A first look at consistency of documentation across care settings during emergency transitions of long-term care residents.

BACKGROUND: Documentation during resident transitions from long-term care (LTC) to the emergency department (ED) can be inconsistent, leading to inappropriate care. Inconsistent documentation can lead to undertreatment, inefficiencies and adverse patient outcomes. Many individuals residing in LTC have some form of cognitive impairment and may not be able to advocate for themselves, making accurate and consistent documentation vital to ensuring they receive safe care. We examined documentation consistency related to reason for transfer across care settings during these transitions. METHODS: We included residents of LTC aged 65 or over who experienced an emergency transition from LTC to the ED via emergency medical services. We used a standardized and pilot-tested tracking tool to collect resident chart/patient record data. We collected data from 38 participating LTC facilities to two participating EDs in Western Canadian provinces. Using qualitative directed content analysis, we categorized documentation from LTC to the ED by sufficiency and clinical consistency. RESULTS: We included 591 eligible transitions in this analysis. Documentation was coded as consistent, inconsistent, or ambiguous. We identified the most common reasons for transition for consistent cases (falls), ambiguous cases (sudden change in condition) and inconsistent cases (falls). Among inconsistent cases, three subcategories were identified: insufficient reporting, potential progression of a condition during transition and unclear reasons for inconsistency. CONCLUSIONS: Shared continuing education on documentation across care settings should result in documentation supports geriatric emergency care; on-the-job training needs to support reporting of specific signs and symptoms that warrant an emergent response, and discourage the use of vague descriptors.

Incidence of Pressure Injury Among Older Adults Transitioning from Long-term Care to the ED.

OBJECTIVE: To identify sociodemographic, health condition, and organizational/process factors associated with pressure injury (PI) incidence during older adults' emergency transitions from long-term care (LTC) to the ED. METHODS: Emergency transitions were tracked for older adults within included LTC facilities to participating EDs in two urban centers located in provinces in Canada. Binary logistic regression was used to examine the influence of sociodemographic, service use, and client health and function factors on the incidence of PIs during transitions from LTC facilities to EDs. RESULTS: Having a mobility issue (odds ratio [OR], 4.318; 95% CI, 1.344-13.870), transitioning from a publicly owned versus a nonprofit volunteer LTC facility (OR, 4.886; 95% CI, 1.157-20.634), and time from ED arrival to return to LTC being 7 to 9 days (OR, 41.327; 95% CI, 2.691-634.574) or greater than 9 days (OR, 77.639; 95% CI, 5.727-1,052.485) significantly increased the odds of experiencing a new skin injury upon return to LTC. A higher number of reported reasons for emergency transition (up to 4) significantly decreased the odds of a new PI upon return to LTC (OR, 0.315; 95% CI, 0.113-0.880). CONCLUSIONS: The study findings can be used to identify LTC residents at increased risk for developing new skin injuries during an emergency transition, namely, those with mobility impairment, those requiring inpatient care for 6 or more days, and those transitioning from publicly owned LTC facilities. Evaluating the uptake and effectiveness of single-pronged and multipronged interventions such as visual cues for patient turning through online monitoring, consistent risk assessments, and improved nutrition in all care settings are vital next steps in preventing skin injuries in this population.

Influences of post-implementation factors on the sustainability, sustainment, and intra-organizational spread of complex interventions.

BACKGROUND: Complex interventions are increasingly applied to healthcare problems. Understanding of post-implementation sustainment, sustainability, and spread of interventions is limited. We examine these phenomena for a complex quality improvement initiative led by care aides in 7 care homes (long-term care homes) in Manitoba, Canada. We report on factors influencing these phenomena two years after implementation. METHODS: Data were collected in 2019 via small group interviews with unit- and care home-level managers (n = 11) from 6 of the 7 homes using the intervention. Interview participants discussed post-implementation factors that influenced continuing or abandoning core intervention elements (processes, behaviors) and key intervention benefits (outcomes, impact). Interviews were audio-recorded, transcribed verbatim, and analyzed with thematic analysis. RESULTS: Sustainment of core elements and sustainability of key benefits were observed in 5 of the 6 participating care homes. Intra-unit intervention spread occurred in 3 of 6 homes. Factors influencing sustainment, sustainability, and spread related to intervention teams, unit and care home, and the long-term care system. CONCLUSIONS: Our findings contribute understanding on the importance of micro-, meso-, and macro-level factors to sustainability of key benefits and sustainment of some core processes. Inter-unit spread relates exclusively to meso-level factors of observability and practice change institutionalization. Interventions should be developed with post-implementation sustainability in mind and measures taken to protect against influences such as workforce instability and competing internal and external demands. Design should anticipate need to adapt interventions to strengthen post-implementation traction.

The Symptom Experience of Patients With Atrial Fibrillation Before Their Initial Diagnosis.

BACKGROUND: Atrial fibrillation (AF), the most common form of dysrhythmia, steadily increases in prevalence with age. If left untreated, AF significantly increases the risk of stroke, heart failure, and death. Despite the increasing prevalence, there are significant research gaps in the prediagnosis symptom experiences of patients with AF. OBJECTIVE: The purpose of this qualitative descriptive study was to explore the prediagnosis symptom experience of patients with AF. METHODS: Participants 19 years or older with AF diagnosed in the previous year were recruited (n = 26) from outpatient cardiac rehabilitation and AF clinics. Semistructured interviews, broadly guided by the Symptom Experience Model, explored perceptions, evaluations, and responses to AF symptoms. Thematic analysis used a 2-step approach, deductively coding for participants' symptom perceptions, evaluations, and responses and inductively coding within these broader Symptom Experience Model concepts. RESULTS: Perception involved awareness of bodily sensations, ranging from imperceptible noticing to commanding attention, heightened by rest and activity. In evaluation, participants used self-derived theories to explain their symptoms, gathered evidence to support/refute their theories, and formulated alternative theories as symptoms changed over time. Responses consisted of nontreatment, self-treatment, and health seeking; most participants needed repeated healthcare visits before diagnosis. CONCLUSIONS: The current study identified challenges participants experienced in developing awareness of their AF symptoms, the complex cognitive processes associated with evaluation, and barriers that made it difficult to respond to AF symptoms in a timely manner. Understanding the prediagnosis symptom experience from the patient's perspective is essential for the enhancement of current AF screening practices.

'It's Like Chicken Talking to Ducks' and Other Challenges to Families of Chinese Immigrant Older Adults in Long-Term Residential Care.

Immigrant older adults are increasingly moving into long term residential care (LTRC) homes; however, most were designed and continue to be run in accordance with Anglocentric norms and values. Participation and interest in Family Councils-through which they might collectively voice concerns-was low within our purposive sample of nine Chinese-origin residents living in LTRC homes and 11 family carers. Our study, conducted in two LTRC homes in British Columbia, Canada between January and March 2016, further explored participants' perceptions of quality of care by staff and quality of life of residents. Our findings negate participants' rationale that they do not attend because they have no issues to raise. Solutions must recognize that carers' time is precious and care-work is gendered; language incongruity and failure to address it marginalizes residents and their family members. A culturally informed reticence to speak out is reinforced when attempts to do so are silenced.

Factors Associated With Residents' Responsive Behaviors Toward Staff in Long-Term Care Homes: A Systematic Review.

BACKGROUND AND OBJECTIVES: When staff experience responsive behaviors from residents, this can lead to decreased quality of work life and lower quality of care in long-term care homes. We synthesized research on factors associated with resident responsive behaviors directed toward care staff and characteristics of interventions to reduce the behaviors. RESEARCH DESIGN AND METHODS: We conducted a mixed-methods systematic review with quantitative and qualitative research. We searched 12 bibliographic databases and "gray" literature, using 2 keywords (long-term care, responsive behaviors) and their synonyms. Pairs of reviewers independently completed screening, data extraction, and risk of bias assessment. We developed a coding scheme using the ecological model as an organizing structure and prepared narrative summaries for each factor. RESULTS: From 86 included studies (57 quantitative, 28 qualitative, 1 mixed methods), multiple factors emerged, such as staff training background (individual level), staff approaches to care (interpersonal level), leadership and staffing resources (institutional level), and racism and patriarchy (societal level). Quantitative and qualitative results each provided key insights, such as qualitative results pertaining to leadership responses to reports of behaviors, and quantitative findings on the impact of staff approaches to care on behaviors. Effects of interventions (n = 14) to reduce the behaviors were inconclusive. DISCUSSION AND IMPLICATIONS: We identified the need for an enhanced understanding of the interrelationships among factors associated with resident responsive behaviors toward staff and processes leading to the behaviors. To address these gaps and to inform theory-based effective interventions for preventing or mitigating responsive behaviors, we suggest intervention studies with systematic process evaluations.

Older Persons' Transitions in Care (OPTIC): a study protocol.

BACKGROUND: Changes in health status, triggered by events such as infections, falls, and geriatric syndromes, are common among nursing home (NH) residents and necessitate transitions between NHs and Emergency Departments (EDs). During transitions, residents frequently experience care that is delayed, unnecessary, not evidence-based, potentially unsafe, and fragmented. Furthermore, a high proportion of residents and their family caregivers report substantial unmet needs during transitions. This study is part of a program of research whose overall aim is to improve quality of care for frail older adults who reside in NHs. The purpose of this study is to identify successful transitions from multiple perspectives and to identify organizational and individual factors related to transition success, in order to inform improvements in care for frail elderly NH residents during transitions to and from acute care. Specific objectives are to: 1. define successful and unsuccessful elements of transitions from multiple perspectives; 2. develop and test a practical tool to assess transition success; 3. assess transition processes in a discrete set of transfers in two study sites over a one year period; 4. assess the influence of organizational factors in key practice locations, e.g., NHs, emergency medical services (EMS), and EDs, on transition success; and 5. identify opportunities for evidence-informed management and quality improvement decisions related to the management of NH - ED transitions. METHODS/DESIGN: This is a mixed-methods observational study incorporating an integrated knowledge translation (IKT) approach. It uses data from multiple levels (facility, care unit, individual) and sources (healthcare providers, residents, health records, and administrative databases). DISCUSSION: Key to study success is operationalizing the IKT approach by using a partnership model in which the OPTIC governance structure provides for team decision-makers and researchers to participate equally in developing study goals, design, data collection, analysis and implications of findings. As preliminary and ongoing study findings are developed, their implications for practice and policy in study settings will be discussed by the research team and shared with study site administrators and staff. The study is designed to investigate the complexities of transitions and to enhance the potential for successful and sustained improvement of these transitions.

A Survey of the Characteristics and Administrator Perceptions of Family Councils in a Western Canadian Province.

Family Councils are independent, self-determining groups composed of family members (inclusive of friends) who have assembled with the main purpose of protecting and improving the quality of life of those living in long-term care (LTC) homes. This study aimed to describe the prevalence and characteristics of Family Councils in British Columbia, Canada. We conducted a cross-sectional survey with administrators of 259 homes and received 222 usable surveys. Of the 151 LTC homes that had Family Councils, it was most common for the homes to be larger (>50 residents), accredited, privately owned, and located in urban areas. Perceived barriers to Family Councils included lack of interest, tendency to focus on individual complaints, and the transitory nature of families. Perceived benefits of Family Councils included enhanced communication between staff and families, peer support, and collective advocacy. Recommendations focus on enhancing accessibility, information sharing, and meaningfulness of Family Councils to improve family engagement.

Addressing Communication Breakdowns during Emergency Care Transitions of Older Adults: Evaluation of a Standardized Inter-Facility Health Care Communication Form.

Transitions for older persons from long-term care (LTC) to the emergency department (ED) and back, can result in adverse events. Effective communication among care settings is required to ensure continuity of care. We implemented a standardized form for improving consistency of documentation during LTC to ED transitions of residents 65 years of age or older, via emergency medical services (EMS), and back. Data on form use and form completion were collected through chart review. Practitioners' perspectives were collected using surveys. The form was used in 90/244 (37%) LTC to ED transitions, with large variation in data element completion. EMS and ED reported improved identification of resident information. LTC personnel preferred usual practice to the new form and twice reported prioritizing form completion before calling 911. To minimize risk of harmful unintended consequences, communication forms should be implemented as part of broader quality improvement programs, rather than as stand-alone interventions.

Quality Indicators for Older Persons' Transitions in Care: A Systematic Review and Delphi Process.

We identified quality indicators (QIs) for care during transitions of older persons (≥ 65 years of age). Through systematic literature review, we catalogued QIs related to older persons' transitions in care among continuing care settings and between continuing care and acute care settings and back. Through two Delphi survey rounds, experts ranked relevance, feasibility, and scientific soundness of QIs. A steering committee reviewed QIs for their feasible capture in Canadian administrative databases. Our search yielded 326 QIs from 53 sources. A final set of 38 feasible indicators to measure in current practice was included. The highest proportions of indicators were for the emergency department (47%) and the Institute of Medicine (IOM) quality domain of effectiveness (39.5%). Most feasible indicators were outcome indicators. Our work highlights a lack of standardized transition QI development in practice, and the limitations of current free-text documentation systems in capturing relevant and consistent data.

The symptom experience of early and late treatment seekers before an atrial fibrillation diagnosis.

BACKGROUND: Atrial fibrillation is a complex condition associated with a broad spectrum of symptoms, coupled with variability in the frequency, duration and severity of symptoms. Early treatment seeking is important to reduce the risk of stroke, heart failure and dementia. Despite the increasing prevalence, there remains a limited understanding of the symptom experience prior to an atrial fibrillation diagnosis, and how these experiences influence treatment-related decisions and time frames. AIMS: This qualitative study aimed to explore the symptom experiences of patients receiving an early diagnosis of less than 48 hours and a late diagnosis of 48 hours or more after symptom awareness. METHODS: Twenty-six adults were interviewed guided by the symptom experience model. The symptom checklist was used to probe patient's symptoms further. Data were analysed using a two-step approach to thematic analysis utilising concepts from the symptom experience model. RESULTS: The two groups differed in their perception, evaluation and response to symptoms. The early diagnosis group (n = 6) experienced traumatic, severe and persistent symptoms, evoking concern and urgent treatment seeking. Conversely, the late diagnosis group (n = 20) reported more vague, paroxysmal symptoms that were readily ignored, self-theorised as non-illness related, and engaged in non-treatment strategies. Healthy self-perceptions, past experiences, atrial fibrillation knowledge and healthcare provider interactions influenced early or late treatment seeking. CONCLUSION: For many, the atrial fibrillation pre-diagnosis was a tumultuous period, requiring prolonged periods to recognise symptoms and formulate treatment-seeking responses. This study may promote future research and strategies aimed at facilitating the early identification and response to symptoms among atrial fibrillation patients.

Gender and the Symptom Experience before an Atrial Fibrillation Diagnosis.

Atrial fibrillation (AF) is the most common arrhythmia in the world. Despite the increasing prevalence, there remains a limited understanding of how the pre-diagnosis symptom experience varies by gender. The purpose of this study was to retrospectively explore gender differences/similarities in the pre-diagnosis period of AF. Twenty-six adults (13 men and 13 women) were interviewed guided by the Symptom Experience in AF (SEAF). Data were analyzed using a two-step approach to thematic analysis. Women had greater challenges receiving a timely diagnosis, with 10 women (77%) experiencing symptoms ≥1 year prior to their diagnosis, in comparison to only three (23%) of the men. Women also reported more severe symptoms, less AF-related knowledge, viewed themselves as low risk for cardiovascular disease, and described how their comorbid conditions confused AF symptom evaluation. This study provides a foundational understanding of differences/similarities in the AF symptom experience by gender.

Development and Validation of Caregiver Risk Evaluation (CaRE): A New Algorithm to Screen for Caregiver Burden.

Objective: The main objective was to develop a decision-support tool to assess the risk of caregiver burden, the Caregiver Risk Evaluation (CaRE) algorithm. Methods: Home care clients were assessed using the Resident Assessment Instrument for Home Care (RAI-HC). Their caregiver completed the 12-item Zarit Burden Interview (ZBI), the main dependent measure, which was linked to the RAI-HC. Results: In the sample (n = 344), 48% were aged 85+ years and 61.6% were female. The algorithm can be collapsed into four categories (low, moderate, high, and very high risk). Relative to the low-risk group, clients in the very high-risk group had an odds ratio of 5.16 (95% confidence interval: [2.05, 12.9]) for long-term care admission, after adjusting for client age, sex, and regional health authority. Discussion: The CaRE algorithm represents a new tool to be used by home care clinicians as they proactively plan for the needs of clients and their caregivers.

Who Doesn't Come Home? Factors Influencing Mortality Among Long-Term Care Residents Transitioning to and From Emergency Departments in Two Canadian Cities.

Residents of long-term care (LTC) whose deaths are imminent are likely to trigger a transfer to the emergency department (ED), which may not be appropriate. Using data from an observational study, we employed structural equation modeling to examine relationships among organizational and resident variables and death during transitions between LTC and ED. We identified 524 residents involved in 637 transfers from 38 LTC facilities and 2 EDs. Our model fit the data, (χ2 = 72.91, df = 56, p = .064), explaining 15% variance in resident death. Sustained shortness of breath (SOB), persistent decreased level of consciousness (LOC) and high triage acuity at ED presentation were direct and significant predictors of death. The estimated model can be used as a framework for future research. Standardized reporting of SOB and changes in LOC, scoring of resident acuity in LTC and timely palliative care consultation for families in the ED, when they are present, warrant further investigation.

Fractured Care: A Window Into Emergency Transitions in Care for LTC Residents With Complex Health Needs.

Objective: For long-term care (LTC) residents, transfers to emergency departments (EDs) can be associated with poor health outcomes. We aimed to describe characteristics of residents transferred, factors related to decisions during transfer, care received in emergency medical services (EMS), ED settings, outcomes on return to LTC, and times of transfer segments along the transition. Method: We prospectively followed 637 transitions to an ED in British Columbia and Alberta, Canada, over a 12-month period. Data were captured through an electronic Transition Tracking Tool and interviews with health care professionals. Results: Common events triggering transfer were falls (26.8%), sudden change in condition (23.5%), and shortness of breath (19.8%). Discrepancies existed between reason for transfer, EMS reported chief complaint, and ED diagnosis. Many transfers resulted in resident return directly to LTC (42.7%). Discussion: Avoidable transfers may put residents at risk of receiving inappropriate care. Standardized communication strategies to highlight changes in resident condition are warranted.

Recruitment and retention of nurse educators: a pilot study of what nurse educators consider important in their workplaces.

To better understand the nature of a quality practice environment for nurse educators, a survey instrument was constructed and pilot tested. he aim of the study was to highlight some of the critical issues needing to be addressed to support the recruitment and retention of nurse educators. The knowledge generated from the survey makes explicit what nurse educators consider to be important to them in their environments and whether they are currently experiencing these elements. Based on the preliminary results, additional research needs to be undertaken to further develop the psychometric properties of the tool along with a closer examination of the culture of schools of nursing. The information generated may serve to enhance nurse educators' environments to better reflect what they consider to be important.

Factors associated with the responsive behaviours of older adults living in long-term care homes towards staff: a systematic review protocol.

INTRODUCTION: In the last decade, increasing research interest has been expressed in responsive behaviours of older adults living in long-term care (LTC) homes, including nursing homes and assisted living facilities. Responsive behaviours are not only a sign of underlying unmet needs, but when directed against (towards) paid staff can lead to decreased quality of work life, and may contribute to lower quality of care. In this systematic review, we aim to synthesise empirically based quantitative and qualitative evidence on factors and stakeholder (eg, staff and family members) experiences of factors associated with the responsive behaviours of people living in LTC directed towards staff. METHODS AND ANALYSIS: This study will be a systematic review of published and 'grey' literature. Twelve bibliographical databases will be searched, and for each database, we will use appropriate subject headings and keywords that cover two concepts: LTC and responsive behaviour. No publication date or language filter will be used. The title and abstract of each extracted record will be screened, followed by screening of full text of included papers. Then data extraction and quality assessments will be undertaken. Each stage will be completed independently by pairs of authors. For quantitative studies, meta-analysis will be conducted if pooling is possible; otherwise, a critical narrative analysis will be conducted. For qualitative studies, thematic analysis will be conducted. Factors will then be organised at the individual, interpersonal, institutional and larger societal levels. Sensitivity analysis will be conducted to explore the influence of risk of bias and publication bias on the results. Subgroup analysis will be conducted for people who live with dementia and those who do not. ETHICS AND DISSEMINATION: Ethics approval is not required for this systematic review. The results of this study will be disseminated via peer-reviewed publication and presentation at professional conferences.

Traditional Versus Hybrid Outpatient Cardiac Rehabilitation: A COMPARISON OF PATIENT OUTCOMES.

PURPOSE: Due to the suboptimal uptake of cardiac rehabilitation (CR), alternative models have been proposed. This study compared the effectiveness of a traditional supervised program in a medical setting versus a hybrid CR model, where patients transition to unsupervised programming. METHODS: This was a prospective, 2-arm, nonrandomized study. Health-related quality of life (HRQoL), functional capacity, physical activity, diet, smoking, blood pressure, lipids, blood glucose, anthropometrics, and depressive symptoms were assessed before and after the 8-week program models. Program adherence and completion were also recorded. Both models offered outpatient supervised exercise sessions, group health education classes, and a resource manual. The hybrid model involved a blend of supervised and unsupervised, independent home-based exercise, and followup phone calls. RESULTS: One hundred twenty-five cardiac patients consented to the study, of whom 72 (57.6%) and 53 chose the traditional and hybrid programs, respectively. One hundred ten (traditional: n = 62, 86.1%; hybrid: n = 48, 92.3%; P > .05) participants completed their program. Significant improvements were observed for both models over time in HRQoL (P < .001), physical activity (P < .001), and diet (P < .001). Significant reductions in smoking (P = .043), systolic blood pressure (P < .001), total cholesterol (P < .001), low-density lipoprotein (P < .001), waist circumference (P < .001), and depressive symptoms (P < .001) were also observed. There were no significant differences pre- and postprograms between models for any outcome. CONCLUSIONS: Hybrid CR was not significantly different from the traditional model in terms of HRQoL, functional capacity, heart health behaviors, and risk factors, with no differences in completion rates.

Family Involvement in Nursing Homes: Are Family Caregivers Getting What They Want?

The provision of person-centered care for nursing home residents with dementia suggests the need for family caregiver involvement. In this article, we argue that optimal family involvement differs by family caregiver and therefore depends on the degree to which family caregivers consider their own involvement to be important. In this Canadian study, we compare the importance that 135 family caregivers of residents with dementia place on 20 kinds of involvement with the degree to which they perceive opportunities for involvement. Family Involvement Congruence Scores are calculated in three ways: those for whom involvement is important, those for whom involvement is not important, and an overall congruence score. Congruence scores varied by involvement type. These scores show promise for use in future research on family caregiver involvement and as tools for use by facilities as they endeavor to meet family caregiver expectations for involvement.

Pain Trajectories of Nursing Home Residents Nearing Death.

BACKGROUND/OBJECTIVES: Although examining point in time prevalence of pain among nursing home (NH) residents has value, there is a lack of evidence describing the actual changes (ie, trajectories) in pain that take place during their last 6 months of life. The main objective of this study is to describe the major pain trajectories experienced by NH residents during their last 6 months of life. DESIGN: Secondary analysis of Resident Assessment Instrument-Minimum Data Set (MDS) 2.0 data captured as part of the longitudinal Translating Research in Elder Care data repository. SETTING: Twenty-seven urban NHs in Western Canada. PARTICIPANTS: A total of 962 NH residents who died, had an MDS assessment completed within 30 days of death, and resided in a NH for at least 6 months. Pain trajectories were stratified by residents who were not severely cognitively impaired [Cognitive Performance Scale (CPS) ≤3] and those with severe impairment (CPS ≥4) at death. MEASUREMENTS: MDS-Pain Scale; CPS. RESULTS: In the 6 months before death, 60.1% of residents without severe cognitive impairment experienced consistently low pain; 34.6% reported experiencing either moderate to severe pain or significant increases in pain during this same period of time, and only 5.3% experienced any degree of pain improvement. When the trajectories were examined, most residents without severe cognitive impairment experienced no to mild pain in the time before their death (65.5%); however, we identified a group of residents who exhibited a pattern of pain that worsened or remained consistently high right until death (38.2%). Although the proportion of residents with "low/mild" pain trajectories was statistically greater among those who were severely impaired vs those without severe cognitive impairment, across both cognitive impairment groups, the general trend in pain trajectories is similar; with about 60% of residents experiencing either consistent low or mild pain in their last 6 months of life, and about 34% experiencing either substantially high or increasing pain levels. CONCLUSIONS: Although a majority of NH residents experienced consistently low or improved pain levels in their last 6 months of life, a substantial number experienced consistently high or substantially worsening pain levels during this same time period. These results highlight the need to better manage pain levels for some NH residents during this important period of time.