Health Care Provider’s’ Opinions on Communication Between Nursing Homes and Emergency Departments.
Gillespie SM, Gleason LJ, et al: JOURNAL OF THE AMERICAN MEDICAL DIRECTORS ASSOCIATION 2010; 11 (MARCH): 204-210
Objectives: To characterize the beliefs and opinions of nursing home (NH) and emergency medicine providers about communication between NH and emergency departments (ED) during transitions of care of NH residents.
Participants: Physicians, nurse practitioners, physicians assistants, and nurses who practice in ED settings and NH settings, affiliated with hospitals of an academic medical center in Rochester, New York.
Measurements: Opinions on communication; beliefs about frequency of information transmission; opinions on how often verbal communication should occur.
Results: A total of 155 nurses and medical providers participated in the survey for a response rate of 32.2% (155/481). Of the survey participants, 63.0% and 56.8% had been more than 5 years in their position and facility, respectively. Most respondents felt that important information was lost during patient transfers between NH and ED settings. Providers from ED and NH settings had different opinions on the likelihood that key information would be readily identifiable at patient transfer and that care would include requested tests and follow-up. Providers from both sites of care supported verbal communication at their position when NH residents are transferred to the other setting.
Conclusion: Nurses and medical providers from both emergency and NH settings agree that transitional communication is poor between NHs and EDs and support a role for verbal communication during the ED transitions of care of NH residents.
Kevin’s comments: A major issue in the care of older adults is care transitions—moving from one environment of care to another. Some of the problems related to care transitions include wrong treatment, adverse medication events, delay in diagnosis, increased length of hospitalization, re-hospitalizations, and increased health care costs. There are several barriers to effective care transitions. Health care is often delivered in "silos" with little effective communication between one care setting and another. The trend toward institution-based specialists (e.g., hospitalists) means that no one health care provider is accountable for the patient’s care in different settings. Nursing staff shortages create time pressures that lead to inaccurate documentation of medical conditions and medications. Patients may not feel empowered to provide input regarding their plan of care.
Poor communication is the main cause of poor transitions between nursing homes and emergency departments. Ten percent of nursing home patients arrive without any documentation whatever. The remaining 90% of nursing home to emergency room transfers are often missing critical information such as the reason for the transfer, the medication list, and the usual cognitive status. This works both ways, as nursing homes often receive patients back from the emergency room with no diagnosis recorded and no information on tests or treatments. Improving care transitions has recently been identified as a 2009 National Patient Safety Goal by the Joint Commission. Many organizations are focusing on care transitions including the American Geriatrics Society, the American Medical Directors Association, the Society of Hospital Medicine, and the National Transitions of Care Coalition. It would seem in our high-tech society that moving information seamlessly between one venue of care and another should be relatively easy. However, implementation of electronic health information systems has been hindered by lack of interoperability, diverse provider and caregiver needs, privacy issues, and expense. Interestingly, direct verbal communication between providers has been identified as an essential element of high-quality transitions. Sometimes the simplest solutions are the best—just picking up the phone and providers talking to each other is one of the best ways of communicating vital information. A real person talking live with another real person—what a concept!
Serum Lipid Levels and Cognitive Change in Late Life.
Reynolds CA, Gatz M, et al: JOURNAL OF THE AMERICAN GERIATRICS SOCIETY; 2010; 58 (MARCH): 501-509
Objective: To assess the effect of lipids and lipoproteins on longitudinal cognitive performance and cognitive health in late life and to consider moderating factors such as age and sex that may clarify conflicting prior evidence.
Participants/Methods: Eight hundred nineteen adults from the Swedish Adoption Twin Study of Aging aged 50 and older at first cognitive testing, including 21 twin pairs discordant for dementia.
Measurements: Up to five occasions of cognitive measurements encompassing verbal, spatial, memory, and perceptual speed domains across a 16-year span; baseline serum lipids and lipoproteins including high-density lipoprotein cholesterol (HDL-C), apolipoprotein (apo)A1, apoB, total serum cholesterol, and triglycerides.
Results: The effect of lipids on cognitive change was most evident before age 65. In women, higher HDL-C and lower apoB and triglycerides predicted better maintenance of cognitive abilities, particularly verbal ability and perceptual speed, than age. Lipid values were less predictive of cognitive trajectories in men and, where observed, were in the contrary direction (i.e., higher total cholesterol and apoB values predicted better perceptual speed performance though faster rates of decline). In twin pairs discordant for dementia, higher total cholesterol and apoB levels were observed in the twin who subsequently developed dementia.
Conclusions: High lipid levels may constitute a more important risk factor for cognitive health before age 65 than after. Findings for women are consistent with clinical recommendations, whereas for men, the findings correspond with earlier age-associated shifts in lipid profiles and the importance of lipid homeostasis to cognitive health.
Kevin’s Comments: More and more attention has focused on the role of vascular risk factors in the development of dementia in later life. We now know that risk factors for heart disease such as hypertension, diabetes, cigarette smoking, elevated blood cholesterol and triglycerides also significantly increase the risk for Alzheimer’s disease and vascular dementia. Since the clinical manifestations of dementia takes years to develop, our attention needs to be focused very early in our lives on lifestyle factors that can reduce risk. This 16-year longitudinal study suggests that high lipid levels before age 65 signifies more risk for cognitive decline than after the age of 65. The sooner we make these lifestyle modifications the better for our brain (and heart!) health later on.
Dr. Kevin O’Neil is the Medical Director for Brookdale Senior Living Inc., the largest senior housing provider in the United States. He is board certified in both Internal Medicine and Geriatric Medicine. Dr.O’Neil is also a Fellow of the American College of Physicians and amember of the American Geriatrics Society as well as being a member of the American Medical Directors Association and a certified medical director.
NOTE: Brookdale associates who serve as nurses, therapists, lifestyle directors or on a community dining team are invited to submit questions for Geriatric News You Can Use directly to GeriatricNews@brookdaleliving.com.
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