Journal Highlights From the March Issue of JAMDA


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Education Improves Prophylaxis

A modest amount of staff education significantly improved adherence to practice guidelines for risk assessment and initiation of therapy to prevent deep vein thrombosis and thromboembolism.

In 2009, the AMDA Foundation, with a grant from Sanofi-Aventis, began a study to document antithrombotic practices in nursing homes, provide educational interventions based on an AMDA information tool kit, and then determine the outcome of the intervention.

The investigators assessed current practice at 17 nursing homes from data on 376 newly admitted or readmitted patients, mean age 77. They provided the facilities the information kit, AMDA’s Clinical Practice Guideline on VTE [venous thromboembolism] Prevention, other educational materials, and access to a study principal for advice. The researchers reviewed data on VTE-prevention measures applied to 363 other patients cared for at the same 17 nursing homes following the educational intervention.

Some 85% percent of patients admitted to the nursing homes during the study had medical or postsurgical indications that normally would warrant prophylactic anticoagulant therapy. These included cancer, recent trauma, history of deep vein thrombosis, confinement to bed, and orthopedic surgery. However, more than half the patients admitted also had contraindications to anticoagulant therapy, such as short life expectancy, history of bleeding, patient or caregiver wishes not to receive such therapy, and quality-of-life factors.

Two-thirds of the patients who presented with indications for prophylaxis received that therapy, including many with contraindications.

Before the educational intervention, “VTE prophylaxis was sometimes used without a complete understanding of the reason or rationalization,” said lead researcher Dr. T.S. Dharmarajan, chief of the division of geriatrics at Montefiore Medical Center, Bronx, N.Y., in an inter- view. During the first phase of the study, in only 51% of cases was risk assessment and initiation of prophylaxis consistent with current clinical practice guidelines.

After the intervention, 82% of cases met that standard. Other indicators of improvement in care emerged, such as reduction in prescribing additional medications to patients already taking anticoagulants for atrial fibrillation; this occurred in 13% of cases following education vs. 23% before. Nondrug prophylactic measures consistent with current guidelines, such as pneumatic compression devices and compression stockings, were more likely to be used after the educational intervention.

Source: Prevention of Venous Thromboembolism: Practice Patterns in 17 Geographically Diverse Long-Term Care Facilities in the United States and Prevention of Venous Thromboembolism in Long-Term Care: Results of a Multicenter Educational Intervention Using Clinical Practice Guidelines – Dharmarajan et al.

Nurses Missed Delirium

Nurses in Quebec detected only half the cases of delirium among nursing home residents that research assistants did during a 6-month, prospective observational study.

The researchers noted that unlike dementia, delirium is an acute, generally reversible disorder. So early detection and prompt management are important. Research assistants identified delirium in 43 of 202 residents, while nurses identified delirium in half as many cases.

The nurses also detected only 25%- 67% of delirium symptoms identified by the research assistants. Improved training among nurses could improve their ability to recognize delirium and improve patient outcomes, the researchers said.

Source: Detection of Delirium and Its Symptoms by Nurses Working in a Long- Term Care Facility – Voyer et al.

Jeffrey S. Eisenberg, a freelance medical writer in Philadelphia, compiled this report.

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