Complex older patients represent about half of all acute public hospital admissions in Australia. People with dementia are a classic example of complex older patients, and have been identified to have higher rates of hospital-acquired complications. Complications contribute to poorer patient outcomes, and increase length of stay and cost to hospitals. The care for older people with dementia is complex, and this has been attributed to: their cognitive response to being hospitalised; their limited ability to self-care; and lack of nursing engagement with the family caregiver. Registered nurses can offer simultaneous assessment and intervention to prevent or mitigate hospital-acquired complications. However, it is known that when demand for nursing care exceeds supply, care is prioritised according to acute medical need. Consequently some basic but essential nursing care activities such as patient mobility, communication, skin care, hydration and nutrition are implicitly rationed. This paper offers a theoretical proposition of 'Failure to Maintain' as a conceptual framework to indicate implicit care rationing by nurses. Care rationing contributes to functional and cognitive decline of complex older patients, which then contributes to higher rates of hospital acquired complications. Four key hospital acquired complications: pressure injuries, pneumonia, urinary tract infections and delirium are proposed as measurable indicators of 'Failure to Maintain'. Hospital focus on throughput constrains nurses to privilege predictable, solvable and medically-related procedures and processes that will lead to efficient discharge over patient mobility, communication, skin care, hydration and nutrition. This privileging, also known as implicit rationing, is theoretically and physiologically associated with a rise in the incidence of complications such as pressure injuries, pneumonia, urinary tract infection, and delirium. Complex older patients, including those with dementia, are at higher risk of the complications, therefore should have higher delivery of prophylactic intervention (ie have higher care needs). 'Failure to Maintain' offers a conceptual framework that is inclusive of, and sensitive to, this vulnerable population. Implicit rationing is occurring and it likely contributes to functional and cognitive decline in complex older patients and hospital-acquired complications. However, the lack of patient functional ability data at admission and discharge for hospitalised patients, and lack of usable ward and hospital level nurse staffing and workload data makes it difficult to monitor, understand and improve quality of care. Current research in the fields of acute geriatrics and nursing work environments show promise through enabling multidisciplinary team communication, and facilitating clinical autonomy to provide patient focussed care, and avoid 'Failing to Maintain'. The research field of acute geriatrics can understand and act on the risk modification role of nurses, including controlling for nurse staffing and work env...

ObjectivesTo identify rates of potentially preventable complications for dementia patients compared with non-dementia patients.DesignRetrospective cohort design using hospital discharge data for dementia patients, case matched on sex, age, comorbidity and surgical status on a 1 : 4 ratio to non-dementia patients.SettingPublic hospital discharge data from the state of New South Wales, Australia for 2006/2007.Participants426 276 overnight hospital episodes for patients aged 50 and above (census sample).Main outcome measuresRates of preventable complications, with episode-level risk adjustment for 12 complications that are known to be sensitive to nursing care.ResultsControlling for age and comorbidities, surgical dementia patients had higher rates than non-dementia patients in seven of the 12 complications: urinary tract infections, pressure ulcers, delirium, pneumonia, physiological and metabolic derangement (all at p<0.0001), sepsis and failure to rescue (at p<0.05). Medical dementia patients also had higher rates of these complications than did non-dementia patients. The highest rates and highest relative risk for dementia patients compared with non-dementia patients, in both medical and surgical populations, were found in four common complications: urinary tract infections, pressure areas, pneumonia and delirium.ConclusionsCompared with non-dementia patients, hospitalised dementia patients have higher rates of potentially preventable complications that might be responsive to nursing interventions.

In a 'communities of practice' model of clinical experience for students, there are benefits for staff as well as students. The implementation of this clinical model in residential aged care was relatively low in cost, a benefit in this sector and has the potential to address the critical issues of recruitment and retention.

AimTo synthesise international research conducted on dementia‐friendly community initiatives.BackgroundThe number of people living with dementia is increasing as a result of population ageing. Impairments related to neurological changes, together with environmental challenges, result in disability for people who have dementia. Led by the World Health Organization and Alzheimer's Disease International, initiatives have been undertaken internationally to promote social inclusion for people who have dementia. Communities where people with dementia are able to remain socially included are known as dementia‐friendly communities.DesignAn integrative review of the literature.MethodsScopus, MEDLINE, Web of Science and CINAHL Plus via Ebsco databases were searched for relevant articles. The PRISMA framework guided the article search and screening; reporting is in accordance with the PRISMA guideline. Eight eligible studies were identified. The methodological quality of the eligible studies was evaluated using the MMAT checklist. The matrix method was used to extract, abstract and analyse the data.ResultsOf the eight studies reviewed, five were from the UK and one each from Australia, New Zealand and Canada. Four major concepts were identified in the literature, and these are characteristics of dementia‐friendly communities, facilitators and barriers to community engagement for people with dementia, strategies for developing dementia‐friendly communities and challenges encountered when developing dementia‐friendly communities.ConclusionPeople with dementia are at the centre of dementia‐friendly initiatives, and these foster social inclusion. Collaborations and partnerships enhance development of dementia‐friendly communities; however, lack of resources and difficulty ensuring representation of marginalised groups provide challenges.Relevance to clinical practiceAn understanding of the impact of marginalisation and inequality on community participation for people with dementia is important for practitioners, enabling them to support those people. Senior nurses with this understanding can ensure services are able to meet the needs of a growing population with dementia.

BackgroundIncreased length of stay and high rates of adverse clinical events in hospitalised patients with dementia is stimulating interest and debate about which costs may be associated and potentially avoided within this population.MethodsA retrospective cohort study was designed to identify and compare estimated costs for older people in relation to hospital-acquired complications and dementia. Australia’s most populous state provided a census sample of 426,276 discharged overnight public hospital episodes for patients aged 50+ in the 2006–07 financial year. Four common hospital-acquired complications (urinary tract infections, pressure areas, pneumonia, and delirium) were risk-adjusted at the episode level. Extra costs were attributed to patient length of stay above the average for each patient’s Diagnosis Related Group, with separate identification of fixed and variable costs (all in Australian dollars).ResultsThese four complications were found to be associated with 6.4% of the total estimated cost of hospital episodes for people over 50 (A$226million/A$3.5billion), and 24.7% of the estimated extra cost of above-average length of stay spent in hospital for older patients (A$226million/A$914million). Dementia patients were more likely than non-dementia patients to have complications (RR 2.5, p <0.001) and these complications comprised 22.0% of the extra costs (A$49million/A$226million), despite only accounting for 10.4% of the hospital episodes (44,488/426,276). For both dementia and non-dementia patients, the complications were associated with an eightfold increase in length of stay (813%, or 3.6 days/0.4 days) and doubled the increased estimated mean episode cost (199%, or A$16,403/A$8,240).ConclusionUrinary tract infections, pressure areas, pneumonia and delirium are potentially preventable hospital-acquired complications. This study shows that they produce a burdensome financial cost and reveals that they are very important in understanding length of stay and costs in older and complex patients. Once a complication occurs, the cost is similar for people with and without dementia. However, they occur more often among dementia patients. Advances in models of care, nurse skill-mix and healthy work environments show promise in prevention of these complications for dementia and non-dementia patients.

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What is known and objective With the ageing of the population also comes increasing comorbidities and the use of multiple medications and administration methods, along with greater susceptibility to adverse drug reactions. Dosage form modification to facilitate drug administration in older adults can be potentially problematic as altering the original licensed formulation can affect medication safety and efficacy. The reporting of adverse drug reactions and medication incidents is a key strategy in avoiding preventable adverse drug events for aged care residents. This study evaluated the effect of an on‐site clinical pharmacist on reducing inappropriate dosage form modification and staff time spent on medication administration, and optimizing the documentation of drug allergies, adverse drug reactions and medication incidents. Methods A pilot‐controlled trial was performed in a purposive sample of two residential aged care homes. Both homes belonged to the same organization; the study site had 104 beds and the control site had 100 beds. All permanent residents were eligible for inclusion in the study if written consent was provided. A residential care pharmacist position was implemented at the study site for six months, with a focus on performing medication reviews and quality improvement activities. Observational audits of medication rounds were performed, and documentation relating to allergies, adverse drug reactions, and medication incidents was obtained from both sites before and after the pharmacist trial period. Results At the study site, there was a significant reduction over the trial in the proportion of inappropriate dosage form modification (from 24% to 0% of all dosage form modifications; P < 0.01). Mean time spent on medication rounds per resident reduced from 4.8 minutes per resident (SD 1.1) to 3.2 minutes per resident (SD 1.7) per round (P < 0.05). The incidence of previous allergy and adverse drug reaction documentation significantly improved from 77% of residents pre‐study to 100% of residents post‐study (P < 0.01). Mean monthly medication incident reports significantly improved from 13.3 (SD 7.4) pre‐study to 25.7 (SD 10.8) post‐study (P < 0.05). There was no change in these outcomes at the control site. What is new and conclusion Including a pharmacist in a residential aged care home can improve medication administration practices by reducing inappropriate dosage form modification and staff time spent on medication administration rounds, and increasing the documentation of resident allergies, adverse drug reactions and medication incidents. These findings warrant further exploration in a large randomized controlled trial.

Background: Hospital acquired infections (HAIs) increase length of hospital stay and lead to poorer clinical outcomes. HAIs are viewed as preventable through risk monitoring and prevention of transmission. These activities are frequently missed. This study explores missed infection control activities through the lens of missed or rationed care. Aim: To determine the factors that contribute to infection control activities being missed. Methods: Semi-structured interviews were conducted with eleven nurses with infection control expertise. Findings: Four major factors were identified as contributing to infection control activities being missed. These are systemic factors such as poor staffing and skillmix which contribute to time constraints and difficulties with identifying signs of infection; environmental factors such as ward layout and access to Personal Protective Equipment (PPE); organisational factors including lack of managerial support and interprofessional relationships; and personal factors, primarily the priority given to infection control by the nurse and knowledge, understanding and application of the principles of infection control. Discussion: Policy responses to HAI frequently focus upon surveillance and education however, resourcing, organisational and interprofessional support and hospital layout all contribute to infection control activities being missed. Conclusion: Further research is required into the impact of systemic factors upon infection control activities being missed.