Effects of Staff Training on Nursing Home Residents’ End-Of-Life Care : A Randomized Controlled Trial

Publisher Copyright: © 2021 AMDA – The Society for Post-Acute and Long-Term Care MedicinePeer reviewe

Training Staff in Long-Term Care Facilities-Effects on Residents' Symptoms, Psychological Well-Being, and Proxy Satisfaction

Context. Long-term care facility (LTCF) residents have unmet needs in end-of-life and symptom care. Objectives. This study examines the effects of an end-of-life care staff training intervention on LTCF residents' pain, symptoms, and psychological well-being and their proxies' satisfaction with care. Methods. We report findings from a single-blind, cluster randomized controlled trial featuring 324 residents with end-of-life care needs in 20 LTCF wards in Helsinki. The training intervention included four 4-hour educational workshops on palliative care principles (advance care planning, adverse effects of hospitalizations, symptom management, communication, supporting proxies, challenging situations). Training was provided to all members of staff in small groups. Education was based on constructive learning methods and included participants' own resident cases, role-plays, and small-group discussions. During a 12-month follow-up we assessed residents' symptoms with the Edmonton Symptom Assessment Scale (ESAS), pain with the PAINAD instrument and psychological well-being using a PWB questionnaire. Proxies' satisfaction with care was assessed using the SWC-EOLD. Results. The change in ESAS symptom scores from baseline to 6 months favored the intervention group compared with the control group. However, the finding was diluted at 12 months. PAINAD, PWB, and SWC-EOLD scores remained unaffected by the intervention. All follow-up analyses were adjusted for age, gender, do-not-resuscitate order, need for help, and clustering. Conclusion. Our rigorous randomized controlled trial on palliative care training intervention demonstrated mild effects on residents' symptoms and no robust effects on psychological well-being or on proxies' satisfaction with care. (C) 2021 The Authors. Published by Elsevier Inc. on behalf of American Academy of Hospice and Palliative Medicine.Peer reviewe

Training nursing home staff to improve residents' end-of-life care : design and baseline findings from a randomized controlled trial

Key summary pointsAimWe present the design, intervention, baseline findings and feasibility of a randomized, controlled trial examining the effectiveness of staff training in palliative care on nursing home residents' hospitalizations and health-related quality-of-life.FindingsMost staff members participated in the training sessions and they gave good feedback. Our patient groups are fairly well balanced in their characteristics.MessageIf our further trial shows patient-related benefits, we will have a well-defined model for improving palliative care in nursing homes. AbstractPurposeWe aim to describe the design, educational intervention, baseline findings and feasibility of our training intervention. Our trial will aim to improve the residents' health-related quality of life (HRQOL) and to reduce unnecessary hospitalizations.MethodsWe recruited 340 residents from 20 nursing home wards in Helsinki, and they were randomized into intervention and control groups. At baseline, all the participants were assessed for demographics, medical history, medication, HRQOL, symptoms, hospitalizations, advance care plans, and proxies' satisfaction with care. The staff in the intervention wards were offered four 4-h educational sessions on the principles of palliative care (advance care planning, the adverse effects of hospitalizations, symptom management, communication, giving support to proxies and challenging situations). The sessions were based on constructive learning methods and patient cases.ResultsThe mean age of residents was 84years and 76% were women. The intervention and control groups did not differ with respect to demographics, terminal diseases, comorbidities, nutritional status, cognition or the use of palliative medication. However, the control residents were more likely to be bed-bound and to have a do-not-resuscitate order on their medical chart. Of about 180 staff members, 132 completed the educational intervention. The discussions in the training sessions were lively and the participants gave an overall rating of 4.6/5 for the education.ConclusionsWe have successfully randomized nursing home wards in this trial and completed staff training with very positive feedback. If our trial shows resident-related benefits, we will have a well-defined model for improving palliative care in nursing homes. The study was registered in the Australian New Zealand Clinical Trials Registry under the intervention code: ACTRN12617001040358.Peer reviewe

Variation in the use of renal replacement therapy in patients with septic shock : a substudy of the prospective multicenter observational FINNAKI study

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Matrix-metalloproteinase-2,-8 and-9 in serum and skin blister fluid in patients with severe sepsis

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Common Inflammation-Related Candidate Gene Variants and Acute Kidney Injury in 2647 Critically Ill Finnish Patients

Acute kidney injury (AKI) is a syndrome with high incidence among the critically ill. Because the clinical variables and currently used biomarkers have failed to predict the individual susceptibility to AKI, candidate gene variants for the trait have been studied. Studies about genetic predisposition to AKI have been mainly underpowered and of moderate quality. We report the association study of 27 genetic variants in a cohort of Finnish critically ill patients, focusing on the replication of associations detected with variants in genes related to inflammation, cell survival, or circulation. In this prospective, observational Finnish Acute Kidney Injury (FINNAKI) study, 2647 patients without chronic kidney disease were genotyped. We defined AKI according to Kidney Disease: Improving Global Outcomes (KDIGO) criteria. We compared severe AKI (Stages 2 and 3, n = 625) to controls (Stage 0, n = 1582). For genotyping we used iPLEX(TM) Assay (Agena Bioscience). We performed the association analyses with PLINK software, using an additive genetic model in logistic regression. Despite the numerous, although contradictory, studies about association between polymorphisms rs1800629 in TNFA and rs1800896 in IL10 and AKI, we found no association (odds ratios 1.06 (95% CI 0.89-1.28, p = 0.51) and 0.92 (95% CI 0.80-1.05, p = 0.20), respectively). Adjusting for confounders did not change the results. To conclude, we could not confirm the associations reported in previous studies in a cohort of critically ill patients.Peer reviewe

Surgically treated acute acalculous cholecystitis in critically ill patients

Abstract Acute acalculous cholecystitis (AAC) is an insidious and increasingly recognized complication of critical illness, whose pathogenesis is poorly understood and clinical picture obscure. Diagnosis is difficult and there is no consensus on treatment. The medical records of all ICU patients who had undergone open cholecystectomy due to AAC during the years 2000–2001 and 2003–2004 were examined for clinical and organ failure data. The indication for open cholecystectomy was a suspicion of AAC based on clinical signs and symptoms of sepsis or deteriorating multiple organ dysfunction without other obvious foci and/or radiological (computed tomography or ultrasound) findings indicative of cholecystitis. A total of 73 patients had operatively treated AAC during the study periods, giving an incidence of 0.9% of all admissions (73/8184) and an incidence of 6.7% among the long-stayers (ICUstay >5 days). The hospital mortality of these patients was 43%. Infection was the most common admission diagnosis followed by cardiovascular surgery. The patients were severely ill, the mean (SD) APACHE II score being 25.5 (6.4) and the mean (SD) SOFA score 10.2 (3.5) on admission. In those patients who had AAC as the only intra-abdominal complication of multiple organ dysfunction, cholecystectomy was followed by a remarkable improvement of individual and total SOFA scores by the seventh postoperative day. The AAC gallbladders were histologically and immunohistologically compared to normal gallbladders and to gallbladders of patients with acute calculous cholecystitis (ACC). The ACC patients were admitted into hospital because of primary acute gallbladder disease, were treated on a normal ward and did not have severe sepsis or multiple organ dysfunction. The typical histopathological features of AAC (34 cases) in the gallbladder wall were bile infiltration, lymphatic dilatation and leucocyte margination of blood vessels, while epithelial degeneration and defects, widespread occurrence of inflammatory cells and extensive and deep muscle layer necrosis were typical features of ACC (28 cases). Tight junction proteins (claudin-1, -2, -3, -4, occludin, ZO-1 and E-cadherin) were uniformly expressed in normal gallbladder epithelium, with the exception of claudin-2, which was present in less than half of the cells. In AAC, the expression of cytoplasmic occludin and claudin-1 was decreased compared to control group. In ACC, the expression of claudin-2 was increased, but the expression of claudin-1, -3 and -4, occludin and ZO-1 was decreased compared to normal or AAC gallbladders. In conclusion, AAC is associated with severe illness, infection, long intensive care unit stay and deteriorating multiple organ dysfunction. Open cholecystectomy is one important contributing factor to reverse the course of multiple organ dysfunction in these patients. Histological and immunohistological studies suggest that AAC is a manifestation of systemic inflammatory disease, while ACC is a local inflammatory and often infectious disease