A cross-sectional study of the catheter management of neurogenic bladder after traumatic spinal cord injury.

AIMS: This cross-sectional study describes the catheter management of neurogenic bladder (NGB) in patients with traumatic spinal cord injury (tSCI) with emphasis on the motivations behind transitions between intermittent (IC) and indwelling catheters. METHODS: Patients at the Minneapolis VA with history of tSCI who utilized either intermittent catheterization (IC), urethral (UC) or suprapubic (SP) catheters, participated in a voluntary, anonymous survey regarding their bladder management strategies. RESULTS: A total of 100 patients participated, 94% were male and 90% Caucasian with median age of 61 years. Patients with current UC or SP were older than those utilizing IC (P = 0.002). The median age at injury and years since SCI were 32 years and 20.5 years, respectively. The median time with current modality was 11 years. A total of 27% of all patients reported at least one transition between catheter type. A total of 14 of 54 patients using IC had prior use of UC or SP, while 12/25 patients using SP and 10/21 patients using UC had prior use of IC. The most common reasons to stop IC included inconvenience, physician recommendation, and dislike of IC. A total of 53% of patients currently using UC or SP reported never using IC. Patients currently using SP were more content with their current catheterization method than those using UC or IC (P = 0.046). CONCLUSIONS: Among patients using catheters for NGB, intermittent catheterization was the most common modality utilized and the transition between intermittent and indwelling catheter was most often influenced by patient preferences and clinician recommendations.

Genetic services and attitudes in primary care pediatrics.

Given the integral role primary care pediatricians (PCPs) play in caring for children with genetic conditions, we aimed to identify current practices of PCPs regarding genetic patients, their attitudes toward genetic medical care and their choices regarding family history taking. We conducted an on-line survey of a national convenience sample of PCPs associated with the American Academy of Pediatrics' Quality Improvement Innovation Networks. Eighty-eight respondents (29% response rate) were included in the analysis. Seventy-four (86%) reported ordering genetic based tests three or less times annually. Eleven (13%) strongly agreed that they discuss with patients the potential risks, benefits, and limitations of genetic tests. Forty-three (49%) agreed or strongly agreed that they feel competent in providing healthcare to patients related to genetics and genomics. Perceived competence was not associated with more recent training (P = 0.29), number of genetic tests ordered annually (P = 0.84) or mean number of weekly patient encounters (P = 0.15). 100% of participants stated that taking a family history is important. 27 (31%) agreed or strongly agreed that they gather a minimum of a three-generation family history. Forty-one of the 63 participants with an electronic health record (65%) reported their system was fair or poor in its ability to easily capture a three-generation family history. PCPs interested in quality improvement reported variation in care practices for children with genetic diseases and a majority did not feel competent to provide genetic related healthcare. Research should focus on improving the care and diagnosis of children with genetic disorders and enhanced integration of genetic medicine into routine primary preventative care.

Improving Retention of Home Health Nurses: Fostering Outcome Sustainability Through an Innovative Orientation and Mentorship Program.

Home healthcare plays an increasingly vital role in contemporary postacute healthcare. Staffing instability and lack of perceived organizational support is a stimulus for nursing attrition from the organization with far-reaching impact on staff morale, patient care, agency budgets, and relationships with other healthcare settings. The purpose of this article is to describe a redesign of an agency's nursing orientation and the development of a mentorship program for newly hired home healthcare nurses within a large Midwestern integrated health system. During this time frame, 154 nurses completed the newly designed orientation program and, of those, 91 participated in the mentorship program. In this article, we evaluate 1-year new-hire nursing retention rates over a 4-year period, examine new-hire job satisfaction and perceptions of preceptors and mentors during their first year, and discuss issues of outcome sustainability. Agency-wide turnover rates for all home healthcare nurses decreased from 15.4% in 2016 to 10.1% in 2018, demonstrating the associated impact of these initiatives on staffing stabilization.

The Bundled Hospital Elder Life Program-HELP and HELP in Home Care-and Its Association With Clinical Outcomes Among Older Adults Discharged to Home Healthcare.

OBJECTIVES: To describe the Bundled Hospital Elder Life Program (HELP and HELP in Home Care), an adaptation of HELP, and examine the association of 30-day all-cause unplanned hospital readmission risk among older adults discharged to home care with and without Bundled HELP. DESIGN: Matched case-control study. SETTING: Two medical-surgical units within two midwestern rural hospitals and patient homes (home health). PARTICIPANTS: Hospitalized patients, aged 65 years and older, discharged to home healthcare with and without Bundled HELP exposure between January 1, 2015, and September 30, 2017. Each case (Bundled HELP, n = 148) was matched to a control (non-Bundled HELP, n = 148) on Charlson Comorbidity Index, primary hospital diagnosis of orthopedic condition or injury, and cardiovascular disease using propensity score matching. MEASUREMENTS: The primary study outcome was 30-day all-cause unplanned hospital readmission. Additional outcomes measured were 30-day emergency department (ED) visit, hospital length of stay (LOS), and total number of skilled home care visits. RESULTS: Fewer cases (16.8%) than controls (28.4%) had a 30-day all-cause unplanned hospital readmission. The fully adjusted model showed significantly lower risk of 30-day hospital readmission for case (Bundled HELP) patients (0.41; 95% confidence interval = 0.22-0.77; P < .01). The difference between case (10.8%) and control (15.5%) 30-day ED visit was not significant (P = .23). A lower LOS for the case group was shown (P < .01), while the number of skilled home care visits was not significantly different between groups (P = .28). CONCLUSION: HELP protocol implementation during a patient's hospital stay and as a continued component of home care among older adults at risk for cognitive and/or functional decline appears to be associated with favorable outcomes. Our initial evaluation supports continued study of the Bundled HELP. Further research is needed to confirm the initial findings and to evaluate the impact of the adapted model on functional outcomes and delirium incidence in the home. J Am Geriatr Soc 67:1730-1736, 2019.

Regional brain activation during hypoglycemia in type 1 diabetes.

CONTEXT: Mechanisms underlying the brain response to hypoglycemia are not well understood. OBJECTIVE: Our objective was to determine the blood glucose level at which the hypothalamus and other brain regions are activated in response to hypoglycemia in type 1 diabetic patients and control subjects. DESIGN: This was a cross-sectional study evaluating brain activity using functional magnetic resonance imaging in conjunction with a hyperinsulinemic hypoglycemic clamp to lower glucose from euglycemia (90 mg/dl) to hypoglycemia (50 mg/dl). SETTING: The study was performed at the Brain Imaging Center in the McLean Hospital. STUDY PARTICIPANTS: Seven type 1 diabetic patients between 18 and 50 yr old and six matched control subjects were included in the study. INTERVENTION: Hyperinsulinemic hypoglycemic clamp was performed. MAIN OUTCOME MEASURES: Blood glucose level at peak hypothalamic activation, amount of regional brain activity during hypoglycemia in both groups, and difference in regional brain activation between groups were calculated. RESULTS: The hypothalamic region activates at 68 +/- 9 mg/dl in control subjects and 76 +/- 8 mg/dl in diabetic patients during hypoglycemia induction. Brainstem, anterior cingulate cortex, uncus, and putamen were activated in both groups (P < 0.001). Each group also activated unique brain areas not active in the other group. CONCLUSIONS: This application of functional magnetic resonance imaging can be used to identify the glucose level at which the hypothalamus is triggered in response to hypoglycemia and whether this threshold differs across patient populations. This study suggests that a core network of brain regions is recruited during hypoglycemia in both diabetic patients and control subjects.

Hippocampal and neocortical activation during repetitive encoding in older persons.

Episodic memory function is known to decline in the course of normal aging; however, compensatory techniques can improve performance significantly in older persons. We investigated the effects of the memory enhancing technique of repetition encoding on brain activation using event-related functional magnetic resonance imaging (fMRI). Twelve healthy older adults without cognitive impairment were studied with fMRI during repetitive encoding of face-name pairs. During the first encoding trials of face-name pairs that were subsequently remembered correctly, activation of the hippocampus and multiple neocortical regions, including prefrontal, parietal and fusiform cortices, was observed. The second and third encoding trials resulted in continued activation in neocortical regions, but no task-related response within the hippocampus. Functional imaging of successful memory processes thus permits us to detect regionally specific responses in the aging brain. Our findings suggest that hippocampal function is preserved in normal aging and that repetition-based memory enhancing techniques may engage primarily neocortical attentional networks.

A Quality Improvement Collaborative to Improve Pediatric Primary Care Genetic Services.

OBJECTIVE: To investigate if a national pediatric primary care quality improvement collaborative (QIC) could improve and sustain adherence with process measures related to diagnosis and management of children with genetic disorders. METHODS: Thirteen practices in 11 states from the American Academy of Pediatrics' Quality Improvement Innovation Networks participated in a 6-month QIC that included regular educational opportunities, access to genetic professionals, and performance feedback. The QIC identified 11 aims related to improving diagnosis and management of children with genetic disorders. The practices evaluated adherence by reviewing patient records at baseline, monthly for 6 months (active improvement period), and then once 6 months after the QIC's conclusion to check for sustainability. Random intercept binomial regression models with practice level random intercepts were used to compare adherence over time for each aim. RESULTS: During the active improvement period, statistically significant improvements in adherence were observed for 4 of the 7 aims achieving minimal data submission levels. For example, adherence improved for family histories created/maintained at health supervision visits documenting all components of the family history (6% vs 60%, P < .001), and for patients with specific genetic disorders who received recommended care (58% vs 85%, P < .001). All 4 of these aims also demonstrated statistically significant improvements during the sustainability period. CONCLUSIONS: A national QIC reveals promise in improving and sustaining adherence with process measures related to the diagnosis and management of genetic disorders. Future research should focus on patient outcome measures and the optimal number of aims to pursue in QICs.