Clinical guidelines for stroke management: chapter 8 of 8: community participation and long-term care

The Stroke Foundation is a national charity that partners with the community to prevent, treat and beat stroke. We stand alongside stroke survivors and their families, healthcare professionals and researchers. We build community awareness and foster new thinking and innovative treatments. We support survivors on their journey to live the best possible life after stroke. We are the voice of stroke in Australia and we work to: • Raise awareness of the risk factors, signs of stroke and promote healthy lifestyles. • Improve treatment for stroke to save lives and reduce disability. • Improve life after stroke for survivors. • Encourage and facilitate stroke research. • Advocate for initiatives to prevent, treat and beat stroke. • Raise funds from the community, corporate sector and government to continue our mission. The Stroke Foundation has been developing stroke guidelines since 2002 and in 2017 released the fourth edition. In order for the Australian Government to ensure up-to-date, best-practice clinical advice is provided and maintained to healthcare professionals, the NHMRC requires clinical guidelines be kept current and relevant by reviewing and updating them at least every five years. As a result, the Stroke Foundation, in partnership with Cochrane Australia, have moved to a model of living guidelines, in which recommendations are continually reviewed and updated in response to new evidence. This approach was piloted in a three year project (July 2018 -June 2021) funded by the Australian Government via the Medical Research Future Fund. This online version of the Clinical Guidelines for Stroke Management updates and supersedes the Clinical Guidelines for Stroke Management 2017. The Clinical Guidelines have been updated in accordance with the 2011 NHMRC Standard for clinical practice guidelines and therefore recommendations are based on the best evidence available. The Clinical Guidelines cover the whole continuum of stroke care, across 8 chapters. Review of the Clinical Guidelines used an internationally recognised guideline development approach, known as GRADE (Grading of Recommendations Assessment, Development and Evaluation), and an innovative guideline development and publishing platform, known as MAGICapp (Making Grade the Irresistible Choice). GRADE ensures a systematic process is used to develop recommendations that are based on the balance of benefits and harms, patient values, and resource considerations. MAGICapp enables transparent display of this process and access to additional practical information useful for guideline recommendation implementation.

Post-polypectomy surveillance colonoscopy: Comparison of the updated guidelines.

BACKGROUND: Recently, three updated guidelines for post-polypectomy colonoscopy surveillance (PPCS) have been published. These guidelines are based on a comprehensive summary of the literature, while some recommendations are similar, different surveillance intervals are recommended after detection of specific types of polyps. AIM: In this review, we aimed to compare and contrast these recommendations. METHODS: The updated guidelines for PPCS were reviewed and the recommendations were compared. RESULTS: For patients with 1-4 adenomas <10 mm with low-grade dysplasia, irrespective of villous components, or 1-4 serrated polyps <10 mm without dysplasia, the European Society of Gastrointestinal Endoscopy (ESGE) and British Society of Gastroenterology (BSG), the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and Public Health England (PHE) (BSG/ACPGBI/PHE) guidelines do not recommend colonoscopic surveillance and instead recommend that the participate in routine CRC screening program (typically based on the fecal immunochemical test), while the USMSTF recommends surveillance colonoscopies 7-10 years after diagnosis of 1-2 tubular adenomas <10 mm and 3-5 years for 3-4 tubular adenomas of the same size. The USMSTF define adenomas with tubulovillous or villous histology as high-risk adenomas; thus, surveillance colonoscopy is recommended after 3 years. However, the ESGE and BSG do not consider such histology as a criterion for repeating colonoscopy at this short interval. For patients with 1-2 sessile serrated polyps (SSPs) <10 mm and those with 3-4 SSPs <10 mm, the USMSTF recommends surveillance colonosocopy after 5-10 and 3-5 years, respectively.

Impact of a Serious Game (Escape COVID-19) on the Intention to Change COVID-19 Control Practices Among Employees of Long-term Care Facilities: Web-Based Randomized Controlled Trial.

BACKGROUND: Most residents of long-term care facilities (LTCFs) are at high risk of complications and death following SARS-CoV-2 infection. In these facilities, viral transmission can be facilitated by shortages of human and material resources, which can lead to suboptimal application of infection prevention and control (IPC) procedures. To improve the dissemination of COVID-19 IPC guidelines, we developed a serious game called "Escape COVID-19" using Nicholson's RECIPE for meaningful gamification, as engaging serious games have the potential to induce behavioral change. OBJECTIVE: As the probability of executing an action is strongly linked to the intention of performing it, the objective of this study was to determine whether LTCF employees were willing to change their IPC practices after playing "Escape COVID-19." METHODS: This was a web-based, triple-blind, randomized controlled trial, which took place between November 5 and December 4, 2020. The health authorities of Geneva, Switzerland, asked the managers of all LTCFs under their jurisdiction to forward information regarding the study to all their employees, regardless of professional status. Participants were unaware that they would be randomly allocated to one of two different study paths upon registration. In the control group, participants filled in a first questionnaire designed to gather demographic data and assess baseline knowledge before accessing regular online IPC guidelines. They then answered a second questionnaire, which assessed their willingness to change their IPC practices and identified the reasons underlying their decision. They were then granted access to the serious game. Conversely, the serious game group played "Escape COVID-19" after answering the first questionnaire but before answering the second one. This group accessed the control material after answering the second set of questions. There was no time limit. The primary outcome was the proportion of LTCF employees willing to change their IPC practices. Secondary outcomes included the factors underlying participants' decisions, the domains these changes would affect, changes in the use of protective equipment items, and attrition at each stage of the study. RESULTS: A total of 295 answer sets were analyzed. Willingness to change behavior was higher in the serious game group (82% [119/145] versus 56% [84/150]; P<.001), with an odds ratio of 3.86 (95% CI 2.18-6.81; P<.001) after adjusting for professional category and baseline knowledge, using a mixed effects logistic regression model with LTCF as a random effect. For more than two-thirds (142/203) of the participants, the feeling of playing an important role against the epidemic was the most important factor explaining their willingness to change behavior. Most of the participants unwilling to change their behavior answered that they were already applying all the guidelines. CONCLUSIONS: The serious game "Escape COVID-19" was more successful than standard IPC material in convincing LTCF employees to adopt COVID-19-safe IPC behavior. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/25595.

Improving Care for Older Adults in China: Development of Long-Term Care Policy and System.

This special issue covers several important topics related to long-term care (LTC) systems and policy development in China. It provides a good contextual background on the development of the LTC system in China as well as the needs and preferences of LTC from family and older adults' perspectives. In addition, this issue covers the topic of evaluation of a recently developed long-term care nursing insurance and provides an example of family caregiving for persons with dementia within the Chinese context. The authors in this special issue also provided insights into the impact of the COVID-19 pandemic on older adults' life and LTC quality, and explored potential strategies to handle the challenges during and post-pandemic.

Expanding health care coverage in Canada: a dramatic shift in the debate.

The coronavirus disease 2019 (COVID-19) pandemic has shifted the health policy debate in Canada. While the pre-pandemic focus of policy experts and government reports was on the question of whether to add outpatient pharmaceuticals to universal health coverage, the clustering of pandemic deaths in long-term care facilities has spurred calls for federal standards in long-term care (LTC) and its possible inclusion in universal health coverage. This has led to the probability that the federal government will attempt to expand medicare as Canadians have known it for the first time in over a half century. However, these efforts are likely to fail if the federal government relies on the shared-cost federalism that marked the earlier introduction of medicare. Two alternative pathways are suggested, one for LTC and one for pharmaceuticals, that are more likely to succeed given the state of the Canadian federation in the early 21st century.

Factors Affecting the Implementation, Use, and Adoption of Real-Time Location System Technology for Persons Living With Cognitive Disabilities in Long-term Care Homes: Systematic Review.

BACKGROUND: As the aging population continues to grow, the number of adults living with dementia or other cognitive disabilities in residential long-term care homes is expected to increase. Technologies such as real-time locating systems (RTLS) are being investigated for their potential to improve the health and safety of residents and the quality of care and efficiency of long-term care facilities. OBJECTIVE: The aim of this study is to identify factors that affect the implementation, adoption, and use of RTLS for use with persons living with dementia or other cognitive disabilities in long-term care homes. METHODS: We conducted a systematic review of the peer-reviewed English language literature indexed in MEDLINE, Embase, PsycINFO, and CINAHL from inception up to and including May 5, 2020. Search strategies included keywords and subject headings related to cognitive disability, residential long-term care settings, and RTLS. Study characteristics, methodologies, and data were extracted and analyzed using constant comparative techniques. RESULTS: A total of 12 publications were included in the review. Most studies were conducted in the Netherlands (7/12, 58%) and used a descriptive qualitative study design. We identified 3 themes from our analysis of the studies: barriers to implementation, enablers of implementation, and agency and context. Barriers to implementation included lack of motivation for engagement; technology ecosystem and infrastructure challenges; and myths, stories, and shared understanding. Enablers of implementation included understanding local workflows, policies, and technologies; usability and user-centered design; communication with providers; and establishing policies, frameworks, governance, and evaluation. Agency and context were examined from the perspective of residents, family members, care providers, and the long-term care organizations. CONCLUSIONS: There is a striking lack of evidence to justify the use of RTLS to improve the lives of residents and care providers in long-term care settings. More research related to RTLS use with cognitively impaired residents is required; this research should include longitudinal evaluation of end-to-end implementations that are developed using scientific theory and rigorous analysis of the functionality, efficiency, and effectiveness of these systems. Future research is required on the ethics of monitoring residents using RTLS and its impact on the privacy of residents and health care workers.

COVID-19 Infection Prevention and Control Adherence in Long-Term Care Facilities, Atlanta, Georgia.

BACKGROUND/OBJECTIVE: Recommendations for infection prevention and control (IPC) of COVID-19 in long-term care settings were developed based on limited understanding of COVID-19 and should be evaluated to determine their efficacy in reducing transmission among high-risk populations. DESIGN AND SETTING: Site visits to 24 long-term care facilities (LTCFs) in Fulton County, Georgia, were conducted between June and July 2020 to assess adherence to current guidelines, provide real-time feedback on potential weaknesses, and identify specific indicators whose implementation or lack thereof was associated with higher or lower prevalence of COVID-19. PARTICIPANTS: Twenty-four LTCFs were visited, representing 2,580 LTCF residents, among whom 1,004 (39%) were infected with COVID-19. MEASUREMENTS: Overall IPC adherence in LTCFs was analyzed for 33 key indicators across five categories: Hand Hygiene, Disinfection, Social Distancing, PPE, and Symptom Screening. Facilities were divided into Higher- and Lower-prevalence groups based on cumulative COVID-19 infection prevalence to determine differences in IPC implementation. RESULTS: IPC implementation was lowest in the Disinfection category (32%) and highest in the Symptom Screening category (74%). Significant differences in IPC implementation between the Higher- and Lower-prevalence groups were observed in the Social Distancing category (Higher-prevalence group 54% vs Lower-prevalence group 74%, P < .01) and the PPE category (Higher-prevalence group 41% vs Lower-prevalence group 72%, P < .01). CONCLUSION: LTCFs with lower COVID-19 prevalence among residents had significantly greater implementation of IPC recommendations compared to those with higher COVID-19 prevalence, suggesting the utility in adhering to current guidelines to reduce transmission in this vulnerable population.

Learning and improving in long-term care internationally: the International Prevalence Measurement of Care Quality (LPZ) / Aprender e melhorar internacionalmente em cuidados de longa duração: a Medição de Prevalência Internacional de Qualidade de Cuidados (LPZ)

Long-term care (LTC) for older adults is an essential part of how health and social care systems respond to population ageing. Different long-term care systems in different countries have taken differing approaches to quality assurance, ranging from inspection-based regulatory systems to data and reporting-based regulatory systems. The significant variability in the ability of long-term care facilities to respond to the COVID-19 pandemic has led to increased recognition of the role of standardized data in informing structured approaches to quality assurance. The International Prevalence Measurement of Care Quality (in Dutch: Landelijke Prevalentiemeting Zorgkwaliteit ­ LPZ) was developed to guide continuous quality improvement in long-term care facilities. This special article describes the LPZ tool, developed to provide input for the learning and improvement cycle of multidisciplinary teams in the LTC sector and to help improve care quality.

O cuidado de longa duração para idosos é uma parte essencial de como os sistemas de cuidados sociais e de saúde respondem ao envelhecimento da população. Distintos países e seus sistemas de cuidados de longa duração adotaram abordagens diferentes para a garantia da qualidade, que vão desde sistemas regulatórios baseados em inspeção até sistemas regulatórios baseados em dados e relatórios. A variabilidade significativa testemunhada entre as instituições de cuidados de longa duração em sua capacidade de responder à pandemia de COVID-19 levou a um maior reconhecimento do papel de dados padronizados para informar abordagens estruturadas para a garantia de qualidade. A Medição de Prevalência Internacional de Qualidade de Atendimento (em holandês: Landelijke Prevalentiemeting Zorgkwaliteit ­ LPZ) foi desenvolvida para orientar as unidades de cuidados de longa duração nas etapas de melhoria contínua da qualidade. Este artigo especial descreve a ferramenta LPZ, desenvolvida para fornecer subsídios para o ciclo de aprendizagem e melhoria de equipes multidisciplinares no setor de cuidados de longa duração e contribuir para a melhoria da qualidade do cuidado.

Factors Affecting Quality of Life Among the Elderly in Long-Term Care Hospitals.

BACKGROUND: There are challenges in sustaining person-centered care in aged care settings. Key related issues of concern such as quality of life among the older people in long-term care hospitals and interactions with nursing staff have been described previously. PURPOSE: This study was designed to explore the factors affecting quality of life among older people living in long-term care hospitals in South Korea. METHODS: Older adult patients (N = 202) in three long-term care hospitals completed measures of cognitive functions, depression, care dependency, and interactions between nurse and patient and a quality-of-life assessment tool. Univariate analyses were used to examine the relationships among these variables, and a multiple linear regression analysis was used to explore the extent to which these variables predicted quality of life in these patients. RESULTS: The significant factors associated with quality of life were found to be cognitive functions (r = .373, p < .001), care dependency (r = .350, p < .001), and depression (r = -.504, p < .001). The regression model with depression and care dependency as predictor variables accounted for 25.7% of the variance in quality of life. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: The correlation found in this study between quality of life and depression and care dependency provides additional evidentiary support for developing and applying nursing interventions that reduce depression and care dependency in older adult populations.

Tracheostomy to Noninvasive Ventilation: From Acute Care to Home.

The number of patients experiencing prolonged mechanical ventilation is increasing over time. Patients who have a tracheostomy placed in a critical care setting have been described as having an average of 4 separate transitions between the acute care setting, long-term acute care (LTAC), and home. Transition points can be problematic if not addressed adequately; however, proactive planning can optimize patient care. Individual patient factors will determine if the patient will require long-term tracheostomy, transitioned to noninvasive positive pressure ventilation, or able to be decannulated. Patients and caregivers should be included in transition planning to optimize outcomes.

Exploration of the acceptability and usability of advance care planning tools in long term care homes.

OBJECTIVES: Despite known benefits, advance care planning (ACP) is rarely a component of usual practice in long-term care (LTC). A series of tools and workbooks have been developed to support ACP uptake amongst the generable population. Yet, their potential for improving ACP uptake in LTC has yet to be examined. This study explored if available ACP tools are acceptable for use in LTC by (a) eliciting staff views on the content and format that would support ACP tool usability in LTC (b) examining if publicly available ACP tools include content identified as relevant by LTC home staff. Ultimately this study aimed to identify the potential for existing ACP tools to improve ACP engagement in LTC. METHODS: A combination of focus group deliberations with LTC home staff (N = 32) and content analysis of publicly available ACP tools (N = 32) were used to meet the study aims. RESULTS: Focus group deliberations suggested that publicly available ACP tools may be acceptable for use in LTC if the tools include psychosocial elements and paper-based versions exist. Content analysis of available paper-based tools revealed that only a handful of ACP tools (32/611, 5%) include psychosocial content, with most encouraging psychosocially-oriented reflections (30/32, 84%), and far fewer providing direction around other elements of ACP such as communicating psychosocial preferences (14/32, 44%) or transforming preferences into a documented plan (7/32, 22%). CONCLUSIONS: ACP tools that include psychosocial content may improve ACP uptake in LTC because they elicit future care issues considered pertinent and can be supported by a range of clinical and non-clinical staff. To increase usability and engagement ACP tools may require infusion of scenarios pertinent to frail older persons, and a better balance between psychosocial content that elicits reflections and psychosocial content that supports communication.

Person-Centered Care Environment Associated With Care Staff Outcomes in Long-Term Care Facilities.

BACKGROUND: Although a general implementation of person-centered care in Korean long-term care delivery systems would be challenging, person-centered care has the potential to improve resident and staff outcomes through changes in current care services. However, little empirical evidence currently supports a positive relationship between person-centered care environments and staff outcomes. PURPOSE: This study was designed to examine the relationship between person-centered care environments and staff outcomes, including job satisfaction and turnover intention, among care staff in Korean long-term care facilities. METHODS: This descriptive, correlational study used data from 235 care staff (94 nursing staff and 141 personal care workers) in 13 long-term care facilities in Korea. Data were collected using structured survey questionnaires, including items related to the person-centered care environment, job satisfaction, and turnover intention. Multilevel linear and logistic regression analyses were performed using Mplus Version 7.0. RESULTS: After controlling for individual (age, education, monthly income, position, shift work, and job tenure) and organizational (type of facility, location, ownership, bed size, and staffing levels) characteristics, a significant relationship was found between the person-centered care environment and job satisfaction and turnover intention among staff in Korean long-term care facilities. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: The study findings indicate that working in a person-centered care environment is key to higher job satisfaction, which is a significant predictor of turnover intention among staff in long-term care facilities. To recruit and retain qualified staff to provide high-quality person-centered care in long-term care facilities, a supportive work environment is crucial. Fostering a person-centered care environment will ultimately improve quality of care for residents.

Balancing the pressures: a review of the quality of care provided to children and young people aged 0-24 years who were receiving long-term ventilation.

Assessing the quality of care for patients receiving long-term ventilation is complex given the diversity of this population (0-24 years in this case) and their differing requirements for treatment. This article details how and why such reviews are necessary.

Acromegaly: Update on Management and Long-Term Morbidities.

Acromegaly is a systemic disease associated with great morbidity and increased mortality if not adequately treated. In the past decades much improvement has been achieved in its treatment and in the knowledge of its comorbidities. We provide an update of acromegaly management with current recommendations. We also address long-term comorbidities emphasizing the changing face of the disease in more recent series, with a decrease of cardiovascular disease severity and an increased awareness of comorbidities like bone disease, manifested mainly as vertebral fractures and the change in the main cause of death (from cardiovascular disease to cancer in more recent series).

Place of death associated with types of long-term care services near the end-of-life for home-dwelling older people in Japan: a pooled cross-sectional study.

BACKGROUND: Many older people wish to die at home. However, there is still a huge gap between the place where older adults wish to die and the place where they, in fact, do die. We aimed to assess the association between each type of long-term care (LTC) services that home-dwelling older individuals utilized at their end of life and place of death. METHODS: A pooled cross-sectional study at the point of death was used for the analysis. Participants included beneficiaries of long-term care insurance in Japan, aged 65 years and above, who passed away between January 2008 and December 2013, excluding those who died due to external factors and those who were using residential services at their time of death. We conducted a multivariate Poisson regression analysis with robust standard errors adjusting for potential confounders and examined the association between the use of each type of LTC service for home-dwelling recipients, including in-home services, day services, and short-stay services, with the interaction terms being time of death (exposure) and home death (outcome). We calculated the adjusted probability of home deaths for each combination pattern of LTC services for home-dwelling recipients using standard marginalization. RESULTS: We analyzed 2,035,657 beneficiaries. The use of in-home services, day services, and short-stay services were associated with an increased probability of home deaths; the incident rate ratio (IRR) was 13.40 (with a 95% confidence interval (CI): 13.23-13.57) for in-home services, the IRR was 6.32 (6.19-6.45) for day services, and the IRR was 1.25 (1.16-1.34) for short-stay services. Those who used day or short-stay services with in-home services exhibited a higher probability of home deaths than those who used only day or short-stay services. CONCLUSIONS: We demonstrated that home-dwelling older persons who used LTC services near end-of-life had a higher probability of home deaths as compared to those who did not. Our findings can clarify the importance of providing and integrating such services to support care recipients who wish to die at home as well as for the benefit of their informal caregivers.