Community Health Workers: Addressing Client Objectives Among Frequent Emergency Department Users.

OBJECTIVES: To evaluate effectiveness of a community health worker (CHW) program designed to address client objectives among frequent emergency department (ED) users. DESIGN: Program evaluation using secondary analysis of client objectives from program records. Client objectives were characterized according to the World Health Organization's social determinants of health framework. Hierarchical generalized linear modeling was used to assess factors associated with objective achievement. SETTING: An ED and the surrounding community in an economically disadvantaged area of Buffalo, New York. PARTICIPANTS: A total of 1600 adults over age 18 eligible for Medicaid and/or Medicare and who had at least 2 ED visits in the prior year. INTERVENTION: Clients worked with CHWs in the community to identify diverse needs and objectives. Community health workers provided individualized services to help achieve objectives. MAIN OUTCOME MEASURE: Achievement of client-focused objectives. RESULTS: Most objectives pertained to linkage to community resources and health care navigation, emphasizing chronic medical conditions and connection to primary care. Clients and CHWs together achieved 43% of total objectives. Objective achievement was positively associated with greater client engagement in CHW services. CONCLUSIONS: Low objective achievement may stem from system- and policy-level barriers, such as lack of affordable housing and access to primary care. Strategies for improving client engagement in CHW services are needed. Community health workers and their clients were most successful in areas in which public health policies and systems made resources easy to access or where the program had formalized relationships with resources, such as primary care.

Can Braden Score Predict Outcomes for Hospitalized Heart Failure Patients?

BACKGROUND: Braden score is a routine assessment of pressure ulcer risk hypothesized to identify the frail phenotype. OBJECTIVES: To investigate the predictive utility of the Braden score on outcomes of inpatients with heart failure (HF). DESIGN: Retrospective cohort study. SETTING: An academic medical center between January 1, 2012 and June 30, 2013. PARTICIPANTS: 642 inpatients with a primary diagnosis of HF (ICD-9 428). MEASUREMENTS: The primary predictor was Braden score. Primary outcome was 30-day mortality. Additional outcomes included 30-day readmission, length of stay (LOS), and discharge destination. Multivariable methods were used to determine the association between the primary predictor and each outcome adjusted for patient demographics and clinical variables. RESULTS: Mean admission and discharge Braden scores were 19.5 ± 2.3 (SD) (range = 9-23) and 20.0 ± 1.9 (range = 11-23), respectively (P < .0001). Mean age was 61.8 ± 16.2 years (range = 19-101). The 30-day mortality rate was 4.4%, 30-day readmission rate was 16.2%, mean LOS was 7.0 ± 8.7 days, and 78.2% were discharged home. After adjustment, higher (better) Braden score was significantly associated with decreased 30-day mortality (discharge Braden AOR 0.81 (95% CI 0.66-0.996)), and decreased average LOS (admission Braden ß -0.52 days (P = .0002)). Higher discharge Braden score was significantly associated with discharge to home (AOR 1.66 (95% CI 1.42-1.95)). Braden score was not significantly associated with 30-day readmission. CONCLUSION: Braden score is an independent predictor of mortality, LOS, and discharge destination among inpatients with HF. Further exploration of the use of Braden scores to identify inpatients who might benefit from specialized intervention is warranted.

Sudden infant death syndrome and residential altitude.

BACKGROUND: Theories of sudden infant death syndrome (SIDS) suggest hypoxia is a common pathway. Infants living at altitude have evidence of hypoxia; however, the association between SIDS incidence and infant residential altitude has not been well studied. METHODS: We performed a retrospective cohort study by using data from the Colorado birth and death registries from 2007 to 2012. Infant residential altitude was determined by geocoding maternal residential address. Logistic regression was used to determine adjusted association between residential altitude and SIDS. We evaluated the impact of the Back to Sleep campaign across various altitudes in an extended cohort from 1990 to 2012 to assess for interaction between sleep position and altitude. RESULTS: A total of 393 216 infants born between 2007 and 2012 were included in the primary cohort (51.4% boys; mean birth weight 3194 ± 558 g). Overall, 79.6% infants resided at altitude <6000 feet, 18.5% at 6000 to 8000 feet, and 1.9% at >8000 feet. There were no meaningful differences in maternal characteristics across altitude groups. Compared with residence <6000 feet, residence at high altitude (>8000 feet), was associated with an adjusted increased risk of SIDS (odds ratio 2.30; 95% confidence interval 1.01-5.24). Before the Back to Sleep campaign, the incidence of SIDS in Colorado was 1.99/1000 live births and dropped to 0.57/1000 live births after its implementation. The Back to Sleep campaign had similar effect across different altitudes (P = .45). CONCLUSIONS: Residence at high altitude was significantly associated with an increased adjusted risk for SIDS. Impact of the Back to Sleep campaign was similar across various altitudes.

Implementation of electronic surveillance of catheter use and catheter-associated urinary tract infection at Nurses Improving Care for Healthsystem Elders (NICHE) hospitals.

BACKGROUND: Manual surveillance of indwelling urinary catheters (IUCs) and catheter-associated urinary tract infections (CAUTIs) is resource intense. METHODS: We implemented electronic surveillance in nonintensive care units of Nurses Improving Care for Healthsystem Elders (NICHE) hospitals. Capacity was created centrally to analyze data collected electronically or manually at each site. We measured the average IUC duration and proportion of patients with IUC duration <3 days. CAUTIs were identified using a validated algorithm based on the Centers for Disease Control and Prevention definition and used to calculate rates and standardized incidence ratios (SIRs). RESULTS: Electronic surveillance was implemented in 25 units at 20 NICHE hospitals. Full automation was achieved at 15 of 16 sites with electronic health records (EHRs). Electronic surveillance challenges included EHR data element formats and IUC documentation. Study units reported on 4,574 patients for 16,105 IUC days over a 6-month period. The mean of the unit-level average IUC duration was 3.2 ± 2.6 days, mean proportion of patients with IUC duration <3 days was 52.4% ± 50%, and mean CAUTI SIR was 0.14 ± 0.31. CONCLUSION: A centralized electronic surveillance strategy for CAUTI is feasible and sustainable. Baseline performance of participating sites was exemplary, with very low SIRs at baseline.

A Trial of electronic surveillance feedback for quality improvement at Nurses Improving Care for Healthsystem Elders (NICHE) hospitals.

BACKGROUND: Catheter-associated urinary tract infection (CAUTI) risk is directly related to duration of indwelling urinary catheters (IUCs), rising beyond 2 days of catheterization. METHODS: We conducted a cluster randomized study in nonintensive care units of Nurses Improving Care for Healthsystem Elders (NICHE) hospitals. Electronic surveillance data were used in an audit and feedback intervention for frontline nurses to reduce IUC duration. Multivariable methods were used to identify the difference in average IUC duration and proportion of patients with IUC duration <3 days between patients in an early intervention group and a delayed intervention group, adjusting for patient, unit, and hospital characteristics. RESULTS: A total of 24 units at 19 NICHE hospitals reported 13,499 adult patients with IUCs over 18 months. Early and delayed intervention groups had important baseline differences in IUC utilization. Use of evidence-based CAUTI prevention measures increased during study participation. In multivariable analysis, the average IUC duration and proportion of patients with IUC duration <3 days were not improved in the early intervention group compared with the delayed intervention group. CONCLUSION: The impact of the audit and feedback intervention was not significant despite the uptake of evidence-based CAUTI prevention practices.