A Novel Research Method for Determining Sedative Exposure in Critically Ill Patients.

BACKGROUND: Although potent sedative and opioid drugs are some of the most commonly used medications to manage pain, anxiety, and discomfort in critically ill patients, conducting clinical trials where sedative and opioid medications are outcome variables within a longitudinal research design can be a methodological challenge. OBJECTIVES: The purpose of this article is to provide in detail a conceptual discussion of the concept and analysis of sedative exposure: A novel research analysis method for aggregating sedative and opioid medication doses from disparate drug classes commonly administered to critically ill patients and used by our team in several clinical research studies. METHODS: Comparing the dose of each sedative and opioid administered to an individual patient (within a defined time interval) to all other patients in a research study receiving the same medications allows for ranking of dosages for each medication by quartiles. Rank values for all sedatives and opioids received can be summed to a single value resulting in a Sedation Intensity Score. In addition, a simple count of how many hours at least one dose of a sedative or opioid medication has been administered can determine sedation frequency. RESULTS: This method can allow for comparison of sedative exposure with medications from disparate drug classes and for analysis of estimates of change in medication use over time. DISCUSSION: This novel research analysis method can overcome the challenges and limitations of determining changes in sedative and opioid medication regimens in cohort and clinical trial study designs.

Religious Coping, Symptoms of Depression and Anxiety, and Well-Being Among Somali College Students.

This study examined the associations between positive and negative religious coping, symptoms of depression and anxiety, physical and emotional well-being among Somali college students in Minnesota. In this online cross-sectional survey study, 156 participants (ages 18-21, M = 21, SD = 2.3) were recruited. Participants reported using more positive religious coping methods. Negative religious coping was associated with an increase in symptoms of both depression (b = .06, p = .003) and anxiety (b = .04, p = .05), and positive religious coping was associated with a decrease in symptoms of depression (b = -.04, p = .05).

Racial disparities in primary prevention of incontinence among older adults at nursing home admission.

AIMS: Maintaining continence of nursing home (NH) residents promotes dignity and well-being and may reduce morbidity and healthcare treatment costs. To determine the prevalence of older continent adults who received primary prevention of incontinence at NH admission, assess whether there were racial or ethnic disparities in incontinence prevention, and describe factors associated with any disparities. METHODS: The design was an observational cross-sectional study of a nation-wide cohort of older adults free of incontinence at NH admission (n = 42,693). Four US datasets describing NH and NH resident characteristics, practitioner orders for NH treatment/care, and socioeconomic and sociodemographic status of the community surrounding the NHs were analyzed. Disparities were analyzed for four minority groups identified on the minimum data set using the Peters-Belson method and covariates at multiple levels. RESULTS: Twelve percent of NH admissions received incontinence prevention. There was a significant disparity (2%) in incontinence prevention for Blacks (P < 0.05): Fewer Black admissions (8.6%) were observed to receive incontinence prevention than was expected had they been part of the White group (10.6%). The percentage of White admissions receiving incontinence prevention was 10.6%. Significant factors associated with disparity in receiving incontinence prevention were having greater deficits in ADL function and cognition and more comorbidities. No disparity disadvantaging the other minority groups was found. CONCLUSIONS: Greater efforts for instituting incontinence prevention at the time of NH admission are needed. Eliminating racial disparities in incontinence prevention seems an attainable goal. Appropriate staff training, organizational commitment, and monitoring progress toward equitable outcomes can help achieve this goal. Neurourol. Urodynam. 36:1124-1130, 2017. © 2016 Wiley Periodicals, Inc.

Incidence and Predictors of Incontinence-Associated Skin Damage in Nursing Home Residents With New-Onset Incontinence.

PURPOSE: The purpose of this study was to determine the incidence and predictors of incontinence-associated dermatitis (IAD) in nursing home residents. METHODS: Records of a cohort of 10,713 elderly (≥65 years) newly incontinent nursing home residents in 448 nursing homes in 28 states free of IAD were followed up for IAD development. Potential multilevel predictors of IAD were identified in 4 national datasets containing information about the characteristics of individual nursing home residents, nursing home care environment, and communities in which the nursing homes were located. A unique set of health practitioner orders provided information about IAD and the predictors of IAD prevention and pressure injuries in the extended perineal area. Analysis was based on hierarchical logistical regression. RESULTS: The incidence of IAD was 5.5%. Significant predictors of IAD were not receiving preventive interventions for IAD, presence of a perineal pressure injury, having greater functional limitations in activities of daily living, more perfusion problems, and lesser cognitive deficits. CONCLUSION: Findings highlight the importance of prevention of IAD and treatment/prevention of pressure injuries. A WOC nurse offers expertise in these interventions and can educate staff about IAD predictors, which can improve resident outcomes. Other recommendations include implementing plans of care to improve functional status, treat perfusion problems, and provide assistance with incontinence and skin care to residents with milder as well as greater cognitive deficits.

Adherence to a Yoga Program in Older Women with Knee Osteoarthritis.

Yoga is beneficial for osteoarthritis (OA) management in older adults; however, adherence to yoga practice is unknown. The purposes of this secondary analysis were to examine: (1) yoga adherence during the intervention and follow-up periods; (2) the relationship between social cognitive theory (SCT) constructs and adherence; and (3) the impact of adherence on OA-related symptoms in 36 community-dwelling older women with knee OA. SCT was used as a framework to promote adherence to a yoga intervention program that included both group/homebased practices. Adherence to yoga was high during the intervention period but decreased over time. Although SCT was a useful framework for reducing attrition during the intervention, self-efficacy was the only construct that correlated with class attendance. Higher yoga adherence was correlated with improved symptoms, physical function, sleep quality, and quality of life. Yoga adherers were likely to be older, less educated, and had a lower body mass index than nonadherers.

Modeling Psychological Functioning in Refugees.

BACKGROUND: Refugee trauma survivors often experience posttraumatic stress disorder, other anxiety disorders, depression, and somatization. As a result, many suffer a disproportionate vulnerability to a variety of interpersonal, health, and social problems. OBJECTIVE: The study purpose was to develop a preliminary predictive model identifying high-risk refugee trauma survivors based on levels of trauma and psychological functioning. METHOD: A subset of 449 Somali and Oromo refugee trauma survivors was randomly selected from a larger study for secondary data analysis. Data from the PTSD Checklist-Civilian version, the Revised Hopkins Symptom Checklist, and the Sheehan Disability Inventory contributed to a psychological functioning score. A researcher-developed survey contributed to a composite trauma score. RESULTS: Predictors associated with functioning level differed by gender. Of interest, caring for children and increasing coping strategies were related to lower functioning in women. The regression relationship between trauma and functioning was linear in men but quadratic in women. CONCLUSION: Understanding the mechanisms linking trauma and function is implicated in the assessment of risk among trauma survivors. Predictive models inform the effective psychosocial interventions targeting those at greatest risk.

Statistical Approaches to Assessing Health and Healthcare Disparities.

Determining whether racial and ethnic disparities exist for a health-related outcome requires first specifying how outcomes will be measured and disparities calculated. We explain and contrast two common approaches for quantifying racial/ethnic disparities in health, with an applied example from nursing research. Data from a national for-profit chain of nursing homes in the US were analyzed to estimate racial/ethnic disparities in incidence of pressure ulcer within 90 days of nursing home admission. Two approaches were used and then compared: logistic regression and Peters-Belson. Advantages and disadvantages of each approach are given. Logistic regression can be used to quantify disparities as the odds of the outcome for one group relative to another. Peters-Belson can be used to quantify an overall disparity between groups as a risk difference and also provides the proportion of that disparity that is explained by available risk factors. Extensions to continuous outcomes, to survival outcomes, and to clustered data are outlined. Both logistic regression and Peters-Belson are easily implementable and interpretable and provide information on the predictors associated with the outcome. These disparity estimation methods have different interpretations, assumptions, strengths, and weaknesses, of which the researcher should be aware when planning an analytic approach.

Analysis of Racial and Ethnic Disparities as Possible Risk Factors for Development of Incontinence by Nursing Home Residents.

Incontinence is a common health problem among nursing home (NH) residents. Differences between black and white NH residents in incontinence prevalence have been reported. Although reducing health disparities is a principal objective of the national health care agenda, little is known about disparities in incidence of new incontinence in NHs. The purpose of this study was to assess whether there were racial/ethnic disparities in the time to development of incontinence in adults over age 65 who had been continent on NH admission. If no racial or ethnic disparities in time to incontinence were found, other predictors of time to incontinence would be explored. Three national databases were sources of data on 42,693 adults over 65 admitted to 446 for-profit NHs in a national chain. Multi-level predictors of time to any type of incontinence were analyzed, using Cox proportional hazards regression for white Non-Hispanic NH admissions and the Peters-Belson method for minority NH admissions: American Indians/Alaskan Natives, Asians/Pacific Islanders, Black non-Hispanics, and Hispanics. No racial/ethnic disparities in time to incontinence were found. Approximately 30% of all racial/ethnic groups had developed incontinence by 6 months. Those who developed incontinence sooner were older and had greater deficits in activities of daily living (ADL) and cognition. Results were consistent with past evidence and suggest that interventions to maintain continence from the time of admission should be applied across racial/ethnic groups.

Incidence and Characteristics of Incontinence-Associated Dermatitis in Community-Dwelling Persons With Fecal Incontinence.

PURPOSE: Little is known about the incidence and characteristics of incontinence-associated dermatitis (IAD) in community-living individuals with fecal incontinence. The primary aim of this study was to describe the incidence and characteristics of self-reported IAD among community-living individuals with fecal incontinence. The study also examined whether IAD was associated with older age, sex, presence of urinary incontinence, or fecal incontinence severity. DESIGN: Secondary data analysis was performed using a prospective cohort design. SUBJECTS AND SETTING: Data were drawn from community-living adults (n = 98) with fecal incontinence (76% female, 34% aged ≥65 years, 90% white) who participated in a study about dietary fiber supplementation and were free of IAD at the start. Thirty five percent also had urinary incontinence. METHODS: Subjects assessed their skin for IAD daily for 52 days, reporting types of IAD damage (redness, rash/fungal infection, and skin loss), location of IAD, and symptoms. They reported fecal incontinence on a diary for the first and last 14 study days. RESULTS: The incidence of IAD was 41% (40 of the 98). The fecal incontinence severity score for subjects developing IAD was 1.2 higher than those who never had IAD (P < .001). There was no significant association of IAD with age, sex, or dual fecal and urinary incontinence. Incontinence-associated dermatitis developed within 2 weeks and healed in approximately 1 week. The most common sign and symptom were redness (60% patients) and soreness (78% patients), respectively. Most subjects (85%) had IAD in one location. CONCLUSIONS: Assessing for IAD in community-living patients with fecal incontinence is important as IAD is common and causes discomfort. The relatively mild severity of IAD offers WOC nurses the opportunity for improving patient outcomes by preventing and managing this problem.

Feasibility of a Pilot Study of Problem-Solving Therapy for Stroke Survivors.

PURPOSE: The purpose of this pilot study was to assess the feasibility and potential effectiveness of problem-solving therapy (PST) on stroke survivors' depressive symptoms and function in the rehabilitation stage of recovery. DESIGN: This study employed a repeated measures experimental design. METHODS: We recruited a convenience sample of 22 ischemic stroke survivors and randomized to treatment group receiving PST and control group receiving standard care. FINDINGS: Our recruitment and retention rates were 54% and 81%, respectively. Results for depression scores in the treatment group as compared to the control group indicated clinical significance but not statistical significance (p>.05). Function was not statistically significant. CONCLUSION: Problem-solving therapy is potentially therapeutic for stroke survivors. CLINICAL RELEVANCE: Rehabilitation nurses could be educated on the use of PST as a potential intervention for stroke survivors.

Yoga for managing knee osteoarthritis in older women: a pilot randomized controlled trial.

BACKGROUND: Osteoarthritis (OA) is a common problem in older women that is associated with pain and disabilities. Although yoga is recommended as an exercise intervention to manage arthritis, there is limited evidence documenting its effectiveness, with little known about its long term benefits. This study's aims were to assess the feasibility and potential efficacy of a Hatha yoga exercise program in managing OA-related symptoms in older women with knee OA. METHODS: Eligible participants (N=36; mean age 72 years) were randomly assigned to 8-week yoga program involving group and home-based sessions or wait-list control. The yoga intervention program was developed by a group of yoga experts (N=5). The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score that measures knee OA pain, stiffness, and function at 8 weeks. The secondary outcomes, physical function of the lower extremities, body mass index (BMI), quality of sleep (QOS), and quality of life (QOL), were measured using weight, height, the short physical performance battery (SPPB), the Pittsburgh Sleep Quality Index (PSQI), the Cantril Self-Anchoring Ladder, and the SF12v2 Health Survey. Data were collected at baseline, 4 weeks and 8 weeks, and 20 weeks. RESULTS: The recruitment target was met, with study retention at 95%. Based on ANCOVAs, participants in the treatment group exhibited significantly greater improvement in WOMAC pain (adjusted means [SE]) (8.3 [.67], 5.8 [.67]; p=.01), stiffness (4.7 [.28], 3.4 [.28]; p=.002) and SPPB (repeated chair stands) (2.0 [.23], 2.8 [.23]; p=.03) at 8 weeks. Significant treatment and time effects were seen in WOMAC pain (7.0 [.46], 5.4 [.54]; p=.03), function (24.5 [1.8], 19.9 [1.6]; p=.01) and total scores (35.4 [2.3], 28.6 [2.1]; p=.01) from 4 to 20 weeks. Sleep disturbance was improved but the PSQI total score declined significantly at 20 weeks. Changes in BMI and QOL were not significant. No yoga related adverse events were observed. CONCLUSIONS: A weekly yoga program with home practice is feasible, acceptable, and safe for older women with knee OA, and shows therapeutic benefits. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01832155.

Dietary fiber supplementation for fecal incontinence: a randomized clinical trial.

Dietary fiber supplements are used to manage fecal incontinence (FI), but little is known about the fiber type to recommend or the level of effectiveness of such supplements, which appears related to the fermentability of the fiber. The aim of this single-blind, randomized controlled trial was to compare the effects of three dietary fiber supplements (carboxymethylcellulose [CMC], gum arabic [GA], or psyllium) with differing levels of fermentability to a placebo in community-living individuals incontinent of loose/liquid feces. The primary outcome was FI frequency; secondary outcomes included FI amount and consistency, supplement intolerance, and quality of life (QoL). Possible mechanisms underlying supplement effects were also examined. After a 14-day baseline, 189 subjects consumed a placebo or 16 g total fiber/day of one of the fiber supplements for 32 days. FI frequency significantly decreased after psyllium supplementation versus placebo, in both intent-to-treat and per-protocol mixed model analyses. CMC increased FI frequency. In intent-to-treat analysis, the number of FI episodes/week after supplementation was estimated to be 5.5 for Placebo, 2.5 for Psyllium, 4.3 for GA, and 6.2 for CMC. Only psyllium consumption resulted in a gel in feces. Supplement intolerance was low. QoL scores did not differ among groups. Patients with FI may experience a reduction in FI frequency after psyllium supplementation, and decreased FI frequency has been shown to be an important personal goal of treatment for patients with FI. Formation of a gel in feces appears to be a mechanism by which residual psyllium improved FI.

Prevalence of pressure ulcers by race and ethnicity for older adults admitted to nursing homes.

Little is known about the prevalence of pressure ulcers (PUs) among racial and ethnic groups of older individuals admitted to nursing homes (NHs). NHs admitting higher percentages of minority individuals may face resource challenges for groups with more PUs or ones of greater severity. This study examined the prevalence of PUs (Stages 2 to 4) among older adults admitted to NHs by race and ethnicity at the individual, NH, and regional levels. Results show that the prevalence of PUs in Black older adults admitted to NHs was greater than that in Hispanic older adults, which were both greater than in White older adults. The PU rate among admissions of Black individuals was 1.7 times higher than White individuals. A higher prevalence of PUs was observed among NHs with a lower percentage of admissions of White individuals. [Journal of Gerontological Nursing, 40(3), 20-26.].

Refinement of an instrument for assessing incontinent-associated dermatitis and its severity for use with darker-toned skin.

PURPOSE: The purpose of this study was to refine an instrument for assessing incontinence-associated dermatitis (IAD) and its severity for use on lighter- and darker-toned skin, the Incontinence-Associated Dermatitis and its Severity Instrument-D (IADS-D), and to test its validity and reliability among WOC nurses. METHODS: Revisions to the existing instrument included examples of colors of normal and IAD-damaged skin that would be observed on light-, medium-, and dark-toned skin using pixels from patient photographs, additional photographs of IAD manifestations on different skin tones, and training materials. Four certified WOC nurse consultants and 2 WOC nurse clinical experts assessed the face and content validity of the IADS-D instrument. The IADS-D instrument was tested for criterion validity and interrater reliability using photo cases by attendees at the Wound, Ostomy, and Continence Nurses Society 2012 conference. RESULTS: The IADS-D instrument had good face and content validity. The overall average intraclass correlation coefficient (ICC) of IADS-D scores for all photo cases of testers (n = 266, 95% female, age 53.0 ± 7.9 years, mean ± SD) and those of investigators, experts, and consultants serving as the criterion was 0.90. The overall ICC for interrater reliability between all nurse testers was 0.99 and the ICC for tester skin tone was 0.99. CONCLUSION: The IADS-D instrument has excellent validity and interrater reliability among WOC nurses. Its refinement for use with lighter- and darker-toned skin addresses the lack of a much-needed instrument in nursing practice and research. Results support continued development and evaluation of the instrument's use in clinical and research settings.

Extending the Peters-Belson approach for assessing disparities to right censored time-to-event outcomes.

The Peters-Belson (PB) method was developed for quantifying and testing disparities between groups in an outcome by using linear regression to compute group-specific observed and expected outcomes. It has since been extended to generalized linear models for binary and other outcomes and to analyses with probability-based sample weighting. In this work, we extend the PB approach to right-censored survival analysis, including stratification if needed. The extension uses the theory and methods of expected survival on the basis of Cox regression in a reference population. Within the PB framework, among the groups to be compared, one group is chosen as the reference group, and outcomes in that group are modeled as a function of available predictors. By using this fitted model's estimated parameters, and the predictor values for a comparator group, the comparator group's expected outcomes are then calculated and compared, formally with testing and informally with graphics, with their observed outcomes. We derive the extension, show how we applied it in a study of incontinence in nursing home elderly, and discuss issues in implementing it. We used the 'survival' package in the R system to do computations.

Effects of patient-directed music intervention on anxiety and sedative exposure in critically ill patients receiving mechanical ventilatory support: a randomized clinical trial.

IMPORTANCE: Alternatives to sedative medications, such as music, may alleviate the anxiety associated with ventilatory support. OBJECTIVE: To test whether listening to self-initiated patient-directed music (PDM) can reduce anxiety and sedative exposure during ventilatory support in critically ill patients. DESIGN, SETTING, AND PATIENTS: Randomized clinical trial that enrolled 373 patients from 12 intensive care units (ICUs) at 5 hospitals in the Minneapolis-St Paul, Minnesota, area receiving acute mechanical ventilatory support for respiratory failure between September 2006 and March 2011. Of the patients included in the study, 86% were white, 52% were female, and the mean (SD) age was 59 (14) years. The patients had a mean (SD) Acute Physiology, Age and Chronic Health Evaluation III score of 63 (21.6) and a mean (SD) of 5.7 (6.4) study days. INTERVENTIONS: Self-initiated PDM (n = 126) with preferred selections tailored by a music therapist whenever desired while receiving ventilatory support, self-initiated use of noise-canceling headphones (NCH; n = 122), or usual care (n = 125). MAIN OUTCOMES AND MEASURES: Daily assessments of anxiety (on 100-mm visual analog scale) and 2 aggregate measures of sedative exposure (intensity and frequency). RESULTS: Patients in the PDM group listened to music for a mean (SD) of 79.8 (126) (median [range], 12 [0-796]) minutes/day. Patients in the NCH group wore the noise-abating headphones for a mean (SD) of 34.0 (89.6) (median [range], 0 [0-916]) minutes/day. The mixed-models analysis showed that at any time point, patients in the PDM group had an anxiety score that was 19.5 points lower (95% CI, -32.2 to -6.8) than patients in the usual care group (P = .003). By the fifth study day, anxiety was reduced by 36.5% in PDM patients. The treatment × time interaction showed that PDM significantly reduced both measures of sedative exposure. Compared with usual care, the PDM group had reduced sedation intensity by -0.18 (95% CI, -0.36 to -0.004) points/day (P = .05) and had reduced frequency by -0.21 (95% CI, -0.37 to -0.05) points/day (P = .01). The PDM group had reduced sedation frequency by -0.18 (95% CI, -0.36 to -0.004) points/day vs the NCH group (P = .04). By the fifth study day, the PDM patients received 2 fewer sedative doses (reduction of 38%) and had a reduction of 36% in sedation intensity. CONCLUSIONS AND RELEVANCE: Among ICU patients receiving acute ventilatory support for respiratory failure, PDM resulted in greater reduction in anxiety compared with usual care, but not compared with NCH. Concurrently, PDM resulted in greater reduction in sedation frequency compared with usual care or NCH, and greater reduction in sedation intensity compared with usual care, but not compared with NCH. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00440700.

Public health nursing competency instrument: scale reduction and reliability of factors.

OBJECTIVES: To reduce the number of items of the Public Health Nursing Competency Instrument (PHNCI) and to report the psychometric properties of the abbreviated instrument. DESIGN AND SAMPLE: The 193-item PHNCI was administered via an online survey tool. A national sample of 2,269 public health nurses was recruited from 25 states. MEASURES: All items of the PHNCI scale were positively stated and participants were asked to rate their skill level via a 4-point Likert scale. RESULTS: A principal component exploratory factor analysis with oblique rotation and examination of scree plot resulted in a final abbreviated scale which included 81 items and six factors: (1) Evaluation Competencies, (2) Individual/Family/Community Competencies, (3) Systems' Competencies, (4) Partnership/Collaboration Competencies, (5) Planning Competencies, and (6) Assessment Competencies. The six factors in the resulting PHNCI Abbreviated (PHNCIa ) demonstrated acceptable internal consistency, ranging from 0.92 to 0.98. CONCLUSION: The six factors of the PHNCIa integrate important concepts of both the nursing process and the intervention wheel. The instrument can be used by educators, administrators, managers, and staff members to assess strengths and challenge areas, guide discussions on performance and expectations, and enhance professional development efforts. Next steps for future research are presented.

Incontinence-associated dermatitis in community-dwelling individuals with fecal incontinence.

PURPOSE: To describe the occurrence and severity of incontinence-associated dermatitis among community-dwelling individuals with fecal incontinence. DESIGN: Descriptive and comparative secondary data analysis. SUBJECTS AND SETTING: One hundred eighty-nine community-dwelling individuals with fecal incontinence who participated in a study comparing the effects of dietary fiber on fecal incontinence. METHODS: A survey on the use of absorbent products that contained questions about subjects' history of skin damage was administered at the start of the study. RESULTS: Incontinence-associated dermatitis occurred in 52.5% of the community-living individuals with fecal incontinence. The severity of incontinence-associated dermatitis was mostly mild to moderate and occurred periodically. Redness without broken skin was the most common manifestation (68%). Most individuals (95%) reported the location of skin damage to be the anal/rectal area. Those with double incontinence also reported dermatitis around the vagina or penis. Individuals with a greater severity of fecal incontinence had a greater severity of incontinence-associated dermatitis (r = 0.27, P = .000). Both the frequency of incontinence (r = 0.23, P < .002) and the amount of feces leaked (r = 0.23, P < .002) had a significant correlation with incontinence-associated dermatitis severity. There were no significant differences in the occurrence or severity of incontinence-associated dermatitis by sex, age, or presence of double incontinence. CONCLUSION: A high percentage of individuals in the community with fecal incontinence suffer from incontinence-associated dermatitis at times. This population may benefit from consultation with a WOC nurse about prevention and management of incontinence-associated dermatitis.

The CARES(®) Observational Tool: a valid and reliable instrument to assess person-centered dementia care.

The goal of the current study was to develop a valid and reliable tool to measure whether person-centered care is delivered by direct care workers to persons with dementia. Face validity was initially established through multiple revisions of the CARES(®) Observational Tool (COT™) by members of the study team. Afterward, content validity of the COT was established by piloting the tool on 31 observations across 7 nursing homes and review by an interdisciplinary panel of nine scientific experts. The final 16-item version of the COT was then tested for inter-rater reliability by 5 reviewers across 5 standardized dementia care videos. An intra-class coefficient of all possible Kappa coefficients resulted in an ICC of .77. The brief and easy-to-use COT has potential to assess person-centered care interactions between direct care workers and persons with dementia.

Effectiveness of wound, ostomy and continence-certified nurses on individual patient outcomes in home health care.

PURPOSE: To assess whether there was a significant improvement and stabilization (not worse at discharge) in pressure ulcers, lower extremity venous ulcers, surgical wounds, urinary incontinence, bowel incontinence, and urinary tract infections in home health care (HHC) patients cared for by a certified WOC nurse. SUBJECTS AND SETTING: There were 449,170 episodes of care from a national convenience sample of 785 HHC agencies with 447,309 nonmaternity, adult patients between October 1, 2008, and December 31, 2009. DESIGN: Descriptive and comparative. INSTRUMENTS AND METHODS: Data from the Outcome and Assessment Information Set documented by HHC clinicians were analyzed using mixed-effects logistic regression, propensity score analysis, and appropriate parametric and nonparametric tests. An Internet survey identified whether WOC nurses provided care to patients in an HHC agency. Home health care agencies identified records of patients receiving WOC nurse visits/consults. RESULTS: An HHC patient assigned to a WOC nurse had surgical wounds, pressure ulcers, and incontinence problems that were significantly worse than HHC patients not assigned to a WOC nurse. Patients cared for by a WOC nurse showed significant improvement and stabilization of the number of pressure ulcers and surgical wounds and the frequency of urinary and bowel incontinence, despite having problems that were more severe than other patients. Home health care patients not cared for by WOC nurses, with less-severe wound and incontinence problems, also got better. CONCLUSIONS: WOC nurses are effective in achieving positive health outcomes for pressure ulcers, surgical wounds, and incontinence in HHC patients with severe health problems.