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Biomedical subjects

D Osterweil

Publications and source records attributed to D Osterweil.

At least 19 recordsLinked to original sources
PubMed1999

Barriers to effective communication in skilled nursing facilities: differences in perception between nurses and physicians.

BACKGROUND: Effective communication between nurses and physicians is central to the clinical care of nursing home residents. Anecdotal evidence suggests that communication between the groups is unsatisfactory, but no empirical data exist with which to validate assumptions. The purpose of this pilot study was to compare perceptions of potential communication barriers among nurses and physicians in four California nursing homes. METHODS: Registered nurses (n = 59), and physicians (n = 47) involved in the direct clinical care of nursing home residents completed a 12-item questionnaire designed to elicit perceptions about potential communication barriers. Five specific categories of barriers were identified. These included nurse competence, time burden of calls, necessity of calls, professional respect, and language comprehension. Responses were compared using t test analysis. RESULTS: Significant differences in perceived communication barriers were identified. Physicians, but not nurses, perceive nursing competence to be a significant barrier. Nurses perceive physicians to be unpleasant. Both physicians and nurses perceive that physicians do not value nurses' opinions. Neither group perceived language expression, language comprehension, or time burden of phone calls to be barriers to communication. CONCLUSIONS: Issues related to the perceived competency of nurses by physicians is consistent with existing data from other clinical settings. Differences in awareness about scope of practice and regulatory requirements between the groups may offer a partial explanation for the discordant perceptions. Perceptions by nurses (but not physicians) of unpleasantness and/or disrespect during telephone encounters may reflect the broader ongoing differences in professional culture, social status, and gender inequality between the two groups. Further clarification of the causes of barriers to effective communication is essential in order to plan appropriate interventions.

Adult↗
PubMed1996

Perioperative care in the elderly urologic patient.

This article summarizes the preoperative evaluation and postoperative care recommended for elderly patients undergoing urologic procedures. Most of the common issues faced during the perioperative period are discussed, but many other topics require reference to other sources or consultation with specialists. A thorough preoperative evaluation is needed, and meticulous attention to postoperative care is mandatory. The most important common problem is assessment of cardiovascular risk in patients and a general approach is suggested by the authors. Surgical risk in elderly patients is increased, but most of this excess risk is because of associated comorbid conditions. Effective pre- and postoperative assessment and care can minimize this risk and maximize the chances of a successful outcome.

Aged↗
PubMed1996

Falls and fall prevention in the nursing home.

The mean incidence of falls in nursing homes is 1.5 falls per bed per year (range 0.2-3.6). The most common precipitating causes include gait and balance disorders, weakness, dizziness, environmental hazards, confusion, visual impairment, and postural hypotension. The most important underlying risk factors for falls and injuries include some of these same items as well as others: leg weakness, gait and balance instability, poor vision, cognitive and functional impairment, and sedating and psychoactive medications. A focused history and physical examination after a fall can usually determine the immediate underlying cause(s) of the fall and contributory risk factors. Many strategies for fall prevention have been tried with mixed success. The most successful take into account the multifactorial causes of falls, and include interventions to improve strength and functional status, reduce environmental hazards, and allow staff to identify and monitor high-risk residents. Regular evaluations in the nursing home can help identify patients at high risk who can then be targeted for specific treatment and prevention strategies. Strategies that reduce mobility through use of restraints have been shown to be more harmful than beneficial and should be avoided. A number of promising fall prevention strategies, involving both specific quality assurance programs and technologic devices, are being evaluated currently.

Accidental Falls↗
PubMed1995

Cost-effectiveness of low-air-loss beds for treatment of pressure ulcers.

BACKGROUND: Cost-effectiveness of low-air-loss beds for the healing of pressure ulcers was analyzed in the nursing home setting. A statistical model of pressure ulcer healing was used to estimate cost-effectiveness based on patient and ulcer characteristics. METHODS: Results of a previous randomized trial (84 patients from three nursing homes in Los Angeles) were reanalyzed and combined with estimates of costs to calculate the cost-effectiveness in dollars per added day free of pressure ulcers achieved by the use of low-air-loss beds compared to conventional foam mattresses. RESULTS: The cost-effectiveness of the low-air-loss bed was $26 per added day free of ulcers for our standard patient. Results were sensitive to low-air-loss bed lease costs and patient and wound healing characteristics. Results were less sensitive to expected mortality, daily wound care costs, and time-frame of consideration. Low-air-loss beds were more cost-effective for patients with good healing characteristics and mild ulcers. CONCLUSIONS: Findings support the expanded use of this technology for patients with mild pressure ulcers and good healing characteristics. For these patients, the cost-effectiveness of low-air-loss beds is comparable to other accepted health treatments. For patients with severe ulcers and poor healing characteristics, low-air-loss bed cost-effectiveness compares poorly with other accepted health treatments unless the lease cost can be substantially reduced, or unless life with a pressure ulcer is valued close to death.

Aged↗
PubMed1995

Predictors of skilled nursing placement in a multilevel long-term-care facility.

OBJECTIVE: To determine if cognitive and functional data gathered before admission to residential care (i.e., board and care) placement can predict nursing home placement. DESIGN: Retrospective study using Cox proportional hazards analysis and pairwise assessment of adjusted relative risk factors to determine which independent variables predicted skilled nursing placement. Subjects were followed for an average of 23.7 months (SD = 18.6 months). SETTING: Multilevel 1,735-bed long-term care facility, Jewish Home for the Aging, Reseda, California. PARTICIPANTS: Of the 248 consecutive residential care admissions studied, 80% were women. Subject's mean age was 84.8 years (SD = 5.0); 67% had no significant cognitive impairment. INDEPENDENT VARIABLES: Categorical variables were classifications with respect to dementia status, incontinence, hearing, and ambulation. Interval variables were number of medications, Katz ADL, and five neuropsychological tests. Demographic variables were gender, age, language of origin, and education. OUTCOME VARIABLE: Time between preadmission testing and the move up to skilled nursing placement. RESULTS: Pairwise assessment of adjusted potential risk factors indicated that cognitive dysfunction, less than perfect Katz ADL performance, and hearing loss were the most important independent risk factors for nursing placement. CONCLUSIONS: The findings remind us to pay careful attention to residents exhibiting even relatively mild cognitive deficits upon admission because these residents are likely to need increased environmental support.

Aged↗
PubMed1995

The medical director in hospital-based transitional care units.

This article begins with a brief overview of what subacute care is and why it is growing exponentially. It then discusses the characteristics of patients appropriate for treatment in a transitional care unit (TCU) and the evolving role of physicians in their care. The process of care in a typical hospital-based TCU from admission to discharge is discussed with an emphasis on documentation and an interdisciplinary approach. The role of the medical director is emphasized. The article closes with strategies the authors feel are useful for improving care in hospital-based TCUs.

Aged↗
PubMed1994

Physician evaluation and management of nursing home residents.

The diverse goals of nursing home care, the heterogeneity of nursing home residents, and the varied circumstances under which physicians care for them make their evaluation and care complex and challenging. When evaluating and caring for nursing home residents, physicians must address many issues besides treatment of multiple chronic diseases (including impairments in cognitive and physical functioning, sensory deficits, depression, and behavioral disorders associated with dementia) and concerns of family members. The physician should be integrated with an interdisciplinary team composed of nurses, rehabilitation therapists, social workers, and others. Recently implemented federal rules for nursing home care, which include the Minimum Data Set and Resident Assessment Protocols, provide a useful framework for interdisciplinary assessment and care planning and should improve the care nursing home residents receive. Better data are needed on the most cost-effective strategies for evaluating and caring for nursing home residents. Reimbursement for physician services, availability of nurse practitioners and physician assistants, and overall quality of nursing home care must be improved so physicians can better achieve the recommendations outlined.

Aged↗
PubMed1994

Cognitive function in old and very old residents of a residential facility: relationship to age, education, and dementia.

OBJECTIVE: To determine if age, education, and dementia status affect neuropsychological performance in old and very old frail residential care subjects. DESIGN: Descriptive study of performance at the time of preadmission assessment. SETTING: Jewish Home for the Aging, Reseda, California. PARTICIPANTS: 201 applicants to the Jewish Home for the Aging residential care setting. Mean age was 84.7 years; SD was 5.6. Ninety-five subjects were 84 years of age or younger, while 106 were age 85 and older. There were 141 nondemented, 21 demented, and 39 were possibly demented applicants. Levels of education were as follows: 0-4 years: n = 25; 5-8: n = 69; 9-12: n = 77; and, 13-20: n = 23. MEASUREMENTS: Independent variables were age, education, and dementia status. Outcome measures were Folstein MMSE, Inglis P-A Learning Test, Digit Span, Cube Copying, selected Boston Diagnostic Aphasia Exam subtests. RESULTS: Subjects with 0 to 4 years of education scored more poorly on cognitive tests than other subjects. The very old tended to score more poorly than the old. Neuropsychological tests discriminated between those with normal cognitive function, possible dementia, and established dementia. About one-third of nondemented elderly scored below the traditional impairment cut-off of 24 points on the Mini-Mental State Exam. CONCLUSIONS: Questions are raised about how to interpret the poorer cognitive performance of very old and often frail subjects, especially in long-term-care settings where there are fewer demands upon residents whose impairments might otherwise cause them more functional difficulty.

Activities of Daily Living↗
PubMed1993

A randomized trial of low-air-loss beds for treatment of pressure ulcers.

OBJECTIVE: To assess the effectiveness of low-air-loss beds for the treatment of pressure ulcers in nursing homes. DESIGN: Prospective, randomized, clinical trial. SETTING: Three teaching nursing homes in Los Angeles, Calif. SUBJECTS: Eighty-four nursing home residents with trunk or trochanter pressure ulcers (Shea stage > or = 2). INTERVENTIONS: Subjects were randomly assigned to use either a low-air-loss bed (n = 43) or a 10-cm corrugated foam mattress (n = 41) throughout the healing of their ulcers. OUTCOME MEASURES: Ulcers were assessed twice weekly using surface area and two observational scales (median follow-up, 37.5 days; range, 4 to 571 days). RESULTS: Groups were similar with respect to demographics, medical variables, wound care, and early dropouts. Results indicate more than a threefold improvement in median rate of healing for low-air-loss beds compared with foam mattresses (9.0 vs 2.5 mm2/d; P = .0002). This finding was true for deep as well as superficial ulcers (deep ulcers, 9.9 vs 0.7 mm2/d; P = .02; superficial ulcers, 9.0 vs 3.2 mm2/d; P = .004). Cox regression models revealed that the bed, ulcer depth, and fecal continence had independent effects on healing. After controlling for fecal continence, the deep and superficial subgroups using low-air-loss beds remained 2.5 times more likely to heal in a given length of time compared with those using foam mattresses (combined cure probability ratio, 2.66; 95% confidence interval, 1.34 to 5.17; P < .004). CONCLUSION: Low-air-loss beds provide substantial improvement compared with foam mattresses despite other factors in pressure ulcer healing.

Aged↗
PubMed1993

Using multidimensional health measures in older persons to identify risk of hospitalization and skilled nursing placement.

We examine the relationship between multidimensional measures of function and outcomes in a cohort of older persons admitted to the residential care level of a multi-level long-term care facility. We collected self-reported measures of various aspects of health using the Medical Outcome Study Short-form Health Survey (SF-20) and the Dartmouth COOP charts, as well as performance-based measures of physical and cognitive function. Subjects (mean age 84.3 years) were followed for a median of 557 days. In multivariate analyses, emotional function (measured by either the SF-20 or COOP method) was a predictor of placement in skilled care. Self-reported overall health (measured by either the SF-20 or COOP method) and timed manual performance were predictive of hospitalization. Change on the functional status measures between 2 points in time was not associated with later placement in skilled care except in the case of timed manual performance. In an older population at risk for frequent and numerous health events, this study shows that two popularized self-report methods for assessing function yield results that predict future outcomes of great importance to older persons. However, measures that predict use of long-term care may not predict use of the hospital and vice versa.

Activities of Daily Living↗
PubMed1993

Change in self-reported functioning in older persons entering a residential care facility.

We evaluated the responsiveness of measures of function in admissions to a long-term care facility. Between baseline and follow-up assessment, one-fifth or more of the subjects either worsened or improved in most aspects of reported function. We compared two measures of self-reported function (COOP charts and a short-form survey). Convergent validity was observed for changes in pain, social health, and mental health (r = 0.39-0.74), but not for physical functioning. Although the short-form physical function measure discriminated worsening on several performance-based external criteria of physical functioning (area under ROC curves up to 0.82), the COOP and other measures of physical functioning were less likely to do so. All physical function measures were less responsive for detecting improvement. Clinicians and investigators intending to monitor change in function must consider the responsiveness of their measures.

Activities of Daily Living↗
PubMed1993

Total quality management: administrative and clinical applications in nursing homes.

OBJECTIVE: Describe the application of the Total Quality Management (TQM) model to the unique work force, resident population, and regulatory issues that characterize long term care settings. DESIGN: The key differences between TQM and current management and training practices in nursing homes are described. A specific data-based example is provided of a successful TQM application to health care involving clinical work processes related to incontinence care. CONCLUSION: Significant organizational and clinical obstacles must be overcome if TQM is to improve the quality of life and satisfaction of nursing home residents and their families as it has improved the efficiency and product quality in hospital and non-health-care settings.

Clinical Competence↗
PubMed1992

Cognitive function in non-demented older adults with hypothyroidism.

PURPOSE: (1) to evaluate objectively changes in cognitive function and electrophysiologic characteristics associated with hypothyroidism of varying severity and duration in primarily older persons; (2) to determine whether these changes are reversible when a euthyroid state has been attained after treatment with thyroid hormone. SUBJECTS AND METHODS: We enrolled 54 non-demented hypothyroid patients (31-99, mean 68.6 +/- 16.4 years) with biochemical evidence of hypothyroidism (38 had overt and 14 had minimal hypothyroidism) and 30 euthyroid controls (31-96, mean 63.7 +/- 18.4 years) screened for good general health. We evaluated attention, orientation, memory, learning, visual-spatial abilities, calculation, language, visual scanning, and motor speed using standardized neuropsychological tests. Electrophysiological measures of neurocognitive function included the P300 latency component of the auditory Event-Related Potentials (ERP) and conduction speed from eye to cortex, the P100 latency component of the Patterned Visual-Evoked Potential (PVEP). All patients were studied when hypothyroid. A subset of patients with minimal initial test abnormalities were available to be retested when euthyroid, 5 and 9 months after onset of thyroid replacement therapy. RESULTS: Hypothyroid patients showed significantly lower scores on the Mini-Mental Status Test (MMS) and on five of 14 neuropsychological tests as compared to controls. The neuropsychological tests affected were copying a cube (visual-spatial function), the Inglis Paired Associates Learning Test-Low and Medium association items (memory and learning), Animal Naming (word fluency/production), and the Trail Making A test (attention, visual scanning and psychomotor function. Hypothyroidism also was associated with longer P100 latencies of PVEPs to 20' checks, but showed no significant differences in PVEP P100 latency to 50' checks, nor in the latency of the auditory ERP component P300. There was a statistically significant correlation between a laboratory index of the severity of hypothyroidism (serum T4) and the Inglis Medium Association items and Animal Naming. There was a statistically significant improvement after 5 months of treatment on three of the timed performance tests that previous studies have shown to be most sensitive to brain dysfunction. CONCLUSION: Hypothyroidism in non-demented older adults is associated with impairments in learning, word fluency, visual-spatial abilities, and some aspect of attention, visual scanning, and motor speed. The MMS by itself was sensitive in differentiating hypothyroid patients with cognitive deficits from controls, while electrophysiological measures did not generally differentiate the hypothyroid patients from normal controls. The MMS was not sensitive to treatment effects, but treatment was associated with significant improvements in three of the most sensitive measures of cognitive dysfunction.

Adult↗
PubMed1991

Detectable serum levels of tumor necrosis factor alpha may predict early mortality in elderly institutionalized patients.

OBJECTIVE: To determine if detectable serum tumor necrosis factor alpha (TNF) levels are associated with higher mortality in nursing home residents. SUBJECTS AND METHODS: The basal serum concentrations of TNF and interleukin-1 alpha (IL-1) were measured in 129 elderly nursing home patients (mean age of 89 years), and survival in the cohort was monitored over a 13-month period. RESULTS: At 4 months follow-up, seven out of 33 patients with detectable serum TNF levels had died (21.2%), and only three out of 96 patients with undetectable serum TNF levels had died (3.1%) (P less than 0.001). The difference in mortality remained significant up to 13 months of follow-up (P less than 0.05). Those with detectable serum TNF levels and those with undetectable levels were comparable in age, body mass index, hematocrit, lymphocyte counts, and serum level of albumin, prealbumin, and retinol-binding protein. When patients with detectable serum IL-1 levels were compared to those with undetectable levels, there were no significant differences in mortality over a 13-month period. CONCLUSION: Detectable serum TNF levels in elderly nursing home patients may be a predictor of early mortality.

Aged↗
PubMed1990

The value of assessing falls in an elderly population. A randomized clinical trial.

OBJECTIVE: To measure the effects of a specialized postfall assessment intended to detect causes and underlying risk factors for falls, and to recommend preventive and therapeutic interventions. DESIGN: Randomized, controlled trial. SETTING: A long-term residential care facility for elderly persons. SUBJECTS: Within 7 days of a fall, 160 ambulatory subjects (mean age, 87 years) were randomly assigned to receive either a comprehensive postfall assessment (intervention group, n = 79) or usual care (control group, n = 81). INTERVENTION: The postfall assessment included a detailed physical examination and environmental assessment by a nurse practitioner; laboratory tests; electrocardiogram; and 24-hour Holter monitoring. Probable cause or causes for the fall, identified risk factors, and therapeutic recommendations were given to the patient's primary physician. MEASUREMENTS AND MAIN RESULTS: Through use of the assessment, many remediable problems (for example, weakness, environmental hazards, orthostatic hypotension, drug side effects, gait dysfunction) were detected. At the end of the 2-year follow-up period, the intervention group had 26% fewer hospitalizations (P less than 0.05) and a 52% reduction in hospital days (P less than 0.01) compared with controls. Patients in the intervention group had 9% fewer falls and 17% fewer deaths than controls by 2 years, but these trends were not statistically significant. CONCLUSIONS: Our study suggests that falls are a marker of underlying disorders easily identifiable by a careful postfall assessment, which in turn can reduce disability and costs.

Accidental Falls↗
PubMed1990

An outbreak of an influenza-like illness in a nursing home.

As part of an ongoing infection surveillance program, data were collected on an outbreak of respiratory illness affecting 29% of residents in a 231-bed long-term care facility. Viral titers could be collected on 60% of the ill residents and respiratory syncytial virus (RSV) was established in 14 of the symptomatic patients and was thought to be the probable cause of the outbreak. Compared with previously reported long-term institutional outbreaks of RSV, there were significantly fewer cases of pneumonia (5% vs. 14% to 55%) and deaths (2% vs. 6% to 20%). However, morbidity was substantial in this outbreak, with 46% of patients suffering prolonged malaise and anorexia; the mean duration of symptoms was four weeks. Respiratory syncytial virus may be an important cause of respiratory illness in nursing homes and may be unappreciated if specific diagnostic methods are not employed. The recent availability of rapid diagnostic tests and specific antiviral therapy for RSV warrant further clinical studies to develop management strategies for this infection.

Aged↗