Scientific Papers

The impact of a national quality register in the analysis of risks and adverse events among older adults in nursing homes and hospital wards—a Swedish Senior Alert survey | Safety in Health

In Sweden, the proportion of elderly in the population is increasing. Half of those born today will live to be 100 years, and, subsequently, life expectancy is predicted to rise from 84 to 89 years for women and from 80 to 87 years for men between 2017 and 2060 [1]. Despite recent positive findings that the elderly population is more active and healthy than ever [2], aging is still associated with declining function in physiological systems leading to the condition of frailty, which can be defined as a state of decreased reserve and resistance to stressors as a result of cumulative decline across multiple physiological systems, causing vulnerability to different outcomes [3]. Due to frailty, older adults are more vulnerable to disease and disability which in turn increases the prevalence of negative events such as pressure ulcers, malnutrition, falls, and oral health problems [4] [5].

Pressure ulcers are common in geriatric care; here, prevalence has been estimated at 18% in Europe and 21% in Sweden [6], causing reduced quality of life, pain, fear, and social isolation [7]. Evidence-based recommendations suggest the use of multifactorial interventions to meet individual needs [8] including, e.g., pressure relieving mattresses, mattresses for treatment, and nutrition intervention [7, 9, 10].

The prevalence of malnutrition is well documented. A multinational study including 24 pooled studies (n = 4500) showed that the prevalence of malnutrition in persons ≥ 65 years old (mean age 82 years) varies between 6 and 51% depending on the type of care setting [11]. In a recent Swedish study of persons ≥ 65 years of age, the prevalence was more than 9% while 55% were at risk of malnutrition when admitted to hospital. Risk factors were overnight fast > 11 h, < 4 eating episodes per day, and not being able to cook independently [12]. Those at risk should undergo an individual assessment to find the cause/causes of malnutrition and enable decisions regarding appropriate treatment. Energy dense meals and oral nutritional supplements (ONS) have been shown to improve energy and protein intakes, increase body weight, improve nutritional status, and reduce complications and mortality [13,14,15,16,17,18,19]. Eating support through verbal encouragement and physical support may also be beneficial [20].

Falls are by far the most common type of accident resulting in a need for hospitalization among older adults with an estimated annual cost to society of approximately SEK 14 billion. In Sweden, approximately 17,000 persons per year suffer hip fractures and 1500 die as a result of falls. In addition, the psychological consequences can be devastating, since fear of falling may have a severe impact on a person’s self-confidence and thereby affect quality of life, health, and activity level. About 40% of older persons who have suffered a hip fracture cannot return to their original residence [21]. The risk of falling is related to frailty, which has an impact on everyday activities, deterioration of balance, and vision in combination with the need for medication [22]. Multifactorial interventions are complex and comprise a combination of exercise and a review of medication, the home environment, feet and footwear, and vision and visual aids, carried out by a multidisciplinary team [23].

The oral health of older adults in Sweden has changed dramatically in recent decades with more people retaining their teeth. The proportion of toothless 80-year-olds has decreased over 30 years from 56 to 6% [24]. In frail older adults, the ability to manage oral hygiene often declines while risk factors for oral diseases increase [25,26,27]. Complicating factors include low competence in oral health and oral care among nursing home staff [28, 29]. In addition, older adults tend to lose contact with dental services [30, 25]. Based on the above, it is not surprising that poor oral health is commonly observed in frail and dependent older adults [27]. Good oral hygiene and fluoride supplements are effective preventive measures. If a person is unable to manage their oral hygiene, it should be included in the routines to be carried out by the nursing staff. Another, crucial preventive factor is maintaining or re-establishing regular dental care [31].

Senior Alert

In Sweden, there are more than 100 national quality registries. These registries contain individual data regarding health care interventions, procedures, and outcomes and are used for increasing the quality and improvements in care, and for research. Senior Alert (SA) is one such registry. Initially, the register focused pro-actively on three risk areas: malnutrition, pressure ulcers, and falls among people ≥ 65 years. In contrast to other registers in which data are registered retrospectively, Senior Alert is unique in that it also promotes quality improvement by stimulating staff to perform screening, action taking, and follow-up. It was started in the early 2000s and became a national quality registry in 2008. The risk areas are related, and it is mandatory to assess risks in all three risk areas in individual’s ≥ 65 years [32].

In 2011, oral health was included as part of the preventive care process (Fig. 1). Registration of oral health is optional, but the proportion of assessments including oral health has increased with time. In 2014, assessment of bladder dysfunction, a global health problem affecting more than 50 million people, especially women, was included for Swedish municipalities. It is estimated that 500,000 people in Sweden suffer from this condition, which is probably an under estimate of the true prevalence [33, 34]. It can lead to a person needing to move to a nursing home, where the prevalence is 70–80% [35]. Bladder dysfunction is related to risk of falling, poly-pharmacy, frailty, and a lower quality of life (QoL) [36]; however, since this is a new risk area in the SA register, the number of registrations is still low and therefore not included in this paper.

Fig. 1
figure 1

The preventive care process for preventing adverse events by identifying risks at an early stage

The preventive care process starts with risk assessment, and if a risk is registered, this is followed by three steps (Fig. 1). In SA, the preventive care process should be repeated for the same individual over time and always when a new care contact is initiated (Fig. 1) [32].

Risk assessments in SA are made using evidence-based tools. Falls can be assessed by using one of two different tools in the registry, the Downton Fall Risk Index (DFRI) [37], or two screening questions recommended by the National Board of Health and Welfare [38] and the Swedish Association of Local Authorities and Regions [39]. For malnutrition and pressure ulcers, there are also two different risk assessment tools available. Malnutrition is assessed using either Minimal Nutrition Assessment—Short Form (MNA-SF) [40] or three screening questions recommended by [38]. Pressure ulcers are assessed using the Modified Norton [41] or the Risk Assessment Pressure Sore (RAPS) [42]. Oral health is performed using the Revised Oral Assessment Guide (ROAG) [43]. These screening tools all produce a risk score. For DFRI, the score is 0–11 points, for MNA-SF 0–14 points, for Norton 7–28 points, and for ROAG 0 2–27 points. Each instrument has a cutoff defining the risk. The cutoff for risk for DFRI is ≥ 3 points, for MNA-SF ≥ 11 points, for Norton ≥ 20 points, and for ROAG ≥ 2 points. If the screening questions are used for assessment, a response of yes to one question indicates risk.

The use of the registry has increased rapidly since it was started (Fig. 2). In 2016, about 90% (n = 270) of municipalities and about 70% (n = 16) of county councils in Sweden participated in order to evaluate and develop elderly care locally. However, the overall potential of the register as a tool to improve the care of older adults has so far not been recognized. The aim of this study is therefore to analyze baseline and follow-up data in terms of risks and adverse events on a national level to show the potential of the register for quality improvement of care and research.

Fig. 2
figure 2

Number of preventive care processes on persons 65 years or older 2008–2015

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