Responsive Behaviors and Pain Management in Hospital Dementia Care: A Before and After Comparison of the "Serial Trial Intervention".

Purpose: Responsive behavior, often referred to as behavioral and psychological symptoms of dementia (BPSD), is among the most critical disorders in dementia whereby nursing personnel in hospitals are increasingly confronted with such symptoms. The purpose was to reduce the level of BPSD in an acute hospital environment through a stepwise procedure followed by the initiation of a needs-oriented treatment. Methods: An open, prospective, interventional study with before-after comparisons was used to implement "Serial Trial Intervention" (STI) in three hospital wards (internal medicine, surgery, geriatric) after its adaption for hospital setting which was supplemented with a detailed pain assessment. Participants were 65 years and older. Potential causes of BPSD were clarified in a stepwise procedure and, if possible, eliminated. The primary outcome was the reduction in BPSD measured by the Neuropsychiatric Inventory (NPI-Q-12) while secondary outcomes were through the use of non-pharmacological and pharmacological interventions. Results: No significant reduction in NPI-Q-12 could be found. However, significantly more mobilizations and changes of position were carried out. Higher antipsychotic use was seen in the after-groups presumably due to the higher rates of delirium and cognitive impairment. Furthermore, the data showed no increase in analgesic use. Conclusion: No significant reduction in NPI-Q-12 was observed in the before-after study. The use of antipsychotics even increased most probably due to a higher incidence of deliriousness in the after-group. However, STI seemed to improve attention to underlying causes of BPSD as well as pain. Proof that STI leads to NPI-Q-12 reduction in hospitals is still pending.

[Tasks and roles of newly bachelor graduates of nursing in acute care settings - A scoping review]. / Tätigkeiten und Rollen von neu graduierten Bachelorabsolvent_innen der Pflege im akutstationären Setting.

Tasks and roles of newly bachelor graduates of nursing in acute care settings - A scoping review Abstract. Background: Despite the need, institutions in the German-speaking health care system are still not prepared for newly qualified bachelor graduates of professional nursing programs, since task and role profiles for their use in the acute care setting are not available. AIM: The aim is to provide an international overview of tasks and roles of newly qualified bachelor graduates in the acute care setting. METHODS: The search covered the period from 2010 to 2021 in the databases CINAHL and MEDLINE. Publications in German and English were included in the scoping review regardless of their study designs. RESULTS: The eight included studies follow mostly a qualitative design (n = 5), two studies had a cross-section design and one a mixed-methods design. They were predominantly conducted in the Scandinavian (n = 3) and North American (n = 3) regions. The results show a mix of tasks and roles in which bachelor graduates are employed in basic nursing care, as educators (including lecturers) and in medication management of all age groups, as well as for advanced pediatric lifesaving, monitoring and maintenance of equipment for assessment and diagnostics plus as managers of nursing teams. CONCLUSIONS: There is a nationally need for the development of task and role profiles for specific care settings derived from existing competency attributions. Training programs based on these profiles support transition into the acute care setting and promote the assurance of quality interprofessional care.

Hygiene management for long-term ventilated persons in the home health care setting: a scoping review.

BACKGROUND: Evidence and recommendations for hygiene management in home mechanical ventilation (HMV) are rare. In Germany, few regionally limited studies show poor hygiene management or a lack of its implementation. This scoping review of international literature identified the evidence in hygiene management for ventilated patients in the home care setting which has to be implemented for infection prevention and control. METHODS: A review of international literature was conducted in CINAHL, PubMed and Web of Science. The search focused on four key domains: HMV, hygiene management, home care setting, and methicillin-resistant Staphylococcus aureus (MRSA). Data of included studies were extracted using a data charting sheet. Extracted data were assigned to the categories (1) study description, (2) setting and participants, and (3) hygiene management. RESULTS: From 1,718 reviewed articles, n = 8 studies met inclusion criteria. All included studies had a quantitative study design. The approaches were heterogeneous due to different settings, study populations and types of ventilation performed. Regarding aspects of hygiene management, most evidence was found for infectious critical activities (n = 5), quality management for hygiene (n = 4), and training and education (n = 4). This review identified research gaps concerning kitchen hygiene, relatives and visitors of HMV patients, and waste management (n = 0). DISCUSSION: Overall evidence was rather scarce. Consequently, this review could not answer all underlying research questions. No evidence was found for measures in hygiene management relating to ventilated patients' relatives. Evidence for kitchen hygiene, waste management and interaction with relatives is available for inpatient care settings. However, this may not be transferable to outpatient care. Binding legal requirements and audits may help regulate the implementation of HMV hygiene measures. CONCLUSION: Infection control programmes included qualified personnel, hygiene plans, and standards for MRSA and multidrug-resistant organisms (MDRO). The appropriateness of hygiene management measures for outpatient care is the basis for their application in practice.

Assessment of patient-reported outcomes after polytrauma - instruments and methods: a systematic review.

OBJECTIVES: We (1) collected instruments that assess health-related quality of life (HRQoL), activities of daily living (ADL) and social participation during follow-up after polytrauma, (2) described their use and (3) investigated other relevant patient-reported outcomes (PROs) assessed in the studies. DESIGN: Systematic Review using the Preferred Reporting Items for Systematic Review and Meta-Analysis guideline. DATA SOURCES: MEDLINE, Embase, CINAHL, PsycINFO, CENTRAL, as well as the trials registers ClinicalTrials.gov and WHO ICTRP were searched from January 2005 to April 2018. ELIGIBILITY CRITERIA: All original empirical research published in English or German including PROs of patients aged 18-75 years with an Injury Severity Score≥16 and/or an Abbreviated Injury Scale≥3. Studies with defined injuries or diseases (e.g. low-energy injuries) and some text types (e.g. grey literature and books) were excluded. Systematic reviews and meta-analyses were excluded, but references screened for appropriate studies. DATA EXTRACTION AND SYNTHESIS: Data extraction, narrative content analysis and a critical appraisal (e.g. UK National Institute for Health and Care Excellence) were performed by two reviewers independently. RESULTS: The search yielded 3496 hits; 54 publications were included. Predominantly, HRQoL was assessed, with Short Form-36 Health Survey applied most frequently. ADL and (social) participation were rarely assessed. The methods most used were postal surveys and single assessments of PROs, with a follow-up period of one to one and a half years. Other relevant PRO areas reported were function, mental disorders and pain. CONCLUSIONS: There is a large variation in the assessment of PROs after polytrauma, impairing comparability of outcomes. First efforts to standardise the collection of PROs have been initiated, but require further harmonisation between central players. Additional knowledge on rarely reported PRO areas (e.g. (social) participation, social networks) may lead to their consideration in health services provision. PROSPERO REGISTRATION NUMBER: CRD42017060825.

An Evidence-Based Guideline on Pain Assessment in Nursing Homes For Residents and Informal Caregivers.

BACKGROUND: Nursing home residents are often affected by pain. Pain assessment aims to determine pain intensity and quality. An evidence-based guideline on pain assessment in nursing homes was developed to support residents and informal caregivers in archiving an adequate pain assessment prerequisite to pain treatment. AIM: The residents' guideline presents key recommendations that is comprehensible and accessible to residents and informal carers. DESIGN: We conducted a content analysis. SETTING/SUBJECTS: Therefore, all recommendations of an evidence-based guideline for pain assessment in nursing home were evaluated on relevance for supporting residents' decision-making process. METHODS: Two researchers conducted the content analysis independently and as a result, 29 recommendations could be included. In addition, representatives of a support-group organization for patients with pain validated the derived recommendations. RESULTS: The present residents' guideline of pain assessment consists of nine thematic categories, written in laymen's terms to enable older persons to make informed choices and optimizing their own pain management process. CONCLUSIONS: The Guideline is available in print format and ready for implementation to enhance the effects on maintaining the physical and psychological well-being and optimal care of older adults in Nursing Homes.

Pain Assessment for Older Persons in Nursing Home Care: An Evidence-Based Practice Guideline.

Up to 80% of nursing home residents are affected by pain. Pain assessment aims to determine pain intensity, quality, and course of pain to underpin diagnostic decision making. In the nursing home population, pain assessment is frequently compromised by cognitive impairment. Characteristics of the nursing home setting, such as resident's age, staff skill mix, and overall aims of the care provided, also need to be taken into account. Therefore, an interdisciplinary evidence-based clinical practice guideline for pain assessment in the nursing home setting was developed. A systematic literature search was carried out covering publications between 2003 and 2015. Thirty-nine studies were included in the preparation of this guideline, supplemented by 12 international reference guidelines. Recommendations were subjected to a structured consensus-finding process with representatives from 37 scientific and professional organizations and patient representatives. The guideline underwent independent peer review before finalization. It comprises 62 recommendations that are grouped into 4 chapters: (1) context of pain assessment in nursing home care; (2) screening; (3) focused assessment; and (4) reassessment/monitoring of pain. Main recommendations stipulate that clinicians should assess the patient's ability to provide self-report of pain when screening for pain and that each resident should be screened for the presence of pain. A focused assessment of pain, performed during rest and activities, should include pain intensity, changed behaviors, general mobility, pain history, comorbidities, and pain medication. Pain should be re-assessed at regular intervals using the same instruments that were used for the focused assessment. Guideline development demonstrated that many aspects of pain assessment in older persons have not received adequate research attention so far. Available studies predominantly possess only low levels of evidence. Therefore, research into this area needs to be systematically developed to address questions of clinical relevance to support patient care.

[Challenging behavior and pain in dementia : Experiences of nursing staff in an acute care hospital]. / Herausfordernde Verhaltensweisen und Schmerz bei Demenz : Erfahrungen von Pflegenden in einem Akutkrankenhaus.

BACKGROUND: People with dementia are receiving treatment in acute care hospitals at increasing rates. Most prominently, patients exhibiting behavioral and psychological symptoms of dementia (BPSD) are perceived as significant burdens for staff members. Non-detected pain is seen as one substantial reason for behavior that is seemingly unexplainable. In order to gather information about dealing with BPSD a survey was performed. The objective of this study was to enable a more cause-oriented treatment. METHODS: The procedure consisted of an anonymous survey of nurses, by semi-structured interviews with open and closed questions about BPSD: type, frequency, perceived burden, therapeutic countermeasures including pain recognition. RESULTS: A total of 46 nurses from 3 wards (internal, geriatric, surgery) were interviewed. 1. Nurses reported being heavily burdened by patients with BPSD. 2. A structured identification of possible causes as part of an established treatment process was not observed. 3. Offering to talk with the patient in order to identify possible causes for BPSD was seen as the first step in the right direction but is inhibited by the limitations of people with severe dementia. 4. Pain as one important cause for BPSD was known by the staff but was often measured by inadequate instruments. 5. Positioning and mobilization were the most commonly used attempts at treatment. CONCLUSION: Nurses are especially affected in their daily work by patients with BPSD. Clarifying the cause may play a crucial role in treating BPSD.

Assessment of patient-reported outcomes after polytrauma: protocol for a systematic review.

INTRODUCTION: Survivors of polytrauma experience long-term and short-term burden that influences their lives. The patients' view of relevant short-term and long-term outcomes should be captured in instruments that measure quality of life and other patient-reported outcomes (PROs) after a polytrauma. The aim of this systematic review is to (1) collect instruments that assess PROs (quality of life, social participation and activities of daily living) during follow-up after polytrauma, (2) describe the instruments' application (eg, duration of period of follow-up) and (3) investigate other relevant PROs that are also assessed in the included studies (pain, depression, anxiety and cognitive function). METHODS AND ANALYSIS: The systematic review protocol is developed in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statement. MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Cochrane Central Register of Controlled Trials and the trials registers ClinicalTrials.gov and WHO International Clinical Trials Registry Platform will be searched. Keywords, for example, 'polytrauma', 'multiple trauma', 'quality of life', 'activities of daily living' or 'pain' will be used. Publications published between January 2005 and the most recent date (currently: August 2016) will be included. In order to present the latest possible results, an update of the search is conducted before publication. The data extraction and a content analysis will be carried out systematically. A critical appraisal will be performed. ETHICS AND DISSEMINATION: Formal ethical approval is not required as primary data will not be collected. The results will be published in a peer-reviewed publication. PROSPERO REGISTRATION NUMBER: CRD42017060825.

Drug-based pain management for people with dementia after hip or pelvic fractures: a systematic review.

BACKGROUND: Studies indicate that people with dementia do not receive the same amount of analgesia after a hip or pelvic fracture compared to those without cognitive impairment. However, there is no systematic review that shows to what extent drug-based pain management is performed for people with dementia following a hip or pelvic fracture. The aim of this systematic review was to identify and analyse studies that investigate drug-based pain management for people with dementia with a hip or pelvic fracture in all settings. Treatment could be surgical or conservative. We also analysed study designs, methods and variables, as well as which assessments were applied to measure pain management and mental status. METHOD/DESIGN: The development of this systematic review protocol was guided by the PRISMA-P requirements, which were taken into consideration during the review procedures. MEDLINE, EMBASE, CINAHL, Web of Knowledge and ScienceDirect were searched. Studies published up to January 2016 were included. The data extraction, content and quantitative descriptive analysis were carried out systematically, followed by a critical appraisal. RESULTS: Eight of the 13 included studies focusing on patient data showed that people with dementia received less drug-based pain management than people without cognitive impairment. Four studies based on surveys of healthcare professionals stated that cognitive impairment is a major barrier for effective pain management. There was heterogeneity regarding the assessment of the mental status and the pain assessment of the patients. The assessment of the drugs administered in all of the studies working with patient data was achieved through chart reviews. CONCLUSION: People with dementia do not seem to receive the same amount of opioid analgesics after hip fracture as people without cognitive impairment. There is need to enhance pain assessment and management for these patients. Future research should pay more attention to the use of the appropriate items for assessing cognitive impairment and pain in people with dementia. TRIAL REGISTRATION: This systematic review was registered at Prospero ( CRD42016037309 ); on 11 April 2016, and the systematic review protocol was published (Syst Rev. 5(1):1, 2016).

Does item overlap render measured relationships between pain and challenging behaviour trivial? Results from a multicentre cross-sectional study in 13 German nursing homes.

Several studies suggest that pain is a trigger for challenging behaviour in older adults with cognitive impairment. However, such measured relationships might be confounded due to item overlap as instruments share similar or identical items. The purpose of this study was to examine whether the frequently observed association between pain and challenging behaviour might be traced back to item overlap. This multicentre cross-sectional study was conducted in 13 nursing homes and examined pain (measure: Pain Assessment in Advanced Dementia Scale) and challenging behaviour (measure: Cohen-Mansfield Agitation Inventory) in 150 residents with severe cognitive impairment. The extent of item overlap was determined by juxtaposition of both measures' original items. As expected, comparison between these instruments revealed an extensive item overlap. The statistical relationship between the two phenomena can be traced back mainly to the contribution of the overlapping items, which renders the frequently stated relationship between pain and challenging behaviour trivial. The status quo of measuring such associations must be contested: constructs' discrimination and instruments' discrimination have to be discussed critically as item overlap may lead to biased conclusions and assumptions in research as well as to inadequate care measures in nursing practice.

Adherence of pain assessment to the German national standard for pain management in 12 nursing homes.

BACKGROUND: Pain is very common among nursing home residents. The assessment of pain is a prerequisite for effective multiprofessional pain management. Within the framework of the German health services research project, 'Action Alliance Pain-Free City Muenster', the authors investigated pain assessment adherence according to the German national Expert Standard for Pain Management in Nursing, which is a general standard applicable to all chronic/acute pain-affected persons and highly recommended for practice. OBJECTIVES: To evaluate the state of pain assessment and to identify need for improvement in 12 nursing homes in a German city. METHODS: In the present study, the authors used an ex-post-facto design (survey methodology). Available written policies for routine pain assessment in residents ≥65 years of age were reviewed and a standardized online survey completed by 151 of 349 nurses in 12 nursing home facilities was conducted between September 2010 and April 2011. RESULTS: Most of the included nursing homes provided written policies for pain assessment, and the majority of nurses reported that they assess and regularly reassess pain. However, observational tools for residents with severe cognitive impairment and written reassessment schedules were lacking in many facilities or were inconsistent. CONCLUSIONS: Essentially, pain assessment appeared to be feasible in the majority of the German nursing homes studied. However, the absence or inconsistency of reassessment schedules indicate that pain management guidelines should include a detailed and explicit reassessment schedule for the heterogenic needs of nursing home residents. For residents with severe cognitive impairment, assessment tools are needed that are simple to use and clearly indicate the presence or absence of pain.

Emerging standards of care in pain management in Germany.

A research project addressing roles of nurses in pain management is described. The role of specialized pain management nurses is discussed. Standards, communication, and multidisciplinary care, as well as roles of nurses in hospitals, nursing homes, and home care are described. Specialization is discussed including training and certification. The German National Expert Standard for Pain Management in Nursing is described.