Christine M.

Khandelwal, DO
Kevin Biese, MD, MAT
Ellen Roberts, PhD, MPH
Jan Busby-Whitehead, MD

The University of North Carolina at Chapel Hill

With Support from The Donald W. Reynolds Foundation
and The John A. Hartford Foundation

© The University of North Carolina at Chapel Hill, Center for

Aging and Health. All Rights Reserved.
 Learning Objectives
• Learners will be able to list the most common
types of iatrogenic injuries.
• 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.

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.

Copyright © 2011 Lighthouse

InternationalAll rights reserved.

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

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, Hofer 2002, Thomas 2000

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
medications
• Increased severity of illness and complexity
of care
• Longer length of stay

Hofer 2002, Thomas

2000

6
Elderly Are the Most Likely to
Suffer…
Adverse Drug Events

Delirium

Nosocomial Infections

Falls

Procedural/Surgical Complications

7
 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. 1991

8
Adverse Drug Events

• Other ADE Predictors:

Multiple medical problems

Multiple medications
New medications added
Low weight, female gender, impaired
creatinine clearance

Carbonin 1991;Thomas and Brennen BMJ 2000

9
 Adverse Drug Events
Common Drugs Common Effects

Anticholinergics Mental Status

Psychotropics Urinary Complications

Sleepers Infections

Narcotics Gastrointestinal

Digoxin Falls

Anti-hypertensives

10
 The Case of Mrs. TW
Twenty four hours after
admission, nursing staff call
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?
Copyright © 2011 Lighthouse

InternationalAll rights reserved.

11
 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!

Elie 1998, Ely 2004, Inouye 1996, Inouye 2006, Pompei 1994

12
 Risk Factors for Delirium
• Age ≥ 70 years
• Existing cognitive impairment
• Functional impairment
• Alcohol abuse
• Abnormal preoperative level of sodium,
potassium or glucose
• Preoperative psychotropic drug use
• Depression
• Increased comorbidity
• Living in a long-term care facility
• Visual or hearing impairment

13
 Preventing Delirium
• At least 3 clinical trials suggest that minimizing risk factors
in hospital can reduce delirium:

» Management of six risk factors for delirium (cognitive

impairment, sleep deprivation, immobility, visual impairment,
hearing impairment, and dehydration) reduced the number
and duration of episodes of delirium ( Inouye, S.K., 1998)

Inouye 1999, Marcantonio 2001, Millsen 2001

14
 Preventing Delirium
» Geriatrics consultation reduced delirium in the
acute hospital management of hip-fracture
patients (Marcantonio, E.R., 2001)

» A nurse-led interdisciplinary intervention

program for delirium led to shorter duration
and less severe delirium (Millisen, K., 2001)

15
 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?
(Donepezil use in the prevention and treatment of post-
surgical delirium did not prevent delirium.)

Liptzin 2005, Sampson 2007

16
 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!

UTIs
Pneumonia
Surgical wound infections
Clostridium difficile colitis

17
 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

18
 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 2002

19
 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

20
 If Not a Foley…What Instead?
• Prevention and Treatment –
» Plan may include reviewing medications
(opiates, anti-cholingerics, diuretics, alpha-
adrenergic agonists, calcium-channel blockers
are offenders)
» Treat UTI (contributes to urge incontinence)
» Treat constipation
» Seek any reversible causes of delirium
» Regular toileting schedule

21
 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?

Copyright © 2011 Lighthouse

InternationalAll rights reserved.

22
 Why are Restraints Used?
• Prevent falls
• Prevent injuries
• Prevent treatment disruption
• Manage confusion

AGS Positional statement 2008, Tzeng 2008, Antonelli 2008

23
 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

American Geriatrics Society, AGS

Position statement: Restraint use.
2008
24
To Restrain or Not to Restrain…

• Restraints are associated with:

 increased rates of pressure sores

 increased incidence of nonsocomial infections
 distress
 falls

American Geriatrics Society, AGS

Position statement: Restraint use.
2008

25
 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)
» Mobility (range of motion, limit IV’s, etc)
» Visual Aids (glasses, large dial phones)
» Hearing Aids (check ear wax)
» Volume repletion for dehydration
Inouye 1999

26
 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 post-op, ICU,
cancer, AIDS, hip fractures

Slide from Rachelle Bernacki MD Bree Johnston MD Division of Geriatrics University of California San
Francisco and San Francisco, VA Medical Center

27
 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

28
 Falls
• Falls frequently occur in hospitals, and the
patients most likely to fall are older patients

• Approximately 2% to 12% of patients

experience at least one fall during their hospital
stay

• These complications often result in a longer

length of stay and lead to greater healthcare
costs

Chelly 2008, Bates 1995, Alexander 1992

29
 Fall Risks
• Visual impairment
• Hypotension / anti-hypertensives
• Anticholinergics / sedative-hypnotics
• Obstacles / slick surfaces
• Elevated bed height
• Confinement ….restraints!

Gillespie 1997, Myers 2003

30
 Fall Prevention Strategies
• Unfortunately, there are no specific
recommendations to reduce the risk for falls in
the acute care setting.

• However, some fall prevention strategies in the

literature appear to offer 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

31
 Fall Prevention Strategies
• Frequent and varied staff education and re-
education 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

32
 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.

33
 Acknowledgements and
Disclaimer
This project was supported by funds from The Donald W.
Reynolds Foundation, the American Geriatrics Society/The John
A. Hartford Foundation Geriatrics for Specialists Grant.  This
information or content and conclusions are those of the author
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, the UNC Division of
Geriatric Medicine, the UNC Department of Emergency Medicine,
and the UNC Department of Family Medicine also provided
support for this activity. This work was compiled and edited
through the efforts of Carol Julian.

34
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© The University of North Carolina at
Chapel Hill, Center for Aging and Health.
All Rights Reserved.