Nursing Strategies to Safeguard COVID-19 Patients From Harm in the Intensive Care Unit.

The aim of this article is to identify quality improvement nursing strategies that have been implemented to safeguard COVID-19 patients from harm while being cared for in the intensive care unit (ICU). This article incorporates a literature review on the experiences of nurses working at a large urban teaching hospital in the areas of critical care, quality, safety, and regulatory. As leaders in the delivery of health care, nurses have always pioneered innovative ways to deliver care despite difficult circumstances. COVID-19 is a novel viral disease with many unknowns, and it required nurses to integrate innovative approaches with evidence-based practice in order to meet the needs of the patient and to ensure patient safety. While in the critical care setting, COVID-19 patients are at an increased risk for various hospital-acquired injuries, threats to personal safety, and decline in mental health. Through ingenuity and adaptability, successful nursing strategies have been identified in the delivery of quality, evidence-based nursing care to safeguard the vulnerable COVID-19 patient population from harm while in the ICU.

Infection control assessment of ambulatory surgical centers.

CONTEXT: More than 5000 ambulatory surgical centers (ASCs) in the United States participate in the Medicare program. Little is known about infection control practices in ASCs. The Centers for Medicare & Medicaid Services (CMS) piloted an infection control audit tool in a sample of ASC inspections to assess facility adherence to recommended practices. OBJECTIVE: To describe infection control practices in a sample of ASCs. DESIGN, SETTING, AND PARTICIPANTS: All State Survey Agencies were invited to participate. Seven states volunteered; 3 were selected based on geographic dispersion, number of ASCs each state committed to inspect, and relative cost per inspection. A stratified random sample of ASCs was selected from each state. Sample size was based on the number of inspections each state estimated it could complete between June and October 2008. Sixty-eight ASCs were assessed; 32 in Maryland, 16 in North Carolina, and 20 in Oklahoma. Surveyors from CMS, trained in use of the audit tool, assessed compliance with specific infection control practices. Assessments focused on 5 areas of infection control: hand hygiene, injection safety and medication handling, equipment reprocessing, environmental cleaning, and handling of blood glucose monitoring equipment. MAIN OUTCOME MEASURES: Proportion of facilities with lapses in each infection control category. RESULTS: Overall, 46 of 68 ASCs (67.6%; 95% confidence interval [CI], 55.9%-77.9%) had at least 1 lapse in infection control; 12 of 68 ASCs (17.6%; 95% CI, 9.9%-28.1%) had lapses identified in 3 or more of the 5 infection control categories. Common lapses included using single-dose medication vials for more than 1 patient (18/64; 28.1%; 95% CI, 18.2%-40.0%), failing to adhere to recommended practices regarding reprocessing of equipment (19/67; 28.4%; 95% CI, 18.6%-40.0%), and lapses in handling of blood glucose monitoring equipment (25/54; 46.3%; 95% CI, 33.4%-59.6%). CONCLUSION: Among a sample of US ASCs in 3 states, lapses in infection control were common.

Prehabilitation before knee arthroplasty increases postsurgical function: a case study.

Conditioning the body to undergo physical stress such as joint arthroplasty has been termed prehabilitation. This case study examined the effect of a 4-week prehabilitation intervention on functional outcomes after total knee arthroplasty (TKA). Two female subjects completed baseline strength and functional assessments before TKA. Subjects were randomized to either a 4-week prehabilitation intervention (ES) aimed at increasing strength and range of motion or a usual care condition (CS). After 4 weeks of training, subjects were reassessed and underwent TKA. Subjects completed a final assessment 12 weeks after TKA. Functional outcomes included 6-minute walk, number of times up from a chair in 30 seconds, proprioception, and self-reported function and pain using the Western Ontario and McMaster Universities Osteoarthritis Index. The data suggest that 4 weeks of prehabilitation had a positive effect on functional task performance and knee proprioception before surgery. After surgery, the ES continued to exhibit higher levels of functioning and less pain compared with the CS. Prehabilitation before TKA may contribute to improved recovery after surgery.

Can older adult volunteers serve effectively to improve asthma management for children? Experience Corps Baltimore.

The present study was conducted to determine whether older adults can learn and retain information on asthma and play a role as community health workers to teach children about asthma. A total of 36 older adults and 28 students in grades K-6 participated. Pre-tests and post-tests were administered to participants. Improvement in older adult scores after training was significant (p = .001), and improvement persisted through the conclusion of teaching sessions (p = 0.001). The increase in lower student scores was significant (p = 0.050). Results suggest that older adults can learn and retain asthma information and schoolchildren can learn asthma-related information taught by older adults.

Racial disparities in access to cardiac rehabilitation.

OBJECTIVE: This study sought to assess the association between race and referral to cardiac rehabilitation programs. DESIGN: A total of 1933 cardiac patients enrolled in the Cardiac Access Study (n = 9275) who met the criteria selection of the American College of Cardiology Guidelines of eligibility for cardiac rehabilitation were evaluated to determine factors associated with accessing cardiac rehabilitation programs. Referral to a cardiac rehabilitation program among eligible participants was the outcome of interest. Potential factors associated with referral were entered into a logistic regression analysis to determine factors associated with referral. RESULTS: Whites were more likely to be referred for cardiac rehabilitation than were blacks (crude odds ratio [OR] = 2.52; 95% confidence interval [CI] = 1.75-3.63). After controlling for age, education, socioeconomic status, and insurance, race was still independently associated with referral for cardiac rehabilitation (OR = 1.81; 95% CI = 1.22-2.68). CONCLUSION: Among those patients who were eligible for cardiac rehabilitation, race is independently associated with the likelihood of referral for cardiac rehabilitation. The decreased utilization of such services in this population could lead to further disparity in cardiac outcomes. Future studies should address ways to eliminate this disparity and increase referral to such services.

Frailty, hospitalization, and progression of disability in a cohort of disabled older women.

PURPOSE: To determine the association between a previously validated frailty phenotype and the development of new-onset dependence in activities of daily living, independent of hospitalizations and other established predictors of disability. SUBJECTS: Seven hundred and forty-nine women enrolled in the Women's Health and Aging Study-I who were independent in all activities in daily living when enrolled in the cohort. METHODS: Assessments and interviews were conducted through home visits at 6-month intervals for 3 years. Frailty was classified using a validated phenotype (> or =3 of the following: weight loss, exhaustion, slow walking, sedentariness, and weak grip), and hospitalizations were identified by self-report. Grouped-time proportional hazard models assessed associations among frailty, hospitalization, and the development of dependence in activities in daily living, adjusting for other factors. RESULTS: Twenty-five percent of the cohort (186/749) were frail at baseline; 56% (104/186) of frail versus 20% (23/117) of nonfrail women developed dependence in activities in daily living (P <.001). In multivariate analysis, frailty was independently associated with the development of dependence in activities in daily living (hazard ratio [HR] = 2.2; 95% confidence interval [CI]: 1.4 to 3.6), adjusting for hospitalization status, age, race, education, baseline functional status, cognition, depressive symptoms, number of chronic diseases, and self-reported health status. Additionally, a dose-response relationship existed between the number of frailty criteria that a woman had and the hazard of subsequent dependence in activities in daily living. CONCLUSION: Frailty, conceptualized as an underlying vulnerability, and hospitalization, which marks an acute deterioration in health, were strongly and independently associated with new-onset dependence in activities in daily living. Additional research is needed to determine if dependence can be minimized by targeting resources and programs to frail older persons.

The Johns Hopkins Geriatric Summer Scholars Program: a model to increase diversity in geriatric medicine.

The Division of Geriatric Medicine and Gerontology at the Johns Hopkins University strives to create a workforce that represents the racial, ethnic, and sex diversity of U.S. society. To that end, the division has developed a summer program for underrepresented minority first-year medical students to expose them to geriatric medicine and research. The ultimate aim of this initiative is to recruit students to academic medicine, specifically geriatric medicine, where they are drastically underrepresented. Nineteen students participated in the program from the summer of 2002 to the summer of 2004. The participants have continued on to win seven other research fellowships, participate in the National Institute on Aging Technical Assistance Workshop, and present at four national conferences, including the American Geriatrics Society conference and the Gerontological Society of America meeting. One of the students, who is completing medical school in May 2005, is returning to begin the internal medicine residency program at Johns Hopkins Bayview, where the majority of the geriatric faculty practice medicine. Another student who is also graduating is obtaining her Masters in Public Health with a concentration in epidemiology from the Johns Hopkins Bloomberg School of Public Health before starting residency. This article describes the outcomes of the first 3 years of the program, with an emphasis on curriculum development and the recruitment and retention of underrepresented minority medical students.

Relationship between lung function and physical performance in disabled older women.

BACKGROUND: Understanding the association between lung function and physical performance in disabled older women helps in determining the potential for prevention and treatment strategies to decrease disability. The aim of this study was to determine the association of lung function with objective and self-reported physical performance in community-dwelling disabled older women. METHODS: The Women's Health and Aging Study I consists of 1002 disabled community-dwelling women aged > or = 65. Of these women, 840 underwent spirometry with determination of forced expiratory volume in one second (FEV1) and forced vital capacity (FVC). Cross-sectional analyses included multivariate linear regression to assess the association between FEV1, FVC, FEV1/FVC, and the time to walk four meters after adjusting for confounders, including age, race, geriatric depression scale score, body mass index, muscle strength, osteoarthritis, smoking status, and cardiovascular disease. Multiple logistic regression was used to assess the association between FEV1, FVC, FEV1/FVC, and self-reported disability in physical performance. RESULTS: FEV1 was independently associated with time to walk 4 meters. For every 100 ml decrease in FEV1, there was a 0.15-second (95% confidence interval: 0.24 to 0.06) increase in time to walk 4 meters. There was an 8% increase in the prevalent odds of self-reported disability in physical performance for every 100 ml decrease in FEV1. FVC was also associated with physical performance measures. In contrast, FEV1/FVC was associated with objective but not subjective physical performance. CONCLUSION: Decreasing lung function is independently associated with decrements in objective and self-reported physical performance in disabled older women.

The influence of anxiety on the progression of disability.

OBJECTIVES: To determine the influence of anxiety on the progression of disability and examine possible mediators of the relationship. DESIGN: Community-based observational study. SETTING: Women's Health and Aging Study I, a prospective observational study with assessments every 6 months for 3 years. PARTICIPANTS: One thousand two functionally limited women aged 65 and older. MEASUREMENTS: Anxiety symptoms were assessed using four questions from the Hopkins Symptom Checklist (nervous or shaky, avoidance of certain things, tense or keyed up, fearful). Participants who reported experiencing two or more of these symptoms at baseline were considered anxious. Anxiety as a predictor of the onset of four types of disability was examined using Cox proportional hazards models. Three models were tested: an unadjusted model, a model adjusted for confounding variables (age, race, vision, number of diseases, physical performance, depressive symptoms), and a mediational model (benzodiazepine and psychotropic medication use, physical activity, emotional support). RESULTS: Nineteen percent of women reported two or more symptoms of anxiety at baseline. Unadjusted models indicate that anxiety was associated with a greater risk of worsening disability: activity of daily living (ADL) disability (relative risk (RR)=1.40, 95% confidence interval (CI)=1.10-1.79), mobility disability (RR=1.41, 95% CI=1.06-1.86), lifting disability (RR=1.54, 95% CI=1.20-1.97), and light housework disability (RR=1.77, 95% CI=1.32-2.37). After adjusting for confounding variables, anxiety continued to predict the development of two types of disability: ADL disability (RR=1.41, 95% CI=1.08-1.84) and light housework disability (RR=1.56, 95% CI=1.14-2.14). Finally, benzodiazepine and psychotropic medication use, physical activity, and emotional support were not significant mediators of the effect of anxiety on the development of a disability. CONCLUSION: Anxiety is a significant risk factor for the progression of disability in older women. Studies are needed to determine whether treatment of anxiety delays or prevents disability.

Modeled cost-effectiveness of the Experience Corps Baltimore based on a pilot randomized trial.

The Experience Corps program was designed to harness the social capital of an aging society to improve outcomes for public elementary schools. The objectives of this article are (1) to model the cost-effectiveness of the Experience Corps Baltimore using data from a pilot randomized trial, including costs, older adults' health status, and quality of life and cost data from the Medical Expenditure Panel Survey, and (2) to describe the relationship between children experiencing increased expected lifetime earnings through improved educational attainment resulting from exposure to the Experience Corps Baltimore volunteers and the program's costs and cost-effectiveness. On average, each quality adjusted life year (QALY) gained by older adults in Experience Corps Baltimore costs $205,000. The lower bound of the 95% confidence interval for the cost-effectiveness is $65,000/QALY. The upper bound is undefined as 15% of the simulations indicated no QALY improvements. If 0.3% of students exposed to the Experience Corps Baltimore changed from not graduating to graduating, the increased lifetime earnings would make the incremental cost-effectiveness ratio $49,000/QALY. If an additional 0.1% changed to graduating from high school, the program would be cost-saving. Using conservative modeling assumptions and excluding benefits to teachers, principals, and the surrounding community, the Experience Corps Baltimore appears expensive for the older adults' health improvements, but requires only small long-term benefits to the target children to make the program cost-effective or cost-saving.

Agreement between self-report of disease diagnoses and medical record validation in disabled older women: factors that modify agreement.

OBJECTIVES: To determine the agreement between self-report of chronic disease and validated evidence of disease using multiple ascertainment methods and to assess effects of cognition, education, age, and comorbidity. DESIGN: Cross-sectional analysis. SETTING: Community Baltimore, Maryland. PARTICIPANTS: One thousand two community-dwelling disabled women aged 65 and older. MEASUREMENTS: Kappa statistics were calculated to determine the relationship between self-report of 14 diseases and standardized algorithms. Analyses were stratified using Mini-Mental State Examination score, education, number of chronic diseases, and age. RESULTS: Kappa was excellent for hip fracture (HF), Parkinson's disease (PD), diabetes mellitus (DM), cancer, stroke, and disc disease (DD); fair to good for angina pectoris, congestive heart failure, and myocardial infarction; and poor for peripheral arterial disease, spinal stenosis, osteoporosis, arthritis, and lung disease. Overall, kappa decreased with decreasing cognition and education, increasing age, and four or more diseases. CONCLUSION: In disabled older women, self-report of physician diagnosis of HF, PD, DM, cancer, stroke, and DD appears valid. In general, increasing comorbidity and age and decreasing cognition and education do not reduce validity for diseases where agreement was excellent overall.