Update: Entwicklungen der Gesundheitsversorgung

Neben dem Mangel an Gesundheitsfachpersonal sind vor allem Veränderungen in der Struktur der Krankenhäuser, der stationären Altenhilfe und der ambulanten Versorgung deutlich spürbar. Aktuell sind unterschiedliche Ansätze zur Neuordnung, wie die Ausgliederung der Finanzierung der Pflege aus dem G-DRG System der Krankenhäuser oder das neue Krankenpflegegesetz mit erstmalig vorbehaltlichen Aufgaben, zu verzeichnen. Grundsätzlich stellt sich bei diesen Ansätzen zur Neuordnung die Frage, welche Perspektive in der Gesundheitsversorgung künftig prioritär verfolgt werden soll: die der Versorgungsanbieter*innen in den jeweiligen Settings, die der Gesundheitsfachpersonen oder vielleicht auch endlich einmal die der Menschen mit medizinischem und/oder pflegerischen Unterstützungsbedarfen?

Förderung der Mundgesundheit in der Pflege – ein interprofessioneller Expertenstandard

Hintergrund

Menschen mit Pflege- oder Unterstützungsbedarf oder einer Behinderung haben einen schlechteren Mundgesundheitsstatus als Menschen ohne diesen Bedarf. Die zunehmende Anzahl älterer Menschen, die über eigene Zähne verfügen, erfordert spezifische Maßnahmen zur Förderung der Mundgesundheit. Während 1997 jeder 4. Mensch zwischen 65 und 74 Jahren zahnlos war, galt dies 2016 nur noch für jeden 8. Besondere Herausforderungen in der Mundpflege stellen sich bei älteren Menschen und Personen mit Demenz. Zur Bewältigung braucht es eine interprofessionelle Herangehensweise und Zusammenarbeit während der gesamten Versorgung.

Zielsetzung

Interprofessionelle Entwicklung eines Expertenstandards zur Förderung der Mundgesundheit durch Pflegefachpersonen mit Fokus auf ältere Menschen.

Methoden

Grundlage des Expertenstandards bildet eine systematische Literaturanalyse. Aufbauend auf den Ergebnissen formulierte eine interprofessionelle Expertinnen- und Expertenarbeitsgruppe unter Beteiligung von Pflege, Zahnmedizin und einem Vertreter aus der Selbsthilfe Empfehlungen zur Förderung der Mundgesundheit von Menschen mit pflegerischem Unterstützungsbedarf.

Ergebnisse

Die interprofessionelle Herangehensweise prägte die Auswahl der leitenden Fragen der Literaturrecherche, die Literaturauswertung und die Formulierung der Empfehlungen. Zu den leitenden Fragen des Expertenstandards konnten Maßnahmen zu Erhalt und Förderung der Mundgesundheit ausgewiesen werden, beispielsweise bei oralen Pilzerkrankungen, Mukositis oder Gingivitis sowie bei Begleiterscheinungen wie Mundtrockenheit und Schmerzen.

Diskussion

Maßnahmen zur Förderung der Mundgesundheit bei Menschen mit Pflege- oder Unterstützungsbedarf oder einer Behinderung konnten im pflegerischen Kontext vertieft fokussiert und durch eine interprofessionelle Gruppe formuliert werden.

Caesarean Section. Guideline of the DGGG, OEGGG and SGGG (S3-Level, AWMF Registry No. 015/084, June 2020)

Purpose This is an official S3-guideline of the German Society of Gynaecology and Obstetrics (DGGG), the Austrian Society of Gynaecology and Obstetrics (ÖGGG) and the Swiss Society of Gynaecology and Obstetrics (SGGG). The guideline contains evidence-based information and recommendations on indications, complications, methods and care associated with delivery by caesarean section for all medical specialties involved as well as for pregnant women. Methods This guideline has adapted information and recommendations issued in the NICE Caesarean Birth guideline. This guideline also considers additional issues prioritised by the Cochrane Institute and the Institute for Research in Operative Medicine (IFOM). The evaluation of evidence was based on the system developed by the Scottish Intercollegiate Guidelines Network (SIGN). A multi-part nominal group process moderated by the AWMF was used to compile this S3-level guideline. Recommendations Recommendations on consultations, indications and the process of performing a caesarean section as well as the care provided to the mother and neonate were drawn up.

An Evidence-Based Guideline on Pain Assessment in Nursing Homes For Residents and Informal Caregivers

BACKGROUND

Nursing home residents are often affected by pain. Pain assessment aims to determine pain intensity and quality. An evidence-based guideline on pain assessment in nursing homes was developed to support residents and informal caregivers in archiving an adequate pain assessment prerequisite to pain treatment.

AIM

The residents' guideline presents key recommendations that is comprehensible and accessible to residents and informal carers.

DESIGN

We conducted a content analysis.

SETTING/SUBJECTS

Therefore, all recommendations of an evidence-based guideline for pain assessment in nursing home were evaluated on relevance for supporting residents' decision-making process.

METHODS

Two researchers conducted the content analysis independently and as a result, 29 recommendations could be included. In addition, representatives of a support-group organization for patients with pain validated the derived recommendations.

RESULTS

The present residents' guideline of pain assessment consists of nine thematic categories, written in laymen's terms to enable older persons to make informed choices and optimizing their own pain management process.

CONCLUSIONS

The Guideline is available in print format and ready for implementation to enhance the effects on maintaining the physical and psychological well-being and optimal care of older adults in Nursing Homes.

Pain in older adults with dementia : A survey across Europe on current practices, use of assessment tools, guidelines and policies

BACKGROUND

We aimed to explore the existing use of pain assessment tools and guidelines, and develop understanding of the practical considerations required to facilitate their use within the nursing home, hospital and community settings.

METHODS

A self-administered web-based survey was conducted with nurses, health and social care workers with an interest in the assessment of pain in older adults with cognitive impairment. The survey was distributed to participants in Austria, Belgium, Denmark, Germany, The Netherlands, Switzerland and United Kingdom.

RESULTS

Only a minority of staff reported use of (inter-)national or local standards or specific pain assessment tools in daily practice. A range of tools were reported as being used, which varied across country. While participants generally reported that these pain assessment tools were easy/very easy to use, many participants reported that they were difficult to interpret. Assessment is generally performed whilst providing nursing care. This was highlighted in 70-80% of all participating countries. While many of these tools rely on facial expression of pain, facial expressions were considered to be the least useful in comparison to other items. Furthermore findings showed that nurses employed in long-term care settings did not feel that they were educated enough in pain assessment and management.

CONCLUSION

Our findings suggest that pain education is required across all countries surveyed. This should include a focus on guidelines and standards for assessment and subsequent management of pain. Findings suggest that clinical staff find interpreting facial expressions in relation to pain more difficult.

Drug-based pain management for people with dementia after hip or pelvic fractures: a systematic review

Background

Studies indicate that people with dementia do not receive the same amount of analgesia after a hip or pelvic fracture compared to those without cognitive impairment. However, there is no systematic review that shows to what extent drug-based pain management is performed for people with dementia following a hip or pelvic fracture.

The aim of this systematic review was to identify and analyse studies that investigate drug-based pain management for people with dementia with a hip or pelvic fracture in all settings. Treatment could be surgical or conservative. We also analysed study designs, methods and variables, as well as which assessments were applied to measure pain management and mental status.

Method/design

The development of this systematic review protocol was guided by the PRISMA-P requirements, which were taken into consideration during the review procedures. MEDLINE, EMBASE, CINAHL, Web of Knowledge and ScienceDirect were searched. Studies published up to January 2016 were included. The data extraction, content and quantitative descriptive analysis were carried out systematically, followed by a critical appraisal.

Results

Eight of the 13 included studies focusing on patient data showed that people with dementia received less drug-based pain management than people without cognitive impairment. Four studies based on surveys of healthcare professionals stated that cognitive impairment is a major barrier for effective pain management. There was heterogeneity regarding the assessment of the mental status and the pain assessment of the patients. The assessment of the drugs administered in all of the studies working with patient data was achieved through chart reviews.

Conclusion

People with dementia do not seem to receive the same amount of opioid analgesics after hip fracture as people without cognitive impairment. There is need to enhance pain assessment and management for these patients. Future research should pay more attention to the use of the appropriate items for assessing cognitive impairment and pain in people with dementia.

Trial registration

This systematic review was registered at Prospero (CRD42016037309); on 11 April 2016, and the systematic review protocol was published (Syst Rev. 5(1):1, 2016).

Drug-based pain management in people with dementia after hip or pelvic fractures: a systematic review protocol

BACKGROUND

Studies show that people with dementia do not receive the same amount of analgesia after a hip or pelvic fracture compared to those without cognitive impairment. However, there is no systematic review that shows to what extent and how drug-based pain management is performed for people with dementia following a hip or pelvic fracture. The aim of this systematic review is to identify studies addressing drug-based pain management for people with dementia who have had a hip or pelvic fracture for which they had either an operation or conservative treatment. We will analyse to what extent and how the drug-based pain treatment for people with dementia is performed across all settings and how it is assessed in the studies.

METHODS

The development of this systematic review protocol was guided by the PRISMA-P requirements, which will be taken into consideration during the review procedure. MEDLINE, EMBASE, CINAHL, Web of Knowledge and ScienceDirect will be searched, using keywords such as "analgesia", "dementia", "cognitive impairment", "pain treatment", "hip fracture" or "pelvic fracture". Publications published up to January 2016 will be included. The data extraction and a content analysis will be carried out systematically, followed by a critical appraisal.

DISCUSSION

This review will provide a valuable overview on the current evidence on drug-based pain management for PwD in all settings who were conservatively treated after a hip or pelvic fracture. The review may expose a need to enhance pain management for PwD. It may also provide motivation for healthcare providers and policymakers to give this topic their attention and to facilitate further research by considering aspects of care transitions in all settings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016037309.

[Diagnostics of pain in old age. Perspectives on a multidimensional phenomenon]

Old people's experience of pain differs markedly from that of younger people. Old people not only suffer from pain more often but also the pain is predominantly chronic in nature. In many cases older patients experience pain from more than one cause at any time due to multimorbidity. Against this backdrop this article examines the question of how diagnostic procedures of pain have to be specific for older patients and how these requirements are currently met in clinical practice. Diagnostic procedures in older persons need to be rooted in a biopsychosocial understanding of pain that also takes into account that the pain experience is always made up of several pain dimensions. A comprehensive understanding of pain communication also has to be taken into account as well as age-specific influences. In older persons pain assessment needs to encompass motivational affective, sensory discriminative and cognitive evaluative aspects. If pain assessment is limited to pain severity or the observation of pain behavior only, important information is lacking and important biographical, health-related, phenomenological and care-specific information cannot be used for the benefit of the patient. Different dimensions of pain cannot be used variably but need to be regarded as complementing elements; however, this approach is currently not always possible to follow through in clinical practice especially with age-related illnesses, such as dementia. Currently, only the geriatric pain interview (Geriatrisches Schmerzinterview) is available as a multidimensional tool for the assessment of pain in older people. There is a clear need for more and extended research and development of tools and processes to comprehensively assess pain in older persons.

Experiences of nursing staff using dementia-specific case conferences in nursing homes

BACKGROUND

Dementia specific-case conferences with the Innovative dementia oriented assessment tool (CC-IdA) could be an important tool with which to analyze and manage challenging behavior. The study gives an insight into nursing staff' experiences using CC-IdA in dementia care.

METHODS

Qualitative interviews were conducted with 18 nursing teams from 12 nursing homes alongside a quasi-experimental study. In addition, observational field notes were taken. Interviews and observational field notes were analyzed using the thematic content analysis.

RESULTS

CC-IdA contributed to a reflective handling of challenging behavior, to changes in the communication with residents and to the identification of potentially triggers of challenging behavior. Factors influencing the implementation of CC-IdA were among others a lack of moderation skills, limited knowledge of dementia, a lack of biographical information and a lack of involvement by other professionals.

CONCLUSIONS

CC-IdA represents an important tool in the management of challenging behavior of people with dementia. For the successful implementation of these case conferences, both structural and personal resources are needed.

[The pain situation for residents of nursing homes. Results of a study in Münster]

BACKGROUND

Little is known about the phenomenon of pain in German nursing homes. In particular, it is unknown to what extent and severity pain occurs among residents and how their pain can be described.

MATERIAL AND METHODS

A total of 13 nursing homes located in the city of Münster, Germany, were included as part of the health services research project "Action Alliance Pain-free City Münster." Data were collected from 436 residents over 65 years old via self-report or the observational pain tool pain assessment in advanced dementia, german version (PAINAD-G), according to the cognitive status of the residents.

RESULTS

At the time of the interview, the majority of the residents questioned reported suffering from pain at rest and/or during movement. Approximately one quarter of residents complained about moderate to intolerable pain at rest and nearly 45% during movement. Residents encountered pain most often when standing up, sitting, resting in bed and walking and three quarters of residents had suffered from pain for more than 1 year. Many residents experienced pain in several body regions. Among residents assessed solely by the observational pain scale PAINAD-G, signs indicating pain existed in 21% (≥ 6) or 69% (≥ 2), respectively, depending on the cut-off value chosen on the PAINAD-G scale.

CONCLUSION

Pain in nursing homes is a challenge that needs more attention as it has considerable negative consequences for the persons concerned. The extent of pain in the studied facilities indicates an urgent need for action on the part of all professionals caring for residents in nursing homes.

[Improvement of oral health care in geriatric care by training of nurses and nursing assistants for the elderly]

Because oral health among residents of German nursing homes is inadequate, this intervention study evaluated the effects of dental training for nurses and nursing assistants (RN and RA) in homes for the elderly on their assessment of oral health in residents and, as a consequence, on the status of residents' oral health. 53 residents and the RNs and RAs from three homes for the elderly participated in this study. The nursing staff received training in dental health care. As primary outcome, the competence in performing the Brief Oral Health Examination (BOHSE) was measured at baseline date and four months after training. Additional outcome measures were dental and denture hygiene in residents, functional status of dentures, and treatment needs. Dental training was shown to improve the nursing staff's competences in oral health assessment in tendency. Residents' oral hygiene improved significantly, whereas no relevant effects on hygiene and functional status of dentures were registered. The need for dental treatment turned out to be considerable at both measurements. Modifications in test tools with identification of dental treatment needs seem to be indicated in order to improve cooperation between nursing staff and dentists in homes for the elderly.

[Health services research project "action alliance pain-free city Münster" : Objectives and methods]

Inadequate pain care in health care facilities is still a major concern. Due to structural and organizational shortcomings the potential of modern analgesia is far from being exhausted. The project "Action Alliance Pain-free City Münster" is designed to analyze the multiprofessional pain management in health care facilities in the model City of Münster in an epidemiologic study and aims to optimize pain management in accordance with nursing standards and medical guidelines. Hospitals, nursing homes, outpatient nursing services, hospices and pain care centers will be examined. After an analysis of the current state on the basis of a pre-test, the necessary optimization measures will be developed and implemented. Subsequently, the pain management will be reevaluated in a post-test. In partly still unexplored health care areas of Germany, epidemiologic data will be generated, barriers to the implementation of standards and guidelines revealed and measures of improvements developed and tested. In addition, interface problems between the evaluated sectors will be identified. In this article the objective and the methods of the project are described.