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Conlin M, Hamard M, Agrinier N, Birgand G. Assessment of implementation strategies adopted for antimicrobial stewardship interventions in long-term care facilities: a systematic review. Clin Microbiol Infect 2024; 30:431-444. [PMID: 38141820 DOI: 10.1016/j.cmi.2023.12.020] [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: 07/24/2023] [Revised: 12/11/2023] [Accepted: 12/17/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND The implementation of antimicrobial stewardship (AMS) interventions in long-term care facilities (LTCFs) is influenced by multi-level factors (resident, organizational, and external) making their effectiveness sensitive to the implementation context. OBJECTIVES This study assessed the strategies adopted for the implementation of AMS interventions in LTCFs, whether they considered organizational characteristics, and their effectiveness. DATA SOURCES Electronic databases until April 2022. STUDY ELIGIBILITY CRITERIA Articles covering implementation of AMS interventions in LTCFs. ASSESSMENT OF RISK OF BIAS Mixed Methods Appraisal Tool for empirical studies. METHODS OF DATA SYNTHESIS Data were collected on AMS interventions and context characteristics (e.g. type of facility, staffing, and residents). Implementation strategies and outcomes were mapped according to the Expert Recommendations for Implementing Change (ERIC) framework and validated taxonomy for implementation outcomes. Implementation and clinical effectiveness were assessed according to the primary and secondary outcomes results provided in each study. RESULTS Among 48 studies included in the analysis, 19 (40%) used implementation strategies corresponding to one to three ERIC domains, including education and training (n = 36/48, 75%), evaluative and iterative strategies (n = 24/48, 50%), and support clinicians (n = 23/48, 48%). Only 8/48 (17%) studies made use of implementation theories, frameworks, or models. Fidelity and sustainability were reported respectively in 21 (70%) and 3 (10%) of 27 studies providing implementation outcomes. Implementation strategy was considered effective in 11/27 (41%) studies, mainly including actions to improve use (n = 6/11, 54%) and education (n = 4/11, 36%). Of the 42 interventions, 18/42 (43%) were deemed clinically effective. Among 21 clinically effective studies, implementation was deemed effective in four and partially effective in five. Two studies were clinically effective despite having non-effective implementation. CONCLUSIONS The effectiveness of AMS interventions in LTCFs largely differed according to the interventions' content and implementation strategies adopted. Implementation frameworks should be considered to adapt and tailor interventions and strategies to the local context.
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Affiliation(s)
- Michèle Conlin
- Regional Center for Infection Prevention and Control Pays de la Loire, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Marie Hamard
- Unité de gériatrie Aiguë, Hôpital Bichat-Claude Bernard, Paris, France
| | - Nelly Agrinier
- Université de Lorraine, Inserm, INSPIIRE, F-54000 Nancy, France; CHRU-Nancy, Inserm, Université de Lorraine, CIC, Epidémiologie clinique, Nancy, France.
| | - Gabriel Birgand
- Regional Center for Infection Prevention and Control Pays de la Loire, Centre Hospitalier Universitaire de Nantes, Nantes, France; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London, London, UK
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Boere TM, El Alili M, van Buul LW, Hopstaken RM, Verheij TJM, Hertogh CMPM, van Tulder MW, Bosmans JE. Cost-effectiveness and return-on-investment of C-reactive protein point-of-care testing in comparison with usual care to reduce antibiotic prescribing for lower respiratory tract infections in nursing homes: a cluster randomised trial. BMJ Open 2022; 12:e055234. [PMID: 36109036 PMCID: PMC9478864 DOI: 10.1136/bmjopen-2021-055234] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES C-reactive protein point-of-care testing (CRP POCT) is a promising diagnostic tool to guide antibiotic prescribing for lower respiratory tract infections (LRTI) in nursing home residents. This study aimed to evaluate cost-effectiveness and return-on-investment (ROI) of CRP POCT compared with usual care for nursing home residents with suspected LRTI from a healthcare perspective. DESIGN Economic evaluation alongside a cluster randomised, controlled trial. SETTING 11 Dutch nursing homes. PARTICIPANTS 241 nursing home residents with a newly suspected LRTI. INTERVENTION Nursing home access to CRP POCT (POCT-guided care) was compared with usual care without CRP POCT (usual care). MAIN OUTCOME MEASURES The primary outcome measure for the cost-effectiveness analysis was antibiotic prescribing at initial consultation, and the secondary outcome was full recovery at 3 weeks. ROI analyses included intervention costs, and benefits related to antibiotic prescribing. Three ROI metrics were calculated: Net Benefits, Benefit-Cost-Ratio and Return-On-Investment. RESULTS In POCT-guided care, total costs were on average €32 higher per patient, the proportion of avoided antibiotic prescribing was higher (0.47 vs 0.18; 0.30, 95% CI 0.17 to 0.42) and the proportion of fully recovered patients statistically non-significantly lower (0.86 vs 0.91; -0.05, 95% CI -0.14 to 0.05) compared with usual care. On average, an avoided antibiotic prescription was associated with an investment of €137 in POCT-guided care compared with usual care. Sensitivity analyses showed that results were relatively robust. Taking the ROI metrics together, the probability of financial return was 0.65. CONCLUSION POCT-guided care effectively reduces antibiotic prescribing compared with usual care without significant effects on recovery rates, but requires an investment. Future studies should take into account potential beneficial effects of POCT-guided care on costs and health outcomes related to antibiotic resistance. TRIAL REGISTRATION NUMBER NL5054.
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Affiliation(s)
- Tjarda M Boere
- Department of Medicine for Older People, Amsterdam Public Health research institute, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Mohamed El Alili
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam Public Health research institute, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Rogier M Hopstaken
- Star-SHL Diagnostic Center, Etten-Leur, The Netherlands
- Department of General Practice, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health research institute, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Maurits W van Tulder
- Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences research institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Judith E Bosmans
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Buck D, Tucker S, Roe B, Hughes J, Challis D. Hospital admissions and place of death of residents of care homes receiving specialist healthcare services: A systematic review without meta-analysis. J Adv Nurs 2021; 78:666-697. [PMID: 34532884 DOI: 10.1111/jan.15043] [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: 01/11/2021] [Revised: 08/09/2021] [Accepted: 08/27/2021] [Indexed: 11/29/2022]
Abstract
AIM To synthesize evidence on the ability of specialist care home support services to prevent hospital admission of older care home residents, including at end of life. DESIGN Systematic review, without meta-analysis, with vote counting based on direction of effect. DATA SOURCES Fourteen electronic databases were searched from January 2010 to January 2019. Reference lists of identified reviews, study protocols and included documents were scrutinized for further studies. REVIEW METHODS Papers on the provision of specialist care home support that addressed older, long-term care home residents' physical health needs and provided comparative data on hospital admissions were included. Two reviewers undertook study selection and quality appraisal independently. Vote counting by direction of effect and binomial tests determined service effectiveness. RESULTS Electronic searches identified 79 relevant references. Combined with 19 citations from an earlier review, this gave 98 individual references relating to 92 studies. Most were from the UK (22), USA (22) and Australia (19). Twenty studies were randomized controlled trials and six clinical controlled trials. The review suggested interventions addressing residents' general health needs (p < .001), assessment and management services (p < .0001) and non-training initiatives involving medical staff (p < .0001) can reduce hospital admissions, while there was also promising evidence for services targeting residents at imminent risk of hospital entry or post-hospital discharge and training-only initiatives. End-of-life care services may enable residents to remain in the home at end of life (p < .001), but the high number of weak-rated studies undermined confidence in this result. CONCLUSION This review suggests specialist care home support services can reduce hospital admissions. More robust studies of services for residents at end of life are urgently needed. IMPACT The review addressed the policy imperative to reduce the avoidable hospital admission of older care home residents and provides important evidence to inform service design. The findings are of relevance to commissioners, providers and residents.
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Affiliation(s)
- Deborah Buck
- Social Care and Society, University of Manchester, Manchester, UK
| | - Sue Tucker
- Social Care and Society, University of Manchester, Manchester, UK
| | - Brenda Roe
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, UK
| | - Jane Hughes
- Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - David Challis
- Institute of Mental Health, University of Nottingham, Nottingham, UK
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Reducing preventable patient transfers from long-term care facilities to emergency departments: a scoping review. CAN J EMERG MED 2021; 22:844-856. [PMID: 32741417 DOI: 10.1017/cem.2020.416] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND In Canada, there were over 60,000 long-term care facility patient transfers to emergency departments (EDs) in 2014, with up to a quarter of them being potentially preventable. Each preventable transfer exposes the patient to transport- and hospital-related complications, contributes to ED crowding, and adds significant costs to the health care system. There have been many proposed and studied interventions aimed at alleviating the issue, but few attempts to assess and evaluate different interventions across institutions. METHODS A systematic search of MEDLINE, CINAHL, and EMBASE for studies describing the impact of interventions aimed at reducing preventable transfers from long-term care facilities to EDs on ED transfer rate. Two independent reviewers screened the studies for inclusion and completed a quality assessment. A tabular and narrative synthesis was then completed. This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines. RESULTS A total of 26 studies were included (Cohen's k = 0.68). One was of low quality (Cohen's k = 0.58). Studies were summarized into five themes based on intervention type: Telemedicine, Outreach Teams, Interdisciplinary Care, Integrated Approaches, and Other. Effective interventions reported reductions in ED transfer rates post intervention ranging from 10 to 70%. Interdisciplinary health care teams staffed within long-term care facilities were the most effective interventions. CONCLUSION There are several promising interventions that have successfully reduced the number of preventable transfers from long-term care facilities to EDs in a variety of health care settings. Widespread implementation of these interventions has the potential to reduce ED crowding in Canada.
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Griffith MF, Levy CR, Parikh TJ, Stevens-Lapsley JE, Eber LB, Palat SIT, Gozalo PL, Teno JM. Nursing Home Residents Face Severe Functional Limitation or Death After Hospitalization for Pneumonia. J Am Med Dir Assoc 2020; 21:1879-1884. [PMID: 33263287 PMCID: PMC7577734 DOI: 10.1016/j.jamda.2020.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/02/2020] [Accepted: 09/06/2020] [Indexed: 11/18/2022]
Abstract
Objectives Pneumonia is a common cause of hospitalization for nursing home residents and has increased as a cause for hospitalization during the COVID-19 pandemic. Risks of hospitalization, including significant functional decline, are important considerations when deciding whether to treat a resident in the nursing home or transfer to a hospital. Little is known about postdischarge functional status, relative to baseline, of nursing home residents hospitalized for pneumonia. We sought to determine the risk of severe functional limitation or death for nursing home residents following hospitalization for treatment of pneumonia. Design Retrospective cohort study. Setting and Participants Participants included Medicare enrollees aged ≥65 years, hospitalized from a nursing home in the United States between 2013 and 2014 for pneumonia. Methods Activities of daily living (ADL), patient sociodemographics, and comorbidities were obtained from the Minimum Data Set (MDS), an assessment tool completed for all nursing home residents. MDS assessments from prior to and following hospitalization were compared to assess for functional decline. Following hospital discharge, all patients were evaluated for a composite outcome of severe disability (≥4 ADL limitations) following hospitalization or death prior to completion of a postdischarge MDS. Results In 2013 and 2014, a total of 241,804 nursing home residents were hospitalized for pneumonia, of whom 89.9% (192,736) experienced the composite outcome of severe disability or death following hospitalization for pneumonia. Although we found that prehospitalization functional and cognitive status were associated with developing the composite outcome, 53% of residents with no prehospitalization ADL limitation, and 82% with no cognitive limitation experienced the outcome. Conclusions and Implications Hospitalization for treatment of pneumonia is associated with significant risk of functional decline and death among nursing home residents, even those with minimal deficits prior to hospitalization. Nursing homes need to prepare for these outcomes in both advance care planning and in rehabilitation efforts.
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Affiliation(s)
- Matthew F Griffith
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO, USA.
| | - Cari R Levy
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO, USA
| | - Toral J Parikh
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Jennifer E Stevens-Lapsley
- Geriatric Research Education and Clinical Center (GRECC), VA Eastern Colorado Health Care System, Aurora, CO, USA
| | | | - Sing-I T Palat
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, RI, USA
| | - Joan M Teno
- Division of General Internal Medicine, Oregon Health and Science University, Portland, OR, USA
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Crayton E, Richardson M, Fuller C, Smith C, Liu S, Forbes G, Anderson N, Shallcross L, Michie S, Hayward A, Lorencatto F. Interventions to improve appropriate antibiotic prescribing in long-term care facilities: a systematic review. BMC Geriatr 2020; 20:237. [PMID: 32646382 PMCID: PMC7350746 DOI: 10.1186/s12877-020-01564-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 04/21/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Overuse of antibiotics has contributed to antimicrobial resistance; a growing public health threat. In long-term care facilities, levels of inappropriate prescribing are as high as 75%. Numerous interventions targeting long-term care facilities' antimicrobial stewardship have been reported with varying, and largely unexplained, effects. Therefore, this review aimed to apply behavioural science frameworks to specify the component behaviour change techniques of stewardship interventions in long-term care facilities and identify those components associated with improved outcomes. METHOD A systematic review (CRD42018103803) was conducted through electronic database searches. Two behavioural science frameworks, the Behaviour Change Wheel and Behaviour Change Technique Taxonomy were used to classify intervention descriptions into intervention types and component behaviour change techniques used. Study design and outcome heterogeneity prevented meta-analysis and meta-regression. Interventions were categorised as 'very promising' (all outcomes statistically significant), 'quite promising' (some outcomes statistically significant), or 'not promising' (no outcomes statistically significant). 'Promise ratios' (PR) were calculated for identified intervention types and behaviour change techniques by dividing the number of (very or quite) promising interventions featuring the intervention type or behaviour change technique by the number of interventions featuring the intervention type or behaviour change technique that were not promising. Promising intervention types and behaviour change techniques were defined as those with a PR ≥ 2. RESULTS Twenty studies (of19 interventions) were included. Seven interventions (37%) were 'very promising', eight 'quite promising' (42%) and four 'not promising' (21%). Most promising intervention types were 'persuasion' (n = 12; promise ratio (PR) = 5.0), 'enablement' (n = 16; PR = 4.33) and 'education' (n = 19; PR = 3.75). Most promising behaviour change techniques were 'feedback on behaviour' (n = 9; PR = 8.0) and 'restructuring the social environment' (e.g. staff role changes; n = 8; PR = 7.0). CONCLUSION Systematic identification of the active ingredients of antimicrobial stewardship in long-term care facilities was facilitated through the application of behavioural science frameworks. Incorporating environmental restructuring and performance feedback may be promising intervention strategies for antimicrobial stewardship interventions within long-term care facilities.
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Affiliation(s)
- Elise Crayton
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
| | - Michelle Richardson
- Institute of Education (IOE), University College London, London, WC1H 0NS, UK
| | - Chris Fuller
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
| | - Catherine Smith
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
| | - Sunny Liu
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Gillian Forbes
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Niall Anderson
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
- Health Protection Research Unit in Evaluation of Interventions, National Institute of Health Research (NIHR), London, BS8 2BN, UK
| | - Laura Shallcross
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
| | - Susan Michie
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
- Health Protection Research Unit in Evaluation of Interventions, National Institute of Health Research (NIHR), London, BS8 2BN, UK
| | - Andrew Hayward
- Institute of Epidemiology & Health, University College London, London, WC1E 7HB, UK
| | - Fabiana Lorencatto
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
- Health Protection Research Unit in Evaluation of Interventions, National Institute of Health Research (NIHR), London, BS8 2BN, UK
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Martin RS, Hayes BJ, Hutchinson A, Tacey M, Yates P, Lim WK. Introducing Goals of Patient Care in Residential Aged Care Facilities to Decrease Hospitalization: A Cluster Randomized Controlled Trial. J Am Med Dir Assoc 2019; 20:1318-1324.e2. [PMID: 31422065 DOI: 10.1016/j.jamda.2019.06.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/14/2019] [Accepted: 06/22/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The "Goals of Patient Care" (GOPC) process uses shared decision making to incorporate residents' prior advance care planning (ACP) or preferences into medical treatment orders, guiding health care decisions at a time of clinical deterioration should they be unable to voice their opinions. The objective was to determine whether GOPC medical treatment orders were more effective than ACP alone in preventing emergency department (ED) visits (no hospitalization), ED visits (with hospitalization), and deaths outside the residential aged care facility (RACF). DESIGN The study was a prospective cluster randomized controlled trial, with the intervention being the completion of GOPC process by a geriatrician, following a shared decision-making process, incorporating ACP documents or residents' preferences. SETTING AND PARTICIPANTS The study took place in 6 RACFs in Northern Metropolitan Melbourne, Australia. Eligible participants included all permanent residents in participating RACFs for whom written informed consent could be obtained. MEASURES The primary outcome was the effect on ED visits and hospitalizations at 6 months. Secondary outcomes included a difference in hospitalization rates at 3 and 12 months, total hospital bed-days, and in-RACF and in-hospital mortality rates. RESULTS More than 75% of residents participated, 181 randomized to Intervention and 145 to Control. The intervention did not result in a statistically significant change at 6 months; however, at 12 months, it reached statistical significance with 40% reduction in ED visits and hospitalizations compared with Control, with an incident rate ratio 0.63 [95% confidence interval (CI) 0.41-0.99, P = .044]. Mortality rates show increased likelihood of dying in the RACF, with statistical significance at 6 months at a relative risk ratio of 2.19 (95% CI 1.16-4.14, P = .016). CONCLUSIONS AND IMPLICATIONS In the RACF population, GOPC medical treatment orders were more effective than ACP alone for decreasing hospitalization and likelihood of dying outside the RACF. GOPC should be considered by both RACF staff and health services to decrease hospitalization and in-hospital mortality.
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Affiliation(s)
- Ruth S Martin
- University of Melbourne, Melbourne, Victoria, Australia.
| | | | - Anastasia Hutchinson
- Northern Health, Epping, Victoria, Australia; Deakin University, Geelong, Victoria, Australia
| | - Mark Tacey
- Northern Health, Epping, Victoria, Australia
| | - Paul Yates
- Northern Health, Epping, Victoria, Australia
| | - Wen Kwang Lim
- University of Melbourne, Melbourne, Victoria, Australia; Melbourne Health, Melbourne, Victoria, Australia
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Thomas RE, Lorenzetti DL. Interventions to increase influenza vaccination rates of those 60 years and older in the community. Cochrane Database Syst Rev 2018; 5:CD005188. [PMID: 29845606 PMCID: PMC6494593 DOI: 10.1002/14651858.cd005188.pub4] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The effectiveness of interventions to increase influenza vaccination uptake in people aged 60 years and older varies by country and participant characteristics. This review updates versions published in 2010 and 2014. OBJECTIVES To assess access, provider, system, and societal interventions to increase the uptake of influenza vaccination in people aged 60 years and older in the community. SEARCH METHODS We searched CENTRAL, which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE, Embase, CINAHL, and ERIC for this update, as well as WHO ICTRP and ClinicalTrials.gov for ongoing studies to 7 December 2017. We also searched the reference lists of included studies. SELECTION CRITERIA Randomised controlled trials (RCTs) and cluster-randomised trials of interventions to increase influenza vaccination in people aged 60 years or older in the community. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as specified by Cochrane. MAIN RESULTS We included three new RCTs for this update (total 61 RCTs; 1,055,337 participants). Trials involved people aged 60 years and older living in the community in high-income countries. Heterogeneity limited some meta-analyses. We assessed studies as at low risk of bias for randomisation (38%), allocation concealment (11%), blinding (44%), and selective reporting (100%). Half (51%) had missing data. We assessed the evidence as low-quality. We identified three levels of intervention intensity: low (e.g. postcards), medium (e.g. personalised phone calls), and high (e.g. home visits, facilitators).Increasing community demand (12 strategies, 41 trials, 53 study arms, 767,460 participants)One successful intervention that could be meta-analysed was client reminders or recalls by letter plus leaflet or postcard compared to reminder (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15; 3 studies; 64,200 participants). Successful interventions tested by single studies were patient outreach by retired teachers (OR 3.33, 95% CI 1.79 to 6.22); invitations by clinic receptionists (OR 2.72, 95% CI 1.55 to 4.76); nurses or pharmacists educating and nurses vaccinating patients (OR 152.95, 95% CI 9.39 to 2490.67); medical students counselling patients (OR 1.62, 95% CI 1.11 to 2.35); and multiple recall questionnaires (OR 1.13, 95% CI 1.03 to 1.24).Some interventions could not be meta-analysed due to significant heterogeneity: 17 studies tested simple reminders (11 with 95% CI entirely above unity); 16 tested personalised reminders (12 with 95% CI entirely above unity); two investigated customised compared to form letters (both 95% CI above unity); and four studies examined the impact of health risk appraisals (all had 95% CI above unity). One study of a lottery for free groceries was not effective.Enhancing vaccination access (6 strategies, 8 trials, 10 arms, 9353 participants)We meta-analysed results from two studies of home visits (OR 1.30, 95% CI 1.05 to 1.61) and two studies that tested free vaccine compared to patient payment for vaccine (OR 2.36, 95% CI 1.98 to 2.82). We were unable to conduct meta-analyses of two studies of home visits by nurses plus a physician care plan (both with 95% CI above unity) and two studies of free vaccine compared to no intervention (both with 95% CI above unity). One study of group visits (OR 27.2, 95% CI 1.60 to 463.3) was effective, and one study of home visits compared to safety interventions was not.Provider- or system-based interventions (11 strategies, 15 trials, 17 arms, 278,524 participants)One successful intervention that could be meta-analysed focused on payments to physicians (OR 2.22, 95% CI 1.77 to 2.77). Successful interventions tested by individual studies were: reminding physicians to vaccinate all patients (OR 2.47, 95% CI 1.53 to 3.99); posters in clinics presenting vaccination rates and encouraging competition between doctors (OR 2.03, 95% CI 1.86 to 2.22); and chart reviews and benchmarking to the rates achieved by the top 10% of physicians (OR 3.43, 95% CI 2.37 to 4.97).We were unable to meta-analyse four studies that looked at physician reminders (three studies with 95% CI above unity) and three studies of facilitator encouragement of vaccination (two studies with 95% CI above unity). Interventions that were not effective were: comparing letters on discharge from hospital to letters to general practitioners; posters plus postcards versus posters alone; educational reminders, academic detailing, and peer comparisons compared to mailed educational materials; educational outreach plus feedback to teams versus written feedback; and an intervention to increase staff vaccination rates.Interventions at the societal levelNo studies reported on societal-level interventions.Study funding sourcesStudies were funded by government health organisations (n = 33), foundations (n = 9), organisations that provided healthcare services in the studies (n = 3), and a pharmaceutical company offering free vaccines (n = 1). Fifteen studies did not report study funding sources. AUTHORS' CONCLUSIONS We identified interventions that demonstrated significant positive effects of low (postcards), medium (personalised phone calls), and high (home visits, facilitators) intensity that increase community demand for vaccination, enhance access, and improve provider/system response. The overall GRADE assessment of the evidence was moderate quality. Conclusions are unchanged from the 2014 review.
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Affiliation(s)
- Roger E Thomas
- University of CalgaryDepartment of Family Medicine, Faculty of MedicineHealth Sciences Centre3330 Hospital Drive NWCalgaryABCanadaT2N 4N1
| | - Diane L Lorenzetti
- Faculty of Medicine, University of CalgaryDepartment of Community Health Sciences3rd Floor TRW3280 Hospital Drive NWCalgaryABCanadaT2N 4Z6
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Romøren M, Gjelstad S, Lindbæk M. A structured training program for health workers in intravenous treatment with fluids and antibiotics in nursing homes: A modified stepped-wedge cluster-randomised trial to reduce hospital admissions. PLoS One 2017; 12:e0182619. [PMID: 28880941 PMCID: PMC5589147 DOI: 10.1371/journal.pone.0182619] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 07/19/2017] [Indexed: 11/22/2022] Open
Abstract
Objectives Hospitalization is potentially detrimental to nursing home patients and resource demanding for the specialist health care. This study assessed if a brief training program in administrating intravenous fluids and antibiotics in nursing homes could reduce hospital transfers and ensure high quality care locally. Design A pragmatic and modified cluster randomized stepped-wedge trial with randomization on nursing home level. Participants 330 cases in 296 nursing home residents from 30 nursing homes were included. Cases were patients provided intravenous antibiotics or intravenous fluids, in nursing home or hospital. Primary outcome was localization of treatment, secondary outcomes were number of days treated, days of hospitalization among admitted patients, type of antibiotics used and 30-day mortality. Intervention The nursing homes sequentially received a one-day educational program for the health workers including theory and practical training in intravenous treatment of dehydration and infection, run by two skilled nurses. After completing the training program, the nursing homes had competence to provide intravenous treatment locally. Results The intervention had a highly significant effect on treatment in nursing homes (OR 8.35, 2.08 to 33.6; P<0.01, or RR 2.23, 1.48 to 2.56). The number treated in nursing homes was stable over time; the number treated in hospital gradually decreased (chi square for trend P< 0.001). Among patients receiving intravenous antibiotics in the nursing homes, 50 (46%) died within 30 days, compared to 30 (36%) treated in the hospital (P = 0.19). Among patients receiving intravenous fluids locally, 21 (19%) died within 30 days, compared to 2 (8%) in the hospital group (P = 0.34). Mortality was associated with reduced consciousness and elevated c-reactive protein. Conclusions A brief educational program delivered to nursing home personnel was feasible and effective in reducing acute hospital admissions from nursing homes for treatment of dehydration and infections.
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Affiliation(s)
- Maria Romøren
- Department of Administration Vestfold Hospital Trust, Tønsberg, Norway
- Department of General Practice Institute of Health and Society, University of Oslo, Blindern, Oslo, Norway
- * E-mail:
| | - Svein Gjelstad
- Department of General Practice Institute of Health and Society, University of Oslo, Blindern, Oslo, Norway
| | - Morten Lindbæk
- Department of General Practice Institute of Health and Society, University of Oslo, Blindern, Oslo, Norway
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Feldstein D, Sloane PD, Feltner C. Antibiotic Stewardship Programs in Nursing Homes: A Systematic Review. J Am Med Dir Assoc 2017; 19:110-116. [PMID: 28797590 DOI: 10.1016/j.jamda.2017.06.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 06/22/2017] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Antibiotic stewardship programs (ASPs) are coordinated interventions promoting the appropriate use of antibiotics to improve patient outcomes and reduce microbial resistance. These programs are now mandated in nursing homes (NHs) but it is unclear if these programs improve resident outcomes. This systematic review evaluated the current evidence regarding outcomes of ASPs in the NH. METHODS PubMed, CINAHL, EMBASE, and the Cochrane Library were systematically searched for intervention trials of ASPs performed in NHs that evaluated final health outcomes (mortality and Clostridium difficile infections), healthcare utilization outcomes (emergency department visits and hospital admissions) and intermediate health outcomes (number of antibiotics prescribed, adherence to recommended guidelines). RESULTS A total of 14 studies rated good or fair quality were included. Eight studies reported a reduction in antibiotic prescriptions. Ten found an increase in adherence to guidelines proposed by the studied ASP. None reported a statistically significant change in NH mortality rates, C. difficile infection rates, or hospitalizations. DISCUSSION The limited research to date suggests that NH ASPs can affect intermediate health outcomes, but not key health outcomes or health care utilization. CONCLUSION Larger trials evaluating more intensive interventions over longer durations may be needed to determine whether ASPs in NHs improve health outcomes as they have in hospitals.
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Affiliation(s)
- Diana Feldstein
- Division of Geriatric Medicine, Center for Aging and Health, University of North Carolina, Chapel Hill, NC.
| | - Philip D Sloane
- Department of Family Medicine, University of North Carolina, Chapel Hill, NC; Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
| | - Cynthia Feltner
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC; Department of Medicine, University of North Carolina, Chapel Hill, NC
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Martin RS, Hayes BJ, Hutchinson A, Yates P, Lim WK. Implementation of 'Goals of Patient Care' medical treatment orders in residential aged care facilities: protocol for a randomised controlled trial. BMJ Open 2017; 7:e013909. [PMID: 28283490 PMCID: PMC5353337 DOI: 10.1136/bmjopen-2016-013909] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Systematic reviews demonstrate that advance care planning (ACP) has many positive effects for residents of aged care facilities, including decreased hospitalisation. The proposed Residential Aged Care Facility (RACF) 'Goals of Patient Care' (GOPC) form incorporates a resident's prior advance care plan into medical treatment orders. Where none exists, it captures residents' preferences. This documentation helps guide healthcare decisions made at times of acute clinical deterioration. METHODS AND ANALYSIS This is a mixed methods study. An unblinded cluster randomised controlled trial is proposed in three pairs of RACFs. In the intervention arm, GOPC forms will be completed by a doctor incorporating advance care plans or wishes. In the control arm, residents will have usual care which may include an advance care plan. The primary hypothesis is that the GOPC form is superior to standard ACP alone and will lead to decreased hospitalisation due to clearer documentation of residents' medical treatment plans. The primary outcome will be an analysis of the effect of the GOPC medical treatment orders on emergency department attendances and hospital admissions at 6 months. Secondary outcome measurements will include change in hospitalisation rates at 3 and 12 months, length of stay and external mortality rates among others. Qualitative interviews, 12 months post GOPC implementation, will be used for process evaluation of the GOPC and to evaluate staff perceptions of the form's usefulness for improving communication and medical decision-making at a time of deterioration. DISSEMINATION The results will be disseminated in peer review journals and research conferences. This robust randomised controlled trial will provide high-quality data about the influence of medical treatment orders that incorporate ACP or preferences adding to the current gap in knowledge and evidence in this area. TRIAL REGISTRATION NUMBER ACTRN12615000298516, Results.
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Affiliation(s)
- Ruth S Martin
- Northern Health, Epping, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | | | - Anastasia Hutchinson
- Northern Health, Epping, Victoria, Australia
- Deakin University, Geelong, Victoria, Australia
| | - Paul Yates
- University of Melbourne, Melbourne, Victoria, Australia
- Austin Health, Heidelberg, Victoria, Australia
| | - Wen Kwang Lim
- Northern Health, Epping, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
- Melbourne Health, Melbourne, Victoria, Australia
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A Systematic Review of Interventions to Change Staff Care Practices in Order to Improve Resident Outcomes in Nursing Homes. PLoS One 2015; 10:e0140711. [PMID: 26559675 PMCID: PMC4641718 DOI: 10.1371/journal.pone.0140711] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 09/28/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We systematically reviewed interventions that attempted to change staff practice to improve long-term care resident outcomes. METHODS Studies met criteria if they used a control group, included 6 or more nursing home units and quantitatively assessed staff behavior or resident outcomes. Intervention components were coded as including education material, training, audit and feedback, monitoring, champions, team meetings, policy or procedures and organizational restructure. RESULTS Sixty-three unique studies were broadly grouped according to clinical domain-oral health (3 studies), hygiene and infection control (3 studies), nutrition (2 studies), nursing home acquired pneumonia (2 studies), depression (2 studies) appropriate prescribing (7 studies), reduction of physical restraints (3 studies), management of behavioral and psychological symptoms of dementia (6 studies), falls reduction and prevention (11 studies), quality improvement (9 studies), philosophy of care (10 studies) and other (5 studies). No single intervention component, combination of, or increased number of components was associated with greater likelihood of positive outcomes. Studies with positive outcomes for residents also tended to change staff behavior, however changing staff behavior did not necessarily improve resident outcomes. Studies targeting specific care tasks (e.g. oral care, physical restraints) were more likely to produce positive outcomes than those requiring global practice changes (e.g. care philosophy). Studies using intervention theories were more likely to be successful. Program logic was rarely articulated, so it was often unclear whether there was a coherent connection between the intervention components and measured outcomes. Many studies reported barriers relating to staff (e.g. turnover, high workload, attitudes) or organizational factors (e.g. funding, resources, logistics). CONCLUSION Changing staff practice in nursing homes is possible but complex. Interventionists should consider barriers and feasibility of program components to impact on each intended outcome.
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Clinical Update on Nursing Home Medicine: 2015. J Am Med Dir Assoc 2015; 16:911-22. [DOI: 10.1016/j.jamda.2015.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 09/02/2015] [Indexed: 01/21/2023]
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Laging B, Ford R, Bauer M, Nay R. A meta-synthesis of factors influencing nursing home staff decisions to transfer residents to hospital. J Adv Nurs 2015; 71:2224-36. [DOI: 10.1111/jan.12652] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Bridget Laging
- School of Nursing, Midwifery and Paramedicine; Australian Catholic University; Melbourne Victoria Australia
- Australian Centre for Evidence Based Aged Care (ACEBAC); La Trobe University; Melbourne Victoria Australia
| | - Rosemary Ford
- School of Nursing, Midwifery and Paramedicine; Australian Catholic University; Melbourne Victoria Australia
| | - Michael Bauer
- Australian Centre for Evidence Based Aged Care (ACEBAC); La Trobe University; Melbourne Victoria Australia
| | - Rhonda Nay
- La Trobe University; Melbourne Victoria Australia
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Predictors of mortality for nursing home-acquired pneumonia: a systematic review. BIOMED RESEARCH INTERNATIONAL 2015; 2015:285983. [PMID: 25821793 PMCID: PMC4363502 DOI: 10.1155/2015/285983] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Revised: 02/12/2015] [Accepted: 02/16/2015] [Indexed: 12/18/2022]
Abstract
Background. Current risk stratification tools, primarily used for CAP, are suboptimal in predicting nursing home acquired pneumonia (NHAP) outcome and mortality. We conducted a systematic review to evaluate current evidence on the usefulness of proposed predictors of NHAP mortality. Methods. PubMed (MEDLINE), EMBASE, and CINAHL databases were searched for articles published in English between January 1978 and January 2014. The literature search elicited a total of 666 references; 580 were excluded and 20 articles met the inclusion criteria for the final analysis. Results. More studies supported the Pneumonia Severity Index (PSI) as a superior predictor of NHAP severity. Fewer studies suggested CURB-65 and SOAR (especially for the need of ICU care) as useful predictors for NHAP mortality. There is weak evidence for biomarkers like C-reactive protein and copeptin as prognostic tools. Conclusion. The evidence supports the use of PSI as the best available indicator while CURB-65 may be an alternative prognostic indicator for NHAP mortality. Overall, due to the paucity of information, biomarkers may not be as effective in this role. Larger prospective studies are needed to establish the most effective predictor(s) or combination scheme to help clinicians in decision-making related to NHAP mortality.
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Thomas RE, Lorenzetti DL. Interventions to increase influenza vaccination rates of those 60 years and older in the community. Cochrane Database Syst Rev 2014; 2014:CD005188. [PMID: 24999919 PMCID: PMC6464876 DOI: 10.1002/14651858.cd005188.pub3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The effectiveness of interventions to increase the uptake of influenza vaccination in people aged 60 and older is uncertain. OBJECTIVES To assess access, provider, system and societal interventions to increase the uptake of influenza vaccination in people aged 60 years and older in the community. SEARCH METHODS We searched CENTRAL (2014, Issue 5), MEDLINE (January 1950 to May week 3 2014), EMBASE (1980 to June 2014), AgeLine (1978 to 4 June 2014), ERIC (1965 to June 2014) and CINAHL (1982 to June 2014). SELECTION CRITERIA Randomised controlled trials (RCTs) of interventions to increase influenza vaccination uptake in people aged 60 and older. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study quality and extracted influenza vaccine uptake data. MAIN RESULTS This update identified 13 new RCTs; the review now includes a total of 57 RCTs with 896,531 participants. The trials included community-dwelling seniors in high-income countries. Heterogeneity limited meta-analysis. The percentage of trials with low risk of bias for each domain was as follows: randomisation (33%); allocation concealment (11%); blinding (44%); missing data (49%) and selective reporting (100%). Increasing community demand (32 trials, 10 strategies)The interventions with a statistically significant result were: three trials (n = 64,200) of letter plus leaflet/postcard compared to letter (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15); two trials (n = 614) of nurses/pharmacists educating plus vaccinating patients (OR 3.29, 95% CI 1.91 to 5.66); single trials of a phone call from a senior (n = 193) (OR 3.33, 95% CI 1.79 to 6.22), a telephone invitation versus clinic drop-in (n = 243) (OR 2.72, 95% CI 1.55 to 4.76), a free groceries lottery (n = 291) (OR 1.04, 95% CI 0.62 to 1.76) and nurses educating and vaccinating patients (n = 485) (OR 152.95, 95% CI 9.39 to 2490.67).We did not pool the following trials due to considerable heterogeneity: postcard/letter/pamphlets (16 trials, n = 592,165); tailored communications (16 trials, n = 388,164); customised letter/phone-call (four trials, n = 82,465) and client-based appraisals (three trials, n = 4016), although several trials showed the interventions were effective. Enhancing vaccination access (10 trials, six strategies)The interventions with a statistically significant result were: two trials (n = 2112) of home visits compared to clinic invitation (OR 1.30, 95% CI 1.05 to 1.61); two trials (n = 2251) of free vaccine (OR 2.36, 95% CI 1.98 to 2.82) and one trial (n = 321) of patient group visits (OR 24.85, 95% CI 1.45 to 425.32). One trial (n = 350) of a home visit plus vaccine encouragement compared to a home visit plus safety advice was non-significant.We did not pool the following trials due to considerable heterogeneity: nurse home visits (two trials, n = 2069) and free vaccine compared to no intervention (two trials, n = 2250). Provider- or system-based interventions (17 trials, 11 strategies)The interventions with a statistically significant result were: two trials (n = 2815) of paying physicians (OR 2.22, 95% CI 1.77 to 2.77); one trial (n = 316) of reminding physicians about all their patients (OR 2.47, 95% CI 1.53 to 3.99); one trial (n = 8376) of posters plus postcards (OR 2.03, 95% CI 1.86 to 2.22); one trial (n = 1360) of chart review/feedback (OR 3.43, 95% CI 2.37 to 4.97) and one trial (n = 27,580) of educational outreach/feedback (OR 0.77, 95% CI 0.72 to 0.81).Trials of posters plus postcards versus posters (n = 5753), academic detailing (n = 1400) and increasing staff vaccination rates (n = 26,432) were non-significant.We did not pool the following trials due to considerable heterogeneity: reminding physicians (four trials, n = 202,264) and practice facilitators (three trials, n = 2183), although several trials showed the interventions were effective. Interventions at the societal level We identified no RCTs of interventions at the societal level. AUTHORS' CONCLUSIONS There are interventions that are effective for increasing community demand for vaccination, enhancing access and improving provider/system response. Heterogeneity limited pooling of trials.
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Affiliation(s)
- Roger E Thomas
- University of CalgaryDepartment of Family Medicine, Faculty of MedicineUCMC#1707‐1632 14th AvenueCalgaryCanadaT2M 1N7
| | - Diane L Lorenzetti
- Faculty of Medicine, University of CalgaryDepartment of Community Health Sciences3rd Floor TRW3280 Hospital Drive NWCalgaryCanadaT2N 4Z6
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Laging B, Bauer M, Ford R, Nay R. Decision to transfer to hospital from the residential aged care setting: a systematic review of qualitative evidence exploring residential aged care staff experiences. ACTA ACUST UNITED AC 2014. [DOI: 10.11124/jbisrir-2014-1141] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Reducing hospital admissions from nursing homes: a systematic review. BMC Health Serv Res 2014; 14:36. [PMID: 24456561 PMCID: PMC3906881 DOI: 10.1186/1472-6963-14-36] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 01/21/2014] [Indexed: 11/18/2022] Open
Abstract
Background The geriatric nursing home population is vulnerable to acute and deteriorating illness due to advanced age, multiple chronic illnesses and high levels of dependency. Although the detriments of hospitalising the frail and old are widely recognised, hospital admissions from nursing homes remain common. Little is known about what alternatives exist to prevent and reduce hospital admissions from this setting. The objective of this study, therefore, is to summarise the effects of interventions to reduce acute hospitalisations from nursing homes. Methods A systematic literature search was performed in Cochrane Library, PubMed, MEDLINE, EMBASE and ISI Web of Science in April 2013. Studies were eligible if they had a geriatric nursing home study population and were evaluating any type of intervention aiming at reducing acute hospital admission. Systematic reviews, randomised controlled trials, quasi randomised controlled trials, controlled before-after studies and interrupted time series were eligible study designs. The process of selecting studies, assessing them, extracting data and grading the total evidence was done by two researchers individually, with any disagreement solved by a third. We made use of meta-analyses from included systematic reviews, the remaining synthesis is descriptive. Based on the type of intervention, the included studies were categorised in: 1) Interventions to structure and standardise clinical practice, 2) Geriatric specialist services and 3) Influenza vaccination. Results Five systematic reviews and five primary studies were included, evaluating a total of 11 different interventions. Fewer hospital admissions were found in four out of seven evaluations of structuring and standardising clinical practice; in both evaluations of geriatric specialist services, and in influenza vaccination of residents. The quality of the evidence for all comparisons was of low or very low quality, using the GRADE approach. Conclusions Overall, eleven interventions to reduce hospital admissions from nursing homes were identified. None of them were tested more than once and the quality of the evidence was low for every comparison. Still, several interventions had effects on reducing hospital admissions and may represent important aspects of nursing home care to reduce hospital admissions.
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