Systematic Review of Interdisciplinary Interventions in Nursing Homes

BackgroundThe role of interdisciplinary interventions in the nursing home (NH) setting remains unclear. We conducted a systematic evidence review to study the benefits of interdisciplinary interventions on outcomes of NH residents. We also examined the interdisciplinary features of successful trials, including those that used formal teams.Data SourcesMedline was searched from January 1990 to August 2011. Search terms included residential facilities, long term care, clinical trial, epidemiologic studies, epidemiologic research design, comparative study, evaluation studies, meta-analysis and guideline.Study SelectionWe included randomized controlled trials (RCTs) evaluating the efficacy of interdisciplinary interventions conducted in the NH setting.MeasurementsWe used the Cochrane Collaboration tools to appraise each RCT, and an RCT was considered positive if its selected intervention had a significant positive effect on the primary outcome regardless of its effect on any secondary outcome. We also extracted data from each trial regarding the participating disciplines; for trials that used teams, we studied the reporting of various team elements, including leadership, communication, coordination, and conflict resolution.ResultsWe identified 27 RCTs: 7 had no statistically significant effect on the targeted primary outcome, 2 had a statistically negative effect, and 18 demonstrated a statistically positive effect. Participation of residents’ own primary physicians (all 6 trials were positive) and/or a pharmacist (all 4 trials were positive) in the intervention were common elements of successful trials. For interventions that used formal team meetings, presence of communication and coordination among team members were the most commonly observed elements.ConclusionOverall interdisciplinary interventions had a positive impact on resident outcomes in the NH setting. Participation of the residents’ primary physician and/or a pharmacist in the intervention, as well as team communication and coordination, were consistent features of successful interventions.     

Effects of Nurse Staffing on Resident Outcomes in Nursing Homes: A Systematic Review

ObjectivesTo evaluate the evidence on effects of nurse staffing in nursing homes on resident outcomes.DesignSystematic review.Setting and ParticipantsStudies evaluating the effects of nurse staffing levels, total staffing, or skill mix on pressure ulcers, nursing home associated infections, and pain outcomes for adult residents in US nursing homes.MethodsWe searched MEDLINE, Embase, CINAHL, and the Cochrane Database for English-language articles published between January 2000 and May 2021. We also searched for gray literature and sought expert referrals. Two reviewers participated in determination of eligibility, assessment of methodological quality, and abstraction of data. Abstracted data included study design; setting and population characteristics; and resident outcomes. We rated overall certainty of evidence (very low, low, moderate, and high) for each outcome using GRADE.ResultsOf 9152 unique citations, 378 articles underwent full-text review. We identified 22 eligible studies that addressed pressure ulcers (k = 15), COVID-19 cases and/or mortality (k = 4), other infections (k = 8), and moderate-severe pain among residents (k = 7); some examined multiple outcomes. Most studies (k = 17) were rated moderate or high quality. All studies were observational. Overall, registered nurse (RN) staffing was probably associated with fewer pressure ulcers (moderate certainty) and possibly fewer COVID-19 infections/mortality (low certainty), other infections (low certainty) and lower rates of moderate-severe pain (low certainty). Higher skill mix was probably associated with fewer pressure ulcers, higher resident COVID-19 infections, fewer other infections, and lower rates of moderate-severe pain (low certainty for all outcomes).Conclusions and ImplicationsHigher RN staffing and skill mix may be associated with better nursing home resident outcomes, while results were mixed for total staffing. Increasing RN staffing levels and skill mix are one of a variety of approaches to improve nursing home care.     

Efficacy and Generalizability of Falls Prevention Interventions in Nursing Homes: A Systematic Review and Meta-analysis

ObjectivesTo determine the efficacy of fall intervention programs in nursing homes (NHs) and the generalizability of these interventions to people living with cognitive impairment and dementia.DesignSystematic review and meta-analysis.Setting and ParticipantsNH residents (n = 30,057) living in NHs defined as residential facilities that provide 24-hours-a-day surveillance, personal care, and some clinical care for persons who are typically aged ≥65 years with multiple complex chronic health conditions.MethodsMeta-analysis of falls prevention interventions on number of falls, fallers, and recurrent fallers.ResultsThirty-six studies met inclusion criteria for the systematic review. Overall, fall prevention interventions reduced the number of falls [risk ratio (RR) = 0.73, 95% confidence interval (CI) = 0.60-0.88], fallers (RR = 0.80, 95% CI = 0.72-0.89), and recurrent fallers (RR = 0.70, 95% CI = 0.60-0.81). Subanalyses revealed that single interventions have a significant effect on reducing fallers (RR = 0.78, 95% CI = 0.69-0.89) and recurrent fallers (RR = 0.60, 95% CI = 0.52-0.70), whereas multiple interventions reduce fallers (RR = 0.69, 95% CI = 0.39-0.97) and multifactorial interventions reduce number of falls (RR = 0.65, 95% CI = 0.45-0.94).Conclusions and ImplicationsExercise as a single intervention reduced the number of fallers and recurrent fallers by 36% and 41%, respectively, in people living in NHs. Other effective interventions included staff education and multiple and multifactorial interventions. However, more research on exercise including people with cognitive impairment and dementia is needed to improve the generalizability of these interventions to the typical NH resident.     

Association Between End-of-Life Conversations in Nursing Homes and End-of-Life Care Outcomes: A Systematic Review and Meta-analysis

Objective

Less aggressive end-of-life (EOL) care has been observed when health care professionals discuss approaching EOL and preferences about life-sustaining treatments with nursing home (NH) residents or their families. We performed a comprehensive systematic review to evaluate the association between health care professionals–residents and health care professionals–family EOL conversations and EOL care outcomes.

Nurse Staffing Impact on Quality of Care in Nursing Homes: A Systematic Review of Longitudinal Studies

BackgroundThe relationship between nurse staffing and quality of care (QoC) in nursing homes continues to receive major attention. The evidence supporting this relationship, however, is weak because most studies employ a cross-sectional design. This review summarizes the findings from recent longitudinal studies.MethodsIn April 2013, the databases PubMed, CINAHL, EMBASE, and PsycINFO were systematically searched. Studies were eligible if they (1) examined the relationship between nurse staffing and QoC outcomes, (2) included only nursing home data, (3) were original research articles describing quantitative, longitudinal studies, and (4) were written in English, Dutch, or German. The methodological quality of 20 studies was assessed using the Newcastle-Ottawa scale, excluding 2 low-quality articles for the analysis.ResultsNo consistent relationship was found between nurse staffing and QoC. Higher staffing levels were associated with better as well as lower QoC indicators. For example, for restraint use both positive (ie, less restraint use) and negative outcomes (ie, more restraint use) were found. With regard to pressure ulcers, we found that more staff led to fewer pressure ulcers and, therefore, better results, no matter who (registered nurse, licensed practical nurse/ licensed vocational nurse, or nurse assistant) delivered care.ConclusionsNo consistent evidence was found for a positive relationship between staffing and QoC. Although some positive indications were suggested, major methodological and theoretical weaknesses (eg, timing of data collection, assumed linear relationship between staffing and QoC) limit interpretation of results. Our findings demonstrate the necessity for well-designed longitudinal studies to gain a better insight into the relationship between nurse staffing and QoC in nursing homes.     

Health Outcomes of Deprescribing Interventions Among Older Residents in Nursing Homes: A Systematic Review and Meta-analysis

Objectives

Deprescribing is effective in addressing concerns relating to polypharmacy in residents of nursing homes. However, the clinical outcomes of deprescribing interventions among residents in nursing homes are not well understood. We evaluated the impact of deprescribing interventions by health care professionals on clinical outcomes among the older residents in nursing homes.

Telehealth Palliative Care in Nursing Homes: A Scoping Review

ObjectivesMany adults older than 65 spend time in a nursing home (NH) at the end of life where specialist palliative care is limited. However, telehealth may improve access to palliative care services. A review of the literature was conducted to synthesize the evidence for telehealth palliative care in NHs to provide recommendations for practice, research, and policy.DesignJoanna Briggs Institute guidance for scoping reviews, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews frameworks were used to guide this literature review.Settings and ParticipantsReviewed articles focused on residents in NHs with telehealth palliative care interventionists operating remotely. Participants included NH residents, care partner(s), and NH staff/clinicians.MethodsWe searched Medline (Ovid), Embase (Elsevier), Cochrane Library (WileyOnline), Scopus (Elsevier), CINHAL (EBSCOhost), Trip PRO, and Dissertations & Theses Global (ProQuest) in June 2021, with an update in January 2022. We included observational and qualitative studies, clinical trials, quality improvement projects, and case and clinical reports that self-identified as telehealth palliative care for NH residents.ResultsThe review yielded 11 eligible articles published in the United States and internationally from 2008 to 2020. Articles described live video as the preferred telehealth delivery modality with goals of care and physical aspects of care being most commonly addressed. Findings in the articles focused on 5 patient and family-centered outcomes: symptom management, quality of life, advance care planning, health care use, and evaluation of care. Consistent benefits of telehealth palliative care included increased documentation of goals of care and decrease in acute care use. Disadvantages included technological difficulties and increased NH financial burden.Conclusions and ImplicationsAlthough limited in scope and quality, the current evidence for telehealth palliative care interventions shows promise for improving quality and outcomes of serious illness care in NHs. Future empirical studies should focus on intervention effectiveness, implementation outcomes (eg, managing technology), stakeholders’ experience, and costs.     

Incidence and Predictive Factors of Functional Decline in Older People Living in Nursing Homes: A Systematic Review

ObjectivesTo review the evidence on incidence and predictive factors of functional decline (FD) in nursing home (NH) residents.DesignA systematic review of the literature.Setting and ParticipantsLongitudinal studies involving individuals age 60 years and older living in a NH and with at least 2 functional capacity assessments were eligible.MethodsThe search was carried out up to June 2021 and was conducted in Embase, PubMed, Web of Science, Cochrane Library, CINAHL, Scopus, SciELO, and Google Scholar databases.ResultsA total of 27 studies met the eligibility criteria, most of which were prospective, recruiting participants in more than 1 NH, and conducted in a single country. Studies reported a high rate of functional dependency at baseline and FD at follow-up; in 1 year, 38.9% to 50.6% of residents experienced FD. Predictive factors of FD that were significant in at least 2 of the included studies were cognitive impairment, functional status at baseline, urinary incontinence, length of institutionalization, age, depression, being married, being male, and stroke disease. Protective factors were licensed nursing hours and presence of a geriatrician within the NH staff.Conclusions and ImplicationsThis review highlights the high incidence of FD in NH residents and identifies risk and protective factors of FD that may support the design of preventative strategies for this vulnerable and frail population.     

Identification and Critical Appraisal of Food Service Satisfaction Questionnaires for Use in Nursing Homes: A Systematic Review

BackgroundFood service provision in nursing homes is a complex, adaptive system through which multiple stakeholders interface. Organizational stakeholders include staff involved in preparing and delivering meals. Consumer stakeholders are the end users including residents and family. Questionnaires can be an economical and efficient method of measuring food service satisfaction in nursing homes and a powerful quality improvement tool.Objective(1) To identify questionnaires that measure food service satisfaction of various stakeholders in a nursing homes and (2) to critically appraise the psychometric properties of identified questionnaires.MethodsFive electronic databases were searched (Cumulative Index to Nursing and Allied Health Literature, Medline, ProQuest, Scopus, and Cochrane) in April 2020. Data from the eligible studies were extracted, and the psychometric properties were critically appraised using the Consensus-Based Standards for the Selection of Health Measurement Instruments.ResultsThis review identified 129 studies that used a questionnaire to measure food service satisfaction in nursing homes. Of those, 107 studies representing 75 unique general nursing home satisfaction questionnaires were excluded for failing to adequately explore aspects related to food service. From the remaining 22 studies, 7 food service satisfaction questionnaires were identified; 5 intended for consumers (residents) and 2 intended for organizational stakeholders (staff). Using the Consensus-Based Standards for the Selection of Health Measurement Instruments quality criteria, most questionnaires had flaws in content validity and construct validity, primarily due to small sample sizes. No questionnaires explored food service satisfaction from the family perspective.ConclusionsNursing homes collect satisfaction information for accreditation, marketing, benchmarking, and quality improvement. Although questionnaires are easy to administer, the quality of the data they collect is impacted by the validity and reliability of the questionnaires used. Using unreliable satisfaction data may mean that nursing homes are not accurately able to understand the impact of changes in the system on stakeholder satisfaction.     

A Social Work Perspective on Ethical Practice in End-Stage Renal Disease

Social workers increasingly are defining problems that they encounter in practice in health settings as ethical dilemmas. A distinction is made between those practice questions that can best be answered by an appeal to theoretical or empirical knowledge and expertise (clinical questions) and those with invoke values and ethical imperatives (ethical questions). End-stage renal disease poses in high relief the practice dilemmas that are encountered by social workers and offers an opportunity to explore and clarify issues resolving them. Using an exchange framework as a basis for analysis, common ethical problems of end-stage renal services are discussed.     

Computerized Decision Support Systems for Nursing Homes: A Scoping Review

ObjectivesTo summarize the research literature describing the outcomes of computerized decision support systems (CDSSs) implemented in nursing homes (NHs).DesignScoping review.MethodsSearch of relevant articles published in the English language between January 1, 2000, and February 29, 2020, in the Medline database. The quality of the selected studies was assessed according to PRISMA guidelines and the Mixed Method Appraisal Tool.ResultsFrom 1828 articles retrieved, 24 studies were selected for review, among which only 6 were randomized controlled trials. Although clinical outcomes are seldom studied, some studies show that CDSSs have the potential to decrease pressure ulcer incidence and malnutrition prevalence. Improvement of process outcomes such as increased compliance with practice guidelines, better documentation of nursing assessment, improved teamwork and communication, and cost saving, also are reported.Conclusions and implicationsOverall, the use of CDSSs in NHs may be effective to improve patient clinical outcomes and health care delivery; however, most of the retrieved studies were observational studies, which significantly weakens the evidence. High-quality studies are needed to investigate CDSS effects and limitations in NHs.     

Telemedicine and Telehealth in Nursing Homes: An Integrative Review

ObjectivesTelemedicine and telehealth are increasingly used in nursing homes (NHs). Their use was accelerated further by the COVID-19 pandemic, but their impact on patients and outcomes has not been adequately investigated. These technologies offer promising avenues to detect clinical deterioration early, increasing clinician's ability to treat patients in place. A review of literature was executed to further explore the modalities' ability to maximize access to specialty care, modernize care models, and improve patient outcomes.DesignWhittemore and Knafl's integrative review methodology was used to analyze quantitative and qualitative studies.Setting and ParticipantsPrimary research conducted in NH settings or focused on NH residents was included. Participants included clinicians, NH residents, subacute patients, and families.MethodsPubMed, Web of Science, CINAHL, Embase, PsycNET, and JSTOR were searched, yielding 16 studies exploring telemedicine and telehealth in NH settings between 2014 and 2020.ResultsMeasurable impacts such as reduced emergency and hospital admissions, financial savings, reduced physical restraints, and improved vital signs were found along with process improvements, such as expedient access to specialists. Clinician, resident, and family perspectives were also discovered to be roundly positive. Studies showed wide methodologic heterogeneity and low generalizability owing to small sample sizes and incomplete study designs.Conclusions and ImplicationsPreliminary evidence was found to support geriatrician, psychiatric, and palliative care consults through telemedicine. Financial and clinical incentives such as Medicare savings and reduced admissions to hospitals were also supported. NHs are met with increased challenges as a result of the COVID-19 pandemic, which telemedicine and telehealth may help to mitigate. Additional research is needed to explore resident and family opinions of telemedicine and telehealth use in nursing homes, as well as remote monitoring costs and workflow changes incurred with its use.     

Outcomes Associated with a Disease Management Program for End-Stage Renal Disease

Disease-state management is gaining in use for the management of chronically ill individuals including those with diabetes mellitus, congestive heart failure, asthma, and some forms of cancer. Recently, disease management (DM) has been applied to patients with chronic kidney disease (CKD), a growing population of patients with high annual costs. CKD is ideally suited to DM since the definition of the condition is unambiguous and current care is highly fragmented. There are currently over 240 000 patients receiving dialysis for end-stage renal disease (ESRD), with projected numbers of nearly 600 000 by 2010, and nearly 9 million individuals with CKD not yet on dialysis. The total cost of care for patients with ESRD alone exceeded $US17 billion in 2000. Over 40% of costs for patients with ESRD result from hospitalizations, many of which can be avoided. In addition, much of the clinical morbidity and cost relates to associated comorbidities rather than ESRD per se, with little management presently provided for these conditions in the dialysis facility setting.DM for CKD uses field-based nurse care managers who can risk-assess patients and provide coordination of care so that the renal issues as well as comorbidities are identified and appropriately managed. Although few results from such efforts have been published, those that have, from RMS Disease Mnagement Inc., show remarkable improvements in a variety of clinical outcomes including mortality and hospitalization.Challenges to expanding DM for CKD include up-front funding to provide the needed DM, the availability of robust information systems to manage and analyze clinical and financial data, and the interest and participation of nephrologists, primary care providers and dialysis facilities, as well as other key providers to ensure that the DM approach is effective. With continuing increases in the number of patients with CKD in managed health plans, DM for this population will be even more important in the future to optimize clinical outcomes while constraining the costs of care.     

Ethical Issues in Treatment of Patients with End-Stage Renal Disease

Ethical issues in the care and treatment of patients with end-stage renal disease are illustrative of problems that confront social workers who practice in a medical setting. Chief among these are dilemmas of informed consent and dealing with the problem patient. Patient advocacy may pose a conflict between respect for a patient's autonomy and acting in the patient's best medical interest. Pressures of resource allocation on a dialysis unit also require a just resolution.