Lorraine C. Mion

Physician - nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients' perception of care.

Increasing demand to deliver and document therapeutic and preventive care sharpens the need for disease management strategies that accomplish these goals efficiently while preserving quality of care. The purpose of this study was to compare selected outcomes for a new chronic disease management program involving a nurse practitioner - physician team with those of an existing model of care. One hundred fifty-seven patients with hypertension and diabetes mellitus were randomly assigned to their primary care physician and a nurse practitioner or their primary care physician alone. Costs for personnel directly involved in patient management, calculated from hourly rates and encounter time with patients, and pre- and post-study glycosylated hemoglobin (HbA1c), high-density lipoprotein cholesterol (HDL-c), satisfaction with care and health-related quality of life (HRQoL) were assessed. Although 1-year costs for personnel were higher in the team-treated group, participants experienced significant improvements in mean HbA1c ( − 0.7%, p = 0.02) and HDL-c ( + 2.6 mg dL − 1, p = 0.02). Additionally, satisfaction with care improved significantly for team-treated subjects in several sub-scales whereas the mean change over time in HRQoL did not differ significantly between groups. This study demonstrates the value of a complementary team approach to chronic disease management in improving patient-derived and clinical outcomes at modest incremental costs.

Health outcomes associated with potentially inappropriate medication use in older adults.

The purpose of this study was to examine the prevalence of potentially inappropriate medication use (PIMs) among community-dwelling older adults and the association between PIMs and health care outcomes. Participants were 17,971 individuals age 65 years and older. PIM use was defined by the Beers criteria. Drug-related problems (DRPs) were defined using ICD-9 codes. Forty percent of the 17,971 individuals filled at least 1 PIM prescription, and 13% filled 2 or more PIM prescriptions. Overall DRP prevalence among those with at least 1 PIM prescription was 14.3% compared to 4.7% in the non-PIM group (p < .001). In conclusion, preventing PIM use may be important for decreasing medication-related problems, which are increasingly being recognized as requiring an integrated interdisciplinary approach.

Establishing a case-finding and referral system for at-risk older individuals in the emergency department setting: The Signet model

Older emergency department (ED) patients have complex medical, social, and physical problems. We established a program at four ED sites to improve case finding of at‐risk older adults and provide comprehensive assessment in the ED setting with formal linkage to community agencies. The objectives of the program are to (1) improve case finding of at‐risk older ED patients, (2) improve care planning and referral for those returning home, and (3) create a coordinated network of existing medical and community services. The four sites are a 1,000‐bed teaching center, a 700‐bed county teaching hospital, a 400‐bed community hospital, and a health maintenance organization (HMO) ED site. Ten community agencies also participated in the study: four agencies associated with the hospital/HMO sites, two nonprofit private agencies, and four public agencies. Case finding is done using a simple screening assessment completed by the primary or triage nurse. A geriatric clinical nurse specialist (GCNS) further assesses those considered at risk. Patients with unmet medical, social, or health needs are referred to their primary physicians or to outpatient geriatric evaluation and management centers and to community agencies. After 18 months, the program has been successfully implemented at all four sites. Primary nurses screened over 70% (n = 28,437) of all older ED patients, GCNSs conducted 3,757 comprehensive assessments, participating agency referrals increased sixfold, and few patients refused the GCNS assessment or subsequent referral services. Thus, case finding and community linkage programs for at‐risk older adults are feasible in the ED setting.

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.

A nonpharmacologic sleep protocol for hospitalized older patients

OBJECTIVES: To evaluate the feasibility of and adherence to a nonpharmacologic sleep protocol targeted to nurses for acutely ill older patients and to test the effectiveness of the protocol on enhancing sleep and reducing sedative‐hypnotic drug (SHD) use.

Introduction of sedative, analgesic, and neuromuscular blocking agent guidelines in a medical intensive care unit: physician and nurse adherence.

Objective: To determine physician and nurse adherence with sedative, analgesic, and neuromuscular blocking agent guidelines in the management of mechanically ventilated patients in a medical intensive care unit. Design: Prospective cohort study. Subjects: One hundred consecutively admitted patients to a medical intensive care unit who required mechanical ventilatory support. A sample of 29 nurses, residents, and attending physicians were interviewed regarding their attitudes and perceptions of the guidelines. Measurement: Data were collected from concurrent medical records and included the following: demographic characteristics; clinical variables; physician prescriptions of sedative, analgesic, and/or neuromuscular blocking agents; nurse administration of these medications; documentation of monitoring; and assessment of patient hemodynamic status and behaviors. A semistructured interview was elicited from both nurses and physicians about their rationale for the use or nonuse of the guidelines. Results: Patients ranged in age from 24 to 87 yrs, mean 60.7 (±15.3) yrs. Admission Acute Physiology and Chronic Health Evaluation III scores ranged from 36 to 192, mean 93.8 (±30.5) and median 88. Length of mechanical ventilatory support ranged from 1 to 112 days, mean 14.8 (±20.0) days, and median 8 days; medical intensive care unit length of stay ranged from 1 to 46 days, with a mean of 9.8 (±8.1) days and a median of 8 days. Of the 100 patients, 47% died, 28% returned home, and 25% were discharged to a nursing facility. Eighty‐five patients were administered one or more sedative, analgesic, and/or neuromuscular blocking agent, range 1‐9 drugs, mean 2.5 (±1.5) drugs. Physicians prescribed 14 different medications; the most commonly administered drug was lorazepam (n = 71), followed by morphine (n = 39). Physicians and nurses had partial or total adherence to the guidelines in 58% of patients. The initial choice of the drug followed the guidelines in 60% of patients; the overall guideline was followed in 23% of patients. The most common rationales for nonadherence to the guidelines stated by both physicians and nurses were patient‐specific factors, resident guideline learning curve, and physician medication preferences. Conclusion: Most patients required treatment for agitated behaviors. The majority of treatment regimens partially or totally adhered to the guidelines. Factors such as patient‐specific disease states, resident guideline learning curve, and physician preferences of medications may have decreased adherence. Improving adherence to the guidelines is essential to assess their effectiveness in improving clinical outcomes.

Falls in the Rehabilitation Setting: Incidence and Characteristics

&NA; A prospective six‐month study was conducted to determine a high‐risk index for medical rehabilitation patients who fall. Variables studied for all patients included demographics, medical conditions, associated symptoms, orthostatic blood pressure measurements, physical function, posture control, proprioception, use of physical restraints, and medications. A detailed examination of the fall events was also conducted. Of the 143 patients studied, 46 (32%) fell at least once, making a total of 84 falls. Impaired ability to follow directions, impaired judgment, impaired proprioception, presence of physical restraints, use of major tranquilizers, use of sedatives, and presence of psychiatric diagnosis were all individually associated with patients who fell. Males fell more than females. Logistic regression identified altered proprioception as the only major predictor of falling. Of those who fell, only 26% called for assistance prior to the fall. Sixty‐eight percent of the falls were from wheelchairs. Importantly, no patients had serious injury or morbidity from the falls.

Effects of an Intervention to Increase Bed Alarm Use to Prevent Falls in Hospitalized Patients: A Cluster Randomized Trial

BACKGROUND Bed alarm systems intended to prevent hospital falls have not been formally evaluated. OBJECTIVE To investigate whether an intervention aimed at increasing bed alarm use decreases hospital falls and related events. DESIGN Pair-matched, cluster randomized trial over 18 months. Nursing units were allocated by computer-generated randomization on the basis of baseline fall rates. Patients and outcome assessors were blinded to unit assignment; outcome assessors may have become unblinded. (ClinicalTrials.gov registration number: NCT00183053) SETTING 16 nursing units in an urban community hospital. PATIENTS 27 672 inpatients in general medical, surgical, and specialty units. INTERVENTION Education, training, and technical support to promote use of a standard bed alarm system (intervention units); bed alarms available but not formally promoted or supported (control units). MEASUREMENTS Pre-post difference in change in falls per 1000 patient-days (primary end point); number of patients who fell, fall-related injuries, and number of patients restrained (secondary end points). RESULTS Prevalence of alarm use was 64.41 days per 1000 patient-days on intervention units and 1.79 days per 1000 patient-days on control units (P = 0.004). There was no difference in change in fall rates per 1000 patient-days (risk ratio, 1.09 [95% CI, 0.85 to 1.53]; difference, 0.41 [CI, -1.05 to 2.47], which corresponds to a greater difference in falls in control vs. intervention units) or in the number of patients who fell, injurious fall rates, or the number of patients physically restrained on intervention units compared with control units. LIMITATION The study was conducted at a single site and was slightly underpowered compared with the initial design. CONCLUSION An intervention designed to increase bed alarm use in an urban hospital increased alarm use but had no statistically or clinically significant effect on fall-related events or physical restraint use. PRIMARY FUNDING SOURCE National Institute on Aging.

Improving the Capture of Fall Events in Hospitals: Combining a Service for Evaluating Inpatient Falls with an Incident Report System

OBJECTIVES: To determine the utility of a fall evaluation service to improve the ascertainment of falls in acute care.

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.