Hypervitaminosis D associated with a vitamin D dispensing error.

OBJECTIVE: To report a case of hypervitaminosis D resulting in hypercalcemia and acute kidney injury in a 70-year-old female who was prescribed a standard dose of vitamin D but given a toxic dose of vitamin D 50,000 IU (1.25 mg) daily resulting from a dispensing error. CASE SUMMARY: A 70-year-old female in her usual state of health was instructed to begin supplementation with vitamin D 1000 IU daily. Three months later she developed confusion, slurred speech, unstable gait, and increased fatigue. She was hospitalized for hypercalcemia and acute kidney injury secondary to hypervitaminosis D. All vitamin D supplementation was discontinued and 5 months after discharge, the patient's serum calcium and vitamin D concentrations, as well as renal function, had returned to baseline values. Upon review of the patient's records, it was discovered that she had been taking vitamin D 50,000 IU daily. DISCUSSION: There is an increased interest in vitamin D, resulting in more health care providers recommending--and patients taking--supplemental vitamin D. Hypervitaminosis D is rarely reported and generally only in the setting of gross excess of vitamin D. This report highlights a case of hypervitaminosis D in the setting of a prescribed standard dose of vitamin D that resulted in toxic ingestion of vitamin D 50,000 IU daily due to a dispensing error. As more and more people use vitamin D supplements, it is important to recognize that, while rare, hypervitaminosis D is a possibility and dosage conversion of vitamin D units can result in errors. CONCLUSIONS: Health care providers and patients should be educated on the advantages and risks associated with vitamin D supplementation and be informed of safety measures to avoid hypervitaminosis D. In addition, health care providers should understand dosage conversion regarding vitamin D and electronic prescribing and dispensing software should be designed to detect such errors.

Summative index: Acute pain management in older adults.

One of the challenges in measuring adoption of complex evidence-based practices (EBPs) such as acute pain management is determining what constitutes adherence to an EBP guideline. Traditionally, individual process indicators extrapolated from an EBP guideline are selected as dependent measures of guideline adoption. When using multiple indicators, the challenge is determining the number of indicators that must be met to define adherence to the EBP guideline. The primary goal of the study reported herein was to develop and test a summative index (SI) of guideline adherence for acute pain management of hospitalized older adults. Steps in formulating the initial index are described as well as refinement of this metric. Techniques used included factor analysis, discriminate validity, and split-half reliability. The resulting SI is composed of 18 indicators each scored as 0 (not present) or 1 (present), with a total SI score of 0 to 18.

Translating research into practice intervention improves management of acute pain in older hip fracture patients.

OBJECTIVE: To test an interdisciplinary, multifaceted, translating research into practice (TRIP) intervention to (a) promote adoption, by physicians and nurses, of evidence-based (EB) acute pain management practices in hospitalized older adults, (b) decrease barriers to use of EB acute pain management practices, and (c) decrease pain intensity of older hospitalized adults. STUDY DESIGN: Experimental design with the hospital as the unit of randomization. STUDY SETTING: Twelve acute care hospitals in the Midwest. DATA SOURCES: (a) Medical records (MRs) of patients > or =65 years or older with a hip fracture admitted before and following implementation of the TRIP intervention and (b) physicians and nurses who care for those patients. DATA COLLECTION: Data were abstracted from MRs and questions distributed to nurses and physicians. PRINCIPAL FINDINGS: The Summative Index for Quality of Acute Pain Care (0-18 scale) was significantly higher for the experimental (10.1) than comparison group (8.4) at the end of the TRIP implementation phase. At the end of the TRIP implementation phase, patients in the experimental group had a lower mean pain intensity rating than those in the comparison group ( p<.0001). CONCLUSION: The TRIP intervention improved quality of acute pain management of older adults hospitalized with a hip fracture.

Evidence-based assessment of acute pain in older adults: current nursing practices and perceived barriers.

OBJECTIVES: To report data on current nurse practice behaviors related to evidence-based assessment of acute pain in older adults, perceived stage of adoption of pain assessment practices, and perceptions of barriers to optimal assessment in this population. METHODS: Medical records from 709 older adult patients hospitalized with hip fractures from 12 acute care settings were abstracted for nurse assessment practices during the first 72 hours after admission. Questionnaires sent to nurses on study units regarding perceived stage of adoption and barriers to assessment in older adults. RESULTS: Data revealed several areas in which pain assessment practices were not optimal. Pain was not routinely assessed every 4 hours, and pain location was assessed even less frequently. Pain behaviors were assessed more in patients with a diagnosis of dementia compared to those without dementia, but the frequency of pain behavior assessments was low. Pain was not routinely assessed within 60 minutes of administering an analgesic. Nurses reported not using optimal pain assessment practices even when they were aware of and persuaded that those practices were desirable. In addition, nurses reported that difficulty communicating with patients created the greatest challenge in managing pain. CONCLUSIONS: Our data suggest that pain is not being assessed and reassessed in a manner that is consistent with current practice recommendations in older adult patients with pathologic processes that highly suggest the presence of acute pain.

Acute pain treatment for older adults hospitalized with hip fracture: current nursing practices and perceived barriers.

This article examines acute pain management practices for patients 65 years of age and older who were hospitalized during 1999 for hip fracture. Data were collected from the medical records of patients (N = 709) admitted to 12 hospitals in the Midwest and from questionnaires on pain practices completed by nurses (N = 172) caring for these patients. The major variables examined were (1). pharmacological and nonpharmacological treatments for acute pain in hospitalized elders, (2). nurses' perceived stage of adoption for avoiding meperidine use and for administering analgesics around-the-clock, and (3). nurses' perceived barriers to optimal treatment of acute pain in elders. Acetaminophen was the most frequently administered analgesic, but administered doses were far less than the maximum daily recommended dose. More than one third (39%) of the nurses reported that they always avoided the use of meperidine, and over half reporting avoiding its use sometimes. However, the majority of patients (56.8%) received at least one dose of meperidine, even though evidence suggests that other analgesic agents are more appropriate for treatment of acute pain in elders. Only 27% of patients received patient-controlled analgesia, and only 22.3% of patients received around-the-clock administration during the first 24 hours after admission of analgesics that had been ordered on a prn basis. The majority of nurses were aware that around-the-clock administration of analgesics was preferable, but only 33.7% were persuaded (believed) that this method should be used. Intramuscular injection was used for 52.2% of patients, even though this route is not recommended for older adults. The most frequently used nonpharmacological intervention was repositioning, followed by use of pressure relief devices and cold application. Nurses reported difficulty contacting physicians and difficulty communicating with them about type and/or dose of analgesics as the greatest barriers to pain management. Findings from this multi-site study show that active and focused "translation" interventions are needed to promote adoption of evidence-based acute pain management practices by health care providers.

Pain management in older adults.

Pain is a common complaint of older adults. Persistent pain has a significant negative impact on elderly individuals' sense of well being, physical function, and quality of life. Increasing age and cognitive impairment are risk factors for undertreatment of persistent pain. Safe and effective therapy is available for pain syndromes that commonly affect older adults. Recognition of failure of health providers to appropriately assess and manage persistent pain has led to the recent development and adoption of regulatory guidelines for the implementation of effective pain management programs.