Development of a Risk Tool to Support Discussions of Care for Older Adults Admitted to the ICU With Pneumonia.

BACKGROUND: Early, data-driven discussion surrounding palliative care can improve care delivery and patient experience. OBJECTIVE: To develop a 30-day mortality prediction tool for older patients in intensive care unit (ICU) with pneumonia that will initiate palliative care earlier in hospital course. DESIGN: Retrospective Electronic Health Record (EHR) review. SETTING: Four urban and suburban hospitals in a Western New York hospital system. PARTICIPANTS: A total of 1237 consecutive patients (>75 years) admitted to the ICU with pneumonia from July 2011 to December 2014. MEASUREMENTS: Data abstracted included demographics, insurance type, comorbidities, and clinical factors. Thirty-day mortality was also determined. Logistic regression identified predictors of 30-day mortality. Area under the receiver operating curve (ROC) was calculated to quantify the degree to which the model accurately classified participants. Using the coordinates of the ROC, a predicted probability was identified to indicate high risk. RESULTS: A total of 1237 patients were included with 30-day mortality data available for 100% of patients. The mortality rate equaled 14.3%. Age >85 years, having active cancer, Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), sepsis, and being on a vasopressor all predicted mortality. Using the derived index, with a predicted probability of mortality >0.146 as a cutoff, sensitivity equaled 70.6% and specificity equaled 65.6%. The area under the ROC was 0.735. CONCLUSION: Our risk tool can help care teams make more informed decisions among care options by identifying a patient group for whom a careful review of goals of care is indicated both during and after hospitalization. External validation and further refinement of the index with a larger sample will improve prognostic value.

What happens to orders written for older primary care patients?

BACKGROUND AND OBJECTIVES: Data are limited on order completion errors in primary care. The objective of this study was to determine the incidence and nature of order completion errors among community-dwelling older adults. METHODS: This prospective, cross-sectional exploratory study was conducted at a suburban family medicine clinical teaching site. Patients ?70 years old who received ?one order at the study enrollment visit were eligible for inclusion. Errors in completion of orders for prescriptions, laboratory tests, imaging studies or screening procedures, and specialist referrals were assessed. Logistic regression was used to identify the independent variables associated with non-system-based errors. RESULTS: A total of 322 orders were written for 93 enrolled patients. An order error was identified in 59 (18.3%) orders written for 39 (41.9%) patients (mean 1.5, range 1--4, SD=0.85): 10 were system-based and 49 were non-system-based errors. Non-system-based errors included unfilled prescriptions (9.0%), uncompleted orders for imaging studies and screening procedures (13.0%), and uncompleted specialist referrals (17.4%). All laboratory orders were completed. In a logistic regression model, females were four times more likely to experience a non-system-based error than males (OR=4.02, 95% CI=1.43, 11.23). CONCLUSIONS: Order completion errors were common in this sample of community-dwelling older adults, with non-system-based errors for prescriptions, imaging studies or screening procedures, and specialist referrals occurring more frequently than system-based errors, particularly among females. Providers should not assume that patients will complete orders as intended; rather, longitudinal management requires regular patient follow-up and review to ensure order completion.

Improving quality of NSAID prescribing by internal medicine trainees with an educational intervention.

BACKGROUND: Prescribing nonsteroidal anti-inflammatory drugs (NSAIDs) for older adults is a safety concern. Education innovations in postgraduate training designed to improve patient safety should comply with the Accreditation Council for Graduate Medical Education (ACGME). PURPOSE: The objective is to evaluate a seven-component education program for internal medicine trainees designed to change prescribing practices while addressing ACGME competencies. METHODS: Pretest, posttest data collection. RESULTS: The baseline chart review found that 28.7% (79/275) patients age 70 or older were prescribed NSAIDs. Approximately 1 year later, the proportion of patients prescribed NSAIDs had declined to 16.4% (30/183; p= .002). The proportion of patients prescribed NSAIDs in conjunction with a diuretic similarly declined from 13.6% (38/278) to 7% (13/187; p= .024). CONCLUSION: A systematically applied education program targeted to a specific prescribing pattern produced significant improvement among internal medicine trainees. This model may assist training programs in reducing polypharmacy, or in other areas of trainee practice.

Effects of multidisciplinary Internet-based program on management of heart failure.

OBJECTIVES: To develop and test the effectiveness of an Internet-based self management program by multidisciplinary health care professionals for patients with heart failure (HF). METHODS: The comprehensive educational material for HF was created and posted on a website. A computer with Internet connection and computer training were provided first. A secure and simple web-based recording system of vital signs and health behaviors and a mechanism for feedback regarding each participant's record were developed. A randomized controlled trial with a one-year intervention was conducted using a total of 40 patients who were assessed three times in their homes. An intention-to-treat analysis used multivariate statistics. RESULTS: The treatment group had a high (85%) adherence to the intervention. Only the treatment group showed a significant improvement in the knowledge level (p < 0.001), amount of exercise (p = 0.001), and quality of life (p = 0.001), and reduction in HF related symptoms (dyspnea, p = 0.001; fatigue, p = 0.003; functional emotion, p < 0.001), blood pressure (systolic, p = 0.002; diastolic, p < 0.001), frequency of emergency room visit, and length of hospital stay (both p = 0.001). CONCLUSIONS: An effective program to change one's behaviors in managing HF takes a multidisciplinary approach to create and provide feedback regarding a patient's daily record, which can be accomplished through Internet use.

Assessment of safety attitudes in a skilled nursing facility.

Safety has not been well studied in the long-term care setting. This pilot study assesses staff attitudes regarding safety culture at one 250-bed skilled nursing facility. A valid and reliable Safety Attitudes Questionnaire (SAQ) was administered once to a sample of 51 employees. Nursing staff and other health care staff were generally satisfied with their jobs (42% and 67% had a positive attitude, respectively) but gave low scores to Management (22% and 13%, respectively) and Safety Climate (28% and 33%, respectively). Registered nurses, licensed practical nurses, and nurse management/supervisors received the highest ratings for quality of collaboration and communication (range: 3.6-4.1 on a 5-point Likert scale with 1 = very low, 5 = very high), whereas nurse practitioners and physician assistants received the lowest (range: 2.5-2.9). The SAQ provided insight into employees' safety attitudes and can be used to identify opportunities for improvements in safety.

A multifactorial intervention to reduce prevalence of delirium and shorten hospital length of stay.

OBJECTIVES: To improve outcomes for cognitively impaired and delirious older adults. DESIGN: Pretest, posttest. SETTING: A university-affiliated hospital. PARTICIPANTS: Physicians and nurses in the emergency department (ED) and on an acute geriatric unit (AGU). INTERVENTION: Multifactorial and targeted to the processes of care for cognitively impaired and delirious older adults admitted to medicine service from the ED. MEASUREMENTS: Prevalence of delirium, admission to AGU, psychotropic medication use, hospital length of stay. RESULTS: Patient characteristics did not differ between baseline and the two outcome cohorts 4 and 9 months postintervention. Prevalence of delirium was 40.9% at baseline, 22.7% at 4 months (P<.002), and 19.1% at 9 months (P<.001). More delirious patients were admitted to the AGU than to non-AGU units at 4 months (P<.01) and 9 months (P<.01). Postintervention medication use in the hospital differed from baseline. Antidepressant use was greater at 4 months (P<.05). Benzodiazepine and antihistamine use were lower at 9 months (P>.01). Antidepressant and neuroleptic use were higher (P<.02) and antihistamine use was lower (P<.02) at 4 months on the AGU than for the baseline group. Benzodiazepine (P<.01) and antihistamine (P<.05) use were lower at 9 months. Each case of delirium prevented saved a mean of 3.42 hospital days. CONCLUSION: A multifactorial intervention designed to reduce delirium in older adults was associated with improved psychotropic medication use, less delirium, and hospital savings.

Correlates of behavioral disturbances and pattern of psychotropic medication use in five skilled nursing facilities.

There are several treatment options for behavioral disturbances (BDs) in dementia. However, the choice of a specific psychotropic agent is directed by personal preferences and local community practice patterns. We examined the relationship between common clusters of BDs and the use of different classes of psychotropic agents in our community. A cross-sectional study of 430 long-term care residents from 5 nursing homes was undertaken. The Behavior Measurement Scale (BMS) was used to measure the frequency of BDs grouped in 4 categories. Residents with > 4 BD episodes in at least one category during a 2-week observation period were the behavior group and were considered to have clinically significant BDs. A sample of patients who had < 4 BDs in all BMS categories during the same observation period defined the nonbehavior group. A BD cluster was defined as > 4 BDs occurring in one or more BMS categories during the 2-week observation. Data on functional status, comorbidity, use of benzodiazepines, antidepressants, and neuroleptic agents were collected with chart review. The chi-square test was used to examine the correlation between variables. Clinically significant BDs were identified in 27.2% (117/430) of the residents in the sample. Five of 15 behavior clusters accounted for 73% of all clinically significant BDs. The 5 clusters were verbally nonaggressive behaviors (cluster 1, 20.5%), behaviors from all 4 categories (cluster 2, 17.9%), verbally and physically nonaggressive behaviors (cluster 3, 14.5%), physically nonaggressive behaviors (cluster 4, 12.8%), and verbally aggressive and nonaggressive behaviors (cluster 5, 7.7%). Cluster 5 had a negative correlation with functional impairment (P = .009). There was a significant correlation between cluster 2 and benzodiazepine use (P = .014). No other significant correlation was found between any of the 5 clusters and demographic variables, comorbidity status, and use of antidepressant or neuroleptic medications. Residents in the behavior group had higher impairment in self-feeding (P = .036) and bathing (P < .001) and were more likely to be treated with benzodiazepines (P = .004) and neuroleptic agents (P = .009) than residents in the nonbehavior group (n = 116). The higher use of neuroleptics and benzodiazepines in the behavior group compared with the nonbehavior group indicates that BDs are being identified for treatment, but the medications used may not be efficacious. The lack of association between specific classes of psychotropic medications and distinct behavior clusters indicates that clinicians are not using a standardized approach to target the neurochemical abnormalities that may underlie certain behavior clusters. Some behavior clusters correlate with impairment in specific activities of daily living categories such as bathing and feeding, making room for nonpharmacologic interventions.

Pneumonia versus aspiration pneumonitis in nursing home residents: diagnosis and management.

OBJECTIVES: To determine the frequency of aspiration pneumonitis in nursing home residents with an initial diagnosis of pneumonia and to compare the clinical characteristics, management, and outcome of aspiration pneumonitis with those of pneumonia. DESIGN: Retrospective chart review. SETTING: Hospital geriatric unit for nursing home residents. PARTICIPANTS: Nursing home residents admitted to the inpatient geriatric unit with suspected pneumonia between May 1999 and April 2001 (n = 195 episodes). MEASUREMENTS: Aspiration events were defined as definite (witnessed or unwitnessed) or suspected. Aspiration pneumonitis was defined as symptoms/signs of lower respiratory tract infection plus a history of an aspiration event plus a lower lobe infiltrate on chest radiograph. Pneumonia was defined as symptoms/signs of lower respiratory tract infection plus an infiltrate on chest radiograph plus no history of an aspiration event. RESULTS: The 195 episodes were stratified into three clinical groups: aspiration pneumonitis (n = 86; aspiration history/infiltrate), pneumonia (n = 43; no aspiration history/infiltrate), and an aspiration event (n = 66; aspiration history/no infiltrate). In general, symptoms, signs, and laboratory tests were not useful in distinguishing between the three groups. Survivors with aspiration pneumonitis (13/75 (17%)) or with an aspiration event (20/60 (33%)) were significantly more likely not to be treated with an antibiotic or to be treated for 1 day or less than those with pneumonia (0/41; P <.001). Excluding those not treated, significantly more patients with pneumonia (33/40 (83%)) were discharged on antibiotic treatment than those with aspiration pneumonitis (35/70 (50%)) or an aspiration event (21/51 (41%); P <.001). There was no significant difference in hospital mortality between the three clinical groups. CONCLUSIONS: The findings of this study have implications for the diagnosis and management of suspected pneumonia in nursing home residents but require prospective validation.

Efficacy and safety of gatifloxacin in elderly outpatients with community-acquired pneumonia.

To evaluate the safety and efficacy of gatifloxacin in adults <65, 65 to 79, or > or =80 years old with community-acquired pneumonia, adult male and female outpatients from general community-based practices were enrolled in an open-label, multicenter, noncomparative study. Gatifloxacin 400 mg once daily was administered for seven to 14 days. Medical history, physical examination, signs and symptoms of infection, Gram stain and culture if specimen available, clinical response, and safety were determined. Of 1655 treated patients, 1103 were at least 65 years old, 405 were 65 to 79, and 147 were at least 80. Patients > or =80 years old presented with chills, chest pain, fever, or headache less often than younger patients. Cure rates were 95.5% for patients <65 years old, 96.2% for those 65 to 79, and 90.2% for those at least 80 years old. Neither the frequency nor susceptibility of isolated pathogens appeared to differ with age. Between 93.7% and 100% of subsets of the two younger groups with verified Streptococcus pneumoniae or Hemophilus influenzae were cured. All oldest-group patients in the subset with verified S. pneumoniae and 71.4% (7) of patients with H. influenzae were cured. Each age group, including current or past smokers and patients receiving medications for concomitant conditions, tolerated treatment well. Gatifloxacin is safe and efficacious in adults of any age with community-acquired pneumonia, including the elderly up to 100 years old and patients with S. pneumoniae including penicillin-resistant strains.