End-of-life care pathways for improving outcomes in caring for the dying (Protocol)

We aim to assess the effects of end-of-life care pathways, compared with usual care or with care guided by another end-of-life care pathway across all healthcare settings (hospitals, residential aged care facilities, community). In particular, we aim to assess the effects on symptom severity and quality of life of people who are dying and/or those related to the care such as families, caregivers and health professionals.

End-of-life care pathways for improving outcomes in caring for the dying (Review)

Background In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans which detail essential steps in caring for patients with specific clinical problems. Particularly, care pathways for the dying have been developed as a model to improve the end-of-life care of all patients. They aim to ensure that the most appropriate management occurs at the most appropriate time and that it is provided by the most appropriate health professional. Clinical pathways for end-of-life care management are used widely around the world and have been regarded as the gold standard. Therefore, there is a significant need for clinicians to be informed about the utilisation of end-of-life care pathways with a systematic review. Objectives To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community). Search strategy The Cochrane Register of controlled Trials (CENTRAL), the Pain, Palliative and Supportive Care Review group specialised register,MEDLINE, EMBASE, review articles and reference lists of relevant articles were searched. The search was carried out in September 2009. Selection criteria All randomised controlled trials (RCTs), quasi-randomised trial or high quality controlled before and after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying. Data collection and analysis Results of searches were reviewed against the pre-determined criteria for inclusion by two review authors. Main results The search identified 920 potentially relevant titles, but no studies met criteria for inclusion in the review. Authors’ conclusions Without further available evidence, recommendations for the use of end-of-life pathways in caring for the dying cannot be made. RCTs or other well designed controlled studies are needed for evaluating the use of end-of-life care pathways in caring for dying people.

Malnutrition and pressure ulcer risk in adults in Australian health care facilities

Aims To determine the effect of nutritional status on the presence and severity of pressure ulcers in statewide? public healthcare facilities, in Queensland, Australia. Research Methods A multicentre, cross sectional audit of nutritional status of a convenience sample of subjects was carried out as part of a large audit of pressure ulcers in a sample of state based public healthcare facilities in 2002 and 2003. Dietitians in 20 hospitals and six residential aged care facilities conducted single day nutritional status audits of 2208 acute and 839 aged care subjects using the Subjective Global Assessment. The effect of nutritional status on the presence, highest stage and number of pressure ulcers was determined by logistic regression in a model controlling for age, gender, medical specialty and facility location. The potential clustering effect of facility was accounted for in the model using an analysis of correlated data approach. Results Subjects with malnutrition had an adjusted odds risk of 2.6 (95% CI 1.8-3.5, p<0.001) of having a pressure ulcer in acute facilities and 2.0 (95% CI 1.5-2.7, p<0.001) for residential aged care facilities. There was also increased odds risk of having a pressure ulcer, having a higher stage pressure ulcer and a higher number of pressure ulcers with increased severity of malnutrition. Conclusion Malnutrition was associated with at least twice the odds risk of having a pressure ulcer of in public healthcare facilities in Queensland. Action must be taken to identify, prevent and treat malnutrition, especially in patients at risk of pressure ulcer.

Empirical derivation and validation of a wandering typology

OBJECTIVES: To develop and validate a wandering typology. ---------- DESIGN: Cross-sectional, correlational descriptive design. ---------- SETTING:: Twenty-two nursing homes and six assisted living facilities. ---------- PARTICIPANTS: One hundred forty-two residents with dementia who spoke English, met Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, criteria for dementia, scored less than 24 on the Mini-Mental State Examination (MMSE), were ambulatory (with or without assistive device), and maintained a stable regime of psychotropic medications were studied. ---------- MEASUREMENTS: Data on wandering were collected using direct observations, plotted serially according to rate and duration to yield 21 parameters, and reduced through factor analysis to four components: high rate, high duration, low to moderate rate and duration, and time of day. Other measures included the MMSE, Minimum Data Set 2.0 mobility items, Cumulative Illness Rating Scale—Geriatric, and tympanic body temperature readings. ---------- RESULTS: Three groups of wanderers were identified through cluster analysis: classic, moderate, and subclinical. MMSE, mobility, and cardiac and upper and lower gastrointestinal problems differed between groups of wanderers and in comparison with nonwanderers. ---------- CONCLUSION: Results have implications for improving identification of wanderers and treatment of possible contributing factors.

Establishing content validity of a survey research instrument : the older patients in acute care survey - United States

Geriatric nursing competency in the acute care setting is a social mandate for the 21st century. This article reports on the content validation of an Australian research instrument, the Older Patients in Acute Care Survey (OPACS) that examines the attitudes, the knowledge, and the practices of nurses working with acute care patients. The OPACS tool was developed primarily to assist nurse educators to assess attitudes, knowledge, and practices of nursing staff in caring for older patients in the acute care setting; to evaluate the implementation of institution-specific educational interventions; and to improve quality of care given to older patients. An overall content validity index (CVI) for the OPACS was calculated (CVI = .918), revealing high content validity. Opinions (CVI = .92) and practices (CVI = .97) subconstructs revealed high content validity as well. Therefore, results indicate that the OPACS has high content validity in the U.S. acute care setting and could assist nurse educators in establishing and enhancing nurse competency in the care for geriatric patients in the future.

Estimates of crowding in long-term care: Comparing two approaches

Objective: Because studies of crowding in long-term care settings are lacking, the authors sought to: (1) generate initial estimates of crowding in nursing homes and assisted living facilities; and (2) evaluate two operational approaches to its measurement. ----- ----- Background: Reactions to density and proximity are complex. Greater density intensifies people's reaction to a situation in the direction (positive or negative) that they would react if the situation were to occur under less dense conditions. People with dementia are especially reactive to the environment. ----- ----- Methods: Using a cross-sectional correlational design in nursing homes and assisted living facilities involving 185 participants, multiple observations (N = 6,455) of crowding and other environmental variables were made. Crowding, location, and sound were measured three times per observation; ambiance was measured once. Data analyses consisted of descriptive statistics, t-tests, and one-way analysis of variance. ----- ----- Results: Crowding estimates were higher for nursing homes and in dining and activity rooms. Crowding also varied across settings and locations by time of day. Overall, the interaction of location and time affected crowding significantly (N = 5,559, df [47, 511], F = 105.69, p < .0001); effects were greater within location-by-hour than between location-by-hour, but the effect explained slightly less variance in Long-Term Care Crowding Index (LTC-CI) estimates (47.41%) than location alone. Crowding had small, direct, and highly significant correlations with sound and with the engaging subscale for ambiance; a similar, though inverse, correlation was seen with the soothing subscale for ambiance. ----- ----- Conclusions: Crowding fluctuates consistent with routine activities such as meals in long-term care settings. Furthermore, a relationship between crowding and other physical characteristics of the environment was found. The LTC-CI is likely to be more sensitive than simple people counts when seeking to evaluate the effects of crowding on the behavior of elders-particularly those with dementia-in long-term care settings. aging in place.

A national roll out of an insufficiently evaluated practice : how evidence based are our end-of-life care policies?

There has been increasing international efforts to ensure that health care policies are evidence based. One area where there is a lack of ‘effectiveness’ evidence is in the use of end-of-life care pathways (EOLCP) (1). Despite the lack of evidence supporting the efficacy of the EOCLP, their use has been endorsed in the recent national palliative care strategy document in the UK (2). In addition, a publication endorsed by the Australian Government (titled: Supporting Australians to live well at the End of Life- National Palliative Care Strategy 2010) (3), recommended a national roll out of EOLCP across all sectors (primary, acute and aged care) in Australia. According to this document, it is a measure of “appropriateness” and “effectiveness” for promoting quality end-of-life care.

A Cochrane review on the effects of end-of-life care pathways : do they improve patient outcomes?

Clinical pathways for end-of-life care management are used widely around the world and have been regarded as the gold standard. The aim of this review was to assess the effects of end-of-life care pathways (EOLCP), compared with usual care (no pathway) or with care guided by a different end-of-life care pathway, across all healthcare settings (e.g. hospitals, residential aged care facilities, community). We searched the Cochrane Register of Controlled Trials (CENTRAL), the Pain, Palliative and Supportive Care Review group specialised register, MEDLINE, EMBASE, review articles and reference lists of relevant articles. The search was carried out in September 2009. All randomised controlled trials (RCTs), quasi-randomised trials or high quality controlled before and after studies comparing use versus non-use of an EOLCP in caring for the dying were considered for inclusion. The search identified 920 potentially relevant titles, but no studies met criteria for inclusion in the review. Without further available evidence, recommendations for the use of end-of-life pathways in caring for the dying cannot be made. There are now recent concerns regarding the big scale roll-out of EOLCP despite the lack of evidence, nurses should report any safety concerns or adverse effects associated with such pathways.

The development of a program to assist international nursing students to be prepared for clinical practice in the Australian health care context

Health education in Western Countries has grown considerably in the last decade and this has occurred for a number of reasons. Specifically Universities actively recruit International students as the health workforce becomes global; also it is much easier for students to move and study globally. Internationally there is a health workforce shortage and if students gain a degree in a reputable university their ability to work globally is improved significantly. However, when studying to practice in the health care field the student must undertake clinical practice in an acute or aged care setting. This can be a significant problem for students who are culturally and linguistically diverse in an English speaking country such as Australia. The issues that can arise stem from the language differences where communication, interpretation understanding and reading the cultural norms of the health care setting are major challenges for International students. To assist international students to be successful in their clinical education, an extra curriculum workshop program was developed to provide additional support. The program which runs twice each year includes on-campus interactive workshops that are complemented by targeted support provided for students and clinical staff who are supervising students’ practice experience in the workplace. As this is an English speaking country the workshop is based on practicing reading, writing, listening and speaking, as well as exploring basic health care concepts and cultural differences. This enables students to gain knowledge of and practice interpretation of cultural norms and expectations in a safe environment. This innovative series of interactive workshops in a highly student-centred learning environment combine education with role play and discussion with peers who are supported by culturally aware and competent Educators. Over the years it has been running, the program has been undertaken by an increasing number of students. In 2011, more than 100 students are expected to participate. Student evaluation of the program has confirmed that it has assisted the majority of them to be successful in their clinical studies. Effectiveness of the project is measured throughout the program and in follow up sessions. This ongoing information allows for continuous development of the program that serves to meet individual needs of the International student, the University and Service providers such as the hospitals. This feedback from students regarding their increased comprehension of the Australian colloquial Language, healthcare terminology, critical thinking and clinical skill development and a cultural awareness also enables them to maintain their feelings of self confidence and self esteem.

A prospective cohort study of geriatric syndromes among older medical patients admitted to acute care hospitals

OBJECTIVES: To identify the prevalence of geriatric syndromes in the premorbid for all syndromes except falls (preadmission), admission, and discharge assessment periods and the incidence of new and significant worsening of existing syndromes at admission and discharge. DESIGN: Prospective cohort study. SETTING: Three acute care hospitals in Brisbane, Australia. PARTICIPANTS: Five hundred seventy-seven general medical patients aged 70 and older admitted to the hospital. MEASUREMENTS: Prevalence of syndromes in the premorbid (or preadmission for falls), admission, and discharge periods; incidence of new syndromes at admission and discharge; and significant worsening of existing syndromes at admission and discharge. RESULTS: The most frequently reported premorbid syndromes were bladder incontinence (44%), impairment in any activity of daily living (ADL) (42%). A high proportion (42%) experienced at least one fall in the 90 days before admission. Two-thirds of the participants experienced between one and five syndromes (cognitive impairment, dependence in any ADL item, bladder and bowel incontinence, pressure ulcer) before, at admission, and at discharge. A majority experienced one or two syndromes during the premorbid (49.4%), admission (57.0%), or discharge (49.0%) assessment period.The syndromes with a higher incidence of significant worsening at discharge (out of the proportion with the syndrome present premorbidly) were ADL limitation (33%), cognitive impairment (9%), and bladder incontinence (8%). Of the syndromes examined at discharge, a higher proportion of patients experienced the following new syndromes at discharge (absent premorbidly): ADL limitation (22%); and bladder incontinence (13%). CONCLUSION: Geriatric syndromes were highly prevalent. Many patients did not return to their premorbid function and acquired new syndromes.

Telehealth for nursing homes: the utilization of specialist services for residential care

Specialist care consultations were identified by two research nurses using documentation in patient records, appointment diaries, electronic billing services and on-site observations at a 441-bed long term care facility. Over a six-month period there were 3333 consultations (a rate of 1511 consultations per year per 100 beds). Most consultations were for general practice (n = 2589, 78%); these consultations were mainly on site (99%), with only 27 taking place off site. There were 744 consultations for specialities other than general practice. A total of 146 events related to an emergency or unplanned hospital admission. The remaining medical consultations (n = 598, 18%) related to 23 medical specialities. The largest number of consultations were for surgery (n = 106), podiatry (n = 100), nursing services including wound care (n = 74), imaging (n = 41) and ophthalmology (n = 40). Many services which are currently being provided on site to metropolitan long-term care facilities could be provided by telehealth in both urban and rural facilities.

A Survey-based Study of Knowledge of Alzheimer's Disease among Health Care Staff

Background Continued aging of the population is expected to be accompanied by substantial increases in the number of people with dementia and in the number of health care staff required to care for them. Adequate knowledge about dementia among health care staff is important to the quality of care delivered to this vulnerable population. The purpose of this study was to assess knowledge about dementia across a range of health care staff in a regional health service district. Methods Knowledge levels were investigated via the validated 30-item Alzheimer's Disease Knowledge Scale (ADKS). All health service district staff with e-mail access were invited to participate in an online survey. Knowledge levels were compared across demographic categories, professional groups, and by whether the respondent had any professional or personal experience caring for someone with dementia. The effect of dementia-specific training or education on knowledge level was also evaluated. Results A diverse staff group (N = 360), in terms of age, professional group (nursing, medicine, allied health, support staff) and work setting from a regional health service in Queensland, Australia responded. Overall knowledge about Alzheimer's disease was of a generally moderate level with significant differences being observed by professional group and whether the respondent had any professional or personal experience caring for someone with dementia. Knowledge was lower for some of the specific content domains of the ADKS, especially those that were more medically-oriented, such as 'risk factors' and 'course of the disease.' Knowledge was higher for those who had experienced dementia-specific training, such as attendance at a series of relevant workshops. Conclusions Specific deficits in dementia knowledge were identified among Australian health care staff, and the results suggest dementia-specific training might improve knowledge. As one piece of an overall plan to improve health care delivery to people with dementia, this research supports the role of introducing systematic dementia-specific education or training.

Appraisal of the quality of care of older people with cognitive impairment presenting to emergency departments

The medical records of 273 patients 75 years and older were reviewed to evaluate quality of emergency department (ED) care through the use of quality indicators. One hundred fifty records contained evidence of an attempt to carry out a cognitive assessment. Documented evidence of cognitive impairment (CI) was reported in 54 cases. Of these patients, 30 had no documented evidence of an acute change in cognitive function from baseline; of 26 patients discharged home with preexisting CI (i.e., no acute change from baseline), 15 had no documented evidence of previous consideration of this issue by a health care provider; and 12 of 21 discharged patients who screened positive for cognitive issues for the first time were not referred for outpatient evaluation. These findings suggest that the majority of older adults in the ED are not receiving a formal cognitive assessment, and more than half with CI do not receive quality of care according to the quality indicators for geriatric emergency care. Recommendations for improvement are discussed.

Exploring the effect of companion robots on emotional expression in older people with dementia : a pilot randomized controlled trial

This pilot study aimed to compare the effect of companion robots (PARO) to participation in an interactive reading group on emotions in people living with moderate to severe dementia in a residential care setting. A randomized crossover design, with PARO and reading control groups, was used. Eighteen residents with mid- to late-stage dementia from one aged care facility in Queensland, Australia, were recruited. Participants were assessed three times using the Quality of Life in Alzheimer’s Disease, Rating Anxiety in Dementia, Apathy Evaluation, Geriatric Depression, and Revised Algase Wandering Scales. PARO had a moderate to large positive influence on participants’ quality of life compared to the reading group. The PARO intervention group had higher pleasure scores when compared to the reading group. Findings suggest PARO may be useful as a treatment option for people with dementia; however, the need for a larger trial was identified.