Care Disposition Research Articles

PL02: Derivation and validation of a feasible emergency department specific frailty index to predict adverse outcomes

Introduction: Frailty is an overarching concept in geriatric medicine. However its utility in the emergency department (ED) was not well understood. Objectives were to derive and validate an ED specific frailty index (FI-ED), using a cumulative deficits model; and to evaluate its ability to predict adverse outcomes. Methods: This was a large multinational prospective cohort study using data from: The Management of Older Persons in Emergency Departments (MOPED) and the interRAI study. The FI-ED was derived from the Canadian sample and validated in the multinational sample. Inclusion criteria were all patients ≥75 years old presenting to an ED. The FI-ED used 24 variables identified in the interRAI ED-Contact Assessment tool, a brief focussed geriatric assessment. Its ability to predict adverse outcomes were analysed by logistic regression with odds ratio (OR). Results: There were 3903 participants: 2153 in the derivation sample and 1750 in the validation sample. In the derivation sample, increasing FI-ED was significantly associated with admission (OR 1.43 [95% CI 1.34-1.52]), death in hospital (OR 1.55 [1.38-1.73]), prolonged hospital stay (OR 1.37 [1.22-1.54]), needs for Comprehensive Geriatric Assessment (OR 1.51 [1.41-1.60]) and discharge to long-term care (OR 1.30 [1.16-1.47]). In the validation sample, results were similar except for long-term care disposition (OR 0.84 [0.75 0.85]). Conclusion: The FI-ED conformed to characteristics previously reported in other geriatric populations. It was accurately derived and validated from a brief geriatric assessment feasible in the ED and can be used to predict adverse outcomes.

Curbing the urge to care: A Bourdieusian analysis of the effect of the caring disposition on nurse middle managers’ clinical leadership in patient safety practices

BackgroundNurse managers play an important role in implementing patient safety practices in hospitals. However, the influence of their professional background on their clinical leadership behaviour remains unclear. Research has demonstrated that concepts of Bourdieu (dispositions of habitus, capital and field) help to describe this influence. It revealed various configurations of dispositions of the habitus in which a caring disposition plays a crucial role. ObjectivesWe explore how the caring disposition of nurse middle managers’ habitus influences their clinical leadership behaviour in patient safety practices. DesignOur paper reports the findings of a Bourdieusian, multi-site, ethnographic case study. SettingsTwo Dutch and two American acute care, mid-sized, non-profit hospitals. ParticipantsA total of 16 nurse middle managers of adult care units. MethodsObservations were made over 560h of shadowing nurse middle managers, semi-structured interviews and member check meetings with the participants. ResultsWe observed three distinct configurations of dispositions of the habitus which influenced the clinical leadership of nurse middle managers in patient safety practices; they all include a caring disposition: (1) a configuration with a dominant caring disposition that was helpful (via solving urgent matters) and hindering (via ad hoc and reactive actions, leading to quick fixes and ‘compensatory modes’); (2) a configuration with an interaction of caring and collegial dispositions that led to an absence of clinical involvement and discouraged patient safety practices; and (3) a configuration with a dominant scientific disposition showing an investigative, non-judging, analytic stance, a focus on evidence-based practice that curbs the ad hoc repertoire of the caring disposition. ConclusionsThe dispositions of the nurse middle managers’ habitus influenced their clinical leadership in patient safety practices. A dominance of the caring disposition, which meant ‘always’ answering calls for help and reactive and ad hoc reactions, did not support the clinical leadership role of nurse middle managers. By perceiving the team of staff nurses as pseudo-patients, patient safety practice was jeopardized because of erosion of the clinical disposition. The nurse middle managers’ clinical leadership was enhanced by leadership behaviour based on the clinical and scientific dispositions that was manifested through an investigative, non-judging, analytic stance, a focus on evidence-based practice and a curbed caring disposition.

Assessing the Quality of Service Using Big Data Analytics

Abstract Many industries are riding the wave of big data as the new era of data-driven decision making is unveiling. The field of big data analytics is gaining fast traction in industry, academia and the government; the healthcare arena is no different. In this paper, big data analytics are applied to healthcare data that is collected from multiple sources to gain quality insights and apprehend best practices of the field (using new healthcare specific big data tools). The US states are unceasingly pursuing potential improvements to their healthcare's Quality of Service (QoS). Recent changes in data sharing provisions, such as the disposition of the recent Affordable Health Care Act (ACA), changed the rules of the game, and provided the US states with a new set of measurable health quality variables that they couldn't overlook anymore. Individuals in those states without health insurance tend to ignore visiting the clinic even if they feel symptoms of a disease; healthy young individuals with insurance can also have the same behavior. Health experts constantly recommend closer immersion in one's health and more engagement with preventive healthcare. In three experimental studies, this multidisciplinary paper examines historical health data from all over the country, assesses the medical QoS for multiple US states using a new healthcare-specific analytical infrastructure, delivers forecasts and correlations for future healthcare activities, and provides data-driven

Caring disposition and subordination. Swedish health and social care teachers’ conceptions of important vocational knowledge

Based on the increasing demands for vocational training in upper secondary school to adapt to workplace conditions, the aim of this article is to explore vocational teachers’ conceptions regarding vocational knowledge. Drawing on a social constructionist perspective, this study analysed data from 17 interviews. The study showed how power dynamics, such as gender and class, affect the teachers’ conceptions. The most important expertise, according to the teachers, was related to a feminine caring disposition in which empathy and communication were identified as core abilities. However, these abilities needed to be balanced in order to avoid becoming too emotional. There was a strong link to class, for example, the hierarchical structure was revealed when the teachers spoke of a nursing assistant having to know when to call a nurse rather than a doctor or an ambulance. The findings raise questions concerning what it means for the construction of vocational habitus when a superordinate group trains a subordinate group.

Caring behaviours of student nurses: Effects of pre-registration nursing education

In an increasing technologised and cost-constrained healthcare environment, the role of pre-registration nursing education in nurturing and developing the professional caring disposition of students is becoming far more critical than before. In view of this growing demand, the aim of this study was to evaluate the impact of Singapore's pre-registration nursing programmes on students' concept of caring. A descriptive quantitative cross-sectional survey collected data using the Caring Behaviour Inventory from first and final year student nurses, nurse lecturers and nurses in practice. The findings based on student surveys indicated a statistically significant reduction in the overall level of caring behaviour in first to final year students. When compared with the findings of lecturers and nurses, less variance to lecturers than to nurses was found amongst the first years' score, and the lowest variance to nurses was demonstrated amongst the final year. A greater reduction was evidenced amongst Singaporean students, which was exaggerated with exposure to pre-enrolled nursing education and magnified with caring job experience. This study indicates more effort is necessary to harness student caring attributes in students' entire educational journey so that expressive caring is not subsumed in the teaching of students to meet demands of complicated contemporary care.

An exploration of the perceptions of caring held by students entering nursing programmes in the United Kingdom: A longitudinal qualitative study phase 1

In a climate of intense international scrutiny of healthcare and nursing in particular, there is an urgent need to identify, foster and support a caring disposition in student nurses worldwide. Yet relatively little is known about how core nursing values are shaped during education programmes and this warrants further investigation. This longitudinal study commencing in February 2013 examines the impact of an innovative nursing curriculum based on a humanising framework (Todres et al. 2009) and seeks to establish to what extent professional and core values are shaped over the duration of a three year nursing programme. This paper reports on Phase One which explores student nurses' personal values and beliefs around caring and nursing at the start of their programme. Undergraduate pre-registration nursing students from two discrete programmes (Advanced Diploma and BSc (Honours) Nursing with professional registration) were recruited to this study. Utilising individual semi-structured interviews, data collection commenced with February 2013 cohort (n = 12) and was repeated with February 2014 (n = 24) cohort.Findings from Phase One show that neophyte student nurses are enthusiastic about wanting to care and aspire to making a difference to patients and their families. This research promises to offer contributions to the debate around what caring means and in particular how it is understood by student nurses. Findings will benefit educators and students which will ultimately impact positively on those in receipt of healthcare.

The role of a caring disposition in service leadership

AbstractA caring disposition is an important and fundamental attribute of a service leader. At the Hong Kong Polytechnic University, a lecture on a caring disposition in the subject “Service Leadership” was designed to help students understand the importance of caring dispositions. The curriculum design with reference to the basic concepts and theories as well as the content of the lecture are presented in this paper. In the first part of the paper, several uncaring cases are presented to serve as negative examples to inspire students’ reflection on caring leaders. Then, the three most important traits of a caring disposition, including awareness, love and nurturing people are introduced. Next, the relationships between a caring disposition and service leadership are analyzed and practical ways of improving a caring disposition are proposed. Finally, the impacts of a caring disposition on the leader-follower relationship are discussed. To provide a general overview of this lecture, the content including detailed lecture sessions and four designed activities relevant to a caring disposition are also presented in the paper.

Core beliefs in the service leadership model proposed by the Hong Kong Institute of Service Leadership and Management

AbstractThe service leadership model and related curriculum were developed by the Hong Kong Institute of Service Leadership and Management. To nurture service leadership qualities in university students, a 2-credit service leadership subject was developed at The Hong Kong Polytechnic University. This paper presents the core beliefs and key components of the service leadership model and outlines the content of one of the lectures in the subject. The lecture attempts to help students recognize the importance of leadership competencies, moral character and caring disposition in successful leadership, and to explore ways to develop service leadership qualities. In addition to the lecture, class activities are adopted, including group discussion, role play, self-reflection, and drawing.

The students were happy, but did they change positively?

AbstractAt The Hong Kong Polytechnic University, a 2-credit General Education subject entitled “Service Leadership” was developed to promote service leadership qualities (including leadership competencies, moral character, and caring disposition) in university students. The subject was piloted in one class with 60 students in the 2012/2013 academic year. Pretest and posttest data utilizing measures of positive youth development, life satisfaction, and service leadership qualities were collected. Positive changes in the program participants were found, particularly for measures in behavioral competence, moral competence, character strengths, general positive youth development qualities, and overall service leadership qualities. The present study provided preliminary support for the effectiveness of the subject in nurturing service leadership qualities of Chinese university students in Hong Kong.

Abstract TMP74: Stroke And Pulmonary Embolism, Clinical Features, Risk Factors And Outcome

Introduction: Pulmonary embolism (PE) is an uncommon medical complication after stroke. Predisposing factors include deep vein thrombosis (DVT) in patients with hemiplegia or an underlying hypercoagulable state. However, little information is known regarding PE in stroke patients. Objective: We evaluated clinical characteristics, predisposing factors, and outcomes in stroke patients who developed PE. Methods: We included patients with an acute ischemic stroke (AIS) admitted to the participating institutions in the Registry of the Canadian Stroke Network between 2003 to 2008. Pulmonary embolism was diagnosed by nuclear imaging within 30 days of the stroke case index. Demographic data and clinical variables were collected. Logistic regression and survival analyses were completed to determine the association of risk factors with the outcomes of interest. Outcome Measures: primary outcome was death or disability at discharge defined as the modified Rankin scale >3. Secondary outcomes include admission to the Intensive Care Unit, disposition, and length of hospital stay, death at 3 months and at 1 year. Results: Among 11,287 patients with AIS, PE was found in 89 (0.78%) of patients. The development of PE was associated with higher risk of death in 30 days (25.8%vs 13.6%;p <0.001) and 1 year, (47.2% vs 24.6%;p <0.001). Disability was also more common in stroke patients with PE (85.4% vs 63.6% without PE; p <0.001). Mean length of stay was longer in stroke patients with PE (36 vs 16 days; p<0.001). Past medical history of cancer or deep vein thrombosis, history of cardiac arrest or deep vein thrombosis during admission were associated with PE. After adjustment, PE was associated with lower survival at 30 days (p value = 0.0012) and 1 year (p value < 0.0001) (Figures 1 & 2 represent survival function). Conclusions: In this large study, PE occurs in approximately 1% of AIS patients. PE was associated with higher disability, longer length of stay and lower short and long-term survival.

Abstract 124: Post-acute Care Disposition To Home Or Acute Rehabilitation Helps Determine Favorable Clinical Outcome In The SENTIS Trial.

Intro: A person with stroke has improved outcomes with post-acute care in an inpatient rehabilitation facility (IRF) or at home compared to those who are discharged to a skilled nursing facility (SNF). However, this research was conducted in an era before acute stroke treatment was fully developed and implemented. In this analysis of a recently completed acute intervention trial, we hypothesize that subjects with similar severity of strokes will have better 90 day outcomes if they are discharged to a IRF or home compared to a SNF. Methods: Using the data from SENTIS, a prospective, multi-center single-blind, randomized trial of use of NeuroFlo technology compared to standard acute stroke therapy, patient demographics, day 4 National Institutes of Health Stroke Scores (NIHSS), and 90 day modified Rankin scores (mRS) was obtained. Severity of stroke was classfied in 3 groups based on NIHSS: less than 8, 8-13, 14+. Disposition following acute hospital care was classified as home, IRF and SNF. A favorable outcome was defined as 90 day mRS ≤ 2. For each stroke severity class, the effect of each disposition on a favorable outcome was calculated. Results: A total of 292 patients were analyzed with a mean age of 65±14 with presenting NIHSS of < 8 in 94/297(31.6%), NIHSS 8-13 in 118/297(39.7%) and 14+ in 85/297(28.6%) of patients. Regardless of day 4 NIHSS, only 2 out of 28 (7.1%) patients who were discharged to SNF achieved a 90 day mRS ≤2, compared to 60/153 (39.2%) in the IRF group (OR 8.02 95%CI[1.83-35.11], p=0.0057). Table 1 shows the distribution of outcomes by post-acute care disposition and day 4 NIHSS. Conclusions: The day 4 NIHSS had an inverse relationship with the likelihood of a favorable outome. Subjects who were discharged home or to an IRF were significantly more likely to have a favorable outcome compared to those who were discharged to a SNF. This analysis supports prior data stating that discharge disposition plays a role in determining outcomes.

Caring and Daring Discourses at Work: Doing Gender Through Occupational Choices in Elderly Care and Police Work

This paper aims to problematise how gender is being done—1. through occupational choices in two occupations that are traditionally gender divided, elderly care and police work, and 2. through the division of work assignments in police work. Interviews with care workers and police officers are analysed using a “doing gender” perspective, a post-structural notion of subjectivity inspired by Michel Foucault and positioning theory. We argue that a caring discourse operates in elderly care workers’ and police officers’ statements concerning occupational choices, while a daring discourse operates in statements concerning occupational choices within police work. Through these discourses, gender is being done in different ways; caring dispositions are constructed as totally female within the context of elderly care but as more gender-neutral in police work. At the same time, a macho or daring attitude is constructed as a male attribute in police work. Such constructions may have social consequences in terms of dividing work tasks for police, where male officers work in more prestigious and “dangerous” areas, while female officers are left with less prestigious, more caring-associated working areas.

Abstract 2275: Frailty Independently Predicts Poor Outcomes But Not Quality Of Care: An Analysis Of VA Ischemic Stroke Patients

Background: Frailty is a geriatric syndrome characterized by progressive multi-system physiologic decline that is difficult to operationalize clinically. Frailty indices which represent an accumulation of age-related deficits are one method of quantifying frailty, but have not been applied to stroke patients. Our objectives were to create a frailty index (FI) and determine its independent contribution to mortality, discharge disposition and quality of care in ischemic stroke patients. Methods: Chart abstraction data were obtained on a sample of 3965 patients admitted with ischemic stroke to 131 VA hospitals in 2007. Data on 38 deficits were used to create a FI that included: co-morbidities (e.g. previous stroke, MI, diabetes), pre-stroke function (e.g. ambulatory status, functional independence measure), social history (e.g. alcohol, smoking, living alone) and first admission lab values (e.g. creatinine, glucose). The FI (expressed as a %) was calculated for each subject as the number of deficits divided by the maximum number (n=38). Multiple logistic regression models were used to determine the independent effect of FI on in-hospital mortality and discharge home, while adjusting for age, sex, and NIHSS. Quality of care was defined by a composite compliance score expressed as a percent of 14 pre-determined quality indicators; a multivariable linear regression model was used to determine the independent effect of FI on the composite score, after adjusting for age, sex, and NIHSS. Results: The mean FI was 15%. In-hospital mortality was 5% and 70% of patients were discharged home. Multivariable logistic regression results ( Table 1 ) showed that for every 1% increase in the FI, the odds of dying in hospital increased by 4% (p=0.0003) independent of age, sex and NIHSS. Similarly for every 1% increase in the FI, the odds of being discharged home was 3% lower (p <0.0001). Results of the multivariable model of quality of care showed that there was no significant relationship between frailty and the composite compliance score. (p=0.34) Conclusions: Higher FI scores were associated with increased in-hospital mortality and decreased likelihood of going home, independent of age, sex and NIHSS. However quality of care was not affected by frailty. Further work is required to define the relationships between frailty and stroke outcomes and quality of care. A FI based measure of frailty could provide added information to stroke prognostic models and assessments of quality of care processes.

Relational learning and interprofessional practice: Transforming health education for the 21st century

Theories and traditions emphasizing the centrality of caring have guided the evolution of the healthcare professions. In contemporary practice, creating a therapeutic context in which healing can occur relies not just on the caring dispositions of individual clinicians, but also on the collective relational capacities of interprofessional healthcare teams. This article describes the intersection and complementarity of relational and interprofessional learning approaches to health education, provides exemplars of shared learning models and discusses the benefits and obstacles to integrating relational and interprofessional philosophies into real world practice.

174 Do Hospital Occupancy Levels Affect Initial Inpatient Level of Care for Emergency Department Admissions?

174 Do Hospital Occupancy Levels Affect Initial Inpatient Level of Care for Emergency Department Admissions?

Orthopedic Injuries in U.S. Casualties Treated on a Hospital Ship during Operation Iraqi Freedom

From March to May 2003, the USNS Comfort was deployed to the Persian Gulf in support of combat operations for Operation Iraqi Freedom. The onboard orthopedic service treated 58 U.S. casualties during that period. Eighty-seven percent of the injuries were to the appendicular skeleton. Twenty-four percent were battle injuries, and 72% were nonbattle injuries. Patients with battle injuries tended to be younger and required more orthopedic operations than did patients with nonbattle injuries. Moreover, all patients with battle injuries were evacuated to higher echelons for further care, whereas 19% of patients with nonbattle injuries returned to duty in the short term. Complications were few, with no infections, amputations, or deaths. A descriptive review of the types of injuries, orthopedic care, and eventual disposition is presented.

Moving from ethical awareness to deeper understanding and practice: kindergarten teachers’ experience with developing caring dispositions in children

The goal of this research is to seek information from the Cleveland (Ohio) and Buffalo (New York) area kindergarten teachers about their experience in development of caring dispositions in children. Two hundred questionnaires were sent, one hundred to each city. There was a low response rate of less than 10% from both cities. A qualitative method of data analysis based on descriptive and thematic approach was applied. The results showed how the teachers model and practise caring. This study gives examples of the programmes and many books these teachers are using for teaching caring. It also provides advice to new teachers on how to model, practise and teach caring.

How Safe Is Triage by an After-Hours Telephone Call Center?

Our goals were to assess (1) compliance with nurse disposition recommendations, (2) frequency of death or potential underreferral associated with hospitalization within 24 hours after a call, and (3) factors associated with potential underreferral, for children receiving care within an integrated health care delivery organization who were triaged by a pediatric after-hours call center. The study population included all pediatric patients enrolled in Kaiser Permanente Colorado whose families called the Children's Hospital after-hours call center in Denver, Colorado, during the period between October 1, 1999, and March 31, 2003. Postcall disposition recommendations were categorized as urgent (visit within 4 hours), next day (visit in > 4 hours but within 24 hours), later visit (visit in > 24 hours), or home care (care at home without a visit). Compliance with the nurses' triage disposition recommendations was calculated as the proportion of cases for which utilization data matched the disposition recommendations. Of the 32,968 eligible calls during the study period, 21% received urgent, 27% next day, 4% later visit, and 48% home care disposition recommendations. Rates of compliance with both urgent and home care disposition recommendations were 74%, and the rate of compliance with next day recommendations was 44%. No deaths occurred within < 1 week after the after-hours calls. The rate of potential underreferral with subsequent hospitalization was 0.2%, or 1 case per 599 triaged calls. In multivariate modeling, age of < 6 weeks or > 12 years and being triaged after 11 pm were associated with higher rates of potential under-referral. Approximately three fourths of families complied with recommendations for their child to be evaluated urgently or to be treated at home, with much lower rates of compliance with intermediate dispositions. The rate of potential underreferral with hospitalization was low, and age and time of call triage were associated with this outcome.

Utility of the Neuropsychological Evaluation in an Acute Medical Hospital

Although recent studies have demonstrated the importance of cognitive assessment in medical settings in general, there have been no specific studies addressing the utility of the neuropsychological evaluation in the acute inpatient hospital setting. The current study examined the use of inpatient neuropsychological evaluation by treating physicians in an acute medical hospital for patient care and discharge disposition. Participants were 100 inpatients within an urban medical center who received a neuropsychological evaluation. Results showed 78% of hospital discharge summaries included information regarding the neuropsychological evaluation, 48% referenced specific results, and 68% reported specific recommendations. Further, actual placement outcomes were consistent with the neuropsychological evaluation placement recommendations 80% of the time. The current study supports the utility of neuropsychological evaluations on overall inpatient care, and discusses ways in which the results may be used to communicate the value of neuropsychological services to medical treatment and discharge planning teams, third party payors, and medical center administrators.

Utility of the NIH Stroke Scale as a predictor of hospital disposition.

Early identification of stroke patients in need of rehabilitation or long-term nursing facility (NF) care may promote more efficient use of health care resources and lead to better outcomes. The NIH Stroke Scale (NIHSS) is an attractive candidate predictor of disposition because it is widely used, is easily learned, and can be performed rapidly on admission. We present a retrospective study of stroke patients admitted within 24 hours of symptom onset to a university hospital from March through June 2000. Medical records were reviewed for demographic information, stroke type, prestroke living arrangement and independence, initial NIHSS, and medical complications during hospitalization. Among 94 patients evaluated during the study period, 59% were discharged home, 30% to rehabilitation, and 11% to NF. In multivariate analyses, disposition was associated only with initial NIHSS. For each 1-point increase in NIHSS, the likelihood of going home was significantly reduced (odds ratio, 0.79; 95% CI, 0.70 to 0.89, P<0.001). Categorization of NIHSS was also predictive of disposition, with NIHSS < or =5 being most strongly associated with discharge home, NIHSS 6 to 13 with rehabilitation, and NIHSS >13 with NF (P<0.001). Although no other baseline characteristics predicted disposition, major medical complications during hospitalization tended to reduce the odds of going home (odds ratio, 0.30; 95% CI, 0.08 to 1.0, P=0.07). The NIHSS predicts postacute care disposition among stroke patients. Predicting disposition on the first day of admission may facilitate the time-consuming and costly process of securing a bed at rehabilitation or NF, and perhaps decrease unnecessary length of stay in acute care settings.