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Abstract Background Acute hospital discharge delays are a pressing concern for many health care administrators. In Canada, a delayed discharge is defined by the alternate level of care (ALC) construct and has been the target of many provincial health care strategies. Little is known on the patient characteristics that influence acute ALC length of stay. This study examines which characteristics drive acute ALC length of stay for those awaiting nursing home admission. Methods Population-level administrative and assessment data were used to examine 17,111 acute hospital admissions designated as alternate level of care (ALC) from a large Canadian health region. Case level hospital records were linked to home care administrative and assessment records to identify and characterize those ALC patients that account for the greatest proportion of acute hospital ALC days. Results ALC patients waiting for nursing home admission accounted for 41.5% of acute hospital ALC bed days while only accounting for 8.8% of acute hospital ALC patients. Characteristics that were significantly associated with greater ALC lengths of stay were morbid obesity (27 day mean deviation, 99% CI = ±14.6), psychiatric diagnosis (13 day mean deviation, 99% CI = ±6.2), abusive behaviours (12 day mean deviation, 99% CI = ±10.7), and stroke (7 day mean deviation, 99% CI = ±5.0). Overall, persons with morbid obesity, a psychiatric diagnosis, abusive behaviours, or stroke accounted for 4.3% of all ALC patients and 23% of all acute hospital ALC days between April 1st 2009 and April 1st, 2011. ALC patients with the identified characteristics had unique clinical profiles. Conclusions A small number of patients with non-medical days waiting for nursing home admission contribute to a substantial proportion of total non-medical days in acute hospitals. Increases in nursing home capacity or changes to existing funding arrangements should target the sub-populations identified in this investigation to maximize effectiveness. Specifically, incentives should be introduced to encourage nursing homes to accept acute patients with the least prospect for community-based living, while acute patients with the greatest prospect for community-based living are discharged to transitional care or directly to community-based care.

Abstract Background Although numerous risk factors for adverse outcomes for older persons after an acute hospital stay have been identified, a decision making tool combining all available information in a clinically meaningful way would be helpful for daily hospital practice. The purpose of this study was to evaluate the ability of the Method for Assigning Priority Levels for Acute Care (MAPLe-AC) to predict adverse outcomes in acute care for older people and to assess its usability as a decision making tool for discharge planning. Methods Data from a prospective multicenter study in five Nordic acute care hospitals with information from admission to a one year follow-up of older acute care patients were compared with a prospective study of acute care patients from admission to discharge in eight hospitals in Canada. The interRAI Acute Care assessment instrument (v1.1) was used for data collection. Data were collected during the first 24 hours in hospital, including pre-morbid and admission information, and at day 7 or at discharge, whichever came first. Based on this information a crosswalk was developed from the original MAPLe algorithm for home care settings to acute care (MAPLe-AC). The sample included persons 75 years or older who were admitted to acute internal medical services in one hospital in each of the five Nordic countries (n = 763) or to acute hospital care either internal medical or combined medical-surgical services in eight hospitals in Ontario, Canada (n = 393). The outcome measures considered were discharge to home, discharge to institution or death. Outcomes in a 1-year follow-up in the Nordic hospitals were: living at home, living in an institution or death, and survival. Logistic regression with ROC curves and Cox regression analyses were used in the analyses. Results Low and mild priority levels of MAPLe-AC predicted discharge home and high and very high priority levels predicted adverse outcome at discharge both in the Nordic and Canadian data sets, and one-year outcomes in the Nordic data set. The predictive accuracy (AUC's) of MAPLe-AC's was higher for discharge outcome than one year outcome, and for discharge home in Canadian hospitals but for adverse outcome in Nordic hospitals. High and very high priority levels in MAPLe-AC were also predictive of days to death adjusted for diagnoses in survival models. Conclusion MAPLe-AC is a valid algorithm based on risk factors that predict outcomes of acute hospital care. It could be a helpful tool for early discharge planning although further testing for active use in clinical practice is still needed.

Abstract Background In long-term care (LTC) homes in the province of Ontario, implementation of the Minimum Data Set (MDS) assessment and The Braden Scale for predicting pressure ulcer risk were occurring simultaneously. The purpose of this study was, using available data sources, to develop a bedside MDS-based scale to identify individuals under care at various levels of risk for developing pressure ulcers in order to facilitate targeting risk factors for prevention. Methods Data for developing the interRAI Pressure Ulcer Risk Scale (interRAI PURS) were available from 2 Ontario sources: three LTC homes with 257 residents assessed during the same time frame with the MDS and Braden Scale for Predicting Pressure Sore Risk, and eighty-nine Ontario LTC homes with 12,896 residents with baseline/reassessment MDS data (median time 91 days), between 2005-2007. All assessments were done by trained clinical staff, and baseline assessments were restricted to those with no recorded pressure ulcer. MDS baseline/reassessment samples used in further testing included 13,062 patients of Ontario Complex Continuing Care Hospitals (CCC) and 73,183 Ontario long-stay home care (HC) clients. Results A data-informed Braden Scale cross-walk scale using MDS items was devised from the 3-facility dataset, and tested in the larger longitudinal LTC homes data for its association with a future new pressure ulcer, giving a c-statistic of 0.676. Informed by this, LTC homes data along with evidence from the clinical literature was used to create an alternate-form 7-item additive scale, the interRAI PURS, with good distributional characteristics and c-statistic of 0.708. Testing of the scale in CCC and HC longitudinal data showed strong association with development of a new pressure ulcer. Conclusions interRAI PURS differentiates risk of developing pressure ulcers among facility-based residents and home care recipients. As an output from an MDS assessment, it eliminates duplicated effort required for separate pressure ulcer risk scoring. Moreover, it can be done manually at the bedside during critical early days in an admission when the full MDS has yet to be completed. It can be calculated with established MDS instruments as well as with the newer interRAI suite instruments designed to follow persons across various care settings (interRAI Long-Term Care Facilities, interRAI Home Care, interRAI Palliative Care).

Abstract Background This manuscript describes a method for adjustment of nursing home quality indicators (QIs) defined using the Center for Medicaid & Medicare Services (CMS) nursing home resident assessment system, the Minimum Data Set (MDS). QIs are intended to characterize quality of care delivered in a facility. Threats to the validity of the measurement of presumed quality of care include baseline resident health and functional status, pattern of comorbidities, and facility case mix. The goal of obtaining a valid facility-level estimate of true quality of care should include adjustment for resident- and facility-level sources of variability. Methods We present a practical and efficient method to achieve risk adjustment using restriction and indirect and direct standardization. We present information on validity by comparing QIs estimated with the new algorithm to one currently used by CMS. Results More than half of the new QIs achieved a "Moderate" validation level. Conclusions Given the comprehensive approach and the positive findings to date, research using the new quality indicators is warranted to provide further evidence of their validity and utility and to encourage their use in quality improvement activities.

Abstract Background Home care plays a vital role in many health care systems, but there is evidence that appropriate targeting strategies must be used to allocate limited home care resources effectively. The aim of the present study was to develop and validate a methodology for prioritizing access to community and facility-based services for home care clients. Methods Canadian and international data based on the Resident Assessment Instrument – Home Care (RAI-HC) were analyzed to identify predictors for nursing home placement, caregiver distress and for being rated as requiring alternative placement to improve outlook. Results The Method for Assigning Priority Levels (MAPLe) algorithm was a strong predictor of all three outcomes in the derivation sample. The algorithm was validated with additional data from five other countries, three other provinces, and an Ontario sample obtained after the use of the RAI-HC was mandated. Conclusion The MAPLe algorithm provides a psychometrically sound decision-support tool that may be used to inform choices related to allocation of home care resources and prioritization of clients needing community or facility-based services.

The purpose of this study, conducted in a small, impoverished Hispanic community on the Texas-Mexico border, was to evaluate the level of participation in a bilingual spay/neuter program offered free of charge to residents with companion animals. Prior to the sterilization project, approximately 11% of dogs and about 27% of cats with guardians underwent surgical sterilization. Over an 8-month period, the spay/neuter program sterilized about 47% of dogs and 38% of cats who had guardians in the community. In spite of residents' early reluctance to neuter their dogs, the project sterilized nearly equal numbers of male and female dogs (200 male; 201 female).

Purpose: The purpose of this article is to present nurse practitioners (NPs) with information on screening for autism spectrum disorders (ASDs) in children between 12 and 24 months of age. Recommendations are also provided for appropriate referrals and initiation of early intervention (EI)., Data Sources: Review of published literature about ASD., Conclusions: Children with ASD exhibit impaired social interaction, verbal and nonverbal communication deficits, and repetitive, restricted, and stereotyped patterns of behavior or interests. Studies show that these children benefit from beginning intensive EI as soon as possible., Implications for Practice: Early detection enables children with suspected ASD to be evaluated by specialists and entered into treatment programs at the earliest possible opportunity. Because of the importance of early diagnosis of ASD, it is critical that NPs use established screening instruments to maximize time and increase the reliability of the assessment.

The researchers surveyed 206 residents of a Hispanic community on the Texas-Mexico border about their behaviors and attitudes toward companion animals. Selected members of the community administered a telephone survey to a systematic random sample of 206 individuals. The majority of participants believed that free-roaming dogs were a problem in their community, and nearly 81% responded that these dogs sometimes prevented them from walking outdoors. About 24% of dog guardians sometimes let their nonhuman animals roam free in the streets. Most study participants believed it was a good idea to sterilize both male and female dogs and cats, but only 11% of respondents' dogs and 27% of cats were sterilized. About 62% of households chained dogs outdoors; persons with an elementary-level education were 7 times more likely to chain their dogs than those who had completed some high school. The Hispanic population of the United States is growing rapidly; to guide officials charged with protecting animal welfare and the public health, it will become increasingly important to understand Hispanics' attitudes and behaviors toward companion animals.

There are between 4 and 10 million dogs and cats killed annually in the United States. Although there are no accurate national estimates of the number of companion animals who are sterilized surgically. Approximately 26,000 companion animals are euthanized annually in El Paso County, Texas, located on the U.S./Mexico border. In an effort to determine if a readily available spay/neuter program would be cost effective and eventually help to lower the county's euthanasia rate, a mobile spay/neuter clinic began operation for a 5-month period in 2004, using a volunteer veterinarian and paid staff. Sterilizations performed totaled 1,108: 959 dogs (372 males and 587 females) and 149 cats (50 males and 99 females). The per companion animal sterilization cost of 15.13 dollars (27.83 dollars had the veterinarian been paid) was considerably cheaper than the rate of 57 dollars per companion animal achieved by a local voucher program contracting with private veterinarians to perform reduced-cost sterilizations.

The purpose of this article is to examine the use of herbal remedies to treat Type 2 diabetes among Mexican Americans in El Paso County, Texas, on the U.S.-Mexico border. Interviews were conducted in Spanish with 22 Mexican American adults diagnosed with Type 2 diabetes mellitus. Open-ended questions were used to elicit theparticipants' beliefs about the appropriate treatment of Type 2 diabetes, including both Western biomedical and herbal therapy. Kleinman's explanatory model of illness served as the framework, and the grounded theory method was used for data analysis. A majority of participants were taking prescribed Western medications in conjunction with traditional Mexican folk remedies. Participants relied on the advice of family, friends, and neighbors to provide them with guidance, and some herbs used by participants were not indicated for the treatment of diabetes. Health care providers should be aware that Mexican American clients may make choices about herbal remedies without expert guidance and advice.

This article discusses the development of a new model representing the synthesis of two models that are often used to study health behaviors: the Health Belief Model and the Theory of Reasoned Action. The new model was developed as the theoretic framework for an investigation of the factors affecting participation by Mexican migrant workers in tuberculosis screening. Development of the synthesized model evolved from the concern that models used to investigate health-seeking behaviors of mainstream Anglo groups in the United States might not be appropriate for studying migrant workers or persons from other cultural backgrounds.

Because of the rapid growth of the non-English-speaking population in the United States, nurses are increasingly likely to be called on to provide care for patients whose first language is not English. As a result, nurse managers may need to make interpreters available to health care providers in a variety of settings to facilitate effective communication and provide quality care. The purpose of this article is to present nurse managers and nurse clinicians with information that will enable them to work effectively with interpreters.

This article details the use of qualitative data in the construction of a Spanish-language, quantitative research instrument designed for a study of Mexican migrant farmworkers' participation in tuberculosis screening. In the qualitative study, 19 Mexican migrant farmworkers were interviewed in Spanish to elicit their explanatory models (EMs) about tuberculosis. The Tuberculosis Interview Instrument (TII) was developed from the results of the qualitative study and concepts from a theoretical framework consisting of a combination of the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA). After its development, the TII was subjected to translation and back-translation procedures to insure the equivalency of the English and Spanish versions, and it was reviewed for content validity. Internal consistency reliability, based on the responses of 206 subjects, was satisfactory for all subscales. Future testing of the TII is recommended to evaluate its stability among Mexican migrant farmworkers in other parts of the United States.

To bridge the widening gap between clients of varied cultural backgrounds and the biomedical system in which nurses practice, nurses should foster the inclusion of health promoters in selected health care settings. Health promoters, who are persons of the same racial or ethnic background as the clients they serve, can help form a link between their community and the dominant health care system.

The timely diagnosis and treatment of tuberculosis is an important public health problem in both developed and developing nations. In the United States, migrant farmworkers are estimated to be about six times more likely than other employed adults to develop tuberculosis. The purpose of this study was to investigate explanatory models of tuberculosis among Mexican migrant farmworkers working in western New York state. In-depth interviews were conducted with 26 farmworkers using an open-ended question format. All interviews were conducted in migrant camps and were audio-taped, translated and transcribed by the researcher. Data analysis was performed using Glaser and Strauss' grounded theory method of analysis which involves continuous and simultaneous data collection, coding, and analysis. Study participants included 21 males and 5 females ranging in age from 18 to 65. Respondents had worked as migrant farmworkers an average of 10 years and had an average of five years of schooling. Two-thirds of the participants had previously attended a tuberculosis education program, and four had received treatment for tuberculosis infection in the past. Farmworkers' explanations of tuberculosis etiology, severity, symptoms, prevention, treatment, and social significance are described as well as their beliefs about tuberculosis skin testing and the bacillus Calmette-Guérin (BCG) vaccine. Migrant farmworkers' explanatory models were similar in many aspects to the medical model of tuberculosis, although farmworkers had numerous misconceptions about BCG vaccination. Health care workers should be aware that Mexican migrant farmworkers may have beliefs about tuberculosis that are very compatible with participation in testing and treatment programs if such programs are made accessible to them.

Because of immigration to the United States, the number of persons who speak languages other than English has grown over the past several decades. In addition, many groups whose primary language is not English are exhibiting rapid population growth rates. As a result, health care providers may find they require an interpreter to communicate with patients. Guidelines are presented to facilitate the effective choice and utilization of interpreters in primary care. Suggestions are also presented to help interpreters work effectively in the health care setting.

Should clinical nursing content be part of the preparation of future nurse executives? This issue has been debated by nursing administrators and nursing educators; many advocate some type of clinical knowledge base for nurse executives. In the graduate program in Nursing Administration at the State University of New York at Buffalo, we have developed a course that focuses on the administrative implications of current clinical issues. This course enables future nurse executives to explore clinical nursing problems and plan appropriate administrative strategies for confronting these problems.

Hepatitis B virus (HBV) infection is prevalent among Southeast Asian refugees. HBV infection causes acute and chronic hepatitis and cirrhosis, and is associated with primary hepatocellular carcinoma. Health care providers must be able to make an accurate diagnosis of acute or chronic HBV infection when performing medical evaluations of Southeast Asian refugees. It is essential that appropriate follow-up care and teaching regarding infection control be provided. In this article, a protocol is presented that aids interpretation of hepatitis B screening tests. The protocol uses testing for the immunoglobulin M antibody against hepatitis B core antigen (anti-HBc/IgM) to aid differentiation between acute and chronic HBV infection. If testing is interpreted to show the presence of the hepatitis B chronic carrier state, a second protocol is used to guide follow-up testing, treatment and referral of patients.

Approximately 850,000 Vietnamese, Cambodian, and Laotian refugees have come to the United States since the end of the war in Vietnam. Because of language, religious, and cultural differences, these refugees present a challenge for health care providers. Nurses who work with Southeast Asians must understand how their beliefs about illness causation and treatment affect their response to health care.

The hepatitis D virus (HDV) was first detected in Italy in 1977 and is the etiologic agent of type D hepatitis. A defective RNA virus, HDV depends completely on the hepatitis B virus for its expression and replication. HDV infection can cause a severe form of hepatitis with high mortality rates. In the United States, hepatitis D most commonly affects intravenous drug abusers and hemophiliacs. Diagnosis is based on interpretation of the body's immune response to the hepatitis D antigen. At present, there is no specific treatment for type D hepatitis. Prophylaxis against HDV infection depends entirely on the prevention of hepatitis B. Patients found to have hepatitis D virus infection should be referred to a gastroenterologist for management.

Since the end of the war in Vietnam, approximately 850,000 Southeast Asian refugees have come to the United States. They present a challenge for health care providers because of language and cultural differences that can create barriers to effective health care. Nurse practitioners who work with Southeast Asian refugees should be aware that hepatitis B virus (HBV) infection is highly endemic in Southeast Asia, and the virus is most commonly transmitted during the perinatal period or during childhood. HBV infection can cause acute hepatitis B, chronic hepatitis, cirrhosis, and primary hepatocellular carcinoma and is associated with considerable morbidity and mortality. Susceptible children and infants born to mothers who are hepatitis B carriers should be vaccinated with the hepatitis B vaccine. Vaccination can prevent the serious sequelae of HBV in a high percentage of the pediatric population.