Randomized trial of postoperative patient-controlled analgesia vs intramuscular narcotics in frail elderly men.

Postoperative use of as-needed intramuscular narcotics is potentially hazardous in frail elderly patients. Patient-controlled analgesia (PCA) allows patients to self-administer small boluses of narcotic, allowing better dose titration, enhanced responsiveness to variability in narcotic requirements, and reduction in serum narcotic level fluctuation. Although theoretically useful, this method has not bee well studied in the elderly or medically ill. A prospective controlled trial among 83 higher-risk elderly men after major elective surgery compared PCA containing morphine sulfate with intramuscular morphine injections as needed (mean [+/- SD] age, 67.4 +/- 5.6 vs 67.0 +/- 6.3 years). Subjects had a variety of medical illnesses, including chronic lung disease (57%), coronary artery disease (43%), heart failure (13%), and liver disease (12%). Preoperative and postoperative assessments included chest roentgenograms; daily mental status and pulmonary function testing; twice-daily serum morphine levels; and oxygen saturation values, linear analogue pain and sedation scores, and vital signs every 2 hours. Care was taken to optimize narcotic administration in control subjects as well as PCA subjects. Analgesia was significantly improved by PCA (3-day mean pain score, 40.5 +/- 18.0 vs 32.5 +/- 15.0), without an increase in sedation. Significant postoperative confusion (18% vs 2.3%) and severe pulmonary complications (10% vs 0%) occurred significantly more frequently in intramuscular-treated controls. Patient-controlled analgesia was quickly mastered by most patients; no major problems referable to its use occurred. Patients who had previously received intramuscular injections reported that PCA was easier to use and provided better analgesia. Serum morphine levels showed significantly less variability on postoperative day 1 with PCA, compared with intramuscular injections. We conclude that PCA is an improved method of postoperative analgesia in high-risk elderly men with normal mental status, compared with as-needed intramuscular injections.

Recommended components of health care provider training programs on intimate partner violence.

Programs that are effective in training health care providers to recognize and meet the needs of victims of intimate partner violence must be identified and replicated. The Centers for Disease Control and Prevention (CDC) has developed criteria for use in developing, enhancing, and evaluating such programs. CDC developed these criteria as a result of continuing efforts to provide useful products for constituents through literature reviews and consultations with experts in the field; evaluations of training programs; creation of an inventory and annotated bibliography of health care provider training programs in the United States and Canada; and development of a framework to assist hospitals and health centers in evaluating their training programs. Training should begin while providers are in professional school and continue in the health care setting. Curricula should be multidisciplinary and should provide information, promote clinical skills, and effectively link providers with resources. Evaluation should assist programs in determining providers' needs and identifying appropriate materials, trainers, and training strategies. CDC is working to establish scientific evidence that provider training programs are effective and to share successful models with others. Providers have an important role in stopping and ultimately preventing intimate partner violence, but they are not alone in this effort. They need to know how to access the growing network of assistance including women's advocates, the criminal justice system, and other members of increasingly dynamic community coalitions.

Evaluation of the module on domestic violence at the UCLA School of Medicine.

Physicians and other hospital staff have a unique opportunity to assist victims of abuse. It is imperative that they develop the skills necessary to identify and diagnose cases and provide the support and referral services needed to help victims end the cycle of violence. This paper describes a comprehensive evaluation of the instructional design, implementation, and learning outcomes of the Domestic Violence Module at the University of California, Los Angeles (UCLA) School of Medicine to determine the effectiveness of this curriculum in helping medical students develop such skills. Expert reviewers found it to be an innovative, well-planned curriculum, and students and faculty tutors expressed a great deal of interest in and satisfaction with the course as a whole. However, the different evaluation components identified the same areas for improvement: (1) students need more opportunity to practice skills and receive feedback during the module, (2) there is inconsistency across classes in what is learned, and (3) tutors need better preparation sessions. The student outcomes reflected these needs and therefore suggest that the study may be useful in determining the components of an effective curriculum. After the training, the students reported significant increases in their feelings of self-efficacy and in their intentions, especially in comparison with a group of control students. Therefore, the module seems to be successful in inspiring medical students to work with victims of abuse.

PIP: In order to provide treatment and support to victims of domestic violence, physicians and other hospital staff must develop skills in identifying abuse cases and an understanding of family violence dynamics. A comprehensive evaluation of the instructional design, implementation, and learning outcomes of the Domestic Violence Module at the University of California, Los Angeles (UCLA) School of Medicine documented the value of such a curriculum. The 4-week module, offered to groups of 8 second-year medical students by faculty tutors, includes practice interviews with simulated family violence victims. Curriculum development specialists who reviewed the module lauded its problem-based learning approach and use of a range of teaching methods. At the same time, evaluators identified a need for more student opportunities to practice and receive feedback on their interviewing skills and to identify personal attitudes that could adversely affect their management of domestic violence cases and for greater consistency across groups in what is taught. Comparison of results of questionnaires completed by 124 UCLA medical students before and after exposure to the module revealed dramatic gains in the ability to diagnose domestic violence and in self-efficacy to intervene in this area, while the scores of 88 nonexposed students from another medical school showed no change from baseline to follow-up. The only component that did not change as a result of the training was students' predisposition to act on suspicions of domestic violence even when the woman was not herself prepared for such action.

Changes in health care providers' knowledge, attitudes, beliefs, and behaviors regarding domestic violence, following a multifaceted intervention.

PURPOSE: To improve domestic violence (DV) identification, management, and referral in a not-for-profit rural health network, training for health care professionals was implemented using a train-the-trainer approach, two one-hour training sessions, and dissemination of a clinical protocol. The multifaceted approach also involved modifications of emergency department medical records, distribution of office enablers, and a local public health campaign. The authors measured the effectiveness of this campaign. METHODS: After implementation of a multifaceted training and public awareness campaign, a questionnaire designed by the Centers for Disease Control to measure knowledge, attitudes, beliefs, and intended behaviors (KABB) of health care providers relative to DV was administered to 380 health care professionals in the fall of 1997, with a follow-up survey completed after the intervention in the fall of 1999. RESULTS: The response rates for the pre- and post-intervention surveys were 67% (n = 380) and 56% (n = 273), respectively. Two scales were correlated in the base-line survey: self-efficacy (related to DV response) and familiarity with referral resources. Reporting of victim identification in the preceding year increased from 36% to 39%. Those with training were more likely to have identified a victim within the year (OR = 2.86; 95% CI, 1.73-4.74). Among the 232 respondents with complete data, multiple analysis of variance demonstrated statistically significant overall improvement across all scales. Nine of the 13 KABB scales revealed significant increases from pre- to posttest and included: screening, workplace resources, making referrals, provider self-efficacy, victim autonomy, victim understanding, legal requirements, staff preparation, and too busy/can't help. CONCLUSION: A comprehensive training program for health care providers can increase their self-efficacy in responding to DV victims.

WomanKind: an innovative model of health care response to domestic abuse.

PIP: This article focuses on the role of the WomanKind program in creating opportunities for discussing domestic violence and training health professionals. The WomanKind program is based on the belief that without such discussion, health care providers will continue to treat the medical and mental health problems that bring women to their doors without addressing the underlying pattern of abuse that is the root cause. WomanKind has evolved to integrate case management/advocacy services for victims of domestic abuse, in addition to education and consultation for health professionals. It also provides case management and advocacy services, including crisis intervention, assessment and evaluation, and ongoing assistance to battered women who suffer from physical, emotional, or sexual abuse by a current or former partner. The WomanKind staff consists of a director who oversees the program, including marketing and public relations, education and training, as well as assisting the full-time program coordinators at each of the three hospital sites. An intensive 40-hour training program provides the new WomanKind volunteers with an understanding of the issues of domestic abuse and violence, as well as knowledge of community resources. The program goals are elaborated in this article as well as the program marketing techniques.^ieng

Medicating the postoperative elderly: how do nurses make their decisions?

Studies show that pain management in postoperative patients often results in undertreatment of pain. Because elderly postoperative patients receive less of the prescribed narcotic dose than their younger counterparts, there may be significant undertreatment of pain. Elderly patients receive less than one fourth of the prescribed narcotic in the first 24 hours after surgery. Type of surgery and vital signs were the factors most frequently used by nurses in their narcotic administration decisions for patients over age 60. According to the study, the factor of age did not appear to be important in the narcotic administration decisions of nurses.