Description and comparison of documentation of nursing assessment between paper-based and electronic systems in Australian aged care homes

PurposeTo describe nursing assessment documentation practices in aged care organizations and to evaluate the quality of electronic versus paper-based documentation of nursing assessment.MethodsThis was a retrospective nursing documentation audit study. Study samples were 2299 paper-based and 6997 electronic resident assessment forms contained in 159 paper-based and 249 electronic resident nursing records, respectively, from three aged care organizations. The practice of nursing assessment documentation in participating aged care homes was described. Three attributes of quality of nursing assessment documentation were evaluated: format and structure, process, and content by seven measures: quantity, completeness, timeliness comprehensiveness, frequencies of documentation specific to care domains and data items, and whether assessment forms were signed and dated.ResultsVarying practice in documentation of nursing assessment was found among different aged care organizations and homes. Electronic resident records contained higher numbers and more comprehensive resident assessment forms than paper-based records. The frequency of documentation was higher in electronic than in paper-based records in relation to most care domains. There was no difference between the two types of documentation systems on other aspects of nursing assessment documentation (overall completeness and timeliness, variation of frequencies among different care domains, and item completion in personal hygiene assessment forms).ConclusionsElectronic nursing documentation systems could improve the quality of documentation structure and format, process and content in the aspects of quantity, comprehensiveness and signing and dating of assessment forms. Further studies are needed to understand the factors leading to the variations of practice and the limitations of nursing assessment documentation and to evaluate documentation quality from a clinical perspective.     

The benefits of introducing electronic health records in residential aged care facilities: A multiple case study

PurposeInformation and communications technology solutions have been introduced into the residential aged care system in order to improve the effectiveness and efficiency of aged care, however to date, the actual benefits have not been systematically analysed. The aim of this study was to identify the benefits of electronic health records (EHR) in residential aged care services and to examine how the benefits have been achieved.MethodA qualitative interview study was conducted in nine residential aged care facilities (RACFs) belonging to three organisations in the Australian Capital Territory (ACT), New South Wales (NSW) and Queensland, Australia. A longitudinal investigation after the implementation of the aged care EHR systems was conducted at two data points: January 2009 to December 2009 and December 2010 to February 2011. Semi-structured interviews were conducted with 110 care staff members selected through theoretical sampling, representing all levels of care staff who worked in those facilities.ResultsThree categories of benefits were perceived by the care staff members according to who gain the benefits: the benefits to individual care staff members, to residents and to the RACFs. The benefits to individual care staff members include an improvement of documentation efficiency, information and knowledge growth as well as empowering the staff; the benefits to residents are an improvement in the quality of individual residents’ health records, the higher quality of care and smoother communication between the residents and aged care staff; the RACFs gain an increased ability to manage information and acquire funding, an increase in their ability to control the care quality and improvements in the working environment and educational benefits. Three factors leading to these benefits were examined: the nature of the aged care EHR systems in comparison with paper-based records; the way the systems were used by the staff and one benefit that could lead to another.ConclusionsIn this study, EHR systems were perceived to have substantial benefits for care staff, residents and the aged care organisations introducing the systems. The benefits were derived from the nature of the aged care EHR systems, staff members’ continuous use of the systems, and one benefit led to the other.     

From a paper-based transmission of discharge summaries to electronic communication in health care regions

OBJECTIVES: In Austria, the general practitioner (GP) is the first point of contact for persons with health problems. Depending on the severity of the person's medical condition, a GP may refer her or him to a secondary care hospital consultant, who reports findings back to the GP in form of a paper-based discharge letter. Researchers report that paper-based communication of medical documents between different health care providers is insufficient in quality, error prone and too slow in many cases. Our aim was to develop and to realise a strategy for a stepwise replacement of the paper-based transmission of medical documents with a distributed, shared medical record. METHODS: In the first step of a three-steps strategy for development of a consistent, comprehensive and secure regional health care network, an electronic communication of discharge letters and diagnostic results between existing information systems of different health care providers in Tyrol, Austria, has been established: in the form of cryptographically signed S/MIME e-mail messages and, additionally, via a secure web portal system. In two further steps, an extension of the system by a bi-directional communication and by improvements of the web portal system is planned, leading to a comprehensive electronic patient record for shared care. RESULTS: After realisation of step 1, in October 2004, about 3500 electronic discharge letters were sent out from the Innsbruck University Hospital (IUH), which represents about 8% of the total number of discharge letters of the IUH. In addition, a lot of feedback was received and legal, organisational, financial and methodical difficulties were overcome. DISCUSSION: The stepwise approach to replace paper-based with electronic communication in the first step was helpful, since knowledge has been gained and cooperations were formed. For the realisation of a distributed, shared medical record (steps 2 and 3), it will not be sufficient only to replace paper-based transmission of medical documents with electronic communication technologies, but in the further steps, organisational changes will become necessary. As well, legal ambiguities must be resolved before a distributed medical record for cooperative care, used by several institutions as well as by patients, could be established.     

Quantifying physical activity in aged residential care facilities: A structured review

BackgroundEngaging aged residential care (ARC) residents with physical activity (PA) may be a useful strategy to decelerate dependence and disability. It is unclear what volume, intensity and patterns of PA ARC residents participate in. This review aims to synthesize the literature to quantify the volume, intensity and pattern of PA that ARC residents participate in across differing care levels (e.g. low, intermediate, high, mixed), and make recommendations for future research.Methods30 studies of 48,760 yielded were reviewed using systematic review strategies.ResultsQuestionnaires and technological tools were used to assess PA, with accelerometers employed in 70% of studies. Overall, studies reported low volumes and intensities of PA across all care levels, and suggested limited variation in patterns of PA (e.g. little day-to-day variation in total PA). There was limited inclusion of people with cognitive impairment, potentially causing representativeness bias. Findings were limited by lack of consistency in methodological approaches and PA outcomes.DiscussionBased on findings and limitations of current research, we recommend that total volume or low-light intensity PA are more useful interventional outcomes than higher-intensity PA. Researchers also need to consider which methodology and PA outcomes are most useful to quantify PA in ARC residents.     

Unintended adverse consequences of introducing electronic health records in residential aged care homes

PurposeThe aim of this study was to investigate the unintended adverse consequences of introducing electronic health records (EHR) in residential aged care homes (RACHs) and to examine the causes of these unintended adverse consequences.MethodA qualitative interview study was conducted in nine RACHs belonging to three organisations in the Australian Capital Territory (ACT), New South Wales (NSW) and Queensland, Australia. A longitudinal investigation after the implementation of the aged care EHR systems was conducted at two data points: January 2009 to December 2009 and December 2010 to February 2011. Semi-structured interviews were conducted with 110 care staff members identified through convenience sampling, representing all levels of care staff who worked in these facilities. Data analysis was guided by DeLone and McLean Information Systems Success Model, in reference with the previous studies of unintended consequences for the introduction of computerised provider order entry systems in hospitals.ResultsEight categories of unintended adverse consequences emerged from 266 data items mentioned by the interviewees. In descending order of the number and percentage of staff mentioning them, they are: inability/difficulty in data entry and information retrieval, end user resistance to using the system, increased complexity of information management, end user concerns about access, increased documentation burden, the reduction of communication, lack of space to place enough computers in the work place and increasing difficulties in delivering care services. The unintended consequences were caused by the initial conditions, the nature of the EHR system and the way the system was implemented and used by nursing staff members.ConclusionsAlthough the benefits of the EHR systems were obvious, as found by our previous study, introducing EHR systems in RACH can also cause adverse consequences of EHR avoidance, difficulty in access, increased complexity in information management, increased documentation burden, reduction of communication and the risks of lacking care follow-up, which may cause negative effects on aged care services. Further research can focus on investigating how the unintended adverse consequences can be mitigated or eliminated by understanding more about nursing staff's work as well as the information flow in RACH. This will help to improve the design, introduction and management of EHR systems in this setting.     

Data quality probes-exploiting and improving the quality of electronic patient record data and patient care

Increasing reliance is being placed on electronic medical records to support clinical care and achieve improved quality standards. In order for clinical information systems (CIS) to deliver excellence the data within it needs to be complete, consistent and accurate. This capture of data is critical but forms only part of the procedure in delivering quality health care during the clinician-patient encounter. A number of processes are involved in this encounter, each of which has to be performed flawlessly to deliver a perfect outcome. This paper outlines a method of assessing the quality of these processes involved in healthcare provision and data quality within a CIS. It proposes the principle of Data Quality Probes (DQP) to assess the performance of the whole encounter system. The main feature of this is the generation of a query which clinical knowledge predicts should not retrieve any cases in a system performing flawlessly. Any cases retrieved (which fail the DQP) indicate an error in either data quality or clinical judgment. This approach is applied practically within the paradigm of a UK family practice testing the hypothesis that a series DQPs can provide a valuable method for monitoring both the data accuracy of a CIS and the provision of quality patient care.     

Medication errors in residential aged care facilities: A distributed cognition analysis of the information exchange process

BackgroundMedication safety is a pressing concern for residential aged care facilities (RACFs). Retrospective studies in RACF settings identify inadequate communication between RACFs, doctors, hospitals and community pharmacies as the major cause of medication errors. Existing literature offers limited insight about the gaps in the existing information exchange process that may lead to medication errors. The aim of this research was to explicate the cognitive distribution that underlies RACF medication ordering and delivery to identify gaps in medication-related information exchange which lead to medication errors in RACFs.MethodsThe study was undertaken in three RACFs in Sydney, Australia. Data were generated through ethnographic field work over a period of five months (May–September 2011). Triangulated analysis of data primarily focused on examining the transformation and exchange of information between different media across the process.ResultsThe findings of this study highlight the extensive scope and intense nature of information exchange in RACF medication ordering and delivery. Rather than attributing error to individual care providers, the explication of distributed cognition processes enabled the identification of gaps in three information exchange dimensions which potentially contribute to the occurrence of medication errors namely: (1) design of medication charts which complicates order processing and record keeping (2) lack of coordination mechanisms between participants which results in misalignment of local practices (3) reliance on restricted communication bandwidth channels mainly telephone and fax which complicates the information processing requirements. The study demonstrates how the identification of these gaps enhances understanding of medication errors in RACFs.ConclusionsApplication of the theoretical lens of distributed cognition can assist in enhancing our understanding of medication errors in RACFs through identification of gaps in information exchange. Understanding the dynamics of the cognitive process can inform the design of interventions to manage errors and improve residents’ safety.     

Variant forms of immunoreactive thyrotropin in aged rats

Immunoreactive thyrotropin, extracted by affinity chromatography from the serum of Fischer 344 male rats and fractionated by gel filtration, is more polymorphic (in terms of molecular weight) in 22- and 30-month-old rats than in younger animals (3- and 12-month-old). Changes in hormonal levels with age involve thyrotropin and thyroxine but not triiodothyronine, serum thyrotropin being significantly decreased at 30 months and thyroxine at 22 and 30 months. Low serum thyroxine levels and increased thyrotropin polymorphism may suggest an impaired pituitary-thyroid axis in aged rats.     

Non-formalin fixative versus formalin-fixed tissue: A comparison of histology and RNA quality

Preanalytical handling of tissue samples can influence bioanalyte quality and ultimately outcome of analytical results. The aim of this study was to compare RNA quality, performance in real time RT PCR and histology of formalin-fixed tissue to that of tissue fixed and stabilized with a formalin-free fixative, the PAXgene Tissue System (PAXgene), in an animal model under highly controlled preanalytical conditions. Samples of rat liver, kidney, spleen, intestine, lung, heart muscle, brain, and stomach tissue were either fixed in formalin or fixed in PAXgene or fresh frozen in liquid nitrogen. RNA was extracted from all samples, examined for integrity in microcapillary electrophoresis, and used in a series of quantitative RT PCR assays with increasing amplicon length. Histology of paraffin-embedded samples was determined by staining with hematoxylin and eosin.     

A comparison of smoking cessation efforts in African Americans by resident physicians in a traditional and primary care internal medicine residency

Tobacco use causes significant morbidity and mortality among African Americans. Physicians may inconsistently counsel patients against smoking. This retrospective chart review evaluated smoking cessation efforts in African Americans by internal medicine resident physicians in a traditional and a primary care residency program. One hundred twenty-nine African-American patients were evaluated by resident physicians in the traditional internal medicine residency. A tobacco use history was obtained in 84 patients. Twenty-eight patients smoked and two patients were counseled against smoking. Fifty-two African-American patients were evaluated by resident physicians in the primary care residency. A tobacco use history was obtained in 47 patients. Twenty patients smoked and 12 patients were counseled against smoking. There was a statistically significant difference in the rate at which smoking histories were obtained (p = 0.0011) and frequency of counseling against smoking (p < 0.0001). Gender analysis revealed that African-American women were less frequently asked about their smoking history (p = 0.0058) and counseled against smoking (p = 0.0016) by resident physicians in the traditional residency. African-American men received less counseling against smoking (p = 0.055) by resident physicians in the traditional residency. Resident physicians in the primary care residency program demonstrated greater smoking cessation efforts for African American patients. Smoking cessation should be emphasized in all internal medicine residency training programs.     

Non-visible versus visible haematuria and bladder cancer risk: a study of electronic records in primary care

Background

Diagnosis of bladder cancer relies on investigation of symptoms presented to primary care, notably visible haematuria. The importance of non-visible haematuria has never been estimated.

Aim

To estimate the risk of bladder cancer with non-visible haematuria.

Design and setting

A case–control study using UK electronic primary care medical records, including uncoded data to supplement coded records.

Method

A total of 4915 patients (aged ≥40 years) diagnosed with bladder cancer between January 2000 and December 2009 were selected from the Clinical Practice Research Datalink and matched to 21 718 controls for age, sex, and practice. Variables for visible and non-visible haematuria were derived from coded and uncoded data. Analyses used multivariable conditional logistic regression, followed by estimation of positive predictive values (PPVs) for bladder cancer using Bayes’ theorem.

Results

Non-visible haematuria (coded/uncoded data) was independently associated with bladder cancer: odds ratio (OR) 20 (95% confidence interval [CI] =12 to 33). The PPV of non-visible haematuria was 1.6% (95% CI = 1.2 to 2.1) in those aged ≥60 years and 0.8% (95% CI = 0.1 to 5.6) in 40–59-year-olds. The PPV of visible haematuria was 2.8% (95% CI = 2.5 to 3.1) and 1.2% (95% CI = 0.6 to 2.3) for the same age groups respectively, lower than those calculated using coded data alone. The proportion of records of visible haematuria in coded, rather than uncoded, format was higher in cases than in controls (P<0.002, χ² test). There was no evidence for such differential recording of non-visible haematuria by case/control status (P = 0.78), although, overall, the uncoded format was preferred (P<0.001).

Conclusion

Both non-visible and visible haematuria are associated with bladder cancer, although the visible form confers nearly twice the risk of cancer compared with the non-visible form. GPs’ style of record keeping varies by symptom and possible diagnosis.     

Attachment and non-maternal care: towards contextualizing the quantity versus quality debate

In this commentary to Friedman's and Boyle's review we focus on the context of early child care as it is reflected in the debate on the effects of quality of care versus amount of care and attachment relations. It is argued that cross-national research should be considered along with the NICHD Study of Early Child Care and Youth Development (SECCYD) in order to promote better understanding of the interface of attachment, child care, and context. In addition, some methodological issues are discussed including the status of the Strange Situation assessment, definition of non-maternal care, and longitudinal correlates of attachment.     

Attachment and non-maternal care: towards contextualizing the quantity versus quality debate

In this commentary to Friedman's and Boyle's review we focus on the context of early child care as it is reflected in the debate on the effects of quality of care versus amount of care and attachment relations. It is argued that cross-national research should be considered along with the NICHD Study of Early Child Care and Youth Development (SECCYD) in order to promote better understanding of the interface of attachment, child care, and context. In addition, some methodological issues are discussed including the status of the Strange Situation assessment, definition of non-maternal care, and longitudinal correlates of attachment.     

An electronic menstrual cycle calendar: comparison of data quality with a paper version

OBJECTIVES: This pilot study compared a prototype electronic menstrual calendar on a handheld computer with a paper calendar for data quality and participants' perceptions. DESIGN: Twenty-three women completed identical information about menstrual bleeding and symptoms using paper and electronic calendars for 1 month each. RESULTS: Use of the paper calendar resulted in more missing data than the electronic calendar for bleeding characteristics (13% vs. 4%) and symptoms (35% vs. 4%). The electronic calendar's ability to log data entries revealed retrospective entry for 61% of the data. Total data entry and cleaning time was reduced by 81% with the electronic calendar. Overall, participants preferred the electronic (70%) to the paper (22%) calendar. CONCLUSIONS: Data quality with conventional paper calendars may be poorer than recognized. The data-logging feature, unique to the electronic calendar, is critical for assessing data quality. Electronic menstrual calendars can be useful data collection tools for research in women's health.     

Designing and evaluating an electronic patient falls reporting system: Perspectives for the implementation of health information technology in long-term residential care facilities

Background and purposePatient falls are the leading cause of unintentional injury and death among older adults. In 2000, falls resulted in over 10,300 elderly deaths, costing the United States approximately $179 million in incidence and medical costs. Furthermore, non-fatal injuries caused by falls cost the United States $19 billion annually. Health information technology (IT) applications, specifically electronic falls reporting systems, can aid quality improvement efforts to prevent patient falls. Yet, long-term residential care facilities (LTRCFs) often do not have the financial resources to implement health IT, and workers in these settings are often not ready to adopt such systems. Additionally, most health IT evaluations are conducted in large acute-care settings, so LTRCF administrators currently lack evidence to support the value of health IT.MethodsIn this paper, we detail the development of a novel, easy-to-use system to facilitate electronic patient falls reporting within a LTRCF using off-the-shelf technology that can be inexpensively implemented in a wide variety of settings. We report the results of four complimentary system evaluation measures that take into consideration varied organizational stakeholders’ perspectives: (1) System-level benefits and costs, (2) system usability, via scenario-based use cases, (3) a holistic assessment of users’ physical, cognitive, and marcoergonomic (work system) challenges in using the system, and (4) user technology acceptance. We report the viability of collecting and analyzing data specific to each evaluation measure and detail the relative merits of each measure in judging whether the system is acceptable to each stakeholder.Results and conclusionsThe electronic falls reporting system was successfully implemented, with 100% reporting at 3-months post-implementation. The system-level benefits and costs approach showed that the electronic system required no initial investment costs aside from personnel costs and significant benefits accrued from user time savings. The usability analysis revealed several fixable design flaws and demonstrated the importance of scenario-based user training. The technology acceptance model showed that users perceived the reporting system to be useful and easy to use, even more so after implementation. Finally, the holistic human factors evaluation identified challenges encountered when nurses used the system as a part of their daily work, guiding further system redesign. The four-pronged evaluation framework accounted for varied stakeholder perspectives and goals and is a highly scalable framework that can be easily applied to health IT implementations in other LTRCFs.     

Ertapenem versus cefepime for initial empirical treatment of pneumonia acquired in skilled-care facilities or in hospitals outside the intensive care unit

The study presented here compared the efficacy and safety of ertapenem and cefepime as initial treatment for adults with pneumonia acquired in skilled-care facilities or in hospital environments outside the intensive care unit (ICU). Non-ventilated patients developing pneumonia in hospital environments outside the ICU, in nursing homes, or in other skilled-care facilities were enrolled in this double-blind non-inferiority study, stratified by APACHE II score (≤15 vs >15) and randomized (1:1) to receive cefepime (2 g every 12 h with optional metronidazole 500 mg every 12 h) or ertapenem (1 g daily). After 3 days of parenteral therapy, participants demonstrating clinical improvement could be switched to oral ciprofloxacin or another appropriate oral agent. Probable pathogens were identified in 162 (53.5%) of the 303 randomized participants. The most common pathogens were Enterobacteriaceae, Streptococcus pneumoniae, and Staphylococcus aureus, isolated from 59 (19.5%), 39 (12.9%), and 35 (11.6%) participants, respectively. At the test-of-cure assessment 7–14 days after completion of all study therapy, pneumonia had resolved or substantially improved in 89 (87.3%) of 102 clinically evaluable ertapenem recipients and 80 (86%) of 93 clinically evaluable cefepime recipients (95% confidence interval for the difference, −9.4 to 11.8%), fulfilling pre-specified criteria for statistical non-inferiority. The frequency and severity of drug-related adverse events were generally similar in both treatment groups. In this study population, ertapenem was as well-tolerated and efficacious as cefepime for the initial treatment of pneumonia acquired in skilled-care facilities or in hospital environments outside the ICU.