Creating a Culture of Mobility: Using Real-Time Assessment to Drive Outcomes.

BACKGROUND: Recent studies have demonstrated the safety and feasibility of early mobilization of patients in the hospital setting. Promoting early mobility improves patients' ability to perform daily activities and attend to basic needs. It also preserves patients' dignity and independence. We implemented a culture of mobility program to promote awareness of the importance of early mobility among health care providers, patients, and family caregivers on an inpatient orthopedic unit. PURPOSE: The goal of the program was to empower clinical RNs, physical therapists (PTs), and occupational therapists to conduct dynamic, ongoing assessment of a patient's functional status so the plan of care could be modified in real time to promote functional independence and prevent immobility-associated complications. METHODS: Nursing and therapy professionals used three mobility assessments to estimate the degree and type of activities a patient could safely perform during a hospital stay: the Johns Hopkins Highest Level of Mobility (JH-HLM) scale, the Physical Therapy Mobility Assessment (PTMA) scale, and the Occupational Therapy Assistance Assessment (OTAA) scale. The three assessment tools were incorporated into the electronic health record. To evaluate their performance, we retrospectively collected patient data before (baseline) and after (intervention) their implementation. There were 61 patients in the baseline group and 59 in the intervention group. RESULTS: The clinical characteristics of patients in the two groups were comparable, including demographics, diagnoses, and activity orders. The JH-HLM and PTMA scores correlated significantly with the maximum distance patients ambulated as measured independently by RNs and PTs, suggesting the tools worked as expected to estimate the actual activity patients performed. Importantly, we found that the intervention improved patient mobility, as evidenced by significant increases in the maximum distances and the number of times patients ambulated. Further, the initial scores on the JH-HLM, PTMA, and OTAA scales correlated significantly with the length of stay (LOS), an important outcome variable. This suggests that the mobility assessments can also be used to predict LOS and thus optimize hospital bed management. CONCLUSIONS: Nursing and therapy professionals successfully implemented three new mobility assessment tools on an inpatient orthopedic unit. The tools captured real-time information about patients' functional ability that was used to encourage patients' mobility.

Factors associated with antidepressant use in residents with and without dementia in Australian aged care facilities.

OBJECTIVE: Depressive symptoms are highly prevalent in residential aged care facilities (RACFs). The prevalence of antidepressant use is increasing but the effectiveness of antidepressants in people with dementia is uncertain. The objective of the study was to investigate factors associated with antidepressant use in residents with and without dementia. METHODS: This was a prospective cross-sectional study of 383 residents in six Australian RACFs. Data on health status, medications and demographics were collected by trained study nurses from April to August 2014. Logistic regression was used to compute adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for factors associated with antidepressant use. Analyses were stratified by dementia and depression. RESULTS: Overall, 183 (47.8%) residents used antidepressants. The prevalence of antidepressant use was similar among residents with and without dementia. Clinician-observed pain was inversely associated with antidepressant use in the main analysis (AOR = 0.56, 95% CI = 0.32-0.99) and in subanalyses for residents with documented depression (AOR = 0.51, 95% CI = 0.27-0.96). In residents with dementia, moderate quality of life was associated with a lower odds of antidepressant use compared with poor quality of life (AOR = 0.35, 95% C I= 0.13-0.95). In residents without dementia, analgesic use was associated with antidepressant use (AOR = 2.34, 95% CI = 1.07-5.18). CONCLUSIONS: The prevalence of antidepressant use was similar in residents with and without dementia. Clinician-observed pain was inversely associated with antidepressant use but there was no association between self-reported pain and antidepressant use.

Analgesic Use and Daytime Sleepiness in Residents With and Without Dementia in Residential Aged Care Facilities.

BACKGROUND: Managing pain in residents of residential aged care facilities (RACFs) is challenging, especially for people with dementia. Clinicians must weigh the benefits of analgesic use against the potential for adverse events, particularly daytime sleepiness. OBJECTIVES: The aim was to investigate the association between analgesic use and daytime sleepiness in residents with and without dementia in RACFs. METHODS: This was a cross-sectional study of 383 permanent residents from six low-level and high-level RACFs in South Australia. Main measures included analgesic use in the previous 24 h, analgesic load and self-reported daytime sleepiness. Covariates included relevant comorbidities (insomnia, depression, painful conditions), Charlson's Comorbidity Index, sedative load, self-reported and clinician-observed pain and dementia severity. Logistic regression was used to compute odds ratios (ORs) and confidence intervals (CIs) for the association between analgesic use and daytime sleepiness. RESULTS: Analgesics were used by 288 residents (75.2%) in the previous 24 h. These included paracetamol (n = 264, 68.9%), opioids (n = 110, 28.7%) and oral NSAIDs (n = 14, 3.7%). Overall, 116 (30.3%) residents were categorized as having daytime sleepiness. Of those with dementia, 77 (45.6%) were categorized as having daytime sleepiness. Opioid use in the previous 24 h was not associated with daytime sleepiness in unadjusted or adjusted analyses. Paracetamol use was positively associated with daytime sleepiness (OR 2.31; 95% CI 1.20-4.42). CONCLUSION: Although daytime sleepiness occurred in a large number of residents, especially those with dementia, this sleepiness was not necessarily associated with use of opioids. The risk of opioid-induced sedation may have been managed by strategies including preferential prescribing of paracetamol to residents at risk of sleepiness, opioid discontinuation in residents who experienced sleepiness, and use of low doses of opioids.

Results of rapid needs assessments in rural and urban Iowa following large-scale flooding events in 2008.

BACKGROUND: On June 8 and 9, 2008, more than 4 inches of rain fell in the Iowa-Cedars River Basin causing widespread flooding along the Cedar River in Benton, Linn, Johnson, and Cedar Counties. As a result of the flooding, there were 18 deaths, 106 injuries, and over 38,000 people displaced from their homes; this made it necessary for the Iowa Department of Health to conduct a rapid needs assessment to quantify the scope and effect of the floods on human health. METHODS: In response, the Iowa Department of Public Health mobilized interview teams to conduct rapid needs assessments using Geographic Information Systems (GIS)-based cluster sampling techniques. The information gathered was subsequently employed to estimate the public health impact and significant human needs that resulted from the flooding. RESULTS: While these assessments did not reveal significant levels of acute injuries resulting from the flood, they did show that many households had been temporarily displaced and that future health risks may emerge as the result of inadequate access to prescription medications or the presence of environmental health hazards. CONCLUSIONS: This exercise highlights the need for improved risk communication measures and ongoing surveillance and relief measures. It also demonstrates the utility of rapid needs assessment survey tools and suggests that increasing use of such surveys can have significant public health benefits.