大河原 啓文

Globally, residents of long-term care facilities (LTCFs) often experience adverse events (AEs) and corresponding lawsuits that result in suffering among the residents, their families, and the facilities. Hence, we conducted a study to clarify the factors related to the facilities' liabilities for damages for the AEs that occur at LTCFs in Japan. We analyzed 1,495 AE reports from LTCFs in one Japanese city. A binomial logistic regression analysis was conducted to identify factors associated with liability for damages. The independent variables were classified as: residents, organizations, and social factors. In total, 14% of AEs resulted in the facility being liable for damages. The predictors of liability for damages were as follows: for the resident factors, the increased need for care had an adjusted odds ratio (AOR) of 2.00 and care levels of 2-3; and AOR of 2.48 and care levels of 4-5. The types of injuries, such as bruises, wounds, and fractures, had AORs of 3.16, 2.62, and 2.50, respectively. Regarding the organization factors, the AE time, such as noon or evening, had an AOR of 1.85. If the AE occurred indoors, the AOR was 2.78, and if it occurred during staff care, the AOR was 2.11. For any follow-ups requiring consultation with a doctor, the AOR was 4.70, and for hospitalization, the AOR was 1.76. Regarding the type of LTCF providing medical care in addition to residential care, the AOR was 4.39. Regarding the social factors, the reports filed before 2017 had an AOR of 0.58. The results of the organization factors suggest that liability tends to arise in situations where the residents and their family expect high quality care. Therefore, it is imperative to strengthen organizational factors in such situations to avoid AEs and the resulting liability for damages.

OBJECTIVES: The quality of care for dementia in acute-care settings has been criticised. In 2016, the Japanese universal health insurance system introduced a financial incentive scheme for dementia care by dementia specialist teams in acute-care hospitals. This study aimed to investigate the effectiveness of this financial incentive scheme on short-term outcomes (in-hospital mortality and 30-day readmission). DESIGN AND METHODS: Using a Japanese nationwide inpatient database, we identified older adult patients with moderate-to-severe dementia admitted for pneumonia, heart failure, cerebral infarction, urinary tract infection, intracranial injury or hip fracture from April 2014 to March 2018. We selected 180 propensity score-matched pairs of hospitals that adopted (n = 180 of 185) and that did not adopt (n = 180 of 744) the financial incentive scheme. We then conducted a patient-level difference-in-differences analysis. In a sensitivity analysis, we restricted the postintervention group to patients who actually received dementia care. RESULTS: There was no association between a hospital's adoption of the incentive scheme and in-hospital mortality (adjusted odds ratio [aOR]: 0.97; 95% confidence interval [CI]: 0.88-1.06; p = 0.48) or 30-day readmission (aOR: 1.04; 95% CI: 0.95-1.14; p = 0.37). Only 29% of patients in hospitals adopting the scheme actually received dementia care. The sensitivity analysis showed that receiving dementia care was associated with decreased in-hospital mortality. CONCLUSIONS: The financial incentive scheme to enhance dementia care by dementia specialist teams in Japan may not be working effectively, but the results do suggest that individual dementia care was associated with decreased in-hospital mortality.

目的:高齢者施設入所者は重症化のリスクが高く、施設職員の急変時初期対応は重要である。われわれは、有料老人ホーム3ヶ所でのヒアリング調査に基づき作成した、高齢者施設職員向けの急変時対応教育プログラムの効果について検証した。対象と方法:このプログラムを用いて有料老人ホームの職員70名を対象に研修を行い、その前後でアンケート調査を行った。結果:55名でアンケートに回答が得られた。研修の前後で急変時対応に関する自信は有意に改善し(20.5vs25、p<0.001)、知識を問う項目では6項目において改善を認めた(p<0.001)。また、本研修への満足度も高く、本プログラムは有効であるが、一部の介護職員について学習効果が不十分と考えられた。結語:有料老人ホームの職員を対象としたヒアリング調査に基づき作成した本急変時対応教育プログラムは、高齢者施設における急変時対応体制の改善に有効と考えられ、継続的な改善と開催が求められる。(著者抄録)

高齢者施設から急性期病院への避けられる救急搬送や入院は、入居者のQOL(quality of life:生活の質)の向上や医療資源の効率的活用のために予防することが望ましい。本研究は、回避可能な救急搬送・入院を予防する介入の有効性と実行可能性に関する有料老人ホーム施設長の認識を明らかにすることを目的とした。首都圏A市の有料老人ホーム150施設に自記式質問紙を郵送し、55施設(36.7%)から回答を得た。文献検討から作成した回避可能な救急搬送・入院を予防する介入15項目について有効性は高く認識されていた(67.3〜87.3%)。15項目すべてにおいて実行可能性よりも有効性の方が高く認識されていた。最も有効と認識された項目は、看護師と医師の「情報連携のためのコミュニケーションツール(87.3%)」で、平均要介護度が高い施設でより有効と認識された(p=0.039)。実行可能性が低いと認識された項目は「高齢者ケアに関する知識や技術のある看護師の雇用(20.0%)」であった。日本の有料老人ホームにおいて回避可能な救急搬送・入院を予防する介入の導入や介入研究の実施のために、介入内容の実行可能性を高める必要性が示唆された。(著者抄録)

MEDLINEとCINAHL、Cochrane Libraryを用いてスコーピングレビューを行った。本研究の目的に合致する文献が39件抽出され、国別の内訳は米国17件、カナダ5件、オーストラリア5件、ニュージーランド4件、香港2件、英国、アイルランド、ノルウェー、フィンランド、台湾、日本が各1件であった。研究デザインはRCTが14件、事前事後デザインが21件、事前事後デザインでインタビューデータを含む混合研究法が4件であった。看護師主導の介入内容は以下の3つに分類された。1)プライマリケアの質向上に関するもの(22件)。2)End-of-Life(EOL)の質向上に関するもの(8件)。3)プライマリケアとEOL双方の要素を含む複合介入(8件)。