Mrs. S had been a lawyer since 1925. She retired at the age of 82 when she suffered a mild stroke. She lived with her daughter and her daughter's husband, corresponded with friends, was an avid reader, and traveled regularly. When Mrs. S was 87 years old she was admitted to the hospital for oral surgery for removal of a primary tumor in her jaw. The doctor had told her she would be intubated during the procedure and immediately following. He told her she would wake up after surgery in the intensive care unit where she would stay for 1 to 2 days. She then would be extubated, transferred to a regular floor, and could anticipate being in the hospital for a little more than 1 week. Mrs. S was quite anxious and feared she would not survive the ordeal.
The surgery was a success, but many untoward events occurred during the postoperative period. Mrs. S developed aspiration pneumonia, contractures, incontinence, pressure sores, and had difficulty being weaned from the respirator. She spent 6 weeks in the intensive care unit and another 6 weeks on a stepdown unit. While in the hospital, Mrs. S rarely was out of bed. The staff was distant, rarely initiated conversations with Mrs. S, and generally did not introduce themselves when they approached her. The staff engaged in procedures and examinations of Mrs. S without explaining them or seeking her permission. They seemed to treat Mrs. S as a nonperson and did not seem to respect her. The result of this was that Mrs. S withdrew into her own thoughts. The staff did not teach the family or Mrs. S about her care.
During this time, the family of Mrs. S was very supportive. Her daughter, son-in-law, and grandchildren visited, called, and wrote regularly. Mrs. S had a companion who visited her every day. The children and companion reported frustration with the nursing staff as well as the medical staff, difficulty obtaining information regarding Mrs. S's condition, and many concerns regarding the quality of care she received.
Three months after the surgery, Mrs. S was transferred from the hospital to a nursing home. She had a permanent gastric tube as well as a tracheostomy tube and remained in the nursing home until she died, just a few days before the anniversary of her surgery.
The story of Mrs. S is tragic but not uncommon. More than one third of older adults in the United States are admitted and discharged from an acute care hospital each year (Graves, 1995), and between 6% (Leape et al., 1991) and 45% (Jahnigen, Hannon, Laxson, & LaForce, 1982) of those people are likely to experience at least one untoward event while hospitalized. Many of these unexpected clinical events could be prevented by a proactive approach toward nursing care. This article explores the incidence of cascade iatrogenesis in hospitalized elders and discusses the role for nurses in early identification and prevention of these occurrences.
The average hospital length of stay for people age 45 to 64 is less than 1 day, the average for people age 65 to 74 is 2 days, and the average for those older than age 75 is almost 4 days (Graves, 1995). Increased length of stay and decreased personal resources increase the susceptibility to complications, many of which are directly related to negligence by the health care team (Brennan et al., 1991). These complications are known as iatrogenic disorders. When they occur in a series, they are known as iatrogenic cascades.
Cascade iatrogenesis refers to a related sequence of two or more serious adverse events resulting from a diagnostic, prophylactic, or therapeutic intervention; an error of omission involving a reasonable clinical standard; or an accidental injury occurring in a hospital setting. (Potts, Fienglass, Kadah, Branson, & Webster, 1993, p. 200)
The term cascade in the biological context suggests a process that once begun proceeds stepwise to its conclusion. This chain of events proceeds with increasing momentum so the further the progress, the harder it is to arrest (Mold & Stein, 1986). latrogenic cascades are triggered by an initial complication that, in retrospect, can be judged to cause morbidity and mortality in excess of what would be expected as a natural consequence of a patient's underlying disease process (Potts et al., 1993).
Several studies have investigated cascade iatrogenesis. The first to be discussed is an interdisciplinary retrospective study of medical injury and medical malpractice which sought to determine the incidence of adverse events occurring to hospitalized patients (Brennan et al., 1991; Leape et al., 1991). Although the focus was not specifically on the elderly, the findings suggest some interesting statistics.
The first part of the Harvard Medical Practice Study (Brennan et al., 1991) reviewed 30,121 randomly selected medical records from acute care nonpsychiatric hospitals in New York state during 1984. The impetus for this investigation was the high incidence of malpractice claims brought against health care providers and the relatively small amount of empirical data available regarding the epidemiology of poor quality care and iatrogenic injury. The goal of the study was to develop current, reliable estimates of adverse events and negligence in the treatment of hospitalized patients. An adverse event was operationally defined as:
an injury that was caused by medical management (rather than the underlying disease) and that prolonged hospitalization, produced disability at the time of discharge, or both (Brennan et al., 1991, p. 370).
Negligence was defined as:
care that fell below the standard expected of physicians in their community (Brennan et al., 1991, p. 370).
The investigators found the incidence of adverse events increased with age and those individuals older than age 64 were more likely to have adverse events associated with physician negligence. The researchers suggest this finding indicates:
care for the elderly less frequently meets the standard expected of reasonable medical practitioners (Brennan et ai., 1991, pp. 373-374).
The Harvard Medical Practice Study was published as several different articles, two of which are referred to in this article. Brennan et al. (1991), reviewed 30,195 medical records of which 7,743 also were reviewed by physicians for adverse events and negligence. The incidence rates reported are based on 1,133 adverse events and 280 adverse events related to negligence.
Adverse events occurred in 3.7% of all cases and were correlated with degree of impairment, duration of disability, and death. The incidence of negligence was found to be greater in patients who had more severe adverse events. Adverse events also were reviewed with respect to age. Patients older than age 65 had more than double the risk of adverse events when compared to patients age 16 to 44. The likelihood of an adverse event as a result of negligence also was highest in those older than age 65. Brennan et al. (1991) estimated patients incurred 98,609 iatrogenic events in hospitals in New York state during 1984. Many of these were minor in nature, but 13,451 may have led to death. The researchers estimated 27,179 iatrogenic events may have occurred from negligence of the health care providers. The discussion focused on medical malpractice and quality review.
Leape et al. (1991) focused on the 1,133 cases in the Brennan et al. (1991) study in which adverse events were identified. The goals of the study were to categorize the adverse events by type, to identify those events most likely to result in serious disability, to identify the types of events most likely to be caused by negligence, to assess the effects of risk factors, and to identify management errors. Leape et al. (1991) categorized the adverse events by type of injury based on the physician review.
The results showed:
* The cause of adverse events were attributable to negligence in 28% of cases.
* Seventy percent of people recovered from the resulting disability within 6 months.
* Although only 27% of the population was older than age 64, this group incurred 48% of the adverse events.
* Forty-eight percent of the adverse events occurred in the operating room, and 27% occurred in the patients' rooms.
Physician error was categorized regarding type and subsequent disability. The discussion focused on preventability of adverse events, error and negligence of the physicians, and risk factors of the patients. The researchers concluded that as research and progress identify causes of iatrogenic complications, the incidence will change and education is the key to reducing adverse events occurring because of health care provider ignorance.
Importantly, neither Brennan et al. (1991) nor Leape et al. (1991) identified nursing care as either contributing to or preventing the adverse events. The studies focused on medical care in relation to malpractice litigation, which was somewhat limiting because this focus showed an assumption that the original adverse event occurred as a result of the physicians. While the report by Leape et al. (1991) was more complete with respect to limitations and implications for the future, both articles lacked a review of the literature or an indepth discussion of the methods of the overall study.
Although study of cascade iatrogenesis is thought to be somewhat incomplete (Brennan et al., 1991), the history is lengthy. In 1982, Jahnigen et al. conducted a study to research if veterans older than age 65 were at greater risk for developing iatrogenic disease than younger veterans. Forty-eight patients younger than age 65 and 178 patients older than age 65 who were admitted consecutively to a single Veteran's Administration hospital were prospectively followed. Participants were monitored daily. In this sample, 45% of elderly patients as compared to only 29% of younger patients (p < .05) had untoward complications, although the researchers found the elderly group to be healthier on admission than anticipated. In both groups, individuals who incurred complications were likely to be in the hospital twice as long as those patients who did not experience complications. Jahnigen et al. (1982) suggest methods of patient surveillance such as:
* Monitoring rates of complications of illness.
* Setting goals to reduce the number of complications.
* Developing profiles of older adults most at risk for complications.
Much of the more recent research discussed in this article has been designed to build on these early findings.
The next articles reviewed report on different aspects of another large study (Potts et al., 1993). The retrospective study was conducted at a large midwestern hospital and examined elderly patients (older than age 65) who had a length of stay of more than 14 days and had a primary diagnosis of congestive heart failure, acute myocardial infarction, or pneumonia. An RN scored each record using the Medicare Mortality Predictor System (MMPS). Each record then was reviewed by an internist. Potts et al. (1993) found the rate of iatrogenic cascade was 40%. The high rate was to be expected because the subjects all had been in the hospital for more than 15 days.
Lefevere et al. (1992) used the same population as Potts et al. (1993), but this study focused on patients from the medical service. Its purpose was to identify areas of potential for improving quality of care. Lef evere et al. (1992) noted the high acuity of patients in the study and mentioned that iatrogenesis may be more likely at teaching hospitals, which tend to attract the sickest patients and perform most procedures. While some iatrogenic events cannot be prevented, Lefevere et al. (1992) found that
more than half of all documented iatrogenic complications [in this study] were potentially preventable, and that worse care was associated with more complications (p. 2078).
The conclusion of the study was that iatrogenic complications are common in high-risk elderly patients, and quality improvement efforts should focus on the process of care, particularly in patients with poor functional status. Nurses are in an excellent position to monitor the process of care and promote function in hospitalized elders.
Hirsch, Sommer, Olsen, Mullen, and Winnograd (1990) investigated changes in the functional status of hospitalized elders. Using a prospective cohort design, the researchers tested 71 patients older than age 74 who were admitted to the medical service at Stanford University Hospital during a 4month period. Patients' functional status was determined at four time points: 2 weeks prior to admission, day 2 of hospitalization, the day prior to discharge, and 1 week postdischarge using an instrument developed specifically for the study. The data pre-hospitalization and posthospitalization were obtained primarily from a caregiver and only from the patient if they lived alone. Nurses scored the patients for the two inhospital measures. Demographic and functional data were reported. The researchers indicated caregivers' and health care workers' estimates of patients' ability were more accurate than the patients' estimates. The findings indicate
functional status was lowest immediately following admission and, although the patients improved slowly, they remained significantly impaired after discharge. Findings also indicated recovery of functional ability took longer than the recovery from the acute illness.
The Hirsch et al. (1990) study is the only one reviewed that included nurses in a meaningful way. At least one of the authors is a nurse, and staff nurses completed the data collection. Certainly, functional ability is an area where nursing staff could have a greater impact than medical staff.
Creditor (1993) documented the hazards of hospitalization for elders. During hospitalization, physical compromises associated with normal aging can be exacerbated by the restrictions imposed by hospitalization, often with disastrous results. Creditor (1993) demonstrated the "cascade to dependency" (p. 220) in an algorithm combining the consequences of individual interactions between the effects of aging and hospitalization with the interaction effects of these consequences leading to loss of health and independence in older adults. The article concludes with recommendations for modifying the hospital environment
on the assumption that for many [elderly patients], hospitalization will propel them over the "threshold of frailty" (Creditor, 1993, p. 222).
Modifications would include increasing the speed and frequency with which assessment of elderly patients occurs and minimizing environmental threats to mobility such as continuous intravenous lines, high hospital beds, poor lighting, and highly polished floors. Creditor (1993) also suggests incorporating a philosophy of care promoting patient independence by minimizing bed rest, promoting communal eating, daily dressing in the individuals' own clothes, and reality-orientation devices. He also suggests early involvement of a social worker and other members of the interdisciplinary team, as well as partnerships between physicians and nurses.
Gorbien et al. (1992) discussed iatrogenic illness in older adults in a grand rounds. Decreased physical reserves of elderly patients were identified as a contributing factor to postsurgical complications. Bed rest in particular was discussed as having deleterious effects, and the article warned against prolonged bed rest. According to Gorbien et al. (1992), nearly half of iatrogenic complications occurring in elderly patients are related to medications. Increased length of stay, severity of illness, comorbidity, and decreased resistance of elderly patients increases their susceptibility to induced infections. The hospital environment is full of hazards to which older adults are likely to succumb, falls being the most frequent. Finally, underdiagnosis of morbidity at admission is a frequent cause of complications later in hospitalization.
The literature on cascade iatrogenesis has several themes. First, elders are at greater risk than other hospitalized people for experiencing complications (Jahnigen et al., 1982; Leape et al., 1991). The longer the hospital stay, the more likely an untoward event will occur (Potts et al., 1993). Hospitalization may have a negative impact on functional ability (Creditor, 1993; Gorbien et al., 1992; Hirsch et al, 1990). Finally, many adverse events during hospitalization may be preventable (Brennan et al., 1991; Jahnigen et al., 1982; Leape et al., 1991; Lefevere et al., 1992; Potts et al, 1993). The climate of health care is changing rapidly; there is a trend toward providing care with less skilled caregivers; and facilities are pressured to discharge patients earlier. Caregivers may be tempted to focus more acutely and less holistically. These changes in the health care environment and the disproportionate amount of inpatient services used by older adults (Graves, 1995) could create an environment where iatrogenic events occur more frequently.
The literature on hospitalization of elders contains many articles about the creation of specialized units for geriatric patients (Fillit, 1994; Hamilton & Lyon, 1995; Palmer, Landefeld, Kresevic, & Kowal, 1994). With the high percentage of total admissions and total patient days accounted for by older adults, small specialized units do not seem to be the answer. Indeed, it may be better to isolate those inpatients younger than age 65 to specific units as they seem to form the smaller and ever-dwindling population of inpatients.
Another approach to inpatient care of older adults is the geriatric expert model. In this model, expert health professionals who specialize in gerontology act as resources to staff members who actually provide care. Examples of this model are the Yale Geriatric Care Program (Fulmer, 1991a, 1991b; Fulmer & Mezey, 1994; Inouye et al., 1993) and the Comprehensive Geriatric Assessment Consultation program (Borok et al., 1994). These programs, particularly the Yale program, have been successful. However, the best solution for improved care of hospitalized elders is to improve the knowledge and expertise of all caregivers, including nurses, hospital staff, physicians, families, and the older adults themselves.
Several authors (Barangan, 1990; Creditor, 1993; Hirsch et al, 1990; Mold & Stein, 1986) emphasize the importance of early and frequent comprehensive assessment of elderly inpatients. Physicians and nurses must develop and practice assessment skills so an accurate patient status may be obtained on admission and at least every 24 hours. This standard may well require individual nurses to seek opportunities to improve their assessment skills. Palmer and Bolla (1997) suggest functional mobility, mental status, nutritional status, and depression are common areas of problems and increase the risk of complications for hospitalized elders. The Core Curriculum for Gerontological Nursing (Luggan, 1996) is an excellent resource for nurses to begin to build skills in promoting health for elderly patients.
The plan of care and the standard of care must be flexible enough to be personalized for each patient's needs. Creditor (1993) and Palmer and Bolla (1997) emphasize the need for interdisciplinary care for hospitalized elders. Physical therapists, occupational therapists, and other health care professionals should be included in the plan of care to assist with reducing the complications of hospitalization. In the following statement, Creditor (1993) identifies the need for consistent nurses:
Just as an attending physician is responsible 24 hours a day..., so must there be a nurse with an equivalent relationship to the patient (p. 223).
As nursing practice continues to move away from the RN model of providing care, hospitals must develop models of care where each nurse has responsibility and accountability for individual patients. Direct care staff such as nurse's aides and technicians must be taught to promote the independence of patients in every interaction and be held to that standard. Addressing the philosophy, attitudes, and practice of the direct caregivers (nurse aides) may be one of the most important and complex interventions required to implement a new model of care. The research suggests a plan of inservice education about normal aging and how to promote independence in hospitalized elders may be indicated for all direct caregivers. Opportunities for discussion of feelings about working with older adults should be incorporated into staff meetings, and nurses should be conscious of their status as role models in practice situations.
Mobily and Kelly (1991), Creditor (1993), and Branagan (1990) suggest directions for change in the hospital environment. The environment should be structured in such a way that promotes functional mobility of patients, rather than reflecting the convenience of the institution. Implementation in acute care of many of the Omnibus Budget Reconciliation Act (1987, Public Law No. 100-203) guidelines with respect to comprehensive assessment, maintenance of functional abilities, use of physical and chemical restraints, and drug therapies may have a positive effect on outcomes as it has in long-term care settings (Mobily & Kelly, 1991).
In a phenomenologie study of surgical patients' experiences in the hospital, Cohen, Hausner, and Johnson (1994) found patients felt cared for when nurses provided them with information and attended to them both physically and cognitively. Orientation prior to planned hospitalization would provide information to older adults in advance of the experience. Many hospitals require preadmission testing, which would be an opportune time to discuss the goals of promoting activity and independence and the rationale behind this philosophy. The orientation program also may include a trip to the unit where individuals would be placed and introduction to the nurses who may be caring for them. Similarly, a tour of the x-ray department may decrease anxiety about procedures that may have to be performed. If surgery is planned, viewing a short videotape about getting ready for surgery and what happens before and after the operation would help familiarize older adults with procedures. During the hospital stay, regular appointments with a nurse designated as the primary nurse or case manager are important to provide daily continuity of caring, even if this nurse is not providing direct care.
Friends or family members should be encouraged to actively participate in the plan of care, providing both support and continuity for the elderly patients. Informal caregivers may be included in the plan of care in meaningful ways such as scheduling visits at meal times to promote nutrition or at times when the patients are scheduled to be out of bed to help promote mobility. Laitinen and Isola (1996) note it is vitally important that informal caregivers understand their roles as well as what they can and cannot do for the elderly patients in the hospital. With the patients' permission, friends or family members could be included in discussions of the patients' health status. This would\ help clarify questions and assist in dissemination of information among family members.
Consider the case of Mrs. S presented at the beginning of this article. If she had a nurse who was accountable for her care while in the hospital, and if that nurse had sufficient knowledge regarding working with older adults and iatrogenic cascade, perhaps the initial incident, aspiration, could have been prevented by conducting a comprehensive assessment including an examination of swallowing. The complications of bed rest and decreasing mobility could have been minimized by positioning Mrs. S in a chair for some time every day and encouraging her participation in completion of activities of daily living. Inclusion of appropriate therapists, such as physical and occupational therapists, could have decreased her immobility and reduced the occurrence of contractures. Mrs. S's mental status and mood would have benefited from the staff's remembering to show Mrs. S the respect she was accustomed to receiving. Finally, the staff could have capitalized on the attentiveness of family and friends to promote engagement of Mrs. S with her surroundings rather than excluding them from the plan of care.
The goal of intervening to alter the incidence of cascade iatrogenesis in hospitalized elders involves no less than a restructuring of the thinking of the hospital staff to encourage early assessment of potential problems and to promote functional mobility of the elderly patients. This change signifies not merely a casual intervention but will require the attention of the entire institution and may involve substantial work redesign. Interim goals related to nursing care could be readily initiated. First, redesign of the delivery of nursing care so individual nurses have accountability for coordinating care for individual patients from admission to discharge from the hospital could be accomplished on individual units. Second, more nurses and nursing personnel could develop specialized knowledge and skills in working with older adults.
In this era of compressed hospital staySy it is often the patient's requirement for nursing care that determines their discharge plan. Those elders with poor functional status may require continued inpatient care at a long-term care setting rather than outpatient services. While the physician prescribes the plan of care and medical management, it is the nurses who may be in the best position to notice small changes in the status of hospitalized elders. These small changes may signal the early signs of iatrogenic cascade.
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