With Support from The Donald W. Reynolds Foundation and The John A. Hartford Foundation

© The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved.

Christine M. Khandelwal, DOKevin Biese, MD, MAT

Ellen Roberts, PhD, MPH

Jan Busby-Whitehead, MD

The University of North Carolina at Chapel Hill

Learning ObjectivesLearning Objectives

• Learners will be able to list the most common types of iatrogenic injuries.

• Learners will be able to identify the most common cause of nosocomial fever in the hospital.

• Learners will be able to identify the reasons for use of restraints and how to avoid using them.

• Learners will be able to list the appropriate use of urinary catheters.

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The Case of Mrs. TWThe Case of Mrs. TW

Mrs. TW is a 79yo female with history of HTN, MCI, and urge incontinence, who was admitted for a pneumonia. She is stable on admission and sent to the floor with a foley catheter in-place.

Mrs. TW has an uneventful 24 hours, clinically stable and doing well with plans for discharge the next morning to home.

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Copyright © 2011 Lighthouse InternationalAll rights reserved.

BACKGROUNDBACKGROUND

• Cascade iatrogenesis is a series of adverse events triggered by an initial medical or nursing intervention initiating a cascade of decline.» Occurs most frequently among the oldest,

most functionally impaired patients and those with a higher severity of illness upon admission.

Creditor 1993, Hofer 2002, Thomas 2000

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BACKGROUNDBACKGROUND

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• Hospitalization for the elderly is often followed by an irreversible decline in functional status and a change in quality and style of life.

Elders are at high risk for poor outcome High 1 year mortality Thirty percent (30%) functional decline High rates of skilled nursing facility placement

Creditor 1993, Hofer 2002, Thomas 2000

Iatrogenesis in Older PatientsIatrogenesis in Older Patients

• Age-related factors that predispose the older patient to iatrogenesis

• More co-morbid, chronic medical conditions that require more diagnostic procedures and medications

• Increased severity of illness and complexity of care

• Longer length of stay

Hofer 2002, Thomas

2000

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Elderly Are the Most Likely to Elderly Are the Most Likely to Suffer…Suffer…

Adverse Drug Events

Delirium

Nosocomial Infections

Falls

Procedural/Surgical Complications

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Adverse Drug EventsAdverse Drug Events

• Most common type of iatrogenic injury

• Predictors» > 4 meds» LOS > 14 days» > 4 active medical problems

• # of drugs is the strongest predictor; potential for interaction: 2 drugs 6%, 5 drugs 50%, ≥ 8 drugs nearly 100%

• 70-80% of ADEs in the elderly are dose related

• 30-50% preventable! Carbonin P et al. 1991

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Adverse Drug EventsAdverse Drug Events

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• Other ADE Predictors:

Multiple medical problemsMultiple medicationsNew medications addedLow weight, female gender, impaired creatinine clearance

Carbonin 1991;Thomas and Brennen BMJ 2000

Adverse Drug EventsAdverse Drug Events

Common Drugs Common Effects

Anticholinergics Mental Status

Psychotropics Urinary Complications

Sleepers Infections

Narcotics Gastrointestinal

Digoxin Falls

Anti-hypertensives

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The Case of Mrs. TWThe Case of Mrs. TW

Twenty four hours after admission, nursing staff call to report that Mrs. TW is “yelling out and trying to catch the butterfly in the hall.” With further report from the nurse, the patient has a fever.

Staff is requesting to keep Mrs. TW “quiet tonight” as they are short-staffed and will not be able to control her tonight.

What is the source of her

fever? Could this have been

prevented?

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DeliriumDelirium

• Delirium is one of the most common iatrogenic complications in hospitalized elders affecting 50% or more post-operative hip fracture and thoracic surgery patients over age 65.

• We don’t diagnose it!

Elie 1998, Ely 2004, Inouye 1996, Inouye 2006, Pompei 1994

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Risk Factors for Delirium

• Age ≥ 70 years• Existing cognitive impairment• Functional impairment • Alcohol abuse • Abnormal preoperative level of sodium,

potassium or glucose• Preoperative psychotropic drug use• Depression • Increased comorbidity • Living in a long-term care facility• Visual or hearing impairment

Preventing DeliriumPreventing Delirium

• At least 3 clinical trials suggest that minimizing risk factors in hospital can reduce delirium:

» Management of six risk factors for delirium (cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration) reduced the number and duration of episodes of delirium (Inouye, S.K., 1998)

Inouye 1999, Marcantonio 2001, Millsen 2001

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Preventing Delirium

» Geriatrics consultation reduced delirium in the acute hospital management of hip-fracture patients (Marcantonio, E.R., 2001)

» A nurse-led interdisciplinary intervention

program for delirium led to shorter duration and less severe delirium (Millisen, K., 2001)

Treatment for DeliriumTreatment for Delirium

• Almost no drug studies of established delirium• Most experts would use traditional or atypical

antipsychotic agents in low dose for agitated delirium treatment» What about anticholinesterase inhibitors?

(Donepezil use in the prevention and treatment of post-

surgical delirium did not prevent delirium.)

Liptzin 2005, Sampson 2007

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Nosocomial InfectionsNosocomial Infections

• Infections are usually related to a procedure or treatment used to diagnose or treat the patient’s initial illness or injury

• 36% of these are preventable!

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UTIsPneumoniaSurgical wound infectionsClostridium difficile colitis

Urinary CathetersUrinary Catheters

• 25% of hospitalized pts have indwelling catheter

• Associated with LOS, inpatient mortality

• Inappropriate for over 50% of inpatient days

• Uncomfortable / Restrictive

Jain 1995, Saint 1999

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Urinary CathetersUrinary Catheters

• Catheter-associated urinary tract infections (CAUTIs) represent the most common nosocomial infection, accounting for 40% of all hospital-acquired infections.

• Foley catheters are commonly placed without a compelling indication, and are a preventable cause of hospital-acquired infections.

Saint 2000, Saint 2002

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Indications for Urinary Indications for Urinary CatheterizationCatheterization

• Output monitoring of unstable patients

• Complete urinary retention

• Urinary incontinence in patients with wounds or skin defects

• Urinary incontinence in general is not an indication for catheterization, but it may be considered for patient comfort at the request of the patient or family

• Terminally ill patients

• Perioperative use

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If Not a Foley…What Instead?If Not a Foley…What Instead?

• Prevention and Treatment – » Plan may include reviewing medications

(opiates, anti-cholingerics, diuretics, alpha-adrenergic agonists, calcium-channel blockers are offenders)

» Treat UTI (contributes to urge incontinence)

» Treat constipation

» Seek any reversible causes of delirium

» Regular toileting schedule

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The Case of Mrs. TWThe Case of Mrs. TW

Wrist restraints were placed on Mrs. TW to help maintain her delirium tonight. Three hours later, nursing staff calls you to report a fall for Mrs. TW. You order a stat hip x-ray and an acute fracture is found.

What was the cascade of events? Could any of this been prevented?

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Why are Restraints Used?Why are Restraints Used?

• Prevent falls• Prevent injuries• Prevent treatment disruption• Manage confusion

AGS Positional statement 2008, Tzeng 2008, Antonelli 2008

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AGS Positional Statement:AGS Positional Statement:Restraints are acceptable to use:

• If there is no safer alternative

• If patient is at significant risk of self-harm or injury to others

• At the patient's request

• Short-term use to enable emergent treatment that may result in a less confused patient

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American Geriatrics Society, AGSPosition statement: Restraint use.2008

To Restrain or Not to Restrain…To Restrain or Not to Restrain…

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• Restraints are associated with:

increased rates of pressure sores increased incidence of nonsocomial infections distress falls

American Geriatrics Society, AGSPosition statement: Restraint use.2008

If Not a Restraint…What If Not a Restraint…What Instead?Instead?

• Non-pharmacological» Cognitive» ◦ Orientation (calendar, caregiver names)» ◦ Activities (cognitively stimulating) » Sleep

• ◦ Regular routine

• ◦ Sleep aids (relaxing music, massage)

• ◦Environmental (eliminate noise, night-time meds)

» Mobility (range of motion, limit IV’s, etc)» Visual Aids (glasses, large dial phones)» Hearing Aids (check ear wax) » Volume repletion for dehydration Inouye 1999

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Pharmacologic TreatmentPharmacologic Treatment

• No medication is FDA approved for the treatment of delirium

• No published double-blind, randomized, placebo controlled trials» ◦ Few controlled trials

» ◦ Small numbers

» ◦ Various patient populations post-op, ICU, cancer, AIDS, hip fractures

Slide from Rachelle Bernacki MD Bree Johnston MD Division of Geriatrics University of California San Francisco and San Francisco, VA Medical Center

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Reduce FallsReduce Falls

• Reduce restraint use / lower bed rails

• Prevent delirium

• Sensor alarms

• Lower the bed

• Non-slip shoes

• Remove obstacles

• Commode / toilet schedule

Gillespie 1997, Myers 2003, Currie 2006

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FallsFalls

• Falls frequently occur in hospitals, and the patients most likely to fall are older patients

• Approximately 2% to 12% of patients experience at least one fall during their hospital stay

• These complications often result in a longer length of stay and lead to greater healthcare costs

Chelly 2008, Bates 1995, Alexander 1992

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Fall RisksFall Risks

• Visual impairment• Hypotension / anti-hypertensives• Anticholinergics / sedative-hypnotics• Obstacles / slick surfaces• Elevated bed height• Confinement ….restraints!

Gillespie 1997, Myers 2003

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Fall Prevention StrategiesFall Prevention Strategies

• Unfortunately, there are no specific recommendations to reduce the risk for falls in the acute care setting.

• However, some fall prevention strategies in the literature appear to offer an overwhelming reduction in the incidence of falls among hospitalized elderly patients.

American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention 2011

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Fall Prevention StrategiesFall Prevention Strategies

• Frequent and varied staff education and re-education to promote and sustain sensitivity to the risk for falls among hospitalized elders.

• Tools to assess risk for falls. Because most patients' fall risks are multifactorial and the factors are intertwined, the most effective strategies will be interdisciplinary.

• The use of "sitters" for confused patients.

American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention 2011

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ConclusionConclusion

• Avoidance of unnecessary Foley catheter placement is an important method to reduce nosocomial infections.

• Immobilizing patients during hospitalization is contrary to therapeutic goals of restoring normal mobility and function as quickly as possible.

• The number and severity of falls can be reduced by adopting quality improvement strategies, relevant and practical fall risk assessment tools, and staff education.

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Acknowledgements and Acknowledgements and DisclaimerDisclaimer

This project was supported by funds from The Donald W. Reynolds Foundation, the American Geriatrics Society/The John A. Hartford Foundation Geriatrics for Specialists Grant.  This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by The Donald W. Reynolds Foundation, the American Geriatrics Society or The John A. Hartford Foundation.

The UNC Center for Aging and Health, the UNC Division of Geriatric Medicine, the UNC Department of Emergency Medicine, and the UNC Department of Family Medicine also provided support for this activity. This work was compiled and edited through the efforts of Carol Julian.

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© The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved.