Experiences of Older Adult Trauma Patients Discharged Home From a Level I Trauma Center.

The number of patients 65 years and older has been rising steadily every year at our Level I trauma center. Our clinical experience demonstrated that once discharged, some of these patients were not managing well. Postdischarge portrait is difficult to ascertain because this information is not captured in the trauma registry database. The purpose of this study was to describe the experiences of hospitalized trauma patients 65 years and older who are discharged home. A descriptive cross-sectional study of hospitalized trauma patients was conducted 1 month postdischarge using PREPARED Patient and 36-item Short Form Health Survey questionnaires. Data were analyzed with SPSS and NVivo. A convenience sample of 33 participants was recruited from four surgical inpatient trauma units of an urban, downtown hospital in Eastern Canada. Participants scored below 50% on most categories related to discharge preparedness and reported not having received enough information about their medication, available community resources, and permitted activities. They had worries about managing at home and 40% experienced unexpected problems. Participants reported feeling confident (80%) to be discharged home mostly because of support or previous experience with illness and 53% felt very prepared to return home. Health status scores were lowest for the domain "role limitation due to physical health" at 16% and highest around 70% for "emotional well-being" and "general health." Patients did not receive enough information; some experienced unexpected problems once home but having support and previous experience with illness seems to help participants be confident with discharge home. There is room for improvement on specific aspects of discharge planning and preparedness.

Description of behaviors in nonverbal critically ill patients with a traumatic brain injury when exposed to common procedures in the intensive care unit: a pilot study.

Behavioral indicators are strongly recommended for pain assessment in nonverbal patients. Although pain-related behaviors have been studied in critically ill patients, those with a traumatic brain injury (TBI) have been either excluded or underrepresented. Because these patients also likely experience pain, research is urgently needed to generate knowledge in this field. This pilot study aimed to explore pain-related behaviors of critically ill TBI patients when exposed to common procedures in the intensive care unit (ICU), using video recording at the bedside and a newly developed coding system. Ten TBI patients hospitalized in the ICU participated. A 44-item behavioral checklist created from existing tools was used as a coding system to identify behaviors before, during, and 20 minutes after a nociceptive procedure (turning) and a nonnociceptive procedure (noninvasive blood pressure [NIBP]). Patients were video recorded to check for interrater agreement between two trained observers. TBI patients exhibited more behaviors during turning than at rest or during NIBP (p < .001). The following behaviors were observed during turning: levator contraction (n = 7), frowning (n = 5), opening eyes (n = 5), weeping eyes (n = 5), raising eyebrows (n = 5), activating the ventilator alarms (n = 7), and muscle tension (n = 5). No change in behaviors was noted during NIBP. After educational training and using videos, the average percentage of agreement for observed behaviors between two trained research assistants was 96%. Pain in critically ill TBI patients can be detrimental to health and recovery. ICU clinicians should be aware of pain-related behaviors to enable better detection and treatment in this highly vulnerable group.

A descriptive study of bicycle helmet use in Montreal, 2011.

OBJECTIVE: The purpose of this study was to describe bicycle helmet use among Montreal cyclists as a step towards injury prevention programming. METHODS: Using a cross-sectional study design, cyclists were observed during 60-minute periods at 22 locations on the island of Montreal. There were 1-3 observation periods per location. Observations took place between August 16 and October 31, 2011. Standard statistical methods were used, unadjusted and adjusted odds ratios and 95% confidence interval were calculated. RESULTS: A total of 4,789 cyclists were observed. The helmet-wearing proportion of all cyclists observed was 46% (95% CI 44-47). Women had a higher helmet-wearing proportion than men (50%, 95% CI 47-52 vs. 44%, 95% CI 42-45, respectively). Youth had the highest helmet-wearing proportion (73%, 95% CI 64-81), while young adults had the lowest (34%, 95% CI 30-37). Visible minorities were observed wearing a helmet 29% (95% CI 25-34) of the time compared to Caucasians, 47% (95% CI 46-49). BIXI (bike sharing program) riders were observed wearing a helmet 12% (95% CI 10-15) of the time compared to riders with their own bike, 51% (95% CI 49-52). CONCLUSIONS: Although above the national average, bicycle helmet use in Montreal is still considerably low given that the majority of cyclists do not wear a helmet. Injury Prevention Programs could target the entire cyclist population, but special attention may be warranted in specific groups such as young men, visible minorities, BIXI riders, and those riding in tourist areas. Additionally, a collaborative enterprise with the bicycle sharing system BIXI Montreal™ could prove to be fruitful in addressing the availability of bike helmets for BIXI riders.

Barriers and facilitators to caring for individuals with stroke in the community: the family's experience.

PURPOSE: This project explored caregivers' perceptions regarding the barriers and facilitators to undertaking the post-stroke caregiving role, particularly as related to the health care system, with the ultimate goal of identifying potential strategies that would assist families in successfully undertaking the role. METHOD: A qualitative study consisting of focus groups and individual interviews with caregivers of persons with stroke. Participants were asked about their needs in managing the care of their family member and the factors that facilitated and/or hindered the transition to the home and influenced them in maintaining their role. RESULTS: Information from 14 caregiver participants identified the following as primary barriers to undertaking and maintaining the caregiving role: lack of collaboration with the health care team, the intensity of the caregiving role, the negative impact on the caregiver, and the lack of community support for the caregiving role. Caregivers identified the following factors as facilitative: coordination of care, progress of the patient towards normalcy, mastery of the caregiving role, supportive social environment, and accessible community resources. DISCUSSION AND CONCLUSIONS: The results indicate there are facilitators that caregivers perceive as important both to undertaking and to sustaining the caregiving role. Consideration of these results in the design of interventions may lead to more effective interventions to support caregivers in undertaking and continuing in the caregiver role.

Practice on an acute stroke unit after implementation of a decision-making algorithm for dietary management of dysphagia.

Dysphagia is a common disability seen in stroke survivors that has been associated with high morbidity and mortality. Research has indicated that implementing clinical guidelines and algorithms improves dysphagia management and patient outcomes. A decision-making algorithm designed to enhance the assessment and dietary treatment of swallowing difficulties in the acute stroke patient was implemented on a dedicated neuroscience unit in January 2002. Following implementation, the medical records of 30 acute stroke patients consecutively admitted to the unit between February and May 2002 were reviewed for stroke and dysphagia characteristics, dysphagia-related complications, discharge dispositions, interdisciplinary baseline assessments, and nursing evaluations throughout the hospitalization. Of those patients admitted with stroke, 56.7% were dysphagic. As compared with the nondysphagic patients, the dysphagic patients had three times' longer inpatient stay, an increased incidence of complications, higher morbidity, and increased need for inpatient rehabilitation services and institutionalized care following discharge. Twenty percent of patients did not receive aformal evaluation of swallowing function within the first 48 hours of admission. In 10% of the patients, diets were changed following the formal evaluation of swallowing to change an unsafe, prescribed diet. More than 70% of patients showed clinical improvement in swallowing function during their hospitalization. Nurses tended to document assessments of general neurological factors (e.g., level of consciousness) related to swallowing function more frequently than factors felt to be more specific to swallowing (e.g., choking) and nutrition (e.g., tolerates diet). The results support the important role of the neuroscience nurse in the early and ongoing assessment of swallowing function and in providing directions to further improve the quality of care delivered to stroke patients with various degrees of swallowing dysfunction.

Myocardial blood flow after chronic cardiac decentralization in anesthetized dogs: effects of ACE-inhibition.

Coronary blood flow regulation was studied in dogs with an intact or chronically decentralized intrinsic cardiac nervous system. We also examined the effect of angiotensin-converting enzyme inhibition (ACEI) on coronary autoregulatory pressure-flow relations and distribution of blood flow since the renin-angiotensin system may play a critical role in vasoregulation. Myocardial oxygen demand was reduced in the chronic decentralized dogs compared to the control dogs. The lower pressure limit of the autoregulatory pressure-flow relation was similar for the control and chronic decentralized dogs (47+/-2 and 44+/-7 mm Hg, respectively; p = NS). After ACEI, the lower pressure limit shifted leftward to 40 mm Hg (p=0.001) in both groups. Concomitant blockade of cyclooxygenase, bradykinin catabolism and nitric oxide synthase had no further effect on the lower pressure limit. Total myocardial blood flow was lower (p=0.001) in the chronic decentralized dogs compared to the control dogs, while transmural distribution of blood flow was preserved in both groups. The results show that even though myocardial oxygen requirements are lower in the chronically decentralized heart compared to controls, coronary autoregulation is maintained at levels observed in normally innervated hearts. The present findings indicate that intrinsic cardiac neurons contribute to coronary autoregulatory control and myocardial blood flow distribution even in the absence of cardiac connections to the central nervous system. In addition, in the chronic decentralized dog, ACEI allows the heart to work at lower coronary perfusion pressures while myocardial blood flow distribution is preserved.

Meeting the nutritional needs of patients with severe dysphagia following a stroke: an interdisciplinary approach.

Dysphagia is a common problem with individuals who have experienced a stroke. The interdisciplinary stroke team noted delays in clinical decision-making, or in implementing plans for patients with severe dysphagia requiring an alternative method to oral feeding, such as enteral feeding via Dobhoff (naso-jejunum) or PEG (percutaneous endoscopic gastrostomy) tubes, occurred because protocols had not been established. This resulted in undernourishment, which in turn contributed to clinical problems, such as infections and confusion, which delayed rehabilitation and contributed to excess disability. The goal of the project was to improve quality of care and quality of life for stroke patients experiencing swallowing problems by creating a dysphagia management decision-making process. The project began with a retrospective chart review of 91 cases over a period of six months to describe the population characteristics, dysphagia frequency, stroke and dysphagia severity, and delays encountered with decision-making regarding dysphagia management. A literature search was conducted, and experts in the field were consulted to provide current knowledge prior to beginning the project. Using descriptive statistics, dysphagia was present in 44% of the stroke population and 69% had mild to moderate stroke severity deficit. Delays were found in the decision to insert a PEG (mean 10 days) and the time between decision and PEG insertion (mean 12 days). Critical periods were examined in order to speed up the process of decision-making and intervention. This resulted in the creation of a decision-making algorithm based on stroke and dysphagia severity that will be tested during winter 2002.