Use of a verbal electronic audio reminder with a patient hand hygiene bundle to increase independent patient hand hygiene practices of older adults in an acute care setting.

BACKGROUND: We hypothesized that the addition of a novel verbal electronic audio reminder to an educational patient hand hygiene bundle would increase performance of self-managed patient hand hygiene. METHODS: We conducted a 2-group comparative effectiveness study randomly assigning participants to patient hand hygiene bundle 1 (n = 41), which included a video, a handout, and a personalized verbal electronic audio reminder (EAR) that prompted hand cleansing at 3 meal times, or patient hand hygiene bundle 2 (n = 34), which included the identical video and handout, but not the EAR. The primary outcome was alcohol-based hand sanitizer use based on weighing bottles of hand sanitizer. RESULTS: Participants that received the EAR averaged significantly more use of hand sanitizer product over the 3 days of the study (mean ± SD, 29.97 ± 17.13 g) than participants with no EAR (mean ± SD, 10.88 ± 9.27 g; t73 = 5.822; P ≤ .001). CONCLUSIONS: The addition of a novel verbal EAR to a patient hand hygiene bundle resulted in a significant increase in patient hand hygiene performance. Our results suggest that simple audio technology can be used to improve patient self-management of hand hygiene. Future research is needed to determine if the technology can be used to promote other healthy behaviors, reduce infections, and improve patient-centered care without increasing the workload of health care workers.

An online course improves nurses' awareness of their role as antimicrobial stewards in nursing homes.

BACKGROUND: To support the role of nurses as active proponents of antimicrobial stewardship in long-term care facilities, we developed an educational intervention consisting of a free online course comprised of 6 interactive modules. Here, we report the effect of the course on the knowledge, beliefs, and attitudes toward antimicrobial stewardship of nurses working in long-term care facilities. METHODS: We used a paired pre- and postcourse survey instrument to assess nurses' knowledge regarding the care of long-term care facility residents with infections and attitudes and beliefs regarding antimicrobial stewardship. RESULTS: There were 103 respondents, registered nurses or licensed practical nurses, who completed the pre- and postsurveys. Their mean knowledge scores improved from 75% (precourse) to 86% (postcourse, P <.001). After the course, nurses' agreement that their role influences whether residents receive antimicrobials increased significantly (P <.001). CONCLUSIONS: The online course improves nurses' knowledge regarding the care of long-term care facility residents with infections and improves their confidence to engage in antimicrobial stewardship activities. Empowering nurses to be antimicrobial stewards may help reduce unnecessary antibiotic use among institutionalized older adults.

Shared Medical Appointments: Impact on Clinical and Quality Outcomes in Veterans With Diabetes.

Managing diabetes poses substantial challenges to the over 29.1 million Americans afflicted, and is financially overwhelming to the US health care system. One potential strategy is utilizing a group approach to care delivery or shared medical appointment (SMA). The purpose of this 3-year retrospective VA study was to investigate differences in clinical and quality outcome measures in veterans with type 2 diabetes who used SMAs and those who received only usual care (UC) one-on-one with their doctor. This observational, 2-group cohort study used abstracted medical records from a large Midwestern Veterans Administration hospital. Clinical outcome metrics included hemoglobin A1c (hbA1c), systolic blood pressure, low-density lipoprotein cholesterol, and emergency department (ED) visits. Quality outcomes included Veterans' Administration (VA) Department of Defense clinical practice guidelines for the management of diabetes. A total of 988 total VA cases were examined retrospectively over 3 years: 371 cases had used SMAs and 617 were in the UC cohort, and had never attended a diabetes SMA. The study period used abstracted VA medical records from 2008 to 2010. There were no statistically significant differences in HbA1c, systolic blood pressure, and ED visits between groups; however, hbA1c for individuals who attended SMAs was 8.55 (standard deviation [SD] = 1.72) and UC was 7.49 (SD = 1.28) (P < .001). All clinical outcomes were worse at baseline for the SMA cohort. UC had mean ED visits/3 years (mean = 18.62, SD = 13.53, P < .001) versus SMA participants (mean = 27.97, SD = 14.00, P <. 001), revealing a propensity for high health care utilization. SMA providers had statistically significant differences over UC cases on quality measures, including ordering annual ophthalmology and podiatry examinations (P < .001) and prescribing aspirin and angiotension-converting enzyme inhibitors (ACE-I). SMAs may provide a venue for assessing and delivering quality care for patients with type 2 diabetes. More research is needed to ascertain effective strategies for diabetes disease management in high-risk patients.

Results of a Veterans Affairs employee education program on antimicrobial stewardship for older adults.

We describe a course in the Veterans Affairs (VA) Employee Education System designed to engage nursing staff working in VA long-term care facilities as partners in antimicrobial stewardship. We found that the course addressed an important knowledge gap. Our outcomes suggest opportunities to engage nursing staff in advancing antimicrobial stewardship, particularly in the long-term care setting.

Four Moments for Patient Hand Hygiene: A Patient-Centered, Provider-Facilitated Model to Improve Patient Hand Hygiene.

We found that a majority of hospitalized patients were aware of the importance of hand hygiene, but observations indicated that performance of hand hygiene was uncommon. An intervention in which healthcare personnel facilitated hand hygiene at specific moments significantly increased performance of hand hygiene by patients.

Knowledge, beliefs, and confidence regarding infections and antimicrobial stewardship: a survey of Veterans Affairs providers who care for older adults.

We conducted an anonymous survey of providers who care for older adults from 10 Veterans Affairs long-term-care facilities to assess their knowledge, beliefs, and confidence toward treating infections and antimicrobial stewardship. The average score on 5 questions assessing knowledge was 3.6 out of 5.0 (95% confidence interval, 3.3-3.9), which supports a need for education regarding the care of older adults with infections.

Exploring family relationships through associations of comfort, relatedness states, and life closure in hospice patients: A pilot study.

OBJECTIVE: Research at the end of life tends to focus on the dying patient's symptoms, often overlooking issues associated with family interactions. However, many families struggle just to maintain or initiate these valuable connections. The purpose of our pilot study was to explore family relationships at the end of life and investigate associations among perceived comfort, relatedness states, and life closure. METHOD: This descriptive study used a cross-sectional design, and a convenience sample (n = 30; 18 women; mean age = 71 years) was recruited from patients admitted to a large not-for-profit hospice in northeastern Ohio. In-person interviews using the Hospice Comfort Questionnaire, Relatedness States Visual Analog Scales, and the Life-Closure Scale provided data for analyses. RESULTS: Family interactions that were not associated with the physical tasks of caregiving were related to life closure (r = 0.36, p = 0.001), and life closure and comfort were highly correlated (r = 0.69, p < 0.001). Participants residing in an inpatient setting had higher levels of involvement (t[18] = -2.07, p = 0.05) and comfort in relationships (t[28] = -2.06, p = 0.05) than those in the home setting. SIGNIFICANCE OF RESULTS: This is the first known study investigating the associations among comfort, relatedness, and life closure at the end of life. The majority of participants had high levels of involvement and comfort in their relationships, and they preferred interactions that required minimal effort. Studies that focus on both patients' and family members' perceptions of relationships are needed as well as outcome studies that test simple interventions.

Using Light to Manage Sleep-Wake Issues in Patients With Dementia.

Although research has yet to provide a definitive answer about whether circadian-active light can benefit patients with dementia, a VA pilot study shows promising results.

Epidermal growth factor receptor (EGFR), HER2 and insulin-like growth factor-1 receptor (IGF-1R) status in ovarian adult granulosa cell tumours.

AIMS: Adult granulosa cell tumours (AGCTs) are uncommon ovarian sex cord-stromal tumours which recur following surgical removal in up to 50% of patients. Treatment options for recurrent and advanced stage AGCTs are limited, with poor response to chemotherapy and radiotherapy. We aimed to assess epidermal growth factor receptor (EGFR), HER2 and insulin-like growth factor-1 receptor (IGF-1R) status in AGCTs with a view to investigating whether or not these receptors might be potential therapeutic targets in these neoplasms. METHODS AND RESULTS: Immunohistochemical staining for EGFR, HER2 and IGF-1R was undertaken in 31 AGCTs. Tumour DNA was also analysed for mutations in the tyrosine kinase domain of EGFR (exons 18-21) by Cobas mutation RT-PCR. Twenty-three of 31 (74%) AGCTs showed some degree of EGFR expression, generally with cytoplasmic or mixed membranous and cytoplasmic staining of variable intensity. Eleven of 27 (41%) cases exhibited strong membranous and cytoplasmic expression of IGF-1R. HER2 expression was not seen. No mutations were found in exons 18-21 of the EGFR gene in hot-spots of therapeutic relevance. CONCLUSIONS: This study raises the possibility that anti-EGFR and/or anti-IGF-1R therapies may be of potential benefit in ovarian AGCTs, and this requires further study. Lack of known mutations within the tyrosine kinase domain of EGFR suggests that EGFR-related tyrosine kinase inhibitors may not be useful therapeutically.

Frailty assessment in the geriatric outpatient clinic.

AIM: Frailty is a common phenomenon in geriatric patients. In the present translational research study, we assessed two frailty instruments (Fried 2001; Gill 2002), comparing the usefulness and scoring classifications for frailty screening in an academically affiliated geriatrics clinic. METHODS: Assessment was completed on 162 male veterans (mean age 83.7 years, 57% African American) enrolled in a geriatric clinic. The instruments' component criteria, which are well known to gerontological clinicians, were administered in a standard order and scoring was identical to original instruments. RESULTS: The five-item Fried frailty instrument required 15-20 min to complete; the two-item Gill frailty instrument required less than 2 min. Of the 162 participants assessed, 72 were determined to be frail by at least one of the instruments, but just 33 were frail by both instruments. Correlations between the instruments were Spearman = 0.55 (P < 0.001) and kappa = 0.25, (P < 0.001). There were no differences in frailty scores based on race, and there were equivocal results based on age, even though this was an older sample, with almost 17% ≥90 years. A total of 63% (103/162) of the sample met the criterion for weak grip strength, and decreasing grip strength correlated with increasing age (r = -0.238, P = 0.002). CONCLUSION: Expedient identification of the frailty syndrome remains an unmet necessity for clinical practice. The different results by the Fried and Gill frailty instruments are likely due to differences in component domains and testing methods. The present results support previous findings that showed that grip strength might be an important indicator of increasing frailty.

Hospital lighting and its association with sleep, mood and pain in medical inpatients.

AIMS: To describe light exposure, sleep-wake patterns, mood, pain and their relationships in adult medical inpatients. BACKGROUND: The hospital environment may contribute to patient discomfort by providing a lighting structure that interferes with circadian rhythmicity, sleep, mood and pain. DESIGN: A descriptive correlational design was used in this preliminary study. METHODS: Between May 2011-April 2012, data were collected from a convenience sample of 23 women and 17 men admitted to a large academically affiliated hospital in the United States. Over 72 hours, light exposure and sleep-wake patterns were continuously measured with wrist actigraph/light meters for each participant. Mood was measured daily using the Profile Of Mood States Brief™ Form. Subjective pain scores were abstracted from medical records. RESULTS: Light exposure levels were low: mean daytime light intensity was 104·80 lux. Sleep time was fragmented and low: mean 236·35 minutes of sleep/night. Intra-daily stability scores indicated little sleep-wake synchronization with light. Fatigue and total mood disturbance scores were high and inversely associated with light. Pain levels were also high and positively associated with fatigue, but not directly with light exposure. Low light exposure significantly predicted fatigue and total mood disturbance. CONCLUSION: Medical inpatients were exposed to light levels insufficient for circadian entrainment. Nevertheless, higher light exposure was associated with less fatigue and lower total mood disturbance in participants with pain, suggesting the need for further investigation to determine if manipulating light exposure for medical inpatients would be beneficial in affecting sleep-wake disturbances, mood and pain.

The complexity of older adults' social support networks.

The purpose of this study was to provide a detailed snapshot of the diversity of social support networks of 95 independent-living older adults (mean age = 76). Participants in the convenience sample were recruited from senior centers and a retirement community. Using the Arizona Social Support Interview Schedule and egocentric network analysis, participants' networks are described in terms of patterns, density, size of positive networks (available and utilized), size of negative networks (available and utilized), support need, and support satisfaction. Each participant and the identified members of his or her network were considered a complex adaptive system. Network boundary was 7 members; average network size was 6.22 members (SD = 1.50); network density was moderate (mean = 0.53, SD = 0.33); positive interaction networks were larger than negative networks; and overall, participants reported moderate support need (mean = 2.5, SD = 0.7) and high support satisfaction (mean = 5.9, SD = 1.0).

The relationship between social roles and self-management behavior in women living with HIV/AIDS.

BACKGROUND: The social roles that women perform can be complicated and may affect their health. While there is some evidence describing traditional social roles of women, there is little evidence exploring the impact of those roles on how a woman manages a chronic condition. The purpose of this paper is to identify and examine the main social roles of 48 HIV infected women, and to explore how these roles relate to their self-management of HIV/AIDS. METHODS: Forty-eight HIV infected, adult women were recruited from HIV clinics and AIDS service organizations in Northeast Ohio. All participants participated in one of 12 digitially recorded focus groups. All data were analyzed using qualitative description methodology. RESULTS: The participants were predominantly middle-aged (mean = 42 years), African American (69%), and single (58%). Analysis revealed six social roles that these women experience and which affect their self-management. These social roles are: Mother/Grandmother, Believer, Advocate, Stigmatized Patient, Pet Owner, and Employee. These roles had both a positive and negative effect on a woman's self-management of her HIV disease and varied by age and time living with HIV. CONCLUSION: Women living with HIV/AIDS struggle to manage the many daily tasks required to live well with this disease. The social context in which this self-management happens is important, and the various social roles that women perform can facilitate or hinder them from completing these tasks. Healthcare and social service providers should learn about these roles in their individual patients, particularly how these roles can be developed to increase HIV/AIDS self-management.

The oncology acuity tool: a reliable, valid method for measuring patient acuity for nurse assignment decisions.

BACKGROUND AND PURPOSE: Matching nurse assignments with patient acuity has critical implications for providing safe, effective, and efficient care. Despite this, we lack well-established methods for accurate assessment of acuity. This study aimed to evaluate the reliability and validity of the Oncology Acuity Tool (OAT), which is used for determining nurse assignments. METHODS: Inter-rater reliability and concurrent validity were assessed via surveys of current users of the tool. Content validity data were collected from expert oncology nurses. Predictive validity was assessed by tracking patients who sustained either of two acute events. RESULTS: Findings included high inter-rater reliability, moderately strong concurrent validity, and moderate content validity. Acuity significantly predicted rapid response team consults but not falls. CONCLUSIONS: The OAT demonstrated sufficient reliability and validity for measuring acuity prospectively in this population.

Perspective: medical education research and the institutional review board: reexamining the process.

Medical school and residency training curricula across the country have undergone extensive revisions and, much like clinical quality improvement (QI) initiatives, require assessments of new programs. Because sharing knowledge is a hallmark of academic medicine, program evaluation may come under the purview of the institutional review board (IRB); however, the distinction between QI and research is often unclear. And yet a medical education (ME) inquiry can be designed according to either paradigm. The purpose of this article is to bring IRBs and ME researchers closer to a shared understanding of key concepts underlying human participation in research and QI activities, and to consensus on the application of these concepts. The current QI discourse provides a useful framework for making this distinction; the authors identify key theoretical principles and practical considerations derived from this work that are relevant to ME and training, such as the application of the regulatory definition of human subject research to ME inquiries. For ME inquiries defined as human subject research, and therefore subject to IRB review, this article explores the application of the human research regulations to ME research. It concludes with practical suggestions for institutions, IRBs, and ME researchers, which range from formal procedures for making the QI versus research distinction, to instruction in study design and development and the human subject regulatory implications. The intent is to promote a discussion that will result in greater consensus and a more consistent application of the regulatory framework.

Rest-activity and light exposure patterns in the home setting: a methodological case study.

BACKGROUND: This methodological case study describes light exposure and rest-activity patterns in an older adult with dementia and his caregiver spouse. METHODS: Two devices were used to measure rest-activity and light exposure data: a wrist-worn actigraph with a light sensor to record full spectrum light exposure data and an eye-level wavelength-sensitive light meter (Daysimeter). The wife wore both devices simultaneously; the husband wore only the actigraph. RESULTS: There were minimal feasibility issues in using the devices in the home setting. The wife's light exposure was considerably better than her husband's, but she spent little time in bright lighting. Her circadian stimulus (CS) and rest-activity values suggest a high level of circadian disruption. CONCLUSION: This case study provides beginning support for the use of the Daysimeter in the home setting while also highlighting unrecognized circadian disturbances and very low light levels in an older couple's home.

Facilitated sensemaking: a feasibility study for the provision of a family support program in the intensive care unit.

Family members of intensive care unit patients may develop anxiety, depression, and/or posttraumatic stress syndrome. Approaches to prevention are not well defined. Before testing preventive measures, it is important to evaluate which interventions the family will accept, use, and value. The purpose of this study was to evaluate the feasibility of an intervention for support for families of mechanically ventilated adults, grounded in a new midrange nursing theory titled "Facilitated Sensemaking." Families were provided a kit of supplies and the primary investigator coached families on how to obtain information, interpret surroundings, and participate in care. Participants were asked to complete an adapted Critical Care Family Needs Inventory and Family Support Program evaluation. Family members of 30 patients consented to participate; 22 participants completed the surveys. Internal consistency reliability of the adapted Critical Care Family Needs Inventory was high (alpha = .96). Results validated the importance of informational needs and provided a score indicating the family member's perception of how well each need was met, weighted by importance, which identified performance improvement opportunities for use by clinical managers. The program evaluation confirmed that families will use this format of support and find it helpful. Personal care supplies (eg, lotion, lip balm) were universally well received. Forty-two referrals to ancillary service were made. Operational issues to improve services were identified. As proposed in the Facilitated Sensemaking model, family members welcomed interventions targeted to help make sense of the new situation and make sense of their new role as caregiver. Planned supportive interventions were perceived as helpful.