Enhanced interdisciplinary care improves self-care ability and decreases emergency department visits for older Taiwanese patients over 2 years after hip-fracture surgery: A randomised controlled trial.

BACKGROUND: Little evidence is available on the longer-term effects (beyond 12 months) of intervention models consisting of hip fracture-specific care in conjunction with management of malnutrition, depression, and falls. OBJECTIVE: To compare the relative effects of an interdisciplinary care, and a comprehensive care programme with those of usual care for elderly patients with a hip fracture on self-care ability, health care use, and mortality. DESIGN: Randomised experimental trial. SETTING: A 3000-bed medical centre in northern Taiwan. PARTICIPANTS: Patients with hip fracture aged 60 years or older (N=299). METHOD: Patients were randomly assigned to three groups: comprehensive care (n=99), interdisciplinary care (n=101), and usual care (control) (n=99). Usual care entailed only one or two in-hospital rehabilitation sessions. Interdisciplinary care included not only hospital rehabilitation, but also geriatric consultation, discharge planning, and 4-month in-home rehabilitation. Building upon interdisciplinary care, comprehensive care extended in-home rehabilitation to 12 months and added management of malnutrition and depressive symptoms, and fall prevention. Patients' self-care ability was measured by activities of daily living and instrumental activities of daily living using the Chinese Barthel Index and Chinese version Instrumental Activities of Daily Living scale, respectively. Outcomes were assessed before discharge, and 1, 3, 6, 12, 18, 24 months following hip fracture. Hierarchical linear models were used to analyse health outcomes and health care utilisation, including emergency department visit and hospital re-admission. RESULTS: The comprehensive care group had better performance trajectories for both measures of activities of daily living and fewer emergency department visits than the usual care group, but no difference in hospital readmissions. The interdisciplinary care and usual care groups did not differ in trajectories of self-care ability and service utilisation. The three groups did not differ in mortality during the 2-year follow-up. CONCLUSION: Comprehensive care, with enhanced rehabilitation, management of malnutrition and depressive symptoms, and fall prevention, improved self-care ability and decreased emergency department visits for elders up to 2 years after hip-fracture surgery, above and beyond the effects of usual care and interdisciplinary care.

Comprehensive care improves physical recovery of hip-fractured elderly Taiwanese patients with poor nutritional status.

OBJECTIVES: The effects of nutritional management among other intervention components have not been examined for hip-fractured elderly persons with poor nutritional status. Accordingly, this study explored the intervention effects of an in-home program using a comprehensive care model that included a nutrition-management component on recovery of hip-fractured older persons with poor nutritional status at hospital discharge. DESIGN: A secondary analysis of data from a randomized controlled trial with 24-month follow-up. SETTING: A 3000-bed medical center in northern Taiwan. PARTICIPANTS: Subjects were included only if they had "poor nutritional status" at hospital discharge, including those at risk for malnutrition or malnourished. The subsample included 80 subjects with poor nutritional status in the comprehensive care group, 87 in the interdisciplinary care group, and 85 in the usual care group. INTERVENTIONS: The 3 care models were usual care, interdisciplinary care, and comprehensive care. Usual care provided no in-home care, interdisciplinary care provided 4 months of in-home rehabilitation, and comprehensive care included management of depressive symptoms, falls, and nutrition as well as 1 year of in-home rehabilitation. MEASUREMENTS: Data were collected on nutritional status and physical functions, including range of motion, muscle power, proprioception, balance and functional independence, and analyzed using a generalized estimating equation approach. We also compared patients' baseline characteristics: demographic characteristics, type of surgery, comorbidities, length of hospital stay, cognitive function, and depression. RESULTS: Patients with poor nutritional status who received comprehensive care were 1.67 times (95% confidence interval 1.06-2.61) more likely to recover their nutritional status than those who received interdisciplinary and usual care. Furthermore, the comprehensive care model improved the functional independence and balance of patients who recovered their nutritional status over the first year following discharge, but not of those who had not yet recovered. CONCLUSIONS: An in-home program using the comprehensive care model with a nutritional component effectively improved the nutritional status of hip-fractured patients with poor nutrition. This comprehensive care intervention more effectively improved recovery of functional independence and balance for patients with recovered nutritional status.

The effect of oral training on vital signs of premature infants.

AIMS AND OBJECTIVES: This study aimed to develop an applicable oral training protocol and test its effects on vital sign stabilisation in premature infants. BACKGROUND: Oral training improves the feeding behaviour of premature infants. However, the inconsistencies of oral training procedures in previous studies obscure the interventional effect of oral training on vital sign stabilisation in premature infants. DESIGN: True experimental design. METHODS: Sixty premature infants with a gestational age <33 weeks were recruited and randomly assigned to the oral training or control group. RESULTS: Heart rate, respiratory rate and oxygen saturation tended to improve in the oral training group compared to those in the control group. However, the intergroup differences with respect to vital signs before and after feeding were not statistically significant. CONCLUSIONS: Further studies comparing protocols with different measurement points and durations are suggested.

Comprehensive care improves health outcomes among elderly Taiwanese patients with hip fracture.

BACKGROUND: Few studies have investigated the effects of care models that combine interdisciplinary care with nutrition consultation, depression management, and fall prevention in older persons with hip fracture. The purpose of this study was to compare the effects of a comprehensive care program with those of interdisciplinary care and usual care for elderly patients with hip fracture. METHODS: A randomized experimental trial was used to explore outcomes for 299 elderly patients with hip fracture receiving three treatment care models: interdisciplinary care (n = 101), comprehensive care (n = 99), and usual care (n = 99). Interdisciplinary care included geriatric consultation, continuous rehabilitation, and discharge planning with post-hospital services. Comprehensive care consisted of interdisciplinary care plus nutrition consultation, depression management, and fall prevention. Usual care included only in-hospital rehabilitation without geriatric consultation, in-home rehabilitation, and home environmental assessment. RESULTS: Participants in the comprehensive care group had better self-care ability (odds ratio, OR = 3.19, p < .01) and less risk of depression (OR = 0.48, p < .01) than those who received usual care. The comprehensive care group had less risk of depression (OR = 0.51, p < .05) and of malnutrition (OR = 0.48, p < .05) than the interdisciplinary care group during the first year following discharge. Older persons with hip fracture benefitted more from the comprehensive care program than from interdisciplinary care and usual care. CONCLUSIONS: Older persons with hip fracture benefitted more from comprehensive care including interdisciplinary care and nutrition consultation, depression management, and fall prevention than simply interdisciplinary care.

Factors associated with dementia care practices among community health nurses: results of a postal survey.

BACKGROUND: The incremental prevalence of dementia is making dementia management a worldwide issue. The role of community health nurses must grow along with the increasing aging population and the resulting increase in dementia cases. OBJECTIVES: Explore the factors related to dementia care practices among the different types of community health nurses in Taiwan. DESIGN: Cross-sectional study. SETTING: Primary care centers or institutions in New Taipei City. PARTICIPANTS: Community health nurses who work in health care centers (district nurses), long-term care centers (care managers), or home care institutions (home health care nurses). METHODS: Self-completion questionnaires sent by mail. RESULTS: A total of 195 participants returned the questionnaires (response rate 81.9%). Although 65.8% of participants had experience in case finding, just 34.6% of them reported using validated cognitive testing tools. Only 15% of participants provided case management following dementia case findings. The regression models showed that the different types of community health nurses, number of years working as a nurse, and their level of confidence was significantly related to their dementia care practice. District nurses identified significantly less suspected dementia cases and provided less nursing care to caregivers of dementia patients than care managers and home health care nurses. Among community health nurses, the care managers most often used formal cognitive instruments. District nurses provided the least amount of supportive resources information, had the most negative attitude and the lowest level of confidence toward dementia care than care managers and home health care nurses. CONCLUSIONS: This study presented the profiles of dementia care practice in Taiwan. It showed the considerable variation in knowledge, attitude, confidence and dementia care practices among the different community health nurses. The professional roles regarding dementia care in Taiwan remain blurred. Future training must focus on promoting the level of confidence of community health nurses to identify and manage people with dementia and raise awareness about demented person's and their caregiver's need. The priority of the policy on dementia care in the community must be raised to high, and the professional responsibilities and roles of the different types of community health nurses for the ever increasing dementia population in Taiwan must be redefined and optimized.

Functional recovery of older people with hip fracture: does malnutrition make a difference?

AIM: To report a study of the effects of protein-energy malnutrition on the functional recovery of older people with hip fracture who participated in an interdisciplinary intervention. BACKGROUND: It is not clear whether protein-energy malnutrition is associated with worse functional outcomes or it affects the interdisciplinary intervention program on the functional recovery of older people with hip fracture. DESIGN: A randomized experimental design. METHODS: Data were collected between 2002-2006 from older people with hip fracture (N = 162) in Taiwan. The generalized estimating equations approach was used to evaluate the effect of malnutrition on the functional recovery of older people with hip fracture. RESULTS: The majority of older patients with hip fracture were malnourished (48/80, 60% in the experimental group vs. 55/82, 67% in the control group) prior to hospital discharge. The results of the generalized estimating equations analysis demonstrated that subjects suffering from protein-energy malnutrition prior to hospital discharge appeared to have significantly worse performance trajectories for their activities of daily living, instrumental activities of daily living, and recovery of walking ability compared with those without protein-energy malnutrition. In addition, it was found that the intervention is more effective on the performance of activities of daily living and recovery of walking ability in malnourished patients than in non-malnourished patients. CONCLUSION: Healthcare providers should develop a nutritional assessment/management system in their interdisciplinary intervention program to improve the functional recovery of older people with hip fracture.

Comprehensive and subacute care interventions improve health-related quality of life for older patients after surgery for hip fracture: a randomised controlled trial.

BACKGROUND: Elderly patients with hip fracture have been found to benefit from subacute care interventions that usually comprise usual care with added geriatric intervention, early rehabilitation, and supported discharge. However, no studies were found on the effects of combining subacute care and health-maintenance interventions on health outcomes for elders with hip fracture. OBJECTIVES: To compare the effects of an interdisciplinary comprehensive care programme with those of subacute care and usual care programmes on health-related quality of life (HRQoL) for elderly patients with hip fracture. DESIGN: Randomised controlled trial. SETTINGS: A 3000-bed medical centre in northern Taiwan. PARTICIPANTS: Patients with hip fracture (N=299) were randomised into three groups: subacute care (n=101), comprehensive care (n=99), and usual care (n=99). METHODS: Subacute care included geriatric consultation, continuous rehabilitation, and discharge planning. Comprehensive care consisted of subacute care plus health-maintenance interventions to manage depressive symptoms, manage malnutrition, and prevent falls. Usual care included only 1-2 in-hospital rehabilitation sessions, discharge planning without environmental assessment, no geriatric consultation, and no in-home rehabilitation. HRQoL was measured using the Medical Outcomes Study Short-Form 36 Taiwan version at 1, 3, 6, and 12 months after discharge. RESULTS: Participants in the comprehensive care group improved more in physical function, role physical, general health and mental health than those in the usual care group. The subacute care group had greater improvement in physical function, role physical, vitality, and social function than the usual care group. The intervention effects for both comprehensive and subacute care increased over time, specifically from 6 months after hip fracture onward, and reached a maximum at 12 months following discharge. CONCLUSIONS: Both comprehensive care and subacute care programmes may improve health outcomes of elders with hip fracture. Our results may provide a reference for health care providers in countries using similar programmes with Chinese/Taiwanese immigrant populations.

Coping processes of Taiwanese families during the postdischarge period for an elderly family member with hip fracture.

The purposes of this study were to develop a conceptual framework explaining the coping processes of Taiwanese families after hospital discharge of an elderly family member with hip fracture and to use the Roy adaptation model to examine their interdependence relationships. In-depth, face-to-face interviews were tape-recorded and transcribed verbatim. Data were analyzed by grounded theory method. Findings revealed that a harmony between receiving and giving relationships was maintained by care receivers and caregivers during the postdischarge period to achieve an outcome of adaptation in their relationships. By understanding these coping processes, nurses can assist families to enhance adaptation.