Medication omission rates in New Zealand Residential Aged Care Homes: a national description

Abstract Background Medication administration is a key service offered to individuals residing in residential aged care homes (RAC homes). A medication omission is an event where a prescribed medication is not taken by a resident before the next scheduled dose. Medication omissions are typically classed as errors, they have the potential to lead to harm if poorly managed, but may also stem from good clinical decision-making. Studies that critically appraise or support medication omissions in healthcare settings are limited. There is uncertainty around which medication omissions are problematic and how many on average a patient should experience. There have been several hospital-based studies, with limited sample sizes, timeframes, and inconsistent reporting of omissions. As the first population-level, RAC Home-specific study of its kind, this study quantifies the incidence, prevalence, and types of medication omissions in RAC homes on a national scale. Methods A retrospective review of de-identified, medication administration e-records from December 1 st 2016 to December 31 st 2017 was conducted. Demographic details of residents, care staff competency levels, medications, and RAC ownership types were included in the review and analysis. Results A total of 11, 015 residents from 374 RAC homes had active medication charts; 8,020 resided in care over the entire data collection period. A mean rate of 3.40 medications doses were omitted per 100 dispensed medications doses per resident (s.d. 7.27). Approximately 73% of residents had at least one dose omission. The most common selected omission category was ‘not-administered’ (49.9%), followed by ‘refused’ (34.6%). The mean rate of omission was found to be slightly higher in corporate operated RAC Homes (3.73 versus 3.33), with greater variation. The most commonly omitted medications were Analgesics and Laxatives. Forty-eight percent of all dose omissions were recorded without a comment justifying the omission. Conclusions Compared to other studies medication omissions within RAC homes in New Zealand are not as common as previously proposed. This study sets out the first national-level rate of medication omissions per resident over a one-year timeframe. Subsequent studies will address the medications omitted, the clinical significance of omissions and the place of medication omissions within clinical decision-making.

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Medication omission rates in New Zealand Residential Aged Care Homes: a national description

10.21203/rs.2.15999/v4 ◽

2020 ◽

Author(s):

Stephanie M Garratt ◽

Ngaire M Kerse ◽

Kathryn Peri ◽

Monique F Jonas

Keyword(s):

New Zealand ◽

Clinical Decision Making ◽

Home Ownership ◽

Medication Administration ◽

Aged Care ◽

Care Staff ◽

Residential Aged Care ◽

Level Of Care ◽

Ownership Type ◽

Level Data

Abstract Background A medication omission is an event where a prescribed medication is not taken before the next scheduled dose. Medication omissions are typically classed as errors within Residential Aged Care (RAC) homes, as they have the potential to lead to harm if poorly managed, but may also stem from good clinical decision-making. This study aimed to quantify the incidence, prevalence, and types of medication omissions in RAC homes on a national scale, using a New Zealand-based sample. Methods We conducted retrospective pharmacoepidemiology of de-identified medication administration e-records from December 1st 2016 to December 31st 2017. Four tiers of de-identified data were collected: RAC home level data (ownership, levels of care), care staff level data (competency level/role), resident data (gender, age, level of care), and medication related data (omissions, categories of omissions, recorded reasons for omission). Data were analysed using SPSS version 24 and Microsoft Excel.Results A total of 11, 015 residents from 374 RAC homes had active medication charts; 8,020 resided in care over the entire sample timeframe. A mean rate of 3.59 medication doses were omitted per 100 (±7.43) dispensed doses/resident. Seventy-three percent of residents had at least one dose omission. The most common omission category used was ‘not-administered’ (49.9%), followed by ‘refused’ (34.6%). The relationship between ownership type and mean rate of omission was significant (p=0.002), corporate operated RAC homes had a slightly higher mean (3.73 versus 3.33), with greater variation. The most commonly omitted medications were Analgesics and Laxatives. Forty-eight percent of all dose omissions were recorded without a comment justifying the omission. Conclusions This unique study is the first to report rate of medication omissions per RAC resident over a one-year timeframe. Although the proportion of medications omitted reported in this study is less than previously reported by hospital-based studies, there is a significant relationship between a resident’s level of care, RAC home ownership types, and the rate of omission.

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Medication omission rates in New Zealand Residential Aged Care Homes: a national description

10.21203/rs.2.15999/v2 ◽

2020 ◽

Author(s):

Stephanie M Garratt ◽

Ngaire M Kerse ◽

Kathryn Peri ◽

Monique F Jonas

Keyword(s):

New Zealand ◽

Clinical Decision Making ◽

Home Ownership ◽

Medication Administration ◽

Aged Care ◽

Care Staff ◽

Residential Aged Care ◽

Level Of Care ◽

Ownership Type ◽

Level Data

Abstract Background A medication omission is an event where a prescribed medication is not taken before the next scheduled dose. Medication omissions are typically classed as errors within Residential Aged Care (RAC) homes, as they have the potential to lead to harm if poorly managed, but may also stem from good clinical decision-making. This study aimed to quantify the incidence, prevalence, and types of medication omissions in RAC homes on a national scale, using a New Zealand-based sample. Methods We conducted retrospective pharmaco-epidemiology of de-identified medication administration e-records from December 1st 2016 to December 31st 2017. Four tiers of de-identified data were collected: RAC home level data (ownership, levels of care), care staff level data (competency level/role), resident data (gender, age, level of care), and medication related data (omissions, categories of omissions, recorded reasons for omission). Data were analysed using SPSS version 24 and Microsoft Excel.Results A total of 11, 015 residents from 374 RAC homes had active medication charts; 8,020 resided in care over the entire sample timeframe. A mean rate of 3.59 medication doses were omitted per 100 (±7.4) dispensed doses/resident (s.d. 7.43). Seventy-three percent of residents had at least one dose omission. The most common omission category used was ‘not-administered’ (49.9%), followed by ‘refused’ (34.6%). The relationship between ownership type and mean rate of omission was significant (p=0.002), corporate operated RAC homes had a slightly higher mean (3.73 versus 3.33), with greater variation. The most commonly omitted medications were Analgesics and Laxatives. Forty-eight percent of all dose omissions were recorded without a comment justifying the omission. Conclusions This unique study is the first to report rate of medication omissions per RAC resident over a one-year timeframe. Although the proportion of medications omitted reported in this study is less than previously reported by hospital-based studies, there is a significant relationship between a resident’s level of care, RAC home ownership types, and the rate of omission.

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Medication omission rates in New Zealand Residential Aged Care Homes: a national description

10.21203/rs.2.15999/v3 ◽

2020 ◽

Author(s):

Stephanie M Garratt ◽

Ngaire M Kerse ◽

Kathryn Peri ◽

Monique F Jonas

Keyword(s):

New Zealand ◽

Clinical Decision Making ◽

Home Ownership ◽

Medication Administration ◽

Aged Care ◽

Care Staff ◽

Residential Aged Care ◽

Level Of Care ◽

Ownership Type ◽

Level Data

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Assessment of advance care planning documentation for residents of residential aged care facilities presenting to the emergency department

Australian Health Review ◽

10.1071/ah19238 ◽

2020 ◽

Vol 44 (6) ◽

pp. 847

Author(s):

Tzy Harn Chua ◽

Jessica Ru-Jia Foong ◽

Ryan Renxin Tan ◽

Princess Natsai Rukasha ◽

Carolyn Hullick

Keyword(s):

Decision Making ◽

Emergency Department ◽

Clinical Decision Making ◽

Clinical Decision ◽

Aged Care ◽

Residential Aged Care ◽

Sufficient Information ◽

Care Planning ◽

Advance Care

ObjectiveThis study assessed the availability and quality of advance care planning (ACP) documentation among older residential aged care facility (RACF) residents who presented to the emergency department (ED). MethodsA prospective review of the medical records of RACF residents aged ≥75 years who presented to the ED from May to June 2018 was conducted. Availability of ACP was determined based on the presence of an ACP document inclusive of an advance care directive (ACD) in the medical record. The quality of ACP documentation was determined based on the presence of nine key components. ResultsIn all, 48.8% of patients presented to the ED with either ACP or an ACD. However, only a mean total of 3.8 (out of 9) ACP components were documented in these documents. ConclusionsJust under half (48.8%) of RACF residents presented to the ED with ACP documentation. There was limited coverage of core ACP components needed to guide clinical decision making. What is known about the topic?RACF residents are in the last years of their life and commonly lack capacity to make decisions regarding health care. Residents are at high risk of dying when acutely unwell in hospital. ACP documentation, when readily available, helps provide appropriate end-of-life care and improves both patient and family satisfaction. What does this paper add?Less than half the residents reporting to the ED from an RACF had ACP documentation available for clinicians. For those who presented to the ED with ACP documentation, most lacked sufficient information needed to provide care in full accordance with the patient’s preferences. What are the implications for practitioners?There is a need to encourage, initiate, actively engage and develop systems for ACP conversations, documentation and availability when acutely unwell for people living in RACFs to provide sufficient information to guide clinical decision making. Without quality ACP, the provision of patient-centred health care may be compromised.

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“A good death but there was all this tension around”- perspectives of residential managers on the experience of delivering end of life care for people living with dementia

BMC Geriatrics ◽

10.1186/s12877-021-02241-7 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Jessica A. L. Borbasi ◽

Allison Tong ◽

Alison Ritchie ◽

Christopher J. Poulos ◽

Josephine M. Clayton

Keyword(s):

End Of Life ◽

End Of Life Care ◽

Aged Care ◽

Care Staff ◽

Care Homes ◽

Residential Aged Care ◽

Life Care ◽

Advanced Dementia ◽

Front Line ◽

Care Managers

Abstract Background End of life care for residents with advanced dementia in the aged care setting is complex. There is prolonged and progressive cognitive decline, uncertain disease trajectory, significant symptom burden and infrequent access to specialist palliative care. Residential aged care managers offer a unique perspective in understanding the experience of providing end of life care for residents with advanced dementia. They bring insight from the coalface to the broader policy context. The aim of this study was to describe the experience and perspectives of residential aged care managers on providing end of life care for residents living with dementia. Methods Focus groups and semi-structured interviews were conducted with residential or care managers from various care homes from one dementia specific aged care organisation in Australia. A comprehensive sampling strategy was used in participating care homes. Transcripts were analysed using thematic analysis. Results 20 residential or care managers from 11 aged care homes in two states of Australia participated in two focus groups (total 16 participants) or individual interviews (4 participants). Six themes were identified: laying the ground work to establish what families understand about dementia, playing the peacemaker in the face of unrealistic family demands and expectations, chipping away at denial and cultivating a path towards acceptance of death, recruiting general practitioners as allies, supporting and strengthening the front line, and dedication to optimal care is relentless but rewarding. Conclusion Aged care manager participants described provision of end of life dementia care as a rewarding but sometimes fraught experience requiring persistent personalisation of care and communication to enable family acceptance of the resident’s terminal condition. The findings suggest that continuous front line aged care staff skill development, iterative family discussions, and partnership building between aged care staff and general practitioners, are all required to promote optimal end of life dementia care in residential aged care settings.

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Challenges faced by residential aged care staff in decision-making for residents with dementia

Dementia ◽

10.1177/1471301220929154 ◽

2020 ◽

pp. 147130122092915

Author(s):

Nadine Cameron ◽

Deirdre Fetherstonhaugh ◽

Michael Bauer

Keyword(s):

Decision Making ◽

Aged Care ◽

Self Determination ◽

Care Staff ◽

Residential Aged Care ◽

Organisational Support ◽

Care Facilities ◽

Aged Care Facilities ◽

Residential Aged Care Facilities ◽

National Framework

Care staff in residential aged care facilities (nursing homes) in Australia are obligated, under the Australian National Framework for Action on Dementia 2015–2019, to support residents to exercise choice and make decisions. Research indicates, however, that care staff are often given little guidance regarding which residents’ decisions should be supported or how to make decisions on their behalf. This lack of guidance can result in a denial of residents’ rights and inconsistent treatment by staff, placing residents’ wellbeing at risk. Through providing an analysis of the responses of staff at RACFs in Victoria and Queensland to two case scenarios, this study seeks to provide some understanding of the difficulties staff face in supporting residents’ self-determination and their own need for greater organisational support.

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New Zealand paramedics are ready for an autonomous pre-hospital thrombolysis protocol

Australasian Journal of Paramedicine ◽

10.33151/ajp.14.3.244 ◽

2017 ◽

Vol 14 (3) ◽

Author(s):

Paul Davis ◽

Graham Howie ◽

Bridget Dicker

Keyword(s):

Decision Making ◽

New Zealand ◽

Clinical Decision Making ◽

Life Support ◽

Advanced Life Support ◽

Clinical Decision ◽

Multiple Choice Questions ◽

Common Error ◽

Paramedic Education ◽

Written Test

IntroductionInternationally, autonomous paramedic-delivered pre-hospital thrombolysis (PHT) administration for ST-elevation myocardial infarction patients has proven to be a highly effective strategy in facilitating expedited delivery of this treatment modality. However, current New Zealand models rely on physician authorised telemetry-based systems which have proved problematic, particularly due to technological failings. The aim of this study is to establish whether current paramedic education in New Zealand is sufficient for the introduction of an autonomous paramedic clinical decision-making model of PHT.MethodsA one-hour workshop introduced a new PHT protocol to 81 self-selected paramedic participants – both rural and metropolitan based – from New Zealand. Paramedics were then tested in protocol application through completion of a scenario-based standardised written test. Four written scenarios constructed from actual field cases assessed 12-lead electrocardiogram interpretation, understanding of protocol inclusion/exclusion criteria, and treatment rationale. Ten multiple-choice questions further tested cardiac and pharmacology knowledge as well as protocol application.Results Overall clinical decision-making showed a sensitivity of 92.0% (95% CI: 84.8–96.5), and a specificity of 95.6% (95% CI: 89.1–98.8). Electrocardiogram misinterpretation was the most common error. University educated paramedics (n=44) were significantly better at clinical decision-making than in-house industry trained paramedics (n=37) (p=0.001), as were advanced life support paramedics (n=36) compared to paramedics of lesser practice levels (n=45) (p=0.006).Conclusion Our New Zealand paramedic sample demonstrated an overall clinical decision-making capacity sufficient to support the introduction of a new autonomous paramedic PHT protocol. Recent changes in paramedic education toward university degree programs are supported.

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A screen-based simulation training program to improve palliative care of people with advanced dementia living in residential aged care facilities and reduce hospital transfers: study protocol for the IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) cluster randomised controlled trial

BMC Palliative Care ◽

10.1186/s12904-019-0474-x ◽

2019 ◽

Vol 18 (1) ◽

Cited By ~ 1

Author(s):

Joanne Tropea ◽

Christina E. Johnson ◽

Debra Nestel ◽

Sanjoy K. Paul ◽

Caroline A. Brand ◽

...

Keyword(s):

Palliative Care ◽

Training Program ◽

Residential Care ◽

Simulation Training ◽

Aged Care ◽

Dementia Care ◽

Care Staff ◽

Care Homes ◽

Residential Aged Care ◽

Advanced Dementia

Abstract Background Many people with advanced dementia live in residential aged care homes. Care home staff need the knowledge and skills to provide high-quality end-of-life (EOL) dementia care. However, several studies have found EOL dementia care to be suboptimal, and care staff have reported they would benefit from training in palliative care and dementia. Simulation offers an immersive learning environment and has been shown to improve learners’ knowledge and skills. However, there is little research on simulation training for residential care staff. This article presents the development and evaluation protocol of IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) - a screen-based simulation training program on palliative dementia care, targeted at residential care staff. IMPETUS-D aims to improve the quality of palliative care provided to people living with dementia in residential care homes, including avoiding unnecessary transfers to hospital. Methods A cluster RCT will assess the effect of IMPETUS-D. Twenty-four care homes (clusters) in three Australian cities will be randomised to receive either the IMPETUS-D intervention or usual training opportunities (control). The primary outcome is to reduce transfers to hospital and deaths in hospital by 20% over 6-months in the intervention compared to the control group. Secondary outcomes include uptake of goals of care plans over 6 and 12 months, change in staff knowledge and attitudes towards palliative dementia care over 6 months, change in transfers to hospital and deaths in hospital over 12 months. For the primary analysis logistic regression models will be used with standard errors weighted by the cluster effects. A mixed methods process evaluation will be conducted alongside the cluster RCT to assess the mechanisms of impact, the implementation processes and contextual factors that may influence the delivery and effects of the intervention. Discussion In Australia, the need for high-quality advanced dementia care delivered in residential aged care is growing. This study will assess the effect of IMPETUS-D a new simulation-based training program on dementia palliative and EOL care. This large multisite trial will provide robust evidence about the impact of the intervention. If successful, it will be distributed to the broader residential care sector. Trial registration ANZCTR, ACTRN12618002012257. Registered 14 December 2018.

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