“Shortage of Nurses Means Death After Hip Fracture”

This is an interesting news article from 3/19/10 about the suggested association between low nurse staffing levels and “increased mortality among elderly patients admitted to hospital with hip fractures.” One author of the study said: “It is estimated that nearly 5% of elderly patients admitted with a hip fracture die during their initial hospitalization, and another third die within a year of their injury… Two of the most common causes of death for hip fracture patients — pulmonary embolism and acute myocardial infarction — are also considered to be the most preventable causes of in-hospital death. If nurses are responsible for a small number of patients, they might be able to identify and deal with impending complications earlier.”

The article points out that orthopedic surgeons don’t have direct access to info on nurse staffing levels. I don’t know how consumers would obtain this info.


Medscape Medical News from the: American Association of Orthopaedic Surgeons (AAOS) 2010 Annual Meeting

From Medscape Medical News
Shortage of Nurses Means Death After Hip Fracture
Fran Lowry

March 19, 2010 (New Orleans, Louisiana) — Low nurse staffing levels are associated with increased mortality among elderly patients admitted to hospital with hip fractures, new research suggests.

In a retrospective cohort study presented here at the American Association of Orthopaedic Surgeons 2010 Annual Meeting, the risk for death among elderly patients in the hospital with hip fractures increased 22% when the nursing staff was reduced by 1 full-time nurse each day, Peter Schilling, MD, from the University of Michigan Medical Center in Ann Arbor, told meeting delegates.

“It is estimated that nearly 5% of elderly patients admitted with a hip fracture die during their initial hospitalization, and another third die within a year of their injury,” he said. “There is very little research on how to reduce the risk of complications in these patients, but there is growing evidence of the importance of nurse staffing levels in reducing morbidity and mortality in this vulnerable population.”

To shed more light on this issue, he and his colleagues conducted a retrospective cohort study of 13,343 elderly patients admitted between 2003 and 2006 to 39 Michigan hospitals with a primary diagnosis of hip fracture.

They used regression models to control for patient age, sex, comorbidities, and hospital characteristics, including teaching status, hip fracture volume, income and racial composition of each hospital’s zip code, and, finally, seasonal influenza.

The study found a statistically significant association between nurse staffing levels and in-hospital mortality among hip fracture patients.

The odds of in-hospital mortality decreased by 0.16 (P < .003) for every additional full-time-equivalent registered nursing staff per patient-day, even after controlling for covariates.

“This association indicates that the absolute risk of mortality increases by 0.35 percentage points for every 1-unit decrease in full-time-equivalent registered nursing staff per patient-day, or a 16% increase in death,” Dr. Schilling said.

He speculated that more nursing attention could decrease occurrences of urinary tract infection, pneumonia, sepsis, and cardiac arrest. “Two of the most common causes of death for hip fracture patients — pulmonary embolism and acute myocardial infarction — are also considered to be the most preventable causes of in-hospital death. If nurses are responsible for a small number of patients, they might be able to identify and deal with impending complications earlier.”

Senior author Paul Joseph Dougherty, MD, associate professor and director of the Orthopaedic Surgery Residency Program at the University of Michigan, said that although the study has limitations and does not give a definite answer, “it certainly points to the fact that nurse staffing may be an important factor in preventing complications.”

“There’s a great deal of concern with cost-cutting measures, but what you may perceive to be excess nursing staff may in fact prevent long-term problems. The problem is, we don’t have a precise value for that,” he told Medscape Orthopaedics.

More work needs to be done to establish acceptable nursing staffing levels, he said. “This is probably where our efforts should be directed, so that we can make some assumptions for staff, based on the type of patient we are seeing. Hip fracture patients are frail and very vulnerable. They tend to be the oldest patients, and they tend to be the sickest.”

Andrew Pollak, MD, head of the Division of Orthopaedic Trauma at the University of Maryland School of Medicine in Baltimore, said the authors should be congratulated for taking on this important topic.

“This study does not definitively show that nurse staffing levels are associated with mortality. But it suggests that there might be a relationship and that further investigation is warranted,” said Dr. Pollak, who moderated the session at which the study was presented.

Orthopaedic surgeons need to pay more attention to this issue, he added. “As orthopaedic surgeons, we pay a lot of attention to having enough personnel in the operating room with us to take care of our patients, but it is pretty rare that we will actually go up on the floor in a hospital, or other places in the hospital outside of the operating room, and pay any attention to the number of staff around. We don’t really have direct access to that kind of information,” he told Medscape Orthopaedics.

“This type of information tells us that we really ought to start thinking about these things when we start to consider where we are going to put our patients, and whether staffing, or the lack of it, could mean a difference in our patients’ well-being.”

Dr. Schilling, Dr. Dougherty, and Dr. Pollak have disclosed no relevant financial relationships.

American Association of Orthopaedic Surgeons (AAOS) 2010 Annual Meeting: Abstract 125. Presented March 10, 2010

“Letting Go of My Father” – terrific article on caregiving

This is a story about a son taking care of his father. The father initially had a diagnosis of Parkinson’s Disease. Many years later, the diagnosis changed to multiple system atrophy. (I do wonder if that was the correct diagnosis given the father’s inability to know how to use the bathroom. I’m thinking here of Lewy body dementia.)

The son feels out of his depth. He says:

“Broaching the subject and confessing desperation was like uttering the password to a secret brotherhood of beleaguered, overwhelmed, weary, or sometimes just resigned adult caregivers. But the sect seemed ashamed to be seen.”

The son asks the father to move into an assisted living facility. And, “to no one’s surprise but his own, gave my father more rather than less independence.”


“…I emerged from the whole experience not a little indignant. The medical infrastructure for elder care in America is good, very good. But the cultural infrastructure is all but nonexistent. How can it be that so many people like me are so completely unprepared for what is, after all, one of life’s near certainties? … I am now convinced that millions of middle-aged Americans need more help than they are getting, and that the critical step toward solving the problem is a cultural change akin to the one demanded by feminists in the 1960s. … There should be no need for anyone to go through this alone, and no glory in trying.”

Three resources are mentioned:

“Had I looked harder, I might have discovered the Web site of the Family Caregiver Alliance (caregiver.org), which offers a wealth of fact sheets; the National Alliance for Caregiving (caregiving.org), which offers an online tool to help coordinate care; strengthforcaring.com, which offers ‘Share Your Story’ and ‘Meet Other Caregivers’ bulletin boards. To get this stuff, however, you have to go look for it, which means you have to have some idea of what you need, and I didn’t. What I needed was for the experts to find me and tell me what I needed. And, indeed, to explain why I needed it.”

Here’s a link to page 1 of the article:


Two hospice misconceptions – according to an MD

I occasionally check out the blog of Dr. Wes Fisher, an internist and cardiologist based in Illinois. He posted about two misconceptions commonly held about hospice back in January 2010. The first is thinking that the hospice is going to “save you from the day to day challenges of caring for your loved one.” (There was some discussion along these lines in a recent post here with the subject “Hospice questions.”) The second is thinking that hospice will come in and make lots of revisions to a medication regimen.

This blog post mentions two resources:

* a government publication on Medicare Hospice Benefits. See:
http://www.medicare.gov/publications/pu … hosplg.pdf

* a Los Angeles Times article from 1/22/10 titled “Hospice care helps patients and loved ones,” which I think is a terrific overview of hospice. See:
http://www.latimes.com/features/health/ … 1030.story

Here’s a link to the short post by Dr. Wes Fisher and the full text:

http://drwes.blogspot.com/2010/01/hospi … tions.html

Posted by Dr. Wes
Monday, January 25, 2010

Hospice: Some Misconceptions

The Los Angeles Times had an earlier starter piece on hospice care recently with some remarkable figures:

Over the last 25 years, the number of Americans turning to hospice for end-of-life care has climbed dramatically — from 25,000 in 1982 to 1.45 million in 2008, as more and more people choose to spend their final days in the comfort of home or a patient facility with a home-like environment rather than in a hospital pursuing aggressive treatments.

I have been involved with hospice twice now – once with my father several years ago, and recently with my mother-in-law who just died of pancreatic cancer.

There are many references out there about hospice, and for a general overview for those thinking about hospice for themselves or a loved one, I’d steer you toward this introduction (pdf), provided by the government. Through both processes I have had a chance to see several misconceptions about what hospice is and how it works for patients who elect to stay at home during their last days. I cannot speak to inpatient hospice services since my family members have not elected to use those resources. For those that might not have a lot of family around, inpatient hospice care is probably a better alternative.

In many ways, hospice brings together a team of support personnel: doctors, nurses, chaplains, social workers, etc. to support the patient and their families through this difficult process, but there are some preconceived ideas that might not be clear to those who elect to go the stay-at-home route:

* First, hospice is not the cavalry, swooping in to save you from the day to day challenges of caring for your loved one. They can mobilize the equipment, the 30-60 minute visits by their staff (I am unaware of doctors making house calls, but trained nurses assess the patient then relay the status to the treating doctor), or arrange for help bathing and dressing the person occasionally, but they will NOT be there 24/7/365 when things get tough to wipe their bottoms or give them their medications. They’ll teach you how to do things, but at home, it’s still up to the caregivers.

Not that this is all bad. There is something very therapeutic about reconnecting in such an intimate way with someone you love. Still, it’s the constancy of this care, even in the middle of the night, can take it’s toll and create intense exhaustion and depression in caregivers, particularly when there is only one caregiver performing these duties. But being at home affords other familiar touches that just aren’t replicated in inpatient facilities. Probably the biggest smile we received from my mother-in-law was when be brought our therapy-dog cocker spaniel up on her bed (she loved that dog) – a no-no at most inpatient facilities.

* Medication revisions are more limited than I expected. It was interested to see family members acquire a regimented approach to medication administration at first. Through no fault of their own, it was not uncommon to observe that every medication was ultimately trying to be forced down the gullet of their loved one in attempt to be conscientious caregivers. No one unfamiliar with medical care and medicine rarely realize that perhaps many of those medications become superfluous during the dying process. No one wants to withhold care initially, we’re trying to help! But as their loved one’s renal and hepatic function decline during the dying process, doses of medications (particularly narcotics or steroids) might need to be reduced slightly to maintain a certain level of alertness or to avoid drug-induced delirium from complicating their loved-one’s care. Not uncommonly, drugs previously thought critical to the well-being of their loved one suddenly become less so or completely unnecessary. Obviously, making these decisions is very tough for lay people when you’re in the trenches of day-to-day care or when a loved one can no longer swallow. I found this was a source of considerable angst. Remembering to communicate with the hospice nurses during their visits or calling to ask about these issues can go a long way to allay any apprehensions and misgivings, should this occur.

In all, hospice was a very nice experience for us, but the experience was more about the family rallying to provide care than hospice providing the day-to-day care. I am aware of others who have found these limitations of what was offered at home by hospice to be an eye-opener. Many were caught off-guard about the need for their involvement and the depths to which their hands-on care would be needed. Hopefully now, a few more people will understand what’s required and not feel so guilty about the care they deliver when they go through what we did.


ElderCareLink, interviewing agencies, working with aides

I saw this post on an online support group recently. It’s about a website called ElderCareLink (see eldercarelink.com) that is a referral network of care agencies. The website also has articles on some good topics: Five Tips for Choosing An Assisted Living Facility, When is the Right Time for Calling Hospice Care, and Why You Need a Healthcare Directive.

The post also gives some suggestions for interviewing agencies and working with home care aides. (I received the author’s permission to share this post.) The post is copied below.



“One resource I have used when looking for a new home health aide agency for my mother with [this disorder] that I found valuable is eldercarelink.com. It is a free referral network of agencies that have registered and are pre-screened. You create a profile of your needs and there is also a dialogue box where you can detail your personal situation and exactly what you are looking for.

It is worthwhile to check out their website but I don’t recommend registering until you are really ready for either home care or placement, as each time I have used it, I immediately start to receive calls and emails from multiple agencies trying to ‘get my business’. I’m sure the response depends on your geographic location, I live in [a large metropolitan area[ and each time received at least 3-4 calls from potential agencies. I have to say that so far with every call I have ever received, it was the owner or a high-level manager who called and was extremely helpful and honest. I have had a few that, once into our conversation, admitted that they couldn’t meet my needs but were still helpful with suggestions and other referrals. I have found eldercarelink to be reliable and trustworthy. But as I said before, wait until your needs are immediate before actually registering. There is no obligation or cost on your part for the service.

If you have never been the home health care route, be ready–it can be a trying experience. Do your homework and prepare before your first home interview with any agency. Write down all your questions and requirements and be BOLD and up-front about your expectations. We have been at this for almost 4 years now and it is still a learning experience.

Don’t assume or take anything for granted when it comes to home health aides, that was my mistake early on. My mother’s care and the care of my home are my only concern, I have gotten to the point that they don’t need to like me and I try not to offend anyone, but I have had aides and agencies from one extreme to the other and I tell it like it is the first day they are there, having learned from experience that what you may think is common sense may not be to them. Aides and agencies will come and go, at their request and at yours, so you will likely go thru this more than once.

Don’t settle for less than you need/expect and don’t be afraid to ask for a change if you see that a particular aide is not right for your situation. In your interviews with agencies, be sure you insist that potential aides have had one-on-one HOME care experience, not just nursing home experience. I learned that the hard way, too. In most cases at nursing homes and re-habs, the aides work in teams and rarely do physical manipulation, transfers, etc alone and are not used to or trained to do it without assistance. Also, in facilities there is always someone else to follow up behind them to do what they failed to finish or clean up. That is not acceptable in the home setting when they are the only aide. Above all, be assertive and express your needs and expectations right up front, and get everything in the care plan from the beginning when you do sign on with an agency. Again, thru experience, I found it easier than trying to add things later that you forgot, when the aide may be resistant to being given more duties.

One [more] thing is the importance of being visible. I work, so most times it is just my mother and the aide during the day. If possible, don’t be afraid to pop in un-announced from time to time. And see if you can get friends/relatives to do the same, to visit. Then get their impressions of what they saw and heard. My mother has different morning and afternoon aides from different agencies, then has “lunch buddies” (various close friends) who come each noon to give her lunch and company. I routinely ask them for feedback on how they found her–was she sitting up in the bed with the side rails up, was she clean and neat, were the bedroom/bathroom/kitchen clean and neat and as odor-free as possible, was she in a good mood or upset? They love my Mom and want the best for her, so they are not hesitant to report anything they are not comfortable with.”

“Picking a Nursing Home” article including a list of ombudsman contacts

This article on selecting a nursing home is in the “Patient Money” series in the New York Times (nytimes.com). Two useful resources mentioned in the article are:

* a list of the ombudsman contacts by state.

* Medicare’s Nursing Home Checklist

Here’s a link to the full article:

Stressful but Vital: Picking a Nursing Home
By Walecia Konrad
New York Times

March 18, 2010