Victimization in Unethical Unlicensed Small Residential Care Homes in the United States: The Case for Whole System Disruption.

In the United States, small residential care homes provide affordable community-based care for disabled older adults. Also called adult foster care homes, residential care facilities, group homes, or board and care homes, small residential care homes are typically private, small businesses operating in single-family dwellings that provide round-the-clock care in a home-like setting in residential neighborhoods. While most states license small residential care homes they also exist, legally and illegally, as unlicensed and unregulated operations. The quality of care in some unlicensed and unregulated small residential care homes can be questionable. Disabled older adults are targeted and victimized by unethical small residential care home operators for financial gain. This commentary highlights the need for whole system disruption to end victimization in unethical unlicensed and unregulated small residential care homes through case studies of the abuse and neglect of residents living in unethical unlicensed operations and recommends ambitious goals centered on reducing secondary financial gains and medically neglectful practices. These recommendations are at federal, state, and local levels, and include creating a federal definition of small residential care homes, increasing and coupling government incomes with state registration and employee misconduct registry checks, increasing oversight and assessment, improving temporary guardianship processes, providing avenues for reporting abuse, and developing older adult fatality review teams.

Learning from suicide deaths in Harris County, Texas.

This study examined individual and community demographic characteristics surrounding suicides in one of the most populous counties in the United States. We paired medical examiner records with U.S. Census data and analyzed them using geospatial software. The majority of decedents were non-Hispanic, white males who died primarily of gunshot wounds. Salient age characteristics included interpersonal violence and depression among ages younger than 40. Despite lower incomes and education levels, areas with higher population density and racial/ethnic minorities had fewer suicides. Additional research should address depression among males and the elderly, interpersonal violence, firearm access, and culture.

Nursing Care for Extracorporeal Membrane Oxygenation in the Trauma Patient.

Trauma patients that survive the immediate threat of death are at risk for potentially life-threatening complications such as acute respiratory distress syndrome and multisystem organ failure. Extracorporeal membrane oxygenation (ECMO) use in trauma patients has largely been controversial for concerns of inducing major hemorrhage with the use of systemic anticoagulation to prevent thrombus development while connected to the ECMO circuit. There is limited data available for specific guidelines for optimal management of the trauma population; however, recent studies suggest comparable outcomes to those of nontrauma patients treated with ECMO. The purpose of this case study was to introduce indications for implementation of ECMO in the trauma patient for pulmonary and hemodynamic compromise, describe the procedure of ECMO insertion, and delineate clinical expectations of the intensive care unit nurse within the multidisciplinary ECMO team. This case study presents a 28-year-old man who sustained a gunshot wound of the chest and was ultimately treated with ECMO for pulmonary compromise due to acute respiratory distress syndrome.

Establishing a Regional Trauma Preventable/Potentially Preventable Death Rate.

OBJECTIVE: To establish a trauma preventable/potentially preventable death rate (PPPDR) within a heavily populated county in Texas. SUMMARY: The National Academies of Sciences estimated the trauma preventable death rate in the United States to be 20%, issued a call for zero preventable deaths, while acknowledging that an accurate preventable death rate was lacking. In this absence, effective strategies to improve quality of care across trauma systems will remain difficult. METHODS: A retrospective review of death-related records that occurred during 2014 in Harris County, TX, a diverse population of 4.4 million. Patient demographics, mechanism of injury, cause, timing, and location of deaths were assessed. Deaths were categorized using uniform criteria and recorded as preventable, potentially preventable or nonpreventable. RESULTS: Of 1848 deaths, 85% had an autopsy and 99.7% were assigned a level of preventability, resulting in a trauma PPPDR of 36.2%. Sex, age, and race/ethnicity varied across preventability categories (P < 0.01). Of 847 prehospital deaths, 758 (89.5%) were nonpreventable. Among 89 prehospital preventable/potentially preventable (P/PP) deaths, hemorrhage accounted for 55.1%. Of the 657 initial acute care setting deaths, 292 (44.4%) were P/PP; of these, hemorrhage, sepsis, and traumatic brain injury accounted for 73.3%. Of 339 deaths occurring after initial hospitalization, 287 (84.7%) were P/PP, of these 117 resulted from sepsis and 31 from pulmonary thromboembolism, accounted for 51.6%. CONCLUSIONS: The trauma PPPDR was almost double that estimated by the National Academies of Sciences. Data regarding P/PP deaths offers opportunity to target research, prevention, intervention, and treatment corresponding to all phases of the trauma system.

Establishing a regional pediatric trauma preventable/potentially preventable death rate.

PURPOSE: Although trauma is the leading cause of death for the pediatric population, few studies have addressed the preventable/potentially preventable death rate (PPPDR) attributable to trauma. METHODS: This is a retrospective study of trauma-related death records occurring in Harris County, Texas in 2014. Descriptive and Chi-squared tests were conducted for two groups, pediatric and adult trauma deaths in relation to demographic characteristics, mechanism of injury, death location and survival time. RESULTS: There were 105 pediatric (age < 18 years) and 1738 adult patients. The PPPDR for the pediatric group was 21.0%, whereas the PPPDR for the adult group was 37.2% (p = 0.001). Analysis showed fewer preventable/potentially preventable (P/PP) deaths resulting from any blunt trauma mechanism in the pediatric population than in the adult population (19.6% vs. 48.4%, p < 0.001). Amongst the pediatric population, P/PP traumatic brain injury (TBI) were more common in the youngest age range (age 0-5) vs. the older (6-12 years) pediatric and adolescent (13-17 years) patients. CONCLUSION: Our results identify areas of opportunities for improving pediatric trauma care. Although the overall P/PP death rate is lower in the pediatric population than the adult, opportunities for improving initial acute care, particularly TBI, exist.

A Descriptive and Geospatial Analysis of Environmental Factors Attributing to Sudden Unexpected Infant Death.

This study examined medicolegal death investigation records and autopsy reports of a medical examiner's office to identify the circumstances surrounding sudden unexpected infant deaths (SUID) and geospatial analyses to pinpoint areas of infant death concentration. Analysis of 732 records of SUID deaths occurring in a 10-year span resulted in the conclusion that environmental factors associated with the sudden death were to some extent modifiable. Co-sleeping (sharing a sleeping surface, or bed-sharing) on various surfaces (mattress, pallet, couch) occurred in 53.4% of the infant deaths. Geographic areas where the largest number of deaths occurred were characterized as areas of high poverty level. The inclusion of additional information at the time of investigation (eg, alcohol and tobacco use of co-sleepers, illness of others in household, exceptions to normal sleep routine of infant) may aid in identifying modifiable circumstances to reduce infant mortality attributable to sudden infant death.

Improving medicolegal death investigative gaps of fatal elder abuse.

The purpose of this brief is to present several case vignettes that illustrate omissions in the investigation of elder deaths. These vignettes demonstrate the need for a standardized approach in the conduct of medicolegal investigations of fatal elder abuse. For each of the described oversights, a recommendation is offered to address the gap in investigation processes, which in turn could improve the determination of cause and manner of elder death. Inherent limitations of resources and practical realities of death investigation are discussed and recommendations are made for future research. Viewed broadly, deficiencies in elder death investigations can lead to the underreporting of elder abuse and the reduction of legal options for victims, which may reflect a systemic pattern of social injustice.

Ethical Considerations on Disclosure When Medical Error Is Discovered During Medicolegal Death Investigation.

In the course of fulfilling their statutory role, physicians performing medicolegal investigations may recognize clinical colleagues' medical errors. If the error is found to have led directly to the patient's death (missed diagnosis or incorrect diagnosis, for example), then the forensic pathologist has a professional responsibility to include the information in the autopsy report and make sure that the family is appropriately informed. When the error is significant but did not lead directly to the patient's demise, ethical questions may arise regarding the obligations of the medical examiner to disclose the error to the clinicians or to the family. This case depicts the discovery of medical error likely unrelated to the cause of death and describes one possible ethical approach to disclosure derived from an ethical reasoning model addressing ethical principles of respect for persons/autonomy, beneficence, nonmaleficence, and justice.

A social media program to increase adolescent seat belt use.

In response to motor vehicle crashes remaining the leading cause of death for teenagers in the United States, a nursing clinical group (n = 10) in conjunction with a local hospital injury prevention program created an educational campaign to bolster seat belt use. The nursing students created an Instagram account to serve as an educational tool to promote seat belt use among teenagers aged 14-19, and the program was presented at three high school health fairs. In all, 135 postings were made to the account over a 3-month period. The number of likes posted by high school students was the unit of analysis. The most significant result (p = .01) was the difference between postings most liked (celebrities wearing seat belts) and least liked (postings made at the high school health fair), otherwise, differences among postings liked (humor postings, response requests, pictures of celebrities, factual data) were not significant. Instagram user engagement, measured in number of likes, is indicative that social media provides platforms to promote injury prevention efforts. Further research is needed to identify measurable elements of social media and to follow-up on behavioral changes following participation.

Effects of a Systematic Quality Improvement Process to Decrease Complications in Trauma Patients With Prehospital Peripheral Intravenous Access.

Peripheral intravenous (PIV) catheterization is commonly performed, and its complications are costly, may result in serious health issues, and may adversely affect patient satisfaction. At our large urban Level I trauma center, we identified a cluster of 7 PIV complications from prehospital insertions in a 5-month period. Several of the patients developed noninfectious as well as infectious, limb-threatening complications requiring aggressive operative intervention. A performance improvement project was chartered to identify the cause of PIV complications and review current nursing practice. The FOCUS-Plan Do Check Act methodology was used to measure and improve practice. With implementation of interventions and outcomes monitoring, no PIV complications were reported for the subsequent 39 consecutive months. Our findings have implications for more controlled studies to establish best practice at other Level I trauma centers across the country.

Suicide Within 72 Hours After Discharge From Health Care Settings: Decedent Characteristics.

Health care providers have the challenge of identifying patients at risk of committing suicide after discharge from their care. The aim of this study was to identify and describe the population committing suicide less than 72 hours after discharge from medical care. Between 2006 and 2014 in Harris County, Texas, 30 individuals were identified who met these criteria. The decedents included 27 men and 3 women with a mean age of 43.5 years. The cause of death in most cases was gunshot wound of the head. Five of the decedents had requested discharge or left against medical advice and 24 committed suicide within 24 hours. Although the sample size is small, it is one of the largest cohorts of its type.

Forensic nursing science knowledge and competency: the use of simulation.

Forensic nursing is a nursing specialty that provides services to a variety of patient populations who have experienced violence, including interpersonal violence, sudden or unexpected death, and motor vehicle collisions. However, many critical care nurses have received the background knowledge or practical skills required to provide the level of care required by many forensic patients. The purpose of this study was to determine whether differences in knowledge or practical competence exist between participants using 2 different learning modalities: medium fidelity simulation versus face-to-face lecture. Participants who were enrolled in an elective online forensic nursing science course were randomly assigned to an intervention or control group. The 18 intervention group participants were given three 2-hour forensic simulation sessions in the laboratory. The 17 control group participants attended 3 face-to-face lectures covering forensic science topics. All study participants also received the same forensic course content via the online Blackboard platform. No significant differences were found between the 2 groups in either knowledge or practical competency. The lack of results may have been heavily influenced by the small sample size, which resulted in insufficient power to detect possible differences.

Comparing survival rates and mortality in operative versus nonoperative treatment for femoral neck fractures among Alzheimer's disease patients: A retrospective cohort study.

Introduction: Addressing femoral neck fractures resulting from ground-level falls in older adults with Alzheimer's disease (AD) involves a personalized treatment plan. There is considerable ongoing debate concerning the relative advantages and disadvantages of surgical treatment (internal fixation or arthroplasty) vs nonoperative treatment for femoral neck fractures in older persons with AD. Methods: This retrospective cohort study compared the mortality, hazard ratio, and survival rate between operative and nonoperative treatments, controlling for patients' demographic information and baseline health status. The study population consisted of Optum beneficiaries diagnosed with AD who experienced an initial femoral neck fracture claim between January 1, 2012, and December 31, 2017. Kaplan-Meier survival curves were applied to compare the treatment groups' post-fracture survival rates and mortality. Cox regression was used to examine the survival period by controlling the covariates. Results: Out of the 4157 patients with AD with femoral neck fractures, 59.8% were women (n = 2487). The median age was 81 years. The 1-year survival rate for nonoperative treatment (70.19%) was lower than that for internal fixation (75.27%) and arthroplasty treatment (82.32%). Compared with the nonoperative group, arthroplasty surgical treatment had significant lower hazard risk of death (arthroplasty hazard ratio: 0.850, 95% CI: 0.728-0.991, P < 0.05). Discussion: The findings suggest that the operative treatment group experiences higher survival rates and lower mortality rates than the nonoperative group. This paper provides insights into treatment outcomes of older adults with AD receiving medical care for femoral neck fractures.

A scoping review of nursing education for firearm safety.

BACKGROUND: Firearm violence, whether intentional or accidental, affects families worldwide. Nurses often encounter firearm-related injury and death with little knowledge or preparation for dealing with firearm safety issues. OBJECTIVES: The aim was to locate published research on nurse education in firearm safety and examine the preparation of nurses to deal with issues of firearm safety as a deterrent toward decreasing violence. The review included nurse perceptions of barriers and facilitators related to firearm safety in clinical situations. DESIGN: A literature scoping review for article identification, examination, and reporting was structured on the extended form of Arksey and O'Malley's 5-step design framework. DATA SOURCES: Databases CINAHL, MEDLINE, Sociological Abstracts, PsychInfo, and ERIC were searched for articles in English language published between 2010 and 2021 that included nurses in the studies' samples. REVIEW METHODS: Searches were managed via Covidence®, a literature screening and data extraction tool. Two independent reviewers screened the articles retrieved from the databases by title, abstract, and full-text review. Data from selected articles were extracted onto a spreadsheet and critically appraised for eligibility. RESULTS: A search of healthcare databases resulted in identification of 645 articles, of which 15 met inclusion criteria. Seven of the 15 articles addressed nurse firearm safety preparation, and seven related to counseling firearm safety for suicide prevention. Main barriers included lack of standardized guidelines, inadequate knowledge, and discomfort discussing firearm safety with patients and families. CONCLUSIONS: The scoping review findings show a noticeable gap: nurse education addressing firearm safety is, for all purposes, non-existent. A need exists for evidence-based training within academic curricula and across acute and behavioral healthcare settings.

The silent killer: Previously undetected pulmonary emboli that result in death after discharge.

INTRODUCTION: Pulmonary embolism (PE) is a recognized cause of death in hospitalized trauma patients, yet less is known about PE after discharge. PATIENTS & METHODS: All post-discharge, autopsy-demonstrated, fatal PE resulting from trauma within a large US county over six years were analyzed. Counts, percentages, mean values, SD, and IQR were calculated for all variables. RESULTS: 1848 trauma deaths were reviewed, of which 85% had an autopsy. Eighty-five patients died from PE after discharge from their initial injury. 53% were initially treated at non-trauma centers, and 9% did not seek medical assistance. 75% were injured by falling, and most injuries occurred in the lower extremities. 86% had an ISS <16, but 87% needed assistance or were bed-bound after injury, despite 75% having no mobility limitations before the injury. 53% died within one month of injury, and 91% within the first year. Before death, only 11% were prescribed chemical thromboprophylaxis or an antiplatelet agent, and only 8% were diagnosed with venous thromboembolism before death. CONCLUSIONS: Fatal PE after discharge typically occurred following activity-limiting lower extremity injuries with an ISS<16.

Trauma-Informed Approaches to Medicolegal Death Investigation: A Forensic Nursing Perspective.

ABSTRACT: Forensic nurses engaged in medicolegal death investigations experience trauma-induced responses in responding to, investigating, and documenting sudden unexpected deaths. The trauma of these repeated experiences often results in diminished performance, job dissatisfaction, and burnout. The principles of trauma-informed care are not new but have not been incorporated into death investigation practices. When coupled with medicolegal death investigation procedures, application of these principles can help to alleviate distress for forensic nurses, colleagues, and decedents of concerned families. This case series illustrates how the principles of trauma-informed care can be implemented to enhance communication, deescalate emotional or threatening situations, and prevent retraumatization in the context of medicolegal death investigations.

Exploring the complexity of firearm homicides in Harris County, Texas, from 2009 to 2021: Implications for theory and prevention.

Firearm violence is a major health problem in the United States that clusters asymmetrically across geographic and demographic lines, and the persistence and unequal distribution of firearm violence suggests that novel causal explanations and theoretical frameworks may be warranted to guide preventive strategies. Thus, this study explores the following three hypotheses that are grounded in complex systems theory: 1) trends in firearm homicides risks have shifted heterogeneously in Harris County across endemic degree of risk; 2) firearm homicides clusters have remained resilient in Harris County across the study time period; and 3), the associations between known contextual correlates of firearm homicides and the distribution of firearm homicides risks in Harris County have manifested as nonlinear. Using a retrospective study design (n = 4,397) from January 1, 2009-June 31, 2021, medicolegal death investigation data from the Harris County Institute of Forensic Sciences and estimates of community characteristics from the American Community Survey were analyzed using Joinpoint trend analysis, kernel density geospatial analysis, and proportion tests. Trend analyses revealed that firearm homicides risks shifted heterogeneously across endemic degree of risk, with geographical areas with lower initial firearm homicides risks experiencing more profound upward shifts across the time period of the study. Geospatial analyses identified the resiliency of firearm homicides clusters across the study period, particularly in central, southern, and south-western districts of the city. Finally, the relationships between known contextual correlates and the distribution of firearm homicides risks in Harris County appeared to be nonlinear, particularly regarding ethnicity. This study provides data-driven results that suggest the plausibility of complex systems theory in advancing the understanding of causality in firearm homicides. Further, these findings support the urgent need for complex systems-informed preventive efforts that account for spatiotemporal heterogeneity, key interactions that generate nonlinearity, and latent feedback loops that underlie resiliency in firearm homicides.

Barriers to consistent and reliable investigation of sudden unexpected infant death: Perspectives from law enforcement.

Despite persistent efforts to advance infant death investigation, most sudden unexpected infant deaths (SUIDs) remain unexplained. Law enforcement officials contribute to SUID investigations throughout the United States, but their impacts on these investigations have not been adequately examined. In this exploratory study, 26 law enforcement officials were interviewed about their experiences and perspectives with SUID investigations. Thematic analysis of qualitative data revealed three specific difficulties law enforcement encounter during SUID investigations: (1) inadequate preparation; (2) overwhelming emotions; and (3) a victim-suspect dilemma. Findings indicate that these barriers may inhibit consistent and reliable investigation of infant death and, therefore, may impede the cause and manner of death determinations. Participants' narratives also offered insights into potential solutions, including expanded SUID training for law enforcement and use of checklists, such as the Sudden Unexpected Infant Death Investigation Reporting Form. The impacts of overwhelming emotions confronted during SUID investigation warrant further study. The victim-suspect dilemma stems from the inability of law enforcement to conclusively eliminate the possibility of homicide. This dilemma may be resolved through a clear distinction between interactions with potential evidence and interactions with the family. Law enforcement must be trained to treat all SUID families in a compassionate and non-accusatory manner, while investigating all SUID with careful attention to detail that is essential in any potential homicide investigation. A consistent, meticulous, and compassionate approach to SUID investigations will improve the reliability of information obtained and offer the best opportunity for providing answers to grieving parents.

Rural-urban, age, and gender disparities and trends in suicide and homicide: Multistate evidence across 12 years.

PURPOSE: Few studies have simultaneously assessed age and gender trends in homicide and suicide across the rural-urban continuum. Herein, we examine geographic and demographic trends in suicide and homicide death rates by: (1) determining overall macro and disaggregated trends; (2) examining differences in trends based on rural-urban county classification; and (3) identifying differences in stratified trends among age and gender classifications. METHODS: A retrospective study design used suicide and homicide data (n = 199,456) from years 2005to 2017 across 16 US states. Suicide and homicide deaths were grouped by age, gender, and rural-urban classification for descriptive analyses, and trends were analyzed using Joinpoint trend analysis software. FINDINGS: Violence resulted in 142,470 suicide and 56,986 homicide deaths between 2005 and 2017. Among both males and females, overall macro trends of suicide and homicide rates generally increased with greater rurality, and trends in rural rates differed from those in nonrural areas. Joinpoint trend analysis revealed significant increases in male suicide rates in large metropolitan (1.66%), micropolitan (1.78%), and rural areas (1.77%); female suicide rates in large metropolitan (2.17%), small metropolitan (3.25%), and micropolitan areas (3.26%); male homicide rates in large metropolitan areas (10.19%); and female homicide rates in rural areas (8.29%). Finally, when stratified by age, several significant trends were found, including increases in suicide rates among females aged 64 and older in rural areas (11.71%). CONCLUSIONS: Heterogeneous trends were found in suicide and homicide rates within specific rural-urban, age, and gender subgroups. Prevention efforts should proactively target those subgroups identified herein as most at-risk of violence.

Medicolegal death investigator workplace safety hazards: A scoping review of the literature.

In the United States, medicolegal death investigation practices and policies pertaining to sudden unexpected deaths are mandated by state government. Practices vary across states, which contributes to inconsistency in job prerequisites and training. In preparation for a study focused on occupational safety and health of medicolegal death investigators in their on-scene and follow-up activities, a scoping review was conducted to document known occupational safety risks and health-related conditions associated with death investigation. Searches used Boolean and subject heading operators both broad and narrow in scope, and search terms included scene responder, hazard, investigator, forensic pathology, injury, and safety. Twenty-five articles met inclusion criteria, which included seventeen survey-mixed method designs, two systematic reviews, five quasi-experimental designs, and one case study. Twelve articles addressed mental health and eleven focused on risks associated with infectious disease. One article addressed the risk of chemical exposure from cyanide among autopsy personnel (including forensic pathologists) and nine included a wide range of employees within the setting of medical examiner or coroner offices. One article, addressing burnout, included employees in a forensic science laboratory setting as well as medicolegal death investigators and two articles included forensic pathologists and medicolegal death investigators. Only one article addressed medicolegal death investigators specifically. Articles addressing occupational and environmental hazards of medicolegal death investigators associated with musculoskeletal, respiratory, cardiovascular, radiological, nuclear, electrical, or explosive threats were not identified. There is little published about safety risks inherent in conducting death investigations. Research is needed to adequately inform health promotion and injury prevention strategies.