Implementation of the Acute Care for Elders Strategy to Improve the Quality of Care Transitions in Quebec and Ontario: a Retrospective Multiple Case Study.

Background: In 2016, two Canadian hospitals participated in a quality improvement (QI) program, the International Acute Care for Elders (ACE) Collaborative, and sought to adapt and implement a transition coach intervention (TCI). Both hospitals were challenged to provide optimal continuity of care for an increasing number of older adults. The two hospitals received initial funding, coaching, educational materials, and tools to adapt the TCI to their local contexts, but the QI project teams achieved different results. We aimed to compare the implementation of the ACE TCI in these two Canadian hospitals to identify the factors influencing the adaptation of the intervention to the local contexts and to understand their different results. Methods: We conducted a retrospective multiple case study, including documentary analysis, 21 semi-structured individual interviews, and two focus groups. We performed thematic analysis using a hybrid inductive-deductive approach. Results: Both hospitals met initial organizational goals to varying degrees. Our qualitative analysis highlighted certain factors that were critical to the effective implementation and achievement of the QI project goals: the magnitude of changes and adaptations to the initial intervention; the organizational approaches to the QI project implementation, management, and monitoring; the organizational context; the change management strategies; the ongoing health system reform and organizational restructuring. Our study also identified other key factors for successful care transition QI projects: minimal adaptation to the original evidence-based intervention; use of a collaborative, bottom-up approach; use of a theoretical model to support sustainability; support from clinical and organizational leadership; a strong organizational culture for QI; access to timely quality measures; financial support; use of a knowledge management platform; and involvement of an integrated research team and expert guidance. Conclusion: Many of the lessons learned and strategies identified from our analysis will help clinicians, managers, and policymakers better address the issues and challenges of adapting evidence-based innovations in care transitions for older adults to local contexts.

Pilot study compares scores of the Resident Assessment Instrument Minimum Data Set Version 2.0 (MDS 2.0) Pressure Ulcer Risk Scale with the Braden Pressure Ulcer Risk assessment for patients in complex continuing care.

OBJECTIVE: To determine if the Braden Scale for Predicting Pressure Sore Risk (Braden Scale) and the Resident Assessment Instrument Minimum Data Set Version 2.0 (MDS 2.0) Pressure Ulcer Risk Scale (PURS) provide a comparable assessment of the level of risk of developing a pressure ulcer at admission in complex continuing care. SETTING: Saint-Vincent Hospital, Bruyère Continuing Care, a 336-bed complex continuing care facility that provides restorative, complex, specialized, and supportive care to adults in Ottawa, Ontario, Canada. METHODS: A retrospective chart review was conducted from February 2012 to April 2012 on 51 patient charts that were chosen based on the completion of an admission Braden Scale assessment within a maximum of 4 weeks from admission and completed admission MDS 2.0. RESULTS: The Braden Scale categorized 63% of patients at risk when using scores between 15 and 23, compared with 33% for the MDS 2.0 PURS scores of 0-2 (low and very low risk). Both scales were comparable in identifying patients in the lower risk categories when data was reviewed using a cutoff point of 18 for the Braden. At the high risk end of the spectrum, the MDS 2.0 PURS categorized more patients, 45%, as high or very high risk, compared with 21% for using the Braden Scale. CONCLUSION: This preliminary study may provide some evidence that the MDS 2.0 PURS may be an alternative risk assessment tool option that utilizes mandatory collected data, reduces workload duplication, and would generate a Resident Assessment Protocol, when indicated, in complex continuing care.

A prospective, descriptive study to assess the reliability and usability of a rapid foot screen for patients with diabetes mellitus in a complex continuing care setting.

Inlow's 60-second Diabetic Foot Screen is a paper-pencil tool developed to guide professionals in the completion of a quick foot assessment of persons with diabetes mellitus to determine recommended frequency of assessments. The tool has been used in various healthcare settings and its reliability and validity previously tested in acute and long-term care settings. The purpose of this study was to assess content, time to complete assessment, ease of use, and reliability of the tool in a complex continuing care setting. The tool includes questions about 10 variables; skin, nails, deformities, footwear, temperature, range of motion, sensation, pulses, dependent rubor, and erythema. Answers convert to a score ranging from 0 (low risk, yearly screenings) to 23 (high risk, weekly screenings). Using the tool, the study questionnaire, and a watch, three nurse assessors experienced in assessing the feet of persons with diabetes completed 70 assessments on 35 patients during a period of 30 days. Content areas assessed included significance of comorbidities and interval screening times. Mean time to complete the assessment was 7 minutes (range 2 to 21 minutes); 39% of assessments took 6 to 7 minutes. Times to perform assessment varied widely due to the functional and cognitive well-being of the patient. Inter-rater reliability was low (ICC 0.608 [95% confidence interval 0.349-0.781]), perhaps due to varying interpretations of assessment parameters related to the complexity of the study patient population. Comments suggest that some tool revisions may increase ease of use as well as tool validity and reliability, especially for complex care patients with multiple comorbidities.