Pilot study to evaluate the need and implementation of a multifaceted nurse-led antimicrobial stewardship intervention in residential aged care.

Objectives: To evaluate the need and feasibility of a nurse-led antimicrobial stewardship (AMS) programme in two Australian residential aged care homes (RACHs) to inform a stepped-wedged, cluster randomized controlled trial (SW-cRCT). Methods: A mixed-methods pilot study of a nurse-led AMS programme was performed in two RACHs in Victoria, Australia (July-December 2019). The AMS programme comprised education, infection assessment and management guidelines, and documentation to support appropriate antimicrobial use in urinary, lower respiratory and skin/soft tissue infections. The programme was implemented over three phases: (i) pre-implementation education and integration (1 month); (ii) implementation of the intervention (3 months); and (iii) post-intervention evaluation (1 month). Baseline RACH and resident data and weekly infection and antimicrobial usage were collected and analysed descriptively to evaluate the need for AMS strategies. Feedback on intervention resources and implementation barriers were identified from semi-structured interviews, an online staff questionnaire and researcher field notes. Results: Six key barriers to implementation of the intervention were identified and used to refine the intervention: aged care staffing and capacity; access to education; resistance to practice change; role of staff in AMS; leadership and ownership of the intervention at the RACH and organization level; and family expectations. A total of 61 antimicrobials were prescribed for 40 residents over the 3 month intervention. Overall, 48% of antibiotics did not meet minimum criteria for appropriate initiation (respiratory: 73%; urinary: 54%; skin/soft tissue: 0%). Conclusions: Several barriers and opportunities to improve implementation of AMS in RACHs were identified. Findings were used to inform a revised intervention to be evaluated in a larger SW-cRCT.

Understanding patient and healthcare worker experiences and perspectives of multidrug-resistant organisms.

Objectives: Transmission of MDR organisms (MROs) such as carbapenemase-producing Enterobacteriaceae (CPE) and VRE in healthcare facilities is a major issue globally. Knowledge gaps exist, including the impact of these microorganisms on patients, and healthcare worker understanding of infection control approaches for MROs. This study aimed to explore patient and healthcare worker experiences and perspectives of MROs. Methods: A sequential exploratory mixed-methods study was performed at a large metropolitan acute and subacute hospital. This involved semi-structured face-to-face interviews with patients with confirmed MROs to explore their understanding of these microorganisms and perceptions of their time in hospital. Healthcare workers participated in an online survey about their understanding of MROs and the care of patients with these microorganisms. Qualitative data were analysed using the COM-B framework, and were triangulated with the descriptive quantitative analysis. Results: The overarching theme from the triangulated data was uncertainty amongst both patients and staff about MROs. Insufficient explanations from staff left patients lacking a proper understanding of their diagnosis, and patients felt that staff did not always follow isolation protocols. Staff felt they did not receive enough education on MROs. However, patients felt that the overall care they received was very good, and most valued the privacy gained from being in isolation. Conclusions: This study demonstrates that there is a need to focus on new strategies of communication with patients and staff education to improve understanding of MROs and increase adherence to protocols.

Carer-reported measures for a dementia registry: A systematic scoping review and a qualitative study.

OBJECTIVES: Informal carers play a critical role in supporting people with dementia. We conducted a scoping review and a qualitative study to inform the identification and development of carer-reported measures for a dementia clinical quality registry. METHODS: Phase 1-Scoping review: Searches to identify carer-reported health and well-being measures were conducted in three databases (MEDLINE, PsycINFO and Embase). Data were extracted to record how the measures were administered, the domains of quality-of-life addressed and whether they had been used in a registry context. Phase 2-Qualitative study: Four focus groups were conducted with carers to examine the acceptability of selected measures and to identify outcomes that were important but missing from these measures. RESULTS: Phase 1: Ninety-nine carer measures were identified with the top four being the Zarit Burden Interview (n = 39), the Short-Form12/36 (n = 14), the Brief Coping Orientation to Problems Experienced scale and the Sense of Coherence scale (both n = 9). Modes of administration included face-to-face (n = 50), postal (n = 11), telephone (n = 8) and online (n = 5). No measure had been used in a registry context. Phase 2: Carers preferred brief measures that included both outcome and experience questions, reflected changes in carers' circumstances and included open-ended questions. CONCLUSIONS: Carer-reported measures for a dementia clinical quality registry need to include both outcome and experience questions to capture carers' perceptions of the process and outcomes of care and services. Existing carer-reported measures have not been used in a dementia registry context and adaption and further research are required.

Perceptions of falls risk and falls prevention among people with osteoarthritis.

PURPOSE: To understand the perceptions of falls risk and falls prevention, and the perceived enablers and barriers to engaging in falls prevention strategies/activities among people with doctor-diagnosed hip and/or knee osteoarthritis. METHODS: A qualitative study utilising semi-structured telephone interviews. Researchers independently analysed qualitative data using an inductive method guided by the COM-B framework. Interviews were analysed thematically using open, axial, and selective coding. Recruitment ceased at 20 interviews, once data saturation was evident. RESULTS: Participants were 18 women and two men aged 52-84 years and half had fallen in the last 12 months. Main themes were the absence of recommendations to access activities after having a fall, inconsistencies between perceptions of the relationship between OA and falls, and individual beliefs of not being at risk of falling because of taking precautions. Knowledge about falls prevention programs was limited, the term "falls prevention" was considered stigmatising and only applicable to older frail people. Home modifications were perceived as broadcasting negativity; participants felt falls terminology should be changed from a negative to a positive focus. CONCLUSIONS: Falls were often seen as inevitable consequence of keeping active. Re-framing the language used to discuss falls is recommended to promote uptake of falls prevention activities.Implications for rehabilitationDespite growing evidence that osteoarthritis (OA) is an independent risk factor for falls, people with OA do not perceive themselves to be at risk and falls prevention is for those who are "old and frail".Re-framing the language used to discuss falls and falls prevention to focus on positive messages may promote the uptake of falls prevention activities in this population.Improving the awareness of falls and falls risk among people with OA through effective health education is needed in order to foster the uptake of, and engagement with, falls prevention activities.

Acquired Brain Injury in the Context of Family Violence: A Systematic Scoping Review of Incidence, Prevalence, and Contributing Factors.

Brain injury is often a precursor to, or result of, family violence. Yet there is little research identifying the connection of these two phenomena. The health cost (personal or societal) of brain injury within the family violence context is difficult to ascertain. Family violence can lead to lifelong psychological or physical scars and even death. A systematic review was conducted over three databases using Medical Subject Heading terms to investigate incidence, prevalence, and contributing factors of brain injury within a family violence context. Inclusion criteria were primary studies, any person who experienced traumatic brain injury in a familial context. Seven hundred and seven studies of varied designs were initially identified with 43 meeting inclusion criteria. Data were extracted and a deductive narrative synthesis was performed. The accuracy and generalizability of incidence and prevalence statistics was hindered by underreporting of family violence and the specificity of some of the population groups (e.g., female inmates). The factors contributing to brain injury within the family violence context had multifactorial causation and varied greatly across the populations studied. Five social determinants of health were identified: biological, behavioral, structural, social, and environmental. These factors included age and gender of parent/baby, crying as an antecedent of family violence, previous exposure to abuse as a child, hostile living environments, previous trauma, financial pressures, employment status, housing availability, and exposure to natural disasters. Future investigation into the nexus between brain injury and family violence is required; however, this is complicated due to global inconsistency of definitions, assessment tools, and research methods used.

Volunteer Programs Supporting People With Dementia/Delirium in Hospital: Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVES: Volunteer-delivered programs to assist people with dementia and/or delirium in-hospital can provide person-centered one-on-one support in addition to usual care. These programs could mitigate hospital resource demands; however, their effectiveness is unknown. This review evaluated literature of volunteer programs in acute hospital settings for people living with dementia and/or delirium. RESEARCH DESIGN AND METHODS: Four databases were searched. Studies that reported patient or program outcomes were included (i.e., delirium incidence, length of stay, number of falls, satisfaction). Risk of bias was completed. Meta-analysis was performed where 2 or more studies measured the same outcome. Narrative synthesis was performed on the qualitative results. RESULTS: Eleven studies were included in the review, with varied design, participant groups and outcomes measured. Risk of bias averaged 71%. Volunteer-delivered programs addressed delirium risk factors, for example, hydration/nutrition, mobility, use of sensory aids. Eight patients and 6 program outcomes were captured, but only 3 patient outcomes could be pooled. Meta-analyses demonstrated a reduction in delirium incidence (rate ratio = 0.65; 95% confidence interval [CI] 0.47, 0.90) but no reduction in length of stay (mean difference -1.09; 95% CI -0.58, 2.77) or number of falls (rate ratio = 0.67; 95% CI 0.19, 2.35). Narrative synthesis identified benefits to patients (e.g., less loneliness), volunteers (sense of meaning), and staff (timesaving, safety). DISCUSSION AND IMPLICATIONS: Volunteer-delivered programs for inpatients with dementia and/or delirium may provide benefits for patients, volunteers, and staff. However, studies conducted with more robust designs are required to determine overall effectiveness on program outcomes. Further high-quality research appropriate for this vulnerable population is required to identify volunteer program effectiveness.

Practitioner perspectives on the nexus between acquired brain injury and family violence.

Family violence has been highlighted by the World Health Organization as a major public health concern. Although family violence occurs to all genders, a higher prevalence of victims are female. Estimates report around 30% of all women experience intimate partner violence worldwide. Experiencing assault in the family violence context can lead to an acquired brain injury (ABI); however, the connection between these two phenomena has not been well established. The aim of this qualitative study was to explore the extent of, and factors contributing to, ABI and family violence. We conducted 22 semi-structured interviews and one focus group (n = 4) with practitioners working with family violence victims and/or perpetrators. Thematic data analysis utilised inductive and deductive coding approaches. The Social Determinants of Health Framework was used to guide analysis. Practitioners estimated 30%-40% of the clients on their caseloads had a suspected or diagnosed ABI. They identified that contributing factors were extremely complex. These included acquiring an ABI through assault (past family violence or other criminal act), and transport crashes. Complicating factors of ABI were identified as mental health conditions, alcohol and drug use, and post-traumatic stress disorder. Additional factors contributing to family violence were recognised as biological (age of parent, twin births, pregnancy, premature births, and children with congenital abnormalities), relationships (intimate partner, father, boyfriend, mother and siblings), previous trauma (family violence), and life stressors (unemployment, financial, and lack of housing). Social determinants of health included cultural (ethnicity, societal attitudes, values, and beliefs) and organisational (legislation and policy) factors which influenced behaviours and outcomes across all sectors. A model of Brain injury Family violence Nexus (BFN) was created to understand the interaction between these phenomena. Utilising the BFN model to understand the interaction can enhance the methods used within health and social services for a more efficacious approach.