Acute Care Medical Units Research Articles

Medical Crises in Older People: cohort study of older people attending acute medical units, developmental work and randomised controlled trial of a specialist geriatric medical intervention for high-risk older people; cohort study of older people with mental health problems admitted to hospital, developmental work and randomised controlled trial of a specialist medical and mental health unit for general hospital patients

BackgroundThis programme of research addressed shortcomings in the care of three groups of older patients: patients discharged from acute medical units (AMUs), patients with dementia and delirium admitted to general hospitals, and care home residents.MethodsIn the AMU workstream we undertook literature reviews, performed a cohort study of older people discharged from AMU (Acute Medical Unit Outcome Study; AMOS), developed an intervention (interface geriatricians) and evaluated the intervention in a randomised controlled trial (Acute Medical Unit Comprehensive Geriatric Assessment Intervention Study; AMIGOS). In the second workstream we undertook a cohort study of older people with mental health problems in a general hospital, developed a specialist unit to care for them and tested the unit in a randomised controlled trial (Trial of an Elderly Acute care Medical and mental health unit; TEAM). In the third workstream we undertook a literature review, a cohort study of a representative sample of care home residents and a qualitative study of the delivery of health care to care home residents.ResultsAlthough 222 of the 433 (51%) patients recruited to the AMIGOS study were vulnerable enough to be readmitted within 3 months, the trial showed no clinical benefit of interface geriatricians over usual care and they were not cost-effective. The TEAM study recruited 600 patients and there were no significant benefits of the specialist unit over usual care in terms of mortality, institutionalisation, mental or functional outcomes, or length of hospital stay, but there were significant benefits in terms of patient experience and carer satisfaction with care. The medical and mental health unit was cost-effective. The care home workstream found that the organisation of health care for residents in the UK was variable, leaving many residents, whose health needs are complex and unpredictable, at risk of poor health care. The variability of health care was explained by the variability in the types and sizes of homes, the training of care home staff, the relationships between care home staff and the primary care doctors and the organisation of care and training among primary care doctors.DiscussionThe interface geriatrician intervention was not sufficient to alter clinical outcomes and this might be because it was not multidisciplinary and well integrated across the secondary care–primary care interface. The development and evaluation of multidisciplinary and better-integrated models of care is justified. The specialist unit improved the quality of experience of patients with delirium and dementia in general hospitals. Despite the need for investment to develop such a unit, the unit was cost-effective. Such units provide a model of care for patients with dementia and delirium in general hospitals that requires replication. The health status of, and delivery of health care to, care home residents is now well understood. Models of care that follow the principles of comprehensive geriatric assessment would seem to be required, but in the UK these must be sufficient to take account of the current provision of primary health care and must recognise the importance of the care home staff in the identification of health-care needs and the delivery of much of that care.Trial registrationCurrent Controlled Trials ISRCTN21800480 (AMIGOS); ClinicalTrials.gov NCT01136148 (TEAM).FundingThis project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 3, No. 4. See the NIHR Journals Library website for further project information.

From research to reality: minimizing the effects of hospitalization on older adults.

This review examines ways to decrease preventable effects of hospitalization on older adults in acute care medical (non-geriatric) units, with a focus on the Israeli experience at the Rambam Health Care Campus, a large tertiary care hospital in northern Israel. Hospitalization of older adults is often followed by an irreversible decline in functional status affecting their quality of life and well-being after discharge. Functional decline is often related to avoidable effects of in-hospital procedures not caused by the patient’s acute disease. In this article we review the literature relating to the recognized effects of hospitalization on older adults, pre-hospitalization risk factors, and intervention models for hospitalized older adults. In addition, this article describes an Israeli comprehensive research study, the Hospitalization Process Effects on Functional Outcomes and Recovery (HoPE-FOR), and outlines the design of a combined intervention model being implemented at the Rambam Health Care Campus. The majority of the reviewed studies identified preadmission personal risk factors and psychosocial risk factors. In-hospital restricted mobility, under-nutrition care, over-use of continence devices, polypharmacy, and environmental factors were also identified as avoidable processes. Israeli research supported the findings that preadmission risk factors together with in-hospital processes account for functional decline. Different models of care have been developed to maintain functional status. Much can be achieved by interdisciplinary teams oriented to the needs of hospitalized elderly in making an impact on hospital processes and continuity of care. It is the responsibility of health care policy-makers, managers, clinicians, and researchers to pursue effective interventions to reduce preventable hospitalization-associated disability.

English

Multiple organ dysfunction syndrome (MODS) is a systemic, dysfunctional inflammatory response that requires longer admissions in acute medical care unit with high mortality rate. The present study was done prospectively to evaluate clinical profile and etiological spectrum of patients admitted in acute medical care unit categorized under multi- organ dysfunction syndrome (MODS) and to correlate outcome of MODS. 50 patients of ≥ 18 years age who were admitted in Acute Medical Care Unit, Department of Medicine, Government General Hospital, Kakinada, with more than one organ dysfunction, requiring intervention were studied during 2010-2012. In all cases provisional diagnosis was made by taking detailed history and clinical examination, and were subjected to the relevant investigations. The criteria were used to include under MODS were assessed on respiratory, renal gastrointestinal, central nervous system, Glasgow coma scale cardiovascular, hematological parameters. The outcome of MODS was correlated by application of APACHE-II score on admission day, serial SOFA score on day 1 and 3, serial serum albumin measurement on day 1 and 5. There was multiorgan involvement .Most common organ failed was renal 30 (60%), followed by CNS 27 (54%), respiratory 25 (50%), CVS 23 (46%), GIT 17 (34%), hematologic 9 (18%). Sepsis was the most common cause of MODS in 24 (48%) patients. Most common organ dysfunction as a predictor of mortality was CNS in 17 (77%) out of 22 patients expired, followed by Respiratory in 13 (59%), Renal 11 (50%), CVS 10 (45%), GIT 9 (40%), Hematologic 2 (9%). Maximum incidence of mortality was seen when ≥5 organs failed. There was significant correlation statistically in our study between APACHE II score on admission and outcome as Pearson chi-square “p”< 0.001Mean SOFA score of survivors on day 1 was 6±2 and on day 3 was 2±1. Mortality significantly decreased (3.44%) on day 3 if SOFA score was ≤7. Multi-Organ Dysfunction Syndrome (MODS) was common in younger age group with the mean age of40 years. Sepsis (48%) was the most common cause of MODS, followed by other causes. Maximum incidence of mortality (55%) was seen if the first failed organ was respiratory system and when ≥5 organs failed. Highest incidence of mortality was seen in 8 th decade (100%). APACHE II score on admission, serial SOFA scores, and serial albumin measurements can help ICU physicians in admitting patients, monitoring the clinical course, assessment of organ dysfunction, predicting mortality and for transferring patients out from ICU and thus in proper utilization of ICU resources.

Barriers to discharge in an acute care medical teaching unit: a qualitative analysis of health providers' perceptions.

BackgroundThe complex process of discharging patients from acute care to community care requires a multifaceted interaction between all health care providers and patients. Poor communication in a patient’s discharge can result in post hospital adverse events, readmission, and mortality. Because of the gravity of these problems, discharge planning has been emphasized as a potential solution. The purpose of this paper is to identify communication barriers to effective discharge planning in an acute care unit of a tertiary care center and to suggest solutions to these barriers.MethodsHealth care providers provided comments to a single open-ended question: “What are the communication barriers between the different health care providers that limit an effective discharge of patients from Unit 36?” We conducted qualitative thematic analysis by identifying themes related to communication barriers affecting a successful discharge process.ResultsThree broad themes related to barriers to the discharge process were identified: communication, lack of role clarity and lack of resources. We also identified two themes for opportunities for improvement, ie, structure and function of the medical team and need for leadership.ConclusionWhile it was evident that poor communication was an overarching barrier identified by health care providers, other themes emerged. In an effort to increase inter-team communication, “bullet rounds”, a condensed form of discharge rounds, were introduced to the medical teaching unit and occurred on a daily basis between the multidisciplinary team. To help facilitate provider-patient communication, electronic transfer of care summaries were suggested as a potential solution. To help role clarity, a discharge coordinator and/or liaison was suggested. Communication can be enhanced through use of electronic discharge summaries, bullet rounds, and implementation of a discharge coordinator(s). The findings from this study can be used to aid future researchers in devising appropriate discharging strategies that are focused around the patient and inter-health care provider communication.

Is This Elderly Patient Dehydrated? Diagnostic Accuracy of Hydration Assessment Using Physical Signs, Urine, and Saliva Markers

ObjectivesDehydration in older adults contributes to increased morbidity and mortality during hospitalization. As such, early diagnosis of dehydration may improve patient outcome and reduce the burden on healthcare. This prospective study investigated the diagnostic accuracy of routinely used physical signs, and noninvasive markers of hydration in urine and saliva. DesignProspective diagnostic accuracy study. SettingHospital acute medical care unit and emergency department. ParticipantsOne hundred thirty older adults [59 males, 71 females, mean (standard deviation) age = 78 (9) years]. MeasurementsParticipants with any primary diagnosis underwent a hydration assessment within 30 minutes of admittance to hospital. Hydration assessment comprised 7 physical signs of dehydration [tachycardia (>100 bpm), low systolic blood pressure (<100 mm Hg), dry mucous membrane, dry axilla, poor skin turgor, sunken eyes, and long capillary refill time (>2 seconds)], urine color, urine specific gravity, saliva flow rate, and saliva osmolality. Plasma osmolality and the blood urea nitrogen to creatinine ratio were assessed as reference standards of hydration with 21% of participants classified with water-loss dehydration (plasma osmolality >295 mOsm/kg), 19% classified with water-and-solute-loss dehydration (blood urea nitrogen to creatinine ratio >20), and 60% classified as euhydrated. ResultsAll physical signs showed poor sensitivity (0%–44%) for detecting either form of dehydration, with only low systolic blood pressure demonstrating potential utility for aiding the diagnosis of water-and-solute-loss dehydration [diagnostic odds ratio (OR) = 14.7]. Neither urine color, urine specific gravity, nor saliva flow rate could discriminate hydration status (area under the receiver operating characteristic curve = 0.49–0.57, P > .05). In contrast, saliva osmolality demonstrated moderate diagnostic accuracy (area under the receiver operating characteristic curve = 0.76, P < .001) to distinguish both dehydration types (70% sensitivity, 68% specificity, OR = 5.0 (95% confidence interval 1.7–15.1) for water-loss dehydration, and 78% sensitivity, 72% specificity, OR = 8.9 (95% confidence interval 2.5–30.7) for water-and-solute-loss dehydration). ConclusionsWith the exception of low systolic blood pressure, which could aid in the specific diagnosis of water-and-solute-loss dehydration, physical signs and urine markers show little utility to determine if an elderly patient is dehydrated. Saliva osmolality demonstrated superior diagnostic accuracy compared with physical signs and urine markers, and may have utility for the assessment of both water-loss and water-and-solute-loss dehydration in older individuals. It is particularly noteworthy that saliva osmolality was able to detect water-and-solute-loss dehydration, for which a measurement of plasma osmolality would have no diagnostic utility.

Screening for older emergency department inpatients at risk of prolonged hospital stay: the brief geriatric assessment tool.

BackgroundThe aims of this study were 1) to confirm that combinations of brief geriatric assessment (BGA) items were significant risk factors for prolonged LHS among geriatric patients hospitalized in acute care medical units after their admission to the emergency department (ED); and 2) to determine whether these combinations of BGA items could be used as a prognostic tool of prolonged LHS.MethodsBased on a prospective observational cohort design, 1254 inpatients (mean age ± standard deviation, 84.9±5.9 years; 59.3% female) recruited upon their admission to ED and discharged in acute care medical units of Angers University Hospital, France, were selected in this study. At baseline assessment, a BGA was performed and included the following 6 items: age ≥85years, male gender, polypharmacy (i.e., ≥5 drugs per day), use of home-help services, history of falls in previous 6 months and temporal disorientation (i.e., inability to give the month and/or year). The LHS in acute care medical units was prospectively calculated in number of days using the hospital registry.ResultsArea under receiver operating characteristic (ROC) curves of prolonged LHS of different combinations of BGA items ranged from 0.50 to 0.57. Cox regression models revealed that combinations defining a high risk of prolonged LHS, identified from ROC curves, were significant risk factors for prolonged LHS (hazard ratio >1.16 with P>0.010). Kaplan-Meier distributions of discharge showed that inpatients classified in high-risk group of prolonged LHS were discharged later than those in low-risk group (P<0.003). Prognostic value for prolonged LHS of all combinations was poor with sensitivity under 77%, a high variation of specificity (from 26.6 to 97.4) and a low likelihood ratio of positive test under 5.6.ConclusionCombinations of 6-item BGA tool were significant risk factors for prolonged LHS but their prognostic value was poor in the studied sample of older inpatients.

A mobility program for an inpatient acute care medical unit.

For many patients, hospitalization brings prolonged periods of bed rest, which are associated with such adverse health outcomes as increased length of stay, increased risk of falls, functional decline, and extended-care facility placement. Most studies of progressive or early mobility protocols designed to minimize these adverse effects have been geared toward specific patient populations and conducted by multidisciplinary teams in either ICUs or surgical units. Very few mobility programs have been developed for and implemented on acute care medical units. This evidence-based quality improvement project describes how a mobility program, devised for and put to use on a general medical unit in a large Midwestern academic health care system, improved patient outcomes.

Intracranial tuberculomata: A computerized tomographic evaluation

Tuberculosis is a global pandemic accounting for 9.2 million new cases and approximately 2 million deaths annually. Tuberculomata of the brain are a common feature of Intracranial tuberculosis. In the past the diagnosis was based on the evidence of active tuberculosis, elsewhere in the body, characteristic Cerebrospinal fluid (CSF) findings, a biopsy of necropsy. CSF findings would be equivocal in the absence of meningeal involvement. In India, its incidence is 12 to 30% of all intra-cranial space occupying lesions. The material consisted of 1000 patients who were admitted during the two year period, presenting with clinical features of headache vomiting, or focal/generalized seizures. These patients belonged to the acute medical care unit and pediatric Medical Units of a tertiary care hospiatl in South India. This study is a retrospective one and only those cases who had their Computerized Tomography (CT) scan of head and brain done were included. A total of 276 patients with definite CT findings of tuberculoma were analyzed for their age, and sex incidence, numbers, size and site of correlated with the clinical presenting features, duration of illness, CT morphology. A definite pattern of CT morphology of tuberculomata was seen, small sized lesions were the commonest 61 % , medium size lesions 30 % large size lesions 9 % . Shape: Ring and disc lesions 79 % irregular ball like nodular lesions 21 %. Number: Single lesions were the most frequent 86 % though multiple lesions were encountered in 14 % cases of our study. Site: Supratentorial involvement we noted in 96 % of patients and only 4 % infratentorial involvement was seen. The commonest site of supratentorial involvement of brain by tuberculoma was the parietal lobes. The advent of CT has definitely helped in the early diagnosis of intracranial tuberculomata. It is cost effective and currently available even at the district headquarter level, and is therefore effective in isolating tuberculomata cases from other intracranial space occupying lesions by its typical CT morphology unsuspected cases are coming to light who and are amenable to medical treatment if diagnosed at the earliest by the help of CT.

A Controlled Quality Improvement Trial to Reduce the Use of Physical Restraints in Older Hospitalized Adults

To implement and evaluate an evidence-informed multicomponent strategy to reduce physical restraint use in older adults admitted to acute care medical units. Stepped-wedge trial. Four acute care medical units in Calgary, Alberta, over a 4-month time period. Data were collected from individuals aged 65 and older present on the study units during monthly restraint audits. Development of opinion leaders among the nursing leadership, education and training of physicians and unit nurses, and implementation of least restraint rounds. The primary outcome was rate of restraint use as determined from walk-around audits. Secondary outcomes included number of physician orders for physical restraints on the electronic medical record and fall reports. Thirteen percent to 27% of individuals were being restrained on the medical units before the intervention, with the vast majority of restraints being bed rails. This decreased to 7% to 14% after the intervention. The intervention resulted in a statistically significant reduction in restraint use measured in the early mornings (P = .01), and this trend continued after adjusting for unit and month (P = .06). Similarly, the rate of restraint use trended down at all other measured time periods but was not statistically significant. A limited number of individuals had an order for physical restraint within their electronic medical record (3% before, 2% after the intervention). The median number of monthly fall reports did not change (three before, three after; P = .60). A multicomponent team-focused quality improvement intervention has the potential to decrease the use of physical restraints in older hospitalized adults.

A Quality Improvement Initiative to Achieve High Nursing Presence During Patient- and Family-Centered Rounds

The objectives of this study were to: (1) identify local barriers to nursing presence on patient- and family-centered rounds (PFCR); and (2) increase nursing attendance during PFCR. An electronic survey needs assessment was administered to nursing staff on a single acute medical care unit to identify local barriers to nursing presence on PFCR. Daily tracking of nursing presence on rounds was then performed over a 7-month period. During this time period, 2 Plan-Do-Study Act cycles were conducted. The first intervention was a workshop for nurses about PFCR. The second intervention was the development of a strategy to contact nurses by using a hands-free communication device so that nurses were notified when rounds were starting on their patients. To evaluate the impact of our interventions, a p-chart was generated for the outcome of average daily nursing attendance (%) on PFCR per week over the 7-month period. Two barriers identified on the survey were: (1) nurses were uncertain if physicians valued their input during PFCR; and (2) nurses were unsure when the physician team would be conducting rounds on their patients. On the p-chart, the average percentage of nursing attendance before interventions was 47%. After the nursing workshop, no change in the mean nursing attendance on PFCR was noted. After initiation of the hands-free contact strategy, nursing attendance on PFCR rose to 80%. A nursing contact strategy using a hands-free device led to a sustained increase in nursing attendance during PFCR.

Putting the ‘patient’ back into patient-centred care: An education perspective

Patient-centred care is a value espoused by most healthcare systems and a concept taught in nursing education programs as a fundamental concept of patient care. In this study, we focused on the patient's experience of patient-centredness, interviewing eighteen patients and eight family members about their experiences as patients on an in-patient acute care medical unit in a large hospital in Canada. Approximately half of the patients expressed satisfaction with their experiences and their involvement in decisions about their healthcare. The remainder expressed concerns about their care that jeopardized their experiences of patient-centredness. These areas concerned issues of communication with and among healthcare professionals, relationships with these care providers, trust and respect in the professional relationships, and general satisfaction with care. Participants provided advice to professional students about ways to interact more effectively with their patients to establish caring, empathetic, patient-centred relationships as the basis for care. We address patient recommendations to support learner understanding of the patient experience both in classrooms and clinical experiences throughout educational programs as a means to enhance their patient-centredness.

The development and piloting of electronic standardized measures on nursing work: combining engineering and nursing knowledge

This paper describes the development and piloting of electronic standardized measures on nursing work (e-SMNW) for rich data gathering on the work and work environment of registered nurses (RNs) and practical nurses (PNs). Efficient and valid methods are needed to measure nursing work to enhance the optimal use of the nursing workforce for safe patient care. The study combined human factors engineering (HFE) and nursing knowledge to develop electronic standardized measures for observational studies on nursing work in acute care. The work and work environment of RNs and PNs in acute care medical and surgical inpatient units was successfully measured using e-SMNW. With predetermined items of work activities and influencing factors in the work of nurses, and full use of computer technology, multi-layered rich standardized data were gathered, analysed and displayed. The combination of nursing knowledge, HFE and computer technology enables observational data collection for a rich picture of the complex work of nursing. Information collected by standardized and multi-layered measures makes it easier to identify potential improvements, with regard to influencing factors and management of the work and work environment of nurses. Further use of computer technology in health services research is encouraged.

Elderly subjects hospitalised in acute care medical unit: baseline date and on-year follow-up

To describe the elderly population hospitalized in a service of short-term care, and to follow during one year its evolution in term of dependence and of rehospitalisation. Inclusion of all the patients of more than 75 years hospitalized in the service during 5 weeks, with initial geriatric evaluation, and phone evaluation in 6 months and one year. Seventy-four patients were included, among which 57 were living at home. The mean length of stay was 11 days. In one year, 22 patients died, 23 went in institution and 29 are always in the place of residence, among which 18 with a rise of the helps. 53% of patients were rehospitalized at least once. This work allows a description, social and functional, of the patients older than 75 years, hospitalized in the service. It confirms the risk of loss of autonomy and of unplanned readmission, in the short and medium term, that a geriatric program could limit.

Evaluation of a Medical and Mental Health Unit compared with standard care for older people whose emergency admission to an acute general hospital is complicated by concurrent 'confusion': a controlled clinical trial. Acronym: TEAM: Trial of an Elderly Acute care Medical and mental health unit.

BackgroundPatients with delirium and dementia admitted to general hospitals have poor outcomes, and their carers report poor experiences. We developed an acute geriatric medical ward into a specialist Medical and Mental Health Unit over an eighteen month period. Additional specialist mental health staff were employed, other staff were trained in the 'person-centred' dementia care approach, a programme of meaningful activity was devised, the environment adapted to the needs of people with cognitive impairment, and attention given to communication with family carers. We hypothesise that patients managed on this ward will have better outcomes than those receiving standard care, and that such care will be cost-effective.Methods/designWe will perform a controlled clinical trial comparing in-patient management on a specialist Medical and Mental Health Unit with standard care. Study participants are patients over the age of 65, admitted as an emergency to a single general hospital, and identified on the Acute Medical Admissions Unit as being 'confused'. Sample size is 300 per group. The evaluation design has been adapted to accommodate pressures on bed management and patient flows. If beds are available on the specialist Unit, the clinical service allocates patients at random between the Unit and standard care on general or geriatric medical wards. Once admitted, randomised patients and their carers are invited to take part in a follow up study, and baseline data are collected. Quality of care and patient experience are assessed in a non-participant observer study. Outcomes are ascertained at a follow up home visit 90 days after randomisation, by a researcher blind to allocation. The primary outcome is days spent at home (for those admitted from home), or days spent in the same care home (if admitted from a care home). Secondary outcomes include mortality, institutionalisation, resource use, and scaled outcome measures, including quality of life, cognitive function, disability, behavioural and psychological symptoms, carer strain and carer satisfaction with hospital care. Analyses will comprise comparisons of process, outcomes and costs between the specialist unit and standard care treatment groups.Trial Registration numberClinicalTrials.gov: NCT01136148

Managing Dysphagia Through Diet Modifications

Dysphagia can lead to malnutrition, dehydration, aspiration pneumonia, and even death. The condition has diverse causes and symptoms vary widely. Nurses are likely to encounter patients with dysphagia in various settings, including acute care medical units, rehabilitation centers, and skilled nursing facilities. Dietary modification--altering the consistency of foods and liquids--is a fundamental aspect of dysphagia management. This article describes normal and impaired swallowing, discusses several types and levels of dietary modification, and offers readers a concise list of nursing considerations.

Psychosocial Profile of Elderly Patients Discharged from a Community Hospital

Social workers have historically been an advocate for vulnerable groups. One such vulnerable group is elderly patients who have been shown to have multiple, chronic health problems. The current fiscal environment favors shortened lengths of stay, potentially leaving these vulnerable patients at risk for adverse outcomes upon discharge, especially for those discharged home as opposed to institutional settings. The purpose of the study was to characterize the biopsychosocial risks for adverse outcomes in the elderly patients discharged home from Guelph General Hospital (Ontario, Canada). The objectives were to (1) estimate the number of elderly people who indicate biopsychosocial risk for adverse outcomes, (2) determine the specific risks and their severity, and (3) estimate the number of readmissions to hospital within three months after discharge. Standardized, self-reported scales were used to measure risks in elderly patients at discharge from acute care medical and surgical units. The sample included 62 patients with a mean age of 79 years. At discharge almost 40% of the patients were considered at risk for adverse outcomes, 11% indicated depression, 45% indicated psychological distress, 13% showed cognitive impairment, and 62.5% (35/56) had at least one nutritional concern. Over the three-month follow-up period, there were 23 readmissions, 8 ED visits (not mutually exclusive), and 7 outpatient visits. The mortality rate over the three-month period was 5% (3/62). Many elderly patients who were discharged from hospital to home experienced several challenges medically, psychologically and some also experienced social adversities. The implication is that these patients may benefit from a more comprehensive discharge plan than is currently practiced that addresses their challenges.

The Use of Knee-Length Versus Thigh-Length Compression Stockings and Sequential Compression Devices

Nurses on an Acute Care Evidence Based Practice Committee, creating a policy to increase patient compliance with thromboembolic deterrent stockings (TEDS) and sequential compression devices (SCDs) for deep vein thrombosis prophylaxis, found limited literature on patient preference and response to this treatment. The study purpose was to determine whether knee-length or thigh-length TEDS and/or SCDs were more comfortable, correctly applied, and worn by patients, and to assess patient reasons for noncompliance. A patient survey and observational data tool was designed. Six surveyors collected data (interrater reliability = 93%) from 137 randomly selected patients with orders for TEDS and/or SCDs admitted to acute care medical or surgical nursing units. Most patients wore thigh-length SCDs and TEDS. However, only 29.2% (n = 40) had SCDs on them at the time of survey, and 62.8% (n = 86) were compliant with TEDS. The most common reasons given for noncompliance with SCDs were that the devices were not reapplied after bathing or ambulating, or were removed because they were hot or itchy. Complaints of discomfort were highest among patients wearing thigh-length SCDs and TEDS. Problems with fit were 50% higher in those who wore thigh-length TEDS, and involved stockings that created restricting bands. Most patients understood the purpose of treatment, and older patients were more compliant than younger patients. Knee-length TEDS and SCDs are more comfortable for patients, encourage higher levels of compliance with treatment, do not pose a risk for venous stasis to patients by creating restricting bands, and are less expensive. Patients need ongoing education to resume wearing TEDS and SCDs after activities of daily living, and knee-length stockings and devices would be easier to reapply. The policy in our institution was changed for the use of knee-length compression stockings and SCDs.

Nursing advocacy in an Australian multidisciplinary context: findings on medico‐centrism

As a follow-up to a recent study which highlighted the existence of medical dominance in multi-disciplinary team (MDT) meetings, this paper presents research findings from an Australian study which shows that medico-centrism is a key cause of tension within MDTs. The findings are from a 1-year qualitative study in a regional hospital that explored the ethical decision-making of health professionals within an acute care medical unit. This exploration was conducted through an iterative, phenomenological, qualitative research methodology that consisted of open-ended interviews with a multi-disciplinary representation of health professionals and a sample of consumers for whom they care. The paper situates the notion of nursing advocacy within the context of medico-centrism and examines how the nursing profession interfaces with other disciplines. The findings indicate that the professional framework of nursing includes the language of advocacy, whilst the framework of doctors centres around the medical decision-making process. All professional groups made reference to the MDT as the modus operandi for patient-centred care. All participants noted that time and familiarity with patients and their families is essential for patient-centred care and this could be achieved through MDT collaboration. However, doctors who have scant time to spend with patients saw it as their responsibility to direct the decisions of the MDT and viewed the MDT as adding confusion to the decision-making process. Nurses reported that the limited amount of time spent by doctors in patient consultation translated into the need for advocacy. Professional and clinical confidence and experience are noted as necessary to successfully engage in the process of advocacy. The findings of this article indicate that the adoption of an advocacy role by nurses represents an important means through which MDT operation can be enhanced, medico-centrism limited and patient-centred care improved.

Prediction of falls using a risk assessment tool in the acute care setting.

BackgroundThe British STRATIFY tool was previously developed to predict falls in hospital. Although the tool has several strengths, certain limitations exist which may not allow generalizability to a Canadian setting. Thus, we tested the STRATIFY tool with some modification and re-weighting of items in Canadian hospitals.MethodsThis was a prospective validation cohort study in four acute care medical units of two teaching hospitals in Hamilton, Ontario. In total, 620 patients over the age of 65 years admitted during a 6-month period. Five patient characteristics found to be risk factors for falls in the British STRATIFY study were tested for predictive validity. The characteristics included history of falls, mental impairment, visual impairment, toileting, and dependency in transfers and mobility. Multivariate logistic regression was used to obtain optimal weights for the construction of a risk score. A receiver-operating characteristic curve was generated to show sensitivities and specificities for predicting falls based on different threshold scores for considering patients at high risk.ResultsInter-rater reliability for the weighted risk score indicated very good agreement (inter-class correlation coefficient = 0.78). History of falls, mental impairment, toileting difficulties, and dependency in transfer / mobility significantly predicted fallers. In the multivariate model, mental status was a significant predictor (P < 0.001) while history of falls and transfer / mobility difficulties approached significance (P = 0.089 and P = 0.077 respectively). The logistic regression model led to weights for a risk score on a 30-point scale. A risk score of 9 or more gave a sensitivity of 91% and specificity of 60% for predicting who would fall.ConclusionGood predictive validity for identifying fallers was achieved in a Canadian setting using a simple-to-obtain risk score that can easily be incorporated into practice.

Rehabilitation needs of an inpatient medical oncology unit

Movsas SB, Chang VT, Tunkel RS, Shah VV, Ryan LS, Millis SR. Rehabilitation needs of an inpatient medical oncology unit. Arch Phys Med Rehabil 2003;84:1642-6. Objective To identify prospectively functional impairments and rehabilitation needs in an acute care medical oncology unit. Design Prospective cohort study. Setting Inpatient medical oncology unit at a Veterans Affairs hospital. Participants Fifty-five patients admitted over a 6-month period. Interventions Not applicable. Main outcome measures FIM™ instrument, functionally based physical examination, Rehabilitation Needs Assessment, and Recreational Needs Assessment. Results On admission, the mean FIM total score was 105 out of 126, the FIM motor score was 72 out of 91, and the FIM cognitive score was 34 out of 35. The functionally based physical examination did not generally correlate with scores obtained on the FIM. Forty-eight (87%) patients had rehabilitation needs on admission. Forty-six (84%) patients had rehabilitation needs on discharge. Rehabilitation Needs Assessment on admission showed deconditioning in 42 (76%) patients; mobility impairment in 32 (58%) patients; a significant decrease in range of motion in 23 (42%) patients; deficits in activities of daily living in 12 (22%) patients; a need for recreational therapy in 7 (13%) patients; potential for benefit from patient education in 30 (55%) patients; and a need for modalities, edema control, or wound care in fever than 5% of patients. The most commonly requested recreational activity was reading. Conclusions Patients admitted to inpatient medical oncology units have many unmet, remediable rehabilitation needs that may not be recognized by nonrehabilitation physicians and other clinical staff. These findings suggest that assessment of medical oncology patients may be enhanced by consultation with rehabilitation medicine specialists.