Background: Prior to the pandemic, every day approximately 28 long term care (LTC) residents were transferred to an emergency department (ED) in Alberta. This was placing increasing strain on healthcare resources and potentially negatively impacting the health and wellness of residents (e.g., exposure to iatrogenic harms). Many residents’ conditions could be managed within LTC if appropriate supports were provided. Poor communication between LTC and EDs can also lead to long ED lengths of stay, unnecessary resource utilization, sub-optimal health outcomes, and exposure to iatrogenic harms for LTC residents. Two INTERACT® tools (tools for early identification of acute medical issues) and a new care and referral pathway were implemented to help identify and address changes in health status among LTC residents sooner, improve communication between LTC and ED providers, and reduce unnecessary ED transfers. Methods: Between October 2019 and April 2022, 40 LTC homes and 4 EDs within the Calgary zone implemented the standardized LTC-to-ED care and referral pathway supported by a centralized telephone advice and transfer system for healthcare providers, community paramedics, and two INTERACT® tools (Stop and Watch for healthcare aides; Change in Condition Cards for nursing). Using a randomized stepped-wedge design, the pathway was implemented within 9 cohorts of (4-5) LTC facilities every 3 months, supported by an implementation coach. Three-hour train the trainer implementation sessions were conducted in-person or online with over 325 health practitioners in the enrolled LTC homes using strategies adapted to consider local context and barriers, as well as considering pandemic-related challenges. Evaluation Methods: Evaluation of the intervention involved both qualitative and quantitative methods. The primary study outcome is change in transfers from LTC to ED; secondary (quantitative) outcomes include hospital admissions, utilization of the centralized telephone advice and transfer system, and community paramedic visits. Analysis of these quantitative outcomes utilized negative binomial regression to estimate the incident rate with 95% confidence intervals (per 1000 residents), while adjusting for the different cohorts. The quantitative evaluation also included an economic analysis to determine potential cost savings. Interviews with healthcare providers were conducted to provide context to their experience with the intervention and ways it can be improved. These interviews will be interpreted with the involvement of members of our project resident and family advisory council. Results: Quantitative results demonstrate a reduction in the LTC-to-ED transfer rate [1.70 (95%CI 1.61-1.79) post-intervention) vs 1.91 (95%CI 1.84-2.00) pre-intervention], along with reduction in hospital admission rates [0.94 (95%CI 0.88-1.00) vs 1.08 (95%CI 1.03-1.14)]. There was an increase in utilization of the centralized telephone advice and transfer system [0.18 (95%CI 0.16-0.22) vs. 0.13 (95%CI 0.11-0.16)], but no increase in the number of community paramedic visits [2.05 (95%CI 1.94-2.16) vs 2.50 (95%CI 2.39-2.61)]. Cost and qualitative outcome data is pending. Advice and Lessons Learned: LTC staff education and use of early warning tools for identifying a change in resident health status (INTERACT® tools) and/or utilization of a centralized telephone advice and transfer system may have played a role in reducing ED transfers. We did not observe the expected relationship between community paramedic visits and reduced LTC-to-ED transfers, possibly as a result of the pandemic-related facility outbreak restrictions. Teams should tailor implementation sessions and materials to site specific needs and contexts to help address their unique barriers and facilitators. Partnerships with key stakeholders across the care continuum are essential to ensure adequate support and effective uptake and sustainability of the mutli-faceted change intervention.
Abstract Aim Efforts to understand how pollinating insect diversity is distributed across large geographic areas are rare despite the importance of such work for conserving regional diversity. We sought to relate the diversity of bees (Hymenoptera: Apoidea), hover flies (Diptera: Syrphidae), and butterflies (Lepidoptera) to ecoregion, landscape context, canopy openness, and forest composition across southeastern U.S. forests. Location Nineteen experimental forests across nine states in the southeastern U.S. Methods We established 5–7 plots on each experimental forest. In each, we sampled pollinators monthly (March–September) using coloured pan traps, and collected data on local forest characteristics. We used the National Land Cover Database (NLCD) to quantify surrounding landcover at different spatial scales. Results Bee richness was negatively correlated with both the amount of conifer (pine) forest and the extent of wetlands in the surrounding landscape but was positively correlated with canopy openness. Hover flies and butterflies were less sensitive to landscape context and stand conditions. Pollinator communities differed considerably among ecoregions, with those of the Central Appalachian and Coastal Plain ecoregions being particularly distinct. Bee richness and abundance peaked 2 months earlier in Central Appalachia than in the Coastal Plain and Southeastern Mixed Forest ecoregions. Main Conclusions Our findings reveal ecoregional differences in pollinator communities across the southeastern U.S. and highlight the importance of landscape context and local forest conditions to this diverse fauna. The closed broadleaf forests of Appalachia and the open conifer‐dominated forests of the Coastal Plain support particularly distinct pollinator communities with contrasting seasonality. Our results suggest pine forests may reduce pollinator diversity in regions historically dominated by broadleaf forests. However, efforts to create more open canopies can help improve conditions for pollinators in planted pine forests. Research exploring associations between forest pollinators and different broadleaf tree taxa is needed to better anticipate the impacts of various management activities.
ABSTRACT Objectives: (1) To articulate my personal philosophy of gerontological nursing. (2) To identify why I professionally do what I do. Method : Using auto-ethnography, I reflected upon my years of work in Supportive Living settings to identify: (a) what tasks I enjoyed and why; (b) how I can best use my passion to honour our older adults: and (c) what about my practice was science, nursing, or anything but . Results : This reflective exercise enabled me to articulate my perspective toward gerontological nursing, thereby helping me to discover that I do what I do in order to bring older adults joy and comfort, and to help maintain their integrity and dignity. If gerontological nursing is to be person-centred, then I will happily do whatever I can to achieve my nursing goals, regardless of whether or not the task is considered traditional nursing. In my professional career while caring for older adults, I have acted as an interior designer, an executive assistant, and a detective, among many other functions. My philosophy reflects that if we are to be truly person-centred, then it should not matter who does what. Implications : To use a truly person-centered Gerontological Nursing model with our older population, the organizational silos must be eliminated. Gerontological nurses will be asked to willingly fill a variety of roles not considered typical nursing roles.
Abstract Background Long term care (LTC) facilities provide health services and assist residents with daily care. At times residents may require transfer to emergency departments (ED), depending on the severity of their change in health status, their goals of care, and the ability of the facility to care for medically unstable residents. However, many transfers from LTC to ED are unnecessary, and expose residents to discontinuity in care and iatrogenic harms. This knowledge translation project aims to implement a standardized LTC-ED care and referral pathway for LTC facilities seeking transfer to ED, which optimizes the use of resources both within the LTC facility and surrounding community. Methods/design We will use a quasi-experimental randomized stepped-wedge design in the implementation and evaluation of the pathway within the Calgary zone of Alberta Health Services (AHS), Canada. Specifically, the intervention will be implemented in 38 LTC facilities. The intervention will involve a standardized LTC-ED care and referral pathway, along with targeted INTERACT® tools. The implementation strategies will be adapted to the local context of each facility and to address potential implementation barriers identified through a staff completed barriers assessment tool. The evaluation will use a mixed-methods approach. The primary outcome will be any change in the rate of transfers to ED from LTC facilities adjusted by resident-days. Secondary outcomes will include a post-implementation qualitative assessment of the pathway. Comparative cost-analysis will be undertaken from the perspective of publicly funded health care. Discussion This study will integrate current resources in the LTC-ED pathway in a manner that will better coordinate and optimize the care for LTC residents experiencing an acute change in health status.
Abstract Efforts to understand how pollinating insect diversity is distributed across large geographic areas are rare despite the importance of such work for conserving regional diversity. We sampled bees (Hymenoptera: Apoidea), hover flies (Diptera: Syrphidae), and butterflies (Lepidoptera) on nineteen National Forests across the southeastern U.S. and related their diversity to ecoregion, landscape context, canopy openness, and forest composition. Bee richness was negatively correlated with both the amount of conifer forest and the extent of wetlands in the surrounding landscape but was positively correlated with canopy openness. Hover flies and butterflies were less sensitive to landscape context and stand conditions. Pollinator communities differed considerably among ecoregions, with those of the Central Appalachian and Coastal Plain ecoregions being particularly distinct. Bee richness and abundance peaked two months earlier in Central Appalachia than in the Coastal Plain and Southeastern Mixed Forest ecoregions. Our findings suggest that hardwood forests may play a particularly important role in supporting forest-associated bees in the southeastern U.S. and that efforts to create more open forest conditions may benefit this fauna.
Healthcare aides (HCAs) are the primary caregivers for vulnerable older persons. They have many titles and are largely unregulated, which contributes to their relative invisibility. The objective of this scoping review was to evaluate the breadth and depth of the HCA workforce literature.We conducted a search of seven online bibliographic databases. Studies were included if published since 1995 in English, peer-reviewed journals. Results were iteratively synthesized within and across the following five categories: education, supply, use, demand and injury and illness.Of 5,045 citations screened, 82 studies met inclusion criteria. Few examined HCA education; particularly trainee characteristics, program location, length and content. Results in supply indicated that the average HCA was female, 36-45 years and had an education level of high school or less. Home health HCAs were, on average, older and were more likely to be immigrants than those working in other settings. The review of studies exploring HCA use revealed that their role was unclear - variation in duties, level of autonomy and work setting make describing "the" role of an HCA near impossible. Projected increased demand for HCAs and high rates of turnover, both at the profession and facility-level, elicit predictions of future HCA shortages. Home health HCAs experienced comparatively lower job stability, earned less, worked the fewest hours and were less likely to have fringe benefits than HCAs employed in hospitals and nursing homes. The review of studies related to HCA illness and injury revealed that they were at comparatively higher risk of injury than registered nurses and licensed practical nurses.This is the largest, most comprehensive scoping review of HCA workforce literature to date. Our results indicate that the HCA workforce is both invisible and ubiquitous; as long as this is the case, governments and healthcare organizations will be limited in their ability to develop and implement feasible, effective HCA workforce plans. The continued undervaluation of HCAs adversely impacts care providers, the institutions they work for and those who depend on their care. Future workforce planning and research necessitates national HCA registries, or at minimum, directories.
