Connie Stewart

How registered nurses, licensed practical nurses and resident aides spend time in nursing homes: An observational study.

BACKGROUND Calls for improved conditions in nursing homes have pointed to the importance of optimizing the levels and skills of care providers. Understanding the work of care providers will help to determine if staff are being used to their full potential and if opportunities exist for improved efficiencies. OBJECTIVES To explore the activities of care providers in different nursing homes and to identify if variations exist within and across homes and shifts. METHODS A multi-centre cross-sectional observational work flow study was conducted in seven different nursing homes sites in one Canadian province. Data were collected by a research assistant who conducted 368 h of observation. The research assistant collected data by following an identical route in each site and recording observations on staff activities. RESULTS Findings indicate staff activities vary across roles, sites and shifts. Licensed practical nurses (nursing assistants) have the greatest variation in their role while registered nurses have the least amount of variability. In some sites both registered nurses and licensed practical nurses perform activities that may be safely delegated to others. Care providers spend as much as 53.7% of their time engaged in non-value added activities. CONCLUSIONS There may be opportunities for registered nurses and licensed practical nurses to delegate some of their activities to non-regulated workers. The time care providers spend in non-value activities suggest there may be opportunities to improve efficiencies within the nursing home setting.

Testing for a change in diet using fatty acid signatures

Determining whether the diet of predators has changed is an important ecological problem and appropriate methodology is needed in order to test for differences or changes in diet. It is known that the fatty acid (FA) signature in a predator’s adipose tissue predictably reflects the prey consumed and that, consequently, a change in the FA signatures can be largely attributed to changes in the predator’s diet composition. The use of FA signatures as a means of detecting change in diet presents some statistical challenges however, since the FA signatures are compositional and sample sizes relative to the dimension of a signature are often small due to biological constraints. Furthermore, the FA signatures often contain zeros precluding the direct use of traditional compositional data analysis methods. In this paper, we provide the methodology to carry out valid statistical tests for detecting changes in FA signatures and we illustrate both independent and paired cases using simulation studies and real life seabird and seal data. We conclude that the statistical challenges using FA data are overcome through the use of nonparametric tests applied to the multivariate setting with suitable test statistics capable of handling the zeros that are present in the data.

Comparison of the SIMARD MD to Clinical Impression in Assessing Fitness to Drive in Patients with Cognitive Impairment

Background The assessment of fitness to drive in patients with cognitive impairment is complex. The SIMARD MD was developed to assist with assessing fitness to drive. This study compares the clinical decision made by a geriatrician regarding driving with the SIMARD MD score. Methods Patients with a diagnosis of mild dementia or mild cognitive impairment, who had a SIMARD MD test, were included in the sample. A retrospective chart review was completed to gather diagnosis, driving status, and cognitive and functional information. Results Sixty-three patients were identified and 57 met the inclusion criteria. The mean age was 77.1 years (SD 8.9). The most common diagnosis was Alzheimer’s disease in 22 (38.6%) patients. The mean MMSE score was 24.9 (SD 3.34) and the mean MoCA was 19.9 (SD 3.58). The mean SIMARD MD score was 37.2 (SD 19.54). Twenty-four patients had a SIMARD MD score ≤ 30, twenty-eight between 31–70, and five scored > 70. The SIMARD MD scores did not differ significantly compared to the clinical decision (ANOVA p value = 0.14). Conclusions There was no association between the SIMARD MD scores and the geriatricians’ clinical decision regarding fitness to drive in persons with mild dementia or mild cognitive impairment.

Alternate Level of Care Patients in Hospitals: What Does Dementia Have To Do With This?

Background Patients in acute care hospitals no longer in need of acute care are called Alternate Level of Care (ALC) patients. This is growing and common all across Canada. A better understanding of this patient population would help to address this problem. Methods A chart review was conducted in two hospitals in New Brunswick. All patients designated as ALC on July 1, 2009 had their charts reviewed. Results Thirty-three per cent of the hospital beds were occupied with ALC patients; 63% had a diagnosis of dementia. The mean length of stay was 379.6 days. Eighty-six per cent were awaiting a long-term care bed in the community. Most patients experienced functional decline during their hospitalization. One year prior to admission, 61% had not been admitted to hospital and 59.2% had had at least one visit to the emergency room. Conclusions The majority of the ALC patients in hospital have a diagnosis of dementia and have been waiting in hospital for over one year for a long-term care bed in the community. Many participants were recipients of maximum home care in the community, suggesting home maker services alone may not be adequate for some community-dwelling older adults. Early diagnosis of dementia, coupled with appropriate care in the community, may help to curtail the number of patients with dementia who end up in hospital as ALC patients.

Zero-inflated beta distribution for modeling the proportions in quantitative fatty acid signature analysis

Quantitative fatty acid signature analysis (QFASA) produces diet estimates containing the proportion of each species of prey in a predators diet. Since the diet estimates are compositional, often contain an abundance of zeros (signifying the absence of a species in the diet), and samples sizes are generally small, inference problems require the use of nonstandard statistical methodology. Recently, a mixture distribution involving the multiplicative logistic normal distribution (and its skew-normal extension) was introduced in relation to QFASA to manage the problematic zeros. In this paper, we examine an alternative mixture distribution, namely, the recently proposed zero-inflated beta (ZIB) distribution. A potential advantage of using the ZIB distribution over the previously considered mixture models is that it does not require transformation of the data. To assess the usefulness of the ZIB distribution in QFASA inference problems, a simulation study is first carried out which compares the small sample properties of the maximum likelihood estimators of the means. The fit of the distributions is then examined using ‘pseudo-predators’ generated from a large real-life prey base. Finally, confidence intervals for the true diet based on the ZIB distribution are compared with earlier results through a simulation study and harbor seal data.

An approach to measure distance between compositional diet estimates containing essential zeros

ABSTRACT For many applications involving compositional data, it is necessary to establish a valid measure of distance, yet when essential zeros are present traditional distance measures are problematic. In quantitative fatty acid signature analysis (QFASA), compositional diet estimates are produced that often contain many zeros. In order to test for a difference in diet between two populations of predators using the QFASA diet estimates, a legitimate measure of distance for use in the test statistic is necessary. Since ecologists using QFASA must first select the potential species of prey in the predators diet, the chosen measure of distance should be such that the distance between samples does not decrease as the number of species considered increases, a property known in general as subcompositional coherence. In this paper we compare three measures of distance for compositional data capable of handling zeros, but not satisfying some of the well-accepted principles of compositional data analysis. For compositional diet estimates, the most relevant of these is the property of subcompositionally coherence and we show that this property may be approximately satisfied. Based on the results of a simulation study and an application to real-life QFASA diet estimates of grey seals, we recommend the chi-square measure of distance.

A Dirichlet Regression Model for Compositional Data with Zeros

Compositional data are met in many different fields, such as economics, archaeometry, ecology, geology and political sciences. Regression where the dependent variable is a composition is usually carried out via a log-ratio transformation of the composition or via the Dirichlet distribution. However, when there are zero values in the data these two ways are not readily applicable. Suggestions for this problem exist, but most of them rely on substituting the zero values. In this paper we adjust the Dirichlet distribution when covariates are present, in order to allow for zero values to be present in the data, without modifying any values. To do so, we modify the log-likelihood of the Dirichlet distribution to account for zero values. Examples and simulation studies exhibit the performance of the zero adjusted Dirichlet regression.

Non-parametric analysis of the spatio-temporal variability in the fatty-acid profiles among Greenland sharks

Shifting prey distributions due to global warming are expected to generate dramatic ecosystem-wide changes in trophic structure within Arctic marine ecosystems. Yet a relatively poor understanding of contemporary Arctic food webs makes it difficult to predict the consequences of such changes for Arctic predators. Doing so requires quantitative approaches that can track contemporary changes in predator diets through time, using accurate, well-defined methods. Here we use fatty acids (FA) to quantify differences in consumer diet using permutational multivariate analysis of variance tests that characterize spatial and temporal changes in consumer FA signatures. Specifically we explore differences in Greenland shark ( Somniosus microcephalus ) FA to differentiate their potential trophic role between Svalbard, Norway and Cumberland Sound, Canada. Greenland shark FA signatures revealed significant inter-annual differences, probably driven by varying seal and Greenland halibut responses to environmental conditions such as the NAO, bottom temperature, and annual sea-ice extent. Uncommon FA were also found to play an important role in driving spatial and temporal differences in Greenland shark FA profiles. Our statistical approach should facilitate quantification of changing consumer diets across a range of marine ecosystems.

Recruitment and Retention Challenges in a Technology‐Based Study with Older Adults Discharged from a Geriatric Rehabilitation Unit

Purpose: Technology has the potential to offer support to older adults after being discharged from geriatric rehabilitation. This article highlights recruitment and retention challenges in a study examining an interactive voice response telephone system designed to monitor and support older adults and their informal caregivers following discharge from a geriatric rehabilitation unit. Methods: A prospective longitudinal study was planned to examine the feasibility of an interactive voice telephone system in facilitating the transition from rehabilitation to home for older adults and their family caregivers. Patient participants were required to make daily calls into the system. Using standardized instruments, data was to be collected at baseline and during home visits. Findings: Older adults and their caregivers may not be willing to learn how to use new technology at the time of hospital discharge. Poor recruitment and retention rates prevented analysis of findings. Conclusions and Clinical Relevancy: The importance of recruitment and retention in any study should never be underestimated. Target users of any intervention need to be included in both the design of the intervention and the study examining its benefit. Identifying the issues associated with introducing technology with a group of older rehabilitation patients should assist others who are interested in exploring the role of technology in facilitating hospital discharge.