Ann F. Minnick

PREVALENCE AND PATTERNS OF PHYSICAL RESTRAINT USE IN THE ACUTE CARE SETTING

Nurse executives usually have the principal responsibility to respond to the national movement to reduce physical restraint use in hospitals. The results of this three-site, interdisciplinary, prospective incidence study (based on more than 49,000 observations collected on 18 randomly selected days) reveal new patterns in the rationale and types of restraints used. The authors discuss how the results can be used in measuring success and allocating resources for restraint reduction programs.

Patient-initiated device removal in intensive care units: a national prevalence study.

Objective: Information is needed about patient‐initiated device removal to guide quality initiatives addressing regulations aimed at minimizing physical restraint use. Research objectives were to determine the prevalence of device removal, describe patient contexts, examine unit‐level adjusted risk factors, and describe consequences. Design: Prospective prevalence. Setting: Total of 49 adult intensive care units (ICUs) from a random sample of 39 hospitals in five states. Methods: Data were collected daily for 49,482 patient‐days by trained nurses and included unit census, ventilator days, restraint days, and days accounted for by men and by elderly. For each device removal episode, data were collected on demographic and clinical variables. Results: Patients removed 1,623 devices on 1,097 occasions: overall rate, 22.1 episodes/1000 patient‐days; range, 0–102.4. Surgical ICUs had lower rates (16.1 episodes) than general (23.6 episodes) and medical (23.4 episodes) ICUs. ICUs with fewer resources had fewer all‐type device removal relative to ICUs with greater resources (relative risk, 0.76; 95% confidence interval, 0.66–0.87) but higher self‐extubation rates (relative risk, 1.27; 95% confidence interval, 1.07–1.52). Men accounted for 57% of the episodes, 44% were restrained at the time, and 30% had not received any sedation, narcotic, or psychotropic drug in the previous 24 hrs. There was no association between rates of device removal with restraint rates, proportion of men, or elderly. Self‐extubation rates were inversely associated with ventilator days (rs = ‐0.31, p = .03). Patient harm occurred in 250 (23%) episodes; ten incurred major harm. No deaths occurred. Reinsertion rates varied by device: 23.5% of surgical drains to 88.9% of monitor leads. Additional resources (e.g., radiography) were used in 58% of the episodes. Conclusion: Device removal by ICU patients is common, resulting in harm in one fourth of patients and significant resource expenditure. Further examination of patient‐, unit‐, and practitioner‐level variables may help explain variation in rates and provide direction for further targeted interventions.

Physical restraint use in the hospital setting : Unresolved issues and directions for research

Although the use of physical restraint has declined in nursing homes, the practice remains widespread in hospitals. The use of physical restraint in hospitals was reviewed to identify the current clinical, legal, and ethical issues and the implications for policy and further research. Clinicians use physical restraints to prevent patient falls, to forestall disruption of therapy, or to control disruptive behavior, but they vary in how they determine to institute these restraints. The evidence to support the reasons for their determinations is not compelling. Fear of litigation remains a powerful motivator. The ethical dilemma of autonomy versus beneficence has not been resolved satisfactorily for patients in this setting. The lack of large-scale studies in any of these areas makes it difficult for policy makers to determine whether it is necessary to address hospital physical restraint practices through additional regulation.

Blood pressure responses to lifestyle physical activity among young, hypertension-prone African-American women.

Background: Physical inactivity and obesity increase the risk for hypertension, and both are more prevalent in African-American than Caucasian women. Regular physical activity serves as an important intervention for reducing cardiovascular risk, yet the ideal physical activity profile to meet the needs of young, sedentary African-American women remains unclear. We performed a randomized, parallel, single-blind study to examine the effect of lifestyle physical activity (LPA) on blood pressure indices in sedentary African-American women aged 18 to 45 years with prehypertension or untreated stage 1 hypertension. Methods: The primary intervention was an 8-week individualized, home-based program in which women randomized to Exercise (n = 14) were instructed to engage in lifestyle-compatible physical activity (eg, walking, stair climbing) for 10 minutes, 3 times a day, 5 days a week, at a prescribed heart rate corresponding to an intensity of 50% to 60% heart rate reserve. Women in the No Exercise group (n = 10) continued with their usual daily activities. Mean changes in cuff, ambulatory, and pressure load indices were compared using paired t tests, and physical activity adherence was expressed as percentages. Results: Women in the Exercise group had a significant reduction in systolic blood pressure (−6.4 mm Hg, P = .036), a decrease in diastolic blood pressure status to the prehypertensive level (90.8 vs 87.4 mm Hg), and greater reductions in nighttime pressure load compared with the No Exercise group. Adherence to LPA was exceedingly high by all measures (65%-98%) and correlated with change in systolic blood pressure (r = −0.620, P = .024). Conclusion: The accumulation of LPA reduced cuff, ambulatory, and pressure load. The accumulation of LPA appears well tolerated and feasible in this sample of young African-American women, demonstrated by the overall high adherence rates. Given the excess burden of pressure-related clinical sequelae among African Americans and the strong correlation between pressure load and target organ damage, LPA may represent a practical and effective strategy in this population.

Anesthesia provider model, hospital resources, and maternal outcomes.

OBJECTIVE Determine the ability of anesthesia provider model and hospital resources to explain maternal outcome variation. DATA SOURCE/STUDY SETTING 1,141,641 obstetrical patients from 369 hospitals that reported at least one live birth in 2002 in six representative states. STUDY DESIGN Logistic regression of death, anesthesia complication, nonanesthesia maternal complication, and obstetrical trauma for all patients and those having cesarean deliveries on anesthesia provider model, obstetrical and anesthesia, and patient variables. DATA COLLECTION/EXTRACTION METHODS Data was assembled from information given by hospitals to state agencies and from a 2004 survey of obstetrical organization resources. PRINCIPAL FINDINGS Anesthesia complication rates in anesthesiologist-only hospitals were 0.27 percent compared with 0.23 percent in certified registered nurse anesthetist (CRNA) only hospitals. Rates among other provider models varied from 0.24 to 0.37 percent with none statistically different from the anesthesiologist-only hospitals. A similar pattern was observed for rates of other outcomes. Multivariate analysis found no systematic differences between hospitals with anesthesiologist-only models and models using CRNAs. There was no consistent pattern of association of other hospital or patient characteristics with outcomes. CONCLUSION Hospitals that use only CRNAs, or a combination of CRNAs and anesthesiologists, do not have systematically poorer maternal outcomes compared with hospitals using anesthesiologist-only models.

Feasibility of screening for preinjury frailty in hospitalized injured older adults

BACKGROUND Frailty assessment of injured older adults (IOAs) is important for clinical management; however, the feasibility of screening for preinjury frailty has not been established in a Level I trauma center. The aims of our study were to assess enrollment rates of IOAs and their surrogates as well as completion rates of selected brief frailty screening instruments. METHODS We conducted a prospective cohort study on patients, age 65 years and older with a primary injury diagnosis. Patients and/or surrogates were interviewed within 48 hours of admission using the Vulnerable Elders Survey (VES-13), Barthel Index (BI), and the Life Space Assessment (LSA). Data analysis included frequency distributions, &khgr;2 statistics, Mann-Whitney and Kruskal-Wallis tests, and general linear modeling (analysis of variance). RESULTS Of 395 admitted patients, 188 were enrolled with subsequent surrogate screening. Corresponding patient interviews were conducted for 77 patients (41%). Screening time was less than 5 minutes for each instrument, and item completion was 100%. Forty-two enrolled patients (22%) had nurse-reported delirium, and 69 (37%) patients either did not feel like answering questions or were unable to be interviewed secondary to their medical condition. The median score of surrogate responses for the VES-13 was 3.5 (interquartile range, 2–7), with 64% of the sample having a score of 3 or greater, indicating vulnerability or frailty. Median scores for the BI (19.0) and LSA (56.0) indicated high numbers with limitations in activities of daily living and limitations in mobilization. CONCLUSION Screening for preinjury frailty in IOAs is feasible yet highly dependent on the presence of a surrogate respondent. A clinically significant percentage of patients have functional deficits consistent with frailty, dependence in activities of daily living, and limitations in mobilization. Implementation of validated brief screening instruments to identify frailty in clinical settings is warranted for targeting timely, efficient, and effective care interventions. LEVEL OF EVIDENCE Epidemiologic study, level II.

Preinjury physical frailty and cognitive impairment among geriatric trauma patients determine postinjury functional recovery and survival.

BACKGROUND Injury is an external stressor that often initiates a cycle of decline in many older adults. The influence of physical frailty and cognitive decline on 6-month and 1-year outcomes after injury is unreported. We hypothesized that physical frailty and cognitive impairment would be predictive of 6-month and 1-year postinjury function and overall mortality. METHODS The sample involved patients who are 65 years or older admitted to a Level I trauma center between October 2013 and March 2014 with a primary injury diagnosis. Surrogates of 188 patients were interviewed within 48 hours of hospital admission to determine preinjury cognitive and physical frailty impairments using brief screening instruments. Follow-up was completed on 172 patients at 6 months and 176 patients at 1 year to determine posthospitalization status and outcomes. Data analysis involved frequencies, measures of central tendency, &khgr;2 analyses, linear and logistic regression. RESULTS The mean age of the patients was 77 years. The median Injury Severity Score (ISS) was 10. The mechanism of injury involved falls from standing (n = 101, 54%). Preinjury vulnerabilities included cognitive impairment (AD8 Dementia Screen [AD8] score ≥ 2, n = 93, 50%) and physical frailty (Vulnerable Elders Survey [VES-13] score ≥ 4, n = 94, 50%). Overall, median physical frailty scores did not return to baseline in the majority of survivors at 1 year. Multivariate regression analysis revealed that preinjury cognitive impairment (6 months, AD8, &bgr; = −0.20, p = 0.002) and preinjury physical frailty (6 months, Barthel Index, &bgr; = 0.60, p < 0.001; 1 year, Barthel Index, &bgr; = 0.52, p < 0.001) are independently associated with physical function (frailty). Multivariate logistic regression analysis revealed that age (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.04–1.14), injury severity (OR, 1.07; 95% CI, 1.02–1.12), and preinjury physical frailty (OR, 1.28; 95% CI, 1.14–1.47) are independently associated with overall mortality at 1 year. CONCLUSION Preinjury physical frailty is the predominant predictor of postinjury functional status and mortality in geriatric trauma patients. Identification of frailty and appropriate follow-up are crucial for decision making by providers, patients, and family caregivers. LEVEL OF EVIDENCE Prognostic study, level II.

The Design of Adult Acute Care Units in U.S. Hospitals

PURPOSE To describe the current state of design characteristics determined to be desirable by the Agency for Health Research and Quality (AHRQ) in U.S. adult medical, surgical, and intensive care units (ICUs). DESIGN Descriptive study of patient visibility; distance to hygiene, toileting, charting, and supplies; unit configuration; percentage of private rooms; and presence or absence of carpeting in 56 ICUs and 81 medical-surgical units in six metropolitan areas. METHODS Data were collected via observation, measurement, and interviews. Unit configurations were classified via an iterative process. Descriptive data were analyzed according to ICU and non-ICU status using SPSS (Version 15). FINDINGS Analysis of unit configurations indicated eight unit designs. Statistical analysis showed inter- and intrahospital variation in unit configurations, percentage private rooms, carpeting, visibility, and distance to supplies and charting. Few units met the AHRQ designated design elements studied. CONCLUSIONS A wide gap exists between desirable characteristics in ICUs and medical-surgical units. Future research is needed to explore operationalization of unit design elements as risk adjustments, how design elements contribute to patient outcomes, and how design elements influence one another. CLINICAL RELEVANCE There is room for improvement on almost every design variable, particularly on medical-surgical units. Future planning should take into consideration the interaction of bed capacity and unit configuration.

How Unit Level Nursing Responsibilities Are Structured in US Hospitals

Objectives: To describe (1) the extent to which acute and intensive care units use the elements of nursing models (team, functional, primary, total patient care, patient-focused care, case management) and (2) the deployment of non-unit-based personnel resources. Background: The lack of current data-based behavioral descriptions of the extent to which elements of nursing models are implemented makes it difficult to determine how work models may influence outcomes. Methods: Nurse managers of 56 intensive care units and 80 acute care adult units from 40 randomly selected US hospitals participated in a structured interview regarding (1) day-shift use of patient assignment behaviors associated with nursing models and (2) the availability and consistency of assignment of non-unit-based support personnel. Results: No model was implemented fully. Almost all intensive care units reported similar assignment behaviors except in the consistency of patient assignment. Non-intensive care units demonstrated wide variation in assignment patterns. Patterns differed intrainstitutionally. There were large differences in the availability and deployment of non-unit-based supportive resources. Conclusions: Administrators must recognize the differences in work models within their institutions as a part of any quality improvement effort. Attempts to test new work models must be rigorous in the measurement of their implementation.

EDUCATION IN ADMINISTRATION : TRENDS IN MSN/MBA AND MSN IN NURSING ADMINISTRATION

Avenues for the preparation of nurses who wish to pursue administrative careers continue to be debated. The author reports changes in the numbers and enrollments of master of science in nursing/master of business administration (MSN/MBA) programs as well as trends in MSN in nursing administration programs since 1993. Respondents to a survey of all U.S. nursing graduate programs indicated that both types of programs have undergone substantial changes on a variety of measures. The author considers these results in suggestions for building new approaches to administrative preparation.