Conducting Clinical Research in Post-acute and Long-term Nursing Home Care Settings: Regulatory Challenges.

Despite multiple initiatives in post-acute and long-term nursing home care settings (NHs) to improve the quality of care while reducing health care costs, research in NHs can prove challenging. Extensive regulation for both research and NHs is designed to protect a highly vulnerable population but can be a deterrent to conducting research. This article outlines regulatory challenges faced by NHs and researchers, such as protecting resident privacy as well as health information and obtaining informed consent. The article provides lessons learned to help form mutually beneficial partnerships between researchers and NHs to conduct studies that grow and advance NH research initiatives and clinical care.

Research Priorities in Post-acute and Long-term Care: Results of a Stakeholder Needs Assessment.

OBJECTIVES: Conduct a needs assessment among post-acute and long-term care (PA-LTC) stakeholder groups to identify (1) research topics of highest priority and (2) perspectives on research, including concerns/barriers to conducting research in the PA-LTC setting. DESIGN: Mixed methods multistakeholder engagement process. Needs assessment conducted with tailored strategies per stakeholder group: interview, survey, and focus group. SETTING AND PARTICIPANTS: Four stakeholder groups-medical directors/providers (n = 89), administrative leadership (n = 5), frontline staff (n = 17), and family members of residents and residents themselves (n = 11)-were recruited from the Colorado PA-LTC community through an academic-community partnership between the University of Colorado and Colorado Medical Directors Association. MAIN OUTCOME(S): Stakeholder perspectives on research and high priority PA-LTC research topics. RESULTS: Research priorities common across stakeholder groups included polypharmacy (overuse of medication generally and overuse of antibiotics specifically), care transitions, mental health (including dementia, Alzheimer's disease, behaviors), chronic pain, urinary tract infection, and quality of life issues. Providers specifically prioritized heart failure, Parkinson's, and other chronic illnesses. Administrators and directors of nurses emphasized hospitalizations. Staff prioritized medication/therapy compliance. Families/residents prioritized neurologic disease. Concerns included staff burden, consenting process, privacy, and family involvement. CONCLUSIONS/IMPLICATIONS: PA-LTC patients have a lot to offer as participants and decision makers in research, frontline staff are enthusiastic about participation, family members want to be involved, and providers value research findings in their practice but need a more supportive environment to produce and participate in research.

Usability Testing of a Mobile Clinical Decision Support App for Urinary Tract Infection Diagnosis in Nursing Homes.

The aim of the current study was to conduct usability testing of a mobile clinical decision support (CDS) prototype designed for urinary tract infection (UTI) assessment by nurses in nursing homes (NHs). Usability of the UTIDecide smartphone application (app) was evaluated using cognitive walk-through and think-aloud protocol sessions with nurses (n = 6) at two NH sites. This evaluation was followed by unsupervised field tests lasting ≥1 week with nurses at one site (n = 4) and posttest interviews and administration of the System Usability Scale (SUS). Cognitive walk-through/think-aloud sessions yielded interface design recommendations that were implemented prior to field tests. All test sessions resulted in highly positive perceived usability and usefulness from participants. Average SUS score was 92.5 (n = 3), which equates to an "A" grade for usability. Design recommendations identified for future app versions are: (a) integration of the mobile CDS app with organizational information systems; and (b) expanded features to support assessment of other conditions. [Journal of Gerontological Nursing, 45(7), 11-17.].

Characterizing Workflow to Inform Clinical Decision Support Systems in Nursing Homes.

BACKGROUND AND OBJECTIVES: Clinical decision support systems (CDSS) hold promise to influence clinician behavior at the point of care in nursing homes (NHs) and improving care delivery. However, the success of these interventions depends on their fit with workflow. The purpose of this study was to characterize workflow in NHs and identify implications of workflow for the design and implementation of CDSS in NHs. RESEARCH DESIGN AND METHODS: We conducted a descriptive study at 2 NHs in a metropolitan area of the Mountain West Region of the United States. We characterized clinical workflow in NHs, conducting 18 observation sessions and interviewing 15 staff members. A multilevel work model guided our data collection and framework method guided data analysis. RESULTS: The qualitative analysis revealed specific aspects of multilevel workflow in NHs: (a) individual, (b) work group/unit, (c) organization, and (d) industry levels. Data analysis also revealed several additional themes regarding workflow in NHs: centrality of ongoing relationships of staff members with the residents to care delivery in NHs, resident-centeredness of care, absence of memory aids, and impact of staff members' preferences on work activities. We also identified workflow-related differences between the two settings. DISCUSSION AND IMPLICATIONS: Results of this study provide a rich understanding of the characteristics of workflow in NHs at multiple levels. The design of CDSS in NHs should be informed by factors at multiple levels as well as the emergent processes and contextual factors. This understanding can allow for incorporating workflow considerations into CDSS design and implementation.

Medical Costs of Fatal and Nonfatal Falls in Older Adults.

OBJECTIVES: To estimate medical expenditures attributable to older adult falls using a methodology that can be updated annually to track these expenditures over time. DESIGN: Population data from the National Vital Statistics System (NVSS) and cost estimates from the Web-based Injury Statistics Query and Reporting System (WISQARS) for fatal falls, quasi-experimental regression analysis of data from the Medicare Current Beneficiaries Survey (MCBS) for nonfatal falls. SETTING: U.S. population aged 65 and older during 2015. PARTICIPANTS: Fatal falls from the 2015 NVSS (N=28,486); respondents to the 2011 MCBS (N=3,460). MEASUREMENTS: Total spending attributable to older adult falls in the United States in 2015, in dollars. RESULTS: In 2015, the estimated medical costs attributable to fatal and nonfatal falls was approximately $50.0 billion. For nonfatal falls, Medicare paid approximately $28.9 billion, Medicaid $8.7 billion, and private and other payers $12.0 billion. Overall medical spending for fatal falls was estimated to be $754 million. CONCLUSION: Older adult falls result in substantial medical costs. Measuring medical costs attributable to falls will provide vital information about the magnitude of the problem and the potential financial effect of effective prevention strategies.

Developing Mobile Clinical Decision Support for Nursing Home Staff Assessment of Urinary Tract Infection using Goal-Directed Design.

BACKGROUND: Unique characteristics of nursing homes (NHs) contribute to high rates of inappropriate antibiotic use for asymptomatic bacteriuria (ASB), a benign condition. A mobile clinical decision support system (CDSS) may support NH staff in differentiating urinary tract infections (UTI) from ASB and reducing antibiotic days. OBJECTIVES: We used Goal-Directed Design to: 1) Characterize information needs for UTI identification and management in NHs; 2) Develop UTI Decide, a mobile CDSS prototype informed by personas and scenarios of use constructed from Aim 1 findings; 3) Evaluate the UTI Decide prototype with NH staff. METHODS: Focus groups were conducted with providers and nurses in NHs in Denver, Colorado (n= 24). Qualitative descriptive analysis was applied to focus group transcripts to identify information needs and themes related to mobile clinical decision support for UTI identification and management. Personas representing typical end users were developed; typical clinical context scenarios were constructed using information needs as goals. Usability testing was performed using cognitive walk-throughs and a think-aloud protocol. RESULTS: Four information needs were identified including guidance regarding resident assessment; communication with providers; care planning; and urine culture interpretation. Design of a web-based application incorporating a published decision support algorithm for evidence-based UTI diagnoses proceeded with a focus on nursing information needs during resident assessment and communication with providers. Certified nursing assistant (CNA) and registered nurse (RN) personas were constructed in 4 context scenarios with associated key path scenarios. After field testing, a high fidelity prototype of UTI Decide was completed and evaluated by potential end users. Design recommendations and content recommendations were elicited. CONCLUSIONS: Goal-Directed Design informed the development of a mobile CDSS supporting participant-identified information needs for UTI assessment and communication in NHs. Future work will include iterative deployment and evaluation of UTI Decide in NHs to decrease inappropriate use of antibiotics for suspected UTI.

Can Braden Score Predict Outcomes for Hospitalized Heart Failure Patients?

BACKGROUND: Braden score is a routine assessment of pressure ulcer risk hypothesized to identify the frail phenotype. OBJECTIVES: To investigate the predictive utility of the Braden score on outcomes of inpatients with heart failure (HF). DESIGN: Retrospective cohort study. SETTING: An academic medical center between January 1, 2012 and June 30, 2013. PARTICIPANTS: 642 inpatients with a primary diagnosis of HF (ICD-9 428). MEASUREMENTS: The primary predictor was Braden score. Primary outcome was 30-day mortality. Additional outcomes included 30-day readmission, length of stay (LOS), and discharge destination. Multivariable methods were used to determine the association between the primary predictor and each outcome adjusted for patient demographics and clinical variables. RESULTS: Mean admission and discharge Braden scores were 19.5 ± 2.3 (SD) (range = 9-23) and 20.0 ± 1.9 (range = 11-23), respectively (P < .0001). Mean age was 61.8 ± 16.2 years (range = 19-101). The 30-day mortality rate was 4.4%, 30-day readmission rate was 16.2%, mean LOS was 7.0 ± 8.7 days, and 78.2% were discharged home. After adjustment, higher (better) Braden score was significantly associated with decreased 30-day mortality (discharge Braden AOR 0.81 (95% CI 0.66-0.996)), and decreased average LOS (admission Braden ß -0.52 days (P = .0002)). Higher discharge Braden score was significantly associated with discharge to home (AOR 1.66 (95% CI 1.42-1.95)). Braden score was not significantly associated with 30-day readmission. CONCLUSION: Braden score is an independent predictor of mortality, LOS, and discharge destination among inpatients with HF. Further exploration of the use of Braden scores to identify inpatients who might benefit from specialized intervention is warranted.

Revision total hip arthroplasty.

Endoscopic visualization and pneumatically-powered ballistic chisels that can be used to remove cement and cementless prostheses are recent developmental improvements for revision total hip arthroplasty (THA). Use of these new tools facilitates the revision procedure, reduces tissue trauma, and may reduce surgical time. Understanding the anatomy of the hip joint, pathophysiology that leads to the need for joint replacement, and the implant selection process can assist perioperative nurses in caring for and teaching patients who require revision THA and their family members. This article describes implant choices based on the type of bone deformity present and the use of the ballistic chiseling system during revision THA. Potential postoperative complications also are described.