Compliance with best practice in oral health: implementing evidence in residential aged care

Background The changing oral health status and the increasing complexity of dental needs for older Australians highlights the importance of oral healthcare within the residential aged care setting. The increasing incidence of oral disease and conditions in older adults is related to higher levels of oral functional dependence, physical frailty, medical conditions, polypharmacy, cognitive impairment and increasing dependence on carers. Objectives The Compliance with Best Practice in Oral Health Project was designed to identify issues in relation to oral healthcare and to identify that evidence-based best practice was demonstrated within the organisation's existing policies and procedures. Evidence-based best practice recommendations were based on the systematic evidence review 'oral hygiene care for adults with dementia in residential aged care' developed by the Joanna Briggs Institute. Results Four aged care facilities participated in the project. In the pre-audit, compliance was achieved in one of the six evidence-based criteria. A plan was implemented to improve compliance with three of the remaining five criteria within a 4-week time frame. Post-audit results indicated an improvement in compliance with evidence-based best practice. Conclusion The Compliance with Best Practice in Oral Health Project provided an opportunity to review and update existing organisational clinical care policies with evidence-based best practice recommendations and highlighted the importance of developing local clinical care leadership at the residential site.     

Reducing physical restraint use in residential aged care: implementation of an evidence-based approach to improve practice

Background This paper describes the approach taken by three high care residential facilities in reducing physical restraint use and improving practice when physical restraint is used as a care strategy. At the time of the project these three facilities provided care for 174 residents, with over half of the residents having a diagnosis of dementia. Method A process of audit and feedback was used to identify initial compliance with best practice and facilitate identification of barriers to changing and improving clinical care. Results Gaps were found in the areas of organisational documentation (including policy, procedures, forms and information for residents and their families) and staff education on the topic of physical restraint. Once these gaps were known, the task was to develop strategies to address the needs of three stakeholder groups: individual clinicians, residents and their families, and the organisation as a whole. Conclusion The paper shows the advantages of auditing compliance with evidence-based criteria as a measure of improvements in clinical care, and describes the changes implemented as a means of improving practice and reducing physical restraint use. The results show that the process has been effective in achieving results in the short term, with large increases in the area of staff education, and improvements in the assessment of people identified as possibly requiring restraint. Future plans for sustaining and consolidating change and moving forward with improvements are discussed. The results so far have been encouraging and the organisation is committed to continue to improve compliance with best practice with the vision of eventually achieving restraint-free care environments.     

Improving and ensuring best practice continence management in residential aged care

Background Continence Management within residential aged care is an every day component of care that requires assessment, implementation of strategies, resource allocation and evaluation. At times the management of incontinence of aged residents can be challenging and unsuccessful. The project chosen through the Clinical Fellowship program was Continence Management with the aim of raising awareness of best practice to assist in improving and providing person-centred resident care. Aims/objectives ? Review the literature on best practice management of incontinence ? Evaluate current practice in continence management for elderly residents within residential aged care services ? Improve adherence to best practice strategies of care for incontinence ? Raise awareness within the nursing home of the best practice management of incontinence ? Promote appropriate and effective use of resources for continence management ? Deliver individualised person-centred care to residents. ? Ensure best practice in continence management Methods The Joanna Briggs Institute (JBI) Practical Application of Clinical Evidence System clinical audit tool was utilised to measure current practice against best practice. The results identify gaps that require improvement. The Getting Research into Practice process then allowed analysis of the level of compliance with each of the audit criteria, which would identify any barriers in implementing a selected course of action and aim to improve compliance. The project team was consulted with additional stakeholder consultation to form an action plan and implement strategies to improve practice. Results Although 100% compliance with all audit criteria in audit 1 and 2 was not achieved, there was improvement in the criteria concerning the documented fluid intake for residents. Further strategies have been identified and implemented and this continues to be a 'work in progress'. Staff now have an acute awareness of what best practice means and the impact their practices have on continence management. The JBI clinical audit and feedback cycle will continue to facilitate the measuring and implementation of best practice for resident outcomes in residential aged care.     

Increase in best practice child car restraint use for children aged 2–5 years in low socioeconomic areas after introduction of mandatory child restraint laws

Objectives : To examine changes in child car restraint practices in low socioeconomic areas following the introduction of mandatory child car restraint legislation in New South Wales (NSW), Australia. Methods : Data from two cross‐sectional studies of child car restraint use at pre‐schools, early childhood centres and primary schools before and after the introduction of legislating mandatory age‐appropriate car restraint use for children up to the age of seven years was used in this analysis. All included observations were from local government areas with socioeconomic status in the lowest 30% of urban Sydney. Children aged 2–5 years were observed in their vehicles as they arrived at observation sites (107 pre‐legislation, 360 post‐legislation). Multilevel logistic regression was used to examine changes in observed age‐appropriate and correct use of car restraints. Results : Age‐appropriate car restraint use was higher post‐legislation than pre‐legislation. After controlling for child's age, parental income, language spoken at home and adjusting for clustering, the odds of children being appropriately restrained post‐legislation were 2.3 times higher than in the pre‐legislation sample, and the odds of them being correctly restrained were 1.6 times greater. Conclusions : Results indicate an improvement in car restraint practices among children aged 2–5 in low socioeconomic areas after introduction of child restraint laws. Implications : Despite improvements observed with enhanced legislation, further efforts are required to increase optimal child car restraint use.     

Reducing and/or minimising physical restraint in a high care, rural aged care facility

Background This report takes you through a journey of implementing evidence-based best practice guidelines in relation to physical restraint in an aged care facility. It describes the processes involved in making changes to an existing system, introducing evidence-based guidelines and collaboratively achieving compliance with best practice. The project formed part of a combined initiative between the Joanna Briggs Institute and the Commonwealth Department of Health and Ageing, called the Aged Care Clinical Fellowship Program. The Joanna Briggs Institute Practical Application of Clinical Evidence System, an online audit-based tool that includes an action research process Getting Research Into Practice was used to facilitate audit data collection and analysis. This report demonstrates that effective clinical leadership and evidence-based research, combined with a strategy of audit, feedback and re-audit, can become an effective change agent to improve clinical practice in residential aged care facilities. Aims/objectives The aims of this project were to increase staff knowledge and awareness of restraints, improve practices in restraint assessment and usage, reduce or minimise the amount and type of restraints used and ensure the least restrictive device possible was utilised in a rural aged care facility. Methods A system of audit, feedback and re-audit was performed using the Joanna Briggs Institute Practical Application of Clinical Evidence System software. This was completed in a series of stages over a period of 6?months. The first stage was to apply defining characteristics to each of the evidence-based audit criteria to determine compliance. A team of staff was set up to assist with the project. An initial audit was conducted, followed by a situational analysis of the findings. From this an action plan for improvement using Getting Research Into Practice was developed. The action plan was then implemented and the criteria re-audited and reviewed. Results The initial audit confirmed non-compliance as expected in two criteria. All criteria showed improvement in the re-audit. Those criteria with the least compliance in the initial audit showed the most improvement in the re-audit. Conclusion Effective change processes can be achieved when there is an identified reason or need for change, and when staff are aware of that need. With clinical leadership and education attitudes, fears and myths can be dispelled and improved performance will come out.     

Implementation of best practice in advance care planning in an 'ageing in place' aged care facility

Background For many older people, a residential aged care facility is home, a place where they should have the choice to die comfortably with a sense of control of care and treatment. An advance care plan describes the process of planning end-of-life care while a person is still able to make decisions with the aim of using this information should a person become unable to communicate their wishes. In the residential aged care setting, an advance care plan should be based on discussions involving the resident, family members and caregivers regarding the beliefs, values and goals of the resident and their family. It is not limited to the final days and weeks before dying, it can encompass a positive and open attitude towards death and dying. Aim The aim of this project was to examine the process of how residents' end-of-life care wishes is recorded and to ensure that the implementation of an advance care plan is performed according to the best available evidence. Method There were four stages to the project. The first stage involved interpretation of the five audit criteria. The criteria related to involving residents and their families in an advance care plan, providing them with appropriate information about end-of-life issues, and ensuring that staff are appropriately trained about an advance care plan. Next, the records of staff and resident were audited using JBI-PACES, the Joanna Briggs Institute's Practical Application of Clinical Evidence System. The next stage (Getting Research into Practice, GRIP) involved a process of situational analysis, action planning and action taking to improve compliance with best practice, followed by a post-implementation audit. Results Initially, compliance with an advance care plan best practice was fairly poor - less than 50% for each audit criterion. The GRIP phase highlighted seven barriers which were addressed during the implementation part of the project. These barriers included deficits related to the knowledge and education of residents, families and staff members, and issues related to administration and documentation, and concerns that any implementation process would not be sustainable. The post-implementation compliance was greater than 75% for each criterion. Conclusion The project highlights the ongoing challenges of educating residents and families, as well as staff on the importance of discussing/completing an advance care plan. Several improvements were made to the facility's documentation and records keeping processes, including the identification of resident's wishes regarding end-of-life treatment. Residents and their families expressed a high level of satisfaction with these changes. Indeed, an increase in completed advance care plans at the facility had a clear benefit in improving care for residents towards the end of their life.     

Likelihood of residential aged care use in later life: a simple approach to estimation with international comparison

Objectives: In New Zealand (NZ), place of death among decedents aged 65+ years has been reported as residential aged care (RAC, 38%), acute hospital (34%) or elsewhere (28%). However, lifetime risk of use of RAC (or nursing homes) is unknown. A simple method of estimation is demonstrated for NZ and Australia, with comparisons to other countries. Methods: Deaths of RAC residents in acute hospitals were estimated for NZ from four separate studies and added to deaths occurring in RAC, to derive the likelihood of using RAC after age 65 years. Academic and other sources were searched for comparative reports. Results: An estimated 18% of RAC residents died in acute hospital in NZ. When added to those who died in RAC, the proportion using RAC for late‐life care was estimated at over 47% (66% if aged 85+ years). Of 12 US reports, the median report was 41%. Elsewhere, Finland was 47%, UK 28%, Australia 34% to 53%, and Germany 22% & 26%. Conclusions: Simple estimation using existing data demonstrates that RAC in late life is common. Implications: Late‐life care services will continue to evolve. Monitoring RAC utilisation is necessary for informed debate about palliative care provision in RAC, use of hospital by RAC residents and for planning and policy setting.     

Literature review to identify factors that support implementation of evidence-based practice in residential aged care

The aim was to undertake a review of the literature on change management, quality improvement, evidence-based practice and diffusion of innovations to identify key factors that might influence the uptake and continued use of evidence in residential aged care. The key factors will be used to shape and inform the evaluation of the Encouraging Best Practice in Residential Aged Care Program which commenced in Australia in 2007. MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews were searched using combinations of search terms. Searching focused on existing literature reviews, discussions of relevant conceptual and theoretical frameworks and primary studies that have examined the implementation of evidence-based practice in residential aged care. Keyword searching was supplemented with snowball searching (following up on the references cited in the papers identified by the search), searching by key authors in the field and hand searching of a small number of journals. In general, the period covered by the searches was from 2002 to 2008. The findings from the literature are often equivocal. Analysis and consolidation of factors derived from the literature that might influence the implementation of evidence-based practice resulted in the identification of eight factors: (i) a receptive context for change; (ii) having a model of change to guide implementation; (iii) adequate resources; (iv) staff with the necessary skills; (v) stakeholder engagement, participation and commitment; (vi) the nature of the change in practice; (vii) systems in place to support the use of evidence; and (viii) demonstrable benefits of the change. Most of the literature included in the review is from studies in healthcare and hence the generalisability to residential aged care is largely unknown. However, the focus of this research is on clinical care, within the context of residential aged care, hence the healthcare literature is relevant. The factors are relatively broad and cover the evidence itself, the process of implementation, the context within which evidence will be implemented and the systems and resources to support implementation. It is likely that the factors are not independent of each other. The set of factors will be refined over the course of the evaluation.     

Improving opportunities for food service and dietetics practice in hospitals and residential aged care facilities

Aim: Food is a phenomenon that everyone has an opinion on because eating is a frequent, often social occurrence, and as such the importance of mealtimes can be undervalued in healthcare settings. Some staff may not share our concerns about suboptimal dietary intakes as they assume that nutritional status will improve as people feel better. However, the provision and consumption of an appealing and adequate diet is a critical aspect of holistic health care. This review examines the role of dietitians in food services to improve the situation. Methods: A narrative review was formed with reference to the literature. Results: Labelling food service departments as a ‘hotel service’ or a ‘non‐clinical service’ does little to assist the perception of these services by others; to enhance the knowledge and skills needed by others about optimising dietary intake opportunities by the sick and elderly; or to enhance the communication that is needed between stakeholders about food and mealtimes. The issue of addressing malnutrition, reviewing and improving menus, mealtime environments, feeding assistance, communication between staff, and acknowledgement of the important care role of food service providers becomes even more relevant as the population ages and the demand for health care grows. Conclusion: This narrative highlights that the importance of dietitians building links with food services, leading high‐quality research, and improving the profile and recognition of food and mealtimes as integral to care, has never been greater.     

The Guidelines International Network: translating best evidence into best practice around the globe

From August 22 to 25, 2007, the Guidelines International Network (G-I-N) met in Toronto for its first North American conference. The theme of G-I-N 2007 was collaboration as it pertains to clinical practice guidelines (CPGs). Delegates from four continents approached the theme from many directions, including development, assessment, translation, implementation and evaluation.     

Do mobile hospital teams in residential aged care facilities increase health care efficiency: an evaluation of French residential care policy

The European Journal of Health Economics - Patients in residential aged care facilities (RACF) are frequently admitted to hospital since the RACF often lack adequate medical resources. Different...     

The changing availability of residential aged care in Australia

Australian aged care services have undergone a series of substantial reforms in recent years under the rubric of the Aged Care Reform Strategy. Overall, there has been a progressive refinement of the targeting of available services on those most in need, defined in terms of both disability levels and financial resources. A key component of this process has been a deliberate reduction in the relative emphasis accorded to nursing home care within the aged care system. This has been accompanied by increases in the resources directed toward less intensive forms of residential care (hostels) and community based services. This paper explores the actual consequences of these intentional policy changes in terms of the availability of nursing home and hostel care, and the changing characteristics of nursing home residents. The results suggest that a more substantial reduction has occurred in the availability of nursing home care than has hitherto been suggested, with consequent decreases in the proportion of aged persons in nursing homes. The effect has been particularly marked amongst women and the very old. These findings raise policy questions about the appropriateness of current and planned future levels of provision.     

Effects of the holding technique for restraint of aggression in children in residential care

The purpose of the present study was to further understanding of the therapeutic value of the holding technique for children who exhibit extreme uncontrolled behavior. The data collection in this study was from reports on the use of the holding technique and a questionnaire based on the RAF (regulation, assessment, follow-up) Method, which includes three subscales of a Teacher's Report Form questionnaire (TRF): Social Problems, Aggressive Behavior and Anxious/Depression. The RAF questionnaires were administered to 91 children in a residential care facility of which 51 underwent holding. The questionnaires were administered twice with an intervening period of one year indicating no improvement in the indices examined, including aggressive behavior, but suicide attempts in children who were held declined.     

Joanna Briggs Collaboration Aged Care Fellowship Project: implementing a smoking cessation program in a young, frail aged residential care facility

Background The subject site (Ian George Court) caters for clients from a socially disadvantaged background. All clients have been homeless or at risk of homelessness and have a history of alcohol and substance abuse often linked to mental health issues. This project was developed to examine if the site provided best practice in the promotion of smoking cessation. Objectives The first objective of this project was to improve client knowledge to make informed choice about smoking cessation, ensuring that client advice was given in line with best available evidence and assist the client in accessing community programs. The second objective was to fully review the current assessment tool used in relation to gathering baseline data about smoking habits and act on the information provided. Search strategy The search strategy sought to find published studies and papers. An initial limited search of MEDLINE and CINAHL was undertaken followed by an analysis of the text words contained in the title and abstract. A second extensive search was then undertaken using all identified keywords. Conclusion A smoking assessment tool was developed and is now in use across all Anglicare sites in South Australia. This provides staff with consistent baseline information and offers evidence-based health care in a package format to aid clients in smoking cessation.