Exploring inappropriate certified nursing assistant glove use in long-term care

BACKGROUND

Certified Nursing Assistants (CNAs) frequently wear gloves when they care for patients in standard precautions. If CNAs use gloves inappropriately, they may spread pathogens to patients and the environment, potentially leading to health care-associated infections (HAIs).

METHODS

Using a descriptive structured observational design, we examined the degree of inappropriate health care personnel glove use in a random sample of 74 CNAs performing toileting and perineal care at 1 long-term care facility.

RESULTS

During the 74 patient care events, CNAs wore gloves for 80.2% (1,774/2,213) of the touch points, failing to change gloves at 66.4% (225/339) of glove change points. CNAs changed gloves a median of 2.0 times per patient care event. A median of 1.0 change occurred at a change point. CNAs failed to change their gloves at a glove change point a median of 2.5 times per patient care event. Most (61/74; 82.4%) patient care events had >1 contaminated touch point. Over 44% (782/1,774) of the gloved touch points were defined as contaminated for a median of 8.0 contaminated glove touch points per patient care event. All contaminated touches were with gloved hands (P <.001).

CONCLUSIONS

Inappropriate glove use was frequently observed in this study. Contaminated gloves may be a significant cause of cross-contamination of pathogens in health care environments. Future research studies should evaluate strategies to improve glove use to reduce HAIs.

Clinical symptoms, signs and tests for identification of impending and current water-loss dehydration in older people

BACKGROUND

There is evidence that water-loss dehydration is common in older people and associated with many causes of morbidity and mortality. However, it is unclear what clinical symptoms, signs and tests may be used to identify early dehydration in older people, so that support can be mobilised to improve hydration before health and well-being are compromised.

OBJECTIVES

To determine the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs and tests to be used as screening tests for detecting water-loss dehydration in older people by systematically reviewing studies that have measured a reference standard and at least one index test in people aged 65 years and over. Water-loss dehydration was defined primarily as including everyone with either impending or current water-loss dehydration (including all those with serum osmolality ≥ 295 mOsm/kg as being dehydrated).

SEARCH METHODS

Structured search strategies were developed for MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL, LILACS, DARE and HTA databases (The Cochrane Library), and the International Clinical Trials Registry Platform (ICTRP). Reference lists of included studies and identified relevant reviews were checked. Authors of included studies were contacted for details of further studies.

SELECTION CRITERIA

Titles and abstracts were scanned and all potentially relevant studies obtained in full text. Inclusion of full text studies was assessed independently in duplicate, and disagreements resolved by a third author. We wrote to authors of all studies that appeared to have collected data on at least one reference standard and at least one index test, and in at least 10 people aged ≥ 65 years, even where no comparative analysis has been published, requesting original dataset so we could create 2 x 2 tables.

DATA COLLECTION AND ANALYSIS

Diagnostic accuracy of each test was assessed against the best available reference standard for water-loss dehydration (serum or plasma osmolality cut-off ≥ 295 mOsm/kg, serum osmolarity or weight change) within each study. For each index test study data were presented in forest plots of sensitivity and specificity. The primary target condition was water-loss dehydration (including either impending or current water-loss dehydration). Secondary target conditions were intended as current (> 300 mOsm/kg) and impending (295 to 300 mOsm/kg) water-loss dehydration, but restricted to current dehydration in the final review.We conducted bivariate random-effects meta-analyses (Stata/IC, StataCorp) for index tests where there were at least four studies and study datasets could be pooled to construct sensitivity and specificity summary estimates. We assigned the same approach for index tests with continuous outcome data for each of three pre-specified cut-off points investigated.Pre-set minimum sensitivity of a useful test was 60%, minimum specificity 75%. As pre-specifying three cut-offs for each continuous test may have led to missing a cut-off with useful sensitivity and specificity, we conducted post-hoc exploratory analyses to create receiver operating characteristic (ROC) curves where there appeared some possibility of a useful cut-off missed by the original three. These analyses enabled assessment of which tests may be worth assessing in further research. A further exploratory analysis assessed the value of combining the best two index tests where each had some individual predictive ability.

MAIN RESULTS

There were few published studies of the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs or tests to be used as screening tests for detecting water-loss dehydration in older people. Therefore, to complete this review we sought, analysed and included raw datasets that included a reference standard and an index test in people aged ≥ 65 years.We included three studies with published diagnostic accuracy data and a further 21 studies provided datasets that we analysed. We assessed 67 tests (at three cut-offs for each continuous outcome) for diagnostic accuracy of water-loss dehydration (primary target condition) and of current dehydration (secondary target condition).Only three tests showed any ability to diagnose water-loss dehydration (including both impending and current water-loss dehydration) as stand-alone tests: expressing fatigue (sensitivity 0.71 (95% CI 0.29 to 0.96), specificity 0.75 (95% CI 0.63 to 0.85), in one study with 71 participants, but two additional studies had lower sensitivity); missing drinks between meals (sensitivity 1.00 (95% CI 0.59 to 1.00), specificity 0.77 (95% CI 0.64 to 0.86), in one study with 71 participants) and BIA resistance at 50 kHz (sensitivities 1.00 (95% CI 0.48 to 1.00) and 0.71 (95% CI 0.44 to 0.90) and specificities of 1.00 (95% CI 0.69 to 1.00) and 0.80 (95% CI 0.28 to 0.99) in 15 and 22 people respectively for two studies, but with sensitivities of 0.54 (95% CI 0.25 to 0.81) and 0.69 (95% CI 0.56 to 0.79) and specificities of 0.50 (95% CI 0.16 to 0.84) and 0.19 (95% CI 0.17 to 0.21) in 21 and 1947 people respectively in two other studies). In post-hoc ROC plots drinks intake, urine osmolality and axillial moisture also showed limited diagnostic accuracy. No test was consistently useful in more than one study.Combining two tests so that an individual both missed some drinks between meals and expressed fatigue was sensitive at 0.71 (95% CI 0.29 to 0.96) and specific at 0.92 (95% CI 0.83 to 0.97).There was sufficient evidence to suggest that several stand-alone tests often used to assess dehydration in older people (including fluid intake, urine specific gravity, urine colour, urine volume, heart rate, dry mouth, feeling thirsty and BIA assessment of intracellular water or extracellular water) are not useful, and should not be relied on individually as ways of assessing presence or absence of dehydration in older people.No tests were found consistently useful in diagnosing current water-loss dehydration.

AUTHORS' CONCLUSIONS

There is limited evidence of the diagnostic utility of any individual clinical symptom, sign or test or combination of tests to indicate water-loss dehydration in older people. Individual tests should not be used in this population to indicate dehydration; they miss a high proportion of people with dehydration, and wrongly label those who are adequately hydrated.Promising tests identified by this review need to be further assessed, as do new methods in development. Combining several tests may improve diagnostic accuracy.

The Anticholinergic Drug Scale as a Measure of Drug-Related Anticholinergic Burden: Associations With Serum Anticholinergic Activity

Anticholinergic Drug Scale (ADS) scores were previously associated with serum anticholinergic activity (SAA) in a pilot study. To replicate these results, the association between ADS scores and SAA was determined using simple linear regression in subjects from a study of delirium in 201 long-term care facility residents who were not included in the pilot study. Simple and multiple linear regression models were then used to determine whether the ADS could be modified to more effectively predict SAA in all 297 subjects. In the replication analysis, ADS scores were significantly associated with SAA (R2 = .0947, P < .0001). In the modification analysis, each model significantly predicted SAA, including ADS scores (R2 = .0741, P < .0001). The modifications examined did not appear useful in optimizing the ADS. This study replicated findings on the association of the ADS with SAA. Future work will determine whether the ADS is clinically useful for preventing anticholinergic adverse effects.

Twelve-month fall outcomes among delirium subtypes

PURPOSE

The purpose of this study was to examine falls as an outcome measure at 12 months for two-group comparison (delirium cases and noncases) and five-group comparison (noncases, hypoactive, hyperactive, mixed delirium cases, and subsyndromal delirium cases).

DESIGN

Three hundred and twenty patients enrolled in the Delirium in Rural Long-Term Care Facilities Study, which examined subjects for delirium during a 28-day surveillance period, were followed longitudinally for fall events for 12 months. Fall events were recorded and data analyzed using date of "first fall" as the referent for statistical analysis.

METHODS

Fall reports were completed for all subjects for 12 months following delirium surveillance. Fall records were reviewed and the number of days until the first fall event was calculated. Data were censored for deaths that occurred during the 12-month period.

FINDINGS

Five group analysis of variance (noncases, hyperactive delirium, hypoactive delirium, mixed delirium, and subsyndromal delirium) showed significant differences in Functional Independence Measure scores (p = .001) and number of medications (p = .001). The percentage of patients who fell was higher in all delirium subtypes than in noncases at 12 months and was statistically significant for subsyndromal subjects. Two patients, one each from the subsyndromal and mixed delirium subtypes, died from injuries sustained during falls.

CONCLUSIONS

Delirium appears to increase the risk for falls.

CLINICAL RELEVANCE

Increased surveillance and fall prevention strategies are needed for patients who experience transient cognitive changes such as delirium and subsyndromal delirium, even after delirium resolution.

Twelve-month mortality among delirium subtypes

This study used data from the Delirium Among the Elderly in Rural Long-Term Care Facilities Study and data from the National Death Index (NDI) to examine mortality among 320 individuals. Individuals were grouped into noncases, subsyndromal cases, hypoactive delirium, hyperactive delirium, and mixed delirium on the basis of scoring using the Confusion Assessment Method (CAM), NEECHAM Scale, Mini-Mental State Examination (MMSE), Clinical Assessment of Confusion-A (CAC-A), and Vigilance A instruments. Risk ratios of mortality using "days of survival" did not reach statistical significance (α = .05) for any subgroup. Underlying cause of death (UCD) using International Classification of Disease, 10th version (ICD-10), showed typical UCD among older adults. There appeared to be clinical differences in UCD between delirium subgroups. Findings supported the conclusion that careful monitoring of patients with delirium and subsyndromal delirium is needed to avoid complications and injuries that could increase mortality.

Relationship of Cardiovascular Disease to Stress and Vital Exhaustion in an Urban, Midwestern Police Department

This study explored risk factors for cardiovascular disease (CVD) among 336 officers of a Midwestern police force. Instruments used included the Perceived Stress Scale, the Maastricht Questionnaire (measuring vital exhaustion), and a general Health Risk Appraisal. Rates of CVD, hypertension, and hypercholesterolemia were 3%, 28%, and 43%, respectively. The relative risk of hypercholesterolemia for male officers, compared to female officers, was 1.98 (95% confidence interval [CI], 1.10 to 3.56). The officers' average body mass index was 28.6 ( SD = 4.9), with 80% being overweight or obese. The average vital exhaustion score was higher for female officers than male officers ( p < .05). Bivariate relationships of CVD with perceived stress, vital exhaustion, and age were statistically significant (p < .05). When controlling for age, odds ratios were 1.20 (95% CI, 1.03 to 1.39; p< .05) for perceived stress and 1.31 (95% CI, 1.12 to 1.53; p < .01) for vital exhaustion.

Relationship of cardiovascular disease to stress and vital exhaustion in an urban, midwestern police department

This study explored risk factors for cardiovascular disease (CVD) among 336 officers of a Midwestern police force. Instruments used included the Perceived Stress Scale, the Maastricht Questionnaire (measuring vital exhaustion), and a general Health Risk Appraisal. Rates of CVD, hypertension, and hypercholesterolemia were 3%, 28%, and 43%, respectively. The relative risk of hypercholesterolemia for male officers, compared to female officers, was 1.98 (95% confidence interval [CI], 1.10 to 3.56). The officers' average body mass index was 28.6 (SD = 4.9), with 80% being overweight or obese. The average vital exhaustion score was higher for female officers than male officers (p < .05). Bivariate relationships of CVD with perceived stress, vital exhaustion, and age were statistically significant (p < .05). When controlling for age, odds ratios were 1.20 (95% CI, 1.03 to 1.39; p < .05) for perceived stress and 1.31 (95% CI, 1.12 to 1.53; p < .01) for vital exhaustion.

The RBANS Effort Index: base rates in geriatric samples

The Effort Index (EI) of the RBANS was developed to assist clinicians in discriminating patients who demonstrate good effort from those with poor effort. However, there are concerns that older adults might be unfairly penalized by this index, which uses uncorrected raw scores. Using five independent samples of geriatric patients with a broad range of cognitive functioning (e.g., cognitively intact, nursing home residents, probable Alzheimer's disease), base rates of failure on the EI were calculated. In cognitively intact and mildly impaired samples, few older individuals were classified as demonstrating poor effort (e.g., 3% in cognitively intact). However, in the more severely impaired geriatric patients, over one third had EI scores that fell above suggested cutoff scores (e.g., 37% in nursing home residents, 33% in probable Alzheimer's disease). In the cognitively intact sample, older and less educated patients were more likely to have scores suggestive of poor effort. Education effects were observed in three of the four clinical samples. Overall cognitive functioning was significantly correlated with EI scores, with poorer cognition being associated with greater suspicion of low effort. The current results suggest that age, education, and level of cognitive functioning should be taken into consideration when interpreting EI results and that significant caution is warranted when examining EI scores in elders suspected of having dementia.

Pesticide handling and exposures among cotton farmers in the gambia

OBJECTIVES

There are substantial health hazards to farmers and the environment associated with pesticide use in developing countries. Based on observations by the authors and previous reports, most previous studies in Africa are descriptive in nature. The aim of this study was to investigate how cotton farmers are exposed to pesticides in The Gambia and quantify their pesticide exposures and provide information for the formulation of a policy on pesticide safety for the country.

METHODS

A representative sample of 20 cotton farmers in the Central and Upper River Divisions (CRD and URD) of The Gambia were surveyed by questionnaires. Dermal pesticide exposures among a subset of 10 farmer/pesticide applicators were assessed by dermal patch samples, observation, and postapplication questionnaires.

RESULTS

The study revealed that a toxic organochlorine insecticide, Callisulfan (endosulfan), is frequently sprayed on cotton plants by the farmers. The farmers wore no protective equipment and were inadequately dressed for work with this pesticide. Laboratory analysis of the mixed formulation showed a wide range in the concentration of the pesticide solution among the farmer/pesticide applicators and dermal patch samples showed very high residues of endosulfan analytes on their body surfaces.

CONCLUSIONS

A low level of awareness of pesticide toxicity prevails amonsg cotton farmers in The Gambia. There is a less than adequate control of pesticides and other hazardous agrichemicals in the country.

Antidepressant treatment of depression in rural nursing home residents

Under-diagnosis and under-treatment of depression are major problems in nursing home residents. The purpose of this study was to determine antidepressant use among nursing home residents who were diagnosed with depression using three different methods: (1) the Geriatric Depression Scale, (2) Minimum Data Set, and (3) primary care provider assessments. As one would expect, the odds of being treated with an antidepressant were about eight times higher for those diagnosed as depressed by the primary care provider compared to the Geriatric Depression Scale or the Minimum Data Set. Men were less likely to be diagnosed and treated with antidepressants by their primary care provider than women. Depression detected by nurses through the Minimum Data Set was treated at a lower rate with antidepressants, which generates issues related to interprofessional communication, nursing staff communication, and the need for geropsychiatric role models in nursing homes.

Bioelectrical impedance analysis and other hydration parameters as risk factors for delirium in rural nursing home residents

BACKGROUND

The study investigators conducted a vigorous screening protocol for delirium in rural long-term care (LTC) facilities for a period of 28 days focusing on Bioelectrical Impedance Analysis (BIA) and other hydration parameters as risk factors.

METHODS

A two-stage cluster sampling procedure was used to randomly select participants (n = 313) from 13 LTC facilities located in southeastern Iowa, stratified on facility bed size. BIA was used to estimate intracellular water (ICW), extracellular water (ECW), and total body water (TBW) on four occasions--baseline and follow-up days 7, 14, and 28. Volume estimates were calculated as a percent of body weight (%WT). Serum electrolytes and hematology were also measured. Delirium was measured with four strict criteria: a NEECHAM Confusion Scale score < 25, Vigilance "A" score > 2, a Mini-Mental Status Examination < baseline, and a positive Confusion Assessment Method score.

RESULTS

There were n = 69 delirium cases (22.0%). Blood urea nitrogen/creatinine ratios greater than 21:1 (odds ratio = 1.76, 95% confidence interval 1.02-3.06). No significant risk for delirium was associated with ICW, ECW, or TBW as a percent of body weight.

CONCLUSIONS

Some changes were observed with a slight decrease in ICW between day 7 and day 14 of follow-up that tended to follow an increase in delirium events, but in general the BIA measures did not predict delirium events.

The relationship of an anticholinergic rating scale with serum anticholinergic activity in elderly nursing home residents

ndings support the validity of the CR-ACh-mod. However, unexplained variance in SAA suggests that the CR-ACh-mod could benefit from improvements. Future research will evaluate the effect of including factors such as dose and the relative anticholinergic burden from drugs at each of the rating levels. An alternative explanation for the variance which is supported by recent research is that nondrug factors contribute to SAA.

An analysis of body weight and hemodialysis adequacy based on the urea reduction ratio

The purpose of this study was to evaluate inadequate hemodialysis risk in patients with body weights in the upper quartile of a sample distribution using the urea reduction ratio (URR). Using a case-control design and a simple random sample (n = 315) of hemodialysis (HD) patients, postdialysis weights were divided into quartiles based with a cut-off value at the upper quartile, which was equal to > 81 kilograms (kg). The dichotomous outcome, URR > 65% and URR < 65% constituted the classification for inadequate dialysis risk. The odds ratio (OR) was used to evaluate inadequate dialysis risk based on this outcome. A multivariate logistic regression model was used to adjust for confounding variables and validated for goodness of fit. Those in the > 81 kg group were given more dialysis session time in minutes and used higher efficiency dialyzers as indicated by the coefficient of ultrafiltration (KUf), yet were more likely to have URRs < 65% compared to other patients in the sample (p < 0.001). This finding persisted in the logistic regression model when simultaneously fitting both gender and dialysis session time. Patients weighing > 81 kg experienced an increased risk of inadequate dialysis when compared to all others (OR 4.02, 95% CI [confidence interval] 2.217-7.29). A postdialysis weight > 81 kg increased the risk of inadequate dialysis for patients in this sample. This effect was confounded by a dialysis time x weight interaction term. Also, women were found to have a lower inadequate dialysis risk compared to men after adjusting for weight classification. We, therefore, conclude that patients who weigh > 81 kg may experience inadequate dialysis despite longer, more efficient dialysis sessions. Longer dialysis sessions may benefit some patients, but the effect in larger patients may not be a uniform response.

Family and client perspectives on alternative residential settings for persons with severe mental illness

OBJECTIVE

The housing preferences of persons with severe mental illness living in three types of community residences were examined, as were their perceptions of problems in these settings and the relationships between clients' and family members' housing preferences and perceptions of problems.

METHODS

A closed-ended questionnaire was developed to gather demographic and diagnostic data and information about housing preferences and seven categories of service-related problems. It was completed by clients who lived in group settings with 24-hour on-site staff, in supported housing with on-site visits by staff, and in homes or apartments with no on-site professional services. Questionnaires were returned by 129 family members and 180 clients.

RESULTS

Clients who lived in group settings were significantly more likely to be older, less educated, unemployed, and diagnosed as having schizophrenia than clients in other settings. Although a larger proportion of family members than clients preferred housing with more support, for both families and clients a statistically significant association was found between current and preferred residence. A strong and significant correlation was found between clients' and family members' perceptions of problems, which included stress on the family and clients' social isolation and relapse to illness. For clients who lived independently, a significantly greater proportion of both clients and families reported that social isolation was a problem.

CONCLUSIONS

Although supported housing works well for some individuals, a continued need exists for an array of housing with varying levels of structure. The results suggest that clients and families identify the same problems as priorities.