From quality assurance to quality management in long term care.

This article describes the continuing evolution of the quality assurance program at Crown Nursing Home, a privately owned, skilled long-term care facility in Brooklyn, New York, into quality management. Activities are intended to improve the systems and processes of resident care, develop and implement practice guidelines, integrate suppliers and vendors into the facility processes, use information systems for indicator monitoring, encourage residents and family participation, provide care through a team approach, and promote human resource management and staff enhancement.

Decubitus ulcers: when to suspect osteomyelitis.

Six nursing home patients developed pressure sores of the foot and ankle, complicated by osteomyelitis of the underlying bone. All patients had advanced multi-infarct dementia with multiple contractures, and were bedridden, debilitated, and nutritionally deficient. All had arteriosclerotic heart and peripheral vascular disease, and other chronic illnesses. The pressure sores progressed rapidly and did not respond to medical and surgical therapy. Cultures yielded organisms usually associated with pressure sores. Diagnosis of osteomyelitis was initially made by radiography and eventually confirmed surgically. Patients with osteomyelitis of the metatarsal bones responded well to intravenous antibiotics and local amputation; all survived. The two patients with osteomyelitis of the calcaneal bone died after a short course. The diagnosis of osteomyelitis of the foot associated with pressure ulcers requires a high index of suspicion when a pressure sore does not respond to medical and surgical therapy in the appropriate clinical setting.

Ophthalmoplegia, ptosis, and miosis in temporal arteritis.

Ophthalmoplegia occurred in 7 of 14 patients with biopsy proved temporal arteritis. Only one patient had diplopia. In six of the seven patients, the pattern of ophthalmoplegia did not conform to the distribution of one of the ocular motor nerves. Impairment of upward gaze was most common. In five patients the ophthalmoplegia was accompanied by ptosis, and in five it was accompanied by a miotic pupil. Ophthalmoplegia and ptosis were the major manifestations of temporal arteritis in one patient. Oculomotor signs and symptoms responded to corticosteroid therapy in all seven patients, but in two patients prolonged therapy was necessary. Ophthalmoplegia or ptosis may be early manifestations and may precede visual loss, so that frequent examination is recommended in patients suspected of temporal arteritis, with prompt administration of adequate doses of corticosteroid as soon as any ocular manifestations of temporal arteritis are noted.

The clinical significance of Raynaud's phenomenon in systemic lupus erythematosus.

In a prospective study of 226 patients with systemic lupus erythematosus (SLE), 91 patients (40%) had Raynaud's phenomenon. These patients were compared to 135 patients without Raynaud's phenomenon. Patients with Raynaud's phenomenon had a greater incidence of arthritis (P less than 0.02), malar rash (P less than 0.003), and photosensitivity (P less than 0.03), and a lesser incidence of severe renal disease as manifested by serum creatinine over 3.0 mg/dl (P less than 0.007) or creatinine clearance below 60 ml/minute. Patients with Raynaud's phenomenon were less likely to have severe, life threatening disease and received a lower average monthly (P less than 0.01) and a lower peak daily corticosteroid dose (P less than 0.01). Fourteen patients (16%) with Raynaud's phenomenon died, compared to 41 without (30%) (P less than 0.03). Raynaud's phenomenon in patients with SLE is associated with milder disease and may be regarded as a favorable prognostic sign.

Rheumatoid arthritis in the elderly, presenting as polymyalgia rheumatica.

Two elderly patients presented with generalized aches and pains (particularly in the shoulders and the pelvic girdle), stiffness, fatigue, anemia, and an elevated erythrocyte sedimentation rate, but there were no signs or symptoms directly referable to the joints. Two and five months later respectively, pain, swelling, and signs of synovitis appeared in several joints in a symmetrical pattern, and a diagnosis of rheumatoid arthritis was made. Rheumatoid arthritis in the elderly may resemble polymyalgia rheumatica. On the other hand, synovitis in many patients with polymyalgia rheumatica may resemble rheumatoid arthritis. In the elderly, the differentiation of these two entities may be difficult. Moreover, patients initially presenting with the signs and symptoms of polymyalgia may eventually manifest typical rheumatoid arthritis.

Systemic lupus erythematosus in the older age group: computer analysis.

A computer analysis was made of the data from a prospective study of the clinical course of systemic lupus erythematosus (SLE) in 234 patients followed for an average of 46 months. All fulfilled four ARA criteria for the diagnosis of SLE. Sixteen of the 234 patients were aged 51 or older. They were compared with the 218 younger SLE patients to determine the influence of age on the signs and symptoms of the disease, the organ systems involved, the laboratory data, amount and duration of corticosteroid or azathioprine therapy, and the prognosis. The older group showed more discoid lupus, photosensitivity and pulmonary fibrosis than did the younger group, but a similar incidence of malar rash, alopecia, arthritis, arthralgia, myalgia and serositis, and a lower incidence of oral ulcers, Raynaud's phenomenon, cutaneous vasculitis, neuropsychiatric manifestations, leukopenia, hypocomplementemia and profus proteinuria. The older patients needed a lower dosage of corticosteroids, and a shorter course of azathioprine therapy. These findings suggest a milder form of SLE with better response to therapy in the older group.

Serum digoxin levels in elderly nursing home patients: appraisal of routine periodic measurements.

An assessment was made of the clinical value of routine periodic measurement of serum digoxin levels in 51 elderly nursing home patients with cardiac disease. The findings showed that the serum digoxin level was not correlated with the dosage of digoxin nor the patient's clinical state of digitalization. All patients were effectively digitalized, as judged clinically, and no digitalis toxicity occurred despite a wide range of serum digoxin levels. When adequate medical supervision, electrocardiograms, roentgenograms, serum electrolyte determinations and renal function tests are available, the routine periodic measurement of serum digoxin concentration does not offer any additional benefit in the management of nursing home patients with cardiac disease.

Computer analysis of factors influencing the appearance of aseptic necrosis in patients with SLE.

A computer analysis of 234 patients with SLE followed for an average of 31 months revealed 22 patients with aseptic necrosis of bone (AN) (9%), with projected frequency approaching 30% at 10-15 years of follow-up. Most patients developed between four and seven years after diagnosis of SLE. When compared to all other patients with SLE and no AN or to three computer-selected groups matched by age of SLE diagnosis, duration of disease, or cumulative corticosteroid dose, AN did not correlate with any of the preliminary ARA criteria, total number of criteria fulfilled, renal disease, skin vasculitis, or disease activity. Although all patients received corticosteroid therapy prior to development of AN, no correlation was found with duration, peak dose, or cumulative dose of corticosteroid therapy.

Electrocardiographic changes and myocardial damage in patients with acute cerebrovascular accidents.

In 100 consecutive patients with acute cerebrovascular accident, due to cerebral thrombosis in 72, cerebral hemorrhage in 12, embolus in 6, and subarachnoid hemorrhage in 10, there were 90 who had electrocardiographic abnormalities during the first three days after admission, compared to 50% in a control group. The patients with cerebrovascular accident had a 7- to 10-fold higher incidence of ST segment depression, prolonged Q-Tc interval and atrial fibrillation, and a 2- to 4-fold higher incidence of T wave inversion, conduction defects, premature ventricular beats and left ventricular hypetrophy. Patients who died had a 2-, 3- and 5-fold higher incidence of electrocardiographic evidence of recent myocardial infarction, atrial fibrillation and conduction defects than those who survived, but these changes occurred in only 5, 21 and 14% of all patients, and other electrocardiographic changes could not be correlated with mortality. During the first three days after admission 29 patients had elevation of serum enzymes which may be derived from cardiac muscle, particularly CPK, which was increased 6-fold, compared to 2-fold increases in HBDH, GOT, and LDH. Only 5 of these patients had electrocardiographic evidence of recent myocardial infarction. Patients with elevated serum CPK had a 2-fold higher incidence of ST segment depression, T wave inversion, conduction defects and atrial fibrillation than those with normal CPK, and a mortality of 66%, compared to 30%. Of 41 patients who died, 49% had elevated serum CPK, compared to 15% of 59 patients who survived. These differences were significant (P less than 0.01). Serum CPK was more frequently helpful than the electrocardiogram in evaluating the extent of cardiac damage and in predicting mortality. Patients with acute cerebrovascular accident should have repeated evaluation of serum CPK and the ECG, and be monitored for arrhythmias.

Importance of Holter monitoring in patients with periodic cerebral symptoms.

Holter monitoring was used in 358 patients with symptoms of intermittent dizziness, blackout, or both. The neurological findings in all patients were normal. None manifested evidence of a pertinent arrhythmia on the one-minute resting ECG; 8.9% of the patients demonstrated arrhythmias known to correlate with cerebral symptoms; and 11.2% demonstrated "predisposing" arrhythmias, ie. rhythms that in and of themselves may not precipitate symptoms but predispose to arrhythmias that do. The latter category included short bursts of ectopic tachycardia and intermittent short-duration asystole. High-frequency ectopic beats were observed in 24.6%. In almost every patient in whom intermittent arrhythmias precipitated symptoms there were many "predisposing" arrhythmias of short duration that occurred during the asymptomatic period. A comparison of 12- and 24-hour recordings demonstrated an increase in pertinent arrhythmias from 13.8 to 22.7%.