTI in nursing homes. The UPCARE study will evaluate whether the use of CRP POCT for suspected LRTI is (cost-) effective in reducing antibiotic prescribing in the nursing home setting. METHODS/DESIGN: A cluster randomized controlled trial will be conducted in eleven nursing homes in the Netherlands, with the nursing home as the unit of randomization. Residents with suspected LRTI who reside at a psychogeriatric, somatic, or geriatric rehabilitation ward are eligible for study participation. Nursing homes in the intervention group will provide care as usual with the possibility to use CRP POCT, and the control group will provide care as usual without CRP POCT for residents with (suspected) LRTI. Data will be collected from September 2018 for approximately 1.5 year, using case report forms that are integrated in the electronic patient record system. The primary study outcome is antibiotic prescribing for suspected LRTI at index consultation (yes/no). DISCUSSION: This is the first randomised trial to evaluate the effect of nursing home access to and training in the use of CRP POCT on antibiotic prescribing for LRTI, yielding high-level evidence and contributing to antibiotic stewardship in the nursing home setting. The relatively broad inclusion criteria and the pragmatic study design add to the applicability and generalizability of the study results. TRIAL REGISTRATION: Netherlands Trial Register, Trial NL5054. Registered 29 August 2018.

Resident-to-resident aggression in Norwegian nursing homes: a cross-sectional exploratory study.
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A. Botngård, A. H. Eide, L. Mosqueda and W. Malmedal.
BMC Geriatr 2020 Jun 24;20(1):222-020-01623-7
Resident-to-resident aggression in nursing homes is a public health problem of growing concern, impacting the safety, health and well-being of all residents involved. Despite this, little research has been conducted on its occurrence particularly in large-scale national studies. The aim of this study was to explore the extent and nature of resident-to-resident aggression in Norwegian nursing homes, as reported by nursing staff. METHODS: We conducted a cross-sectional exploratory study, where nursing staff in 100 randomly selected Norwegian nursing homes completed a pen and paper survey measuring how often they had observed incidents of resident-to-resident aggression during the past year. These rates were separated according to nursing home size, location and units of workplace. RESULTS: Of the 3693 nursing staff who participated (response rate 60.1%), 88.8% had observed one or more incidents of resident-to-resident aggression during the past year, with acts of verbal and physical aggression being the most commonly reported. Nursing staff working in dementia special care units, larger nursing homes and nursing homes located in suburban/urban municipalities, reported more incidents of resident-to-resident aggression than staff in short-term and long-term units, small institutions, and nursing homes located in rural municipalities. CONCLUSIONS: This is the first national study of resident-to-resident aggression in Norwegian nursing homes and is one of the largest surveys worldwide exploring the extent and nature of resident-to-resident aggression in long-term care settings. Overall, we found a high occurrence of all types of aggression, suggesting a need for strategies to improve residents’ safety and quality of life in nursing homes.

Patterns and Predictors of Transitions across Residential Care Settings and Nursing Homes Among Community-Dwelling Older Adults in the United States.
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L. C. Chyr, E. F. Drabo and C. D. Fabius.
Gerontologist 2020 Jun 29
Older adults prefer to age in place, but sociodemographic, health, and socioeconomic factors may influence their decision to remain in the community. Guided by Andersen’s behavioral model, we characterize incident transitions out of the community into residential care settings or nursing homes and identify predictors of these transitions. RESEARCH DESIGN AND METHODS: Study participants include 2,725 (weighted n=13,704,390) community-dwelling U.S. older adults of the National Health and Aging Trends Study from 2011 to 2018. We examined the associations between sociodemographic, socioeconomic and health factors and the probability of transition using a multinomial logit model. RESULT: 86.2% of older adults remained in the community, whereas 9.0% and 4.9% transitioned to residential care settings and nursing homes, respectively. Older age, living alone, having functional and cognitive limitations, and hospitalization were associated with increased risk of transitioning to residential care settings or nursing homes from the community. Blacks and Hispanics were less likely to transition to residential care settings or nursing homes. Adults with lower income had a greater risk of transitioning to nursing homes. Medicaid enrollment did not impact the likelihood of transition. DISCUSSION AND IMPLICATIONS: Majority of older adults remained in the community and incident transition to residential care settings was more common than to nursing homes. Policy should target sociodemographic, health, and socioeconomic factors that enable older adults to age in place. Future work should examine whether these new residential care settings enhance quality of life or result in subsequent transitions back into the community.

Nursing Home Residents’ Functional Trajectories and Mortality After a Transfer to the Emergency Department.
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Vincent Guion, Philipe De Souto Barreto and Yves Rolland.
Journal of the American Medical Directors Association 2020/07
To describe nursing home residents? (NHRs) functional trajectories and mortality after a transfer to the emergency department (ED).; ObjectiveTo describe nursing home residents? (NHRs) functional trajectories and mortality after a transfer to the emergency department (ED).

Lack of Effect of a Multicomponent Palliative Care Program for Nursing Home Residents on Hospital Use in the Last Month of Life and on Place of Death: A Secondary Analysis of a Multicountry Cluster Randomized Control Trial.
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E. Honinx, T. Smets, R. Piers, et al.
J Am Med Dir Assoc 2020 Jul 6
PACE Steps to Success is a 1-year train-the-trainer program aiming to integrate nonspecialist palliative care into nursing homes via staff education and organizational support. In this study, we aimed to explore whether this program resulted in changes in residents’ hospital use and place of death. DESIGN: Secondary analysis of the PACE cluster randomized controlled trial (ISRCTN14741671). Data were collected on deaths over the previous 4 months via questionnaires at baseline and postintervention. SETTING AND PARTICIPANTS: Questionnaires were completed by the nurse/care-assistant most involved from 78 nursing homes in 7 European Union countries. MEASURES: We measured number of emergency department visits, hospital admissions, length of hospital stay, and place of death. Baseline and postintervention scores between intervention and control groups were compared, and we conducted exploratory mixed-model analyses. We collected 551 out of 610 questionnaires at baseline and 984 out of 1178 at postintervention in 37 intervention and 36 control homes. RESULTS: We found no statistical significant effects of the program on emergency department visits [odds ratio (OR) = 1.38, P = .32], hospital admissions (OR = 0.98, P = .93), length of hospital stay (geometric mean difference = 0.85, P = .44), or place of death (OR = 1.08, P = .80). CONCLUSIONS AND IMPLICATIONS: We found no effect of the PACE program on either hospital use in the last month of life or place of death. Although this may be related to implementation problems in some homes, the program might also require a more specific focus on managing acute end-of-life situations and a closer involvement of general practitioners or specialist palliative care services to influence hospital use or place of death.

Sounds in nursing homes and their effect on health in dementia: a systematic review
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S. I. M. Janus, J. Kosters, K. A. van den Bosch, T. C. Andringa, S. U. Zuidema and H. J. Luijendijk.
Int Psychogeriatr 2020 Jun 29:1-18
Nursing home residents with dementia are sensitive to detrimental auditory environments. This paper presents the first literature review of empirical research investigating (1) the (perceived) intensity and sources of sounds in nursing homes, and (2) the influence of sounds on health of residents with dementia and staff. DESIGN: A systematic review was conducted in PubMed, Web of Science and Scopus. Study quality was assessed with the Mixed Methods Appraisal Tool. We used a narrative approach to present the results. RESULTS: We included 35 studies. Nine studies investigated sound intensity and reported high noise intensity with an average of 55-68 dB(A) (during daytime). In four studies about sound sources, human voices and electronic devices were the most dominant sources. Five cross-sectional studies focused on music interventions and reported positives effects on agitated behaviors. Four randomized controlled trials tested noise reduction as part of an intervention. In two studies, high-intensity sounds were associated with decreased nighttime sleep and increased agitation. The third study found an association between music and less agitation compared to other stimuli. The fourth study did not find an effect of noise on agitation. Two studies reported that a noisy environment had negative effects on staff. CONCLUSIONS: The need for appropriate auditory environments that are responsive to residents’ cognitive abilities and functioning is not yet recognized widely. Future research needs to place greater emphasis on intervention-based and longitudinal study design.

Nursing home residents’ perspectives on their social relationships.
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B. Kang, K. Scales, E. S. McConnell, Y. Song, M. Lepore and K. Corazzini.
J Clin Nurs 2020 Apr;29(7-8):1162-1174
To explore nursing home residents’ perspectives on their relationships with other residents, family members and staff. BACKGROUND: The cultivation of social relationships is central to promoting well-being in nursing homes, as these relationships allow residents, family members and staff to be valued as unique persons and empowered as partners in care. Few studies have examined how nursing home residents perceive the relationships in their social networks, both within and beyond the facility. DESIGN: Qualitative secondary analysis. METHODS: We analysed individual and group interviews obtained during “stakeholder engagement sessions” with cognitively intact residents (N = 11 sessions; N = 13 participants) from two nursing homes in North Carolina. The interviews were conducted as part of a larger study on person-directed care planning. We integrated thematic and narrative analytic approaches to guide the analysis of interview data, using a three-cycle coding approach. The COREQ checklist was followed. RESULTS: Four broad themes emerged from this analysis: (a) peer relationships foster a sense of belonging, purpose, achievement and significance; (b) residents’ relationships with family members support a sense of belonging, continuity and significance; (c) mutual respect and reciprocity between residents and nursing home staff promote a sense of belonging and significance; and (d) organisational factors pose barriers to forging meaningful relationships. Each type of relationship-peer, family and staff-made distinctive contributions residents’ psychosocial well-being. CONCLUSION: Recognising the diverse roles of different actors from residents’ social networks raises questions for future research to optimise the distinctive contributions of network members that promote residents’ psychosocial well-being. RELEVANCE TO CLINICAL PRACTICE: This study highlights the need for nursing home staff to understand how residents’ social relationships influence residents’ psychosocial outcomes. Staff training programmes are needed to support residents’ rights and to dispel inaccurate interpretations of regulations that threaten sustained meaningful relationships.

Validation of the MEDSAIL Tool to Screen for Capacity for Safe and Independent Living Among Nursing Home Residents.
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W. L. Mills, M. E. Kunik, P. A. Kelly, et al.
J Am Med Dir Assoc 2020 Jul 4
Capacity for safe and independent living (SAIL) refers to an individual’s ability to solve problems associated with everyday life and perform activities necessary for living independently. Little guidance exists on the assessment of capacity for SAIL among nursing home residents. As a result, capacity for SAIL is not fully considered in the development of discharge plans to ensure safety and independence in the community. We reasoned that this problem could be addressed with the Making and Executing Decisions for Safe and Independent Living (MEDSAIL) tool, developed to screen for capacity for SAIL among community-dwelling older adults. In this report, we describe findings on the validity of the MEDSAIL when used with nursing home residents. DESIGN: Prospective cross-sectional pilot study. SETTING AND PARTICIPANTS: Twenty-four residents of a Veterans Health Affairs Community Living Center (CLC; nursing home); exclusion criteria were cognitive impairment too severe to complete the protocol, diagnosis of serious mental illness or developmental disability, inability to hear, or inability to communicate verbally. METHODS: Participants completed 2 assessments: the MEDSAIL interview administered by a research assistant and the criterion standard capacity interview administered by a geriatric psychiatrist. We examined internal consistency, divergent validity, and criterion-based validity. RESULTS: Five of 7 MEDSAIL scenarios approximated acceptable levels of internal consistency (α >0.70). MEDSAIL scores were highly positively correlated with criterion standard capacity determination (0.88, P = .001), and the Wilcoxon rank-sum test statistic for the 2 assessments was also statistically significant (P = .001). CONCLUSIONS AND IMPLICATIONS: MEDSAIL has promise as a user-friendly brief screening tool for use by nursing home staff to understand resident capacity for SAIL. This information can be used in the development of discharge plans to keep the resident safe and independent in the community. In addition, tailoring the MEDSAIL scenarios specifically to the nursing home setting may further enhance the tool’s validity and utility in this new application.

What matters to you when the nursing is your home: a qualitative study on the views of residents with dementia living in nursing homes.
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A. Nygaard, L. Halvorsrud, E. K. Grov and A. Bergland.
BMC Geriatr 2020 Jun 29;20(1):227-020-01612-w
Dementia is recognised as one of the greatest global public health challenges. A central tenet of national health and social care policy is to ensure that services support people in achieving their personal well-being and outcomes, defined as the things important to people in their lives, also people with dementia. The aim of this study is to explore what matters to nursing home residents with dementia based on their perceptions of nursing homes as home. METHODS: There were conducted 35 interviews with people with dementia in nursing homes. We conducted the in-depth unstructured qualitative interviews. Thematic analysis was applied to analyse the data. RESULTS: The analysis resulted in one over-arching theme “tension between the experiences of a nursing home being a home and an institution” and five themes; “myself and my relationships with fellow residents”, “creation of individualised living spaces”, “single rooms with personal decor that enhances a sense of connectedness”, “transition between the old home and the new home” and “significant activities providing meaning”. The participants stated that the transition to the supported, structured living environment in nursing homes to be a clear need based on immediate, serious safety concerns. They went from being masters of their own lives to adhering to nursing home routines. Fellow residents could be both resources and burdens, creating feelings of security and insecurity. A home-like environment was created by allowing the participants to bring their important personal belongings into private spaces. The participants said they needed to be able to decorate their rooms to their own specifications. They wanted involvement in meaningful activities. CONCLUSIONS: The findings showed that ‘home’ was an emotive word that awakened many associations. The participants reported mixed feelings and stated that they could thrive even if they missed their old homes. What mattered was that the participants felt safe, had single rooms where they could retire from the community, their own belongings and did activities. The participants wanted greater possibilities for meaningful relations. They appreciate that nursing home were similar to their previous homes. They desired opportunities to continue some activities they did in their former home.

EQ-5D-3L for Assessing Quality of Life in Older Nursing Home Residents with Cognitive Impairment.
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P. Perez-Ros and F. M. Martinez-Arnau.
Life (Basel) 2020 Jun 30;10(7):10.3390/life10070100
Quality of life (QoL) is recognized as an important patient-reported outcome measure. Assessing QoL in older people with cognitive impairment is a challenge due to discrepancies in the collection of data via proxies versus self-report. This study aimed to assess the psychometric properties of the self-reported EQ-5D (including the EQ index and EQ visual analog scale (VAS)) in nursing homes residents with cognitive impairment and to analyze its validity based on scales included in the comprehensive geriatric assessment. METHODS: Cross-sectional, multicenter study analyzing the feasibility, acceptability, reliability, and validity of the EQ-5D based on 251 self-administered questionnaires in a sample of nursing home residents with cognitive impairment. Reference scales were those from the comprehensive geriatric assessment, equivalent to the five dimensions of the EuroQol. RESULTS: The EQ index was 0.31 (0.37) and the EQ VAS was 35.96 (29.86), showing adequate acceptability and feasibility. Cronbach’s alpha was 0.723. The EQ index and EQ VAS, as outcome variables for multiple linear regression models including CGA titration scales, showed better validity for the EQ index than the EQ VAS. CONCLUSIONS: As a self-administered generic scale, the EQ-5D-3L could be a good tool for QoL assessment in nursing home residents with cognitive impairment.

An exploration of nursing home residents’ experiences of a non-powered static air mattress overlay to prevent pressure ulcers.
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B. Serraes, A. V. Hecke, H. Van Tiggelen, C. Anrys, S. Verhaeghe and D. Beeckman.
Int Wound J 2020 Jun 30
Pressure ulcers are injuries to the skin and underlying tissue and are associated with a negative impact on well-being and health-related quality of life. This explorative, qualitative study aimed to explore the true meaning of elderly nursing home residents’ perspectives and critical success factors when implementing a new non-powered static air mattress overlay to prevent pressure ulcers. Individual, loosely structured interviews were conductedin 12 nursing homes in Flanders, the Northern region of Belgium, a convenience sampling of 14 nursing home residents were selected based on the following eligibility criteria: high risk for pressure ulcer and/or with category 1 pressure ulcer, being bedbound and/or chair-bound, aged >65 years, and use of an alternating air pressure mattress previous to the application of the non-powered static air mattress overlay. Interviews were conducted in the participants’ personal rooms between June 2017 and March 2018. Interviews included broad, open-ended questions, to invite and encourage participants to openly discuss their perspectives and experiences. Participants were interviewed once during the 14-day observation period between day 3 and day 14. All interviews were audio-recorded and fully transcribed by an experienced transcriber. Interviews were read several times to reveal emerging patterns and were marked with codes into NVivo 10 qualitative data analysis software. During the process, (sub) themes were discussed by the authors until a consensus was reached. Three main themes emerged from the analysis process: rest and sleep; mobility; and discomfort and pain associated with the use of the support surface. Themes were divided into multiple subthemes: motion, noise, sensation, repositioning, and transfer in and out of bed. Through interviews, critical success factors associated with the implementation were identified, including the lack of information and time needed to evaluate the functionality and effects of a new mattress overlay. Implementation of a non-powered static air mattress overlay to prevent pressure ulcers has a far-reaching impact on nursing home residents’ experiences. This study provides insight into the true meaning of patients’ perspectives by focusing on learning from the patients’ experiences that provide valuable information for healthcare professionals and other stakeholders.

Nursing Home Staff’s Perceptions of Noise Compared to Measured Noise Levels: A Descriptive Study.
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V. Steiner, A. Ames, S. A. Milz and S. Dubin.
J Gerontol Nurs 2020 Jul 8:1-9
A noisy environment may cause annoyance to nursing home staff and affect their ability to provide quality care to residents. The current descriptive study examined differences between staff’s perceived noise levels and measured noise levels in four nursing home facilities in Ohio. Most participants (N = 90) were White females. Consistent with measured noise levels, participants described all facilities as being moderately noisy. The loudest perceived noise sources included door/patient alarms and floor cleaners, which were confirmed by measured noise levels. Inconsistent with measured noise levels, most participants identified the nurses’ station as one of the noisiest locations. Overall, participants at all facilities were neutral or disagreed that noise levels impacted themselves or residents. However, nursing home staff should be educated about how they contribute to noise levels and the potential effects of noise on work performance and quality of care provided to residents. [Journal of Gerontological Nursing, xx(x), xx-xx.].

Very frequent physical aggression and vocalizations in nursing home residents with dementia.
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A. E. Veldwijk-Rouwenhorst, S. U. Zuidema, M. Smalbrugge, et al.
Aging Ment Health 2020 Jun 30:1-10
We investigated the 2-week prevalence and correlates of very frequent physical aggression (PA) and vocalizations in nursing home (NH)-residents with dementia.Method/Design: This cross-sectional study used combined data of 2074 NH-residents from four studies, collected from 119 dementia special care units in 26 Dutch NH. Very frequent PA was defined as scoring 6 or 7 on the items ‘hitting’, pushing’, ‘biting’ and ‘kicking’ of the Cohen Mansfield Agitation Inventory; very frequent vocalizations as scoring 6 or 7 on ‘screaming’ and ‘making strange noises’. We compared NH-residents with very frequent PA or vocalizations with residents with less frequent PA or vocalizations, assessing correlates using univariate and multivariate multilevel logistic regression analyses.Results: We found a 2-week prevalence of 2.2% (95% confidence interval (CI): 1.63-2.89) of very frequent PA and 11.5% of very frequent vocalizations (95% CI: 10.23-12.98). Very frequent PA was only associated with apathy (odds ratio (OR)=1.93, 95% CI: 1.04-3.61). Correlates of very frequent vocalizations were age (OR = 0.97, 95% CI: 0.951-0.998), dementia severity (overall p-value 0.020), antipsychotic drug use (OR = 1.56, 95% CI: 1.08-2.26), antiepileptic drug use (OR = 2.75, 95% CI: 1.34-5.68) and euphoria (OR = 2.01, 95% CI: 1.22-3.31).Conclusion: Characteristics of NH-residents with very frequent PA or very frequent vocalizations differ from those of NH-residents with less frequent PA or vocalizations. Frontal lobe damage, boredom, pain and/or external factors may explain several of the found associations, but further research is necessary. Our findings may contribute to better care for these residents and thereby to improving their quality of life.


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Events & Training Opportunities

COVID-19 Infection in Persons Living With Dementia

Available on demand
The COVID-19 pandemic has disproportionately affected older persons with comorbidities, with a high fatality rate in this group.

In this webinar, we review the basics of SARS-CoV-2 (the virus that causes COVID-19); what is known so far about its effects on the body and on the brain; and on outcomes when infection occurs in persons living with dementia. We discuss the ethics of allocating scarce medical resources during a pandemic, and the effects it may have on access to care for persons with dementia.

This integrated KTE webinar event is brought to you by brainXchange in partnership with the Alzheimer Society of Canada and the Canadian Consortium on Neurodegeneration in Aging (CCNA).

IFA Virtual Town Hall | COVID-19 and Older People: Through the Eyes of the Janaseva Foundation

Friday 17 July 05:00 MT
Presenter: Vinod Shah
Across the health and social care sector in low and middle income countries civil society organizations are working alongside older people, their families and caregivers to overcome challenges of the COVID-19 pandemic. In conversation with Dr. Vinod Shah, Chairman of the Janaseva Foundation in Pune, India, the upcoming IFA Virtual Town Hall explores initiatives that galvanize communities and support the health and wellbeing of older people experiencing extraordinary hardships.

Knowledge Translation Certificate

28 September–December 11, 2020
$300/Alberta attendees, $1500/outside of Alberta attendees. A subsidy is available for Alberta residents
The Knowledge Translation (KT) Certificate covers theory, methodology, and practical work, encompassing elements that are common across KT theory, methods, and frameworks. This course is intended to provide a breadth of knowledge and skill in knowledge translation with ample opportunity to discuss the concepts with other learners and the course moderators. Examples used throughout the course will primarily focus on the context in Alberta, but the course is open to participants from outside Alberta.

At the end of this course, learners will be able to:

Discuss different KT concepts and approaches and describe when and how to use them
Select and apply theories, models, and frameworks to address a knowledge to practice gap
Describe strategies for assessing and determining stakeholder/organizational/system knowledge needs and/or readiness for change
Consider barriers and facilitators when selecting implementation/KT strategies
Select and apply appropriate evaluation tools, models and frameworks to develop an evaluation plan
Identify important considerations for sustaining long term impact of a project or intervention

Social Media Strategies for Knowledge Translation

26, 28, & 30 October 11:00-15:00 MT
Presenter: KTDRR
This Year’s KDTRR Virtual Knowledge Translation Conference covers three areas for using social media in KT: Using social media to design outcomes (Oct 26), participating recruitment and stakeholder engagement (Oct 28), and creating impact (Oct 30). Registration is free. CART and accessible options will be available.

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Infographic on Social connectedness for residents of long-term care homes: A scoping review of research on the mental health impacts and strategies to address social connectedness

Communication Tip Sheet for redeployed staff working in long-term care with residents with cognitive impairment

Physical Distancing in Long-Term Care Homes: Providing Social Engagement and Inspiring Hope

What is Cross Functional Collaboration?

How to Engage in a Time of Social Distancing

Outbreaks, break-outs and break-times: Creating caring online workshops

How to optimize your work-from-home set up for a remote summer

Researcher activism: A voice of experience


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Canada’s proportion of COVID-19 deaths in long-term care double the average of other countries, study shows

Canada’s hardest-hit nursing homes lost 40% of residents in just 3 months of the pandemic

The Pandemic Is Pushing Scientists To Rethink How They Read Research Papers

Women academics worry the pandemic is squeezing their research productivity

Working 60 hours a week does not automatically make you
a good researcher

Can Knowledge Translation Training Really Change Workplace Practices?

The U.S. Is Repeating Its Deadliest Pandemic Mistake

The American Nursing Home Is a Design Failure

Continued bans on nursing home visitors are unhealthy and unethical

12% of Canadians would reject COVID-19 vaccine: Stats Can

Ontario will fully fund nursing homes regardless of lower occupancies

Plan to restart surgeries slowed by long-term care patients in N.S. hospital beds

Dealing with COVID-19: An open letter to Canada’s prime minister and provincial and territorial premiers

The brutal blow that pandemic isolation has dealt residents of long-term care residences

Covid-19: risk of death in UK care homes 13 times higher than in Germany

Ethical policy for visitors to long-term-care homes needed

Will COVID-19 be evidence-based medicine’s nemesis?

Debra Sheets: Safety is not enough, seniors need vital family visits during COVID isolation

Detrimental effects of confinement and isolation on the cognitive and psychological health of people living with dementia during COVID-19: emerging evidence

Top experts call for major new coalition on non-medical pandemic research

Why lockdown of the elderly is not ageist and why levelling down equality is wrong

Boris Johnson sparks anger by blaming care home providers for coronavirus deaths

Underfunded, unappreciated care homes were given little chance against Covid-19

Seniors who survived COVID now at risk from lack of air-conditioning in long-term-care homes

States Allow In-Person Nursing Home Visits As Families Charge Residents Die ‘Of Broken Hearts’

The COVID-19 Long-Term Care situation in Austria

The Impact of Covid-19 on Long-term Care Facilities in South Africa, with a specific focus on Dementia Care

Staffing levels, not just hotspots, can predict nursing home COVID deaths, study says

Bridging the Gap: From Research to Policy

Acknowledging and responding to criticisms of interdisciplinarity / Reconnaître et répondre aux critiques de l’interdisciplinarité

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Education Manager at The Schlegel-UW Research Institute for Aging

Waterloo, ON
This role will be leading the development, implementation and delivery of educational programs and resources designed to serve the needs of older adults, including long-term care and retirement living environments. Emphasis will be on the development of virtual and digital education strategies (e.g., eLearning, webinars, mobile applications) and facilitating workshops, coaching, presenting and delivering education. The position requires a self-motivated, organized and dynamic individual who is able to work on more than one initiative at a time, and take on additional work as required.

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