Susan Hazelett

The association between indwelling urinary catheter use in the elderly and urinary tract infection in acute care

BackgroundThe use of indwelling urinary catheters (IUCs) is thought to be the most significant risk factor for developing nosocomial urinary tract infections (UTIs). However, it is unclear how many elderly patients have preexisting bacteriuria prior to IUC placement. The purpose of this study was to determine 1) the frequency and appropriateness of IUC use in the Emergency Department (ED) in elderly patients admitted to our acute care hospital, 2) the percentage of elderly patients with an IUC who were discharged from the hospital with a diagnosis of UTI, 3) the percentage of patients with IUCs who were diagnosed and treated for UTI in the ED or who had admission bacteriuria ≥105 organisms/ml indicating preexisting UTI, and 4) the percentage of patients with no indication of UTI on admission who had inappropriately placed IUCs and subsequently were diagnosed with a UTI.MethodsRetrospective chart review. Chi square used to test significance of differences in proportions.ResultsSeventy three percent of patients who received an IUC in the ED were elderly (≥65 years old). During the study period, 277 elderly patients received an IUC prior to admission. Of these, 77 (28%) were diagnosed with UTI during their hospitalization. Fifty three (69%) of those diagnosed with a UTI by discharge either had the UTI diagnosed in the ED or had bacteriuria ≥105 organisms/ml prior to IUC placement. Of the 24 elderly patients who developed a catheter-associated UTI (i.e., 9% of the elderly population who received an IUC), 11 of the IUCs were placed inappropriately. Thus, 4% of elderly patients with no indication of UTI on admission who received an inappropriate IUC in the ED had a primary or secondary diagnosis of UTI by discharge. The overall rate of nosocomial UTI due to an inappropriately placed IUC was the same in males and females.ConclusionThis study indicates that the strong association between IUC use and UTI may be partly explained by the high prevalence of preexisting UTI prior to IUC placement. Further prospective studies are needed to clarify the true risk vs benefit ratio for IUC use in acutely ill elderly patients.

A Randomized Trial Testing the Superiority of a Postdischarge Care Management Model for Stroke Survivors

OBJECTIVE We sought to evaluate whether comprehensive postdischarge care management for stroke survivors is superior to organized acute stroke department care with enhanced discharge planning in improving a profile of health and well-being. METHODS This was a randomized trial of a comprehensive postdischarge care management intervention for patients with ischemic stroke and National Institutes of Health Stroke Scale scores greater than or equal to 1 discharged from an acute stroke department. An advanced practice nurse performed an in-home assessment for the intervention group from which an interdisciplinary team developed patient-specific care plans. The advanced practice nurse worked with the primary care physician and patient to implement the plan during the next 6 months. The intervention and usual care groups were compared using a global and closed hypothesis testing strategy. Outcomes fell into 5 domains: (1) neuromotor function, (2) institution time or death, (3) quality of life, (4) management of risk, and (5) stroke knowledge and lifestyle. RESULTS Treatment effect was near 0 SD for all except the stroke knowledge and lifestyle domain, which showed a significant effect of the intervention (P = .0003). CONCLUSIONS Postdischarge care management was not more effective than organized stroke department care with enhanced discharge planning in most domains in this population. The intervention did, however, fill a postdischarge knowledge gap.

Physician Knowledge, Attitude, and Experience With Advance Care Planning, Palliative Care, and Hospice: Results of a Primary Care Survey

Purpose: To evaluate primary care physicians’ understanding of and experience with advance care planning (ACP), palliative care, and hospice and how this might affect their utilization of these services. Methods: Investigator-generated survey. Results: Older age, more years in practice, and more personal and professional experience with ACP were correlated with an increase in the percentage of patients with progressive, chronic life-limiting diseases with whom physicians discussed advance directives. Overall, 97.5% of physician’s expressed comfort in discussing ACP yet reported discussing advance directives with only 43% of appropriate patients. Discussion: Often, discussions about ACP or referrals to palliative care or hospice do not occur until the patient is near the end of life. Our results indicate that primary care physician’s personal and professional experience with ACP may be contributing to some of the barriers to these discussions.

Accuracy of a Bedside Dysphagia Screening: A Comparison of Registered Nurses and Speech Therapists

&NA; Evidence‐based guidelines suggest that stroke patients should be screened for dysphagia before oral intake. The purpose of this study was to validate a dysphagia screening tool comparing registered nurses (RNs) with speech therapists (STs). All stroke unit patients who received predetermined scores on specific items of the National Institutes of Health Stroke Scale were eligible for screening. The trial consisted of three parts (with swallow, cough, and vocal quality observed during each part): 1 teaspoon lemon ice, 1 teaspoon applesauce, and 1 teaspoon water. RNs performed five screenings that were compared with independent screenings performed on the same patient within 1 hour by a speech therapist (ST). Eighty‐three paired screenings were completed, with 94% agreement between the RNs and the STs. This screening identifies patients who are able to swallow and can eat from a safe menu until formally evaluated by an ST while maintaining nothing by mouth (NPO) status for those at risk for aspiration.

Developing a Stroke Unit Using the Acute Care for Elders Intervention and Model of Care

The Acute Care for Elders (ACE) model of care is a multicomponent intervention that improves outcomes for older patients hospitalized for acute medical illnesses. Likewise, stroke units improve outcomes for patients with acute stroke, yet the descriptions of their structure and approach to stroke management are heterogeneous. The purpose of this article is to describe how implementing the ACE model of care, using a continuous quality‐improvement process, can serve as a foundation for a successful stroke unit aimed at improving stroke care. The ACE intervention (a prepared environment, interdisciplinary team management, patient‐centered nursing care plans, early discharge planning, and review of medical care) was amplified in a community teaching hospital for stroke‐specific care by creating a stroke interdisciplinary team, evidence‐based stroke orders and protocols, and a redesigned environment. Administrative data show that the ACE model can be successfully adapted to create a disease‐specific program for stroke patients, having the potential to improve the process of care and clinical stroke outcomes.

Effectiveness of Chloraprep in reduction of blood culture contamination rates in emergency department.

Contaminated blood cultures result in increased healthcare utilization. Poor skin preparation is usually the cause of contamination. Our study results showed a significant decrease in contamination rates using 2% chlorhexidine and 70% isopropanol (Chloraprep™) versus tincture of iodine. Adoption of this technique throughout our institution is expected to result in a savings of

Vitamin D Supplementation to Prevent Falls in the Elderly: Evidence and Practical Considerations

875000 per year, as well as decreased discomfort for the patient.

A Validation of Self-Reported Substance Use with Biochemical Testing Among Patients Presenting to the Emergency Department Seeking Treatment for Backache, Headache, and Toothache

Pharmacists in both ambulatory and institutional settings are often in a position to help optimize the drug regimens of patients who are experiencing falls. Supplementation with vitamin D is an important emerging therapy for the prevention of falls. Numerous investigators have recently studied or reviewed the association between vitamin D supplementation and decreased risk of falls in elderly patients, yet little of this information is available in the pharmacy literature. A MEDLINE search was conducted to collect relevant articles about the role of vitamin D in preventing falls among elderly patients; recently published meta‐analyses and randomized controlled trials were identified and reviewed. The studies indicated a statistically significant positive relationship between vitamin D supplementation with either cholecalciferol 700 IU/day or greater or ergocalciferol 800 IU/day or greater and decreased risk of falls. Other practical issues, including who should receive vitamin D replacement, what form of vitamin D should be used, and what dosage is required to prevent falls, are discussed.

The Promoting Effective Advance Care for Elders (PEACE) Randomized Pilot Study: Theoretical Framework and Study Design

Purpose: This study tests the validity of self-reported illicit substance use against biochemical testing among Emergency Department (ED) patients seeking treatment with narcotics for backache, headache, and toothache and to characterize patients who provide false reports. Methods: Retrospective chart review comparing the self-reported drug use history obtained during an ED visit during a six-year period (1995–2001) with the results of a biochemical drug screen obtained the same day. Results: 248 patients met screening criteria, 79 (32%) of whom tested positive for unclaimed “drugs of abuse.” Patients with a history of “drug abuse” and chronic pain were significantly more likely to test positive for unclaimed drugs than were their counterparts (p =. 05 and p <. 0001, respectively). No significant difference was found in comparing those with and without multiple ED visits or those requesting a specific narcotic. Conclusion: Self-reported drug use is unreliable in this ED subpopulation. When this knowledge is critical for patient care, biochemical testing may be indicated.

Managing in the Trenches of Consumer Care: The Challenges of Understanding and Initiating the Advance Care Planning Process

Practice guidelines are available for hospice and palliative medicine specialists and geriatricians. However, these guidelines do not adequately address the needs of patients who straddle the 2 specialties: homebound chronically ill patients. The purpose of this article is to describe the theoretical basis for the Promoting Effective Advance Care for Elders (PEACE) randomized pilot study. PEACE is an ongoing 2-group randomized pilot study (n=80) to test an in-home interdisciplinary care management intervention that combines palliative care approaches to symptom management, psychosocial and emotional support, and advance care planning with geriatric medicine approaches to optimizing function and addressing polypharmacy. The population comprises new enrollees into PASSPORT, Ohios community-based, long-term care Medicaid waiver program. All PASSPORT enrollees have geriatric/palliative care crossover needs because they are nursing home eligible. The intervention is based on Wagners Chronic Care Model and includes comprehensive interdisciplinary care management for these low-income frail elders with chronic illnesses, uses evidence-based protocols, emphasizes patient activation, and integrates with community-based long-term care and other community agencies. Our model, with its standardized, evidence-based medical and psychosocial intervention protocols, will transport easily to other sites that are interested in optimizing outcomes for community-based, chronically ill older adults.