Development of a tool to assess risk for falls in women in hospital obstetric units.

Because women hospitalized in obstetric units are typically young and healthy, they might be overlooked when health care providers assess for risk for falls. Recent literature has identified pregnant and postpartum women as being prone to falls, with hospitalization compounding their risk. A review of current practices among perinatal units for assessing risk for falls revealed that existing fall risk tools, which were created for geriatric and/or medical surgical patients, are used. Without any focused prevention efforts, hospitalized obstetric patients are vulnerable to a preventable event. The Obstetric Fall Risk Assessment System™ is intended to improve safety among hospitalized women on obstetric units, using an assessment tool and scoring system to determine fall risk.

Effects of a home-based exercise program on clinical outcomes in heart failure.

BACKGROUND: The aim of this study was to determine the effects of a home-based exercise program on clinical outcomes. Exercise training improves exercise capacity in patients with heart failure (HF) but the long-term effects on clinical outcomes remain unknown. METHODS: We randomized 173 patients with systolic HF to control (n = 87) or home-based exercise (n = 86). The primary end point was a composite of all-cause hospitalizations, emergency department admissions, urgent transplantation, and death at 12 months. Functional performance (as assessed by cardiopulmonary exercise testing and the 6-minute walk test), quality of life, and psychological states were measured at baseline, 3 months, and 6 months. RESULTS: There was no significant difference between experimental and control groups in the combined clinical end point at 12 months and in functional status, quality of life, or psychological states over 6 months. Patients in the exercise group had a lower incidence of multiple (2 or more) hospitalizations compared with the control group: 12.8% versus 26.6%, respectively (P = .018). CONCLUSIONS: A home-based walking program that incorporated aerobic and resistance exercise did not result in improved clinical outcomes at 1-year follow-up in this cohort of patients with systolic HF. However, the exercise program resulted in reduced rehospitalization rates.

Two-year follow-up of quality of life in patients referred for heart transplant.

BACKGROUND: Assessment of physical and mental health has become one of the ultimate tests of health-related quality of life (HRQOL) for patients with advanced heart failure. Little is known, however, about the comparative effects of surgical or medical treatment on the HRQOL of these chronically ill patients over time. METHODS: We examined 77 patients (74% of whom were male), aged 56.1 +/- 12.7 years who were referred for heart transplant evaluation at a single heart failure center to describe the effects of time and treatment status on changes in HRQOL scores (physical and mental health and depression) using the Short Form-12 and the Beck Depression Inventory at 2 time points during their illness trajectory. The 2 evaluations on average were 2 years apart (mean 24.5 +/- 2.8 months). All patients were evaluated at baseline, and 3 groups were identified at the time of the 2-year follow-up: transplant recipients (n = 17), transplant candidates (n = 13), and medically stable patients considered too well to receive a transplant (n = 47). Nonparametric statistics were used to analyze group differences in HRQOL scores. The significance level was set at a P value less than .05. RESULTS: Demographic and HRQOL scores were not significantly different among the 3 groups at baseline. During follow-up, physical health and depression scores significantly improved over time in all patients, but changes in mental health were minimal. Group comparisons showed that although all patients continued to have low HRQOL scores at the time of follow-up evaluation, medically stable patients had higher mental health scores and less depressive symptoms than their counterparts. CONCLUSION: Our results support the need for ongoing HRQOL assessment with an emphasis on timely recognition and treatment of psychologic distress throughout the heart failure illness trajectory. Heart transplant recipients and candidates equally need special attention and follow-up because they both seem to have emotional and psychologic repercussions.

Validity of pedometers for measuring exercise adherence in heart failure patients.

BACKGROUND: Measuring adherence to exercise is important to clinicians and researchers because inadequate adherence can adversely affect the effectiveness of an exercise program and cloud the relationship between exercise and clinical outcomes. Hence, assessment strategies for adherence to exercise, as with assessment strategies for other outcomes, must have demonstrated validity if they are to be employed with confidence. We conducted this study to determine the validity of pedometers as a measure of exercise adherence to a home-based walking program in heart failure patients. METHODS AND RESULTS: Exercise adherence was measured using pedometers in 38 patients (74% men) age 54.1 +/- 11.7 years who participated in a 12-month home-based walking program. A comparison of functional status as measured by the 6-minute walk distance and peak oxygen uptake (VO2 max) at 6 months into the exercise training program was made between 2 groups of participants who were thought to represent adherers and nonadherers: participants who demonstrated > or = 10% change in pedometer scores (n = 20) and those who showed no change in pedometer scores (n = 18) from baseline to 6 months. Patients who showed improvements in their pedometer scores over 6 months had better functional status at 6 months (6-minute walk distance 1718 +/- 46 versus 1012 +/- 25 meters, F = 5.699, P = .022; VO 2 max 17 +/- 0.7 versus 10 +/- 0.5 units, F = 7.162, P = .011) when compared with patients whose pedometers reflected minimal change in distance walked (ie, < or = 10%). CONCLUSION: Pedometers are inexpensive and readily available to both clinicians and researchers. The results of this study suggest that they may be a valid indicator of exercise adherence in heart failure patients who participate in a home-based walking program.

Is coping style linked to emotional states in heart failure patients?

BACKGROUND: Negative emotional states such as anxiety and depression are associated with increased mortality and morbidity in cardiac patients. Clinicians who counsel patients with heart disease often focus on enhancing coping skills to reduce negative emotions. METHODS: To identify the relationship between 3 coping styles (active behavioral, active cognitive, and avoidance) and emotional states, we studied 84 advanced heart failure patients and used the Dealing with Illness-R Checklist to measure coping and the Profile of Mood States to measure emotional distress. RESULTS: Patients who reported greater use of active behavioral coping demonstrated less fatigue and more vigor than patients who reported lower use of that coping style. When demographic and clinical variables were taken into account, the avoidance coping style was associated with significantly higher anxiety, anger, depression, confusion, and fatigue in patients with advanced heart failure. CONCLUSIONS: Incorporating interventions that support active behavioral coping in lieu of avoidance coping may improve the emotional well-being of patients with heart failure.

Sleep disturbance symptoms in patients with heart failure.

Sleep disturbances have a major impact on physical functioning, emotional well-being, and quality of life, but are not well described in patients with heart failure (HF). Eighty-four HF patients completed a sleep survey and provided demographic and clinical data. Seventy percent of the patients were male with a mean age of 54 years and a mean left ventricular ejection fraction of 22%. Forty-seven patients (56%) reported trouble sleeping and one-third used sleeping medication. The most frequently reported problems were inability to sleep flat (51%), restless sleep (44%), trouble falling asleep (40%), and awakening early (39%). Using logistic regression, physiological variables were tested as predictors of sleep disturbance. Severity of HF, age, gender, etiology, obesity, smoking, and use of beta-blockers were not predictors of sleep disturbance. HF patients experience significant sleep disturbances, which are not predicted by severity of symptoms or clinical status. Problems with sleep are an important component of a clinical assessment in this vulnerable population.

Perceived control reduces emotional stress in patients with heart failure.

We studied patients with heart failure (HF) to determine if perceived control reduces emotional distress (i.e., anxiety, depression and hostility) in chronic, debilitating cardiac illness and whether the demographic, clinical and psychologic characteristics of patients with high and low perceived control differed. Psychological assessment of 222 patients with heart failure included an evaluation of perceived control using the Control Attitudes Scale, as well as anxiety, depression and hostility using the Multiple Affect Adjective Checklist. Using multivariate analysis to control for differences in demographic and clinical characteristics, we found that patients with high perceived control had significantly greater 6-minute walk distances and less emotional distress than patients with low perceived control. Interventions designed to increase perceived control may be an important aspect of HF care, but require testing in randomized trials.

An educational project to improve knowledge related to pulse oximetry.

BACKGROUND: Pulse oximetry is a frequently used, noninvasive monitoring tool for assessing arterial blood oxygenation. Physicians, registered nurses, and respiratory therapists are responsible for the accurate interpretation of pulse oximetry data as part of the evaluation and management of acutely and critically ill patients. OBJECTIVES: (1) To evaluate the extent of current knowledge about pulse oximetry and (2) to increase clinicians' knowledge of research-based practices related to the appropriate use of pulse oximetry and interpretation of its results. METHODS: A test/survey of 17 true-false questions based on the research-based practice protocol of the American Association of Critical-Care Nurses was developed to evaluate current knowledge of pulse oximetry. A convenience sample of medical, nursing, and respiratory therapy staff was invited to complete the test/survey before and several months after an educational program to improve staff members' knowledge of pulse oximetry. The program included educational forums, policy changes, competency checklists, and verification of inclusion of research-based principles in orientation programs. RESULTS: A total of 442 staff members completed the test/survey given before the educational program: 331 nurses, 82 physicians, and 29 respiratory therapists. The overall mean percentage of correct answers was 66%. Differences between disciplines were significant: respiratory therapists scored slightly higher (76%) than did nurses (64%) and physicians (66%) (P = .01). The scores on the test/survey given after the educational program increased significantly, from 66% to 82% (P < .01). CONCLUSIONS: This educational project improved staff members' knowledge of pulse oximetry monitoring.