Taxonomy of Interventions to Reduce Acute Care Transfers From Long-term Care Homes: A Systematic Scoping Review.

OBJECTIVE: To develop a taxonomy of interventions aimed at reducing emergency department (ED) transfers and/or hospitalizations from long-term care (LTC) homes. DESIGN: A systematic scoping review. SETTING AND PARTICIPANTS: Permanent LTC home residents. METHODS: Experimental and comparative observational studies were searched in MEDLINE, CINAHL, Embase Classic + Embase, the Cochrane Library, PsycINFO, Social Work Abstracts, AMED, Global Health, Health and Psychosocial Instruments, Joanna Briggs Institute EBP Database, Ovid Healthstar, and Web of Science Core Collection from inception until March 2020. Forward/backward citation tracking and gray literature searches strengthened comprehensiveness. The Mixed Methods Appraisal Tool was used to assess study quality. Intervention categories and components were identified using an inductive-deductive thematic analysis. Categories were informed by 3 intervention dimensions: (1) "when/at what point(s)" on the continuum of care they occur, (2) "for whom" (ie, intervention target resident populations), and (3) "how" these interventions effect change. Components were informed by the logistical elements of the interventions having the potential to influence outcomes. All interventions were mapped to the developed taxonomy based on their categories, components, and outcomes. Distributions of components by category and study year were graphically presented. RESULTS: Ninety studies (25 randomized, 23 high quality) were included. Six intervention categories were identified: advance care planning; palliative and end-of-life care; onsite care for acute, subacute, or uncontrolled chronic conditions; transitional care; enhanced usual care (most prevalent, 31% of 90 interventions); and comprehensive care. Four components were identified: increasing human resource capacity (most prevalent, 93%), training or reorganization of existing staff, technology, and standardized tools. The use of technology increased over time. Potentially avoidable ED transfers and/or hospitalizations were measured infrequently as primary outcomes. CONCLUSIONS AND IMPLICATIONS: This proposed taxonomy can guide future intervention designs. It can also facilitate systematic reviews and precise effect size estimations for homogenous interventions when outcomes are comparable.

A long-term care center interdisciplinary education program for antipsychotic use in dementia: program update five years later.

BACKGROUND: While antipsychotic (AP) medications are frequently used in long-term care, current evidence suggests that the risks may offset the benefits, necessitating periodic reassessment of their use. The aims of this present study were: (1) to assess rates of AP use five years after our first intervention to determine the long-term impact; and (2) to implement an updated AP reduction educational intervention program at the same center five years later in order to determine whether AP use could be further reduced. METHODS: Participants were residents with dementia receiving AP medication. The educational program component included separate lectures on pharmacologic and non-pharmacologic treatment of behavioral and psychological symptoms of dementia (BPSD). Completion of the Nursing Home Behavior Problems Scale (NHBPS), physician interviews concerning AP treatment plans for subjects with dementia, and AP administration and dose assessment occurred both at baseline and again between four to five months after the educational program. RESULTS: Of 308 long-term residents with dementia, 53 (17.2%) were receiving regular APs, primarily for agitation, aggressivity, other behavioral problems and psychosis. Of these, six died and one was transferred, leaving 46 participants. At five months, ten (21.7%) residents were no longer receiving APs and seven (15.2%) were on a lower dose; thus, 17 (37.0%) were either discontinued or on a lower dose. There was no worsening of NHBPS scores. CONCLUSION: Despite the low prevalence (17.2%) of AP users at the beginning of the current study compared to that observed five years prior (30.5%), it is still possible to further decrease the proportion of users.

Educating nursing home staff about the progression of dementia and the comfort care option: impact on family satisfaction with end-of-life care.

OBJECTIVE: There is a growing consensus on the relevance of a palliative care approach in end-stage dementia. The objective of this study was to assess the impact, in terms of family satisfaction with end-of-life care, of a nursing home (NH) pilot educational program for nursing staff and physicians on comfort care and advanced dementia. METHODS: The intervention, implemented in one voluntary NH, consisted of an educational program that included providing an information booklet to all NH staff, and optionally to families. Satisfaction with care was compared using a validated instrument, the "After death bereaved family member interview" pre- and post-intervention. Pre and post groups were composed of close relatives of residents who died in the context of advanced dementia. RESULTS: Twenty-seven contact persons were interviewed pre-intervention and 21 post-intervention (participation rate of 60% for both groups). Descriptive statistics showed better scores on satisfaction with pain control, emotional support, treating patient with respect, and information on what to expect while patient was dying, in the post-intervention group. Comparison of overall scale scores revealed no statistical differences between the 2 groups, although the post-intervention group expressed greater satisfaction in the area of communication with the health care team (8.0 versus 6.6, P = .109) and greater global satisfaction with care (8.3 versus 7.3, P = .087). DISCUSSION: Although not significant, results as to the effectiveness of such an intervention to improve family satisfaction with end-of-life care are encouraging. CONCLUSION: The booklet, as support tool, and the educational program may have facilitated communication within the team, and between the team and family members. Replication of this intervention in a multicenter NH population is needed to adequately assess its effectiveness.

Identifying black swans in NextGen: predicting human performance in off-nominal conditions.

OBJECTIVE: The objective is to validate a computational model of visual attention against empirical data--derived from a meta-analysis--of pilots' failure to notice safety-critical unexpected events. BACKGROUND: Many aircraft accidents have resulted, in part, because of failure to notice nonsalient unexpected events outside of foveal vision, illustrating the phenomenon of change blindness. A model of visual noticing, N-SEEV (noticing-salience, expectancy, effort, and value), was developed to predict these failures. METHOD: First, 25 studies that reported objective data on miss rate for unexpected events in high-fidelity cockpit simulations were identified, and their miss rate data pooled across five variables (phase of flight, event expectancy, event location, presence of a head-up display, and presence of a highway-in-the-sky display). Second, the parameters of the N-SEEV model were tailored to mimic these dichotomies. RESULTS: The N-SEEV model output predicted variance in the obtained miss rate (r = .73). The individual miss rates of all six dichotomous conditions were predicted within 14%, and four of these were predicted within 7%. CONCLUSION: The N-SEEV model, developed on the basis of an independent data set, was able to successfully predict variance in this safety-critical measure of pilot response to abnormal circumstances, as collected from the literature. APPLICATIONS: As new technology and procedures are envisioned for the future airspace, it is important to predict if these may compromise safety in terms of pilots' failing to notice unexpected events. Computational models such as N-SEEV support cost-effective means of making such predictions.

Effect of an interdisciplinary educational program on antipsychotic prescribing among nursing home residents with dementia.

OBJECTIVE: To assess the effect of an interdisciplinary educational program in reducing the use of antipsychotics in nursing home residents with dementia. METHODS: We conducted a longitudinal pilot study to test the implementation of a 7-month interdisciplinary educational program in a fixed cohort of residents with dementia receiving antipsychotics. The program included consciousness-raising, educational sessions, and clinical follow-up. Administrators, physicians, pharmacists, nursing staff, and personal care attendants were involved. The effect of the program was assessed over a 6-month period, in terms of the proportion of discontinuations and dose reductions of antipsychotics. Repeated measures for use of other psychotropics and restraints, frequency of disruptive behaviors, and stressful events experienced by nursing staff and personal care attendants were simultaneously assessed. RESULTS: Among the 81 residents still present at the end of the program, there were 40 (49.4%) discontinuations and 11 (13.6%) dose reductions. No significant changes were found in the use of other psychotropics, the use of restraints, or in the number of stressful events experienced by nursing staff and personal care attendants. The frequency of disruptive behaviors decreased significantly over the 6-month period (p<0.001). CONCLUSIONS: Our interdisciplinary educational program led to a substantial reduction in the number of residents receiving antipsychotics and to a decrease in the frequency of disruptive behaviors. Our findings suggest that implementation of recognized practice guidelines could be an effective way to target residents who might not benefit from antipsychotics or who may tolerate a dose reduction.

A flowchart system to improve fall data documentation in a long-term care institution: a pilot study.

BACKGROUND: Falls are an important cause of morbidity and mortality in older people. In many long-term care (LTC) institutions, current practice focuses only on the injury consequences with a lack in the assessment of main risk factors, characteristics of the fall episode, and secondary prevention. OBJECTIVES: To document current practice in our center and to determine whether implementation of a flowchart system may improve fall data documentation. METHODS: A flowchart system with an ad hoc form was designed to advise on falls characteristics, post-fall risk factors identification, and appropriate referral. Educational sessions explaining the rationale for the flowchart system were given before the implementation of the system. An audit was conducted on incident report data in order to register the fall data documentation in our facility. The audit was repeated 2 months after implementation of the flowchart system. RESULTS: There were 107 incident reports audited before and after the implementation of the flowchart system. Seven observations were excluded. Average age of the participants with falls was 82.7 (SD: 3) and 53% of the participants had dementia. Comparisons between the first and second audit revealed significance differences in the history of previous falls (95% vs 35%, P < .001), the place of fall (89% vs 32%, P < .002). After the implementation new information not previously gathered, such as polypharmacy prevalence, use of benzodiazepines and psychotropic medication, and potential etiologies and contributors of the falls episodes were obtained. CONCLUSION: After the introduction of the flowchart system, documentation of risk factors and characteristics of fall episodes have improved significantly and referrals to a geriatrician for falls evaluation have significantly increased. The process of education and implementation of a flowchart system with an ad hoc form improved data documentation performed following a fall. This simple strategy could help the development of falls prevention program in the nursing home.

Enteral feeding in end-stage dementia: a comparison of religious, ethnic, and national differences in Canada and Israel.

BACKGROUND: Although enteral feeding in end-stage dementia is thought by many clinicians to be "futile," it is still widely used. We examined rates of tube feeding (gastrostomy or nasogastric) in end-stage dementia in hospitals in both Canada and Israel, and hypothesized that Canadian non-Jewish affiliated hospitals would have the lowest (and Israeli institutions the highest), with Canadian Jewish hospitals exhibiting intermediate rates. METHODS: We conducted a cross-sectional survey of six geriatric long-term hospitals: two in Israel and four in Canada (two Jewish affiliated, two not; two in Ontario, two in Quebec province). Patients with end-stage dementia were assessed and further analyzed for type of feeding. RESULTS: In the six hospitals, 2287 long-term beds were surveyed, of which 1358 (59.4%) were used by demented patients of whom 376 (27.7%) were severely demented (Global Deterioration Scale-level 7). Of these, 24.5% (92) were fed by nasogastric tube or gastrostomy tube. Significant differences in tube-feeding prevalence were found between Canada (11%) and Israel (52.9%), with only 4.7% seen in non-Jewish Canadian institutions. Jewish affiliated hospitals in Canada exhibited an intermediate rate of 19.6%. However, for within-country dyads, wide differences were also found. When we examined patient religion, we found that Canadian non-Jewish patients had the lowest rates (3.2%), Israeli Jewish patients the highest (51.7%), and Canadian Jewish patients exhibited an intermediate rate (19.0%) of tube use. CONCLUSIONS: Despite reservations concerning its utility, feeding tube use is reasonably widespread in patients who have reached the stage of severe dementia. Canadian institutions exhibited a lower prevalence of feeding tube use than did Israeli hospitals. Between-country and between-province differences in practice may be explained by some combination of administrative and/or financial incentives, religion, and culture; within-country and within-ethnic group differences may be caused, at least in part, by differing institutional cultures.

Human performance cognitive-behavioral modeling: a benefit for occupational safety.

Human Performance Modeling (HPM) is a computer-aided job analysis software methodology used to generate predictions of complex human-automation integration and system flow patterns with the goal of improving operator and system safety. The use of HPM tools has recently been increasing due to reductions in computational cost, augmentations in the tools' fidelity, and usefulness in the generated output. An examination of an Air Man-machine Integration Design and Analysis System (Air MIDAS) model evaluating complex human-automation integration currently underway at NASA Ames Research Center will highlight the importance to occupational safety of considering both cognitive and physical aspects of performance when researching human error.