Bakgrund: Äldre personer som bor i särskilt boende (SÄBO) är ofta multisjuka, sköra och har ett omfattande behov av vård och omsorg. De löper stor risk att bli undernärda, falla och att utveckla trycksår. Inom äldreomsorgen är det därför viktigt att arbeta förebyggande inom dessa tre områden. Ett grundläggande krav
,
och en kvalitetsfråga, är att vården ska vara säker.
En säker vård kännetecknas av att personer, genom olika åtgärder ska skyddas från att råka ut för vårdskador. Personalen ska kunna utföra sitt arbete med rätt förutsättningar och bra metoder så att en säker och evidensbaserad vård och omsorg kan ges. För att stödja ett sådant preventivt arbetssätt utvecklades kvalitetsregistret Senior Alert. Registret är uppbyggt kring den s.k. vårdpreventiva processen, som består av riskbedömning, orsaksanalys, åtgärd och uppföljning. I registret finns omkring 100 olika evidensbaserade åtgärder som kan användas för att utforma en individuell plan. Trots att registret är väl spritt och har använts sedan 2008 behövs mer kunskap kring vilka resultat den vårdpreventiva processen genererar.Design och metod: Tre longitudinella kvantitativa studier (I, III, IV) baserades på olika urval ur en SÄBO registerpopulation från Senior Alert (N=1595) samt en studie population från SÄBO som inte använde registret (N=429). Medelåldern var 85 år och uppföljningstiden var 6 månader. I Studie I jämfördes två grupper; den första bestod av personer som inkluderades i Senior Alert under åren 2010–2012 (N=567) och den andra gruppen inkluderades 2013–2014 (N=536). Syftet var att undersöka om det fanns skillnader i processmått och utfallsmått beroende på om personerna var registrerade i ett tidigt eller i ett senare skede. Dessutom studerades om mått på nutrition skiljde sig mellan register populationen och studie populationen (III). I Studie IV studerades associationerna mellan variablerna i skattningsskalorna och utfall för viktförlust, fall och trycksår. Syftet med denna studie var att hitta de variabler i skattningsskalorna som hade starkast koppling till utfallen. En kvalitativ studie (II) baserades på fokusgruppsintervjuer med vårdpersonal på SÄBO kring deras erfarenheter av att arbeta med den vårdpreventiva processen i Senior Alert. Materialet analyserade med innehållsanalys.
61
Resultat: Gruppen som registrerades i registret under åren 2013-2014 hade en högre andel rapporterade åtgärder, 75% jämfört med 60% i den tidigare gruppen 2010-2012. Andelen personer med nya riskbedömningar inom 6 månader skiljde sig också; 30% i den senare och 20% i den tidigare. Andelen personer med risk för undernäring som följdes upp med vikt inom 6 månader var i den senare gruppen 44% jämfört med 30% i den tidigare. Andelen med registrerade fall händelser och trycksår var låg och ingen skillnad mellan grupperna kunde påvisas. Andelen som hade minskat 5% i vikt var ca 16% i båda grupperna. Ingen skillnad i vikt eller viktförändring kunde påvisas beroende på om Senior Alert användes eller inte, men vid undergruppsanalyser kunde en viktuppgång påvisas hos de med lägst BMI i Senior Alert gruppen. Studie IV visade att mobilitetsvariablerna generellt hade störst betydelse för samtliga testade utfall, fast på olika sätt. Resultatet från studie II speglade både positiva och negativa erfarenheter. Deltagarna beskrev att Senior Alert stimulerade ett bättre teamarbete, men beskrev samtidigt en ökad dokumentationsbörda och tidsbrist som försvårande omständigheter. Vårdpersonalen ansåg också att bedömningsinstrumenten överskattade riskerna för fall och undernäring jämfört med deras egen kliniska bedömning. De hade liten erfarenheten av att följa kliniska resultat baserat på data från registret. Vårdpersonalen uttryckte också tvivel om arbetssättets förmåga att kunna påvisa bättre resultat eftersom de äldre personerna var i slutskedet av livet.
Slutsats: Trots att processmåtten påvisade fler registreringar i den senare inkluderade gruppen, vilket kan bero på att det tar tid arbeta upp vårdrutiner, var uppföljningen fortsatt låg. Det indikerar behovet av att oftare följa upp och utvärdera insatta åtgärder. Detta är viktigt för den äldre personen, men också för möjligheterna att kunna använda kvalitetsregisterdata. Ett tydligt ledarskap behövs för att stimulera det preventiva arbetet. Någon behöver efterfråga resultat och samsynen kring riskbedömningarna behöver förbättras. Då andelen som följdes upp inom 6 månader var låg så blev underlaget för att mäta utfall lågt. Det indikerar behovet av studier i större studie populationer, men också behovet av att oftare följa upp och utvärdera resultat, alternativt att införa en fast mätpunkt för uppföljning.
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Acknowledgement
During three years I have been employed as a doctoral student, financed by the project “Health development in late life”. My special thanks to the former project leader Åke Wahlin, who sadly passed away in 2016, and to Boel Andersson Gäre, who both encouraged me to start. Thanks also to Futurum, the academy for Health and Care in Region Jönköping County for economical support.
Thanks to Marie Ernsth Bravell who encouraged me to write my first paper before I became a doctoral student. Marie introduced me to run regressions and taught me a lot in the field of quantitative research.
Thanks to the Research School of Health and Research for accepting me as a doctoral student although I didn´t “really” meet the requirements for admission.
Many people have supported and encouraged me during this research journey. To name a few; my main supervisor Marie Ernsth Bravell, and my co-supervisor Linda Johansson - thank you for always being there and for your support. Our work has included a lot of good laughs. After my half seminar Ann-Christine Andersson became a co-supervisor. I am very grateful to have your support during this last part, when I decided to angle the fourth paper and the thesis towards a “safety and quality” perspective. Thanks to Anna Trinks and Dennis Nordvall at Senior Alert for answering all my questions.
Thanks to my colleagues at Futurum and at the Institute for Gerontology (IFG) for your encouragement. Special thanks to Bosse for answering tricky SPSS questions and to Pingo for statistical support, to Lisbeth for listening to my complaints, and to Eva for reading my thesis.
I would also like to acknowledge SWEAH (Swedish National Graduate School for Competitive Science of Ageing and Health) for economical support.
To Måns - thank you for taking care of all practical things in life - and for taking care of me when my mind was elsewhere
Jönköping April 2018 Christina Lannering
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