Utility of Pulse Oximetry to Detect Aspiration: An Evidence-Based Systematic Review.

Pulse oximetry is a commonly used means to measure peripheral capillary oxyhemoglobin saturation (SpO2). Potential use of pulse oximetry to detect aspiration is attractive to clinicians, as it is readily available, quick, and noninvasive. However, research regarding validity has been mixed. This systematic review examining evidence on the use of pulse oximetry to detect a decrease in SpO2 indicating aspiration during swallowing is undertaken to further inform clinical practice in dysphagia assessment. A multi-engine electronic search was conducted on 8/25/16 and updated on 4/8/17 in accordance with standards published by the Preferred Reporting for Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA). Inclusion criteria included use of pulse oximetry to detect aspiration with simultaneous confirmation of aspiration via a gold standard instrumental study. Keywords included dysphagia or aspiration AND pulse oximetry. Articles meeting criteria were reviewed by two blinded co-investigators. The search yielded 294 articles, from which 19 were judged pertinent and reviewed in full. Ten met the inclusion criteria and all were rated at Level III-2 on the Australian Diagnostic Levels of Evidence. Study findings were mixed with sensitivity ranging from 10 to 87%. Potentially confounding variables were observed in all studies reviewed, and commonly involved defining "desaturation" within a standard measurement error range (~ 2%), mixed populations, mixed viscosities/textures observed during swallowing, and lack of comparison group. The majority of studies failed to demonstrate an association between observed aspiration and oxygen desaturation. Current evidence does not support the use of pulse oximetry to detect aspiration.

Association of living alone and hospitalization among community-dwelling elders with and without dementia.

BACKGROUND: Older persons account for the majority of hospitalizations in the United States.1 Identifying risk factors for hospitalization among elders, especially potentially preventable hospitalization, may suggest opportunities to improve primary care. Certain factors-for example, living alone-may increase the risk for hospitalization, and their effect may be greater among persons with dementia and the old-old (aged 85+). OBJECTIVES: To determine the association of living alone and risk for hospitalization, and see if the observed effect is greater among persons with dementia or the old-old. DESIGN: Retrospective longitudinal cohort study. PARTICIPANTS: 2,636 participants in the Adult Changes in Thought (ACT) study, a longitudinal cohort study of dementia incidence. Participants were adults aged 65+ enrolled in an integrated health care system who completed biennial follow-up visits to assess for dementia and living situation. MAIN MEASURES: Hospitalization for all causes and for ambulatory care sensitive conditions (ACSCs) were identified using automated data. KEY RESULTS: At baseline, the mean age of participants was 75.5 years, 59 % were female and 36 % lived alone. Follow-up time averaged 8.4 years (SD 3.5), yielding 10,431 approximately 2-year periods for analysis. Living alone was positively associated with being aged 85+, female, and having lower reported social support and better physical function, and negatively associated with having dementia. In a regression model adjusted for age, sex, comorbidity burden, physical function and length of follow-up, living alone was not associated with all-cause (OR = 0.93; 95 % CI 0.84, 1.03) or ambulatory care sensitive condition (ACSC) hospitalization (OR = 0.88; 95 % CI 0.73, 1.07). Among participants aged 85+, living alone was associated with a lower risk for all-cause (OR = 0.76; 95 % CI 0.61, 0.94), but not ACSC hospitalization. Dementia did not modify any observed associations. CONCLUSION: Living alone in later life did not increase hospitalization risk, and in this population may be a marker of healthy aging in the old-old.

Rehabilitation following pediatric traumatic brain injury: variability in adherence to psychosocial quality-of-care indicators.

OBJECTIVE: To examine variations in processes of pediatric inpatient rehabilitation care related to family-centered care, management of neurobehavioral and psychosocial needs, and community reintegration after traumatic brain injury. SETTING: Nine acute rehabilitation facilities from geographically diverse areas of the United States. PARTICIPANTS: A total of 174 children with traumatic brain injury. DESIGN: Retrospective chart review. MAIN MEASURES: Adherence to care indicators (the number of times recommended care was delivered or attempted divided by the number of times care was indicated). RESULTS: Across facilities, adherence rates (adjusted for difficulty of delivery) ranged from 33.6% to 73.1% (95% confidence interval, 13.4-53.9, 58.7-87.4) for family-centered processes, 21.3% to 82.5% (95% confidence interval, 6.6-36.1, 67.6-97.4) for neurobehavioral and psychosocial processes, and 22.7% to 80.3% (95% confidence interval, 5.3-40.1, 68.1-92.5) for community integration processes. Within facilities, standard deviations for adherence rates were large (24.3-34.9, family-centered domain; 22.6-34.2, neurobehavioral and psychosocial domain; and 21.6-40.5, community reintegration domain). CONCLUSION: The current state of acute rehabilitation care for children with traumatic brain injury is variable across different quality-of-care indicators addressing neurobehavioral and psychosocial needs and facilitating community reintegration of the patient and the family. Individual rehabilitation facilities demonstrate inconsistent adherence to different indicators and inconsistent performance across different care domains.

Variations in the quality of inpatient rehabilitation care to facilitate school re-entry and cognitive and communication function for children with TBI.

OBJECTIVE: To examine variations in processes of paediatric inpatient rehabilitation care related to school re-entry and management of cognitive and communication impairments after traumatic brain injury. DESIGN: Retrospective cohort study. METHODS: Adherence to care processes recommended for children (aged 0-17) with moderate-to-severe traumatic brain injury and admitted for inpatient rehabilitation was assessed. Quality-of-care indicators for processes supporting school re-entry and cognitive and communication rehabilitation were applied to measure variations in care delivered to 174 children across nine facilities using medical record review. MAIN OUTCOMES AND RESULTS: Adherence rates (the number of times recommended care was delivered or attempted divided by the number of times care was indicated) were calculated, revealing substantial variations in care within and between facilities. Overall, children received 51.3% (95% CI = 31.9-70.7) and 72.3% (95% CI = 61.1-83.5), of the care recommended for school re-entry and cognitive and communication rehabilitation, respectively. CONCLUSION: Substantial variations exist in the delivery of paediatric inpatient rehabilitation care processes for managing school re-entry and cognitive and communication impairments after traumatic brain injury. Measures of association of these care processes with patient outcomes are necessary. Reduction in this variation is essential to improving quality of care.

Variation in adherence to new quality-of-care indicators for the acute rehabilitation of children with traumatic brain injury.

OBJECTIVE: To determine variations in care provided by 9 inpatient rehabilitation units for children with traumatic brain injury (TBI) using newly developed quality indicators. DESIGN: Retrospective cohort study. SETTING: Nine inpatient rehabilitation units. PARTICIPANTS: Children (N=174; age range, 0-17y) admitted for the inpatient rehabilitation of moderate to severe TBI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Adherence to 119 newly developed quality-of-care indicators in 7 different domains: general care, family-centered care, cognitive-communication, motor, neuropsychological, school, and community integration. RESULTS: There was substantial variation both within and between institutions in the percentage of patients receiving recommended care in the 7 domains. The lowest scores were found for the school domain. Only 5 institutions scored above 50% for all quality indicators, and only 1 institution scored above 70% overall. Greater adherence to quality indicators was found for facilities with a higher proportion of therapists with pediatric training and for facilities that only admitted children. Patient volume was not associated with adherence to quality indicators. CONCLUSIONS: The results indicate a tremendous variability and opportunity for improvement in the care of children with TBI.

Quality of care indicators for the rehabilitation of children with traumatic brain injury.

OBJECTIVE: To develop measurement tools for assessing compliance with identifiable processes of inpatient care for children with traumatic brain injury (TBI) that are reliable, valid, and amenable to implementation. DESIGN: Literature review and expert panel using the RAND/UCLA Appropriateness Method and a Delphi technique. SETTING: Not applicable. PARTICIPANTS: Children with TBI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Quality of care indicators. RESULTS: A total of 119 indicators were developed across the domains of general management; family-centered care; cognitive-communication, speech, language, and swallowing impairments; gross and fine motor skill impairments; neuropsychologic, social, and behavioral impairments; school reentry; and community integration. There was a high degree of agreement on these indicators as valid and feasible quality measures for children with TBI. CONCLUSIONS: These indicators are an important step toward building a better base of evidence about the effectiveness and efficiency of the components of acute inpatient rehabilitation for pediatric patients with TBI.

Quality of care indicators for the structure and organization of inpatient rehabilitation care of children with traumatic brain injury.

OBJECTIVES: To develop evidence-based and expert-driven quality indicators for measuring variations in the structure and organization of acute inpatient rehabilitation for children after traumatic brain injury (TBI) and to survey centers across the United States to determine the degree of variation in care. DESIGN: Quality indicators were developed using the RAND/UCLA modified Delphi method. Adherence to these indicators was determined from a survey of rehabilitation facilities. SETTING: Inpatient rehabilitation units in the United States. PARTICIPANTS: A sample of rehabilitation programs identified using data from the National Association of Children's Hospitals and Related Institutions, Uniform Data System for Medical Rehabilitation, and the Commission on Accreditation of Rehabilitation Facilities yielded 74 inpatient units treating children with TBI. Survey respondents comprised 31 pediatric and 28 all age units. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Variations in structure and organization of care among institutions providing acute inpatient rehabilitation for children with TBI. RESULTS: Twelve indicators were developed. Pediatric inpatient rehabilitation units and units with higher volumes of children with TBI were more likely to have: a census of at least 1 child admitted with a TBI for at least 90% of the time; adequate specialized equipment; a classroom; a pediatric subspecialty trained medical director; and more than 75% of therapists with pediatric training. CONCLUSIONS: There were clinically and statistically significant variations in the structure and organization of acute pediatric rehabilitation based on the pediatric focus of the unit and volume of children with TBI.