Clinical Briefs
By Louis Kuritzky, MD
Use of Hip Protectors in Nursing Homes: Cluster Randomized Controlled Trial
Despite the fact that use of hip protectors (HIP) has demonstrated excellent outcomes reduction when used among elderly persons ie, as much as a 50% reduced incidence of hip fractures, actual use among at-risk populations is markedly suboptimal. For clinicians who have not seen hip protectors before, they are disk-shaped cushions that can be worn under clothing to act as a mechanical defense if a patient falls.
One of the reasons for tepid responsiveness of senior citizens to use of HIP may be inadequate education of healthcare providers and nursing home staff. To that end, Meyer and associates studied a 2-part intervention in 86 German nursing homes. The initial intervention included a 60-90 minute education session for nursing home staff about risk factors for hip fracture, consequences of hip fracture, and effectiveness of hip protectors. Staff was also instructed in steps to address potential obstacles to successful HIP implementation. HIP-educated staff members were assigned to provide a similar information base to resident patients in their nursing homes. Nursing staff also used a documentation sheet on resident falls and their outcomes. HIP were provided for residents free of charge in the intervention group. The control group ("usual care") received a brief informative demonstration of HIP, and 2 HIP for demonstration purposes. The primary end point of the trial was hip fracture. The secondary end point was frequency of HIP use.
The relative risk of hip fracture was 0.57 in HIP users (NNT = 29). Frequency of HIP use was significantly higher in the intervention group (68% vs 15%). Use of HIP, especially when accompanied by an intensive staff education, can reduce hip fractures by more than 40%.
Meyer G, et al. BMJ. 2003;326:76-78.
Disclosing Unanticipated Outcomes and Medical Errors
According to the 1999 institute of Medicine report, medical errors are an important cause of loss of life, resulting in as many as 98,000 deaths annually in the United States. The Lexington, Kentucky VA has followed a policy of full disclosure about medical errors for more than 15 years. They rank in the lowest quartile of VA centers for liability costs, which appears to have resulted not from a reduction in the frequency of malpractice claims—indeed, the absolute number of claims actually has increased—but rather from willingness of injured persons and their families to negotiate fair settlements, after complete and open disclosure.
Steps in adequate disclosure after unanticipated adverse outcome without medical error should include: 1) Without defensiveness, be aware of and respond to the needs of the patient and their family; 2) Keep family members apprised of continued clinical care progress; 3) Clarify how the unanticipated outcome may have occurred; 4) Communicate your understanding, empathically, of the concerns of the family; 5) Acknowledge the areas of uncertainty, with an offer to clarify these areas as soon as possible.
When medical error has led to injury, additional steps should include 1) apology and acceptance of responsibility—reluctance to provide a full accountability may actually drive patients to seek legal counsel; 2) determine who best should be included in future disclosure conversations and identify an individual to respond to the family’s nonclinical (eg, financial compensation) inquiries; and 3) be proactive in addressing the patient’s financial needs, such as costs of family members needing to stay in hotels for a prolonged hospital stay.
O’Connell D, et al. J Clin Outcomes Man. 2003;10(1):25-29.
Non-Invasive Positive Pressure Ventilation to Treat Respiratory Failure Resulting from Exacerbations of COPD
When the traditional interventions (eg, bronchodilators, steroids, antibiotics, oxygen) for COPD exacerbation are insufficient to reverse clinical deterioration, clinicians typically rely upon invasive ventilation, with its attendant morbidity, and occasional difficulty in weaning. Noninvasive positive pressure ventilation (NPPV) provides an air/oxygen mixture from a flow generator through a full facial or nasal mask. The subsequent unloading of flagging respiratory musculature enhances respiratory efficiency. Failure rates of this technique have been reported between 9-50%. Lightowler and colleagues performed a Cochrane review and meta-analysis to ascertain effectiveness of NPPV in patients with respiratory failure secondary to COPD exacerbations.
NPPV, when coupled with usual medical care of COPD exacerbations, was shown to significantly reduce mortality (59%), need for intubation (58%), treatment failure (49%), complications (68%), and length of hospital stay. These data should encourage clinicians to use NPPV earlier in the therapeutic course, before serious acidosis ensues.
Lightowler JV, et.al. BMJ. 2003;326: 185-187.
Dr. Kuritzky is Clinical Assistant Professor at the University of Florida in Gainesville.
Use of Hip Protectors in Nursing Homes: Cluster Randomized Controlled Trial; Disclosing Unanticipated Outcomes and Medical Errors; Non-Invasive Positive Pressure Ventilation to Treat Respiratory Failure Resulting from Exacerbations of COPDYou have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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