Shelli Feder

The relationship between pain, fatigue, depression and functional performance in stable heart failure

OBJECTIVE Evaluate the relationship between pain, fatigue, depression, demographic, clinical, and functional variables in stable heart failure (HF). BACKGROUND Pain, fatigue and depression are common in HF. Little is known about the relationship between pain, fatigue and depression and functional measures in this population. METHODS Secondary data analysis of a cross sectional study of 173 stable HF patients. Associations between clinical and demographic factors, pain (SF-36), depression (CES-D), and fatigue (MAF) to functional performance and capacity (SF-36 role limitations due to physical functioning and 6-Minute Walk Test) were evaluated using hierarchical multiple regressions. RESULTS The sample was 65% male with a mean age of 60. Fifty-seven percent (n = 100) had pain, 54% (n = 94) had fatigue, and 46% (n = 79) had depression. Pain, depression and fatigue were negatively associated with functional performance but not functional capacity when controlling for demographic and clinical covariates. CONCLUSIONS Pain, fatigue and depression were associated with decreased functional performance in stable HF. Symptom management interventions are needed in HF.

Symptom Burden Among Patients Who Were Hospitalized for Heart Failure

Author Affiliations: Department of Medicine, University of Toronto, Toronto, Ontario, Canada (Yin, Leis); Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Kiss, Leis); Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (Kiss, Leis); Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Leis); Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada (Leis).

Over-monitoring and alarm fatigue: for whom do the bells toll?

Telemetry monitors with rhythm strips streaming out and the clamor of alarms are ubiquitous on hospital units. Once monitors were present only in intensive care units (ICUs), but have now become a cornerstone of care in non-ICU hospital settings. But are telemetry monitors used too much? Although the American Heart Association (AHA) practice standards for electrocardiographic monitoring1 specify the indications and duration of monitoring, research has shown that monitoring is overused.2,3 Because monitoring is noninvasive, it seems harmless. But there are unintended consequences, like deaths related to alarm fatigue. When nurses work among constantly beeping monitors, they may begin to ignore the alarm signals. For instance, in 2010 at a Massachusetts hospital, a patient death was directly linked to telemetry monitoring after alarms signaling a critical event went unnoticed by 10 nurses.4,5 Although alarms were created to enhance patient safety, they have recently become an urgent patient safety issue themselves. Some argue that more is better when it comes to telemetry monitoring. Perhaps detecting that one critical event in one patient without an indication for monitoring justifies its widespread use. However, one of the major consequences of over-monitoring is the proliferation of alarms, of which 72e99% have been deemed clinically insignificant.6e11 More monitoring means more alarms, and more alarms mean more false alarms. The din of alarms is not only annoying to staff, patients, and visitors, but can also result in sentinel events. Important clinical events may be missed amid the cacophony. Patient safety and regulatory agencies are addressing the problem of alarms and alarm fatigue. For instance, the ECRI Institute has placed alarm hazards in first or second place on their Top 10 Health Technology Hazards annual list since 2007.12 The Joint Commission recently released a sentinel event alert regarding alarms based, in part, on reports of 98 patient-related events resulting in 80 deaths from January of 2009 to June of 2012.13 The Joint Commission has made the task of improving the safety of clinical alarm systems a National Patient Safety Goal for 2014.14 More monitoring does not necessarily lead to better patient outcomes. Multiple studies have suggested that telemetry monitoring does not contribute to early detection of clinically relevant arrhythmias, decrease long-term mortality, or alter medical management, such as transfer to an ICU, changes in medication, or the use of revascularization procedures.15e20 Telemetry as a means of preventing, detecting, and improving survival from cardiac arrest is not supported, as research indicates that cardiac arrests occur infrequently in patients on telemetry and when arrests do happen, telemetry plays a small role in patient survival.21

Federal Funding for Mixed Methods Research in the Health Sciences in the United States Recent Trends

Although investigators in health sciences are increasingly interested in using mixed methods, greater adoption requires funding opportunities. Funding allocations can signal recognition of a particular methodology and proficiency of investigators in using such methods. We examined trends in prevalence of mixed methods research funded by federal agencies in the United States. We reviewed abstracts to describe the content and terminology related to mixed methods. The number of self-identified mixed methods awards (n = 535; 2009-2014) increased modestly from previous trends (n = 226; 1997-2008). Abstracts were highly variable in their depth of description and use of mixed methods terminology. We propose five elements to address when developing a scientific abstract for a mixed methods study to facilitate clear description of study design and methods.

Validation of the ICD-9 Diagnostic Code for Palliative Care in Patients Hospitalized With Heart Failure Within the Veterans Health Administration:

Background: Patients with heart failure (HF) are at increased risk of unmet palliative care needs. The International Classification of Diseases, Ninth Revision (ICD-9) code, V66.7, can identify palliative care services. However, code validity for specialist palliative care in the Veterans Health Administration (VHA) has not been determined. Objective: To validate the ICD-9 code for specialist palliative care and determine common reasons for specialist palliative care consultation among VHA patients hospitalized with HF. Design: Electronic health record review of data from the Veterans Aging Cohort Study. Setting/Participants: The sample included 100 patients hospitalized with HF from 2003 to 2012. Measurements: Data from 50 patients with V66.7 were matched by age, race, site of care, hospital length of stay, intensive care unit admission, and fiscal year of study discharge to 50 patients with HF without V66.7 who had died within a year of hospitalization. We calculated positive and negative predictive values (PPV, NPV), sensitivity, and specificity. Results: All patients included in the sample were male, 66% black ethnicity, and mean age = 65 years (standard deviations [SD] ± 10.5 for cases; SD ± 9.8 for matches). Specialist palliative care was documented for 49 of 50 patients with V66.7 (PPV = 98%, 95% confidence interval [CI]: 88-99) and 9 of 50 patients without the code (NPV = 82%, 95% CI: 68-91). Sensitivity was 84% (95% CI: 72-92), and specificity was 98% (95% CI: 86-99). Establishing goals of care was the most frequent reason for palliative care consultation (43% of the sample). Conclusion: The ICD-9 code V66.7 identifies specialist palliative care for hospitalized patients with HF in the VHA. Replication of findings in other data sources and populations is needed.

Developing and Evaluating a Self-Management Intervention for Women With Breast Cancer

Reports of self-management interventions usually focus on efficacy and do not detail processes of intervention development and evaluation. We describe the development and evaluation of Managing Cancer Care: A Personal Guide, a patient-oriented cancer self-management intervention consisting of seven modules on the topics of self-management, care options, transitions, communication, symptom management, and self-efficacy. We developed and evaluated the intervention in stages by partnering with women with breast cancer. Stages were as follows: individual interviews (n = 25), intervention design, focus group (n = 6), pilot testing with metastatic patients (n = 23), and population testing with non-metastatic patients (n = 105). We used interpretive description and content analysis for qualitative analyses and used descriptive statistics to analyze module ratings and frequency of use. We report results of each stage and discuss the challenges of creating a self-management intervention that has broad appeal without taking a one-size-fits-all approach and implementing a self-management intervention in a real-world versus research setting.

AN ALARMING RATE OF UNNECESSARY MONITORING IN THE PRACTICAL USE OF THE LATEST STANDARDS OF ELECTROCARDIOGRAPHY (PULSE) TRIAL

Continuous electrocardiographic (ECG) monitoring is ubiquitous in hospitals. An unintended consequence of the increasingly widespread use of monitoring is a cacophony of alarms, 72-99% of which are false. Frequent false alarms have caused staff to ignore or deactivate alarms, which has resulted in

Risk Stratification in Older Patients With Acute Myocardial Infarction Physicians’ Perspectives

Objective: Risk stratification models support clinical decision making in acute myocardial infarction (AMI) care. Existing models were developed using data from younger populations, potentially limiting accuracy and relevance in older adults. We describe physician-perceived risk factors, views of existing models, and preferences for future model development in older adults. Method: Qualitative study using semi-structured telephone interviews and the constant comparative method. Results: Twenty-two physicians from 14 institutions completed the interviews. Median age was 37, and median years of clinical experience was 11.5. Perceived predictors included cardiovascular, comorbid, functional, and social risk factors. Physicians viewed models as easy to use, yet neither inclusive of risk factors nor predictive of non-mortality outcomes germane to clinical decision making in older adults. Ideal models included multidimensional risk domains and operational requirements. Discussion: Physicians reported limitations of available risk models when applied to older adults with AMI. New models are needed to guide AMI treatment in this population.

A taxonomy and cultural analysis of intra-hospital patient transfers

Existing research on intra-hospital patient transitions focuses chiefly on handoffs, or exchanges of information, between clinicians. Less is known about patient transfers within hospitals, which include but extend beyond the exchange of information. Using participant observations and interviews at a 1,541-bed, academic, tertiary medical center, we explored the ways in which staff define and understand patient transfers between units. We conducted observations of staff (n = 16) working in four hospital departments and interviewed staff (n = 29) involved in transfers to general medicine floors from either the Emergency Department or the Medical Intensive Care Unit between February and September 2015. The collected data allowed us to understand transfers in the context of several hospital cultural microsystems. Decisions were made through the lens of the specific unit identity to which staff felt they belonged; staff actively strategized to manage workload; and empty beds were treated as a scarce commodity. Staff concepts informed the development of a taxonomy of intra-hospital transfers that includes five categories of activity: disposition, or determining the right floor and bed for the patient; notification to sending and receiving staff of patient assignment, departure and arrival; preparation to send and receive the patient; communication between sending and receiving units; and coordination to ensure that transfer components occur in a timely and seamless manner. This taxonomy widens the study of intra-hospital patient transfers from a communication activity to a complex cultural phenomenon with several categories of activity and views them as part of multidimensional hospital culture, as constructed and understood by staff.

Facilitators and Barriers to Oncologists’ Conduct of Goals of Care Conversations

Introduction: Goals of care (GoC) conversations optimally begin early in the course of cancer care, yet most happen near the end of life. We sought to describe oncologist-reported facilitators of and barriers to GoC conversations with patients who have advanced cancer. Methods and Materials: We conducted individual, semistructured qualitative interviews with oncologists from 4 academic, community, municipal, and rural hospitals in New York and Connecticut. Interview topics included approach to GoC conversations, facilitators, barriers, and organizational influences. We analyzed data using interpretive description. We collected demographic and practice information and surveyed oncologists on their communication skills training. We calculated descriptive statistics for quantitative data. Results: Oncologists (n = 21) had a mean age of 46 years (range: 34-68), 67% were male, 71% were White, 24% were Asian, 10% were Hispanic, and 5% were Black. They reported an average of 20 years in practice (range: 8-42), and 62% had received training on having GoC conversations. Facilitators included patient’s poor functional status, patient’s high health literacy, family understanding and acceptance, oncologist’s practice experience, and a supportive practice environment. Barriers included certain patient demographic and clinical characteristics, patient religion and culture, patient’s denial, and lack of time. Conclusion: GoC conversations may be facilitated by enabling oncologists to conduct these conversations despite difficult circumstances and emotional reactions by activating patients and family via increased health literacy and by advancing palliative-informed practice environments.