Residential Aged Care Homes Research Articles

The impact of electronic medication administration records in a residential aged care home

PurposesThis study aimed to compare between electronic medication administration records and paper-based records in the nursing time spent on various activities in a medication round and the medication administration processes followed by nurses in an Australian residential aged care home. It also aimed to identify the benefits and unintended adverse consequences of using the electronic medication administration records. MethodsTime–motion observation, taking of field notes, informal conversation and document review were used to collect data in two units of a residential aged care home. Each unit had one nurse administer medication. Seven nurses were observed over 12 morning shifts. Unit 1 used electronic medication administration records and Unit 2 used paper-based records. ResultsNo significant difference between the two units was found in the nursing time spent on various activities in a medication round, including documentation, verbal communication, medication administration, infection control and transit.Comparison of the medication administration processes between the electronic and paper-based medication administration records identified a procedural problem which violated the organization's documentation requirement. This problem was documenting before providing medication to a resident when using the paper-based records. It was not observed with the electronic medication administration records.Benefits of introducing the electronic medication administration records included improving nurses’ compliance with documentation requirements, freedom from the error of signing twice, reducing the possibility of forgetting to medicate a resident, facilitating nurses to record the time of medication administration to a resident and increasing documentation space. Unintended adverse consequences of introducing the electronic medication administration records included inadequate information about residents, late addition of a new resident's medication profile in the records and nurses’ forgetting to medicate a resident due to power outage of the portable device. ConclusionsThe electronic medication administration records may not change nursing time spent on various activities in a medication round or substantially alter the medication administration processes, but can generate both benefits and unintended adverse consequences. Future research may investigate whether and how the adverse consequences can be prevented.

Hand hygiene campaign to all the residential care home for elderly (RCHE) in Hong Kong

Multidrug Resistant Organisms (MDROs) is a global public health challenge. Vancomycin Resistant Enterococcus(VRE) is a type of MDRO. There is a surge of incidence of infection and colonization with VRE in Hong Kong in 2013. Outbreaks caused by VRE occurred in hospitals; and previous experience showed that elderly population were at high risk. Infection Control Branch (ICB) anticipated that there might be increased involvement of RCHE residents following the pan-screening exercise in a public hospital. In an effort to prevent the spread of VRE within the RCHEs, a territory-wide hand hygiene campaign to all RCHEs was initiated in late 2013.

The quality of paper-based versus electronic nursing care plan in Australian aged care homes: A documentation audit study

IntroductionThe nursing care plan plays an essential role in supporting care provision in Australian aged care. The implementation of electronic systems in aged care homes was anticipated to improve documentation quality. Standardized nursing terminologies, developed to improve communication and advance the nursing profession, are not required in aged care practice. The language used by nurses in the nursing care plan and the effect of the electronic system on documentation quality in residential aged care need to be investigated. PurposeTo describe documentation practice for the nursing care plan in Australian residential aged care homes and to compare the quantity and quality of documentation in paper-based and electronic nursing care plans. MethodsA nursing documentation audit was conducted in seven residential aged care homes in Australia. One hundred and eleven paper-based and 194 electronic nursing care plans, conveniently selected, were reviewed. The quantity of documentation in a care plan was determined by the number of phrases describing a resident problem and the number of goals and interventions. The quality of documentation was measured using 16 relevant questions in an instrument developed for the study. ResultsThere was a tendency to omit ‘nursing problem’ or ‘nursing diagnosis’ in the nursing process by changing these terms (used in the paper-based care plan) to ‘observation’ in the electronic version. The electronic nursing care plan documented more signs and symptoms of resident problems and evaluation of care than the paper-based format (48.30 vs. 47.34 out of 60, P<0.01), but had a lower total mean quality score. The electronic care plan contained fewer problem or diagnosis statements, contributing factors and resident outcomes than the paper-based system (P<0.01). Both types of nursing care plan were weak in documenting measurable and concrete resident outcomes. ConclusionsThe overall quality of documentation content for the nursing process was no better in the electronic system than in the paper-based system. Omission of the nursing problem or diagnosis from the nursing process may reflect a range of factors behind the practice that need to be understood. Further work is also needed on qualitative aspects of the nurse care plan, nurses’ attitudes towards standardized terminologies and the effect of different documentation practice on care quality and resident outcomes.

Fitting clinical workflow: the case for wound care in a residential aged care home.

Residential aged care homes have, or are in the process of implementing, electronic health record (EHR) systems to improve quality of care and reduce cost. For the system to deliver benefits, it must support nursing tasks and be seamlessly integrated into the nursing workflow. To identify whether and how an EHR system can do this most effectively, direct observation was conducted in a residential aged care home on nurses' use of EHR for wound care. The work processes of wound care and its documentation were investigated. Problems in the use of EHR were identified: 1) functional deficiencies of the EHR system which included a lack of functions to remind nurses of the existence of a wound chart, unavailability of an existent function when needed and a lack of sufficient detail in the information provided; 2) a lack of mobile devices to allow nurses to access the EHR system at the point-of-care, resulting in nurses using paper for point-of-care documentation. The findings suggest that continuous improvement in both the EHR system and its management is required to achieve integration of people, task, process and technology for the optimal benefits of EHR.

The effectiveness of audit and feedback as a quality improvement strategy in residential aged care: a systematic review protocol

Review question/objective The objective of this systematic review is to synthesize the best available evidence for the effectiveness of audit and feedback as a quality improvement strategy. More specifically, the objectives are to identify: 1. What characteristics contribute to an effective audit and feedback cycle in aged care. 2. Whether audit and feedback is an effective quality improvement strategy for improving health outcomes for older people in residential aged care facilities. 3. What the most effective feedback mechanisms as part of an audit and feedback cycle in implementing practice change are. Inclusion criteria Types of participants This review will consider studies that include people aged 65 years or older in nursing homes, long-term care and/or residential aged care. Types of intervention(s)/phenomena of interest This review will consider studies that evaluate the effect of (i) audit and feedback or clinical audit alone and (ii) audit and feedback or clinical audit and feedback combined with other interventions as an initial review of available studies indicate that there are limited or no studies that have evaluated the impact of audit and feedback as the sole intervention. Audit and feedback will review the system and process utilized within the audit whilst other interventions will relate to how feedback was provided. The review will consider the system and processes use to develop the audit tool and the outcome of the interventions used to provide feedback. Types of outcomes This review will consider studies that have evaluated the impact on clinical outcome (quality indicators/measures): such as but not limited to behaviors of concern, chemical or physical restraint, end of life, falls and pain.

Predictors of Discharge Destination in a Geriatric Population After Undergoing Rehabilitation

Patients undertaking inpatient rehabilitation comprise a diverse group, including patients with stroke and other neurological conditions, patients who have fallen with or without a resulting fracture, and patients with joint replacements, general debility, or various cardiopulmonary conditions. It is not clear whether diagnosis has an impact on discharge destination in a heterogeneous patient group. The purpose of this study was to determine whether diagnostic category matters or whether it is rehabilitation length of stay (LOS), ability on the 10-Meter Walk Test (10MWT), or Balance Outcome Measure for Elder Rehabilitation (BOOMER) at discharge that predicts discharge destination in elderly patients undergoing rehabilitation who had previously lived at home.A retrospective audit was undertaken at a single rehabilitation facility in South East Queensland, Australia, that serviced 4 local short-term care hospitals. Participants were admitted consecutively to the facility between June 2010 and March 2012 who met inclusion criteria. These included a primary diagnosis category of orthopedic conditions, debility, stroke, and other neurological conditions according to the Australasian Rehabilitation Outcomes Centre and older than 60 years (n = 248). Interventions while being a rehabilitation inpatient comprised usual care physiotherapy individually tailored and incorporating elements of balance, strengthening, and functional exercise. Main outcome measures were discharge to residential aged care facility (RACF) versus home, differences between diagnostic categories in terms of discharge destination, LOS, and performance on outcome measures. Prediction of discharge destination by LOS, 10MWT, and BOOMER performance at discharge was explored.A total of 28 patients (12.3%) were discharged to RACF. Diagnosis was not correlated with discharge destination (Pearson χ2 = 1.26, P = .74). The variables rehabilitation LOS, an inability to perform the 10MWT at discharge, and discharge BOOMER score of less than 4 can predict discharge destination with 86.4% accuracy (P = .002). This model had a sensitivity of 71.4% (discharge to RACF) and specificity of 93.3% (discharge home).To return home after rehabilitation, patients need to be able to walk at least 10 m and undertake tasks such as moving from sitting to standing, turning around, as well as managing steps. The study revealed that a standardized suite of measures of functional ability and balance may not be appropriate for patients in all diagnostic categories undergoing rehabilitation. Therefore, just as intervention needs to be tailored for the individual patient, the measure of their progress also should be unique.

PerCEN: a cluster randomized controlled trial of person-centered residential care and environment for people with dementia

There is good evidence of the positive effects of person-centered care (PCC) on agitation in dementia. We hypothesized that a person-centered environment (PCE) would achieve similar outcomes by focusing on positive environmental stimuli, and that there would be enhanced outcomes by combining PCC and PCE. 38 Australian residential aged care homes with scope for improvement in both PCC and PCE were stratified, then randomized to one of four intervention groups: (1) PCC; (2) PCE; (3) PCC +PCE; (4) no intervention. People with dementia, over 60 years of age and consented were eligible. Co-outcomes assessed pre and four months post-intervention and at 8 months follow-up were resident agitation, emotional responses in care, quality of life and depression, and care interaction quality. From 38 homes randomized, 601 people with dementia were recruited. At follow-up the mean change for quality of life and agitation was significantly different for PCE (p = 0.02, p = 0.05, respectively) and PCC (p = 0.0003, p = 0.002 respectively), compared with the non-intervention group (p = 0.48, p = 0.93 respectively). Quality of life improved non-significantly for PCC+PCE (p = 0.08), but not for agitation (p = 0.37). Improvements in care interaction quality (p = 0.006) and in emotional responses to care (p = 0.01) in PCC+PCE were not observed in the other groups. Depression scores did not change in any of the groups. Intervention compliance for PCC was 59%, for PCE 54% and for PCC+PCE 66%. The hypothesis that PCC+PCE would improve quality of life and agitation even further was not supported, even though there were improvements in the quality of care interactions and resident emotional responses to care for some of this group. The Australian New Zealand Clinical Trials Registry Number is ACTRN 12608000095369.

Time spent on daytime direct care activities by personal carers in two Australian residential aged care facilities: a time–motion study

To examine the time, frequency and duration of each direct care activity conducted by personal carers in Australian residential aged care homes. A time-motion study was conducted to observe 46 personal carers at two high-care houses in two facilities (14 days at Site 1 and 16 days at Site 2). Twenty-three direct care activities were classified into eight categories for analysis. Overall, a personal carer spent approximately 45% of their time on direct care, corresponding to 3.5h in an 8-h daytime shift. The two sites had similar ratios of personal carers to residents, and each resident received 30 min of direct care. No significant differences between the two sites were found in the time spent on oral communication, personal hygiene and continence activities. Personal carers at Site 1 spent significantly less time on toileting and mobility activities than those at Site 2, but more time on lunch activity. Although oral communication took the longest time (2h), it occurred concurrently with other activities (e.g. dressing) for 1.5h. The findings provide information that may assist decision makers in managing the operation of high-care residential aged care facilities, such as planning for task allocation and staffing. What is known about the topic? Overall, 30%-45% of the care staff's time is spent on direct care in residential aged care facilities. What does this paper add? This paper adds knowledge about how much time is required to conduct each direct care activity and the frequency and duration of conducting these activities to meet residents' day-to-day care needs in two high-care houses in two aged care facilities. What are the implications for practitioners? On average, a resident with high-care needs requires 30 min direct care. There may exist a basic minimum desirable ratio of personal carers to residents in high-care facilities. Residents' toileting needs are high after meals. Communication with residents represents an essential role in providing care.

Editorial

Editorial

Unintended adverse consequences of introducing electronic health records in residential aged care homes

PurposeThe aim of this study was to investigate the unintended adverse consequences of introducing electronic health records (EHR) in residential aged care homes (RACHs) and to examine the causes of these unintended adverse consequences. MethodA qualitative interview study was conducted in nine RACHs belonging to three organisations in the Australian Capital Territory (ACT), New South Wales (NSW) and Queensland, Australia. A longitudinal investigation after the implementation of the aged care EHR systems was conducted at two data points: January 2009 to December 2009 and December 2010 to February 2011. Semi-structured interviews were conducted with 110 care staff members identified through convenience sampling, representing all levels of care staff who worked in these facilities. Data analysis was guided by DeLone and McLean Information Systems Success Model, in reference with the previous studies of unintended consequences for the introduction of computerised provider order entry systems in hospitals. ResultsEight categories of unintended adverse consequences emerged from 266 data items mentioned by the interviewees. In descending order of the number and percentage of staff mentioning them, they are: inability/difficulty in data entry and information retrieval, end user resistance to using the system, increased complexity of information management, end user concerns about access, increased documentation burden, the reduction of communication, lack of space to place enough computers in the work place and increasing difficulties in delivering care services. The unintended consequences were caused by the initial conditions, the nature of the EHR system and the way the system was implemented and used by nursing staff members. ConclusionsAlthough the benefits of the EHR systems were obvious, as found by our previous study, introducing EHR systems in RACH can also cause adverse consequences of EHR avoidance, difficulty in access, increased complexity in information management, increased documentation burden, reduction of communication and the risks of lacking care follow-up, which may cause negative effects on aged care services. Further research can focus on investigating how the unintended adverse consequences can be mitigated or eliminated by understanding more about nursing staff's work as well as the information flow in RACH. This will help to improve the design, introduction and management of EHR systems in this setting.

Challenges in the provision of community aged care in China

<h3>Objective</h3> Population ageing in China is a significant challenge for the Chinese government, the society and Chinese people. The dramatic process of population ageing together with social and economic diversity in China has created issues in the availability, equality and sustainability of social and financial support for older people. The aims of this review are to identify the social and economic challenges to the traditional caregiving system in China, and to examine possible solutions to improve the care of older people in China using the framework of ageing in place. <h3>Methods</h3> Electronic literature searches were conducted in May and June 2013 using PubMed, CNKI, and MEDLINE. Statistical data and reports were retrieved from the United Nations, the World Health Organisation, the World Bank and National Bureau of Statistics of China. Government policy documents were found through government websites and formal publications. <h3>Results</h3> Family-centred care for older people in China is recognised as a cultural tradition in the Chinese community. However, driven by large-scale social, political and economic changes, this model of caring for older people has dynamically changed over the last 50 years. Traditionally the family has been the most important source of social support for older people followed by neighbour support and support from friends. Today family obligations of caring are still centred in a cultural and practical context; however, support from family and children has weakened incrementally. Community-based aged services are absent in most areas, while older people and their families have to pay out-of-pocket expenses for non-residential services. There is a severe shortage of aged care or nursing home resources in China and those that exist are of low quality and expensive. The staff who work in these facilities rarely have any formal training in aged care. In addition, a market approach to the funding of residential aged care has the potential to create a moral hazard due to the poor regulatory control of aged care in China. While the building of residential aged care homes is seen as the solution to the care of older people in China, older people prefer to age in their own homes and expect the restoration of the family care tradition as well as more government support for them to “age in place”. This approach has the potential to be more cost effective than expensive aged care facilities. <h3>Conclusion</h3> Given older people’s preferences, ageing in place, with the provision of community services and family support, potentially provides a fair and financially viable approach to promote healthy ageing and supportive care in China. Further studies are required to identify 1) how ageing in place can be supported by a national strategy, 2) the financial arrangements required to fund such an approach, and 3) how to train high quality community-based professionals in both rural and urban areas to support the care of older people.

Are Older Workers Less Productive? A Case Study of Aged Care Workers in Australia*

Employers are reluctant to employ older workers. Is this because they are less productive than equivalent younger workers? This paper uses data from a 2007 census of residential aged care homes in Australia to examine the productivity differentials of workers at different ages. We estimate production functions that take into account the age profile of the workforce in each aged care residential facility. We find that for the facilities having high care residents only, the productivity of nurses, whose work is more demanding of specialist knowledge, keeps increasing with age while the rate of increase declines after age 50. In contrast, the productivity of carers, whose work is more demanding of physical capacity, is highest in middle age. The facilities with low care residents only provide a much lower level of services because their residents are less frail and more independent. In this case, none of the coefficients regarding the impacts of age on productivity is statistically significant – suggesting that older workers are good substitutes for younger ones.

Molecular epidemiology of methicillin-resistant Staphylococcus aureus in residential care homes for the elderly in Hong Kong

This territory-wide study evaluated the molecular epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) in residential care homes for elderly (RCHEs) in Hong Kong. MRSA colonization was assessed by taking swab culture from anterior nares and active skin lesions. Of 487 RCHEs surveyed, 80 MRSA strains were recovered from 1563 residents, giving a prevalence of 5.1%. Twenty-four isolates had SCC mec II, 2 had SCC mec III, 17 had SCC mec IV, 36 had SCC mec V, and 1 had a composite SCC mec type. Pulsed-field gel electrophoresis typing clustered 75 isolates into 7 clones (HKU10 to 50, HKU80, and HKU90). Two predominant types, HKU30 and HKU50, which together account for 75% of all MRSA strains, were found in 13 and 15 of the 18 geographic districts in Hong Kong, respectively. The main features for HKU50 strains were spa t1081/ST45-IV or V, capsular type 8, agrIV, and hla, seg, sei positive. On the other hand, HKU30 strains had spa t002/ST5-II, capsular type 5, agrII, and were hla, seg, sei positive. HKU30 strains were often multidrug resistant (MDR, involving ciprofloxacin, erythromycin, gentamicin, and tetracycline). In contrast, HKU50 strains exhibit both multidrug resistance (MDR) (involving ciprofloxacin, erythromycin, and tetracycline, but not gentamicin) and non-MDR patterns.

The dynamics of residential aged care in Australia: 8-year trends in admission, separations and dependency

The aims of this paper are to analyse changes in dependency of residents in residential aged care homes consequent upon the passing of the Commonwealth Aged Care Act in late 1997, and to establish the extent of resultant changes in the dynamics of residential aged care. The paper outlines the major changes brought by the Aged Care Act, and evidence for the effects of these changes is examined to test the hypothesis that changes in dependency generated changes in turnover and length of stay. The findings show that the proportion of admissions classified at higher categories of the Resident Classification Scale has increased over time, and that the trend to higher classification is even more pronounced by the time residents separate. As funding of residential aged care is based on resident dependency, change in dependency and in the dynamics of the aged care system have potentially significant consequences for Commonwealth funding of providers to ensure care can be provided commensurate with resident needs. The conclusions take up a number of implications of the findings for future policy in relation to planning and funding of residential aged care as a new resident funding system based on the Aged Care Funding Instrument (ACFI) is phased in from mid 2007.

The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia

The need for a specialized clinical regimen for patients with dementia who require palliative care has only recently been recognized. Structured approaches to palliative care are not well developed. The recognition and treatment of pain is an important part of this management risk. However, pain is consistently underdiagnosed and undertreated in this population. A factor contributing to this has been a lack of appropriate tools to help recognize and document pain. This study sought to develop and validate an easy-to-use pain scale for use in residential aged care homes. The tool was developed with residents with end- or late-stage dementia who were unable to articulate their needs, identified by the registered nurses who knew them. Results showed that following pain-relief intervention the average pain score recorded using the scale fell by more than half. A paired Student's t-test showed the reduction to be highly significant (P<0.001). Validity and internal reliability, assessed by calculating Gamma and Cronbach's alpha, were found to be satisfactory. Qualitative evidence gathered from users of the scale indicated that it was considered a useful clinical device that could be completed within one minute. Further analysis of the use of the scale in clinical settings, testing of inter-rater reliability and examination of the limitations found in this study will commence early in 2004.

Regulating Residential Aged Care Homes in Hong Kong: Issues for the Asia-Pacific Region

Many countries in the Asia-Pacific Region, most notably Hong Kong, are experiencing rapid demographic ageing. Such trends in other parts of the world have created an inexorable demand for formal residential care and support services. In the UK, the private sector has responded rapidly to these demands and become an important provider of such care. A similar trend is already evident in Hong Kong. This article examines the development of residential aged care in Hong Kong and considers how approaches have been devised to safeguard standards and quality of care in such homes, whether in the public or private sector. The legislation introduced in 1994 to regulate all sectors of residential aged care in Hong Kong is discussed and some of the potential implementation problems are identified. Questions are raised about the costs for home owners, staff recruitment, the operation of inspection, and the extent to which regulation can improve the quality of care. If residential accommodation for older people grows n...