Concurrent incidence of adverse events in hospitals and nursing homes.

PURPOSE: To describe the concurrent incidence of pressure ulcers, urinary tract infections, and falls in hospitals and nursing homes, and the preventive care given. Additionally, the correlation between the occurrence of these adverse events and preventive care was explored. DESIGN AND SETTINGS: A prospective, 3-month, cohort study at 10 hospitals and 10 nursing homes in the Netherlands. PARTICIPANTS: 687 hospital patients and 241 nursing home patients. MAIN OUTCOME MEASURES: The incidence of three adverse events and preventive care given to patients at risk. During weekly visits, the patients and their files were assessed. Additionally, observations were performed. RESULTS: Seventy-seven hospital patients (11%) and 111 nursing home patients (46%) developed one or more adverse events. The incidence rate for both types of patients, and for the three adverse events combined, was 9% adverse events per patient week. In hospitals, 34% of the patients received adequate pressure ulcer preventive care, while 47% of the patients received adequate urinary tract infection preventive care, and none of the patients received adequate falls preventive care. In nursing homes, 18% of the patients received adequate pressure ulcer preventive care, 42% of the patients received adequate urinary tract infection preventive care, and less than 1% of the patients received adequate falls prevention care. Negative or no correlations were found between the incidence rates for the three adverse events. In nursing homes the incidence of pressure ulcers and preventive care were positively correlated. CONCLUSIONS: There is a high incidence of adverse events in hospitals and nursing homes. Many patients at risk do not receive adequate preventive care.

User-centered development and testing of a monitoring system that provides feedback regarding physical functioning to elderly people.

PURPOSE: To involve elderly people during the development of a mobile interface of a monitoring system that provides feedback to them regarding changes in physical functioning and to test the system in a pilot study. METHODS AND PARTICIPANTS: The iterative user-centered development process consisted of the following phases: (1) selection of user representatives; (2) analysis of users and their context; (3) identification of user requirements; (4) development of the interface; and (5) evaluation of the interface in the lab. Subsequently, the monitoring and feedback system was tested in a pilot study by five patients who were recruited via a geriatric outpatient clinic. Participants used a bathroom scale to monitor weight and balance, and a mobile phone to monitor physical activity on a daily basis for six weeks. Personalized feedback was provided via the interface of the mobile phone. Usability was evaluated on a scale from 1 to 7 using a modified version of the Post-Study System Usability Questionnaire (PSSUQ); higher scores indicated better usability. Interviews were conducted to gain insight into the experiences of the participants with the system. RESULTS: The developed interface uses colors, emoticons, and written and/or spoken text messages to provide daily feedback regarding (changes in) weight, balance, and physical activity. The participants rated the usability of the monitoring and feedback system with a mean score of 5.2 (standard deviation 0.90) on the modified PSSUQ. The interviews revealed that most participants liked using the system and appreciated that it signaled changes in their physical functioning. However, usability was negatively influenced by a few technical errors. CONCLUSION: Involvement of elderly users during the development process resulted in an interface with good usability. However, the technical functioning of the monitoring system needs to be optimized before it can be used to support elderly people in their self-management.

A nurse-led interdisciplinary primary care approach to prevent disability among community-dwelling frail older people: a large-scale process evaluation.

BACKGROUND: The complex healthcare needs of frail older people and their increased risk of disability require an integrated and proactive approach. In the Netherlands, an interdisciplinary primary care approach has recently been developed, involving individualized assessment and interventions (tailor-made care), case management and long-term follow-up. The practice nurse as part of a general practice is case manager and plans, organizes and monitors the care process and facilitates cooperation between professionals. The approach has shown positive indications regarding its feasibility in a small pilot, but its implementation on a large scale had not hitherto been investigated. OBJECTIVES: To examine the extent to which the interdisciplinary care approach is implemented as planned and to gain insight into healthcare professionals' and frail older people's experiences regarding the benefits, burden, stimulating factors and barriers. DESIGN: A process evaluation was conducted using a mixed methods design. SETTINGS: Six GP practices in the south of the Netherlands. PARTICIPANTS: Practice nurses (n=7), GPs (n=12), occupational therapists (n=6) and physical therapists (n=20) participated in the process evaluation. Furthermore, 194 community-dwelling frail older people (≥ 70 years) were included using the Groningen Frailty Indicator. People who were terminally ill, were confined to bed, had severe cognitive or psychological impairments or were unable to communicate in Dutch were excluded. METHODS: Quantitative data (logbooks and evaluation forms) were collected from all the participating frail older people and 13 semi-structured interviews with a selection of them were conducted. In addition, data from healthcare professionals were collected through 12 semi-structured interviews and four focus group discussions. RESULTS: Although some parts of the protocol were insufficiently executed, healthcare professionals and frail older people were satisfied with the care approach, as it provided a useful structure for the delivery of geriatric primary care and increased the attention to preventive treatment. Frail older people felt acknowledged by healthcare professionals and experienced support in handling their problems and fulfilling their wishes. CONCLUSIONS: The findings of the study revealed several positive aspects of the interdisciplinary primary care approach. Given its complexity, the implementation of the nurse-led interdisciplinary care approach is challenging and some parts of the protocol need special attention.

A disability prevention programme for community-dwelling frail older persons.

OBJECTIVE: To describe and justify a primary care interdisciplinary programme for community-dwelling frail older people aimed to prevent disability. BACKGROUND: Disability is a negative outcome of frailty among older persons. Policy reports and research studies emphasize the need for programmes to reduce disability progression. Between 2008 and 2010 we developed such a programme. DEVELOPMENT: Following the Intervention Mapping protocol, a research team and a multidisciplinary professional developed the programme. Literature reviews and an expert meeting led to identification of basic elements, theory-based methods and practical tools. THE PROGRAMME: The general practitioner and the practice nurse comprise the core team that can be extended by other professionals such as occupational and physical therapist. The programme includes six steps: (1) screening, (2) assessment, (3) analysis and preliminary action plan, (4) agreement on an action plan, (5) execution of the action plan (toolbox parts) and (6) evaluation and follow-up. The main features are: identifying risks for developing disability and targeting risk factors using professional standards and the 5A Behavioural Change Model to support self management, and identifying problems in performing activities and enhancing meaningful activities based on the Model of Human Occupation. Screening, individual assessment, tailor-made and client-centred care, self-management support, case management and interdisciplinary cooperation are important principles in delivering the programme. DISCUSSION: The disability-prevention programme seems promising for addressing the needs of frail older people for independent living and for targeting risk factors. Its feasibility and effects are currently being tested in a randomized controlled trial.

Fewer adverse events as a result of the SAFE or SORRY? programme in hospitals and nursing homes. part i: primary outcome of a cluster randomised trial.

BACKGROUND: Patient care guidelines are usually implemented one at a time, yet patients are at risk for multiple, often preventable, adverse events simultaneously. OBJECTIVE: This study aimed to test the effect of the SAFE or SORRY? programme on the incidence of three adverse events (pressure ulcers, urinary tract infections and falls). This paper describes Part I of the study: the effect on the incidence of adverse events. DESIGN: A cluster randomised trial was conducted between September 2006 and November 2008. After a three-month baseline period the intervention was implemented followed by a nine-month follow-up period. SETTINGS: Ten wards from four hospitals and ten wards from six nursing homes were stratified for institute and ward type and then randomised to intervention or usual care group. PARTICIPANTS: During baseline and follow-up, patients (≥18 years) with an expected length of stay of at least five days, were asked to participate. METHODS: The SAFE or SORRY? programme consisted of the essential recommendations of guidelines for the three adverse events. A multifaceted implementation strategy was used for the implementation: education, patient involvement and feedback on process and outcome indicators. The usual care group continued care as usual. Data were collected on the incidence of adverse events and a Poisson regression model was used to estimate the rate ratio of the adverse events between the intervention and the usual care group at follow-up. RESULTS: At follow-up, 2201 hospital patients with 3358 patient weeks and 392 nursing home patients with 5799 patient weeks were observed. Poisson regression analyses showed a rate ratio for the development of an adverse event in favour of the intervention group of 0.57 (95% CI: 0.34-0.95) and 0.67 (95% CI: 0.48-0.99) for hospital patients and nursing home patients respectively. CONCLUSION: This study showed that implementing multiple guidelines simultaneously is possible, which is promising. Patients in the intervention groups developed 43% and 33% fewer adverse events compared to the usual care groups in hospitals and nursing homes respectively. Even so, more research is necessary to underline these results. TRIAL REGISTRATION: clinicaltrials.gov, number NCT00365430.

Home visiting programme for older people with health problems: process evaluation.

AIM: This paper is a report of a process evaluation of the content, patient compliance and participant experiences of a home visiting programme for older people with self-reported health problems. BACKGROUND: Systematic home visits by nurses to older people are a public health strategy to improve their functional abilities and prevent institutionalization. Evidence of the usefulness of these visits is conflicting, partly due to a lack of information on the intervention process in these programmes. METHOD: One hundred and sixty people (aged 70-84 years) participated in the programme and were visited eight times during an 18-month period (February 2003-October 2004) by experienced home nurses. The nurses recorded key elements of each visit on standard forms: topics discussed, interventions regarding health problems and risks, and compliance with these interventions. Participants' and nurses' opinions on the visits were obtained through interviews at the end of the programme. FINDINGS: Nearly 80% of the group received the complete programme. Problems were detected in nearly all visits, mainly regarding social and psychological functioning, circulatory and musculoskeletal problems, and vision or hearing impairment. On average, ten problems and 11 interventions were recorded per participant. Nearly 40% of interventions related to referrals, 45% to advice and 17% consisted of information-giving. The compliance rate was 65% for referrals and 58% for advice. Both nurses and participants were positive about the programme. CONCLUSION: A health visiting programme, performed by home nurses, is feasible and appreciated by frail elders. The latter seem to be a relevant target population in view of the many and varied problems detected.