Biomedical subjects
S V Wilking
Publications and source records attributed to S V Wilking.
Do-not-resuscitate orders at a chronic care hospital.
Do-not-resuscitate (DNR) orders have become an accepted part of medical practice. While these orders have been extensively evaluated in acute care hospitals, little is known about their use in the long-term care setting. We reviewed the medical records of all admissions to a chronic care hospital over a 13-month period, collecting data on selected patient characteristics, use of DNR orders, and patient outcomes during the 6-week period following admission. Fifty-eight of the 301 patients (19.3%) had a DNR order written. Patients' families were involved predominantly in the DNR decision in 73% of the cases while patients themselves were involved in only 18%. Physicians made the decision unilaterally in 6% of the cases. Patients' functional status rather than specific diagnoses predicted the use of DNR orders. Patients with DNR orders were twice as likely to receive new intravenous therapies than patients without those orders (71% vs 33%, P less than 0.01) and four times as likely to die (38% vs 9%, P less than 0.01). They were no more likely to be transferred emergently to an acute care hospital (5% vs 9%, P greater than 0.2). We conclude that DNR orders are not infrequently used, and physicians rarely make the decision unilaterally. Patients with DNR orders have a high likelihood of dying and are infrequently transferred to acute care facilities.
The short-term outcome of pressure sores.
Patients with pressure sores have been observed to have a poor prognosis. The short-term outcome of pressure sores at a long-term care hospital was therefore evaluated. Medical records on the 301 admissions to this hospital over a 13-month period were reviewed. One hundred patients (33%) had a pressure sore present on admission. Using ordinary therapies, 79% of these pressure sores improved and 40% completely healed during the 6-week follow-up period. Remaining bed- or chair-bound was the sole patient characteristic associated with a failure of the pressure sore to improve. Mortality rates were significantly increased in patients with a pressure sore present on admission (relative risk [RR] = 1.9), in patients who developed a new sore (RR = 3.1), and in patients in whom the pressure sore failed to improve (RR = 3.3). However, the pressure sores did not appear to be the direct cause of this increased mortality. These data suggest that the majority of pressure sores encountered at a long-term care hospital can be successfully managed in this setting. Although patients with pressure sores have an increased mortality rate, this is most likely due to coexisting medical conditions.
Risk factors for pressure sores. A comparison of cross-sectional and cohort-derived data.
The purpose of this study was to identify prospectively risk factors for pressure sores and to compare these results with a cross-sectional analysis in the same population. Medical records on all admissions to a chronic care hospital over a 13-month period were reviewed. Data on potential risk factors were abstracted from the initial history, physical examination, nursing assessment, and laboratory studies. Pressure sore status on admission and at three weeks was determined from a standardized from completed on all patients with a score. The cross-sectional analysis was performed by comparing patients with and without a pressure sore at the time of admission. The cohort analysis used patients initially without a pressure sore and monitored for a new sore at three weeks. Factors associated with pressure sores on univariate testing were entered into a stepwise logistic regression model. One hundred of the 301 admissions presented with a pressure sore. Factors significantly associated with the presence of a sore were altered level of consciousness (OR = 4.1), bed- or chair-bound (OR = 2.4), impaired nutritional intake (OR = 1.9), and hypoalbuminemia (OR = 1.8 for 10 mg/mL decrease). Of the 185 patients without a pressure sore, 20 (10.8%) developed a sore. Factors significantly associated with the development of a new pressure sore were a history of cerebrovascular accident (OR = 5.0), bed- or chair-bound (OR = 3.8), and impaired nutritional intake (OR = 2.8). Neither urinary nor fecal incontinence, nor the presence of hypoalbuminemia, was associated with sore development. We have prospectively identified risk factors for pressure sores.(ABSTRACT TRUNCATED AT 250 WORDS)
Determinants of isolated systolic hypertension.
Isolated systolic hypertension (ISH), defined as systolic blood pressure of 160 mm Hg or greater when the diastolic pressure is less than 95 mm Hg, is a common form of hypertension among the elderly. We collected incidence and prevalence data on ISH and evaluated several potential factors for its occurrence in the Framingham Heart Study during 16 biennial examinations. The factors evaluated were age, sex, all components of the blood pressure (systolic and diastolic blood pressure, pulse pressure, and mean arterial pressure), Metropolitan relative weight, serum cholesterol level, serum uric acid level, cigarette smoking, ventricular heart rate, glucose intolerance, and hematocrit. The population at risk (1687 men and 1992 women) were those members of the Framingham cohort with a systolic blood pressure less than 160 mm Hg in the first four biennial examinations. Results showed ISH in 14.4% of the men and 22.8% of the women. Cumulative incidence rates were 418 per 1000 in men and 533 per 1000 in women. Significant risk factors for ISH were age, sex, all components of the blood pressure, and increased relative weight in women. We conclude that ISH is a highly prevalent disorder. Its major determinants are age, sex, increasing levels of blood pressure, and obesity in women.
An elderly woman with isolated auditory hallucinations.
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