Continuity of care for acutely unwell older adults from nursing homes

The development and validation of a conceptual definition of avoidable transitions from long-term care to the emergency department: A mixed methods study

Background/Objectives

Transitions to and from Emergency Departments (EDs) can be detrimental to long-term care (LTC) residents and burden the healthcare system. While reducing avoidable transfers is imperative, various terms are used interchangeably including inappropriate, preventable, or unnecessary transitions. Our study objectives were to develop a conceptual definition of avoidable LTC-ED transitions and to verify the level of stakeholder agreement with this definition.

Methods

The EXamining Aged Care Transitions study adopted an exploratory sequential mixed-method design. The study was conducted in 2015-2016 in 16 LTC facilities, 1 ED, and 1 Emergency Medical Service (EMS) in a major urban center in western Canada. Phase 1 included 80 participants, (healthcare aides, licensed practical nurses, registered nurses, LTC managers, family members of residents, and EMS staff). We conducted semistructured interviews (n = 25) and focus groups (n = 19). In Phase 2, 327 ED staff, EMS staff, LTC staff, and medical directors responded to a survey based on the qualitative findings.

Results

Avoidable transitions were attributed to limited resources in LTC, insufficient preventive care, and resident or family wishes. The definition generated was: A transition of an LTC resident to the ED is considered avoidable if: (a) Diagnostic testing, medical assessment, and treatment can be accessed in a timely manner by other means; (b) the reasons for a transfer are unclear and the transition would increase the disorientation, pain, or discomfort of a resident, outweighing a clear benefit of a transfer; and (c) the transition is against the wishes expressed by the resident over time, including through informal and undocumented conversations. There was a high level of agreement with the definition across the four participant groups.

Conclusions and Implications

To effectively reduce LTC resident avoidable transitions, stakeholders must share a common definition. Our conceptual definition may significantly contribute to improved care for LTC residents.

Exploring the implementation of an outreach specialist program for nursing home residents in Macao: A multisite, qualitative study

Background

The "Specialist Medical Outreach Project (SMOP)" involving inter-disciplinary hospital-based healthcare professionals is a government initiative that aims to provide integrative specialist care to high-risk residents at the nursing homes. However, research exploring the implementation and impact of SMOP is lacking. This study aimed to evidence the impact of SMOP on the quality of care at the nursing home and the key contextual determinants influencing SMOP outcomes.

Method

Semi-structured key informant audio-recorded face-to-face interviews were conducted with eight managers, six doctors, 28 nursing staff, and seven pharmacy staff at the nursing homes participating in the SMOP to collect insights about how SMOP was operated and performed, and the impact of SMOP as observed and expected. Participants were recruited with purposive sampling. A thematic analysis approach was employed and key themes were identified using open coding, grouping, and categorizing.

Results

Forty-nine interviews were conducted. Thematic analysis identified three principal themes: the overall perception about SMOP, the benefits as observed; and the areas of improvement. Together with the 10 subthemes, the results highlighted the expectations for SMOP to address the unmet needs and promote patient-centered care, and the benefits of SMOP in supporting effective use of resources for the nursing home, reducing the risks of adverse events for the residents, promoting communication and capacity building for the healthcare providers and facilitating efficient use of healthcare resources for the health system. Requests for more frequent visits by a larger inter-disciplinary specialist team were raised. Careful staff and workflow planning, and mechanisms for data-sharing and communication across care settings were deemed the most important actions for improvement.

Conclusion

It is a general perception that the SMOP is beneficial in enhancing the quality of care for high-risk residents in the nursing home in Macao. Cross-sector inter-disciplinary collaboration and efficient data-sharing and communication mechanism play a crucial role in ensuring the success of the program. A robust assessment framework to monitor and evaluate the cost-effectiveness of the program is yet to be developed.

Discontinuation of long-term care among persons affected by the 2018 Japan Floods: a longitudinal study using the Long-term Care Insurance Comprehensive Database

BACKGROUND

Most older people with disabilities or illnesses continue to use long-term care (LTC) services for the rest of their lives. However, disasters can cause a discontinuation of LTC services, which usually means tragic outcomes of affected persons. In view of the recent progression of population aging and the increase in natural disasters, this study focuses on the impact of disasters on older people's discontinuation of LTC services, and those more risk of such discontinuation than others. However, current evidence is scarce.

METHODS

We conducted a retrospective cohort study with 259,081 subjects, 2,762 of whom had been affected by disaster and 256,319 who had not been affected during the 2018 Japan Floods. The sample in the three most disaster-affected prefectures was drawn from the Long-term Care Insurance Comprehensive Database and included older people certified with care-need level. The observation period was two months before the disaster and five months after it. We calculated the hazard ratio (HR) of municipality-certified subjects affected by the disaster versus those who were not. Subgroup analyses were conducted for categories of individual-, facility- and region-associated factors.

RESULTS

Affected persons were twice as likely to discontinue LTC services than those who were not affected (adjusted HR, 2.06 95% CI, 1.91-2.23). 34% of affected persons whose facilities were closed discontinued their LTC services at five months after the disaster. A subgroup analysis showed that the risk of discontinuing LTC services for affected persons compared to those who were not affected in the relatively younger subgroup (age < 80: adjusted HR, 2.55; 95% CI, 2.20-2.96 vs. age ≥ 80 : 1.91; 1.75-2.10), and the subgroup requiring a lower level of care (low: 3.16; 2.74-3.66 vs. high: 1.71; 1.50-1.96) were more likely to discontinue than the older and higher care level subgroups.

CONCLUSIONS

A natural disaster has a significant effect on the older people's discontinuation of LTC services. The discontinuations are supposedly caused by affected persons' death, hospitalization, forced relocation of individuals, or the service provider's incapacity. Accordingly, it is important to recognize the risk of disasters and take measures to avoid discontinuation to protect older persons' quality of life.

Quality Indicators for Older Persons' Transitions in Care: A Systematic Review and Delphi Process

We identified quality indicators (QIs) for care during transitions of older persons (≥ 65 years of age). Through systematic literature review, we catalogued QIs related to older persons' transitions in care among continuing care settings and between continuing care and acute care settings and back. Through two Delphi survey rounds, experts ranked relevance, feasibility, and scientific soundness of QIs. A steering committee reviewed QIs for their feasible capture in Canadian administrative databases. Our search yielded 326 QIs from 53 sources. A final set of 38 feasible indicators to measure in current practice was included. The highest proportions of indicators were for the emergency department (47%) and the Institute of Medicine (IOM) quality domain of effectiveness (39.5%). Most feasible indicators were outcome indicators. Our work highlights a lack of standardized transition QI development in practice, and the limitations of current free-text documentation systems in capturing relevant and consistent data.

Addressing Communication Breakdowns during Emergency Care Transitions of Older Adults: Evaluation of a Standardized Inter-Facility Health Care Communication Form

Transitions for older persons from long-term care (LTC) to the emergency department (ED) and back, can result in adverse events. Effective communication among care settings is required to ensure continuity of care. We implemented a standardized form for improving consistency of documentation during LTC to ED transitions of residents 65 years of age or older, via emergency medical services (EMS), and back. Data on form use and form completion were collected through chart review. Practitioners' perspectives were collected using surveys. The form was used in 90/244 (37%) LTC to ED transitions, with large variation in data element completion. EMS and ED reported improved identification of resident information. LTC personnel preferred usual practice to the new form and twice reported prioritizing form completion before calling 911. To minimize risk of harmful unintended consequences, communication forms should be implemented as part of broader quality improvement programs, rather than as stand-alone interventions.

The development of a measurement instrument focusing on team collaboration in patient transfer processes

Purpose

Team collaboration is essential to ensure the quality of care and patient safety when critically ill patients are transferred from an intensive care unit (ICU) to a general ward. Measuring team collaboration in the patient transfer process can help gain insights into how team collaboration is perceived and how it can be improved. The purpose of this paper is to describe the development and testing of a questionnaire aiming to measure perceived team collaboration in the patient transfer process from ICU to the general ward. This study also aims to analyze the results to see how the survey could help improve team collaboration within ICU transitional care.

Design/methodology/approach

Statements, factors and main areas intended to measure perceived team collaboration were developed from a theory. The questionnaire was tested in two ICUs at two hospitals located in Sweden, and the results were analyzed statistically.

Findings

The results showed that the questionnaire could be used for measuring perceived team collaboration in this process. The results from the survey gave insights that can be useful when improving team collaboration in ICU transitional care.

Research limitations/implications

The collaboration between two research subjects, Nursing Science and Quality Management, has given new perspectives in how cultural and systemic differences and opportunities can help improving team collaboration in ICU transitional care, by shifting focus from the individual to team, culture, system, process and continuous improvement.

Practical implications

The developed questionnaire can be used to measure perceived team collaboration and to identify areas for improving team collaboration in the ICU transitional care process.

Originality/value

There is a sparse amount of research about measuring team collaboration in ICU transitional care, and this study contributes to filling this research gap.

Effects of a Transitional Telehealth Program on Functional Status, Rehospitalization, and Satisfaction With Care in Thai Patients with Heart Failure

Limited functional status is a common health problem in patients living with heart failure (HF), which often requires rehospitalization.Home-based transitional telehealth programs (TTPs) focused on health monitoring, education, promotion of self-management, and multidisciplinary team consultation have been shown to improve functional status and satisfaction with care while reducing rehospitalization rates in this population. Nonetheless, these variables and outcomes have yet to be assessed in a Thai patient with HF. Thus, the aim of this study was to investigate the effectiveness of a TTP on functional status, rehospitalization, and satisfaction with care in Thai patients with HF. Eligible participants (N = 146) were randomly assigned to either the control or TTP group. The TTP included in-hospital discharge planning and 6-week telemonitoring via a mobile phone application to provide follow-up home care. Data on the outcome variables were collected at 6 and 8 weeks post-enrollment and analyzed by descriptive statistics, independent t-tests, repeated measures ANOVA, and Z-tests. Functional status and satisfaction with care scores in the TTP group were significantly higher than those of the control group, and rehospitalization rates in the TTP group were significantly lower than those of the control group at 6 and 8 weeks post-enrollment. Thus, the TTP effectively improved functional status, increased satisfaction with care, and reduced rehospitalization rates in Thai patients with HF. TTP implementation could be considered to improve the quality of transitional care in Thailand.

Understanding registered nurse decision-making, communication and care delivery between emergency departments and residential aged care facilities: A research protocol

OBJECTIVES

Nursing staff in residential aged care facilities (RACF)s often make decisions about the transfer of residents to the emergency department (ED). This paper describes the protocol of a study that aims to understand decision-making process utilised by RACF registered nurses (RNs) and to explore the perceptions of RNs about the decision and communication process between RACF and ED.

METHODS

The proposed mixed-method study will survey and interview RACF RNs to understand their decision to transfer a resident and collect information about older people referred to the ED. Data collection will involve telephone survey, ED information system (EDIS) data and semistructured interviews.

RESULTS

The project outcomes will provide an understanding of existing ED service provision, communication between facilities and the reasons for transfer of older person to ED. This may inform redesign in communication processes between the ED and local RACFs and outreach care from the ED to RACFs.

Models of care that avoid or improve transitions to hospital services for residential aged care facility residents: An integrative review

Care transitions for older people moving from residential aged care facilities (RACFs) to hospital services are associated with greater challenges and poorer outcomes. An integrative review was conducted to investigate models of care designed to avoid or improve transitions for older people residing in RACFs to hospital settings. Twenty-one studies were included in the final analysis. Models of care aimed to either improve or avoid transitions of residents through enhanced primary care in RACFs, promoting quality improvement in RACFs, instilling comprehensive hospital care, conducting outreach services, transferring information, or involved a combination of outreach services and comprehensive hospital care. As standalone interventions, standardised communication tools may improve information transfer between RACFs and hospital services. For more complex models, providing quality improvement and outreach to RACFs may prevent some types of hospital admissions.

The Geriatric Emergency Department Intervention model of care: a pragmatic trial

BACKGROUND

To evaluate a Geriatric Emergency Department Intervention (GEDI) model of service delivery for adults aged 70 years and older.

METHODS

A pragmatic trial of the GEDI model using a pre-post design. GEDI is a nurse-led, physician-championed, Emergency Department (ED) intervention; developed to improve the care of frail older adults in the ED. The nurses had gerontology experience and education and provided targeted geriatric assessment and streamlining of care. The final format included 2.4 full time equivalent nurses working 7 days from 0700 h to 1730 h (1530 h at weekends). There were three implementations periods: pre-implementation (2012); a developmental phase from January 2013 to August 2015; and full implementation from September 2015 to August 2016. The outcomes measured were disposition (discharged home, admitted or died); ED length of stay; hospital length of stay; all cause in-hospital mortality within 28 days; time to ED re-presentation up to 28 days post-discharge; in-hospital costs. The setting was a tertiary hospital ED, with 385 beds, in Queensland, Australia. Approximately 53,000 patients presented to the ED annually with 20% aged 70 years and older. All patients over the age 70 who presented to the ED between January 2012 and August 2016 (n = 44,983) were included in the trial.

RESULTS

Older persons who presented to the ED when the GEDI team were working had increased likelihoods of discharge (Hazard ratio (HR) = 1.19; 95% CI: 1.13-1.24) and reduced ED length of stay (HR = 1.42; 95% CI: 1.33-1.52) compared with those who presented when GEDI were not working. There was no increase in the risk of mortality (HR = 1.01; 95% CI = 0.23-4.43) or risk of same cause re-presentation to 28 days (HR = 1.21; 95% CI: 0.99-1.49). The GEDI service resulted in average cost savings per ED presentation of $35 [95% CI, $21, $49] and savings of $1469 [95% CI, $1105, $1834] per hospital admission.

CONCLUSIONS

Implementation of a nurse-led physician-championed model of ED care, focused on frail older adults, reduced ED length of stay, hospital admission and if admitted, hospital length of stay and cost, without increasing mortality or same cause re-presentation. These increases were sustained over time and after the initial implementation team had changed roles.

TRIAL REGISTRATION

Australian Clinical Trials Registration Number ACTRN12615001157561 - retrospectively registered on 29/10/2015. Data were retrieved via retrospective access to clinical information systems. First data access was on 1/7/2015.

Fractured Care: A Window Into Emergency Transitions in Care for LTC Residents With Complex Health Needs

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.

A structure, process and outcome evaluation of the Geriatric Emergency Department Intervention model of care: a study protocol

BACKGROUND

Emergency departments are chaotic environments in which complex, frail older persons living in the community and residential aged care facilities are sometimes subjected to prolonged emergency department lengths of stay, excessive tests and iatrogenic complications. Given the ageing population, the importance of providing appropriate, quality health care in the emergency department for this cohort is paramount. One possible solution, a nurse-led, physician-championed, emergency department gerontological intervention team, which provides frontload assessment, early collateral communication and appropriate discharge planning, has been developed. The aim of this Geriatric Emergency Department Intervention is to maximise the quality of care for this vulnerable cohort in a cost effective manner.

METHODS

The Geriatric Emergency Department Intervention research project consists of three interrelated studies within a program evaluation design. The research comprises of a structure, process and outcome framework to ascertain the overall utility of such a program. The first study is a pre-post comparison of the Geriatric Emergency Department Intervention in the emergency department, comparing the patient-level outcomes before and after service introduction using a quasi-experimental design with historical controls. The second study is a descriptive qualitative study of the structures and processes required for the operation of the Geriatric Emergency Department Intervention and clinician and patient satisfaction with service models. The third study is an economic evaluation of the Geriatric Emergency Department Intervention model of care.

DISCUSSION

There is a paucity of evidence in the literature to support the implementation of nurse-led teams in emergency departments designed to target frail older persons living in the community and residential aged care facilities. This is despite the high economic and patient morbidity and mortality experienced in these vulnerable cohorts. This research project will provide guidance related to the optimal structures and processes required to implement the model of care and the associated cost related outcomes.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registration Number is 12615001157561 . Date of registration 29 October 2015.

Radiography on wheels arrives to nursing homes - an economic assessment of a new health care technology in southern Sweden

RATIONALE, AIMS AND OBJECTIVES

The process of transferring older, vulnerable adults from an elder care facility to the hospital for medical care can be an emotionally and physically stressful experience. The recent development of modern mobile radiography may help to ease this anxiety by allowing for evaluation in the nursing home itself. Up until this point, no health economic evaluation of the technology has been attempted in a Swedish setting. The objective of this study was to determine whether examinations of patients in elder care facilities with mobile radiography were cost-effective from a societal perspective compared with hospital-based radiological examinations.

METHODS

This prospective study included two groups of nursing home residents in two different areas in southern Sweden. All residents in the nursing homes were targeted for the study. Seventy-one patients were examined with hospital-based radiography at two hospitals, and 312 patients were examined using mobile radiography in nursing homes. Given that the diagnostic effects are regarded as equivalent, a cost minimization method was applied. Direct costs were estimated using prices from the county council, Region Skåne, Sweden.

RESULTS

From a societal perspective, mobile radiography was shown to have significantly lower costs per examination compared with hospital-based radiography. The difference in health care-related costs was also significant in favour of mobile radiography.

CONCLUSION

Mobile radiography can be used to examine patients in nursing homes at a lower cost than hospital-based radiography. Patients benefit from not having to transfer to a hospital for radiography, resulting in reduced anxiety for patients.

The Older Persons' Transitions in Care (OPTIC) study: pilot testing of the transition tracking tool

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.

Continuity of care in day surgical care - perspective of patients

BACKGROUND

The realisation of continuity in day surgical care is analysed in this study. The term 'continuity of care' is used to refer to healthcare processes that take place in time (time flow) and require coordination (coordination flow), rapport (caring relationship flow) and information (information flow). Patients undergoing laparoscopic cholecystectomy or inguinal hernia day surgery are ideal candidates for studying the continuity of care, as the diseases are very common and the treatment protocol is mainly the same in different institutions, in addition to which the procedure is elective and most patients have a predictable clinical course.

AIM

The aim of the study was to describe, from the day surgery patients' own perspective, how continuity of care was realised at different phases of the treatment, prior to the day of surgery, on the day of surgery and after it.

METHOD

The study population consisted of 203 day surgical patients 10/2009-12/2010 (N = 350, response rate 58%). A questionnaire was developed for this study.

RESULTS

Based on the results, the continuity of care was well realised as a rule. Continuity is improved by the fact that patients know the nurse who will look after them in the hospital before the day of surgery and have a chance to meet the nurse even after the operation. Meeting the surgeon who performed the operation afterwards also improves patients' perception of continuation of care.

CONCLUSIONS

Continuity of care may be improved by ensuring that the patient meets caring staff prior to the day of operation and after the procedure. An important topic for further research would be how continuation of care is realised in the case of other patient groups (e.g. in internal medicine). On the other hand, realisation of continuation of care should also be studied from the viewpoint of those taking part in patient care in order to find similarities/differences between patients' perceptions and professionals' views. Studying interventions aimed to promote continuity of care, for example in patient guidance, would also be of great importance.

Older Persons' Transitions in Care (OPTIC): a study protocol

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.

Positive experience of a mobile radiography service in nursing homes

BACKGROUND

For elderly people living in nursing homes, a transport to hospital for a radiological examination can lead to increased anxiety, disorientation and other problems related to the new environment.

OBJECTIVE

To investigate the usefulness of a mobile radiography service for radiological assessment of patients in nursing homes from the patient and staff perspectives.

METHODS

Lightweight equipment with a digital flat-panel detector was used for mobile radiography on nursing home patients in their own rooms. Data on patient and staff experiences from the service were collected using a questionnaire with closed and open-ended questions. Image quality was evaluated by the radiographer and a radiologist.

RESULTS

The majority of 241 radiography examinations were of the musculoskeletal system (94%). Twelve of 123 patients had pathology that required hospital treatment, while 22 patients with radiographic pathology could be treated locally. The main beneficial factors were security and comfort, acceptance from the patients, no need for transportation, no need for staff to be absent from the nursing homes.

CONCLUSION

Mobile radiography in nursing homes is technically feasible, with good image quality. The most beneficial results were that patients avoided unnecessary transport back and forth to the hospital, and that the majority of patients could be treated locally.

A qualitative study on the transfer of residents between a nursing home and an emergency department

Nursing home (NH) residents who have exacerbations of chronic health conditions or new illnesses must generally go the emergency department (ED) for health care, later returning to the nursing home when it is felt that they are no longer require acute care. Transfers between settings of care are referred to as transitions, and research has shown that residents are at risk of experiencing negative health outcomes during these periods. This article reports on a qualitative study of resident transfers between one NH and one ED in Canada. Data were collected using interviews, participant observation, and examination of institutional policies and standard practices. Three themes emerged from the data: (1) work of executing transfers; (2) creating and exchanging resident information; and (3) feelings of guilt but not being responsible about how residents' transfers occurred. Although completion of organization-specific forms consumed a considerable amount of practitioners' time, they contributed little to resident transfers or to the sharing of information. There is a need for integrated models of care that transcend settings and promote an understanding of the roles and responsibilities of practitioners working along the entire continuum of care.

A conceptual framework for understanding interorganizational relationships between nursing homes and emergency departments: examples from the Canadian setting

Nursing home residents who experience exacerbations of chronic health conditions or new illnesses must generally go to the emergency department for health care. This reliance on two distinct settings of care requires organizations to engage in an interorganizational relationship, which can be problematic, particularly when each organization has its own governing structures, policies, practices, and culture. Although it is widely acknowledged that interorganizational relationships can be the source of much frustration and conflict, little is known about their underpinnings. In this article, the authors draw on the literature to explore the interorganizational relationship that emerges each time a resident transfers between a nursing home and an emergency department in Canada. The authors apply this knowledge to develop a conceptual model that can be used to explore other interorganizational relationships that are formed when patients move between settings of care.

Continuity of nursing and the time of sickness

This paper explores the relationship between temporal continuity in nursing and temporal features of sickness. It is based on phenomenological and hermeneutical philosophy, empirical studies of sickness time, and the nursing theories of Nightingale, of Benner and of Benner and Wrubel. In the first part, temporal continuity is defined as distinct from interpersonal continuity. Tensions between temporal continuity and discontinuity are discussed in the contexts of care management, of conceptualisations of disease and of time itself. Temporal limitations to the methodological concept of situation are discussed. The main part of this paper explores nurses' possibilities to relate to their patients' time, and how temporal features of sickness may warrant temporal continuity of nursing. Three temporal characteristics of sickness are discussed: the immediacy of patients' suffering, the basic continuity of life through sickness and health care, and the indeterminism and precariousness of sickness. The timing of nursing acts is discussed. The paper explores how sickness is both part of the continuity of life, and threatens this continuity. It concludes that this tension is implicitly recognised in the temporal continuity of nursing, which allows for discontinuous and continuous aspects of sickness time. Nurses accordingly perceive the sick person's time at several levels of temporality, and distinguish highly complex temporal processes in their patients' trajectory. Temporal continuity provides the time, flexibility, and closeness for nurses to perceive and act into time dimensions of individual sickness. The paper shows that temporal continuity of nursing is grounded in temporal characteristics of severe sickness. It suggests that temporal continuity is an important theoretical concept in nursing.

Feasibility and sustainability of a model of multidisciplinary case conferencing in residential aged care

This paper reports a pilot study examining the feasibility, acceptability and sustainability of a multidisciplinary case conferencing model in residential aged care. The model was developed through a consultation process and then implemented in 31 case conferences over a 6-month period between May and October 2008. This paper explores the feasibility and acceptability of model implementation, the experience of the facility staff, general practitioners and residents/family carers and the perceived sustainability of the model in clinical practice. It shows that although there was a degree of confusion around the concept of multidisciplinary case conferencing, implementation of this partnership model significantly improved communication between health workers, facilitated interaction between staff and family carers, and provided a focus for reflecting on individual residents’ health needs.

Nursing home residents in emergency departments: a Foucauldian analysis

AIM

This paper is a critical review of current knowledge about use of emergency departments by nursing home residents.

BACKGROUND

A great deal of literature focuses on the challenges presented by older adults in acute care environments. Nursing home residents who transfer to emergency departments have been identified as being particularly problematic because they use considerable resources and their needs are not always amenable to acute interventions.

METHOD

A literature search was conducted in May 2006 using the CINAHL, Medline and Cochrane databases and Google Scholar with the keywords 'nursing home resident', 'long-term care resident', 'hospital transfer', and 'acute illness and emergency room'. No date restrictions were imposed. Foucault's concept of subjectivity was used to demonstrate how power derived from medical knowledge is used by emergency department personnel to construct nursing home residents as problematic.

FINDINGS

Knowledge about the use of emergency departments by nursing home residents has been derived mainly from retrospective record reviews, while the events in nursing homes that lead to transfers have been virtually ignored. Moreover, the primary focus of these investigations has been the effect of residents on emergency departments, rather than how residents themselves were affected.

CONCLUSION

Current understanding of the care of nursing home residents in emergency departments is embedded in a complex web of social, historical and political factors. Research is needed that considers multiple perspectives, including those of both emergency department and nursing home staff, residents and ambulance personnel who act as mediators between the two settings.