David R. Gifford

Detection of Delirium in the Intensive Care Unit: Comparison of Confusion Assessment Method for the Intensive Care Unit with Confusion Assessment Method Ratings

Objectives: To compare the Confusion Assessment Method (CAM) and CAM for the Intensive Care Unit (CAM‐ICU) methods for detecting delirium in alert, nonintubated older ICU patients.

Ameliorating pain in nursing homes: A collaborative quality-improvement project

Objectives: To evaluate a multifaceted intervention to improve pain‐management processes of care and outcomes in nursing homes.

Collaborative Clinical Quality Improvement for Pressure Ulcers in Nursing Homes

The National Nursing Home Improvement Collaborative aimed to reduce pressure ulcer (PU) incidence and prevalence. Guided by subject matter and process experts, 29 quality improvement organizations and six multistate long‐term care corporations recruited 52 nursing homes in 39 states to implement recommended practices using quality improvement methods. Facilities monitored monthly PU incidence and prevalence, healing, and adoption of key care processes.

Survival After Percutaneous Endoscopic Gastrostomy Among Older Residents of Quebec

CONTEXT: Percutaneous endoscopic gastrostomy has become a mainstay of nutritional support for individuals with swallowing dysfunction. There is little population‐based data to guide the use of this intervention in older individuals.

Community Outbreak of Mycoplasma pneumoniae Infection: School-Based Cluster of Neurologic Disease Associated with Household Transmission of Respiratory Illness

BACKGROUND We investigated an outbreak of severe neurologic disease and pneumonia that occurred among students at 4 schools in Rhode Island. METHODS We identified cases of encephalitis, encephalomyelitis, and pneumonia that occurred among schoolchildren from 1 September 2006 through 9 February 2007, and we performed serologic tests, polymerase chain reaction (PCR) analysis, and culture for the detection of multiple pathogens in oropharyngeal and nasopharyngeal specimens. Students with positive results of M. pneumoniae IgM serologic testing and no alternative diagnosis were considered to be infected with M. pneumoniae. At school A, we used questionnaires to identify students and their household contacts who made visits to physicians for pneumonia and cough. We compared observed and expected rates of pneumonia. RESULTS Rates of pneumonia among elementary students (122 cases/1000 student-years) were > 5-fold higher than expected. Three students had encephalitis or encephalomyelitis, and 76 had pneumonia. Of these 2 groups of students, 2 (66%) and 57 students (75%), respectively, had M. pneumoniae infection. M. pneumoniae was detected by PCR in 10 students with pneumonia; 5 of these specimens were cultured, and M. pneumoniae was isolated in 4. Of 202 households of students attending school A, 20 (10%) accounted for 61% of visits to physicians for pneumonia or cough. Of 19 household contacts of students with pneumonia, 8 (42%) developed pneumonia and 6 (32%) reported visits for cough. CONCLUSIONS M. pneumoniae caused a community-wide outbreak of cough illness and pneumonia and was associated with the development of life-threatening neurologic disease. Although M. pneumoniae was detected in schools, its transmission in households amplified the outbreak. Interrupting household transmission should be a priority during future outbreaks.

Do malpractice concerns, payment mechanisms, and attitudes influence test-ordering decisions?

Greater understanding is needed of nonclinical factors that determine neurologists’ decisions to order tests. The authors surveyed 595 US neurologists and utilized demographic information, attitude scales, and clinical scenarios to evaluate the influence of nonclinical factors on test-ordering decisions. Greater test reliance, higher malpractice concerns, and receiving reimbursement for testing were all associated with a higher likelihood of test ordering. These findings have implications for training needs and suggest malpractice worries may inflate health care costs.

Comorbidity and Drug Use in Cognitively Impaired Elderly Living in Long-Term Care

Cognitive impairment is associated with an increased mortality in older people. The prevalence and impact of comorbidity on functional status and mortality of demented patients has not been fully elucidated. Using a population-based data set, we describe the prevalence of cognitive impairment, functional status, principal comorbid conditions and 1-year survival for over 300,000 patients admitted to the nursing homes in five US states. Sixty-one percent of patients have some level of cognitive impairment, and this correlates with the degree of physical frailty. Severer cognitive impairment is associated with a higher mortality rate. Yet, patients with cognitive impairment appear to have fewer comorbid conditions and are less likely to receive medications and special treatments than residents with normal cognitive status. Additional studies are needed to understand whether demented patients may paradoxically be considered healthier or, instead, are only neglected.

Quality Improvement for Pressure Ulcer Care in the Nursing Home Setting: The Northeast Pressure Ulcer Project

OBJECTIVES The objectives of this study were to evaluate the impact of a collaborative model of quality improvement in nursing homes on processes of care for the prevention and treatment of pressure ulcers. STUDY DESIGN The study design was experimental. SETTING We studied 29 nursing homes in New Jersey, Pennsylvania, and Rhode Island. PARTICIPANTS Participants consisted of pressure ulcer quality improvement teams in 29 nursing homes. INTERVENTION Quality improvement teams attended a series of workshops to review clinical guidelines and quality improvement principles and to share best practices, and worked one-on-one with mentors to implement quality improvement techniques and to collect data independently. MEASUREMENTS We calculated process measures based on the Agency for Healthcare Research and Quality (AHRQ) guidelines. Process measures addressed each facilitys processes of care for the prevention and treatment of pressure ulcers at baseline and after 12 months of intervention. Prevention measures focused on recent admissions and high-risk residents; treatment measures focused on patients newly diagnosed with pressure ulcers and all patients with pressure ulcers. RESULTS Overall, 6 of 8 prevention process measures improved significantly, with percent difference between baseline and follow up ranging from 11.6% to 24.5%. Three of 4 treatment process measures improved significantly, with 5.0%, 8.9%, and 25.9% difference between baseline and follow up. For each process measure, between 5 and 12 facilities demonstrated significant improvement between baseline and follow up, and only 2 or fewer declined for each process measure. CONCLUSION Improvement in processes of care after the use of a structured collaborative quality improvement approach is possible in the nursing home setting.

Critical Review of Resident Assessment Protocols

OBJECTIVES: To evaluate the quality of all 18 federally mandated Resident Assessment Protocols (RAPs) by measuring their adherence to established criteria for clinical practice guidelines (CPGs).

External threats and nursing home administrator turnover.

External threats and volatility in the long-term-care sector in recent decades have posed serious challenges for nursing home administrators. Greater job complexity and administrative responsibilities resulting from public policies and more specialization and competitiveness in nursing home markets have made turnover a significant issue. This article examines administrator turnover from 1970 through 1997 in New York State and describes how turnover increased markedly in the late 1980s and early 1990s.