Exploring Predictive Factors for Potentially Avoidable Emergency Department Transfers: Findings From the FINE Study.

OBJECTIVES: To assess the prevalence of potentially avoidable transfers (PAT) and identify factors associated with these transfers to emergency departments (EDs) among nursing home (NH) residents. DESIGN: This is a secondary outcome analysis of the FINE study, a multicenter observational study collecting data on NH residents, NH settings, and contextual factors of ED transfers. SETTINGS AND PARTICIPANTS: NHs in the former Midi-Pyrénées region of the southwest of France (n = 312); a total of 1037 NH residents who experienced ED transfers (n = 1017) between January 2016 and December 2016. METHODS: The analysis included resident baseline characteristics and NH and transfer decision-making characteristics. An expert group categorized the transfer status as either PAT or unavoidable. Multivariable analysis using a mixed logistic model, accounting for intra-NH correlation, was conducted to assess factors independently associated with PAT. RESULTS: Among 1017 included transfers, 87.02% (n = 885) were identified as PAT and 12.98% (n = 132) unavoidable transfers. Multivariable analysis revealed that the following patient-related factors were associated with a likely high rate of PAT: usual behavior disturbances before transfer, including productive trouble (OR 2.04, 95% CI 1.25-3.33; P = .0044) and unusual symptom of falling during the week preceding the transfer (OR 4.55, 95% CI 1.76-11.82; P = .0019). On the other hand, distance between ED and NH (OR 0.98, 95% CI 0.97-0.998; P = .0231), NH staff trained in palliative care in the last 3 years (OR 0.52, 95% CI 0.29-0.95; P = .0324), the impossibility of direct hospitalization to an appropriate unit (OR 0.54, 95% CI 0.34-0.87; P = .0117), and the resident Charlson Comorbidity Index (OR 0.90, 95% CI 0.82-0.99; P = .0369) were associated with a lower probability of PAT. CONCLUSION AND IMPLICATIONS: Transfers from NHs to hospital EDs were frequently potentially avoidable, meaning that there are still significant opportunities to reduce PAT. Our findings may help to specifically identify interventions that should be targeted at both NH and resident levels.

Intervention of companion clowns in a special care unit: a 1-year pilot study.

AIMS: Our 1-year pilot study aims to compare Behavioral and Psychological Symptoms of Dementia (BPSDs): number and frequency, globally an in sub-domains, and distress, of 20 residents with dementia, during periods with companion clown intervention and BPSDs during periods without companion clown intervention. METHODS: A duo of accompanying clowns intervened 24 times for a total of 72 h (two interventions of 3 h each per week for 4 weeks, 3 months of the year spaced 13 weeks apart) in the Special Care Unit. This unit was dedicated to residents with severe BPSDs. BPSDs were measured monthly by Health Care Professional using Neuro-Psychiatric Inventory (NPI). RESULTS: Baseline NPI total score of the 20 residents (10 women, mean age 76.9 years; standard deviation, SD 8.1, 70.6% with Alzheimer's disease) was 37.5 (SD = ± 19.7). The total score of the NPI was not significantly different between the periods with the clowns (median total score at 63; 25p-75p = 57-67) and the periods without the clowns (59; 25p-75p = 43-76) (p = 0.08). Compared to the period without clowns, residents presented significantly fewer delusions, hallucinations, euphoria, aberrant motor behavior but significantly more depression, apathy, disinhibition and more appetite disorders (all p value < 0.05). No statistically significant difference was observed on the distress the symptoms caused on the HCP during periods with the clowns. CONCLUSION: Accompanying clowns may not significantly reduce the overall BPSD of the residents, but may have beneficial effects in some behavioral issues.

Factors Associated with Potentially Inappropriate Transfer to the Emergency Department among Nursing Home Residents.

OBJECTIVES: To determine the factors associated with the potentially inappropriate transfer of nursing home (NH) residents to emergency departments (EDs) and to compare hospitalization costs before and after transfer of individuals addressed inappropriately vs those addressed appropriately. DESIGN: Multicenter, observational, case-control study. SETTING AND PARTICIPANTS: 17 hospitals in France, 1037 NH residents. MEASURES: All NH residents transferred to the 17 public hospitals' EDs in southern France were systematically included for 1 week per season. An expert panel composed of family physicians, emergency physicians, geriatricians, and pharmacists defined whether the transfer was potentially inappropriate or appropriate. Residents' and NHs' characteristics and contextual factors were entered into a mixed logistic regression to determine factors associated independently with potentially inappropriate transfers. Hospital costs were collected in the national health insurance claims database for the 6 months before and after the transfer. RESULTS: A total of 1037 NH residents (mean age 87.2 ± 7.1, 68% female) were transferred to the ED; 220 (21%) transfers were considered potentially inappropriate. After adjustment, anorexia [odds ratio (OR) 2.41, 95% confidence interval (CI) 1.57-3.71], high level of disability (OR 0.90, 95% CI 0.81-0.99), and inability to receive prompt medical advice (OR 1.67, 95% CI 1.20-2.32) were significantly associated with increased likelihood of potentially inappropriate transfers. The existence of an Alzheimer's disease special care unit in the NH (OR 0.66, 95% CI 0.48-0.92), NH staff trained on advance directives (OR 0.61, 95% CI 0.41-0.89), and calling the SAMU (mobile emergency medical unit) (OR 0.47, 95% CI 0.34-0.66) were significantly associated with a lower probability of potentially inappropriate transfer. Although the 6-month hospitalization costs prior to transfer were higher among potentially inappropriate transfers compared with appropriate transfers (€6694 and €4894, respectively), transfer appropriateness was not significantly associated with hospital costs. CONCLUSIONS AND IMPLICATIONS: Transfers from NHs to hospital EDs were frequently appropriate. Transfer appropriateness was conditioned by NH staff training, access to specialists' medical advice, and calling the SAMU before making transfer decisions. TRIAL REGISTRATION: clinicaltrials.gov, NCT02677272.

Systematic Dementia Screening by Multidisciplinary Team Meetings in Nursing Homes for Reducing Emergency Department Transfers: The IDEM Cluster Randomized Clinical Trial.

Importance: Dementia is often underdiagnosed in nursing homes (NHs). This potentially results in inappropriate care, and high rates of emergency department (ED) transfers in particular. Objective: To assess whether systematic dementia screening of NH residents combined with multidisciplinary team meetings resulted in a lower rate of ED transfer at 12 months compared with usual care. Design, Setting, and Participants: Multicenter, cluster randomized trial with NHs as the unit of randomization. The IDEM (Impact of Systematic Tracking of Dementia Cases on the Rate of Hospitalization in Emergency Care Units) trial took place at 64 public and private NHs in France. Recruitment started on May 1, 2010, and was completed on March 31, 2012. Residents who were aged 60 years or older, had no diagnosed or documented dementia, were not bedridden, had lived in the NH for at least 1 month at inclusion, and had a life expectancy greater than 12 months were included. The residents were followed up for 18 months. The main study analyses were completed on October 14, 2016. Intervention: Two parallel groups were compared: an intervention group consisting of NHs that set up 2 multidisciplinary team meetings to identify residents with dementia and to discuss an appropriate care plan, and a control group consisting of NHs that continued their usual practice. During the inclusion period of 23 months, all residents of participating NHs who met eligibility criteria were included in the study. Main Outcomes and Measures: The primary end point (ED transfer) was analyzed at 12 months, but the residents included were followed up for 18 months. Results: A total of 64 NHs participated in the study and enrolled 1428 residents (mean [SD] age, 84.7 [8.1] years; 1019 [71.3%] female): 599 in the intervention group (32 NHs) and 829 in the control group (32 NHs). The final study visit was completed by 1042 residents (73.0%). The main reason for early discontinuation was death (318 residents [22.7%]). The intervention did not reduce the risk of ED transfers during the 12-month follow-up: the proportion of residents transferred at least once to an ED during the 12-month follow-up was 16.2% in the intervention group vs 12.8% in the control group (odds ratio, 1.32; 95% CI, 0.83-2.09; P = .24). Conclusions and Relevance: This study failed to demonstrate that systematic screening for dementia in NHs resulted in fewer ED transfers. The findings do not support implementation of multidisciplinary team meetings for systematic dementia screening of all NH residents, beyond the national recommendations for dementia diagnosis, to reduce ED transfers. Trial Registration: ClinicalTrials.gov Identifier: NCT01569997.

[Swallowing disorders, training and assessment of geriatric practices]. / Troubles de la déglutition en gériatrie, formation et évaluation des pratiques professionnelles.

In geriatrics, swallowing disorders are frequent, representing a daily source of anxiety for the nursing teams. Training in this area, aimed at caregivers in a long-stay care unit, has been developed based on an assessment of professional practices.

[Humour therapy, laughter and the intervention of clowns in gerontology]. / La thérapie par l'humour, le rire et l'intervention de clowns en gérontologie.

Confronted with the growing incidence of age-related pathologies and the limits of so-called traditional medicine oriented towards the prescribing of medicines, non-pharmacological approaches have grown considerably in the geriatric community. A literature review focused on the therapeutic benefit of humour, laughter and the use of clowns on the physical and psychological health of elderly people.

Factors predisposing nursing home resident to inappropriate transfer to emergency department. The FINE study protocol.

BACKGROUND: Each year, around one out of two nursing home (NH) residents are hospitalized in France, and about half to the emergency department (ED). These transfers are frequently inappropriate. This paper describes the protocol of the FINE study. The first aim of this study is to identify the factors associated with inappropriate transfers to ED. METHODS/DESIGN: FINE is a case-control observational study. Sixteen hospitals participate. Inclusion period lasts 7 days per season in each center for a total period of inclusion of one year. All the NH residents admitted in ED during these periods are included. Data are collected in 4 times: before transfer in the NH, at the ED, in hospital wards in case of patient's hospitalization and at the patient's return to NH. The appropriateness of ED transfers (i.e. case versus control NH residents) is determined by a multidisciplinary team of experts. RESULTS: Our primary objective is to determine the factors predisposing NH residents to inappropriate transfer to ED. Our secondary objectives are to assess the cost of the transfers to ED; study the evolution of NH residents' functional status and the psychotropic and inappropriate drugs prescription between before and after the transfer; calculate the prevalence of potentially avoidable transfers to ED; and identify the factors predisposing NH residents to potentially avoidable transfer to ED. DISCUSSION: A better understanding of the determinant factors of inappropriate transfers to ED of NH residents may lead to proposals of recommendations of better practice in NH and would allow implementing quality improvement programs in the health organization.

[Reinforced accommodation units and the management of patients with dementia]. / Prise en charge des patients déments en unités d'hébergement renforcées.

Dementia is frequently associated with behavioural disorders that can be difficult to manage. In regards to these symptoms, psychoactive drugs are not very effective and have many potential side effects. In order to take care of patients with such severe disorders, specific units called "reinforced hosting units" ("UHR; Unités d'Hébergement Renforcées" in French) have been developed within long term care units. Specifically trained teams take care of these patients in specially designed settings. A French national inquiry has studied the development, the characteristics and the activity of these units in 2013 and 2012.

[Improvement of oral health at institutionalized patients. Choice and validation of an adapted oral hygiene kit in long-term care unit]. / Amélioration de la santé orale chez des patients institutionnalisés Choix et validation d'un kit d'hygiène bucco-dentaire adapté au sein d'une USLD (unité de soins de longue durée).

The initiatives to improve the quality are widely developed in the healthcare sector. So, an evaluation of the professional practices (EPP) concerning oral diseases in elderly was organized in the long term care unit of the teaching hospital of Toulouse. In the dynamic of this EPP, a pilot study consisted in estimating a new kit of oral hygiene. This hygiene kit was chosen according to defined criteria adapted to the elderly. The results show a clear improvement of the oral health measured with a specific index (Oral health assessment tool).

[Oral ecosystem in elderly people]. / L'écosystème buccal chez le patient âgé

The mouth is a complex natural cavity which constitutes the initial segment of the digestive tract. It is an essential actor of the vital functions as nutrition, language, communication. The whole mouth (teeth, periodontium, mucous membranes, tongue) is constantly hydrated and lubricated by the saliva. At any age, a balance becomes established between the bacterial proliferations, the salivary flow, the adapted tissular answer: it is the oral ecosystem. The regulation of this ecosystem participates in the protection of the oral complex against current inflammatory and infectious pathologies (caries, gingivitis, periodontitis, candidiasis). In elderly, the modification of the salivary flow, the appearance of specific pathologies (root caries, edentulism, periodontitis), the local conditions (removable dentures), the development of general pathologies, the development of general pathologies (diabetes, hypertension, immunosuppression, the insufficient oral care are so many elements which are going to destabilize the oral ecosystem, to favor the formation of the dental plaque and to weaken oral tissues. The preservation of this ecosystem is essential for elderly: it allows to eat in good conditions and so to prevent the risks of undernutrition. The authors describe the oral physiopathology (oral microflora, salivary secretion) and the strategies to be adopted to protect the balance of the oral ecosystem in geriatric population.

[Pastel in the urine bag]. / Du pastel dans la poche à urine.

Purple urine bag syndrome is a relatively unknown phenomenon in which the urine bag and the collector of chronically catheterized patients turn purple or blue. It affects predominantly women, and is mainly reported in elderly patients. The mechanism seems to be related to the appearance in the urine of two compounds that have been identified as indigo (blue) and indirubin (red) which bind to the urine bag and the collector. Several associated factors are usually mentioned such as constipation, alkaline urine, bed rest, institutionalization or cognitive impairment. They are risk factor of this phenomenon. On the other hand, an infection or a urinary bacterial colonization is necessary and high bacterial counts seem to be the critical step in the development of the purple urine bag syndrome. We report on two cases of purple urine bag syndrome observed in two patients being treated in a long-term care unit. Both of whom were diagnosed with indwelling urinary bacterial colonization, with Escherichia coli and Pseudomonas aeruginosa respectively.

[Walking problems and falls in patients suffering from Alzheimer's disease]. / Les troubles de la marche et les chutes chez les patients souffrant de la maladie d'Alzheimer.

Walking problems and falls are a daily concern for healthcare professionals working with patients suffering from Alzheimer's disease. These problems and their complications often have consequences in terms of functional prognosis. The disease is not solely responsible and several aggravating factors need to be identified and investigated as some of them can be effectively prevented.