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Autonomic impairment may lead to increased prevalence of heart rate (HR) and blood pressure (BP) abnormalities in veterans with spinal cord injury (SCI). In addition, comorbid medical conditions and prescription medication use may influence these abnormalities, including bradycardia, and tachycardia, hypotension, hypertension as well as autonomic dysreflexia (AD), and orthostatic hypotension (OH).A retrospective review of clinical and administrative datasets in veterans with SCI and compared the prevalence rates between clinical values and ICD-9 diagnostic codes in individuals with tetraplegia (T: C1-C8), high paraplegia (HP: T1-T6), and low paraplegia (LP: T7 and below).The prevalence of clinical values indicative of a HR ≥ 80 beats per minute was higher in the HP compared to the LP and T groups. A systolic BP (SBP) ≤ 110 mmHg was more common in the T compared to the HP and LP groups, whereas the prevalence of a SBP ≥ 140 mmHg was increased in the LP compared to the HP and T groups. Diagnosis of hypertension was 39-60% whereas the diagnosis of hypotension was less than 1%. Diagnosis of AD and OH was highest in the T group, but remained below 10%, regardless of categorical lesion level. Antihypertensive medications were commonly prescribed (55%), and patients on these medications were less likely to have high BP. The odds ratio of higher SBP and DBP increased with age and body mass index (BMI).In veterans with SCI, the prevalence of HR and BP abnormalities varied depending on level of lesion, age, BMI, and prescription medication use.

High-quality care for intensive care unit patients and families includes palliative care. To promote performance improvement, the Agency for Healthcare Research and Quality's National Quality Measures Clearinghouse identified nine evidence-based processes of intensive care unit palliative care (Care and Communication Bundle) that are measured through review of medical record documentation. We conducted this study to examine how frequently the Care and Communication Bundle processes were performed in diverse intensive care units and to understand patient factors that are associated with such performance.Prospective, multisite, observational study of performance of key intensive care unit palliative care processes.A surgical intensive care unit and a medical intensive care unit in two different large academic health centers and a medical-surgical intensive care unit in a medium-sized community hospital.Consecutive adult patients with length of intensive care unit stay ≥5 days.None.Between November 2007 and December 2009, we measured performance by specified day after intensive care unit admission on nine care process measures: Identify medical decision-maker, advance directive and resuscitation preference, distribute family information leaflet, assess and manage pain, offer social work and spiritual support, and conduct interdisciplinary family meeting. Multivariable regression analysis was used to determine predictors of performance of five care processes. We enrolled 518 (94.9%) patients and 336 (83.6%) family members. Performances on pain assessment and management measures were high. In contrast, interdisciplinary family meetings were documented for20% of patients by intensive care unit day 5. Performance on other measures ranged from 8% to 43%, with substantial variation across and within sites. Chronic comorbidity burden and site were the most consistent predictors of care process performance.Across three intensive care units in this study, performance of key palliative care processes (other than pain assessment and management) was inconsistent and infrequent. Available resources and strategies should be utilized for performance improvement in this area of high importance to patients, families, and providers.

Critical care nurse communication training has largely been limited to didactic materials, interactive training for nurse supervisors, or brief participatory learning programs within the context of comprehensive end-of-life care educational seminars. Preliminary evidence suggests that an interactive approach can also be effective in communication skills training for intensive care unit (ICU) nurses.We implemented a 1-day educational intervention in five acute care hospitals within Veterans Integrated Service Network (VISN) 3 (New York-New Jersey region) of the Department of Veterans Affairs and focused solely on communication skills and targeted specifically to nurses providing bedside care for critically ill patients. A "learner centered" approach to skills training that has several integral components was employed. AMONG THESE ARE: a cognitive, evidence-based foundation upon which to build new skills; a method such as role-play that allows participants to practice newly learned skills; and an affective component, during which trainees can freely discuss their impressions of the exercise or explore difficulties that may have been encountered. Before and after the program we conducted a detailed assessment of participants' self-rated communication skills and of the techniques and materials we used.Post-program responses documented significant improvement in self-evaluated skills for each of the core tasks we assessed. Evidence suggests that communication with patients and families in the ICU can be most effectively approached in an interdisciplinary way. For nurses to fully realize their potential for optimal communication as members of the multidisciplinary team, they must be equipped with the necessary skills. We believe this new program helps to expand the range of approaches for training nurses in essential communication skills.

Background Intensive care unit (ICU) care could be improved by implementation of time-triggered evidence-based interventions including identification of a patient/family medical decision maker, the patient's advance directive status, and cardiopulmonary resuscitation preferences by Day 1; offer of social work and spiritual support by Day 3; and a family meeting establishing goals of care by Day 5. We implemented a program to improve care for ICU patients in five Department of Veterans Affairs' ICUs. Measures We measured the percent of ICU patients with lengths of stay of five or more days that received the care processes by the appropriate day. Intervention Critical care and palliative care providers trained ICU nurse teams to improve care through auditing, performance feedback, improvement tools, education, and monthly team meetings. Outcomes Pre- and postintervention care were compared. Offering social work and spiritual support, identification of the medical decision maker, and documentation of family meetings significantly improved. Conclusions/Lessons Learned ICU nurse teams can be engaged to improve care under the aegis of a collaborative quality improvement project.

Background: National-level data are needed on predictors of mild physical impairment among older adults to assist policy makers with resource allocation. Method: We analyzed data on adults above age 64 from the Medicare Current Beneficiary Survey (MCBS) with no activity of daily living (ADL) difficulties at baseline ( n = 14,226). Five ADLs were measured annually and recovery was defined as regaining complete ADL function at follow-up. Results: The strongest correlates of ADL difficulty were use of antipsychotic medications (adjusted odds ratio [AOR] = 1.93, 95% confidence interval [CI] = 1.44 to 2.58), instrumental ADL difficulty (AOR = 1.90, 95% CI = 1.74 to 2.07), and fair-poor general health (AOR = 1.59, 95% CI = 1.42 to 1.78). Only the number of incident ADL difficulties was associated with recovery (AOR = 0.02, 95% CI = 0.01 to 0.02). Conclusion: Identifying factors associated with development of mild physical impairment could help direct patients toward preventive care programs to preempt decline in physical function.

Objectives: Increases in emergency department (ED) visits may place a substantial burden on both the ED and hospital-based laboratories. Studies have identified laboratory turnaround time (TAT) as a barrier to patient process times and lengths of stay. Prolonged laboratory study results may also result in delayed recognition of critically ill patients and initiation of appropriate therapies. The objective of this study was to determine how ED patient volume itself is associated with laboratory TAT. Methods: This was a retrospective cohort review of patients at five academic, tertiary care EDs in the United States. Data were collected on all adult patients seen in each ED with troponin laboratory testing during the months of January, April, July, and October 2007. Primary predictor variables were two ED patient volume measures at the time the troponin test was ordered: 1) number of all patients in the ED/number of beds (occupancy) and 2) number of admitted patients waiting for beds/beds (boarder occupancy). The outcome variable was troponin turnaround time (TTAT). Adjusted covariates included patient characteristics, triage severity, season (month of the laboratory test), and site. Multivariable adjusted quantile regression was carried out to assess the association of ED volume measures with TTAT. Results: At total of 9,492 troponin tests were reviewed. Median TTAT for this cohort was 107 minutes (interquartile range [IQR] = 73–148 minutes). Median occupancy for this cohort was 1.05 patients (IQR = 0.78–1.38 patients) and median boarder occupancy was 0.21 (IQR = 0.11–0.32). Adjusted quantile regression demonstrated a significant association between increased ED patient volume and longer times to TTAT. For every 100% increase in census, or number of boarders over the number of ED beds, respectively, there was a 12 (95% confidence interval [CI] = 9 to 14) or 33 (95% CI = 24 to 42)-minute increase in TTAT. Conclusions: Increased ED patient volume is associated with longer hospital laboratory processing times. Prolonged laboratory TAT may delay recognition of conditions in the acutely ill, potentially affecting clinician decision-making and the initiation of timely treatment. Use of laboratory TAT as a patient throughput measure and the study of factors associated with its prolonging should be further investigated. ACADEMIC EMERGENCY MEDICINE 2010; 17:501–507 © 2010 by the Society for Academic Emergency Medicine

Background: Multifactor prognostic scoring systems have been developed for acute pancreatitis to identify those patients with a potentially poor prognosis. A similar system for patients with acute cholangitis is still lacking. Goals: To identify common clinical, biochemical, and etiologic variables that can be used to predict mortality and the need for early endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute cholangitis. Study: A retrospective study of 108 patients with acute cholangitis was performed at a single center. Univariate analysis and logistic regression were used to identify variables that were significantly associated and predictive of mortality and need for early ERCP. Results: Univariate analysis identified 18 variables significantly associated with mortality and 15 variables that predicted the need for early ERCP. Through logistic regression total bilirubin (P < 0.01), partial prothrombin time (P < 0.01), and presence of a liver abscess (P < 0.01) were found to be significant in predicting mortality. Alanine aminotransferase (P < 0.01) and white blood cell count (P < 0.01) were determined to be predictive of a need for early ERCP. The scoring systems for predicting mortality (93.9%, 80.7%) and early ERCP (98%, 91%) were both highly sensitive and specific, respectively. Conclusions: Acute cholangitis is a disease that presents with varying severity. We report a scoring system that can be used to identify patients at high risk of early mortality and those that may benefit from earlier ERCP.

The objective of this study was to evaluate the association of emergency department (ED) crowding factors with the quality of pain care.This was a retrospective observational study of all adult patients (or =18 years) with conditions warranting pain care seen at an academic, urban, tertiary care ED from July 1 to July 31, 2005, and December 1 to December 31, 2005. Patients were included if they presented with a chief complaint of pain and a final ED diagnosis of a painful condition. Predictor ED crowding variables studied were 1) census, 2) number of admitted patients waiting for inpatient beds (boarders), and 3) number of boarders divided by ED census (boarding burden). The outcomes of interest were process of pain care measures: documentation of clinician pain assessment, medications ordered, and times of activities (e.g., arrival, assessment, ordering of medications).A total of 1,068 patient visits were reviewed. Fewer patients received analgesic medication during periods of high census (50th percentile; parameter estimate = -0.47; 95% confidence interval [CI] = -0.80 to -0.07). There was a direct correlation with total ED census and increased time to pain assessment (Spearman r = 0.33, p0.0001), time to analgesic medication ordering (r = 0.22, p0.0001), and time to analgesic medication administration (r = 0.25, p0.0001). There were significant delays (1 hour) for pain assessment and the ordering and administration of analgesic medication during periods of high ED census and number of boarders, but not with boarding burden.ED crowding as measured by patient volume negatively impacts patient care. Greater numbers of patients in the ED, whether as total census or number of boarders, were associated with worse pain care.

The Geriatric Scholar Program (GSP) is a Department of Veterans Affairs' (VA) workforce development program to infuse geriatrics competencies in primary care. This multimodal educational program is targeted to primary care providers and ancillary staff who work in VA's rural clinics. GSP consists of didactic education and training in geriatrics and gerontology and in quality improvement (QI) and support to implement a local QI project; in addition, elective options include webinars, audio conferences, clinical practica, and mentoring. The program is effective in improving core competencies in geriatrics and in improving clinical care for older Veterans who receive health care in rural clinics.

Medication reconciliation (MR) has proven to be a problematic task for many hospitals to accomplish. It is important to know the clinical impact of physician- versus pharmacist-initiated MR in the resource-limited hospital environment.This quasi-experimental study took place from December 2005 to February 2006 at an urban US Veterans Affairs hospital. MR was implemented on 2 similar general medical units: one received physician-initiated MR and the other received pharmacist-initiated MR. Adverse drug events (ADEs) and a 72-hour medication-prescribing risk score were ascertained by research pharmacists for all admitted patients by structured record review. Multivariable models were tested for intervention effect, accounting for quasi-experimental design and clustered observations, and were adjusted for patient and encounter covariates.Pharmacists completed the MR process in 102 admissions and physicians completed the process in 116 admissions. In completing the MR process, pharmacists documented statistically more admission medication changes than physicians (3.6 vs 0.8; P0.001). The adjusted odds of an ADE caused by an admission prescribing change with pharmacist-initiated MR compared with a physician-initiated MR were 1.04 with a 95% CI of 0.53 to 2.0. The adjusted odds of an ADE caused by an admission prescribing change that was a prescribing error with pharmacist-initiated MR compared with a physician-initiated MR were 0.38 with a confidence interval of 0.14 to 1.05. No difference was observed in 72-hour prescribing risk score (coefficient = 0.10; 95% CI, -0.54 to 0.75).MR performed by pharmacists versus physicians was more comprehensive and was followed by lower odds of ADEs from admission prescribing errors but with similar odds of all types of ADEs. Further research is warranted to examine how MR tasks may be optimally divided among clinicians and the mechanisms by which MR affects the likelihood of subsequent ADEs.

Palliative care consultation teams in hospitals are becoming increasingly more common. Palliative care improves the quality of hospital care for patients with advanced disease. Less is known about its effects on hospital costs.To evaluate the relationship between palliative care consultation and hospital costs in patients with advanced disease.An observational study of 3321 veterans hospitalized with advanced disease between October 1, 2004 and September 30, 2006. The sample includes 606 (18%) veterans who received palliative care and 2715 (82%) who received usual hospital care. October 1, 2004 and September 30, 2006.We studied the costs and intensive care unit (ICU) use of palliative versus usual care for patients in five Veterans Affairs hospitals over a 2-year period. We used an instrumental variable approach to control for unmeasured characteristics that affect both treatment and outcome.The average daily total direct hospital costs were $464 a day lower for the 606 patients receiving palliative compared to the 2715 receiving usual care (p0.001). Palliative care patients were 43.7 percentage points less likely to be admitted to ICU during the hospitalization than usual care patients (p0.001).Palliative care for patients hospitalized with advanced disease results in lower costs of care and less utilization of intensive care compared to similar patients receiving usual care. Selection on unobserved characteristics plays an important role in the determination of costs of care.

Objectives 1. Recognize that wounds have significant negative impact on a person’s quality of life and wound pain is reported as the most distressing symptom. 2. Discuss the medications that have been studied in clinical trials as topical agents aimed at reducing pain in the wound. 3. Recognize Dermafill Cellulose Wound Care Dressing as a cost-effective treatment option for the management of wound pain in the hospice and palliative care setting. Background. There is growing evidence that wounds have significant negative impact on a person’s quality of life and wound pain is reported as the most distressing symptom. When reviewing evidence-based literature, the focus of the majority of studies is relief of pain during dressing changes as patients report the pain at time of dressing removal as the greatest pain related to the wound. The few studies that focused on overall wound pain reduction in the wound had limited success of pain reduction. Case description. A 67-year-old male admitted to hospice with end-stage cardiac disease presents with a painful leg wound as a result of ‘‘bumping into the coffee table.’’ Patient lives at home with his caregiver-wife. The patient has no known allergies. Patient’s chief complaint is pain and inability to ‘‘do anything because of this darn leg!’’ Patient rates pain at an 8 on the 0-10 scale with the pain escalating to a 10 when manipulated or touched. Patient currently takes oral pain medication without relief from pain. During this presentation, we will review past treatments, potential future treatment options, and conclude by presenting the treatment option we chosedDermafill, which reduced patient’s pain to a 0 on the 0e10 scale without any oral pain medications. Patient was able to walk without pain and reported a significant increase in his quality of life because of this product. Conclusion. The presenter recognizes Dermafill Cellulose Wound Care Dressing as a cost-effective treatment option for the management of wound pain in the hospice and palliative care setting. It is a valuable dressing in the treatment of wound pain. Physicians and nurses can perform weekly assessments without removing the dressing: eliminating the need for frequent and painful dressing changes in our patients.

Background Our objective was to examine the frequencies of medication error and adverse drug events (ADEs) at the time of patient transfer in a system with an electronic health record (EHR) as compared with a system without an EHR. It was hypothesised that the frequencies of these events would be lower in the EHR system because of better information exchange across sites of care. Methods 469 patients transferred between seven nursing homes and three hospitals in New York and Connecticut between 1999 and 2005 were followed retrospectively. Two groups of patients were compared: US Veterans Affairs (VA) patients, with an EHR, and non-VA patients, without an EHR, on the following measures: (1) medication prescribing discrepancies at nursing home/hospital transfer, (2) high-risk medication discrepancies and (3) ADEs caused by medication discrepancies according to structured medical record review by pairs of physician and pharmacist raters. Results The overall incidence of ADE caused by medication discrepancies was 0.20 per hospitalisation episode. After controlling for demographic and clinical covariates, there were no significant differences between VA and non-VA groups in medication discrepancies (mean difference 0.02; 95% CI −0.81 to 0.85), high-risk medication discrepancies (−0.18; 95%CI −0.22 to 0.58) or occurrence of an ADE caused by a medication discrepancy (OR 0.96; 95% CI 0.18 to 5.01). Conclusions There was no difference, with and without an EHR, in the occurrence of medication discrepancies or ADEs caused by medication discrepancies at the time of transfer between sites of care. Reducing such problems may require specialised computer tools to facilitate medication review.

Tumor necrosis factor (TNF)-alpha plays a significant role in conditioning related toxicities and the development of acute graft-versus-host disease (aGVHD). TNF-alpha gene polymorphisms are associated with rejection after organ transplantation and aGVHD in matched related donor blood and marrow transplantation (BMT) recipients. Few studies have been published on unrelated donor BMT in the pediatric age group. In this study, we examined the relationship between specific polymorphisms in TNF pathway genes and the occurrence and severity of aGVHD. Recipient single-nucleotide polymorphisms (SNPs) in TNF-alpha and TNF receptor superfamily members 1A (TNFRSF1A) and 1B (TNFRSF1B) were investigated. In a multi-institutional Pediatric Blood and Marrow Transplant Consortium trial, a total of 180 pediatric patients (mean age, 11.0 years) were prospectively evaluated for clinical outcomes after matched unrelated donor BMT. All patients received myeloablative conditioning and two-drug GVHD prophylaxis with cyclosporine or tacrolimus, with methotrexate in the majority of patients. TNF-alpha genotypes were not correlated with the overall incidence of aGVHD. Significant associations were seen between TNF-alpha variant alleles and the severity of aGVHD (grade II-IV and grade III-IV), especially when analyzed in whites only (n = 165). Grade II-IV aGVHD was correlated with recipient -857T allele (hazard ratio [HR], 0.47; P = .04), -238A allele (HR, 1.76; P = .002), and d3/d3 genotype (HR, 0.64; P = .03). Severe (grade III-IV) aGVHD was associated with TNF-alpha -1031C allele (HR, 2.38; P = .03), -863A allele (HR, 3.18; P = .003), and d4/d4 genotype (HR, 2.82; P = .01). After adjusting for clinical factors, the association of -1031C, -863A, -238A, and d4/d4 genotypes with severity of aGVHD remained statistically significant. No correlation between selected SNPs in TNFRSF1A or TNFRSF1B and the incidence or severity of aGVHD was found. Our findings indicate clinically important relationships between genetic polymorphisms in TNF-alpha and the severity of aGVHD in this cohort. Improved understanding of this relationship may allow for a risk-adjusted approach to GVHD prevention in pediatric BMT.

Communication about the deactivation of implantable cardioverter-defibrillators (ICDs) in patients near the end of life is rare.To determine whether hospices are admitting patients with ICDs, whether such patients are receiving shocks, and how hospices manage ICDs.Cross-sectional survey.Randomly selected hospice facilities.900 hospices, 414 of which responded fully.Frequency of admission of patients with ICDs, frequency with which patients received shocks, existence of ICD deactivation policies, and frequency of deactivation.97% of hospices admitted patients with ICDs, and 58% reported that in the past year, a patient had been shocked. Only 10% of hospices had a policy that addressed deactivation. On average, 42% (95% CI, 37% to 48%) of patients with ICDs had the shocking function deactivated.The study relied on the knowledge of hospice administrators.Hospices are admitting patients with ICDs, and patients are being shocked at the end of life. Ensuring that hospices have policies in place to address deactivation may improve the care for patients with these devices. The authors provide a sample deactivation policy.National Institute of Aging and National Institute of Nursing Research.

Feasibility of Symptom and Quality-of-Life (QOL) Assessment in a VA Network-Based Palliative Care (PC) Program Elayne Livote, MPH MS MA, Bronx VAMC, Bronx, NY. Victor Chang, MD, VA New Jersey Health Care System, East Orange, NJ. Therese Cortez. Robert Heyding, MD, Brooklyn, NY. Carol Luhrs, MD FAAHPM, VA New York Harbor Healthcare System, Brooklyn, NY. Joan Penrod, PhD, and James J. Peters, VAMC, Bronx, NY. (All speakers have disclosed no relevant financial relationships.)