Raymond J. Mayewski

Fall risk index for elderly patients based on number of chronic disabilities

The present study was designed to identify prospectively the individual chronic characteristics associated with falling among elderly persons and to test the hypothesis that risk of falling increases as the number of chronic disabilities increases. Seventy-nine consecutive admissions to three intermediate care facilities were evaluated. Twenty-five of the subjects became recurrent fallers. The nine risk factors included in the fall risk index were mobility score, morale score, mental status score, distant vision, hearing, postural blood pressure, results of back examination, postadmission medications, and admission activities of daily living score. A subjects fall risk score was the number of index factors present. The proportions of recurrent fallers increased from 0 percent (0 of 30) in those with 0 to three risk factors, to 31 percent (11 of 35) in those with four to six factors, to 100 percent (14 of 14) in those with seven or more factors. Falling, at least among some elderly persons, appears to result from the accumulated effect of multiple specific disabilities. Some of these disabilities may be remediable. The mobility test, the best single predictor of recurrent falling, may be useful clinically because it is simple, recreates fall situations, and provides a dynamic, integrated assessment of mobility.

Can Aviation-Based Team Training Elicit Sustainable Behavioral Change?

OBJECTIVE To quantify effects of aviation-based crew resource management training on patient safety-related behaviors and perceived personal empowerment. DESIGN Prospective study of checklist use, error self-reporting, and a 10-point safety empowerment survey after participation in a crew resource management training intervention. SETTING Seven hundred twenty-two-bed university hospital; 247-bed affiliated community hospital. PARTICIPANTS There were 857 participants, the majority of whom were nurses (50%), followed by ancillary personnel (28%) and physicians (22%). MAIN OUTCOME MEASURES Preoperative checklist use over time; number and type of entries on a Web-based incident reporting system; and measurement of degree of empowerment (1-5 scale) on a 10-point survey of safety attitudes and actions given prior to, immediately after, and a minimum of 2 months after training. RESULTS Since 2003, 10 courses trained 857 participants in multiple disciplines. Preoperative checklist use rose (75% in 2003, 86% in 2004, 94% in 2005, 98% in 2006, and 100% in 2007). Self-initiated reports increased from 709 per quarter in 2002 to 1481 per quarter in 2008. The percentage of reports related to environment as opposed to actual events increased from 15.9% prior to training to 20.3% subsequently (P < .01). Perceived self-empowerment, creating a culture of safety, rose by an average of 0.5 point in all 10 realms immediately posttraining (mean [SD] rating, 3.0 [0.07] vs 3.5 [0.05]; P < .05). This was maintained after a minimum of 2 months. There was a trend toward a hierarchical effect with participants less comfortable confronting incompetence in a physician (mean [SD] rating, 3.1 [0.8]) than in nurses or technicians (mean [SD] rating, 3.4 [0.7] for both) (P>.05). CONCLUSIONS Crew resource management programs can influence personal behaviors and empowerment. Effects may take years to be ingrained into the culture.

3H-cortisol radioactivity in hepatic smooth endoplasmic reticulum.

Abstract After a lag of 15 minutes, the microsomal fraction of liver rapidly accumulates injected cortisol radioactivity at a rate parallel to the liver homogenate. The hormone binds mainly to the smooth membrane fraction, poorly to the rough membrane fraction and virtually not at all to the ribosomes. The bound radioactivity is not released by extensive water washing of either membrane fraction but can be extracted with n-butanol. Anionic metabolites, electrophoretically similar to those found in the cytosol, are formed with time on the smooth membrane. The data suggest hormone binding to metabolizing enzymes of the smooth membrane and possibly to other structural sites which may be obscured by ribosomes in the rough membrane.

Physicians’ and nurses’ attitudes toward withholding treatment in a community hospital

Physician and nurse attitudes regarding aggressiveness of patient care were prospectively surveyed by questionnaire in a small rural community hospital. All patient admissions during one year, excluding routine obstetrical cases, were surveyed. Physicians and nurses used a simple continuous scale to indicate care level (1=comfort care to 5=full care). Nurses were more willing than physicians to limit care efforts for patients (mean scores of 4.35 vs 4.79, respectively). Both physicians and nurses indicated nearly identical factors important in making decisions to limit full resuscitative efforts: quality of life, nature of underlying illness, and age. A significant communication gap existed between nurses and physicians regarding aggressiveness of care: physicians indicated communication with nursing staff in 564 cases; nurses acknowledged this in only 56 of these same cases. These data suggest that current policies regarding do not resuscitate (DNR) orders should be broadened to include guidelines for less than full aggressive patient care. These policies should ensure adequate, documented communication between professional staff, patients, and others significantly involved with patient care decisions.