Association between emergency department modifiable risk factors and subsequent delirium among hospitalized older adults.

STUDY OBJECTIVE: To evaluate the association between potential emergency department (ED)-based modifiable risk factors and subsequent development of delirium among hospitalized older adults free of delirium at the time of ED stay. METHODS: Observational cohort study of patients aged ≥75 years who screened negative for delirium in the ED, were subsequently admitted to the hospital, and had delirium screening performed within 48 h of admission. Potential ED-based risk factors for delirium included ED length of stay (LOS), administration of opioids, benzodiazepines, antipsychotics, or anticholinergics, and the placement of urinary catheter while in the ED. Odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CIs) were calculated. RESULTS: Among 472 patients without delirium in the ED (mean age 84 years, 54.2% females), 33 (7.0%) patients developed delirium within 48 h of hospitalization. The ED LOS of those who developed delirium was similar to those who did not develop delirium (312.1 vs 325.6 min, MD -13.5 min, CI -56.1 to 29.0). Patients who received opioids in the ED were as likely to develop delirium as those who did not receive opioids (7.2% vs 6.9%: OR 1.04, CI 0.44 to 2.48). Patients who received benzodiazepines had a higher risk of incident delirium, the difference was clinically but not statistically significant (37.3% vs 6.5%, OR 5.35, CI 0.87 to 23.81). Intermittent urinary catheterization (OR 2.05, CI 1.00 to 4.22) and Foley placement (OR 3.69, CI 1.55 to 8.80) were associated with a higher risk of subsequent delirium. After adjusting for presence of dementia, only Foley placement in the ED remained significantly associated with development of in-hospital delirium (adjusted OR 3.16, CI 1.22 to 7.53). CONCLUSION: ED LOS and ED opioid use were not associated with higher risk of incident delirium in this cohort. Urinary catheterization in the ED was associated with an increased risk of subsequent delirium. These findings can be used to design ED-based initiatives and increase delirium prevention efforts.

Implementing lung cancer screening: baseline results from a community-based 'Lung Health Check' pilot in deprived areas of Manchester.

We report baseline results of a community-based, targeted, low-dose CT (LDCT) lung cancer screening pilot in deprived areas of Manchester. Ever smokers, aged 55-74 years, were invited to 'lung health checks' (LHCs) next to local shopping centres, with immediate access to LDCT for those at high risk (6-year risk ≥1.51%, PLCOM2012 calculator). 75% of attendees (n=1893/2541) were ranked in the lowest deprivation quintile; 56% were high risk and of 1384 individuals screened, 3% (95% CI 2.3% to 4.1%) had lung cancer (80% early stage) of whom 65% had surgical resection. Taking lung cancer screening into communities, with an LHC approach, is effective and engages populations in deprived areas.

Second round results from the Manchester 'Lung Health Check' community-based targeted lung cancer screening pilot.

We report results from the second annual screening round (T1) of Manchester's 'Lung Health Check' pilot of community-based lung cancer screening in deprived areas (undertaken June to August 2017). Screening adherence was 90% (n=1194/1323): 92% of CT scans were classified negative, 6% indeterminate and 2.5% positive; there were no interval cancers. Lung cancer incidence was 1.6% (n=19), 79% stage I, treatments included surgery (42%, n=9), stereotactic ablative radiotherapy (26%, n=5) and radical radiotherapy (5%, n=1). False-positive rate was 34.5% (n=10/29), representing 0.8% of T1 participants (n=10/1194). Targeted community-based lung cancer screening promotes high screening adherence and detects high rates of early stage lung cancer.

Pressure Injury Knowledge in Critical Care Nurses.

PURPOSE: The purpose of this study was to identify pressure injury knowledge in critical care nurses related to prevention and staging following multimodal education initiatives. DESIGN: Postintervention descriptive study. SETTING AND SAMPLE: The sample comprised 32 RNs employed in medical intensive care/coronary intensive care or surgical intensive care units. The study setting was a 237-bed Veterans Affairs acute care hospital in the Midwestern United States. METHODS: Critical care RNs were asked to participate in this project over a 3-week period following a multimodal 2-year education initiative. Nurses completed the paper version of the 72-item Pieper-Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT) to determine pressure injury knowledge level. Calculated mean cumulative scores and subscores for items related to prevention and staging, respectively. Pearson correlations were used to examine associations between nursing staff characteristics and the PZ-PUKT prevention and staging scores. RESULTS: The cumulative score on the PZ-PUKT was 51.66 (72%); nurses with 5 to 10 years' experience had a higher mean score than nurses with experiences of 20 years or more (mean ± SD = 54.25 ± 4.37 vs 49.5 ± 7.12), but the difference was not statistically significant. Nurses scored higher on the staging system-related items as compared to the prevention-related items (81% vs 70%). Nurses achieved higher staging subscale scores if they were younger (r =-0.41, P < .05), had less experience (r =-0.43, P < .05), and if they worked in the medical intensive care unit (r = 0.37, P < .05). CONCLUSIONS: Study findings indicate gaps in knowledge related to pressure injury practice; participants had greater knowledge of staging rather than prevention. Cumulative and subscale findings can be used to direct educational efforts needed to improve and maintain an effective pressure injury prevention program.

Linkage of 1986-2009 National Health Interview Survey with 1981-2010 Florida Cancer Data System.

BACKGROUND: National survey data linked with state cancer registry data has the potential to create a valuable tool for cancer prevention and control research. A pilot project-developed in a collaboration of the Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS) and the Florida Cancer Data System (FCDS) at the University of Miami -links the records of the 1986-2009 National Health Interview Survey (NHIS) and the 1981-2010 FCDS. The project assesses the feasibility of performing a record linkage between NCHS survey data and a state-based cancer registry, as well as the value of the data produced. The linked NHIS-FCDS data allow researchers to follow NHIS survey participants longitudinally to examine factors associated with future cancer diagnosis, and to assess the characteristics and quality of life among cancer survivors. METHODS: This report provides a preliminary evaluation of the linked national and state cancer data and examines both analytic issues and complications presented by the linkage. CONCLUSIONS: Residential mobility and the number of years of data linked in this project create some analytic challenges and limitations for the types of analyses that can be conducted. However, the linked data set offers the ability to conduct analyses not possible with either data set alone.

Relationships Between Time-at-Bedside During Hospital Ward Rounds, Clinician-Patient Agreement, and Patient Experience.

Hospital medicine ward rounds are often conducted away from patients' bedsides, but it is unknown if more time-at-bedside is associated with improved patient outcomes. Our objective is to measure the association between "time-at-bedside," patient experience, and patient-clinician care agreement during ward rounds. Research assistants directly observed medicine services to quantify the amount of time spent discussing each patient's care inside versus outside the patient's room. "Time-at-bedside" was defined as the proportion of time spent discussing a patient's care in his or her room. Patient experience and patient-clinician care agreement both were measured immediately after ward rounds. Results demonstrated that the majority of patient and physicians completely agreement on planned tests (66.3%), planned procedures (79.7%), medication changes (50.6%), and discharge location (66.9%), but had no agreement on the patient's main concern (74.4%) and discharge date (50.6%). Time-at-bedside was not correlated with care agreement or patient experience (P > .05 for all comparisons). This study demonstrates that spending more time at the bedside during ward rounds, alone, is insufficient to improve patient experience.

Predicting Delirium Risk Using an Automated Mayo Delirium Prediction Tool: Development and Validation of a Risk-Stratification Model.

OBJECTIVE: To develop a delirium risk-prediction tool that is applicable across different clinical patient populations and can predict the risk of delirium at admission to hospital. METHODS: This retrospective study included 120,764 patients admitted to Mayo Clinic between January 1, 2012, and December 31, 2017, with age 50 and greater. The study group was randomized into a derivation cohort (n=80,000) and a validation cohort (n=40,764). Different risk factors were extracted and analyzed using least absolute shrinkage and selection operator (LASSO) penalized logistic regression. RESULTS: The area under the receiver operating characteristic curve (AUROC) for Mayo Delirium Prediction (MDP) tool using derivation cohort was 0.85 (95% confidence interval [CI], .846 to .855). Using the regression coefficients obtained from the derivation cohort, predicted probability of delirium was calculated for each patient in the validation cohort. For the validation cohort, AUROC was 0.84 (95% CI, .834 to .847). Patients were classified into 1 of the 3 risk groups, based on their predicted probability of delirium: low (≤5%), moderate (6% to 29%), and high (≥30%). In the derivation cohort, observed incidence of delirium was 1.7%, 12.8%, and 44.8% (low, moderate, and high risk, respectively), which is similar to the incidence rates in the validation cohort of 1.9%, 12.7%, and 46.3%. CONCLUSION: The Mayo Delirium Prediction tool was developed from a large heterogeneous patient population with good validation results and appears to be a reliable automated tool for delirium risk prediction with hospitalization. Further prospective validation studies are required.

A hospitalist's role in preventing patient falls.

Despite decades of fall prevention efforts, patient falls remain a common cause of harm in hospitalized older adults. While fall prevention strategies have been historically championed by nurses, hospitalist physicians, nurse practitioners, and physician assistants play a vital role in the multidisciplinary care team in ensuring the safety of our patients. Multiple fall risk assessment tools exist, but no one tool has demonstrated excellence in predicting patient falls in the hospital. Any fall risk assessment tool should be complemented by a clinician's individualized evaluation of patient-specific, situational, and environmental risk factors. A particular emphasis on medication review is critical, as numerous medication classes can increase the risk of falls, and medications are a potentially modifiable risk factor. Multiple studies of individual and multicomponent nursing-based interventions have failed to demonstrate success in reducing falls or fall injuries. Promising strategies for fall prevention include tailoring interventions to patient risk factors and individualized patient education. In addition to nursing-based interventions, the hospitalist's role in fall prevention is to (1) identify and address potentially modifiable risk factors, (2) reinforce individualized education to patients, and (3) advise behavior choices that promote safe mobility. If a patient does sustain a fall, the hospitalist should partner with the multidisciplinary care team in post fall care to assess for injury, evaluate underlying causes of the fall, and determine plans for secondary prevention.

Delirium in hospitalized older adults.

Delirium is a common and underdiagnosed problem in hospitalized older adults. It is associated with an increased risk of poor cognitive and functional outcomes, institutionalization, and death. Timely diagnosis of delirium and non-pharmacological prevention and management strategies can improve patient outcomes. The Confusion Assessment Method (CAM) is the most widely used clinical assessment tool for the diagnosis of delirium. Multiple variations of the CAM have been developed for ease of administration and for the unique needs of specific patient populations, including the 3-min diagnostic CAM (3D CAM), CAM-Intensive Care Unit (CAM-ICU), Delirium Triage Screen (DTS)/Brief CAM (b-CAM), 4AT tool, and ultrabrief delirium assessment. Strong evidence supports the effectiveness of nonpharmacologic strategies as the primary intervention for the prevention of delirium. Multicomponent delirium prevention strategies can reduce the incidence of delirium by 40%. Investigation of underlying medical precipitants and optimization of non-pharmacological interventions are first line in the management of delirium. Despite a lack of evidence supporting use of antipsychotics, low dose antipsychotics remain second line for off-label treatment of distressing psychoses and/or agitated behaviors that are refractory to non-pharmacological behavioral interventions and pose an imminent risk of harm to self or others. Any antipsychotic prescription for delirium should be accompanied by an appropriate taper plan. Follow up with primary care providers on discharge from hospital for ongoing screening of cognitive impairment is important.

Polypharmacy in older adults: the role of the multidisciplinary team.

Patients over the age 65 are a quickly expanding segment of the US population and represent a large percentage of patients requiring inpatient care. Older adults are more likely to experience polypharmacy and adverse drug effects. This review explains the risks of polypharmacy and potentially inappropriate medications in the elderly. Specific classes of medications frequently used in older adults in acute care settings are examined, including anticholinergic, sedative hypnotics, and antipsychotic medications. We discuss strategies aimed at addressing polypharmacy in this population including a drug regimen review (which is distinct from medication reconciliation), screening tools, pharmacist-led interventions, and computer-based strategies in the context of current literature and research findings. We provide a summary of general guidelines that may be helpful for geriatricians and hospitalists in improving patient care and clinical outcomes.

Assessment and Management of Delirium in Critically Ill Veterans.

BACKGROUND: Delirium is a complex syndrome prevalent in the intensive care unit. It has been associated with significant morbidity including distress, longer hospital stays, prolonged cognitive impairment, and increased mortality. OBJECTIVE: To describe a nurse-led interdisciplinary quality improvement initiative to increase nurses' knowledge of delirium, documentation of delirium assessment, and patient mobility. METHODS: Sixty-seven nurses in medical and surgical intensive care units were required to attend an interactive education program on delirium assessment and management. Scores on tests taken before and after the education program were used to evaluate knowledge. Medical records and bedside rounds were used to validate Confusion Assessment Method for the Intensive Care Unit documentation and interventions. Descriptive statistics were used to describe changes over time. A delirium resource team composed of nurses, physicians, and therapists provided didactic education paired with simulation training and bedside coaching. Mobility screening tests and computer templates guided assessments and interventions. RESULTS: Documentation of the Confusion Assessment Method improved from less than 50% to consistently 99%. Mobilization in the surgical intensive care unit increased from 90% to 98% after intervention. Days of delirium significantly decreased from 51% before intervention to 31% after intervention (χ12=7.01, P = .008). CONCLUSIONS: The success of this quality improvement project to enhance recognition of delirium and increase mobility (critical components of the pain assessment, breathing, sedation choice, delirium, early mobility, and family education bundle) was contingent on nursing leaders hip, interdisciplinary team collaboration, and interactive education.

The Missing Record of Mental Status in Written Sign-Outs.

OBJECTIVE: The aim of the study was to determine how frequently mental status and mental status changes are documented in the written patient summary ("sign-out") provided to covering physicians. PATIENTS AND METHODS: This was a retrospective cohort study of general medical patients hospitalized between March 16, 2009, and March 15, 2010, conducted at 2 teaching hospitals. Participants included patients with mental status change adverse events (MSAEs) and their providers. Chart review was performed to identify patients with MSAEs and details about these events. Sign-outs were reviewed for documentation of mental status. Main outcome measures were (1) proportion of patients with MSAEs who had mental status ever recorded in sign-out entries and (2) the proportion of patients with MSAEs whose change in mental status was recorded in the sign-out. RESULTS: Sixty-eight patients had MSAEs and were included in the sample. Fifty percent of MSAEs were attributed to medications; 75% of these events were first detected by nurses. Only 25% of patients with MSAEs had their change in mental status recorded in sign-outs. CONCLUSIONS: Recording mental status in written sign-outs is uncommon. Particularly concerning is that patients with MSAEs identified by chart review seldom had sign-outs that reflected those events. Interventions should be designed to increase the recording of this information in sign-outs.

Fall Risk and Outcomes Among Patients Hospitalized With Cardiovascular Disease in the Community.

Background As the population with cardiovascular disease ages, geriatric conditions are of increasing relevance. A possible geriatric prognostic indicator may be a fall risk score, which is mandated by The Joint Commission to be measured on all hospitalized patients. The prognostic value of a fall risk score on outcomes after dismissal is not well known. Thus, we aimed to determine whether a fall risk score is associated with death and hospital readmissions in patients with a recent incident cardiovascular disease event. Methods and Results In this retrospective cohort study, Olmsted County, MN patients with incident heart failure, myocardial infarction, or atrial fibrillation between August 1, 2005, and December 31, 2011, who were hospitalized within 180 days after the event were studied. Fall risk was measured by the Hendrich II fall risk model. Patients were followed for death or readmission within 30 days or 1 year. Among 2456 hospitalized patients with recent incident cardiovascular disease (549 heart failure, 784 myocardial infarction, 1123 atrial fibrillation; mean [SD] age, 71 [15] years; 55% men), the fall risk score was high in 22% of patients and moderate in 38%. The risk of death was increased if the fall risk score was increased, independent of age and comorbidities (moderate hazard ratio, 1.51; 95% CI, 1.09-2.08; high hazard ratio, 3.49; 95% CI, 2.52-4.85). Similarly, the risk of 30-day readmissions was substantially increased with a greater fall risk score (moderate hazard ratio, 1.29; 95% CI, 1.03-1.62; high hazard ratio, 1.63; 95% CI, 1.23-2.15). Results were similar for readmissions within 1 year. Conclusions More than half of hospitalized patients with recent incident cardiovascular disease have an elevated fall risk score, which is associated with an increased risk in readmissions and death. These results delineate an approach for risk stratification and management that may prevent readmissions and improve survival.

Diffuse neurofibrillary tangles with calcification (DNTC): Kosaka-Shibayama disease in America.

Alzheimer's disease and Pick's disease are representative dementias. Cases which do not fit prototypes are termed unclassifiable dementias. New dementia subtypes are identified when a conglomerate of clinical, radiologic and pathologic findings are consistently identified. One such variant is diffuse neurofibrillary tangles with calcification (DNTC), which has been reported almost exclusively from Japan. Significant pathological advances in this decade have established DNTC as a distinct entity. Although initially the diagnosis was neuropathologic, increasing knowledge about DNTC has made it possible for a clinical diagnosis to be made. We report a clinical case of DNTC in a Caucasian American. The diagnosis of DNTC was based on his atypical senile dementia, anomia, apathy and parkinsonian features, normal serum biochemistry, and evidence of basal ganglia and cerebellar calcification with predominant temporal lobe atrophy on neuroimaging. To the best of our knowledge, this is the first clinical description of DNTC from the United States.

The relationship between linkage refusal and selected health conditions of survey respondents.

To maximize limited resources and reduce respondent burden, there is an increased interest in linking population health surveys with other sources of data, such as administrative records. Health differences between adults who consent to and refuse linkage could bias study results with linked data. National Health Interview Survey (NHIS) data are routinely linked to administrative records from the Social Security Administration and the Centers for Medicare and Medicaid Services. Using the NHIS 2010-2013, we examined the association between selected health conditions and respondents' linkage refusal. Linkage refusal was significantly lower for adults with serious psychological distress, chronic obstructive pulmonary disease, diabetes, heart disease, stroke, hypertension, and cancer compared to those without these conditions. Linkage refusal decreased as the number of conditions increased and health status decreased. Our finding that linkage consent was associated with respondents' health characteristics suggests that researchers should try to address potential linkage bias in their analyses.

Changes in written sign-out composition across hospitalization.

BACKGROUND: Inaccurate or incomplete information in the written portion of the patient handoff, or sign-out, may be associated with adverse events in hospitalized patients. Little is known about what information providers actually include in written sign-out documents and how sign-outs change over time. OBJECTIVES: (1) Provide a descriptive analysis of initial and subsequent hospital day-written sign-out content, and (2) evaluate the relationship between team workload and sign-out composition. DESIGN: Retrospective review of sign-out documents from a larger observational study of general medicine patients admitted to housestaff and hospitalist teams at 3 hospitals. MAIN MEASURES: The presence of 13 components of a high-quality sign-out. We performed descriptive analyses and compared initial and subsequent day sign-outs for content. KEY RESULTS: We reviewed 200 patient hospitalizations (200 initial handoffs, 580 subsequent day handoffs). Initial sign-out entries contained a mean of 7.54 (standard deviation: 2.27) key sign-out components. Subsequent day sign-outs contained a higher percentage of certain key elements but had more vague language. The number of elements present in the sign-out was reduced as patient census increased (r = -0.295, P < 0.01). CONCLUSIONS: Sign-out composition changes over time, and is associated with workload. Future interventions to improve quality should take these factors into consideration.

Rib fractures in the elderly: a marker of injury severity.

OBJECTIVES: To examine the relationship between the number of rib fractures (RIBFs) and mortality, injury severity, and resource consumption in elderly patients admitted to trauma centers. DESIGN: Thirteen-year retrospective statewide database analysis. SETTING: Participating trauma centers in Pennsylvania. PARTICIPANTS: A total of 27,855 trauma patients, including 8,648 elderly patients, admitted to a trauma center with more than one RIBF. MEASUREMENTS: Patient demographics, number of RIBFs, Injury Severity Score, complications, patient mortality, preexisting conditions (PECs), and hospital and intensive care unit length of stay. RESULTS: Mortality for elderly patients (aged>/=65) with RIBFs was greater than for patients younger than 65 (20.1% vs 11.4%, P<.001). Mortality rates increased with increasing numbers of RIBFs for both age groups and were always significantly higher in elderly trauma patients. The effect of PECs on patient mortality was inversely related to number of RIBFs and was most pronounced for patients with four or more RIBFs. Seven of 10 complications were more common in elderly patients despite lower mean+/-standard deviation Injury Severity Score (19.4+/-13.4 vs 23.2+/-14.2, P<.001). CONCLUSION: Overall trauma-related mortality is higher in elderly patients with RIBFs than younger patients with RIBFs. Mortality rates rise with increasing number of RIBFs. The number of RIBFs is easy to quantify and may be a useful predictor of overall injury severity and outcome for elderly trauma patients.

Bioelectronic DNA detection of human papillomaviruses using eSensor: a model system for detection of multiple pathogens.

BACKGROUND: We used human papillomaviruses (HPV) as a model system to evaluate the utility of a nucleic acid, hybridization-based bioelectronic DNA detection platform (eSensor) in identifying multiple pathogens. METHODS: Two chips were spotted with capture probes consisting of DNA oligonucleotide sequences specific for HPV types. Electrically conductive signal probes were synthesized to be complementary to a distinct region of the amplified HPV target DNA. A portion of the HPV L1 region that was amplified by using consensus primers served as target DNA. The amplified target was mixed with a cocktail of signal probes and added to a cartridge containing a DNA chip to allow for hybridization with complementary capture probes. RESULTS: Two bioelectric chips were designed and successfully detected 86% of the HPV types contained in clinical samples. CONCLUSIONS: This model system demonstrates the potential of the eSensor platform for rapid and integrated detection of multiple pathogens.