Evaluation of an intervention to improve the safety of medication therapy via HIT-supported interprofessional cooperation in long-term care - a mixed method study.

BACKGROUND: In order to ensure the provision of appropriate and safe medication therapy in long-term care, close interprofessional cooperation and high levels of expertise are required. Online digital documentation and communication technology facilitate this process. The aim of the present study (sub-study 2 of the SiMbA-Study) was to evaluate a three-part health information technology (HIT) driven intervention on medication therapy safety in Austrian nursing homes (NHs) regarding its usefulness, practicability and implementation in routine care. METHODS: A concurrent embedded mixed-methods design was conducted to evaluate the intervention. Data was collected via expert interviews, focus group discussions and quantitative survey of general practitioners, nurses, and pharmacists in 3 NHs. Usefulness and effectiveness of the intervention were investigated through summative evaluation. Formative evaluation was utilized to gain insights regarding features and factors of the implementation process necessary to a successful integration in routine care. RESULTS: The sample comprised general practitioners, pharmacists, and nurses. 23 participants were interviewed, of which 17 participated in the focus group discussions and completed the quantitative Survey. All components of the intervention were deemed to be useful and effective. Effort and benefit of using health information technology were well balanced. Implementation success was mainly attributed to socio-normative factors. CONCLUSIONS: The implementation of HIT-based measures can be effective but is prone to various pitfalls that are highlighted in the study. A critical challenge for successful implementation is the combination of both, ensuring its prerequisites, while anticipating new problems that arise from HIT-integration on the one hand and changes in interprofessional cooperation on the other. TRIAL REGISTRATION: DRKS Data Management, ID: DRKS00012246 . Registered 16.05.2017 - Retrospectively registered.

Improving medication appropriateness in nursing homes via structured interprofessional medication-review supported by health information technology: a non-randomized controlled study.

BACKGROUND: In nursing home residents (NHRs), polypharmacy is widespread, accompanied by elevated risks of medication related complications. Managing medication in NHRs is a priority, but prone to several challenges, including interprofessional cooperation. Against this background, we implemented and tested an interprofessional intervention aimed to improve medication appropriateness for NHRs. METHODS: A non-randomized controlled study (SiMbA; "Sicherheit der Medikamentherapie bei AltenheimbewohnerInnen", Safety of medication therapy in NHRs) was conducted in six nursing homes in Austria (2016-2018). Educational training, introduction of tailored health information technology (HIT) and a therapy check process were combined in an intervention aimed at healthcare professionals. Medication appropriateness was assessed using the Medication Appropriateness Index (MAI). Data was collected before (t0), during (t1, month 12) and after (t2, month 18) intervention via self-administered assessments and electronic health records. RESULTS: We included 6 NHs, 17 GPs (52.94% female) and 240 NHRs (68.75% female; mean age 85.0). Data of 159 NHRs could be included in the analysis. Mean MAI-change was - 3.35 (IG) vs. - 1.45 (CG). In the subgroup of NHRs with mean MAI ≥23, MAI-change was - 10.31 (IG) vs. -3.52 (CG). The intervention was a significant predictor of improvement in MAI when controlled for in a multivariable regression model. CONCLUSIONS: Improvement of medication appropriateness was clearest in residents with inappropriate baseline MAI-scores. This improvement was independent of variances in certain covariates between the intervention and the control group. We conclude that our intervention is a feasible approach to improve NHRs' medication appropriateness. TRIAL REGISTRATION: DRKS Data Management, ID: DRKS00012246 . Registered 16.05.2017 - Retrospectively registered.

Pain treatment for nursing home residents differs according to cognitive state - a cross-sectional study.

BACKGROUND: Communication skills are known to decrease with advancing cognitive impairment. Analgesic treatment in long-term care may be deficient due to the residents' impaired ability to communicate their pain and needs. Undertreated pain frequently leads to rising BPSD in residents with cognitive impairment, resulting in a treatment with antipsychotics. Aim of this study was the analysis of differences in assessment and pharmacological treatment of pain in nursing home residents relative to their cognitive state and ability to articulate pain. METHODS: Data stems from the baseline of a non-experimental pre-post-study in 12 Austrian nursing homes. Residents' pain prevalence in relation to pain assessment and cognitive decline was assessed, data on medical diagnoses and prescriptions were retrieved from the nursing homes' documentation (n = 425). Residents were first divided into two groups: Residents with MMSE ≥ 18 were selected into group CUS (cognitively unimpaired/slightly impaired), residents with MMSE ≤ 17 were selected into group CI (cognitively moderately to severely impaired). CI residents were then sub-grouped according to their ability to communicate pain via the Verbal Rating Scale (VRS) (i.e. group CI-V, group CI-NV). Pain behavior of CI residents was assessed with a modified German version of PAINAD. Group differences were tested with ANOVA and H-test, 95 % confidence intervals were calculated and associations were tested with log-binomial regression. RESULTS: Pain prevalence in CI residents irrespective of their ability to communicate pain was 80 % and exceeded the CUS group prevalence significantly by 14 %. CI residents had significantly less analgesic prescriptions. Furthermore, CI residents have a significantly higher risk of getting no analgesics when in pain than CUS residents (CI-V: RR =2.6, CI-NV: RR =3.4). Use of antipsychotics was high in all groups (49 - 65 %) with more prescriptions in the cognitively impaired group. CONCLUSION: Results point toward an underuse of pain medication in cognitively impaired residents, especially those unable to communicate pain verbally. The implementation of standardized pain assessments adapted to the cognitive abilities of residents may foster the recognition of pain, warrant optimized pain management, reduce inadequate medication and consequently raise the chance of equally effective pain treatment regardless of cognitive state.

Polypharmacy, potentially inappropriate medication and cognitive status in Austrian nursing home residents: results from the OSiA study.

There is little research investigating polypharmacy and potentially inappropriate medications (PIM) in connection with cognitive status in residents of Austrian nursing homes. Our findings result from a cross-sectional survey of 425 residents (315 women, 110 men, mean 83.6 years) from 12 Austrian nursing homes. The number of systemically administered permanent prescription drugs was 8.99 ± 3.9 and decreased significantly with increasing cognitive impairment. Irrespective of cognitive status, polypharmacy (> 5 individual substances) was present in approximately 75% of the residents. Hyper-polypharmacy (> 10 individual substances) was present among almost 50% of the cognitively intact residents, and hence, significantly more frequent as compared with the group with the lowest cognitive performance (23.4%). At least one PIM was found in 72.4% of residents regardless of cognitive status. Predominantly, PIMs consisted of tranquilizers, antipsychotics, osmotic laxatives, non-steroidal anti-inflammatory drugs (NSAIDs) and anticholinergics, where only the number of NSAIDs decreased significantly with increasing cognitive impairment. In summary, our study shows a continued high prevalence of polypharmacy and PIM in long-term care institutions in Austria.

Fitness training for the old and frail. Effectiveness and impact on daily life coping and self-care abilities.

BACKGROUND: Limitations of functionality and mobility due to age-related decrease in muscle strength, balance and physical endurance are closely related to weakness, risk of falls, malnutrition as well as an increase in morbidity and mortality. STUDY PARTICIPANTS AND METHODS: In a pilot study we developed and evaluated an 8-week equipment-based progressive resistance training program for geriatric day hospital patients (> 65 years) to improve strength, endurance and coordination. Of the 38 patients who entered the study, 20 were randomly assigned to the intervention group (ALFIT training) and 18 to the control group who only participated in the routine program of the day hospital. Motivation, experiences during training and the subjective impact on coping with daily life were examined with qualitative interviews. RESULTS: Muscular strength, endurance, coordination and balance improved during the implementation of the ALFIT training program. The most pronounced effects were seen for the leg pressing with an average increase of 27.8 ± 16 kg (mean ± SD) in terms of 1 repetition maximum and an increase of 12.6 ± 23.7 (mean ± SD) in terms of muscular endurance (number of repetitions). Positive effects were also evident for mobility and nutritional status. The results of the interviews suggest that the ALFIT training leads to noticeably better physical function and confidence and can have a positive impact on coping in daily life and self-care abilities. CONCLUSION: The results show that ALFIT training was appropriate for the needs of geriatric patients and demonstrated beneficial effects on muscular strength, functionality and mobility. The results of the interviews suggest that even frail old people can be motivated to engage in sports.

[Risk for dysphagia screening tools - a review of the international literature]. / Screening-Verfahren zur Identifikation einer Dysphagie bei älteren Menschen - Ein systematischer Literaturüberblick.

Elderly people have an increased risk to suffer from dysphagia due to age-related physiological alterations and neurological disorders. The consequences of untreated dysphagia are malnutrition and dehydration and the aspiration of solid and liquid food into the respiratory tract, which can lead to life-threatening pneumonia. On this background the care of the elderly people in nursing homes is a challenge for nurses. The aim of this literature review is to identify suitable screening tools and to evaluate their practicability for nurses' everyday work. The database search was conducted in CINAHL, Ovid Medline and EMBASE. Ten screening tools fitted the selection criteria. Most of them are developed by speech and language therapists and physicians, only two tools are designed by nursing scientists. A swallowing test is part of all screening tools; the target population are stroke patients in their acute phase. Other relevant criteria besides the swallowing test are, e. g. the patients' health status, taking of psychotropic drugs, and posture. All instruments are described as simple to use. They are tested for validity, and sometimes for reliability, but the tools are mostly not appropriate for the use in institutional geriatric care settings. The two instruments developed by nurse scientists are only of limited use in nursing homes, because both instruments were not tested in nursing homes and only one of these tools shows acceptable values of interrater reliability and criterion-related validity. As a result, a screening tool for the target group and a training programme for nurses should be developed.

[Comment about the policy statement of the MDS. A position statement of the assessment group of the University Witten/Herdecke with regard to nursing documentation]. / Kommentar zur Grundsatzstellungnahme "Pflegeprozess und Dokumentation" des MDS. Positionspapier der Assessmentgruppe, Universität Witten/Herdecke, zur Pflegedokumentation.

In 2005 the Medical Advisory Service of Social Health Insurance (MDS) in Germany published a policy statement with regard to the nursing process and documentation. According to the intention of the association, this statement should be considered as recommendations which are able to improve nursing practice and to contribute to streamlining of bureaucracy in nursing care. Recognising the broad impact of this publication on nursing institutions, a working group on nursing assessment of the University Witten/Herdecke conducted a critical review of the statement. Significant criteria for evaluation were the primary role of nursing documentation, quality requirements for the documentation as well as recent scientific results concerning the implementation of nursing process and assessment-based nursing diagnoses. The review revealed that the statement lacks of a clear rationale and its content appears to be merely research-based. Therefore it has to be questioned if the publication will accomplish the claimed effects. In fact, future quality criteria for health care are to be developed independently on the basis of scientific results and in consideration of the experiences of all concerned social groups.

[Position statement of the National Nursing Assessment Group of Germany: regarding the basic "nutrition and fluid requirements" policy of the elderly by the MDS (Medical Service of the Central Associations of the Health Insurance Companies), July 2003]. / Positionspapier der Nationalen Pflegeassessmentgruppe Deutschland: zur Grundsatzstellungnahme "Ernährung und Flüssigkeitsversorgung älterer Menschen", Abschlussbericht Projektgruppe P 39 des Medizinischen Dienstes der Spitzenverbände der Krankenkassen (MDS), Juli 2003.

Assessing the nutritional state of old and dependent people demands a distinctive consideration of all aspects which might influence the individual's nutritional habits. An isolated consideration of the body mass index (BMI) does not serve the needs of elderly, because the BMI seems not to be a valid indicator for their nutrtional state. In order to prove the risk of malnutrition, also the individual life conditions as well as social, religious, cultural and economic circumstances besides the amount of energy and nu triments are to be taken into account.