Nursing Home Physicians Research Articles

Nursing Home Physicians’ Assessments of Barriers and Strategies for End-of-Life Care in Norway and The Netherlands

ObjectivesWorking conditions in nursing homes (NHs) may hamper teamwork in providing quality end-of-life (EOL) care, especially the participation of NH physicians. Dutch NH physicians are specialists or trainees in elderly care medicine with NHs as the main workplace, whereas in Norway, family physicians usually work part time in NHs. Thus, we aimed at assessing and comparing NH physicians’ perspectives on barriers and strategies for providing EOL care in NHs in Norway and in The Netherlands. DesignA cross-sectional study using an electronic questionnaire was conducted in 2015. Setting and ParticipantsAll NH physicians in Norway (approximately 1200–1300) were invited to participate; 435 participated (response rate approximately 35%). Of the total 1664 members of the Dutch association of elderly care physicians approached, 244 participated (response rate 15%). MeasurementsWe explored NH physicians’ perceptions of organizational, educational, financial, legal, and personal prerequisites for quality EOL care. Differences between the countries were compared using χ2 test and t-test. ResultsMost respondents in both countries reported inadequate staffing, lack of skills among nursing personnel, and heavy time commitment for physicians as important barriers; this was more pronounced among Dutch respondents. Approximately 30% of the respondents in both countries reported their own lack of interest in EOL care as an important barrier. Suggested improvement strategies were routines for involvement of patients’ family, pain- and symptom assessment protocols, EOL care guidelines, routines for advance care planning, and education in EOL care for physicians and nursing staff. ConclusionsInadequate staffing levels, as well as lack of competence, time, and interest emerge as important barriers to quality EOL care according to Dutch and Norwegian NH physicians. Their perspectives were mostly similar, despite large educational and organizational differences. Key strategies for improving EOL care in their facilities comprise education and incorporating available palliative care tools and systems.

Supporting clinical rules engine in the adjustment of medication (SCREAM): protocol of a multicentre, prospective, randomised study

BackgroundIn the nursing home population, it is estimated that 1 in every 3 patients is polymedicated and given their considerable frailty, these patients are especially prone to adverse drug reactions. Clinical pharmacist-led medication reviews are considered successful interventions to improve medication safety in the inpatient setting. Due to the limited available evidence concerning the benefits of medication reviews performed in the nursing home setting, we propose a study aiming to demonstrate a positive effect that a clinical decision support system, as a health care intervention, may have on the target population. The primary objective of this study is to reduce the number of patients with at least one event when using the clinical decision support system compared to the regular care. These events consist of hospital referrals, delirium, falls, and/or deaths.Method/DesignThis study is a multicentre, prospective, randomised study with a cluster group design. The randomisation will be per main nursing home physician and stratified per ward (somatic and psychogeriatric). In the intervention group the clinical decision support system will be used to screen medication list, laboratory values and medical history in order to obtain potential clinical relevant remarks. The remarks will be sent to the main physician and feedback will be provided whether the advice was followed or not. In the control group regular care will be applied.DiscussionWe strongly believe that by using a clinical decision support system, medication reviews are performed in a standardised way which leads to comparable results between patients. In addition, using a clinical decision support system eliminates the time factor to perform medication reviews as the major problems related to medication, laboratory values, indications and/or established patient characteristics will be directly available. In this way, and in order to make the medication review process complete, consultation within healthcare professionals and/or the patient itself will be time effective and the medication surveillance could be performed around the clock.Trial registrationThe Netherlands National Trial Register NTR5165. Registered 2nd April 2015.

The perspective of frail elderly on their care networks in primary care

Introduction : Integration of care services is crucial for high quality elderly care. Multidisciplinary primary care networks who deliver integrated care to frail elderly consists of general practitioners, home care professionals, nursing home physician specialists, elderly counsellors, physiotherapists and others. It is known that soft factors of cooperation can influence the quality of care positively. However, little is known about the way in which patients experience soft factors such as culture (shared values), professionalism, team spirit and leadership. More is known about hard factors of cooperation. These factors regard to participants in the networks, interconnecting between participants and the strength of these correlations. In this research project we experimented whether it was possible to make professional care networks with frail elderly and reflect on hard and soft factors of collaboration. Methods : We selected four primary care networks, which were known for their innovative way of organizing elderly care. From these, we interviewed 44 frail elderly about the composition and functioning of their care network. During these interviews, we used questionnaires to map background characteristics. In open questions we related to soft elements of cooperation between professionals. We asked the respondents about the hard factors of cooperation using a social network map. They were asked about the participants in their professional care and welfare network (including their most important informal care giver), the frequency of contact with the care professionals, the quality of the contact, cooperation between the members of the network and the quality of the co-operation. The interviews we transcribed verbatim and analyzed qualitatively with Atlas-ti 7.1.. The quantitative data were processed and analyzed with SPSS. The information about the professional networks of the elderly was analyzed using SPSS, entered into Excel and processed into network figures using UCINET. Results : We were able to analyze 44 interviews (male/female 30%/70%, average age 84). The care networks consisted in average of nine care and welfare professionals. The frail elderly were well able to respond to questions about the hard factors of cooperation . They were able to mention the most important participants in their care networks spontaneously and reflect on their cooperation. Questions about the quality of cooperation proved difficult to answer. The GP is for frail elderly the central person in care. Most frequently, cooperation between the GP and home care professionals is mentioned. Elderly observe less cooperation from the GP with the physiotherapist and the welfare professionals. The cooperation between the GP and the informal care givers differs between the four care networks (25-50%). We found a little over one thousand quotes about soft factors of cooperation. It proved easier for the respondents to reflect on the quality of professionals and patient centeredness then on the way in which professionals work together or culture in multidisciplinary teams. One third of the respondents could tell us something about the existence of multidisciplinary team meetings. Only three elderly were able to tell us in detail about the cooperation between professionals. Perceived quality of care was found to correlate with the experienced continuity of care. Negative experiences correlated with the absence of continuity in home care. Experienced continuity between the GP and the district nurse correlated positively with quality of care. We didn’t find a relation between the presence of a care coordinator and the experienced continuity of care. Discussion : It is possible to draw up professional care networks with frail elderly. With help of a trained interviewer they are able to tell something mainly about the ‘hard’ factors. Often, an overview of the organisation of their care is missing. It turned out to be difficult for respondents to tell us something about the soft factors of cooperation. Respondents usually related to questions on this matter in terms of an impression. It is easier to tell something about practical cooperation shown by references, letters, sometimes consultations on coordination of care. Much of what happened behind the scenes eludes the eye of the elderly. Conclusion : This study was a case study and an experiment in gaining more insight in the way which frail elderly perceive hard and soft factors of collaboration. A next step would be to follow up the multidisciplinary teams in their improvement of integrated care for frail elderly, based on the outcomes of the interviews with their patients in a participatory action research approach.

Clinical diagnosis of heart failure in nursing home residents based on history, physical exam, BNP and ECG: Is it reliable?

IntroductionHeart failure (HF) is highly prevalent in nursing home residents. To diagnose HF properly, echocardiography is recommended by cardiology guidelines. In nursing homes, the nursing home physician (NHP) usually diagnoses HF based on history, clinical examination, electrocardiography (ECG) and levels of B-type natriuretic peptide only, which is in contrast to the cardiologist who probably always will apply for an echocardiogram. Therefore, we aimed (1) to investigate the agreement on the diagnosis of HF made by the NHP without echocardiography and (2) to determine the clinical characteristics that may contribute to the proper diagnosis of HF in nursing home residents. Materials and methodsThe study followed a cross-sectional design. Nursing home residents in the southern part of the Netherlands, aged over 65 years and receiving long-term somatic or psychogeriatric care, were included in the study. The NHP decided (stepwise) on the diagnosis of HF; first after anamnesis and physical examination, second after additional information on NTproBNP and ECG, and finally, on all available information, except echocardiography. An expert team consisting of two cardiologists and one hospital geriatrician decided on the final diagnosis, based on all available information. Results and conclusionThere was an overall agreement on both correctly identifying residents with HF and correctly excluding HF of 80.4% (kappa 0.57). Characteristics with a high contribution in predicting HF were a history of HF, a high NT-proBNP level, the presence of rales, arrhythmias and use of cardiac medication. NHPs are fairly capable of diagnosing HF in nursing home residents without echocardiography.

Give Serious Thought Before Starting Antipsychotics in Delirious Elders

Give Serious Thought Before Starting Antipsychotics in Delirious Elders

Discussing end-of-life issues in nursing homes: a nationwide study in France.

discussing end-of-life issues with nursing home residents and their relatives is needed to ensure patient-centred care near the end of life. this study aimed to estimate the frequency of nursing home physicians discussing end-of-life issues with residents and their relatives and to investigate how discussing end-of-life issues was associated with care outcomes in the last month of life. post-mortem cohort study in a nationwide, representative sample of 78 nursing home facilities in France. Residents who died from non-sudden causes between 1 October 2013 and 31 May 2014 in these facilities were included (n = 674). end-of-life issues were discussed with at most 21.7% of the residents who died during the study period. In one-third of the situations (32.8%), no discussion about end-of-life-related topics ever occurred, either with the resident or with the relatives. Older people with severe dementia were less likely to have discussed more than three of the six end-of-life topics we investigated, compared with residents without dementia (OR = 0.17, 95% CI = 0.08-0.22). In the last month of life, discussing more than three end-of-life issues with the residents or their relatives was significantly associated with reduced odds of dying in a hospital facility (adjusted OR = 0.51, 95% CI = 0.33-0.79) and with a higher likelihood of withdrawing potentially futile life-prolonging treatments (adjusted OR = 2.37, 95% CI = 1.72-3.29). during the last months of life, discussions about end-of-life issues occurred with only a minority of nursing home decedents, although these discussions may improve end-of-life care outcomes.

Nursing Home Provider Perceptions of Telemedicine for Reducing Potentially Avoidable Hospitalizations

ObjectivePotentially avoidable hospitalizations (PAHs) of nursing home (NH) residents are common, costly, and can have significant economic consequences. Telemedicine has been shown to reduce emergency department and hospitalization of NH residents, yet adoption has been limited and little is known about provider's perceptions and desired functionality for a telemedicine program. The goal of this study was to survey a nationally representative sample of NH physicians and advanced practice providers to quantify provider perceptions and desired functionality of telemedicine in NHs to reduce PAHs. Design/Setting/Participants/MeasurementWe surveyed physicians and advanced practice providers who attended the 2015 AMDA–The Society for Post-Acute and Long-Term Care Medicine Annual Conference about their perceptions of telemedicine and desired attributes of a telemedicine program for managing acute changes of condition associated with PAHs. ResultsWe received surveys from 435 of the 947 conference attendees for a 45.9% response rate. Providers indicated strong agreement with the potential for telemedicine to improve timeliness of care and fill existing service gaps, while disagreeing most with the ideas that telemedicine would reduce care effectiveness and jeopardize resident privacy. Responses indicated clear preferences for the technical requirements of such a program, such as high-quality audio and video and inclusion of an electronic stethoscope, but with varying opinions about who should be performing the consults. ConclusionAmong NH providers, there is a high degree of confidence in the potential for a telemedicine solution to PAHs in NHs, as well as concrete views about features of such a solution. Such consensus could be used to drive an approach to telemedicine for PAHs in NHs that retains the theoretical strengths of telemedicine and reflects the needs of facilities, providers, and patients. Further research is needed to objectively study the impact of successful telemedicine implementations on patient, provider, and economic outcomes.

Society for Vascular Surgery Calls for Caution in PAD Care

Society for Vascular Surgery Calls for Caution in PAD Care

"Everyone else gets ice cream here more often than I do--It burns me up"--Perspectives on Diabetes Care from Nursing Home Residents and their Doctors.

BackgroundTo explore the perspectives of nursing home (NH) residents with diabetes and their doctors regarding the burdens of living with diabetes and diabetes treatments.MethodsQualitative study of nursing home residents aged 65 and older with diabetes (n = 14) and nursing home physicians (n = 9) at a Department of Veterans Affairs nursing home (known as the Community Living Center). A semi-structured interview was used to elicit nursing home residents’ and physicians’ perspectives on the burden of diabetes and diabetes treatments. Transcripts were analyzed using constant comparative methods.ResultsThe mean age of the nursing home residents was 74; Most (93 %) were male and 50 % self-identified themselves as white. The mean age of nursing home physicians was 39 and 55 % were geriatricians. Dietary restrictions, loss of independence and fingersticks/insulin were noted to be the most burdensome aspects of diabetes. Nursing home residents with a more positive outlook were generally more engaged in their care, while nursing home residents with a more pessimistic outlook were less engaged, allowing their physicians to assume complete control of their care. While physicians noted the potential negative impact of dietary restrictions, nursing home residents’ comments suggest that physicians underestimate the burden of dietary restrictions.ConclusionsVeterans Affairs nursing home residents were substantially burdened by their diabetes treatments, especially dietary restrictions and fingerstick monitoring. Since there is little evidence that dietary restrictions improve outcomes, fewer dietary restrictions may be appropriate and lead to lower treatment burdens for nursing home residents with diabetes.Electronic supplementary materialThe online version of this article (doi:10.1186/s12877-016-0199-0) contains supplementary material, which is available to authorized users.

Usually Available Clinical and Laboratory Data Are Insufficient for a Valid Medication Review: A Crossover Study.

To establish the quality of medication reviews performed by nursing home physicians, general practitioners and pharmacists. 15 Pharmacists, 13 general practitioners and 18 nursing home physicians performed a medication review for three cases (A, B and C), at three evaluation moments. First, they received the medication list. Secondly, they also received laboratory results and reason for admission and finally, we added medical history. Remarks were divided into 6 categories, i.e. indication without medication, medication without indication, contraindications/ interactions, dosage problems, double medication and wrong medication. Remarks were compared to the remarks made by our expert panel and scored according to our grading model as appropriate (0 to +3) or missed or potentially harmful (-1). For each medication error category, the percentage of participants who made this error was computed. After the first evaluation moment, the overall estimated mean percentage score was -1.7% for case A, 3.9% for case B, and 8.7% for case C. After the second review, this score was 15.0% for case A, 19.8% for case B, and 22.2% for case C. This further increased to 30.0% for case A, 36.7% for case B and 44% for case C at the final evaluation. The absence of medication where there was an indication (indication without medication) was frequently missed and did not improve after adding the extra information regarding laboratory results, reason for admission and finally medical history. Increasing clinical information helps physicians and pharmacists to improve their medication reviews, however, additional information was still related with a high margin of error. Detection of certain errors becomes easier with additional information, whereas other errors remain undetected. To achieve a high standard of medication review, we have to change the way medication reviews should be performed.

Eye Care by Dutch Nursing Home Physicians: A Descriptive Study

<p>Currently, 4% of older adults reside in long-term care facilities in the Netherlands. Nursing home residents tend to have multimorbidity that is associated with considerable disabilities and a high level of care dependency. In the Dutch adult population the highest estimated prevalence (>40%) of visual impairment (low vision and blindness) was found in the subgroup of residents in nursing homes (NHs). The aim of this study is to describe the current practice of eye care by Dutch nursing home physicians (NHPs).</p><p>A digital online survey was developed to describe the eye care activities of nursing home physicians and their cooperation in this perspective with other professionals.</p><p>Of 1573 NHPs present in the Netherlands, 125 (8%) responded.</p><p>Results show that more than 50% of the NHPs regularly examine ‘distant vision’, ‘near vision’ and ‘the visual field’. However, 23%, 33% and 45% almost never or never examine the ‘visual field’, ‘near vision’ and ‘distant vision’, respectively. Data regarding eye care, regularly recorded in the client files by more than 50% of the NHPs, are medical data involving ‘use of eye medication’, ‘eye disease’, and ‘eye surgery in the past’. Less commonly recorded is ‘the use of reading glasses’ as well as ‘eye pain’.</p><p>Inside of the NH, (head) nurses and ward nurses (chi<sup>2</sup> = 309, df = 5, p = 0.000), and outside of the NH, ophthalmologists and low vision specialists are most frequently contacted about eye related issues (chi<sup>2</sup> = 224, df = 4, p = 0.000). Opticians are rarely contacted, and optometrists and orthoptists are ‘never’ contacted by more than 50% of the NHPs. Moreover, 50% of the NHPs noted that collaboration with external eye care professionals is ‘not structural’.</p><p>This study shows that, according to NHPs, relevant visual aspects are not structurally examined and recorded in the client files. Outside of the NH, NHPs tend to have a less frequent collaborative relationship with optometrists, orthoptists and opticians compared to ophthalmologists and low vision specialists. The NHP’s role in providing eye care can be improved by development of guidelines for structural eye screening, improvement of recording in client files, and exploring plus undertaking collaboration with other eye care professionals.</p>

The Practice of Continuous Palliative Sedation in Long-Term Care for Frail Patients with Existential Suffering.

Some guidelines and recommendations identify existential suffering as a potential refractory symptom for which continuous palliative sedation (CPS) can be administered under certain conditions. However, there has been little research on the characteristics of patients with existential suffering treated with CPS and the degree to which the preconditions are fulfilled. The aim of this study was to provide insight into this specific indication for CPS. Questionnaires were sent to nursing home physicians in The Netherlands, who described 314 patients. Existential suffering was a refractory symptom in 83 of the patients. For most of the patients with refractory existential suffering, other refractory symptoms were also reported, and life expectancy was seven days or less; informed consent for initiating CPS had been obtained in all cases. Consultation and intermittent sedation before the start of CPS were far less frequently reported than one would expect based on the guidelines. Multivariate analysis showed that being male, having previously requested euthanasia, having a nervous system disease, or having an other diagnosis were positively correlated with the administration of CPS for existential suffering. We conclude that more attention should be paid to the suggested preconditions and to the presence of existential suffering in male patients or patients with a nervous system disease.

Heart failure management in skilled nursing facilities: a scientific statement from the American Heart Association and the Heart Failure Society of America.

Heart failure (HF) is a complex syndrome in which structural or functional cardiac abnormalities impair the filling of ventricles or left ventricular ejection of blood. HF disproportionately occurs in those ≥65 years of age.1 Among the estimated 1.5 to 2 million residents in skilled nursing facilities (SNFs) in the United States, cardiovascular disease is the largest diagnostic category, and HF is common.2,3 Despite the high prevalence of HF in SNF residents, none of the large randomized clinical trials of HF therapy included SNF residents, and very few included patients >80 years of age with complex comorbidities. Several issues make it important to address HF care in SNFs. The healthcare environment and characteristics of SNF residents are distinct from those of community-dwelling adults. Comorbid illness unrelated to HF (eg, dementia, hip fracture) increases with age >75 years, and these conditions may complicate both the initial HF diagnosis and ongoing management.4–6 Morbidity and mortality rates are significantly increased for hospitalized older adults with HF discharged to SNFs compared with those discharged to other sites.7 Transitions between hospitals and SNFs may be problematic.8 SNF 30-day rehospitalization rates for HF range from 27% to 43%,7,9,10 and long-term care residents sent to the emergency department are at increased risk for hospital admission and death.11 The purpose of this scientific statement is to provide guidance for management of HF in SNFs to improve patient-centered outcomes and reduce hospitalizations. This statement addresses unique issues of SNF care and adapts HF guidelines and other recommendations to this setting. This scientific statement on HF management in SNFs was developed by a writing group of experts representing nursing, medicine (cardiology, geriatrics, nursing home physicians, and palliative medicine), pharmacology, physical therapy, dietary clinical management, research, and …

Chace Touts Love for Patients, Quality Care as New Medical Director of the Year

Chace Touts Love for Patients, Quality Care as New Medical Director of the Year

Provider Perspectives on the Influence of Family on Nursing Home Resident Transfers to the Emergency Department: Crises at the End of Life.

Background. Nursing home (NH) residents often experience burdensome and unnecessary care transitions, especially towards the end of life. This paper explores provider perspectives on the role that families play in the decision to transfer NH residents to the emergency department (ED). Methods. Multiple stakeholder focus groups (n = 35 participants) were conducted with NH nurses, NH physicians, nurse practitioners, physician assistants, NH administrators, ED nurses, ED physicians, and a hospitalist. Stakeholders described experiences and challenges with NH resident transfers to the ED. Focus group interviews were recorded and transcribed verbatim. Transcripts and field notes were analyzed using a Grounded Theory approach. Findings. Providers perceive that families often play a significant role in ED transfer decisions as they frequently react to a resident change of condition as a crisis. This sense of crisis is driven by 4 main influences: insecurities with NH care; families being unprepared for end of life; absent/inadequate advance care planning; and lack of communication and agreement within families regarding goals of care. Conclusions. Suboptimal communication and lack of access to appropriate and timely palliative care support and expertise in the NH setting may contribute to frequent ED transfers.

An Educational Intervention on Drug Use in Nursing Homes Improves Health Outcomes Resource Utilization and Reduces Inappropriate Drug Prescription

ObjectiveInappropriate drug prescription is a common problem in people living in nursing homes and is linked to adverse health outcomes. This study assessed the effect of an educational intervention directed to nursing home physicians in reducing inappropriate prescription and improving health outcomes and resource utilization. DesignProspective, randomized, multicenter study. SettingA private organization of nursing homes in Spain. ParticipantsSixty nursing home physicians caring for approximately 3900 nursing home residents in 37 centers were randomized to receive an educational intervention (30) or as a control group (30). Intervention10 hours educational program, followed by on demand support by phone. Outcome MeasurementsOutcomes were assessed in 1018 randomly selected nursing home residents. Appropriateness of drug use [measured by the Screening Tool of Older Persons Prescriptions (STOPP) and Screening Tool to Alert Doctors to Right Treatment (START) criteria], incidence of selected geriatric syndromes (falls, delirium) and health resource utilization (visits to physicians and nursing homes, visits to the emergency room, days of hospitalization) were recorded for 3 months before the intervention started and 3 months after the intervention finished. ResultsO total of 716 residents finished the study (344 cared for by the intervention group physicians, 372 cared for by control physicians). Mean age was 84.4 ± 12.7 years; 73% were women. The mean number of inappropriate drugs (STOPP criteria) was higher at the end of the study in the control than in the intervention group (1.29 ± 1.56 vs 0.81 ± 1.13), as was the number of residents on 6 or more drugs (76.5% vs.67.0%), using antipsychotics (9.1% vs 3.2%) or duplicate medications (32.5% vs 9.2%). The number of fallers increased in the control group (from 19.3% to 28%) and did not significantly change in the intervention group (from 25.3% to 23.9%); the number of residents with delirium increased in the control group (from 3.8% to 9.1%) and decreased in the intervention group (from 6.1% to 3.2%). The number of visits to a physician did not change in the control group (−0.22, P = .3) but were significantly reduced in the intervention group (−0.76, P = .01), the same happened with the number of visits to a nurse (−0.38, P = .4 in controls, −1.43 in the intervention group, P < .001). Visits to the emergency room and days in hospital significantly increased in the control group (+0.12 and +0.38) but were unchanged in the intervention group (+0.03 and +0.01). ConclusionsAn educational intervention on drug use is feasible in nursing home physicians and improves the use of inappropriate drugs, use of antipsychotics, and drug duplications in their residents. It may also improve the risk of delirium and falls, and reduce the use of health care resources.

Ergebnisse der Einführung des „mre-Netzwerk Nordwest“-Qualitätssiegels für Alten- und Pflegeheime in der Bundesstadt Bonn

The Commission for Hospital Hygiene and Infection Prevention of the Robert Koch Institute (KRINKO) published a Recommendation for Prevention of Infection in Nursing Homes in 2005 [Kommission für Krankenhaushygiene und Infektionsprävention beim Robert Koch-Institut (KRINKO)]. The recommended measures for infection control of multidrug-resistant pathogens (MRP) are well known in most institutions. The "mre-Netzwerk Nordwest" quality certification is new, and was implemented by the KRINKO recommendation on a standardized basis for the first time in 2012 in Bonn, Germany. This study describes the first results of this initiative. The certification contains guidelines based on the above-mentioned KRINKO recommendation and a survey on the status of infections and antibiotic therapies. Nursing homes in Bonn were asked to fulfill a list of ten criteria. The process was supervised by the local health authority and evaluated. Of 38 nursing homes in Bonn, 19 acquired the certification. The survey showed that 1.4% of the residents were treated with antibiotics. Four pathogens were identified as MRP, but did not belong to the classic spectrum. In all, 42% of infections were treated with beta-lactams and 8% with quinolones. The evaluation showed that at least ten urinary tract catheters were removed because of the certification and a related re-evaluation of the indication was made by the treating physician. Implementation of the certification was assessed as positive, although it involves additional investments. The application of the approach was considered feasible as compared with other regions. The portion of antibiotic therapy use and partly that of other drugs was comparable to the findings of Wischnewski et al., Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 54(11):1147-1152, 2011. Re-assessing the indication for urinary tract catheters might have a positive influence on the prevention of infections. The certification can trigger the exchange of information on MRP and antibiotic stewardship between nursing home physicians.

PS-062 To what extent is information used to perform medicines review?

BackgroundPolypharmacy increases the risk of adverse drug reactions and possibly undertreatment.PurposeTo evaluate to what extent laboratory data, actual drug treatment, medical history and drug indications are interpreted in daily practice.Materials...

A Conceptual Model of Family Surrogate End-of-Life Decision-Making Process in the Nursing Home Setting: Goals of Care as Guiding Stars

An increasing proportion of dying is occurring in America's nursing homes (NH). Family members are involved in (and affected by) medical decision-making on behalf of NH residents approaching the end of life, especially when the resident is cognitively impaired. This article proposes an empirically derived conceptual model of the key factors NH family surrogate decision-makers consider when establishing or changing goals of care and the iterative process as applied to the NH setting. This model also establishes the importance of family social role expectations toward their loved one as well as the concept, “stance toward dying,” as key in establishing or changing the main goal of care. NH staff and physicians can use the model as a framework for providing information and support to family members. Research is needed to better understand how to prepare staff and settings to support family surrogate decision-makers, in particular around setting goals of care. The model can be generalized beyond nursing homes.

A survey of nursing home physicians to determine laboratory monitoring adverse drug event alert preferences.

We conducted a survey of nursing home physicians to learn about (1) the laboratory value thresholds that clinical event monitors should use to generate alerts about potential adverse drug events (ADEs); (2) the specific information to be included in the alerts; and (3) the communication modality that should be used for communicating them. Nursing home physician attendees of the 2010 Conference of AMDA: The Society for Post-Acute and Long-Term Care Medicine. A total of 800 surveys were distributed; 565 completed surveys were returned and seven surveys were excluded due to inability to verify that the respondents were physicians (a 70% net valid response rate). Alerting threshold preferences were identified for eight laboratory tests. For example, the majority of respondents selected thresholds of ≥5.5 mEq/L for hyperkalemia (63%) and ≤3.5 without symptoms for hypokalemia (54%). The majority of surveyed physicians thought alerts should include the complete active medication list, current vital signs, previous value of the triggering lab, medication change in the past 30 days, and medication allergies. Most surveyed physicians felt the best way to communicate an ADE alert was by direct phone/voice communication (64%), followed by email to a mobile device (59%). This survey of nursing home physicians suggests that the majority prefer alerting thresholds that would generally lead to fewer alerts than if widely accepted standardized laboratory ranges were used. It also suggests a subset of information items to include in alerts, and the physicians' preferred communication modalities. This information might improve the acceptance of clinical event monitoring systems to detect ADEs in the nursing home setting.