Randomized Trial of a Delirium Abatement Program for Postacute Skilled Nursing Facilities

OBJECTIVES: To determine whether a delirium abatement program (DAP) can shorten duration of delirium in new admissions to postacute care (PAC). DESIGN: Cluster randomized controlled trial. SETTING: Eight skilled nursing facilities specializing in PAC within a single metropolitan region. PARTICIPANTS: Four hundred fifty‐seven participants with delirium at PAC admission. INTERVENTION: The DAP consisted of four steps: assessment for delirium within 5 days of PAC admission, assessment and correction of common reversible causes of delirium, prevention of complications of delirium, and restoration of function. MEASUREMENTS: Trained researchers screened eligible patients. Those with delirium defined according to the Confusion Assessment Method were eligible for participation using proxy consent. Regardless of location, researchers blind to intervention status re‐assessed participants for delirium 2 weeks and 1 month after enrollment. RESULTS: Nurses at DAP sites detected delirium in 41% of participants, versus 12% in usual care sites (P<.001), and completed DAP documentation in most participants in whom delirium was detected, but the DAP intervention had no effect on delirium persistence based on two measurements at 2 weeks (DAP 68% vs usual care 66%) and 1 month (DAP 60% vs usual care 51%) (adjusted P≥.20). Adjusting for baseline differences between DAP and usual care participants and restricting analysis to DAP participants in whom delirium was detected did not alter the results. CONCLUSION: Detection of delirium improved at the DAP sites, but the DAP had no effect on the persistence of delirium. This effectiveness trial demonstrated that a nurse‐led DAP intervention was not effective in typical PAC facilities.     

Understanding, recognizing, and managing chronic critical illness syndrome

Purpose: No evidence-based guidelines exist for the care of patients with chronic critical illness syndrome (CCIS), a growing population of patients being cared for by nurse practitioners (NPs). The purpose of this article is to provide NPs with a beginning physiological framework, allostasis, to guide their understanding and management of patients with CCIS.
Data sources: Scientific publications, related clinical guidelines.
Conclusions: Patients with CCIS are a distinct group of critically ill patients whose care needs are different from those of patients who are acutely critically ill. These patients demonstrate widespread tissue and organ damage. The widespread tissue and organ damage results in a syndrome of interrelated elements, which include neuroendocrine problems, severe malnutrition, wounds, infections, bone loss, polyneuropathy and myopathy, delirium and depression, and suffering.
Implications for practice: In caring for patients with CCIS, NPs need to focus on treating the elements of the syndrome as a cohort of interrelated elements and on re-establishing normalcy for the patient.     

Individualizing Prevention for Older Adults

Prevention can help older adults avoid illness by identifying and addressing conditions before they cause symptoms, but prevention can also harm older adults if conditions that are unlikely to cause symptoms in the individual's lifetime are identified and treated. To identify older adults who preventive interventions are most likely to benefit (and most likely to harm), we propose a framework that compares an individual's life expectancy (LE) with the time to benefit (TTB) for an intervention. If LE is less than the TTB, the individual is unlikely to benefit but is exposed to the risks of the intervention, and the intervention should generally NOT be recommended. If LE is longer than the TTB, the individual could benefit, and the intervention should generally be recommended. If LE is similar to the TTB, the individual's values and preferences should be the major determinant of the decision. To facilitate the use of this framework in routine clinical care, we explored ways to estimate LE, identified the TTB for common preventive interventions, and developed strategies for communicating with individuals. We have synthesized these strategies and demonstrate how they can be used to individualize prevention for a hypothetical beneficiary in the setting of a Medicare annual wellness visit. Finally, we place prevention in the context of curative and symptom‐oriented care and outline how prevention should be focused on healthier older adults, whereas symptom‐oriented care should predominate in sicker older adults.     

An exploration of caregiver choice through the lens of Sartrean existentialism

There are innumerable social and ethical factors which affect one's decision to become an informal caregiver for someone with chronic illness. The existential philosophy of Jean‐Paul Sartre provides unique insight into human motivation and choice. The purpose of this paper was to examine the social and ethical influences on the individual's decision to become a caregiver through the lens of Sartrean existentialism and discuss how this unique philosophy can advance nursing knowledge. The factors affecting one's choice to become a caregiver were considered using the Sartrean existential concepts of The Other, human freedom, choice, bad faith, shame and authenticity. When explored through the perspective of Sartrean existentialism, the choice to become a caregiver is strongly influenced by fear of judgement from The Other and the resulting sense of social obligation and shame. However, the interaction with The Other often results in the loss of authenticity through the pursuit of bad faith. To avert bad faith, potential caregivers must act authentically by exercising their freedom to choose and by choosing an action for its own sake and not for some extraneous purpose. The results of this philosophical inquiry contribute to nursing knowledge by providing a unique, alternative perspective by which nurses may understand the choices of potential caregivers and support them in making authentic decisions. This perspective may provide a foundation for theory development and promote further nursing knowledge which will improve caregiver health and well‐being.     

Potentially Avoidable Hospitalizations of Nursing Home Residents: Frequency,Causes, and Costs

OBJECTIVES: To examine the frequency and reasons for potentially avoidable hospitalizations of nursing home (NH) residents. DESIGN: Medical records were reviewed as a component of a project designed to develop and pilot test clinical practice tools for reducing potentially avoidable hospitalization. SETTING: NHs in Georgia. PARTICIPANTS: In 10 NHs with high and 10 with low hospitalization rates, 10 hospitalizations were randomly selected, including long‐ and short‐stay residents. MEASUREMENTS: Ratings using a structured review by expert NH clinicians. RESULTS: Of the 200 hospitalizations, 134 (67.0%) were rated as potentially avoidable. Panel members cited lack of on‐site availability of primary care clinicians, inability to obtain timely laboratory tests and intravenous fluids, problems with quality of care in assessing acute changes, and uncertain benefits of hospitalization as causes of these potentially avoidable hospitalizations. CONCLUSION: In this sample of NH residents, experienced long‐term care clinicians commonly rated hospitalizations as potentially avoidable. Support for NH infrastructure, clinical practice and communication tools for health professionals, increased attention to reducing the frequency of medically futile care, and financial and other incentives for NHs and their affiliated hospitals are needed to improve care, reduce avoidable hospitalizations, and avoid unnecessary healthcare expenditures in this population.