Christine M. Khandelwal, DO
Kevin Biese, MD, MAT
Ellen Roberts, PhD, MPH
Jan Busby-Whitehead, MD
University of North Carolina School of
Medicine at Chapel Hill
Division of Geriatric Medicine
Center for Aging and Health
Department of Emergency Medicine
With Support from The Donald W. Reynolds Foundation, John A.
Hartford Foundation
& American Geriatrics Society
Copyright © 2011 The University of North Carolina School of Medicine at Chapel Hill
Learning Objectives
• Learners will be able to list the most common
type of iatrogenic injury.
• Learners will be able to identify the most
common cause of nosocomial fever in the
hospital.
• Learners will be able to identify the reasons
for use of restraints and how to avoid using
them.
• Learners will be able to list the appropriate
use of urinary catheters.
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2
The Case of Mrs. TW
Mrs. TW is a 79yo female with
history of HTN, MCI, and
urge incontinence, who
was admitted for a
pneumonia. She is stable
on admission and sent to
the floor with a foley
catheter in-place.
Mrs. TW has an uneventful 24
hours, clinically stable and
doing well with plans for
discharge the next
morning to home.
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3
BACKGROUND
• Cascade iatrogenesis is a series of adverse
events triggered by an initial medical or
nursing intervention initiating a cascade of
decline.
» Occurs most frequently among the oldest,
most functionally impaired patients and those
with a higher severity of illness upon
admission.
Creditor 1993, Hofer 2002, Thomas 2000
»
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4
BACKGROUND
• Hospitalization for the elderly is often
followed by an irreversible decline in
functional status and a change in quality and
style of life.
»
»
»
»
Elders are at high risk for poor outcome
High 1 year mortality
Thirty percent (30%) functional decline
High rates of skilled nursing facility placement
Creditor 1993, Hofner 2002, Thomas 2000
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5
Iatrogenesis in Older Patients
• Age-related factors that predispose the older
patient to iatrogenesis
• More co-morbid, chronic medical conditions,
that require more diagnostic procedures and
medications2,4
• Increased severity of illness and complexity
of care
• Longer length of stay
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6
Adverse Outcomes in
Hospitalized Older Patients
• Harvard Medical Malpractice Study:
» 5% rate of disabling injury if >65 yrs.
» RR= 4.12 (2.6-6.5) for therapeutic mishap
Brennan TA et al. N Engl J Med 1991
• Associated with immobility, abnormal mental
status, worse initial physician assessment
Rachelle Bernacki MD Bree Johnston MD Division of Geriatrics University of California San Francisco and
San Francisco VA Medical Center, Lefevre F et al. Arch Intern Med 1992
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7
Question 1
• Which is the most common type of iatrogenic
injury occurring in hospitalized patients?
a) Adverse drug events (ADEs)
b) Infections
c) Falls
d) Pressure sores
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8
Preventable Adverse Events
Age is a risk factor for bad outcomes
Rachelle Bernacki MD Bree Johnston MD Division of Geriatrics University of California San Francisco and San
Francisco VA Medical Center, Thomas and Brennan 2000
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9
Elderly Most Likely to Suffer…
Adverse Drug Events
Delirium
Nosocomial Infections
Falls
Procedural/Surgical Complications
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10
Adverse Drug Events
• Most common type of iatrogenic injury
• Predictors
» > 4 meds
» LOS > 14 days
» > 4 active medical problems
• # of drugs is the strongest predictor;
potential for interaction: 2 drugs 6%, 5
drugs 50%, ≥ 8 drugs nearly 100%
• 70-80% of ADEs in the elderly are dose
related
• 30-50% preventable!
Carbonin P et al. JAGS 1991
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11
Adverse Drug Events
• Other ADE Predictors:
»
»
»
»
Multiple medical problems
Multiple medications
New medications added
Low weight, female gender, impaired
creatinine clearance
Carbonin 1991, Evans 2005, Bates 1999, Gray 1998, Thomas and Brennan
BMJ 2000
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Adverse Drug Events
Common Drugs
Common Effects
Anticholinergics
Mental Status
Psychotropics
Urinary Complications
Sleepers
Infections
Narcotics
Gastrointestinal
Digoxin
Falls
Anti-hypertensives
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13
The Case of Mrs. TW
Twenty four hours after
admission, nursing staff calls
to report that Mrs. TW is
“yelling out and trying to catch
the butterfly in the hall.” With
further report from the nurse,
the patient has a fever.
Staff is requesting to keep Mrs.
TW “quiet tonight” as they are
short-staffed and will not be
able to control her tonight.
What is the source of her
fever? Could this have been
prevented?
.
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Delirium
• Delirium is one of the most common
iatrogenic complications in hospitalized
elders affecting 50% or more post-operative
hip fracture and thoracic surgery patients
over age 65.
• We don’t diagnose it!
Inouye 1996, Han 2009, Pompei 1994
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Preventing Delirium
• At least 3 clinical trials suggest that
minimizing risk factors in hospital can reduce
delirium
» Pain, sleep, hydration, orientation, minimizing
tubes and lines, minimizing problem drugs
Inouye NEJM 1999
Lundstrom M et al 2007
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Procedures: Inpatient Delirium
4/13/2015
Predictor
Relative Risk
Bladder Catheter
2.4
Physical Restraints
4.4
> 3 Meds Added
2.9
Any latrogenic Event
1.9
17
Treatment for Delirium
• Almost no drug studies of established
delirium
• Most experts would use traditional or atypical
antipsychotic agents in low dose for agitated
delirium treatment
» What about anticholinesterase inhibitors?
Sampson 2007
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Question 2
The most common cause of iatrogenic fever in hospitalized
older patients on a general ward is which of the following?
a) Pneumonia
b) Urinary tract infection
c) Diarrhea
d) Pressure sores
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Nosocomial Infections
• UTIs
• Pneumonia
• Surgical wound infections
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Nosocomial Infections
• Infections are usually related to a procedure
or treatment used to diagnose or treat the
patient's initial illness or injury
• 36% of these are preventable!
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Question 3
A urinary catheter should not be placed for which of the
following reasons?
a) Management of all types of urinary incontinence
b) For terminally ill patients
c) Patient’s preference if they have not responded to
specific incontinence treatment
d) Managing urinary retention
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Urinary Catheters
• 25% of hospitalized pts have indwelling
catheter
• Associated with  LOS,  inpatient mortality
• Inappropriate for over 50% of inpatient days
• Uncomfortable / Restrictive
Jain 1995, Saint 1999
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Urinary Catheters
• Catheter-associated urinary tract infections
(CAUTIs) represent the most common
nosocomial infection, accounting for 40% of
all hospital-acquired infections.
• Foley catheters are commonly placed without
a compelling indication, and are a
preventable cause of hospital-acquired
infections.
Saint 2000, Saint
2006
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Indications for Urinary
Catheterization
• Output monitoring of unstable patients
• Complete urinary retention
• Urinary incontinence in patients with wounds
or skin defects
• Urinary incontinence in general is not an
indication for catheterization, but it may be
considered for patient comfort at the request
of the patient or family.
• Terminally ill patients.
• Perioperative use
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If not a foley…what instead?
• Prevention and Treatment –
» Plan may include reviewing medications
(opiates, anti-cholingerics, diuretics, alphaadrenergic agonists, calcium-channel blockers
are offenders)
» Treat UTI (contributes to urge incontinence)
» Treat constipation
» Seek any reversible causes of delirium
» Regular toileting schedule
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The Case of Mrs. TW
Wrist restraints were placed
on Mrs. TW to help
maintain her delirium
tonight. Three hours later,
nursing staff calls you to
report a fall for Mrs. TW.
You order a stat hip x-ray
and an acute fracture is
found.
What was the cascade of
events? Could any of this
been prevented?
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27
Why are Restraints Used?
•
•
•
•
Prevent falls
Prevent injuries
Prevent treatment disruption
Manage confusion
AGS Positional statement 2008, Tzeng 2008, Antonelli 2008
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28
AGS Positional Statement:
Restraints are acceptable to use:
• If there is no safer alternative
• If patient is at significant risk of self-harm or
injury to others
• At the patient's request
• Short-term use to enable emergent treatment
that may result in a less confused patient
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Question 4
Which of the following is not a type of
restraint?
a)
b)
c)
d)
Wheelchair tables
Bed rails
Sensor alarms
Antianxiety medications
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Question 5
Restraint use has been shown to lead to which
of the following?
a) Decreased mortality rates
b) Shorter length of hospital stays
c) Pressure sore development
d) Decreased incidence of nosocomial
infections
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To restrain or not to restrain…
• Associated with:
»
»
»
»
increased rates of pressure sores
increased incidence of nosocomial infections
distress
falls
American Geriatrics Society.AGS position statement:
restraint use. 2008, Wang et al.2005
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Question 6
Restraint use may be used in which of the
following cases?
a) As an initial means to prevents falls and
injuries
b) As a last resort and only after less
restrictive alternatives have been tried
c) For the convenience of the facility staff
d) As a substitute for activities or treatment
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If not a restraint…what instead?
• Non-pharmacological
»
»
»
»
Cognitive
◦ Orientation (calendar, caregiver names)
◦ Activities (cognitively stimulating)
Sleep
• ◦ Regular routine
• ◦ Sleep aids (relaxing music, massage
• ◦Environmental (eliminate noise, night-time
meds)
»
»
»
»
4/13/2015
Mobility (range of motion, limit IV’s, etc)
Visual Aids (glasses, large dial phones)
Hearing Aids (check ear wax)
Volume repletion for dehydration
34
Pharmacologic Treatment
• No medication is FDA approved for the
treatment of delirium
• No published double-blind, randomized,
placebo controlled trials
» ◦ Few controlled trials
» ◦ Small numbers
» ◦ Various patient populations
cancer, AIDS, hip fractures
post-op, ICU,
Rachelle Bernacki MD Bree Johnston MD Division of Geriatrics University of California San Francisco and
San Francisco VA Medical Center
4/13/2015
35
Reduce Falls
•
Reduce restraint use / lower bed rails
•
Prevent delirium
•
Sensor alarms
•
Lower the bed
•
Non-slip shoes
•
Remove obstacles / commode / toilet schedule
Gillespie 1997, Myers 2003, Currie 2006
4/13/2015
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Falls
• Falls frequently occur in hospitals, and the
patients most likely to fall are older patients.32
• Approximately 2% to 12% of patients
experience at least one fall during their
hospital stay.32
• These complications often result in a longer
length of stay and lead to greater healthcare
costs.33,34
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37
Fall Risks
•
•
•
•
•
•
Visual impairment
Hypotension / anti-hypertensives
Anticholinergics / sedative-hypnotics
Obstacles / slick surfaces
Elevated bed height
Confinement ….restraints!
Gillespie 1997, Myers 2003
4/13/2015
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Fall Prevention Strategies
• Unfortunately, there are no specific
recommendations to reduce the risk for falls
in the acute care setting.
• However, some strategies in the literature
appear to offer some benefit, if not on an
overwhelming reduction in the incidence of
falls among hospitalized elderly patients.
American Geriatrics Society, British Geriatrics Society, and American Academy of
Orthopaedic Surgeons Panel on Falls Prevention 2011
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Fall Prevention Strategies
• Frequent and varied staff education and reeducation to promote and sustain sensitivity
to the risk for falls among hospitalized elders.
• Tools to assess risk for falls. Because most
patients' fall risks are multifactorial and the
factors are intertwined, the most effective
strategies will be interdisciplinary.
• The use of "sitters" for confused patients.
American Geriatrics Society, British Geriatrics Society, and American Academy of
Orthopaedic Surgeons Panel on Falls Prevention 2011
4/13/2015
40
Answer Key
• Case of Mrs. TW
»
»
»
»
»
»
4/13/2015
Question 1: a
Question 2: b
Question 3: a
Question 4: c
Question 5: b
Question 6: c
41
Conclusion
• Avoidance of unnecessary foley catheter
placement is an important method to reduce
nosocomial infections.
• Immobilizing patients during hospitalization is
contrary to therapeutic goals of restoring
normal mobility and function as quickly as
possible.
• The number and severity of falls can be
reduced by adopting quality improvement
strategies, relevant and practical fall risk
assessment tools, and staff education.
4/13/2015
42
Acknowledgements and
Disclaimer
This project was supported by funds from the Donald
W. Reynolds Foundation, the American Geriatrics
Society/John A. Hartford Geriatrics for Specialists
Grant. This information or content and conclusions are
those of the authors and should not be construed as
the official position or policy of, nor should any
endorsements be inferred by the Donald W. Reynolds
Foundation, the American Geriatrics Society or the
John A. Hartford Foundation.
The UNC Center for Aging and Health and Department
of Emergency Medicine also provided support for this
activity.
4/13/2015
43
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Copyright © 2011 The University of North
Carolina School of Medicine at Chapel Hill