Medication administration in Australian residential aged care: A time-and-motion study

Surveillance of Antimicrobial Use in Long-Term Care Facilities: An Antimicrobial Mapping Survey

OBJECTIVES

To explore antimicrobial management processes in Australian residential aged care facilities (RACFs), including antimicrobial prescribing, supply, administration, and documentation to inform surveillance activities.

DESIGN

Voluntary, online cross-sectional survey.

SETTING AND PARTICIPANTS

The survey was disseminated to all South Australian RACFs (n = 237) seeking participation from an infection prevention and control lead (preferred respondent), a nurse or senior RACF staff member, or an aged care pharmacist.

METHODS

The survey was open during May-June 2023. Questions aimed to understand clinical and medication management systems, sources of antimicrobial prescription and supply, management by external health care providers and documentation of antimicrobial administration. A process map of antimicrobial management in RACFs was developed.

RESULTS

Of the 54 RACFs included in the analysis (29.5% response rate), most used an electronic clinical documentation system (74.1%) or a hybrid electronic paper-based system (22.2%). Medication charts were either electronic (81.0%), hybrid (5.6%), or paper-based (13.0%). Antimicrobials were prescribed by the resident's usual general practitioner, but also by locums, hospital or specialist physicians, nurse practitioners, virtual care physicians, and dentists. Oral, topical, and inhaled antimicrobial formulations were usually supplied by community pharmacies, and intravenous formulations were predominately supplied by hospitals for administration by outreach nurses. Almost all RACFs (96.2%) had imprest stock of antimicrobials that included both oral and intravenous formulations. Antimicrobials were predominately administered by an enrolled nurse or a registered nurse.

CONCLUSIONS AND IMPLICATIONS

Antimicrobial management in RACFs is complex, particularly during care transitions. Multiple prescribers and sources of antimicrobials, use of different systems for clinical documentation, particularly by external health care providers, and clinical governance relating to imprest supplies were identified as key areas where medication management could be improved. Addressing these gaps will facilitate comprehensive, real-time antimicrobial surveillance in Australian RACFs.

Medication administration in aged care facilities: A mixed-methods systematic review

AIM(S)

To synthesize aged care provider, resident and residents' family members' perspectives and experiences of medication administration in aged care facilities; to determine the incidence of medication administration errors, and the impact of medication administration on quality of care and resident-centredness in aged care facilities.

DESIGN

A mixed-methods systematic review.

PROSPERO ID

CRD42023426990.

DATA SOURCES

The AMED, CINAHL, MEDLINE, EMBASE, EMCARE, PsycINFO, Scopus and Web of Science core collection databases were searched in June 2023.

REVIEW METHODS

Included studies were independently screened, selected and appraised by two researchers. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist was followed, with the Mixed Methods Appraisal Tool was used for critical appraisal. Convergent synthesis of data, thematic synthesis and meta-analysis were performed.

RESULTS

One hundred and twenty-eight studies were included (33 qualitative, 85 quantitative and 10 mixed-methods). Five themes were formulated, including 1) Staffing concerns, 2) The uncertain role of residents, 3) Medication-related decision-making, 4) Use of electronic medication administration records and 5) Medication administration errors. Educational interventions for aged care workers significantly reduced medication administration errors, examined across five studies (OR = 0.37, 95%CI 0.28-0.50, p < .001).

CONCLUSIONS

Medication administration in aged care facilities is challenging and complex on clinical and interpersonal levels. Clinical processes, medication errors and safety remain focal points for practice. However, more active consideration of residents' autonomy and input by aged care workers and providers is needed to address medication administration's interpersonal and psychosocial aspects. New directions for future research should examine the decision-making behind dose form modification, aged care workers' definitions of medication omission and practical methods to support residents' and their family members' engagement during medication administration.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

It is important that medication administration in aged care facilities be more clearly acknowledged as both a clinical and interpersonal task. More attention is warranted regarding aged care workers clinical decision-making, particularly concerning dose form modification, covert administration and medication omissions. Resident-centred care approaches that support resident and family engagement around medication administration may improve adherence, satisfaction and quality of care.

IMPACT

What Problem Did the Study Address? Medication administration in aged care facilities is a complex clinical and interpersonal activity. Still, to date, no attempts have been made to synthesize qualitative and quantitative evidence around this practice. There is a need to establish what evidence exists around the perspectives and experiences of aged care workers, residents and resident's family members to understand the challenges, interpersonal opportunities and risks during medication administration. What Were the Main Findings? There is a lack of empirical evidence around resident-centred care approaches to medication administration, and how residents and their families could be enabled to have more input. Dose form modification occurred overtly and covertly as part of medication administration, not just as a method for older adults with swallowing difficulties, but to enforce adherence with prescribed medications. Medication administration errors typically included medication omission as a category of error, despite some omissions stemming from a clear rationale for medication omission and resident input. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: The findings of this systematic review contribute to aged care policy and practice regarding medication administration and engagement with older adults. This review presents findings that provide a starting point for aged care workers in regards to professional development and reflection on practice, particularly around clinical decision-making on dose form modification, medication administration errors and the tension on enabling resident input into medication administration. For researchers, this review highlights the need to develop resident-centred care approaches and interventions, and to assess whether these can positively impact medication administration, resident engagement, adherence with prescribed medications and quality of care.

REPORTING METHOD

This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Page et al., 2021).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution to this systematic review.

Polypharmacy and medicine regimens in older adults in residential aged care

OBJECTIVE

To describe medicines regimens used by older people living in residential aged care facilities (RACFs).

MATERIALS AND METHODS

This cross-sectional study presents baseline data from a randomised controlled trial in seventeen Australian RACFs that recruited residents aged 65 years and older at the participating facilities. The main outcome measures were to evaluation of medicines utilisation, including the number of medicines, medicine regimen complexity, potential under-prescribing and high-risk prescribing (prescribing cascades, anticholinergic or sedative medicines or other potentially inappropriate medicines) with data analysed descriptively.

RESULTS

Medicines regimens were analysed for 303 residents (76% female) with a mean age of 85.0 ± 7.5 years, of whom the majority were living with dementia (72%). Residents were prescribed an average of 10.3 ± 4.5 regular medicines daily. Most participants (85%) had highly complex regimens. Most residents (92%) were exposed to polypharmacy (five or more medicines). Nearly all, 302 (98%) residents had at least one marker of potentially suboptimal prescribing. At least one instance of potential under-prescribing was identified in 86% of residents. At least one instance of high-risk prescribing was identified in 81% of residents including 16% of participants with at least one potential prescribing cascade.

CONCLUSION(S)

Potentially suboptimal prescribing affected almost all residents in this study, and most had highly complex medicines regimens. If generalisable, these findings indicate most older people in RACFs may be at risk of medicines-related harm from suboptimal prescribing, in addition to the burden of administration of complex medicines regimens for facility staff and residents.

Examining the Needs-Based Time Use of Chinese Nursing Assistants: A Time-Motion Study

BACKGROUND

In light of the worldwide shortage of nurses and to maximize the effectiveness of the nursing care available, it is important to investigate the components of the care regularly provided by nursing assistants (NAs) to older adults. Well-organized allocation of NA care activities is directly linked to the quality of care provided to nursing home (NH) residents and their quality of life. However, relevant knowledge about the actual time allocation of NAs in this context is lacking, as previous related studies have focused only on the duration necessary for NAs to complete nursing activities.

PURPOSE

This study was designed to investigate the time allocation of NAs in completing job tasks necessary to meet the needs of residents in nursing care units at an NH in China.

METHODS

A time-motion method and nonparticipatory observations were used to collect data. Two postgraduate students observed 15 NAs' time expenditure and nursing content simultaneously during day shifts for 3 weeks as the NAs provided care to residents in four different nursing care levels. Data on nursing time and activity frequency were collected using a worklist based on the Zuluaga-Raysmith model.

RESULTS

The 119.6 hours of observation included 8,907 discrete observed activities. In terms of the care provided to meet the needs of residents, the most time-consuming activities were physical health care (26.8%) and communication care (18.3%), followed by mental, emotional, social, and spiritual health care (14.1%) and protection and security care (12.6%). The higher the level of care, the higher the proportion of somatic nursing time and nursing activity frequency. However, the time and frequency of psychological and spiritual care showed an opposite trend.

CONCLUSIONS

Because of their lack of formal nursing training and skills, NAs pay more attention to meeting the physiological needs of residents while ignoring their mental needs. Moreover, their effectiveness in providing spiritual care tends to be quite low. Furthermore, the NA nursing activity classification system based on the Zuluaga-Raysmith model developed in this study is applicable for designing nursing work tasks, organizing NH units, and improving the quality of life of residents, as this model accurately reflects the essence of NA work.

Solid Oral Dosage Forms Use in Adults with Neurological Disorders and Swallowing Difficulties: A Scoping Review

Swallowing difficulties affects the deglutition of solid oral dosage forms (SODFs) and it is a common problem among neurological disorders. Interventions may improve the use of SODFs in healthcare settings. The aim of this study was to map the available research about the interventions aiming the effective and safe use of SODFs in adults with neurological disorders and swallowing difficulties and to identify potential literature gaps in this scientific field. A scoping review was carried out based on Joanna Briggs Institute guidelines and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, in PubMed, Scopus, and SciELO databases (March 2021). Peer-reviewed observational studies assessed the effectiveness and safety of SODFs in adults with neurological disorders and swallowing difficulties in the healthcare organizations setting were included. 11 studies were included (three case reports, two mixed-methods intervention studies, and six analytic studies). The frequency of women ranged from 49 to 67%, and the age from 57 to 91 years. Most studies (n = 7) included elderly patients, Parkinson (n = 6) and dementia (n = 3). Medication review was the most frequently reported intervention, 35% (9/26). In most studies, interventions were targeted to patients during hospitalization (n = 7) and performed by physicians (n = 8). At least 20 different outcomes were evaluated in the studies. Implementing specific protocols for using SODFs aimed at the swallowing difficulties of this population is not a common practice. Additional studies on interventions aimed at optimizing SODFs are needed to support the safety and efficacy of oral therapy in this patient group.

Impact of Medication Regimen Simplification on Medication Incidents in Residential Aged Care: SIMPLER Randomized Controlled Trial

In the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) cluster-randomized controlled trial, we investigated the impact of a structured medication regimen simplification intervention on medication incidents in residential aged care facilities (RACFs) over a 12-month follow-up. A clinical pharmacist applied the validated 5-step Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE) for 96 of the 99 participating residents in the four intervention RACFs. The 143 participating residents in the comparison RACFs received usual care. Over 12 months, medication incident rates were 95 and 66 per 100 resident-years in the intervention and comparison groups, respectively (adjusted incident rate ratio (IRR) 1.13; 95% confidence interval (CI) 0.53-2.38). The 12-month pre/post incident rate almost halved among participants in the intervention group (adjusted IRR 0.56; 95%CI 0.38-0.80). A significant reduction in 12-month pre/post incident rate was also observed in the comparison group (adjusted IRR 0.67, 95%CI 0.50-0.90). Medication incidents over 12 months were often minor in severity. Declines in 12-month pre/post incident rates were observed in both study arms; however, rates were not significantly different among residents who received and did not receive a one-off structured medication regimen simplification intervention.

Impact of Medication Regimen Simplification on Medication Administration Times and Health Outcomes in Residential Aged Care: 12 Month Follow Up of the SIMPLER Randomized Controlled Trial

In the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) cluster-randomized controlled trial, we evaluated the impact of structured medication regimen simplification on medication administration times, falls, hospitalization, and mortality at 8 residential aged care facilities (RACFs) at 12 month follow up. In total, 242 residents taking ≥1 medication regularly were included. Opportunities for simplification among participants at 4 RACFs were identified using the validated Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE). Simplification was possible for 62 of 99 residents in the intervention arm. Significant reductions in the mean number of daily medication administration times were observed at 8 months (-0.38, 95% confidence intervals (CI) -0.69 to -0.07) and 12 months (-0.47, 95%CI -0.84 to -0.09) in the intervention compared to the comparison arm. A higher incidence of falls was observed in the intervention arm (incidence rate ratio (IRR) 2.20, 95%CI 1.33 to 3.63) over 12-months, which was primarily driven by a high falls rate in one intervention RACF and a simultaneous decrease in comparison RACFs. No significant differences in hospitalizations (IRR 1.78, 95%CI 0.57-5.53) or mortality (relative risk 0.81, 95%CI 0.48-1.38) over 12 months were observed. Medication simplification achieves sustained reductions in medication administration times and should be implemented using a structured resident-centered approach that incorporates clinical judgement.