Obtaining the Best Possible Medication History at Hospital Admission: Description of a Pharmacy Technician-Driven Program to Identify Medication Discrepancies.

PURPOSE: Describe the process of obtaining the best possible medication history (BPMH) by Certified Pharmacy Technicians (CPhTs) on hospital admission to identify medication discrepancies. METHODS: Cross-sectional, descriptive study conducted between December 2016 and June 2017 at a quaternary center in New York, including all patients 18 years and older admitted to the medicine service through the Emergency Department (ED) and seen by a CPhT. CPhTs obtained the BPMH using a systematic approach involving a standardized interview, checking medications with secondary sources and updating the electronic health record (EHR). Medication discrepancies were identified and categorized by type and risk. Summary statistics were provided as average and standard deviation (SD) for continuous variables, and as frequencies and percentages for categorical variables. Multivariable regression was used to test for associations between patient factors and presence of a medication discrepancy. RESULTS: Of the 3,087 patient visits, the average age was 69 (SD 17.8), 54% were female (n = 1652) and 65% white (n = 2017); comorbidity score breakdown was: 0 (25%, n = 757), 1-2 (33%, n = 1023), 3-4 (23%, n = 699), > 4 (20%, n = 608). The average number of home and discharge medications were 10 (SD 6.1) and 10 (SD 5.4), respectively. The average time spent obtaining the BPMH was 30.6 minutes (SD 12.9). 69% of patients (n = 2130) had at least 1 discrepancy with an average of 4.2 (SD 4.6), of which 43% (n = 920) included high-risk medications. Having a medication discrepancy was associated with a higher number of home medications (p < 0.0001) comorbidities (p < 0.0001), and source of information (p < 0.04). CONCLUSION: Obtaining the BPMH by CPhTs on hospital admission frequently identifies medication discrepancies. Further studies are needed to evaluate the association between obtaining the BPMH and clinical outcomes.

Patterns of alcohol use among early head and neck cancer survivors: A cross-sectional survey study using the alcohol use disorders identification test (AUDIT).

OBJECTIVE: Alcohol use among survivors of head and neck cancer (HNC) negatively impacts patient outcomes and is an important risk factor for recurrent and second primary tumors. Despite recommendations from several cancer societies, alcohol consumption remains a common problem in this population. METHODS: A cross-sectional study was performed with the Alcohol Use Disorders Identification Test (AUDIT) Self-Report questionnaire. Patients with HNC completed surveys at pre-treatment and follow-up appointments every 3-6 months for at least 2-years after treatment. RESULTS: 796 surveys were available for analysis. Most participants were male (75.7%) and had either oropharyngeal (34.5%) or laryngeal (16.7%) cancer. The percentage of alcohol drinkers decreased from 56.1% at pre-treatment to 40.4% at 0-3 months post-treatment, but then increased and surpassed baseline levels by 24 + months post-treatment (64.4%, p = 0.0079). Concurrently, moderate drinkers (AUDIT = 1 - 3) decreased from 34.2% at pre-treatment to 25.2% at 0-3 months post-treatment, but then increased and surpassed baseline levels at 24 + months post-treatment (39.7%, p = 0.0129). Trends among heavy (AUDIT > 3), and heaviest (AUDIT > 6) drinkers were similar, but not statistically significant. At 24 + months post-therapy, we observed a statistically significant increase in female users (39.1% to 63.2%, p = 0.0213) and moderate drinkers < 55 years old (43.4% to 61.9%, p = 0.0184). CONCLUSION: Alcohol consumption in survivors of HNC transiently decreases in the immediate months after treatment, but then increases and remains largely stable by 24 months. This pattern is particularly concerning and highlights the need for timely interventions.

Chronic perinatal hypoxia delays cardiac maturation in a mouse model for cyanotic congenital heart disease.

Compared with acyanotic congenital heart disease (CHD), cyanotic CHD has an increased risk of lifelong mortality and morbidity. These adverse outcomes may be attributed to delayed cardiomyocyte maturation, since the transition from a hypoxic fetal milieu to oxygen-rich postnatal environment is disrupted. We established a rodent model to replicate hypoxic myocardial conditions spanning perinatal development, and tested the hypothesis that chronic hypoxia impairs cardiac development. Pregnant mice were housed in hypoxia beginning at embryonic day 16. Pups stayed in hypoxia until postnatal day (P)8 when cardiac development is nearly complete. Global gene expression was quantified at P8 and at P30, after recovering in normoxia. Phenotypic testing included electrocardiogram, echocardiogram, and ex vivo electrophysiology study. Hypoxic P8 animals were 47% smaller than controls with preserved heart size. Gene expression was grossly altered by hypoxia at P8 (1,427 genes affected), but normalized after recovery (P30). Electrocardiograms revealed bradycardia and slowed conduction velocity in hypoxic animals at P8, with noticeable resolution after recovery (P30). Notable differences that persisted after recovery (P30) included a 65% prolongation in ventricular effective refractory period, sinus node dysfunction, 23% reduction in ejection fraction, and 16% reduction in fractional shortening in animals exposed to hypoxia. We investigated the impact of chronic hypoxia on the developing heart. Perinatal hypoxia was associated with changes in gene expression and cardiac function. Persistent changes to the electrophysiological substrate and contractile function warrant further investigation and may contribute to adverse outcomes observed in the cyanotic CHD population.NEW & NOTEWORTHY We utilized a new mouse model of chronic perinatal hypoxia to simulate the hypoxic myocardial conditions present in cyanotic congenital heart disease. Hypoxia caused numerous abnormalities in cardiomyocyte gene expression, the electrophysiologic substrate of the heart, and contractile function. Taken together, alterations observed in the neonatal period suggest delayed cardiac development immediately following hypoxia.

Age-dependent changes in electrophysiology and calcium handling: implications for pediatric cardiac research.

Rodent models are frequently employed in cardiovascular research, yet our understanding of pediatric cardiac physiology has largely been deduced from more simplified two-dimensional cell studies. Previous studies have shown that postnatal development includes an alteration in the expression of genes and proteins involved in cell coupling, ion channels, and intracellular calcium handling. Accordingly, we hypothesized that postnatal cell maturation is likely to lead to dynamic alterations in whole heart electrophysiology and calcium handling. To test this hypothesis, we employed multiparametric imaging and electrophysiological techniques to quantify developmental changes from neonate to adult. In vivo electrocardiograms were collected to assess changes in heart rate, variability, and atrioventricular conduction (Sprague-Dawley rats). Intact, whole hearts were transferred to a Langendorff-perfusion system for multiparametric imaging (voltage, calcium). Optical mapping was performed in conjunction with an electrophysiology study to assess cardiac dynamics throughout development. Postnatal age was associated with an increase in the heart rate (181 ± 34 vs. 429 ± 13 beats/min), faster atrioventricular conduction (94 ± 13 vs. 46 ± 3 ms), shortened action potentials (APD80: 113 ± 18 vs. 60 ± 17 ms), and decreased ventricular refractoriness (VERP: 157 ± 45 vs. 57 ± 14 ms; neonatal vs. adults, means ± SD, P < 0.05). Calcium handling matured with development, resulting in shortened calcium transient durations (168 ± 18 vs. 117 ± 14 ms) and decreased propensity for calcium transient alternans (160 ± 18- vs. 99 ± 11-ms cycle length threshold; neonatal vs. adults, mean ± SD, P < 0.05). Results of this study can serve as a comprehensive baseline for future studies focused on pediatric disease modeling and/or preclinical testing.NEW & NOTEWORTHY This is the first study to assess cardiac electrophysiology and calcium handling throughout postnatal development, using both in vivo and whole heart models.

Constant Observation Practices for Hospitalized Persons With Dementia: A Survey Study.

Despite substantial staffing and cost implications, the use of constant observation (CO) has been poorly described in the acute care setting. The purpose of this cross-sectional, multicenter, survey study was to assess hospital provider practices regarding the use of CO. Of the 543 surveys distributed, 231 were completed across 5 sites. Most respondents worked on medical units (67.5%), as nurses (49.1%); 44.8% were white; and 75.6% were female. The majority (84.2%) reported at least 1 patient/wk requiring CO. Most frequent indication for CO was dementia with agitation (60.7%), in patients older than 70 (62.3%) and predominantly by nurse assistants (93.9%). Almost half (47.3%) stated they felt pressured to discontinue CO, despite a strong perceived benefit (76%). Enhanced observation (92.6%) was most frequently used to decrease CO. Finally, 77.9% perceived that those performing CO lacked training. Our study highlights the widespread use of CO for hospitalized older adults with dementia.

Nonadherence to Geriatric-Focused Practices in Older Intensive Care Unit Survivors.

BACKGROUND: Older adults account for more than half of all admissions to intensive care units; most remain alive at 1 year, but with long-term sequelae. OBJECTIVE: To explore geriatric-focused practices and associated outcomes in older intensive care survivors. METHODS: In a 1-year, retrospective, cohort study of patients admitted to the medical intensive care unit and subsequently transferred to the medicine service, adherence to geriatric-focused practices and associated clinical outcomes during intensive care were determined. RESULTS: A total of 179 patients (mean age, 80.5 years) met inclusion criteria. Nonadherence to geriatric-focused practices, including nothing by mouth (P = .004), exposure to benzodiazepines (P = .007), and use of restraints (P < .001), were associated with longer stay in the intensive care unit. Nothing by mouth (P = .002) and restraint use (P = .003) were significantly associated with longer hospital stays. Bladder catheters were associated with hospital-acquired pressure injuries (odds ratio, 8.9; 95% CI, 1.2-67.9) and discharge to rehabilitation (odds ratio, 8.9; 95% CI, 1.2-67.9). Nothing by mouth (odds ratio, 3.2; 95% CI, 1.2-8.0) and restraints (odds ratio, 2.8; 95% CI, 1.4-5.8) were also associated with an increase in 30-day readmission. Although 95% of the patients were assessed at least once by using the Confusion Assessment Method for the Intensive Care Unit (overall 2334 assessments documented), only 3.4% had an assessment that indicated delirium; 54.6% of these assessments were inaccurate. CONCLUSION: Although initiatives have increased awareness of the challenges, implementation of geriatric-focused practices in intensive care is inconsistent.

A Multicomponent Model to Improve Hospital Care of Older Adults with Cognitive Impairment: A Propensity Score-Matched Analysis.

OBJECTIVES: To determine whether a multicomponent intervention improves care in hospitalized older adults with cognitive impairment. DESIGN: One-year retrospective chart review with propensity score matching on critical demographic and clinical variables was used to compare individauls with cognitive impairmenet on intervention and nonintervention units. SETTING: Large tertiary medical center. PARTICIPANTS: All hospitalized individuals age 65 and older with cognitive impairment admitted to medicine who required constant or enhanced observation for behavioral and psychological symptoms. INTERVENTION: Multicomponent intervention (geographic unit cohorting, multidisciplinary approach, patient engagement specialists (PES), staff education) or usual care. MEASUREMENTS: In-hospital mortality, length of stay, readmission, management of behavioral disturbances. RESULTS: After propensity score matching, 476 of the 712 intervention visits were pair-matched with 476 of the 558 usual care visits. Matching was successful in balancing baseline covariates between intervention and usual care units. Individuals admitted to the intervention unit had lower in-hospital mortality (1.1% vs 2.9%, p=0.05) and shorter stays (5.0 vs 5.8 days, p=0.04). There was no difference in discharge home (p=0.90) or 30-day readmission rates (p=0.44). Individuals on the intervention unit were less likely than those receivng usual care to have an order for constant (12.0% vs 45.8%, p<0.01) or enhanced (22.1% vs 79.6%, p<0.01) observation, to be taking benzodiazepines (26.3% vs 38.0%, p<0.01), to be taking nothing by mouth (29.6% vs 40.8%, p=0.01), to be on bedrest (17.0% vs 25.8%, p=0.01), to be taking antipsychotics (41.2% vs 54.0%, p<0.01), or to have restraints (3.2% vs 6.9%, p=.01). CONCLUSION: A multicomponent intervention of geographic cohorting, multidisciplinary approach, PES, and staff education may offer a new paradigm in the management of hospitalized older adults with cognitive impairment.

Measuring Functional Status in Hospitalized Older Adults Through Electronic Health Record Documentation.

OBJECTIVES: Hospitalization-associated disability affects up to 60% of older adults; however, standardized measures of function are not routinely used and documented. We sought to determine whether nursing documentation in electronic medical records can be used to determine mobility status and associated clinical outcomes. METHODS: A retrospective study of 2383 medical patients aged 75 years and older was conducted at a large academic tertiary hospital in New York. Mobility (low, intermediate, and high) was the primary variable of interest. Short-term clinical outcomes, including length of stay (LOS), discharge disposition, and readmissions, were the primary outcome variables. RESULTS: Average age and Charlson Comorbidity Index were 84.7 (range 74-107) and 6.46, respectively; 84.5% of patients were documented to have been ambulatory before admission. More than half (52.8%) of the subjects with in-hospital mortality were in the low mobility group (27.2 vs 0.27 vs 0, P < 0.0001). Low mobility was associated with increased LOS (7.42 vs 5.69 vs 4.14, P < 0.0001), discharge to a skilled nursing facility (39.36 vs 14.67 vs 1.91, P < 0.0001), and 30-day readmission (24.40 vs 16.67 vs 10.93, P < 0.0001). After controlling for demographics, ambulatory status before admission, and Charlson Comorbidity Index, low mobility was statistically significantly associated with increased LOS, discharge to a skilled nursing facility, and 30-day readmissions. CONCLUSIONS: The use of documented nursing observation may provide a practical way to systematically identify patients at risk for poor outcomes associated with low mobility to ultimately improve outcomes of hospitalized older adults.

Patterns and outcomes of prescribing venous thromboembolism prophylaxis in hospitalized older adults: a retrospective cohort study.

Venous thromboembolism (VTE) is a major cause of morbidity and mortality in the United States. Hospitalized, medically ill older adults have increased risk; despite guidelines, data suggest suboptimal pharmacologic prophylaxis rates. Factors influencing provider prescribing non-compliance are unclear. We aimed to describe VTE prophylaxis practices and identify risk factors for, and outcomes of, prescribing non-compliance. A retrospective study was conducted of hospitalized adults aged ≥ 75 years, admitted to the medicine service of a large academic tertiary center from May 1, 2014 to June 30, 2015. The primary outcome was non-compliance, defined as the absence of an order for VTE prophylaxis for the duration of hospitalization or an interruption of prophylaxis exceeding 24 h. Secondary measures included in-hospital mortality, length of stay (LOS), and 30-day readmissions. Of 3751 patients (mean age 84.7 years), 97.6% of charts had prophylaxis orders; 11.0% showed non-compliance. Pharmacologic prophylaxis was prescribed in 83.3% of patients and mechanical prophylaxis alone in 14.3%. Factors associated with non-compliance included: higher body mass index (BMI) (p = 0.04), myocardial infarction (p = 0.01), congestive heart failure (p = 0.001), metastatic tumor (p = 0.01). Low mobility was not significantly associated with compliance. Subcutaneous unfractionated heparin was associated with compliance (p < 0.0001); warfarin (p < 0.0001), heparin infusion (p < 0.0001) and low-molecular-weight heparin (p < 0.0001) with non-compliance. Non-compliance was associated with increased mortality (p = 0.01), LOS (p < 0.0001), readmissions (p = 0.0004). Known VTE risk factors (mobility, BMI, comorbidities) were not associated with prescriber compliance patterns. Integrating risk assessment models into provider practice may improve compliance.