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      Potentially preventable complications of urinary tract infections, pressure areas, pneumonia, and delirium in hospitalised dementia patients: retrospective cohort study

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          Abstract

          Objectives

          To identify rates of potentially preventable complications for dementia patients compared with non-dementia patients.

          Design

          Retrospective cohort design using hospital discharge data for dementia patients, case matched on sex, age, comorbidity and surgical status on a 1 : 4 ratio to non-dementia patients.

          Setting

          Public hospital discharge data from the state of New South Wales, Australia for 2006/2007.

          Participants

          426 276 overnight hospital episodes for patients aged 50 and above (census sample).

          Main outcome measures

          Rates of preventable complications, with episode-level risk adjustment for 12 complications that are known to be sensitive to nursing care.

          Results

          Controlling for age and comorbidities, surgical dementia patients had higher rates than non-dementia patients in seven of the 12 complications: urinary tract infections, pressure ulcers, delirium, pneumonia, physiological and metabolic derangement (all at p<0.0001), sepsis and failure to rescue (at p<0.05). Medical dementia patients also had higher rates of these complications than did non-dementia patients. The highest rates and highest relative risk for dementia patients compared with non-dementia patients, in both medical and surgical populations, were found in four common complications: urinary tract infections, pressure areas, pneumonia and delirium.

          Conclusions

          Compared with non-dementia patients, hospitalised dementia patients have higher rates of potentially preventable complications that might be responsive to nursing interventions.

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          Most cited references23

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          The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis.

          Robert Kane, Tatyana Shamliyan, Christine Mueller … (2007)
          To examine the association between registered nurse (RN) staffing and patient outcomes in acute care hospitals. Twenty-eight studies reported adjusted odds ratios of patient outcomes in categories of RN-to-patient ratio, and met inclusion criteria. Information was abstracted using a standardized protocol. Random effects models assessed heterogeneity and pooled data from individual studies. Increased RN staffing was associated with lower hospital related mortality in intensive care units (ICUs) [odds ratios (OR), 0.91; 95% confidence interval (CI), 0.86-0.96], in surgical (OR, 0.84; 95% CI, 0.80-0.89), and in medical patients (OR, 0.94; 95% CI, 0.94-0.95) per additional full time equivalent per patient day. An increase by 1 RN per patient day was associated with a decreased odds ratio of hospital acquired pneumonia (OR, 0.70; 95% CI, 0.56-0.88), unplanned extubation (OR, 0.49; 95% CI, 0.36-0.67), respiratory failure (OR, 0.40; 95% CI, 0.27-0.59), and cardiac arrest (OR, 0.72; 95% CI, 0.62-0.84) in ICUs, with a lower risk of failure to rescue (OR, 0.84; 95% CI, 0.79-0.90) in surgical patients. Length of stay was shorter by 24% in ICUs (OR, 0.76; 95% CI, 0.62-0.94) and by 31% in surgical patients (OR, 0.69; 95% CI, 0.55-0.86). Studies with different design show associations between increased RN staffing and lower odds of hospital related mortality and adverse patient events. Patient and hospital characteristics, including hospitals' commitment to quality of medical care, likely contribute to the actual causal pathway.
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            Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability.

            Sharon Inouye, Kevin P Charpentier (1996)
            To prospectively develop and validate a predictive model for delirium based on precipitating factors during hospitalization, and to examine the interrelationship of precipitating factors and baseline vulnerability. Two prospective cohort studies, in tandem. General medical wards, university teaching hospital. For the development cohort, 196 patients aged 70 years and older with no delirium at baseline, and for the validation cohort, 312 comparable patients. New-onset delirium by hospital day 9, defined by the Confusion Assessment Method diagnostic criteria. Delirium developed in 35 patients (18%) in the development cohort. Five independent precipitating factors for delirium were identified; use of physical restraints (adjusted relative risk [RR], 4.4; 95% confidence interval [CI], 2.5 to 7.9), malnutrition (RR, 4.0; 95% CI, 2.2 to 7.4), more than three medications added (RR, 2.9; 95% CI, 1.6 to 5.4), use of bladder catheter (RR, 2.4; 95% CI, 1.2 to 4.7), and any iatrogenic event (RR, 1.9; 95% CI, 1.1 to 3.2). Each precipitating factor preceded the onset of delirium by more than 24 hours. A risk stratification system was developed by adding 1 point for each factor present. Rates of delirium for low-risk (0 points), intermediate-risk (1 to 2 points), and high-risk groups (> or equal to 3 points) were 3%, 20%, and 59%, respectively (P < .001). The corresponding rates in the validation cohort, in which 47 patients (15%) developed delirium, were 4%, 20%, and 35%, respectively (P < .001). When precipitating and baseline factors were analyzed in cross-stratified format, delirium rates increased progressively from low-risk to high-risk groups in all directions (double-gradient phenomenon). The contributions of baseline and precipitating factors were documented to be independent and statistically significant. A simple predictive model based on the presence of five precipitating factors can be used to identify elderly medical patients at high risk for delirium. Precipitating and baseline vulnerability factors are highly interrelated and contribute to delirium in independent substantive, and cumulative ways.
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              Selection of controls in case-control studies. III. Design options.

              Sholom Wacholder, Debra Silverman, Joseph K. McLaughlin … (1992)
              Several design options available in the planning stage of case-control studies are examined. Topics covered include matching, control/case ratio, choice of nested case-control or case-cohort design, two-stage sampling, and other methods that can be used for control selection. The effect of potential problems in obtaining comparable accuracy of exposure is also examined. A discussion of the difficulty in meeting the principles of study base, deconfounding, and comparable accuracy (S. Wacholder et al. Am J Epidemiol 1992;135:1019-28) in a single study completes this series of papers.
              Article 0 comments Cited 110 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): BMJ Open
                Journal ID (iso-abbrev): BMJ Open
                Journal ID (hwp): bmjopen
                Journal ID (publisher-id): bmjopen
                Title: BMJ Open
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Electronic): 2044-6055
                Publication date Collection: 2013
                Publication date (Electronic): 31 May 2013
                Volume: 3
                Issue: 6
                Electronic Location Identifier: e002770
                Affiliations
                [1 ]Faculty of Health, University of Canberra , Canberra, Australian Capital Territory, Australia
                [2 ]Centre for Research and Action in Public Health, The University of Canberra , Canberra, Australian Capital Territory, Australia
                [3 ]University of New South Wales, Academic Department for Old Age Psychiatry, Euroa Centre, Prince of Wales Hospital , Randwick, New South Wales, Australia
                [4 ]Data Linkage Unit, Australian Institute of Health and Welfare , Canberra, Australian Capital Territory, Australia
                [5 ]Ageing and Aged Care, Australian Institute of Health and Welfare , Canberra, Australian Capital Territory, Australia
                Author notes
                [Correspondence to ] Dr Kasia Bail; kasia.bail@ 123456canberra.edu.au
                Article
                Publisher ID: bmjopen-2013-002770
                DOI: 10.1136/bmjopen-2013-002770
                PMC ID: 3669724
                PubMed ID: 23794540
                SO-VID: eb0bfa88-b90d-4d91-8264-d7cea255fc61
                Copyright © Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

                History
                Date received : 21 February 2013
                Date revision received : 8 May 2013
                Date accepted : 8 May 2013
                Categories
                Subject: Health Services Research
                Subject: Research
                Subject: 1506
                Subject: 1704
                Subject: 1698
                Subject: 1722
                Subject: 1715
                Subject: 1737
                Subject: 1724

                ScienceOpen disciplines: Medicine
                Keywords: health services administration & management
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: health services administration & management

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