Outcomes of Nursing Management Practice in Nursing Homes

描述（由申请人提供）：尽管疗效试验已经确定了可减少不良结局（如疗养院（NH）居民的福尔斯）的干预措施，但使用当前标准的护理质量改善（QI）技术将这些干预措施转化为实践的尝试尚未成功。使用复杂性科学的框架，我们以前的RO 1已经表明，低连接，信息流，和NH工作人员之间的认知多样性解释了许多复杂的问题，如福尔斯提供的护理质量差。我们的试点测试的“EQUECT”，一个多组件的干预，鼓励员工使用简单的策略，使新的连接与他人，加强信息流，并使用认知多样性，表明员工可以学习，以提高他们的互动的密度和质量，这种行为的变化是与下降率的趋势。我们假设，在复杂的老年问题（如福尔斯）的任何QI干预成功之前，需要更高水平的连接、信息流和认知多样性。 这项为期5年的研究将采用前瞻性、随机分组、结局评估设盲设计，将NH（n=16）随机分配至ECOECT和标准福尔斯QI程序（ECOECT + ECOLS）或单独ECOLS。我们估计将有800名居民和576名工作人员参加。具体目标是，在疗养院：1）比较的影响，ECOECT干预加上福尔斯减少QI干预（跌倒ECT+跌倒风险干预）到福尔斯减少QI干预（跌倒风险降低指标）（直立性血压、感觉障碍、鞋类适当性、步态;辅助设备;运动需求、环境和精神药物）; 2）比较单用抗癫痫ECT+抗癫痫LS与单用抗癫痫LS对跌倒率和伤害性福尔斯的影响，并确定这些是否由跌倒风险降低指标的变化介导; 3）比较BLEECT+福尔斯与福尔斯单独对复杂性科学测量的影响（沟通、参与决策、当地互动、安全氛围、员工对质量的看法），并确定这些是否会介导对跌倒风险降低指标、跌倒率和伤害性福尔斯的影响。在基线、3个月、6个月和9个月时对复杂性科学措施进行横截面观察。在第一次干预前6个月和最终干预完成后6个月测量居民跌倒风险降低指标、跌倒率和伤害性福尔斯。跌倒风险降低指标是主要结果。次要结局指标包括跌倒率、伤害性福尔斯和复杂性科学指标（沟通、参与决策、当地互动、安全气候、员工对质量的看法）。分析将使用3级混合模型来解释疗养院内患者和工作人员的复杂嵌套，并控制与跌倒风险相关的协变量，包括基线设施跌倒率和工作人员更替率。 公共卫生相关性：为了促进健康的脆弱的NH人口，这是至关重要的，以确定干预措施，以改善转化为实际实践的研究进展。ECOECT干预将行为和复杂性科学与卫生服务研究的原则相结合，并有可能改善NHS对体弱老年人中许多复杂的医疗和心理社会问题的护理。

DESCRIPTION (provided by applicant): Although efficacy trials have identified interventions that reduce adverse outcomes such as falls in nursing home (NH) residents, attempts to translate those interventions into practice using current standard of care quality improvement (QI) techniques have not been successful. Using a complexity science framework, our previous RO1 has shown that low connection, information flow, and cognitive diversity among NH staff explains much of the poor quality of care delivered for complex problems such as falls. Our pilot test of "CONNECT", a multi-component intervention that encourages staff use simple strategies to make new connections with others, enhance information flow, and use cognitive diversity, demonstrated that staff can learn to improve the density and quality of their interactions, and that this change in behavior is associated with a trend to lower fall rates. We hypothesize that higher levels of connection, information flow and cognitive diversity fostered in the CONNECT Intervention are necessary before any QI intervention for a complex geriatric problem such as falls can be successful. This 5-year study will use a prospective, cluster-randomized, outcome assessment blinded design, with NHs (n=16) randomized to either CONNECT and a standard falls QI program (CONNECT + FALLS) or FALLS alone. We estimate that 800 residents and 576 staff members will participate. Specific aims are to, in nursing homes: 1) Compare the impact of the CONNECT intervention plus a falls reduction QI intervention (CONNECT+FALLS) to a falls reduction QI intervention (FALLS) on fall risk reduction indicators (orthostatic blood pressure, sensory impairment, footwear appropriateness, gait; assistive device; toileting needs, environment, and psychotropic medication); 2) Compare the impact of CONNECT+FALLS to FALLS alone on fall rates and injurious falls, and determine whether these are mediated by the change in fall risk reduction indicators; 3) Compare the impact of CONNECT+FALLS to FALLS alone on complexity science measures (communication, participation in decision making, local interactions, safety climate, staff perceptions of quality) and determine whether these mediate the impact on fall risk reduction indicators and fall rates and injurious falls. Cross-sectional observations of complexity science measures are taken at baseline, at 3 months, at 6 months, and at 9 months. Resident fall risk reduction indicators, fall rates, and injurious falls are measured for the 6 months prior to the first intervention and the 6 months after the final intervention is completed. Fall risk reduction indicators are the primary outcome. Secondary outcome measures include fall rates, injurious falls, and complexity science measures (communication, participation in decision making, local interactions, safety climate, staff perceptions of quality). Analysis will use a 3-level mixed model to account for the complex nesting of patients and staff within nursing homes, and to control for covariates associated with fall risk, including baseline facility fall rates and staff turnover rates. PUBLIC HEALTH RELEVANCE: In order to promote the health of the frail NH population, it is essential to identify interventions to improve the translation of research advances into actual practice. The CONNECT intervention integrates behavioral and complexity science with principles of health services research, and has the potential to improve care in NHs for many complex medical and psycho-social problems among frail older adults.