Care In Long-term Care Facilities Research Articles

Quality indicators of long-term care for older people in OECD countries; a rapid scoping review

Abstract Background The COVID-19 pandemic has exposed the vulnerability of older people living in long-term care facilities (LTCF), highlighting the urgent need for research on the quality of care for this group of the population. There is no universal definition for quality of care in LTCF, and yet, multiple tools and indicators have been developed to measure it. In this rapid scoping review, we aim to provide a comprehensive overview of the current knowledge on quality of care concepts and indicators for older people in LTCF in OECD countries. Methods This review follows the World Health Organization (WHO) guide for rapid reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-ScR) extension for scoping reviews, including protocol registration (https://doi.org/10.17605/OSF.IO/34B2S). The electronic bibliographic databases MEDLINE (PubMed), EMBASE, and CINAHL were searched in September 2023 for studies published between 2013 and 2023 for quality indicators in LTCF. Experts in quality of care in LTCF were contacted and consulted to retrieve sources of grey literature. Information on the definition or framework of quality of care, quality of care dimensions, measurement instruments, context and purpose of the measurement will be extracted. Results Of the 8,516 identified records, 6,449 were screened by title and abstract after removing duplicates. A total of 469 publications will be screened in full-text. Experts recommended 40 websites to be screened for quality indicators. The PRISMA flowchart diagram will be provided to describe the selection process. Conclusions This review aims to improve the quality of care for older people living in LTCF. Our results will identify which concepts and dimensions of care are currently being measured in OECD countries, whether they are backed by any definition and scientific framework of quality of care for older residents of LTCF, and whether there is consideration of closing gaps in quality measurement. Key messages • Quality of care is an understudied field in the context of long-term care facilities for older people. • In order to further improve quality in long-term care for older people, it is necessary to systematically review the current state of knowledge on quality concepts and indicators.

Professional dental care and survival rates in long-term care recipients: A cohort study of 1 459 163 individuals in South Korea.

To determine the dental care pattern and survival rates of participants who received long-term care (LTC) and a matched control cohort in South Korea. Global ageing trends and the development of superaged societies pose healthcare challenges. South Korea's LTC system aids those with chronic illnesses and disabilities. Despite the link between oral health and systemic diseases, providing dental care in LTC facilities often reflects social neglect. We identified 1 459 163 individuals eligible for LTC insurance in the Korean National Health Insurance Service database from July 2008 to 2015 (LTC cohort) and 1 459 544 individuals matched through propensity-score matching (matched cohort). The LTC recipients were further categorised into subgroups based on their care type (institutional, home or mixed care). Population of utilising dental services and the average number of dental visits were counted in each cohort, and the survival rate of the LTC cohort was determined according to dental utilisation. Population of utilising dental services increased steadily in all cohorts except for institutional care, with the highest utilisation (around 30%) observed in the matched cohort. Lower independence in LTC cohorts was associated with lower dental utilisation: 18-27% for home care, 12-18% for mixed care, and 10% for institutional care. The survival rates in the LTC cohort were significantly lower than in the matched cohort (P < .0001), with 28.1% survival in LTC vs 59.3% in the matched cohort. Long-term care recipients experience social neglect for oral care, while higher survival rates were observed in those utilised dental services.

Healthcare Personnel Interactions with Floors and Pathogen Transmission in Long-Term Care: A Qualitative Exploration

Background: We know relatively little about how healthcare personnel (HCP) in long-term care facilities (LTCFs) integrate hand hygiene (HH) and personal protective equipment (PPE; e.g., gloves) use into their care processes. To address this gap, we are examining HH and PPE adherence at critical and contaminating moments in LTCFs. Methods: We conducted ethnographic observations of HCP’s processes of care in 2 LTCFs in Iowa to examine HH and PPE adherence during contaminating tasks in resident care sequences. We captured care observations and additional data on topics related to our study focus (e.g., unit/room layouts, PPE storage, facility policies/procedures) in field notes. We transcribed and imported fieldnotes into MAXQDA qualitative data management software and analyzed the data using a combined deductive-inductive coding approach. Results: Between 1/2023-7/2023, we observed 60 (30 per facility) care episodes. Most observations included toileting activities and perineal care during which HCP would be expected to use gloves and/or do HH. Most HCP appropriately donned/doffed gloves and practiced HH at key moments (e.g., before clean/aseptic procedures, after perineal care), but were less compliant before/after touching residents’ clothing or bare skin during these activities. In addition, some held soiled items next to their scrubs between tasks, which could contaminate their clothing and arms and could facilitate transmission of pathogens to other residents. Moreover, HCP’s interactions with floors emerged inductively as a topic of interest during our observations and preliminary analyses. We observed HCP interact with the floor during these activities in ways that could increase risk of pathogen transmission. HCP frequently dropped soiled towels or wipes used in perineal care onto the floor during tasks for later pick up. HCP also moved or placed trash bags containing soiled or contaminated items on the floor. HCP routinely knelt on, sat on, or touched their hands on the same floor when talking with residents, helping residents change clothes or diapers, changing bedding, or adjusting wheelchair footpads. In one case, the HCP picked up clean towels that fell to the floor near soiled towels and then used the “clean towels” in resident perineal care. Conclusion: Despite practicing HH and appropriate PPE use, HCP in LTCFs may increase the risk of pathogen transmission unintentionally through their interactions with soiled items and the environment, including floors. Given the nature of resident care in LTCFs, HCP in LTCF may be more likely than HCP in acute care settings to interact with contaminated floors.

National trends in utilisation of glucose lowering medicines by older people with diabetes in long-term care facilities

AimsTo examine national trends in glucose lowering medicine (GLM) use among older people with diabetes in long-term care facilities (LTCFs) during 2009–2019. MethodsA repeated cross-sectional study of individuals ≥65 years with diabetes in Australian LTCFs (n = 140,322) was conducted. Annual age-sex standardised prevalence of GLM use and number of defined daily doses (DDDs)/1000 resident-days were estimated. Multivariable Poisson or Negative binomial regression models were used to estimate adjusted rate ratios (aRRs) and 95 % confidence intervals (CIs). ResultsPrevalence of GLM use remained steady between 2009 (63.9%, 95 %CI 63.3–64.4) and 2019 (64.3%, 95 %CI 63.9–64.8) (aRR 1.00, 95 %CI 1.00–1.00). The percentage of residents receiving metformin increased from 36.0% (95 %CI 35.3–36.7) to 43.5% (95 %CI 42.9–44.1) (aRR 1.01, 95 %CI 1.01–1.01). Insulin use also increased from 21.5% (95 %CI 21.0–22.0) to 27.0% (95 %CI 26.5–27.5) (aRR 1.02, 95 %CI 1.02–1.02). Dipeptidyl peptidase-4 inhibitor use increased from 1.0% (95 %CI 0.9–1.1) to 21.1% (95 %CI 20.7–21.5) (aRR 1.24, 95 %CI 1.24–1.25), while sulfonylurea use decreased from 34.4% (95 %CI 33.8–35.1) to 19.3% (95 %CI 18.9–19.7) (aRR 0.93, 95 %CI 0.93–0.94). Similar trends were observed in DDDs/1000 resident days. ConclusionsThe increasing use of insulin and ongoing use of sulfonylureas suggests a need to implement evidence-based strategies to optimise diabetes care in LTCFs.

Acute Health Care Provision in Rural Long-Term Care Facilities: AScoping Review of Integrated Care Models.

We aimed to map integrated care models for acute health care in rural long-term care facilities (LTCFs) for future investigation. Systematic scoping review. Residential LTCFs in rural areas worldwide. The common health-related online databases were systematically searched complemented by a manual search of gray literature. Following the 5-stage framework of Arksey and O'Malley, the extent of included literature was identified and findings were summarized using qualitative meta-summary. A total of 35 references were included for synthesis, predominantly primary research on completed and ongoing projects reporting on integrated health care services in rural LTCFs. Incorporating previous research, we extracted 5 approaches of integrated acute-health care models: (1) Availability of Specialists, (2) Networks, (3) Quality Management (QM) and Organization, (4) Telemedicine, and (5) Telehealth. This research presents the result of a literature review examining integrated care models as a way to improve acute health care in LTCFs in rural areas. Integrated care models in rural settings can help face the challenging situation and fulfil the complex health care needs of LTCF residents by reducing fragmentation and thereby improve continuity and coordination of acute health care services. These results can guide policy making in creating interventions and support adequate implementation of care models by knowledge translation in health care.

How about an Educational Framework for Nursing Staff in Long-Term Care Facilities to Improve the Care of Behavioral and Psychological Symptoms of Dementia?

Behavioral and psychological symptoms of dementia (BPSD) are common in residents of long-term care facilities (LTCFs). In LTCFs, nursing staff, including nurses and care workers, play a crucial role in managing BPSD as those most in contact with the residents. However, it is ambiguous where their focus should be for effective BPSD care. Thus, this paper aims to reveal BPSD care competencies for nursing staff in LTCFs and to outline an initial frame of education. A multiphase mixed-methods approach, which was conducted through topic modeling, qualitative interviews, and a Delphi survey, was used. From the results, a preliminary educational framework for nursing staff with categories of BPSD care competence was outlined with the four categories of BPSD care competence: using knowledge for assessment and monitoring the status of residents, individualizing approaches on how to understand residents and address BPSD, building relationships for shared decision-making, and securing a safe environment for residents and staff in LTCFs. This preliminary framework illuminates specific domains that need to be developed for competent BPSD care in LTCFs that are centered on nursing staff who directly assess and monitor the changing and deteriorating state of residents in LTCFs.

Standards and quality of care for older persons in long term care facilities: a scoping review

BackgroundCaring for older persons has become a global necessity to ensure functional ability and healthy ageing. It is of paramount importance that standards of care are monitored, especially for older persons who live in long term care facilities (LTCF). We, therefore, scoped and summarised evidence relating to standards and the quality of care for older persons in LTCFs in gerontological literature globally.MethodsWe conducted a scoping review using Askey and O’Malley’s framework, including Levac et al. recommendations. PubMed, CINAHL, Health Sources, Scopus, Cochrane Library, and Google Scholar were searched with no date limitation up to May 2020 using keywords, Boolean terms, and medical subject headings. We also consulted the World Health Organization website and the reference list of included articles for evidence sources. This review also included peer-reviewed publications and grey literature in English that focused on standards and quality of care for older residents in LTCFs. Two reviewers independently screened the title, abstract, and full-text of evidence sources screening stages and performed the data extraction. Thematic content analysis was used, and a summary of the findings are reported narratively.ResultsSixteen evidence sources published from 1989 to 2017 met this study’s eligibility criteria out of 73,845 citations obtained from the broader search. The majority of the studies were conducted in the USA 56% (9/16), and others were from Canada, Hong Kong, Ireland, Norway, Israel, Japan, and France. The included studies presented evidence on the effectiveness of prompted voiding intervention for urinary incontinence in LTCFs (37.5%), the efficacy of professional support to LTCF staff (18.8%), and the prevention-effectiveness of a pressure ulcer programme in LTCFs (6.3%). Others presented evidence on regulation and quality of care (12.5%); nursing documentation and quality of care (6.3%); medical, nursing, and psychosocial standards on the quality of care (6.3%); medication safety using the Beer criteria (6.3%); and the quality of morning care provision (6.3%).ConclusionThis study suggests most studies relating to standards and quality of care in LTCFs focus on effectiveness of interventions, few on people-centredness and safety, and are mainly conducted in European countries and the United States of America. Future studies on people-centerdness, safety, and geographical settings with limited or no evidence are recommended.

The Italian Experience in Protecting Older People During COVID-19: Lessons Learned for Long-Term Care Facilities (LTCF)

<strong>Context:</strong> Older people living in LTCF were particularly affected by COVID-19. Italy was the first country in Europe to experience high death rates among older people. Analysing the factors which may have determined high mortality rates in LTCF and identifying actions to safeguard older people’s health in long-term care settings may be critical for future public health emergencies. <strong>Objectives: </strong>Identify the main challenges and failures faced by a small number of Italian professionals working in LTCF and suggest key actions to better protect older people’s health in future emergencies. <strong>Methods: </strong>Rapid survey conducted among Italian professionals working in the LTC sector in Italy during the pandemic. <strong>Findings: </strong>Several factors contributed to higher death rates in LTCF for older people in Italy. To better protect LTCF residents in case of future health emergencies, actions need to be implemented in relation to LTCF’s management, governance and capacity building. Furthermore, safety plans and strategies need to be put in place to ensure older residents’ protection and maintain high level of care in LTCF during public health emergencies, such as COVID-19. <strong>Limitations:</strong> The article reflects the opinions of a limited number of professionals working in the long-term care sector, which may not be representative of all workers operating in the sector. <strong>Implications: </strong>Policy and system changes are needed to strengthen the capacity of the Italian long- term care sector to respond to the needs of a growing older population in the context of COVID-19 and beyond.

The revised index for social engagement (RISE) in long-term care facilities: reliability and validity in Japan.

This study aimed to establish the validity and reliability of a revised index for social engagement (RISE) in the Japanese context. We analysed the data of 1377 participants over 65 years of age who had been admitted to two types of long-term care facilities (LTCF) in Japan: four health facilities for older adults and eight nursing homes. Resident level data based on the Japanese version of the interRAI assessment instrument were collected from 623 residents in the former and 754 in the latter. From these data, we calculated RISE by adding six dichotomous items on social engagement in the assessment form. Factorial validity was evaluated by exploratory factorial analysis and confirmatory factor analysis, convergent validity by the correlation between average activity time and the RISE score, and discriminant validity by the correlation between cognitive levels and the RISE scores. Lastly, we assessed internal consistency using Cronbach's alpha. We identified a two-factor model in the exploratory factorial analysis with a factor loading >0.40, except for one RISE item. The confirmatory factor analysis confirmed that the two-factor model had appropriate model fits. The correlation between time involved in activities and the RISE score was r=0.45, while the correlation between cognitive function and the RISE score was r=-0.32. The convergent and discriminant validities supported the use of Japanese LTCF. Cronbach's alpha ranged 0.70-0.72. Although further revision may be needed to improve factorial validity, RISE is reliable and valid for assessing social engagement of older adults admitted to LTCF in Japan. By using the Japanese version of RISE, the positive aspects of social functioning can be appropriately assessed and provide more evidence for improving the quality of care in LTCF.

Modelling resource requirements and physician staffing to provide virtual urgent medical care for residents of long-term care homes: a cross-sectional study.

The coronavirus disease 2019 (COVID-19) outbreak increases the importance of strategies to enhance urgent medical care delivery in long-term care (LTC) facilities that could potentially reduce transfers to emergency departments. The study objective was to model resource requirements to deliver virtual urgent medical care in LTC facilities. We used data from all general medicine inpatient admissions at 7 hospitals in the Greater Toronto Area, Ontario, Canada, over a 7.5-year period (Apr. 1, 2010, to Oct. 31, 2017) to estimate historical patterns of hospital resource use by LTC residents. We estimated an upper bound of potentially avoidable transfers by combining data on short admissions (≤ 72 h) with historical data on the proportion of transfers from LTC facilities for which patients were discharged from the emergency department without admission. Regression models were used to extrapolate future resource requirements, and queuing models were used to estimate physician staffing requirements to perform virtual assessments. There were 235 375 admissions to general medicine wards, and residents of LTC facilities (age 16 yr or older) accounted for 9.3% (n = 21 948) of these admissions. Among the admissions of residents of LTC facilities, short admissions constituted 24.1% (n = 5297), and for 99.8% (n = 5284) of these admissions, the patient received laboratory testing, for 86.9% (n = 4604) the patient received plain radiography, for 41.5% (n = 2197) the patient received computed tomography and for 81.2% (n = 4300) the patient received intravenous medications. If all patients who have short admissions and are transferred from the emergency department were diverted to outpatient care, the average weekly demand for outpatient imaging per hospital would be 2.6 ultrasounds, 11.9 computed tomographic scans and 23.9 radiographs per week. The average daily volume of urgent medical virtual assessments would range from 2.0 to 5.8 per hospital. A single centralized virtual assessment centre staffed by 2 or 3 physicians would provide services similar in efficiency (measured by waiting time for physician assessment) to 7 separate centres staffed by 1 physician each. The provision of acute medical care to LTC residents at their facility would probably require rapid access to outpatient diagnostic imaging, within-facility access to laboratory services and intravenous medication and virtual consultations with physicians. The results of this study can inform efforts to deliver urgent medical care in LTC facilities in light of a potential surge in COVID-19 cases.

Palliative Care Implementation in Long-Term Care Facilities: European Association for Palliative Care White Paper

ObjectivesThe number of older people dying in long-term care facilities (LTCFs) is increasing globally, but care quality may be variable. A framework was developed drawing on empirical research findings from the Palliative Care for Older People (PACE) study and a scoping review of literature on the implementation of palliative care interventions in LTCFs. The PACE study mapped palliative care in LTCFs in Europe, evaluated quality of end-of-life care and quality of dying in a cross-sectional study of deceased residents of LTCFs in 6 countries, and undertook a cluster-randomized control trial that evaluated the impact of the PACE Steps to Success intervention in 7 countries. Working with the European Association for Palliative Care, a white paper was written that outlined recommendations for the implementation of interventions to improve palliative and end-of-life care for all older adults with serious illness, regardless of diagnosis, living in LTCFs. The goal of the article is to present these key domains and recommendations. DesignTransparent expert consultation. SettingInternational experts in LTCFs. ParticipantsEighteen (of 20 invited) international experts from 15 countries participated in a 1-day face-to-face Transparent Expert Consultation (TEC) workshop in Bern, Switzerland, and 21 (of 28 invited) completed a follow-up online survey. MethodsThe TEC study used (1) a face-to-face workshop to discuss a scoping review and initial recommendations and (2) an online survey. ResultsThirty recommendations about implementing palliative care for older people in LTCFs were refined during the TEC workshop and, of these, 20 were selected following the survey. These 20 recommendations cover domains at micro (within organizations), meso (across organizations), and macro (at national or regional) levels addressed in 3 phases: establishing conditions for action, embedding in everyday practice, and sustaining ongoing change. Conclusions and implicationsWe developed a framework of 20 recommendations to guide implementation of improvements in palliative care in LTCFs.

Hospice Utilization Among Residents in Long-Term Care Facilities.

Hospice care can improve quality of life for persons nearing end of life, yet little is known about utilization of hospice care among persons residing in long-term care facilities (LTCFs). Given the increasing number of deaths that occur in LTCFs, it is important to examine hospice care practices in LTCFs. The aim of the cross-sectional study was to describe residents who received hospice care in LTCFs and explore factors that can predict hospice use in LTCFs across Canada. This study included 185 715 residents aged 19 years or older in LTCFs in Canada in 2015. Of all residents, 2.7% (n = 4973) received hospice care and 6.8% (n = 12 684) were profiled as having an end-stage disease. Among those who received hospice care, most were noted as end stage (89.5%) and had severe physical impairment (Activities of Daily Living Hierarchy Scale ≥ 5, 74.3%), mild-to-severe pain (Pain Scale ≥ 1, 76.0%), and moderate-to-severe health instability (Changes in Health, End-Stage Disease, Signs, and Symptoms Scale ≥3, 82.9%). Residents who received hospice care were in more severe and complex clinical conditions than those who did not receive hospice care. Only a small proportion of residents in LTCFs received hospice care. Further investigation of standardized assessment of terminal status is needed as accuracy of end-stage diagnosis continues to be challenging and criteria for hospice eligibility are narrow. Special attention should be paid to improve access to hospice care among residents with dementia or other progressive chronic diseases with severe and complex clinical needs.

Multiple brief training sessions to improve nurses' knowledge, attitudes, and confidence regarding nursing care of older adults with depression in long-term care facilities.

In long-term care facilities (LTCFs), nurses are key healthcare providers for older residents who have depressive symptoms or depression; therefore, they need accurate knowledge of late-life depression, positive attitudes towards depression, and confidence in providing depression care. This cluster-randomized trial was designed to examine the effectiveness of multiple, face-to-face, brief training sessions in improving nurses' knowledge, attitudes, and confidence in providing late-life depression care in LTCFs. Nine LTCFs were included in the study. In total, 30 nurses from the four LTCFs assigned to the intervention group received three 30-min training sessions and 36 nurses in the five comparison group LTCFs did not. A self-report questionnaire was administered before and after the intervention. There were significant differences between groups concerning improvement in nurses' knowledge of late-life depression, attitudes towards depression, and confidence in providing depression care. The effect size (Cohen's d) was 1.55 for knowledge, 1.38 for attitudes, and 0.89 for confidence. This training program was effective in improving LTCF nurses' knowledge, attitudes, and confidence in providing depression care. On the basis of these findings, we recommend that nurse managers and directors implement similar training programs for nurses in LTCFs to enhance the care quality for older residents.

Provision of Resident-Centered Care by Nurse Practitioners in Saskatchewan Long-Term Care Facilities: Qualitative Findings From a Mixed Methods Study.

With their education and skill set, nurse practitioners (NPs) are ideally situated to provide primary care to long-term care (LTC) residents, and this is a timely development as physician presence in LTC has been decreasing. A sequential follow-up explanatory mixed methods design was used for the current study, which focused on the interviews that followed the initial survey. The sample included seven NPs who work with LTC residents in urban and rural settings in a western Canadian province. The interviews provided an opportunity for in-depth discussion regarding survey results. Interpretive description guided the data analysis. NPs provide timely access to primary care, address medication reconciliation, decrease transfers to hospitals, and take part in collaborative practice. NPs promote the health care goals of LTC residents. Departments of health would benefit from the inclusion of a wider range of health providers, including NPs, to provide timely access to quality care in LTC facilities. [Research in Gerontological Nursing, 13(2), 73-81.].

Evaluating the technical efficiency of care among long-term care facilities in Xiamen, China: based on data envelopment analysis and Tobit model

BackgroundThe technical efficiency (TE) of care among the elderly in long-term care facilities (LTCF) have become increasingly crucial policy concerns faced by developing countries and Asia, especially China. The purpose of this study was to evaluate the TE and the quality of care and identify its influencing factors among LTCF.MethodsA total of 32 registered LTCF in Xiamen of China were surveyed in 2016. The Banker-Charnes-Cooper (BCC) model and Slacks-Based Measure (SBM) model of Data Envelopment Analysis (DEA) were used to evaluate the TE of LTCF. The TE has been decomposed into pure technical efficiency and scale efficiency. Utilization of DEA with human, financial, and material resources as inputs and quantity, quality of nursing care as outputs allowed estimation of the relative TE of care in LTCF. In addition, this study applied SBM to measuring the efficiencies and slacks. Furthermore, Tobit model was performed to explore factors associated with TE.ResultsThere were 7 public and 25 private LTCF respectively, with a total of 6729 beds and 3154 elderly people. 17 LTCF were technically efficient (53.1%). In the BCC model, the average TE was 0.963. The average pure technical efficiency and scale efficiency of LTCF were 0.979, 0.984, respectively. There were 5 LTCF with increasing returns to scale, 8 LTCF with decreasing returns to scale. In the SBM model, the average TE was 0.813, and it had the same effective decision-making unit with SBM model. Depending on TE score from high to low, the top eight are private LTCF, and the last four were public LTCF. The slack analysis showed that they can be reduced in 8 LTCF with decreasing returns to scale such as 53.31% administrative staffs, 67.73% medical staffs, 33.1% caregivers, 51.66% paramedical staffs and 4.1% beds on average. The TE of private LTCF was higher than that of public LTCF. The LTCF in urban were more effective than rural. The TE of LTCF raised by increasing of working hours, training frequency and institutional occupancy.ConclusionsThe overall TE of LTCF in Xiamen of China was relatively high, especially in private institutions. However, LTCF still needs to further improve the utilization of physical resources and the management and training of human resources. The TE of LTCF was associated to their location, institutional nature, allocation of human resources and occupancy rate. It was needed to focus on promoting the efficiency and quality of LTCF in order to achieve sustainability.

Unpacking the multiple dimensions and levels of responsibility of the charge nurse role in long-term care facilities.

The charge nurse in long-term care facilities (LTCFs) performs a multiplicity of tasks that range from oversight of the entire facility to directly assisting residents in activities of daily living. In order to refine resident-centred care strategies and to increase the quality of care provided in LTCFs, this study aims at gaining a more nuanced understanding of the different dimensions of the charge nurse role as a central figure in these institutions. Data were generated through semi-structured interviews. A purposive sample of ten Registered Nurses in a charge nurse role, diverse in experience, age, gender and background, was recruited from five LTCFs in Ontario, Canada. The study used a combination of conventional and direct qualitative content analyses. All tasks performed by the charge nurses were categorised in four dimensions: clinical, supervisory, team support and managerial. Administration was a cross-cutting sub-dimension which has gained presence over the years. Depending on the shift worked and the organisational structure of the facility, each dimension gained or lost weight as part of the overall role. These findings suggest that the charge nurse role is in a state of flux and lacking standardisation within and across facilities. LTCFs would benefit from increasing recognition of the role according to the wide range of tasks performed and responsibilities assumed, and by recruiting their charge nurses accordingly. The proposed conceptual framework could be used to map and assess charge nurses' workloads and responsibilities, in order to enhance staff satisfaction and resident-centred care in LTCFs.

Nursing Staff Time and Care Quality in Long-Term Care Facilities: A Systematic Review.

In long-term care (LTC) facilities, nursing staff are important contributors to resident care and well-being. Despite this, the relationships between nursing staff coverage, care hours, and quality of resident care in LTC facilities are not well understood and have implications for policy-makers. This systematic review summarizes current evidence on the relationship between nursing staff coverage, care hours, and quality of resident care in LTC facilities. A structured literature search was conducted using four bibliographic databases and gray literature sources. Abstracts were screened by two independent reviewers using Covidence software. Data from the included studies were summarized using a pretested extraction form. The studies were critically appraised, and their results were synthesized narratively. The systematic searched yielded 15,842 citations, of which 54 studies (all observational) were included for synthesis. Most studies (n = 53, 98%) investigated the effect of nursing staff time on resident care. Eleven studies addressed minimum care hours and quality of care. One study examined the association between different nursing staff coverage models and resident outcomes. Overall, the quality of the included studies was poor. Because the evidence was inconsistent and of low quality, there is uncertainty about the direction and magnitude of the association between nursing staff time and type of coverage on quality of care. More rigorously designed studies are needed to test the effects of different cutoffs of care hours and different nursing coverage models on the quality of resident care in LTC facilities.

Falls and long-term care: a report from the care by design observational cohort study

BackgroundFalls and the resulting complications are common among frail older adults. We aimed to explore risk factors and potential prevention strategies for falls in elderly residents of Long-Term Care Facilities (LTCF).MethodsThis was a cross sectional study design using data from the Care by Design (CBD) study, within Nova Scotia’s Capital District Health Authority. This observational time series cohort study collected data before, during and after the implementation of CBD, a new model of coordinated primary care in LTCF. Here, we analyzed data collected after the implementation of CBD (September 1, 2011- February 28, 2012).ResultsFalls were frequent; 56.2% of our sample of 395 residents fell at least once. In univariate analyses, male gender (p = 0.009), dementia (p = 0.005), and use of Selective Serotonin Reuptake Inhibitors or Selective Serotonin-Norepinepherine Reuptake Inhibitors (SSRI/SNRI) (p = 0.084) showed statistically significant associations with having fallen. Benzodiazepine use appeared to be protective for falls (p = 0.058). In a fully adjusted multivariable linear regression model, dementia (β coefficient 0.96, 95% CI: 0.83,1.84; p = 0.032), visual impairment (β 0.84, 95% CI: 0.13,1.56; p = 0.021), and use of any PIMs (β 0.34, 95% CI: 0.037,0.65; p = 0.028) were associated with increased risk of having fallen. Benzodiazepine use remained associated with reduced numbers of falls (p = 0.009), and SSRI/SNRI use was associated with increased numbers of falls (p = 0.007). Male gender was associated with increased falls in the model which excluded frailty (p = 0.022), though gender lost statistical significance once frailty was added to the model (p = 0.06).ConclusionsIn our sample of LTCF residents, falls were common. Cognitive impairment, male gender, visual impairment, PIM use and use of SSRI/SNRI medications were associated with increased risk of falls, while benzodiazepine use appeared to be associated with a decreased risk of having fallen. Falls remain an important problem among LTC residents. Screening for falls during patient encounters is recommended, along with further research to identify risk factors and target interventions.

Polypharmacy and use of potentially inappropriate medications in long-term care facilities: does coordinated primary care make a difference?

Polypharmacy is both common and harmful for frail residents of long-term care facilities (LTCF). We aimed to study rates of polypharmacy and potentially inappropriate medications (PIMs) before and after the implementation of a new model of coordinated primary care in LTCF, 'Care by Design (CBD)'. This was an observational before/after study in 10 LTCFs in Halifax, NS, Canada. Chart reviews were conducted for 529 LTCF residents for whom medication use was available. Both regularly scheduled and PRN medications were included but topical, inhaled and other non-systemic agents were excluded. Polypharmacy was defined as the concomitant use of more than 10 medications. PIMs were identified using Beers Criteria. Mean age of LTCF residents was older pre- versus post-CBD (85.7 versus 82.1 years; P = 0.0015). The burden of polypharmacy was high, but decreased significantly from 86.8% pre-CBD to 79.5% post-CBD (P = 0.046). The mean number of medications per resident decreased from 16.7 (SD 5.6) pre- to 15.5 (SD 6.2) post-CBD (P = 0.037). Residents with dementia were taking fewer medications both overall and following the implementation of CBD (mean 15.9, SD 0.6 pre-CBD versus 14.4, SD 0.4 post-CBD; P = 0.04). PIM rates were high and showed no change with CBD (86.2% versus 81.1%, P = 0.16). Polypharmacy was the norm of this sample of LTCF residents. Implementation of coordinated care through the CBD model was associated with a small decrease in polypharmacy but not overall use of PIMs. Further targeted efforts are required to substantially reduce both polypharmacy and PIMs in clinical practice.

Semantic and conceptual equivalence of the observable indicatorsof Nursing Home Care Quality Instrument

Long-term care facilities (LTCFs) for the elderly are an important health care alternative in the world, though Brazil does not yet have a valid instrument to monitor the quality of these institutions. This study sought to describe the initial stages of the cross-cultural adaptation of the Observable Indicators of Nursing Home Care Quality (OIQ) instrument used to assess the quality of care in LTCFs. Conceptual equivalence was conducted to assess the relevance and feasibility of the OIQ within the Brazilian context, using the Content Validity Index (CVI). The operational, idiomatic and semantic equivalence was then performed. This item consisted of 5 phases: (1) two translations; (2) the respective back translations; (3) formal appraisal; (4) review; and (5) application of the pre-test in three LTCFs. Significant changes were made to ensure the validity of the OIQ. The CVI instrument for the Brazilian contextwas 94.3% (viability) and 95.3% (relevance). The OIQ proved to be easy to understand and apply in the pre-test. Cross-cultural adaptation of the OIQ contributes to assessing and improving quality in Brazilian LTCFs, though the findings should be complemented by a psychometric evaluation of the instrument.