Nancy M. Watson

Systemic Antibiotic Use in Nursing Homes: A Quality Assessment

In this evaluation of the prevalence and quality of systemic antibiotic use in nursing homes, 42 skilled nursing facilities (SNFs) and their 11 attached intermediate care facilities (ICFs) were surveyed. A random sample of 2238 patients (51%) from the total of 4378 beds was selected and of these, 7.7% of the total (8.6% of the SNF and 4.5% of the ICF) patients were on systemic antibiotics on the day of the survey. The most common suspected sites of infection were urinary tract (58.4%), lower respiratory tract (19.1%), and skin or subcutaneous tissue (4.6%). Criteria for appropriateness of initiating systemic antibiotics, for adequacy of initial diagnostic workup, and for appropriate specific antibiotics were developed by the authors, with input from a group of medical directors of nursing homes, based on Centers for Disease Control and Federal Drug Administration guidelines. Evidence to start an antibiotic was judged adequate in 62.4% of cases. Workups were considered inadequate in a high proportion of cases. For example, urinalysis was ordered in only 23.8% and urine culture in 57.4% of suspected urinary tract infections; chest x‐ray was ordered in 24.2% and sputum culture in 3.0% of suspected lower respiratory infections. Recommendations are made as to minimum adequate workup for suspected infections and appropriate evidence to justify start of a systemic antibiotic, recognizing the limitations in diagnostic modalities in the nursing home setting and the special problems of their resident populations.

Oral Care Provided by Certified Nursing Assistants in Nursing Homes

The purpose of this study was to describe the actual daily oral care provided by certified nursing assistants (CNAs) for dentate elderly nursing home (NH) residents who required assistance with oral care. The study was conducted in five nonrandomly selected NHs in upstate New York using real‐time observations of CNAs providing morning care to residents, retrospective chart review, and CNA screening interviews. Oral care standards developed and validated by a panel of 10 experts (dentists, dental hygienists, registered nurses) to be appropriate for dentate NH residents were used to evaluate the oral care provided by 47 primary dayshift CNAs to a convenience sample of 67 residents. CNAs were blinded to the studys specific focus on oral care. Adherence to individual standards was low, ranging from a high of 16% to a low of 0%. Teeth were brushed and mouths rinsed with water in 16% of resident observations. One resident had her tongue brushed.

Use of the Agency for Health Care Policy and Research Urinary Incontinence Guideline in nursing homes

The objective of this study was to assess the use of the Agency for Health Care Policy and Research (now called the Agency for Healthcare Research and Quality) Urinary Incontinence (UI) Guideline (1996) in nursing homes (NHs) using retrospective chart review and nursing assistant screening interviews. The study was conducted in a nonrandom sample of 52 NHs in upstate New York. Two hundred residents developing new UI or newly admitted with UI on the dayshift and who met criteria for evaluation and treatment/management were evaluated in the 12 weeks after onset of or admission with UI. Fifteen percent of newly admitted residents needed evaluation. Of residents already in NHs, 2.3 per 100 beds developed new UI over the 12 weeks. Aspects of UI evaluation rarely done were rectal examination (15%), digital examination of prostate (15%), and pelvic examination (2%). Sixty‐eight percent had a culture/sensitivity, 56% a urinalysis, and 6% a postvoid residual. Eighty‐one percent had a reversible cause at the time of onset, but only 34% had all addressed. Few (2%) needed urologist evaluation. Treatment was rare (3%), but management using toileting and absorbent products were common. Only 6% achieved resolution of UI. These results suggest that assessment and treatment of UI is manageable (a total of 4.2 new cases per 100 beds per 12 weeks) but quality is not adequate. On average, only 20% of the standards applicable were met, due primarily to lack of awareness of new UI and lack of familiarity with the guideline. Thus, improvements are needed. Recommendations for guideline revision are made.

Review of nurse home visiting interventions for community-dwelling older persons with existing disability.

Despite there being a considerable number of meta-analyses and reviews synthesizing the nurse in-home visiting literature, there have been no reviews examining nurse in-home visiting for patients who are already disabled. This article presents a literature review and synthesis of 10 trials targeted on older adults with disability. The review is organized into structure and process components related to the outcome variable disability based on the classic Donabedian model. The review suggests that the components of in-home visiting associated with favorable disability outcomes include multiple home visits, geriatric training and experience, health provider collaboration, multidimensional assessment, and theory use. In contrast, lack of process measures, physician collaboration, training, and specific intervention components targeting disability are associated with ineffective interventions. This review helps provide insight into variables that influence disability outcomes as well as the development of best-practice models of in-home visiting to older adults with existing disability.

Translating research on incontinence into practice

Background: Translating research evidence into clinical practice (TRIP) is an important initiative for health services so that care delivered is cost-effective, is efficient, and improves patient outcomes. Most TRIP studies have reported on disseminating and implementing clinical practice guidelines, protocols, or care pathways and have been undertaken in acute rather than community settings. Objectives: To identify the factors that influence incontinence TRIP and to present key international studies on incontinence TRIP. Methods: Existing literature on TRIP was analyzed to generate a plan for future research. Results: Several methods to effect incontinence TRIP are described, including clinical practice guidelines and protocols, clinical pathways, partnerships between organizations, a model for incorporating UI research based on generic questions, and implementation strategies that incorporate change theory and consideration of barriers. Conclusions: Future research is needed on incontinence TRIP in the following areas: barriers, the best theoretical approaches, the effectiveness of empowerment approaches, the value of mentors, effective strategies for nurses and unlicensed personnel, the impact of international collaboration, and regulations across settings.

Rocking chair therapy for dementia patients: Its effect on psychosocial well-being and balance

The use of platform style rocking chairs to improve psychological well-being and balance of nursing home residents with dementia was studied. Despite significant cognitive impairment, most medically stable unrestrained residents accepted the chairs and learned to actively rock. During the six week program, residents were able to rock an average of 101 minutes per day. Using a cross-over design (n=25), there were improvements in depression/anxiety and reductions in PRN pain medication significantly related to amount of rocking. Those who liked rocking and wanted to continue it at the end of the study also demonstrated significant improvements in balance as measured by center of gravity.

Spiritual nurturance and support for nursing home residents with dementia

This mixed method study examined nursing home resident, family and staff views regarding spiritual nurturance and support for persons with dementia and analyzed institutional resources/approaches for meeting residents’ spiritual needs. For residents able to communicate in words (n = 47/83 or 57%), this topic evoked a range of emotional content, brought back memories, and yielded information about what mattered to them spiritually/religiously. Some observations and reported behaviors of residents unable to be interviewed directly (n = 36/83 or 43%) suggested emotional awareness of spiritual activities. Family member/staff perspectives revealed beliefs, concerns, and needs for support/training in the provision of spiritual care. Quantitative findings were consistent and identified differences between surveyed nursing homes (n = 48) with and without religious affiliations. Discussion of personhood, spiritual/ religious coping, and meeting spiritual care needs led to conclusions about the role of professional chaplaincy in educating and modeling for staff and others appropriate behaviors for providing spiritual support as well as the importance of accommodating diversity and maximizing resources.

Which Components of a Primary Care Affiliated Home Visiting Nurse Program Are Associated With Disability Maintenance/Improvement?

A process evaluation of a primary care affiliated home visiting nurse intervention was performed to determine which intervention components were associated with disability maintenance/improvement. This secondary analysis (N = 238) used data recorded in intervention databases and patient interviews among community-dwelling elders with disability. Intervention components were examined in descriptive, correlational, bivariate, and logistic regression analyses. Results demonstrated that two structure components—physician-patient-family-nurse conference visits and intervention (education) materials—and three process components—disease management activities, goal setting, and medication management activities—were linked to maintaining/improving activities of daily living disability status. Confirmation of these findings may help home care nurses to delay disability worsening.