Aug 272014
 
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The Relationship Between a Chief Complaint of "Altered Mental Status" and Delirium in Older Emergency Department Patients.

Acad Emerg Med. 2014 Aug 24;

Authors: Han JH, Schnelle JF, Ely EW

Abstract
BACKGROUND: Altered mental status is a common chief complaint among older emergency department (ED) patients. Patients with this chief complaint are likely delirious, but to the authors' knowledge, this relationship has not been well characterized. Additionally, health care providers frequently ascribe "altered mental status" to other causes, such as dementia, psychosis, or depression.
OBJECTIVES: The objective was to determine the relationship between altered mental status as a chief complaint and delirium.
METHODS: This was a secondary analysis of a cross-sectional study designed to validate three brief delirium assessments, conducted from July 2009 to March 2012. English-speaking patients who were 65 years or older and in the ED for <12 hours were included. Patients who were comatose or nonverbal or unable to follow simple commands prior to the acute illness were excluded. Chief complaints were obtained from the ED nurse triage assessment. The reference standard for delirium was a comprehensive psychiatrist assessment using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. Sensitivity, specificity, positive likelihood ratio (LR), and negative LR with their 95% confidence intervals (CIs) were calculated using the psychiatrist's assessment as the reference standard.
RESULTS: A total of 406 patients were enrolled. The median age was 73.5 years old (interquartile range [IQR] = 69 to 80 years), 202 (49.8%) were female, 57 (14.0%) were nonwhite race, and 50 (12.3%) had delirium. Twenty-three (5.7%) of the cohort had chief complaints of altered mental status. The presence of this chief complaint was 38.0% sensitive (95% CI = 25.9% to 51.9%) and 98.9% specific (95% CI = 97.2% to 99.6%). The negative LR was 0.63 (95% CI = 0.50 to 0.78), and the positive LR was 33.82 (95% CI = 11.99 to 95.38).
CONCLUSIONS: The absence of a chief complaint of altered mental status should not reassure the clinician that delirium is absent. This syndrome will be missed unless it is actively looked for using a validated delirium assessment. However, patients with this chief complaint are highly likely to be delirious, and no additional delirium assessment is necessary.

PMID: 25154589 [PubMed - as supplied by publisher]

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Aug 272014
 
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Use of Echocardiography to Identify Appropriate Placement of a Central Venous Catheter Wire in the Vena Cava Prior to Cannulation.

Acad Emerg Med. 2014 Aug 25;

Authors: Avila JO, Smith BC, Seaberg DC

Abstract
Ultrasound guidance is now the standard of care when placing a central venous catheter (CVC), resulting in decreased complications and increased first-pass success rates. However, even with ultrasound guidance being used for the initial venipuncture, misplacement of a CVC in either an unwanted vein or in an artery still occurs. Here, we discuss a simple technique to assist in the adequate placement of the CVC in the vena cava using bedside echocardiography.

PMID: 25156809 [PubMed - as supplied by publisher]

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Aug 272014
 
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Use of potentially inappropriate medications in hospitalized elderly at a teaching hospital: a comparison between Beers 2003 and 2012 criteria.

Indian J Pharmacol. 2013 Nov-Dec;45(6):603-7

Authors: Momin TG, Pandya RN, Rana DA, Patel VJ

Abstract
OBJECTIVES: To detect the prevalence and pattern of use of Potentially inappropriate medications (PIMs) in hospitalized elderly patients of a tertiary care teaching hospital using Beers 2012 criteria and to compare the same with Beers 2003 criteria.
MATERIALS AND METHODS: Prescriptions of the elderly patients aged 65 years and above were collected from the medicine ward and analyzed. PIMs were identified with help of Beers 2003 and Beers 2012 criteria and comparison was made between the two criteria. Predictors associated with use of PIM were identified using bivariate and multivariate logistic regression analysis.
RESULTS: A total of 210 patients received 2,267 drugs. According to Beers 2003 criteria, 60 (28.57%) elderly patients received at least one PIM and 2.9% drugs were prescribed inappropriately. According to Beers 2012 criteria, 84 (40%) elderly received at least one PIM while 22 (10.47%) received multiple PIMs and about 5% drugs were prescribed inappropriately. The most commonly prescribed PIM was mineral oil-liquid paraffin (30, 14.3%) followed by spironolactone (25, 11.9%), digoxin (19, 9%), and benzodiazepines (14, 6.7%). There was a significant association between the number of patients receiving more than six drugs and the use of PIMs (P < 0.01). Use of more than 10 drugs was a significant predictor for use of PIMs in the elderly.
CONCLUSION: The study shows high prevalence of prescribing PIMs in hospitalized elderly patients. Beers 2012 criteria are more effective in identifying PIMs than Beers 2003 criteria.

PMID: 24347769 [PubMed - indexed for MEDLINE]

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Aug 272014
 
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Why is your patient sedated?

Int J Health Care Qual Assur. 2014;27(4):284-92

Authors: Murphy O, King G, Callanan I, Butler MW

Abstract
PURPOSE: The purpose of this paper is to examine the recording of clinical indication for prescribed sedative/hypnotic (SH) medications in a large, acute tertiary referral hospital.
DESIGN/METHODOLOGY/APPROACH: All hospital inpatients' medications (n = 367) were audited for prescription details regarding SH medications. Medical notes were then examined for evidence of a recorded indication for such medications.
FINDINGS: SH medications were prescribed to many hospital inpatients (42.5 per cent) during admission. An indication was documented in the nursing or medical records for 24.4 per cent of patients who were prescribed such medications. Nurses rather than by doctors prescribed most SH medications (74 vs 26 per cent, respectively, p = 0.003). Some patients receiving SH medications were both over 65 and impaired in their mobility (19.2 per cent). The treatment indication was documented in 47 per cent.
PRACTICAL IMPLICATIONS: Most patients prescribed SH medications have nothing in their medical record explaining why these drugs are being used, including half of the elderly, less mobile patients. All health professionals dealing with SH medications and doctors in particular need to justify the use of such medications in the medical record. For the particularly high-risk groups where SH medications are potentially more dangerous, explicit guidance on why and how such medications are to be used must be provided by prescribers.
ORIGINALITY/VALUE: For the first time, data are presented on documentation rates for clinical indication of prescribed SH medications across a large acute hospital, and highlights significant shortcomings in practice. This study should inform other organisations of the need to be mindful of facilitating greater compliance with good prescribing practice.

PMID: 25076603 [PubMed - indexed for MEDLINE]

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Aug 272014
 
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Trends in patient perception of hospital care quality.

Int J Health Care Qual Assur. 2014;27(5):414-26

Authors: Batailler P, François P, Dang VM, Sellier E, Vittoz JP, Seigneurin A, Labarere J

Abstract
PURPOSE: The purpose of this paper is to investigate trends in patient hospital quality perceptions between 1999 and 2010.
DESIGN/METHODOLOGY/APPROACH: Original data from 11 cross-sectional surveys carried out in a French single university hospital were analyzed. Based on responses to a 29-item survey instrument, overall and subscale perception scores (range 0-10) were computed covering six key hospital care quality dimensions.
FINDINGS: Of 16,516 surveyed patients, 10,704 (64.8 percent) participated in the study. The median overall patient perception score decreased from 7.86 (25th-75th percentiles, 6.67-8.85) in 1999 to 7.82 (25th-75th percentiles, 6.67-8.74) in 2010 (p for trend < 0.001). A decreasing trend was observed for the living arrangement subscale score (from 7.78 in 1999 to 7.50 in 2010, p for trend < 0.001). Food service and room comfort perceptions deteriorated over the study period while patients increasingly reported better explanations before being examined.
PRACTICAL IMPLICATIONS: Patient perception scores may disguise divergent judgments on different care aspect while individual items highlight specific areas with room for improvement.
ORIGINALITY/VALUE: Despite growing pressure on healthcare expenditure, this single-center study showed only modest reduction in patients' hospital-care perceptions in the 2000s.

PMID: 25087339 [PubMed - indexed for MEDLINE]

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Aug 272014
 
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Resting Heart Rate Is a Risk Factor for Mortality in Chronic Obstructive Pulmonary Disease, but Not for Exacerbations or Pneumonia.

PLoS One. 2014;9(8):e105152

Authors: Warnier MJ, Rutten FH, de Boer A, Hoes AW, De Bruin ML

Abstract
BACKGROUND: Although it is known that patients with chronic obstructive pulmonary disease (COPD) generally do have an increased heart rate, the effects on both mortality and non-fatal pulmonary complications are unclear. We assessed whether heart rate is associated with all-cause mortality, and non-fatal pulmonary endpoints.
METHODS: A prospective cohort study of 405 elderly patients with COPD was performed. All patients underwent extensive investigations, including electrocardiography. Follow-up data on mortality were obtained by linking the cohort to the Dutch National Cause of Death Register and information on complications (exacerbation of COPD or pneumonia) by scrutinizing patient files of general practitioners. Multivariable cox regression analysis was performed.
RESULTS: During the follow-up 132 (33%) patients died. The overall mortality rate was 50/1000 py (42-59). The major causes of death were cardiovascular and respiratory. The relative risk of all-cause mortality increased with 21% for every 10 beats/minute increase in heart rate (adjusted HR: 1.21 [1.07-1.36], p = 0.002). The incidence of major non-fatal pulmonary events was 145/1000 py (120-168). The risk of a non-fatal pulmonary complication increased non-significantly with 7% for every 10 beats/minute increase in resting heart rate (adjusted HR: 1.07 [0.96-1.18], p = 0.208).
CONCLUSIONS: Increased resting heart rate is a strong and independent risk factor for all-cause mortality in elderly patients with COPD. An increased resting heart rate did not result in an increased risk of exacerbations or pneumonia. This may indicate that the increased mortality risk of COPD is related to non-pulmonary causes. Future randomized controlled trials are needed to investigate whether heart-rate lowering agents are worthwhile for COPD patients.

PMID: 25157876 [PubMed - as supplied by publisher]

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