A Report of Information Technology and Health Deficiencies in U.S. Nursing Homes.

OBJECTIVE: The aim of the study was to investigate the impact of nursing home (NH) information technology (IT) sophistication on publically reported health safety deficiency scores documented during standard inspections. METHODS: The sample included 807 NHs from every U.S. state. A total of 2187 health inspections were documented in these facilities. A national IT sophistication survey describing IT capabilities, extent of IT use, and degree of IT integration in resident care, clinical support, and administrative activities in U.S. NHs was used. The relationship between NH health deficiencies and IT sophistication survey scores was examined, using weighted regression. RESULTS: Controlling for registered nurse hours per resident day, deficiency scores decreased as total IT sophistication increased. Controlling for total IT sophistication score, deficiency scores decreased as registered nurse hours per resident day increased. Ownership status significantly influenced health deficiency scores. CONCLUSIONS: These results highlight the necessity to understand benefits of implementing NH IT and demonstrating its impact on patient safety.

Exploring Perceptions of Health Care Providers' Use of Electronic Advance Directive Forms in Electronic Health Records.

The current study explored the perceptions of health care providers' use of electronic advance directive (AD) forms in the electronic health record (EHR). The Technology Acceptance Model (TAM) was used to guide the study. Of 165 surveys distributed, 151 participants (92%) responded. A moderately strong positive correlation was noted between perceived usefulness and actual system usage (r = 0.70, p < 0.0001). Perceived ease of use and actual system usage also had a moderately strong positive correlation (r = 0.70, p < 0.0001). In contrast, the strength of the relationship between behavioral intention to use and actual system usage was more modest (r = 0.22, p < 0.004). There was a statistically significant difference in actual system usage of electronic ADs across six departments (χ2[5] = 79.325, p < 0.001). The relationships among primary TAM constructs found in this research are largely consistent with previous TAM studies, with the exception of behavioral intention to use, which is slightly lower. These data suggest that health care providers' perceptions have great influence on the use of electronic ADs. [Journal of Gerontological Nursing, 45(1), 17-21.].

The State of Nursing Home Information Technology Sophistication in Rural and Nonrural US Markets.

OBJECTIVE: To test for significant differences in information technology sophistication (ITS) in US nursing homes (NH) based on location. METHODS: We administered a primary survey January 2014 to July 2015 to NH in each US state. The survey was cross-sectional and examined 3 dimensions (IT capabilities, extent of IT use, degree of IT integration) among 3 domains (resident care, clinical support, administrative activities) of ITS. ITS was broken down by NH location. Mean responses were compared across 4 NH categories (Metropolitan, Micropolitan, Small Town, and Rural) for all 9 ITS dimensions and domains. Least square means and Tukey's method were used for multiple comparisons. PRINCIPAL FINDINGS: Methods yielded 815/1,799 surveys (45% response rate). In every health care domain (resident care, clinical support, and administrative activities) statistical differences in facility ITS occurred in larger (metropolitan or micropolitan) and smaller (small town or rural) populated areas. CONCLUSIONS: This study represents the most current national assessment of NH IT since 2004. Historically, NH IT has been used solely for administrative activities and much less for resident care and clinical support. However, results are encouraging as ITS in other domains appears to be greater than previously imagined.

A national report of nursing home information technology: year 1 results.

OBJECTIVE: To provide a report on year 1 results of a national study investigating nursing home information technology (IT) adoption, called IT sophistication. METHODS: A reliable and valid survey was used to measure IT sophistication. The target goal was 10% from each state in the United States, 1570 nursing homes. A random sample of homes from each state was recruited from Nursing Home Compare. RESULTS: The team reached 2627 nursing home administrators, among whom 1799 administrators agreed to participate and were sent a survey. A total of 815 surveys were completed (45.3% response rate), which was below the goal. Facilities in the participating sample have similar demographic characteristics (ownership, total population in a location, and bed size) to the remaining homes not participating. There are greater IT capabilities in resident care and administrative activities, less in clinical support. The extent of use of these capabilities appears to be highest in administrative activities and lowest in clinical support. IT in resident care appears to be the most integrated with internal and external stakeholders. IT capabilities appear to be greater than IT extent of use in all health domains, with the greatest difference in resident care. DISCUSSION: National evaluations of nursing home IT are rare. Measuring trends in IT adoption in a nationally representative sample provides meaningful analytics that could be more useful for policy makers and nursing home leaders in the future. CONCLUSION: Discovering national baseline assessments is a first step toward recognizing nursing home trends in IT adoption.

Levodopa as a possible treatment of visual loss in nonarteritic anterior ischemic optic neuropathy.

PURPOSE: To determine the clinical effectiveness and potential neuroprotection of levodopa in improving visual acuity, visual field, and retinal nerve fiber layer (RNFL) thickness in eyes affected by NAION. METHOD: Retrospective cohort study involving 59 eyes of 59 participants with NAION who were evaluated within 15 days of NAION onset. Participants received 25 mg carbidopa/100 mg levodopa three times daily with meals for 12 weeks (levodopa group) or were untreated (control group). Best-corrected visual acuity converted to logMAR, mean deviation (MD) threshold sensitivity on automated perimetry, and mean RNFL thickness on optical coherence tomography (OCT) were assessed. The primary outcome was the categorization of eyes into improved visual acuity (by 0.3 logMAR difference), worsened visual acuity (by 0.3 logMAR difference), or no change in visual acuity. The proportions in each category were compared between the levodopa and control groups. RESULTS: Among participants with 20/60 or worse initial visual acuity, levodopa-treated participants had significant improvement (P < 0.0001) in the mean change from initial to final logMAR visual acuity of -0.74 ± 0.56 (95 % CI, -0.98 to -0.50), while the mean change for the control group at -0.37 ± 1.09 (95 % confidence interval estimate, -1.00 to +0.26) was not significant (P = 0.23). A significant difference between groups was observed (P = 0.0086) such that 19/23 (83 %) in the levodopa group improved and none got worse, as compared with 6/14 (43 %) in the control group improving while four (29 %) worsened. The change in visual field MD and RNFL thickness on OCT showed no significant difference at P = 0.23 and P = 0.75 respectively. No levodopa-treated participant had any adverse event from the levodopa. CONCLUSIONS: Treatment within 15 days of onset of NAION with levodopa improved central visual acuity by an average of 6 lines on Snellen acuity chart. Levodopa may promote neuroprotection of the maculopapular retinal ganglion cell fibers in NAION.

Effects of Staffing and Regional Location on Influenza and Pneumococcal Vaccination Rates in Nursing Home Residents.

Vaccinations reduce the risk of hospitalizations and adverse health outcomes in older adult populations, which has led to initiatives such as the Healthy People 2010 goal to vaccinate 90% of all nursing home residents. The current analysis looked at the percentage of residents who received vaccinations in 15,653 nursing homes in the United States and relationships of vaccination to staffing intensity and regional location. Overall, approximately 75% of facilities reached the optimum 90% vaccination levels for long-term residents, but less than 50% reached this goal for short-term residents. Further analyses revealed a consistently lower median rate of vaccination for metropolitan areas and indicated a weak relationship between staffing levels of RNs and short-term resident vaccination. Factors influencing staffing levels, and the possible connection between vaccination and technology, are discussed, as well as suggestions for future research aimed at better understanding mechanisms involved in suboptimal influenza and pneumococcal vaccination in nursing homes. [Journal of Gerontological Nursing, 42(2), 38-44.].

Effects of repeated gas sterilization on closure rates of ameroid ring constrictors in vitro.

OBJECTIVE: To determine the effect of repeated gas sterilization on rate of closure of ameroid ring constrictors in vitro. SAMPLE: Twenty-four 3.5-mm ameroid ring constrictors. PROCEDURES: Ameroid ring constrictors were allocated to 1 of 4 treatment groups (6/group) to undergo gas sterilization 0, 1, 5, or 10 times. After sterilization, constrictors were incubated in canine plasma at a protein concentration of 3 g/dL for 27 days. A digital camera was used to obtain images of the constrictors prior to and at various points during incubation, and lumen diameter was measured. RESULTS: Mean ± SD percentage of lumen closure for all groups of ameroid ring constrictors combined was 85.2 ± 1.6% at day 0 (prior to plasma incubation) and 95.4 ± 0.8% at day 27. Mean lumen area was 3.64 ± 0.43 mm(2) (95% confidence interval, 2.67 to 4.77 mm(2)) at day 0 and 1.32 ± 0.25 mm(2) (95% confidence interval, 0.76 to 2.04 mm(2)) at day 27. None of the ameroid ring constrictors had closed completely by day 27. CONCLUSIONS AND CLINICAL RELEVANCE: Overall closure rates for ameroid ring constrictors appeared to be unaffected by repeated gas sterilization up to 10 times. Findings suggested that veterinary surgeons can resterilize ameroid ring constrictors up to 10 times with confidence that ring properties would remain suitable for clinical use.

Long-term outcome of sudden acquired retinal degeneration syndrome in dogs.

OBJECTIVE: To investigate long-term outcomes and owner-perceived quality of life associated with sudden acquired retinal degeneration syndrome (SARDS) in dogs. DESIGN: Survey study. ANIMALS: 100 dogs with SARDS examined at 5 academic veterinary institutions from 2005 to 2010. PROCEDURES: The diagnosis was based on documented acute vision loss, normal results of ophthalmic examinations, and evaluation of extinguished bright-flash electroretinograms. Primary owners of affected dogs completed a questionnaire addressing outcome measures including vision, systemic signs, and perceived quality of life for their dogs. RESULTS: Age at diagnosis was significantly correlated with positive outcome measures; dogs in which SARDS was diagnosed at a younger age were more likely to have alleged partial vision and higher owner-perceived quality of life. Polyphagia was the only associated systemic sign found to increase in severity over time. Medical treatment was attempted in 22% of dogs; visual improvement was not detected in any. Thirty-seven percent of respondents reported an improved relationship with their dog after diagnosis, and 95% indicated they would discourage euthanasia of dogs with SARDS. CONCLUSIONS AND CLINICAL RELEVANCE: Blindness and concurrent systemic signs associated with SARDS appeared to persist indefinitely, but only polyphagia increased in severity over time. Most owners believed their pets had good quality of life and would discourage euthanasia of dogs with SARDS.

Comparison of two portable lactate meters in dogs.

The objective of this study was to compare two portable lactate analyzers for testing canine patients in a clinical setting with a previously accepted methodology for measuring plasma lactate. Between Jan 1, 2005 and Jun 1, 2006, all samples were analyzed using two different portable analyzers (devices A and B), and 86 of those samples were also analyzed by a reference laboratory (REF). The concordance correlation coefficient (CCC) for device A and the REF was 0.949 (95% confidence interval [95% CI], 0.923-0.966). For device B and REF, the CCC was 0.990 (95% CI, 0.985-0.993). Only 8 of 85 samples (9.4%) exceeded a relative difference of 20% for device B (note that 1 of the 86 samples was not included because the lactate level fell below the detectable limit of device B), but 48 of 85 samples (56.5%) exceeded a relative difference of 20% for device A. Both portable lactate analyzers appeared to be effective in detecting clinically significant elevations in plasma lactate compared with the REF but device B had better agreement. A positive correlation among all three analyzers existed; however, the analyzers do not yield directly interchangeable results.

Assessment of hereditary retinal degeneration in the English springer spaniel dog and disease relationship to an RPGRIP1 mutation.

Intensive breeding and selection on desired traits have produced high rates of inherited diseases in dogs. Hereditary retinal degeneration, often called progressive retinal atrophy (PRA), is prevalent in dogs with disease entities comparable to human retinitis pigmentosa (RP) and Leber's congenital amaurosis (LCA). Recent molecular studies in the English Springer Spaniel (ESS) dog have shown that PRA cases are often homozygous for a mutation in the RPGRIP1 gene, the defect also causing human RP, LCA, and cone rod dystrophies. The present study characterizes the disease in a group of affected ESS in USA, using clinical, functional, and morphological studies. An objective evaluation of retinal function using electroretinography (ERG) is further performed in a masked fashion in a group of American ESS dogs, with the examiner masked to the genetic status of the dogs. Only 4 of 6 homozygous animals showed clinical signs of disease, emphasizing the need and importance for more precise studies on the clinical expression of molecular defects before utilizing animal models for translational research, such as when using stem cells for therapeutic intervention.

Short-term use of inhaled and intranasal corticosteroids is not associated with glaucoma progression on optical coherence tomography.

PURPOSE: To compare the changes in retinal nerve fiber layer (RNFL) thickness and optic nerve cup/disc ratio on optical coherence tomography (OCT) between users and nonusers of inhaled and intranasal corticosteroids (ICS). METHODS: Retrospective study of participants with glaucoma or glaucoma suspect having 2 or more OCTs during a 6-year period. The rates of change in Stratus OCT fast RNFL thickness scan and fast optic disc scan data were compared between ICS users and nonuser controls using random coefficient models. RESULTS: A total of 170 participants met the inclusion criteria, of whom 42 (25%) were ICS users and 128 (75%) were controls. The mean duration of follow-up was 3.2 years. There were no significant differences in the mean rates of change in superior RNFL (-0.8874 µm/y ICS users; -0.8592 µm/y controls; p=0.943), nasal RNFL (-0.0529 µm/y ICS users; -0.3577 µm/y controls; p=0.419), inferior RNFL (0.2703 µm/y ICS users; -0.1910 µm/y controls; p=0.165), and temporal RNFL (-0.3618 µm/y ICS users; -0.3612 µm/y controls; p=0.998) between ICS users and controls. There were no significant differences in the mean rates of change in horizontal cup/disc ratio (-0.0047 µm/y ICS users; 0.0002 µm/y controls; p=0.212) and vertical cup/disc ratio (0.0013 µm/y ICS users; 0.0029 µm/y; p=0.717) between ICS users and controls. CONCLUSIONS: We found no significant difference in the rates of RNFL or optic nerve cup/disc ratio progression among individuals with glaucoma or glaucoma suspect following short-term ICS use.

Randomized multilevel intervention to improve outcomes of residents in nursing homes in need of improvement.

OBJECTIVES: A comprehensive multilevel intervention was tested to build organizational capacity to create and sustain improvement in quality of care and subsequently improve resident outcomes in nursing homes in need of improvement. DESIGN/SETTING/PARTICIPANTS: Intervention facilities (N = 29) received a 2-year multilevel intervention with monthly on-site consultation from expert nurses with graduate education in gerontological nursing. Attention control facilities (N = 29) that also needed to improve resident outcomes received monthly information about aging and physical assessment of elders. INTERVENTION: The authors conducted a randomized clinical trial of nursing homes in need of improving resident outcomes of bladder and bowel incontinence, weight loss, pressure ulcers, and decline in activities of daily living. It was hypothesized that following the intervention, experimental facilities would have higher quality of care, better resident outcomes, more organizational attributes of improved working conditions than control facilities, higher staff retention, similar staffing and staff mix, and lower total and direct care costs. RESULTS: The intervention did improve quality of care (P = .02); there were improvements in pressure ulcers (P = .05) and weight loss (P = .05). Organizational working conditions, staff retention, staffing, and staff mix and most costs were not affected by the intervention. Leadership turnover was surprisingly excessive in both intervention and control groups. CONCLUSION AND IMPLICATIONS: Some facilities that are in need of improving quality of care and resident outcomes are able to build the organizational capacity to improve while not increasing staffing or costs of care. Improvement requires continuous supportive consultation and leadership willing to involve staff and work together to build the systematic improvements in care delivery needed. Medical directors in collaborative practice with advanced practice nurses are ideally positioned to implement this low-cost, effective intervention nationwide.

Cost, staffing and quality impact of bedside electronic medical record (EMR) in nursing homes.

OBJECTIVE: There is growing political pressure for nursing homes to implement the electronic medical record (EMR) but there is little evidence of its impact on resident care. The purpose of this study was to test the unique and combined contributions of EMR at the bedside and on-site clinical consultation by gerontological expert nurses on cost, staffing, and quality of care in nursing homes. METHODS: Eighteen nursing facilities in 3 states participated in a 4-group 24-month comparison: Group 1 implemented bedside EMR, used nurse consultation; Group 2 implemented bedside EMR only; Group 3 used nurse consultation only; Group 4 neither. Intervention sites (Groups 1 and 2) received substantial, partial financial support from CMS to implement EMR. Costs and staffing were measured from Medicaid cost reports, and staff retention from primary data collection; resident outcomes were measured by MDS-based quality indicators and quality measures. RESULTS: Total costs increased in both intervention groups that implemented technology; staffing and staff retention remained constant. Improvement trends were detected in resident outcomes of ADLs, range of motion, and high-risk pressure sores for both intervention groups but not in comparison groups. DISCUSSION: Implementation of bedside EMR is not cost neutral. There were increased total costs for all intervention facilities. These costs were not a result of increased direct care staffing or increased staff turnover. CONCLUSIONS: Nursing home leaders and policy makers need to be aware of on-going hardware and software costs as well as costs of continual technical support for the EMR and constant staff orientation to use the system. EMR can contribute to the quality of nursing home care and can be enhanced by on-site consultation by nurses with graduate education in nursing and expertise in gerontology.

Fall and balance outcomes after an intervention to promote leg strength, balance, and walking in people with diabetic peripheral neuropathy: "feet first" randomized controlled trial.

BACKGROUND: Weight-bearing exercise has been discouraged for people with diabetes mellitus and peripheral neuropathy (DM+PN). However, people with diabetes mellitus and insensate feet have an increased risk of falling. Lower-extremity exercise and balance training reduce fall risk in some older adults. It is unknown whether those with neuropathy experience similar benefits. OBJECTIVE: As part of a study of the effects of weight-bearing exercise on foot ulceration in people with DM+PN, the effects of a lower-extremity exercise and walking intervention on balance, lower-extremity strength (force-generating capacity), and fall incidence were determined. Design The study was an observer-masked, 12-month randomized controlled trial. SETTING: Part 1 of the intervention took place in physical therapy offices, and part 2 took place in the community. PATIENTS: The participants were 79 people who were mostly sedentary, who had DM+PN, and who were randomly assigned to either a control group (n=38) or an intervention group (n=41). Intervention Part 1 included leg strengthening and balance exercises and a graduated, self-monitored walking program; part 2 included motivational telephone calls. Both groups received regular foot care, foot care education, and 8 sessions with a physical therapist. MEASUREMENTS: The measurements collected were strength, balance, and participant-reported falls for the year after enrollment. RESULTS: There were no statistically significant differences between the groups for falls during follow-up. At 12 months, there was a small increase in the amount of time that participants in the intervention group could stand on 1 leg with their eyes closed. No other strength or balance measurements differed between the groups. LIMITATIONS: The study was designed to detect differences in physical activity, not falls. The intensity of the intervention was insufficient to improve strength and balance in this population. CONCLUSIONS: The training program had a minimal effect on participants' balance and lower-extremity strength. Increasing weight-bearing activity did not alter the rate of falling for participants in the intervention group relative to that for participants in the control group. People who are sedentary and who have DM+PN appear to be able to increase activity without increasing their rate of falling.

Pain management in nursing homes: what do quality measure scores tell us?

Pain management for older adults residing in nursing homes continues to present multifaceted challenges to health care practitioners and researchers. This study, which focuses on improvement in pain assessment and management, is a secondary analysis of data from a larger study, which used an intervention simultaneously directed at all levels of staff with change in quality measure (QM)/quality indicator (QI) scores to determine improvement in resident outcomes. We anticipated that focused improvement efforts in resident care regarding pain management would be reflected by correspondingly lower QM/QI scores over time. Findings of increased QM/QI scores may be positive in that they may point to increased attention by staff regarding pain management for residents.

Medication safety teams' guided implementation of electronic medication administration records in five nursing homes.

BACKGROUND: The 1.6 million nursing home residents in the United States are at high risk for adverse effects from medication errors. In an attempt to decrease medication errors and improve safety practices, from 2003 through 2007 the study investigators partnered with five Midwestern nursing homes in implementing electronic point-of-care medication administration records (eMARs) and focused quality improvement (QI) efforts. METHODS: The eMAR, designed by a vendor as a part of a larger integrated electronic health record, provided a point of information integration for a variety of users, including practitioners, nursing staff, medication administrators, and nursing home leadership. At each nursing home, a medication safety team guided the transition from traditional paper-based systems to the eMAR. RESULTS: The implementation and integration of the eMAR was monitored in more than 300 hours of detailed observation, resulting in nearly 16,000 medication doses across approximately 200 medication administrations (passes) for 3,700 residents. The types of medication errors most receptive to the combined impact of the eMAR and focused QI efforts were late and omitted (or missing) medications. DISCUSSION: Technology provided the structures and processes that improved communication and integrated complex processes. Yet, regardless of how effectively the technology was designed, it was "laid upon" nursing home medication administration systems that were archaic and fragmented. The implementation of technology could not solve chronic structure and process issues in isolation. However, using the technology to streamline processes, support effective decision making, integrate complex tasks, and bring real-time data to a medication safety team provided an effective mechanism to maximize the impact of technology and to minimize the unintended consequences of large-scale change.

Effect of weight-bearing activity on foot ulcer incidence in people with diabetic peripheral neuropathy: feet first randomized controlled trial.

BACKGROUND: Weight-bearing exercise has been contraindicated among people with diabetic peripheral neuropathy (DM+PN). However, recent cohort studies have suggested that daily weight-bearing activity is associated with lower risk for foot ulceration. OBJECTIVE: The objective of this study was to determine the effect of a lower-extremity exercise and walking intervention program on weight-bearing activity and foot ulcer incidence in people with DM+PN. DESIGN: This was an observer-blinded, 12-month randomized controlled trial. SETTING: The settings were physical therapy offices in part 1 of the intervention and the community in part 2 of the intervention. PARTICIPANTS: The participants were 79 individuals with DM+PN who were randomly assigned either to a control group (n=38) or an intervention group (n=41) group. INTERVENTION: Intervention components included leg strengthening and balance exercises; a graduated, self-monitored walking program (part 1); and motivational telephone calls every 2 weeks (part 2). Both groups received diabetic foot care education, regular foot care, and 8 sessions with a physical therapist. MEASUREMENTS: Total and exercise bout-related daily steps at baseline and at 3, 6, and 12 months were measured by accelerometers. Foot lesions/ulcers were photographed and classified by an independent panel of dermatologists. Use of adequate footwear was monitored. RESULTS: At 6 months, bout-related daily steps increased 14% from baseline in the intervention group and decreased 6% from baseline in the control group. Although the groups did not differ statistically in the change in total daily steps, at 12 months steps had decreased by 13% in the control group. Foot ulcer rates did not differ significantly between groups. CONCLUSION: Promoting weight-bearing activity did not lead to significant increases in foot ulcers. Weight-bearing activity can be considered following adequate assessment and counseling of patients with DM+PN.

Field testing, refinement, and psychometric evaluation of a new measure of quality of care for assisted living.

Field test results are reported for the Observable Indicators of Nursing Home Care Quality Instrument-Assisted Living Version, an instrument designed to measure the quality of care in assisted living facilities after a brief 30-minute walk-through. The OIQ-AL was tested in 207 assisted-living facilities in two states using classical test theory, generalizability theory, and exploratory factor analysis. The 34-item scale has a coherent six-factor structure that conceptually describes the multidimensional concept of care quality in assisted living. The six factors can be logically clustered into process (Homelike and Caring, 21 items) and structure (Access and Choice; Lighting; Plants and Pets; Outdoor Spaces) subscales and for a total quality score. Classical test theory results indicate most subscales and the total quality score from the OIQ-AL have acceptable interrater, test-retest, and strong internal consistency reliabilities. Generalizability theory analyses reveal that dependability of scores from the instrument are strong, particularly by including a second observer who conducts a site visit and independently completes an instrument, or by a single observer conducting two site visits and completing instruments during each visit. Scoring guidelines based on the total sample of observations (N = 358) help guide those who want to use the measure to interpret both subscale and total scores. Content validity was supported by two expert panels of people experienced in the assisted-living field, and a content validity index calculated for the first version of the scale is high (3.43 on a four-point scale). The OIQ-AL gives reliable and valid scores for researchers, and may be useful for consumers, providers, and others interested in measuring quality of care in assisted-living facilities.