A cross sectional study on the different domains of frailty for independent living older adults.

BACKGROUND: With the ageing population, there is a stronger focus on supporting older people to live independently as long as possible. One of the important factors to take into consideration for independent living older adults is frailty. This manuscript aims to provide insight into the relation between the different domains of frailty (physical, social and psychological or a combination), health outcomes and wellbeing aspects for independent living older adults. METHODS: This cross sectional community-based study included independent living older adults of 65 years and over who are member of a welfare organisation. The questionnaire contained items on background characteristics, health, quality of life, frailty (Tilburg Frailty Indicator), activities and loneliness. A multivariate analysis, one Way ANOVA's and chi-square tests with post-hoc analyses were used to identify significant differences between the following outcomes: Age, gender, marital status, living situation, income, health perception, number of conditions, activities of daily living, home care and informal care, Quality of life, loneliness, going outside, meeting people and the different domains of frailty. RESULTS: 1768 (35.1%) participants completed the questionnaire. 68.9% of the respondents was frail on one or multiple domains and 51.6% of the respondents was frail based on the total score on the TFI. Social frailty (18.4%) was most often present followed by 10.3% for frailty on all three domains of the TFI. All variables tested, except for income, showed significant differences between the different domains of frailty. CONCLUSION: Distinguishing the different domains of frailty provides information about the older adult's needs which is valuable for policymakers and care providers, to anticipate to the increasing number of independent living older adults and deliver them tailored care and support to contribute to their independent living situation and wellbeing.

Multicentre analysis of current ST-elevation myocardial infarction acute care pathways.

BACKGROUND: Rapid reperfusion with percutaneous coronary intervention (PCI) is vital for patients with ST segment elevation myocardial infarction (STEMI). However, the guideline-recommended time targets are regularly exceeded. The goal of this study was to gain insight into how Dutch PCI centres try to achieve these time targets by comparing their care processes with one another and with the European guideline-recommended process. In addition, accelerating factors perceived by care providers were identified. METHODS: In this multiple case study, interviews with STEMI care providers were conducted, transcribed and used to create process descriptions per centre. Analyses consisted of within-case and between-case analyses of the processes. Accelerating factors were identified by means of open and axial coding. RESULTS: In total, 28 interviews were conducted in six PCI centres. The centres differed from the guideline-recommended process on, for example, additional, unavoidable patient routings and monitoring delays, and from one another on the communication of diagnostic information (eg, transmitting all, only ambiguous or no ECGs) and catheterisation room preparation. These differences indicated diverging choices to maintain a balance between speed and diagnostic accuracy. Factors perceived by care providers as accelerating the process included trust in the tentative diagnosis, and avoiding unnecessary intercaregiver consultations. The combination of processes and accelerating factors were summarised in a model. CONCLUSIONS: Numerous differences in processes between PCI centres were identified. Several time-saving strategies were applied by PCI centres, however, in different configurations. To further improve the care for patients with STEMI, best practices can be shared between centres and countries.

[Pain registration: for the benefit of the inspectorate or the patient?]. / Pijnregistratie niet voor Inspectie maar voor patiënt.

Increasing attention is currently being directed to the measurement and treatment of pain. A recent study concluded that the implementation of a patient safety programme was successful because 99% of the hospitals indicated that they measure postoperative pain. However, another recent study, evaluating this safety programme, concluded that hospitals could improve the implementation of pain measurements, as only 56% of the postoperative patients were subject to standardized pain measurements during the first 3 days following surgery. The reason for this notable difference may be the tendency to implement pain registration mainly for external justification purposes. The attitude towards pain needs to change; too often it is still considered as an uninteresting side effect of treatment. Insight in the internal utility and effects of pain registration might help to further improve the quality of postoperative pain management. Acute Pain Service teams should have a facilitating role.

Compliance with a time-out procedure intended to prevent wrong surgery in hospitals: results of a national patient safety programme in the Netherlands.

OBJECTIVE: To prevent wrong surgery, the WHO 'Safe Surgery Checklist' was introduced in 2008. The checklist comprises a time-out procedure (TOP): the final step before the start of the surgical procedure where the patient, surgical procedure and side/site are reviewed by the surgical team. The aim of this study is to evaluate the extent to which hospitals carry out the TOP before anaesthesia in the operating room, whether compliance has changed over time, and to determine factors that are associated with compliance. DESIGN: Evaluation study involving observations. SETTING: Operating rooms of 2 academic, 4 teaching and 12 general Dutch hospitals. PARTICIPANTS: A random selection was made from all adult patients scheduled for elective surgery on the day of the observation, preferably involving different surgeons and different procedures. RESULTS: Mean compliance with the TOP was 71.3%. Large differences between hospitals were observed. No linear trend was found in compliance during the study period. Compliance at general and teaching hospitals was higher than at academic hospitals. Compliance decreased with the age of the patient, general surgery showed lower compliance in comparison with other specialties and compliance was higher when the team was focused on the TOP. CONCLUSIONS: Large differences in compliance with the TOP were observed between participating hospitals which can be attributed at least in part to the type of hospital, surgical specialty and patient characteristics. Hospitals do not comply consistently with national guidelines to prevent wrong surgery and further implementation as well as further research into non-compliance is needed.

Guideline adherence for identification and hydration of high-risk hospital patients for contrast-induced nephropathy.

BACKGROUND: Contrast-induced nephropathy (CIN) is a common cause of acute renal failure in hospital patients. To prevent CIN, identification and hydration of high-risk patients is important. Prevention of CIN by hydration of high-risk patients was one of the themes to be implemented in the Dutch Hospital Patient Safety Program. This study investigates to what extent high-risk patients are identified and hydrated before contrast administration. Hospital-related and admission-related factors associated with the hydration of high-risk patients are identified. METHODS: The adherence to the guideline concerning identification and hydration of high-risk patients for CIN was evaluated retrospectively in 4297 patient records between November 2011 and December 2012. A multilevel logistic regression analysis was used to investigate the association between hospital-related and patient-related factors and hydration. RESULTS: The mean percentage patients with a known estimated Glomerular Filtration Rate before contrast administration was 96.4%. The mean percentage high-risk patients for CIN was 14.6%. The mean percentage high-risk patients hydrated before contrast administration was 68.5% and was constant over time. Differences between individual hospitals explained 19% of the variation in hydration. The estimated Glomerular Filtration Rate value and admission department were statistically significantly associated with the execution of hydration. CONCLUSION: The identification of high-risk patients was almost 100%, but the subsequent step in the prevention of CIN is less performed, as only two third of the high-risk patients were hydrated before contrast administration. Large variation between individual hospitals confirmed the difference in hospitals in correctly applying the guideline for preventing CIN.

Protocol compliance of administering parenteral medication in Dutch hospitals: an evaluation and cost estimation of the implementation.

OBJECTIVES: Preventable adverse drug events (ADEs) are closely related to administration processes of parenteral medication. The Dutch Patient Safety Program provided a protocol for administering parenteral medication to reduce the amount of ADEs. The execution of the protocol was evaluated and a cost estimation was performed to provide insight in the associated costs of protocol compliance. METHODS: A longitudinal evaluation study was performed in secondary care. A total of 2154 observations of the administration process of parenteral medication were carried out within 10 measurements in 19 hospitals between November 2011 and December 2012. The total time needed for the process was measured in a sample of five hospitals. Multilevel linear and logistic regression analyses were used to analyse the trend over time of the implementation and to assess the association between hospital and administration characteristics, and compliance of the protocol. A cost estimation provided insight into the costs of performing a complete administration process and the costs at department level for 1 year. RESULTS: The complete protocol was performed in 19% of the observations. The proceeding 'check by a second nurse' was least performed. Large differences were found between individual hospitals in performing the administration protocol. The compliance of the protocol was negatively influenced in case of disturbance of the administrator. The overall trend over time of completion of the protocol fluctuated during the study period. On average, 3 min 26 s were needed to perform the complete protocol, which costs €2.42. Extrapolating the costs to department level, including cost for clinical lessons, the difference in costs in performing the complete protocol and an incomplete protocol was €7.891 for 1 year. CONCLUSIONS: The protocol for administering parenteral medication is still not implemented completely, therefore an investment in time and Euros is needed.

Improving long-term care provision: towards demand-based care by means of modularity.

BACKGROUND: As in most fields of health care, societal and political changes encourage suppliers of long-term care to put their clients at the center of care and service provision and become more responsive towards client needs and requirements. However, the diverse, multiple and dynamic nature of demand for long-term care complicates the movement towards demand-based care provision. This paper aims to advance long-term care practice and, to that end, examines the application of modularity. This concept is recognized in a wide range of product and service settings for its ability to design demand-based products and processes. METHODS: Starting from the basic dimensions of modularity, we use qualitative research to explore the use and application of modularity principles in the current working practices and processes of four organizations in the field of long-term care for the elderly. In-depth semi-structured interviews were conducted with 38 key informants and triangulated with document research and observation. Data was analyzed thematically by means of coding and subsequent exploration of patterns. Data analysis was facilitated by qualitative analysis software. RESULTS: Our data suggest that a modular setup of supply is employed in the arrangement of care and service supply and assists providers of long-term care in providing their clients with choice options and variation. In addition, modularization of the needs assessment and package specification process allows the case organizations to manage client involvement but still provide customized packages of care and services. CONCLUSION: The adequate setup of an organization's supply and its specification phase activities are indispensible for long-term care providers who aim to do better in terms of quality and efficiency. Moreover, long-term care providers could benefit from joint provision of care and services by means of modular working teams. Based upon our findings, we are able to elaborate on how to further enable demand-based provision of long-term care by means of modularity.

Improving client-centred care and services: the role of front/back-office configurations.

AIM: This paper is a report of a study conducted to explore the application of designing front- and back-office work resulting in efficient client-centred care in healthcare organizations that supply home care, welfare and domestic services. BACKGROUND: Front/back-office configurations reflect a neglected domain of design decisions in the development of more client-centred processes and structures without incurring major cost increases. METHOD: Based on a literature search, a framework of four front/back-office configurations was constructed. To illustrate the usefulness of this framework, a single, longitudinal case study was performed in a large organization, which provides home care, welfare and domestic services for a sustained period (2005-2006). FINDINGS: The case study illustrates how front/back-office design decisions are related to the complexity of the clients' demands and the strategic objectives of an organization. The constructed framework guides the practical development of front/back-office designs, and shows how each design contributes differently to such performance objectives as quality, speed and efficiency. CONCLUSIONS: The front/back-office configurations presented comprise an important first step in elaborating client-centred care and service provision to the operational level. It helps healthcare organizations to become more responsive and to provide efficient client-centred care and services when approaching demand in a well-tuned manner. In addition to its applicability in home care, we believe that a deliberate front/back-office configuration also has potential in other fields of health care.

Demand-based provision of housing, welfare and care services to elderly clients: from policy to daily practice through operations management.

Practical implementation of notions such as patient-orientation, client-centredness, and demand-driven care is far from straightforward in care and service supply to elderly clients living independently. This paper aims to provide preliminary insights into how it is possible to bridge the gap between policy intent, which reflects an increasing client orientation, and actual practice of care and service provision. Differences in personal objectives and characteristics generate different sets of needs among elderly clients that must have an appropriate response in the daily routines of care and service providers. From a study of the available literature and by conceptual reasoning, we identify several important operational implications of client-oriented care and service provision. To deal with these implications the authors turn to the field of operations management. This field has deepened the understanding of translating an organisation's policy into daily activities and working methods. More specifically, we elaborate on the concept of modularity, which stems from the field of operations management. With respect to elderly people who live independently, this concept, among others, seems to be particularly useful in providing options and variation in individual care and service packages. Based on our line of reasoning, we propose that modularity provides possibilities to enhance the provision of demand-based care and services. Furthermore, our findings offer direction on how organisations in housing, welfare and care can be guided in translating demand-based care to their operational processes.