Enhancing care for hospitalized older adults with cognitive impairment: a randomized controlled trial.

BACKGROUND: Approximately 40% of hospitalized older adults have cognitive impairment (CI) and are more prone to hospital-acquired complications. The Institute of Medicine suggests using health information technology to improve the overall safety and quality of the health care system. OBJECTIVE: Evaluate the efficacy of a clinical decision support system (CDSS) to improve the quality of care for hospitalized older adults with CI. DESIGN: A randomized controlled clinical trial. SETTING: A public hospital in Indianapolis. POPULATION: A total of 998 hospitalized older adults were screened for CI, and 424 patients (225 intervention, 199 control) with CI were enrolled in the trial with a mean age of 74.8, 59% African Americans, and 68% female. INTERVENTION: A CDSS alerts the physicians of the presence of CI, recommends early referral into a geriatric consult, and suggests discontinuation of the use of Foley catheterization, physical restraints, and anticholinergic drugs. MEASUREMENTS: Orders of a geriatric consult and discontinuation orders of Foley catheterization, physical restraints, or anticholinergic drugs. RESULTS: Using intent-to-treat analyses, there were no differences between the intervention and the control groups in geriatric consult orders (56% vs 49%, P = 0.21); discontinuation orders for Foley catheterization (61.7% vs 64.6%, P = 0.86); physical restraints (4.8% vs 0%, P = 0.86), or anticholinergic drugs (48.9% vs 31.2%, P = 0.11). CONCLUSION: A simple screening program for CI followed by a CDSS did not change physician prescribing behaviors or improve the process of care for hospitalized older adults with CI.

Improving delirium care in the intensive care unit: the design of a pragmatic study.

BACKGROUND: Delirium prevalence in the intensive care unit (ICU) is high. Numerous psychotropic agents are used to manage delirium in the ICU with limited data regarding their efficacy or harms. METHODS/DESIGN: This is a randomized controlled trial of 428 patients aged 18 and older suffering from delirium and admitted to the ICU of Wishard Memorial Hospital in Indianapolis. Subjects assigned to the intervention group will receive a multicomponent pharmacological management protocol for delirium (PMD) and those assigned to the control group will receive no change in their usual ICU care. The primary outcomes of the trial are (1) delirium severity as measured by the Delirium Rating Scale revised-98 (DRS-R-98) and (2) delirium duration as determined by the Confusion Assessment Method for the ICU (CAM-ICU). The PMD protocol targets the three neurotransmitter systems thought to be compromised in delirious patients: dopamine, acetylcholine, and gamma-aminobutyric acid. The PMD protocol will target the reduction of anticholinergic medications and benzodiazepines, and introduce a low-dose of haloperidol at 0.5-1 mg for 7 days. The protocol will be delivered by a combination of computer (artificial intelligence) and pharmacist (human intelligence) decision support system to increase adherence to the PMD protocol. DISCUSSION: The proposed study will evaluate the content and the delivery process of a multicomponent pharmacological management program for delirium in the ICU. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00842608.

Screening, referral, and participation in a weight management program implemented in five CHCs.

Community health centers have the potential to lessen obesity. We conducted a retrospective evaluation of a quality improvement program that included electronic body mass index (BMI) screening with provider referral to an in-clinic lifestyle behavior change counselor with weekly nutrition and exercise classes. There were 26,661 adult patients seen across five community health centers operating the weight management program. There were 23,593 (88%) adult patients screened, and 12,487 (53%) of these patients were overweight or obese (BMI >or=25). Forty percent received a provider referral, 15.6% had program contact, and 2.1% had more than 10 program contacts. A mean weight loss of seven pounds was observed among those patients with more than 10 program contacts. No significant weight change was observed in patients with less contact. Achieving public health impact from guideline recommended approaches to CHC-based weight management will require considerable improvement in patient and provider participation.

Using computerized provider order entry and clinical decision support to improve referring physicians' implementation of consultants' medical recommendations.

OBJECTIVES: Only half of consultants' medical recommendations are implemented. We created a tool that lets referring providers review and implement electronic recommendations made by consultants, with the hypothesis that facilitation with our tool could improve implementation. MEASUREMENTS: The tool was piloted among geriatrics consultants and hospitalists. Pre-post evaluation was done with control (before pilot; N=20) and intervention (after pilot; N=20) patients. Consultants wrote notes containing recommendations for all study patients, and entered electronic recommendations only for intervention patients. We analyzed all recommendations and surveyed hospitalists. RESULTS: A total of 249 recommendations were made for intervention patients versus 192 for controls (p<0.05). Of all recommendations about intervention patients, 78% were implemented, compared to 59% for controls (p=0.01). Of the intervention recommendations, 77% were entered electronically using our tool; of these, 86% were implemented. All 24 survey respondents indicated that the system improved quality, saved time, and should be expanded. CONCLUSION: Consultant recommendations were implemented 30% more often when there was electronic facilitation of recommendations.

A pilot study of usefulness of clinician-patient videoconferencing for making routine medical decisions in the nursing home.

OBJECTIVES: To pilot and assess the role of videoconferencing in clinicians' medical decision-making and their interactions with nursing home residents (NHRs). DESIGN: Paired virtual and bedside examinations. Face-to-face (FTF) examination of NHRs by off-site clinicians immediately followed videoconferencing between the same clinician-NHR pair. SETTING: A 240-bed, county-managed, urban nursing home. PARTICIPANTS: NHRs (n=35) and clinicians (n=3) receiving or providing routine care between 2002 and 2003. MEASUREMENTS: Orders generated by clinicians, clinicians' ratings of videoconferencing, and coded review of video encounters. After both examinations, clinicians rated the encounters and generated orders necessary for NHRs. Orders were categorized and counted according to timing (before or after the FTF visit). Clinician-NHR interactions were assessed using coding videos with a 31-item instrument. RESULTS: For 71% of the encounters, clinicians stated that videoconferencing facilitated their assessment. Difficulties included sound quality (19%) and participants' familiarity with videoconferencing (7%). Although NHRs were alert in 50% of encounters, 62% of alert NHRs did not indicate understanding of the recommended treatment. CONCLUSION: FTF examination was superior for most assessments, but videoconferencing was judged to be valuable, especially for wound care. Even when NHRs were alert, informed medical decision-making by NHRs with their clinicians was limited. Enhancing videoconferencing quality and providing more training about informed decision-making using videoconferencing might improve the effectiveness of the technology.

SPIN query tools for de-identified research on a humongous database.

The Shared Pathology Informatics Network (SPIN), a research initiative of the National Cancer Institute, will allow for the retrieval of more than 4 million pathology reports and specimens. In this paper, we describe the special query tool as developed for the Indianapolis/Regenstrief SPIN node, integrated into the ever-expanding Indiana Network for Patient care (INPC). This query tool allows for the retrieval of de-identified data sets using complex logic, auto-coded final diagnoses, and intrinsically supports multiple types of statistical analyses. The new SPIN/INPC database represents a new generation of the Regenstrief Medical Record system - a centralized, but federated system of repositories.

Clinicians' and patients' experiences and satisfaction with unscheduled, nighttime, Internet-based video conferencing for assessing acute medical problems in a nursing facility.

Videoconferencing between patients and their physicians can increase patients' access to healthcare. Unscheduled videoconferencing can benefit patients with acute medical problems but has not been studied extensively. We conducted a clinical trial of unscheduled, nighttime videoconferencing in a nursing home, where on-call physicians usually provide care by telephone from remote locations. Although most calls for medical problems did not lead to videoconferencing, physicians and nursing-home residents were satisfied with videoconferencing when it did occur, and physicians reported that making medical decisions was easier with videoconferencing. Videoconferencing was most often conducted to assess residents with changes in mental status, abnormal laboratory values, or falls. Physicians often lacked immediate access to videoconferencing equipment when medical problems with residents occurred. This application could benefit from improved access and portability of equipment.

Conducting a study of Internet-based video conferencing for assessing acute medical problems in a nursing facility.

We expect the use of real-time, interactive video conferencing to grow, due to more affordable technology and new health policies. Building and implementing portable systems to enable conferencing between physicians and patients requires durable equipment, committed staff, reliable service, and adequate protection and capture of data. We are studying the use of Internet-based conferencing between on-call physicians and patients residing in a nursing facility. We describe the challenges we experienced in constructing the study. Initiating and orchestrating unscheduled conferences needs to be easy, and requirements for training staff in using equipment should be minimal. Studies of health outcomes should include identification of medical conditions most amenable to benefit from conferencing, and outcomes should include positive as well as negative effects.