Functional trajectories of older acute medical inpatients / Trayectorias funcionales en mayores ingresados por enfermedad aguda

OBJECTIVES: To describe the changes in basic activities of daily living (BADL) function before and during hospital admission in older patients admitted to an acute medical unit and to assess the effect of age on loss of BADL function. METHODS: Prospective observational study. The study included 91 patients aged 65 and older consecutively admitted to an acute medical unit of an urban public teaching hospital in Portugal, between May and September 2017. Functional status was measured at three times: at hospital admission; at about 2 weeks before hospital admission (baseline); an on the discharge day. The functional condition was evaluated using the Katz index. Differences in scores for BADL between baseline and admission, between admission and discharge, and between baseline and discharge were used to define pre-admission, in-hospital and overall functional decline. RESULTS: Pre-admission, in-hospital and overall functional decline occurred in 78.0%, 4.4% and 63.7% of the participants, respectively. In contrast, in-hospital functional improvement occurred in a minority of the patients (14.3%). Hospitalized older people are discharged with BADL function that is worse than their baseline function. The oldest patients are at high risk of poorer functional outcomes because they are less likely to recover BADL function lost before admission. CONCLUSION: These results emphasize the overriding need for implementing in-hospital processes to prevent functional decline and enhance functional recovery. This study also highlights the need for nurses to closely monitor the functional status of hospitalized older people, particularly in oldest-old patients

OBJETIVOS: Describir los cambios en las actividades básicas de la vida diaria (ABVD) en los pacientes mayores de 65 años que ingresan por una patología aguda en una unidad médica de un hospital y evaluar el efecto de la edad en la pérdida de la función en las ABVD. MÉTODOS: Estudio observacional prospectivo. La muestra se realizó mediante selección consecutiva de pacientes de 65 o más años que ingresaron en una unidad médica de un hospital docente público urbano de Portugal entre mayo y septiembre del 2017 por una enfermedad aguda. El estado funcional se midió en: el ingreso; alrededor de 2 semanas antes del ingreso (línea de base), y el día del alta. Las diferencias en los puntajes de las ABVD se utilizaron para definir el deterioro funcional. RESULTADOS: El estudio incluyó a 91 pacientes. El deterioro funcional en la preadmisión y en el hospital, y el deterioro funcional global ocurrieron en el 78, el 4,4 y el 63,7% de los enfermos, respectivamente. En contraste, la mejoría funcional hospitalaria ocurrió en una minoría de los enfermos (14,3%). Las personas mayores hospitalizadas son dadas de alta con una pérdida de autonomía en las ABVD con respecto a la línea base. En los pacientes de edades más avanzadas existe un mayor riesgo de empeorar las ABVD y además tienen menos posibilidades de recuperación de las funciones de ABVD perdidas antes del ingreso. CONCLUSIÓN: Los resultados evidencian la necesidad de implementar procesos hospitalarios específicos para prevenir el deterioro funcional en el ingreso y mejorar la recuperación funcional

Hospital Elder Life Program in Long-Term Care (HELP-LTC): A Cluster Randomized Controlled Trial.

BACKGROUND/OBJECTIVES: The Hospital Elder Life Program (HELP) has been shown to prevent delirium in hospitalized older adults. The objective of this study was to test the efficacy of HELP adapted to long-term care (HELP-LTC). DESIGN: Cluster randomized controlled trial. SETTING: A 514-bed academic urban nursing home. PARTICIPANTS: A total of 219 long-term nursing home residents who developed an acute illness or change in condition were randomly assigned to HELP-LTC (n = 105) or usual care (n = 114) by unit. INTERVENTION: HELP-LTC is a multicomponent intervention targeting delirium risk factors of cognitive impairment, immobility, dehydration, and malnutrition. Two certified nursing assistants (CNAs) delivered HELP-LTC components twice daily 7 days per week. In addition, recommendations were given to primary providers to reduce medications associated with delirium. MEASUREMENTS: Delirium (primary outcome) and delirium severity were ascertained each weekday by a research assistant blinded to group assignment, using the Confusion Assessment Method (CAM) and CAM severity score (CAM-S), respectively. Cognitive function was determined using the Cognitive Performance Scale (CPS). Hospitalization was ascertained by chart review. RESULTS: Participants were 81.7 years of age on average and 65.3% female. At baseline, usual care group participants had better cognitive function than intervention group participants (CPS = 1.33 vs 2.25; P = .004). Delirium symptoms declined over the course of the episode (mean CAM-S = 3.63 at start vs 3.27 at end). Overall, 33.8% of the total sample experienced incident delirium. After adjusting for baseline cognitive function, no significant differences were found in delirium or delirium severity between intervention and usual care groups. Hospitalization was not significantly different between groups. CONCLUSION: An intervention targeting delirium risk in long-term nursing home residents did not prevent delirium or reduce delirium symptoms. Baseline differences in cognitive function between groups, greater than expected improvements in both groups, quality-enhancing practices such as consistent assignments delivered to both groups, and adaptations of the intervention may have biased results toward null. J Am Geriatr Soc 68:2329-2335, 2020.

Serious Illness Conversations: A Case Management Quality Improvement Project.

PURPOSE/OBJECTIVES: The purpose of this project was to develop, implement, and evaluate an educational program and a serious illness (SI) protocol for a case management team of nurses and social workers to achieve the following: (1) utilize an SI protocol to identify patients with SI; (2) utilize a Serious Illness Structured Communication Guide to elicit these patients' goals and preferences for SI care; and (3) document in the electronic medical record the patients' elicited values and goals using a structured SI documentation template. PRIMARY PRACTICE SETTING AND SAMPLE: Seventeen nurse and 3 social work case managers in an Accountable Care Organization (ACO) in a large health system in a western suburb of Chicago participated in this project. The practice setting was the primary care clinics associated with the health system. Patients eligible for the project met the SI criteria and were part of the organization's ACO or Bundle Payment for Care Improvement program. METHODOLOGY: Twenty members of the case management staff participated in a 4-hr face-to-face educational program, based in part on review of best practices related to SI care and communication. Participants completed a pre- and posttest survey of knowledge; self-rated their confidence in conducting SI conversations; and evaluated the educational program. Participants then engaged in the established protocol inclusive of the following: (1) identify patients appropriate for an SI conversation; (2) initiate the SI conversation; and (3) document components of the SI in the electronic medical record. FINDINGS/CONCLUSIONS: Educational Program: Ninety-five percent of the RN and SW case managers reported that that the educational module objectives were met to a moderate or great extent. One hundred percent of the participants reported that the format to deliver the program was effective, the content of the program was directly relevant to their clinical practice, and they would change their practice because of learning/understanding the content in the program. Educational program pretest scores ranged from 46.2% to 84.6%, with posttest scores ranging from 69.2% to 100%. A paired-samples t test demonstrated a statistically significant increase in posttest scores. Baseline confidence scores ranged from 1 to 4, with postproject confidence scores ranging from 2 to 4. A paired-samples t test demonstrated a statistically significant increase in confidence.Serious Illness Protocol: The case managers correctly identified 92% of patients who met the established SI identification criteria for this project. In 91.8% of cases, the case managers conducted an SI conversation in adherence to the protocol. In 76% of the cases, documentation about the SI conversation was completed in accordance with the protocol. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: .

Building therapeutic connections with the acutely ill through standardised patient simulation in nurse education an evaluation study.

BACKGROUND: Phenomenological empathy and sense of coherence are two researched communication approaches used to improve therapeutic connections with patients in a variety of nurse related settings. The aim of this study is to evaluate students' feedback concerning how this event has enabled that understanding, development and refinement of skill-sets in PE and SoC when managing the acutely ill during simulation. METHODS: 114 third year bachelor degree-nursing students were given the opportunity to complete an evaluation, developed for the specific purpose of this study. The evaluation contained six closed questions on a four point Likert-scale and three open questions, handed out upon completion of the standardised patient simulation of the acutely ill. Comments written in response to the open questions were analysed using manifest content analysis and closed questions using SPSS to produce descriptive frequencies. RESULTS: 100 students completed the evaluation. Student nurses', regardless of previous experience or age, indicated the need for more education and practice in phenomenological empathy and sense of coherence to enhance their ability to build therapeutic connections with the acutely ill. CONCLUSIONS: Teaching phenomenological empathy and sense of coherence, as an integral part of standardised patient simulation is necessary to motivate student nurses ability to build therapeutic relationships with the acutely ill to enhance person centred care.

Level of function mobility scale for nurse-driven early mobilisation in people with acute cardiovascular disease.

BACKGROUND: There are currently no validated tools that are reliable and easy to use for nurses to assess mobility in people with acute cardiovascular disease in the Cardiovascular Intensive Care Unit (CICU). METHODS: A multidisciplinary team at an academic tertiary care centre developed the Level of Function (LOF) Mobility Scale for use in a nurse-driven early progressive mobilisation in the CICU. To determine inter-rater reliability, the prehospital and admission LOF were assessed independently by two CICU nurses. Pairwise comparisons between raters were evaluated using Cohen's kappa statistic. To determine convergence validity, the LOF and Activity Measure for Post-Acute Care 6-Clicks score upon admission were compared with Spearman's correlation. To determine feasibility, a 9-item mobility scale questionnaire was distributed to CICU nurses with and without experience using the LOF Mobility Scale. The STROBE reporting guidelines were used. RESULTS: The LOF Mobility Scale had good inter-rater reliability for assessment of LOF prior to hospitalisation (N = 131, kappa = 0.66, p < .001) and at the time of CICU admission (N = 131, kappa = 0.71, p < .001). There was a moderate correlation (N = 79 observations; correlation coefficient = 0.525; p < .01) between the bedside nurses LOF and the 6-Clicks score. All nurses surveyed (N = 54; 100%) thought that the LOF Mobility Scale was clear and unambiguous, the LOFs were well-defined and the scale was an appropriate length. Nearly all of the nurses with experience using the scale (N = 22/24; 92%) felt that the scale took less than one minute to complete, compared with about half (N = 14/30; 47%) in the group of nurses without experience using the scale. CONCLUSION: The LOF Mobility Scale is reliable and feasible for mobility assessment in a nurse-driven early progressive mobilisation programme in patients with acute cardiovascular disease in the CICU. RELEVANCE TO CLINICAL PRACTICE: A nurse-driven EM programme can be implemented in the CICU.

Nurses' perceptions of high-alert medication administration safety: A qualitative descriptive study.

AIMS: The aim of this study was to determine nurses' perceptions of supports and barriers to high-alert medication (HAM) administration safety. DESIGN: A qualitative descriptive design was used. METHODS: Eighteen acute care nurses were interviewed about HAM administration practices. Registered nurses (RNs) working with acutely ill adults in two hospitals participated in one-on-one interviews from July-September, 2017. Content analysis was conducted for data analysis. RESULTS: Three themes contributed to HAM administration safety: Organizational Culture of Safety, Collaboration, and RN Competence and Engagement. Error factors included distractions, workload and acuity. Work arounds bypassing bar code scanning and independent double check procedures were common. Findings highlighted the importance of intra- and interprofessional collaboration, nurse engagement and incorporating the patient in HAM safety. CONCLUSIONS: Current HAM safety strategies are not consistently used. An organizational culture that supports collaboration, education on safe HAM practices, pragmatic HAM policies and enhanced technology are recommended to prevent HAM errors. IMPACT: Hospitals incorporating these findings could reduce HAM errors. Research on nurse engagement, intra- and interprofessional collaboration and inclusion of patients in HAM safety strategies is needed.

The dose of physical activity to minimise functional decline in older general medical patients receiving 24-hr acute care: A systematic scoping review.

AIMS AND OBJECTIVES: To identify evidence for a recommended and feasible activity dose to minimise functional decline in older hospitalised general medical patients. BACKGROUND: Quality 24-hr care of older patients involves balancing activity to minimise functional decline, with rest to aid recovery. However, there is limited guidance regarding an optimal type and dose of activity to minimise functional decline in hospitalised elders receiving acute medical care. DESIGN: A systematic search and scoping review of the literature were conducted following Joanna Briggs methodological guidance. METHODS: The results were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. Study bias was determined using the Joanna Briggs Institute Critical Appraisal Tools. RESULTS: Fifteen primary studies of variable design, rigour and potential for bias were included. Study contexts were general medical wards (n = 11, 73.3%), Acute care of the elderly unit (n = 3, 20%) and a nursing unit (n = 1, 6.7%) located in tertiary referral acute hospitals. Most participants were aged 75-84 years (n = 10, 66%), had variable medical diagnoses and samples were either physically capable (n = 4, 26.7%) of limited physical capability (n = 1, 6.7%) or of mixed capability to mobilise independently (n = 10, 66.7%). Walking at least twice a day for approximately 20 min in total appeared to be associated with less functional decline in older patients of variable physical capabilities, and the overall efficacy of twice-daily exercise to reduce functional decline was supported. CONCLUSION: The evidence tentatively supported walking for hospitalised elders, irrespective of physical capability, and based on one RCT, suggested likely benefits of graduated exercise in dependent elders. Insufficient evidence limits prescription of optimal doses of physical activity to minimise functional decline. RELEVANCE TO CLINICAL PRACTICE: This review could provide evidence for nurses to promote function in older patients by specifying a dose of physical activity to be undertaken in hospital.

[Concept analysis: Nurse demand management]. / Análisis de concepto: gestión enfermera de la demanda.

Nurse demand management (NDM) is an emerging concept that requires some useful clarification, not only for professionals and users but also for managers. The NDM was born in 2009 after the need to reorganize the flow of demand, but it has become more than this. NDM is understood as a program led by the primary care nurse to take care of people with acute minor illnesses. Nurses, under a consensual protocol and within their competence area, can be autonomous in patient care and in the resolution of acute minor illnesses. Therefore, following Primary Care's philosophy, both the doctor and the nurse are the professionals that will follow up the health-disease process throughout the user's life. This article was written according to the methodology described by Wilson.

Have you SCAND MMe Please? A framework to prevent harm during acute hospitalisation of older persons: A retrospective audit.

AIMS AND OBJECTIVES: To test the mnemonic Have you SCAND MMe Please? as a framework to audit nursing care to prevent harms common to older inpatients. BACKGROUND: It is not known if acute hospital care comprehensively addresses eight interrelated factors that contribute to preventable harms common in older hospitalised patients. DESIGN: Retrospective audit of medical records. METHODS: A random selection of 400 medical records of inpatients over 65 years of age with an unplanned admission of longer than 72 hr in acute medical wards at four hospitals in Victoria, Australia, during 2011-12, was examined for frequency of documented evidence of assessments, interventions or new problems related to eight factors contributing to common preventable harms during hospitalisation. RESULTS: Assessments of skin integrity (94%-97%), mobility (95%-98%) and pain (93%-97%) were most often documented. Gaps in assessment of continence (4%-31%), nutrition (9%-49%), cognition (delirium, depression and dementia) (10%-24%) were most common. No patient record had evidence of all eight factors being assessed. Almost 80% of records had interventions documented for one or more factors that contribute to preventable harms. In almost 20% of patient records, a new preventable harm was documented during hospitalisation. CONCLUSIONS: The mnemonic Have you SCAND MMe Please? brings together eight factors known to contribute to preventable harms common in older hospitalised patients. This framework was useful to identify gaps in assessment and interventions for factors that contribute to preventable harms during acute hospital care. Future research should test if the mnemonic can assist nurses with comprehensive harm prevention during acute hospitalisation. RELEVANCE TO CLINICAL PRACTICE: The mnemonic Have you SCAND MMe Please? represents eight factors that contribute to preventable harms common in older hospitalised patients. This framework provides a model for harm prevention to assist nurses to implement comprehensive harm prevention to improve quality of care and safety for older hospitalised patients.

How do emergency nurse practitioners experience managing acutely unwell patients in minor injury units? An Interpretative Phenomenological Analysis.

INTRODUCTION AND AIM: Emergency nurse practitioners (ENPs) working autonomously within minor injury units (MIUs) sometimes have to manage acutely unwell patients who self present. It is likely that whilst emergency departments remain under increasing pressure, this subsection of patients will continue to attend. There is little published research exploring ENPs' experiences during such incidents. This small qualitative study aims to explore emergency nurse practitioners' experiences of managing acutely unwell patients in MIU. METHOD: Data were collected using semi-structured face-to-face interviews via a purposive sample of six ENPs from a countywide MIU service within one UK Trust. An Interpretative Phenomenological Analysis framework (IPA) was used to interpret data. FINDINGS: Three superordinate themes evolved: emotional resilience, ENP identity and external factors. These were explored further through six further subthemes; emotional responses, coping, clinical competence, who is the MIU ENP? environmental factors and 'why didn't you call 999?' DISCUSSION: ENPs regularly manage a diverse range of high acuity patients in MIUs, often with limited resources available. Such events are highly stressful, resulting in professional role disparity and leaving ENPs vulnerable to burnout and PTSD. Robust research is needed to determine how ENPs can prepare for such events, and the frequency of such incidents.

The Impact of Pediatric Palliative Care Involvement in the Care of Critically Ill Patients without Complex Chronic Conditions.

Background: The impact of pediatric palliative care (PPC) is well established for children with chronic complex diseases. However, PPC likely also benefits previously healthy children with acute life-threatening conditions. Objective: To determine the incidence and impact of PPC for previously healthy patients who died in a pediatric hospital. Design: Retrospective chart review of all pediatric deaths over four years. Setting/Subjects: Patients were 0 to 25 years old, died during an inpatient stay at an academic pediatric hospital ≥48 hours after admission, and had no complex chronic conditions (CCCs) before admission. Measurements: One hundred sixty-seven patients met the eligibility criteria. Most died in intensive care settings (n = 149, 89%), and few (n = 34, 20%) received PPC consultations or services. Results: Patients who received PPC services were more likely to receive a multidisciplinary care conference than did patients without PPC support (70.5% vs. 39.9%; p = 0.001), which also occurred earlier for patients who received PPC services (seven days vs. two days before death; p = 0.04). Most patients had documented end-of-life planning in their medical records; however, this occurred earlier for patients who received PPC consultation (9.5 days before death) than for those who did not (two days before death; p < 0.0001). Patients receiving PPC support (67.7%) were also more likely to have a do-not-resuscitate/intubate order before death than those who did not (39.9%; p = 0.004). Conclusions: Pediatric patients without known CCCs who subsequently die as inpatients benefit from PPC in terms of goals of care discussions and documentation of end-of-life care preferences.

Collaboration Between Relatives of Older Patients and Nurses in Acute Medical Wards: Confirmatory Factor Analysis of the Revised Family Collaboration Scale.

BACKGROUND: Relatives of older people are often involved in their care prior to hospital admission, and may hold valuable knowledge which, if involved, could improve decision-making related to care. Hence, collaboration is required and to monitor this, valid and feasible instruments are needed. The Family Collaboration Scale (FCS) was developed for this purpose, and has been found valid and reliable. Our study tested a shorter version, while assessing collaboration between nurses and 388 relatives. RESULTS: The study provided support for reliability and construct validity of the revised scale. Its feasibility may benefit from adjustments, as older relatives, those with less education and those delivering extensive help, were less likely to complete the scale. Collaboration was rated as poor to average. Poor collaboration was significantly more often reported by women and relatives reporting guilt and powerlessness.

Organizational readiness for implementing change in acute care hospitals: An analysis of a cross-sectional, multicentre study.

AIM: To assess nurse-reported organizational readiness for implementing change in acute care hospitals. BACKGROUND: An organization's success at implementing new policies and programmes depends largely on its stakeholders' readiness for change. Organizational readiness is a multilevel, multifaceted construct associated with staffing, leadership and quality of care. DESIGN: This is a secondary analysis of the cross-sectional multicentre "Matching Registered Nurse Services with Changing Care Demands" study. METHODS: In 23 acute care hospitals across Switzerland, 1,833 nurses working in 124 units completed a survey between September 2015 and January 2016. Organizational readiness was measured with two subscales: "change commitment" and "change efficacy". Work environment factors were assessed using the Practice Environment Scale of the Nursing Work Index. RESULTS: Nurses were positive about implementing change in their hospitals. Intraclass correlation was higher at the unit level than at the hospital level for both change commitment and change efficacy. Nursing foundation for quality of care and supportive leadership were positively associated with readiness, change commitment and change efficacy. However, staffing and resource adequacy was positively associated only with change efficacy. No association was found with standardized staffing. CONCLUSION: While organizational readiness scores vary among hospitals and units, they are positively associated with supportive leadership and a foundation for quality of care. Further research should consider organizational readiness as an important factor of change and ultimately of the quality of care.

[Patient-related complexity in nursing care - Collective case studies in the acute care hospital]. / Patientenbezogene Komplexität in der Pflege ­ Kollektive Case Studies im Akutspital.

Patient-related complexity in nursing care - Collective case studies in the acute care hospital Abstract. BACKGROUND: Patient-related complexity of nursing is defined by the three characteristics "instability", "uncertainty", and "variability". Complexity increased in the past years, due to reduced hospital length of stay and a growing number of patients with chronic and multiple diseases. AIM: We investigated the phenomenon of patient-related complexity from the point of view of nurses and clinical nurse specialists in an acute care hospital. METHODS: In the context of a collective case study design, nurses and clinical nurse specialists assessed the complexity of nursing situations with a questionnaire. Subsequently, we interviewed nurses and clinical nurse specialists about their evaluation of patient-related complexity. In a within-case-analysis we summarized data inductively to create case narratives. By means of a cross-case-analysis we compared the cases with regard to deductively derived characteristics. RESULTS: The four cases exemplarily showed that the degree of complexity depends on the controllability and predictability of clinical problems. Additionally, complexity increases or decreases, according to patients' individual resources. CONCLUSIONS: Complex patient situations demand professional expertise, experience, communicative competencies and the ability for reflection. Beginner nurses would benefit from support and advice by experienced nurses to develop these skills.

Development of tools to measure dignity for older people in acute hospitals.

BACKGROUND: Dignity is a concept that applies to all patients. Older patients can be particularly vulnerable to experiencing a loss of dignity in hospital. Previous tools developed to measure dignity have been aimed at palliative and end-of-life care. No tools for measuring dignity in acute hospital care have been reported. OBJECTIVES: To develop tools for measuring patient dignity in acute hospitals. SETTING: A large UK acute hospital. We purposively selected 17 wards where at least 50% of patients are 65 years or above. METHODS: Three methods of capturing data related to dignity were developed: an electronic patient dignity survey (possible score range 6-24); a format for nonparticipant observations; and individual face-to-face semi-structured patient and staff interviews (reported elsewhere). RESULTS: A total of 5,693 surveys were completed. Mean score increased from 22.00 pre-intervention to 23.03 after intervention (p < 0.001). Staff-patient interactions (581) were recorded. Overall 41% of interactions (239) were positive, 39% (228) were neutral, and 20% (114) were negative. The positive interactions ranged from 17%-59% between wards. Quality of interaction was highest for allied health professionals (76% positive), lowest for domestic staff (22% positive) and pharmacists (29% positive), and intermediate for doctors, nurses, healthcare assistants and student nurses (40%-48% positive). A positive interaction was more likely with increased length of interaction from 25% (brief)-63% (longer interactions) (F[2, 557] = 28.67, p < 0.001). CONCLUSIONS: We have developed a simple format for a dignity survey and observations. Overall, most patients reported electronically that they received dignified care in hospital. However, observations identified a high percentage of interactions categorised as neutral/basic care, which, while not actively diminishing dignity, will not enhance dignity. There is an opportunity to make these interactions more positive.