Biomedical subjects
K Culp
Publications and source records attributed to K Culp.
Delirium in elderly patients: an overview of the state of the science.
Delirium is a common and potentially preventable and reversible cause of functional disability, morbidity, mortality, and increased health care use among elderly individuals. Much has been learned about delirium in the past decade. Highlighted in this article are recent advances in the diagnosis of delirium, delirium in long-term care, use of health care resources, outcomes of delirium, etiologies, and interventions to prevent and treat delirium. Suggestions for future research also are proposed.
Training of acute confusion resource nurses. Knowledge, perceived confidence, and role.
Most nurses function as generalists; however, some function in "expert" roles based on informal training as Resource Nurses. Training usually focuses on assessment and management of a specific problem, with the goal of creating a readily available "expert" for every unit. The primary activity of the Resource Nurse is to provide expert care, education, and consultation for patients, families, and staff. The Iowa-Veterans Affairs Nursing Research Consortium (IVANRC) addressed the need to manage acutely confused/delirious clients by training staff nurse volunteers (N = 129) from all units of the four Iowa Veterans Affairs facilities to act as unit-based acute confusion Resource Nurses (ACRNs). A day-long workshop included didactic content addressing etiology and presentation of acute confusion (AC), use of the IVANRC protocol to assess for AC, and basic information on treatment and management of AC. The nurses also participated in an efficacy-based experiential learning program on AC assessment that involved demonstrating assessment of AC and role enactment practice exercises in which ACRNs practiced the assessment. A test of knowledge of AC and perceived level of confidence in assessing acutely confused patients was administered before and after completion of the program. Paired t tests comparing pre- and posttest scores showed that knowledge and confidence significantly increased for the nurses as a result of their participation in the educational program. Eighteen months later, a second program was conducted to update current ACRNs and train additional RNs to enact this role. Pre- and posttest scores were obtained, with paired t tests showing a significant increase in knowledge for the participants. Twenty-four (49%) of the second program attendees had attended the first program. These participants had significantly higher scores on the second program pretest than those participants who had not attended the previous program, indicating a retention of knowledge from the first program.
Studying acute confusion in long-term care: clinical investigation or secondary data analysis using the minimum data set?
Clinical investigations of acute confusion have largely been initiated in the acute care setting, where no uniform patient assessment exists. No reliable estimates of the prevalence of acute confusion in long-term care (LTC) residents have been reported. Delirium indicators are present in the nursing home Minimum Data Set (MDS), suggesting that MDS assessments could be used to facilitate studies of acute confusion in LTC. Methods to study acute confusion in LTC are discussed, with an emphasis on the advantages and disadvantages of using secondary analysis of MDS assessments as one research strategy.
Renal osteodystrophy in older adults with end-stage renal disease.
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Acute confusion assessment instruments: clinical versus research usability.
Acute confusion (AC), also referred to as delirium (AC/delirium), is a common problem seen by health professionals who work in a variety of care settings. This is an evaluative report on the clinical usability of instruments to assess AC/delirium as a part of nursing practice. Specifically, five instruments [the Confusion Assessment Method (CAM), Delirium Rating Scale (DRS), Delirium Symptom Inventory (DSI), Mini-Mental State Examination (MMSE), and Neelon/Champagne (NEECHAM) Confusion Scale] are discussed. The work demonstrates how the cooperation of nurses in practice, education, and research can improve both patient and staff outcomes.
Health status and resources of rural homeless women and children. Iowa Homeless Research Team.
The purpose of this research is to describe the health status and health resources for homeless women and children in a Midwestern rural community. A group of 31 rural homeless women in a shelter participated in the study by answering questions on the Rural Homeless Interview developed by the investigators. The findings revealed higher than expected rates of illness, accidents, and adverse life events, with the incidence of substance abuse and mental illness being comparable to data from other homeless populations. The data on children were limited by lack of knowledge on the part of their mothers. Some mothers reported that their children were in foster care, had been adopted, or were being cared for by others. The inability to access health and dental care was reported by half of the participants.
Acute confusion indicators: risk factors and prevalence using MDS data.
Long-term care (LTC) Minimum Data Set (MDS) data from a Midwestern state were analyzed to validate whether components of a conceptual model developed from findings in acute care identified acute confusion risk variables in LTC. The prevalence of probable acute confusion in this sample was 13.98% (n = 324). Using a cross-sectional design, both univariate and unconditional stepwise logistic regression analyses were accomplished with presence or absence of probable acute confusion as the outcome variable (N = 2,318). Variables significantly related to acute confusion by univariate analysis were included in the logistic regression analysis. Inadequate fluid intake was the first variable to enter the stepwise equation and was highly significant (OR 3.40, 95% CI 2.99-3.81, p < .0001). Other significant variables included a diagnosis of dementia or a fall in the last 30 days. Implications for nursing practice, education and research are discussed.
Computer simulation: making better operational and architectural ED design decisions.
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Unit-based acute confusion resource nurse: an educational program to train staff nurses.
Despite the high prevalence of acute confusion among elders and the importance of its early detection, there are few reports of systematic efforts to increase staff competence. This article describes the development and evaluation of an 8-hour educational program designed to prepare staff nurses to perform in a new role, the unit-based acute confusion Resource Nurse (ACRN). Pre- and posttest scores were obtained for the 80 registered nurses who participated in the program. Paired t tests showed that knowledge and confidence significantly increased for participants as a result of their participation in the educational program. This program can serve as an effective model for geriatric staff education.
Using the Quetelet body mass index as a mortality indicator for patients starting renal replacement therapy.
OBJECTIVE: The purpose of this study was to compare clinical profiles and mortality risk of patients starting renal replacement therapy (RRT) across three Quetelet body mass index (BMI) classifications: lean, normal, and obese. SAMPLE/SETTING: All patients applying for dialysis services using Health Care Financing Administration (HCFA) from 2728-U4 were sampled during the period of April 1, 1995 through June 30, 1995 in two end-stage renal disease (ESRD) Networks. These two ESRD networks encompassed 7 states and provided 846 patients for this analysis. DESIGN: A descriptive survival study was used with a follow-up period of 18 months. METHODS: The Quetelet BMI was calculated based on dividing the predialysis (i.e. before the first dialysis) weight in kilograms by the height in meters squared (kg/m2). Lean, normal, and obese groups were established by quartiles for each gender. A normal BMI consisted of all patients in which the observed BMI was greater than the 25th percentile or less than the 75th percentile. RESULTS: The lean risk group had more health problems than either the normal or obese group, most notably, a higher prevalence of chronic obstructive pulmonary disease (n = 35, 16.99%) [p = 0.007] and peripheral vascular disease (n = 51, 24.76%) [p = 0.005]. CONCLUSIONS: Death risk was higher in the lean group compared to the normal group after adjusting for age, sex, diabetes, coronary artery disease (CAD), and albumin ratio levels. Based on the simplicity of this technique, recommendations for using the Quetelet BMI as a part of routine patient screening is advocated. Obtaining height and weight are necessary assessment parameters for patients starting dialysis therapy. Using the Quetelet BMI will help nurses to identify those patients who are at nutritional risk.
Screening for acute confusion in elderly long-term care residents.
While acute confusion (AC) is frequently studied in the hospitalized elderly population, this phenomena has been largely ignored in elders who are residents in long-term care (LTC) facilities. The purpose of this study was to estimate the prevalence of AC in older LTC residents, the antecedent conditions present at the time of the AC event and the recognition rate of AC when assessed by staff nurses in two LTC facilities. This is a descriptive, longitudinal study with a 14 day follow-up period which incorporates a screening algorithm using AC instruments with established psychometric properties. A behavioral symptom instrument was also used in order to classify AC cases into clinical subtypes: hyperkinetic, hypokinetic and mixed. Staff nurses, using traditional assessment techniques and blinded to the case screening algorithm outcome, were asked to randomly evaluate both residents who were "clear" and those experiencing AC. Screening was conducted at both daytime and evening time-points. Of the 37 subjects followed. 15 (40.5%) screened positive for AC. Those AC cases with compromised cortical functioning indicative of Alzheimer's disease (n = 4) were particularly vulnerable to poor fluid intake. High risk medications (n = 7) and urinary tract infections (n = 7) were the most frequent antecedents. Most of the subjects experienced two or more antecedent conditions at the time of their AC. Staff nurses were able to identify 4 (26.7%) of the 15 instrument-positive residents, none of which were of a hypokinetic clinical subtype. These early results suggest a high prevalence of AC among elders in LTC, which may go unrecognized by bedside care providers.
Modeling mortality risk in hemodialysis patients using laboratory values as time-dependent covariates.
Proportional hazards analyses assume that the magnitude of mortality risk for a predictor variable remains proportional over time. In a time-dependent model, the explanatory variable violates this assumption, and repeat observations are required to accommodate the change in risk that occurs over time. Using a retrospective cohort design, we tested the following laboratory values for a time-by-covariate interaction: hematocrit (HCT), serum albumin (ALB), and serum creatinine (CR). A random sample of 4,083 hemodialysis patients whose specimens were analyzed in a central laboratory over a 3-year period served as the study group. Using the baseline observation, we discovered significant probability values for the interaction terms TIME*CR (P = 0.013) and TIME*ALB (P < 0.01). The beta coefficient for TIME*HCT was not significant, indicating that the proportional hazard assumption was not violated by this covariate. Based on these results, we fitted a multivariate regression model containing two time-dependent covariates (CR and ALB) using a data structure that incorporated repeat observations of these laboratory values. Patients with high ALB levels experienced the lowest mortality risk. Similarly, serum CR levels were higher in long-term survivors. This analysis verifies the clinical importance of monitoring ALB and CR levels over time and the hazard of using a single laboratory observation to make long-term projections. Additionally, the predictive values of the time-dependent covariates ALB and CR affirm the significance of nutritional approaches directed toward maintaining visceral and somatic protein content throughout renal replacement therapy.
Geriatric hemodialysis patients: a comparative study of vascular access.
OBJECTIVES: To compare vascular access in hemodialysis patients > or = 65 years of age with those < 65 years on the following: 1) comorbid disease status, 2) types of vascular access used, and 3) outcome. SAMPLE/SETTING: Hemodialysis patients in a four-state region (Iowa, Kansas, Nebraska, and Missouri) from both free-standing and hospital-affiliated providers were sampled (n = 267). A stratified sampling strategy was used in order to obtain approximately equal-sized age groups (< 65 years and > or = 65 years). DESIGN: A descriptive, longitudinal study with a 1-year follow-up period. METHODS: Following the placement of a permanent vascular access, information was collected by the dialysis nursing staff about the configuration of the access, needle gauge used for cannulation, dialysis prescriptions, diabetic status, and other comorbid disease conditions. Odds ratios (OR) for vascular access thrombosis (VAT) risk were calculated between the two age groups. RESULTS: Comparisons between the two age groups suggest a higher frequency of polytetrafluorethylene (PTFE) grafts in the > or = 65-year-old age group. Peripheral vascular disease (PVD) prevalence was also higher in elders. Oral anticoagulants reduced the risk of VAT in those < 65-year-old group. Patients age > or = 65 years with a PTFE graft experienced a higher risk of VAT (OR 3.38, 95% confidence interval 1.43, 8.11) than those in the same age group with an arteriovenous fistula (AVF). CONCLUSIONS: PTFE grafts are used more frequently among geriatric hemodialysis patients, possibly due to the increased prevalence of peripheral vascular disease (PVD). While use of oral anticoagulants is effective in reducing the risk of VAT among those < 65 years, it did not significantly reduce VAT risk in geriatric hemodialysis patients. This observation may be due to the higher frequencies of PTFE grafts in elderly patients.
Vascular access thrombosis in new hemodialysis patients.
This study identifies factors that are associated with the risk of access thrombosis in 267 new hemodialysis patients. There are few longitudinal studies evaluating the risk of access thrombosis despite the need for long-term use of the access for maintenance hemodialysis. We used a prospective design following patients from 26 providers in Renal Network Council #12 (Iowa, Missouri, Kansas, and Nebraska) for 1 year who were starting hemodialysis. There were significant increases in access thrombosis relative risk (RR) associated with the placement of a polytetrafluoroethylene graft compared with patients with the arteriovenous fistula (RR 1.98; 95% confidence interval [CI] = 1.3, 3,01). The probability of remaining thrombosis free 90 days after first use was 90.1% (95% CI = 82.9, 94.4) for arteriovenous fistula patients, but only 71.6% (95% CI = 63.5, 78.2) for polytetrafluoroethylene graft patients. In arteriovenous fistula patients with more than 30 days maturity time the risk of thrombosis was significantly lower than in those with less maturity time (RR 0.40; 95% CI = 0.14, 0.84); however, there was no significant difference for maturity time among patients with a polytetrafluoroethylene graft. Reduced thrombosis risk also was observed in patients with dialyzer blood flow rates greater than 300 mL/min (RR 0.66; 95% CI = 0.44, 0.99). Total heparin dose and erythropoietin therapy were not associated with the risk of thrombosis. No differences in risk were found for age, renal diagnosis, or type of dialyzer.
Comparison of autofocus methods for automated microscopy.
Traditional autofocus methods were designed for microscopes driven by single processor computers. As computers are developed that exploit massive parallelism when acquiring and analyzing images, parallel cellular logic techniques became available to focus automatically. This paper introduces the reader to both cellular logic techniques for autofocus and a new spectral moment autofocus measure. It then compares these methods with more traditional autofocus methods. It is shown that traditional methods based on measurements of image power-give the best results when tested on one set of real images and two sets of synthetic images. The next best methods are the cellular logic and spectral moment techniques, while the worst are those based on the image probability density function or histogram.
Intrahospital transport of the critically ill adult: a research review and implications.
Transporting the critically ill adult from the relative stability of the critical care environment to a testing site or new area is a nursing responsibility. Yet current research about the risks and benefits of intrahospital transport is at times conflicting. This article provides an analysis of available research on the critical elements involved in intrahospital transport and suggests recommendations for clinical practice.