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Older adults undergoing emergency abdominal surgery have significantly poorer outcomes than younger adults. For those who survive, the level of care required on discharge from hospital is unknown and such information could guide decision-making. The ELF (Emergency Laparotomy and Frailty) study aimed to determine whether preoperative frailty in older adults was associated with increased dependence at the time of discharge.The ELF study was a UK-wide multicentre prospective cohort study of older patients (65 years or more) undergoing emergency laparotomy during March and June 2017. The objective was to establish whether preoperative frailty was associated with increased care level at discharge compared with preoperative care level. The analysis used a multilevel logistic regression adjusted for preadmission frailty, patient age, sex and care level.A total of 934 patients were included from 49 hospitals. Mean(s.d.) age was 76·2(6·8) years, with 57·6 per cent women; 20·2 per cent were frail. Some 37·4 per cent of older adults had an increased care level at discharge. Increasing frailty was associated with increased discharge care level, with greater predictive power than age. The adjusted odds ratio for an increase in care level was 4·48 (95 per cent c.i. 2·03 to 9·91) for apparently vulnerable patients (Clinical Frailty Score (CFS) 4), 5·94 (2·54 to 13·90) for those mildly frail (CFS 5) and 7·88 (2·97 to 20·79) for those moderately or severely frail (CFS 6 or 7), compared with patients who were fit.Over 37 per cent of older adults undergoing emergency laparotomy required increased care at discharge. Frailty scoring was a significant predictor, and should be integrated into all acute surgical units to aid shared decision-making and discharge planning.Los adultos mayores sometidos a cirugía abdominal de urgencia tienen resultados significativamente peores que los adultos jóvenes. Para aquellos pacientes que sobreviven, el nivel de atención que requieren tras el alta hospitalaria se desconoce y esta información podría servir de guía en la toma de decisiones. El estudio ELF (Emergency Laparotomy and Frailty) tenía como objetivo determinar si la fragilidad preoperatoria en adultos mayores se asociaba con un aumento de la dependencia en el momento del alta. MÉTODOS: El estudio ELF era un estudio multicéntrico extenso efectuado en el Reino Unido (n = 49) que incluyó una cohorte prospectiva de 934 pacientes mayores ( 65 años) sometidos a laparotomía de urgencia durante marzo-junio de 2017. El objetivo fue establecer si la fragilidad preoperatoria aumentaba el nivel de asistencia en el momento del alta en comparación con el nivel de asistencia preoperatorio. Para el análisis se utilizó una regresión logística multinivel ajustada a características previas al ingreso: fragilidad, edad del paciente, género, y nivel de asistencia.La edad media de los pacientes fue 76,2 años (DE = 6,83), con un 57% de mujeres, un 20,2% de pacientes frágiles y un 37,4% de adultos mayores que presentaron un aumento en el nivel de asistencia en el momento del alta. Un aumento de la fragilidad se asoció con un incremento en el nivel de asistencia en el momento del alta (y mayor poder predictivo que la edad). La razón de oportunidades (odds ratio, OR) ajustada por el aumento del nivel de asistencia fue 4,48 (i.c. del 95% 2,03-9,91) para pacientes aparentemente vulnerables (Clinical Frailty Scale, CFS 4); 5,94 (i.c. del 95% 2,54-13,90) para aquellos ligeramente frágiles (CFS 5); y 7,88 (i.c. del 95% 2,97-20,79) para aquellos con fragilidad moderada o grave (CFS 6 and 7) en comparación con pacientes en buenas condiciones. CONCLUSIÓN: Este es el primer estudio que documenta que más del 37% de adultos mayores sometidos a laparotomía de urgencia precisaron un aumento en el nivel de asistencia en el momento del alta. La evaluación de la fragilidad debería integrarse en todas las unidades quirúrgicas de agudos para ayudar a compartir la toma de decisiones y los planes de tratamiento.

This study aims to investigate the factors of care-level deterioration in older adults with mild and moderate disabilities using nationally standardized survey data for care-needs certification. We enrolled people aged 68 years or older, certified as support levels 1–2 (mild disability) or care levels 1–2 (moderate disability) with no cancer. The outcome was care-level deterioration after two years. The possible factors were physical and mental functions which were categorized as the following five dimensions according to the survey for care-needs certification: body function, daily life function, instrumental activities of daily living (IADL) function, cognitive function, and behavioral problems. A multivariate logistic regression analysis was conducted after stratifying the care level at baseline. A total of 2844 participants were included in our analysis. A low IADL function was significantly associated with a risk of care-level deterioration in all participants. In addition, low cognitive function was linked to care-level deterioration, except for those with support level 1 at baseline. Participants with more behavioral problems were more likely to experience care-level deterioration, except for those with care level 2 at baseline. Our study showed the potential utility of the care-needs certification survey for screening high-risk individuals with care-level deterioration.

Private rooms are widely preferred by residents in senior homes. However, having roommates may help them to maintain social networks, leading to promoted social cohesion and health. The differences in social cohesion among senior-home residents who reside in private or shared rooms need investigation. Focusing on social cohesion and room arrangement, on-site questionnaire surveys recruited 345 residents from eight senior homes in Beijing and Shanghai, China. Controlling for personal and facility factors, ANOVA tests were employed to investigate the differences in social cohesion among residents who resided in private or shared rooms. Room arrangement was found significant to social cohesion in assisted-living and nursing-care residents. At the assisted-living level, triple-room (room shared by three) residents had stronger social cohesion than private-room or double-room (room shared by two) residents (p ≤ 0.01). At the nursing-care level, residents with less roommates had stronger social cohesion (p ≤ 0.05). At the independent-living level, no factors significant to social cohesion was found. The influences of room arrangement on social cohesion vary by care level and facility. To promote social cohesion, triple rooms are suggested for assisted-living care whereas private rooms are more appropriate for nursing care. Senior-living rooms should be social-friendly through appropriate arrangement in cultural contexts.

Background To evaluate the success of plaque reduction after external toothbrushing by instructed laypeople versus dental professionals using either a manual or powered toothbrush. Longitudinal, randomized, parallel-group intervention study in periodontitis patients with reduced oral hygiene quality undergoing anti-infective therapy. Patients were randomly and equally assigned to one of four groups: laypeople using a manual or powered toothbrush or dental professionals using a manual or powered toothbrush. Plaque reduction (Quigley–Hein-Index (QHI), Marginal Plaque Index (MPI)), gingivitis (papilla bleeding index), and cleaning time (seconds) were investigated. Results Thirty-nine patients participated in the study. Neither the choice of toothbrush (p = 0.399) nor the use of a dental professional (p = 0.790) had a significant influence on plaque levels achieved. However, multivariate modeling indicated statistically significant differences in the external cleaning time between brushing groups, with longer time required by laypeople (p = 0.002) and longer use of the powered toothbrush (p = 0.024). Conclusion When the ability to carry out personal oral hygiene is reduced, external brushing by dental professionals or instructed laypeople who meet previously defined criteria such as sufficient personal oral hygiene at home could help to fill the emerging dental care gap. A combination of oral hygiene approaches adapted to the individual needs of the patients in need of external help is necessary for optimum oral hygiene. Trial registration: German Clinical Trials register (https://www.germanctr.de; number DRKS00018779; date of registration 04/11/2019).

Background Although the overall quality of high-risk neonatal care has improved recently, there is still concern about a difference in the quality of care when comparing off-hour births and regular-hour births. Moreover, there are no data in Korea regarding the impact of time of birth on mortality and morbidities in preterm infants. Methods A total of 3,220 infants weighing < 1,000 g and born at 23–34 weeks in 2013–2017 were analyzed based on the Korean Neonatal Network data. Mortality and major morbidities were analyzed using logistic regression according to time of birth during off-hours (nighttime, weekend, and holiday) and regular hours. The institutes were sub-grouped into hospital group I and hospital group II based on the neonatal intensive care unit (NICU) care level defined by the mortality rates of < 50% and ≥ 50%, respectively, in infants born at 23–24 weeks' gestation. Results The number of births during regular hours and off-hours was similar. In the total population and hospital group I, off-hour births were not associated with increased neonatal mortality and morbidities. However, in hospital group II, increased early mortality was found in the off-hour births when compared to regular-hour births. Conclusion Efforts to improve the overall quality of NICU are required to lower the early mortality rate in off-hour births. Also, other sensitive indexes for the evaluation of quality of NICU care should be further studied., Graphical Abstract

Background To improve harm prevention, patient engagement in safety at the direct care level is advocated. For patient safety to most effectively include patients, it is critical to reflect on existing evidence, to better position future research with implications for education and practice. Methods As part of a multi‐phase study, which included a qualitative descriptive study (Duhn & Medves, 2018), a scoping review about patient engagement in safety was conducted. The objective was to review papers about patients’ attitudes and behaviours concerning their involvement in ensuring their safe care. The databases searched included MEDLINE, CINAHL and EMBASE (year ending 2019). Results This review included 35 papers about “Patient Attitudes” and 125 papers about “Patient Behaviours”—indicative of growing global interest in this field. Several patterns emerged from the review, including that most investigators have focused on a particular dimension of harm prevention, such as asking about provider handwashing, and there is less known about patients’ opinions about their role in safety generally and how to actualize it in a way that is right for them. While patients may indicate favourable attitudes toward safety involvement generally, intention to act or actual behaviours may be quite different. Conclusion This review, given its multi‐focus across the continuum of care, is the first of its kind based on existing literature. It provides an important international “mapping” of the initiatives that are underway to engage patients in different elements of safety and their viewpoints, and identifies the gaps that remain.

To evaluate the oral-health of preschool-children of incarcerated-mothers at nine United Arab Emirates (UAE) prison-nurseries and assess the oral-health knowledge and attitudes of the prison nurseries’ caregivers. Cross sectional comparative study. A total of 128 and 254 preschool children formed the study and control groups respectively. All were examined clinically for dental caries using the dmft score and oral health and hygiene status indices. Knowledge and attitudes of all caregivers (n = 45) at prison nurseries were assessed using an interview questionnaire. The prevalence of caries was not significantly different between the two groups with 89.9% [mean-dmft 4.97 (± 3.61)] in the study group and 92.1% [mean-dmft 4.48 (± 3.60)] in the controls. Oral-hygiene in the control group was better with 18.2% having good oral-hygiene compared to 6.2% in the study-group. Oral-health knowledge and attitude of the caregivers of prison nurseries were not satisfactory. Despite the non-significant difference in the caries prevalence between the study and control groups, oral hygiene and care level of vulnerable-children of incarcerated-mothers were significantly poorer. Prisons’ caregivers had poor knowledge and attitude of dental health matters.

BackgroundThough mass evacuation may increase the need for long-term care (LTC) services, how the need for LTC services increases and how the public LTC system affects it is not well understood. We evaluated changes in public LTC benefits for the people living in the mandatory evacuation areas established after the 2011 Fukushima nuclear disaster and examined the roles of the universal LTC insurance system in Japan.MethodsIn order to evaluate the effect of the mandatory evacuation on LTC benefits, we examined the trends of LTC benefits in the Fukushima evacuation group and the nationwide non-evacuation group. We first decomposed per-elderly-individual benefits at the municipality level into the LTC certification rate and per-certified-individual benefits, and then implemented difference-in-differences analysis using these variables as outcomes.ResultsPer-elderly-individual benefits significantly increased from 2012 onward in the evacuation group, and this was explained by an increase in the certification rate rather than in per-certified-individual benefits. Increases in per-elderly-individual benefits and the certification rate in the post-disaster period were observed in all but the highest care level, and the corresponding outcomes for the highest care level decreased immediately after the disaster. We also found that the increase in the certification rate had been mostly realized by an increase in the number of certified individuals.ConclusionsThe increase in LTC benefits can be associated with the impact of the increase in the number of people newly certified to receive LTC benefits after the mandatory evacuation. In order to cope with the increase in utilization of long-term care and associated costs after disasters in aging societies, both formal long-term care services and social support for informal care for evacuees should be considered important.

Background The association between oral health and malnutrition has been investigated in detail. The nutrition of elderly subjects in residential care homes is determined by caregivers, dietitians or nutritionists and managed by changing the consistency of their supplied food. However, few reports have described the relationship between oral condition and supplied food consistency. The objective of this study was to determine dentition status and care levels that correlate with supplied food consistency among elderly residents of care facilities. In addition, we estimated the care level at which ordinary food consistency can be supplied by caregivers who cannot diagnose dental status. Method Several factors, including dentition, wearing removable dentures, meals categorized as ordinary or processed (sliced, mashed, or liquefied), and care levels according to the Japanese standardized care-needs certification system were investigated in 276 elderly residents (male, n = 56; female, n = 220; mean age, 87.68 ± 5.94 years) of 12 fee-based care facilities. Results The results of this study showed that care levels were significantly correlated with the consistency of the food supplied to the residents. When supplied food consistency was categorized as ordinary or processed, the number of remaining teeth and the number of tooth contact pairs, either natural or artificial, were statistically significant. From logistic regression analysis, it was determined that the numbers of tooth contact pairs were statistically significant among residents requiring high levels of care. Conclusion The number of tooth contact pairs, either natural or artificial, was one of the contributing factors for deciding supplied food consistency among elderly residents of care facilities. Elderly residents requiring less than care level 3 should have ordinary meals. Electronic supplementary material The online version of this article (10.1186/s12903-019-0770-0) contains supplementary material, which is available to authorized users.

Care erosion - gradual decline in care level - is an important problem in health care today. Unfortunately, the mechanism whereby it occurs is complex and poorly understood. This paper seeks to address this by emphasising problems in reflective nursing practice. Critical reflection on quality of care which should drive good care instead spawns justifications, denial, and trivialisation of deficient care. This perpetuates increasingly poor care levels. We argue that cognitive dissonance theory provides a highly effective understanding of this process and suggest for this approach to be incorporated in all efforts to address care erosion. The paper includes a detailed discussion of examples and implications for practice, in particular the need to restore critical reflection in nursing, the importance of embracing strong values and standards, and the need for increased awareness of signs of care erosion.

The tongue surface in older people requiring nursing care is often coated with a layer believed to comprise, keratinized products of degeneration, food residue, bacteria, and leukocytes attached to the tongue papillae. Which factors affect the status of this tongue coating remain to be elucidated, however. The purpose of this study was to evaluate factors related to tongue coating status in older people requiring nursing care. The study participants comprised 41 individuals admitted to special nursing homes for the elderly. After undergoing tooth brushing and tongue cleaning by the facility staff, the participants were required to refrain from oral cleaning until evaluation of tongue coating status, which was performed just after lunch. The moisture level of the tongue surface was measured and total number of oral microbes determined. Food type, care level, and sex were determined by a questionnaire given by the attending nurses. Correlations between the tongue coating status and various factors were analyzed using Spearman's rank correlation coefficient. The participants were divided into 2 groups according to the median value of the tongue coating status. Factors related to tongue coating were analyzed using binomial logistic regression analysis (α=0.05). Tongue coating status showed a significant correlation with the total number of oral microbes on the tongue surface (rS=0.449, p=0.003), type of food (rS=0.388, p=0.012), and care level (rS=-0.308, p=0.050). Logistic regression analysis revealed that the food type of the side dish significantly affected tongue coating status. These results showed a correlation between tongue coating status and type of food of the side dish in older people requiring nursing care.

Background Mobility decrease is reportedly age-dependent in community dwelling elderly, and a major factor of disability in the geriatric population. The purpose of this study is to examine whether mobility decrease, as assessed using a set of tests, is similarly age-dependent in elderly adults who already have disability. Methods One hundred thirty-five community-dwelling elderly (54 men, 81 women) with disability and 1469 independent community dwellers (1009 men, 460 women) were analyzed. Disability was defined having a certified need for care under the long-term care insurance system in Japan. Lower extremity mobility decrease was quantified using the Locomotive Syndrome Risk Test, which comprises the two-step test, stand-up test, and 25-Question Geriatric Locomotive Function Scale (GLFS-25). Results Multivariable regression analyses indicated no age-related decrease in the three test scores among elderly with disability, whereas these scores all decreased with age among independent community dwellers. All the test scores decreased as care level increased. Conclusions Mobility decrease among elderly adults with disability is unrelated to age. However, the severity of care level is associated with mobility decrease.

Disparities in Acute Myocardial Infarction (AMI) care and outcomes have been frequently reported in racial-ethnic minorities in the U.S. Some studies have attributed disparities in Hispanics and other minorities to lower quality of services at hospitals where they seek care. Current information from hospitals with large Hispanic representations and updated quality resources is needed.Retrospective observational study of 839 AMI patients discharged in 2013 from three Southern California Hospitals (A, B, C) with tertiary cardiac care level. Non-Hispanic Whites (NHW) and Hispanics (H) were the larger racial-ethnic groups (68.3%), and the comparison of these two groups constitutes the focus of the study. Mortality, 30day readmissions, medication/performance measures (PRx); aspirin, statins/anti-lipids, beta-blockers, ACEI/ARB for LV systolic dysfunction,90min door-balloon time, and revascularization procedures were compared between hospitals, NHW and H, using Chi-squared tests (χNo significant differences in hospital, 30day mortality, PRx or procedures were observed between NHW, H and other racial-ethnic minority groups, or hospitals. Hospital C had 47.3% H and Hospitals A+B 14.6% (p0.001, effect size=0.430). AMI performance measures exceeded 2013 national rates across all facilities. NHW had more private/commercial insurance (52.5% vs. 25.4%, OR 3.24, 95% CI 2.19-4.80, p0.001) than H.Equitable access to quality hospital services in three Southern California hospitals offset previously reported disparities in AMI management in Hispanics. These results may not necessarily reflect the reality of AMI care for Hispanics in other U.S. regions.

This study extends an earlier investigation (DiIorio et al., 2004) regarding neuroscience studies published in four nursing journals over the period from 1989 to 2000. A literature review was conducted from 2001 to 2010 with the same search strategy performed by DiIorio from 1989 to 2000. A trend analysis comparing the articles published in the period of 2001-2008 with those published from 1993 to 2000 (odds ratio [OR], 95% confidence interval [CI]) was performed. From 1989 to 2010, a total of 607 articles were published, 2.2 articles per month. A significantly increased number of publications on neuroscience nursing research have emerged comparing 2001-2008 versus 1993-2000 (OR = 2.1, 95% CI [1.22, 3.29]; p = .00). From 1989 to 2000, neurological problems were the predominant object of study (389 articles, 64.1%), followed by neurotrauma problems (156, 25.7%) and those neurosurgical problems (31, 5.1%). Moreover, a progressive reduction of studies focusing on neurological problems (OR = 0.42, 95% CI [0.26, 0.68]; p = .00) has emerged comparing 2001-2008 versus 1993-2000. The setting chosen for the study from 1989 to 2000 was mainly hospitals (211, 34.8%) followed by long-term care (125, 20.6%) and the home environment (77, 12.7%). Over the years (2001- 2008 vs. 1993-2000), studies performed at the home level were lower (OR = 0.27, 95% CI [0.15, 0.47]; p = .00), whereas those carried out at the hospital level and at the long-term care level have increased. Research in neuroscience nursing has continued to grow in the last decade, involving more patients who are mainly women. In the coming years, quasiexperimental, experimental, or complex intervention designs, involving the various care settings and along the trajectories of illnesses of patients who have an acute phase but especially in a long-term phase, are needed.

Aim: To develop a Japanese version of the Care Planning Assessment Tool (J-CPAT), originally developed in Australia as a comprehensive assessment of people with dementia. Methods: The process of adapting the CPAT into Japanese included translation into Japanese, assessment of item comprehension, and a validity and reliability study. The J-CPAT is composed of eight domains: Communication, physical problems, self-help skills, confusion, behaviour, social interaction, psychiatric observations and carer dependency. The participants were 199 aged care clients. Measures were the J-CPAT, Mini-Mental State Examination (MMSE) and Care Levels used in the Long-term Care Insurance scheme. Results: Cronbach's alpha values in each J-CPAT domain were 0.74–0.95. The correlation coefficient between the score of Confusion and MMSE was −0.90, and those between physical problems, self-help skills, carer dependency in the J-CPAT, and care level were 0.70, 0.75 and 0.67. Conclusions: The J-CPAT appears to be a reliable and valid tool for care planning in Japan.

A validity test was conducted to determine how care level–based nurse-to-resident ratios compare with actual daily care times per resident in Germany. Stability across different long-term care facilities was tested. Care level–based nurse-to-resident ratios were compared with the standard minimum nurse-to-resident ratios. Levels of care are determined by classification authorities in long-term care insurance programs and are used to distribute resources. Care levels are a powerful tool for classifying authorities in long-term care insurance. We used observer-based measurement of assignable direct and indirect care time in 68 nursing units for 2028 residents across 2 working days. Organizational data were collected at the end of the quarter in which the observation was made. Data were collected from January to March, 2012. We used a null multilevel model with random intercepts and multilevel models with fixed and random slopes to analyze data at both the organization and resident levels. A total of 14% of the variance in total care time per day was explained by membership in nursing units. The impact of care levels on care time differed significantly between nursing units. Forty percent of residents at the lowest care level received less than the standard minimum registered nursing time per day. For facilities that have been significantly disadvantaged in the current staffing system, a higher minimum standard will function more effectively than a complex classification system without scientific controls.

The practice of perinatal regionalization is designed to ensure that newborns are born in facilities with a care level designation that is consistent with expected pregnancy outcomes. Regionalization practices have resulted in lower neonatal mortality and morbidity rates. However, despite regionalization efforts, approximately 10 percent of newborns will require some level assistance with breathing, and a few (

Objective Measures of maternal mortality and severe maternal morbidity have risen in the United States, sparking national interest regarding hospitals' ability to provide maternal risk-appropriate care. We examined the extent to which hospitals could be classified by increasingly sophisticated maternal levels of care. Study Design We performed a cross-sectional survey to identify hospital-specific resources and classify hospitals by criteria for basic, intermediate, and regional maternal levels of care in all nonmilitary childbirth hospitals in California. We measured hospital compliance with maternal level of care criteria that were produced via consensus based on professional standards at 2 regional summits funded by the March of Dimes through a cooperative agreement with the Community Perinatal Network in 2007 (California Perinatal Summit on Risk-Appropriate Care). Results The response rate was 96% (239 of 248 hospitals). Only 82 hospitals (34%) were classifiable under these criteria (35 basic, 42 intermediate, and 5 regional) because most (157 [66%]) did not meet the required set of basic criteria. The unmet criteria preventing assignment into the basic category included the ability to perform a cesarean delivery within 30 minutes 100% of the time (only 64% met), pediatrician availability day and night (only 56% met), and radiology department ultrasound capability within 12 hours (only 83% met). Only 29 of classified hospitals (35%) had a nursery or neonatal intensive care unit level that matched the maternal level of care, and for most remaining hospitals (52 of 53), the neonatal intensive care unit level was higher than the maternal care level. Conclusion Childbirth services varied widely across California hospitals, and most hospitals did not fit easily into proposed levels. Cognizance of this existing variation is critical to determining the optimal configuration of services for basic, intermediate, and regional maternal levels of care.

The purpose of this study was to clarify the effects of dementia based on the changes of independence conditions targeting the home-care elderly classified as Care level 1 of care needs or support. The care managers entered the basic information and assessment including oral health care for them. The independence level and other aspects of the elderly with and without dementia were examined comparatively for eight weeks. The results were as follows: 1. The highest independence level was observed for oral health care of the elderly without dementia, and it remained at the highest level for eight weeks. 2. Almost all independence levels of the elderly with dementia were significantly lower than those without dementia. 3. The willingness of the elderly without dementia was high among all areas, it was the highest of oral health care. A significant difference was observed between those with and without dementia. 4. As for cooperation from family members, the lowest value was oral health care. It is suggested that the elderly requiring home-based long-term light care or support have a high independence level concerning oral health care. The willingness toward oral health care of the elderly with mild dementia was still high. The elderly with dementia were less independent regarding oral health care. Moreover, an increasing number of elderly people live by themselves, and do not expect support from their families. Active intervention by experts is necessary to improve their independence concerning oral health care.

In this paper an evaluation approach to assess the co-ordination of supportive community cancer care is presented. The aim of the study was to identify current gaps in co-ordination of services in a selected region in the province of Ontario, Canada, determine how consistent these gaps were across the province of Ontario, and develop service design considerations for improving the co-ordination of supportive cancer care services in the province of Ontario. The study addressed services required by two populations -clients who had been recently diagnosed and those in the palliative stages of cancer. The evaluation was theory-driven and incorporated evidence from three methods: a systematic literature review, a community case study and a provincial scan. The results revealed the absence of a formal supportive cancer care system and a complex community care system. Supportive cancer care was shown to be delivered by a range of generalist programs that lacked specialisation in addressing the unique needs of cancer clients. In addition, there was no clear evidence of leadership for co-ordinating supportive cancer care, where client care was most often provided by multiple programs at any given point in time. The study generated recommendations to improve co-ordination of supportive cancer care at both the administrative as well as direct care level.

Many patients in nursing homes receive limited services. In 1996, approximately 17% of the 1.6 million nursing home residents received assistance with two or less activities of daily living (ADL). This descriptive study addressed this issue by investigating why residents with light care needs enter and remain in nursing homes. Residents with light care needs (N = 20) identified by directors of nursing were interviewed to elicit why they entered and remain in nursing homes. Their care level was estimated using the Minimum Data Set (MDS) and Resource Utilization Groups, Version III (RUGIII). In this study, older adults with light care needs who decide to enter and remain in nursing homes were found to be influenced by a prior Hospitalization or a health event; the perceived inability to manage instrumental ADLs (IADLs), ADLs, or health monitoring at home; and lack of knowledge about alternatives to nursing home care. This study demonstrates the vital role nurse case managers can play in both acute care settings and nursing homes. They can help older adults with light care needs to make informed decisions about longterm care, seek out community options, and set in place assistive care systems that can help them age in the community.

Background: Within the setting of a public health service we analyse the distribution of resources between individuals in nursing homes funded by global budgets. Three questions are pursued. Firstly, whether there are systematic variations between nursing homes in the level of care given to patients. Secondly, whether such variations can be explained by nursing home characteristics. And thirdly, how individual need-related variables are associated with differences in the level of care given. Methods: The study included 1204 residents in 35 nursing homes and extra care sheltered housing facilities. Direct time spent with patients was recorded. In average each patient received 14.8 hours direct care each week. Multilevel regression analysis is used to analyse the relationship between individual characteristics, nursing home characteristics and time spent with patients in nursing homes. The study setting is the city of Trondheim, with a population of approximately 180 000. Results: There are large variations between nursing homes in the total amount of individual care given to patients. As much as 24 percent of the variation of individual care between patients could be explained by variation between nursing homes. Adjusting for structural nursing home characteristics did not substantially reduce the variation between nursing homes. As expected a negative association was found between individual care and case-mix, implying that at nursing home level a more resource demanding case-mix is compensated by lowering the average amount of care. At individual level ADL-disability is the strongest predictor for use of resources in nursing homes. For the average user one point increase in ADL-disability increases the use of resources with 27 percent. Conclusion: In a financial reimbursement model for nursing homes with no adjustment for case-mix, the amount of care patients receive does not solely depend on the patients’ own needs, but also on the needs of all the other residents.

Several reports have recently been published regarding dysphagia in very elderly patients, and centenarian dysphagia patients have become more common in Japan. The aim of this study was to assess the prognosis of dysphagia in very elderly patients. Participants were 24 centenarian dysphagia patients. For each patient, we collected information on age, care level, past medical history, and changes in oral intake according to the Functional Oral Intake Scale (FOIS). Patients were divided into two groups based on the mode of food intake at the time of transfer or discharge: the per oral-only group (the PO-only group, i.e., oral intake alone) and the tube feeding-dependent group (the TF-dependent group, i.e., combination of oral intake and tube feeding, or tube feeding alone). In both groups, the FOIS score decreased significantly from pre-hospitalization to the time of transfer or discharge (p=0.006 for both). The FOIS score at initial assessment was higher in the PO-only group with the TF-dependent group (p=0.0004). Furthermore, the frequency of a FOIS score of 4 at initial assessment was significantly higher in the PO-only group, and the frequency of a FOIS score of 1 was significantly higher in the TF-dependent group (p=0.0006). These findings collectively suggest that oral intake can be recovered if the FOIS score is ≥ 4 at initial assessment, is difficult if the score is 1, and may be possible with a FOIS score of 2.

OBJECTIVES The aim of this study was to investigate the association between social roles (engaged in working outside or house work) or hobbies and changes in care level among users of Preventive Care Service under Long-Term Care Insurance. METHODS A total of 8,734 Preventive Care Service users were analyzed. The assessment was conducted between February 2007 and December 2008. The improvement, maintenance, and aggravation in care level were defined by changes in care level from the beginning to the end. To assess their activities in daily life, the participants were asked, "Which is the major activity in your daily life? Please select one from the following: working outside, house work, hobbies, watching television, others, or none." We used the multiple logistic regression model to calculate the odds ratio (OR) and 95% confidence interval (CI) of the maintenance or improvement in care level according to the category of activity. RESULTS As compared with subjects who answered none, the multivariate adjusted ORs (95% CI) of the maintenance or improvement in care level were 2.0 (1.4-2.9) for those who answered working outside, 1.5 (1.2-1.8) for those who answered house work, and 1.5 (1.2-1.9) for those who answered hobbies. However, those who answered watching television or others did not show a significant association with the maintenance or improvement in care level. CONCLUSIONS In this study, compared with subjects who answered none, those who answered that they were engaged in working outside, house work, or hobbies were associated with having significantly higher ORs of the maintenance or improvement in care level.

Background For 2 consecutive years, a care level III neonatal intensive care unit (NICU) in a 700-bed health care facility experienced an increase in health care-associated methicillin-resistant Staphylococcus aureus (MRSA). To decrease transmission, standard infection prevention techniques, active surveillance cultures, and deoxyribonucleic acid typing were done. After control was achieved, members of the organization outside of infection prevention and control requested health care worker (HCW) screening for MRSA, believing that it would decrease chances of future transmission. Methods To develop effective tools to communicate with organization members: (1) questions that must be resolved before HCW screening can be done accurately, (2) operational requirements for HCW screening, and (3) a “trigger point” for HCW screening should MRSA activity increase in the future. Results Developed tools to determine when MRSA screening of HCWs is warranted and for the preparation process when MRSA screening is necessary. Without performing HCW screening in the NICU, there were no health care-associated infections with MRSA for 20 months or colonization for 5 months. Conclusion Proactive consideration of HCW screening can be achieved by designing and implementing tools to illustrate the complexity of the HCW screening process and by defining a “trigger point” for HCW culturing if needed for MRSA control. Decreasing MRSA transmission in this NICU was accomplished without culturing health care workers.

Regionalization of health care for trauma has become commonplace, and the same concept for critically ill medical/surgical patients is developing. Recent evidence suggests that current stabillization measures used by transport teams can be inadequate for this critically ill patient population. In trauma, speed has been considered a necessity to get the patient to a facllity which cannot be carried out to the field, eg, an operating room. For acute medical Illnesses, critical care transport teams can bring intensive care technology to the patient. Accumulating evidence supports the premise that speed of transport is not as important as stabilization before transport, knowledge of hemodynamics during transport, and early use of critical care monitoring systems. Other reports identify the need for initial evaluation and stabilization of critically ill patients by physicians at the critical care level of expertise. Accordingly, critical care transportation teams have evolved, creating new notions of pretransport stabilization not applicable to previous transport systems.

In order to identify the factors influencing residents' involvement in the decision-making process prior to admission to a long-term care setting, we analyzed results of a national survey of residents of long-term care settings in France. We interviewed 3538 residents in 584 long-term care settings. Only 38.1% of residents said they had taken part in the admission process. Risk factors for non-involvement were the care level of the long-term care settings (odds ratio=OR=8.11 [5.63-11.68] and 2.73 [2.26-3.30], respectively, for long-term care units and retirements homes as compared to residential homes), lack of autonomy (dressing/washing) (OR=1.95 [1.66-2.30] versus autonomous), inability to answer questions on income (OR=2.16 [1.83-2.56]), age under 80 (OR=1.29 [1.04-1.61]) versus >90 years old patients, and being married (OR=1.60 [1.13-2.26]). Resident involvement in the decision-making process influenced subsequent feelings about institutional life. Older adults said that they were frequently not involved in the decision-making process prior to admission to a long-term care setting. This was particularly true for the high-care level long-term care settings, where organizational factors might intervene and for vulnerable elders for whom loss of autonomy could be lived as a loss of citizenship.

The competency framework developed by the critical care education group of the London Standing Conference aims to serve every grade and level of practitioner. It is neither time specific nor static. The patient is the central focus of the framework and the elements of competence reflect patient need at any critical care level [Comprehensive Critical Care: A Review of Adult Critical Care Services, The Stationary Office, London]. A group of expert nurses have developed the competency framework, with widespread consultation and collaboration. This approach intended to develop consistency for critical care education and practice. It is envisaged that this will reduce pockets of repeated activity, which places huge demands on limited resources. The critical care competency framework was developed using the method of functional analysis. A plan for the future has been identified, including continued collaboration and consultation with Trusts and Higher Educational Institutions and the development of an online manual to support the competency framework. Key points: • Critical care delivery has been under close scrutiny and a number of key contemporary drivers have led to the development of this competency framework. • The development of a consistent pan-London approach to critical care education has been identified. • The patient is the focus of critical care delivery and therefore patient need is central to the critical care competency framework. • Wider collaboration is needed with other agencies and groups to prevent the repetition of work already carried out.

Background A new long-term care insurance system was launched in Japan in April 2000. Objectives We performed the first national survey on special units of psychiatric hospitals for dementia patients to examine whether their disabilities were well reflected in the eligibility assessment. Methods Of all 248 dementia special units of psychiatric hospitals in Japan, 180 units (72.6%) participated in the survey. Five patients were randomly selected in each unit, and we used data of 802 (89.1%) of 900 patients whose care levels were obtained by the primary computer assessment. These patients were assessed using the Mini-Mental State Examination (MMSE), dementia rating scale by Gottfries et al. (1982) (GBS), and Activities of Daily Living (ADL). The mean score (SD) of the MMSE was 9.3 (6.9). Results Multiple regression analysis revealed that the scores of motor function in GBS, ADL, MMSE, and the degree of bedridden explained 73% of the variation of care level. The higher care levels were inversely related to lower MMSE scores. In the group of people who were not bedridden, the MMSE score sharply decreased even though their physical functions were maintained. There were no significant differences in the MMSE scores among the care level 1 and 5 groups except between care level 1 and 3 after controlling for the motor function scores in GBS. Conclusions Our results suggest that care level and cognitive impairment are generally correlated in the primary assessment, but some adjustment measure for cognitive impairment is needed in mildly or moderately physically disabled patients. Copyright © 2001 John Wiley & Sons, Ltd.

Validation of outcomes of different levels of neonatal care through the analysis of the relationship between process and outcome of care was attemped as part of an effectiveness study and quality assurance programme. Adequacy rates and outcome measures were calculated for second- and third-level units and centres. according to the babies‘ level of risk. Differences in adequacy rates were apparently Influenced by the differential distribution of babies by care level sectors among maternity centres. The comparison of mortality rates for “treated” and “untreated” subgroups did not show higher mortality rates for the “untreated” subgroups. This finding could be related to the phenomenon of “confounding by indication”. Consistency of differences in average rates of adequacy with differences In general outcomes was observed for most subgroups analysed; lack of consistency could be related to low effectiveness. Indications of low effectiveness related to secondary and more so to tertiary level technologies were observed. The study approach was found more useful for comparisons made at the level of maternity services as a whole, where “confounding by Indication” does not operate than at the level of sectors. ©1997 Elsevier Science Ltd. All rights reserved.

Background Increasing incidences of dementia necessitate the improvement of supportive measures for patients suffering from this disease and their proxies. Clinicians without psychiatric backgrounds and others involved in appraising the supportive needs of dementia patients, such as those who allocate nursing insurance, base their appraisals on the ability of patients to perform basic and instrumental activities of daily living (B-ADL, iADL). Our aim was to investigate whether a reduced ability of the patient to perform ADL is sufficient to adequately assess the supportive needs of family caregivers. Methods Cross-sectional baseline data were obtained from dementia patients and their proxies in the context of a nationwide prospective cohort study on non-pharmacological treatment of dementia. To our knowledge, the present study is the first country-wide study to assess patients and proxies in their domestic surroundings (e.g. Mini-Mental State Examination (MMSE) Behave-AD, B-ADL and iADL for patients; Quality of Life (QOL) and depression of the proxy). Results Logistic and linear regression analysis show that the allocation of nursing care allowance provided by German mandatory nursing insurance is associated with scores on the B-ADL- and iADL scales, but not with the severity of behavioural symptoms or the supportive time the proxies spend on caring. However, the severity of cognitive and non-cognitive symptoms of dementia patients, correlate with each other and both parameters correlate with the time the proxy spends on caring. The time spent on caring is associated with an increase in depression and a reduction in the quality of life of the proxy. Conclusions Basic and instrumental activities of daily living do not sufficiently reflect the perceived burden of care experienced by the proxy who has to cope with the imposition of the dementia patients’ behavioural symptoms. When allocating nursing care, patients’ behavioural symptoms should also be taken into consideration, because depressive symptoms of proxies are linked to non-cognitive symptoms in dementia patients. To provide better health care, it is necessary to identify and treat psychiatric symptoms in proxies who care for dementia patients as early as possible.