Elderly Care Physicians Research Articles

Navigating Dilemmas on Advance Euthanasia Directives of Patients with Advanced Dementia

ObjectivesThis study revisited the complexities faced by physicians in meeting due care criteria for euthanasia in patients with advanced dementia in The Netherlands. Despite increasing cases and legal provisions for advance euthanasia directives (AEDs), physicians encounter challenges with ethical issues, including patient communication and assessing unbearable suffering in patients who lack decisional capacity. This study examines the perspectives of elderly care physicians (ECPs), support and consultation on euthanasia in The Netherlands (SCEN) physicians, and euthanasia expertise center (EEC) physicians. DesignA multimethod descriptive study using a questionnaire with both closed and open-ended questions. Setting and ParticipantsThis study explores the complexities faced by physicians in handling AED-based euthanasia requests of patients with advanced dementia. MethodsBaseline characteristics of physician subgroups were analyzed descriptively, and subgroup variations were assessed using univariate regression. Qualitative data underwent thematic content analysis. ResultsWith a 13.8% response rate, the study included 290 participants: 108 ECPs, 188 SCEN physicians, and 53 EEC physicians. Some had combined roles: ECP and SCEN physicians (n = 29), ECP and EEC physician (n = 1), SCEN physicians and EEC physicians (n = 17), and ECP, SCEN physicians, and EEC physicians (n = 6). ECPs received most AED-based euthanasia requests but only 7 EEC physicians and 1 SCEN physician performed euthanasia. All subgroups stressed the importance of patient communication. ECPs found euthanasia ethically justifiable only when communication was possible, highlighting the need to understand current euthanasia wishes and verify unbearable suffering. Effective communication was deemed crucial for confirming request relevance, identifying obstacles, involving patients, fostering trust, and alleviating fears. Physicians generally agreed that unbearable suffering could be assessed through patient expressions, observations, and family input. Conclusions and ImplicationsDespite receiving AED-based euthanasia requests, few physicians proceeded. Subgroup analysis showed varying views, with ECPs emphasizing communication and EEC physicians focusing on determining unbearable suffering. All subgroups highlighted the importance of current patient expressions and involvement in the decision-making process.

Organizational characteristics of highly specialized units for people with dementia and severe challenging behavior

BackgroundPeople with dementia and severe challenging behavior in the Netherlands can be temporarily admitted to highly specialized units when their behavior is not manageable in regular dementia special care units (DSCUs). With scarce evidence available for the treatment of these patients, treatment in these units is in a pioneering phase. To gain more insight into these units, this study investigated organizational characteristics, i.e. admission and discharge characteristics, staffing, the physical environment, and the management of severe challenging behavior.MethodsThree data collection methods were used: 1) a digital questionnaire to be completed by the unit manager, 2) an interview with the physician responsible for medical care and often another practitioner, and 3) an observation of the physical environment for which the OAZIS-dementia questionnaire was used. Descriptive analysis was used for quantitative data and thematic analysis for qualitative data, after which data was interpreted together. Thirteen units participated, with their sizes ranging from 10 to 28 places.ResultsPatients were mainly admitted from regular DSCUs, home or mental health care, and discharged to regular DSCUs. A multidisciplinary team comprising at least an elderly care physician or geriatrician, psychologist, and nursing staff member and other therapists as needed provided the treatment. Nursing staff hours per patient considerably differed among units. Nursing staff played a central role in the treatment. Competences such as reflectiveness on one’s own behavior, and being able to cope with stressful situations were described as relevant for nursing staff. Investing in a stable nursing staff team was described as important. The units varied in whether their work-up was more intuitive or methodological. In the diagnostic phase, observation together with an extensive analysis of the patient’s biography was essential. The units used a broad variety of interventions, and all paid attention to sensory stimuli. In the observation of the physical environment, the safety scored well and domesticity relatively low.ConclusionHighly specialized units show strong heterogeneity in organizational characteristics and management, which can be understood in the light of the pioneering phase. Despite this, similarities were found in nursing staff roles, frequent multidisciplinary evaluation, and attention to sensory stimuli.

An emergency department transitional care team prevents unnecessary hospitalization of older adults: a mixed methods study.

Older adults with acute functional decline may visit emergency departments (EDs) for medical support despite a lack of strict medical urgency. The introduction of transitional care teams (TCT) at the ED has shown promise in reducing avoidable admittances. However, the optimal composition and implementation of TCTs are still poorly defined. We evaluated the effect of TCTs consisting of an elderly care physician (ECP) and transfer nurse versus a transfer nurse only on reducing hospital admissions, as well as the experience of patients and caregivers regarding quality of care. We assessed older adults (≥ 65 years) at the ED with acute functional decline but no medical indication for admission. Data were collected on type and post-ED care, and re-visits were evaluated over a 30-day follow-up period. Semi-structured interviews with stakeholders were based on the Consolidated-Framework-for-Implementation-Research, while patient and caregiver experiences were collected through open-ended interviews. Among older adults (N = 821) evaluated by the TCT, ECP and transfer nurse prevented unnecessary hospitalization at the same rate (81.2%) versus a transfer nurse alone (79.5%). ED re-visits were 15.6% (ECP and transfer nurse) versus 13.5%. The interviews highlighted the added value of an ECP, which consisted of better staff awareness, knowledge transfer and networking with external organizations. The TCT intervention in general was broadly supported, but adaptability was regarded as an important prerequisite. Regardless of composition, a TCT can prevent unnecessary hospitalization of older adults without increasing ED re-visiting rates, while the addition of an ECP has a favourable impact on patient and professional experiences.

How to enhance standardized and structured recording by elderly care physicians for the reuse of EHR data?: an interview study (Preprint)

How to enhance standardized and structured recording by elderly care physicians for the reuse of EHR data?: an interview study (Preprint)

Physicians’ views on the role of relatives in euthanasia and physician-assisted suicide decision-making: a mixed-methods study among physicians in the Netherlands

BackgroundRelatives have no formal position in the practice of euthanasia and physician-assisted suicide (EAS) according to Dutch legislation. However, research shows that physicians often involve relatives in EAS decision-making. It remains unclear why physicians do (not) want to involve relatives. Therefore, we examined how many physicians in the Netherlands involve relatives in EAS decision-making and explored reasons for (not) involving relatives and what involvement entails.MethodsIn a mixed-methods study, 746 physicians (33% response rate) completed a questionnaire, and 20 were interviewed. The questionnaire included two statements on relatives’ involvement in EAS decision-making. Descriptive statistics were used, and multivariable logistic regression analyses to explore characteristics associated with involving relatives. In subsequent interviews, we explored physicians’ views on involving relatives in EAS decision-making. Interviews were thematically analysed.ResultsThe majority of physicians want to know relatives’ opinions about an EAS request (80%); a smaller group also takes these opinions into account in EAS decision-making (35%). Physicians who had ever received an explicit EAS request were more likely to want to know opinions and clinical specialists and elderly care physicians were more likely to take these opinions into account. In interviews, physicians mentioned several reasons for involving relatives: e.g. to give relatives space and help them in their acceptance, to tailor support, to be able to perform EAS in harmony, and to mediate in case of conflicting views. Furthermore, physicians explained that relatives’ opinions can influence the decision-making process but cannot be a decisive factor. If relatives oppose the EAS request, physicians find the process more difficult and try to mediate between patients and relatives by investigating relatives’ objections and providing appropriate information. Reasons for not taking relatives’ opinions into account include not wanting to undermine patient autonomy and protecting relatives from a potential burdensome decision.ConclusionsAlthough physicians know that relatives have no formal role, involving relatives in EAS decision-making is common practice in the Netherlands. Physicians consider this important as relatives need to continue with their lives and may need bereavement support. Additionally, physicians want to perform EAS in harmony with everyone involved. However, relatives’ opinions are not decisive.

Aftercare Provision for Bereaved Relatives Following Euthanasia or Physician-Assisted Suicide: A Cross-Sectional Questionnaire Study Among Physicians.

Objectives: Relatives of patients who died after euthanasia or physician-assisted suicide (EAS) might need (specific) aftercare. We examined if and how physicians provide aftercare to bereaved relatives of patients who died after EAS, and which patient-, physician- and process characteristics are associated with providing aftercare. Methods: A cross-sectional questionnaire study was conducted among 127 physicians (general practitioners, clinical specialists, and elderly care physicians) in the Netherlands. Associations were examined using multivariable logistic regression analyses. Results: Most physicians had had at least one follow-up conversation with bereaved relatives (77.2%). Clinical specialists less often provided aftercare compared to GPs. Also, aftercare was more often provided when the deceased had a cohabiting partner. Topics addressed during aftercare conversations included looking back on practical aspects of the EAS trajectory, the emotional experience of relatives during the EAS trajectory and relatives' current mental wellbeing. A minority of aftercare conversations led to referral to additional care (6.3%). Conclusion: Aftercare conversations with a physician covering a wide-range of topics are likely to be valuable for all bereaved relatives, and not just for "at risk" populations typically targeted by policies and guidelines.

Engaging healthcare professionals in refining the target group of a new care type: The Acute Geriatric Community Hospital (AGCH) referral decision study

Background: The acute geriatric community hospital (AGCH) is an alternative to conventional hospitalisation of older adults. At the AGCH, patients receive acute medical specialist treatment in combination with early rehabilitation in an fitting environment by an interdisciplinary team of professionals. Ambiguity exists on the exact definition of the target group for the AGCH and the difference with the target groups for bed-based intermediate care and geriatric hospital care models.
 Objective: Limited guidelines and methods exist to refine the target group of new care model or (complex) health interventions. The aim of this study was to provide refined assessment criteria for the AGCH by using a target-group refinement procedure with case vignettes.
 Design: A design based research using qualitative research techniques. 
 Setting: Two pioneer sites who have an AGCH in their region and seven pioneer sites who have the ambition to implement an AGCH in their region.
 Subjects: A total of 20 healthcare professionals (elderly care physicians, clinical geriatricians and other medical specialists, physician assistants, nurse specialists) participated in the AGCH target group refinement project, either active in hospitals (n=10) or intermediate care facilities (n=7) or skilled nursing facilities (n=3), and all involved in the implementation of an AGCH in their region.
 Methods: The developed target-group refinement procedure consisted of three phases. 1) Healthcare professionals from the pioneer sites were asked to submit case vignettes for a specific care type or an ambiguous boundary between the AGCH and other care models. These case vignettes were reviewed during 2) web-based vignette questionnaires and 3) two online working sessions. Both during phase 2 and 3, participants were asked to make a referral decision for the case vignettes they were presented with and to report their considerations during this process.
 
 Results: In total, 23 case vignettes were collected and reviewed by 18 healthcare professionals. Triage dilemmas were identified and discussed during online working sessions, following from which the AGCH assessment criteria were refined. We found that the final referral outcome is the result of an interplay of clinical and organisational triage factors.
 Conclusions: This target group refinement procedure enabled involving of a variety of healthcare professionals and was suitable to refine the AGCH assessment criteria. In a short time period, it provided us further insight into (1) the required changes to the AGCH assessment criteria; (2) the (ambiguous) boundaries between the AGCH and other care models, and (3) the considerations made by healthcare professionals during referral decision-making for older adults with an acute care need. We recommend to use this novel procedure as a tool for specifying the target group of (new) care models or healthcare interventions.

Two Approaches to Advance Care Planning for People with Dementia: Acceptability among US and Dutch Healthcare Providers

AbstractBackgroundAdvance care planning (ACP) may include concrete treatment orders or important goals or both. Providers may differ on these approaches to ACP, which may also differ across countries. We investigated the acceptability and preferences for these two ACP approaches for people with dementia among healthcare providers from the Netherlands (NL) and the US.MethodFifty providers from each country, whose specialty includes providing end‐of‐life care for people with dementia, viewed short animation videos about the two approaches of ACP and completed a semi‐structured interview. Qualitative content analysis summarized the comments of the providers on each ACP approach (reasons and conditions for acceptability, (dis)advantages, barriers and facilitators), and the reasons for their preferences.ResultExcept for three nurse practitioners from the US, all participants were physicians (e.g., NL: elderly care physicians, family physicians; US: geriatricians, internists, family medicine physicians). The acceptability and preferences were similar in the two countries. Both approaches were considered acceptable for people with dementia by the vast majority of providers (concrete orders approach: 86% (both countries); important goals approach: 96% (NL) and 98% (US)). Slightly more providers preferred the important goals approach compared to the concrete one (NL: 42% vs. 34%; US: 46% vs. 36%), others had no preference. While the concrete approach may facilitate immediate decisions in emergent situations and may be easier for providers to conduct with available forms, the important goals approach takes the life view of the person with dementia into consideration, can be implemented in more situations and may be easier for the person with dementia. Differences between the two countries included the role of the family caregivers and the power of providers to make decisions.ConclusionProviders found both approaches acceptable, but there was diversity in the preferred approach in both countries. Future research should investigate how the preference of individual providers interacts with the preferences of people with dementia and family caregivers, and whether this influences the experience of ACP and subsequent care provision. Examining administrative, legal, and educational issues that may shape preferences may inform more patient‐centered ACP.

P160: Electroconvulsive therapy for neuropsychiatric symptoms in dementia: survey among Dutch physicians

Objective:Neuropsychiatric symptoms (NPS) are common in people with dementia and have a negative effect. Commonly used pharmacological and psychosocial interventions are not always effective and NPS can become refractory. Electroconvulsive therapy (ECT) may be effective for (severe) agitation and aggression and is well tolerated. Nevertheless, its application seems limited in the Netherlands. We explored the application of and attitudes of physicians towards ECT for (severe) NPS in older people with dementia in the Netherlands.Methods:A survey study among geriatricians, elderly care physicians and old-age psychiatrists in the Netherlands in July 2020. An online invitation was included in the digital newsletter of the professional society or directly sent to the professional network of one of the authors (in case of old-age psychiatrists). The questionnaire included 20 closed- and open ended questions on demographic characteristics, experiences with (consideration of) referral for/application of ECT and attitudes towards ECT.Results:Sixty-one respondents completed the survey, eight had ever considered ECT. Two of these eight referred patient(s) for depressive behavior, sometimes combined with agitation. Lack of experience, ECT not being included in guidelines for this indication, unfamiliarity with possible (side) effects and risks, ethical and practical issues were the main reasons of the respondents for not considering ECT. Most respondents were open to referring patients with dementia for ECT to treat (severe) NPS, specifically in case of refractory symptoms.Conclusion:Respondents are not negative about ECT, yet rarely consider it due to lack of awareness and knowledge and the ethical and practical issues related to its application. Although the response to our survey was low and the number of respondents is limited, we do feel that ECT may be an alternative for palliative sedation, which is used incidentally in cases of refractory NPS in the Netherlands. Further exploring the support base and possibilities for application of ECT-treatment for refractory NPS might therefore be worthwhile.

The effect of regional transmural agreements on the information transfer of frail older patients

IntroductionFrail older patients are at risk for many complications when admitted to the hospital. Multidisciplinary regional transmural agreements (RTA) in which guidelines were set concerning the information transfer of frail older patients might improve outcomes. We aim to investigate the effect of implementation of the RTA on the completeness of the information transfer of frail older patients when admitted to and discharged from the hospital.MethodsThis is a retrospective cohort study in which we collected data from 400 randomly selected hospitalized frail older patients (70+) before the implementation of the RTA, January through March 2021, and after, October through December 2021. The cohort was split up into four groups, which determined what correspondence would be checked (referral letter by General Practitioner (GP) and three groups of ‘hospital letters’: ED letter upon admittance, clinical discharge letter to the elderly care physician and clinical discharge letter to the GP. We assessed for mention of frailty, a medication list and mention of resuscitation orders.ResultsIn the period before implementation the mean age of patients was 82.6 years (SD 7.4) and 101 were female (50.5%), after implementation mean age was 82.3 (SD 6.9) and 112 were female (56.0%). Frailty was mentioned in hospital letters in 12.7% before and 15.3% after implementation (p = 0.09). More GP referral letters were present after implementation (32.0% vs. 54.0%, p = 0.03), however frailty was mentioned only in 12.5% before and 7.4% after (p = 0.58). There was a good handover of medication lists from the hospital (89.3% before, 94% after, p = 0.20) and even better from the GP (93.8% before, 100% after, p = 0.19). Resuscitation orders were mentioned in 59.3% of letters from the hospital before implementation and 57.3% after (p = 0.77), which is higher than in the referral letters (18.8% before and 22.2% after (p = 0.91).DiscussionThe implementation of RTA improved the number of GP referral letters present; however, it did not lead to other significant improvements in communication between the hospital and the GP’s. Frailty and resuscitation orders are still frequently not mentioned in the reports. After a successful reimplementation, the improvements of outcomes could be investigated.

Transferring people with dementia to severe challenging behavior specialized units, an in-depth exploration

Objectives One of the main reasons for people with dementia to move to a dementia special care unit of a nursing home is challenging behavior. This behavior is often difficult to manage, and in the Netherlands, residents are sometimes relocated to a severe challenging behavior specialized unit. However, relocation often comes with trauma and should be prevented if possible. This study aimed to investigate the patient- and context-related reasons for these relocations. Methods Qualitative multiple case study using individual (n = 15) and focus group interviews (n = 4 with n = 20 participants) were held with elderly care physicians, physician assistants, psychologists, nursing staff members, and relatives involved with people with dementia and severe challenging behavior who had been transferred to a severe challenging behavior specialized unit. Audio recordings were transcribed and analyzed with thematic analysis, including directed content analysis. Results After five cases, data-saturation occurred. The thematic analysis identified three main processes: increasing severity of challenging behavior, increasing realization that the clients’ needs cannot be met, and an increasing burden of nursing staff. The interaction between these processes, triggered mainly by a life-threatening situation, led to nursing staff reaching their limits, resulting in relocation of the client. Conclusion Our study resulted in a conceptual framework providing insight into reasons for relocation in cases of severe challenging behavior. To prevent relocation, the increasing severity of challenging behavior, increasing burden on nursing staff, and increasing realization that the clients’ needs cannot be met need attention.

Exploring fraity and sarcopenia in older adults admitted to acute medical unit, looking at prevalence, trajectory, and outcomes: A protocol testing the feasibility and acceptability of the TYSON study.

Frailty and sarcopenia are common in older people and are associated with adverse outcomes including increased mortality and morbidity. It is unclear whether screening for frailty and sarcopenia would identify specific populations most at risk of poor outcomes during unplanned hospital admissions, which screening tools should be used and what the trajectory of both conditions are over the course of an admission. The TYSON study is an observational cohort study aiming to determine the prevalence, trajectory and outcomes associated with frailty and sarcopenia in different patient cohorts. This protocol tests the feasibility and acceptability of TYSON processes. To determine in acutely admitted medical patients who are older adults: Primary: The feasibility and acceptability of frailty and sarcopenia assessments; Secondary: (1) Differences in community and hospital frailty assessments, as assessed by the medical team, the patient and elderly care physicians, (2) The dynamic changes in frailty and sarcopenia during a hospital admission, and patient outcomes; Exploratory: Inflammatory and metabolic mediators associated with frailty and sarcopenia. A single centre, prospective observational study including patients aged ≥ 65 years admitted to an acute medical unit. Frailty assessments include the Rockwood clinical frailty and e-frailty index. Sarcopenia assessments include the Bilateral Anterior Thigh Thickness (BATT) measurement. Each participant will be asked to complete 5 visits, at day 0, day 3, day 7, month 3 and month 6. Blood samples will be collected to explore inflammatory and metabolic markers associated with frailty and sarcopenia. The study and protocol have been ethically approved by the Health Research Authority (REC 20/WA/0263). The study will determine the feasibility and acceptability of frailty and sarcopenia assessments in an acute hospital setting, and inform on the prevalence, trajectory and associated outcomes of frailty and sarcopenia in this group of patients. An inflammatory and metabolic profile will be explored in frailty and sarcopenia.

The role of medical speciality input in the management of older neurosurgical inpatients

Background With an increasing elderly population, the number of neurosurgical patients aged 65 and over is rising. Ageing is closely related to multimorbidity and frailty, which are both recognised risk factors for postoperative complications and mortality. Comanagement by geriatricians and surgeons has been shown to reduce the length of admission and improve postoperative outcomes in orthopaedics, but evidence for this in neurosurgical patients is limited. Aims To evaluate the demographics of the elderly neurosurgical population, and determine if input by medical teams or completion of frailty scores impacts patient outcomes. Methods A retrospective notes review and review of coding and HES data, including length of stay, number of comorbidities, and mortality rate, was collected for geriatric neurosurgery and spinal surgery patients 65 years and older who were discharged following inpatient admission from April 2019 – March 2020. Full medical notes were retrieved for patients with a length of stay exceeding 14 days, with data on frailty scores and involvement of medical teams collected. Statistical tests were applied to evaluate the difference in outcomes between those reviewed and those not reviewed by medical teams. Results Eighty-one patients had a length of stay over 14 days. 43% of these 81 patients were reviewed by medical teams during their admission. The mean length of stay was significantly shorter in those receiving medical input (22.8 ± 10.6 days vs 32.4 ± 16.0 days, p = 0.003). There was also a significant association between the completion of a frailty score and subsequent input by medical teams. Conclusions The reduction in length of stay observed when patients were reviewed by medical teams supports the role of elderly care physician comanagement in the elderly inpatient neurosurgical population.

The development ofindicators to measure the quality ofcare ingeriatric rehabilitation.

Quality of care is an essential aspect of geriatric rehabilitation. Usually, there are national standards for the quality of care or indicators to measure the quality of care. However, this is not the case for geriatric rehabilitation. Therefore, the aim of this study was to develop structure, process, and outcome indicators to measure the quality of geriatric rehabilitation. To develop quality indicators for geriatric rehabilitation, a literature search was performed to identify indicators for all types of rehabilitation that can also be suitable for geriatric rehabilitation. Thereafter, in the qualitative phase, different stakeholders were inte. Indicators from the literature and indicators developed based on the interviews were merged and processed in a questionnaire. Through this questionnaire, elderly care physicians and managers of geriatric rehabilitation facilities were asked to rate the indicators on relevance and feasibility. Indicators that were considered relevant and feasible by the respondents were included in the final quality indicator set for geriatric rehabilitation. Thirty-six indicators suitable for geriatric rehabilitation were identified from the literature. Additionally, 55 quality indicators were developed based on the interviews. Merging the indicators and omitting duplicates resulted in 69 quality indicators. Analysis of the data from the questionnaires resulted in a final set of 27 quality indicators for geriatric rehabilitation that consists of 17 structure, 8 process, and 2 outcome indicators. This study contributes to the quality of geriatric rehabilitation by providing a first set of quality indicators ready to use in practice. Follow-up research is recommended and may include an assessment of the applicability, reliability, and validity of the developed indicator set.

Advance Care Planning in Huntington Disease: The Elderly Care Physician's Perspective

ObjectiveHuntington disease (HD) has a poor prognosis. Decision-making capacity and communication ability may become impaired as the disease progresses. Therefore, HD patients are encouraged to engage in advance care planning (ACP). Elderly care physicians (ECPs) can play an important role in ACP in HD patients. However, little is known about their experiences in this role. The aim of this study is to gain insight into how ECPs practice ACP with HD patients. DesignA qualitative interview study. Setting and ParticipantsNine ECPs working in HD-specialized nursing homes in the Netherlands. MethodsWe conducted semistructured interviews with ECPs between June 2018 and July 2020. ResultsTwo phases could be identified in the process of ACP. In the first phase, when the feared future seems to be far away, the ECP asks about the patient's wishes for the future in an accommodating manner. In the second phase, when the feared future is closer, future medical treatment and care becomes less hypothetical. Agreement has to be reached on upcoming treatment decisions. In this phase, the ECP takes a more guiding role, and consequently encounters more difficulties, such as maintaining a positive patient/family-physician relationship while dealing with disagreements with patient or family. Most participants shared their experiences with euthanasia when asked about ACP. When making a comparison of ACP between HD patients and patients with other neurodegenerative disorders in nursing homes, the ECPs emphasized the similarities. Conclusions and ImplicationsACP in HD can be classified into 2 phases, which differ in ECPs’ approach and the complexity experienced by the ECP. Awareness of this finding may help to further develop training and education in ACP, including dealing with euthanasia, to make ECPs feel better equipped in practicing ACP in HD.

Advance Care Planning in the Netherlands

The Dutch health care system fosters a strong public health sector offering accessible generalist care including generalist palliative care. General practitioners are well positioned to conduct ACP, for example, to continue or initiate conversations after hospitalization. However, research shows that ACP conversations are often ad hoc and in frail patients, ACP is often only initiated when admitted to a nursing home by elderly care physicians who are on the staff. Tools that raise awareness of triggers to initiate ACP, screening tools, information brochures, checklists and training have been developed and implemented with funding by national programs which currently focus on implementation projects rather than or in addition to, research. The programs commonly require educational deliverables, patient and public involvement and addressing diversity in patient groups. A major challenge is how to implement ACP systematically and continuously across sectors and disciplines in a way that supports a proactive yet person-centered approach rather than an approach with an exclusive focus on medical procedures. Digital solutions can support continuity of care and communication about care plans. Solutions should fit a culture that prefers trust-based, informal deliberative approaches. This may be supported by involving disciplines other than medicine, such as nursing and spiritual caregiving, and public health approaches.

Priority measures to prevent infections and maintain residents’ well-being during COVID-19 outbreaks in nursing homes: Consensus among staff and resident representatives determined in an online nominal group technique study

BackgroundCOVID-19 infection prevention measures can negatively impact nursing home residents’ well-being. Society has been concerned about the imbalance between infection prevention and residents’ well-being, and about nursing home residents’ autonomy in COVID-19 policymaking. ObjectiveThis study explores consensus among nursing home staff about which measures they found to be most important in contributing to preventing infections and to maintaining well-being of residents during COVID-19 outbreaks. In addition, this study explores the decision-making processes regarding COVID-19 measures and the involvement of residents or their representatives. DesignMixed methods based on an online nominal group technique. Setting(s)Dutch nursing homes, June–November 2020. ParticipantsManagers, policy advisors, elderly care physicians, psychologists, a spiritual counselor, nurses, care assistants, and resident representatives (N = 35). MethodsFour panels from the viewpoint of infection prevention, and four panels from the viewpoint of well-being were performed with 3 to 7 participants per panel. Participants individually selected the measure they found most important, discussed these measures together in an online conversation, and rated the importance and urgency of these measures during COVID-19 outbreaks on a 5-point Likert scale. The measures that were rated as (very) important and (very) urgent by all members of that panel were defined as ‘prioritized in consensus’. Panels also discussed the decision-making process regarding COVID-19 measures and the involvement of residents or their representatives. These conversations were transcribed verbatim and thematically coded using an inductive approach. ResultsThe infection prevention panels prioritized isolation measures; testing measures; testing and isolation combinations; use of personal protective equipment around (suspected) infected residents; and preparation for outbreaks by COVID-19 outbreak teams. The well-being panels prioritized cohort isolation, testing combined with cohort isolation and with isolation in residents’ rooms, exceptions to visitor bans, maximum numbers of visitors, and registration and accompanying visitors to the residents’ rooms. Resident representatives and staff were dissatisfied with their reduced involvement in policy making during the first months of the COVID-19 pandemic, although they understood that decisions had to be made quickly. ConclusionsStaff and resident representatives should be involved in COVID-19 policy making. According to them, priority COVID-19 measures should include: cohort isolation, testing and isolation combinations, use of personal protective equipment, crisis management by COVID-19 outbreak teams, and nursing home visit regulations and instruction of visitors. Combining these measures may be a first step towards packages of COVID-19 measures that better balance infection prevention and maintaining residents’ well-being. RegistrationN/A Tweetable abstractPriority COVID-19 nursing home measures are isolation, testing, testing and isolation combinations, PPE use, preparations by outbreak teams, and visit regulations @wilcoachterberg

Usability of an app-based clinical decision support system to monitor psychotropic drug prescribing appropriateness in dementia

BackgroundGuidelines recommend reluctant psychotropic drug (PD) prescribing in nursing home residents with dementia and neuropsychiatric symptoms (NPS), as efficacy of PDs is limited, and side effects are common. Nevertheless, PDs are commonly prescribed to reduce NPS. A smartphone application that evaluates appropriateness of PD prescriptions and provides recommendations from the revised Dutch guideline on problem behaviour in dementia may promote guideline adherence and increase appropriate prescribing. ObjectiveThis study aimed to assess user experiences, barriers and facilitators of the Dutch ‘Psychotropic Drug Tool’ smartphone application (PDT) in the context of appropriate prescribing of PDs to nursing home residents with dementia and NPS. Methods/designThe PDT was developed according to the recommendations of the Dutch guideline for treatment of NPS in people with dementia. Feedback provided during usability testing with two end-users was applied to improve the PDT before implementation in day-to-day practice. Sixty-three prescribers were asked to use the PDT at their own convenience for four months. User expectations and experiences were assessed at baseline and after four months with the System Usability Scale and the Assessment of Barriers and Facilitators for Implementation. ResultsExpected usability (M = 72.59; SD = 11.84) was similar to experienced usability after four months (M = 69.13; SD = 16.48). Appreciation of the PDTs user-friendliness (on average 6.7 out of 10) and design (7.3) were moderately positive, in contrast to the global rating of the PDT (5.7). Perceived barriers for PDT use were time consumption and lack of integration with existing electronic systems. Perceived facilitators were ease of use and attractive lay out. For broader implementation, physicians suggested a change in direction of the PDT: start assessment of appropriateness based on the list of NPS instead of PD as primary input. ConclusionsIn this pragmatic prospective cohort study we found that the PDT was used by elderly care physicians, with mediocre user satisfaction. The PDT will be optimized based on user feedback regarding experienced usability, barriers and facilitators, after which broader implementation can be initialized.The Medical Ethics Review Board of the University Medical Center Groningen declared this is a non-WMO study (UMCG RR Number: 201800284).

Naar een toekomstbestendige medische zorg voor ouderen met complexe multimorbiditeit door interprofessionele samenwerking: leren van ervaringen uit de langdurige zorg

delivering medical care of appropriate quality to older people with complex multimorbidity will be challenging in the next few decades and is already under pressure in the long term care setting. Interprofessional collaboration between elderly care physicians, nurse practitioners and physician assistants can contribute to the sustainability of this care. to describe the experience with interprofessional collaboration of physicians, nurse practitioners and physician assistants in long term care and get insight in facilitators and challenges for it. focus group interviews were conducted with elderly care physicians, nurse practitioners and physician assistants from several long term care organisations were conducted, who collaborated as professionals for some time. interprofessional collaboration was valued positively. Themes emerging from the interviews were: 'scarcity of physicians as reason employing nurse practitioners and physician assistants'; 'unfamiliarity with competencies of nurse practitioners and physician assistant among physicians'; 'trust'; 'added value'; 'absence of protocols/formats' and 'legal and regulation barriers'. the emerging themes fit within an existing theoretical model about development of interprofessional collaboration. The development of interprofessional collaboration in long term care fits in the first phases of this model. Important steps for realizing further interprofessional collaboration in daily practice is being aware of and valuing each other's competencies. Also formats that describe competencies and collaboration procedures are considered helpful. Positive for further development is the recent formal support of the three professional organisations together, offering perspective for sustainability of medical care for older people with complex multimorbidity in the coming decades.].

The role of Dutch guidelines in the diagnostic outcomes and treatment decisions of hospitalised older adults with a suspected urinary tract infection: a retrospective cohort study.

Urinary tract infections (UTIs) are highly prevalent and difficult to diagnose in older adults. We aimed to evaluate the applicability of Dutch Association of Urology (NVU) and Dutch Association of Elderly Care Physicians (Verenso) guidelines in terms of diagnostic outcomes and treatment decisions in hospitalised older adults with suspected UTIs. A retrospective cohort study was conducted on 225 geriatric patients with a urine culture taken in 2019, to determine conformity of the studied population to NVU and Verenso. Of 225 patients with suspected UTI (mean age 86years; 56.4% female), 67.6% had urinary tract-related symptoms, of whom 96 received antibiotics, including those with a negative urine dipstick (n = 12) or urine culture (n = 28). Hundred seventy-seven and 147 patients were assessed and treated conforming to the NVU and Verenso guidelines, respectively. The 38 patients who were assessed and treated non-conforming to NVU, including patients with negative urine diagnostics, received antibiotics more often compared with 177 patients treated conforming to NVU (p < 0.001). A large number of patients with negative urine tests were treated conforming to Verenso and antibiotics were withheld in 75.5% of the patients. The non-conforming Verenso-treated patients with prescribed antibiotics had significantly more negative dipstick results (p = 0.05), fewer urinary tract-related symptoms (p < 0.001) and more often a different infectious focus (p < 0.001). The common practice performed on the studied geriatric population was more in accordance with the NVU guideline than Verenso. The results indicated that compliance with the guidelines might lead to fewer antibiotic prescriptions in the study population.