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      A mixed methods quality improvement study to implement nurse practitioner roles and improve care for residents in long-term care facilities

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          Abstract

          Background

          To better meet long-term care (LTC) residents’ (patients in LTC) needs, nurse practitioners (NPs) were proposed as part of a quality improvement initiative. No research has been conducted in LTC in Québec Canada, where NP roles are new. We collected provider interviews, field notes and resident outcomes to identify how NPs in LTC influence care quality and inform the wider implementation of these roles in Québec. This paper reports on resident outcomes and field notes.

          Methods

          Research Design: This mixed methods quality improvement study included a prospective cohort study in six LTC facilities in Québec. Participants: Data were collected from September 2015–August 2016. The cohort consisted of all residents ( n = 538) followed by the nurse practitioners. Nurse practitioner interventions ( n = 3798) related to medications, polypharmacy, falls, restraint use, transfers to acute care and pressure ulcers were monitored. Analysis: Bivariate analyses and survival analysis of occurrence of events over time were conducted. Content analysis was used for the qualitative data.

          Results

          Nurse practitioners ( n = 6) worked half-time in LTC with an average caseload ranging from 42 to 80 residents. Sites developed either a shared care or a consultative model. The average age of residents was 82, and two thirds were women. The most common diagnosis on admission was dementia (62%, n = 331). The number of interventions/resident (range: 2.2–16.3) depended on the care model. The average number of medications/resident decreased by 12% overall or 10% for each 30-day period over 12 months. The incidence of polypharmacy, falls, restraint use, and transfers to acute care decreased, and very few pressure ulcers were identified.

          Conclusions

          The implementation of NPs in LTC in Québec can improve care quality for residents. Results show that the average number of medications per day per resident, the incidence of polypharmacy, falls, restraint use, and transfers to acute care all decreased during the study, suggesting that a wider implementation of NP roles in LTC is a useful strategy to improve resident care. Although additional studies are needed, the implementation of a consultative model should be favoured as our project provides preliminary evidence of the contributions of these new roles in LTC in Québec.

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          Most cited references 47

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          Observational studies: cohort and case-control studies.

          Observational studies constitute an important category of study designs. To address some investigative questions in plastic surgery, randomized controlled trials are not always indicated or ethical to conduct. Instead, observational studies may be the next best method of addressing these types of questions. Well-designed observational studies have been shown to provide results similar to those of randomized controlled trials, challenging the belief that observational studies are second rate. Cohort studies and case-control studies are two primary types of observational studies that aid in evaluating associations between diseases and exposures. In this review article, the authors describe these study designs and methodologic issues, and provide examples from the plastic surgery literature.
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            Potentially avoidable hospitalizations of nursing home residents: frequency, causes, and costs: [see editorial comments by Drs. Jean F. Wyman and William R. Hazzard, pp 760-761].

            To examine the frequency and reasons for potentially avoidable hospitalizations of nursing home (NH) residents. Medical records were reviewed as a component of a project designed to develop and pilot test clinical practice tools for reducing potentially avoidable hospitalization. NHs in Georgia. In 10 NHs with high and 10 with low hospitalization rates, 10 hospitalizations were randomly selected, including long- and short-stay residents. Ratings using a structured review by expert NH clinicians. Of the 200 hospitalizations, 134 (67.0%) were rated as potentially avoidable. Panel members cited lack of on-site availability of primary care clinicians, inability to obtain timely laboratory tests and intravenous fluids, problems with quality of care in assessing acute changes, and uncertain benefits of hospitalization as causes of these potentially avoidable hospitalizations. In this sample of NH residents, experienced long-term care clinicians commonly rated hospitalizations as potentially avoidable. Support for NH infrastructure, clinical practice and communication tools for health professionals, increased attention to reducing the frequency of medically futile care, and financial and other incentives for NHs and their affiliated hospitals are needed to improve care, reduce avoidable hospitalizations, and avoid unnecessary healthcare expenditures in this population.
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              Distinguishing case series from cohort studies.

              Case series are a commonly reported study design, but the label "case series" is used inconsistently and sometimes incorrectly. Mislabeling impairs the appropriate indexing and sorting of evidence. This article tries to clarify the concept of case series and proposes a way to distinguish them from cohort studies. In a cohort study, patients are sampled on the basis of exposure and are followed over time, and the occurrence of outcomes is assessed. A cohort study may include a comparison group, although this is not a necessary feature. A case series may be a study that samples patients with both a specific outcome and a specific exposure, or one that samples patients with a specific outcome and includes patients regardless of whether they have specific exposures. Whereas a cohort study, in principle, enables the calculation of an absolute risk or a rate for the outcome, such a calculation is not possible in a case series.
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                Author and article information

                Contributors
                kelley.kilpatrick@mcgill.ca
                eric.tchouaket@uqo.ca
                kkilpatrick.hmr@ssss.gouv.qc.ca
                Sylvie.hains@hotmail.com
                Journal
                BMC Nurs
                BMC Nurs
                BMC Nursing
                BioMed Central (London )
                1472-6955
                29 January 2020
                29 January 2020
                2020
                : 19
                Affiliations
                [1 ]ISNI 0000 0004 1936 8649, GRID grid.14709.3b, Susan E. French Chair in Nursing Research and Innovative Practice, Ingram School of Nursing, , McGill University, ; Montréal, Canada
                [2 ]ISNI 0000 0004 4910 4652, GRID grid.459278.5, Centre intégré universitaire de santé et de services sociaux de l’Est-de-l’Île-de-Montréal-Hôpital Maisonneuve-Rosemont (CIUSSS-EMTL-HMR), ; Montréal, Canada
                [3 ]ISNI 0000 0001 2112 1125, GRID grid.265705.3, Department of Nursing, , Université du Québec en Outaouais, ; Saint-Jérôme, Canada
                [4 ]CIUSSS EMTL-HMR, Montréal, Canada
                [5 ]Retired, Ministère de la Santé et des services sociaux du Québec, Québec, Canada
                Article
                395
                10.1186/s12912-019-0395-2
                6990528
                b67765ca-26b3-4b6b-99c6-6e209dc32a53
                © The Author(s). 2020

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Funding
                Funded by: Ministère de la Santé et des Services sociaux du Québec
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2020

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