Prevention of unintentional weight loss in nursing home residents: a controlled trial of feeding assistance

OBJECTIVES: To determine the effects of a feeding assistance intervention on food and fluid intake and body weight. DESIGN: Crossover controlled trial. SETTING: Four skilled nursing homes (NHs). PARTICIPANTS: Seventy‐six long‐stay NH residents at risk for unintentional weight loss. INTERVENTION: Research staff provided feeding assistance twice per day during or between meals, 5 days per week for 24 weeks. MEASUREMENTS: Research staff independently weighed residents at baseline and monthly during a 24‐week intervention and 24‐week control period. Residents' food and fluid intake and the amount of staff time spent providing assistance to eat was assessed for 2 days at baseline and 3 and 6 months during each 24‐week period. RESULTS: The intervention group showed a significant increase in estimated total daily caloric intake and maintained or gained weight, whereas the control group showed no change in estimated total daily caloric intake and lost weight over 24 weeks. The average amount of staff time required to provide the interventions was 42 minutes per person per meal and 13 minutes per person per between‐meal snack, versus usual care, during which residents received, on average, 5 minutes of assistance per person per meal and less than 1 minute per person per snack. CONCLUSION: Two feeding assistance interventions are efficacious in promoting food and fluid intake and weight gain in residents at risk for weight loss. Both interventions require more staff time than usual NH care. The delivery of snacks between meals requires less time than mealtime assistance and thus may be more practical to implement in daily NH care practice.     

Quality assessment in nursing homes by systematic direct observation: feeding assistance

Background. Direct observation of care is an important data source for nursing home (NH) quality assessment, especially in light of evidence that chart information is inaccurate or incomplete for many daily care areas. The purpose of this study was to describe a standardized feeding assistance observational protocol that is designed for routine use by external (survey teams) and internal (licensed NH staff) quality assurance personnel to (i) maximize the amount of useful information gained from relatively brief observational periods; (ii) provide specific rules of measurement, which allow for replication and valid comparisons between NHs; and (iii) provide specific scoring rules that allow defensible categorical statements to be made about feeding assistance care quality within the NH. Methods. Four feeding assistance care quality indicators (QIs) were defined and operationalized in this study for 302 long-term residents in 10 skilled NHs: (i) Staff ability to accurately identify residents with clinically significant low oral food and fluid intake during mealtime; (ii) Staff ability to provide feeding assistance to at-risk residents during mealtime; (iii) Staff ability to provide feeding assistance to residents identified by the Minimum Data Set as requiring staff assistance to eat; and (iv) Staff ability to provide a verbal prompt to residents who receive physical assistance at mealtimes. Results. There were significant differences between facilities for three of the four QIs. The proportion of participants in each facility where staff "failed" the QIs ranged as follows: (Quality Indicator i) 42% to 91%; (ii) 25% to 73%; (iii) 11% to 82%; and (iv) 0% to 100%. Conclusions. A standardized observational protocol can be used to accurately measure the quality of feeding assistance care in NHs. This protocol is replicable and shows significant differences between facilities with respect to accuracy of oral intake documentation and the adequacy and quality of feeding assistance during mealtimes.     

Translating clinical research into practice: a randomized controlled trial of exercise and incontinence care with nursing home residents

OBJECTIVES: To examine clinical outcomes and describe the staffing requirements of an incontinence and exercise intervention. DESIGN: Randomized controlled trial with blinded assessments of outcomes at three points over 8 months. SETTING: Four nursing homes. PARTICIPANTS: Two hundred fifty-six incontinent residents. INTERVENTION: Research staff provided the intervention, which integrated incontinence care and exercise every 2 hours from 8:00 a.m. to 4:00 p.m. 5 days a week. MEASUREMENTS: Average and maximum distance walked or wheeled, level of assistance required to stand, maximum pounds lifted by arms, fecal and urinary incontinence frequency, and time required to implement intervention. RESULTS: Intervention residents maintained or improved performance whereas the control group's performance declined on 14 of 15 outcome measures. Repeated measures analysis of variance group-by-time significance levels ranged from P <.0001 to.05. The mean time required to implement the intervention each time care was provided was 20.7 +/- 7.2 minutes. We estimate that a work assignment of approximately five residents to one aide would be necessary to provide this intervention. CONCLUSIONS: The incontinence care and exercise intervention resulted in significant improvement for most residents, and most who could be reliably interviewed expressed a preference for such care. Fundamental changes in the staffing of most nursing homes will be necessary to translate efficacious clinical interventions into everyday practice.     

A preliminary evaluation of the paid feeding assistant regulation: impact on feeding assistance care process quality in nursing homes

PURPOSE: The Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality sponsored a nationwide study to evaluate the federal paid feeding assistant (PFA) regulation that allows nursing homes to hire single-task workers to provide feeding assistance to nursing home residents. Organizers designed the PFA regulation to increase the number of staff available to provide assistance with eating and improve nutritional care process quality. DESIGN AND METHODS: Trained research staff used standardized protocols to conduct direct observations during meals and face-to-face staff interviews in a convenience sample of seven facilities with PFA programs to evaluate care process quality. RESULTS: Most (84%) of the trained PFAs in the seven site visit facilities were non-nursing staff within the facility; the quality of feeding assistance care provided by these workers was comparable to that provided by indigenous nurse aides. There were no reported changes in existing staffing levels (nurse aide or licensed nurses) following PFA program implementation, and the majority (> 90%) of indigenous staff at all levels reported positive benefits of the PFA program for both staff and residents. IMPLICATIONS: Findings from this preliminary study indicate that the PFA regulation may serve to increase the utilization of existing non-nursing staff to improve feeding assistance care during meals without having a negative impact on existing nurse aide and licensed nurse staffing levels.     

Prevalence of Constipation Symptoms in Fecally Incontinent Nursing Home Residents

OBJECTIVES: To determine the prevalence of constipation symptoms and the effects of a brief toileting assistance trial on constipation in a sample of fecally incontinent nursing home (NH) residents.
DESIGN: Observational study.
SETTING: Five NHs.
PARTICIPANTS: One hundred eleven fecally incontinent NH residents.
MEASURES: Research staff measured bowel movement frequency every 2 hours for 10 days. The following week, residents were offered toileting assistance every 2 hours for 2 days to determine resident straining, time required for a bowel movement, and resident perceptions of feeling empty after a bowel movement. Constipation data were abstracted from the medical record.
RESULTS: The frequency of bowel movements during usual NH care was low (mean=0.32 per person per day), and most episodes were incontinent. The frequency of bowel movements increased significantly, to 0.82 per person per day, and most episodes were continent during the 2 days that research staff provided toileting assistance. Eleven percent of residents showed evidence of straining, and 21% of the time after a continent bowel movement, residents reported not feeling empty. Five percent of participants had medical record or Minimum Data Set documentation indicative of constipation symptoms.
CONCLUSION: Low rates of bowel movements during the day that are potentially indicative of constipation were immediately improved during a 2-day trial of toileting assistance in approximately 68% of the residents, although other symptoms of constipation remained in a subset of residents who increased toileting frequency.     

Frontline caregiver daily practices: a comparison study of traditional nursing homes and the Green House project sites

OBJECTIVES: To describe differences in frontline caregiver daily practice in two types of skilled nursing facility (SNF) settings, Green House (GH) homes and traditional SNF units, related to overall staffing (nursing and nonnursing departments), direct care and indirect care time per resident day, and staff time interacting with residents. DESIGN: Observational, interview, and survey study comparing frontline caregiver daily practice in GH homes and traditional SNFs. SETTING: Twenty‐seven sites (GH homes and traditional SNF units). PARTICIPANTS: Two hundred forty staff from participating sites. MEASUREMENTS: Site and resident characteristics, nursing and nonnursing department staff hours per resident day (HPRDs), certified nursing assistant (CNA) direct and indirect care HPRDs, and CNA HPRDs engaged with residents. RESULTS: Staffing from nursing and nonnursing departments combined, excluding administrative, was 0.3 less HPRDs (18 minutes) in GH homes than in traditional SNFs. CNAs in GH homes, although responsible for more nonnursing activities such as laundry and housekeeping, spent 0.4 more HPRDs (24 minutes) in direct care activities than CNAs in traditional SNFs. CONCLUSION: The results challenge the assumption that staffing efficiencies cannot be achieved in small environments such as a GH home. Although the GH model has higher ratio of CNA staff to residents than traditional SNF units, overall staff time (combined total of nursing and nonnursing HPRDs) is slightly less in GH homes. The GH model allows for expanded responsibilities of CNAs in indirect care activities and more time in direct care activities and engaging directly with resident.     

The effects of an exercise and incontinence intervention on skin health outcomes in nursing home residents

OBJECTIVES: To examine skin health outcomes of an exercise and incontinence intervention. DESIGN: Randomized controlled trial with blinded assessments of outcomes at three points over 8 months. SETTING: Four nursing homes (NHs). PARTICIPANTS: One hundred ninety incontinent NH residents. INTERVENTION: In the intervention group, research staff provided exercise and incontinence care every 2 hours from 8:00 a.m. to 4:30 p.m. (total of four daily care episodes) 5 days a week for 32 weeks. The control group received usual care from NH staff. MEASUREMENTS: Perineal skin wetness and skin health outcomes (primarily blanchable erythema and pressure ulcers) as measured by direct assessments by research staff, urinary and fecal incontinence frequency, and percentage of behavioral observations with resident engaged in standing or walking. RESULTS: Intervention subjects were significantly better in urinary and fecal incontinence, physical activity, and skin wetness outcome measures than the control group. However, despite these improvements, differences in skin health measures were limited to the back distal perineal area, which included the sacral and trochanter regions. There was no difference between groups in the incidence rate of pressure ulcers as measured by research staff, even though those residents who improved the most on fecal incontinence showed improvement in pressure ulcers in one area. CONCLUSION: A multifaceted intervention improved four risk factors related to skin health but did not translate into significant improvements in most measures of skin health. Even if they had adequate staffing resources, NHs might not be able to improve skin health quality indicators significantly if they attempt to implement preventive interventions on all residents who are judged at risk because of their incontinence status.     

An intervention to increase fluid intake in nursing home residents: prompting and preference compliance

OBJECTIVE: To evaluate a three-phase, behavioral intervention to improve fluid intake in nursing home (NH) residents. DESIGN: Controlled clinical intervention trial. SETTING: Two community NHs. PARTICIPANTS: Sixty-three incontinent NH residents. INTERVENTION: Participants were randomized into intervention and control groups. The intervention consisted of three phases for a total of 32 weeks: (1) 16 weeks of four verbal prompts to drink per day, in between meals; (2) 8 weeks of eight verbal prompts per day, in between meals; and (3) 8 weeks of eight verbal prompts per day, in between meals, plus compliance with participant beverage preferences. MEASUREMENTS: Between-meal fluid intake was measured in ounces by research staff during all three phases of the intervention. Percentage of fluids consumed during meals was also estimated by research staff for a total of nine meals per participant (3 consecutive days) at baseline and at 8 and 32 weeks into the intervention. Serum osmolality, blood urea nitrogen, and creatinine values were obtained for all participants in one of the two sites at the same three time points. RESULTS: The majority (78%) of participants increased their fluid intake between meals in response to the increase in verbal prompts (phase 1 to 2). A subset of residents (21%), however, only increased their fluid intake in response to beverage preference compliance (phase 3). There was a significant reduction in the proportion of intervention participants who had laboratory values indicative of dehydration compared with the control participants. Cognitive and nutritional status were predictive of residents' responsiveness to the intervention. CONCLUSIONS: A behavioral intervention that consists of verbal prompts and beverage preference compliance was effective in increasing fluid intake among most of a sample of incontinent NH residents. Verbal prompting alone was effective in improving fluid intake in the more cognitively impaired residents, whereas preference compliance was needed to increase fluid intake among less cognitively impaired NH residents.     

Nutritional intake monitoring for nursing home residents: a comparison of staff documentation, direct observation, and photography methods

BACKGROUND: The current approach to assessing nutritional intake requires nursing home (NH) staff to document total percentage of food and fluid consumed at each meal. Because NH staff tend to significantly overestimate total food intake, methods need to be developed to improve the accuracy of food intake measurement. OBJECTIVE: To compare three methods of assessing the nutritional intake of NH residents. RESEARCH DESIGN: Validation Study. SUBJECTS: Fifty-six NH residents in one facility. MEASURES: Total percentage of food and fluid intake of each resident for each of nine meals, or all three meals for 3 consecutive days, was assessed by: (1) Nursing home staff chart documentation, (2) Research staff documentation according to direct observations, and (3) Research staff documentation according to photographs of residents' trays before and after each meal. RESULTS: Research staff documentation of total intake and intake of all individual food and fluid items was similar for the direct observation and photography methods. In comparison with these two methods, NH staff documentation reflected a significant overestimate (22%) of residents' total intake levels. In addition, NH staff failed to identify the more than half (53%) of those residents whose intake levels were equal to or below 75% for most meals. CONCLUSIONS: The photography method of nutritional assessment yielded the same information as direct observations by research staff, and both of these methods showed the intake levels of NH residents to be significantly lower than the intake levels documented by NH staff. The photography method also has several advantages over a documentation system that relies on an observer to be present to record food and fluid intake levels.     

The Minimum Data Set Weight‐Loss Quality Indicator: Does It Reflect Differences in Care Processes Related to Weight Loss?

OBJECTIVES: To determine whether nursing homes (NHs) that score differently on prevalence of weight loss, according to a Minimum Data Set (MDS) quality indicator, also provide different processes of care related to weight loss. DESIGN: Cross-sectional. SETTING: Sixteen skilled nursing facilities: 11 NHs in the lower (25th percentile-low prevalence) quartile and five NHs in the upper (75th percentile-high prevalence) quartile on the MDS weight-loss quality indicator. PARTICIPANTS: Four hundred long-term residents. MEASUREMENTS: Sixteen care processes related to weight loss were defined and operationalized into clinical indicators. Trained research staff conducted measurement of NH staff implementation of each care process during assessments on three consecutive 12-hour days (7 a.m. to 7 p.m.), which included direct observations during meals, resident interviews, and medical record abstraction using standardized protocols. RESULTS: The prevalence of weight loss was significantly higher in the participants in the upper quartile NHs than in participants in the lower quartile NHs based on MDS and monthly weight data documented in the medical record. NHs with a higher prevalence of weight loss had a significantly larger proportion of residents with risk factors for weight loss, namely low oral food and fluid intake. There were few significant differences on care process measures between low- and high-weight-loss NHs. Staff in low-weight-loss NHs consistently provided verbal prompting and social interaction during meals to a greater proportion of residents, including those most at risk for weight loss. CONCLUSION: The MDS weight-loss quality indicator reflects differences in the prevalence of weight loss between NHs. NHs with a lower prevalence of weight loss have fewer residents at risk for weight loss and staff who provide verbal prompting and social interaction to more residents during meals, but the adequacy and quality of feeding assistance care needs improvement in all NHs.     

Predictors of adherence to the use of hip protectors in nursing home residents

OBJECTIVES: To assess predictors of hip-protector use in nursing home residents under usual-care conditions and after intervention consisting of structured education of nurses and nursing home residents and provision of free hip protectors. DESIGN: Nested cohort analyses within a cluster randomized, controlled trial with 18 months follow-up. SETTING: Forty-nine nursing home clusters in Hamburg, Germany. PARTICIPANTS: Residents with at least one fall during the study period (intervention group, n=237; usual-care group, n=274). MEASUREMENTS: Use of hip protector while falling. Regression analyses were performed for each of the two cohorts of fallers using the time to the first fall without hip protector as the dependent variable. Predefined nursing home cluster-related parameters (center, staffing ratio, proportion of registered nurses in nursing staff, hip-protector use before study period) and resident-related parameters (sex, history of falls and fractures, fear of falling, urinary incontinence, use of walking aid, degree of disablement) were considered as explanatory variables. RESULTS: Under usual care, 97% of fallers (n=266), compared with 62% (n=148) in the intervention group, experienced at least one fall without hip protection. Using Cox proportional hazards models with and without frailty parameter (random cluster effect), the following predictors were identified: intervention group: use of walking aid, hazard ratio (HR)=1.53 (95% confidence interval (CI):0.98-2.39) and no urinary incontinence, HR=1.47 (95% CI:1.03-2.09); usual care: nursing staff per 10 residents, HR=0.78 (95% CI=0.63-0.96); high degree of disablement, HR=1.38 (95% CI=1.06-1.80); strong fear of falling, HR=0.78 (95% CI=0.60-1.02). The nursing home cluster was a significant predictor in the control group (P=.029), but not in the intervention group (P=.100). CONCLUSION: Only a few and weak predictors of hip-protector use of questionable relevance could be identified in both groups. Future research should concentrate on the implementation of interventions of proven efficacy, such as provision of hip protectors combined with structured education of staff and residents.     

A Controlled Trial of an Intervention to Improve Urinary and Fecal Incontinence and Constipation

OBJECTIVES: To evaluate effects of a multicomponent intervention on fecal incontinence (FI) and urinary incontinence (UI) outcomes. DESIGN: Randomized controlled trial. SETTING: Six nursing homes (NHs). PARTICIPANTS: One hundred twelve NH residents. INTERVENTION: Intervention subjects were offered toileting assistance, exercise, and choice of food and fluid snacks every 2 hours for 8 hours per day over 3 months. MEASUREMENTS: Frequency of UI and FI and rate of appropriate toileting as determined by direct checks from research staff. Anorectal assessments were completed on a subset of 29 residents. RESULTS: The intervention significantly increased physical activity, frequency of toileting, and food and fluid intake. UI improved (P=.049), as did frequency of bowel movements (P<.001) and percentage of bowel movements (P<.001) in the toilet. The frequency of FI did not change. Eighty‐nine percent of subjects who underwent anorectal testing showed a dyssynergic voiding pattern, which could explain the lack of efficacy of this intervention program alone on FI. CONCLUSION: This multicomponent intervention significantly changed multiple risk factors associated with FI and increased bowel movements without decreasing FI. The dyssynergic voiding pattern and rectal hyposensitivity suggest that future interventions may have to be supplemented with bulking agents (fiber), biofeedback therapy, or both to improve bowel function.     

Incontinence and PPS: a new era

Urinary incontinence (UI) is a prevalent and costly problem in nursing homes. Assessing residents with incontinence is necessary to determine the pathophysiologic causes and associated factors that can interfere with self-toileting. Nurses can perform this assessment at the bedside. Guideline tools have been developed to assist nursing home staff through the evaluation of UI and intervention. Treatment techniques, specifically behavioral interventions and toileting assistance programs, can be readily incorporated into nursing practice. Most nursing home staffs can easily implement interventions such as bowel and nighttime voiding management and dietary modifications. Nursing home research has demonstrated the effectiveness of toileting assistance programs; however, very little of this research and documented techniques has been used by nursing home staff. Scheduled toileting and bladder training programs can be successfully implemented in nursing home residents. The key to the success of these programs is identifying residents who should be targeted for each specific program. Staff education remains an ongoing issue, as caregivers must be aware of attitudes and beliefs about the aging process and its impact on the genitourinary system in order to provide effective care. Under the Prospective Payment System, nursing homes need to change business as usual and remain abreast of new innovations and research in different behavioral interventions and continence technology.     

Quality of care in the nursing home: effects of staff assignment and work shift

PURPOSE: The purpose of this study was to compare a variety of resident and staff outcomes across two types of staffing patterns, permanent and rotating assignment, and work shift. Although studies have examined these staffing patterns as part of multicomponent intervention packages, few studies have examined the isolated effects of staffing pattern by using an experimental design. DESIGN AND METHODS: A between-groups comparison design was used to compare residents and certified nursing assistants (CNAs) from four nursing homes; two self-identified as using permanent assignment (PA) staffing and two as using rotating assignment (RA) staffing. Measures yielded data on verbal interaction among residents and staff, resident disruptive behavior, and specific aspects of resident-staff behavior during care routines. Other assessments included resident personal appearance and hygiene, expressed affect, and CNAs' job satisfaction, burnout, absenteeism, and turnover rates. A treatment fidelity check was conducted to confirm PA and RA staffing patterns. RESULTS: Staffing patterns were significantly different between self-identified PA and RA nursing homes. Residents in PA nursing homes and on morning shifts received significantly higher ratings of personal appearance and hygiene. Rates of expressed sadness and interest among residents differed by staffing patterns and shift. However, these differences do not appear to be clinically significant. Although absenteeism was higher in PA nursing homes, these CNAs reported greater job satisfaction than CNAs from RA nursing homes. As expected, evening shifts across nursing homes had significantly higher turnover rates and significantly more resident disruptive behavior. IMPLICATIONS: Quality-of-care outcomes were similar among the two types of nursing homes, despite significantly different staffing patterns. Though staff permanency rates in PA nursing homes (50%) were twice that of RA nursing homes (26%), more research is needed to determine feasibility of higher rates of staff permanency (i.e., > 50%) and effects on resident and CNA outcomes.     

Pilot Testing of Intervention Protocols to Prevent Pneumonia in Nursing Home Residents

OBJECTIVES: To test intervention protocols for feasibility, staff adherence, and effectiveness in reducing pneumonia risk factors (impaired oral hygiene, swallowing difficulty) in nursing home residents.
DESIGN: Prospective study.
SETTING: Two nursing homes.
PARTICIPANTS: Fifty-two nursing home residents.
INTERVENTION: Thirty residents with impaired oral hygiene were randomly assigned to manual oral brushing plus 0.12% chlorhexidine oral rinse at different frequencies daily. Twenty-two residents with swallowing difficulty were randomly assigned to upright feeding positioning, teaching swallowing techniques, or manual oral brushing. All protocols were administered over 3 months.
MEASUREMENTS: Feasibility was assessed monthly and defined as high if the protocol took less than 10 minutes to administer. Adherence was assessed weekly and defined as high if full staff adherence was demonstrated in more than 75% of assessments. Effectiveness for improved oral hygiene (reduction in oral plaque score) and swallowing (reduction in cough during swallowing) was compared at baseline and 3 months.
RESULTS: Daily manual oral brushing plus 0.12% chlorhexidine rinse demonstrated high feasibility, high staff adherence, and effectiveness in improving oral hygiene ( P <.001 vs baseline); this combination administered twice per day showed the highest plaque score reduction. Daily manual oral brushing and upright feeding positioning demonstrated high feasibility, high staff adherence, and effectiveness in improving swallowing.
CONCLUSION: Manual oral brushing, 0.12% chlorhexidine oral rinse, and upright feeding positioning demonstrated high feasibility, high staff adherence, and effectiveness in pneumonia risk factor reduction. A protocol combining these components warrants testing for its ability to reduce pneumonia in nursing home residents.