Predicting substance use disorder treatment follow-ups and relapse across the continuum of care at a single behavioral health center.

INTRODUCTION: Substance use disorder is often a chronic condition, and its treatment requires patient access to a continuum of care, including inpatient, residential, partial hospitalization, intensive outpatient, and outpatient programs. Ideally, patients complete treatment at the most suitable level for their immediate individual needs, then transition to the next appropriate level. In practice, however, attrition rates are high, as many patients discharge before successfully completing a treatment program or struggle to transition to follow-up care after program discharge. Previous studies analyzed up to two programs at a time in single-center datasets, meaning no studies have assessed patient attrition and follow-up behavior across all five levels of substance use treatment programs in parallel. METHODS: To address this major gap, this retrospective study collected patient demographics, enrollment, discharge, and outcomes data across five substance use treatment levels at a large Midwestern psychiatric hospital from 2017 to 2019. Data analyses used descriptive statistics and regression analyses. RESULTS: Analyses found several differences in treatment engagement based on patient-level variables. Inpatients were more likely to identify as Black or female compared to lower-acuity programs. Patients were less likely to step down in care if they were younger, Black, had Medicare coverage were discharging from inpatient treatment, or had specific behavioral health diagnoses. Patients were more likely to relapse if they were male or did not engage in follow-up SUD treatment. CONCLUSIONS: Future studies should assess mechanisms by which these variables influence treatment access, develop programmatic interventions that encourage appropriate transitions between programs, and determine best practices for increasing access to treatment.

Association of Geriatric Emergency Department post-discharge referral order and follow-up with healthcare utilization.

BACKGROUND: Compared with younger adults who receive care in the emergency department (ED), older patients who are discharged home have greater risk of adverse health outcomes. Connecting older adults with outpatient care following ED discharge are among the guidelines of the Geriatric Emergency Department (GED). The objective of this study was to examine the association between referral order placed during the ED visit for older adults and post-discharge follow-up to the outcomes of 72-h ED revisit, 30-day ED revisit, and 30-day all cause and unplanned hospital admission. METHODS: We conducted a retrospective cohort study. Ten accredited GEDs within one midwestern health system and all ED encounters of older adults aged 65 years and older who were discharged home from the ED between July 2019 and December 2020 were included. Predictor variables included age, sex, race, ISAR©, ED Length of Stay, post-ED referral order, and follow-up. RESULTS: Among the older adults discharged home from the ED, 17% of older adult encounters had an outpatient referral ordered in the ED, 48.4% attended a follow-up appointment. Referrals were ordered for 69 referral order types with orthopedic, family practice, and urology referrals as the top 3. In mixed-effect regression models, compared with older adults with follow-up, those with a referral order but no follow-up had 19% higher odds of having a 30-day ED revisit (OR = 1.19; 95% CI = 1.07-1.31) and 11% higher odds of having 30-day unplanned hospital admission (OR = 1.11; 95% CI = 0.98-1.26). CONCLUSIONS: Older adults who had an outpatient referral ordered prior to ED discharge and followed up had lower odds of a 30-day ED revisit and 30-day subsequent unplanned hospital admission. However, less than half of patients with a referral order attended a follow-up appointment. Designing interventions for older adults aimed at improving follow-up after an ED visit is needed.

Can Variables From the Electronic Health Record Identify Delirium at Bedside?

Delirium, a common and serious disorder in older hospitalized patients, remains underrecognized. While several delirium predictive models have been developed, only a handful have focused on electronic health record (EHR) data. This prospective cohort study of older inpatients (≥65 years old) aimed to determine if variables within our health system's EHR could be used to identify delirium among hospitalized patients at the bedside. Trained researchers screened daily for delirium using the 3-minute diagnostic Confusion Assessment Method (3D-CAM). Patient demographic and clinical variables were extracted from the EHR. Among 408 participants, mean age was 75 years, 60.8% were female, and 82.6% were Black. Overall rate of delirium was 16.7%. Patients with delirium were older and more likely to have an infection diagnosis, prior dementia, higher Charlson comorbidity severity of illness score, lower Braden Scale score, and higher Morse Fall Scale score in the EHR (P<0.01 for all). On multivariable analysis, a prior diagnosis of dementia (odds ratio: 5.0, 95% CI: 2.5-10.3) and a Braden score of <18 (odds ratio: 2.8, 95% CI: 1.5-5.1) remained significantly associated with delirium among hospitalized patients. Further research in the development of an automated delirium prediction model is needed.

New Problems and Iatrogenic Events Among Older Adults in the First 30 Days of Post-Acute Rehabilitation.

The current prospective study of 126 older adults examined the new problems and iatrogenic events developing in post-acute rehabilitation. Data were extracted from the electronic health record and a consensual agreement process was used for coding. Of the 578 new problems, 66% (n = 381) were not related to the primary problem treated at the hospital; 41.7% (n = 241) were iatrogenic adverse events. The median problem-free duration was 3 days and median duration to a moderate to severe problem was 8 days. Medication-related adverse events were common. This study did not show that comorbidity or functional level should be used in determining the likelihood of older adults developing new problems or iatrogenic events during post-acute rehabilitation. Inferential findings suggest older adults with a psychiatric diagnosis, cognitive impairment, or failure to thrive may require extra measures, such as comprehensive assessment and early intervention, to prevent new problems and iatrogenic events. [Research in Gerontological Nursing, 14(6), 293-304.].

Energy-dense, low-volume paediatric oral nutritional supplements improve total nutrient intake and increase growth in paediatric patients requiring nutritional support: results of a randomised controlled pilot trial.

Children with or at risk of faltering growth require nutritional support and are often prescribed oral nutritional supplements (ONS). This randomised controlled trial investigated the effects of energy-dense paediatric ONS (2.4 kcal/ml, 125 ml: cONS) versus 1.5 kcal/ml, 200 ml ONS (sONS) in community-based paediatric patients requiring oral nutritional support. Fifty-one patients (mean age 5.8 years (SD 3)) with faltering growth and/or requiring ONS to meet their nutritional requirements were randomised to cONS (n = 27) or sONS (n = 24) for 28 days. Nutrient intake, growth, ONS compliance and acceptability, appetite and gastro-intestinal tolerance were assessed. Use of the cONS resulted in significantly greater mean total daily energy (+ 531 kcal/day), protein (+ 10.1 g/day) and key micronutrient intakes compared with the sONS group at day 28 and over time, due to high ONS compliance (81% of patients ≥ 75%), maintained intake from diet alone and improved appetite in the cONS group, compared with the sONS group. Although growth increased in both intervention groups, results were significant in the cONS group (weight (p = 0.007), height (p < 0.001) and height z-score (p = 0.006)).Conclusions: This study shows that use of energy-dense (2.4 kcal/ml) low-volume paediatric-specific ONS leads to improved nutrient intakes, growth and appetite in paediatric patients requiring oral nutrition support compared with standard energy density ONS.Trial registration: The trial is registered at clinicaltrials.gov , identification number NCT02419599. What is Known: • Faltering growth is the failure of children to achieve adequate growth at a normal rate for their age and requires nutritional support, including the use of oral nutritional supplements (ONS). • Energy-dense, low-volume ONS have benefits over standard ONS in adults. What is New: • This is the first RCT to investigate the effects of energy-dense, low-volume ONS (2.4 kcal/ml, 125 ml) in children with faltering growth, showing significant improvements in total nutrient intake and increased growth. • Energy-dense, low-volume ONS can play a key role in the management of faltering growth.

The Bundled Hospital Elder Life Program-HELP and HELP in Home Care-and Its Association With Clinical Outcomes Among Older Adults Discharged to Home Healthcare.

OBJECTIVES: To describe the Bundled Hospital Elder Life Program (HELP and HELP in Home Care), an adaptation of HELP, and examine the association of 30-day all-cause unplanned hospital readmission risk among older adults discharged to home care with and without Bundled HELP. DESIGN: Matched case-control study. SETTING: Two medical-surgical units within two midwestern rural hospitals and patient homes (home health). PARTICIPANTS: Hospitalized patients, aged 65 years and older, discharged to home healthcare with and without Bundled HELP exposure between January 1, 2015, and September 30, 2017. Each case (Bundled HELP, n = 148) was matched to a control (non-Bundled HELP, n = 148) on Charlson Comorbidity Index, primary hospital diagnosis of orthopedic condition or injury, and cardiovascular disease using propensity score matching. MEASUREMENTS: The primary study outcome was 30-day all-cause unplanned hospital readmission. Additional outcomes measured were 30-day emergency department (ED) visit, hospital length of stay (LOS), and total number of skilled home care visits. RESULTS: Fewer cases (16.8%) than controls (28.4%) had a 30-day all-cause unplanned hospital readmission. The fully adjusted model showed significantly lower risk of 30-day hospital readmission for case (Bundled HELP) patients (0.41; 95% confidence interval = 0.22-0.77; P < .01). The difference between case (10.8%) and control (15.5%) 30-day ED visit was not significant (P = .23). A lower LOS for the case group was shown (P < .01), while the number of skilled home care visits was not significantly different between groups (P = .28). CONCLUSION: HELP protocol implementation during a patient's hospital stay and as a continued component of home care among older adults at risk for cognitive and/or functional decline appears to be associated with favorable outcomes. Our initial evaluation supports continued study of the Bundled HELP. Further research is needed to confirm the initial findings and to evaluate the impact of the adapted model on functional outcomes and delirium incidence in the home. J Am Geriatr Soc 67:1730-1736, 2019.

Comparison of the effectiveness of two protocols for treating nursing home residents with advanced dementia.

The Serial Trial Intervention (STI) is a decision support tool to address the problem of underassessment and undertreatment of pain and other unmet needs of people with dementia. This study compared the effectiveness of the 5-step and 9-step versions of the STI using a two-group repeated measures quasi-experimental design with randomization of 12 matched nursing homes. The sample consisted of 125 residents with moderate to severe dementia. Both the 5- and 9-step STIs significantly decreased discomfort and agitation from pre- to posttest (effect sizes = 0.45 to 0.90). The 9-step version was more effective for comorbid burden and increased cortisol slope (effect sizes = 0.50 and 0.49). Process variables were all statistically significantly improved using the 9-step STI. Nurse time was not different between the two groups. The clinical decision support rules embedded in the STI, particularly the 9-step version, helped nurses change practice and improved resident outcomes.

Predictors of nonpharmacological and pharmacological treatments stopped and started among nursing home residents with dementia.

The purpose of this study was to describe the nonpharmacological and pharmacological treatments stopped and started over 6 weeks among a sample of nursing home residents with moderate to severe dementia and to identify nurse and resident factors associated with starting new and stopping ineffective/unnecessary nonpharmacological and pharmacological treatments. One hundred thirty-four nursing home residents with dementia and 39 nurses from 12 nursing homes in the Midwest participated in this study. Resident and nursing process data were collected on daily tracking forms completed by the primary nurse over a 6-week period. Both assessment-driven intervention and evaluation-driven follow through significantly predicted treatments stopped and new treatments started. The findings demonstrate that nurses serve an essential role in maintaining resident physiological and psychological homeostasis by vigilantly responding to residents' physical problems and behaviors with assessment-driven intervention and evaluation-driven follow through.

Development and psychometric evaluation of the Core Nurse Resource Scale.

AIMS: To examine the factor structure, internal consistency reliability and concurrent-related validity of the Core Nurse Resource Scale. METHODS: A cross-sectional survey study design was used to obtain a sample of 149 nurses and nursing staff [Registered Nurse (RNs), Licensed Practical Nurse (LPNs) and Certified Nursing Assistant (CNAs)] working in long-term care facilities. Exploratory factor analysis, Cronbach's alpha and bivariate correlations were used to evaluate validity and reliability. RESULTS: Exploratory factor analysis yielded a scale with 18 items on three factors, accounting for 52% of the variance in scores. Internal consistency reliability for the composite and Core Nurse Resource Scale factors ranged from 0.79 to 0.91. The Core Nurse Resource Scale composite scale and subscales correlated positively with a measure of work engagement (r=0.247-0.572). CONCLUSIONS: The initial psychometric evaluation of the Core Nurse Resource Scale demonstrates it is a sound measure. Further validity and reliability assessment will need to be explored and assessed among nurses and other nursing staff working in other practice settings. IMPLICATIONS FOR NURSING MANAGEMENT: The intent of the Core Nurse Resource Scale is to evaluate the presence of physical, psychological and social resources of the nursing work environment, to identify workplaces at risk for disengaged (low work engagement) nursing staff and to provide useful diagnostic information to healthcare administrators interested in interventions to improve the nursing work environment.

Do personality traits predict work outcomes of certified nursing assistants?

The purposes of this study were to describe personality traits of certified nursing assistants (CNAs) employed at nursing homes and explore relationships between personality traits, job satisfaction, and job performance. The sample included 177 CNAs providing direct care to residents in three nursing homes. CNAs with high and low job performance skills were distinguished by the cluster of traits associated with teamwork skills. Overall, 21.3% of the variance in job satisfaction was explained by the personality traits of Adjustment, Prudence, Likeability, Excitable, and Dutiful, F(8, 145) = 4.899, p < 0.001. The links found between personality, job satisfaction, and job performance provide important information about the personality traits of nursing staff who are most likely to enjoy and perform well in the nursing home setting. Knowledge of these links may be useful for hiring the appropriate person for direct care nursing home positions.

Factors associated with time to identify physical problems of nursing home residents with dementia.

This study describes new problems emerging over 6 weeks for nursing home residents with advanced dementia and factors associated with time to identify the problems. The sample of 65 developed 149 new acute problems or exacerbations of existing conditions over the 6 weeks of data collection. The majority of these problems involved uncontrolled pain, new infections, and severe psychoses. Nurse assessment skill was associated with a shorter time to identify the new problem and more time spent on the problem. A higher ratio of new to existing interventions was also associated with a shorter time to identify the problem. Other patient characteristics associated with time to identify problems included nonspecific vocalizations, physical signs, cognitive status, and length of stay. While future research is warranted, findings from this study highlight the frequency of problems requiring treatment and suggest that improved assessment of residents may decrease the time to identify new problems.

Engagement at work: a review of the literature.

OBJECTIVES: Engagement at work has emerged as a potentially important employee performance and organizational management topic, however, the definition and measurement of engagement at work, and more specifically, nurse engagement, is poorly understood. The objective of this paper is to examine the current state of knowledge about engagement at work through a review of the literature. This review highlights the four lines of engagement research and focuses on the determinants and consequences of engagement at work. Methodological issues, as identified in the current research, and recommendations for future nurse-based engagement research are provided. DESIGN: A systematic review of the business, organizational psychology, and health sciences and health administration literature about engagement at work (1990-2007) was performed. DATA SOURCES: The electronic databases for Health Sciences and Health Administration (CINAHL, MEDLINE), Business (ABI INFORM), and Psychology (PsycINFO) were systematically searched. REVIEW METHODS: Due to the limited amount of research that has examined engagement among the nursing workforce, published research that included varying employee types were included in this review. The selection criteria for this review include those studies that were: (1) written in English and (2) examined engagement at work in employee populations of any type within any work setting. RESULTS: The literature review identified four distinct lines of research that has focused on engagement within the employee work role. Of the 32 engagement-based articles referenced in this paper, a sample of 20 studies report on the examination of antecedents and/or consequences of engagement at work among varying employee types and work settings. Key findings suggest organizational factors versus individual contributors significantly impact engagement at work. A common implication in this body of research was that of the performance-based impact. CONCLUSIONS: The study of nurses' work engagement and its relationship to nurses' organizational behavior, including work performance and healthcare organizational outcomes can be achieved by first building upon a conceptually consistent definition and measurement of work engagement. Future research is needed to provide nurse leaders with a better understanding of how nurse work engagement impacts organizational outcomes, including quality of care indicators.

Predictors of work engagement among medical-surgical registered nurses.

This descriptive, cross-sectional study examines the relationship of job satisfaction, turnover cognitions, job search behavior, and nurse demographics to work engagement among a sample of 167 registered nurses employed on medical and/or surgical units within six hospitals. Professional status, interaction, and thinking of quitting together explain 46%, F(3,160) = 47.546, p < .001, of the variance in work engagement. Additionally, the job satisfaction components of professional status and interaction are shown to significantly moderate the relationship between thinking of quitting and work engagement (t = 1.96, p < .05). Results suggest improvements in work environment processes that are consistent with professional status and interaction at work, such as integration of a professional nursing practice model and development and positioning of transformational leaders at every level of the organization, are needed.

Site-specific conjugation of a cytotoxic drug to an antibody improves the therapeutic index.

Antibody-drug conjugates enhance the antitumor effects of antibodies and reduce adverse systemic effects of potent cytotoxic drugs. However, conventional drug conjugation strategies yield heterogenous conjugates with relatively narrow therapeutic index (maximum tolerated dose/curative dose). Using leads from our previously described phage display-based method to predict suitable conjugation sites, we engineered cysteine substitutions at positions on light and heavy chains that provide reactive thiol groups and do not perturb immunoglobulin folding and assembly, or alter antigen binding. When conjugated to monomethyl auristatin E, an antibody against the ovarian cancer antigen MUC16 is as efficacious as a conventional conjugate in mouse xenograft models. Moreover, it is tolerated at higher doses in rats and cynomolgus monkeys than the same conjugate prepared by conventional approaches. The favorable in vivo properties of the near-homogenous composition of this conjugate suggest that our strategy offers a general approach to retaining the antitumor efficacy of antibody-drug conjugates, while minimizing their systemic toxicity.

Nurses' experience with the clinical application of a research-based nursing protocol in a long-term care setting.

AIM: To describe nurses' experience with the clinical application of a research-based nursing protocol (The Serial Trial Intervention) within a long-term care setting. DESIGN: A descriptive, qualitative study was conducted with a convenience sample of eight nurses from three nursing homes, who assessed and treated residents with dementia according to the Serial Trial Intervention protocol. METHODS: Each nurse participated in a semi-structured interview between September 2003 and May 2004. Interviews were audiotaped and transcribed verbatim. Qualitative content analysis of the data, including thematic analysis, was used to identify patterns of experience. RESULTS: Three themes emerged that offer insight into the factors contributing to implementation of research-based practice in a clinical setting. These include determining to intervene, pertinent steps of the protocol and facilitators and barriers. CONCLUSIONS: The interplay between the protocol, the residents receiving care, the nurses providing care and the setting in which the care is provided, are interacting to affect the outcomes expected. RELEVANCE TO CLINICAL PRACTICE: Nurses who recognize the research process, the need for continual improvement in patient care and who possess competency in comprehensive physical assessment are needed to implement this evidence-based protocol successfully. The regulatory atmosphere, workload structure and interdisciplinary collaboration are additional factors contributing to the successful use of the Serial Trial Intervention.

Effects of the Serial Trial Intervention on discomfort and behavior of nursing home residents with dementia.

This study tested the effectiveness of the Serial Trial Intervention (STI), an innovative clinical protocol for assessment and management of unmet needs in people with late-stage dementia. A double-blinded randomized experiment was conducted in 14 nursing homes with 114 subjects. The treatment group had significantly less discomfort than the control group at posttesting and more frequently had behavioral symptoms return to baseline. The group of nurses using the STI also showed more persistence in assessing and intervening than control group nurses did. There was a statistically significant difference between the groups in the use of pharmacological, but not nonpharmacological, comfort treatments. Results suggest that the STI is effective and that effective treatment of discomfort is possible for people with late-stage dementia.

Behaviors of nursing home residents with dementia: examining nurse responses.

It is challenging for nurses to understand and respond to behaviors expressed by individuals with dementia. Nurses in this study responded to behaviors in 4 discrete ways--with no treatment, treatment without assessment, repetitive use of ineffective treatments, and with comprehensive assessment followed by treatment. Using ineffective treatments and treating without assessing were associated with recurrence of behaviors. This study suggests there is a need for more assessment and critical thinking when addressing behavior change in individuals with dementia.