Acute Elderly Care Research Articles

Strategies to deliver dementia training and education in the acute hospital setting

Aims and objectives: This UK study aimed to generate new ideas about training strategies for healthcare staff caring for people with dementia in the acute hospital setting. Background: A review of related literature exposed topical debate regarding current educational deficits, yet revealed few examples of the implementation of training initiatives for practising healthcare professionals. Design: A descriptive qualitative approach was used. Methods: Data were generated using two focus groups comprised of Staff Nurses (four) and Healthcare Assistants (three) working in a mixed gender acute elderly care unit in the North of England. Dialogues explored individuals’ experiences of delivering care to people with dementia hospitalised with physical illnesses and, usefully, their thoughts about learning in the workplace. Results: Four broad categories emerged from transcript-based analysis: learning about dementia; learning about the person; learning from each other; learning from specialists. Specific recommendations included the improvement of staff preparedness through fundamental training, improved flow of information about individuals, dementia-specialist input for situation-based advice, and structured opportunities to reflect on practice. Conclusion: The National Dementia Strategy for England emphasises the pressing need to improve care for people with dementia when they are admitted to hospital with physical illness, and highlights the importance of staff education in contributing to improved care. This study provides an insider view from a potential target population of such healthcare providers regarding their perceived educational needs. Relevance to clinical practice: The results of this study point the way forward to practical and achievable ways of increasing and improving knowledge about dementia, and enhancing skills in caring for people who are cognitively impaired, among general hospital staff.

Innovation Pilot Study: Acute Care for Elderly (ACE) Unit—Promoting Patient-Centric Care

Older patients, defined as age 65 years or older, comprise more than 40% of admissions to the acute care environment. These patients' needs are different; cognitive impairment, chronic health issues, caregiver burden, and maintenance of functional level present challenges to healthcare organizations when caring for this population on a general medical-surgical unit. A pilot project, the creation of a six-bed Acute Care for Elderly (ACE) unit situated within a 33-bed medical-surgical unit, was established to meet the unique needs of this older patient population. Outcomes including falls, pressure ulcers, functional level (the latter as measured by the KATZ), and length of stay were examined and demonstrated marked improvement compared to similar patients outside the ACE unit. Older patients need individualized care planning by staff competent in elder care and a specialty unit to address their specific needs.

Malnutrition screening and early nutrition intervention in hospitalised patients in acute aged care: a randomised controlled trial.

High rates of malnutrition have been reported in the older hospitalized patient population. This is recognised to impact on patient outcomes and health costs. This study aimed to assess the impact of nutrition screening and intervention on these parameters. Randomised controlled prospective study. The study was performed in the acute geriatric medicine wards of the Prince of Wales Hospital, Sydney Australia. All patients admitted to these wards under a geriatrician with an expected length of stay of at least 72 hours were considered for the study. Patients were screened on admission for malnutrition using the Mini Nutritional Assessment (MNA) tool and randomly assigned to control or intervention groups. Intervention patients were immediately commenced on a malnutrition care plan (MCP). Control patients were only commenced on a MCP if referred by clinical staff. Length of stay (LOS), weight change and frequency of readmission to hospital were compared between the groups. 143 patients were screened. 119 were identified as malnourished (MN) or at risk of malnutrition (AR). Overall LOS was not different between the two groups (control v. intervention: 13.4 ± 1.3 days v. 12.5 ± 1.2 days, p=0.64). However there was a significant decrease in LOS in the MN (control v. intervention: 19.5 ± 3 days v. 10.6 ± 1.6 days, p=0.013) and a trend to reduced readmissions. There was no difference in weight change over admission between the groups. Without screening, clinical staff identified only a small proportion of malnourished patients (35% of MN and 20% of AR). Malnutrition in the older hospital population is common. Malnutrition screening on hospital admission facilitated targeted nutrition intervention, however length of stay and re-presentations were only reduced in older malnourished patients with an MNA score less than 17.

Skin tear prevention and management among patients in the acute aged care and rehabilitation units in the Australian Capital Territory: a best practice implementation project

A skin tear is a traumatic wound that results from the separation of the skin layers due to shearing forces, friction or blunt trauma that affects all people. Numerous preventative measures aim to reduce the skin tears and minimise conditions that predispose the epidermis to injury. With the increasing elderly population in acute aged care, implementation of an evidence-based guideline is critical as changes to ageing skin integrity make this population more susceptible to skin tear. The aim of this project was to ensure the practice of skin tear assessment, prevention and management among acute aged care causes and rehabilitation patients was performed according to best available evidence. This project utilised a pre- and post-implementation audit design using the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice programs. The project was conducted from June to November 2010 with the audits conducted in the acute aged care and rehabilitation units of two public hospitals in the Australian Capital Territory involving a sample size of 96 patients at pre-audit and 95 patient at post-audit admitted during the audit period. A convenience sample of 20 nurses also consented to be observed. The audits were conducted after obtaining ethics approval and consent from patients and nurses. The results showed a significant change in compliance to the skin tear guidelines at post-implementation audit. Staff education in particular had a dramatic increase from 20% to 98% and the point prevalence rate of hospital-acquired skin tear decreased from 10% to 0.15%. This project emphasised the importance of education of all personnel involved in patient care and that a simple assessment of skin integrity is critical in preventing and managing skin tear especially among the susceptible elderly population.

An advanced nurse practitioner-led service - consequences of service redesign for managers and organizational infrastructure

A service review of a secondary care advanced nurse practitioner-led service. An acute hospital-based elderly care rehabilitation service evolved over a 9-year period from a traditional consultant/junior doctor configuration to a consultant/advanced nurse practitioner configuration. The review evaluated the advanced nurse practitioner team's role in the clinical setting, and the constraints experienced as a result of the traditions of the hospital organization. The review drew its conclusions from opinion data collected from 38 professionals and non-professionals within the rehabilitation service. The organizational infrastructure and traditions that had an impact on service delivery by the advanced nurse practitioner team. There is a demand for senior management to act on developmental constraints. The advanced nurse practitioner-led rehabilitation service was fit for purpose and an emerging model of a non-medical led care. However, important organizational constraints were identified. An advanced nurse practitioner team, working in collaboration with medical consultants, was a model for future service redesign in the acute hospital setting. Nevertheless, it presented challenges to senior health-care managers on current organizational infrastructures.

Outcomes of a behavioral unit in an acute aged care service

This study involves a retrospective review of the patients admitted to a unit providing specialized management to patients displaying difficult behaviors due to delirium and/or dementia. Medical records from 45 consecutive admissions have been reviewed. A great proportion of patients had dementia with superimposed delirium. Compared to care in general aged care wards, there was no reduction in length of stay (LOS) of patients in this study, ostensibly due to the delayed placement for long-term care. However there was a marked reduction in fall incidence and lesser use of ‘specials’. Psychotropic medications (PMs) were frequently used but their indications were carefully reviewed. Upon discharge there was improvement in the behavioral profile of the patients. Questionnaires completed by carers and staff were used to further assess the efficacy of the unit. There was general satisfaction of the care provided in the unit whist a few areas have been identified that require further attention. This model of intervention presents an improvement to the quality of care for acutely ill elderly patients with behavioral problems.

Evaluation of a Medical and Mental Health Unit compared with standard care for older people whose emergency admission to an acute general hospital is complicated by concurrent 'confusion': a controlled clinical trial. Acronym: TEAM: Trial of an Elderly Acute care Medical and mental health unit.

BackgroundPatients with delirium and dementia admitted to general hospitals have poor outcomes, and their carers report poor experiences. We developed an acute geriatric medical ward into a specialist Medical and Mental Health Unit over an eighteen month period. Additional specialist mental health staff were employed, other staff were trained in the 'person-centred' dementia care approach, a programme of meaningful activity was devised, the environment adapted to the needs of people with cognitive impairment, and attention given to communication with family carers. We hypothesise that patients managed on this ward will have better outcomes than those receiving standard care, and that such care will be cost-effective.Methods/designWe will perform a controlled clinical trial comparing in-patient management on a specialist Medical and Mental Health Unit with standard care. Study participants are patients over the age of 65, admitted as an emergency to a single general hospital, and identified on the Acute Medical Admissions Unit as being 'confused'. Sample size is 300 per group. The evaluation design has been adapted to accommodate pressures on bed management and patient flows. If beds are available on the specialist Unit, the clinical service allocates patients at random between the Unit and standard care on general or geriatric medical wards. Once admitted, randomised patients and their carers are invited to take part in a follow up study, and baseline data are collected. Quality of care and patient experience are assessed in a non-participant observer study. Outcomes are ascertained at a follow up home visit 90 days after randomisation, by a researcher blind to allocation. The primary outcome is days spent at home (for those admitted from home), or days spent in the same care home (if admitted from a care home). Secondary outcomes include mortality, institutionalisation, resource use, and scaled outcome measures, including quality of life, cognitive function, disability, behavioural and psychological symptoms, carer strain and carer satisfaction with hospital care. Analyses will comprise comparisons of process, outcomes and costs between the specialist unit and standard care treatment groups.Trial Registration numberClinicalTrials.gov: NCT01136148

Inhospital Study: Do older people, carers and nurses share the same priorities of care in the acute aged care setting?

The aim of the INHospital study was to compare the level of importance of care priorities and satisfaction levels with care among patients, carers, and nurse caregivers in the acute aged care setting. The INHospital study used sequential mixed methods approach for data collection. Survey data was completed within five metropolitan acute aged care wards on patients (n = 78), their carers (n = 45) and nurses (n = 37). The caring activity scale (CAS) survey was administered to participants in order to determine and compare the perceptions of the importance and satisfaction of care. Semistructured interviews of patients (n = 7) and carers (n = 7) were conducted after completion of the CAS survey. This qualitative data aimed to probe more deeply into the patient's and carer's care priorities and satisfaction as measured in the CAS. The CAS data demonstrated that patients, carers and nurses rated implementing, observing and reporting doctor's orders similarly, while differences between groups were observed in relation to prioritising physical and psychosocial care and discharge. There were significant differences between patients, carers and nurses on overall importance (p = 0.001) and satisfaction with respect to nursing care (p = 0.001). Qualitative data generated fie themes (1) Nurses doing the best they can in challenging circumstances; (2) Achieving a balancing act in a pressured environment; (3) Striving to maintain and sustain independence; (4) The discharge process: not a shared priority; and (5) Challenges of the carer role. A key implication of this study is the incongruence between what patients consider a priority for care and the priority ascribed to those tasks by nurses. Qualitative findings added depth to the survey data and qualified responses by confirming that patients thought that nurses did the best they could within a culture of busyness, while patients strived to maintain and sustain their own independence. However, the themes of managing the discharge process and carer burden arose mainly from the carer semi-structured interviews.

Ambulatory Activity of Older Adults Hospitalized with Acute Medical Illness

To describe the amount and patterns of ambulatory activity in hospitalized older adults over consecutive hospital days. Observational cohort study. University teaching hospital Acute Care for Elderly (ACE) unit. Adults aged 65 and older (N = 239) who wore a step activity monitor during their hospital stay. Total number of steps per 24-hour day. Mean daily steps were calculated based on number of days the step activity monitor was worn. Mean age was 76.6 ± 7.6; 55.1% of participants were female. Patients took a mean number of 739.7 (interquartile range 89-1,014) steps per day during their hospital stay. Patients with shorter stays tended to ambulate more on the first complete day of hospitalization and had a markedly greater increase in mobility on the second day than patients with longer lengths of stay. There were no significant differences in mean daily steps according to illness severity or reason for admission. Objective information on patient mobility can be collected for hospitalized older persons. Findings may increase understanding of the level of ambulation required to maintain functional status and promote recovery from acute illness.

P17.15 The point prevalence study of MRSA colonization in long-term-care facilities in the elderly acute care population in Krakow, Poland

P17.15 The point prevalence study of MRSA colonization in long-term-care facilities in the elderly acute care population in Krakow, Poland

Age and outcome in acute emergency medical admissions

there is a lack of outcome information with respect to older health service users. The purpose of this study was to examine 30-day in-hospital mortality and its predictors in all elderly patients admitted as a medical emergency to our hospital. all patients admitted between 2002 and 2008 were studied, linking anonymised clinical, administrative, laboratory and mortality data. Significant univariate predictors of outcome, including co-morbidity and illness severity score, were entered into a multivariate logistic regression model, adjusting the univariate estimates of the effect of age on in-hospital mortality. we admitted 23,114 consecutive acute medical admissions between 2002 and 2008; 30-day in-hospital mortality was 20.7% in the over 75 age category versus 4.5% in those younger. The unadjusted OR for a 30-day in-hospital mortality in the over 75 category of 5.21 (95% CI 4.73, 5.73) fell to 4.69 (95% CI 4.04, 5.44) when adjusted for outcome predictors excluding acute illness severity and 2.93 (95% CI 2.50, 3.42) when acute illness severity was added as a covariate. When the interaction between age and co-morbidity is examined, the odds ratio adjusts to 3.22 (95% CI 2.63, 3.6). acute illness severity is more important than co-morbidity in explaining the outcome in older patients admitted as medical emergencies. Service planning for acute elderly care should be based on effective disease management programmes but recognise the contribution of acute illness severity to outcome when conditions deteriorate.

Training Nurses in Cognitive Assessment: Uses and Misuses of the Mini-Mental State Examination

The Mini-Mental State Examination (MMSE) is one of the most commonly used instruments to screen for cognitive deficits within the hospital setting. However training in how to administer this widely used tool is scarce with little, if any, formal training for nursing staff. Scores are also often misused with over reliance on results and cut-offs to support a diagnosis of dementia within the acute and sub-acute aged care context. The present study assessed the level of training and accuracy in administering the MMSE within a geriatric in-patient rehabilitation ward. Ratings of the level of knowledge, training and confidence in administering the MMSE were obtained from 16 registered nurses and two medical officers before and after an education session on the uses of the MMSE and correct administration. Objective assessment of competencies in administration was also obtained with interrater reliability scores demonstrating high accuracy in the use of this screening instrument. Knowledge improved following the training session, but confidence scores remained unchanged. Results also indicated limited knowledge regarding the necessity for cognitive screening in an aged care setting. Inconsistency in administration of certain items was also identified as a concern. Strategies for improving the quality of administration are identified and discussed.

An exploration of mental health nursing students' experiences and attitudes towards using cigarettes to change client's behaviour

Using cigarettes to change client behaviour is a common, yet little studied, practice in mental health care. A questionnaire survey was used to explore mental health nursing student's experiences and attitudes to this practice. The sample was four cohorts of mental health nursing students (n= 151). Of them, 84% had experienced the practice of using cigarettes to change client behaviour in acute wards (73%), rehabilitation wards (28%) and elderly care (14%). Cigarettes were used to change client behaviour in areas such as attending to personal hygiene (57%) or engaging in the ward routine (39%). However, items such as leave (60%) or drinks (tea and coffee) (38%) were also reportedly used. Of the respondents, 54% inferred that the practice did not work well with 46% stating it was not written up in care plans; 52% felt it was an ad hoc practice, 60% inferred that at times it was used as a punishment while 55% intimated that they felt bad withholding cigarettes. There are ethical and moral dilemmas around using lifestyle risk factors as rewards or using client's nicotine addiction as a means of controlling behaviour. The question of whether this intervention should ever be used, given its associated health risk, requires more critical debate in clinical practice.

Octogenarian Abdominal Surgical Emergencies: Not So Grim a Problem With the Acute Care Surgery Model?

As the aging population continues to increase, the surgical needs of the elderly will increase. The acute care surgery model has been developed in which the trauma team also manages all general surgical emergencies to improve patient outcomes. We retrospectively reviewed our elderly acute care surgery population during the past 5 years to determine the variables affecting major abdominal surgery outcomes. Patients aged 80 years and older who received an emergent major abdominal operation by our Acute Care Surgery team between July 2000 and November 2006 were included. We assessed after-hours operations, length of stay, duration of operation, gender, comorbidities, and mortality. Administrative, operating room, and corporate databases were used for demographics, comorbidities, admission logistics, American Society of Anesthesiologists (ASA) score, and mortality. We performed SPSS, chi2, and logistic regression analyses. A total of 183 operations were performed with a mortality of 15%. Significant predictors were ASA score and female gender, with increasing ASA scores leading to worse outcomes and women faring worse than men as an independent variable. Neither operative duration nor off-hours surgery was associated with increased mortality. This is the first study to report mortality data and expected survival curves for major abdominal surgery in the octogenarian population. Our data prove that it is safer than previously thought to operate on the elderly. Our mortality data and survival curves provide real data for the surgeon to be able to risk stratify and discuss predicted outcomes with consultants, patients, and families.

REFINE (Reducing Falls in In-patient Elderly)--a randomised controlled trial.

BackgroundFalls in hospitals are common, resulting in injury and anxiety to patients, and large costs to NHS organisations. More than half of all in-patient falls in elderly people in acute care settings occur at the bedside, during transfers or whilst getting up to go to the toilet. In the majority of cases these falls are unwitnessed. There is insufficient evidence underpinning the effectiveness of interventions to guide clinical staff regarding the reduction of falls in the elderly inpatient. New patient monitoring technologies have the potential to offer advances in falls prevention. Bedside sensor equipment can alert staff, not in the immediate vicinity, to a potential problem and avert a fall. However no studies utilizing this assistive technology have demonstrated a significant reduction in falls rates in a randomised controlled trial setting.Methods/DesignThe research design is an individual patient randomised controlled trial of bedside chair and bed pressure sensors, incorporating a radio-paging alerting mode to alert staff to patients rising from their bed or chair, across five acute elderly care wards in Nottingham University Hospitals NHS Trust. Participants will be randomised to bedside chair and bed sensors or to usual care (without the use of sensors). The primary outcome is the number of bedside in-patient falls.DiscussionThe REFINE study is the first randomised controlled trial of bedside pressure sensors in elderly inpatients in an acute NHS Trust. We will assess whether falls can be successfully and cost effectively reduced using this technology, and report on its acceptability to both patients and staff.Trial RegistrationISRCTN trial number: ISRCTN44972300.

Factors related to withholding life-sustaining treatment in hospitalized elders

ObjectivesTo look for predictors in the clinical records of orders for “limitation of life sustaining treatment” (LLST) or “do not attempt resuscitation” (DNAR) in hospitalized elders and to assess the relationship between the presence of these orders and the quality of end-of-life (EOL) care. DesignRetrospective clinical record review. SettingInpatients of an inner city elderly acute care unit (EACU) in Spain. ParticipantsOf 103 hospitalized patients who died in the EACU during one year, 90 dying an expected death either from acute or chronic disease were included. MeasurementsDemographic, functional, cognitive, clinical, and end-of-life (EOL) parameters. The influence of identifying closeness to death and the number of LLST suborders on the quality of EOL-management were considered simultaneously using structural equation modelling with LISREL 8.30 software. ResultsLLST and specific DNAR orders were registered in 91.1% and 83.3% of patients, respectively. Failure of acute treatment, discussions with the patient/family, recognizing the presence of common EOL symptoms, and prescribing specific symptomatic treatment were recorded in 88.9%, 93.3%, 94.4%, and 86.7% of patients, respectively. LLST-orders were more likely to be documented if there was severe functional impairment prior to admission (p<0.001), advanced organ disease criteria were met (p=0.006), or closeness to death was acknowledged in writing (p<0.001). The quality of the EOL-management was better in patients for whom there were LLST-orders (p =0.01) and written acknowledgement of closeness to death (p<0.001). ConclusionsLLST-orders were more likely to be written in an EACU for patients with previous severe impairment, co-morbidity, or advanced disease. Written acknowledgement of closeness to death and LLST-orders were predictors of better EOL-management.

Improving outcomes for dementia care in acute aged care: Impact of an education programme

Abstract The aim of this paper is to report on the transformation of a small local hospital offering, for the first time, anacute geriatric service. At the start of this process in 2005 it became evident that many of the staff wereinexperienced in providing care to older patients, specifically, and most obviously, in the area of dementia care.Previously, the clinical focus had been on medical and surgical care and the staff therefore needed to develop anew range of skills and knowledge. A practice development process was adopted to transform the service withthe overall aims of: • creating a workforce competent to provide safe, effective, patientcentred care for olderpatients; and • developing and implementing a staff education programme to meet the needs of the staff andpatients. This involved using a survey to gather baseline data about the level of dementia competence anddeveloping a dementia educational programme. In this paper, we present the evaluation of this dementiaeducational programme and its impact on knowledge in a new specialist aged care clinical setting.

Adverse drug reactions in Acute Elderly Care Unit

Adverse drug reactions in Acute Elderly Care Unit

The acute–aged care interface: Exploring the dynamics of ‘bed blocking’

To understand the dynamics underlying 'bed-blocking' in Australian public hospitals that is frequently blamed on older patients. Analysis of primary and secondary data of utilisation patterns of hospital and aged care services by older Australians. A model of the dynamics at the acute-aged care interface was developed, in which the pathway into permanent high-care Residential Aged Care (RAC) is conceptualised as competing queues for available places by applicants from the hospital, the community and from within RAC facilities. The hospital effectively becomes a safety net to accommodate people with high-care needs who cannot be admitted into RAC in a timely manner. The model provides a useful tool to explore some of the issues that give rise to access-block within the public hospital system. Access-block cannot be understood by viewing the hospital system in isolation from other sectors that support the health and well-being of older Australians.

Inflammation and disability as risk factors for mortality in elderly acute care patients

Although the role of inflammation has been studied in specific diseases or in community living elderly, data in hospitalized acute care elderly patients are scarce. The present study was designed to determine the predictive value of sociodemographic, clinical and biological factors for mortality in acute care geriatric wards. Retrospective study was conducted in two acute care wards in a university-based geriatric hospital with elderly patients ( n = 224) consecutively admitted to acute care wards with available medical files. Sociodemographic variables, primary medical diagnosis and number of associated conditions, dementia, depression, pressure sores, functional status (measure by the activities of daily living = ADL scale), weight, and plasma levels of albumin, transthyretin, C-reactive protein (CRP) and orosomucoid were recorded at admission. Patients who died in the acute care wards were compared to those who survived. The mean length of stay was 16 ± 13 days; mortality was 12%. Univariate analysis revealed that disability, no anti-depressant drug, pressure ulcers, a higher number of associated conditions, living with another person, and biological markers of malnutrition (albumin <35 g/l, transthyretin <200 mg/l) and inflammation (CRP ≤30 mg/l, orosomucoid ≥1.25 g/l) were significantly associated with an increase in the risk of death. The logistic regression model retained CRP ≥30 mg/l (odds ratio (OR) = 3.72, 95% confidence interval (CI) = 1.34–10.31; p = 0.009) and disability for at least one ADL item (OR = 2.16, 95% CI = 1.55–2.99; p < 0.001) as independent risk factors for death. We conclude that CRP and disability are strong independent risk factors for death in this population, and special attention should be paid to these patients in an integrated therapeutic approach to geriatric care.