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With Support from The Donald W. Reynolds Foundation and The John A. Hartford Foundation © The University of North Carolina at Chapel Hill, Center for Aging.

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Presentation on theme: "With Support from The Donald W. Reynolds Foundation and The John A. Hartford Foundation © The University of North Carolina at Chapel Hill, Center for Aging."— Presentation transcript:

1 With Support from The Donald W. Reynolds Foundation and The John A. Hartford Foundation © The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved. Christine M. Khandelwal, DO Kevin Biese, MD, MAT Ellen Roberts, PhD, MPH Jan Busby-Whitehead, MD The University of North Carolina at Chapel Hill

2 Learning Objectives Learners will be able to list the most common types of iatrogenic injuries. Learners will be able to identify the most common cause of nosocomial fever in the hospital. Learners will be able to identify the reasons for use of restraints and how to avoid using them. Learners will be able to list the appropriate use of urinary catheters. 2

3 The Case of Mrs. TW Mrs. TW is a 79yo female with history of HTN, MCI, and urge incontinence, who was admitted for a pneumonia. She is stable on admission and sent to the floor with a foley catheter in-place. Mrs. TW has an uneventful 24 hours, clinically stable and doing well with plans for discharge the next morning to home. 3 Copyright © 2011 Lighthouse InternationalAll rights reserved.

4 BACKGROUND Cascade iatrogenesis is a series of adverse events triggered by an initial medical or nursing intervention initiating a cascade of decline. »Occurs most frequently among the oldest, most functionally impaired patients and those with a higher severity of illness upon admission. Creditor 1993, Hofer 2002, Thomas 2000 4

5 BACKGROUND 5 Hospitalization for the elderly is often followed by an irreversible decline in functional status and a change in quality and style of life.  Elders are at high risk for poor outcome  High 1 year mortality  Thirty percent (30%) functional decline  High rates of skilled nursing facility placement Creditor 1993, Hofer 2002, Thomas 2000

6 Iatrogenesis in Older Patients Age-related factors that predispose the older patient to iatrogenesis More co-morbid, chronic medical conditions that require more diagnostic procedures and medications Increased severity of illness and complexity of care Longer length of stay Hofer 2002, Thomas 2000 6

7 Elderly Are the Most Likely to Suffer… Adverse Drug Events Delirium Nosocomial Infections Falls Procedural/Surgical Complications 7

8 Adverse Drug Events Most common type of iatrogenic injury Predictors »> 4 meds »LOS > 14 days »> 4 active medical problems # of drugs is the strongest predictor; potential for interaction: 2 drugs 6%, 5 drugs 50%, ≥ 8 drugs nearly 100% 70-80% of ADEs in the elderly are dose related 30-50% preventable! Carbonin P et al. 1991 8

9 Adverse Drug Events 9 Other ADE Predictors:  Multiple medical problems  Multiple medications  New medications added  Low weight, female gender, impaired creatinine clearance Carbonin 1991;Thomas and Brennen BMJ 2000

10 Adverse Drug Events Common DrugsCommon Effects AnticholinergicsMental Status PsychotropicsUrinary Complications SleepersInfections NarcoticsGastrointestinal DigoxinFalls Anti-hypertensives 10

11 The Case of Mrs. TW Twenty four hours after admission, nursing staff call to report that Mrs. TW is “yelling out and trying to catch the butterfly in the hall.” With further report from the nurse, the patient has a fever. Staff is requesting to keep Mrs. TW “quiet tonight” as they are short-staffed and will not be able to control her tonight. What is the source of her fever? Could this have been prevented? 11 Copyright © 2011 Lighthouse InternationalAll rights reserved.

12 Delirium Delirium is one of the most common iatrogenic complications in hospitalized elders affecting 50% or more post-operative hip fracture and thoracic surgery patients over age 65. We don’t diagnose it! Elie 1998, Ely 2004, Inouye 1996, Inouye 2006, Pompei 1994 12

13 13 Risk Factors for Delirium Age ≥ 70 years Existing cognitive impairment Functional impairment Alcohol abuse Abnormal preoperative level of sodium, potassium or glucose Preoperative psychotropic drug use Depression Increased comorbidity Living in a long-term care facility Visual or hearing impairment

14 Preventing Delirium At least 3 clinical trials suggest that minimizing risk factors in hospital can reduce delirium: »Management of six risk factors for delirium (cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration) reduced the number and duration of episodes of delirium ( Inouye, S.K., 1998) Inouye 1999, Marcantonio 2001, Millsen 2001 14

15 15 Preventing Delirium »Geriatrics consultation reduced delirium in the acute hospital management of hip-fracture patients ( Marcantonio, E.R., 2001) »A nurse-led interdisciplinary intervention program for delirium led to shorter duration and less severe delirium ( Millisen, K., 2001)

16 Treatment for Delirium Almost no drug studies of established delirium Most experts would use traditional or atypical antipsychotic agents in low dose for agitated delirium treatment »What about anticholinesterase inhibitors? ( Donepezil use in the prevention and treatment of post- surgical delirium did not prevent delirium.) Liptzin 2005, Sampson 2007 16

17 Nosocomial Infections Infections are usually related to a procedure or treatment used to diagnose or treat the patient’s initial illness or injury 36% of these are preventable! 17  UTIs  Pneumonia  Surgical wound infections  Clostridium difficile colitis

18 Urinary Catheters 25% of hospitalized pts have indwelling catheter Associated with  LOS,  inpatient mortality Inappropriate for over 50% of inpatient days Uncomfortable / Restrictive Jain 1995, Saint 1999 18

19 Urinary Catheters Catheter-associated urinary tract infections (CAUTIs) represent the most common nosocomial infection, accounting for 40% of all hospital-acquired infections. Foley catheters are commonly placed without a compelling indication, and are a preventable cause of hospital-acquired infections. Saint 2000, Saint 2002 19

20 Indications for Urinary Catheterization Output monitoring of unstable patients Complete urinary retention Urinary incontinence in patients with wounds or skin defects Urinary incontinence in general is not an indication for catheterization, but it may be considered for patient comfort at the request of the patient or family Terminally ill patients Perioperative use 20

21 If Not a Foley…What Instead? Prevention and Treatment – »Plan may include reviewing medications (opiates, anti-cholingerics, diuretics, alpha- adrenergic agonists, calcium-channel blockers are offenders) »Treat UTI (contributes to urge incontinence) »Treat constipation »Seek any reversible causes of delirium »Regular toileting schedule 21

22 The Case of Mrs. TW Wrist restraints were placed on Mrs. TW to help maintain her delirium tonight. Three hours later, nursing staff calls you to report a fall for Mrs. TW. You order a stat hip x-ray and an acute fracture is found. What was the cascade of events? Could any of this been prevented? 22 Copyright © 2011 Lighthouse InternationalAll rights reserved.

23 Why are Restraints Used? Prevent falls Prevent injuries Prevent treatment disruption Manage confusion AGS Positional statement 2008, Tzeng 2008, Antonelli 2008 23

24 AGS Positional Statement: Restraints are acceptable to use: If there is no safer alternative If patient is at significant risk of self-harm or injury to others At the patient's request Short-term use to enable emergent treatment that may result in a less confused patient 24 American Geriatrics Society, AGS Position statement: Restraint use. 2008

25 To Restrain or Not to Restrain… 25 Restraints are associated with:  increased rates of pressure sores  increased incidence of nonsocomial infections  distress  falls American Geriatrics Society, AGS Position statement: Restraint use. 2008

26 If Not a Restraint…What Instead? Non-pharmacological »Cognitive » ◦ Orientation (calendar, caregiver names) » ◦ Activities (cognitively stimulating) »Sleep ◦ Regular routine ◦ Sleep aids (relaxing music, massage) ◦Environmental (eliminate noise, night-time meds) »Mobility (range of motion, limit IV’s, etc) »Visual Aids (glasses, large dial phones) »Hearing Aids (check ear wax) »Volume repletion for dehydration Inouye 1999 26

27 Pharmacologic Treatment No medication is FDA approved for the treatment of delirium No published double-blind, randomized, placebo controlled trials »◦ Few controlled trials »◦ Small numbers »◦ Various patient populations  post-op, ICU, cancer, AIDS, hip fractures Slide from Rachelle Bernacki MD Bree Johnston MD Division of Geriatrics University of California San Francisco and San Francisco, VA Medical Center 27

28 Reduce Falls Reduce restraint use / lower bed rails Prevent delirium Sensor alarms Lower the bed Non-slip shoes Remove obstacles Commode / toilet schedule Gillespie 1997, Myers 2003, Currie 2006 28

29 Falls Falls frequently occur in hospitals, and the patients most likely to fall are older patients Approximately 2% to 12% of patients experience at least one fall during their hospital stay These complications often result in a longer length of stay and lead to greater healthcare costs Chelly 2008, Bates 1995, Alexander 1992 29

30 Fall Risks Visual impairment Hypotension / anti-hypertensives Anticholinergics / sedative-hypnotics Obstacles / slick surfaces Elevated bed height Confinement ….restraints! Gillespie 1997, Myers 2003 30

31 Fall Prevention Strategies Unfortunately, there are no specific recommendations to reduce the risk for falls in the acute care setting. However, some fall prevention strategies in the literature appear to offer an overwhelming reduction in the incidence of falls among hospitalized elderly patients. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention 2011 31

32 Fall Prevention Strategies Frequent and varied staff education and re- education to promote and sustain sensitivity to the risk for falls among hospitalized elders. Tools to assess risk for falls. Because most patients' fall risks are multifactorial and the factors are intertwined, the most effective strategies will be interdisciplinary. The use of "sitters" for confused patients. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention 2011 32

33 Conclusion Avoidance of unnecessary Foley catheter placement is an important method to reduce nosocomial infections. Immobilizing patients during hospitalization is contrary to therapeutic goals of restoring normal mobility and function as quickly as possible. The number and severity of falls can be reduced by adopting quality improvement strategies, relevant and practical fall risk assessment tools, and staff education. 33

34 Acknowledgements and Disclaimer This project was supported by funds from The Donald W. Reynolds Foundation, the American Geriatrics Society/The John A. Hartford Foundation Geriatrics for Specialists Grant. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by The Donald W. Reynolds Foundation, the American Geriatrics Society or The John A. Hartford Foundation. The UNC Center for Aging and Health, the UNC Division of Geriatric Medicine, the UNC Department of Emergency Medicine, and the UNC Department of Family Medicine also provided support for this activity. This work was compiled and edited through the efforts of Carol Julian. 34

35 REFERENCES 1.Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. Am J Public Health 1992;82:1020–1030. 2.American Geriatrics Society. AGS position statement: restraint use. 2008; 3.American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc. 2011;49:664-672. 4.Antonelli MT. Restraint management: moving from outcome to process. J Nurs Care Qual. Jul-Sep 2008;23(3) 227-232. 5.Bates DW, Pruess K, Souney P et al. Serious falls in hospitalized patients: Correlates and resource utilization. Am J Med 1995;99:137–143. 6.Carbonin P, Pahor M, Bernabei R, Sgadari A. Is age an independent risk factor of adverse drug reactions in hospitalized medical patients? J Am Geriatr Soc 1991;39(11):1093-9. 7.Chelly, JE, Conroy L, Miller, Gregory E, Marc N, Horne JL, Hudson, ME. Risk Factors and Injury Associated With Falls in Elderly Hospitalized Patients in a Community Hospital J Am Geriatr Soc 56:29–36, 2008. 8.Creditor, MJ. Hazards of hospitalization of the elderly. Annals of Internal Medicine. 1993;118:219-223. 9.Currie LM. Fall and injury prevention. Annu Rev Nurs Res. 2006;24:39-74. 10.Dasgupta M, Dumbrell AC. Preoperative risk assessment for delirium after noncardiac surgery: a systematic review. J Am Geriatr Soc. 2006;54:1578-89. 11.Elie, M., Cole, M. G., Primeau, F. J., & Bellavance, F. (1998). Delirium risk factors in elderly hospitalized patients. Journal of General Internal Medicine, 13, 204–212. Evidence Level I: Systematic Review. 12.Ely, E. W., Shintani, A., Truman, B., Speroff, T., Gordon, S. M., Harrell, F. E., Jr., et al. (2004). Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. Journal of the American Medical Association, 291, 1753–1762. 13.Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing falls in elderly people. Cochr Database Syst Rev. 1997;CD000340. 14.Hofer, TF, Hayward, RA. Are bad outcomes from questional clinical decisions preventable medical errors? A case of cascade iatrogenesis. Part 1. Annals of Internal Medicine. 2002;137. 15.Inouye, SK (2006). Delirium in older persons. New England Journal of Medicine, 354, 1157-1165. Evidence Level VI: Expert Opinion. 16.Inouye, SK, Bogardus, SK, Charpentier PA, Leo-summers L, Acampora, D, Holford, TR, Cooney LM. A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patient. N Engl J Med 1999; 341- 369-370.

36 REFERENCES 16.Inouye, S. K., & Charpentier, P. A. (1996). Precipitating factors for delirium in hospitalized elderly persons: Predictive model and interrelationship with baseline vulnerability. Journal of AMA, 275, 852–857. 17.Jain P JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Int Med. 1995; 155:1425-1429. 18.JK, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med. 2000;109:476-480. 19.Liptzin B, Laki A, Garb JL, et al. Donepezil in the prevention and treatment of post-surgical delirium. Am J Geriatric Psychiatry 2005; 13:1100-6. 20.Marcantonio E.R., Flacker J.M., Wright R.J. & Resnick N.M. Reducing delirium after hip fracture: a randomized trial. Jol of the Am Geriatrics Society 2001.49, 546-522. 21.Millisen K., Foreman M.D., Abraham I.L., De Geest S., Godderis J., Vandermeulen E., Fischier B., Delooz H.H., Spessens B. & Broos P.L. A nurse-led interdisciplinary intervention program for delirium in elderly hip- fracture patients. Jo of the Am Geriatrics Society 2001.49, 516-522. 22.Myers H, Nikoletti S. Fall risk assessment: a prospective investigation of nurses' clinical judgement and risk assessment tools in predicting patient falls. Int J Nurs Pract. 2003;9:158-16. 23.Pompei, P., Foreman, M., Rudberg, M. A., Inouye, S. K., Braund, V., & Cassel, C. K. (1994). Delirium in hospitalized older persons: Outcomes and predictors. J of the Am Geriatrics Society, 42, 809–815. 24.Saint S LB, Goold SD. Urinary catheters: A one-point restraint? Ann Int Med. 2002;137:125-127. 25.Saint S LB. Preventing catheter-related bacteriuria: Should we? Can we? How? Arch Int Med.1999;159:800- 808. 26.Saint S, Wiese J, Amory JK, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med. 2000;109:476-480. 27.Sampson ELA randomized, double-blind, placebo-controlled trial of donepezil hydrochloride (Aricept) for reducing the incidence of postoperative delirium after elective total hip replacement..Int J Geriatr Psychiatry. 2007;4:343-9. 28.Scott V, Votova K, Scanlan A, Close J. Multifactorial and functional mobility assessment tools for fall risk among older adults in community, home-support, long-term and acute care settings. Age Ageing. 2007;36:130-139. 29.Thomas E, Brennen T. Incidence and types of preventable adverse events in elderly patients: Population based review of medical records. British Medical Journal, 2000, 320, 741-744. 27. Tzeng HM, Yin CY, Grunawalt J. Effective assessment of use of sitters by nurses in inpatient care settings. J Adv Nurs. Oct 2008;64(2):176-183. 28. Vassallo M, Poynter L, Sharma JC, Kwan J, Allen SC. Fall risk-assessment tools compared with clinical judgment: an evaluation in a rehabilitation ward. Age Ageing. 2008;37:277-281

37 © The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved.

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