A Cluster-Randomized Trial of an Educational Intervention to Reduce the Use of Physical Restraints with Psychogeriatric Nursing Home Residents

OBJECTIVES: To investigate the effects of an educational intervention on the use of physical restraints with psychogeriatric nursing home residents.
DESIGN: Cluster-randomized trial.
SETTING: Fifteen psychogeriatric nursing home wards in the Netherlands.
PARTICIPANTS: In total, 432 psychogeriatric nursing home residents from 15 psychogeriatric nursing home wards in seven nursing homes were selected for participation; 404 consented, and 371 of these were available at baseline. Two hundred forty-one from 14 wards had complete data and were included in the data analyses.
INTERVENTION: The nursing home wards were assigned at random to educational intervention or control status. The educational intervention consisted of an educational program for nursing staff combined with consultation with a nurse specialist (registered nurse (RN) level).
MEASUREMENTS: Data were collected at baseline and 1, 4, and 8 months postintervention. At each measurement, the use of physical restraints was measured using observations of blinded, trained observers on four separate occasions over a 24-hour period. Other resident characteristics, such as cognitive status, were determined using the Minimum Data Set.
RESULTS: Logistic and linear regression analyses showed no treatment effect on restraint status, restraint intensity, or multiple restraint use in any of the three postintervention measurements. Furthermore, only small changes occurred in the types of restraints used with residents in the experimental group.
CONCLUSION: An educational program for nursing staff combined with consultation with a nurse specialist (RN level) had no effect on the use of physical restraints with psychogeriatric nursing home residents. In addition to restraint education and consultation, new measures to reduce the use of physical restraints with psychogeriatric nursing home residents should be developed.     

Prevalence of Methicillin-Resistant Staphylococcus aureus Colonization in Residents and Staff in Nursing Homes in Northern Ireland

OBJECTIVES: To determine the prevalence of, and factors associated with, methicillin-resistant Staphylococcus aureus (MRSA) colonization in residents and staff in nursing homes in one geographically defined health administration area of Northern Ireland.
DESIGN: Point prevalence study.
SETTING: Nursing homes.
PARTICIPANTS: Residents and staff in nursing homes.
MEASUREMENTS: Nasal swabs were taken from all consenting residents and staff. If relevant, residents also provided urine samples, and swabs were taken from wounds and indwelling devices.
RESULTS: A total of 1,111 residents (66% of all residents) and 553 staff (86% of available staff) in 45 nursing homes participated. The combined prevalence rate of MRSA in the resident population was 23.3% (95% confidence interval (CI)=18.8–27.7%) and 7.5% in staff (95% CI=5.1–9.9%). Residents who lived in nursing homes that were part of a chain were more likely to be colonized with MRSA (odds ratio (OR)=1.91, 95% CI=1.21–3.02) than those living in independently owned facilities. Residents were also more likely to be colonized if they lived in homes in which more than 12.5% of all screened healthcare staff (care assistants and nurses) were colonized with MRSA (OR=2.46, 95% CI=1.41–4.29) or if they lived in homes in which more than 15% of care assistants were colonized with MRSA (OR=2.64, 95% CI=1.58–4.42).
CONCLUSION: The findings suggest that there is substantial colonization of MRSA in nursing home residents and staff in this one administrative health area. Implementation of infection control strategies should be given high priority in nursing homes.     

Prevention of falls in nursing homes: subgroup analyses of a randomized fall prevention trial

OBJECTIVES: To evaluate the effectiveness of a multifactorial fall prevention program in prespecified subgroups of nursing home residents.
DESIGN: Secondary analysis of a cluster-randomized, controlled trial.
SETTING: Six nursing homes in Germany.
PARTICIPANTS: Seven hundred twenty-five long-stay residents; median age 86; 80% female.
INTERVENTION: Staff and resident education on fall prevention, advice on environmental adaptations, recommendation to wear hip protectors, and progressive balance and resistance training.
MEASUREMENTS: Time to first fall and the number of falls. Falls were assessed during the 12-month intervention period. Univariate regression analyses were performed, including a confirmatory test of interaction.
RESULTS: The intervention was more effective in people with cognitive impairment (hazard ratio (HR)=0.49, 95% confidence interval (CI)=0.35–0.69) than in those who were cognitively intact (HR=0.91, 95% CI=0.68–1.22), in people with a prior history of falls (HR=0.47, 95% CI=0.33–0.67) than in those with no prior fall history (HR=0.77, 95% CI=0.58–1.01), in people with urinary incontinence (HR=0.59, 95% CI=0.45–0.77) than in those with no urinary incontinence (HR=0.98, 95% CI=0.68–1.42), and in people with no mood problems (incidence rate ratio (IRR)=0.41, 95% CI=0.27–0.61) than in those with mood problems (IRR=0.74, 95% CI=0.51–1.09).
CONCLUSION: The effectiveness of a multifactorial fall prevention program differed between subgroups of nursing home residents. Cognitive impairment, a history of falls, urinary incontinence, and depressed mood were important in determining response.     

Is Dementia Special Care Really Special? A New Look at an Old Question

OBJECTIVES: To quantify differences in care provided to nursing home (NH) residents with dementia living on and off dementia special care units (SCUs).
DESIGN: Cross-sectional study using propensity score adjustment for resident and NH characteristics.
SETTING: Free-standing NHs in nonrural U.S. counties that had an SCU in 2004 (N=1,896).
PARTICIPANTS: Long-stay (≥90 days) NH residents with a diagnosis of Alzheimer's disease or dementia and at least moderate cognitive impairment (N=69,131).
MEASUREMENTS: Resident-level NH care processes such as physical restraints, bed rails, feeding tubes, psychotropic medications, and incontinence care.
RESULTS: There was no difference in the use of physical restraints (adjusted odds ratio (AOR)=0.94, 95% confidence interval (CI)=0.79–1.11), but SCU residents were less likely to have had bed rails (AOR=0.55, 95% CI=0.46–0.64) and to have been tube fed (AOR=0.36, 95% CI=0.30–0.43). SCU residents were more likely to be on toileting plans (AOR=1.23, 95% CI=1.08–1.39) and less likely to use pads or briefs in the absence of a toileting plan (AOR=0.73, 95% CI=0.61–0.88). SCU residents were more likely to have received psychotropic medications (AOR=1.23, 95% CI=1.05–1.44), primarily antipsychotics (SCU=44.9% vs non-SCU=30.0%).
CONCLUSION: SCU residents received different care than comparable non-SCU residents. Most strikingly, SCU residents had greater use of antipsychotic medications.     

Environmental Risk Factors for Community-Acquired Pneumonia Hospitalization in Older Adults

OBJECTIVES: To investigate the risk of hospitalization for pneumonia in older adults in relation to biophysical environmental factors.
DESIGN: Population-based case control study with collection of personal interview data.
SETTING: Hamilton, Ontario, and Edmonton, Alberta, Canada.
PARTICIPANTS: Seven hundred seventeen people aged 65 and older hospitalized for community-acquired pneumonia (CAP) from September 2002 to April 2005 and 867 controls aged 65 and older randomly selected from the same communities as the cases.
MEASUREMENTS: Odds ratios (ORs) for risk of pneumonia in relation to environmental and other variables.
RESULTS: Exposure to secondhand smoke in the previous month (OR=1.73, 95% confidence interval (CI)=1.04–2.90); poor nutritional score (OR=1.83, 95% CI=1.19–2.80); alcohol use per month (per gram; OR=1.69, 95% CI=1.08–2.61); history of regular exposure to gases, fumes, or chemicals at work (OR=3.69, 95% CI=2.37–5.75); history of regular exposure to fumes from solvents, paints, or gasoline at home (OR=3.31, 95% CI=1.59–6.87); and non-English language spoken at home (OR=5.31, 95% CI=2.60–10.87) were associated with a greater risk of pneumonia hospitalization in multivariable analysis. Age, congestive heart failure, chronic obstructive lung disease, dysphagia, renal disease, functional status, use of immunosuppressive disease medications, and lifetime history of smoking of more than 100 cigarettes were other variables associated with hospitalization for pneumonia.
CONCLUSION: In elderly people, present and past exposures in the physical environmental are associated with hospitalization for CAP.     

Effect of Antibiotic Guidelines on Outcomes of Hospitalized Patients with Nursing Home–Acquired Pneumonia

OBJECTIVES: To compare the 2003 community-acquired pneumonia (CAP) guideline and the 2005 healthcare-associated pneumonia (HCAP) guideline on time to clinical stability, length of hospital stay, and mortality in nursing home patients hospitalized for pneumonia.
DESIGN: Retrospective study.
SETTING: Three tertiary-care hospitals.
PARTICIPANTS: Three hundred thirty-four nursing home patients.
MEASUREMENTS: Patients were classified according to the antibiotic regimens they received based on the 2003 CAP guideline or the 2005 HCAP guideline. Time to clinical stability, time to switch therapy, and mortality were evaluated in an intention-to-treat analysis. A multivariate survival model using propensity analysis was used to adjust for heterogeneity between the two groups.
RESULTS: Of the 334 patients, 258 (77%) were treated according to the 2003 HCAP guideline. Time to clinical stability did not differ between those treated according to the 2003 CAP or the 2005 HCAP guidelines. Only the Pneumonia Severity Index ( P =.006) and multilobar involvement ( P =.005) were significantly associated with delay in achieving clinical stability. Adjusted in-hospital and 30-day mortality were comparable in both cohorts (odds ratio (OR)=0.87, 95% confidence interval (CI)=0.49–1.34, and OR=0.79, 95% CI=0.42–1.31, respectively), although time to switch therapy and length of stay were longer for those treated according to the 2005 HCAP guideline.
CONCLUSION: In hospitalized nursing home patients with pneumonia, treatment with an antibiotic regimen according to the 2003 CAP guideline achieved comparable time to clinical stability and in-hospital and 30-day mortality with a regimen based on the 2005 HCAP guideline.     

Outcomes of infection in nursing home residents with and without early hospital transfer

Objectives: To compare outcomes of infection in nursing home residents with and without early hospital transfer.
Design: Observational cohort study.
Setting: Fifty-nine nursing homes in Maryland.
Participants: Two thousand one hundred fifty-three individuals admitted to nursing homes between 1992 and 1995.
Measurements: Incident infection was recorded when a new infectious diagnosis was documented in the medical record or nonprophylactic antibiotic therapy was prescribed. Early hospital transfer was defined as transfer to the emergency department or admission to the hospital within 3 days of infection onset. Infection, resident, and facility characteristics were entered into a multivariate model to create a propensity score for early hospital transfer. Association between early hospital transfer and outcomes of infection, namely pressure ulcers and death between Days 4 and 34 after infection onset, were examined, controlling for propensity score.
Results: Four thousand nine hundred ninety infections occurred in 1,301 residents. Genitourinary (28%), skin (19%), upper respiratory (13%), and lower respiratory (12%) were the most common types. Three hundred seventy-five episodes in which residents survived 3 days (7.6%) resulted in early hospital transfer. In multivariate regression, individuals with early hospital transfer had higher mortality (odds ratio (OR) 1.44, 95% confidence interval (CI)=1.04–1.99) and, in 1-month survivors, a greater occurrence of pressure ulcers (OR 1.61, 95% CI=1.17–2.20) than those without, after adjusting for propensity score.
Conclusion: Using observational data and propensity score methods, outcomes were worse in nursing home residents transferred to the hospital within 3 days of infection onset than in those who remained in the nursing home.     

Predictors of continued physical restraint use in nursing home residents following restraint reduction efforts

OBJECTIVES: To examine predictors of continued restraint use in nursing home residents following efforts aimed at restraint reduction. DESIGN: Secondary analysis of data from a clinical trial using a one-group, pre-test post-test design. SETTING: Three nonprofit, religion-affiliated nursing homes in a metropolitan area. PARTICIPANTS: The sample consisted of 201 physically restrained nursing home residents. Following restraint reduction efforts, 135 of the sample were still restrained. Mean age of participants was 83.9 years. MEASUREMENTS: Physical restraint use was measured by observation and included any chest/vest, wrist, mitt, belt, crotch, suit, or harness restraint plus any sheet used as restraint or a geriatric chair with fixed tray table. Nursing home residents were subjected to any one of three conditions aimed at restraint reduction, including adherence to the mandate of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87), staff education, and education with consultation from a gerontological clinical nurse specialist. Resident characteristics including dependency, health status, mental status, depression, behavior, fall risk; presence of treatment devices and institutional factors were determined. RESULTS: Physical dependency, lower cognitive status, behavior, presence of treatment devices, presence of psychiatric disorders, fall risk, and fall risk as staff rationale for restraint were associated (P < .10) with continued restraint use. Nursing hours, staff mix, prevalence of restraint use by unit, and site were also associated (P < .10) with continued use of physical restraints. Following bivariate analysis, associated resident characteristics were subjected to logistic regression. Lower cognitive status (OR = 2.4 (for every 7-point decrease in MMSE), 95% CI, 1.7, 3.3) and fall risk as staff rationale for restraint (OR = 3.5, 95% CI., 1.5, 8.0) were predictive of continued restraint use. Adding nursing hours, staff mix, and prevalence of restraint use by unit to the logistic regression model was not statistically significant (partial chi-square = 2.79, df = 6, P = .834). Nursing home site was added to the model without changing the significance (P < .05) of cognitive status or fall risk as a staff rationale for restraint use. CONCLUSION: Continued restraint use in nursing home residents in this study most often occurred with severe cognitive impairment and/or when fall risk was considered by staff as a rationale for restraint. Efforts to reduce or eliminate physical restraint use with these groups will require greater efforts to educate staff in the assessment and analysis of fall risk, along with targeted interventions, particularly when cognition is also impaired.     

Functional recovery after hip fracture: the combined effects of depressive symptoms, cognitive impairment, and delirium

OBJECTIVES: To measure the prevalence of depressive symptoms, cognitive impairment, and delirium in patients with hip fracture and to estimate their effect on functional recovery, institutionalization, and death after surgical repair.
DESIGN: Prospective cohort.
SETTING: Hospital, follow-up to community and nursing home.
PARTICIPANTS: One hundred twenty-six patients aged 65 and older admitted for hip fracture repair.
MEASUREMENTS: Baseline measurements: Mini-Mental State Examination, Blessed Dementia Rating Scale, Geriatric Depression Scale, prefracture activities of daily living (ADLs), ambulatory status. The Confusion Assessment Method was used to diagnose in-hospital delirium. One- and 6-month outcomes were ADL decline, loss of ambulation, and new nursing home placement or death.
RESULTS: Twenty-two percent of patients had one cognitive or mood disorder, 30% had two, and 7% had three. At 1 month, each cognitive or mood disorder was independently associated with one or more adverse outcome. Considered together, each additional cognitive or mood disorder was associated with greater odds of 1 month outcomes (ADL decline: odds ratio (OR)=1.8, 95% confidence interval (CI)=1.1–2.9; decline in ambulation: OR=1.8, 95% CI=1.1–3.0; nursing home placement or death: OR=3.9, 95% CI=1.9–8.1).
CONCLUSION: Cognitive and mood disorders were common in elderly hip fracture patients and were associated with greater risk of poor outcomes, both independently and in combination. Recognition and treatment of these conditions may reduce adverse outcomes in this vulnerable population.     

Restraint reduction reduces serious injuries among nursing home residents.

OBJECTIVES: To describe how removing physical restraints affected injuries in nursing home settings. DESIGN: A 2-year prospective study of an educational intervention for physical restraint reduction. SETTING: Sixteen diverse nursing homes with 2075 beds in California, Michigan, New York, and North Carolina. PARTICIPANTS: Study A: 859 residents who were physically restrained at the onset of the intervention on October 1, 1991. Study B: all residents who occupied the 2075 beds in the 16 facilities 3 months before the intervention and 3 months after its completion. INTERVENTION: Educational program for nursing home staff followed by quarterly site consultations to participating nursing homes. MAIN OUTCOME MEASURES: Rate of physical restraint use and injuries. RESULTS: Study A: Serious injuries declined significantly among the 859 residents restrained initially when restraint orders were discontinued (X2 = 6.2, P = .013). Study B: During the intervention period, physical restraint use among the 2075 residents decreased from 41% to 4%, a 90% reduction. The decrease in the percentage of injuries of moderate to serious severity was significant (i.e., 7.5% vs 4.4%, P2-tail = .0004) as was the rate of moderate and serious injuries combined (Rate Ratio = 1.580, P2-tail = .0033). CONCLUSIONS: A substantial decrease in restraint use occurred without an increase in serious injuries. Although minor injuries and falls increased, restraint-free care is safe when a comprehensive assessment is done and restraint alternatives are used.     

Brief report: Risk factors for pneumococcal vaccine refusal in adults

Background: Invasive pneumococcal disease is a significant cause of morbidity and mortality in the United States. Despite availability of an effective vaccine, many patients refuse vaccination.
Objective: To investigate patient characteristics and features of the patient–provider relationship associated with pneumococcal vaccine refusal.
Design: Case–control study using chart review.
Patients: Five hundred adults from the medical clinics of a 1,000-bed inner-city teaching hospital.
Measurements and Main Results: Independent risk factors for pneumococcal vaccine refusal included patient–provider gender discordance (odds ratio (OR)=2.09, 95% confidence interval (CI) 1.07 to 4.09); a visit to a not-usual provider at the time of vaccine offering (OR=2.26, 95% CI 1.13 to 4.49); never having received influenza vaccination (OR=7.44, 95% CI 3.76 to 14.76); prior pneumococcal vaccine refusals (OR=3.45, 95% CI 1.60 to 7.43); and a history of ever having refused health maintenance tests (OR=2.86, 95% CI 1.40 to 5.84).
Conclusions: We have identified both patient factors and factors related to the patient–provider relationship that are risk factors for pneumococcal vaccine refusal. By identifying patients at risk for pneumococcal vaccine refusal, efforts to increase vaccination rates can be better targeted.     

Effect of a Statewide Fall Prevention Program on Incidence of Femoral Fractures in Residents of Long-Term Care Facilities

OBJECTIVES: To evaluate the effect of a statewide dissemination of a modified evidence-based fall prevention program on incidence of femoral fractures in nursing homes.
DESIGN: Observational study of a staged implementation of a successful fall prevention program.
SETTING: One thousand three hundred fifty-nine nursing homes in two federal states in the south of Germany.
PARTICIPANTS: Nine thousand seventy-seven residents in the intervention homes and 43,583 residents in control homes from the same and a different federal state.
INTERVENTION: Staff education on fall prevention, advice on environmental adaptations, and progressive strength and balance training over at least 1 year.
MEASUREMENTS: Incident femoral fractures.
RESULTS: One thousand five hundred eighteen femoral fractures occurred in the total study population during the intervention period. The crude incidence rate of femoral fractures was 39.5/1,000 person-years in residents from the intervention homes and 40.9 and 39.7/1,000 person-years in residents from two sets of control homes. In a multivariate model, there was no evidence of an effect of the fall prevention program on incidence of femoral fracture when compared with control homes from the same federal state (adjusted hazard ratio (AHR)=0.96, 95% confidence interval (CI)=0.83–1.11) or from a different federal state (AHR=1.00, 95% CI=0.86–1.16).
CONCLUSION: The statewide dissemination of a multifactorial fall prevention program did not appear to reduce the burden of femoral fractures in residents of nursing homes.     

Physical Restraint Among Hospitalized Nursing Home Residents

Abstract

We examined physical restraint use among 1856 nursing home residents hospitalized with hip fracture using a data set of hip fracture patients in 20 U. S. hospitals from 1983-1993. Mean age of patients was 85.2 years, 81.7% were women, and 91.3% were white. Rate of physical restraint use was 59.4%. Pre-operative physical restraint use was predicted by younger age, confusion, dementia, and needing assistance or dependency in activities of daily living (ADL). Physical restraint use following surgery was predicted by pre-operative physical restraint use, confusion, dementia, and lower co-morbidity of illness. At hospital discharge, restrained patients were more likely to be dependent in ADL and continence. The reduction of physical restraints among hospitalized nursing home residents will require attention to a multiplicity of factors that contribute to restraint use.     

Consequences of an intervention to reduce restrictive side rail use in nursing homes

OBJECTIVES: To examine the effect of an advanced practice nurse (APN) intervention on restrictive side rail usage in four nursing homes and with a sample of 251 residents. A secondary question explored the association between restrictive side rail reduction and bed-related falls. DESIGN: Pre- and posttest design. SETTING: Four urban nursing homes. PARTICIPANTS: All nursing home residents present in the nursing home at three time points (n=710, 719, and 707) and a subset of residents (n=251) with restrictive side rail use at baseline. INTERVENTION: APN consultation with individual residents and facility-wide education and consultation. MEASUREMENTS: Direct observation of side rail status, resident and nurse interview for functional status, mobility, cognition, behavioral symptoms, medical record review for demographics and treatment information, and incident reports for fall data. RESULTS: At the institutional level, one of the four nursing homes significantly reduced restrictive side rail use (P=.01). At the individual participant level, 51.4% (n=130) reduced restrictive side rail use. For the group that reduced restrictive side rails, there was a significantly (P<.001) reduced fall rate (-0.053; 95% confidence interval (CI)=-0.083 to -0.024), whereas the group that continued restrictive side rail did not demonstrate a significantly (P=.17) reduced fall rate (-0.013; 95% CI=-0.056-0.030). CONCLUSION: An APN consultation model can safely reduce side rail use. Restrictive side rail reduction does not lead to an increase in bed-related falls. Although side rails serve many purposes, routine use of these devices to restrict voluntary movement and prevent falls is not supported.     

Delirium in the Nursing Home Patients Seen in the Emergency Department

OBJECTIVES: To determine whether nursing home patients are more likely than non-nursing home patients to present to the emergency department (ED) with delirium and to explore how variations in their delirium risk factor profiles contribute to this relationship.
DESIGN: Prospective cross-sectional study.
SETTING: Tertiary care academic ED.
PARTICIPANTS: Three hundred forty-one English-speaking patients aged 65 and older.
MEASUREMENTS: Delirium status was determined using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) administered by trained research assistants. Multivariable logistic regression was used to determine whether nursing home residence was independently associated with delirium. Adjusted odds ratios (ORs) with their 95% confidence intervals (95% CIs) were reported.
RESULTS: Of the 341 patients enrolled, 58 (17.0%) resided in a nursing home and 38 (11.1%) were considered to have delirium in the ED. Of the 58, (22 (37.9%) nursing home patients and 16 of 283 (5.7%) non-nursing home patients had delirium; unadjusted OR=10.2, 95% CI=4.9–21.2). After adjusting for dementia, a Katz activity of daily living score less than or equal to 4, hearing impairment, and the presence of systemic inflammatory response syndrome, nursing home residence was independently associated with delirium in the ED (adjusted OR=4.2, 95% CI=1.8–9.7).
CONCLUSION: In the ED setting, nursing home patients were more likely to present with delirium, and this relationship persisted after adjusting for delirium risk factors.     

A Quality Improvement Intervention to Facilitate the Transition of Older Adults from Three Hospitals Back to Their Homes

OBJECTIVES: To study the feasibility and effectiveness of a discharge planning intervention.
DESIGN: Quasi-experimental pre–post study design.
SETTING: General medicine wards at three hospitals: an academic medical center, a community teaching hospital, and a community-based nonteaching hospital.
PARTICIPANTS: All patients aged 65 and older admitted to the hospitalist services.
INTERVENTION: The intervention toolkit had five core elements: admission form with geriatric cues, facsimile to the primary care provider, interdisciplinary worksheet to identify barriers to discharge, pharmacist–physician collaborative medication reconciliation, and predischarge planning appointments.
MEASUREMENTS: Thirty-day readmission and return to emergency department rates and patient satisfaction with discharge. Odds ratios were determined, and site effects were examined accordig to interaction terms and Breslow Day statistics.
RESULTS: Two hundred thirty-seven patients were followed during the preintervention period, and 185 were exposed to the intervention. Patients characteristics were similar across the two time periods. The proportion of patients with high-quality transitions home, measured according to Coleman's Care Transition Measures, increased from 68% to 89% (odds ratio (OR)=3.49, 95% confidence interval (CI)=2.06–5.92). Return to the emergency department within 3 days of discharge was lower in the intervention period (10% vs 3%, OR=0.25, 95% CI=0.10–0.62). At 30 days, there was a lower rate of readmission (22% vs 14%, OR=0.59, 95% CI=0.34–0.97) and fewer visits to the emergency department (21% vs 14%, OR=0.61, 95% CI=0.36–1.03) ( P =.06).
CONCLUSION: When hospitalized elderly patients are treated with consideration of their specific needs, healthcare outcomes can be improved.     

Precipitants of emergency room visits and acute hospitalization in short-stay medicare nursing home residents

OBJECTIVES: To determine what precipitates rehospitalization for residents who become acutely ill in the first 90 days of a nursing home (NH) admission. DESIGN: NH medical record review comparing acutely ill Medicare admissions transferred back to hospital with those not transferred. SETTING: Sixty skilled nursing facilities in five states during 1994. PARTICIPANTS: Six hundred thirty-six residents who became acutely ill with urinary tract infection (UTI), pneumonia, or congestive heart failure (CHF) during the first 90 days of their nursing home admission were identified from 2,414 random NH Medicare admissions, excluding those with orders not to be hospitalized. MEASUREMENTS: Diagnosis, age, gender, advance care directives, nursing shift during which problem occurred, comorbidity, symptoms, and signs of acutely ill NH residents transferred to the hospital or emergency department were compared with those not transferred. RESULTS: Rates of hospitalization varied markedly by acute illness: 11 of residents with UTI, 46 with pneumonia, and 58 with an exacerbation of CHF (P< .001). In stratified multivariate analysis, older age decreased the odds of rehospitalization only for CHF. Male gender increased odds of hospitalization for pneumonia (odds ratio (OR) = 2.94) and decreased odds of hospitalization for CHF (OR = 0.28). Do not resuscitate orders were negatively associated with hospitalization only for pneumonia (OR = 0.23), whereas weekend and evening/night shifts increased odds of hospitalization for UTI. Each illness had its own set of symptoms, signs, and comorbidities associated with hospitalization.CONCLUSIONS: Whether an acutely ill NH Medicare patient was rehospitalized depended primarily on the particular illness. The relative importance of age, gender, shift, advance care directives, symptom severity, signs, and comorbid illnesses varied by diagnosis.     

An Outpatient Multifactorial Falls Prevention Intervention Does Not Reduce Falls in High-Risk Elderly Danes

OBJECTIVES: To evaluate the effect of multifactorial fall prevention in community-dwelling people aged 65 and older in Denmark.
DESIGN: Randomized, controlled clinical trial.
SETTING: Geriatric outpatient clinic at Glostrup University Hospital.
PARTICIPANTS: Three hundred ninety-two elderly people, mean age 74, 73.7% women, who had visited the emergency department or had been hospitalized due to a fall.
INTERVENTION: Identification of general medical, cardiovascular, and physical risk factors for falls and individual intervention in the intervention group. Participants in the control group received usual care.
MEASUREMENTS: Falls were registered prospectively in falls diaries, with monthly telephone calls for collection of data. Outcomes were fall rates and proportion of participants with falls, frequent falls, and injurious falls in 12 months.
RESULTS: Groups were comparable at baseline. Follow-up exceeded 90.0%. A total of 422 falls were registered in the intervention group, 398 in the control group. Intention-to-treat analysis revealed no effect of the intervention on fall rates (relative risk=1.06, 95% confidence interval (CI)=0.75–1.51), proportion with falls (odds ratio (OR)=1.20, 95% CI 0.81–1.79), frequent falls (OR=0.97, 95% CI=0.60–1.56), or injurious falls (OR=0.97, 95% CI=0.57–1.62).
CONCLUSION: A program of multifactorial fall prevention aimed at elderly Danish people experiencing at least one injurious fall was not effective in preventing further falls.     

Raising adult vaccination rates over 4 years among racially diverse patients at inner-city health centers

OBJECTIVES: To increase adult immunizations at inner-city health centers serving primarily minority patients.
DESIGN: A before–after trial with a concurrent control.
SETTING: Five inner-city health centers.
PARTICIPANTS: All adult patients at the health centers eligible for influenza and pneumococcal vaccines.
INTERVENTION: Four intervention sites chose from a menu of culturally appropriate interventions based on the unique features of their respective health centers.
MEASUREMENTS: Immunization and demographic data from medical records of a random sample of 568 patients aged 50 and older who had been patients at their health centers since 2000.
RESULTS: The preintervention influenza vaccination rate of 27.1% increased to 48.9% ( P <.001) in intervention sites in Year 4, whereas the concurrent control rate remained low (19.7%). The pneumococcal polysaccharide vaccine (PPV) rate in subjects aged 65 and older increased from 48.3% to 81.3% ( P <.001) in intervention sites in Year 4. Increase in PPV in the concurrent control was not significant. In logistic regression analysis, the likelihood of influenza vaccination was significantly associated with the intervention (odds ratio (OR)=2.07, 95% confidence interval (CI)=1.77–2.41) and with age of 65 and older (OR=2.0, 95% CI=1.62–2.48) but not with race. Likelihood of receiving the pneumococcal vaccination was also associated with older age and, to a lesser degree, with intervention.
CONCLUSION: Culturally appropriate, evidence-based interventions selected by intervention sites resulted in increased adult vaccinations in disadvantaged, racially diverse, inner-city populations over 2 to 4 years.