Home Care Admission Research Articles

The transition of a mental health facility to a COVID-19 isolation ward and unit to deliver remote inpatient mental health care

Throughout the COVID-19 pandemic, mental health services were confronted with significant challenges and mental health staff have not only had to provide a continued service for, often distressed, service users but have had to adapt practice and comply with the ever-changing public guidelines for containing the virus. There is a pressing need, therefore, to learn from the challenges that mental health services have faced and continue to face throughout different stages of the pandemic. While uncertainty is inevitable in pandemics, mental health nurses as a community can learn from individual experiences of adaptation. This article describes the unique and rapid transition of one Irish mental health facility to a COVID-19 isolation ward and unit for delivery of remote admission to a mental health service (home care admission). In order to capture this transitory experience, the areas discussed include preparation of the site, key challenges and the role of nursing staff, mental health service delivery, managing home care packages, the nurse management role and remote ward nursing. This discussion demonstrates how one mental health setting successfully evolved and met the challenges brought by the global pandemic through a combination of adaptability and flexibility in service delivery.

Assessments of Heart Failure and Frailty-Related Health Instability Provide Complementary and Useful Information for Home-Care Planning and Prognosis

BackgroundHealth instability, measured with the Changes in Health and End-Stage Disease Signs and Symptoms (CHESS) scale, predicts hospitalizations and mortality in home-care clients. Heart failure (HF) is also common among home-care clients. We seek to understand how HF contributes to the odds of death, hospitalization, or worsening health among new home-care clients, depending on admission health instability. MethodsWe undertook a retrospective cohort study of home-care clients, aged 65 years and older, between January 1, 2010, and March 31, 2015 from Alberta, British Columbia, Ontario, and the Yukon, Canada. We used multistate Markov models to derive adjusted odds ratios (ORs) for transitions to different health instability states, hospitalization, and death. We examined the role of HF and CHESS at 6 months after home-care admission. ResultsThe sample included 286,232 clients. Those with HF had greater odds of worsening health instability than those without HF. At low-to-moderate admission health instability (CHESS 0-2), clients with HF had greater odds of hospitalization and death than those without HF. Clients with HF and high health instability (CHESS≥3) had slightly greater odds of hospitalization (OR, 1.08; 95% confidence interval (CI), 1.02-1.13) but similar odds of death (OR, 1.024; 95% CI, 0.937-1.120) compared with clients without HF. ConclusionsAmong new home-care clients, a diagnosis of HF predicts death, hospitalization, and worsening health, predominantly among those with low-to-moderate admission health instability. A diagnosis of HF and admission CHESS score provide complementary information to support care planning in this population.

Planning the Episode: Home Care Admission Nurse Decision-Making Regarding the Patient Visit Pattern.

During home health care (HHC) admissions, nurses provide input into decisions regarding the skilled nursing visit frequency and episode duration. This important clinical decision can impact patient outcomes including hospitalization. Episode duration has recently gained greater importance due to the Centers for Medicare and Medicaid Services (CMS) decrease in reimbursable episode length from 60 to 30 days. We examined admissions nurses’ visit pattern decision-making and whether it is influenced by documentation available before and during the first home visit, agency standards, other disciplines being scheduled, and electronic health record (EHR) use. This observational mixed-methods study included admission document analysis, structured interviews, and a think-aloud protocol with 18 nurses from 3 diverse HHC agencies (6 at each) admitting 2 patients each (36 patients). Findings show that prior to entering the home, nurses had an information deficit; they either did not predict the patient’s visit frequency and episode duration or stated them based on experience with similar patients. Following patient interaction in the home, nurses were able to make this decision. Completion of documentation using the EHR did not appear to influence visit pattern decisions. Patient condition and insurance restrictions were influential on both frequency and duration. Given the information deficit at admission, and the delay in visit pattern decision making, we offer health information technology recommendations on electronic communication of structured information, and EHR documentation and decision support.

Improving Patient Prioritization During Hospital-Homecare Transition: Protocol for a Mixed Methods Study of a Clinical Decision Support Tool Implementation.

BackgroundHomecare settings across the United States provide care to more than 5 million patients every year. About one in five homecare patients are rehospitalized during the homecare episode, with up to two-thirds of these rehospitalizations occurring within the first 2 weeks of services. Timely allocation of homecare services might prevent a significant portion of these rehospitalizations. The first homecare nursing visit is one of the most critical steps of the homecare episode. This visit includes an assessment of the patient’s capacity for self-care, medication reconciliation, an examination of the home environment, and a discussion regarding whether a caregiver is present. Hence, appropriate timing of the first visit is crucial, especially for patients with urgent health care needs. However, nurses often have limited and inaccurate information about incoming patients, and patient priority decisions vary significantly between nurses. We developed an innovative decision support tool called Priority for the First Nursing Visit Tool (PREVENT) to assist nurses in prioritizing patients in need of immediate first homecare nursing visits.ObjectiveThis study aims to evaluate the effectiveness of the PREVENT tool on process and patient outcomes and to examine the reach, adoption, and implementation of PREVENT.MethodsEmploying a pre-post design, survival analysis, and logistic regression with propensity score matching analysis, we will test the following hypotheses: compared with not using the tool in the preintervention phase, when homecare clinicians use the PREVENT tool, high-risk patients in the intervention phase will (1) receive more timely first homecare visits and (2) have decreased incidence of rehospitalization and have decreased emergency department use within 60 days. Reach, adoption, and implementation will be assessed using mixed methods including homecare admission staff interviews, think-aloud observations, and analysis of staffing and other relevant data.ResultsThe study research protocol was approved by the institutional review board in October 2019. PREVENT is currently being integrated into the electronic health records at the participating study sites. Data collection is planned to start in early 2021.ConclusionsMixed methods will enable us to gain an in-depth understanding of the complex socio-technological aspects of the hospital to homecare transition. The results have the potential to (1) influence the standardization and individualization of nurse decision making through the use of cutting-edge technology and (2) improve patient outcomes in the understudied homecare setting.Trial RegistrationClinicalTrials.gov NCT04136951; https://clinicaltrials.gov/ct2/show/NCT04136951International Registered Report Identifier (IRRID)PRR1-10.2196/20184

Prognostication in Home-Dwelling Patients with Advanced Dementia: The Palliative Support DEMentia Model (PalS-DEM)

ObjectiveDifficulties with prognostication prevent more patients with advanced dementia from receiving timely palliative support. The aim of this study is to develop and validate a prognostic model for 6-month and 1-year mortality in home-dwelling patients with advanced dementia. DesignProspective cohort study. Setting and ParticipantsThe data set of 555 home-dwelling patients with dementia at Functional Assessment Staging Test stage 7 was split into derivation (n = 275) and validation (n = 280) cohorts. MethodsCox proportional hazards regression modeled survival in the derivation cohort using prognostic variables identified in univariate analysis. The model was validated internally and using 10-fold cross-validation. Area under the receiver operating characteristic curve measured the accuracy of the final model. ResultsFour hundred nineteen (75.5%) patients died with a median follow-up of 47 days [interquartile range (IQR) 161]. Prognostic variables in the multivariate model included serum albumin level, dementia etiology, number of homecare admission criteria fulfilled, presence of moderate to severe chronic kidney disease, peripheral vascular disease, quality of life in late-stage dementia scores, housing type, and the Australian National Sub-Acute and Non-Acute Patient palliative care phase.The model was refined into a parsimonious 6-variable model [Palliative Support DEMentia Model (PalS-DEM)] consisting of age, dementia etiology, Functional Assessment Staging Test stage, Charlson Comorbidity Index scores, Australian National Sub-Acute and Non-Acute Patient palliative care phase, and 30-day readmission frequency for the prediction of 1-year mortality. The area under the receiver operating characteristic curve was 0.65 (95% confidence interval 0.59–0.70). Risk scores categorized patients into 3 prognostic groups, with a median survival of 175 days (IQR 365), 104 days (IQR 246), and 19 days (IQR 88) for the low-risk (0‒1 points), moderate-risk (2‒4), and high-risk (≥5) groups, respectively. Conclusions and ImplicationsThe PalS-DEM identifies patients at high risk of death in the next 1 year. The model produced consistent survival results across the derivation, validation, and cross-validation cohorts and will help healthcare providers identify patients with advanced dementia earlier for palliative care.

There's a Problem With the Problem List: Incongruence of Patient Problem Information Across the Home Care Admission

ObjectivesIllustrate patterns of patient problem information received and documented across the home health care (HHC) admission process and offer practice, policy, and health information technology recommendations to improve information transfer. DesignObservational field study. Setting and ParticipantsThree diverse HHC agencies using different commercial point-of-care electronic health records (EHRs). Six nurses per agency each admitted 2 patients (36 total). MethodsResearchers observed the admission process and photographed documents and EHR screens across 3 phases: referral, assessment, and plan of care (POC). To create a standardized data set, we mapped terms within medical diagnoses, signs, symptoms, and Problems to 5 of the 42 Omaha System Problem Classification Scheme problem terms. This created 180 problem pattern cases (5 problem patterns per patient). ResultsEach pattern of problem information being present or absent was observed. In 52 cases (28.9%), a problem did not appear. In 36 cases (20%), the problem appeared in all 3 phases. In 46 cases (25.6%), the problem appeared in referral and/or assessment phases and not on the POC. Conversely, in 37 cases (20.5%), the problem appeared in referral or assessment phases and on the POC. In 9 cases (5%), the problem only appeared on the POC. Within the EHRs, there were no rationale fields to clarify including Problems or not and no problem status fields to identify active, resolved, or potential ones. Conclusions and ImplicationsDiagnosis or problem information transferred from the referral source or gathered during an in-home assessment did not appear in the POC. Because of the EHR structure, clinicians could not identify inactive problem or problem priority. Documentation or mapping of a structured problem list using a standardized interprofessional terminology such as the Omaha System coupled with identification of rationale could support the documentation of problem status and priority and reduce information loss.

A Staged Approach for Facilitating Joint End User, Vendor, and Multi-Disciplinary Subject Matter Expert Input to Health Information Technology Recommendations

Design of health information technology (HIT) that improves patient outcomes is an ongoing process. We propose a methodology that takes a human factors engineering approach to develop systems-engineering-style requirements and design recommendations for both HIT and aspects beyond the scope of the HIT itself (e.g., policies and procedures). Our approach includes: (1) data collection and analysis; (2) preliminary recommendations generation; (3) recommendation review by methodological and domain subject matter experts; (4) revised recommendation review by end users; (5) revised recommendation review by HIT vendors; and (6) final recommendation generation. We illustrate the methodology by presenting a case study focusing on home health care nurses using HIT during the home care admission process.

Incongruence of Patient Problem Information Across Three Phases of Home Care Admission: There's a Problem with the Problem List.

In home health care, the patient problem list is an important component of the admission and care planning processes and determines the subsequent care received. We examined the information received from the referring facilities and its relationship with the final patient problem list generated at home health care admission. Researchers observed 12 admissions and collected available documents related to the admission and care planning process. Problems identified in documents provided to admission nurses (input documents) and in documents subsequently created by those nurses (output documents) were coded to form a standardized set of problem terms across the documents. Documents available, distribution of problems within the documents, and concordance between input and output documents were assessed. A varying number of the 17 unique problems found across the documents were distributed by document type. Patients were referred to home health care with more clinical problems than were documented in the output documents.

Home Care Program Increases the Engagement in Patients With Heart Failure

Heart failure patients seen in the outpatient home care setting and in cardiology clinics have repeated emergency department visits, hospital admissions, and readmissions despite receiving education about their medications diet and self-care interventions such as daily weights. The objective of this evidence-based practice change was to determine, in home care patients, whether the use of standardized teach-back methodology educational materials would improve their knowledge and confidence in the self-care of their chronic disease. Of the 22 patients enrolled, 15 were not readmitted to the hospital within 9 months of home care admission. The Self-Care of Heart Failure Index revealed an improvement in patient and caregiver contributions to heart failure self-care maintenance (daily adherence and symptom monitoring). The findings suggest that engaging patients by increasing their knowledge of their disease and their self-confidence can reduce hospitalizations and subsequent readmissions.

Impact of Home Care Admission Nurses' Goals on Electronic Health Record Documentation Strategies at the Point of Care.

Home care nurses have multiple goals at the patient admission visit. Electronic health records support some of these goals, including high-quality documentation, but nurses may not complete the electronic documentation at the point of care. To characterize admission nurses' practices at the point of care and lay the foundation for design recommendations, this study investigates admission nurses' documentation strategies with respect to entering electronic data and how nursing goals affect them. We conducted 10 observations of home care agency admissions with five admission nurses in rural Pennsylvania. We collected screenshots and recorded the admission process. We asked the nurses questions outside the point of care. We coded the nurses' strategies at the data-entry screen level. Using thematic analysis, we investigated the influence of nursing goals on documentation strategies. Subject matter experts reviewed our findings. Several goals affect nurses' documentation strategies: ensure data accuracy, reduce time in the patient's home, and prevent infection. Home care admission nurses distribute the electronic documentation temporally due to their goals. Nurses developed memory aids to support completion of the documentation after leaving the patients' homes. Design and training should support the distributed manner in which home care nurses document patient encounters.

Distributed Electronic Documentation Practices of Homecare Admission: Informing Electronic Health Record Design Guidelines

Home care nurses complete many activities as part of the admission process. A pilot study of the home care admission process indicated that a nurse distributes data entry tasks between the patient’s home and a post-documentation period later in the day. We found evidence of a strategy to document information that requires direct observation (either from the patient or through viewing the home environment) in the home. We found evidence of a strategy to document outside of the home for data elements based on clinical judgment or assessments as well as information supported by clinical decision support in the Electronic Health Record (EHR). These finding inform recommendations for data entry and navigation design guidelines for home care admission EHR systems.

Factors That Influence Care Transitions of End-Stage Heart Failure Patients to Palliative Home Care

Although palliative care has been shown to be an effective way to manage distressing symptoms in end-stage heart failure, patients are infrequently referred to palliative home care following hospital discharge for an exacerbation. The purpose of this 2-phase mixed-methods study was to examine factors that influence the transition of patients with end-stage heart failure to palliative home care. A 45-item online survey was randomly distributed to 92 home care agencies across New York State. Two-thirds of the home care agencies offered palliative care, whereas one-third had only hospice. Although the majority of nurses (87.7%) reported ability to refer patients to palliative care, nurse managers were identified as the main source for referrals. Nurse demographics were not correlated with a greater number of palliative care referrals, whereas experience with palliative care was. Diagnosis was associated with a greater number of palliative care referrals than presence of pain or declining functional status. Improvements in discharge planning protocols that can evaluate patients who could benefit from palliative care prior to home care admission are needed. Home-based palliative care could improve quality of life by managing symptoms and exacerbations, which could reduce hospital readmissions.

Patient Health Goals Elicited During Home Care Admission: A Categorization.

Home care agencies are initiating "patient health goal elicitation" activities as part of home care admission planning. We categorized elicited goals and identified "clinically informative" goals at a home care agency. We examined patient goals that admitting clinicians documented in the point-of-care electronic health record; conducted content analysis on patient goal data to develop a coding scheme; grouped goal themes into codes; assigned codes to each goal; and identified goals that were in the patient voice. Of the 1,763 patient records, 16% lacked a goal; only 15 goals were in a patient's voice. Nurse and physician experts identified 12 of the 20 codes as clinically important accounting for 82% of goal occurrences. The most frequent goal documented was safety/falls (23%). Training and consistent communication of the intent and operationalization of patient goal elicitation may address the absence of patient voice and the less than universal recording of home care patients' goals.

The Impact of Depression on Discharge to Hospitals and Other Outcomes in Medicare Home Health Care Patients

The aim of this study was to determine the association of active depressive symptoms in older home health care (home care) patients and discharge to the hospital. This study was based on a cross-sectional secondary data analysis. The data were from the Montefiore Home Healthcare Agency, Bronx, New York. Patients 65 years and older who were admitted to home care in 2010 ( N = 3,761) with a valid depression screen in the medical record were included. Disposition at discharge and the Patient Health Questionnaire–2 depression screen were collected from the home care nursing assessment. Demographic and clinical factors were collected from the medical record. The adjusted odds ratio (AOR) was greater for discharge resulting in hospitalization (AOR = 1.70, 95% confidence interval = [1.29, 2.25]) among those with positive depression screens compared with those with a negative screen at the time of admission. Conclusion: Active depressive symptoms at the time of admission to home care were associated with increased odds of hospitalization at discharge. Interventions to reduce depression during the home care admission may have implications for readmission rates and overall health care utilization.

Subtypes of potentially inappropriate medications in older Chinese-Americans during care transitions: Cross sectional retrospective study

BackgroundThe number of Chinese Americans is growing and nearly 20% of older Chinese-American home care patients have at least one potentially inappropriate medications (PIMs) prescribed at hospital discharge. Further examination of PIMs during care transition is warranted, especially among older Chinese-Americans. ObjectivesTo describe, during care transitions from hospital to home care: (i) the subtypes of PIMs, (ii) the difference of PIM prevalence prescribed at hospital discharge as compared to home care admission, (iii) the relationship between subtypes of PIMs, and (iv) issues affecting medication reconciliation among older Chinese-Americans. MethodsThis cross-sectional, retrospective study was conducted in a large urban home care agency from June 2010 to July 2011. From data collected by in-home survey and chart abstraction, PIMs were identified using 2002 diagnosis-independent Beers criteria. The difference of PIM prevalence at hospital discharge and at home care admission was analyzed by Wilcoxon Signed Ranks test. The relationship between subtypes of PIMs was evaluated using Phi coefficient. Participants82 older (age 65 years and above) Chinese-American home care patients following recent hospital discharge. Results3.38% (22) and another 3.72% (28) of prescribed medications were identified as PIMs at hospital discharge and home care admission, respectively. There was no statistically significant difference in PIM prevalence identified at hospital discharge and at homecare admission (z=−1.732, p=.083). PIMs included: long-term use of stimulant laxatives and high-dosages of ferrous sulfate, and a significant relationship between these two PIMS (r=.224, p=.04). More than 80% (n=65) of study participants reported low education levels and limited English proficiency. ConclusionsSubtypes of PIMs were ordered during the post-hospital transfers, indicating the necessity to review the appropriateness of medications during this transition. Guidelines such as Beer's criteria regarding appropriateness of medications should be incorporated in medication reconciliation before adding new medications to treat the older adult's health problems. The medication management process needs to be both culturally sensitive and adapted to literacy level; validating the patients’ full understanding of their medications is paramount.

Prognostic Factors of Survival in Patients With Advanced Cancer Admitted to Home Care

ContextData regarding prognostication of life expectancy in patients with advanced cancer are of paramount importance to patients, families, and clinicians. However, data regarding patients followed at home are lacking. ObjectivesThe aim of this study was to evaluate the correlation between various factors recorded at the beginning of home care assistance and survival. MethodsA sample of consecutive patients admitted to two home care programs was surveyed. A preliminary consensus was achieved as to the possible variables easy to be recorded at home. These included age at the time of home care admission, gender, residence, marital status, primary cancer diagnosis, Karnofsky Performance Status (KPS) score, measures of systolic blood pressure and heart rate, cyanosis, use of oxygen, and body temperature. The Edmonton Symptom Assessment System was used to record the intensity of each symptom. Patients were divided into two groups: patients with a survival of less than 10 days (short survival) and patients with a survival of 10 days or more (medium-long survival). ResultsThree hundred seventy-four consecutive patients admitted to home care programs were surveyed, of which 187 were male. The mean±SD age was 72.1±12.7 years. The mean survival was 56.2±65 days. Mean survival was 71.5±67 days (287 patients) and 5.6±2.7 days (87 patients) in the short and medium-long survival groups, respectively. No association between type of tumor and survival was observed (P=0.162). Univariate logistic regression analysis revealed that male gender (P=0.020), older age (P=0.012), lower KPS scores (P<0.0005), systolic blood pressure less than 100mmHg (P=0.003), heart rate greater than 100 beats per minute (P=0.0006), delirium (P=0.004), the use of oxygen (P=0.002), intensity of fatigue (P=0.006), drowsiness (P<0.0005), anorexia (P<0.0005), dyspnea (P<0.0005), poor sense of well-being (P<0.0005), and distress score (P<0.0005) were associated with a survival of less than 10 days. Marital status, residence, cognitive function, fever, pain, depression, and anxiety were not found to be significantly correlated with survival. In a multiple logistic regression model, low systolic blood pressure and high heart rate, gender, delirium, use of oxygen, KPS score, drowsiness, anorexia, and dyspnea were significantly correlated with a shorter survival. ConclusionLow systolic blood pressure and high heart rate, male gender, poor KPS score, anorexia, and dyspnea were correlated with a shorter survival. Moreover, patients with low systolic blood pressure and high heart rate, male gender, poor KPS score, and greater intensity of anorexia and dyspnea are more likely to die within one week. The combination of physical symptoms from the Edmonton Symptom Assessment System and other parameters included in this study, which are simple to assess and are repeatable at home, should be further explored in future studies to provide a simple tool for use with patients with advanced cancer admitted to a home care program.

Medication Discrepancy and Potentially Inappropriate Medication in Older Chinese-American Home-Care Patients After Hospital Discharge

BackgroundStudies of potential medication problems among older adults have focused on English-speaking populations in a single health care setting or a single potential medication problem. No previous studies investigated potential inappropriate medications (PIMs) and medication discrepancies (MDs) among older Chinese Americans during care transitions from hospital discharge to home care. ObjectiveThe aims of this study were to examine, in older Chinese Americans, the prevalence of both PIMs and MDs; the relationship between PIMs and MDs; and the patient and hospitalization characteristics associated with them during care transitions from hospital discharge to home care. MethodsThis cross-sectional study was conducted with a sample of older Chinese Americans from a large certified nonprofit home-care agency in New York City from June 2010 to July 2011. PIMs were identified by using 2002 diagnosis-independent Beers criteria. MDs were identified by comparing the differences between hospital discharge medication order and home-care admission medication order. Prevalence of PIMs and MDs and their relationship was determined. Logistic regression examined the relationship between hospitalization and patient characteristics with PIMs and MDs. ResultsThe sample consisted of 82 older Chinese-American home-care patients. Twenty (24.3%) study participants were prescribed at least one PIM at hospital discharge. Fifty-one (67.1%) study participants experienced at least one MD. A positive correlation was found between the occurrence of PIMs and MDs (r = 0.22; P = 0.05). Number of medications was the only significant factor associated with both PIMs and MDs. In addition, older age and more hospitalization days were associated with PIMs. ConclusionsThe evident prevalence of PIMs and MDs supports the practice of evaluating the appropriateness of medications while reconciling inconsistencies in medication regimens. The number of medications was the only factor associated with both PIMs and MDs, underscoring the need to address polypharmacy as a multifaceted threat to patient health.

How End-Of-Life Home Care Services Are Used from Admission to Death: A Population-Based Cohort Study

Our goal was to describe the trajectories of end-of-life nursing and personal support worker (PSW) use from home care admission until death. We studied a historical prospective cohort of end-of-life home care patients in Ontario, Canada, linking administrative databases. We calculated the odds of using any nursing or PSW hours and the incidence rate ratio of services used for each week approaching death, controlling for confounders. Among all patients (n = 11,867), the odds of using any nursing and PSW hours increased by 4 percent and 10 percent, respectively, each week closer to death. Among patients using services, the ratio of nursing and PSW hours increased 20 percent and 11 percent, respectively, in the last 4 weeks of life compared to use at 24 weeks before death. Use of nursing and PSW hours increases slightly each week before death and sharply in the last month of life. Understanding the trajectory of home care services use can help decision makers design better end-of-life care.

Using More End-of-Life Homecare Services is Associated With Using Fewer Acute Care Services

Healthcare systems are investing in end-of-life homecare to reduce acute care use. However, little evidence exists on the timing and amount of homecare services necessary to reduce acute care utilization. To investigate whether admission time to homecare and the amount of services, as measured by average nursing and personal support and homemaking (PSH) hours/week (h/wk), are associated with using acute care services at end-of-life. Retrospective observational cohort study. Decedents admitted to end-of-life homecare in Ontario, Canada. The odds ratios (OR) of having a hospitalization or emergency room visit in the 2 weeks before death and dying in a hospital. The cohort (n = 9018) used an average of 3.11 (SD = 4.87) nursing h/wk, 3.18 (SD = 6.89) PSH h/wk, and 18% were admitted to homecare for <1 month. As admission time to death and homecare services increased, the adjusted OR of an outcome decreased in a dose response manner. Patients admitted earlier than 6 months before death had a 35% (95% CI: 25%-44%) lower OR of hospitalization than those admitted 3 to 4 weeks before death; patients using more than 7 nursing h/wk and more than 7 PSH h/wk had a 50% (95% CI: 37%-60%) and 35% (95% CI: 21%-47%) lower OR of a hospitalization, respectively, than patients using 1 h/wk, controlling for other covariates. Other outcomes had similar results. These results suggest that early homecare admission and increased homecare services will help alleviate the demand for hospital resources at end-of-life.

Editor's note:

The above letter was sent to the author of the original article, and Dr. Ferrell's reply follows. We were also disturbed by our findings that a substantial number of patients with pressure sores appeared to be managed rather haphazardly before admission to home care.1 The extent to which these observations are related to oversight, deficits in knowledge, miscommunication, arrogance, or negligence has not been fully explored. Others have witnessed this in nursing homes as well.2,3 Unfortunately, exploration of these issues was beyond the scope of our study and we do not have data to describe processes of care before home care admission. We do not know how many physicians even knew their patients had pressure sores or how they were being treated. Little is known about physicians' knowledge, attitudes, and practice patterns with regard to pressure sores. In a random survey of Minnesota family physicians in 1997, 99% of respondents said that it was the family physician's responsibility to provide pressure sore care, but 70% felt that they had not been adequately trained to do so. Moreover, despite wide circulation by the time of the survey, 70% of physicians were not aware of the Agency for Health Care Policy and Research's clinical practice guidelines on the subject.4 Physicians and nurses choose most pressure sore products and devices based on clinical judgment rather than on results of well-controlled studies. Indeed, there are only a few randomized trials of pressure sore care in the medical literature. In fact, recommendations from highly quoted clinical practice guidelines are largely based on weakly designed observations and consensus rather than results of well-controlled clinical outcome studies. Today there are hundreds of devices and products being actively marketed for the prevention and treatment of pressure sores. The care of patients becomes more perplexing with every new product that is brought to market based on in vitro studies or weakly designed clinical outcomes. With few good studies and inadequate formal training, perhaps it should not be so surprising that pressure ulcer care remains problematic.5