Encouraging Best Practice in Residential Aged Care Program: Final Evaluation Report

Appendices 1 to 6

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• Appendix 1 - National Ageing Research Institute pain management project
• Appendix 2 - University of Newcastle nutrition and hydration project
• Appendix 3 - National Ageing Research Institute falls prevention project
• Appendix 4 - South Australian Dental Service oral health project
• Appendix 5 - Drugs and Therapeautic Information Service prn medications project
• Appendix 6 - Queensland University of Technology wound management project

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Appendix 1 - National Ageing Research Institute pain management project

Project title	Implementation of sustainable evidence-based practice for the assessment and management of pain in residential aged care facilities.
Leader	Professor Stephen Gibson, National Ageing Research Institute, Melbourne, Victoria.
Consortium partners	Australian Centre for Evidence Based Aged Care, La Trobe University, Victoria. School of Nursing and Midwifery, Curtin University, Western Australia. Dementia Collaborative Study Centre, Queensland University of Technology, Queensland. Department of Pain Management, Sir Charles Gairdner Hospital, Perth, Western Australia.
Participating facilities	Five facilities in three states, Victoria, Queensland and Western Australia.
Sources of evidence implemented by the project	The project used the Australian Pain Society evidence-based guidelines Pain in Residential Aged-Care Facilities: Management Strategies (2005) and an implementation toolkit that can be used in conjunction with the APS guidelines, published in 2006. The project also drew on five other sources of evidence, which contributed to the education and training program.
Model of change for implementing the evidence	The design of the project was primarily based on the previous experience of the project team. Later in the project the ADKAR Change Management Model was used to guide project activities. ADKAR is a goal-oriented change management model that allows change management teams to focus their activities on specific organisational results. The model shows the phases that individuals go through in any kind of change - personal or professional. ADKAR refers to A (Awareness of the need to change); D (Desire to participate and support the change); K (Knowledge of how to change (and what the change looks like)); A (Ability to implement the change on a day-to-day basis); R (Reinforcement to keep the change in place). The ADKAR change management model was first published in the 1998 book The Perfect Change by Jeff Hiatt, founder and CEO of Prosci Research. The project had four phases, including ‘pre-operational activities’ to establish the project, a pre-implementation audit of existing pain management practices, a 12 month education and training program for staff, and a post implementation audit to evaluate project outcomes. In addition to education the main activities for implementing change included establishment of regular evidence-based pain assessment; appointment of pain champions and a pain team; and coordination of available resources for pain management. Implementation was generally consistent with the original project plan, with some delays. Implementation was tailored to fit the specific needs of individual facilities. For example, the education program varied in content and format across the facilities based on staff requirements, the areas identified in the pre-implementation audit and practical considerations, such as the capability to backfill staff to attend education.
Main intended outcomes	Improved quality of pain management practices for residents with bothersome pain. Raised awareness about the importance of pain management. Evidence-based practice in pain management embedded into the routine clinical care practices of residential aged care facilities. Better integration of external pain management resources into residential aged care facilities.
Examples of changes implemented	Use of pain medication on a regular, rather than PRN, basis. Use of non-pharmacological therapies, including use of heat packs, repositioning, passive/active exercises, massage, hernia belts, prostheses (such as hand splints) and aromatherapy. Use of analgesia patches.
Project evaluation	Pre- and post-implementation data collection included: Quantitative data e.g. incidence of pain, incidence of untreated pain, number of pain reports that are unaddressed, resident levels of pain and pain impact. Audits of assessment procedures to identify and monitor pain, and environmental audits. Qualitative data (e.g. focus groups with residents and/or family to evaluate perceptions about new procedures, and documentation of action learning activities, goals and achievements). Each facility received two reports, a pre-implementation audit review which included recommendations to guide implementation and a post-implementation audit review describing the outcomes of the project. The project developed a tool for ascertaining the current level of compliance of any facility against 27 key standards for the provision of best practice pain management. It could potentially be used by facilities to identify areas for improvement but it has yet to be formally validated across a range of settings.

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Appendix 2 - University of Newcastle nutrition and hydration project

Project title	Encouraging best practice nutrition and hydration in residential aged care.
Leader	Professor Julie Byles, Research Centre for Gender, Health and Ageing, University of Newcastle, Newcastle, New South Wales.
Consortium partners	UnitingCare Ageing, Hunter, New England, Central Coast regions, New South Wales. Baptist Community Services, New South Wales. Nutrition Department, Gosford Hospital, Northern Sydney Central Coast Area Health Service, New South Wales.
Participating facilities	Nine facilities in New South Wales, all owned by either Uniting Care or Baptist Community Services.
Sources of evidence implemented by the project	Bartl, R & Bunney, C (2004) Best Practice Food and Nutrition Manual for Aged Care Facilities. Addressing nutrition, hydration and catering issues. Central Coast Health NSW: ISBN 1 74139 002 8
Model of change for implementing the evidence	Participatory action research and a practice development framework were the main change management approaches used by the project, with a process of staged implementation (32-week cycle for each facility). Each facility developed its own nutrition plan once facility staff decided what they wanted to implement. Change champions in each facility were supported by an external nutrition support person. The project used audit and feedback which involved assessing residents’ nutritional status and feeding the results back to staff.
Main intended outcomes	Impact on residents’ nutrition. Impact on residents’ quality of life. Change in nutrition practice and use of evidence. Tool kit for best practice nutrition and hydration. System level changes. Change in food services.
Examples of changes implemented	Changes to type and manner of meal items, including the use of bread-makers and soup tureens. Changes to the preparation of pureed meals. Use of nutritional supplements. Changing menus to include fresh-cooked items. Use of coloured plates to help visually impaired residents with their meals.
Project evaluation	Evaluation of the project included a mix of quantitative and qualitative methods to collect data on processes and outcomes. The nutritional status of consenting residents was assessed at three points in time (beginning, middle and end of the project). The evaluation was generally implemented as intended. One change was the use of a survey based on the Promoting Action on Research Implementation in Health Services framework which was added to the evaluation during the course of the project. The original framework was published in 1998 and has continued to be refined ever since. It is probably the most frequently cited framework in the literature on implementing evidence-based practice but there has been little testing of the framework. There is the potential for some useful results to emerge from its use in the project evaluation.

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Appendix 3 - National Ageing Research Institute falls prevention project

Project title	An individualised, facilitated and sustainable approach to implementing the evidence in preventing falls in residential aged care facilities (the STAR project).
Leader	Professor Keith Hill and Kirsten Moore, National Ageing Research Institute, Melbourne, Victoria.
Consortium partners	University of Tasmania, Tasmania. Princess Alexandra Hospital / University of Queensland, Queensland.
Participating facilities	Nine facilities across three states, of which four provided a mix of high and low level care, two were high care (including one dementia specific unit and one that had a dementia specific unit on site), one provided dementia specific low level care and two provided psycho-geriatric care.
Sources of evidence implemented by the project	Victorian Quality Council (2004) Minimising the risk of falls and falls injuries: Guidelines for acute, sub-acute and residential care setting. Australian Safety and Quality Council (2005) Preventing falls and harm from falls in older people. Best practice guidelines for Australian hospitals and residential aged care facilities.
Model of change for implementing the evidence	The project primarily used action research as the driver of change, with most decisions and planning of activities taking place in regular action research meetings. Falls resource nurses were appointed in each facility and provided with training to fulfil the role. Training was provided for general staff on falls prevention, including falls ‘expos’ in some facilities. Baseline environmental audits and falls risk assessments of individual residents were undertaken with the results provided to each facility which then developed its own action plan. Environmental modifications were undertaken to reduce risk of falls and some equipment purchased to also reduce the risk of falls e.g. high-low beds and hip protectors.
Main intended outcomes	Reduced rate of falls and fall related injuries for residents in participating facilities. Improved knowledge of falls prevention amongst residents. Improved access to falls prevention training. Improved knowledge of falls prevention by falls resource nurses. Improved falls prevention practices within participating facilities. Reduced environmental hazards that may contribute to residents’ falling. Improved safety culture within participating facilities.
Examples of changes implemented	Individual and group exercise programs. Regular review of sensory aids (hearing and sight). System for purchasing appropriate footwear for residents. Use of vitamin D and calcium supplements. Increased use of physiotherapy.
Project evaluation	Evaluation included pre and post intervention (scoping) audits of falls prevention activities and falls injury prevention activities; pre and post knowledge testing for a falls resource nurse training day; interviews with facility managers and falls resource nurses; and use of a safety culture survey, sustainability model questionnaire and Revised Professional Practice Environment survey. Data on falls and falls injury rates were collected for four six-month periods: the six months prior to project commencement and the first 18 months of the project. It was intended to undertake an economic evaluation but this did not eventuate.

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Appendix 4 - South Australian Dental Service oral health project

Project title	Better oral health in residential care.
Leader	Anne Fricker, South Australian Dental Service, Central Northern Adelaide Health Service, South Australia.
Consortium partners	Department of Human Services, Victoria. Centre for Oral Health Strategy, NSW Department of Health, New South Wales. Australian Research Centre for Population Oral Health, Adelaide University, South Australia.
Participating facilities	Six facilities in South Australia, Victoria and New South Wales, including the most remote facility in either Round 1 or Round 2 at Coober Pedy, run by Umoona Aged Care Aboriginal Corporation.
Sources of evidence implemented by the project	Pearson A & Chalmers, J (2004) Oral hygiene care for adults with dementia in residential aged care facilities, Joanna Briggs Reports, 2: 65–113. Joanna Briggs Institute (2004) Oral hygiene care for adults with dementia in residential aged care facilities, Best Practice: Evidence Based Practice Information Sheets for Health Professionals, Adelaide, Joanna Briggs Institute, 8(4): 1-6
Model of change for implementing the evidence	The model of change for this project included the recognition and emphasis of four key processes to ensure improved oral care, and their alignment to the relevant skills and roles of those working in aged care: oral health assessments by general practitioners and registered nurses; care planning by registered nurses with possibly general practitioner and dental professional involvement; daily oral hygiene by personal carers; and dental treatment by dental professionals (e.g. dentists, dental hygienists, and dental technicians). This was supported by the development and implementation of an oral hygiene education program which included educational tools and resources that could easily be adapted for the relevant audiences. Agreements were reached with public dental services that residents referred for dental treatment would receive priority treatment.
Main intended outcomes	Improved oral hygiene. Oral health assessment of approximately 80% of residents in participating facilities. Improved access of residents to dental services. Improved use of oral hygiene products. Staff will be confident in administering oral health assessments. Staff will be confident in addressing oral health needs of residents. Staff will be using oral care plans. The behaviour of staff towards oral health care will have changed. The facilities meet Accreditation Standard 2.15 (oral and dental care). Raise the profile of oral health care in participating facilities.
Examples of changes implemented	The changes had six key components: Brushing teeth morning and night. Using high fluoride toothpaste on teeth. Using a soft toothbrush on gums, tongue and teeth. Using an antibacterial product (in the form of a gel) after lunch. Keeping the residents’ mouth moist. Reducing sugar intake.
Project evaluation	There were two components to the evaluation. The first included pre and post-intervention oral health and hygiene behaviour surveys and evaluation of the oral health education program. In addition, eleven focus groups were undertaken: five comprising nursing staff, four comprising personal carers, one group of general practitioners and one group of residents. The second component involved evaluation of the education and training program, and the oral health care plans.

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Appendix 5 - Drugs and Therapeautic Information Service prn medications project

Project title	Time for Evidence based Action around prn Medicines in Aged Care (TEAM Aged Care project)
Leader	Debra Rowett, Drug and Therapeutics Information Service, Repatriation General Hospital, Adelaide, South Australia.
Consortium partners	Australian Medicines Handbook Pty Ltd. National Prescribing Service, New South Wales. General Practice Network South, South Australia. Pathways Health and Education Consultants, Wodonga, Victoria.
Participating facilities	Ten facilities were involved, some within the sphere of influence of a participating local division of general practice and a small number in regional Victoria.
Sources of evidence implemented by the project	An extensive literature search was undertaken to develop the evidence base for the three learning modules delivered by this project (pain, behaviours of concern, sleep). The Aged Care Companion to the Australian Medicines Handbook was the key resource for this project.
Model of change for implementing the evidence	The project used an evidence-based behaviour change strategy involving 1:1 education (known as educational visiting or academic detailing) to influence the use of PRN (from the Latin ‘pro re nata’ meaning ‘when necessary’) medications in residential aged care. Academic detailing is well established within the medical sector, particularly in regard to impacting on general practitioners’ prescribing practices, but this was the first project of its kind to systematically test the approach within residential aged care to influence the drug administration practices of nurses. The project built on work previously undertaken by the Drug and Therapeutic Information Service, including authoring of the Aged Care Companion to the Australian Medicines Handbook (AMH). Three educational modules were developed and delivered sequentially, which enabled the reinforcement of key messages, resources and approaches referred to in earlier modules. This facilitated the opportunity for reflective practice which was an important component of the training.
Main intended outcomes	Analgesia is tailored to meet the individual residents needs through regular and PRN use to improve resident pain control. The needs of residents with challenging behaviour are managed effectively in line with Aged Care Accreditation Standard 2.13. Residents are able to achieve natural sleep patterns. Residents are assessed for effectiveness and adverse effects of medicines to reduce potential harm from the targeted PRN medications. Residents and their families/carers have improved understanding of the management of pain and sleep. Improved staff confidence in the use of PRN medications through increased knowledge and skills relating to PRN medications. Improved staff competency in the use of PRN medications. Increased awareness of evidence based resources that they can access to inform medication management decisions and generally find information about medicines. Provides education to enhance the confidence and competence of all aged care staff with respect to PRN medicine use according to the role and scope of practice of the staff member. Educational training at a time convenient to their staff in the workplace, minimizing the need for staff travel, backfill of staff or the need to attend training out of work hours. Improved staff skills, knowledge and attitudes with regard PRN medicines - to improve resident outcomes and reduce potential harm from under and overuse of PRN medicines. Quality improvement activity valued by staff.
Examples of changes implemented	Regular use of paracetamol to improve pain management, rather than giving paracetamol when requested by residents. Use of alternatives to sedatives to promote sleep e.g. giving residents Milo or warm milk to drink at night instead of tea/coffee. Delaying the use of night time sedation until the night shift, when the medication is only given if needed. Reduced use of antipsychotics for behaviours of concern.
Project evaluation	The evaluation tested the use of educational visiting by considering the impacts of the intervention at a number of levels, including drug utilisation, staff confidence and competence, and resident knowledge and understanding. The evaluation was not designed to measure clinical outcomes for individual residents but rather to see how drug utilisation had changed, with some qualitative data about how practices had changed, based on the assumption that if practices improve (e.g. increased use of regular panadol) then resident outcomes will improve (e.g. decreased pain). The evaluation was comprehensive, with data collected on 750 residents using relevant industry assessment tools such as drug use evaluations developed by the National Prescribing Service. The Medication Appropriateness Index (MAI) tool, which measures the appropriateness of prescribing for elderly patients using 10 criteria for each medication prescribed, was undertaken at project beginning and project end on a random sample of 20% of all residents. Staff were asked to complete questionnaires at project beginning, project end and after each training module. Evaluation of the impact on staff included an assessment of staff self-rated skills and competence at project beginning and project end which included consideration of staff confidence, competence, knowledge and behaviour with regards to medication management, in particular PRN medications. The questionnaire included five questions on competency and five questions on confidence. Unfortunately, no data regarding staff competency and confidence were included in the project final report. Reports for individual facilities on evaluation data were not envisaged at the outset of the project, however were subsequently incorporated, resulting in 30 additional reports (one for each of the three modules for each of the 10 facilities).

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Appendix 6 - Queensland University of Technology wound management project

Project title	Creating champions for skin integrity.
Leader	Professor Helen Edwards, School of Nursing & Midwifery, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland.
Consortium partners	Nil
Participating facilities	Seven facilities, six in Queensland and one in New South Wales, of which five were from two organisations (Blue Care and Masonic Care Queensland). Facility size ranged from 20 to 495 beds.
Sources of evidence implemented by the project	The Australian Wound Management Association Standards for Wound Management (published in 2002 and updated in 2010) formed the basis for the evidence but the standards are very broad. For more detailed evidence the project drew on a wide range of other sources, including published guidelines. The evidence was synthesised into 2-3 page evidence summaries for individual topics that could be used during implementation - wound assessment and management, skin tears, pressure ulcers, arterial leg ulcers, venous leg ulcers, diabetic foot ulcers and maintaining general skin integrity. The evidence summaries were used as the basis for ‘tip sheets’ and flow charts to provide simple messages about wound management.
Model of change for implementing the evidence	The project used multiple change management approaches which strongly accord with what is known about how best to change the practices of clinicians: education, audit and feedback, use of internal champions and external link nurses, establishment of wound care networks in each facility, use of decision support tools and reminder systems. This was well thought out following a review of the evidence about how to implement evidence-based practice undertaken at the beginning of the project. The Champions for Skin Integrity in each facility either volunteered or were chosen by facility management and have not necessarily been the staff with the greatest interest in wound management, resulting in the project being ‘championed’ by a mix of formally appointed ‘champions’ and ‘informal champions’. The project used an action research approach which is similar in many ways to Plan-Do-Study-Act quality improvement cycles i.e. one cycle (of audit and feedback) at the beginning of implementation and another cycle at the end of implementation. It was anticipated that facilities might undertake their own Plan-Do-Study-Act cycles during the process of implementation, based on doing their own audits, but this did not eventuate in a consistent way. The project used a staggered approach to implementation whereby implementation in each facility commenced one after the other, rather than all at the same time.
Main intended outcomes	Improved skin integrity for residents. Improved wound healing. Improved communication between facility staff, residents and family on skin integrity. Improved knowledge and understanding of evidence based management of wounds. Enhanced knowledge, skills and attitudes of care staff towards skin integrity assessment, prevention and management. Improved awareness of evidence based wound management. Improved resources to facilitate implementation of evidence based wound management. The development of an evidence-based model of practice for wound management. Improved documentation of evidence based prevention, assessment and management of wounds. Development of a Wound Management Education and Self-evaluation Resource Package that can be used by all residential aged care facilities.
Examples of changes implemented	Implementation generally consisted of a lot of small changes rather than big changes, mostly to prevent wounds e.g. using soap-free body wash rather than soap, moisturising the skin of residents after showering, protective padding on wheelchair footplates, use of pressure relieving mattresses. What was implemented varied between facilities depending on local needs and priorities.
Project evaluation	The project evaluation used an action research approach including audits and feedback, surveys and meetings with staff. The evaluation had a particular focus on the factors that facilitate or hinder the implementation of evidence-based wound management. Collection of pre- and post-implementation data including skin integrity surveys and audits, staff wound care surveys, feedback questionnaires for education materials and sessions and surveys with open-ended questions for use in interviews and focus groups; interviews with residents, families, project leaders, project staff, facility managers, key clinicians, champions; and focus groups with key project participants.

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