Catherine D. Catrambone

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.

Improving asthma self-efficacy: Developing and testing a pilot community-based asthma intervention for African American adults

BACKGROUND Low-income African American adults in Chicago have disproportionately high asthma morbidity and mortality rates. Interventions that improve asthma self-efficacy for appropriate self-management behaviors might ultimately improve asthma control in this population. OBJECTIVE We sought to pilot test an intervention to improve asthma self-efficacy for appropriate self-management behaviors. METHODS Participants for this trial were recruited through 2 primary care clinics located in the largest African American community in Chicago. Participants were then randomized into one of 2 groups. The control group received mailed asthma education materials. The intervention group was offered 4 group sessions led by a community social worker and 6 home visits by community health workers. Telephone interviews were conducted at baseline (before intervention), 3 months (after intervention), and 6 months (maintenance). RESULTS The 42 participants were predominantly African American and low income and had poorly controlled persistent asthma. The intervention group had significantly higher asthma self-efficacy at 3 months (P < .001) after the completion of the intervention. Asthma action plans were more common in the intervention group at 3 months (P = .06). At 6 months, the intervention group had improved asthma quality of life (P = .002) and improved coping (P = .01) compared with control subjects. Trends in behavioral and clinical outcomes favored the intervention group but were not statistically significant. CONCLUSIONS This community-based asthma intervention improved asthma self-efficacy, self-perceived coping skills, and asthma quality of life for low-income African American adults. Larger trials are needed to test the efficacy of this intervention to reduce asthma morbidity in similar high-risk populations.

The burden of asthma in the Chicago community fifteen years after the availability of national asthma guidelines: The design and initial results from the CHIRAH study☆

Since the early 1990s, asthma burden has been recognized as a national public health concern in the United States [1]. The asthma burden has disproportionately affected persons of certain racial/ethnic backgrounds, principally African Americans [2] and those persons living in urban environments [3,4]. Concern about the growing problem of asthma has led to a number of national, state, and local efforts towards improving asthma outcomes and control [5,6,7,8]. No national effort toward asthma control has been more celebrated than the implementation of the National Heart, Lung and Blood Institutes National Asthma Education and Prevention Program (NAEPP). Initiated in 1989, to a large extent in response to the publics concern about the increased asthma prevalence and burden, the NAEPP set its first programmatic effort to the establishment of guidelines to improve asthma care [9]. Since the initial release of these guidelines in 1991, hundreds of thousands of copies have been distributed [10] and there have been countless efforts directed toward moving these guidelines into practice including continuing medical education (CME) programs, disease management programs, clinical performance measures, and research efforts. The NAEPP continues efforts in the establishment of national guidelines through a series of updates to the original guidelines, including the recent release of a major update in November 2007 [11,12]. While there continues to be numerous reports of progress of local implementation and health plan efforts, these reports have focused on changes in asthma processes of care or on outcomes limited primarily to health care utilization among selected, mostly health plan or practice-based samples. To date, there is a rather modest literature on community-wide population-based status of asthma burden and quality of care. The Chicago Initiative to Raise Asthma Health Equity (CHIRAH) is one of the NHLBI Centers of Excellence in Reducing Asthma Disparities. The core activity of the CHIRAH has been to conduct a community-based cohort study designed to characterize those factors that are contributing to racial/ethnic disparities with the purpose of identifying mutable factors that may provide the basis for new intervention strategies to eliminate these disparities. The CHIRAH project therefore provides a unique opportunity to report on a population-based understanding of the burden of asthma in a large urban environment known to have one of the highest asthma mortality rates in the US [13]. The purpose of this report is to examine the overall burden of asthma morbidity and treatment as seen from the perspective of this community-based study.

Obesity and asthma morbidity in a community-based adult cohort in a large Urban area: The chicago initiative to raise asthma health equity (CHIRAH)

Background. Urban minority populations experience increased rates of obesity and increased asthma prevalence and severity. Objective. The authors sought to determine whether obesity, as measured by body mass index (BMI), was associated with asthma quality of life or asthma-related emergency department (ED)/urgent care utilization in an urban, community-based sample of adults. Methods. This is a cross-sectional analysis of 352 adult subjects (age 30.9 ± 6.1, 77.8% females, forced expiratory volume in one second (FEV1)% predicted = 87.0% ± 18.5%) with physician-diagnosed asthma from a community-based Chicago cohort. Outcome variables included the Juniper Asthma Quality of Life Questionnaire (AQLQ) scores and health care utilization in the previous 12 months. Bivariate tests were used as appropriate to assess the relationship between BMI or obesity status and asthma outcome variables. Multivariate regression analyses were performed to predict asthma outcomes, controlling for demographics, income, depression score, and β-agonist use. Results. One hundred ninety-one (54.3%) adults were obese (BMI > 30 kg/m2). Participants with a higher BMI were older (p = .008), African American (p < .001), female (p = .002), or from lower income households (p = .002). BMI was inversely related to overall AQLQ scores (r = −.174, p = .001) as well as to individual domains. In multivariate models, BMI remained an independent predictor of AQLQ. Obese participants were more likely to have received ED/urgent care for asthma than nonobese subjects (odds ratio [OR] = 1.8, p = .036). Conclusions. In a community-based sample of urban asthmatic adults, obesity was related to worse asthma-specific quality of life and increased ED/urgent care utilization. However, compared to other variables measured such as depression, the contribution of obesity to lower AQLQ scores was relatively modest.

Improving pediatric asthma care through surveillance : The illinois emergency department asthma collaborative

OBJECTIVES. To better understand and improve the care of asthma patients who require emergency department (ED) care, the Illinois Emergency Department Asthma Collaborative (IEDAC) was created to develop, test, and disseminate an ED-based surveillance system. This report describes the development and testing of the pediatric IEDAC surveillance instruments and demonstrates how these instruments can be used to describe the health status, healthcare delivery, and outcome of children using ED services. METHODS. A convenience sample of 128 children presenting to 5 EDs in Illinois for asthma care was the study base. Data were collected on monthly samples of children aged 2 through 17 years who presented to these EDs from May to November 2003. Three instruments were used to collect data regarding the children’s pre-ED, ED, and post-ED experience. RESULTS. At the ED visit, 73.4% of children met national guideline criteria for persistent-level asthma symptoms. Among this group, 53.2% were using inhaled corticosteroid (ICS) medications. At 1 month follow-up, 66.6% of the children met the criteria for persistent-level asthma symptoms, which was statistically unchanged from the ED visit. Among the latter group, 64.2% were using ICS medications, again statistically unchanged compared with the ED visit. At follow-up, 24.5% of children were reported to have returned to an ED or were subsequently hospitalized. The majority of children were noted at follow-up to have limitation of at least some activity. CONCLUSIONS. Children who presented to IEDAC EDs were found to have a high level of asthma burden that continued at follow-up despite treatment. Moreover, a substantial proportion of children had returned to an ED or were subsequently hospitalized. Encouraging trends in medication use were observed, although suboptimal medication use was also observed.

A Nurse Coach Quality Improvement Intervention Feasibility and Treatment Fidelity

As the U.S. population ages and chronic illness prevalence increases, new approaches to care are needed. Although large health systems have begun to respond to this challenge, most Americans seek care from practitioners functioning in small office settings. Implementing systematic sustainable changes for quality improvement in this setting remains an unresolved challenge. In this study, trained Nurse Coaches (NCs) were employed to assist practices in adopting a new model of patient care called Virtual Integrated Practice (VIP). The feasibility and treatment fidelity of this approach were assessed through process measures and interviews in three practices. Findings document high acceptance of the NC approach and consistent delivery of the intervention. Enactment of the VIP model took place across practices, although to a variable degree. The study suggests that NCs may be an effective delivery method for quality and organizational improvements in small primary care practices.

The asthma emergency department visit: treating a crisis in the midst of uncontrolled disease

BACKGROUND Patients with asthma who require emergency department (ED) care are burdened with asthma symptoms, are at risk for hospitalization, and use expensive resources. OBJECTIVE To examine whether an ED-based surveillance system that characterized asthma symptoms and care before, during, and after an ED visit enhances our understanding of the natural history of asthma exacerbations. METHODS This cross-sectional follow-up enrolled 225 adult patients who presented to 1 of 6 Illinois EDs for asthma care. Clinical characteristics before ED presentation, care provided in the EDs, and 1-month follow-up status were assessed by self-administered questionnaire, medical record review, and telephone interview, respectively. RESULTS Persistent asthma symptoms were reported by 85.8% and 84.9% (P = .37) of patients before their ED visit and follow-up call, respectively. For patients with persistent symptoms before the ED visit and follow-up call, 54.4% and 73.8% (P = .02) reported using an inhaled corticosteroid, respectively. Inhaled corticosteroids were recommended for 49.4% of discharged patients with persistent symptoms. Relapse rates for return ED visits and return hospitalizations were 26.4% and 9.6%, respectively. Patients had low asthma-specific and general quality-of-life scores at follow-up. CONCLUSIONS Patients with asthma exacerbations most often had uncontrolled asthma before the ED visit that subsequently deteriorated, temporarily improved with ED treatment, and continued as uncontrolled asthma after the ED visit. Although improvements in care were reported 1 month after the ED visit, opportunities for additional improvement were observed.

A Guideline-based Approach to Asthma Management

The management of asthma has dramatically improved in recent years because of a better understanding of the disease and an organized approach to therapy. All of the various components and tools for evaluating individuals with asthma may be found in the Expert Panel Report Guidelines by the National Heart, Lung, and Blood Institute, initially published in 2007. These comprehensive guidelines help health care professionals care for individuals with asthma throughout their lifespan. This article will assist the health care provider to use these evidence-based guidelines.

Cardiovascular Disease Prevention Preferences of a Sample of Urban American Indians

This study identified program delivery preferences and barriers to physical activity and healthy eating. Ninety-nine urban dwelling American Indians completed a questionnaire at powwows, community events, and a community health center. Most frequently selected program delivery preferences were coaching or other human contact, with fewer willing to use computer or telephone coaching. Fifty-six selected attending 8, 12, or 16 sessions. Most frequently selected barriers to physical activity were lack of time (n = 48) and pain from existing problems (n = 33). Frequently identified barriers to eating healthy foods included expense (n = 42), uncertainty regarding what foods are healthy (n = 25), extra time needed for preparation (n = 22), and lack of knowledge of how to prepare healthy food (n = 22). Findings showed the need for programs to focus on decreasing the barriers of time for physical activity and healthy eating and encourage doing organized physical activity (not necessarily exercise) with others to increase physical activity.