Relationship of nursing home staffing to quality of care

OBJECTIVE

To compare nursing homes (NHs) that report different staffing statistics on quality of care.

DATA SOURCES

Staffing information generated by California NHs on state cost reports and during onsite interviews. Data independently collected by research staff describing quality of care related to 27 care processes.

STUDY DESIGN

Two groups of NHs (n=21) that reported significantly different and stable staffing data from all data sources were compared on quality of care measures.

DATA COLLECTION

Direct observation, resident and staff interview, and chart abstraction methods.

PRINCIPAL FINDINGS

Staff in the highest staffed homes (n=6), according to state cost reports, reported significantly lower resident care loads during onsite interviews across day and evening shifts (7.6 residents per nurse aide [NA]) compared to the remaining homes that reported between 9 to 10 residents per NA (n=15). The highest-staffed homes performed significantly better on 13 of 16 care processes implemented by NAs compared to lower-staffed homes.

CONCLUSION

The highest-staffed NHs reported significantly lower resident care loads on all staffing reports and provided better care than all other homes.

The epidemiology of prostate cancer in Jamaica

PURPOSE

Before this study, the highest reported incidence of prostate cancer in the world was thought to be among United States black men. The age adjusted rates in 1992 for United States black and white men were 249 and 182/100,000 respectively. The epidemiology of prostate cancer in Jamaica, a country of 2.5 million people of primarily African descent, was studied and compared with that of white and black Americans.

MATERIALS AND METHODS

The study included 1,121 cases of prostate cancer diagnosed from 1989 to 1994. Sources of information included the Jamaican Cancer Registry, government pathology laboratory, hospital and clinic records, and physician office records. Incidence rates were computed using data from the 1991 Jamaican census. Age adjustments were made using the 1970 United States standard population.

RESULTS

The average age adjusted incidence of prostate cancer in Kingston, Jamaica was 304/100,000 men. Median patient age at diagnosis was 72 years. More than 80% of the cases were pathologically confirmed. Of the patients 30% presented with acute urinary retention, 16% presented with bone metastases, 15% had gross hematuria at the time of diagnosis and an abnormal rectal examination suspicious for cancer was noted in 42%. Prostate specific antigen was measured in only 7% of cases in 1989 but in 48% of cases by 1994.

CONCLUSIONS

These data demonstrate that Jamaican men in Kingston have a high incidence of prostate cancer, much higher than even black Americans during a similar period. Furthermore, the cancers are more significant clinically with greater morbidity in Jamaica than in the United States.

The minimum data set pressure ulcer indicator: does it reflect differences in care processes related to pressure ulcer prevention and treatment in nursing homes?

OBJECTIVES

To determine whether nursing homes (NHs) that score in the extreme quartiles of pressure ulcer (PU) prevalence as reported on the Minimum Data Set (MDS) PU quality indicator provide different PU care.

DESIGN

Descriptive, cohort.

SETTING

Sixteen NHs.

PARTICIPANTS

Three hundred twenty-nine NH residents at risk for PU development as determined by the PU Resident Assessment Protocol of the MDS.

MEASUREMENTS

: Sixteen care process quality indicators (10 specific to PU care processes, five related to nutrition, and one related to incontinence management) were scored using medical record data, direct human observation, interviews, and data from wireless thigh movement monitors.

RESULTS

There were no differences between homes with low- and high-PU prevalence rates reported on the MDS PU quality indicator on most care processes. NHs with high PU prevalence rates used pressure-reduction surfaces more frequently and were better at documentation of four wound characteristics when PUs were present. No measure of PU care processes was better in low-PU NHs. Neither low- nor high-PU prevalence NHs routinely repositioned residents every 2 hours, even though 2-hour repositioning was documented in the medical record for nearly all residents.

CONCLUSION

The assumption that homes with fewer PUs and thus low PU prevalence according to the MDS PU quality indicator are providing better PU care was not supported in this sample. NHs that scored low on the MDS PU quality indicator did not provide significantly better care than NHs that scored high. All NHs could improve PU prevention, as evidenced by the poor performance on prevention care processes by low- and high-PU NHs. The MDS PU quality indicator is not a useful measure of the quality of PU care in NHs and can be misleading if not presented with an explanation of the meaning of the indicator.

The effect of low and ultra-low dosages Thymoglobulin on peripheral T, B and NK cells in kidney transplant recipients

INTRODUCTION

Rabbit Anti-Thymocyte Globulin (r-ATG) is a polyclonal antibody preparation, used to prevent and treat acute rejection episodes after organ transplantation. However, despite more than 40 years of clinical use, the optimal dose of r-ATG is still not defined. To find a better balance between efficacy and infectious complications, we embarked on a controlled study and monitored the effect of low and ultra-low dosages Thymoglobulin (Genzyme) on peripheral T, B, and NK cells.

PATIENTS AND METHODS

Kidney transplant recipients received either 0.5 mg/kg, 1.0 mg/kg or 2.0 mg/kg on the first 3 consecutive days post-transplantation. Thus, total doses were 1.5 mg/kg, 3.0 mg/kg and 6.0 mg/kg. A total of 40 patients were enrolled, including 11 controls. All patients were treated with Prednisolon, Advagraf (Astellas) and Mycophenolate Mofetil (Roche). T (CD3+), B (CD19+) and NK (CD3-CD16+56+) cells were analyzed by flow cytometry. Baseline cell counts were compared to forty age and sex matched healthy persons. Post-transplantation cell counts of the 3 Thymoglobulin groups were compared to the 11 control patients, who received no induction therapy.

RESULTS

Absolute numbers of T, B, and NK cells were comparable in all patients pre-transplantation, but T and B cells were lower than in healthy persons (p=0.007 and p=0.0003, Mann Whitney test). In the first week, T cells and NK cells were significantly lower in all Thymoglobulin groups compared to controls. B cells were not affected. One month after Thymoglobulin NK cells had returned to control numbers in all groups, while T cells had already recovered to control counts in the 1.5 mg/kg group. During follow-up, T cells in the 3.0mg/kg group also returned to control values, but at one year the patients in the 6.0 mg/kg group still had significantly lower T cells (p=0.03). Patient and graft survival, rejection and infection incidence and renal function did not differ between groups.

CONCLUSION

Patients with end stage renal disease have significantly lower peripheral T and B cell counts than healthy persons. (Ultra-) low Thymoglobulin schedules deplete peripheral lymphocytes in a dose dependent way. Knowledge of the duration of this depletion contributes to finding the optimal immunosuppressive strategy for kidney transplant recipients.

The Minimum Data Set Bedfast Quality Indicator

BACKGROUND

Excessive time in bed has negative effects on both physical conditioning and functioning. There are no data or practice guidelines relevant to how nurses should manage the in-bed times of nursing home residents, although all nursing homes receive a bedfast prevalence quality indicator report generated from the Minimum Data Set.

OBJECTIVES

To compare nursing homes that score in the upper and lower quartiles on the Minimum Data Set bedfast prevalence quality indicator for proportion of bedfast residents, activity and mobility nursing care, and amount of time all residents spend in bed, and to evaluate whether residents who spend more time in bed are different from those who spend less time in bed according to functional measures.

METHODS

A cohort design used medical records, resident interviews, and direct observation data to compare 15 nursing homes (n = 451 residents) on the proportion of bedfast residents, the amount of time residents spent in bed, the frequency of activity, and the scores on six activity and mobility care process indicators.

RESULTS

Significant differences were found between upper (i.e., higher prevalence of bedfast residents) and lower quartile nursing homes in the proportion of time residents were observed in bed (43% vs. 34%, respectively; p =.007), and in the proportion of residents who spent more than 22 hours in bed per day (18% vs. 8%, respectively; p =.002). All nursing homes underestimated the number of bedfast residents. The residents of upper quartile homes showed more activity episodes and reported receiving more walking assistance than the residents of lower quartile homes.

DISCUSSION

Minimum Data Set bedfast quality indicator identified nursing homes in which residents spent more time in bed, but did not reflect differences in activity and mobility care. In fact, upper quartile homes provided more activity and mobility care than lower quartile homes. Across all the nursing homes, most of the residents spent at least 17 hours a day in bed. Further study of activity and mobility care and bedfast outcomes in nursing homes is needed, and nurses need to note the amount of time nursing home residents spend in bed.

The Minimum Data Set Prevalence of Restraint Quality Indicator: Does It Reflect Differences in Care?

PURPOSE

This study investigated whether the use of restraining devices and related measures of care quality are different in nursing homes that score in the upper and lower quartiles on the Minimum Data Set (MDS) "prevalence of restraint" quality indicator, which assesses daily use of restraining devices when residents are out of bed.

DESIGN AND METHODS

The study was a cross-sectional study, with 413 residents in 14 nursing facilities. Eight homes scored in the lower quartile (25th percentile; low prevalence, 0-5%) on the MDS restraint prevalence quality indicator, and six homes scored in the upper quartile (75th percentile; high prevalence, 28-48%). Eight care processes related to the management of restraints and gait and balance problems were defined and operationalized into clinical indicators. Research staff conducted direct observations during three 12-hr days (7 a.m.-7 p.m.) to determine the prevalence of restraining devices and identify resident and staff behaviors that may be affected by restraint use.

RESULTS

Residents in high-restraint homes were in bed during the day on more observations than residents in low-restraint homes (44% vs. 33%; p <.001), were more frequently observed with bed rails in use (74% of residents vs. 64% of residents; p <.03), and received less feeding assistance during meals (2.7 min vs. 4.1 min; p <.001). There were no differences between homes in the use of out-of-bed restraints, nor were there any differences on any care process measure related to the management of restraints, gait and balance problems, or measures of physical or social activity.

IMPLICATIONS

A home's score on the MDS-generated prevalence of restraint quality indicator was not associated with differences in the use of restraints, physical activity, or any care process measure when residents were out of bed. However, there were differences in the use of in-bed restraining devices, and residents in high-restraint homes were in bed more often during the day. These differences were associated with poor feeding assistance and reflect important differences in quality of care between homes, even though these differences are not what the restraint prevalence quality indicator purports to measure. Methods to monitor and improve the quality of care related to exercise, in-bed times, and resident freedom of movement are discussed.

Standardized quality-assessment system to evaluate pressure ulcer care in the nursing home

OBJECTIVES

To demonstrate reliability and feasibility of a standardized protocol to assess and score quality indicators relevant to pressure ulcer (PU) care processes in nursing homes (NHs).

DESIGN

Descriptive.

SETTING

Eight NHs.

PARTICIPANTS

One hundred ninety-one NH residents for whom the PU Resident Assessment Protocol of the Minimum Data Set was initiated.

MEASUREMENTS

Nine quality indicators (two related to screening and prevention of PU, two focused on assessment, and five addressing management) were scored using medical record data, direct human observation, and wireless thigh monitor observation data. Feasibility and reliability of medical record, observation, and thigh monitor protocols were determined.

RESULTS

The percentage of participants who passed each of the indicators, indicating care consistent with practice guidelines, ranged from 0% to 98% across all indicators. In general, participants in NHs passed fewer indicators and had more problems with medical record accuracy before a PU was detected (screening/prevention indicators) than they did once an ulcer was documented (assessment and management indicators). Reliability of the medical record protocol showed kappa statistics ranging from 0.689 to 1.00 and percentage agreement from 80% to 100%. Direct observation protocols yielded kappa statistics of 0.979 and 0.928. Thigh monitor protocols showed kappa statistics ranging from 0.609 to 0.842. Training was variable, with the observation protocol requiring 1 to 2 hours, medical records requiring joint review of 20 charts with average time to complete the review of 20 minutes, and the thigh monitor data requiring 1 week for training in data preparation and interpretation.

CONCLUSION

The standardized quality assessment system generated scores for nine PU quality indicators with good reliability and provided explicit scoring rules that permit reproducible conclusions about PU care. The focus of the indicators on care processes that are under the control of NH staff made the protocol useful for external survey and internal quality improvement purposes, and the thigh monitor observational technology provided a method for monitoring repositioning care processes that were otherwise difficult to monitor and manage.

Characterization of a Trypanosoma brucei SR domain-containing protein bearing homology to cis-spliceosomal U1 70 kDa proteins

The protozoan parasite Trypanosoma brucei relies on trans-splicing of a common spliced leader (SL) RNA to maturate mRNAs. Using the yeast two-hybrid system a protein (TSR1IP) was identified that interacts with the T. brucei serine-arginine (SR) protein termed TSR1. TSR1IP shows homology to U1 70 kDa proteins, and contains an SR rich domain as well as an acidic/arginine domain homologous to the U1 70 kDa poly(A) polymerase inhibiting domain. This protein is localized in the nucleoplasm and excluded from the nucleolus in trypanosomal bloodstream and procyclic forms. Based on structural modelling predictions and on the identification of a RNA recognition motif (RRM), it was possible to demonstrate by the yeast three-hybrid system that TSR1IP interacts with the 5' splice region of the SL RNA. All the above characteristics suggest that TSR1IP could be involved in trans-splicing.

Initial development and validation of a mitochondrial disease quality of life scale

Mitochondrial diseases are a clinically diverse group of genetic disorders that often present to neurologists. Health related quality of life (HRQOL) is increasingly recognised as a fundamental patient based outcome measure in both clinical intervention and research. Generic outcome measures have been extensively validated to assess HRQOL across populations and different disease states. However, due to their inclusive construct, it is acknowledged that not all relevant aspects of a specific illness may be captured. Hence there is a need to develop disease specific HRQOL measures that centre on symptoms characteristic of a specific disease or condition and their impact. This study presents the initial conceptualisation, development and preliminary psychometric assessment (validity and reliability) of a mitochondrial disease specific HRQOL measure (Newcastle Mitochondrial Quality of life measure (NMQ)). NMQ is a valuable assessment tool and consists of 63 items within 16 unidimensional domains, each demonstrating good internal reliability (Cronbach's α≥0.83) and construct validity.

Improving end-of-life care in nursing facilities: the Community State Partnership To Improve End-of-Life Care--California

BACKGROUND

The California Coalition for Compassionate Care formed in 1998 when activists and organizational leaders in several arenas sought to link their efforts for synergistic impact on end-of-life care and to obtain funding to sustain their forward momentum and collaboration. The Coalition focused on public engagement, professional education, and reforms in skilled nursing facilities. With skilled nursing facilities, the Coalition's work built on the efforts of the ECHO (Extreme Care, Human Options) Long Term Care Task Force, which served as a precursor to the Coalition.

OBJECTIVE

The Coalition's objective was to assist committed facilities in devising processes of care that would operationalize basic end-of-life care principles in a manner specific to their particular facility.

DESIGN

The Coalition recruited three-member leadership teams from nursing facilities throughout California to attend a 2-day training program, write an action plan, and receive 6 months of modest follow-up support. To assess its success, the group used posttraining evaluations, a follow-up evaluation, a focus group, and informal feedback over several years to assess the dynamics, achievements, and challenges of their efforts.

RESULTS

In 2000-2002 the training reached 298 people representing 109 nursing facilities and each district office of the nursing facility surveyors. Response to the training was enthusiastic. Self-reported improvements in 27 care practices were best in the areas of pain assessment and management. Completion of nursing facilities' self-identified action plans varied widely. Participants generally perceived the commitment to improving end-of-life care as a vehicle for improving the overall care and quality management in nursing facilities.

CONCLUSIONS

The specific challenges of organizational change in nursing facilities require sustained, focused leadership and hands-on guidance to overcome the inevitable barriers and setbacks. The Coalition's experience confirms that coalitions depend upon personal commitments and relationships, a focus on practical products, and a consistent infrastructure.

Frequency and impact of high-resolution monitor failure in a filmless imaging department

The purpose of this study was to assess the image quality and the rate of failure of the high-resolution (2,048 x 1536 pixel) monitors used for primary diagnosis in a filmless radiology department and to analyze the type of problems encountered as well as the action taken to repair the monitors. Data were collected from Picture Archival and Communication System (PACS) service logs to determine rates of monitor adjustment and replacement, the symptoms reported, and the action taken. Additionally, random surveys of the high-resolution monitors were performed using a standard test pattern to assess spatial and contrast resolution in the center and outer corners of the monitors. Analysis of monitor service records showed a high rate of monitor replacement (41% per year) resulting in a relatively short "life expectancy" (defined as average time required before replacement) of 2.4 years. Random surveys of monitor quality using a standard test pattern showed suboptimal image quality in approximately 54% of the monitors with moderate image quality degradation present in at least one region of 27% of the high-resolution monitors, despite our vendor's quality control program. The results of this study support our subjective impression and those of other colleagues in the PACS community of an unacceptably high monitor failure rate and persistent image quality problems with 2,000 pixel monitors used for primary diagnosis. The relatively high incidence of suboptimal quality monitors suggests that more frequent quality control should be performed using a test pattern particularly given the fact that radiologists often are unable to discern degradation of monitor performance using clinical images. The high incidence of problems with image quality on high-resolution monitors indicates that vendors need to develop better quality control in monitor design and testing. Radiologists should review briefly a test pattern on each monitor at the beginning of each day. A computer program should be incorporated into the PACS, which asks radiologists to evaluate a test pattern and records the results in a central database, which is communicated to the service engineers. Further studies should be evaluated to determine the clinical impact of monitor image degradation, which is relatively easily seen using a test pattern but may be difficult to discern on clinical images. Requests for proposals (RFPs) for PACS and service contracts must specify carefully requirements for monitor image quality and conditions under which the vendor is required to replace these monitors.

Culture-broker and medical decoder: contributions of caregivers in American Indian cancer trajectories

BACKGROUND

Caregivers play a special role in the management and control of cancer-related pain. For American Indians with cancer, caregivers can contribute to patient education, medication compliance, and can facilitate communication between the patient and the provider and the patient and the family.

OBJECTIVE

To identify the role(s) of caregivers of American Indian cancer survivors.

METHODS

As a part of a large randomized intervention designed to improve barriers to cancer symptom management, 13 focus groups were held among American Indian cancer survivors and their caregivers at Southwest reservations and urban sites. Focus groups, audiotaped and transcribed, used constant comparative methods in the analysis of caregiver dialogues.

RESULTS

Caregivers are patient educators and provider culture-brokers and their communication strategies use a combination of cultural and conventional strategies in their care of American Indian cancer patients. Cultural communication styles include "talk stories" (storytelling), group (talking circles), and dialogue to manage cancer pain, educate the patient and community, and to protect the patient from stigma, reduce barriers to care, and provide support to patients and families. Active discussion with providers "re-packaged" the patient's reporting/responses to specific clinical measures (pain measure scores) and identified the need for pain medication and compliance-related issues.

LIMITATIONS

Findings are not generalizable to the American Indian population outside of the sites and focus groups from which data were collected.

CONCLUSIONS

Caregivers are "cultural brokers" who inform providers of the cultural nuances associated with American Indian patient care. However, caregivers voiced that cultural restriction for not discussing illness openly was a sanction and an important barrier.

Evaluation of the Nurses Caring for Older Adults Young Scholars Program

There is a "perfect storm" brewing in nursing. We are faced with a growing number of older patients, while at the same time nurses with expertise in gerontological nursing are aging and retiring. This critical shortage is most evident for nurses with research-intensive preparation needed to replenish actual and anticipated nurse faculty vacancies across the United States, especially those in underrepresented minority groups. We describe one solution to this problem; the Nurses Caring for Older Adults Young Scholars Program (YSP) that selects promising, ethnically diverse students and offers them a 1- to 3-year mentorship experience with the focus on students continuing to PhD studies on completion of their basic nursing studies. The YSP has mentored 15 prelicensure students with an identified interest in gerontological nursing research, with 8 young scholars (53%) going on to pursue doctoral studies. Program elements are described as well as philosophical and practical challenges of program implementation. Formative evaluations including student and faculty perceptions of the program as well as summative evaluation including admission success rate, student products, and progression in the doctoral program are discussed. Students indicate that establishing a strong mentor relationship with opportunities to participate in their mentor's research activities leading to the generation of a commitment to a research topic is the strongest factor in young scholars following through with enrollment into a doctoral program. A synergistic outcome of the YSP was the development of a critical mass of students interested in pursuing PhD studies that further extended the impact of the program.

Predictors of Pain Management among American Indian Cancer Survivors

There is little research on cancer symptom management among Indigenous populations. This paper reports on the predictors of cancer pain management among American Indian cancer patients/survivors and their caregivers/family. The intervention was a symptom management toolkit delivered via traditional talking circles vs. standard care (control) at eight randomized reservation and urban clinic sites in the Southwest. Participants (N=184) were American Indian adults diagnosed with cancer and/or caregiver/family members. The primary outcome measure collected via pre-test and post-test questionnaires was the ability to manage cancer pain. Significant differences at post-test were the ability to manage cancer-related pain (p=.02) and a close relationship (p=.0018) that proved significant for intervention participants and was instrumental in fostering their ability to manage pain. The study also showed improvement in the desire and ability to improve cancer pain management among intervention participants. Programs targeting American Indians should use culturally appropriate education to improve management of cancer-related symptoms.

We Don't Talk about It: Cancer Pain and American Indian Survivors

Pain is a common symptom among cancer survivors, yet is rarely talked about by American Indians. Understanding the reasons for reduced communication by American Indian cancer survivors is important for healthcare providers, family members, and others providing treatment and support for cancer symptoms. Thirteen focus groups with Southwest American Indian adult cancer survivors were audiotaped and transcribed as part of a randomized intervention to remove barriers to cancer symptom management. Constant comparative methods were employed in the data analysis, topic categories were grouped for comparison, and final assessment followed Grounded Theory methods. Findings were categorized into two major groupings: communication with family members and communication with health care providers. Within these two groupings, three themes emerged to describe cancer pain experiences and communication barriers: (1) We don’t talk about it, (2) Respect for healthcare providers; and (3) Culturally prohibitive topics on death and pain experiences. Not talking about their cancer diagnosis and cancer-related pain leaves many American Indian cancer survivors without much-needed social support, contributing to reduced treatment compliance and access to healthcare. Findings have implications for educational interventions and quality of life improvement for American Indian and other underrepresented communities.

Assessing Informal and Formal Diabetes Knowledge in African American Older Adults With Uncontrolled Diabetes

Some researchers attribute the excess rates of diabetes complications among African American older adults compared to other racial/ethnic subgroups to low diabetes knowledge. Diabetes knowledge measures have a biomedical orientation, including knowledge of glycemic control and using diet and exercise to control blood sugar. Measures do not assess informal knowledge that patients obtain outside of the clinical environment. The distinction between formal and informal knowledge is meaningful for cultural groups such as African American individuals who have historically transferred knowledge about maintaining their health "through the grapevine." A qualitative approach was used to understand participants' informal diabetes knowledge. Three major themes identified addressed the threat that participants perceived when diagnosed, the social construction of diabetes knowledge through their lived and observed experiences, and the limited role that clinicians played in participants' diabetes knowledge acquisition. Findings reveal ways nurses can individualize the diabetes education they provide to African American older adults based on their experiential understanding. [Journal of Gerontological Nursing, 45(2), 35-41.].

Aging, Genetic Variations, and Ethnopharmacology: Building Cultural Competence Through Awareness of Drug Responses in Ethnic Minority Elders

Unique drug responses that may result in adverse events are among the ethnocultural differences described by the Agency for Healthcare Research and Quality. These differences, often attributed to a lack of adherence on the part of the older adult, may be linked to genetic variations that influence drug responses in different ethnic groups. The paucity of research coupled with a lack of knowledge among health care providers compound the problem, contributing to further disparities, especially in this era of personalized medicine and pharmacogenomics. This article examines how age-related changes and genetic differences influence variations in drug responses among older adults in unique ethnocultural groups. The article starts with an overview of age-related changes and ethnopharmacology, moves to describing genetic differences that affect drug responses, with a focus on medications commonly prescribed for older adults, and ends with application of these issues to culturally congruent health care.

Recognizing hospital-acquired disability among older adults

Approximately one third of hospitalized older adults develop a new disability by discharge, which places them at risk for readmission, institutionalization, and death. Various risk factors, both modifiable and nonmodifiable, coalesce in the acute care setting. As frontline health care providers, nurses are crucial to the process of altering modifiable risk factors by assessing patients’ risk for functional decline during hospitalization using a standardized instrument and treating risk with evidence-based interventions. Barriers to meeting this goal must be overcome, such as a lack of evidence to recommend use of one functional assessment tool over another, as well as the paucity of evidence-based interventions. Other obstacles such as the tacit acceptance of functional decline by health care providers and a lack of resources for mobilizing older adults contribute to the ongoing problem. Nurses are encouraged to develop new innovations to prevent the widespread and frequently untreated problem of hospital-acquired disability.

WITHDRAWN: Goat serum product "Aimspro" restores conduction in demyelinated human optic nerve fibres

Ahead of Print article withdrawn by publisher.