Care quality: reliability and usefulness of observation data in bench marking nursing homes and homes for the aged in the Netherlands

Before including quality of care indicators in the Benchmark of Nursing Homes and Homes for the Aged in the Netherlands the reliability of the patient data collection, and usefulness had to be established. The patient data items were derived from the Resident Assessment Instruments (RAI) and a questionnaire on social interaction in elderly people. Three nursing homes and three homes for the aged participated in the test with 550 patients. 279 x 2 assessments were collected by independent raters for an inter rater reliability test; 259 x 2 by the same rater for a reliability test-retest; and 24 by a single rater. The scores on paired assessment forms were compared with the weighted Kappa agreement test. The test results allowed 10 of the 13 quality indicators from RAI to be retained. In addition new quality indicators could be defined on 'giving attention' and 'unrespectful addressing'. We estimate on the basis of a questionnaire for the raters that on average 9 to 12 minutes per patient are needed to collect and enter data for the resulting 12 quality indicators.     

Three new observational scales for use in Dutch nursing homes: scales from the Resident Assessment Instrument for Activities of Daily Living, cognition and depression

The reliability and validity of three MDS scales for ADL, cognition and depression are described. The scales consist of items of the Minimum Data Set of the Resident Assessment Instrument and are available just after an MDS assessment. Data collection took place in nine Dutch nursing homes (N = 227) and consisted of three MDS assessments within one month to determine reliability. Several criterion measures were assessed in order to determine convergent validity. Intra- and inter-rater reliability and internal consistency were determined as well as correlation coefficients of the criterion measures and the MDS scales. All three MDS scales appear reliable, especially the ADL-Hierarchy has very good psychometric properties (intra- and inter-rater Intra Class Correlation were 0.81 and 0.83, respectively). Convergent validity of the ADL-Hierarchy and the Cognitive Performance Scale is good, the Depression Rating Scale appears valid in residents with moderate cognitive disorders at the most, but the results are more difficult to interpret in residents with severe cognitive disorders. The MDS scales appear useful in clinical practice and for research purposes in the Dutch nursing homes.     

Integrated health information system based on Resident Assessment Instruments

The paper explores the meaning of Resident Assessment Instruments. It gives a summary of existing RAI instruments and derived applications. It argues how all of these form the basis for an integrated health information system for "chain care" (home care, home for the elderly care, nursing home care, mental health care and acute care). The primary application of RAI systems is the assessment of client care needs, followed by an analysis of the required and administered care with the objective to make an optimal individual care plan. On the basis of RAI, however, applications have been derived for reimbursement systems, quality improvement programs, accreditation, benchmarking, best practice comparison and care eligibility systems. These applications have become possible by the development on the basis of the Minimum Data Set of RAI of outcome measures (item scores, scales and indices), case-mix classifications and quality indicators. To illustrate the possibilities of outcome measures of RAI we present a table and a figure with data of six Dutch nursing homes which shows how social engagement is related to ADL and cognition. We argue that RAI/MDS assessment instruments comprise an integrated health information system because they have consistent terminology, common core items, and a common conceptual basis in a clinical approach that emphasizes the identification of functional problems.     

A multilevel latent Markov model for the evaluation of nursing homes' performance

The periodic evaluation of health care services is a primary concern for many institutions. We consider services provided by nursing homes with the aim of ranking a set of these structures with respect to their effect on resident health status. Since the overall health status is not directly observable, and given the longitudinal and multilevel structure of the available data, we rely on latent variable models and, in particular, on a multilevel latent Markov model where residents and nursing homes are the first and the second level units, respectively. The model includes individual covariates to account for resident characteristics. The impact of nursing home membership is modelled through a pair of random effects affecting the initial distribution and the transition probabilities between different levels of health status. Through the prediction of these random effects we obtain a ranking of the nursing homes. Furthermore, the proposed model accounts for nonignorable dropout due to resident death, which typically occurs in these contexts. The motivating dataset is gathered from the Long Term Care Facilities programme, a health care protocol implemented in Umbria (Italy). Our results show that differences in performance between nursing homes are statistically significant.     

De Richtlijn Mondzorg voor zorgafhankelijke cliënten in verpleeghuizen, 2007: bittere noodzaak!

The oral health status of residents in Dutch nursing homes is rather poor, especially of those depending on caregivers for their oral health care. Moreover, when care dependency is rising, the provision of good oral health care becomes more difficult. With more elderly people still having (parts of) their natural teeth, the need for good oral health care is increasing even more. Therefore a specific guideline was developed. The ultimate aim of the guideline "Oral health care for dependent residents in long term care facilities" is to improve the oral health of nursing home residents. Oral health care needs to be incorporated in daily nursing home care routine and in the integral care plan of every resident. Attention is given to the importance of an adequate implementation of this guideline as well as to the necessity of research evaluating the effects of it's implementation.     

The 'Soarchmjitter'. The use of a Frisian lingual measurement instrument in care of the elderly

In this article a research has been described funded by the province Fryslan. The aim of this research project is bipartite. First, to determine the reliability and the validity of the instrument and, secondly, to inquire the involved residents living in old people's homes after the valuation of the use of the Frisian language in the care. The research is conducted among 73 residents living in nine old people's homes in the province Fryslan. On two moments in time residents of the old people's homes are asked to fill in a questionnaire with regard to their own care (in)dependency and once with regard to the use of the Frisian language in the care. Reliability analysis shows with regard to internal consistency high Cronbach's alpha values. Test-retest reliability (Cohen's kappa and Spearman Correlation) reveals fair to moderate values. Factor analysis (principal components analysis) results in a one-factor solution. According to the residents, the 'Soarchmjitter' gives a good picture of their care dependency and its questions and answers join their needs. It can be concluded that the 'Soarchmjitter' is a useful instrument to communicate in the own spoken language of the resident and to come in this way to an agreement with nurses about their care demands.     

Effects of emotion-oriented care on elderly people with cognitive impairment and behavioral problems in residential homes

This study investigates the effects of emotion-oriented care on the behavior of elderly people with cognitive impairment and behavioral problems. This approach is mainly based on the validation approach, but uses also insights from other approaches like reminiscence and sensory stimulation. Sixteen homes for the aged with structured day care units were randomly allocated to an intervention or control group. 151 Residents with cognitive impairment and behavioral problems were included in the study. The eight intervention homes received a training program with regard to emotion-oriented care. In the eight control homes usual care was continued. Measurements were performed at baseline and after three, six and twelve months of follow-up (assessment by caregivers and relatives). The primary outcome measure was the change in behavior of the residents. The results of multilevel analyses (overall, subgroup and per protocol) showed no statistically significant, nor clinically relevant effects in favor of the intervention group on the behavioral outcome measures. A possible reason for this is that the intervention did not result in significant contrast between the study groups. There is insufficient scientific evidence yet to justify the implementation of emotion-oriented care in residential homes, for residents with moderate to severe cognitive impairment and behavioral problems, on a large scale. Additional studies are needed in which special attention should be given to the implementation process.     

Modeling the spread of methicillin-resistant Staphylococcus aureus in nursing homes for elderly

Methicillin-resistant Staphylococcus aureus (MRSA) is endemic in many hospital settings, including nursing homes. It is an important nosocomial pathogen that causes mortality and an economic burden to patients, hospitals, and the community. The epidemiology of the bacteria in nursing homes is both hospital- and community-like. Transmission occurs via hands of health care workers (HCWs) and direct contacts among residents during social activities. In this work, mathematical modeling in both deterministic and stochastic frameworks is used to study dissemination of MRSA among residents and HCWs, persistence and prevalence of MRSA in a population, and possible means of controlling the spread of this pathogen in nursing homes. The model predicts that: (i) without strict screening and decolonization of colonized individuals at admission, MRSA may persist; (ii) decolonization of colonized residents, improving hand hygiene in both residents and HCWs, reducing the duration of contamination of HCWs, and decreasing the resident∶staff ratio are possible control strategies; (iii) the mean time that a resident remains susceptible since admission may be prolonged by screening and decolonization treatment in colonized individuals; (iv) in the stochastic framework, the total number of colonized residents varies and may increase when the admission of colonized residents, the duration of colonization, the average number of contacts among residents, or the average number of contacts that each resident requires from HCWs increases; (v) an introduction of a colonized individual into an MRSA-free nursing home has a much higher probability of leading to a major outbreak taking off than an introduction of a contaminated HCW.     

Treatment of residents in 74 nursing homes: the opinion of caregivers

This study is based on the outcomes of the program "Privacy In Nursing Homes" that has been initiated by the Dutch Department of Health in the late 90's. In this study, personnel of 74 nursing homes were asked to reflect on the way they treat residents. The attitudes of personnel were measured with a questionnaire that contains 80 propositions about their behaviour towards residents. The propositions can be reduced to five factors: kindness, structural environment, control, freedom to choose, and respect. First, we give the general results on these five factors. After that we give insight in the correlations between the five different aspects of treatment and the results of regression analysis. The general conclusion is that the behaviour towards residents in nursing homes at the beginning of the 21st Century is far from optimal. Residents most notably lack personal freedom and control over their received care and their way of living. This result is especially worrying because client conformed care has been an important point of attention for some time now. Another important conclusion is that the care for residents has a positive relation with the mangement policy of an organization and so, it is possible to improve the care.     

Quality of care in unlicensed homes for the aged in the Eastern Townships of Quebec

BACKGROUND: The recent proliferation of unlicensed homes for the aged in Quebec, coupled with the increased needs of the population they serve, has raised concerns about the quality of case these homes provide. The authors compared the quality of care in unlicensed homes with that in licensed long-term care facilities in a region of Quebec. METHODS: The study involved 301 impaired people aged 65 and over in 88 residential care facilities (52 unlicensed, 36 licensed) in the Eastern Townships of Quebec. Study participants were chosen according to a 2-stage sampling scheme: stratified sampling of the primary units (facilities) and random sampling of the secondary units (residents). Quality of care was measured using the QUALCARE scale, a multidimensional instrument that uses a 5-point scale to assess 6 dimensions of care: environmental, physical, medical management, psychosocial, human rights and financial. A mean score of more than 2 was considered indicative of inadequate care. RESULTS: Overall, the quality of care was similar in the unlicensed and licensed facilities (mean global score 1.61 [standard error of the mean (SEM) 0.06] and 1.47 [SEM 0.09] respectively). Examination of dimension-specific quality-of-care scores revealed that the unlicensed homes performed worse than the licensed facilities in 2 areas of care: physical care (mean score 1.80 [SEM 0.08] v. 1.51 [SEM 0.09] respectively, p = 0.017) and medical management (1.37 [SEM 0.06] v. 1.14 [SEM 0.05], p = 0.004). The dimension-specific scores also revealed that both types of homes lacked appropriate attention to the psychosocial aspect of care. Overall, 25% of the facilities provided inadequate care to at least one resident. This situation was especially prevalent among homes with fewer than 40 residents, where up to 20% of the residents received inadequate care. INTERPRETATION: Most of the unlicensed homes for the aged that were studied delivered care of relatively good quality. However, some clearly provided inadequate care.     

Psychiatric consultation in the nursing home. An inquiry among Amsterdam nursing home physicians

Psychiatric disorders are common among nursing home residents. However, little is known about psychiatric consultation in Dutch nursing homes. As an exploration of the topic, Amsterdam-based nursing home physicians were asked to rate a number of aspects of psychiatric consultation as performed in their nursing home. Striking differences are reported between 14 participating nursing homes with regard to the intensity of psychiatric consultation and the number of consultation requests, which seems low compared with the perceived psychiatric problems. Somatically ill and psychogeriatric residents are estimated to generate an equal number of consultation requests. Psychiatric consultation appears to be characterized by diagnostic clarification, medication recommendations and behavioral management advice whereas staff-directed activities are scarce. Physicians report shortcomings in psychiatric skills among care staff. Research is necessary concerning the psychiatric care delivered to nursing home residents, as well as with regard to the optimal model for psychiatric consultation services. Integration of psychiatric care in nursing homes with mental health care services appears to be desirable.     

Posterior Teeth Occlusion Associated with Cognitive Function in Nursing Home Older Residents: A Cross-Sectional Observational Study

Early detection and subsequent reduction of modifiable risk factors for cognitive decline is important for extending healthy life expectancy in the currently aging society. Although a recent increase in studies on the state or number of the teeth and cognitive function, few studies have focused on the association between posterior teeth occlusion necessary to maintain chewing function and cognitive function among older adults. This study examined the association between posterior teeth occlusion and cognitive function in nursing home older residents. In this cross-sectional study, 279 residents aged ≥60 years from eight nursing homes in Aso City, Japan participated in cognitive function and dental status assessments and completed a comprehensive questionnaire survey in 2014. Cognitive function was measured using a Mini-Mental State Examination (MMSE). Posterior teeth occlusion was assessed using a total number of functional tooth units (total-FTUs), depending on the number and location of the remaining natural and artificial teeth on implant-supported, fixed, and removable prostheses. Linear regression models were used to assess univariate and multivariate associations between total-FTUs and MMSE scores. Models were sequentially adjusted for demographic characteristics, number of natural teeth, socioeconomic status, health behaviors, comorbidities, physical function, and nutritional status. Among the 200 residents included in our analysis, mean MMSE scores and total-FTUs were 11.0 ± 8.6 and 9.3 ± 4.6, respectively. Higher total-FTUs were significantly associated with higher MMSE scores after adjustment for demographics and teeth number (B = 0.48, 95% confidence interval [CI] = 0.22–0.74). The association remained significant even after adjustment for all covariates (B = 0.25, 95% CI = 0.01–0.49). The current findings demonstrated that loss of posterior teeth occlusion was independently associated with cognitive decline in nursing home older residents in Japan. Maintenance and restoration of posterior teeth occlusion may be a preventive factor against cognitive decline in aged populations.     

A Systematic Review of Interventions to Change Staff Care Practices in Order to Improve Resident Outcomes in Nursing Homes

Background

We systematically reviewed interventions that attempted to change staff practice to improve long-term care resident outcomes.

Methods

Studies met criteria if they used a control group, included 6 or more nursing home units and quantitatively assessed staff behavior or resident outcomes. Intervention components were coded as including education material, training, audit and feedback, monitoring, champions, team meetings, policy or procedures and organizational restructure.

Results

Sixty-three unique studies were broadly grouped according to clinical domain—oral health (3 studies), hygiene and infection control (3 studies), nutrition (2 studies), nursing home acquired pneumonia (2 studies), depression (2 studies) appropriate prescribing (7 studies), reduction of physical restraints (3 studies), management of behavioral and psychological symptoms of dementia (6 studies), falls reduction and prevention (11 studies), quality improvement (9 studies), philosophy of care (10 studies) and other (5 studies). No single intervention component, combination of, or increased number of components was associated with greater likelihood of positive outcomes. Studies with positive outcomes for residents also tended to change staff behavior, however changing staff behavior did not necessarily improve resident outcomes. Studies targeting specific care tasks (e.g. oral care, physical restraints) were more likely to produce positive outcomes than those requiring global practice changes (e.g. care philosophy). Studies using intervention theories were more likely to be successful. Program logic was rarely articulated, so it was often unclear whether there was a coherent connection between the intervention components and measured outcomes. Many studies reported barriers relating to staff (e.g. turnover, high workload, attitudes) or organizational factors (e.g. funding, resources, logistics).

Conclusion

Changing staff practice in nursing homes is possible but complex. Interventionists should consider barriers and feasibility of program components to impact on each intended outcome.     

The ZZP Questionnaire. Reliability of a new resource utilization measure

Data to determine the resource utilization of care recipients need to be reliable and the items that are measured need to be useful. In 2006, the Dutch Ministry of Health and Welfare has mandated all nursing homes and homes for the elderly to measure the Resource Utilization of all residents with the ZZP Questionnaire. Are the data resulting from this measurement reliable and is each of the 54 items of the ZZP Questionnaire useful? To answer this we tested the reliability of the data in a nursing home and a home for the elderly in two wards each. For 122 residents questionnaires were completed such that the inter- and intra-rater reliability of the answers could be assessed. Ten of the 54 items in the questionnaire showed insufficient inter rater reliability (<0.40) on the weighted Cohen kappa and another sixteen moderate (0.40 - 0.60). On the intra rater reliability test seven items had an insufficient kappa and another fifteen moderate. Besides, ten clusters of items could be formed with in-cluster Spearman correlation rates of .75 or higher. From the results of the reliability tests and the item intercorrelation rates we concluded that a substantial number of items needs to be improved and that in the ZZP Questionnaire 15 of the 54 items appear to be redundant on statistical grounds.     

Basal metabolic rate and energetic cost of thermoregulation among migratory and resident blue tits

Metabolic rates may be informative of adaptations to migration or wintering at high latitudes and may therefore be particularly interesting in partial migrants requiring adaptations to both migration and residency. To study the extent of physiological adaptations in migratory and resident blue tits Cyanistes caeruleus during the period of autumn migration in southern Sweden, we measured basal metabolic rate (BMR) and cost of thermoregulation at 0°C (CTR0). In contrast to other migrants en route, migratory blue tits had lower BMR than residents. As migratory blue tits travel extraordinarily slowly on autumn migration and residents suffer from harsher climate and severe competition, residents may need dynamic adjustments that involve larger metabolic costs than migrants. Resident males had lower CTR0 than migrants and resident females. Resident males are socially dominant, which suggests that they have priority of access to food sources during summer and early autumn. They also spend more time on moult, which would give them the time and energy needed for molting into a plumage of higher insulation quality than is possible for migrants and resident females.     

Endemic institutional salmonellosis due to lactose-fermenting Salmonella newport in Nova Scotia.

We report two outbreaks of salmonellosis due to lactose-fermenting Salmonella newport in a Halifax nursing home in August 1983 and July 1986 that we believe were related. The relative rarity of this serotype and other epidemiologic evidence suggest that the organism was endemic in the institution for at least 3 years. Persistent carriers as well as ill and convalescing patients presumably were responsible for propagation of the outbreak. We recommend adequate microbiologic follow-up of infected residents and implementation of surveillance and infection control measures for nursing homes and special care institutions.     

Effect evaluation of a supervised versus non‐supervised implementation of an oral health care guideline in nursing homes: a cluster randomised controlled clinical trial

doi: 10.1111/j.1741‐2358.2010.00418.x
Effect evaluation of a supervised versus non‐supervised implementation of an oral health care guideline in nursing homes: a cluster randomised controlled clinical trial Objective: To compare a supervised versus a non‐supervised implementation of an oral health care guideline in Flanders (Belgium). Background: The key factor in realising good oral health is daily oral hygiene care. In 2007, the Dutch guideline ‘Oral health care in care homes for elderly people’ was developed to improve oral health of institutionalised elderly. Materials and Methods: A random sample of 12 nursing homes was randomly allocated to the intervention or the control group. Representative samples of 30 residents in each home were monitored during a 6‐month study period. The intervention included a supervised implementation of the guideline. Results: At the 6‐month follow‐up, only a small but statistically significant (p = 0.002) beneficial effect (0.32) of the intervention was observed for denture plaque after adjustment for baseline value and the random effect of the institution. In the linear mixed regression models, including a random institution effect, difference in denture plaque level was no longer statistically significant at the 5% level. Conclusion: Only denture hygiene has been improved by the supervised implementation, although with lower benefits than presumed. Factors on institutional level, difficult to assess quantitatively, may play an important role in the final result.     

NP岗位设置对促进住院医师规范化培训的探索与思考

高级职业护师是一些发达国家护理队伍中的重要组成部分。通过介绍如何通过注册护士岗位设置与住院医师规范化培训相结合,探索注册护士对规范化培训的影响与作用,以期为推进高品质的住院医规范化培训提供借鉴。     

An Approach to Patient Care Classification

Employing the principles of progressive patient care and using data obtained from charts, nurses and resident physicians, 265 patients on the wards of a teaching hospital were classified into one of six optimal levels of care by the resident physicians and also by an outside observer. It was assumed that facilities for the three alternatives to general hospital care, i.e. long-term hospital care, nursing care and sheltered care, were available in the community. It was also assumed that socio-economic factors presented no barrier to hospital discharge.The outside observer allocated 96 patients, approximately one-third, to the alternative facilities outside the general hospital. Those factors found to have statistically significant effects on assigned levels of care were the diagnoses, length of stay, region of residence, bed status, extent of nursing care, hospital service and discharge status. The residents allocated 60 patients, approximately one-fifth, to alternative facilities.The extent of agreement between the residents and the outside observer reached 81% for those to alternate versus general hospital care.This method could be used by nurses and residents to screen out those most suitable for care in alternate facilities.