Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: A randomized controlled trial of Acute Care for Elders (ACE) in a community hospital
depression; illness; program; Geriatrics & Gerontology; consultation; institutionalization; functional decline; aged; medical unit; comprehensive geriatric assessment; decline; hospital outcomes; quality of care
BACKGROUND: Older persons frequently experience a decline in function following an acute medical illness and hospitalization. OBJECTIVE: To test the hypothesis that a multicomponent intervention, called Acute Care for Elders (ACE), will improve functional outcomes and the process of care in hospitalized older patients. DESIGN: Randomized controlled trial. SETTING: Community teaching hospital. PATIENTS: A total of 1531 community-dwelling patients, aged 70 or older, admitted for an acute medical illness between November 1994 and May 1997. INTERVENTION: ACE includes a specially designed environment (with, for example, carpeting and uncluttered hallways); patient-centered care, including nursing care plans for prevention of disability and rehabilitation; planning for patient discharge to home; and review of medical care to prevent iatrogenic illness. MEASUREMENTS: The main outcome was change in the number of independent activities of daily living (ADL) from 2 weeks before admission (baseline) to discharge. Secondary outcomes included resource use, implementation of orders to promote function, and patient and provider satisfaction. RESULTS: Self-reported measures of function did not differ at discharge between the intervention and usual care groups by intention-to-treat analysis. The composite outcome of ADL decline from baseline or nursing home placement was less frequent in the intervention group at discharge (34% vs 40%; P =.027) and during the year following hospitalization (P = .022). There were no significant group differences in hospital length of stay and costs, home healthcare visits, or readmissions. Nursing care plans to promote independent function were more often implemented in the intervention group (79% vs 50%; P = .001), physical therapy consults were obtained more frequently (42% vs 36%; P = .027), and restraints were applied to fewer patients (2% vs 6%; r = .001). Satisfaction with care was higher for the intervention group than the usual care group among patients, caregivers, physicians, and nurses (P <.05). CONCLUSIONS: ACE in a community hospital improved the process of care and patient and provider satisfaction without increasing hospital length of stay or costs. A lower frequency of the composite outcome ADL decline or nursing home placement may indicate potentially beneficial effects on patient outcomes.
Counsell S R; Holder C M; Liebenauer L; Palmer R M; Fortinsky R H; Kresevic D M; Quinn L M; Allen K R; Covinsky K E; Landefeld C S
Journal of the American Geriatrics Society
2000
2000-12
Journal Article or Conference Abstract Publication
<a href="http://doi.org/10.1111/j.1532-5415.2000.tb03866.x" target="_blank" rel="noreferrer noopener">10.1111/j.1532-5415.2000.tb03866.x</a>
Streptococcus bovis Group Bacteremia in the 21st Century Review of 42 Episodes Over a 12-Year Period (2006-2017) at a Large Community Teaching Hospital
association; bacteremia; colonic neoplasia; consultation; endocarditis; identification; Immunology; Infectious Diseases; liver-disease; lutetiensis; mortality; Streptococcus; Streptococcus bovis group; Streptococcus gallolyticus; Streptococcus infantarius; Streptococcus pasteurianus; update
Introduction Advanced phenotypic, genomic, and proteomic laboratory techniques have recently modified Streptococcus bovis group (SBG) nomenclature. We wished to determine if physicians continue to recognize the importance of SBG and its association with gastrointestinal (GI) tract abnormalities and infective endocarditis amid the changes in microbiologic identification and nomenclature of these organisms. Methods We reviewed the medical records of adult patients (>= 18 years of age) with positive blood cultures for SBG organisms admitted to our 510-bed teaching hospital from January 1, 2006, to December 31, 2017. We report the epidemiology, sources of bacteremia, comorbid conditions, courses of treatment, and the mortality for these patients. We also assess the hospital treatment team's (HTT's) knowledge of SBG nomenclature and of the associations of SBG bacteremia and underlying GI disease and infective endocarditis amid the changes in nomenclature of these organisms. Results There were 42 cases of SBG bacteremia during the 12-year study period: 22 in women (52.4%) and 20 in men (47.6%). Patient ages ranged from 51 to 96 years (mean age, 74.3 years; median age, 72.0 years). All but 2 patients had multiple comorbid conditions. Diabetes mellitus was the most common comorbidity. Colonoscopy was performed during hospitalization in 22 (52.5%) of 42 patients. The identifiable sources of bacteremia were as follows: lower GI tract in 19 patients (45.2%), upper GI tract in 5 patients (11.9%), Laennec cirrhosis in 3 patients (7.1%), and pancreatic disorders in 2 patients (4.6%). Eleven patients (26.2%) had primary bacteremia. Two patients with primary bacteremia had prior splenectomy. The historic association between SBG bacteremia and underlying GI tract disease was recognized by 37 (88.1%) of 42 HTTs, but all available provider progress notes mention only "colon carcinoma" as the possibly associated GI tract pathology. The historic association of SBG bacteremia with infective endocarditis was recognized in writing by 32 (76.2%) of 42 HTTs. Endocarditis was diagnosed in 12 patients (28.6%): 9 definite endocarditis and 3 possible endocarditis. The mitral valve was the most commonly involved valve. Four SBG isolates were intermediately susceptible to penicillin G with minimum inhibitory concentrations of 0.125 mu g/mL or greater. Twenty-three (54.8%) of 42 SBG strains were resistant or intermediately susceptible to clindamycin. Twenty-four (57.1%) of 42 strains were resistant or intermediately susceptible to erythromycin. All strains were tested for susceptibility to ceftriaxone and vancomycin and retained susceptibility to both antimicrobial agents throughout the study period. Six of 42 patients died, for a mortality rate of 11.9%. Infectious disease consultation was obtained in 35 (80.0%) of 42 patients. Infectious disease consultation was positively associated with survival (P = 0.0041, Fisher exact test). The new nomenclature schemes for prior members of the SBG were recognized by all HTTs because our microbiology laboratory reported each member of the group, regardless of new name, with "bovis group" added to the identification on all positive culture reports. Conclusions Streptococcus bovis group bacteremia is a disease of older adults with all but 3 patients 60 years or older and a mean age at onset of 73.4 years. Most HTTs considered colon carcinoma as a possible source for and infective endocarditis as a potential complication of SBG bacteremia. However, most HTTs were not aware that SBG bacteremia could be associated with nonmalignant colonic lesions especially polyps, Laennec cirrhosis, or with pancreatic, biliary, and upper GI tract anatomic abnormalities. Of our SBG isolates, 54.8% were not sensitive to clindamycin. Clindamycin should not be used for empiric treatment of SBG bacteremia. The ID service should be consulted on all patients with SBG bacteremia because such consultation had a positive correlation with patient survival (P = 0.0041).
Sidda A; Kallstrom G; Myers J P
Infectious Diseases in Clinical Practice
2019
2019-01
Journal Article
<a href="http://doi.org/10.1097/ipc.0000000000000690" target="_blank" rel="noreferrer noopener">10.1097/ipc.0000000000000690</a>
What Is "Telemedicine" and What Does It Mean for a Pediatric Surgeon?
barriers; challenges; consultation; da-vinci; definition; experience; laparoscopic surgery; nephrectomy; pediatric surgery; Pediatrics; Surgery; telehealth; telemedicine; telementoring; telepresence; teleradiology; telesurgery
Telemedicine is a broad term and has recently become a household term in the medical field. However, there are many interpretations as to what the term "telemedicine" means. There are many facets to telemedicine and here we describe all of the elements of telemedicine, a glossary of terms, and how they relate to pediatric surgery.
Nalugo M; Craner D R; Schwachter M; Ponsky T A
European Journal of Pediatric Surgery
2014
2014-08
Journal Article
<a href="http://doi.org/10.1055/s-0034-1386647" target="_blank" rel="noreferrer noopener">10.1055/s-0034-1386647</a>