Development of a clinical pathway for behavioural and psychological symptoms of dementia care: A tool to improve resident outcomes.

OBJECTIVES: Clinical pathways are used to improve the quality of care, reduce variation and maximise health or treatment outcomes in selected populations. The aim of this study was to develop a draft clinical pathway based on the best practice evidence for use in the management of behavioural and psychological symptoms of dementia (BPSD) in residential aged care facilities (RACFs). METHODS: The pathway was developed using the best practice evidence from clinical practice guidelines, operational guides and a systematic literature review. A multidisciplinary team of health professionals and researchers worked in an iterative process to contextualise the proposed pathway to local needs and context, and improve its clarity and user-friendliness. The pathway was then re-assessed for accuracy and adherence to the evidence. RESULTS: The draft pathway outlines processes for BPSD prevention, watchful waiting for mild-to-moderate BPSD, and specific interventions for severe BPSD. Ongoing risk assessment is required throughout, and non-pharmacological options are first-line interventions. Person-centred care was found to be an important care component across all three phases. An instruction guide with colour-coded flow charts was developed to assist staff with determining the best care and treatment for each person living with dementia. Feasibility testing is underway. CONCLUSIONS: A draft clinical pathway based on clinical practice guidelines was developed to enhance the translation of evidence into practice for the management of BPSD, by nursing and clinical leaders in RACFs.

Clinical pathways for the evidence-based management of behavioural and psychological symptoms of dementia in a residential aged care facility: A rapid review.

OBJECTIVES: We aimed to identify a clinical pathway, or practice guidelines to inform a clinical pathway, for the management of behavioural and psychological symptoms of dementia (BPSD) in residential aged care facilities (RACFs). METHODS: Fifteen evidence sources were searched, and publications were appraised for methodological quality. RESULTS: Seven publications met the inclusion criteria, but no clinical pathways were found. These publications emphasised prevention via respectful, person-centred care; non-pharmacological interventions prioritised; and potential dangers of antipsychotic use. Pharmacological management was only recommended: when there is a high risk of harm; as a short-term option, to be regularly monitored and discontinued as soon as possible; and used in conjunction with investigation into the causes of BPSD and the introduction of non-pharmacological therapies. CONCLUSION: This rapid review provided high-quality, current guidelines and recommendations on the prevention and management of BPSD that can inform the development of an evidence-based clinical pathway for use in Australian RACFs.

Ensuring healthy skin as part of wound prevention: an integrative review of health professionals' actions.

OBJECTIVE: To provide a synthesis of the best available, recent primary or secondary research evidence on early preventative activities taken to increase skin health, and reduce the incidence of facility-acquired skin tears and pressure ulcers (PUs) in community, residential and health-care institutions. METHOD: An integrative review focusing on a 10-year period, 2007-2017. A literature search of health databases was carried out, as well as a search of grey literature in relevant skin, wound care and nursing association journals. A second search was also conducted focused on literature from policy and guideline development organisations. Primary outcomes of interest were reduction in dry skin (xerosis), friable skin, or increases in healthy skin maintenance activities. Secondary outcomes of interest were reductions in PU or skin tear occurrences. Opinion, non-systematic literature reviews and discussion papers were excluded. RESULTS: Of the 4932 references obtained from the searches, a total of 33 articles were included in the review: 27 peer-reviewed journal articles and six articles from the grey literature search. No guideline was found that focused on maintaining skin health as a person ages. Studies identified the main factors for maintaining skin health as nutrition, hydration and skin care regimen. CONCLUSION: Skin care regimens, including a focus on good nutrition and pH balance, should start immediately on arrival in institutions such as hospitals or residential aged care, and continue throughout the stay.

Education and process change to improve skin health in a residential aged care facility.

We report on an intervention and evaluation in relation to changes in staff knowledge, time spent on healing and wound prevention and proportion of wounds in the facilities before and after. A rapid review of recent peer-reviewed literature (2006-2016) found 14 education-based intervention articles and provided the background and context for this intervention. A cohort of 164 nurses and personal care workers and 261 residents at two aged care-approved facilities contributed to this intervention on the effect of education, mentoring and practice change on staff knowledge and wound prevalence between 2015 and 2016. There was a significant decrease in pressure injury prevalence and an increase in the early identification of potential wounds between phase 1 and 3 across the two facilities. Overall, registered nurses and enrolled nurses showed significant increase in mean knowledge scores. There was a reorganisation of time spent on various wound care and prevention strategies that better represented education and knowledge. Wound management or prevention education alone is not enough; this study, using an educational intervention in conjunction with resident engagement, practice change, mentorship, onsite champions for healthy skin and product choice suggestions, supported by an organisation that focuses on a healthy ageing approach, showed improvement across two residential sites.