Exploring family relationships through associations of comfort, relatedness states, and life closure in hospice patients: A pilot study.

OBJECTIVE: Research at the end of life tends to focus on the dying patient's symptoms, often overlooking issues associated with family interactions. However, many families struggle just to maintain or initiate these valuable connections. The purpose of our pilot study was to explore family relationships at the end of life and investigate associations among perceived comfort, relatedness states, and life closure. METHOD: This descriptive study used a cross-sectional design, and a convenience sample (n = 30; 18 women; mean age = 71 years) was recruited from patients admitted to a large not-for-profit hospice in northeastern Ohio. In-person interviews using the Hospice Comfort Questionnaire, Relatedness States Visual Analog Scales, and the Life-Closure Scale provided data for analyses. RESULTS: Family interactions that were not associated with the physical tasks of caregiving were related to life closure (r = 0.36, p = 0.001), and life closure and comfort were highly correlated (r = 0.69, p < 0.001). Participants residing in an inpatient setting had higher levels of involvement (t[18] = -2.07, p = 0.05) and comfort in relationships (t[28] = -2.06, p = 0.05) than those in the home setting. SIGNIFICANCE OF RESULTS: This is the first known study investigating the associations among comfort, relatedness, and life closure at the end of life. The majority of participants had high levels of involvement and comfort in their relationships, and they preferred interactions that required minimal effort. Studies that focus on both patients' and family members' perceptions of relationships are needed as well as outcome studies that test simple interventions.

Epidermal growth factor receptor (EGFR), HER2 and insulin-like growth factor-1 receptor (IGF-1R) status in ovarian adult granulosa cell tumours.

AIMS: Adult granulosa cell tumours (AGCTs) are uncommon ovarian sex cord-stromal tumours which recur following surgical removal in up to 50% of patients. Treatment options for recurrent and advanced stage AGCTs are limited, with poor response to chemotherapy and radiotherapy. We aimed to assess epidermal growth factor receptor (EGFR), HER2 and insulin-like growth factor-1 receptor (IGF-1R) status in AGCTs with a view to investigating whether or not these receptors might be potential therapeutic targets in these neoplasms. METHODS AND RESULTS: Immunohistochemical staining for EGFR, HER2 and IGF-1R was undertaken in 31 AGCTs. Tumour DNA was also analysed for mutations in the tyrosine kinase domain of EGFR (exons 18-21) by Cobas mutation RT-PCR. Twenty-three of 31 (74%) AGCTs showed some degree of EGFR expression, generally with cytoplasmic or mixed membranous and cytoplasmic staining of variable intensity. Eleven of 27 (41%) cases exhibited strong membranous and cytoplasmic expression of IGF-1R. HER2 expression was not seen. No mutations were found in exons 18-21 of the EGFR gene in hot-spots of therapeutic relevance. CONCLUSIONS: This study raises the possibility that anti-EGFR and/or anti-IGF-1R therapies may be of potential benefit in ovarian AGCTs, and this requires further study. Lack of known mutations within the tyrosine kinase domain of EGFR suggests that EGFR-related tyrosine kinase inhibitors may not be useful therapeutically.

Hospital lighting and its association with sleep, mood and pain in medical inpatients.

AIMS: To describe light exposure, sleep-wake patterns, mood, pain and their relationships in adult medical inpatients. BACKGROUND: The hospital environment may contribute to patient discomfort by providing a lighting structure that interferes with circadian rhythmicity, sleep, mood and pain. DESIGN: A descriptive correlational design was used in this preliminary study. METHODS: Between May 2011-April 2012, data were collected from a convenience sample of 23 women and 17 men admitted to a large academically affiliated hospital in the United States. Over 72 hours, light exposure and sleep-wake patterns were continuously measured with wrist actigraph/light meters for each participant. Mood was measured daily using the Profile Of Mood States Brief™ Form. Subjective pain scores were abstracted from medical records. RESULTS: Light exposure levels were low: mean daytime light intensity was 104·80 lux. Sleep time was fragmented and low: mean 236·35 minutes of sleep/night. Intra-daily stability scores indicated little sleep-wake synchronization with light. Fatigue and total mood disturbance scores were high and inversely associated with light. Pain levels were also high and positively associated with fatigue, but not directly with light exposure. Low light exposure significantly predicted fatigue and total mood disturbance. CONCLUSION: Medical inpatients were exposed to light levels insufficient for circadian entrainment. Nevertheless, higher light exposure was associated with less fatigue and lower total mood disturbance in participants with pain, suggesting the need for further investigation to determine if manipulating light exposure for medical inpatients would be beneficial in affecting sleep-wake disturbances, mood and pain.

The oncology acuity tool: a reliable, valid method for measuring patient acuity for nurse assignment decisions.

BACKGROUND AND PURPOSE: Matching nurse assignments with patient acuity has critical implications for providing safe, effective, and efficient care. Despite this, we lack well-established methods for accurate assessment of acuity. This study aimed to evaluate the reliability and validity of the Oncology Acuity Tool (OAT), which is used for determining nurse assignments. METHODS: Inter-rater reliability and concurrent validity were assessed via surveys of current users of the tool. Content validity data were collected from expert oncology nurses. Predictive validity was assessed by tracking patients who sustained either of two acute events. RESULTS: Findings included high inter-rater reliability, moderately strong concurrent validity, and moderate content validity. Acuity significantly predicted rapid response team consults but not falls. CONCLUSIONS: The OAT demonstrated sufficient reliability and validity for measuring acuity prospectively in this population.

Facilitated sensemaking: a feasibility study for the provision of a family support program in the intensive care unit.

Family members of intensive care unit patients may develop anxiety, depression, and/or posttraumatic stress syndrome. Approaches to prevention are not well defined. Before testing preventive measures, it is important to evaluate which interventions the family will accept, use, and value. The purpose of this study was to evaluate the feasibility of an intervention for support for families of mechanically ventilated adults, grounded in a new midrange nursing theory titled "Facilitated Sensemaking." Families were provided a kit of supplies and the primary investigator coached families on how to obtain information, interpret surroundings, and participate in care. Participants were asked to complete an adapted Critical Care Family Needs Inventory and Family Support Program evaluation. Family members of 30 patients consented to participate; 22 participants completed the surveys. Internal consistency reliability of the adapted Critical Care Family Needs Inventory was high (alpha = .96). Results validated the importance of informational needs and provided a score indicating the family member's perception of how well each need was met, weighted by importance, which identified performance improvement opportunities for use by clinical managers. The program evaluation confirmed that families will use this format of support and find it helpful. Personal care supplies (eg, lotion, lip balm) were universally well received. Forty-two referrals to ancillary service were made. Operational issues to improve services were identified. As proposed in the Facilitated Sensemaking model, family members welcomed interventions targeted to help make sense of the new situation and make sense of their new role as caregiver. Planned supportive interventions were perceived as helpful.

Predicting posthospital recovery of physical function among older adults after lower extremity surgery in a short-stay skilled nursing facility.

This study describes the posthospital recovery of physical function among 131 older adults after lower extremity surgery in a short-stay skilled nursing facility (SNF), and identifies admission factors predicting physical function at discharge. Multiple regression analyses found that older adults with low baseline physical function, pressure ulcer, malnutrition, memory loss upon admission, and not enough physical therapy had poor physical function at the time of discharge from the facility. This study generated the following recommendations for nurses working in short-stay SNFs: (1) screen all posthospital residents at admission with predictors to identify people at risk for physical functional decline, (2) design and implement targeted nursing and rehabilitation interventions to improve physical function, and (3) develop discharge plans that provide ongoing monitoring and interventions for community or nursing home nurses.

Use of a verbal electronic audio reminder with a patient hand hygiene bundle to increase independent patient hand hygiene practices of older adults in an acute care setting.

BACKGROUND: We hypothesized that the addition of a novel verbal electronic audio reminder to an educational patient hand hygiene bundle would increase performance of self-managed patient hand hygiene. METHODS: We conducted a 2-group comparative effectiveness study randomly assigning participants to patient hand hygiene bundle 1 (n = 41), which included a video, a handout, and a personalized verbal electronic audio reminder (EAR) that prompted hand cleansing at 3 meal times, or patient hand hygiene bundle 2 (n = 34), which included the identical video and handout, but not the EAR. The primary outcome was alcohol-based hand sanitizer use based on weighing bottles of hand sanitizer. RESULTS: Participants that received the EAR averaged significantly more use of hand sanitizer product over the 3 days of the study (mean ± SD, 29.97 ± 17.13 g) than participants with no EAR (mean ± SD, 10.88 ± 9.27 g; t73 = 5.822; P ≤ .001). CONCLUSIONS: The addition of a novel verbal EAR to a patient hand hygiene bundle resulted in a significant increase in patient hand hygiene performance. Our results suggest that simple audio technology can be used to improve patient self-management of hand hygiene. Future research is needed to determine if the technology can be used to promote other healthy behaviors, reduce infections, and improve patient-centered care without increasing the workload of health care workers.

Cytokines in chronically critically ill patients after activity and rest.

Inflammation, a common problem for patients in the intensive care unit (ICU), frequently is associated with serious and prolonged critical illnesses. To date, no study has examined whether physical activity influences inflammatory factors in critically ill adults. The objectives of this study were to (a) examine the relationships between type and duration of physical activity and serum levels of interleukin 6 (IL-6), a proinflammatory cytokine; IL-10, an anti-inflammatory cytokine; and their ratio and (b) determine if there are associations between cytokines or their ratio and activity or outcomes. This descriptive feasibility study investigated the approaches to measuring levels of physical activity and its relationship to serum levels of IL-6 and IL-10 and the ratio between them in patients with prolonged mechanical ventilation during periods of activity and rest. Measurements included serum IL-6 and IL-10 levels, direct observation and actigraphy, and prospective chart review. Ten critically ill patients who were mechanically ventilated for an average of 10 days in a large, urban, teaching hospital were enrolled. The average ratio of IL-6 to IL-10 improved after an average of 14.7 min of passive physical activity, typically multiple in-bed turns associated with hygiene. IL-6, IL-10, and their ratio were not associated with patient outcomes of weaning success or length of stay. High levels of IL-6 were associated with mortality. Cytokine balance may be improved by low levels of activity among patients with prolonged critical illness. The pattern of cytokines produced after activity may improve patients' recovery from prolonged critical illness and mechanical ventilation.

An online course improves nurses' awareness of their role as antimicrobial stewards in nursing homes.

BACKGROUND: To support the role of nurses as active proponents of antimicrobial stewardship in long-term care facilities, we developed an educational intervention consisting of a free online course comprised of 6 interactive modules. Here, we report the effect of the course on the knowledge, beliefs, and attitudes toward antimicrobial stewardship of nurses working in long-term care facilities. METHODS: We used a paired pre- and postcourse survey instrument to assess nurses' knowledge regarding the care of long-term care facility residents with infections and attitudes and beliefs regarding antimicrobial stewardship. RESULTS: There were 103 respondents, registered nurses or licensed practical nurses, who completed the pre- and postsurveys. Their mean knowledge scores improved from 75% (precourse) to 86% (postcourse, P <.001). After the course, nurses' agreement that their role influences whether residents receive antimicrobials increased significantly (P <.001). CONCLUSIONS: The online course improves nurses' knowledge regarding the care of long-term care facility residents with infections and improves their confidence to engage in antimicrobial stewardship activities. Empowering nurses to be antimicrobial stewards may help reduce unnecessary antibiotic use among institutionalized older adults.

Initial evaluation of a computer-based medication management tool in a geriatric clinic.

BACKGROUND: Optimal management of medication regimens remains a challenge for elderly patients and their providers. Tools that aid communication and adherence can be valuable but often do not meet expectations. OBJECTIVE: The purpose of this article was to describe the development and preliminary evaluation of a computer-based medication management tool, the Visual Medication Profile (VMP), and to report initial feedback from geriatric patient and provider focus groups. METHODS: For VMP development, an interdisciplinary team (ie, physicians, nurses, pharmacists, computer analysts, and programmers) designed the fully automated, Web-based intervention that integrates the Veterans Affairs Medical Center (VAMC) computer pharmacy system with the computerized patient record system. In addition to development of the required technology, a mixed methods design and a convenience sample were used to collect pilot data related to patient-provider issues about medication management, and the acceptance, feasibility, and usefulness of the VMP. This involved the use of focus groups and a pilot study group. RESULTS: First, the interdisciplinary team developed the VMP by integrating data from the pharmacy database, the patient's database, and a pill photograph database. Second, patients and providers in the focus groups discussed medication management issues and evaluated a sample VMP. Patients (n = 8; mean age, 76 years; 5 black, 3 white) noted the following medication management problems: (1) not understanding the information provided by the physician; (2) multiple providers; and (3) unpronounceable names of medications. Providers (n = 8 [4 physicians, 4 nurse practitioners]) noted that patients and providers use different language to discuss medications; that there is a lack of congruence between patients' self-report of current medications and their medical record; and that there are severe time constraints for clinic appointments and concern regarding introducing a new clinical tool. Both groups favored a VMP-like tool to improve communication. In the VMP prototype pilot study, a patient-specific VMP was developed for each of 6 subjects (mean age, 79.7 years; 3 black, 3 white) from the outpatient geriatric clinic. Congruence rates ranged from 51% to 100%. Five of the 6 subjects participated in follow-up. The nurse's telephone log from the pilot study revealed that although 4 out of the 5 subjects and/or caregivers reported that they favored the VMP as a medical management tool, the use of the VMP at home varied considerably. CONCLUSIONS: The VMP is a promising tool for use by both patients and providers to improve medication management. Although it was developed in the VAMC system, its Web-based platform has the potential for export to other systems.

Assessing nutritional status in chronically critically ill adult patients.

BACKGROUND: Numerous methods are used to measure and assess nutritional status of chronically critically ill patients. OBJECTIVES: To discuss the multiple methods used to assess nutritional status in chronically critically ill patients, describe the nutritional status of chronically critically ill patients, and assess the relationship between nutritional indicators and outcomes of mechanical ventilation. METHODS: A descriptive, longitudinal design was used to collect weekly data on 360 adult patients who required more than 72 hours of mechanical ventilation and had a hospital stay of 7 days or more. Data on body mass index and biochemical markers of nutritional status were collected. Patients' nutritional intake compared with physicians' orders, dieticians' recommendations, and indirect calorimetry and physicians' orders compared with dieticians' recommendations were used to assess nutritional status. Relationships between nutritional indicators and variables of mechanical ventilation were determined. RESULTS: Inconsistencies among nurses' implementation, physicians' orders, and dieticians' recommendations resulted in wide variations in patients' calculated nutritional adequacy. Patients received a mean of 83% of the energy intake ordered by their physicians (SD 33%, range 0%-200%). Patients who required partial or total ventilator support upon discharge had a lower body mass index at admission than did patients with spontaneous respirations (Mann-Whitney U = 8441, P = .001). CONCLUSIONS: In this sample, the variability in weaning progression and outcomes most likely reflects illness severity and complexity rather than nutritional status or nutritional therapies. Further studies are needed to determine the best methods to define nutritional adequacy and to evaluate nutritional status.

Shared Medical Appointments: Impact on Clinical and Quality Outcomes in Veterans With Diabetes.

Managing diabetes poses substantial challenges to the over 29.1 million Americans afflicted, and is financially overwhelming to the US health care system. One potential strategy is utilizing a group approach to care delivery or shared medical appointment (SMA). The purpose of this 3-year retrospective VA study was to investigate differences in clinical and quality outcome measures in veterans with type 2 diabetes who used SMAs and those who received only usual care (UC) one-on-one with their doctor. This observational, 2-group cohort study used abstracted medical records from a large Midwestern Veterans Administration hospital. Clinical outcome metrics included hemoglobin A1c (hbA1c), systolic blood pressure, low-density lipoprotein cholesterol, and emergency department (ED) visits. Quality outcomes included Veterans' Administration (VA) Department of Defense clinical practice guidelines for the management of diabetes. A total of 988 total VA cases were examined retrospectively over 3 years: 371 cases had used SMAs and 617 were in the UC cohort, and had never attended a diabetes SMA. The study period used abstracted VA medical records from 2008 to 2010. There were no statistically significant differences in HbA1c, systolic blood pressure, and ED visits between groups; however, hbA1c for individuals who attended SMAs was 8.55 (standard deviation [SD] = 1.72) and UC was 7.49 (SD = 1.28) (P < .001). All clinical outcomes were worse at baseline for the SMA cohort. UC had mean ED visits/3 years (mean = 18.62, SD = 13.53, P < .001) versus SMA participants (mean = 27.97, SD = 14.00, P <. 001), revealing a propensity for high health care utilization. SMA providers had statistically significant differences over UC cases on quality measures, including ordering annual ophthalmology and podiatry examinations (P < .001) and prescribing aspirin and angiotension-converting enzyme inhibitors (ACE-I). SMAs may provide a venue for assessing and delivering quality care for patients with type 2 diabetes. More research is needed to ascertain effective strategies for diabetes disease management in high-risk patients.

Results of a Veterans Affairs employee education program on antimicrobial stewardship for older adults.

We describe a course in the Veterans Affairs (VA) Employee Education System designed to engage nursing staff working in VA long-term care facilities as partners in antimicrobial stewardship. We found that the course addressed an important knowledge gap. Our outcomes suggest opportunities to engage nursing staff in advancing antimicrobial stewardship, particularly in the long-term care setting.

Activity in the chronically critically ill.

Although therapeutic activity prevents functional decline and reduces mortality, little is known about typical levels of activity among intensive care unit (ICU) patients. This report of a preliminary study describes typical therapeutic activity and compares the use of two measures of activity in a small sample of chronically critically ill adults. Type, frequency, and duration of therapeutic activity were measured simultaneously with direct observation and actigraphy. The only consistent activity documented was turning (frequency: 3 turns/8 hours; duration: mean average of 11 minutes). Analysis demonstrated acceptable agreement between the two measures of activity for both frequency and duration of therapeutic but not for type of activity. Congruence between measures for duration of activity was also supported. This study provides information for investigators and practitioners who are interested in measuring or implementing therapeutic activity in selected critically ill adults.

Adult failure to thrive in the older rehabilitation patient.

Increasing numbers of older adults require rehabilitation therapy upon discharge from a hospital. This pilot study tested a tool developed to assess failure to thrive syndrome (FTT) in patients admitted to a long-term rehabilitation unit (N = 34), examined the association among commonly recognized FTT factors (persistent, unexpected impairment in physical function, cognitive impairment, and poor nutrition and mood state), and investigated relationships between FTT factors and discharge disposition. Patients with a high level of physical function differed from those with a low level of function in terms of age, mood state, and discharge disposition. Patients discharged home differed from patients who were unable to return home in mood state, physical function score, and admission serum albumin. Suggestions for practice and further research are offered.

Using Light to Manage Sleep-Wake Issues in Patients With Dementia.

Although research has yet to provide a definitive answer about whether circadian-active light can benefit patients with dementia, a VA pilot study shows promising results.

Four Moments for Patient Hand Hygiene: A Patient-Centered, Provider-Facilitated Model to Improve Patient Hand Hygiene.

We found that a majority of hospitalized patients were aware of the importance of hand hygiene, but observations indicated that performance of hand hygiene was uncommon. An intervention in which healthcare personnel facilitated hand hygiene at specific moments significantly increased performance of hand hygiene by patients.