Nursing Home Residents’ Functional Trajectories and Mortality After a Transfer to the Emergency Department

ObjectiveTo describe nursing home residents’ (NHRs) functional trajectories and mortality after a transfer to the emergency department (ED).DesignCase-control observational multicenter study.Setting and ParticipantsIn total, 1037 NHRs presenting to 17 EDs in France over 4 nonconsecutive weeks in 2016.MethodsFinite mixture models were fitted to longitudinal data on activities of daily living (ADL) scores before transfer (time 1), during hospitalization (time 2), and within 1 week after discharge (time 3) to identify groups of NHRs following similar functional evolution. Factors associated with mortality were investigated by Cox regressions.ResultsTrajectory modeling identified 4 distinct trajectories of ADL. The first showed a high and stable (across time 1, time 2, and time 3) functional capacity around 5.2/6 ADL points, with breathlessness as the main condition leading to transfer. The second displayed an initial 37.8% decrease in baseline ADL performance (between time 1 and time 2), followed by a 12.5% recovery of baseline ADL performance (time 2?time 3), with fractures as the main condition. The third displayed a similar initial decrease, followed by a 6.7% recovery. The fourth displayed an initial 70.1% decrease, followed by an 8.5% recover, with more complex geriatric polypathology situations. Functional decline was more likely after being transferred for a cerebrovascular condition or for a fracture, after being discharged from ED to a surgery department, and with a heavier burden of distressing symptoms during transfer. Mortality after ED transfer was more likely in older NHRs, those in a more severe condition, those who were hospitalized more frequently in the past month, and those transferred for cerebrovascular conditions or breathlessness.Conclusions and ImplicationsIdentified trajectories and factors associated with functional decline and mortality should help clinicians decide whether to transfer NHRs to ED. NHRs with high functional ability seem to benefit from ED transfers whereas on-site alternatives should be sought for those with poor functional ability.     

Nurse Decision-making for Suspected Urinary Tract Infections in Nursing Homes: Potential Targets to Reduce Antibiotic Overuse

ObjectivesTo determine what information is most important to registered nurses' (RNs) decisions to call clinicians about suspected urinary tract infections (UTIs) in nursing home residents.DesignWeb-based discrete choice experiment with 19 clinical scenarios.Setting and ParticipantsOnline survey with a convenience sample of RNs (N = 881) recruited from a health care research panel.MethodsClinical scenarios used information from 10 categories of resident characteristics: UTI risk, resident type, functional status, mental status, lower urinary tract status, body temperature, physical examination, urinalysis, antibiotic request, and goals of care. Participants were randomized into 2 deliberation conditions (self-paced, n = 437 and forced deliberation, n = 444). The degree to which evidence- and non–evidence-based information was important to decision-making was estimated using unconditional multinomial logistic regression.ResultsFor all nurses (22.8%) and the self-paced group (24.1%), lower urinary tract status had the highest importance scores for the decision to call a clinician about a suspected UTI. For the forced-deliberation group, body temperature was most important (23.7%), and lower urinary tract status was less important (21%, P = .001). The information associated with the highest odds of an RN calling about a suspected UTI was painful or difficult urination [odds ratio (OR) 4.85, 95% confidence interval (CI) 4.16–5.65], obvious blood in urine (OR 4.66, 95% CI 3.99–5.44), and temperature at 101.5° (OR 3.80, 95% CI 3.28–4.42). For the self-paced group, painful or difficult urination (OR 5.65, 95% CI 4.53–7.04) had the highest odds, whereas obvious blood in urine (OR 4.39, 95% CI 3.53–5.47) had highest odds for the forced-deliberation group.Conclusions and ImplicationsThis study highlighted the importance of specific resident characteristics in nurse decision-making about suspected UTIs. Future antimicrobial stewardship efforts should aim to not only improve the previously studied overprescribing practices of clinicians, but to improve nurses' assessment of signs and symptoms of potential infections and how they weigh resident information.     

自我角色认同护理在躁狂症护理中的应用效果分析

目的探讨自我角色认同护理在躁狂症中的应用效果。方法选取2017-2019年沈阳市铁西区精神卫生中心收治的成人躁狂症发作期患者50例,随机分为对照组和干预组各25例。对照组给予常规护理,干预组给予自我角色认同护理。分别采用激越行为量表和社交技能量表对两组的干预效果进行评价。结果干预后两组激越行为量表和社交技能评定目录量表各维度评分及总分差异均有统计学意义(P<0.05)。结论自我角色认同护理能进一步改善躁狂症患者的激越行为和社交技能,值得临床推广应用。     

慢性病护理质量评价指标体系研究现状及启示

对国内外慢性病护理质量评价指标体系构建的理论框架、方法以及构建范围进行归纳总结,认为我国慢性病护理质量评价指标体系中应加强对患者结局指标的关注,应注意指标体系构建方法的科学性,还应积极探索多病种慢性病护理质量评价指标体系,构建统一的适合我国国情的慢性病护理质量评价指标体系。     

基于分级诊疗的“互联网+护理服务”模式探索

“互联网+护理服务”是满足居家患者服务需求的主要形式之一。以分级诊疗为基础,依托“互联网医院”平台,初步探索构建了医联体内“互联网+护理服务”模式。认为基于分级诊疗的“互联网+护理服务”模式能够满足患者延续性护理服务需求,保障患者享受同质化护理服务,促使护理资源合理分配和有效利用。     

血液病专科护士培养模式构建

目的构建血液病专科护士培养模式,为提高血液病专科护士能力提供参考。方法检索专科护士培养的国内外文献及政策法规,对1 792名血液科护士及6名专家进行问卷调查,获取血液病专科护士培养需求及建议,构建血液病专科护士培养模式草案,针对草案邀请15名专家进行两轮Deiphi专家函询,确定血液病专科护士培养模式各级指标及权重。结果两轮函询专家积极系数均为100%,权威系数为0.83,肯德尔协调系数为0.24（P＜0.05）,专家意见趋于一致。经两轮函询,最终形成包含7个一级指标、31个二级指标、111个三级指标的血液病专科护士培养模式。结论本研究构建的血液病专科护士培养模式科学、可靠,对于血液病专科护士的培养具有指导意义。     

项目管理在管道护理中的实践效果评价

留置导管在为患者缓解症状的同时,也带来了非计划性拔管、导管相关性感染等问题。2015年-2018年,南方医科大学南方医院护理部组织全院各护理单元,围绕非计划性拔管、导管相关性感染和其他管路并发症三方面,从项目启动、计划、实施、控制和收尾5大阶段展开项目管理专项活动。项目管理专项活动实施以来,全院共上报管道护理项目36项,开展25项,非计划性拔管、导管相关性感染及其他并发症分别开展12项、4项和9项;非计划性拔管率、导管相关性感染发生率降低;共制定9项管道护理相关流程和指引,7个管道护理视频;护理人员工作满意度和团队凝聚力提高（P＜0.001）。下一步尝试在项目管理中引入叙事医学和磁性护理元素。     

Implementation of Goals of Care Communication Innovation Among Nursing Homes: A Multiple Case Study Design

ObjectiveNursing homes (NHs) provide care to residents with serious illness and related complex health care needs. As such, discussions about end-of-life care between NH staff and residents and families are necessary to ensure residents receive care consistent with their goals. Interventions such as video decision aids have been developed to promote discussions and improve advance care planning, but few studies have examined how NH characteristics may relate to the implementation of these interventions; such information might lead toward more use of successful interventions. The purpose of this study is to understand NH characteristics that are associated with the implementation of the Goals of Care (GOC) intervention, which combined a video decision aid with a structured discussion to guide decision-making in advanced dementia.DesignA multiple case study.Setting and ParticipantsStaff surveys were conducted to examine factors related to implementation effectiveness in 11 NHs in North Carolina that participated in the GOC trial.MethodsQuestions measured the dependent variable of implementation effectiveness: the consistency and quality of use of the GOC intervention. NH organizational characteristics were measured using publicly available data and an administrator survey. The analysis consisted of pattern matching logic.ResultsHigh management support aligned with implementation effectiveness within NHs. In addition, the within case pattern analysis indicated additional characteristics related to implementation effectiveness. Facility size, Medicare beds, residents’ racial composition, and star rating were related to implementation effectiveness across 6 of the 11 NHs. NH financial resources, such as size and number of Medicare beds, may be important factors for successful implementation.Conclusion and ImplicationsNHs seeking to implement advance care planning interventions should focus on within and across NH differences, such as adequate management and financial support prior to implementation to increase the likelihood of implementation effectiveness.     

A Novel Collaborative Care Program to Augment Nursing Home Care During and After the COVID-19 Pandemic

The 2019 novel coronavirus (COVID-19) pandemic created an immediate need to enhance current efforts to reduce transfers of nursing home (NH) residents to acute care. Long-Term Care Plus (LTC+), a collaborative care program developed and implemented during the COVID-19 pandemic, aimed to enhance care in the NH setting while also decreasing unnecessary acute care transfers. Using a hub-and-spoke model, LTC+ was implemented in 6 hospitals serving as central hubs to 54 geographically associated NHs with 9574 beds in Toronto, Canada. LTC+ provided NHs with the following: (1) virtual general internal medicine (GIM) consultations; (2) nursing navigator support; (3) rapid access to laboratory and diagnostic imaging services; and (4) educational resources. From April 2020 to June 2021, LTC+ provided 381 GIM consultations that addressed abnormal bloodwork (15%), cardiac problems (13%), and unexplained fever (11%) as the most common reasons for consultation. Sixty-five nurse navigator calls addressed requests for non-GIM specialist consultations (34%), wound care assessments (14%), and system navigation (12%). One hundred seventy-seven (46%, 95% CI 41%-52%) consults addressed care concerns sufficiently to avoid the need for acute care transfer. All 36 primary care physicians who consulted the LTC+ program reported strong satisfaction with the advice provided. Early results demonstrate the feasibility and acceptability of an integrated care model that enhances care delivery for NH residents where they reside and has the potential to positively impact the long-term care sector by ensuring equitable and timely access to care for people living in NHs. It represents an important step toward health system integration that values the expertise within the long-term care sector.