The interRAI Acute Care instrument incorporated in an eHealth system for standardized and web-based geriatric assessment: strengths, weaknesses, opportunities and threats in the acute hospital setting

Digital health technologies supporting the application of comprehensive geriatric assessments in long-term care settings or community care: A systematic review

Objective

To provide high-quality elderly care, digital health technologies (DHTs) can potentially assist in reaching the full capacity of comprehensive geriatric assessments (CGAs) to improve communication and data transfer on patients' medical and treatment plan information and health decision-making. This systematic review aimed to describe the evidence on the feasibility and usability, efficacy and effectiveness, and implementation outcomes of DHTs developed to facilitate the administration of CGAs for long-term care settings or community care and to describe their technical features and components.

Methods

A search strategy was conducted in three databases, targeting studies evaluating the DHTs facilitating the administration of CGAs used in long-term care settings or community care. Studies in English and Spanish published up to 5 April 2023 were considered.

Results

Four DHTs supporting the administration of the CGAs were identified. Limited information was found on the technical features and required hardware. Some of the barriers identified regarding usability can be overcome with novel technologies; however, training of health professionals on the assessments and staff knowledge regarding the purpose of the data collected are not technology related and need to be addressed.

Conclusions

Barriers regarding usability were related to experienced difficulties navigating the software, unstable network connectivity, and length of the assessment. Feasibility obstacles were associated with the lack of training to use the DHT, availability and accessibility to hardware (e.g. laptops), and lack of insight into the clinical benefits of collected data. Further research must focus on these areas to improve the implementation and usefulness of these DHTs.

The uptake and use of a minimum data set (MDS) for older people living and dying in care homes: a realist review

BACKGROUND

Care homes provide long term care for older people. Countries with standardised approaches to residents' assessment, care planning and review (known as minimum data sets (MDS)) use the aggregate data to guide resource allocation, monitor quality, and for research. Less is known about how an MDS affects how staff assess, provide and review residents' everyday care. The review aimed to develop a theory-driven understanding of how care home staff can effectively implement and use MDS to plan and deliver care for residents.

METHODS

The realist review was organised according to RAMESES (Realist And Meta-narrative Evidence Synthesis: and Evolving Standards) guidelines. There were three overlapping stages: 1) defining the scope of the review and theory development on the use of minimum data set 2) testing and refining candidate programme theories through iterative literature searches and stakeholders' consultations as well as discussion among the research team; and 3) data synthesis from stages 1 and 2. The following databases were used MEDLINE via OVID, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ASSIA [Applied Social Sciences Citation Index and Abstracts]) and sources of grey literature.

RESULTS

Fifty-one papers informed the development of three key interlinked theoretical propositions: motivation (mandates and incentives for Minimum Data Set completion); frontline staff monitoring (when Minimum Data Set completion is built into the working practices of the care home); and embedded recording systems (Minimum Data Set recording system is integral to collecting residents' data). By valuing the contributions of staff and building on existing ways of working, the uptake and use of an MDS could enable all staff to learn with and from each other about what is important for residents' care CONCLUSIONS: Minimum Data Sets provides commissioners service providers and researchers with standardised information useful for commissioning planning and analysis. For it to be equally useful for care home staff it requires key activities that address the staff experiences of care, their work with others and the use of digital technology.

REGISTRATION

PROSPERO registration number CRD42020171323.

Towards the development of a national patient transfer document between residential and acute care-A pilot study

BACKGROUND

A lack of standardisation of documentation accompanying older people when transferring from residential to acute care is common and this may result in gaps in information and in care for older people. In Ireland, this lack of standardisation prompted the development of an evidence based national transfer document.

OBJECTIVES

To pilot a new national transfer document for use when transferring older people from residential to acute care and obtain the perceptions of its use from staff in residential and acute care settings.

METHODS

This was a pre- and post-study design using purposive sampling following the STROBE guidelines. The pilot was conducted in 26 sites providing residential care and three university hospitals providing acute care. Pre-pilot questionnaires focused on current documentation and were distributed to staff in residential care (n = 875). A pilot of the new paper-based transfer document was then conducted over three months and post-pilot questionnaires distributed to staff from both residential and acute care settings (n = 1085). The findings of the pilot study were discussed with multidisciplinary expert advisory and stakeholder groups who recommended some revisions. This consensus informed the development of the final design of the new revised transfer document.

RESULTS

Pre-pilot: 23% response rate; 83% (n = 168) participants agreed/strongly agreed that existing documentation was straightforward to complete but could be more person-centred. Post-pilot: 11% response rate; 75% (n = 93) of participants agreed/strongly agreed that the new transfer document promoted person-centred care but recommended revisions to the new document regarding layout and time to complete.

CONCLUSIONS

This study highlighted some of the challenges of providing safe, effective and relevant transfer information that is feasible and usable in everyday practice.

IMPLICATIONS FOR PRACTICE

Standardisation and being person-centred are important determining factors in the provision of relevant up to date information on the resident being transferred.

Implementation and Evaluation of a Standardized Nurse-Administered Assessment of Functional and Psychosocial Issues for Patients in Acute Care

BACKGROUND

Increasingly, adults presenting to healthcare facilities have multiple morbidities that impact medical management and require initial and ongoing assessment. The interRAI Acute Care (AC), one of a suite of instruments used for integrated care, is a nurse-administered standardized assessment of functional and psychosocial domains that contribute to complexity of patients admitted to acute care.

AIM

This study aimed to implement and evaluate the interRAI AC assessment system using a multi-strategy approach based on the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework.

METHODS

This nurse-led quality improvement study was piloted in a 200-bed public hospital in Brisbane, Australia, over the period 2017 to 2018. The interRAI AC is a set of clinical observations of functional and psychosocial domains, supported by software to derive diagnostic and risk screeners, scales to measure and monitor severity, and alerts to assist in care planning. Empirical data, surveys, and qualitative feedback were used to measure process and impact outcomes using the RE-AIM evaluation framework (Reach, Efficacy, Adoption, Implementation, and Maintenance).

RESULTS

In comparison to usual practice, the interRAI assessment system and supporting software was able to improve the integrity and compliance of nurse assessments, identifying key risk domains to facilitate management of care. Pre-implementation documentation (630 items in 45 patient admissions) had 39% missing data compared with 1% missing data during the interRAI implementation phase (9,030 items in 645 patient admissions). Qualitative feedback from nurses in relation to staff engagement and behavioral intention to use the new technology was mixed.

LINKING EVIDENCE TO ACTION

Despite challenges to implementing a system-wide change, evaluation results demonstrated considerable efficiency gains in the nursing assessment system. For successful implementation of the interRAI AC, study findings suggest the need for interoperability with other information systems, access to training, and continued leadership support.

"Establishing the criterion validity of the interRAI Check-Up Self-Report instrument"

Background

Low and middle-income countries have growing older populations and could benefit from the use of multi-domain geriatric assessments in overcoming the challenge of providing quality health services to older persons. This paper reports on the outcomes of a study carried out in Cape Town, South Africa on the validity of the interRAI Check-Up Self-Report instrument, a multi-domain assessment instrument designed to screen older persons in primary health settings. This is the first criterion validity study of the instrument. The instrument is designed to identify specific health problems and needs, including psychosocial or cognition problems and issues related to functional decline. The interRAI Check-Up Self-Report is designed to be compatible with the clinician administered instruments in the interRAI suite of assessments, but the validity of the instrument against clinician ratings has not yet been established. We therefore sought to establish whether community health workers, rather than trained healthcare professionals could reliably administer the self-report instrument to older persons.

Methods

We evaluated the criterion validity of the self-report instrument through comparison to assessments completed by a clinician assessor. A total of 112 participants, aged 60 or older were recruited from 7 seniors clubs in Khayelitsha, Cape Town. Each participant was assessed by one of two previously untrained, non-healthcare personnel using the Check-Up Self-report version and again by a trained assessor using the clinician version of the interRAI Check-Up within 48 h. Our analyses focused on the degree of agreement between the self-reported and clinician-rated versions of the Check-Up based on the simple or weighted kappa values for the two types of ratings. Binary variables used simple kappas, and ordinal variables with three or more levels were examined using weighted kappas with Fleiss-Cohen weights.

Results

Based on Cohen’s Kappa values, we were able to establish that high levels of agreement existed between clinical assessors and lay interviewers, indicating that the instrument can be validly administered by community health workers without formal healthcare training. 13% of items had kappa values ranging between 0.10 and 0.39; 51% of items had kappa values between 0.4 and 0.69; and 36% of items had values of between 0.70 and 1.00.

Conclusion

Our findings indicate that there is potential for the Check-Up Self-Report instrument to be implemented in under-resourced health systems such as South Africa’s.

Key stakeholders' perspectives on the development of a national transfer document, for older persons, when transferring between the residential and acute care settings: A qualitative descriptive study

AIMS AND OBJECTIVES

This study has aimed to examine key stakeholders' perspectives, views and experiences regarding transfer documents, used when an older person is being transferred from a residential to an acute care setting. The objective of the study was to inform, in part, the development of an effective national transfer document.

BACKGROUND

For the effective and safe transfer of older persons from residential to acute care settings, it is important to ensure that the transfer document encapsulates relevant, current and person-centred information to ensure a smooth, quality and safe transition. Evidence highlights that, where documentation has lacked vital and relevant information, the older persons experience negative impacts during the transfer process.

DESIGN

A qualitative descriptive study was conducted, following the COREQ checklist, to establish participants' perspectives, views and experiences of using transfer documents.

METHODS

Focus group interviews (n = 8) were conducted with a convenience sample of key stakeholders (n = 68) in an Irish setting. The data were analysed using content analysis.

RESULTS

The findings have highlighted the important aspects for consideration in the development of future transfer documentation. The three broad categories, used to present the data findings, are (a) existing transfer documentation; (b) design framework; and (c) essentials of care.

CONCLUSIONS

The transfer document of the future is required to be concise, regularly reviewed and with a user-friendly colour-coded design. Essential and current information, with an emphasis on person centeredness, must be in the first page, with more detailed supporting information in the subsequent sections.

Factors Determining the Success and Failure of eHealth Interventions: Systematic Review of the Literature

Background

eHealth has an enormous potential to improve healthcare cost, effectiveness, and quality of care. However, there seems to be a gap between the foreseen benefits of research and clinical reality.

Objective

Our objective was to systematically review the factors influencing the outcome of eHealth interventions in terms of success and failure.

Methods

We searched the PubMed database for original peer-reviewed studies on implemented eHealth tools that reported on the factors for the success or failure, or both, of the intervention. We conducted the systematic review by following the patient, intervention, comparison, and outcome framework, with 2 of the authors independently reviewing the abstract and full text of the articles. We collected data using standardized forms that reflected the categorization model used in the qualitative analysis of the outcomes reported in the included articles.

Results

Among the 903 identified articles, a total of 221 studies complied with the inclusion criteria. The studies were heterogeneous by country, type of eHealth intervention, method of implementation, and reporting perspectives. The article frequency analysis did not show a significant discrepancy between the number of reports on failure (392/844, 46.5%) and on success (452/844, 53.6%). The qualitative analysis identified 27 categories that represented the factors for success or failure of eHealth interventions. A quantitative analysis of the results revealed the category quality of healthcare (n=55) as the most mentioned as contributing to the success of eHealth interventions, and the category costs (n=42) as the most mentioned as contributing to failure. For the category with the highest unique article frequency, workflow (n=51), we conducted a full-text review. The analysis of the 23 articles that met the inclusion criteria identified 6 barriers related to workflow: workload (n=12), role definition (n=7), undermining of face-to-face communication (n=6), workflow disruption (n=6), alignment with clinical processes (n=2), and staff turnover (n=1).

Conclusions

The reviewed literature suggested that, to increase the likelihood of success of eHealth interventions, future research must ensure a positive impact in the quality of care, with particular attention given to improved diagnosis, clinical management, and patient-centered care. There is a critical need to perform in-depth studies of the workflow(s) that the intervention will support and to perceive the clinical processes involved.

A systematic review of reviews to identify key research opportunities within the field of eHealth implementation

INTRODUCTION

This paper is a systematic review of the relevant literature surrounding the implementation and utilisation of eHealth to identify key challenges and opportunities to future eHealth applications.

METHODS

NHS Evidence, PubMed, IEEE Explorer, Cochrane Library and JMIR Publications were all searched for reviews published between 1 January 2010 and 30 June 2017.

RESULTS

A total of 47 papers met the final inclusion criterion. The published literature focused on a wide array of challenges categorised into five areas, facing the implementation and utilisation of eHealth; from this, four areas of opportunity to advance eHealth were identified.

DISCUSSION

The five challenge areas are (C1) stakeholders and system users, (C2) technology and interoperability, (C3) cost-effectiveness and start-up costs, (C4) legal clarity and legal framework and (C5) local context and regional differences. The four opportunity areas are (O1) participation and contribution, (O2) foundation and sustainability, (O3) improvement and productivity and (O4) identification and application.

CONCLUSION

The literature analysed in this systematic review identifies design and implementation priorities that can guide the development and utilisation of future eHealth initiatives.

Organisational framework and outputs of International medical evacuation in Guinea: A need for change

The study aims to describe the organizational framework of International Medical Evacuation (IME), the profile of persons evacuated, and the associated cost of IME in Guinea. This was a descriptive study of IME policy in Guinea. We described the politico-structural organization of IME and the profile of patient accessing IME through the Ministry of Health (MOH: 2001-2015) and through the National Social Security Fund (NSSF: 2011-2015). From 1958 to 1992 since the health system was restricted, the country negotiated the free medical treatment with Socialist countries. Since 1992, a medical assistance line was included in the sector budgets, and IME was officially managed by the MOH and with a parallel system existing at the NSSF. With an average cost of US $34 251 per case, cardiovascular diseases (20%), Traumatology/Orthopedic diseases (20%), and Neurologic/neurosurgery diseases (12.5%) have motivated more than half of 2445 IME supported by the MOH between 2001 and 2015. With a diagnostic exploration (38.7%) as main motivation, the majority of the IMEs (80.0%) endorsed by the NSSF (2011-2015) concerned their employees/workers or those of the NSSF's supervisory ministry and their families. Despite a strict regulatory framework, the emergence and sustainability of parallel IME systems in other departments with different procedures than MOH's procedure represent a major weakness/deficiency. The new prospects for the free medical treatment of state employees could eventually lead to an effective correction of this structural failure if efficiently managed.

Does using the interRAI Palliative Care instrument reduce the needs and symptoms of nursing home residents receiving palliative care?

Objective:

This study aimed to evaluate whether using the interRAI Palliative Care instrument (the interRAI PC) in nursing homes is associated with reduced needs and symptoms in residents nearing the end of their lives.

Method:

A quasi-experimental pretest–posttest study using the Palliative care Outcome Scale (POS) was conducted to compare the needs and symptoms of residents nearing the end of their lives in the control and intervention nursing homes. Care professionals at the intervention nursing homes filled out the interRAI PC over the course of a year for all residents aged 65 years and older who were nearing the end of their lives. This intervention was not implemented in the control nursing homes.

Results:

At baseline, POS scores in the intervention nursing homes were lower (more favorable) than in the control nursing homes on the items “pain”, “other symptoms”, “family anxiety”, and the total POS score. Posttest POS scores for “wasted time” were higher (less favorable) than pretest scores in the intervention nursing homes. In the intervention nursing homes where care professionals did not have prior experience with the interRAI Long-Term Care Facilities (LTCF) assessment instrument (n = 8/15), total POS scores were lower (more favorable) at posttest.

Significance of results:

One year after introducing the interRAI PC, no reduction in residents' needs and symptoms were detected in the intervention nursing homes. However, reductions in needs and symptoms were found in the subgroup of intervention nursing homes without prior experience with the interRAI LTCF instrument. This may suggest that the use of an interRAI instrument other than the interRAI PC specifically can improve care. Future research should aim at replicating this research with a long-term design in order to evaluate the effect of integrating the use of the interRAI PC in the day-to-day practices at nursing homes.

Usefulness, feasibility and face validity of the interRAI Palliative Care instrument according to care professionals in nursing homes: A qualitative study

BACKGROUND

Nursing homes are important locations for palliative care. High quality palliative care requires an evaluation of the different care needs of the nursing home residents. The interRAI Palliative Care instrument is a comprehensive assessment that evaluates the needs and preferences of adults receiving palliative care.

OBJECTIVES

This study aims to evaluate the usefulness, feasibility and face validity of the interRAI Palliative Care instrument.

DESIGN

A qualitative study was conducted, based on the abductive reasoning approach.

SETTING

Fifteen nursing homes in Flanders (Belgium).

PARTICIPANTS

Calls for participation were sent out by four umbrella organizations of Flemish nursing homes (Belgium) and at a national conference for nursing home staff. Nineteen care professionals (nurses, certified nursing assistants, psychologists, physiotherapists, quality coordinators and directors) of 15 nursing homes voluntarily agreed to participate in the study.

METHODS

During one year, care professionals evaluated the needs and preferences of all nursing home residents receiving palliative care by means of the interRAI Palliative Care instrument. Data on the usefulness, feasibility and face validity of the interRAI Palliative Care instrument were derived from notes, semi-structured interviews and focus groups with participating care professionals and were thematically analyzed and synthesized. Data were gathered between December 2013 and March 2015.

RESULTS

In general, the interRAI Palliative Care (interRAI PC instrument) is a useful instrument according to care professionals in nursing homes. However, care professionals made a series of recommendations in order to optimize the usefulness of the instrument. The interRAI PC instrument is not always feasible to complete because of organizational reasons. Furthermore, the face validity of the instrument could be improved since certain items are incomplete, lacking, redundant or too complex.

CONCLUSIONS

Findings highlight the importance of adapting the content of the interRAI Palliative Care instrument for use in nursing homes. Furthermore, the use of the instrument should be integrated in the organization of daily care routines in the nursing homes. Tackling the critical remarks of care professionals will help to optimize the interRAI Palliative Care instrument and hence support palliative care of high quality in nursing homes.

Updating the Cognitive Performance Scale

This study presents the first update of the Cognitive Performance Scale (CPS) in 20 years. Its goals are 3-fold: extend category options; characterize how the new scale variant tracks with the Mini-Mental State Examination; and present a series of associative findings. Secondary analysis of data from 3733 older adults from 8 countries was completed. Examination of scale dimensions using older and new items was completed using a forward-entry stepwise regression. The revised scale was validated by examining the scale's distribution with a self-reported dementia diagnosis, functional problems, living status, and distress measures. Cognitive Performance Scale 2 extends the measurement metric from a range of 0 to 6 for the original CPS, to 0 to 8. Relating CPS2 to other measures of function, living status, and distress showed that changes in these external measures correspond with increased challenges in cognitive performance. Cognitive Performance Scale 2 enables repeated assessments, sensitive to detect changes particularly in early levels of cognitive decline.

[The development and validation of a standardised transfer sheet for care transitions between residential and acute care settings in Leuven, Belgium]

BACKGROUND

When elderly patients are transferred from a residential to an acute care setting, important information regarding their health care can be lost. Over the past years, the concept of advance care planning has also been given a more prominent place in the care for the elderly. However it remains a challenge to communicate the results achieved by this process when patients are referred to another health care setting. Developing a sound method for transferring information is a key element in the transitional care for the elderly patient.

OBJECTIVES

In collaboration with the residential and acute care settings in Leuven, Flemish Brabant, Belgium this study aimed to develop a validated, standardized transfer-sheet.

METHODS

After a literature search a topic list was generated to be used as the basis for a Delphi-procedure in which 16 experts from both the acute and the residential care settings participated. The transfer-sheet was then evaluated for content validity by an expert-panel (n = 9) from the acute and residential care settings. Face validity was assessed by two nurses and two doctors, randomly selected from the above settings.

RESULTS

All 44 subthemes in the transfer-sheet showed excellent content validity. The scale content validity universal agreement (S CVIUA) for the entire transfer-sheet was 0.68. The average scale content validity (S CVIAve) was 0.96. After a second and final Delphi-round a final transfer-sheet was constructed consisting of 8 themes and 50 sub-themes.

CONCLUSIONS

Based on these results standardized transfer-sheet was developed and validated.

Derivation of a frailty index from the interRAI acute care instrument

BACKGROUND

A better understanding of the health status of older inpatients could underpin the delivery of more individualised, appropriate health care.

METHODS

1418 patients aged ≥ 70 years admitted to 11 hospitals in Australia were evaluated at admission using the interRAI assessment system for Acute Care. This instrument surveys a large number of domains, including cognition, communication, mood and behaviour, activities of daily living, continence, nutrition, skin condition, falls, and medical diagnosis.

RESULTS

Variables across multiple domains were selected as health deficits. Dichotomous data were coded as symptom absent (0 deficit) or present (1 deficit). Ordinal scales were recoded as 0, 0.5 or 1 deficit based on face validity and the distribution of data. Individual deficit scores were summed and divided by the total number considered (56) to yield a Frailty index (FI-AC) with theoretical range 0-1. The index was normally distributed, with a mean score of 0.32 (±0.14), interquartile range 0.22 to 0.41. The 99% limit to deficit accumulation was 0.69, below the theoretical maximum of 1.0. In logistic regression analysis including age, gender and FI-AC as covariates, each 0.1 increase in the FI-AC increased the likelihood of inpatient mortality twofold (OR: 2.05 [95% CI 1.70-2.48]).

CONCLUSIONS

Quantification of frailty status at hospital admission can be incorporated into an existing assessment system, which serves other clinical and administrative purposes. This could optimise clinical utility and minimise costs. The variables used to derive the FI-AC are common to all interRAI instruments, and could be used to precisely measure frailty across the spectrum of health care.