Strategies to Improve Emergency Transitions from Long-Term Care Facilities: A Scoping Review.

BACKGROUND AND OBJECTIVES: Older adults residing in residential aged care facilities (RACFs) often experience sub-standard transitions to emergency departments (EDs) through rationed and delayed ED care. We aimed to identify research describing interventions to improve transitions from RACFs to EDs. RESEARCH DESIGN AND METHODS: In our scoping review, we included English language articles that 1) examined an intervention to improve transitions from RACF to EDs, and 2) focused on older adults (>65 years). We employed content analysis. Dy et al.'s Care Transitions Framework was used to assess the contextualization of interventions and measurement of implementation success. RESULTS: Interventions in 28 studies included: geriatric assessment or outreach services (n=7), standardized documentation forms (n=6), models of care to improve transitions from RACFs to EDs (n=6), telehealth services (n=3), nurse-led care coordination programs (n=2), acute-care geriatric departments (n=2), an extended paramedicine program (n=1), and a web-based referral system (n=1). Many studies (n=17) did not define what 'improvement' entailed and instead assessed documentation strategies and distal outcomes (e.g., hospital admission rates, length of stay). Few authors reported how they contextualized interventions to align with care environments and/or evaluated implementation success. Few studies included clinician perspectives and no study examined resident or family/friend caregiver reported outcomes. DISCUSSION AND IMPLICATIONS: Mixed or non-significant results prevent us from recommending (or discouraging) any interventions. Given the complexity of these transitions and the need to create sustainable improvement strategies, future research should describe strategies used to embed innovations in care contexts and to measure both implementation and intervention success.

A qualitative case study of community experiences with Tungiasis in high prevalence villages of Bungoma County, Kenya: "The whole body aches and the jiggers are torturing me!"

INTRODUCTION: Tungiasis is a painful skin infection caused by a flea called Tunga Penetrans/jiggers, which enters the epidermis of humans and animals. If untreated it may result in bacterial infection, sepsis, necrosis, and disability. In Kenya, it is estimated that 4% of the population suffer from jigger infestation. The aim of this study was to contribute with knowledge about the experiences of those affected, perceived causes and local coping strategies, to improve the control and elimination of this neglected condition. METHOD: A qualitative case study research design was applied involving fieldwork in Bungoma County, a high-prevalence rural area in Western Kenya. Multiple data collection methods were combined: participant observation, home visits, semi- structured in-depth interviews, and group discussions. In total, 48 informants participated, including infected children and adults, teachers and pupils, public health officers, community health workers and NGO volunteers. RESULTS: Those infected suffered with multiple penetrating wounds on hands and feet that cause disability, resulting in an incapacity to work and school drop-out. People described feeling stigmatized, and at school pupils preferred not to play with infected classmates. People perceived that the sand flea infestation was caused by poverty and that those affected were not even able to cover their basic needs. They were often living in sandy huts that they shared with their animals, without access to soap and clean water. Moreover, those infected were often viewed as ignorant by the rest of the community. Informants perceived recurrence after treatment as inevitable, resulting in creation of hopelessness. Those infected felt that they were left alone with an irremediable plague. There was confusion about effective approaches regarding prevention and treatment at all levels. CONCLUSION: Tungiasis is a debilitating and neglected ailment, inflicting severe suffering and increasing the circle of poverty. To address fatalist attitudes among those affected, national guidelines need to be implemented, and coordination of public health measures regarding prevention and treatment need to be strengthened. Further research is recommended to enable the control and elimination of this neglected tropical disease.

Physiotherapists´ experiences with older adults´ rehabilitation trajectory after hip fracture: A qualitative study in Western Norway.

BACKGROUND: Norway reports the highest prevalence of hip fractures in the world. Physiotherapists play a key-role in rehabilitation. PURPOSE: To explore physiotherapists' experiences with rehabilitation trajectories of older adults after hip fracture across levels of care in Norway. METHODS: A case-study design combined interviews and group-discussions with 22 physiotherapists in four hospitals and 12 primary health care settings in urban and rural municipalities in 2016 and 2018. A thematic content analysis was applied. RESULTS: The physiotherapists viewed the rehabilitation trajectory after hip fracture as fragmented and poorly suited for patients with complex needs. Early hospital discharge, multiple transfers and insufficient staffing, put patients at risk of not receiving adequate services. Most at risk were patients with cognitive impairment. The physiotherapists' role and influence during the patients' rehabilitation course varied, depending on the health-care level. They viewed that current reforms and structural conditions limited the quality of geriatric care and the prioritization of patients with dementia, who risked getting no rehabilitation at all. CONCLUSION: An orthogeriatric, person-centered approach to rehabilitation after hip fracture seems beneficial. A focus on cognitive impairment is needed requiring investment and professional skills' development. Political, economic, and organizational interventions should secure that, geriatric patients receive necessary rehabilitation services.

"The midwife helped me ... otherwise I could have died": women's experience of professional midwifery services in rural Afghanistan - a qualitative study in the provinces Kunar and Laghman.

BACKGROUND: Afghanistan has one of the world's highest maternal mortality ratios, with more than 60% of women having no access to a skilled birth attendant in some areas. The main challenges for childbearing Afghan women are access to skilled birth attendance, emergency obstetric care and reliable contraception. The NGO-based project Advancing Maternal and Newborn Health in Afghanistan has supported education of midwives since 2002, in accordance with the national plan for midwifery education. The aim of this study is to explore women's experiences of professional midwifery care in four villages in Afghanistan covered by the project, so as to reveal challenges and improve services in rural and conflict-affected areas of the country. METHODS: An exploratory case-study approach was adopted. Fourteen in-depth interviews and four focus-group discussions were conducted. A total of 39 women participated - 25 who had given birth during the last six months, 11 mothers-in-law and three community midwives in the provinces of Kunar and Laghman. Data generated by the interviews and observations was analysed using thematic content analysis. FINDINGS: Many of the women greatly valued the trained midwives' life-saving experience, skills and care, and the latter were important reasons for choosing to give birth in a clinic. Women further appreciated midwives' promotion of immediate skin-to-skin contact and breastfeeding. However, some women experienced rudeness, discrimination and negligence on the part of the midwives. Moreover, relatives' disapproval, shame and problems with transport and security were important obstacles to women giving birth in the clinics. CONCLUSIONS: Local recruitment and professional education of midwives as promoted by Afghan authorities and applied in the project seem successful in promoting utilisation and satisfaction with maternal and neonatal health services in rural Afghanistan. Nevertheless, the quality of the services is still lacking, with some women complaining of disrespectful care. There seems to be a need to focus more on communication issues during the education of midwives. An increased focus on in-service training and factors promoting quality care and respectful communication is necessary and should be prioritised.

Musculoskeletal symptoms among hospital cleaners.

Studies have indicated that cleaners are at risk for musculoskeletal symptoms (MSS). In 2001, the Norwegian Labor Inspectorate suggested improvements in cleaners' work environment to reduce MSS. We estimate prevalence of MSS among cleaners in a Norwegian hospital that had implemented improvements to reduce risk of MSS and calculate relative risk of MSS among cleaners compared to a group of office workers. Data were collected from 255 participants. MSS were investigated using the Nordic Questionnaire for Analysis of Musculoskeletal Symptoms. Cleaners reported a significantly higher prevalence of MSS compared to office workers but a lower prevalence compared to similar studies among cleaners in other countries. This may indicate that working conditions in Norway are better than in other countries; further studies are needed to compare MSS and working conditions in different settings.

Gerontology across the professions and the Atlantic: Development and evaluation of an interprofessional and international course on aging and health.

The need for interprofessional teamwork and the global challenges for health care systems of dramatically increasing numbers of older adults have received increased recognition in gerontological and geriatrics education. The authors report on the pilot development of a hybrid course on aging and health for graduate-level health professions students from Norway, Canada, and the United States. International faculty from partnering universities developed, taught, and evaluated the course. Course assignments included online forum postings, reflections, and a problem-based learning group assignment and presentation. Directed readings and discussion included topics related to health care systems and services in the three participating countries, teamwork, and patient-centered care. To evaluate the course, quantitative and qualitative data were collected and analyzed. Results indicate a significant impact on student learning outcomes, including understanding of issues in international aging and health, attitudes and skills in teamwork, and application to clinical practice. This course clearly established the importance of developing innovative interprofessional educational experiences that respond to the increasingly universal impacts of aging populations on health and social care systems around the world.

Longstanding pain and social strain: patients' and health care providers' experiences with fracture management by skeletal traction; a qualitative study from Malawi.

AIM: The aim of the study is to contribute to a more holistic evidence based on lower limb fracture management in low-income settings, by exploring the perspectives of those actually experiencing and administering skeletal traction in Malawi. METHODS: The study took place at Queen Elizabeth Central Hospital in Blantyre and Kamuzu Central Hospital in Lilongwe, the two largest public hospitals of Malawi. Qualitative data were collected by participant observation, individual interviews with eight patients, two orthopedic surgeons, one physiotherapist, and two focus group discussions with multidisciplinary teams. RESULTS: Patients experienced physical and psychological pain from the prolonged traction treatment in bed. Anxiety, indignity and emotional distress in the ward environment were commonly observed. Patients emphasized the negative impact on their families and the significant economic consequences due to prolonged hospitalization. Health care providers identified the major obstacles for quality treatment due to the lack of staff, equipment, specialized knowledge and skills. Rehabilitation services were nearly absent, thus little effort was made to maintain function and enhance recovery during and after long-term bed confinement. CONCLUSION: The use of long-term skeletal traction has a devastating impact on the patients and families, and causes major frustrations to health workers involved with fracture management in a low-resource setting. Implications for Rehabilitation As stated by various health care providers, there is a need to improve trauma care, strengthen rehabilitation services and educate more rehabilitation staff so they can take up the different roles and functions required in treatment and rehabilitation after injuries and other debilitating conditions. In the current situation, sufficient pain relief for patients is required. This should go hand in hand with the empowerment of patients so as to fulfill their rights to quality health services. For health care providers, multidisciplinary teamwork, enhanced specialized education and skills, improved access to adequate equipment and developing standardized procedures appear essential in order to improve fracture management. With injuries representing a growing portion of the global burden of disease, and in the changing demographic panorama with aging populations in Africa and the world at large, injury prevention, trauma care- and rehabilitation need a stronger focus in public health globally.

Use of healthcare services by injured people in Khartoum State, Sudan.

BACKGROUND: Trauma care is an important factor in preventing death and reducing disability. Injured persons in low- and middle-income countries are expected to use the formal healthcare system in increasing numbers. The objective of this paper is to examine use of healthcare services after injury in Khartoum State, Sudan. METHODS: A community-based survey using a stratified two-stage cluster sampling technique in Khartoum State was performed. Information on healthcare utilisation was taken from injured people. A logistic regression analysis was used to explore factors affecting the probability of using formal healthcare services. RESULTS: During the 12 months preceding the survey a total of 441 cases of non-fatal injuries occurred, with 260 patients accessing formal healthcare. About a quarter of the injured persons were admitted to hospital. Injured people with primary education were less likely to use formal healthcare compared to those with no education. Formal health services were most used by males and in cases of road traffic injuries. The lowest socio-economic strata were least likely to use formal healthcare. CONCLUSIONS: Public health measures and social security should be strengthened by identifying other real barriers that prevent low socio-economic groups from making use of formal healthcare facilities. Integration and collaboration with traditional orthopaedic practitioners are important aspects that need further attention.

Socioeconomic and disability consequences of injuries in the Sudan: a community-based survey in Khartoum State.

BACKGROUND: Fatal and non-fatal injuries are of increasing public health concern globally, particularly in low and middle-income countries. Injuries sustained by individuals also impact society, creating a loss of productivity with serious economic consequences. In Sudan, there is no documentation of the burden of injuries on individuals and society. METHODS: A community-based survey was performed in Khartoum State, using a stratified two-stage cluster sampling technique. Households were selected in each cluster by systematic random sampling. Face-to-face interviews during October and November 2010 were conducted. Fatal injuries occurring during 5 years preceding the survey and non-fatal injuries occurring during 12 months preceding interviews were included. RESULTS: The total number of individuals included was 5661, residing in 973 households. There were 28 deaths due to injuries out of a total of 129 reported deaths over 5 years. A total of 441 cases of non-fatal injuries occurred during the 12 months preceding the survey. The number of disability days differed significantly between mechanisms of injury. Road traffic crashes and falls caused the longest duration of disability. Men had a higher probability than women of losing a job due to an injury. CONCLUSIONS: This study demonstrates the importance of prioritising prevention of road traffic crashes and falls. The loss of productivity in lower socioeconomic strata highlights the need for social security policies. Further research is needed for estimating the economic cost of injuries in Sudan.

Injuries in Khartoum state, the Sudan: a household survey of incidence and risk factors.

Low- and middle-income countries have a higher burden of fatal and non-fatal injuries. The lack of evidence-based information hampers efforts for injury prevention. The aim of this study was to calculate non-fatal injury incidence rates and to investigate causes and risk factors for non-fatal injuries in Khartoum state. Information was gathered in a community-based survey using a stratified two-stage cluster sampling technique. Methods of data collection were face-to-face interviews during October and November 2010. The total number of individuals included was 5661, residing in 973 households. The overall injury incidence rate was 82.0/1000 person-years-at-risk. The three leading causes were falls, mechanical forces and road traffic crashes. Low socio-economic status was a risk factor for injuries in urban areas. Males had a significantly higher risk of being injured in both urban and rural areas. Our findings can contribute to the planning of prevention programmes.