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.     

Evidence-Based Practice Among Swedish Medical Social Workers

We have explored Swedish medical social workers’ attitudes, beliefs, knowledge, and behavior concerning evidence-based practice (EBP) and investigated the properties of a questionnaire to measure EBP. One hundred seventy-four Swedish medical social workers within university hospital care and primary care participated in a cross-sectional survey. Our results showed positive attitudes toward EBP and the use of evidence to support clinical decision making. EBP was seen as necessary and something that needed to be implemented more often. The main barriers to implementing EBP were lack of time (78%), the perception that EBP does not take into account the limitations of the clinical practice setting (78%), and lack of knowledge about relevant research (46%).     

Epilepsy: a disease audit

An audit was made of the management of epilepsy in an Australian general practice using a computerized medical record system. The aim was to determine whether disease audit is practical and worth the effort involved. It was concluded that even a sophisticated medical record system can be an inefficient tool for the monitoring of chronic illness. A specific diagnostic and management protocol suitable for later computerization is required. A number of audit objectives were identified: (1) Has the practice diagnosed all cases of epilepsy as predicted by community prevalence studies? (2) Has it correctly classified these diagnoses and supported them by evidence from neurological referral and appropriate investigations (EEG and CT scan)? (3) To what extent has the practice adequately managed these patients? In particular, what percentage of patients have remained free of fits in the previous 12 months? (4) Has the doctor used the simplest drug regimen possible, preferably monotherapy, and avoided side effects? (5) Does the medical record allow analysis and effective audit? Audits of this type in a practice of this size requires a suitable practice register to identify the medical records to be analysed, otherwise a manual search of every record is a major deterrent to audit. Computerized records of the future should be designed so that data and analyses can be produced by automated printout.     

Influence of a preventive care educational intervention on physician knowledge, attitudes, beliefs, and practice

We evaluated the effect of a three-part intervention on knowledge, attitudes, beliefs, and practices relevant to preventive care. A group of 13 second-year internal medicine residents (Group I) were exposed to a lecture, chart-based reminder, and biweekly feedback during a 3-month ambulatory care rotation. The remaining two groups of residents (Group II, n = 12; Group III, n = 11) were not exposed to the intervention. We performed a chart review to assess preventive care practice at a clinical site separate from the intervention and surveyed residents to assess preventive care knowledge, self-reported practice, professional attitudes, and health beliefs. Chart reviews revealed the intervention to be associated with improved performance of preventive care (0.52 vs 0.35 and 0.42, P = 0.01). In addition, the intervention was associated with improved scores for preventive care knowledge (90 vs 74 and 77, P = 0.001) and self-reported practice (85 vs 65 and 72, P = 0.007). Although attitudes toward prevention and health locus of control were not measurably influenced by the intervention, stepwise multiple linear regression analysis demonstrated these factors to be independently related to preventive practice. Our data support the notion that physician preventive practice is subject to a variety of influences involving not only knowledge, and practice environment, but also training, professional attitudes, and health beliefs.     

Adult immunization in a network of family practice residency programs

A substantial proportion of morbidity and mortality associated with vaccine-preventable diseases occurs among adults. Teaching residents about disease prevention is mandated in the curriculum guidelines for family practice programs. A cooperative study among the Kansas City family practice residency programs was begun to look at immunization behaviors in these teaching programs. A retrospective audit of medical records and a prospective survey of residents and faculty were performed. From the medical records of 400 patients seen for health maintenance examinations, the frequency of tetanus-diphtheria immunizations recorded was 4.75%. The pooled immunization rate recorded for pneumococcal vaccine was 25%, and for influenza vaccine, 24%. Although 93% of respondents knew patients need tetanus-diphtheria immunization every 10 years, on a written questionnaire giving clinical examples, they were less likely to elect to immunize older patients eligible for tetanus-diphtheria vaccine. The following immunization criteria were listed by respondents: for pneumococcal vaccine, age over 65 years (86%); for influenza vaccine, age over 65 years (85%), chronic diseases (69%), residence in a chronic care facility (7%), and being a health care worker (28%). Educational interventions stressing the appropriate criteria and involvement of the patient are planned at the separate programs.     

Barriers to accessing ambulance services in rural Victoria for acute asthma: patients' and medical professionals' perspectives

OBJECTIVE: To study the attitudes and perceptions of rural asthma patients and medical health professionals towards accessing ambulance services for acute asthma. DESIGN: Health professional and patient based focus groups, audit of ambulance patient care records and self administered survey. SETTING: Asthma patients and medical professionals from rural south-western Victoria. RESULTS: The audit of patient care records included 69 asthma case records, and identified short response times (mean, 7 min; SD, 5 min), and documented patient improvement in clinical status in response to ambulance treatment. The focus group analysis identified patient perceptions which act as barriers to accessing ambulance services in acute asthma. These included the perception of response time delays, '000' call centre delays and misunderstanding of the role of paramedics, and when it is appropriate to call an ambulance for acute asthma. These perceptions were expressed by both patients and medical professionals, and both groups had poor knowledge of how and when to access ambulance services for acute asthma. CONCLUSIONS: The misperceptions expressed are of particular concern in a rural population where distance can cause prolonged response times to treatment, and patients who are acutely ill need to contact emergency services promptly and appropriately to improve patient health outcomes.     

Nutritional issues in long-term care

Because long-term care residents often have chronic illnesses and complex care regimens, nutritional issues are common in these populations. Furthermore, management is complicated because some residents are terminally ill and under palliative care treatment plans that allow for dehydration and low oral intake. As a result, the medical management of nutrition is complex and challenging for medical providers caring for residents of nursing homes, assisted living facilities, and other long-term care settings. Quality nutritional practice in long-term care involves careful assessment of barriers to adequate nutrition; reduction of risk factors; attention to specialized diets, food presentation, and supplements, when appropriate; awareness of the importance of psychosocial and environmental issues; and consideration of the role of medication both as a cause and a therapeutic adjunct. Optimal practice at a facility level would involve a systematic approach to applying the best evidence-based approaches, with a focus on individualizing each resident's nutritional management.     

Understanding physicians' attitudes towards hormone therapy.

OBJECTIVE: We sought to understand the relationship among components of residency education about hormone therapy (HT), knowledge about HT, and provider attitudes toward HT during a time of rapidly changing practice guidelines. METHODS: We surveyed residents in the University of Pittsburgh Internal Medicine residency programs between February to April 2002 (after the release of the Heart Estrogen/Progestin Replacement Study and prior to the release of preliminary Women's Health Initiative data) regarding demographics, educational (didactic and experiential) exposures to HT and menopause management, knowledge about HT, and attitudes toward HT. RESULTS: Sixty-nine of 92 (75%) eligible residents completed the survey; 38% were women. The race and gender of responders did not differ from nonresponders. Residents had significant didactic exposure to HT and menopause management with 80% reporting more than one didactic exposure. Despite this, HT knowledge was low (mean knowledge score 47 +/- 16%) and only 26% of residents felt prepared to counsel patients about HT. We identified four factors related to provider attitudes toward HT: "persistence" in universally recommending HT, confidence in "HT benefits," concern about "HT cardiac risks," and concern about "HT noncardiac risks." More appropriate attitudes were associated with attending a lecture, having a rotation with a discussion of menopause management (i.e., Women's Health), and a continuity practice including more than 30% women. Pharmaceutical detailing and self-directed study were associated with less appropriate attitudes. Knowledge did not influence attitudes. Strongly held beliefs about the benefits of HT, appropriate or inappropriate, were associated with increasing "persistence." CONCLUSIONS: In an area of rapidly changing information, such as the risks and benefits of HT, knowledge is low. Experiential learning appropriately influences attitudes, while pharmaceutical detailing was associated with inappropriate attitudes toward HT risks.     

Health care access of poverty-level older adults in subsidized public housing.

OBJECTIVE. To assess the health status, access and use of health care and unmet health care needs of poverty-level residents of the Seattle Housing Authority over the age of 62. METHODS. An in-person interview survey of a quota sample of community residents. RESULTS. About half of SHA residents reported problems accessing care and sixteen percent reported being denied care. Multivariate analysis showed that encountering barriers of health care use were associated with having insufficient funds for monthly living expenses and lack of transportation. Over 90% of the population knew where to seek health care, so knowledge about sources of care did not appear to be a barrier. SHA residents met or exceeded national goals for completion of six out of nine recommended exams and procedures. SHA residents had unmet needs for services not covered by Medicare or provided by visiting nurse services. CONCLUSIONS. The results suggest that SHA residents know how to access medical care, and that visiting nurse services may be remarkably effective in meeting some medical care needs of SHA residents. It appears access to care by residents of subsidized housing could be improved by addressing transportation and financial barriers, and by providing more services to residents on site.     

崇义县农村居民健康档案管理存在的问题及对策

目的探索农村居民健康档案管理存在的关键问题并提出完善对策,为我国农村居民健康档案管理工作提供借鉴。方法以崇义县为例,分别对乡镇卫生院的医务人员、乡村医生和建立健康档案的农民进行问卷调查,并采用利用焦点组访谈和鱼骨图分析法进一步验证调查的结果。结果崇义县农村居民健康档案工作仅有对农村居民进行体检的每人20元的补助,而建一份档案的成本至少是55．5元,其中体检经费需要42．7元,因此,经费投入明显不足;在建立健康档案108个乡村中,配备电脑的仅有60个,设备明显缺乏;乡镇卫生院的医护人员相当缺乏,每千农业人口乡镇卫生院人员仅为1．49人;工作人员积极性不高、农村居民认识不足、健康档案缺乏规范管理及对档案利用不足。结论应加大政府投入、提高居民健康档案意识,建立完善的管理制度与信息系统并加强培训来完善农村居民健康档案管理工作。     

Emergency department chart auditing in a family practice residency program

A prospective audit of process on 1,200 consecutive patients seen in the emergency department by family practice residents was performed at the Family Practice Residency Program in Gainesville, Florida. The overall quality of care delivered conformed to the standards of "good medical care" as judged by the author in 85.6 percent of cases. Resident errors were detected in the remaining 14.4 percent of cases, and occurred most frequently among physicians in the earlier years of training (P less than .005). Ultimate patient management was changed by the audit in only 1 percent of cases but potentially had an important impact on the care of these patients. Errors of inadequate documentation were common among residents irrespective of their level of training. An ongoing audit of emergency department charts with regular feedback on medical process and recording appears to be useful both as an educational tool and as a method of improving emergency care.     

Advance care planning for residents in aged care facilities: what is best practice and how can evidence-based guidelines be implemented?

Background Advance care planning in a residential care setting aims to assist residents to make decisions about future healthcare and to improve end-of-life care through medical and care staff knowing and respecting the wishes of the resident. The process enables individuals and others who are important to them, to reflect on what is important to the resident including their beliefs/values and preferences about care when they are dying. This paper describes a project conducted as part of the Joanna Briggs Institute Clinical Aged Care Fellowship Program implemented at the Manningham Centre in metropolitan Melbourne in a unit providing services for 46 low and high care residents. Objectives The objectives of the study were to document implementation of best practice in advance care planning in a residential aged care facility using a cycle of audit, feedback and re-audit cycle audit with a clinical audit software program, the Practical Application of Clinical Evidence System. The evidence-based guidelines found in 'Guidelines for a Palliative Approach in Residential Aged Care' were used to inform the process of clinical practice review and to develop a program to implement advance care planning. Results The pre-implementation audit results showed that advance care planning practice was not based on high level evidence as initial compliance with five audit criteria was 0%. The barriers to implementation that became apparent during the feedback stage included the challenge of creating a culture where advance care planning policy, protocols and guidelines could be implemented, and advance care planning discussions held, by adequately prepared health professionals and carers. Opportunities were made to equip the resident to discuss their wishes with family, friends and healthcare staff. Some residents made the decision to take steps to formally document those wishes and/or appoint a Medical Enduring Power of Attorney to act on behalf of the resident when they are unable to communicate wishes. The post-implementation audit showed a clear improvement as compliance ranged from 15-100% for the five audit criteria. Strong leadership by the project team was effective in engaging staff in this quality improvement program. Conclusion The outcomes of the project were extremely positive and demonstrate a genuine improvement in practice. All audit criteria indicate that the Manningham Centre is now positively working towards improved practice based on the best available evidence. It is hoped that as the expertise developed during this project is shared, other areas of gerontological practice will be similarly improved and more facilities caring for the older person will embrace evidence-based practice.     

Knowledge,attitudes, and practices for tick bite prevention and tick control among residents of Long Island,New York,USA

In the United States, tick-borne diseases (TBDs) are a major public health concern and a source of significant morbidity. To reduce tick-borne disease incidence, understanding factors associated with increased risk in humans for tick bites is necessary. These risk factors can include TBD knowledge, attitudes about prevention and care, and associated practices of individuals and their communities, including paying for preventive services. Our study focused on Long Island, New York, a region with high endemicity of ticks and TBDs. The purpose of our study was to identify gaps in the knowledge, attitudes, and practices regarding TBDs in residents of this region to inform priorities for TBD interventions. To this end, we performed a knowledge, attitudes, and practices (KAP) survey and collected 803 responses from Long Island residents. Our survey results demonstrated that Long Island residents had a low to moderate level of knowledge regarding ticks and TBDs. Still, residents expressed concern regarding TBDs, with increased levels of concern associated with increased likelihood of paying for tick control and for practicing tick bite prevention strategies. Individuals with pets were more likely to practice these tick bite prevention strategies. Residents with more frequent exposure to ticks, with a history of TBD in their household, and with higher general concern over ticks were also more likely to pay for tick control services. These findings highlight gaps in resident knowledge, differences in attitudes towards tick preventative behavior, and potential factors affecting motivation towards implementing tick control measures, which can inform future public health messaging regarding tick bite prevention.     

Cholesterol management in patients hospitalized for coronary heart disease

There is now substantial scientific evidence that patients with coronary heart disease (CHD) have a high prevalence of hypercholesterolemia and stand to benefit significantly from efforts to lower cholesterol levels. To evaluate physician practice patterns and attitudes concerning cholesterol assessment and management of patients hospitalized with an admitting diagnosis of CHD, one-month medical record audits were performed during 1983, 1984, and 1985, and a physician survey was administered in early 1986. Medical records of 154 inpatients hospitalized with a diagnosis of CHD before 60 years of age showed that, on the average, 18% had lipid profiles ordered and 11% received a low-fat diet in the hospital. The admission history and follow-up notes mentioned the presence or absence of lipid abnormalities in 53% of CHD inpatients. No significant changes occurred from 1983 to 1985. Survey results from 184 hospital staff physicians caring for these patients showed that less than half believed that a reduction in blood cholesterol lowers risk for heart disease in middle-aged patients with CHD. Interns and residents indicated less confidence in the efficacy of cholesterol-lowering diet and drug therapy than did attending physicians. The implications of these findings for physician training are discussed in light of recent studies of the efficacy of cholesterol lowering in secondary prevention.     

Cold/flu knowledge, attitudes and health care practices: results of a two-city telephone survey.

The purpose of this paper is to describe knowledge, attitudes and practices of cold and flu self-care and health care utilization, and to identify the predictors of health care utilization for the cold and flu among residents of London and Windsor. Using a random digit dialing survey method, 417 residents were interviewed between November-December, 1993 and February-March, 1994. This survey revealed good knowledge about colds and flu and understanding of appropriate physician visits. Only seven percent reported a doctor visit for their last cold. Socio-demographic, health status, attitude and knowledge level variables were subjected to a logistic regression analysis to identify which variables predicted self-reported physician visits. Only attitudes and health status showed statistically significant log odds (3.6 and 1.5, respectively). In summary, consistent with other studies, attitude and health status, not knowledge, appear to be significant predictors of physician visits for colds/flu.     

Mouth Care in Assisted Living: Potential Areas for Improvement

BackgroundPoor oral care may lead to systemic disease, and there is evidence that assisted living (AL) residents lack quality oral care; in AL, poor care may be due to staff knowledge and attitudes, as well as organizational barriers to providing care.ObjectivesDetermine AL staff knowledge and attitudes regarding mouth care and barriers to changing care.DesignSelf-administered repeated-measures questionnaires completed before and after oral care training.Setting and ParticipantsA total of 2012 direct care staff and administrators from 180 AL communities.MethodsNine knowledge questions and 8 attitude and practice intention questions, and open-ended questions regarding training and obstacles to providing oral care.ResultsOverall, 2012 participants completed pretraining questionnaires, and 1977 completed posttraining questionnaires. Baseline knowledge was high, but staff were not uniformly aware of the systemic-oral link whereby mouth care affects pneumonia and diabetes. Almost all staff reported learning a new technique (96%), including for residents who resist care (95%). Suggested areas to improve mouth care included having more hands-on experience. The primary perceived obstacles to care centered around residents who resist care and a lack of time.Conclusions and ImplicationsBased on reports of having benefitted from training, AL staff overwhelmingly noted that new knowledge was helpful, suggesting the benefit of skills-based training, especially in dementia care. Mouth care in AL has been sorely understudied, and merits additional attention.     

All-Terrain Vehicle Injury Prevention: Healthcare Providers’ Knowledge, Attitudes, and the Anticipatory Guidance They Provide

All-terrain vehicles (ATVs) continue to be an increasing cause of injuries and deaths in children, especially in rural communities. More children die in the United States each year from ATV-related events than from bicycle crashes. The purpose of this study was to determine the ATV anticipatory guidance practices of primary care providers, as well as their attitudes, knowledge, and the barriers faced in educating families about the risk of ATV use. An electronic survey was administered to primary care providers belonging to state medical societies. More than 60% of respondents (Total N?= 218) believed that ATV anticipatory guidance was important to provide to pediatric patients and their families. However, 78% stated they provide ATV safety counseling less than 10% of the time during regular pediatric exams, and only 12% stated they do so greater than 25% of the time. Families rarely ask providers for advice on ATV safety issues; 84% of providers were asked once a year or less. ATV knowledge scores were low (median score 2 of 12); however, those with previous ATV exposure had significantly higher scores. Many respondents affirmed insufficient knowledge (47%) and inadequate resources (63%), but the most commonly identified barrier was that it was not a routine part of their practice. Providers in the study demonstrated limited knowledge, reported multiple barriers, and provided little or no ATV safety counseling. However, they consider ATV anticipatory guidance important for their patients. Armed with increased knowledge and appropriate resources, providers could play a significant role in promoting ATV safety.     

Barriers to managing pain in the nursing home: findings from a statewide survey

OBJECTIVES: The objective of this study was to identify pain management demographics, perceived resources, and perceived barriers to adequately manage pain in the nursing home setting. DESIGN: Mailed survey. SETTING: All licensed Connecticut nursing homes. PARTICIPANTS: Directors of Nursing (DONs). MEASUREMENTS: Survey eliciting pain management demographics, perceived resources, and perceived barriers to adequately manage pain in respondents' nursing home. RESULTS: A total of 113 of 260 DONs (43%) responded to the survey. Respondents believed pain was suboptimally managed, particularly for residents with malignant and nonmalignant chronic pain. Perceived barriers to providing adequate pain management included lack of knowledge about pain management among nurses and physicians, lack of a standardized approach to treating pain, physicians' personal attitudes toward treating pain (eg, fear of addiction or overdose), lack of diagnostic precision in treating pain, and difficulty in choosing the right analgesic. Other barriers are also discussed, including low hospice enrollment of nursing home residents. CONCLUSION: Improving pain management in nursing homes requires improving provider knowledge and attitudes, enhancing diagnostic precision, standardizing pain treatment, and achieving an institutional commitment. Although responding DONs seemed aware of the need for improved pain management outcomes at their facilities, the required institutional commitment to accomplish this was not evidenced by these findings.     

Management of primary antibody deficiency by consultant immunologists in the United Kingdom: a paradigm for other rare diseases.

Variation in clinical practice and its effect on outcome is little known for rare diseases such as primary antibody deficiency. As part of a national audit a survey of all 30 consultant immunologists in the United Kingdom dealing with primary antibody deficiency syndromes in adults and children was carried out in 1993 to ascertain their practices in diagnosis and management. Consensus guidelines were published after the survey was completed. Comparison of the survey results of clinical practice at the time the guidelines were published with the standards identified highlighted that the practice of a minority of specialists was at variance with their peers and with the consensus document, particularly in the use of intramuscular immunoglobulin, the dose and frequency of intravenous immunoglobulin, and target trough immunoglobulin G concentration, which has implications for the quality of patient care. However, much closer agreement existed in the key areas of management, such as diagnosis and selection of intravenous immunoglobulin. The approach and the problems identified are relevant to the management of other rare diseases, in which diagnosis and management is complex and there are few specialists with the necessary knowledge to undertake such care. This survey, the first attempted audit of practice, shows that within a motivated group of specialists highly significant differences in practice may exist and the authors emphasise the importance of setting clear guidelines against which care can be assessed.