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Özkaytan Y, Kukla H, Schulz-Nieswandt F, Zank S. We need a radical change to take place now´-The potential of integrated healthcare for rural long-term care facilities. Geriatr Nurs 2024; 56:270-277. [PMID: 38402806 DOI: 10.1016/j.gerinurse.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVES This study explores healthcare professionals' perceptions in rural German long-term care facilities, focusing on integrated health systems. The aim is to understand experiences, challenges, and preferences. METHODS Twenty nurses and paramedics participated in in-depth interviews. Thematic analysis was applied to transcripts, revealing key themes: acute healthcare provision, interdisciplinary collaboration, telemedicine use, and preferences for the future healthcare landscape. RESULTS Themes highlighted factors influencing acute care situations and the crucial role of interdisciplinary collaboration. Integrated care was infrequently encountered despite high demand in rural long-term care facilities. CONCLUSIONS Though uncommon, integrated healthcare remains crucial in addressing long-term care facility residents' complex needs. Healthcare professionals express a strong demand for integrated care in rural areas, citing potential benefits for resident wellbeing, healthcare effectiveness, and job satisfaction. The findings guide healthcare organizations in developing institutional-level strategies for integrated care integration, emphasizing its importance in rural settings.
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Affiliation(s)
- Yasemin Özkaytan
- Faculty of Human Sciences, Graduate School GROW - Gerontological Research on Well-being, University of Cologne, Cologne, Germany.
| | - Helena Kukla
- Faculty of Medicine and University Hospital, Department of Palliative Medicine, University of Cologne, Cologne, Germany
| | - Frank Schulz-Nieswandt
- Department of Social Policy and Methods of Qualitative Social Research, Faculty of Management, Economics and Social Sciences, University of Cologne, Cologne, Germany
| | - Susanne Zank
- Faculty of Human Sciences, Rehabilitative Gerontology, University of Cologne, Germany
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Luna G, Kim M, Miller R, Parekh P, Kim ES, Park SY, Abdulbaseer U, Gonzalez C, Stiehl E. Interprofessional relationships and their impact on resident hospitalizations in nursing homes: A qualitative study. Appl Nurs Res 2023; 74:151747. [PMID: 38007247 DOI: 10.1016/j.apnr.2023.151747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 08/09/2023] [Accepted: 10/24/2023] [Indexed: 11/27/2023]
Abstract
AIM The aim of this study is to explore experiences and perspectives of nurses and providers (e.g., physicians, medical directors, fellows, and nurse practitioners) on reducing preventable hospitalizations of nursing home (NH) residents in relation to interprofessional relationship and hospitalization decision-making process. BACKGROUND Preventable NH resident hospitalization continues to be a pressing public health issue. Studies show that improved interprofessional relationship may help reduce hospitalization, yet research on communication processes and interactions among different NH staff remains limited. METHODS This is a qualitative descriptive study. Two focus groups were held with fourteen nurses and thirteen in-depth, qualitative interviews were conducted with providers from two Chicagoland NHs. Focus group sessions and interviews were transcribed, coded, and analyzed for common themes based on qualitative description method. RESULTS All study participants agreed that providers have the ultimate responsibility for hospitalization decisions. However, nurses believed they could influence those decisions, depending on provider characteristics, trust, and resident conditions. Nurses and providers differed in the way they experienced and conveyed emotions, and differed in key elements affecting hospitalization decisions such as structural or environmental factors (e.g., lacking staff and equipment at the facility, poor communication between the NH and hospitals) and interpersonal factors (e.g., characteristics of effective nurses or providers and the effective interactions between them). CONCLUSIONS Interpersonal factors, including perceived competence, respect, and trust, may influence NH hospitalization decisions and be targeted for reducing preventable hospitalizations of residents.
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Affiliation(s)
- Geraldine Luna
- Chicago Department of Public Health, 333 S State St #200, Chicago, IL 60604, United States of America.
| | - Mhinjine Kim
- University of Illinois Chicago, 1603 W. Taylor St., Chicago, IL 60612, United States of America.
| | - Richard Miller
- University of Illinois Chicago, 2170 West Bowler Street, Chicago, IL 60612, United States of America.
| | - Pooja Parekh
- University of Illinois Chicago, 1355 S. Halsted St., Chicago, IL 60607, United States of America.
| | - Esther S Kim
- University of Illinois Chicago, 625 W Madison St., Chicago, IL 60661, United States of America.
| | - Sophia Yaejin Park
- University of Illinois Chicago, 1853 W Polk St, Chicago, IL 60612, United States of America.
| | - Ummesalmah Abdulbaseer
- University of Illinois Chicago, 1853 W Polk St, Chicago, IL 60612, United States of America.
| | - Cristina Gonzalez
- University of Illinois Chicago, 1853 W Polk St, Chicago, IL 60612, United States of America.
| | - Emily Stiehl
- University of Illinois Chicago, 1603 W. Taylor St., Chicago, IL 60612, United States of America.
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Tate K, Palfreyman S, Reid RC, McLane P, Cummings GG. Incidence of Pressure Injury Among Older Adults Transitioning from Long-term Care to the ED. Adv Skin Wound Care 2023; 36:651-657. [PMID: 37983578 DOI: 10.1097/asw.0000000000000069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
OBJECTIVE To identify sociodemographic, health condition, and organizational/process factors associated with pressure injury (PI) incidence during older adults' emergency transitions from long-term care (LTC) to the ED. METHODS Emergency transitions were tracked for older adults within included LTC facilities to participating EDs in two urban centers located in provinces in Canada. Binary logistic regression was used to examine the influence of sociodemographic, service use, and client health and function factors on the incidence of PIs during transitions from LTC facilities to EDs. RESULTS Having a mobility issue (odds ratio [OR], 4.318; 95% CI, 1.344-13.870), transitioning from a publicly owned versus a nonprofit volunteer LTC facility (OR, 4.886; 95% CI, 1.157-20.634), and time from ED arrival to return to LTC being 7 to 9 days (OR, 41.327; 95% CI, 2.691-634.574) or greater than 9 days (OR, 77.639; 95% CI, 5.727-1,052.485) significantly increased the odds of experiencing a new skin injury upon return to LTC. A higher number of reported reasons for emergency transition (up to 4) significantly decreased the odds of a new PI upon return to LTC (OR, 0.315; 95% CI, 0.113-0.880). CONCLUSIONS The study findings can be used to identify LTC residents at increased risk for developing new skin injuries during an emergency transition, namely, those with mobility impairment, those requiring inpatient care for 6 or more days, and those transitioning from publicly owned LTC facilities. Evaluating the uptake and effectiveness of single-pronged and multipronged interventions such as visual cues for patient turning through online monitoring, consistent risk assessments, and improved nutrition in all care settings are vital next steps in preventing skin injuries in this population.
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Affiliation(s)
- Kaitlyn Tate
- At the University of Alberta, Edmonton, Alberta, Canada, Kaitlyn Tate, PhD, RN, is Assistant Professor, Faculty of Nursing, College of Health Sciences, and Simon Palfreyman, PhD, RN, is Associate Teaching Professor. R. Colin Reid, PhD is Assistant Professor, School of Health and Exercise Sciences, University of British Columbia-Okanagan campus, Kelowna. Patrick McLane, PhD, is Assistant Scientific Director, Emergency Strategic Clinical Network, Alberta Health Services, Edmonton. Also at University of Alberta, Greta G. Cummings, PhD, RN, FAAN, FCAHS, FCAN, is Dean and Professor, Faculty of Nursing, College of Health Sciences. Acknowledgment: The authors acknowledge the OPTIC (Older Persons' Transitions in Care) study team for their contributions to the parent study from which this analysis and paper were generated. This study was funded by the Canadian Institutes of Health Research (CIHR grant CIHR PHE 101863); the Michael Smith Foundation for Health Research; Alberta Foundation of Medical Research; Alberta Health Services; Interior Health Authority, Kelowna, British Columbia; the University of Alberta Hospital Foundation; and the British Columbia Network for Aging Research. The authors have disclosed no other financial relationships related to this article. Submitted September 7, 2022; accepted in revised form January 9, 2023
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Stephens CE, Tay D, Iacob E, Hollinghaus M, Goodwin R, Kelly B, Smith K, Ellington L, Utz R, Ornstein K. Family Ties at End-of-Life: Characteristics of Nursing Home Decedents With and Without Family. Palliat Med Rep 2023; 4:308-315. [PMID: 38026144 PMCID: PMC10664558 DOI: 10.1089/pmr.2023.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 12/01/2023] Open
Abstract
Background Little is known about nursing home (NH) residents' family characteristics despite the important role families play at end-of-life (EOL). Objective To describe the size and composition of first-degree families (FDFs) of Utah NH residents who died 1998-2016 (n = 43,405). Methods Using the Utah Population Caregiving Database, we linked NH decedents to their FDF (n = 124,419; spouses = 10.8%; children = 55.3%; siblings = 32.3%) and compared sociodemographic and death characteristics of those with and without FDF members (n = 9424). Results Compared to NH decedents with FDF (78.3%), those without (21.7%) were more likely to be female (64.7% vs. 57.1%), non-White/Hispanic (11.2% vs. 4.2%), less educated (<9th grade; 41.1% vs. 32.4%), and die in a rural/frontier NH (25.3% vs. 24.0%, all p < 0.001). Despite similar levels of disease burden (Charlson Comorbidity score 3 + 37.7% vs. 38.0%), those without FDF were more likely to die from cancer (14.2% vs. 12.4%), Chronic Obstructive Pulmonary Disease (COPD) (6.0% vs. 4.0%), and dementia (17.1% vs. 16.6%, all p < 0.001), and were less likely to have 2+ hospitalizations at EOL (20.5% vs. 22.4%, p < 0.001). Conclusions Among NH decedents, those with and without FDF have different sociodemographic and death characteristics-factors that may impact care at EOL. Understanding the nature of FDF relationship type on NH resident EOL care trajectories and outcomes is an important next step in clarifying the role of families of persons living and dying in NHs.
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Affiliation(s)
| | - Djin Tay
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Eli Iacob
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Michael Hollinghaus
- Kem C. Gardner Policy Institute, University of Utah, Salt Lake City, Utah, USA
| | - Rebecca Goodwin
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Brenna Kelly
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Ken Smith
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
- College of Social & Behavioral Sciences, Department of Family and Consumer Studies, University of Utah, Salt Lake City, Utah, USA
| | - Lee Ellington
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Rebecca Utz
- College of Social & Behavioral Sciences, Department of Sociology, University of Utah, Salt Lake City, Utah, USA
| | - Katherine Ornstein
- Johns Hopkins School of Nursing, Center for Equity in Aging, Baltimore, Maryland, USA
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Peguero-Rodriguez G, Polomeno V, Backman C, Chartrand J, Lalonde M. The Experience of Families Accompanying a Senior to the Emergency Department: A Scoping Review. J Emerg Nurs 2023:S0099-1767(23)00062-4. [PMID: 37178091 DOI: 10.1016/j.jen.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 05/15/2023]
Abstract
INTRODUCTION Seniors are often accompanied by a family member to the emergency department. Families advocate for their needs and contribute to the continuity of care. However, they often feel excluded from care. To improve the quality and safety of care for seniors, it is necessary to consider the experience of families in the emergency department. The aim was to identify and synthesize the available scientific literature dealing with the experience of families accompanying a senior to the emergency department. To identify and synthesize the available scientific literature dealing with the experience of families accompanying a senior to the emergency department. METHODS A scoping review was conducted using the Arksey and O'Malley framework. Six databases were targeted. A description of the identified scientific literature and an inductive content analysis were performed. RESULTS Of the 3082 articles retrieved, 19 met the inclusion criteria. Most articles (89%) were published since 2010, were from nursing (63%), and used a qualitative research design (79%). The content analysis identified 4 main categories related to the experience of families accompanying a senior to the emergency department: (1) process leading to the emergency department, families feel uncertainty and ambiguity with the decision to go to the emergency department; (2) staying in the emergency department, families' experiences are influenced by the triage, the ED environment, and the interactions with ED personnel; (3) discharge from the emergency department, families consider that they should be part of the discharge planning; and (4) recommendations and possible solutions, there is a paucity of recommendations specifically focused on families. DISCUSSION The experience of families of seniors in the emergency department is multifactorial and part of a trajectory of care and health services.
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Tate K, Ma R, Reid RC, McLane P, Waywitka J, Cummings GE, Cummings GG. A first look at consistency of documentation across care settings during emergency transitions of long-term care residents. BMC Geriatr 2023; 23:17. [PMID: 36631759 PMCID: PMC9835322 DOI: 10.1186/s12877-023-03731-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 01/05/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Documentation during resident transitions from long-term care (LTC) to the emergency department (ED) can be inconsistent, leading to inappropriate care. Inconsistent documentation can lead to undertreatment, inefficiencies and adverse patient outcomes. Many individuals residing in LTC have some form of cognitive impairment and may not be able to advocate for themselves, making accurate and consistent documentation vital to ensuring they receive safe care. We examined documentation consistency related to reason for transfer across care settings during these transitions. METHODS We included residents of LTC aged 65 or over who experienced an emergency transition from LTC to the ED via emergency medical services. We used a standardized and pilot-tested tracking tool to collect resident chart/patient record data. We collected data from 38 participating LTC facilities to two participating EDs in Western Canadian provinces. Using qualitative directed content analysis, we categorized documentation from LTC to the ED by sufficiency and clinical consistency. RESULTS We included 591 eligible transitions in this analysis. Documentation was coded as consistent, inconsistent, or ambiguous. We identified the most common reasons for transition for consistent cases (falls), ambiguous cases (sudden change in condition) and inconsistent cases (falls). Among inconsistent cases, three subcategories were identified: insufficient reporting, potential progression of a condition during transition and unclear reasons for inconsistency. CONCLUSIONS Shared continuing education on documentation across care settings should result in documentation supports geriatric emergency care; on-the-job training needs to support reporting of specific signs and symptoms that warrant an emergent response, and discourage the use of vague descriptors.
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Affiliation(s)
- Kaitlyn Tate
- grid.17089.370000 0001 2190 316XFaculty of Nursing, University of Alberta, Edmonton, AB Canada
| | - Rachel Ma
- grid.17091.3e0000 0001 2288 9830University of British Columbia - Okanagan Campus, Kelowna, BC Canada
| | - R. Colin Reid
- grid.17091.3e0000 0001 2288 9830School of Health and Exercise Sciences, University of British Columbia - Okanagan Campus, Kelowna, BC Canada
| | - Patrick McLane
- grid.413574.00000 0001 0693 8815Emergency Strategic Clinical NetworkTM, Alberta Health Services (AHS), Edmonton, AB Canada ,grid.17089.370000 0001 2190 316XDepartment of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB Canada
| | - Jen Waywitka
- grid.413574.00000 0001 0693 8815Alberta Health Services, Edmonton, Canada
| | - Garnet E. Cummings
- grid.17089.370000 0001 2190 316XFaculty of Nursing, University of Alberta, Edmonton, AB Canada
| | - Greta G. Cummings
- grid.17089.370000 0001 2190 316XFaculty of Nursing, University of Alberta, Edmonton, AB Canada
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Just and inclusive end-of-life decision-making for long-term care home residents with dementia: a qualitative study protocol. BMC Palliat Care 2022; 21:202. [PMID: 36419147 PMCID: PMC9684772 DOI: 10.1186/s12904-022-01097-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 11/04/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Many people living with dementia eventually require care services and spend the remainder of their lives in long-term care (LTC) homes. Yet, many residents with dementia do not receive coordinated, quality palliative care. The stigma associated with dementia leads to an assumption that people living in the advanced stages of dementia are unable to express their end-of-life needs. As a result, people with dementia have fewer choices and limited access to palliative care. The purpose of this paper is to describe the protocol for a qualitative study that explores end-of-life decision-making processes for LTC home residents with dementia. METHODS/DESIGN This study is informed by two theoretical concepts. First, it draws on a relational model of citizenship. The model recognizes the pre-reflective dimensions of agency as fundamental to being human (irrespective of cognitive impairment) and thereby necessitates that we cultivate an environment that supports these dimensions. This study also draws from Smith's critical feminist lens to foreground the influence of gender relations in decision-making processes towards palliative care goals for people with dementia and reveal the discursive mediums of power that legitimize and sanction social relations. This study employs a critical ethnographic methodology. Through data collection strategies of interview, observation, and document review, this study examines decision-making for LTC home residents with dementia and their paid (LTC home workers) and unpaid (family members) care partners. DISCUSSION This research will expose the embedded structures and organizational factors that shape relationships and interactions in decision-making. This study may reveal new ways to promote equitable decision-making towards palliative care goals for LTC home residents with dementia and their care partners and help to improve their access to palliative care.
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Marincowitz C, Preston L, Cantrell A, Tonkins M, Sabir L, Mason S. What influences decisions to transfer older care-home residents to the emergency department? A synthesis of qualitative reviews. Age Ageing 2022; 51:6834152. [PMID: 36413591 PMCID: PMC9681131 DOI: 10.1093/ageing/afac257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND care home residents aged over 65 have disproportionate rates of emergency department (ED) attendance and hospitalisation. Around 40% attendances may be avoidable, and hospitalisation is associated with harms. We synthesised the evidence available in qualitative systematic reviews of different stakeholders' experiences of decisions to transfer residents to the ED. METHODS six electronic databases, references and citations of included reviews and relevant policy documents were searched. Reviews of qualitative studies exploring factors that influenced care home staff, medical practitioners, residents' family or residents' experiences and factors influencing decisions to transfer residents to the ED were included. Thematic analysis was used to synthesise findings. RESULTS six previous reviews were included, which synthesised the findings of 34 primary studies encompassing 152 care home residents, 283 resident family members or carers and 447 care home staff. Of the primary studies, 19 were conducted in the North America, seven in Australia, five were conducted in Scandinavia, two in the United Kingdom and one in Holland. Three themes were identified: (i) power dynamics between residents, family members, care home staff and health care professionals (external to the care home) influence decisions; (ii) admission can be necessary; however, (iii) some decisions may be driven by factors other than clinical need. CONCLUSION transfer decisions are complex and are determined not just by changes in health status interventions aimed at reducing avoidable transfers need to address the key role family members have in transfer decisions, the medical legal fears of care home staff and barriers to accessing community services.
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Affiliation(s)
- Carl Marincowitz
- Address correspondence to: Carl Marincowitz, Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK.
| | - Louise Preston
- Health Economics and Decision Science, Health Services Research School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Anna Cantrell
- Health Economics and Decision Science, Health Services Research School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Michael Tonkins
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
| | - Lisa Sabir
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
| | - Suzanne Mason
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
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Carbone S, Kokorelias KM, Berta W, Law S, Kuluski K. Stakeholder involvement in care transition planning for older adults and the factors guiding their decision-making: a scoping review. BMJ Open 2022; 12:e059446. [PMID: 35697455 PMCID: PMC9196186 DOI: 10.1136/bmjopen-2021-059446] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To synthesise the existing literature on care transition planning from the perspectives of older adults, caregivers and health professionals and to identify the factors that may influence these stakeholders' transition decision-making processes. DESIGN A scoping review guided by Arksey and O'Malley's six-step framework. A comprehensive search strategy was conducted on 7 January 2021 to identify articles in five databases (MEDLINE, Embase, CINAHL Plus, PsycINFO and AgeLine). Records were included when they described care transition planning in an institutional setting from the perspectives of the care triad (older adults, caregivers and health professionals). No date or study design restrictions were imposed. SETTING This review explored care transitions involving older adults from an institutional care setting to any other institutional or non-institutional care setting. Institutional care settings include communal facilities where individuals dwell for short or extended periods of time and have access to healthcare services. PARTICIPANTS Older adults (aged 65 or older), caregivers and health professionals. RESULTS 39 records were included. Stakeholder involvement in transition planning varied across the studies. Transition decisions were largely made by health professionals, with limited or unclear involvement from older adults and caregivers. Seven factors appeared to guide transition planning across the stakeholder groups: (a) institutional priorities and requirements; (b) resources; (c) knowledge; (d) risk; (e) group structure and dynamic; (f) health and support needs; and (g) personality preferences and beliefs. Factors were described at microlevels, mesolevels and macrolevels. CONCLUSIONS This review explored stakeholder involvement in transition planning and identified seven factors that appear to influence transition decision-making. These factors may be useful in advancing the delivery of person and family-centred care by determining how individual-level, group-level and system-level values guide decision-making. Further research is needed to understand how various stakeholder groups balance these factors during transition planning in different health contexts.
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Affiliation(s)
- Sarah Carbone
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Kristina Marie Kokorelias
- St John's Rehab Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Whitney Berta
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Susan Law
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Kerry Kuluski
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
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Marincowitz C, Preston L, Cantrell A, Tonkins M, Sabir L, Mason S. Factors associated with increased Emergency Department transfer in older long-term care residents: a systematic review. THE LANCET. HEALTHY LONGEVITY 2022; 3:e437-e447. [PMID: 36098321 DOI: 10.1016/s2666-7568(22)00113-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 01/15/2023] Open
Abstract
The proportion of adults older than 65 years is rapidly increasing. Care home residents in this age group have disproportionate rates of transfer to the Emergency Department (ED) and around 40% of attendances might be avoidable. We did a systematic review to identify factors that predict ED transfer from care homes. Six electronic databases were searched. Observational studies that provided estimates of association between ED attendance and variables at a resident or care home level were included. 26 primary studies met the inclusion criteria. Seven common domains of factors assessed for association with ED transfer were identified and within these domains, male sex, age, presence of specific comorbidities, polypharmacy, rural location, and care home quality rating were associated with likelihood of ED transfer. The identification of these factors provides useful information for policy makers and researchers intending to either develop interventions to reduce hospitalisations or use adjusted rates of hospitalisation as a care home quality indicator.
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Affiliation(s)
- Carl Marincowitz
- Centre for Urgent and Emergency Care Research (CURE), Health Services Research, School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Louise Preston
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Michael Tonkins
- Centre for Urgent and Emergency Care Research (CURE), Health Services Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Lisa Sabir
- Centre for Urgent and Emergency Care Research (CURE), Health Services Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Suzanne Mason
- Centre for Urgent and Emergency Care Research (CURE), Health Services Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
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Curtis F, Jayawickrama WIU, Laparidou D, Weligamage D, Kumarawansha WKWS, Ortega M, Siriwardena AN. Perceptions and experiences of residents and relatives of emergencies in care homes: a systematic review and metasynthesis of qualitative research. Age Ageing 2021; 50:1925-1934. [PMID: 34591971 PMCID: PMC8581376 DOI: 10.1093/ageing/afab182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 07/05/2021] [Indexed: 11/30/2022] Open
Abstract
Background the perceptions and experiences of care home residents and their families are important for understanding and improving the quality of emergency care. Methods we conducted a systematic review and metasynthesis to understand the perceptions and experiences of care home residents and their family members who experienced medical emergencies in a care home setting. The review protocol was registered in PROSPERO (CRD42020167018). We searched five electronic databases, MEDLINE, CINAHL, PubMed, Cochrane Library and PsycINFO, supplemented with internet searches and forward and backward citation tracking from included studies and review articles. Data were synthesised thematically following the Thomas and Harden approach. The Critical Appraisal Skills Programme qualitative checklist was used to assess the quality of studies included in this review. Results of the 6,140 references retrieved, 10 studies from four countries (Australia, Canada, UK and USA) were included in the review and metasynthesis. All the included studies were assessed as being of good quality. Through an iterative approach, we developed six analytical themes: (i) infrastructure and process requirements in care homes to prevent and address emergencies; (ii) the decision to transfer to hospital; (iii) experiences of transfer and hospitalisation for older patients; (iv) good communication is vital for desirable outcomes; (v) legal, regulatory and ethical concerns and (vi) trusting relationships enabled residents to feel safe. Conclusions the emergency care experience for care home residents can be enhanced by ensuring resources, staff capacity and processes for high quality care and trusting relationships between staff, patients and relatives, underpinned by good communication and attention to ethical practice.
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Affiliation(s)
- Ffion Curtis
- Lincoln International Institute of Rural Health, University of Lincoln, Lincoln, Lincolnshire, UK
| | - Withanage Iresha Udayangani Jayawickrama
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, Lincolnshire, UK
- Postgraduate Institute of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Despina Laparidou
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, Lincolnshire, UK
| | - Dedunu Weligamage
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, Lincolnshire, UK
- Postgraduate Institute of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Weerapperuma Kankanamge Wijaya Sarathchandra Kumarawansha
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, Lincolnshire, UK
- Postgraduate Institute of Medicine, University of Colombo, Colombo, Sri Lanka
| | | | - Aloysius Niroshan Siriwardena
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, Lincolnshire, UK
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Williamson LE, Evans CJ, Cripps RL, Leniz J, Yorganci E, Sleeman KE. Factors Associated With Emergency Department Visits by People With Dementia Near the End of Life: A Systematic Review. J Am Med Dir Assoc 2021; 22:2046-2055.e35. [PMID: 34273269 DOI: 10.1016/j.jamda.2021.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/10/2021] [Accepted: 06/04/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Emergency department (ED) attendance is common among people with dementia and increases toward the end of life. The aim was to systematically review factors associated with ED attendance among people with dementia approaching the end of life. DESIGN Systematic search of 6 databases (MEDLINE, EMBASE, ASSIA, CINAHL, PsycINFO, and Web of Science) and gray literature. Quantitative studies of any design were eligible. Newcastle-Ottawa Scales and Cochrane risk-of-bias tools assessed study quality. Extracted data were reported narratively, using a theoretical model. Factors were synthesized based on strength of evidence using vote counting (PROSPERO registration: CRD42020193271). SETTING AND PARTICIPANTS Adults with dementia of any subtype and severity, in the last year of life, or in receipt of services indicative of nearness to end of life. MEASUREMENTS The primary outcome was ED attendance, defined as attending a medical facility that provides 24-hour access to emergency care, with full resuscitation resources. RESULTS After de-duplication, 18,204 titles and abstracts were screened, 367 were selected for full-text review and 23 studies were included. There was high-strength evidence that ethnic minority groups, increasing number of comorbidities, neuropsychiatric symptoms, previous hospital transfers, and rural living were positively associated with ED attendance, whereas higher socioeconomic position, being unmarried, and living in a care home were negatively associated with ED attendance. There was moderate-strength evidence that being a woman and receiving palliative care were negatively associated with ED attendance. There was only low-strength evidence for factors associated with repeat ED attendance. CONCLUSIONS AND IMPLICATIONS The review highlights characteristics that could help identify patients at risk of ED attendance near the end of life and potential service-related factors to reduce risks. Better understanding of the mechanisms by which residential facilities and palliative care are associated with reduced ED attendance is needed.
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Affiliation(s)
- Lesley E Williamson
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom.
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom; Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, United Kingdom
| | - Rachel L Cripps
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
| | - Javiera Leniz
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
| | - Emel Yorganci
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
| | - Katherine E Sleeman
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
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13
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Tuohy D, Fahy A, O'Doherty J, Meskell P, O'Reilly P, O'Brien B, Murphy J, Doody O, Graham M, Barry L, Kiely M, O'Keeffe J, Dewing J, Lang D, Coffey A. Towards the development of a national patient transfer document between residential and acute care-A pilot study. Int J Older People Nurs 2021; 16:e12374. [PMID: 33760384 PMCID: PMC8365739 DOI: 10.1111/opn.12374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 01/31/2021] [Accepted: 02/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND A lack of standardisation of documentation accompanying older people when transferring from residential to acute care is common and this may result in gaps in information and in care for older people. In Ireland, this lack of standardisation prompted the development of an evidence based national transfer document. OBJECTIVES To pilot a new national transfer document for use when transferring older people from residential to acute care and obtain the perceptions of its use from staff in residential and acute care settings. METHODS This was a pre- and post-study design using purposive sampling following the STROBE guidelines. The pilot was conducted in 26 sites providing residential care and three university hospitals providing acute care. Pre-pilot questionnaires focused on current documentation and were distributed to staff in residential care (n = 875). A pilot of the new paper-based transfer document was then conducted over three months and post-pilot questionnaires distributed to staff from both residential and acute care settings (n = 1085). The findings of the pilot study were discussed with multidisciplinary expert advisory and stakeholder groups who recommended some revisions. This consensus informed the development of the final design of the new revised transfer document. RESULTS Pre-pilot: 23% response rate; 83% (n = 168) participants agreed/strongly agreed that existing documentation was straightforward to complete but could be more person-centred. Post-pilot: 11% response rate; 75% (n = 93) of participants agreed/strongly agreed that the new transfer document promoted person-centred care but recommended revisions to the new document regarding layout and time to complete. CONCLUSIONS This study highlighted some of the challenges of providing safe, effective and relevant transfer information that is feasible and usable in everyday practice. IMPLICATIONS FOR PRACTICE Standardisation and being person-centred are important determining factors in the provision of relevant up to date information on the resident being transferred.
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Affiliation(s)
- Dympna Tuohy
- Department of Nursing & MidwiferyUniversity of LimerickLimerickIreland
| | - Anne Fahy
- Department of Nursing & MidwiferyUniversity of LimerickLimerickIreland
| | - Jane O'Doherty
- Department of Nursing & MidwiferyUniversity of LimerickLimerickIreland
| | - Pauline Meskell
- Department of Nursing & MidwiferyUniversity of LimerickLimerickIreland
| | - Pauline O'Reilly
- Department of Nursing & MidwiferyUniversity of LimerickLimerickIreland
| | - Brid O'Brien
- Department of Nursing & MidwiferyUniversity of LimerickLimerickIreland
| | - Jill Murphy
- Department of Nursing & MidwiferyUniversity of LimerickLimerickIreland
| | - Owen Doody
- Department of Nursing & MidwiferyUniversity of LimerickLimerickIreland
| | - Margaret Graham
- Department of Nursing & MidwiferyUniversity of LimerickLimerickIreland
| | - Louise Barry
- Department of Nursing & MidwiferyUniversity of LimerickLimerickIreland
| | | | | | - Jan Dewing
- Queen Margaret UniversityEdinburghScotland
| | - Deirdre Lang
- HSE Clinical Strategy and Programmes Division and the Royal College of Physicians of IrelandDublinIreland
| | - Alice Coffey
- Department of Nursing & MidwiferyUniversity of LimerickLimerickIreland
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Testa L, Ryder T, Braithwaite J, Mitchell RJ. Factors impacting hospital avoidance program utilisation in the care of acutely unwell residential aged care facility residents. BMC Health Serv Res 2021; 21:599. [PMID: 34162385 PMCID: PMC8221986 DOI: 10.1186/s12913-021-06575-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 05/25/2021] [Indexed: 12/23/2022] Open
Abstract
Background An existing hospital avoidance program, the Aged Care Rapid Response Team (ARRT), rapidly delivers geriatric outreach services to acutely unwell or older people with declining health at risk of hospitalisation. The aim of the current study was to explore health professionals’ perspectives on the factors impacting ARRT utilisation in the care of acutely unwell residential aged care facility residents. Methods Semi-structured interviews were conducted with two Geriatricians, two ARRT Clinical Nurse Consultants, an ED-based Clinical Nurse Specialist, and an Extended Care Paramedic. Interview questions elicited views on key factors regarding care decisions and care transitions for acutely unwell residential aged care facility residents. Thematic analysis was undertaken to identify themes and sub-themes from interviews. Results Analysis of interviews identified five overarching themes affecting ARRT utilisation in the care of acutely unwell residents: (1) resident care needs; (2) family factors; (3) enabling factors; (4) barriers; and (5) adaptability and responsiveness to the COVID-19 pandemic. Conclusion Various factors impact on hospital avoidance program utilisation in the care of acutely unwell older aged care facility residents. This information provides additional context to existing quantitative evaluations of hospital avoidance programs, as well as informing the design of future hospital avoidance programs. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06575-1.
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Affiliation(s)
- Luke Testa
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia.
| | - Tayhla Ryder
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
| | - Rebecca J Mitchell
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
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15
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Salehi V, Hanson N, Smith D, McCloskey R, Jarrett P, Veitch B. Modeling and analyzing hospital to home transition processes of frail older adults using the functional resonance analysis method (FRAM). APPLIED ERGONOMICS 2021; 93:103392. [PMID: 33639319 DOI: 10.1016/j.apergo.2021.103392] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 01/15/2021] [Accepted: 02/14/2021] [Indexed: 06/12/2023]
Abstract
The main purpose of this study was to model and analyze hospital to home transition processes of frail older adults in order to identify the challenges within this process. A multi-phase, multi-sited and mixed methods design was utilized, in which, Phase 1 included collecting semi-structured interviews and focus group data, and Phase 2 consisted of six patient/caregiver dyad prospective case studies. This study was conducted in three hospitals in three cities in a single province in Canada. The Functional Resonance Analysis Method (FRAM) was employed to model daily operations of the transition process. The perspectives of both healthcare providers and patients/caregivers were used to build the FRAM model. The transition model was then tested using a customized version of the FRAM. The six patient/caregiver cases were used in the process of testing the FRAM model. The results of building the FRAM model showed that five categories of functions contributed to the transition model, including admission, assessment, synthesis, decision-making, and readmission. The outcomes of using the customized version of the FRAM revealed challenges affecting the transition process including waitlists for geriatric units, team-based care, lack of a discharge planner, financial concerns, and follow-up plans. The findings of this study could assist managers and other decision makers to improve the transition processes of frail older adults by addressing these challenges. The FRAM method employed in this study can be applied widely to identify work practices that are more or less successful, so that procedures and practices can be adapted to nudge healthcare processes towards paths that will yield better outcomes.
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Affiliation(s)
- Vahid Salehi
- Faculty of Engineering and Applied Science, Memorial University of Newfoundland, St. John's, Canada.
| | - Natasha Hanson
- Research Services, Horizon Health Network, Saint John Regional Hospital, Saint John, Canada
| | - Doug Smith
- Faculty of Engineering and Applied Science, Memorial University of Newfoundland, St. John's, Canada
| | - Rose McCloskey
- Department of Nursing & Health Sciences, University of New Brunswick, Saint John, Canada
| | - Pamela Jarrett
- Department of Geriatric Medicine, Horizon Health Network, St. Joseph's Hospital, Saint John, Canada
| | - Brian Veitch
- Faculty of Engineering and Applied Science, Memorial University of Newfoundland, St. John's, Canada
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16
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Chen BA, Lai FC, Tsao LI, Chien HH, Chen CF, Jeng C. Decision difficulties of long-term-care facility nurses in transferring residents to the emergency department: A cross-sectional nationwide study. J Adv Nurs 2021; 77:2728-2738. [PMID: 33624335 DOI: 10.1111/jan.14802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/22/2021] [Accepted: 01/27/2021] [Indexed: 11/28/2022]
Abstract
AIMS To examine the level of decision difficulties of long-term-care facility (LTCF) nurses when transferring residents to the emergency department (ED) and associated influencing factors. DESIGN A cross-sectional nationwide study. METHODS The LTCFs were selected through random stratified sampling across the whole Taiwan during February 2018 to January 2019. LTCF nurses who met the selection criteria were invited to participate with two or three nurses selected from each LTCF. The Patient Transfer Decision Difficulty Scale (PTDDS) was used to measure the level of difficulty in making decisions related to the transfer of residents to the ED. Data were collected by mailing the questionnaires and asking the nurses to return the completed form in 2 weeks. Data were analysed using simple linear regression and multiple regression with stepwise methods. RESULTS In total, 618 valid questionnaires with an 85.32% response rate from 319 LTCFs were used for the data analysis. Decision difficulties that LTCF nurses experienced were moderate, the nursing personnel-bed ratio, LTCF professional training and basic life support training were predictive factors of the level of difficulty experience (scores of PTDDS) for the LTCF nurse (F = 6.81, p < .001). CONCLUSIONS Enhancing emergency training in LTCF can improve nurses' decision-making ability to refer LTCF residents to emergency treatment. IMPACT What problem did the study address? The study addressed the difficult decision LTCF nurses may experience when transferring a resident to the emergency department. What were the main findings? All LTCF nurses faced a moderate level of difficulty in decision-making. 'Transfer timing' was most often considered in the decision-making process when a resident was transferred to the ED. Where and on whom will the research have impact? Results of this study have considerable reference value for LTCF managers and nurses in the decision-making ability and suitability of transferring residents for emergency treatment.
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Affiliation(s)
- Bor-An Chen
- Emergency Department, Keelung Hospital, Ministry of Health and Welfare, Keelung, Taiwan.,Department of Nursing, Ching Kuo Institute of Management and Health, Keelung, Taiwan
| | - Fu-Chih Lai
- Post-Baccalaureate Nursing Program in Nursing and College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Lee-Ing Tsao
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Hui-Hui Chien
- Nursing Department, Yuanshan Branch, Taipei Veterans General Hospital, Ilan, Taiwan
| | - Chun-Fu Chen
- Taipei Medical University-Shuang HO Hospital, Ministry of Health and Welfare
| | - Chii Jeng
- School of Nursing, Taipei Medical University, Taipei, Taiwan
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17
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Dooley J, Booker M, Barnes R, Xanthopoulou P. Urgent care for patients with dementia: a scoping review of associated factors and stakeholder experiences. BMJ Open 2020; 10:e037673. [PMID: 32938596 PMCID: PMC7497532 DOI: 10.1136/bmjopen-2020-037673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 06/22/2020] [Accepted: 07/08/2020] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES People with dementia are more vulnerable to complications in urgent health situations due to older age, increased comorbidity, higher dependency on others and cognitive impairment. This review explored the factors associated with urgent care use in dementia and the experiences of people with dementia, informal carers and professionals. DESIGN Scoping review. The search strategy and data synthesis were informed by people with dementia and carers. DATA SOURCES Searches of CINAHL, Embase, Medline, PsycINFO, PubMed were conducted alongside handsearches of relevant journals and the grey literature through 15 January 2019. ELIGIBILITY CRITERIA Empirical studies including all research designs, and other published literature exploring factors associated with urgent care use in prehospital and emergency room settings for people with dementia were included. Two authors independently screened studies for inclusion. DATA EXTRACTION AND SYNTHESIS Data were extracted using charting techniques and findings were synthesised according to content and themes. RESULTS Of 2967 records identified, 54 studies were included in the review. Specific factors that influenced use of urgent care included: (1) common age-related conditions occurring alongside dementia, (2) dementia as a diagnosis increasing or decreasing urgent care use, (3) informal and professional carers, (4) patient characteristics such as older age or behavioural symptoms and (5) the presence or absence of community support services. Included studies reported three crucial components of urgent care situations: (1) knowledge of the patient and dementia as a condition, (2) inadequate non-emergency health and social care support and (3) informal carer education and stress. CONCLUSIONS The scoping review highlighted a wider variety of sometimes competing factors that were associated with urgent care situations. Improved and increased community support for non-urgent situations, such as integrated care, caregiver education and dementia specialists, will both mitigate avoidable urgent care use and improve the experience of those in crisis.
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Affiliation(s)
- Jemima Dooley
- Centre for Academic Primary Care, School for Social and Community Medicine, Bristol University, Bristol, UK
| | - Matthew Booker
- Centre for Academic Primary Care, School for Social and Community Medicine, Bristol University, Bristol, UK
| | - Rebecca Barnes
- Centre for Academic Primary Care, School for Social and Community Medicine, Bristol University, Bristol, UK
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18
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Sutherland N. Structures, tensions, and processes shaping long-term care home staff's role in end of life decision-making for residents with dementia. J Aging Stud 2020; 54:100874. [PMID: 32972618 DOI: 10.1016/j.jaging.2020.100874] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 08/23/2020] [Accepted: 08/26/2020] [Indexed: 12/27/2022]
Abstract
Although long-term care (LTC) home staff of nurses and personal support workers spend the most time providing direct care, their role in end of life decision-making for residents with dementia has largely been unacknowledged. Staff's perceptions of their role play a significant part in how they support people with dementia and family care partners. The purpose of this study was to examine LTC home staff's perspectives of their role in end of life decision-making for LTC home residents with dementia. For this interpretive descriptive study, 21 semi-structured interviews were conducted in two urban LTC homes with nine personal support worker (PSWs), eight registered practical nurses (RPNs), and four registered nurses (RNs). Additionally, a focus group was conducted, consisting of each a PSW, RPN, and RN. A voice-centred relational analysis was used to situate LTC home staff's perspectives within broader social contexts. Findings suggest that little has changed in LTC homes in the last 50 years. Rooted in dichotomies between medical and social care paradigms, ideologies of rationality and professionalism created tensions, hierarchical roles, and staff's minimal involvement in decision-making. A relational approach is needed to account for the interdependency of care and the relationships that LTC home staff have with residents, family care partners, and the sociopolitical environment.
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Affiliation(s)
- Nisha Sutherland
- Lakehead University, 955 Oliver Road, Thunder Bay, ON P7B 5E1, Canada.
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19
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Baxter R, Shannon R, Murray J, O’Hara JK, Sheard L, Cracknell A, Lawton R. Delivering exceptionally safe transitions of care to older people: a qualitative study of multidisciplinary staff perspectives. BMC Health Serv Res 2020; 20:780. [PMID: 32831038 PMCID: PMC7444052 DOI: 10.1186/s12913-020-05641-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/10/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Transitions of care are often risky, particularly for older people, and shorter hospital stays mean that patients can go home with ongoing care needs. Most previous research has focused on fundamental system flaws, however, care generally goes right far more often than it goes wrong. We explored staff perceptions of how high performing general practice and hospital specialty teams deliver safe transitional care to older people as they transition from hospital to home. METHODS We conducted a qualitative study in six general practices and four hospital specialties that demonstrated exceptionally low or reducing readmission rates over time. Data were also collected across four community teams that worked into or with these high-performing teams. In total, 157 multidisciplinary staff participated in semi-structured focus groups or interviews and 9 meetings relating to discharge were observed. A pen portrait approach was used to explore how teams across a variety of different contexts support successful transitions and overcome challenges faced in their daily roles. RESULTS Across healthcare contexts, staff perceived three key themes to facilitate safe transitions of care: knowing the patient, knowing each other, and bridging gaps in the system. Transitions appeared to be safest when all three themes were in place. However, staff faced various challenges in doing these three things particularly when crossing boundaries between settings. Due to pressures and constraints, staff generally felt they were only able to attempt to overcome these challenges when delivering care to patients with particularly complex transitional care needs. CONCLUSIONS It is hypothesised that exceptionally safe transitions of care may be delivered to patients who have particularly complex health and/or social care needs. In these situations, staff attempt to know the patient, they exploit existing relationships across care settings, and act to bridge gaps in the system. Systematically reinforcing such enablers may improve the delivery of safe transitional care to a wider range of patients. TRIAL REGISTRATION The study was registered on the UK Clinical Research Network Study Portfolio (references 35272 and 36174 ).
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Affiliation(s)
- Ruth Baxter
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK
| | - Rosemary Shannon
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK
| | - Jenni Murray
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK
| | | | | | - Alison Cracknell
- Leeds Centre for Older People’s Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rebecca Lawton
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK
- School of Psychology, University of Leeds, Leeds, UK
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20
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Paramedics' Perspectives on the Hospital Transfers of Nursing Home Residents-A Qualitative Focus Group Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17113778. [PMID: 32466568 PMCID: PMC7312002 DOI: 10.3390/ijerph17113778] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 01/09/2023]
Abstract
Emergency department (ED) visits and hospital admissions are common among nursing home residents (NHRs). Little is known about the perspectives of emergency medical services (EMS) which are responsible for hospital transports. The aim of this study was to explore paramedics’ experiences with transfers from nursing homes (NHs) and their ideas for possible interventions that can reduce transfers. We conducted three focus groups following a semi-structured question guide. The data were analyzed by content analysis using the software MAXQDA. In total, 18 paramedics (mean age: 33 years, male n = 14) participated in the study. Paramedics are faced with complex issues when transporting NHRs to hospital. They mainly reported on structural reasons (e.g., understaffing or lacking availability of physicians), which led to the initiation of an emergency call. Handovers were perceived as poorly organized because required transfer information (e.g., medication lists, advance directives (ADs)) were incomplete or nursing staff was insufficiently prepared. Hospital transfers were considered as (potentially) avoidable in case of urinary catheter complications, exsiccosis/infections and falls. Legal uncertainties among all involved professional groups (nurses, physicians, dispatchers, and paramedics) seemed to be a relevant trigger for hospital transfers. In paramedics’ point of view, emergency standards in NHs, trainings for nursing staff, the improvement of working conditions and legal conditions can reduce potentially avoidable hospital transfers from NHs.
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22
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Stephens CE, Halifax E, David D, Bui N, Lee SJ, Shim J, Ritchie CS. "They Don't Trust Us": The Influence of Perceptions of Inadequate Nursing Home Care on Emergency Department Transfers and the Potential Role for Telehealth. Clin Nurs Res 2020; 29:157-168. [PMID: 31007055 PMCID: PMC10242499 DOI: 10.1177/1054773819835015] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
In this descriptive, qualitative study, we conducted eight focus groups with diverse informal and formal caregivers to explore their experiences/challenges with nursing home (NH) to emergency department (ED) transfers and whether telehealth might be able to mitigate some of those concerns. Interviews were transcribed and analyzed using a grounded theory approach. Transfers were commonly viewed as being influenced by a perceived lack of trust in NH care/capabilities and driven by four main factors: questioning the quality of NH nurses' assessments, perceptions that physicians were absent from the NH, misunderstandings of the capabilities of NHs and EDs, and perceptions that responses to medical needs were inadequate. Participants believed technology could provide "the power of the visual" permitting virtual assessment for the off-site physician, validation of nursing assessment, "real time" assurance to residents and families, better goals of care discussions with multiple parties in different locations, and family ability to say goodbye.
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Affiliation(s)
- Caroline E. Stephens
- Department of Community Health Systems, University of California, San Francisco, CA, USA
| | - Elizabeth Halifax
- Department of Physiological Nursing, University of California, San Francisco, CA, USA
| | - Daniel David
- Department of Community Health Systems, University of California, San Francisco, CA, USA
| | - Nhat Bui
- Asian Health Services, Oakland, CA, USA
| | - Sei J. Lee
- Division of Geriatrics, University of California, San Francisco, CA, USA
- San Francisco VA Healthcare System, San Francisco, CA, USA
| | - Janet Shim
- Department of Social and Behavioral Sciences, University of California, San Francisco, CA, USA
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23
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Fassmer AM, Pulst A, Spreckelsen O, Hoffmann F. Perspectives of general practitioners and nursing staff on acute hospital transfers of nursing home residents in Germany: results of two cross-sectional studies. BMC FAMILY PRACTICE 2020; 21:29. [PMID: 32046652 PMCID: PMC7014634 DOI: 10.1186/s12875-020-01108-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 02/05/2020] [Indexed: 02/08/2023]
Abstract
Background Visits in emergency departments and hospital admissions are common among nursing home (NH) residents and they are associated with significant complications. Many of these transfers are considered inappropriate. This study aimed to compare the perceptions of general practitioners (GPs) and NH staff on hospital transfers among residents and to illustrate measures for improvement. Methods Two cross-sectional studies were conducted as surveys among 1121 GPs in the German federal states Bremen and Lower Saxony and staff from 1069 NHs (preferably nursing staff managers) from all over Germany, each randomly selected. Questionnaires were sent in August 2018 and January 2019, respectively. The answers were compared between GPs and NH staff using descriptive statistics, Mann-Whitney U tests and χ2-tests. Results We received 375 GP questionnaires (response: 34%) and 486 NH questionnaires (response: 45%). GPs estimated the proportion of inappropriate transfers higher than NH staff (hospital admissions: 35.0% vs. 25.6%, p < 0.0001; emergency department visits: 39.9% vs. 20.9%, p < 0.0001). The majority of NH staff and nearly half of the GPs agreed that NH residents do often not benefit from hospital admissions (NHs: 61.4% vs. GPs: 48.8%; p = 0.0009). Both groups rated almost all potential measures for improvement differently (p < 0.0001), however, GPs and NH staff considered most areas to reduce hospital transfers importantly. The two most important measures for GPs were more nursing staff (91.6%) and better communication between nursing staff and GP (90.9%). NH staff considered better care / availability of GP (82.8%) and medical specialists (81.3%) as most important. Both groups rated similarly the importance of explicit advance directives (GPs: 77.2%, NHs: 72.4%; p = 0.1492). Conclusions A substantial proportion of hospital transfers from NHs were considered inappropriate. Partly, the ratings of possible areas for improvement differed between GPs and NH staff indicating that both groups seem to pass the responsibility to each other. These findings, however, support the need for interprofessional collaboration.
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Affiliation(s)
- Alexander Maximilian Fassmer
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, School VI - Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany.
| | - Alexandra Pulst
- Department of Health Services Research, Institute for Public Health and Nursing Research, University of Bremen, Bremen, Germany.,Health Sciences, University of Bremen, Bremen, Germany
| | - Ove Spreckelsen
- Division of General Practice, Department of Health Services Research, School VI - Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Falk Hoffmann
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, School VI - Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
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Unroe KT, O'Kelly Phillips E, Effler S, Ersek MT, Hickman SE. Comfort Measures Orders and Hospital Transfers: Insights From the OPTIMISTIC Demonstration Project. J Pain Symptom Manage 2019; 58:559-566. [PMID: 31233842 DOI: 10.1016/j.jpainsymman.2019.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/13/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
Abstract
CONTEXT Nursing facility residents and their families may identify "comfort measures" as their overall goal of care, yet some hospital transfers still occur. OBJECTIVES Describe nursing facility residents with comfort measures and their hospital transfers. METHODS Mixed methods, including root cause analyses of transfers by registered nurses and interviews with a subset of health care providers and family members involved in transfers. Participants were residents in 19 central Indiana facilities with comfort measures orders who experienced unplanned transfers to the hospital between January 1, 2015 and June 30, 2016. Project demographic and clinical characteristics of the residents were obtained from the Minimum Data Set 3.0. Interviews were conducted with stakeholders involved in transfer decisions. Participants were prompted to reflect on reasons for the transfer and outcomes. Interviews were transcribed and coded using qualitative descriptive methods. RESULTS Residents with comfort measures orders (n = 177) experienced 204 transfers. Most events were assessed as unavoidable (77%). Communication among staff, or between staff and the resident/family, primary care provider, or hospital was the most frequently noted area needing improvement (59.5%). In interviews, participants (n = 11) highlighted multiple issues, including judgments about whether decisions were "good" or "bad," and factors that were important to decision-making, including communication, nursing facility capabilities, clinical situation, and goals of care. CONCLUSION Most transfers of residents with comfort measures orders were considered unavoidable. Nonetheless, we identified several opportunities for improving care processes, including communication and addressing acute changes in status.
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Affiliation(s)
- Kathleen T Unroe
- Indiana University School of Medicine, Indianapolis, Indiana, USA; Regenstrief Institute, Indianapolis, Indiana, USA.
| | | | | | - Mary T Ersek
- Department of Veterans Affairs, Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Susan E Hickman
- Indiana University School of Medicine, Indianapolis, Indiana, USA; Regenstrief Institute, Indianapolis, Indiana, USA; Indiana University School of Nursing, Indianapolis, Indiana, USA
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Pulst A, Fassmer AM, Schmiemann G. Experiences and involvement of family members in transfer decisions from nursing home to hospital: a systematic review of qualitative research. BMC Geriatr 2019; 19:155. [PMID: 31164101 PMCID: PMC6549333 DOI: 10.1186/s12877-019-1170-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 05/23/2019] [Indexed: 11/23/2022] Open
Abstract
Background Nursing home residents (NHR) are characterized by increasing frailty, multimorbidity and care dependency. These conditions result in frequent hospital transfers which can lead to negative effects on residents’ health status and are often avoidable. Reasons for emergency department (ED) visits or hospital admissions are complex. Prior research indicated factors influencing transfer decisions in view of nursing staff and general practitioners. The aim of this systematic review is to explore how family members experience and influence transfers from nursing home (NH) to hospital and how they are involved in the transfer decision. Methods A systematic literature search was performed in Medline via PubMed, Ebsco Scopus and CINAHL in May 2018. Studies were eligible if they contained information a) about the decision to transfer NHR to hospital and b) the experiences or influence of family members. The review followed Joanna Briggs Institute's (JBI) approach for qualitative systematic reviews. Screening, selection and quality appraisal of studies were performed independently by two reviewers. Synthesis of qualitative data was conducted through meta-aggregation. Results After screening of n = 2863 articles, in total n = 10 qualitative studies were included in the review. Results indicate that family members of NHR experience decision-making before hospitalization differently. They mainly reported NH-related, hospital-related, and family/resident-related factors influencing the transfer decision. The involvement of family members in the decision-making process varies - from no involvement to insistence on a decision in favor of their personal preferences. However, hospital transfer decisions and other treatment decisions (e.g. advance care planning (ACP) discussions) were commonly discussed with physicians and nurses. Conflicts between family members and healthcare providers mostly arose around the interpretation of resident’s best interest. In general, family members perceive discussions as challenging thus leading to emotional stress and discomfort. Conclusion The influence of NHR family members concerning hospital transfer decisions varies. Family members are an important link for communication between resident and medical staff and for communication between NH and hospital. Interventions aiming to reduce hospitalization rates have to take these findings into account. Electronic supplementary material The online version of this article (10.1186/s12877-019-1170-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexandra Pulst
- Department of Health Services Research, Institute for Public Health and Nursing Research, University of Bremen, Grazer Str. 4, 28359, Bremen, Germany. .,Health Sciences Bremen, University of Bremen, 28359, Bremen, Germany.
| | - Alexander Maximilian Fassmer
- Department of Health Services Research, School VI - Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Ammerländer Heerstraße 114-118, 26129, Oldenburg, Germany
| | - Guido Schmiemann
- Department of Health Services Research, Institute for Public Health and Nursing Research, University of Bremen, Grazer Str. 4, 28359, Bremen, Germany.,Health Sciences Bremen, University of Bremen, 28359, Bremen, Germany
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Barriers to Staff Involvement in End-of-Life Decision-Making for Long-Term Care Residents with Dementia. Can J Aging 2019; 38:255-267. [PMID: 30739636 DOI: 10.1017/s0714980818000636] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
ABSTRACTAlthough providing direct care to residents with dementia, long-term care (LTC) home staff of registered nurses', registered practical nurses', and personal support workers' involvement in end-of-life decision-making is rarely acknowledged. The purpose of this study was to examine barriers and facilitators to LTC home staff involvement in end-of-life decision-making for people with advanced dementia. We report on the barriers to staff involvement in decision-making. Using an interpretive descriptive design, four major barriers to staff involvement in decision-making were identified: (a) the predominance of a biomedical model of care; (b) a varied understanding of a palliative approach; (c) challenging relationships with families; and (d) a discomfort with discussing death. Findings suggest that the predominant biomedical model in LTC homes, while important, must be imbued with a philosophy that emphasizes relationships among residents with dementia, family and staff.
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Chen BA, Chien HH, Chen CC, Chen HT, Jeng C. Patient Transfer Decision Difficulty Scale: Development and psychometric testing of emergency department visits by long-term care residents. PLoS One 2019; 14:e0210946. [PMID: 30707709 PMCID: PMC6358069 DOI: 10.1371/journal.pone.0210946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 01/06/2019] [Indexed: 11/29/2022] Open
Abstract
Background and objectives Nurses serve as gatekeepers of the health of long-term care facility (LTCF) residents and are key members deciding whether residents should visit an emergency department (ED). Inappropriate decisions as to ED visits may result in ED overcrowding, excessive medical expenses, and nosocomial infections. Currently, there is a lack of effective tools for assessing the barriers and level of difficulty experienced by LTCF nurses. The purposes of this study were to develop a Patient Transfer Decision Difficulty Scale (PTDDS) and test its effectiveness. Methods This study randomly sampled LTCFs in Taiwan and surveyed two or three nurses in every institution selected. Registered return envelopes were provided for participants to return self-completed questionnaires. Three steps were used to develop the scale and items: in step I, the instrument was developed; in step II, psychometric testing was conducted, which entailed performing an exploratory factor analysis (EFA) to verify the construct validity and reliability of the developed items; and in step III, a confirmation study was conducted using a confirmatory factor analysis (CFA) and structural equation modeling to cross-validate the factors and items. Results The cumulative sum of variance explained by the measurement models of the three factors in the PTDDS was 63.54%.When deciding whether to transfer LTCF residents to EDs, the most pronounced barrier experienced by nurses were for judging the severity of “clinical episodes”, which had an explanatory power of 37.49%. The second and third pronounced barriers and decision difficulty experienced by nurses were “communication and information” and “timing of the residents’ emergency visits,” which explained 16.81% and 9.24% of the variance, respectively. Conclusions The cross-validation results obtained using the EFA and CFA showed favorable reliability and validity of the PTDDS. For future studies, this study recommends performing large-scale investigations of the level of decision difficulty and related factors experienced by nurses in LTCFs of varying levels and types.
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Affiliation(s)
- Bor-An Chen
- School of Nursing, Taipei Medical University, Taipei, Taiwan
- Emergency Department, Keelung Hospital, Ministry of Health and Welfare, Keelung, Taiwan
| | - Hui-Hui Chien
- Nursing Department, Yuanshan Branch, Taipei Veterans General Hospital, Ilan, Taiwan
| | - Chun-Chung Chen
- Emergency Department, Keelung Hospital, Ministry of Health and Welfare, Keelung, Taiwan
| | - Hui-Tsai Chen
- Emergency Department, Keelung Hospital, Ministry of Health and Welfare, Keelung, Taiwan
| | - Chii Jeng
- School of Nursing, Taipei Medical University, Taipei, Taiwan
- * E-mail:
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Cummings GG, McLane P, Reid RC, Tate K, Cooper SL, Rowe BH, Estabrooks CA, Cummings GE, Abel SL, Lee JS, Robinson CA, Wagg A. Fractured Care: A Window Into Emergency Transitions in Care for LTC Residents With Complex Health Needs. J Aging Health 2018; 32:119-133. [PMID: 30442040 DOI: 10.1177/0898264318808908] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: For long-term care (LTC) residents, transfers to emergency departments (EDs) can be associated with poor health outcomes. We aimed to describe characteristics of residents transferred, factors related to decisions during transfer, care received in emergency medical services (EMS), ED settings, outcomes on return to LTC, and times of transfer segments along the transition. Method: We prospectively followed 637 transitions to an ED in British Columbia and Alberta, Canada, over a 12-month period. Data were captured through an electronic Transition Tracking Tool and interviews with health care professionals. Results: Common events triggering transfer were falls (26.8%), sudden change in condition (23.5%), and shortness of breath (19.8%). Discrepancies existed between reason for transfer, EMS reported chief complaint, and ED diagnosis. Many transfers resulted in resident return directly to LTC (42.7%). Discussion: Avoidable transfers may put residents at risk of receiving inappropriate care. Standardized communication strategies to highlight changes in resident condition are warranted.
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Affiliation(s)
| | | | - R Colin Reid
- The University of British Columbia, Okanagan campus, Kelowna, Canada
| | | | | | - Brian H Rowe
- University of Alberta, Edmonton, Canada.,Alberta Health Services, Edmonton, Canada
| | | | | | | | - Jacques S Lee
- University of Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Carole A Robinson
- The University of British Columbia, Okanagan campus, Kelowna, Canada
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Nursing Home Physicians Discuss Caring for Elderly Residents: An Exploratory Study. Can J Aging 2018; 37:133-144. [PMID: 29618397 DOI: 10.1017/s0714980818000089] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
RÉSUMÉMalgré la complexité croissante des soins en foyers de soins de longue durée, le rôle des médecins dans la prestation des soins aux résidents a été peu étudié. Cette étude exploratoire internationale visait à mieux comprendre les rôles des médecins, leurs responsabilités et leurs tâches, ainsi qu’à explorer les caractéristiques uniques de la pratique médicale dans les foyers de soins de longue durée. Des entrevues ont été menées avec 18 médecins. Ces médecins ont mentionné qu’ils contribuaient fortement à la qualité des soins pour les résidents, en clarifiant les objectifs des soins, en prenant des mesures pour réduire les hospitalisations et les prescriptions de médicaments non nécessaires, et en contribuant à la formation du personnel. Les pratiques en foyers de soins de longue durée impliquaient les médecins au centre de réseaux de relations qui assuraient non seulement une meilleure qualité des soins médicaux, mais aussi une satisfaction professionnelle chez les médecins. L’importance de ces relations est telle qu’elle permettait d’aller au-delà des démarcations traditionnelles entre le domaine médical et le domaine social, et mettait en évidence qu’une bonne pratique médicale implique de bonnes pratiques sociales. Considérant la nature exploratoire de l’étude, les auteurs recommandent que de futures recherches soient menées pour mieux comprendre les dimensions relationnelles associées à la pratique de la médecine en foyers de soins de longue durée.
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Abrahamson K, Bernard B, Magnabosco L, Nazir A, Unroe KT. The experiences of family members in the nursing home to hospital transfer decision. BMC Geriatr 2016; 16:184. [PMID: 27842502 PMCID: PMC5109810 DOI: 10.1186/s12877-016-0359-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 11/06/2016] [Indexed: 12/03/2022] Open
Abstract
Background The objective of this study was to better understand the experiences of family members in the nursing home to hospital transfer decision making process. Semi-structured interviews were conducted with 20 family members who had recently been involved in a nursing home to hospital transfer decision. Results Family members perceived themselves to play an advocacy role in their resident’s care and interview themes clustered within three over-arching categories: Family perception of the nursing home’s capacity to provide medical care: Resident and family choices; and issues at ‘hand-off’ and the hospital. Multiple sub-themes were also identified. Conclusions Findings from this study contribute to knowledge surrounding the nursing home transfer decision by illuminating the experiences of family members in the transfer decision process.
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Affiliation(s)
- Kathleen Abrahamson
- Purdue University School of Nursing, 502 N. University Street, West Lafayette, Indiana, 47907, USA.
| | - Brittany Bernard
- Indiana University Center for Aging Research, Indianapolis, Indiana, USA.,Regenstrief Institute, Inc, Indianapolis, Indiana, USA
| | - Lara Magnabosco
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Arif Nazir
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kathleen T Unroe
- Indiana University Center for Aging Research, Indianapolis, Indiana, USA.,Regenstrief Institute, Inc, Indianapolis, Indiana, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Decisions to Transfer Nursing Home Residents to Emergency Departments: A Scoping Review of Contributing Factors and Staff Perspectives. J Am Med Dir Assoc 2016; 17:994-1005. [DOI: 10.1016/j.jamda.2016.05.012] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 05/07/2016] [Accepted: 05/10/2016] [Indexed: 11/22/2022]
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Houghton C, Murphy K, Brooker D, Casey D. Healthcare staffs' experiences and perceptions of caring for people with dementia in the acute setting: Qualitative evidence synthesis. Int J Nurs Stud 2016; 61:104-16. [PMID: 27343469 DOI: 10.1016/j.ijnurstu.2016.06.001] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 06/02/2016] [Accepted: 06/03/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Dementia is a global issue, with increasing prevalence rates impacting on health services internationally. People with dementia are frequently admitted to hospital, an environment that may not be suited to their needs. While many initiatives have been developed to improve their care in the acute setting, there is a lack of cohesive understanding of how staff experience and perceive the care they give to people with dementia in the acute setting. OBJECTIVES The aim of this qualitative synthesis was to explore health care staffs' experiences and perceptions of caring for people with dementia in the acute setting. Qualitative synthesis can bring together isolated findings in a meaningful way that can inform policy development. SETTINGS A screening process, using inclusion/exclusion criteria, identified qualitative studies that focused on health care staff caring for people with dementia in acute settings. PARTICIPANTS Twelve reports of nine studies were included for synthesis. Data extraction was conducted on each report by two researchers. METHODS Framework synthesis was employed using VIPS framework, using Values, Individualised, Perspective and Social and psychological as concepts to guide synthesis. The VIPS framework has previously been used for exploring approaches to caring for people with dementia. Quality appraisal was conducted using Critical Appraisal Skills Programme (CASP) and NVivo facilitated sensitivity analysis to ensure confidence in the findings. RESULTS Key themes, derived from VIPS, included a number of specific subthemes that examined: infrastructure and care pathways, person-centred approaches to care, how the person interacts with their environment and other patients, and family involvement in care decisions. The synthesis identified barriers to appropriate care for the person with dementia. These include ineffective pathways of care, unsuitable environments, inadequate resources and staffing levels and lack of emphasis on education and training for staff caring for people with dementia. CONCLUSIONS This review has identified key issues in the care of people with dementia in the acute setting: improving pathways of care, creating suitable environments, addressing resources and staffing levels and placing emphasis on the education for staff caring for people with dementia. Recommendations are made for practice consideration, policy development and future research. Leadership is required to instil the values needed to care for this client group in an effective and personcentred way. Qualitative evidence synthesis can inform policy and in this case, recommends VIPS as a suitable framework for guiding decisions around care for people with dementia in acute settings.
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Affiliation(s)
- Catherine Houghton
- School of Nursing and Midwifery, National University of Ireland, Galway, Galway, Ireland.
| | - Kathy Murphy
- School of Nursing and Midwifery, National University of Ireland, Galway, Galway, Ireland.
| | - Dawn Brooker
- University of Worcester Association for Dementia Studies, Institute of Health and Society, University of Worcester, United Kingdom.
| | - Dympna Casey
- School of Nursing and Midwifery, National University of Ireland, Galway, Galway, Ireland.
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Tsai HH, Tsai YF, Huang HL. Nursing home nurses’ experiences of resident transfers to the emergency department: no empathy for our work environment difficulties. J Clin Nurs 2016; 25:610-8. [DOI: 10.1111/jocn.13084] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2015] [Indexed: 01/15/2023]
Affiliation(s)
- Hsiu-Hsin Tsai
- School of Nursing; College of Medicine; Chang Gung University; Tao-Yuan Taiwan
| | - Yun-Fang Tsai
- School of Nursing; College of Medicine; Chang Gung University; Tao-Yuan Taiwan
- Department of Nursing; Chang Gung Memorial Hospital at Keelung; Keelung Taiwan
| | - Hsiu-Li Huang
- School of Nursing; College of Medicine; Chang Gung University; Tao-Yuan Taiwan
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Stephens C, Halifax E, Bui N, Lee SJ, Harrington C, Shim J, Ritchie C. Provider Perspectives on the Influence of Family on Nursing Home Resident Transfers to the Emergency Department: Crises at the End of Life. Curr Gerontol Geriatr Res 2015; 2015:893062. [PMID: 26379704 PMCID: PMC4561315 DOI: 10.1155/2015/893062] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 08/16/2015] [Indexed: 11/29/2022] Open
Abstract
Background. Nursing home (NH) residents often experience burdensome and unnecessary care transitions, especially towards the end of life. This paper explores provider perspectives on the role that families play in the decision to transfer NH residents to the emergency department (ED). Methods. Multiple stakeholder focus groups (n = 35 participants) were conducted with NH nurses, NH physicians, nurse practitioners, physician assistants, NH administrators, ED nurses, ED physicians, and a hospitalist. Stakeholders described experiences and challenges with NH resident transfers to the ED. Focus group interviews were recorded and transcribed verbatim. Transcripts and field notes were analyzed using a Grounded Theory approach. Findings. Providers perceive that families often play a significant role in ED transfer decisions as they frequently react to a resident change of condition as a crisis. This sense of crisis is driven by 4 main influences: insecurities with NH care; families being unprepared for end of life; absent/inadequate advance care planning; and lack of communication and agreement within families regarding goals of care. Conclusions. Suboptimal communication and lack of access to appropriate and timely palliative care support and expertise in the NH setting may contribute to frequent ED transfers.
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Affiliation(s)
- Caroline Stephens
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, 2 Koret Way, N531E, UCSF Box 0608, San Francisco, CA 94143-0608, USA
| | - Elizabeth Halifax
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, 2 Koret Way, N531E, UCSF Box 0608, San Francisco, CA 94143-0608, USA
| | - Nhat Bui
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, 2 Koret Way, N531E, UCSF Box 0608, San Francisco, CA 94143-0608, USA
| | - Sei J. Lee
- Department of Geriatrics, Palliative & Extended Care, San Francisco VA Medical Center, Division of Geriatrics, School of Medicine, University of California, San Francisco, 4150 Clement Street, Building 1, Room 220F, San Francisco, CA 94121, USA
| | - Charlene Harrington
- Department of Social & Behavioral Sciences, School of Nursing, University of California, San Francisco, 3333 California Street, Suite 455, UCSF Box 0612, San Francisco, CA 94118, USA
| | - Janet Shim
- Department of Social & Behavioral Sciences, School of Nursing, University of California, San Francisco, 3333 California Street, Suite 455, UCSF Box 0612, San Francisco, CA 94118, USA
| | - Christine Ritchie
- Division of Geriatrics, School of Medicine, University of California, San Francisco, 3333 California Street, Suite 380, San Francisco, CA 94143-1265, USA
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Biese K, LaMantia M, Shofer F, McCall B, Roberts E, Stearns SC, Principe S, Kizer JS, Cairns CB, Busby-Whitehead J. A randomized trial exploring the effect of a telephone call follow-up on care plan compliance among older adults discharged home from the emergency department. Acad Emerg Med 2014; 21:188-95. [PMID: 24673675 DOI: 10.1111/acem.12308] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Revised: 08/22/2013] [Accepted: 08/26/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Older patients discharged from the emergency department (ED) have difficulty comprehending discharge plans and are at high risk of adverse outcomes. The authors investigated whether a postdischarge telephone call-mediated intervention by a nurse would improve discharge care plan adherence, specifically by expediting post-ED visit physician follow-up appointments and/or compliance with medication changes. The second objectives were to determine if this telephone call intervention would reduce return ED visits and/or hospitalizations within 35 days of the index ED visit and to determine potential cost savings of this intervention. METHODS This was a 10-week randomized, controlled trial among patients aged 65 and older discharged to home from an academic ED. At 1 to 3 days after each patient's index ED visit, a trained nurse called intervention group patients to review discharge instructions and assist with discharge plan compliance; placebo call group patients received a patient satisfaction survey call, while the control group patients were not called. Data collection calls occurred at 5 to 8 days and 30 to 35 days after the index ED visits for all three groups. Chi-square or Fisher's exact tests were performed for categorical data and the Kruskal-Wallis test examined group differences in time to follow-up. RESULTS A total of 120 patients completed the study. Patients were 60% female and 72% white, with a mean age of 75 years (standard deviation [SD] ± 7.58 years). Intervention patients were more likely to follow up with medical providers within 5 days of their ED visits than either the placebo or the control group patients (54, 20, and 37%, respectively; p = 0.04). All groups performed well in medication acquisition and comprehension of medication indications and dosage. There were no differences in return visits to the ED or hospital within 35 days of the index ED visit for intervention patients, compared to placebo or control group patients (22, 33, and 27%, respectively; p = 0.41). An economic analysis showed an estimated 70% chance that this intervention would reduce total costs. CONCLUSIONS Telephone call follow-up of older patients discharged from the ED resulted in expedited follow-up for patients with their primary care physicians. Further study is warranted to determine if these results translate into improved patient outcomes, decreased return ED visits or hospital admissions, and cost savings resulting from this intervention.
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Affiliation(s)
- Kevin Biese
- Department of Emergency Medicine; The University of North Carolina at Chapel Hill; Chapel Hill NC
- Division of Geriatric Medicine; Department of Medicine; The University of North Carolina at Chapel Hill; Chapel Hill NC
| | - Michael LaMantia
- Division of Geriatric Medicine; Department of Medicine; The University of North Carolina at Chapel Hill; Chapel Hill NC
- Indiana University Center for Aging Research Regenstrief Institute, Inc.; Indianapolis IN
| | - Frances Shofer
- Department of Emergency Medicine; The University of North Carolina at Chapel Hill; Chapel Hill NC
- Department of Emergency Medicine; University of Pennsylvania; Philadelphia PA
| | | | - Ellen Roberts
- Division of Geriatric Medicine; Department of Medicine; The University of North Carolina at Chapel Hill; Chapel Hill NC
| | - Sally C. Stearns
- Department of Health Policy and Management; The Gillings School of Global Public Health; The University of North Carolina at Chapel Hill; Chapel Hill NC
| | | | - John S. Kizer
- Division of Geriatric Medicine; Department of Medicine; The University of North Carolina at Chapel Hill; Chapel Hill NC
| | - Charles B. Cairns
- Department of Emergency Medicine; The University of North Carolina at Chapel Hill; Chapel Hill NC
| | - Jan Busby-Whitehead
- Division of Geriatric Medicine; Department of Medicine; The University of North Carolina at Chapel Hill; Chapel Hill NC
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Laugaland K, Aase K, Waring J. Hospital discharge of the elderly--an observational case study of functions, variability and performance-shaping factors. BMC Health Serv Res 2014; 14:365. [PMID: 25175924 PMCID: PMC4159506 DOI: 10.1186/1472-6963-14-365] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 08/27/2014] [Indexed: 11/13/2022] Open
Abstract
Background Understanding and improving hospital discharge has assumed major importance since it represents an error-prone transition in care. One barrier to improvement is the lack of detailed understanding of how hospital discharge is organized, including its interdependencies and influential performance-shaping factors (PSFs). This study examines the discharge of elderly patients using the Functional Resonance Analysis Method, developed to analyze performance variability in complex systems. Our main aim was to identify hospital discharge functions, variability, and PSFs that may explain the variability and different outcomes in discharge practices by incorporating multiple-stakeholder perceptions (health-care providers, patients, next of kin). Methods The data consisted of moderate participant observations of 20 elderly patients (>75) discharged from hospital to primary health care. The data comprised 90 hours’ observations at hospital wards, including 173 conversations with patients, next of kin, and health-care personnel involved in discharge. Results We identified 10 common functions in the discharge of elderly patients to primary health care. We found substantial variability in terms of timing, duration, and precision. Duration is a significant source of variability, primarily determined by the time of day the patient was determined medically fit for discharge. Precision issues related to (1) decision-making criteria concerning the medical fitness decision and appropriate level of care, (2) quality of discharge planning, (3) degree of patient involvement, and (4) quality of information transfer. PSFs were temporal conditions (degree of time pressure), individual and team characteristics, patient factors, organizational factors (unit, specialization, leadership, institutionalized routines), work environment factors (bed availability, availability in municipal services, quality of discharge planning, familiarity with the patient, pressure from next of kin, doctor’s specialization) and regulatory influences (financial incentives). Conclusions The study provides a detailed understanding of the discharge of elderly patients by describing common functions and variability in performance caused by multiple PSFs. Our findings indicate the necessity for studying multiple factors related to discharge, interdependencies, and their effects on a range of discharge outcomes incorporating a multiple-stakeholder perspective. We argue that the existing sequential approaches to the complexity surrounding hospital discharge are inadequate. Given the interdependencies among functions, there is a need for corresponding multi-factorial interventions. Electronic supplementary material The online version of this article (doi:10.1186/1472-6963-14-365) contains supplementary material, which is available to authorized users.
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Reid RC, Cummings GE, Cooper SL, Abel SL, Bissell LJ, Estabrooks CA, Rowe BH, Wagg A, Norton PG, Ertel M, Cummings GG. The Older Persons' Transitions in Care (OPTIC) study: pilot testing of the transition tracking tool. BMC Health Serv Res 2013; 13:515. [PMID: 24330805 PMCID: PMC3867622 DOI: 10.1186/1472-6963-13-515] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 12/09/2013] [Indexed: 11/13/2022] Open
Abstract
Background OPTIC is a mixed method Partnership for Health System Improvement (http://www.cihr-irsc.gc.ca/e/34348.html) study focused on improving care for nursing home (NH) residents who are transferred to and from emergency departments (EDs) via emergency medical services (EMS). In the pilot study we tested feasibility of concurrently collecting individual resident data during transitions across settings using the Transition Tracking Tool (T3). Methods The pilot study tracked 54 residents transferred from NHs to one of two EDs in two western Canadian provinces over a three month period. The T3 is an electronic data collection tool developed for this study to record data relevant to describing and determining success of transitions in care. It comprises 800+ data elements including resident characteristics, reasons and precipitating factors for transfer, advance directives, family involvement, healthcare services provided, disposition decisions, and dates/times and timing. Results Residents were elderly (mean age = 87.1 years) and the majority were female (61.8%). Feasibility of collecting data from multiple sources across two research sites was established. We identified resources and requirements to access and retrieve specific data elements in various settings to manage data collection processes and allocate research staff resources. We present preliminary data from NH, EMS, and ED settings. Conclusions While most research in this area has focused on a unidirectional process of patient progression from one care setting to another, this study established feasibility of collecting detailed data from beginning to end of a transition across multiple settings and in multiple directions.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Greta G Cummings
- Faculty of Nursing, University of Alberta, 5-110 Edmonton Clinical Health Academy, 11405 87 Avenue, Edmonton, Alberta T6G 1C9, Canada.
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Cummings GG, Reid RC, Estabrooks CA, Norton PG, Cummings GE, Rowe BH, Abel SL, Bissell L, Bottorff JL, Robinson CA, Wagg A, Lee JS, Lynch SL, Masaoud E. Older Persons' Transitions in Care (OPTIC): a study protocol. BMC Geriatr 2012; 12:75. [PMID: 23241360 PMCID: PMC3570479 DOI: 10.1186/1471-2318-12-75] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Accepted: 11/30/2012] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Changes in health status, triggered by events such as infections, falls, and geriatric syndromes, are common among nursing home (NH) residents and necessitate transitions between NHs and Emergency Departments (EDs). During transitions, residents frequently experience care that is delayed, unnecessary, not evidence-based, potentially unsafe, and fragmented. Furthermore, a high proportion of residents and their family caregivers report substantial unmet needs during transitions. This study is part of a program of research whose overall aim is to improve quality of care for frail older adults who reside in NHs. The purpose of this study is to identify successful transitions from multiple perspectives and to identify organizational and individual factors related to transition success, in order to inform improvements in care for frail elderly NH residents during transitions to and from acute care. Specific objectives are to: 1. define successful and unsuccessful elements of transitions from multiple perspectives; 2. develop and test a practical tool to assess transition success; 3. assess transition processes in a discrete set of transfers in two study sites over a one year period; 4. assess the influence of organizational factors in key practice locations, e.g., NHs, emergency medical services (EMS), and EDs, on transition success; and 5. identify opportunities for evidence-informed management and quality improvement decisions related to the management of NH - ED transitions. METHODS/DESIGN This is a mixed-methods observational study incorporating an integrated knowledge translation (IKT) approach. It uses data from multiple levels (facility, care unit, individual) and sources (healthcare providers, residents, health records, and administrative databases). DISCUSSION Key to study success is operationalizing the IKT approach by using a partnership model in which the OPTIC governance structure provides for team decision-makers and researchers to participate equally in developing study goals, design, data collection, analysis and implications of findings. As preliminary and ongoing study findings are developed, their implications for practice and policy in study settings will be discussed by the research team and shared with study site administrators and staff. The study is designed to investigate the complexities of transitions and to enhance the potential for successful and sustained improvement of these transitions.
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Affiliation(s)
- Greta G Cummings
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
- Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, 11405-87 Ave, Edmonton, AB, T6G 0C1, Canada
| | - R Colin Reid
- School of Health and Exercise Sciences, University of British Columbia’s Okanagan campus, Kelowna, BC, Canada
| | | | - Peter G Norton
- Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Garnet E Cummings
- Department of Emergency Medicine, Faculty of Medicine and Dentistry and School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, Faculty of Medicine and Dentistry and School of Public Health, University of Alberta, Edmonton, AB, Canada
| | | | - Laura Bissell
- School of Health and Exercise Sciences, University of British Columbia’s Okanagan campus, Kelowna, BC, Canada
| | - Joan L Bottorff
- School of Nursing, University of British Columbia’s Okanagan campus, Kelowna, BC, Canada
| | - Carole A Robinson
- School of Nursing, University of British Columbia’s Okanagan campus, Kelowna, BC, Canada
| | - Adrian Wagg
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Jacques S Lee
- Department of Emergency Services, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Susan L Lynch
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
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