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Biomedical subjects

M Mezey

Publications and source records attributed to M Mezey.

At least 19 recordsLinked to original sources
PubMed2000

Experts recommend minimum nurse staffing standards for nursing facilities in the United States.

The experts concluded that current data show that the average nurse staffing levels (for RNs, LVN/LPNs, and NAs) in nursing homes are too low in some facilities to provide high quality of care. Caregiving, the central feature of a nursing home, needs to be improved to ensure high quality of care to residents. Because detailed time studies have not been conducted on the amount of time that is required to provide high quality of care to residents, expert opinion is currently the best approach to addressing the problem of inadequate staffing. Increases in the education level and training of nursing staff are also strongly recommended as a step to improving quality of care and reducing turnover rates in nursing homes. These recommendations are designed for consideration by Congress, HCFA regulators, policymakers, nursing home administrators, and nurses. Ideally, Congress would pass legislation establishing these recommendations as minimum standards for all nursing homes or direct HCFA to establish detailed minimum nurse staffing standards to ensure that staffing levels take into account the number and the case-mix of the residents. Alternatively, HCFA could introduce minimum staffing standards through the regulatory process. In 1999 there were a number of efforts at the state level to increase minimum staffing levels. Mohler (1999) surveyed selected states and found that 21 states had either proposed new legislation or were considering proposals for new legislation or new regulations. In California, for example, in 1999 the state budget approved $31 million in new state funds (to be matched with $31 million in federal Medicaid dollars) to increase nursing home staffing minimum requirements from 2.8 to 3.2 hr per resident day and to increase wage rates. Overall, nursing facilities need to be held accountable by HCFA for providing adequate levels and types of staffing to meet the needs of their residents, especially because government is paying for 61% of the expenditures. Adopting these minimum standards will have an important impact on improving the quality of the nation's nursing home care. Additional research is needed to determine appropriate levels and types of staff to provide high quality of care to residents. These studies could test the proposed staffing standards against existing staffing levels to examine the impacts on quality. As new data become available on staffing levels, revisions of staffing standards should be made if necessary to ensure that high standards are maintained.

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PubMed2000

Decision-making capacity to execute a health care proxy: development and testing of guidelines.

OBJECTIVE: To evaluate the reliability and validity of guidelines to determine the capacity of nursing home residents to execute a health care proxy (HCP). DESIGN: A cross-sectional study. SETTING: A 750-bed not-for-profit nursing home located in New York City. PARTICIPANTS: A random sample of 200 nursing home residents: average age, 87; 99% white; 83% female; average length of stay, 3.05 years; mean Mini-Mental State Exam (MMSE) score, 15.9. MEASUREMENTS: Demographic characteristics (Minimum Data Set (MDS)); function and cognitive status (Institutional Comprehensive Assessment and Referral Evaluation (INCARE)); Reisberg Dementia Staging; MMSE; Minimum Data Set-Cognitive Performance Scale (MDS-COGS)); an investigator-developed measure of a nursing home resident's capacity to execute a health care proxy (Health Care Proxy (HCP) Guidelines.) RESULTS: The internal consistency of the decision-making scales in the HCP Guidelines, paraphrased recall and recognition, reached acceptable levels, alphas of .85 and .73, respectively. Interrater reliability estimates were .92 and .94, respectively, for the recall and recognition scales; test-retest reliability estimates were .83 and .90. The discriminant validity of these scales is promising. For example, the MMSE correlation was .51 with the Recall scale and .57 with the Recognition scale. Of residents with severe cognitive impairment (MMSE < 10), 71% completed 50% or more of the scaled items in the HCP guidelines and 95% consistently named a proxy. CONCLUSIONS: Seventy-three percent of testable residents, approximately three-quarters of whom were cognitively impaired, evidenced sufficient capacity to execute an HCP. Of residents with severe cognitive impairment, the HCP guidelines are potentially useful in identifying those with the capacity to execute a HCP. The guidelines are more predictive than the MMSE in identifying residents able to execute a HCP.

Activities of Daily Living↗
PubMed2000

Enhancing geriatric nursing scholarship: specialization versus generalization.

This article explores the relative merits of encouraging preparation of more nurses with specialization in geriatrics as compared to encouraging geriatric preparation among nurses whose major field of study is outside geriatrics. The article explores two approaches to examining capacity for geriatric nursing scholarship among nurse scholars not involved in geriatrics, and in schools of nursing with strength in research but with little geriatric research. The findings show an ongoing need to strengthen geriatric nursing as an area of specialization. Faculty prepared in geriatric nursing are underrepresented in schools of nursing, and only a small number of doctoral students specialize in geriatric nursing. Academic nursing programs with strength in geriatric nursing need ongoing support to maintain and expand current geriatric programs. Data support that encouraging individual non-geriatric nurse faculty and doctoral candidates to focus their work on areas of concern to geriatric nursing, and strengthening geriatrics in research-intensive schools of nursing that have not heavily invested in geriatric scholarship are viable options for strengthening academic geriatric nursing. Establishing mechanisms to attract nurse scholars working outside the scope of geriatric nursing to address clinical issues of concern to older adults offers promise in rapidly attracting new scholars to geriatric nursing.

Adult↗
PubMed1998

Nutrition and health status assessment of community-residing elderly in New York City: a pilot study.

Ninety-five percent of persons over the age of 65 years live in the community and benefit from community-based health and nutrition services. The purpose of this project was to evaluate diet, function, and mental health in 40 men and women aged 65 years and older who were residing in a large metropolitan community. Nutritional status was assessed using two 24-hour recalls, 5 days of food records, a food frequency, and anthropometric measurements. Participants responded to standardized activities of daily living and instrumental activities of daily living instruments and an investigator-developed, performance-based appraisal of food preparation and management. Cognition and mood were assessed using the Folstein Mini-Mental Examination and the Yesavage Depression Scale. The nutrient intakes for individuals were compared with the Recommended Dietary Allowances (RDAs) and the Food Guide Pyramid. Mean energy intake was 1,625 kcal (range = 787 to 2,910 kcal); 7 persons consumed more than 2,000 kcal. The mean vitamin and mineral intake for participants met the RDAs except for calcium, vitamin D, zinc, and magnesium intakes. The average percentages of carbohydrate, protein, and fat were 53%, 16%, and 30%, respectively. Nutritional assessments of subjects with and without congregate meals were contrasted. Six of the 13 congregate-meal participants were at nutritional risk, compared with 6 of 27 not receiving congregate meals. The interrelationships of diet, functional status, and mental health factors were examined along with recommendations for future data collection in similar studies.

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PubMed1997

Implementation of the Patient Self-Determination Act (PSDA) in nursing homes in New York City.

OBJECTIVE: To examine implementation of the Patient Self Determination Act (PSDA), verbal directives, procedures for determination of resident' decision-making capacity, and role of ethics committees in nursing homes in New York City. DESIGN: Telephone survey. PARTICIPANTS: Social workers in 109 (69%) nursing homes in New York City. MEASUREMENT: An 80-item instrument addressing: (1) social worker knowledge of the PSDA; (2) informing residents about advance directives (living wills and durable power of attorney for health care [health care proxies]); (3) determination of decision-making capacity to be informed about advance directives; (4) estimates of advance directives executed; (5) perceptions of PSDA effect; (6) ethics committees; (7) follow-up and documentation; and (8) staff and community education. MAIN RESULTS: Virtually all social workers in nursing homes stated that they made what they perceived to be a "serious effort" to inform residents about advance directives and to have residents execute directives (preferentially a health care proxy). More residents were thought to have executed a directive pursuant to the PSDA law than before the Act went into effect. Social workers in most homes informed residents about directives through face-to-face discussions. Most homes, however, did not inform residents who were thought to lack decision-making capacity about their right to execute a directive. Only 37% of homes had written procedures to determine a resident's decision-making capacity to be informed about directives; most homes relied on physician and social work assessments. Voluntary homes differed significantly from proprietary homes in that they were larger, more likely to have an ethics committee, and more aggressive in their implementation of the PSDA. Forty-five percent of homes with an ethics committee had written procedures for determination of resident decision-making capacity compared with 26% of homes without a committee. Overall, 24% of residents were thought to have executed an advance directive. The number of directives per bed did not vary significantly by facility size, ownership, religious affiliation, or whether they did or did not have an ethics committee. CONCLUSIONS: The fact that social workers in nursing homes speak with most residents about advance directives has the potential to improve resident understanding around end of life decisions. The practice of not informing residents about advance directives when they are perceived to lack decision-making capacity is problematic given that most homes have no clear procedures for determining residents' cognitive capacity to execute a directive. There is a need to replicate the benefits achieved by homes with ethics committees in implementing the PSDA in other homes.

Advance Directives↗
PubMed1997

Educational assessment and teaching of older clients with pressure ulcers.

The importance of education in preventing and treating patients with pressure ulcers is evident by the inclusion of recommendations for educational objectives in the clinical guidelines by the Agency for Health Care Policy and Research. Both caregiver and client should be assessed for knowledge of pressure ulcers. Physical changes in vision, hearing, and cognition that might affect educating older clients are described. Strategies suitable for teaching older clients about the prevention and treatment of pressure ulcers are given.

Age Factors↗
PubMed1996

Life-sustaining treatment decisions by spouses of patients with Alzheimer's disease.

OBJECTIVE: To examine the anticipated decisions to consent to or to forgo life-sustaining treatment by spouses of patients with Alzheimer's disease and to describe the relationship of spouse and patient characteristics to predicted decisions. DESIGN: Prospective quantitative study. SETTING: The Aging and Dementia Research Center (ADRC), part of an Alzheimer's Disease Center Core Grant, at New York University Medical Center. PARTICIPANTS: Fifty spouse caregivers of Alzheimer's disease patients, evaluated at the ADRC, who had a minimum Stage 4 on the Global Deterioration Scale. MEASUREMENTS: Spouses were presented with two conditions (critical illness and irreversible coma) and rated their agreement with, certainty of, and comfort with four treatments (resuscitation, breathing machine, feeding tube, and antibiotics). Data were also obtained as to patients' current quality of life, spouses' standard of decision-making, and spouse burden. RESULTS: Eighteen of 50 patients had a durable power of attorney for health care, 20 of 50 had a living will, and 26 of 50 had neither. In the face of critical illness, almost equal numbers of spouses would consent to or forgo CPR, 28 of 50 would forgo a breathing machine, 21 of 50 a would forgo a feeding tube, and 5 of 50 would forgo antibiotics. Five of 50 would forgo all four treatments, and 12 of 50 all but antibiotics. Spouses were significantly more likely to forgo treatment in the face of coma than for critical illness (P < .001). Spouses were more certain about decisions related to coma than to critical illness (P < .001), and there was a positive and significant correlation between certainty and comfort (P = .001). Those consenting to treatment were more comfortable than those forgoing treatment (for CPR and antibiotics P = .001). Spouses of patients with Stage 7 AD were more likely to forgo CPR than those with Stages 4 to 6 AD (P < .001). Only two of 50 spouses selected descriptors congruent with a purely substituted judgment standard of decision-making. An equal number of spouses rated patient quality of life as good, fair, or poor. For critical illness, the poorer the quality of life rating, the more likely the spouses were to forgo feeding tubes (P < .001). There was a trend for highly burdened spouses to consent to treatment. CONCLUSIONS: The results provide evidence that spouses of patients with AD anticipate forgoing life-sustaining treatments in the face of coma but are less sure about choices for critical illness. Although preliminary in nature, findings suggest that doctors, nurses, and social workers need to provide additional support to spouses choosing to forgo rather than consent to treatment and need to inquire as to what spouses perceive as the factors that are important to them in making a decision.

Advance Directives↗
PubMed1994

Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial.

OBJECTIVE: To study the effects of a comprehensive discharge planning protocol, designed specifically for the elderly and implemented by nurse specialists, on patient and caregiver outcomes and cost of care. DESIGN: Randomized clinical trial. SETTING: Hospital of the University of Pennsylvania. PATIENTS: 276 patients and 125 caregivers. Patients were 70 years and older and were placed in selected medical and surgical cardiac diagnostic-related groups. MEASUREMENTS: Group differences in patient outcomes (length of initial hospital stay, length of time between initial hospital discharge and readmission, and rehospitalization rates) and charges for care (charges for initial hospitalization, rehospitalizations, health services after discharge, and nurse specialist services) were measured 2, 6, and 12 weeks after discharge. RESULTS: From the initial hospital discharge to 6 weeks after discharge, patients in the medical intervention group had fewer readmissions, fewer total days rehospitalized, lower readmission charges, and lower charges for health care services after discharge. No differences in these outcomes were found between the surgical intervention and control groups during this period. CONCLUSIONS: Study findings support the need for comprehensive discharge planning designed for the elderly and implemented by nurse specialists to improve their outcomes after hospital discharge and to achieve cost savings. The findings also suggest that this intervention had its greatest effect in delaying or preventing rehospitalization of patients in the medical intervention group during the first 6 weeks after discharge.

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PubMed1994

Nurse practitioners, certified nurse midwives, and nurse anesthetists: changing care in acute care hospitals in New York City.

To respond to the shrinking pool of primary care physicians and to demands from managed care programs for cost containment, hospitals in New York City have increased their use of nurse practitioners, certified nurse midwives, and nurse anesthetists, creating an increased demand for these personnel. We report here on a survey of hospitals and schools of nursing in New York City and present findings on (a) current use of, and projected demand for nurse practitioners (NPs), certified nurse midwives (midwives) and nurse anesthetists (anesthetists) in hospitals in New York City; (b) the practice patterns of NPs, midwives, and anesthetists currently employed in hospitals; and (c) current and projected enrollment and curriculum in NP, midwifery, and anesthetist education programs in the New York metropolitan area.

Adult↗
PubMed1992

Consensus among geriatric experts on the components of a complete nursing-home admission assessment.

Standards of practice for nursing-home admissions have not been established, and it is not known if geriatric clinicians agree on the components of an appropriate patient-admission evaluation. This study describes the consensus expressed by experts in clinical geriatrics regarding the most important components of nursing-home admission assessments. Directors of all geriatric-nurse-practitioner and geriatric-medicine fellowship programs (n = 79) were sent a two-round questionnaire asking them to describe and rate the components of a "complete admission assessment for every elderly patient entering a nursing home." Nurse practitioners and physicians ranked medication review, evaluation of urinary incontinence, mental status, vision and bowel status the highest, and gave them equal priority. Routine laboratory tests were not included among the highest-ranked items by either nurses or doctors. An enhanced assessment focusing on the functional consequences of diseases rather than on the traditional "head-to-toe" systems approach emerged as the most appropriate assessment for elderly nursing-home patients.

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PubMed1991

Registered nurse staffing in Pennsylvania nursing homes: comparison before and after implementation of Medicare's Prospective Payment System.

This paper examines changes in resident acuity and registered nurse staffing in all nursing homes in Pennsylvania before and after the introduction of the Medicare Prospective Payment System (PPS) in 1983. The analysis is based on 1980, 1982, 1985, and 1987 data from the Long Term Care Facilities Survey conducted by the State Health Data Center, Pennsylvania Department of Health. Although the acuity of nursing home residents has increased significantly since the introduction of PPS, full-time registered nurse staffing has remained unchanged, and part-time registered nurse staffing has declined. This alarming trend threatens the quality of care patients receive, yet remains largely unaddressed.

Aged↗
PubMed1991

Completeness of admission of residents assessments in teaching nursing homes.

In order to assess one aspect of the quality of care within teaching nursing homes, we examined how well these homes conform to geriatric experts' expectations for the admission assessment of elderly nursing home residents. Four hundred-sixty records representing new admissions to five teaching nursing homes over a 1-year period were assessed for completion of items considered important parts of the admission assessment by geriatric experts. Univariate and multivariate analyses both suggest the following four findings. First, the admission assessments performed at teaching nursing homes reflect geriatric experts' priority areas with two exceptions: (1) the assessment of affective disorders and (2) the identification of advance directives. Second, physician-nurse practitioner teams perform the high priority parts of the admission assessment to a degree similar to that of physicians alone. Third, resident's age and expected length of stay partially determine the extent of the admission assessment, as patients with shorter lengths of stay generally received a more complete assessment. Fourth, even among teaching nursing homes, there are significant differences between nursing homes in the performance of comprehensive admission assessment by nursing home clinicians.

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