Nursing home leader response during COVID-19: a qualitative descriptive study about use of external resources during the pandemic.

BACKGROUND: US nursing homes were ground zero for COVID-19 and nursing home leaders faced multiple challenges to keep residents and staff safe. Understanding the leader's role and their use of external resources to rapidly respond to the pandemic is important to better prepare for the next infectious disease outbreak emergency. The purpose of this study is to describe Missouri nursing home leaders' use of external resources to manage challenges encountered during the pandemic. METHODS: This qualitative descriptive study uses data from semi-structured interviews conducted with leaders from 24 Midwestern nursing homes between March 2022 and March 2023. Interviews were transcribed verbatim and analyzed using Dedoose software. Directed content analysis, guided by Donabedian's Structure, Process, Outcome framework, was used for analysis. Interviews were conducted as part of a larger mixed-methods study focused on developing knowledge and recommendations to improve US nursing homes' capacity to respond to infectious disease outbreaks. RESULTS: Forty-three interviews were conducted across the 24 homes. Participants included administrators (n = 24), nurse leaders (n = 19), and infection preventionists (n = 16). Six sub-categories of external resources/support were used by leaders to manage challenges during the pandemic:1) corporate support and communications, 2) statewide resources, 3) community-based resources, 4) health care coalitions focused on emergency response planning, 5) existing affiliations with local organizations i.e., hospitals, and 6) community members and families. Corporate support was a primary resource; however, it was limited to chain-based homes. Leaders from standalone homes seemed most reliant on statewide agencies, existing affiliations, and other community-based resources due to their lack of corporate connections. Health care coalitions were few, but when available, helped nursing homes prepare for the pandemic onset. Family and community members were vital despite being off-site from nursing homes at the pandemic onset. CONCLUSION: Leaders played a pivotal role in accessing and using external resources to manage challenges during the pandemic. Statewide and community-based agencies and existing affiliations were particularly critical for standalone homes who otherwise had little to no means of support. Federal, state and local agencies must consider opportunities to build multi-agency regional collaborations, local health care coalitions and community-based partnerships that include nursing homes as member. Finally, community members and family were important in providing support, thus closing visitation is a double-edged sword that needs careful, future consideration.

Psychosocial Distress Among Certified Nursing Assistants in Long-Term Care During the COVID-19 Pandemic: A Social Ecological Model Informed Scoping Review.

OBJECTIVES: This scoping review maps the literature on psychosocial distress and coping among nursing assistants (CNAs) in long-term care facilities (LTC) during the COVID-19 pandemic onto the Social Ecological Model (SEM) of Occupational Stress. METHODS: Searches yielded 862 unique studies. Inclusion criteria were sample CNAs or equivalent in LTC; includes psychosocial variable; and collect data from February 2020-. A multi-phasic, meta-synthesis was used to synthesize qualitative data. RESULTS: We identified 20 studies (13 quantitative, 7 qualitative) conducted between March 2020 and December 2021 from 14 countries. Prevalence rates were reported for perceived stress (31-33%; n = 1 study), post-traumatic stress (42%; n = 1), anxiety (53%; n = 1), depression (15-59%; n = 2), suicidal thoughts (11-15%; n = 1), and everyday emotional burnout (28%; n = 1). Qualitative studies identified factors contributing to psychosocial distress and coping at each SEM level (i.e. individual, microsystem, organization, and peri-/extra-organizational). Quantitative studies primarily measured factors relating to psychosocial distress and coping at the individual and organizational levels. CONCLUSIONS & CLINICAL IMPLICATIONS: This review identifies specific targets for intervention for psychosocial distress among CNAs in LTC at multiple levels, including job clarity; workload; facility culture; community relations; and policy. These intervention targets remain relevant to the LTC industry beyond the context of the COVID-19 pandemic.

Longitudinal Evaluation of a Statewide Quality Improvement Program for Nursing Homes.

OBJECTIVES: The National Academies of Sciences, Engineering, and Medicine (NASEM) Nursing Home Quality report recommends that states "develop and operate state-based…technical assistance programs…to help nursing homes…improve care and…operations." The Quality Improvement Program for Missouri (QIPMO) is one such program. This longitudinal evaluation examined and compared differences in quality measures (QMs) and nursing home (NH) characteristics based on intensity of QIPMO services used. DESIGN: A descriptive study compared key QMs of clinical care, facility-level characteristics, and differing QIPMO service intensity use. QIPMO services include on-site clinical consultation by expert nurses; evidence-based practice information; teaching NHs use of quality improvement (QI) methods; and guiding their use of Centers for Medicare and Medicaid Services (CMS)-prepared QM comparative feedback reports to improve care. SETTING AND PARTICIPANTS: All Missouri NHs (n = 510) have access to QIPMO services at no charge. All used some level of service during the study, 2020-2022. METHODS: QM data were drawn from CMS's publicly available website (Refresh April 2023) and NH characteristics data from other public websites. Service intensity was calculated using data from facility contacts (on-site visits, phone calls, texts, emails, webinars). NHs were divided into quartiles based on service intensity. RESULTS: All groups had different beginning QM scores and improved ending scores. Group 2, moderate resource intensity use, started with "worse" overall score and improved to best performing by the end. Group 4, most resource intensity use, improved least but required highest service intensity. CONCLUSIONS AND IMPLICATIONS: This longitudinal evaluation of QIPMO, a statewide QI technical assistance and support program, provides evidence of programmatic stimulation of statewide NH quality improvements. It provides insight into intensity of services needed to help facilities improve. Other states should consider QIPMO success and develop their own programs, as recommended by the NASEM report so their NHs can embrace QI and "initiate fundamental change" for better care for our nation's older adults.

Exploring Type 2 Diabetes Self-Management Practices Among African Americans in Rural Counties: A Qualitative Study.

PURPOSE: The purpose of the study was to understand diabetes self-management practices among African American individuals living with type 2 diabetes (T2D) in rural communities. METHODS: This qualitative descriptive study, undergirded by the theory of integration, purposively sampled African Americans (N = 34) diagnosed with T2D living in rural communities. Thematic analysis employed both a priori and inductive coding to identify salient themes. RESULTS: Participants' mean age was 65.9 (SD 12.3) years, with an average T2D diagnosis duration of 14 (SE 11.2) years. Two major themes emerged: deciphering the cues and body sensing, which the participants used to monitor their glucose level using a personalized feedback loop. Those with longer diabetes duration demonstrated an ability to recognize hypoglycemic or hyperglycemic symptoms (deciphering the cues), informing their decision-making and self-management strategies (body sensing). CONCLUSIONS: The decision-making involved in glycemic level management emerges as a complex developmental process influenced by disease trajectory and cultural and environmental factors. These findings may inform a conceptual framework to guide future inquiries and provide insights for primary care clinicians and diabetes educators to better understand the complexities of T2D management among African American individuals in rural settings.

Metabolic discrimination of select list agents by monitoring cellular responses in a multianalyte microphysiometer.

Harnessing the potential of cells as complex biosensors promises the potential to create sensitive and selective detectors for discrimination of biodefense agents. Here we present toxin detection and suggest discrimination using cells in a multianalyte microphysiometer (MMP) that is capable of simultaneously measuring flux changes in four extracellular analytes (acidification rate, glucose uptake, oxygen uptake, and lactate production) in real-time. Differential short-term cellular responses were observed between botulinum neurotoxin A and ricin toxin with neuroblastoma cells, alamethicin and anthrax protective antigen with RAW macrophages, and cholera toxin, muscarine, 2,4-dinitro-phenol, and NaF with CHO cells. These results and the post exposure dynamics and metabolic recovery observed in each case suggest the usefulness of cell-based detectors to discriminate between specific analytes and classes of compounds in a complex matrix, and furthermore to make metabolic inferences on the cellular effects of the agents. This may be particularly valuable for classifying unknown toxins.

Toward Common Data Elements for International Research in Long-term Care Homes: Advancing Person-Centered Care.

To support person-centered, residential long-term care internationally, a consortium of researchers in medicine, nursing, behavioral, and social sciences from 21 geographically and economically diverse countries have launched the WE-THRIVE consortium to develop a common data infrastructure. WE-THRIVE aims to identify measurement domains that are internationally relevant, including in low-, middle-, and high-income countries, prioritize concepts to operationalize domains, and specify a set of data elements to measure concepts that can be used across studies for data sharing and comparisons. This article reports findings from consortium meetings at the 2016 meeting of the Gerontological Society of America and the 2017 meeting of the International Association of Gerontology and Geriatrics, to identify domains and prioritize concepts, following best practices to identify common data elements (CDEs) that were developed through the US National Institutes of Health/National Institute of Nursing Research's CDEs initiative. Four domains were identified, including organizational context, workforce and staffing, person-centered care, and care outcomes. Using a nominal group process, WE-THRIVE prioritized 21 concepts across the 4 domains. Several concepts showed similarity to existing measurement structures, whereas others differed. Conceptual similarity (convergence; eg, concepts in the care outcomes domain of functional level and harm-free care) provides further support of the critical foundational work in LTC measurement endorsed and implemented by regulatory bodies. Different concepts (divergence; eg, concepts in the person-centered care domain of knowing the person and what matters most to the person) highlights current gaps in measurement efforts and is consistent with WE-THRIVE's focus on supporting resilience and thriving for residents, family, and staff. In alignment with the World Health Organization's call for comparative measurement work for health systems change, WE-THRIVE's work to date highlights the benefits of engaging with diverse LTC researchers, including those in low-, middle-, and high-income countries, to develop a measurement infrastructure that integrates the aspirations of person-centered LTC.

Advancing Long-Term Care Science Through Using Common Data Elements: Candidate Measures for Care Outcomes of Personhood, Well-Being, and Quality of Life.

To support the development of internationally comparable common data elements (CDEs) that can be used to measure essential aspects of long-term care (LTC) across low-, middle-, and high-income countries, a group of researchers in medicine, nursing, behavioral, and social sciences from 21 different countries have joined forces and launched the Worldwide Elements to Harmonize Research in LTC Living Environments (WE-THRIVE) initiative. This initiative aims to develop a common data infrastructure for international use across the domains of organizational context, workforce and staffing, person-centered care, and care outcomes, as these are critical to LTC quality, experiences, and outcomes. This article reports measurement recommendations for the care outcomes domain, focusing on previously prioritized care outcomes concepts of well-being, quality of life (QoL), and personhood for residents in LTC. Through literature review and expert ranking, we recommend nine measures of well-being, QoL, and personhood, as a basis for developing CDEs for long-term care outcomes across countries. Data in LTC have often included deficit-oriented measures; while important, reductions do not necessarily mean that residents are concurrently experiencing well-being. Enhancing measurement efforts with the inclusion of these positive LTC outcomes across countries would facilitate international LTC research and align with global shifts toward healthy aging and person-centered LTC models.

Biliary strictures after liver transplantation. Predictive factors for response to endoscopic management and long-term outcome.

BACKGROUND: Biliary strictures after liver transplantation are frequent. The long-term prognosis and predictive factors of response to endoscopic treatment are not well known. METHODS: The aim of this study was to demonstrate the role of endoscopic treatment, predictive factors of response, and outcome in patients with biliary stricture after liver transplantation. We performed a retrospective review of medical records of all consecutive post-liver transplantation patients who underwent endoscopic retrograde cholangiography in our center during the period from October 2001 to October 2006. RESULTS: Twenty-five of 43 patients referred for endoscopic retrograde cholangiography had biliary stricture. Eighteen had stricture at the area of the anastomosis alone, 2 patients had a stricture at the area of the anastomosis and also another area, and 5 had nonanastomotic biliary strictures. Twenty-one patients had a single stricture and 4 had more than 1 stricture. Initially 19 of 24 patients (79%) responded to endoscopic management with normalization of liver enzymes. Four patients (16%) did not respond clinically despite a successful endoscopic approach. All patients who did not respond to endoscopic dilation had more than 1 area of stricture. There was a significantly better response to endoscopic treatment in patients with an anastomotic stricture versus patients with nonanastomotic strictures 17/19 versus 2/5 (P = 0.042). CONCLUSIONS: In our experience, endoscopic treatment of anastomotic biliary strictures is highly effective with a good long-term outcome. The presence of nonanastomotic and multiple strictures should be considered a factor associated with poor response to endoscopic management.

Acute and chronic aquatic toxicity of ammonium perfluorooctanoate (APFO) to freshwater organisms.

Recent concerns have been raised concerning the widespread distribution of perfluorinated compounds in environmental matrices and biota. The compounds of interest include ammonium perfluorooctanoate (APFO, the ammonium salt of perfluorooctanoic acid, PFOA). APFO is used primarily as a processing aid in the production of fluoropolymers and fluoroelastomers. The environmental presence of perfluorooctanoate (PFO(-), the anion of APFO) and its entry into the environment as APFO make quality aquatic toxicity data necessary to assess the aquatic hazard and risk of APFO. We conducted acute and chronic freshwater aquatic toxicity studies with algae, Pseudokirchneriella subcapitata, the water flea, Daphnia magna, and embryo-larval rainbow trout, Oncorhynchus mykiss, using OECD test guidelines and a single, well-characterized sample of APFO. Acute 48-96 h LC/EC(50) values were greater than 400mg/l APFO and the lowest chronic NOEC was 12.5mg/l for inhibition of the growth rate and biomass of the freshwater alga. Un-ionized ammonia was calculated to be a potential significant contributor to the observed toxicity of APFO. Based on environmental concentrations of PFO(-) from various aquatic ecosystems, the PNEC value from this study, and unionized ammonia contributions to observed toxicity, APFO demonstrates little or no risk for acute or chronic toxicity to freshwater and marine aquatic organisms at relevant environmental concentrations.