Implementing Diabetes Care Guidelines in Long Term Care

Objective

The objectives of this article are to (1) describe the outcomes of a diabetes care program in a long term care facility dedicated to diabetes excellence and (2) compare the relevant outcome variables of research published between 2007 and 2012 with the results found in the studied facility.

Design

Three-year retrospective chart review of the facility's residents with comparison to extant literature.

Participants

A total of 224 resident charts within the studied facility were reviewed. Residents with a diagnosis of diabetes, or who were on diabetes medications, or whose fasting blood sugars exceeded 126 mg/dL on 2 occasions, and whose length of stay exceeded 6 months, were tracked for adherence to diabetes guidelines (n = 48). Participant outcomes from relevant studies in the literature were compared to these 48 participants' outcomes.

Intervention

All levels of staff in the studied facility were educated in general diabetes care. A nurse practitioner was contracted to provide medical care for all diabetic residents (with primary care provider approval). A scorecard for adherence to diabetes guidelines was completed by the nurse practitioner. Over a 3-year period following the education program and scorecard implementation, a chart review of all residents was completed by a consulting diabetes educator/nurse practitioner/nurse faculty member and 6 undergraduate nursing students.

Results

In general, the nursing home in the present study compared favorably with other relevant studies, demonstrating lower A1C levels, tracking blood sugars more regularly, monitoring blood pressure and lipids more regularly, having a greater percentage of patients on lipid-lowering medications among those in need, more appropriate use of sliding scale insulin, greater adherence to recommendations regarding diet, and had more patients who fit criteria on preventive anticoagulation.

Discussion

The results for the studied facility were very similar, often better, when compared with the most current nursing home literature. Areas of weakness provided focused strategic planning for the facility. Regrettably, the research is sparse, and evidence supporting guideline adherence data is often missing, making data comparison difficult. This model of care, linking health care agencies with academia, could offer a supportive and affordable method for identifying responses to evidence-based care guidelines.

Conclusion

This narrative review points to the need for continued work in the application of evidence-based guidelines in long term care, specifically in the area of interventions that must be adjusted to the needs of the nursing home population, with increased awareness in maintaining or improving quality of life.     

Applying Activity-Based Costing in Long Term Care

As greater numbers of the elderly use health services, and as health care costs climb, effective financial tracking is essential. Cost management in health care can benefit if costs are linked to the care activities where they are incurred. Activity-based costing (ABC) provides a useful approach. The framework aligns costs (inputs), through activities (process), to outputs and outcomes. It allocates costs based on client care needs rather than management structure. The ABC framework was tested in a residential care facility and in supportive housing apartments. The results demonstrate the feasibility and advantages of ABC for long term care agencies, including community-based care.     

21世纪质量形势与医院质量管理

２１世纪是质量世纪。质量的超严要求,数字化管理、技术进步以及质量创新构成２１世纪的质量形势。面对２１世纪质量形势的挑战,医院质量管理的主要任务,一是注重提高服务质量;二是持续质量改进;三是实行质量管理创新战略,引入先进的医院管理模式。     

Insulin Use in Long Term Care Settings for Patients With Type 2 Diabetes Mellitus: A Systematic Review of the Literature

Objective

To summarize currently available data about insulin therapy in patients with diabetes mellitus (DM), focusing on patients with type 2 DM (T2DM), in long term care (LTC) settings.

Data Sources

Ovid Medline, EMBASE, Cochrane Library databases, and United Kingdom National Health Service (NHS) Economic Evaluation Database, last accessed on November 12, 2012.

Study Eligibility Criteria

We included studies that reported insulin use in patients with T2DM, and studies with combined samples of patients with type 1 DM or T2DM, that were conducted in LTC settings. Excluded were review articles and studies published before 2000.

Results

We identified 11 articles that met all inclusion and exclusion criteria. Insulin use in patients with DM in LTC settings varied widely, from 2.7% to 58.0%. It is difficult to draw conclusions from these proportions, as many studies did not define whether their populations were exclusively patients with T2DM. Despite recommendations against its use by the American Diabetes Association, the American Geriatrics Society, and the American Medical Directors Association, treatment with sliding-scale insulin (insulin injections adjusted to current blood glucose levels) was prevalent in the LTC setting. Although the recommended target hemoglobin A1c (A1C) for this patient population varies from ≤6.5% to ≤8.0%, higher A1C values (8.0%–8.9%) were associated with better patient outcomes in a study examining insulin treatment in community-dwelling elderly patients enrolled in an outpatient LTC setting. Insulin pen-devices seemed associated with a high incidence of needle-stick injuries in workers in LTC settings but, compared with insulin vials, showed cost advantages for use in very short-term (≤30 days) patients with DM in LTC settings.

Limitations

Paucity of available data; only published studies for which full-text articles could be retrieved and which were identified by our search strategy were included; insufficient detail about patient samples were available in many included studies; and potential biases across studies might be introduced by funding sources or study designs.

Conclusions

Available data about insulin therapy in patients with DM in LTC settings are very scarce and great treatment variability of this patient population seems to prevail in the current clinical practice. Additional, randomized, prospective clinical trials are needed to expand our knowledge and allow clinicians to make informed treatment decisions for patients with DM in LTC settings.     

Gait Speed in Ambulant Older People in Long Term Care: A Systematic Review and Meta-Analysis

BackgroundGait speed, recently proposed as the sixth vital sign of geriatric assessment, is a strong predictor of adverse outcomes. Walking faster than 1.0 m/s is associated with better survival in community-dwelling older adults, and a recent meta-analysis of older adults in clinical settings estimated usual gait speed to be 0.58 m/s. Here, we aimed to review gait speed values for long term care residents.MethodsRelevant databases were systematically searched for original research studies published prior to December 2012. Inclusion criteria were participants living in long term care, mean age >70 years, and gait speed measured over a short distance. Meta-analysis determined gait speed data adjusting for covariates including age, sex, and cognition.ResultsFinal data included 2888 participants from 34 studies. The percentage of residents ineligible because of inability to mobilize was stated in only 1 study. Of the 34 studies, 22 reported cognitive status using the Mini-Mental State Examination. Usual pace and maximal pace gait speeds were determined separately using a random effects model. No association between gait speed and covariates was found. Usual pace gait speed was 0.475 m/s (95% confidence interval 0.396–0.554) and maximal pace was 0.672 m/s (95% confidence interval 0.532–0.811).ConclusionsIn ambulant older people in long term care, gait speed is slow but remains functional. However, since many residents are likely to have been ineligible to participate in assessments, these results cannot be generalized to the long term care population as a whole.     

培养适应21世纪需要的高级护理人才的思考

从护理专业现状及其发展趋势来看,培养高素质护理人才、改革护理教育模式是护理教育亟待解决的问题。根据我国国情,护理教育应提高层次;加强人文素质和道德素质教育;改革教学方法,重视综合能力培养;改革课程设置,突出专业特色;加强护理师资队伍建设。     

Applying Evidence-based Principles to Guide Emergency Surgery in Older Adults

Although outcomes for older adults undergoing elective surgery are generally comparable to younger patients, outcomes associated with emergency surgery are poor. These adverse outcomes are in part because of the physiologic changes associated with aging, increased odds of comorbidities in older adults, and a lower probability of presenting with classic “red flag” physical examination findings. Existing evidence-based perioperative best practice guidelines perform better for elective compared with emergency surgery; so, decision making for older adults undergoing emergency surgery can be challenging for surgeons and other clinicians and may rely on subjective experience.To aid surgical decision making, clinicians should assess premorbid functional status, evaluate for the presence of geriatric syndromes, and consider social determinants of health. Documentation of care preferences and a surrogate decision maker are critical. In discussing the risks and benefits of surgery, patient-centered narrative formats with inclusion of geriatric-specific outcomes are important. Use of risk calculators can be meaningful, although limitations exist. After surgery, daily evaluation for common postoperative complications should be considered, as well as early discharge planning and palliative care consultation, if appropriate. The role of the geriatrician in emergency surgery for older adults may vary based on the acuity of patient presentation, but perioperative consultation and comanagement are strongly recommended to optimize care delivery and patient outcomes.     

21世纪的临床营养

在过去的20年里，对能量和脂肪代谢的重点研究使人们对一些普通疾病的营养基础有了新的认识，如肥胖症、高血压、动脉硬化和糖尿病等。人们认识到这些疾病与饮食密切相关。因此，对现代临床营养进行新的定义是十分必要的。临床营养应该被定义为一种科学和临床相结合的学科，包括那些与营养摄人、肠吸收功能障碍和对营养物质代谢障碍有关的疾病，     

Healthcare Marketing in the 21st Century

No abstract available for this article.     

Film Psychotherapy in the 21st Century

Psychotherapy is commonly depicted in films. Films, then, help to inform the public about the nature of psychotherapy and psychotherapists. Although much has been written about the portrayal of psychotherapy in films, there has been little empirical investigation of films from the 21st century. The current study provides a systematic investigation of the portrayal of therapists and therapy in films released between 2000 and 2013. Trained volunteers coded films with characters identified as psychotherapists. Data are presented for ratings on 22 films in which therapist characters appeared on screen for at least 15 minutes. Therapists were predominantly Caucasian, male, and between ages 40 and 60 years. Their most common characteristics were generally positive—intelligent, caring, knowledgeable, and compassionate. More than half were portrayed as unethical, and more than one-third as manipulative. Therapists were also commonly shown as touching clients in some way, disclosing client information without permission, and becoming involved in social relationships with clients. In addition, it was often unclear whether clients benefitted from their engagement in therapy. The observed portrayals raise serious concerns about their potential impact on viewers. Viewers may be discouraged from seeking help and may have increased vulnerability to exploitation because of a lack of understanding of what is appropriate and inappropriate therapist behavior.