Birgitte Graverholt

Acute hospital admissions among nursing home residents: a population-based observational study

BackgroundNursing home residents are prone to acute illness due to their high age, underlying illnesses and immobility. We examined the incidence of acute hospital admissions among nursing home residents versus the age-matched community dwelling population in a geographically defined area during a two years period. The hospital stays of the nursing home population are described according to diagnosis, length of stay and mortality. Similar studies have previously not been reported in Scandinavia.MethodsThe acute hospitalisations of the nursing home residents were identified through ambulance records. These were linked to hospital patient records for inclusion of demographics, diagnosis at discharge, length of stay and mortality. Incidence of hospitalisation was calculated based on patient-time at risk.ResultsThe annual hospital admission incidence was 0.62 admissions per person-year among the nursing home residents and 0.26 among the community dwellers. In the nursing home population we found that dominant diagnoses were respiratory diseases, falls-related and circulatory diseases, accounting for 55% of the cases. The median length of stay was 3 days (interquartile range = 4). The in-hospital mortality rate was 16% and 30 day mortality after discharge 30%.ConclusionAcute hospital admission rate among nursing home residents was high in this Scandinavian setting. The pattern of diagnoses causing the admissions appears to be consistent with previous research. The in-hospital and 30 day mortality rates are high.

Reducing hospital admissions from nursing homes: a systematic review

BackgroundThe geriatric nursing home population is vulnerable to acute and deteriorating illness due to advanced age, multiple chronic illnesses and high levels of dependency. Although the detriments of hospitalising the frail and old are widely recognised, hospital admissions from nursing homes remain common. Little is known about what alternatives exist to prevent and reduce hospital admissions from this setting. The objective of this study, therefore, is to summarise the effects of interventions to reduce acute hospitalisations from nursing homes.MethodsA systematic literature search was performed in Cochrane Library, PubMed, MEDLINE, EMBASE and ISI Web of Science in April 2013. Studies were eligible if they had a geriatric nursing home study population and were evaluating any type of intervention aiming at reducing acute hospital admission. Systematic reviews, randomised controlled trials, quasi randomised controlled trials, controlled before-after studies and interrupted time series were eligible study designs. The process of selecting studies, assessing them, extracting data and grading the total evidence was done by two researchers individually, with any disagreement solved by a third. We made use of meta-analyses from included systematic reviews, the remaining synthesis is descriptive. Based on the type of intervention, the included studies were categorised in: 1) Interventions to structure and standardise clinical practice, 2) Geriatric specialist services and 3) Influenza vaccination.ResultsFive systematic reviews and five primary studies were included, evaluating a total of 11 different interventions. Fewer hospital admissions were found in four out of seven evaluations of structuring and standardising clinical practice; in both evaluations of geriatric specialist services, and in influenza vaccination of residents. The quality of the evidence for all comparisons was of low or very low quality, using the GRADE approach.ConclusionsOverall, eleven interventions to reduce hospital admissions from nursing homes were identified. None of them were tested more than once and the quality of the evidence was low for every comparison. Still, several interventions had effects on reducing hospital admissions and may represent important aspects of nursing home care to reduce hospital admissions.

Acute hospital admissions from nursing homes: predictors of unwarranted variation?

Background: The geriatric nursing home population is frail and vulnerable to sudden changes in their health condition. Very often, these incidents lead to hospitalization, in which many cases represent an unfavourable discontinuity of care. Analysis of variation in hospitalization rates among nursing homes where similar rates are expected may identify factors associated with unwarranted variation. Objectives: To 1) quantify the overall and diagnosis specific variation in hospitalization rates among nursing homes in a well-defined area over a two-year period, and 2) estimate the associations between the hospitalization rates and characteristics of the nursing homes. Method: The acute hospital admissions from 38 nursing homes to two hospitals were identified through ambulance records and linked to hospital patient journals (n = 2451). Overall variation in hospitalization rates for 2 consecutive years was tested using chi-square and diagnosis-specific variation using Systematic Component of Variation. Associations between rates and nursing home characteristics were tested using multiple regression and ANOVA. Results: Annual hospitalization rates varied significantly between 0.16 and 1.49 per nursing home. Diagnoses at discharge varied significantly between the nursing homes. The annual hospitalization rates correlated significantly with size (r = −0.38) and percentage short-term beds (r = 0.41), explaining 32% of the variation observed (R2 = 0.319). No association was found for ownership status (r = 0.05) or location of the nursing home (p = 0.52). Conclusion: A more than nine-fold variation in annual hospitalization rates among the nursing homes in one municipality suggests the presence of unwarranted variation. This finding demands for political action to improve the premises for a more uniform practice in nursing homes.

Assessment of quality in psychiatric nursing documentation – a clinical audit

BackgroundQuality in nursing documentation facilitates continuity of care and patient safety. Lack of communication between healthcare providers is associated with errors and adverse events. Shortcomings are identified in nursing documentation in several clinical specialties, but very little is known about the quality of how nurses document in the field of psychiatry. Therefore, the aim of this study was to assess the quality of the written nursing documentation in a psychiatric hospital.MethodA cross-sectional, retrospective patient record review was conducted using the N-Catch audit instrument. In 2011 the nursing documentation from 21 persons admitted to a psychiatric department from September to December 2010 was assessed. The N-Catch instrument was used to audit the record structure, admission notes, nursing care plans, progress and outcome reports, discharge notes and information about the patients’ personal details. The items of N-Catch were scored for quantity and/or quality (0–3 points).ResultsThe item ‘quantity of progress and evaluation notes’ had the lowest score: in 86% of the records progress and outcome were evaluated only sporadically. The items ‘the patients’ personal details’ and ‘quantity of record structure’ had the highest scores: respectively 100% and 71% of the records achieved the highest score of these items.ConclusionsDeficiencies in nursing documentation identified in other clinical specialties also apply to the clinical field of psychiatry. The quality of electronic written nursing documentation in psychiatric nursing needs improvements to ensure continuity and patient safety. This study shows the importance of the existence of a validated tool, readily available to assess local levels of nursing documentation quality.

Educating change agents: a qualitative descriptive study of graduates of a Master’s program in evidence-based practice

BackgroundHealth care professionals are expected to build decisions upon evidence. This implies decisions based on the best available, current, valid and relevant evidence, informed by clinical expertise and patient values. A multi-professional master’s program in evidence-based practice was developed and offered. The aims of this study were to explore how students in this program viewed their ability to apply evidence-based practice and their perceptions of what constitute necessary conditions to implement evidence-based practice in health care organizations, one year after graduation.MethodsA qualitative descriptive design was chosen to examine the graduates’ experiences. All students in the first two cohorts of the program were invited to participate. Six focus-group interviews, with a total of 21 participants, and a telephone interview of one participant were conducted. The data was analyzed thematically, using the themes from the interview guide as the starting point.ResultsThe graduates reported that an overall necessary condition for evidence-based practice to occur is the existence of a “readiness for change” both at an individual level and at the organizational level. They described that they gained personal knowledge and skills to be “change-agents” with “self-efficacy, “analytic competence” and “tools” to implement evidence based practice in clinical care. An organizational culture of a “learning organization” was also required, where leaders have an “awareness of evidence- based practice”, and see the need for creating “evidence-based networks”.ConclusionsOne year after graduation the participants saw themselves as “change agents” prepared to improve clinical care within a learning organization. The results of this study provides useful information for facilitating the implementation of EBP both from educational and health care organizational perspectives.

Implementing guidelines in nursing homes: a systematic review

BackgroundResearch on guideline implementation strategies has mostly been conducted in settings which differ significantly from a nursing home setting and its transferability to the nursing home setting is therefore limited. The objective of this study was to systematically review the effects of interventions to improve the implementation of guidelines in nursing homes.MethodsA systematic literature search was conducted in the Cochrane Library, CINAHL, Embase, MEDLINE, DARE, HTA, CENTRAL, SveMed + and ISI Web of Science from their inception until August 2015. Reference screening and a citation search were performed. Studies were eligible if they evaluated any type of guideline implementation strategy in a nursing home setting. Eligible study designs were systematic reviews, randomised controlled trials, non-randomised controlled trials, controlled before-after studies and interrupted-time-series studies. The EPOC risk of bias tool was used to evaluate the risk of bias in the included studies. The overall quality of the evidence was rated using GRADE.ResultsFive cluster-randomised controlled trials met the inclusion criteria, evaluating a total of six different multifaceted implementation strategies. One study reported a small statistically significant effect on professional practice, and two studies demonstrated small to moderate statistically significant effects on patient outcome. The overall quality of the evidence for all comparisons was low or very low using GRADE.ConclusionsLittle is known about how to improve the implementation of guidelines in nursing homes, and the evidence to support or discourage particular interventions is inconclusive. More implementation research is needed to ensure high quality of care in nursing homes.Protocol registrationPROSPERO 2014:CRD42014007664

Self-reported and objectively assessed knowledge of evidence-based practice terminology among healthcare students: A cross-sectional study

Background Self-reported scales and objective measurement tools are used to evaluate self-perceived and objective knowledge of evidence-based practice (EBP). Agreement between self-perceived and objective knowledge of EBP terminology has not been widely investigated among healthcare students. Aim The aim of this study was to examine agreement between self-reported and objectively assessed knowledge of EBP terminology among healthcare students. A secondary objective was to explore this agreement between students with different levels of EBP exposure. Methods Students in various healthcare disciplines and at different academic levels from Norway (n = 336) and Canada (n = 154) were invited to answer the Terminology domain items of the Evidence-Based Practice Profile (EBP2) questionnaire (self-reported), an additional item of ‘evidence based practice’ and six random open-ended questions (objective). The open-ended questions were scored on a five-level scoring rubric. Interrater agreement between self-reported and objective items was investigated with weighted kappa (Kw). Intraclass correlation coefficient (ICC) was used to estimate overall agreement. Results Mean self-reported scores varied across items from 1.99 (‘forest plot’) to 4.33 (‘evidence-based practice’). Mean assessed open-ended answers varied from 1.23 (‘publication bias’) to 2.74 (‘evidence-based practice’). For all items, mean self-reported knowledge was higher than that assessed from open-ended answers (p<0.001). Interrater agreement between self-reported and assessed open-ended items varied (Kw = 0.04–0.69). The overall agreement for the EBP2 Terminology domain was poor (ICC = 0.29). The self-reported EBP2 Terminology domain discriminated between levels of EBP exposure. Conclusion An overall low agreement was found between healthcare students’ self-reported and objectively assessed knowledge of EBP terminology. As a measurement tool, the EBP2 Terminology scale may be useful to differentiate between levels of EBP exposure. When using the scale as a discriminatory tool, for the purpose of academic promotion or clinical certification, users should be aware that self-ratings would be higher than objectively assessed knowledge.

Den sårbare tiden etter utskrivelse fra psykiatrisk sykehus – selvmordsrisiko og dokumentasjonspraksis

Tiden like etter utskrivelse fra psykiatrisk dognenhet innebaererforhoyet selvmordsrisiko. Nasjonale retningslinjer for selvmordsforebyggingi psykisk helsevern anbefaler at nar selvmordsrisiko harvaert en problemstilling under oppholdet eller tidligere skal pasienterselvmordsrisikovurderes og det er en fordel med timeavtale hosoppfolgende instans. Hensikten med denne studien var a kartleggedokumentert etterlevelse av disse anbefalingene og identifisering avprediktorer for manglende timeavtale.En journalstudie i Divisjon psykisk helsevern, Haukeland Universitetssykehus,ble gjennomfort for a vurdere i hvilken grad dokumentasjonspraksisi epikriser og overforingsnotat samsvarte medretningslinjeanbefalingene. Opplysninger om selvmordsrisikovurderingog timeavtale ble kartlagt sammen med kjonn, alder, tidligereselvmordsforsok, andre risikofaktorer og mulige beskyttende faktorerfor selvmord, hoveddiagnoser, henvisnings- og mottaksformalitet.Analyser var deskriptiv statistikk og Generalized Estimating Equation.Selvmordsrisikovurdering var dokumentert i nesten alle epikriser/overforingsnotat. Begrunnelser for selvmordsrisikovurderingene vari liten grad dokumentert. Lavere sannsynlighet for dokumentasjon avtimeavtale var knyttet til utskrivelser med rus som hoveddiagnose,schizofrenidiagnose for kvinner, samt a bli henvist til tvangsinnleggelsemen mottatt til frivillig sykehusopphold for kvinner.Dokumentasjonspraksis vedrorende selvmordsrisikovurdering vargod, men vurderingene inneholdt i liten grad utdypende beskrivelserslik retningslinjen anbefaler. Gode beskrivelser gir oppfolgendeinstans viktig informasjon for videre pasientbehandling. Bedret dokumentasjonspraksis kan bidra til okt kontinuitet i helsetjenestetilbudetfor pasientene.

Cancellations of elective cardiac radiofrequency ablation procedures and compliance with a national quality indicator: A clinical audit

Abstract Background A late cancellation of surgical procedures is a major problem in specialist health care, resulting in substantial waste of resources. For catheter-based radiofrequency ablation (RFA) therapy for cardiac arrhythmias, there have been no studies published on the pervasiveness of cancellations. The aims of this study were to determine in our cardiac surgical services (i) the percentage of RFA therapy procedures cancelled, (ii) the cause of cancellations, and (iii) whether administrative data accurately reflect the true causes of cancellations. Methods A retrospective observational design was used. We included all patients assigned to elective RFA during a 1-year period at one large university hospital in Norway. The annual cancellation rate was calculated and compared to the national indicator of 5% cancellations. Causes of cancellations were also analysed to determine the rate of delays versus cancellations, and the distribution of the different causes was determined. Results In total, 471 elective RFA procedures were scheduled. Of these, 70 procedures (15%) were cancelled after patients’ admission. The two most frequent causes of cancellation were ‘capacity problem at the operating room’ (n=38) and ‘no indication for treatment’ (n=20). Only 13 of the 70 cases were registered in the administrative database ORBIT. In 10 of these 13 cases, the causes of cancellation recorded in ORBIT matched those recorded in the accompanying patients’ medical records. Conclusion There appears to be a discrepancy between current practice and the standard set by the health authorities. Both organisational and patient-related factors caused cancellations. We suggest that nurses in the arrhythmia team should perform a preoperative evaluation to reduce cancellations.