Evaluation of IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) a staff simulation training intervention to improve palliative care of people with advanced dementia living in nursing homes: a cluster randomised controlled trial

Abstract

Background People with dementia have unique palliative and end-of-life needs. However, access to quality palliative and end-of-life care for people with dementia living in nursing homes is often suboptimal. There is a recognised need for nursing home staff training in dementia-specific palliative care to equip them with knowledge and skills to deliver high quality care. Objective The primary aim was to evaluate the effectiveness of a simulation training intervention (IMPETUS-D) aimed at nursing home staff on reducing unplanned transfers to hospital and/or deaths in hospital among residents living with dementia. Design Cluster randomised controlled trial of nursing homes with process evaluation conducted alongside. Subjects & setting One thousand three hundred four people with dementia living in 24 nursing homes (12 intervention/12 control) in three Australian cities, their families and direct care staff. Methods Randomisation was conducted at the level of the nursing home (cluster). The allocation sequence was generated by an independent statistician using a computer-generated allocation sequence. Staff from intervention nursing homes had access to the IMPETUS-D training intervention, and staff from control nursing homes had access to usual training opportunities. The predicted primary outcome measure was a 20% reduction in the proportion of people with dementia who had an unplanned transfer to hospital and/or death in hospital at 6-months follow-up in the intervention nursing homes compared to the control nursing homes. Results At 6-months follow-up, 128 (21.1%) people with dementia from the intervention group had an unplanned transfer or death in hospital compared to 132 (19.0%) residents from the control group; odds ratio 1.14 (95% CI, 0.82-1.59). There were suboptimal levels of staff participation in the training intervention and several barriers to participation identified. Conclusion This study of a dementia-specific palliative care staff training intervention found no difference in the proportion of residents with dementia who had an unplanned hospital transfer. Implementation of the intervention was challenging and likely did not achieve adequate staff coverage to improve staff practice or resident outcomes. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618002012257. Registered 14 December 2018.

An integrative review of measures of transitions and care coordination for persons living with dementia and their caregivers

“…Mortality was frequently measured in studies that explored transitional care and care coordination. Twelve reports measured rate of death or time to death via EHR, caregiver report, or a national registry 26,27,34,40,42,46,49,60,64,65,67,68,85,86 . Mortality was sometimes used to measure differences in survival among persons living with dementia who received an evidence‐based intervention versus a control or comparison group 42,68,85,86 .…”

Dementia and Palliative Care: Sex Differences

“…It consisted of 11 different modules that included videos of realistic events or situations happening with patients suffering from advanced dementia that served for learning and practicing and could be accessed online. Unfortunately, this specific study did not show any changes due to low staff participation and the idea for future projects is to create a more simple version of IMPETUS-D, since there is no doubt that more staff education is needed in this area, especially with the increasing number of the aging population [11].…”

Staff perspectives on end-of-life care for people living with dementia in residential aged care homes: qualitative study

“…Managers and nurses highlighted their appreciation for team-based education sessions, whereby staff had the opportunity to "talk through what made them uncomfortable" (service manager 15) and problem-solve complex situations among one another to normalize uncertainties. One service manager recalled observing and experiencing challenging advance care planning conversations, which prompted her to facilitate multidisciplinary training within her service, including workshopping "potential responses we can give to the families in the event they ask these tricky questions" (10). Another clinical care manager employed an end-of-life care flipchart "that goes through the basics of care" for nurses to use as a supportive tool for training careworkers, highlighting "what to expect in every scenario, to be able to provide mouth care, eye care, whatever it may be" (18).…”

“…"Families have all reported how much they feel supported, and they can come and go as they choose, they never feel like a burden" (10).…”

“…Literature suggests residents living with advanced dementia would benefit from palliative care that focusses on the management of physical and psychological symptoms, and care home staff need more support from external healthcare services to provide this level of care (8,9). Dementia specific models of palliative care have emerged in recent years (10)(11)(12)(13), including the PACE Steps to Success (14), which identified a generalist and non-disease specific palliative care program for care homes has the potential to improve quality of care and dying in the last month of life for both residents with and without dementia.…”