Do gerontology nurse specialists make a difference in hospitalization of long-term care residents? Results of a randomized comparison trial

Residents of long-term care facilities have highly complex care needs and quality of care is of international concern. Maintaining resident wellness through proactive assessment and early intervention is key to decreasing the need for acute hospitalization. The Residential Aged Care Integration Program (RACIP) is a quality improvement intervention to support residential aged care staff and includes on-site support, education, clinical coaching, and care coordination provided by gerontology nurse specialists (GNSs) employed by a large district health board. The effect of the outreach program was evaluated through a randomized comparison of hospitalization 1 year before and after program implementation. The sample included 29 intervention facilities (1,425 residents) and 25 comparison facilities (1,128 residents) receiving usual care. Acute hospitalization rate unexpectedly increased for both groups after program implementation, although the rate of increase was significantly less for the intervention facilities. The hospitalization rate after the intervention increased 59% for the comparison group and 16% for the intervention group (rate ratio (RR) = 0.73, 95% confidence interval (CI) = 0.61-0.86, P < .001). Subgroup analysis showed a significantly lower rate change for those admitted for medical reasons for the intervention group (13% increase) than the comparison group (69% increase) (RR = 0.67, 95% CI = 0.56-0.82, P < .001). Conversely, there was no significant difference in the RR for surgical admissions between the intervention and comparison groups (RR = 1.0, 95% CI = 0.68-1.46, P = .99). The integration of GNS expertise through the RACIP intervention may be one approach to support staff to provide optimal care and potentially improve resident health.

The Aged Residential Care Healthcare Utilization Study (ARCHUS): a multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities

OBJECTIVE

To assess effect of a complex, multidisciplinary intervention aimed at reducing avoidable acute hospitalization of residents of residential aged care (RAC) facilities.

DESIGN

Cluster randomized controlled trial.

SETTING

RAC facilities with higher than expected hospitalizations in Auckland, New Zealand, were recruited and randomized to intervention or control.

PARTICIPANTS

A total of 1998 residents of 18 intervention facilities and 18 control facilities.

INTERVENTION

A facility-based complex intervention of 9 months' duration. The intervention comprised gerontology nurse specialist (GNS)-led staff education, facility bench-marking, GNS resident review, and multidisciplinary (geriatrician, primary-care physician, pharmacist, GNS, and facility nurse) discussion of residents selected using standard criteria.

MAIN OUTCOME MEASURES

Primary end point was avoidable hospitalizations. Secondary end points were all acute admissions, mortality, and acute bed-days. Follow-up was for a total of 14 months.

RESULTS

The intervention did not affect main study end points: number of acute avoidable hospital admissions (RR 1.07; 95% CI 0.85-1.36; P = .59) or mortality (RR 1.11; 95% CI 0.76-1.61; P = .62).

CONCLUSIONS

This multidisciplinary intervention, packaging selected case review, and staff education had no overall impact on acute hospital admissions or mortality. This may have considerable implications for resourcing in the acute and RAC sectors in the face of population aging. Australian and New Zealand Clinical Trials Registry (ACTRN12611000187943).

Biases in describing residents in long-term residential aged care

AIM

In New Zealand, no reliable information describes use of long-term residential aged care. Instead, when estimating use, records of government subsidy payments are upscaled to adjust for private payers. This paper assesses consequential bias in reporting use of long-term care and considers the implications.

METHODS

Data from OPAL, a census-type survey of residents of aged-care facilities in Auckland in 2008, linked to routinely-collected hospitalisation, mortality and subsidy data from national databases. Demographic, functional and service use characteristics of unsubsidised residents were compared to subsidised.

RESULTS

Records of 5961 OPAL residents aged 65+ years were matched with subsidy data; 25% were unsubsidised. In low-level care (51% of all), unsubsidised residents had similar care needs to subsidised residents, but were 1.7 years older on average (p<0.001) with shorter length of stay. In high-level care (41% of all), unsubsidised residents had significantly lower care needs on six different measures and were less likely to die during the follow-up period. Upscaling yields undercounts at all care levels.

CONCLUSIONS

National reports derived from current upscaling methods undercount residents. Stratification by region and age group would improve estimates. Age and care needs are misrepresented. Population policies that depend upon upscaled counts should, where possible, ascertain the biases introduced.

Improving emergency department management of paediatric clavicle fractures: a complete audit cycle

A protocol was devised to address the issue of unnecessary attendance at fracture clinic by children who have a fracture of the clavicle that is deemed to be uncomplicated. For the purposes of this protocol, the clavicle was divided into three zones. Fractures of the middle clavicle for which displacement was minimal, heal quickly in the majority of cases, without the need for follow up. As a result these children can be discharged provided the parents are adequately advised. This article outlines a study which investigated the effectiveness of the protocol. The study found that implementation of the protocol reduced unnecessary attendance at clinic from 85% (47/55) to 17% (4/23). This resulted in cost savings to the trust and reduced the pressure on staff working in busy fracture clinics.

Selecting long-term care facilities with high use of acute hospitalisations: issues and options

BACKGROUND

This paper considers approaches to the question "Which long-term care facilities have residents with high use of acute hospitalisations?" It compares four methods of identifying long-term care facilities with high use of acute hospitalisations by demonstrating four selection methods, identifies key factors to be resolved when deciding which methods to employ, and discusses their appropriateness for different research questions.

METHODS

OPAL was a census-type survey of aged care facilities and residents in Auckland, New Zealand, in 2008. It collected information about facility management and resident demographics, needs and care. Survey records (149 aged care facilities, 6271 residents) were linked to hospital and mortality records routinely assembled by health authorities. The main ranking endpoint was acute hospitalisations for diagnoses that were classified as potentially avoidable. Facilities were ranked using 1) simple event counts per person, 2) event rates per year of resident follow-up, 3) statistical model of rates using four predictors, and 4) change in ranks between methods 2) and 3). A generalized mixed model was used for Method 3 to handle the clustered nature of the data.

RESULTS

3048 potentially avoidable hospitalisations were observed during 22 months' follow-up. The same "top ten" facilities were selected by Methods 1 and 2. The statistical model (Method 3), predicting rates from resident and facility characteristics, ranked facilities differently than these two simple methods. The change-in-ranks method identified a very different set of "top ten" facilities. All methods showed a continuum of use, with no clear distinction between facilities with higher use.

CONCLUSION

Choice of selection method should depend upon the purpose of selection. To monitor performance during a period of change, a recent simple rate, count per resident, or even count per bed, may suffice. To find high-use facilities regardless of resident needs, recent history of admissions is highly predictive. To target a few high-use facilities that have high rates after considering facility and resident characteristics, model residuals or a large increase in rank may be preferable.

Perceptions towards lesbian, gay and bisexual people in residential care facilities: a qualitative study

BACKGROUND

Internationally, increases in the numbers of older people will be reflected in larger numbers of more socioculturally diverse groups of older people requiring care provided by residential care facilities. Covert and overt instances of homophobia are evident within residential care services provided to older lesbian, gay and bisexual people.

AIMS

To explore the perceptions of care staff working in residential care homes towards older lesbian, gay and bisexual people.

DESIGN

Critical gerontology formed the methodological foundations for focus group discussions with care staff from seven residential care facilities. Hypothetical vignettes were used to stimulate discussion amongst participants.

RESULTS

Thematic analysis of the seven focus group interviews illuminated three themes: 'Knowing me knowing you', 'Out of sight out of mind' and 'It's a generational thing'. Subtle as well as not so subtle forms of homophobia were evident in each of the themes. Care staff felt they were largely unprepared to provide care to older lesbian, gay and bisexual people.

CONCLUSION

This small-scale New Zealand study identifies that the residential care sector is not always supportive, or prepared, to provide a care service to those people identifying as lesbian, gay and bisexual.

IMPLICATIONS FOR PRACTICE

Findings from this study recommend the implementation of principle-based guidelines, opportunities to participate in ongoing education and partnering with non-heterosexual community organisations in order to provide culturally appropriate care to older lesbian, gay and bisexual people.

A regional approach to the education of nurse practitioner candidates to meet the health needs of rural Australians

BACKGROUND

Local health services expressed interest in supporting a nurse practitioner (NP) program specifically designed for rural practice environments.

AIM

To develop and deliver a generalist NP program that prepares candidates for practice in rural contexts.

METHODS

The Master of Clinical Nursing (Nurse Practitioner) program was designed with an understanding of the burden of disease impacting on rural Australians, application of the national health priorities, the Australian Government's refocus on preventative health care and rural health workforce shortages.

RESULTS

This program offers nurses who work in rural and remote settings an opportunity to advance their careers. Increasing the numbers of rural NPs will improve rural populations access to healthcare and potentially improve health outcomes.

CONCLUSION

This program will equip those seeking endorsement as a NP to effectively work in rural contexts.

Clinical staff perceptions of palliative care-related quality of care, service access, education and training needs and delivery confidence in an acute hospital setting

CONTEXT

Central to appropriate palliative care management in hospital settings is ensuring an adequately trained workforce. In order to achieve optimum palliative care delivery, it is first necessary to create a baseline understanding of the level of palliative care education and support needs among all clinical staff (not just palliative care specialists) within the acute hospital setting.

OBJECTIVES

The objectives of the study were to explore clinical staff: perceptions concerning the quality of palliative care delivery and support service accessibility, previous experience and education in palliative care delivery, perceptions of their own need for formal palliative care education, confidence in palliative care delivery and the impact of formal palliative care training on perceived confidence.

METHODS

A purposive sample of clinical staff members (598) in a 710-bed hospital were surveyed regarding their experiences of palliative care delivery and their education needs.

RESULTS

On average, the clinical staff rated the quality of care provided to people who die in the hospital as 'good' (x̄=4.17, SD=0.91). Respondents also reported that 19.3% of their time was spent caring for end-of-life patients. However, only 19% of the 598 respondents reported having received formal palliative care training. In contrast, 73.7% answered that they would like formal training. Perceived confidence in palliative care delivery was significantly greater for those clinical staff with formal palliative care training.

CONCLUSIONS

Formal training in palliative care increases clinical staff perceptions of confidence, which evidence suggests impacts on the quality of palliative care provided to patients. The results of the study should be used to shape the design and delivery of palliative care education programmes within the acute hospital setting to successfully meet the needs of all clinical staff.

The nature of, and reasons for, 'inappropriate' hospitalisations among patients with palliative care needs: a qualitative exploration of the views of generalist palliative care providers

BACKGROUND

Recent studies have concluded that there is significant potential to reduce the extent of 'inappropriate' hospitalisations among patients with palliative care needs. However, the nature of, and reasons for, inappropriate hospitalisations within a palliative care context is under-explored.

AIM

To explore the opinions of 'generalist' palliative care providers regarding the nature of, and reasons for, inappropriate admissions among hospital inpatients with palliative care needs.

DESIGN

Qualitative study with data collected via individual interviews and focus groups.

SETTING/PARTICIPANTS

Participants (n = 41) comprised 'generalist' palliative care providers working in acute hospital and community settings.

SETTING

One District Health Board in an urban area of New Zealand.

RESULTS

The majority of participants discussed 'appropriateness' in relation to their own understanding of a good death, which typically involved care being delivered in a 'homely' environment, from known people. Differing attitudes among cultural groups were also evident. The following reasons for inappropriate admissions were identified: family carers being unable to cope, the 'rescue culture' of modern medicine, the financing and availability of community services and practice within aged residential care.

CONCLUSIONS

On the basis of our findings, we recommend a shift to the term 'potentially avoidable' admission rather than 'inappropriate admission'. We also identify an urgent need for debate regarding the role of the acute hospital within a palliative care context. Interventions to reduce hospital admissions within this population must target societal understandings of death and dying within the context of medicalisation, as well as take into account cultural and ethnic diversity in attitudes, if they are to be successful.

Therapeutic activity of 9-chloro-2-methylellipticinium acetate in an orthotopic model of human brain cancer

A series of ellipticinium derivatives with selective cytotoxicity towards brain tumor cell lines has been identified through in vitro screening against disease-oriented panels of human tumor cell lines. Unfortunately 9-methoxy-2-methylellipticinium, the lead compound of this series, has shown only very limited evidence for in vivo activity when examined in a variety of human tumor xenograft models. This lack of activity has been postulated to be due to metabolism. To address this issue, a derivative was synthesized which was blocked at the theoretically vulnerable 9-position and yet could be shown to retain brain tumor selectivity in vitro. In vivo xenograft testing was performed to assess the therapeutic potential of this second generation compound. To maintain continuity with the in vitro screening data, in vivo experimental therapeutic models were devised employing one of the in vitro sensitive cell lines, the U-251 glioblastoma. Cells were cultivated in vitro and injected into female athymic nude mice for therapeutic studies. The 9-chloro-derivative of the lead compound produced growth delay of subcutaneously implanted tumor cells when. administered by seven-day continuous infusion. Based on this evidence for activity in a systemic chemotherapy mode, further studies were conducted using an orthotopic brain cancer model. In three separate experiments, intracranial implantation of 1x10(7) tumor cells resulted in 100% mortality of control mice with median survival ranging from 15-18.5 days. In all experiments, mice treated by subcutaneous infusion with 9-chloro-2-methylellipticinium acetate showed increases in survival. Statistically significant effects and individual long-term survivors were observed in two experiments; These results provide support for the further preclinical development of 9-chloro-2-methylellipticinium acetate as a candidate for clinical trials against human brain cancer.

Patient reported outcome measures in military patients with shoulder instability

OBJECTIVES

The Oxford Shoulder Instability Score (OSIS) is a measure of functional impairment of the upper limb, but it is unclear how it translates into military patients where lower scores, implying higher function, may still be insufficient to meet the increased demands of military service and necessitating surgery. This study aimed to compare OSIS in military and civilian patients undergoing shoulder stabilisation surgery.

METHODS

We undertook a prospective, blinded cohort-controlled study with a null hypothesis that there was no difference in the Oxford Instability Scores between military and civilian patient groups. 40 patients were required in each group. A prospective clinical data base (iParrot, ByResults, Oxford, UK) was interrogated for consecutive patients undergoing shoulder stabilisation surgery at a single centre. The senior author-blinded to the outcome score-matched patients according to age, gender and diagnosis. Statistical analysis showed the data to be normally distributed and a paired samples t test was used to compare the two groups.

RESULTS

110 patients were required to provide a matched cohort of 40 in each group (70 male, 10 female subjects). Age distribution was 16-19 years (n=6); 20-24 years (n=28); 25-29 (n=16); 30-34 (n=12); 35-49 (n=12); and 40-44 (n=6). 72 patients (90%) had polar group 1 instability and eight patients (10%) had polar group 2 instability. The mean OSIS in the civilian group was 17.25 and in the military group 18.25. There was no statistical difference between the two groups (p=0.395).

CONCLUSIONS

This study supports the use of the OSIS to assess military patients with shoulder instability and monitor the progress of their condition.

Dose calculations for [(131)i] meta-iodobenzylguanidine-induced bystander effects

Targeted radiotherapy is a potentially useful treatment for some cancers and may be potentiated by bystander effects. However, without estimation of absorbed dose, it is difficult to compare the effects with conventional external radiation treatment.

METHODS

Using the Vynckier - Wambersie dose point kernel, a model for dose rate evaluation was created allowing for calculation of absorbed dose values to two cell lines transfected with the noradrenaline transporter (NAT) gene and treated with [(131)I]MIBG.

RESULTS

The mean doses required to decrease surviving fractions of UVW/NAT and EJ138/NAT cells, which received medium from [(131)I]MIBG-treated cells, to 25 - 30% were 1.6 and 1.7 Gy respectively. The maximum mean dose rates achieved during [(131)I]MIBG treatment were 0.09 - 0.75 Gy/h for UVW/NAT and 0.07 - 0.78 Gy/h for EJ138/NAT. These were significantly lower than the external beam gamma radiation dose rate of 15 Gy/h. In the case of control lines which were incapable of [(131)I]MIBG uptake the mean absorbed doses following radiopharmaceutical were 0.03 - 0.23 Gy for UVW and 0.03 - 0.32 Gy for EJ138.

CONCLUSION

[(131)I]MIBG treatment for ICCM production elicited a bystander dose-response profile similar to that generated by external beam gamma irradiation but with significantly greater cell death.

Validation of a measurement tool for self-assessment of teamwork in intensive care

BACKGROUND

Teamwork is an important contributor to patient safety and a validated teamwork measurement tool could help healthcare teams identify areas for improvement and measure progress. We explored the psychometric properties of a teamwork measurement tool when used for self-assessment. We hypothesized that the tool had a valid factor structure and that scores from participants and external assessors would correlate.

METHODS

Forty intensive care teams (one doctor, three nurses) participated in four simulated emergencies, and each independently rated their team's performance at the end of each case using the teamwork measurement tool, without prior training in the use of the tool. We used exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), and compared factor structure between participants and external assessors (using previously reported data). Scores from participants and external assessors were compared using Pearson's correlation coefficient.

RESULTS

EFA demonstrated items loaded onto three distinct factors which were supported by the CFA. We found significant correlations between external and participant scores for overall teamwork scores and the three factors. Participants agreed with external assessors on the ranking of overall team performance but scored themselves significantly higher than external assessors.

CONCLUSIONS

The teamwork measurement tool has a valid structure when used for self-assessment. Participant and external assessor scores correlated significantly, suggesting that participants could discriminate between different levels of performance, although leniency in self-assessed scores indicated the need for calibration. This tool could help structure reflection on teamwork and potentially facilitate self-directed, workplace-based improvement in teamwork.

Palliative care need and management in the acute hospital setting: a census of one New Zealand Hospital

Background

Improving palliative care management in acute hospital settings has been identified as a priority internationally. The aim of this study was to establish the proportion of inpatients within one acute hospital in New Zealand who meet prognostic criteria for palliative care need and explore key aspects of their management.

Methods

A prospective survey of adult hospital inpatients (n = 501) was undertaken. Case notes were examined for evidence that the patient might be in their last year of life according to Gold Standards Framework (GSF) prognostic indicator criteria. For patients who met GSF criteria, clinical and socio-demographic information were recorded.

Results

Ninety-nine inpatients met GSF criteria, representing 19.8% of the total census population. The patients’ average age was 70 years; 47% had a primary diagnosis of cancer. Two thirds had died within 6 months of their admission. Seventy-eight of the 99 cases demonstrated evidence that a palliative approach to care had been adopted; however documentation of discussion about goals of care was very limited and only one patient had evidence of an advance care plan.

Conclusion

One fifth of hospital inpatients met criteria for palliative care need, the majority of whom were aged >70 years. Whilst over three quarters were concluded to be receiving care in line with a palliative care approach, very little documented evidence of discussion with patients and families regarding end of life issues was evident. Future research needs to explore how best to support ‘generalist’ palliative care providers in initiating, and appropriately recording, such discussions.

Ageing and long-term CD4 cell count trends in HIV-positive patients with 5 years or more combination antiretroviral therapy experience

OBJECTIVES

The aim of this study was to describe the long-term changes in CD4 cell counts beyond 5 years of combination antiretroviral therapy (cART). If natural ageing leads to a long-term decline in the immune system via low-grade chronic immune activation/inflammation, then one might expect to see a greater or earlier decline in CD4 counts in older HIV-positive patients with increasing duration of cART.

METHODS

Retrospective and prospective data were examined from long-term virologically stable HIV-positive adults from the Australian HIV Observational Database. We estimated mean CD4 cell count changes following the completion of 5 years of cART using linear mixed models.

RESULTS

A total of 37 916 CD4 measurements were observed for 892 patients over a combined total of 9753 patient-years. Older patients (> 50 years old) at cART initiation had estimated mean (95% confidence interval) changes in CD4 counts by year-5 CD4 count strata (< 500, 500-750 and > 750 cells/μL) of 14 (7 to 21), 3 (-5 to 11) and -6 (-17 to 4) cells/μL/year. Of the CD4 cell count rates of change estimated, none were indicative of long-term declines in CD4 cell counts.

CONCLUSIONS

Our results suggest that duration of cART and increasing age do not result in decreasing mean changes in CD4 cell counts for long-term virologically suppressed patients, indicating that the level of immune recovery achieved during the first 5 years of treatment is sustained through long-term cART.