Victimization in Unethical Unlicensed Small Residential Care Homes in the United States: The Case for Whole System Disruption.

In the United States, small residential care homes provide affordable community-based care for disabled older adults. Also called adult foster care homes, residential care facilities, group homes, or board and care homes, small residential care homes are typically private, small businesses operating in single-family dwellings that provide round-the-clock care in a home-like setting in residential neighborhoods. While most states license small residential care homes they also exist, legally and illegally, as unlicensed and unregulated operations. The quality of care in some unlicensed and unregulated small residential care homes can be questionable. Disabled older adults are targeted and victimized by unethical small residential care home operators for financial gain. This commentary highlights the need for whole system disruption to end victimization in unethical unlicensed and unregulated small residential care homes through case studies of the abuse and neglect of residents living in unethical unlicensed operations and recommends ambitious goals centered on reducing secondary financial gains and medically neglectful practices. These recommendations are at federal, state, and local levels, and include creating a federal definition of small residential care homes, increasing and coupling government incomes with state registration and employee misconduct registry checks, increasing oversight and assessment, improving temporary guardianship processes, providing avenues for reporting abuse, and developing older adult fatality review teams.

Learning from suicide deaths in Harris County, Texas.

This study examined individual and community demographic characteristics surrounding suicides in one of the most populous counties in the United States. We paired medical examiner records with U.S. Census data and analyzed them using geospatial software. The majority of decedents were non-Hispanic, white males who died primarily of gunshot wounds. Salient age characteristics included interpersonal violence and depression among ages younger than 40. Despite lower incomes and education levels, areas with higher population density and racial/ethnic minorities had fewer suicides. Additional research should address depression among males and the elderly, interpersonal violence, firearm access, and culture.

Nursing Care for Extracorporeal Membrane Oxygenation in the Trauma Patient.

Trauma patients that survive the immediate threat of death are at risk for potentially life-threatening complications such as acute respiratory distress syndrome and multisystem organ failure. Extracorporeal membrane oxygenation (ECMO) use in trauma patients has largely been controversial for concerns of inducing major hemorrhage with the use of systemic anticoagulation to prevent thrombus development while connected to the ECMO circuit. There is limited data available for specific guidelines for optimal management of the trauma population; however, recent studies suggest comparable outcomes to those of nontrauma patients treated with ECMO. The purpose of this case study was to introduce indications for implementation of ECMO in the trauma patient for pulmonary and hemodynamic compromise, describe the procedure of ECMO insertion, and delineate clinical expectations of the intensive care unit nurse within the multidisciplinary ECMO team. This case study presents a 28-year-old man who sustained a gunshot wound of the chest and was ultimately treated with ECMO for pulmonary compromise due to acute respiratory distress syndrome.

Establishing a Regional Trauma Preventable/Potentially Preventable Death Rate.

OBJECTIVE: To establish a trauma preventable/potentially preventable death rate (PPPDR) within a heavily populated county in Texas. SUMMARY: The National Academies of Sciences estimated the trauma preventable death rate in the United States to be 20%, issued a call for zero preventable deaths, while acknowledging that an accurate preventable death rate was lacking. In this absence, effective strategies to improve quality of care across trauma systems will remain difficult. METHODS: A retrospective review of death-related records that occurred during 2014 in Harris County, TX, a diverse population of 4.4 million. Patient demographics, mechanism of injury, cause, timing, and location of deaths were assessed. Deaths were categorized using uniform criteria and recorded as preventable, potentially preventable or nonpreventable. RESULTS: Of 1848 deaths, 85% had an autopsy and 99.7% were assigned a level of preventability, resulting in a trauma PPPDR of 36.2%. Sex, age, and race/ethnicity varied across preventability categories (P < 0.01). Of 847 prehospital deaths, 758 (89.5%) were nonpreventable. Among 89 prehospital preventable/potentially preventable (P/PP) deaths, hemorrhage accounted for 55.1%. Of the 657 initial acute care setting deaths, 292 (44.4%) were P/PP; of these, hemorrhage, sepsis, and traumatic brain injury accounted for 73.3%. Of 339 deaths occurring after initial hospitalization, 287 (84.7%) were P/PP, of these 117 resulted from sepsis and 31 from pulmonary thromboembolism, accounted for 51.6%. CONCLUSIONS: The trauma PPPDR was almost double that estimated by the National Academies of Sciences. Data regarding P/PP deaths offers opportunity to target research, prevention, intervention, and treatment corresponding to all phases of the trauma system.

Establishing a regional pediatric trauma preventable/potentially preventable death rate.

PURPOSE: Although trauma is the leading cause of death for the pediatric population, few studies have addressed the preventable/potentially preventable death rate (PPPDR) attributable to trauma. METHODS: This is a retrospective study of trauma-related death records occurring in Harris County, Texas in 2014. Descriptive and Chi-squared tests were conducted for two groups, pediatric and adult trauma deaths in relation to demographic characteristics, mechanism of injury, death location and survival time. RESULTS: There were 105 pediatric (age < 18 years) and 1738 adult patients. The PPPDR for the pediatric group was 21.0%, whereas the PPPDR for the adult group was 37.2% (p = 0.001). Analysis showed fewer preventable/potentially preventable (P/PP) deaths resulting from any blunt trauma mechanism in the pediatric population than in the adult population (19.6% vs. 48.4%, p < 0.001). Amongst the pediatric population, P/PP traumatic brain injury (TBI) were more common in the youngest age range (age 0-5) vs. the older (6-12 years) pediatric and adolescent (13-17 years) patients. CONCLUSION: Our results identify areas of opportunities for improving pediatric trauma care. Although the overall P/PP death rate is lower in the pediatric population than the adult, opportunities for improving initial acute care, particularly TBI, exist.

A Descriptive and Geospatial Analysis of Environmental Factors Attributing to Sudden Unexpected Infant Death.

This study examined medicolegal death investigation records and autopsy reports of a medical examiner's office to identify the circumstances surrounding sudden unexpected infant deaths (SUID) and geospatial analyses to pinpoint areas of infant death concentration. Analysis of 732 records of SUID deaths occurring in a 10-year span resulted in the conclusion that environmental factors associated with the sudden death were to some extent modifiable. Co-sleeping (sharing a sleeping surface, or bed-sharing) on various surfaces (mattress, pallet, couch) occurred in 53.4% of the infant deaths. Geographic areas where the largest number of deaths occurred were characterized as areas of high poverty level. The inclusion of additional information at the time of investigation (eg, alcohol and tobacco use of co-sleepers, illness of others in household, exceptions to normal sleep routine of infant) may aid in identifying modifiable circumstances to reduce infant mortality attributable to sudden infant death.

Improving medicolegal death investigative gaps of fatal elder abuse.

The purpose of this brief is to present several case vignettes that illustrate omissions in the investigation of elder deaths. These vignettes demonstrate the need for a standardized approach in the conduct of medicolegal investigations of fatal elder abuse. For each of the described oversights, a recommendation is offered to address the gap in investigation processes, which in turn could improve the determination of cause and manner of elder death. Inherent limitations of resources and practical realities of death investigation are discussed and recommendations are made for future research. Viewed broadly, deficiencies in elder death investigations can lead to the underreporting of elder abuse and the reduction of legal options for victims, which may reflect a systemic pattern of social injustice.

Ethical Considerations on Disclosure When Medical Error Is Discovered During Medicolegal Death Investigation.

In the course of fulfilling their statutory role, physicians performing medicolegal investigations may recognize clinical colleagues' medical errors. If the error is found to have led directly to the patient's death (missed diagnosis or incorrect diagnosis, for example), then the forensic pathologist has a professional responsibility to include the information in the autopsy report and make sure that the family is appropriately informed. When the error is significant but did not lead directly to the patient's demise, ethical questions may arise regarding the obligations of the medical examiner to disclose the error to the clinicians or to the family. This case depicts the discovery of medical error likely unrelated to the cause of death and describes one possible ethical approach to disclosure derived from an ethical reasoning model addressing ethical principles of respect for persons/autonomy, beneficence, nonmaleficence, and justice.

A social media program to increase adolescent seat belt use.

In response to motor vehicle crashes remaining the leading cause of death for teenagers in the United States, a nursing clinical group (n = 10) in conjunction with a local hospital injury prevention program created an educational campaign to bolster seat belt use. The nursing students created an Instagram account to serve as an educational tool to promote seat belt use among teenagers aged 14-19, and the program was presented at three high school health fairs. In all, 135 postings were made to the account over a 3-month period. The number of likes posted by high school students was the unit of analysis. The most significant result (p = .01) was the difference between postings most liked (celebrities wearing seat belts) and least liked (postings made at the high school health fair), otherwise, differences among postings liked (humor postings, response requests, pictures of celebrities, factual data) were not significant. Instagram user engagement, measured in number of likes, is indicative that social media provides platforms to promote injury prevention efforts. Further research is needed to identify measurable elements of social media and to follow-up on behavioral changes following participation.

Effects of a Systematic Quality Improvement Process to Decrease Complications in Trauma Patients With Prehospital Peripheral Intravenous Access.

Peripheral intravenous (PIV) catheterization is commonly performed, and its complications are costly, may result in serious health issues, and may adversely affect patient satisfaction. At our large urban Level I trauma center, we identified a cluster of 7 PIV complications from prehospital insertions in a 5-month period. Several of the patients developed noninfectious as well as infectious, limb-threatening complications requiring aggressive operative intervention. A performance improvement project was chartered to identify the cause of PIV complications and review current nursing practice. The FOCUS-Plan Do Check Act methodology was used to measure and improve practice. With implementation of interventions and outcomes monitoring, no PIV complications were reported for the subsequent 39 consecutive months. Our findings have implications for more controlled studies to establish best practice at other Level I trauma centers across the country.