Barriers to transition of obese patients from hospital to community.

OBJECTIVES: To identify barriers encountered by case managers in hospitals, home care agencies, and nursing homes in the transition of the obese patient from the hospital to the community. STUDY DESIGN: Exploratory descriptive design was used. Hospital case managers, nursing home administrators, and Medicare-certified home healthcare agency administrators were surveyed to identify barriers. METHODS: Hospital case managers in each licensed acute care hospital, directors of licensed nursing homes, and administrators of the Medicarecertified home healthcare agencies in 1 southern state were surveyed. The survey instrument was designed by the investigators based on variables identified in the literature or encountered within their practice. Instruments consisted of items related to the respondent's experience with barriers such as patient size, degree of patient independence, patient care requirements, staffing levels, and the need for assistive equipment, as well as items used to collect basic demographic information. RESULTS: Both hospital case managers and nursing home directors reported as major barriers the equipment, the size of the patient, patient independence, and finances. Home care agency directors reported that the presence or absence of a competent caregiver was the major factor in the decision to accept or not accept an obese patient. CONCLUSIONS: Transition of the obese patient presents major challenges. Further exploration is needed to identify the extent of problems and make policy recommendations toward a solution.

The association of BMI and Braden total score on the occurrence of pressure ulcers.

PURPOSE: We compared pressure ulcer (PU) prevalence patients with a body mass index (BMI) of 40 or more, and Braden Scale scores of 16 or more to patients with lower BMI. METHODS: A cross-sectional study by using existing data was conducted combining patient skin status with BMI. Subjects underwent skin assessment for evidence of skin breakdown by nurses trained in PU assessment. Data from this assessment were combined with historic data gathered from review of medical records and BMI. SUBJECTS AND SETTING: The study was carried out in a tertiary medical center in Eastern North Carolina. Three hundred sixty-two patients were included in the prevalence study. RESULTS: Fourteen percent of all patients had at least 1 PU. The prevalence among patients with a BMI of less than 40 was 12.5% as compared to 26% in patients with a BMI of more than 40 (P 5 .01). When controlling for the effects of BMI, patients with a Braden Scale score of 16 or less were almost 6 times more likely to have a PU as compared to those with Braden Scale scores of more than 16 (P, .001). Body mass index had an independent association with the probability of PU occurrence. Patients with BMIs of more than 40 were almost 3 times more likely to have a PU compared to those with BMIs of 40 or less, after controlling for Braden risk (P 5 .01). CONCLUSION: A BMI of more than 40 and Braden Scale score of 16 or less were found to have an independent and statistically significant association with PU occurrence. Future studies should investigate the predictive validity of BMI along with individual Braden subscales.

Tissue oxygenation monitoring in the field: a new EMS vital sign.

BACKGROUND: A tissue hemoglobin oxygen saturation (STO2) monitor was created to assess the perfusion status of a peripheral muscle bed using near infrared light to directly measure oxygen saturation in the microcirculation. Hypoperfusion has been noted when the STO2 is <75%. The use of this technology has not been tested in the prehospital setting. This pilot study was performed to assess the technology's ease of use in the field and to correlate STO2 readings with patient outcomes. METHODS: Hospital-based transport vehicles were equipped with STO2 monitors and personnel were asked to evaluate the functionality of the technology. Initial, average, and minimal STO2 values were collected and compared with data of the trauma registry. RESULTS: Forty five of 55 surveys were returned with 100% reporting ease of use and no reports of interference with monitors or avionics. Monitoring length averaged 16.9 minutes +/- 6.9 minutes. Forty-one patients had complete data sets and five deaths were reported for a mortality rate of 12%. STO2 endpoints revealed and increased risk of death for every 10% decrease in STO2. CONCLUSION: The STO2 monitor can easily be used in the prehospital environment. In addition, initial recordings were significantly different between survivors and nonsurvivors with every 10% decrease in STO2 increasing mortality threefold. This monitor seems to give the prehospital provider a noninvasive tool for assessment of hypoperfusion in the field and may allow for earlier resuscitative efforts to commence.