Association Between Social Determinants of Health and Glycemic Control Among African American People with Type 2 diabetes: The Jackson Heart Study.

BACKGROUND: Social determinants of health have a significant impact on health outcomes. However, the complexity and interaction of multiple factors influencing glycemic control remain understudied. PURPOSE: This study examined associations of socioeconomic position (income, education, and occupation), environmental (physical activity facilities, neighborhood social cohesion, neighborhood problem, and violence), behavioral (physical activity, nutrition, and smoking), and psychological factors (depressive symptoms, stress, and discrimination) with glycemic control (hemoglobin A1c [A1c]) using the World Health Organization Social Determinants of Health framework in African American adults with type 2 diabetes. METHODS: A secondary data analysis was conducted using a longitudinal cohort of 1,240 African American adults with type 2 diabetes who participated in the community-based Jackson Heart Study. Socioeconomic position, environmental, behavioral, and psychological factors were measured using validated instruments in the Jackson Heart Study. Longitudinal structural equation modeling was used with glycemic control (A1c) collected over time (Exams 1-3) as the study outcome. RESULTS: Our study presents the complex interplay of socioeconomic determinants of health and glycemic control over time. Higher socioeconomic position (higher income, higher level of education, and professional occupation) was directly associated with improvement in glycemic control over time. An association of socioeconomic position on glycemic control mediated through health behavior factors was also observed. CONCLUSIONS: In this analysis, socioeconomic position components were determinants of glycemic control in African American adults with type 2 diabetes. Future studies aimed at reducing health disparities and achieving equality of outcomes in this population will benefit from embedding socioeconomic position components into their design.

SAR-Connect: A Socially Assistive Robotic System to Support Activity and Social Engagement of Older Adults.

Multi-domain activities that incorporate physical, cognitive, and social stimuli can enhance older adults' overall health and quality of life. Several robotic platforms have been developed to provide these therapies in a quantifiable manner to complement healthcare personnel in resource-strapped long-term care settings. However, these platforms are primarily limited to one-to-one human robot interaction (HRI) and thus do not enhance social interaction. In this paper, we present a novel HRI framework and a realized platform called SAR-Connect to foster robot-mediated social interaction among older adults through carefully designed tasks that also incorporate physical and cognitive stimuli. SAR-Connect seamlessly integrates a humanoid robot with a virtual reality-based activity platform and a multimodal data acquisition module including game interaction, audio, visual and electroencephalography responses of the participants. Results from a laboratory-based user study with older adults indicates the potential of SAR-Connect that showed this system could 1) involve one or multiple older adults to perform multi-domain activities and provide dynamic guidance, 2) engage them in the robot-mediated task and foster human-human interaction, and 3) quantify their social and activity engagement from multiple sensory modalities.

Use of robots to encourage social engagement between older adults.

We designed a robotic architecture system within a commercially available socially assistive robot to engage pairs of older adults in multimodal activities over 3 weeks for 6 sessions. The study took place in two assisted living facilities. Seven pairs (14 individuals) completed the experiment. Ages ranged from 70 to 90 years with a mean age of 83.0 (± 6.1). Most were women (79%). Three adults were screened as having normal cognition, 10 had mild cognitive impairment, and 1 adult self-reported a diagnosis of Alzheimer's disease. All sessions were video recorded and analyzed using Noldus Observer XT. Individuals demonstrated high levels of both human-human interaction and human-robot interaction, but the activity influenced the type of interaction. Engagement measures (visual, verbal, behavioral) also varied by type of activity. Future studies will focus on further development of activities that can engage older adults with varying levels of cognitive impairment and apathy.

Nursing Care Practices for Patients With Pulmonary Embolism Undergoing Treatment With Ultrasound-Assisted Thrombolysis: An Integrative Review.

BACKGROUND: Pulmonary embolism (PE) remains a common and life-threatening event. The use of ultrasound-assisted thrombolysis (USAT) for the delivery of thrombolytic agents to the clot has developed in the last 10 years. A search yielded no evidence-based practice guidelines for the nursing care of the patient with PE during and post USAT treatment and specifically when using the EKOS machine. OBJECTIVE: The objective of this integrative review was to explore the literature and web for any information on the use of USAT for adults with PE both during and post treatment. Our goal was to examine nurse-specific practices to develop appropriate protocols. METHODS: We conducted a search of PubMed, Web of Science, EBSCOhost, CINAHL, Google Scholar, and Google for any guidelines, observational studies, or experimental studies using USAT for PE in adults. Nurse authors independently reviewed the articles using a standardized data coding form. Information abstracted included sample and setting characteristics, access characteristics, medication, sheath removal, compression, and bleeding events. RESULTS: Twenty-two articles, published in 2008-2019, met the eligibility criteria. Most studies were small retrospective studies at single sites. Variation existed on the clinician, the clinical area for placement, the amount and duration of delivery of medication, and where care was provided during the infusion. Few studies noted sheath removal or compression procedures. Fifteen studies reported 1 fatal, 12 major, 4 moderate, and 36 minor bleeding events at the catheter insertion sites. CONCLUSION: There is lack of sufficient information for the development of nursing practice guidelines for this new technology.

Unit-level variation in bed alarm use in US hospitals.

Bed and chair alarms are widely used in hospitals, despite lack of effectiveness and unintended negative consequences. In this cross-sectional, observational study, we examined alarm prevalence and contributions of patient- and unit-level factors to alarm use on 59 acute care nursing units in 57 US hospitals participating in the National Database of Nursing Quality Indicators®. Nursing unit staff reported data on patient-level fall risk and fall prevention measures for 1,489 patients. Patient-level propensity scores for alarm use were estimated using logistic regression. Expected alarm use on each unit, defined as the mean patient propensity-for-alarm score, was compared with the observed rate of alarm use. Over one-third of patients assessed had an alarm in the "on" position. Patient characteristics associated with higher odds of alarm use included recent fall, need for ambulation assistance, poor mobility judgment, and altered mental status. Observed rates of unit alarm use ranged from 0% to 100% (median 33%, 10th percentile 5%, 90th percentile 67%). Expected alarm use varied less (median 31%, 10th percentile 27%, and 90th percentile 45%). Only 29% of variability in observed alarm use was accounted for by expected alarm use. Unit assignment was a stronger predictor of alarm use than patient-level fall risk variables. Alarm use is common, varies widely across hospitals, and cannot be fully explained by patient fall risk factors; alarm use is driven largely by unit practices. Alarms are used too frequently and too indiscriminately, and guidance is needed for optimizing alarm use to reduce noise and encourage mobility in appropriate patients.

A National Dataset Analysis of older adults in emergency department observation units.

BACKGROUND: Emergency Department (ED) Observation Units (Obs Units) are prevalent in the US, but little is known regarding older adults in observation. Our objective was to describe the Obs Units nationally and observation patients with specific attention to differences in care with increasing age. DESIGN: This is an analysis of 2010-2013 data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a national observational cohort study including ED patients. Weighted means are presented for continuous data and weighted percent for categorical data. Multivariable logistic regression was used to identify variables associated with placement in and admission from observation. RESULTS: The number of adult ED visits varied from 100 million to 107 million per year and 2.3% of patients were placed in observation. Adults ≥65 years old made up a disproportionate number of Obs Unit patients, 30.6%, compared to only 19.7% of total ED visits (odds ratio 1.5 (95% CI 1.5-1.6), adjusting for sex, race, month, day of week, payer source, and hospital region). The overall admission rate from observation was 35.6%, ranging from 31.3% for ages 18-64 years to 47.5% for adults ≥85 years old (p < 0.001). General symptoms (e.g., nausea, dizziness) and hypertensive disease were the most common diagnoses overall. Older adults varied from younger adults in that they were frequently observed for diseases of the urinary system (ICD-9 590-599) and metabolic disorders (ICD-9 270-279). CONCLUSIONS: Older adults are more likely to be cared for in Obs Units. Older adults are treated for different medical conditions than younger adults.

In-Hospital Sequelae of Injurious Falls in 24 Medical/Surgical Units in Four Hospitals in the United States.

BACKGROUND: Up to 50% of patient falls in the hospital result in injury. This study was conducted to determine whether injurious falls were associated with increased hospital length of stay (LOS), discharge to a place other than home, and in-hospital mortality. METHODS: A secondary data analysis from a prospective case-control study was conducted in 24 medical/surgical units in four hospitals in the United States. Patients who fell and sustained an injury were matched with at least one control patient who was on the same unit, at the same time, for a similar number of days on the unit at the time of the fall. Data were collected by viewing patients' electronic health records, as well as the hospitals' incident reporting systems. Logistic regression and Cox regression analyses were conducted. RESULTS: The 1,033 patients (mean age, 63.7 years; 510 males [49.4%]) who sustained an injurious fall were matched with 1,206 controls (mean age, 61.6 years; 486 males [40.3%]). Fallers were significantly more likely than controls to stay longer than 10 days in the hospital (odds ratio [OR], 1.59; 95% confidence interval [CI] = 1.46-1.74) and to be discharged to a place other than home (OR, 1.52; 95% CI = 1.21-1.91). CONCLUSION: Compared to controls, hospital patients who sustained an injurious fall had longer LOS and were more likely discharged to a place other than home. These associations remained when controlling for patient-level confounders, suggesting that the fall altered trajectory was sustained toward these outcomes. Injurious falls were not significantly associated with increased risk of mortality.

Critical Care Helicopter Overtriage: A Failure Mode and Effects Analysis.

OBJECTIVE: Overtriage (OT) of helicopter emergency medical services (HEMS) poses significant burden to multiple stakeholders. The project aims were to identify the following: 1) associated factors, 2) downstream effects, and 3) focus areas for change. METHODS: We undertook a failure mode and effects analysis (FMEA) to evaluate our HEMS interfacility transport process. Data were collected from organizational finances and 3 key stakeholder groups: 1) interfacility patients transferred by HEMS in 2017 who were discharged from the receiving facility within 24 hours (n = 149), 2) flight registered nurses (n = 19), and 3) referring emergency medicine providers (EMPs) (n = 30) from the top HEMS users of 2017. The completed FMEA identified failure modes, the frequency and severity of effects, and unique risk profile numbers (RPNs). RESULTS: Twelve failure modes were identified with 30 potential causes. Leading failure modes included inappropriate HEMS requests by EMPs (RPN = 343), inappropriate activation by EMS for interfacility transport (RPN = 343), and minimizing patient/family involvement in decision making (RPN = 315). Significant burdens to organizational finances and flight registered nurse satisfaction were identified. CONCLUSION: Associated factors for interfacility HEMS OT, downstream effects, and areas for change were identified. EMP and emergency medical services practices, HEMS processes, and shared decision making may affect regional OT rates.

Home Health Nurses' Perspectives and Care Processes Related to Older Persons with Frailty and Depression: A Mixed Method Pilot Study.

The objectives of this study were (1) to describe home health care (HHC) nurses' perception of and care processes related to geriatric depression and frailty, and (2) to identify barriers to care delivery for older persons with these two conditions. Ten semi-structured interviews were conducted with HHC nurses, and 16 HHC nursing visits to 16 older patients (≥65 years) were observed. Mixed method analysis showed that HHC nurses did not routinely assess for frailty and depression. Major barriers to care delivery included insufficient training, documentation burden, limited reimbursement, and high caseload. Addressing these barriers would facilitate HHC nursing care for frail, depressed elders.

Socially Assistive Robots: Measuring Older Adults' Perceptions.

To address manpower shortages, health care leaders recommend technology, including robots, to facilitate and augment processes for delivery of efficient, safe care. Little is known regarding older adults' perceptions of socially assistive robots (SARs). Using the Unified Theory of Acceptance and Use Technology framework, a survey was developed and tested for capturing older adults' likelihood to use SARs. The Robot Acceptance Survey (RAS) comprises three subscales: Performance Expectancy, Effort Expectancy, and Attitude. Older adults completed the RAS pre- and post-experimental procedure with a SAR. Cronbach's alpha coefficients for the subscales ranged from 0.77 to 0.89. Subscales were sensitive to change, with more positive reactions after exposure to SAR activities. Future studies must identify robotic programming capable of providing cognitive, physical, and social assistance, as well as person-, activity-, situation-, and robot-specific factors that will influence older adults' acceptance of SARs. [Journal of Gerontological Nursing, 43(12), 35-43.].

Decision Factors Nurses Use to Assess Pain in Nursing Home Residents With Dementia.

Nurses caring for older people with various psychiatric illnesses face many obstacles when treating pain. One setting with a high percentage of psychiatric conditions is long-term care where more than half of residents have some form of dementia, and behavioral symptoms of dementia (BSDs) may mimic behavioral displays of pain. Furthermore, two-thirds of nursing home residents have pain. Thus, many nursing home residents with dementia have pain that may be confounded by BSDs. Since many people with dementia are at risk for poor pain management, determining current methods in which nurses assess and manage pain in nursing home residents will aid in recognizing potential barriers to using current pain management guidelines and help develop strategies to enhance nurses' assessment and management of pain in this vulnerable population. The aim of this study was to explore nursing home nurses' cues and practices to identify and alleviate pain in nursing home residents with dementia. Nurses use the constructs of 'comfort' and 'quality of life' as key components in their overall pain assessment strategy in people with dementia. Indeed, the extensive process they use involving frequent reassessment and application of interventions is geared towards "appearance of comfort." Nurses reported difficulty in ascertaining whether a person with dementia was in pain, and they expressed further difficulty determining the intensity associated with resident pain. Nurses further reported that residents with dementia who are not well know by the staff were are greater risk of poor pain management. It was not unusual for nurses to discuss the importance of conflict resolution among family members as well as allowing for open expression of family's concerns. Nurses had to focus not only on the resident's comfort, but also the families' level of comfort with pain management, especially at the end-of-life. Findings support further use and development of discomfort behavior scales to help manage pain.

Improving Adherence to Screening Colonoscopy Preparation and Appointments: A Multicomponent Quality Improvement Program.

Colorectal screening for cancer by colonoscopy is recommended for adults 50 years and older. Scheduling patients for sedated endoscopic procedures involves balancing physician schedules, room availability and equipment, proper patient preparedness, and necessary personnel. Both nonattendance and poor preparations contribute to inefficiency, wasted resources, and increased costs. We noted nonattendance rates ranging from 21% to 29%. As a first step, we examined patient factors associated with nonattendance using a retrospective case control study. Younger patients (<60 years), screening appointment, and insurance type were associated with nonattendance. On the basis of these findings, initial efforts focused on additional nurse strategies of follow-up contact and education for screening colonoscopies. As we improved attendance rate, concomitantly we discovered cancellation rates increasing. Subsequently, an interdisciplinary and interdepartmental quality improvement program has been ongoing to target a number of system-, nurse-, and patient-specific factors contributing to nonattendance and cancellations due to poor preparations. Rates have improved but require ongoing monitoring and surveillance. We describe the ongoing efforts and challenges aimed at both nonattendance and cancellations.

Association of health literacy with elevated blood pressure: a cohort study of hospitalized patients.

BACKGROUND: The clinical consequences of low health literacy are not fully understood. OBJECTIVES: We evaluated the relationship between low health literacy and elevated blood pressure (BP) at hospital presentation. RESEARCH DESIGN AND SUBJECTS: We conducted a cross-sectional evaluation of adult patients hospitalized at a university hospital between November 1, 2010 and April 30, 2012. MEASURES: Health literacy was assessed using the Brief Health Literacy Screen (BHLS). Low health literacy was defined as a BHLS score ≤9. BP was assessed using clinical measurements. The outcome was elevated BP (≥140/90 mm Hg; ≥130/80 mm Hg with diabetes or renal disease) or extremely elevated BP (>160/100 mm Hg) at hospital presentation. Multivariate logistic regression adjusted for age, sex, race, insurance, comorbidities, and antihypertensive medications; preplanned restricted analysis among patients with diagnosed hypertension was performed. RESULTS: Of 46,263 hospitalizations, 23% had low health literacy, which occurred more often among patients who were older (61 vs. 54 y), less educated (28.4% vs. 11.2% had not completed high school), and more often admitted through the emergency department (54.3% vs. 48.1%) than those with BHLS>9. Elevated BP was more frequent among those with low health literacy [40.0% vs. 35.5%; adjusted odds ratio (aOR) 1.06; 95% confidence interval (CI), 1.01-1.12]. Low health literacy was associated with extremely elevated BP (aOR 1.08; 95% CI, 1.01-1.16) and elevated BP among those without diagnosed hypertension (aOR 1.09; 95% CI, 1.02-1.16). CONCLUSIONS: More than ⅓ of patients had elevated BP at hospital presentation. Low health literacy was independently associated with elevated BP, particularly among patients without diagnosed hypertension.

Assisted and unassisted falls: different events, different outcomes, different implications for quality of hospital care.

BACKGROUND: Many hospitals classify inpatient falls as assisted (if a staff member is present to ease the patient's descent or break the fall) or unassisted for quality measurement purposes. Unassisted falls are more likely to result in injury, but there is limited research quantifying this effect or linking the assisted/unassisted classification to processes of care. A study was conducted to link the assisted/unassisted fall classification to both processes and outcomes of care, thereby demonstrating its suitability for use in quality measurement. This was only the second known published study to quantify the increased risk of injury associated with falling unassisted (versus assisted), and the first to estimate the effects of falling unassisted (versus assisted) on the likelihood of specific levels of injury. METHODS: A cross-sectional analysis of falls from all available 2011 data for 6,539 adult medical, surgical, and medical-surgical units in 1,464 general hospitals participating in the National Database of Nursing Quality Indicators" (NDNQI) was performed. RESULTS: Participating units reported 166,883 falls (3.44 falls per 1,000 patient-days). Excluding repeat falls, 85.5% of falls were unassisted. Assisted and unassisted falls were associated with different processes and outcomes: Fallers for whom a fall prevention protocol was not in place were more likely to fall unassisted than those for whom one was in place (adjusted odds ratio [aOR], 1.39 [95% confidence interval (CI), 1.32, 1.46]), and unassisted falls were more likely to result in injury (aOR, 1.59 [95% CI, 1.52, 1.67]). CONCLUSIONS: The assisted/unassisted fall classification is associated with care processes and patient outcomes, making it suitable for quality measurement. Unassisted falls are more likely than assisted falls to result in injury and should be considered a target for future prevention efforts.

Implementing routine health literacy assessment in hospital and primary care patients.

BACKGROUND: Patients with inadequate health literacy often have poorer health outcomes and increased utilization and costs. The Institute of Medicine has recommended that health literacy assessment be incorporated into health care information systems, which would facilitate large-scale studies of the effects of health literacy, as well as evaluation of system interventions to improve care by addressing health literacy. As part of the Health Literacy Screening (HEALS) study, a Brief Health Literacy Screen (BHLS) was incorporated into the electronic health record (EHR) at a large academic medical center. METHODS: Changes were implemented to the nursing intake documentation across all adult hospital units, the emergency department, and three primary care practices. The change involved replacing previous education screening items with the BHLS. Implementation was based on a quality improvement framework, with a focus on acceptability, adoption, appropriateness, feasibility, fidelity and sustainability. Support was gained from nursing leadership, education and training was provided, a documentation change was rolled out, feedback was obtained, and uptake of the new health literacy screening items was monitored. RESULTS: Between November 2010 and April 2012, there were 55,611 adult inpatient admissions, and from November 2010 to September 2011, 23,186 adult patients made 39,595 clinic visits to the three primary care practices. The completion (uptake) rate was 91.8% for the hospital and 66.6% for the outpatient clinics. CONCLUSIONS: Although challenges exist, it is feasible to incorporate health literacy screening into clinical assessment and EHR documentation. Next steps are to evaluate the association of health literacy with processes and outcomes of care across inpatient and outpatient populations.

Hospitals' adoption of targeted cognitive and functional status quality indicators for vulnerable elders.

Cognitive and functional impairments are leading predictors of poor outcomes in hospitalized older adults. This study reports adoption rates of 9 Assessing Care of Vulnerable Elders quality indicators in a sample of US hospitals (N = 128). Chief nursing officers were surveyed using a 6-point scale (no activity to full implementation) for each Assessing Care of Vulnerable Elders quality indicator. Adoption rates were low, highlighting the need for greater efforts to heighten awareness among senior executives and nursing leaders.

Pain assessment in hospitalized older adults with dementia and delirium.

Pain can have negative effects leading to prolonged hospital stays. Determining the presence of uncontrolled and untreated pain in patients with cognitive impairments such as delirium, dementia, and delirium superimposed on dementia (DSD) is challenging. One tool commonly suggested for use in assessment of pain in older adults with cognitive impairment is the Pain Assessment In Advanced Dementia (PAINAD) scale. Proper use of the PAINAD scale as part of a comprehensive pain management plan can help reduce the likelihood of a patient experiencing unrecognized and untreated pain. Using an individual example, this article illustrates best practices in pain assessment and management for a woman experiencing DSD during an acute hospitalization.