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Avoidability of Hospital Transfers of Nursing Home Residents: Perspectives of Frontline Staff Lamb G, Tappen R, et al.The Journal of the American Geriatrics Society: published online - August 24, 2011
OBJECTIVES: To describe nursing home (NH) staff perceptions of avoidability of hospital transfers of NH residents.
DESIGN: Mixed methods qualitative and quantitative analysis of 1,347 quality improvement (QI) review tools completed by staff at 26 NHs and transcripts of conference calls.
SETTING: Twenty-six NHs in three states participating in the Interventions to Reduce Acute Care Transfers (INTERACT II) QI project.
PARTICIPANTS: Site coordinators and staff who participated in project orientation and conference calls and completed QI tools.
MEASUREMENTS: NH and hospitalization data collected for the INTERACT II project. An interprofessional team coded and quantified reasons for hospital transfer on 1,347 QI review tools.
RESULTS: Staff rated 76% of the transfers in the QI review tools as not avoidable. Common reasons for transfers rated as unavoidable were acute change in resident status, family insistence, and physician order for transfer. These same reasons were given for transfers rated as avoidable.
Avoidable ratings were associated with a broader set of reasons and recommendations for improvement, including earlier identification and management of changes in clinical status, earlier discussion with family members about advance directives, and more-comprehensive communication with physicians.
NHs that were more actively engaged in the INTERACT II interventions rated more transfers as avoidable. Percentage of transfers rated avoidable was not correlated with change in hospitalization rates.
CONCLUSION: NH staff rated fewer hospital transfers as avoidable than published estimates. Greater attention to the complex array of reasons that staff provide for hospital transfer should be considered in strategies to reduce avoidable hospitalizations of NH residents. J Am Geriatr Soc 2011.
Kevin’s Comments: Previous research has demonstrated that a substantial number of transfers from nursing homes to hospitals are potentially avoidable. However, in this study nursing home staff felt that a substantial number of these transfers were unavoidable. The most common reasons cited were a sudden change in the resident’s condition, the insistence of the family, and the doctor ordering the transfer.
This suggests several areas on which to focus for quality improvement and reducing unnecessary transfers. Staff training to identify changes in condition promptly so that appropriate interventions can be initiated early may stabilize the resident so that transfer may be avoided. Early and effective communication with health care providers is essential.
Timely onsite evaluation by a physician, nurse practitioner, or physician assistants could likely reduce the number of residents transferred to emergency rooms for evaluation. Advance directives are best discussed before there is a crisis.
Many hospital transfers from nursing homes could likely be avoided if candid conversations occurred earlier with the resident and family regarding prognosis, quality of life, and the benefits versus risks of medical interventions.
Psychoactive Medications and Crash Involvement Requiring Hospitalization for Older Drivers: A Population-Based Study Meuleners LB, Duke J, et al. The Journal of the American Geriatrics Society: published online August 24, 2011
OBJECTIVES: To determine the association between psychoactive medications and crash risk in drivers aged 60 and older.
DESIGN: Retrospective population-based case-crossover study.
SETTING: A database study that linked the Western Australian Hospital Morbidity Data System and the Pharmaceutical Benefits Scheme.
PARTICIPANTS: Six hundred sixteen individuals aged 60 and older who were hospitalized as the result of a motor vehicle crash between 2002 and 2008 in Western Australia.
MEASUREMENTS: Hospitalization after a motor vehicle crash.
RESULTS: Greater risk for a hospitalization crash was found for older drivers prescribed benzodiazepines (odds ratio (OR)55.3, 95% confidence interval (CI)53.6–7.8, Po.001), antidepressants (OR51.8, 95% CI51.0–3.3, P5.04), and opioid analgesics (OR51.5, 95% CI51.0–2.3, P5.05). Crash risk was significantly greater in men prescribed a benzodiazepine (OR56.2, 95% CI53.2–12.2, Po.001) or an antidepressant (OR52.7, 95% CI51.1–6.9, P5.03).Women prescribed benzodiazepines (OR54.9, 95% CI53.1–7.8, Po.001) or opioid analgesics (OR51.8, 95% CI51.1–3.0, P5.03) also had a significantly greater crash risk. Subgroup analyses further suggested that drivers with (OR54.0, 95% CI52.9–8.1, Po.001) and without (OR56.0, 95% CI53.8–9.5, Po.001) a chronic condition who were prescribed benzodiazepines were at greater crash risk. Drivers with a chronic condition taking antidepressants (OR53.4, 95% CI51.3–8.5, P5.01) also had a greater crash risk.
CONCLUSION: Psychoactive medication usage was associated with greater risk of a motor vehicle crash requiring hospitalization in older drivers.
Kevin’s Comments: Aging is associated with physical changes that may affect driving ability. Aging of the eye may be associated with cataracts, macular degeneration, and glaucoma. Hearing loss may make it difficult to appreciate sirens. Arthritis and Parkinson’s disease may affect the ability to turn the wheel or look around.
Damage to peripheral nerves from diabetes can impair sensations in the feet and affect the ability to feel the gas or brake pedals. In additions, many medicines may have effects on driving performance. Antianxiety drugs, sleeping pills, and some antidepressants cause drowsiness. Similar problems can occur with antihistamines and pain relievers. Drug metabolism is altered with aging.
Thus, the effects of drugs on the body and mind may be heightened. This study from Australia demonstrated that sedative drugs in the benzodiazepine class and antidepressant medications were associated with a higher crash risk requiring hospitalization in older drivers.
Fall Prevention and Monitoring of Assisted Living Patients: An Exploratory Study of Physician Perspectives Nyrop KA, Zimmerman S, et al. The Journal of the American Medical Directors Association: Published online, September 2011
(Affiliations School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC)
Objective: Explore physician perspectives on their involvement in fall prevention and monitoring for residential care/assisted living (RC/AL) residents
Design: Exploratory cross-sectional study; mailed questionnaire.
Setting: Four RC/AL communities, North Carolina.
Participants: Primary physicians for RC/AL residents.
Measurements: Past Behavior and future Intentions of physicians with regard to (1) fall risk assessment and (2) collaboration with RC/AL staff to reduce falls and fall risks among RC/AL residents were explored using Theory of Planned Behavior (TPB) constructs. Predictor variables examined (1) physicians’ views on their own responsibilities (Attitude), (2) their views of expectations from important referent groups (Subjective Norms), and (3) perceived constraints on engaging in fall prevention and monitoring(Perceived Behavioral Control).
Results: Physicians reported conducting fall risk assessments of 47% of RC/AL patients and collaborating with RC/AL staff to reduce fall risks for 36% of RC/AL patients (Behavior). These proportions increased to 75% and 62%, respectively, for future Intentions. TPB-based models explained approximately 60% of the variance in self-reported Behavior and Intentions. Physician’s involvement in fall prevention and monitoring was significantly associated (P < .05) with their perceptions of barriers and facilitators—ease, time, reimbursement, and expertise.
Conclusion: This study provides first data on physician beliefs regarding their involvement in fall risk assessment of RC/AL patients and collaboration with RC/AL staff to reduce fall risks of individual patients. Challenges to physician involvement identified in our study are not unique or specific to the RC/AL setting, and instead relate to clinical practice and reimbursement constraints in general.
Kevin’s Comments: Falls and balance problems are among the most common and serious impairments facing older people. Falls are the leading cause not only for injury-related visits to emergency rooms in the United States but also for accidental deaths among people aged 75 years and older. In the United States, 75% of deaths due to falls occur in the 13% of the population aged 65 and over.
Falls are also responsible for appreciable disability due to fractures, impaired mobility, and fear of falling. Falls are often a major reason for admission to long-term care facilities. It is estimated that about one-third of adults over age 65 fall and one-half of those over age 80 fall annually. The numbers are even higher for those residing in assisted living and nursing home settings. Seldom is there one reason for a person to fall, and therefore a thorough assessment requires a very detailed history of the circumstances of a fall.
Evaluating the medications being taken, any acute or chronic medical conditions, and mobility level is essential. The physical examination focuses on gait and balance, musculoskeletal system, heart, nervous system, and vision. An assessment of the home environment by an occupational therapist is very worthwhile. The evaluation might detect multiple contributors to the fall, including gait and balance abnormalities.
Specific treatment for each contribution should be considered. This assessment and intervention approach has produced many important benefits, such as improved survival and function, reduced health care utilization and costs, and greater patient satisfaction.
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