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Reducing incidents of illness posttransfer
REDUCING INCIDENTS OF ILLNESS POSTTRANSFER Stress-related effects of relocation can be reduced if patients are prepared. MARTHA F. PETROU JEANNE V. OBENCHAIN Within this decade, it is estimated that 8 million veterans will be eligible for the geriatric services that the Veterans Administration (VA) provides on an in-patient and out-patient basis. In attempting to meet this challenge, the VA is expanding the number of geriatric beds within its institutions and building a significant number of new nursing home facilities. As a result, there will be an increase in the number of veterans relocated from one institution to another, as well as admitted from the community. While relocating has been shown to be disruptive, stressful, and someMartha F. Petrou, RN, C, is head nurse/supervisor at the Veterans Administration Medical Center, Coatesville, PA, and Jeanne V. O ~ n chain, RN, MSN, CS, is clinical specialist in psychiatric nursing at the Veterans Administration Medical Center, Perry Point, MD.
times debilitating for the elderly, potential problems can be minimal with some preparation(l-5). Planned prevention measures can often offset adverse effects from anxiety-generated stress(6,7). Researchers have postulated that outcomes of relocation depend upon a number of factors(8-10): • Degree of control the individual has over his or her environment • Degree of preparation • Degree of difference in the new environment • The person's age Researchers who used temperature, pulse, respirations, weight, medications, and consultations as health/illness indicators found a significant difference in patients who were prepared to move as compared with those who were "nonprepared"(8).
Methodology This study was based on the outcomes of 101 patients who were relocated to a newly constructed 120-bed nursinghome care unit (NHCU) at the Coatesville Veterans Administration Medical Center (CVAMC). The study posed three specific ques-
264 Geriatric Nursing September/October 1987
tions in order to evaluate to what extent planned nursing interventions prior to relocation reduced physical health problems after patients were transferred to the new unit. • Following relocation, what is the type and frequency of the physical health problems that occur in a geriatric population? • Does preparation decrease the incidence of these physical health problems following relocation? • Does age affect the incidence of physical health problems following relocation? Of the study group, 46 patients, who had been prepared for the move by the nursing staff, were relocated en masse from an "'old" NHCU of the CVAMC. A nonprepared group, consisting of 55 patients who met the criteria f o r admission into the NHCU, had been moved from other wards at the CVAMC (n = 14), from community institutions (n = 31), and directly from their own homes (n = 10). The investigators considered five dependent variables as indicators of physical stress: • Temperatures above 100°F (oral) or 101*F (rectal); recurrence of
fever after five days was considered a separate incident • Upper respiratory infections as evidenced by cold symptoms, congestion, and sputum production • Pneumonia as evidenced by chest x-rays • Hospital admission for acute medical or surgical exacerbations The investigators monitored each patient for a three-month period from the date of arrival in the new facility. All data were obtained from the patients' medical records, and percentages were calculated. The prepared group (n = 46) of 44 male and 2 female patients varied in their physical abilities. Nine were confined to Geri-chairs; 20 were wheelchair dependent; and 18 were ambulatory. Their primary diagnoses included arteriosclerotic heart disease (n = 16), status postcerebrovascular accident (n = 11), organic brain syndrome or senility (n = 18), and a variety of psychiatric diagnoses (n = 6).
100
80 70
50 40 30
20 10
Upper respiratory infection
Prepared group ~ open; nonprepared group = shaded.
All levels of nursing personnel in the NHCU received one hour of in-
wheelchair dependent; and 24 were ambulatory. These patients' primary diagnoses included arteriosclerotic heart disease (n = 17), organic brain syndrome or senility (n = 14), and a variety of psychiatric diagnoses (n = 9).
90
Pneumonia
Preparation
Familiarity with the new environment, availability of choice, and degree of preparation determine relocation outcome.
Percentages of Physical Health Problems in Prepared and Nonprepared Subjects
Fever
They ranged in age from 60 through 95 years; 37 were 75 years and below and 18 were 76 years and above. The median age of this group was 71 years.
They ranged in age from 60 through 96 years; 21 were 75 years and below and 25 were 76 years and above. The median age of the group was 77 years. The nonprepared group (n = 55) of 47 male and 8 female patients also varied in their physical abilities. Ten were confined to Geri-chairs; 21 were
Urinar tract infection
I
Hospital
admission
service training by an instructor in nursing service on the effects of relocation. The next day, the head nurse outlined the program to all nursing staff and allowed time for discussions to take place. Four months before the move, patients learned of the approximate date of relocation in patient discussion groups. Families were notified by mail at the same time. Within one week following these announcements, a member of the nursing staff met with each patient individually to further discuss the move, answer questions, and clarify the information, since many older residents had hearing difficulties and may have misunderstood or misinterpreted the information given to the group. In addition, staff nurses held a discussion group each week for three months for the relocating patient. In these groups, patients were allowed to choose their roommates and, from the available artwork, the pictures that would hang in their new rooms. To encourage active control over some aspects of their environment, each patient was given a plant that they would care for and bring with them to the new nursing home. Each month, the staff scheduled trips to the prospective new location for all the patients who were able to visit the site. During these visits, photographs were displayed on the bulletin board that was centrally located in the current living area. Thus, all those unable to visit the site also
Geriatric Nursing September/October 1987 265
became involved in the various phases of the construction process. Preparation for relocation became an integral part of each patient's nursing care plan: Patients were shown pictures and printed material regarding the progress of the new facility and were asked to comment monthly on the move. By asking patients to pack their clothing and belongings two days before the move, nursing personnel were able to bring the items to the new N H C U and unpack them a day ahead.
per respiratory infections and 14 cases (25 percent) of urinary tract infections. Nine patients (20 percent) in the prepared group were admitted to the hospital, as compared with 28 hospital admissions (51 percent) in the nonprepared group. Regardless of age, preparation appeared to be helpful. In both age groups (those below and those above 75 years), the prepared patients fared better postrelocation than the nonprepared patients. This was true even though the median age of the prepared group was 77 years while the
Physical health indicators occurred in the first month after relocation, peaked in the second, and declined in the third.
Patients' families were told about the moving plans and asked to visit more frequently in the month following the move. On moving day, family members were invited to help their relatives settle into the new unit. When the long-awaited day arrived, patients were served breakfast at 7:00 AM and showered. Accompanied by the nursing staff, they were taken via van, bus, and ambulance to the new N H C U between 9:00 and 11:00 AM. Patients were shown their rooms and then lunch was served in the new unit.
Results Overall, the prepared group of patients experienced fewer incidents of negative physical health indicators than the group who were admitted to the nursing h o m e without any known preparation. Prepared patients had a total of 23 fevers (50 percent) and 14 cases (30 percent) of pneumonia, while nonprepared patients had 52 fevers (95 percent) and 26 cases (47 percent) of pneumonia. In the prepared group, there were 21 cases (46 percent) of upper respiratory infections and 6 cases (13 percent) of urinary tract infections, as opposed to the nonprepared group who had 33 cases (60 percent) of up-
2 6 6 Geriatric N u r s i n g
S e p t e m b e r / O c t o b e r 1987
median age of the nonprepared group was 71 years. The results of the study support the findings that the greater the number of choices an individual has and the more predictable the new environment is, the less adverse effects there will be(8). The results also uphold the conclusion that the degree of choice, preparation, and difference in the new environment affect relocation outcome(9). In addition, it is interesting to note that the physical health indicators began to occur in the first month following relocation, peaked during the second, and began to decline during the third.
Nursing Implications It appears that nursing staff in institutions can mitigate negative physical health problems following relocation by using the simple inexpensive nursing interventions identified in the literature and by making use of available resources to prepare patients for moving from institution to institution. If a group of patients are to be moved en masse, whenever possible, extra nursing staff should be scheduled before and for the first three months after the move so that there
will be sufficient help when administering to the problems the patients will more than likely experience. Nursing staffshould be alert to early signs and symptoms denoting changes in physical status, especially if patients have not been prepared. In addition, nursing home policy should permit patients to visit the sites if at all possible. When families are investigating placement of relatives from home, they should be told of available materials and information regarding relocation stress. Arrangements can be made for day-care programs for prospective patients prior to their institutionalization. In light of recent changes in the delivery of health care and the resource allocation model and with the advent of DRGs and RUGs, there is a likelihood that there will be an increase in the number of relocated patients and in the number of times they may be relocated. Most often nurses will be the professionals who work with these patients. Therefore, it is necessary to continue to design and evaluate methods that will help patients adjust more readily without increasing cost.
References I. Borup, J. H., and others. Relocation: its effect on health, functioning and mortality. Gerontologist 20:468-479, Aug. 1980. 2. Ferraro, K. The health consequences of relocation among the aged in the community. J.GerontoL 38:90--96, 1982. 3. Leiberman, E. Relocated research and social policy. Gerontologist 14:494--497, 1974. 4. Jasnau, IC F. Individualized versus mass transfer of nonpsychotie geriatric patients from mental hospitals to nursing homes with special reference to the death rate. J.Amer.Geriatr.Soe. 15:280-284, Mar. 1967. 5. Zweig, J. P., and Csank, J. Z. Mortality fluctuations among chronically ill medical geriatric patients as an indicator ofstress before and after relocation. ZAm.Geriatr.Soc. 24:264-277, June 1976. 6. Pastalan, L A. Report on Pennsyh'ania nursing home relocation program: Interim research findings. Ann Arbor, MI, Institute of Gerontology, 1976. 7. Brown, M. M., and others. Reducing the risks to the institutionalized elderly: Part l--depersonalization, negative relocation effects, and medical care deficiencies..LGerontol.Nurs. 7:401-407, July 1981. 8. Mirotznik, J., and Ruskin, P. Inter-institutional relocation and its effects on health. Gerontologist 24:286-291, ! 984. 9. Pablo, R. Y. Intrainstitutional relocation: its impact on long-term care patients. Gerontologist 17:426--435, Oct. 1977. 10. Borup, J. H. Relocation: attitudes, information network ~ind problems encountered. Gerontologist 21:501-51 I, Oct. 1981.
times debilitating for the elderly, potential problems can be minimal with some preparation(l-5). Planned prevention measures can often offset adverse effects from anxiety-generated stress(6,7). Researchers have postulated that outcomes of relocation depend upon a number of factors(8-10): • Degree of control the individual has over his or her environment • Degree of preparation • Degree of difference in the new environment • The person's age Researchers who used temperature, pulse, respirations, weight, medications, and consultations as health/illness indicators found a significant difference in patients who were prepared to move as compared with those who were "nonprepared"(8).
Methodology This study was based on the outcomes of 101 patients who were relocated to a newly constructed 120-bed nursinghome care unit (NHCU) at the Coatesville Veterans Administration Medical Center (CVAMC). The study posed three specific ques-
264 Geriatric Nursing September/October 1987
tions in order to evaluate to what extent planned nursing interventions prior to relocation reduced physical health problems after patients were transferred to the new unit. • Following relocation, what is the type and frequency of the physical health problems that occur in a geriatric population? • Does preparation decrease the incidence of these physical health problems following relocation? • Does age affect the incidence of physical health problems following relocation? Of the study group, 46 patients, who had been prepared for the move by the nursing staff, were relocated en masse from an "'old" NHCU of the CVAMC. A nonprepared group, consisting of 55 patients who met the criteria f o r admission into the NHCU, had been moved from other wards at the CVAMC (n = 14), from community institutions (n = 31), and directly from their own homes (n = 10). The investigators considered five dependent variables as indicators of physical stress: • Temperatures above 100°F (oral) or 101*F (rectal); recurrence of
fever after five days was considered a separate incident • Upper respiratory infections as evidenced by cold symptoms, congestion, and sputum production • Pneumonia as evidenced by chest x-rays • Hospital admission for acute medical or surgical exacerbations The investigators monitored each patient for a three-month period from the date of arrival in the new facility. All data were obtained from the patients' medical records, and percentages were calculated. The prepared group (n = 46) of 44 male and 2 female patients varied in their physical abilities. Nine were confined to Geri-chairs; 20 were wheelchair dependent; and 18 were ambulatory. Their primary diagnoses included arteriosclerotic heart disease (n = 16), status postcerebrovascular accident (n = 11), organic brain syndrome or senility (n = 18), and a variety of psychiatric diagnoses (n = 6).
100
80 70
50 40 30
20 10
Upper respiratory infection
Prepared group ~ open; nonprepared group = shaded.
All levels of nursing personnel in the NHCU received one hour of in-
wheelchair dependent; and 24 were ambulatory. These patients' primary diagnoses included arteriosclerotic heart disease (n = 17), organic brain syndrome or senility (n = 14), and a variety of psychiatric diagnoses (n = 9).
90
Pneumonia
Preparation
Familiarity with the new environment, availability of choice, and degree of preparation determine relocation outcome.
Percentages of Physical Health Problems in Prepared and Nonprepared Subjects
Fever
They ranged in age from 60 through 95 years; 37 were 75 years and below and 18 were 76 years and above. The median age of this group was 71 years.
They ranged in age from 60 through 96 years; 21 were 75 years and below and 25 were 76 years and above. The median age of the group was 77 years. The nonprepared group (n = 55) of 47 male and 8 female patients also varied in their physical abilities. Ten were confined to Geri-chairs; 21 were
Urinar tract infection
I
Hospital
admission
service training by an instructor in nursing service on the effects of relocation. The next day, the head nurse outlined the program to all nursing staff and allowed time for discussions to take place. Four months before the move, patients learned of the approximate date of relocation in patient discussion groups. Families were notified by mail at the same time. Within one week following these announcements, a member of the nursing staff met with each patient individually to further discuss the move, answer questions, and clarify the information, since many older residents had hearing difficulties and may have misunderstood or misinterpreted the information given to the group. In addition, staff nurses held a discussion group each week for three months for the relocating patient. In these groups, patients were allowed to choose their roommates and, from the available artwork, the pictures that would hang in their new rooms. To encourage active control over some aspects of their environment, each patient was given a plant that they would care for and bring with them to the new nursing home. Each month, the staff scheduled trips to the prospective new location for all the patients who were able to visit the site. During these visits, photographs were displayed on the bulletin board that was centrally located in the current living area. Thus, all those unable to visit the site also
Geriatric Nursing September/October 1987 265
became involved in the various phases of the construction process. Preparation for relocation became an integral part of each patient's nursing care plan: Patients were shown pictures and printed material regarding the progress of the new facility and were asked to comment monthly on the move. By asking patients to pack their clothing and belongings two days before the move, nursing personnel were able to bring the items to the new N H C U and unpack them a day ahead.
per respiratory infections and 14 cases (25 percent) of urinary tract infections. Nine patients (20 percent) in the prepared group were admitted to the hospital, as compared with 28 hospital admissions (51 percent) in the nonprepared group. Regardless of age, preparation appeared to be helpful. In both age groups (those below and those above 75 years), the prepared patients fared better postrelocation than the nonprepared patients. This was true even though the median age of the prepared group was 77 years while the
Physical health indicators occurred in the first month after relocation, peaked in the second, and declined in the third.
Patients' families were told about the moving plans and asked to visit more frequently in the month following the move. On moving day, family members were invited to help their relatives settle into the new unit. When the long-awaited day arrived, patients were served breakfast at 7:00 AM and showered. Accompanied by the nursing staff, they were taken via van, bus, and ambulance to the new N H C U between 9:00 and 11:00 AM. Patients were shown their rooms and then lunch was served in the new unit.
Results Overall, the prepared group of patients experienced fewer incidents of negative physical health indicators than the group who were admitted to the nursing h o m e without any known preparation. Prepared patients had a total of 23 fevers (50 percent) and 14 cases (30 percent) of pneumonia, while nonprepared patients had 52 fevers (95 percent) and 26 cases (47 percent) of pneumonia. In the prepared group, there were 21 cases (46 percent) of upper respiratory infections and 6 cases (13 percent) of urinary tract infections, as opposed to the nonprepared group who had 33 cases (60 percent) of up-
2 6 6 Geriatric N u r s i n g
S e p t e m b e r / O c t o b e r 1987
median age of the nonprepared group was 71 years. The results of the study support the findings that the greater the number of choices an individual has and the more predictable the new environment is, the less adverse effects there will be(8). The results also uphold the conclusion that the degree of choice, preparation, and difference in the new environment affect relocation outcome(9). In addition, it is interesting to note that the physical health indicators began to occur in the first month following relocation, peaked during the second, and began to decline during the third.
Nursing Implications It appears that nursing staff in institutions can mitigate negative physical health problems following relocation by using the simple inexpensive nursing interventions identified in the literature and by making use of available resources to prepare patients for moving from institution to institution. If a group of patients are to be moved en masse, whenever possible, extra nursing staff should be scheduled before and for the first three months after the move so that there
will be sufficient help when administering to the problems the patients will more than likely experience. Nursing staffshould be alert to early signs and symptoms denoting changes in physical status, especially if patients have not been prepared. In addition, nursing home policy should permit patients to visit the sites if at all possible. When families are investigating placement of relatives from home, they should be told of available materials and information regarding relocation stress. Arrangements can be made for day-care programs for prospective patients prior to their institutionalization. In light of recent changes in the delivery of health care and the resource allocation model and with the advent of DRGs and RUGs, there is a likelihood that there will be an increase in the number of relocated patients and in the number of times they may be relocated. Most often nurses will be the professionals who work with these patients. Therefore, it is necessary to continue to design and evaluate methods that will help patients adjust more readily without increasing cost.
References I. Borup, J. H., and others. Relocation: its effect on health, functioning and mortality. Gerontologist 20:468-479, Aug. 1980. 2. Ferraro, K. The health consequences of relocation among the aged in the community. J.GerontoL 38:90--96, 1982. 3. Leiberman, E. Relocated research and social policy. Gerontologist 14:494--497, 1974. 4. Jasnau, IC F. Individualized versus mass transfer of nonpsychotie geriatric patients from mental hospitals to nursing homes with special reference to the death rate. J.Amer.Geriatr.Soe. 15:280-284, Mar. 1967. 5. Zweig, J. P., and Csank, J. Z. Mortality fluctuations among chronically ill medical geriatric patients as an indicator ofstress before and after relocation. ZAm.Geriatr.Soc. 24:264-277, June 1976. 6. Pastalan, L A. Report on Pennsyh'ania nursing home relocation program: Interim research findings. Ann Arbor, MI, Institute of Gerontology, 1976. 7. Brown, M. M., and others. Reducing the risks to the institutionalized elderly: Part l--depersonalization, negative relocation effects, and medical care deficiencies..LGerontol.Nurs. 7:401-407, July 1981. 8. Mirotznik, J., and Ruskin, P. Inter-institutional relocation and its effects on health. Gerontologist 24:286-291, ! 984. 9. Pablo, R. Y. Intrainstitutional relocation: its impact on long-term care patients. Gerontologist 17:426--435, Oct. 1977. 10. Borup, J. H. Relocation: attitudes, information network ~ind problems encountered. Gerontologist 21:501-51 I, Oct. 1981.