Greg Petroski

Comorbidity and 1-year mortality risks in nursing home residents.

Objectives: To investigate the effect of chronic diseases and disease combinations on 1‐year mortality in nursing home residents.

Clinical Outcomes of Aging in Place

BackgroundPrograms such as Medicaid Home and Community-based Services (HCBS) have provided an alternative to institutionalization through community-based, long-term care services; however, there are limited studies on the clinical outcomes of participants in these programs as compared to nursing home (NH) residents. ObjectiveTo compare clinical outcomes of individuals in a community-based, long-term care program to individuals of similar case mix in institutional-based, long-term care. MethodsA program called Aging in Place (AIP) was developed by the Sinclair School of Nursing in cooperation with the state of Missouris HCBS program. The AIP intervention consisted of nurse coordination of the HCBS program and Medicare home health services. A total of 78 AIP participants were matched with 78 NH residents on admission period, activities of daily living (ADLs), cognitive status, and age. The Minimum Data Set (MDS) was collected on the AIP group at admission and every 6 months over a 30-month period. Cognition was measured by the MDS Cognitive Performance Scale (CPS), ADLs by the sum of 5 MDS ADL items, depression by the MDS-Depression Rating Scale, and incontinence by rating on 2 MDS items related to urinary continence. The Cochran–Mantel–Haenszel method was used to test the association between the AIP intervention and clinical outcomes. ResultsThe AIP group clinical outcomes were better at a statistically significant level (less than .05) for the following outcomes: (a) cognition at 6, 12, and 18 months (p = .00); (b) depression at 6 and 12 months (p = .00); (c) ADL at 6 (p = .02), 12 (p = .04), and 24 (p = .00) months; and (d) incontinence at 24 (p = .02) months. In all 4 outcome measures, the AIP group stabilized or improved outcome scores whereas the NH groups outcome scores deteriorated. DiscussionStudy results suggest that community-based care with nurse coordination enhances clinical outcomes of long-term care participants.

Nursing Home Error and Level of Staff Credentials

Providing safe nursing home care is both a clinical and fiscal challenge in many countries. The fiscal realities result in the addition of other workers, such as medication technicians or aides (CMT/A), to the health care team. The purpose of this study was to determine the impact of various levels of credentialing among nursing home staff who deliver medications (RN, LPN, or CMT/A) on medication error. In addition, the impact of distractions and interruptions was explored. Using naïve observation, 39 medication administrators representing various levels of credentialing were unobtrusively observed to determine the number of medication errors, distractions, and interruptions in five nursing homes. There were no differences in medication error rates by level of credential. However, RNs had more interruptions during their medication administration, and these increased interruptions were associated with increased medication error rates when wrong time errors were excluded (p = .0348).

Evaluating motor end-plate-targeted injections of botulinum toxin type A in a canine model.

Tarsal joint forces were measured in dogs over 70 days following botulinum toxin type A (BTX‐A) injections. Three dogs were injected at motor end‐plates located by electromyography (EMG), while 3 dogs were similarly injected, but without EMG guidance. Extension forces were significantly (P < 0.05) smaller in limbs injected at motor end‐plates than in corresponding limbs on days 14 and 35. There were no significant differences at other times. Using these techniques, EMG end‐plate targeting potentiates effects of BTX‐A.

The Quality Improvement Knowledge Application Tool Revised (QIKAT-R).

Purpose Quality improvement (QI) has been part of medical education for over a decade. Assessment of QI learning remains challenging. The Quality Improvement Knowledge Application Tool (QIKAT), developed a decade ago, is widely used despite its subjective nature and inconsistent reliability. From 2009 to 2012, the authors developed and assessed the validation of a revised QIKAT, the “QIKAT-R.” Method Phase 1: Using an iterative, consensus-building process, a national group of QI educators developed a scoring rubric with defined language and elements. Phase 2: Five scorers pilot tested the QIKAT-R to assess validity and inter- and intrarater reliability using responses to four scenarios, each with three different levels of response quality: “excellent,” “fair,” and “poor.” Phase 3: Eighteen scorers from three countries used the QIKAT-R to assess the same sets of student responses. Results Phase 1: The QI educators developed a nine-point scale that uses dichotomous answers (yes/no) for each of three QIKAT-R subsections: Aim, Measure, and Change. Phase 2: The QIKAT-R showed strong discrimination between “poor” and “excellent” responses, and the intra- and interrater reliability were strong. Phase 3: The discriminative validity of the instrument remained strong between excellent and poor responses. The intraclass correlation was 0.66 for the total nine-point scale. Conclusions The QIKAT-R is a user-friendly instrument that maintains the content and construct validity of the original QIKAT but provides greatly improved interrater reliability. The clarity within the key subsections aligns the assessment closely with QI knowledge application for students and residents.

Inhibitory casting decreases a vibratory inhibition index of the H-reflex in the spastic upper limb.

OBJECTIVE To test the hypothesis that application of an inhibitory cast to the spastic upper limb will decrease a vibratory inhibition index (VII) of the H-reflex in the spastic upper limb. DESIGN Prospective, nonrandomized, open-label trial. SETTING University tertiary care center. PARTICIPANTS Eight adults with upper limb spasticity. INTERVENTION Fiberglass cast application spanning the wrist to the upper arm. MAIN OUTCOME MEASURE The amplitude of the H-reflex with and without continuous 60Hz vibration to the tendon of the flexor carpi radialis was measured, and the VII was calculated using the formula: [H-reflex amplitude (vibrated)/H-reflex amplitude (control)] x 100%. RESULTS Mean VII decreased from baseline (70.7) on day 1 (67.6, p = .699), day 2 (55.9, p =.066), and day 3 (43.5, p = .033) of casting, and increased on day 4 (89.9, p = .146) after removal of the cast. CONCLUSION Findings lend support to the idea that during application of an inhibitory cast motor neuron excitability is decreased in the spastic upper limb.

The usefulness of the Brief Symptom Inventory in the neuropsychological evaluation of traumatic brain injury

Changes in the health care delivery system are forcing clinicians to use less timely and more cost efficient measures. In rehabilitation, more efficient measures of emotional-behavioural functioning are being administered to patients with traumatic brain injury (TBI), including the Brief Symptom Inventory (BSI), a 53 item short version of the Symptom Checklist-90 that assesses nine different dimensions of emotional-behavioural functioning. Because the BSI was developed for use with psychiatric populations, research of the measure with TBI populations is needed. The current study evaluated the utility of the BSI in a sample of 62 patients (34 male, 28 female, average age 35, average education 12 years) with TBI evaluated as outpatients at a midwestern rehabilitation hospital. Results indicated that: (1) subjects endorsed clinically elevated distress on seven of the nine subscales when compared to the normative sample; (2) the Obsessive-Compulsive (OC) subscale achieved the highest t-score (70.31); 3) the most frequent two-point profiles included the OC-Somatic (21%) and OC-Psychoticism (13%) subscales; and (3) the Global Symptom Index was significantly correlated with all nine subscales. It was concluded that caution must be used when administering the BSI to individuals with TBI due to a lack of a TBI standardization sample, the limited number of test items per subscale, and questionable labels for the different subscales (e.g. OC subscale items appear to be more reflective of TBI-related cognitive impairment than obsessive-compulsive traits).

Exploring the Collective Hospice Caregiving Experience

BACKGROUND Collective caregiving, performed by caregivers working in pairs (informal primary and secondary caregivers working together), is common in the hospice setting. Research suggests that caregiving pairs may experience different caregiver outcomes. However, little is known about how caregiving pairs differ from solo caregivers (informal primary caregivers) on outcome measures. OBJECTIVE The goal of this study was to determine whether being in a caregiver pair affected caregiver anxiety and depression and how outcomes changed over time. DESIGN A mixed model analysis was used. SETTING/SUBJECTS Hospice caregivers (260 solo caregivers and 44 caregivers in 22 pairs) who participated in a larger, randomized controlled trial completed caregiver measures upon hospice admission and periodically until the death of the patient or hospice decertification. MEASUREMENTS Measured were caregiver quality of life, social support, anxiety, and depression. RESULTS Caregiver pairs had higher anxiety and depression scores than solo caregivers. Emotional, financial, and physical quality of life were associated with decreased depression, whereas only emotional and financial quality of life were correlated with lower levels of anxiety. Social support was associated with lower levels of depression and anxiety. CONCLUSIONS Despite assumptions that social support is positively facilitated vis-a-vis collective caregiving, caregiving pairs may be at higher risk for anxiety and depression. Future research is needed to address why individuals become anxious and/or depressed when working as part of a caregiving pair.

The Negative Impact of Anemia in Outcome from Traumatic Brain Injury

BACKGROUND Whether anemia complicating traumatic brain injury (TBI) has an impact on patient outcomes is controversial; therefore, recommendations for blood transfusions for such patients are inconsistent. We hypothesized that patient outcome after TBI would be worse in patients with lower hemoglobin levels. METHODS We retrospectively reviewed records of patients with TBI and head Abbreviated Injury Scale >3 with abnormal head computed tomography findings and neurologic injury. The relationships between initial hemoglobin and lowest hemoglobin during hospitalization at threshold values of ≤7, ≤8, ≤9, and ≤10 g/dL were investigated relative to Glasgow Outcome Score at last follow-up not exceeding 1 year. RESULTS Of 939 patients meeting inclusion criteria, initial and lowest hemoglobin concentrations were significant predictors of poor outcome (P < 0.0001). For each 1 g/dL higher hemoglobin value, the likelihood of a good outcome increased by 33%. More severe levels of initial anemia were associated with lower Glasgow Coma Scale, greater head Abbreviated Injury Scale, and greater Injury Severity Score (P < 0.0001). Female patients had worse outcome than male patients only for initial hemoglobin between 7 and 8 g/dL (P < 0.05). Blood transfusion was associated with poorer outcome at hemoglobin levels ≤9 and ≤10 g/dL (P < 0.05), but not at lower hemoglobin thresholds. CONCLUSIONS Patient outcome after TBI is worse in patients with lower hemoglobin. Initial hemoglobin and lowest hemoglobin after admission are independently associated with poor outcome. Our data support consideration of blood transfusion when hemoglobin is ≤8 g/dl.

Evaluation of a statewide program in genetic diseases

We used the Genetics Office Automation System (GOAS), a database management system designed to facilitate collection and analysis of medical genetic data, to evaluate the Missouri Genetics Disease Program (MGDP). From 1985 through 1995, patient data were collected at four tertiary care genetic centers. The number of genetic visits per 100,000 people more than doubled from 1985 through 1995. The results of subpopulation analyses indicate that the MGDP has facilitated improvements in: (1) services for newborns and infants, (2) rural outreach programs, and (3) evaluation of the incidence and impact of genetic disorders.