Forslag til endring av retningslinje for behandlingslengde av mild til moderat samfunnserverva pneumoni i sjukehus

BAKGRUNN Det eksisterer mange ulike retningslinjer for kor lang antibiotikabehandling av samfunnserverva pneumoni (SEP) i sjukehus bør vera. Kortare behandlingstid vil kunna ha fordeler økonomisk, helsemessig og med høve til resistensutvikling. Me ser i oppgåva på eksisterande retningslinjer for lengda av antibiotikabehandling av vaksne pasientar med mild til moderat SEP i norske sjukehus i dag, og vil gå gjennom det vitskaplege grunnlaget for desse. Me ser òg på behovet for å laga og implementera ny retningslinje på bakgrunn av ny kunnskap. METODE Søk i www.helsebiblioteket.no gav norske retningslinjer. Det vart funne to relevante metaanalysar om behandlingslengd via søk i Pubmed, likeeins artiklar som omhandla samfunnsmessige konsekvensar av kortare behandlingslengd. RESULTAT Norske retningslinjer tilrår alle behandling i 7-10 dagar ved mild til moderat SEP. Metaanalysane viser at kortare behandlingslengde (7 dagar eller mindre) er likeverdig med lengre (over 7 dagar) med omsyn til symptomfridom og tilbakefall. Me føreslår implementering av ny retningslinje med behandlingslengde 7 dagar eller mindre. FORSLAG TIL IMPLEMENTERING OG EVALUERING I implementering og evaluering av retningslinja i sjukehusavdeling føreslår me å bruka prosessindikator og registrera delen pasientar som får langtidsbehandling versus kortisdbehandling ved hjelp av sjekkliste, med evaluering etter 6 månader. Som organiseringsmodel for betringsprosjektet nyttar me Demings kvalitetshjul. KONKLUSJON Kortare behandklingstid er like effektiv som lang. Innføring av ei oppdatert retningslinje vil kunna bidra til å halda norske resistensforhold på eit lågt nivå, og gjev òg potensielt kortare liggetid, tidlegare mobilisering av pasienten og færre biverknader, med føremoner både samfunnet og for pasiengruppa

Medication management for patients with hip fracture at a regional hospital and associated primary care units in Norway: a descriptive study based on a survey of clinicians' experience and a review of patient records

Objective: Patients with hip fracture are at high risk of medication errors due to a combination of high age, comorbidities, polypharmacy and several care transitions after fracture. The aim was to study medication management tasks concerning patient safety: medication reconciliation, medication review and communication of key medication information in care transitions. Design: Descriptive study comprising a self-administered clinician survey (MedHipPro-Q) and a retrospective review of hospital medical records of patients with hip fracture. Setting: Regional hospital and the associated primary care units (South-Eastern Norway). Participants: The survey received responses from 253 clinicians, 61 medical doctors and 192 nurses, involved in the medication management of patients with hip fracture, from acute admittance to the regional hospital, through an in-hospital fast track, primary care rehabilitation and back to permanent residence. Respondents' representativeness was unknown, introducing a risk of selection and non-response bias, and extrapolating findings should be done with caution. The patient records review included a random sample of records of patients with hip fracture (n=50). Outcome measures: Medication reconciliation, medication review and communication of medication information from two perspectives: the clinicians' (ie, experiences with medication management) and the practice (ie, documentation of completed medication management). Results: In the survey, most clinicians stated they performed medication reconciliation (79%) and experienced that patients often arrived without a medication list after care transition (37%). Doctors agreed that more patients would benefit from medication reviews (86%). In the hospital patient records, completed medication reconciliation was documented in most patients (76%). Medication review was documented in 2 of 50 patients (4%). Discharge summary guidelines were followed fully for 3 of 50 patients (6%). Conclusion: Our study revealed a need for improved medication management for patients with hip fracture. Patients were at risk of medication information not being transferred correctly between care settings, and medication reviews seemed to be underused in clinical practice

Clinical pharmacist intervention to improve medication safety for hip fracture patients through secondary and primary care settings: a nonrandomised controlled trial

Background: Hip fracture patients face a patient safety threat due to medication discrepancies and adverse drug reactions when they have a combination of high age, polypharmacy and several care transitions. Consequently, optimised pharmacotherapy through medication reviews and seamless communication of medication information between care settings is necessary. The primary aim of this study was to investigate the impact on medication management and pharmacotherapy. The secondary aim was to evaluate implementation of the novel Patient Pathway Pharmacist intervention for hip fracture patients. Methods: Hip fracture patients were included in this nonrandomised controlled trial, comparing a prospective intervention group (n = 58) with pre-intervention controls who received standard care (n = 50). The Patient Pathway Pharmacist intervention consisted of the steps: (A) medication reconciliation at admission to hospital, (B) medication review during hospitalisation, (C) recommendation for the medication information in the hospital discharge summary, (D) medication reconciliation at admission to rehabilitation, and (E) medication reconciliation and (F) review after hospital discharge. The primary outcome measure was quality score of the medication information in the discharge summary (range 0-14). Secondary outcomes were potentially inappropriate medications (PIMs) at discharge, proportion receiving pharmacotherapy according to guidelines (e.g. prophylactic laxatives and osteoporosis pharmacotherapy), and all-cause readmission and mortality. Results: The quality score of the discharge summaries was significantly higher for the intervention patients (12.3 vs. 7.2, p Conclusion: The intervention steps were successfully implemented for hip fracture patients and contributed to patient safety through a higher quality medication information in the discharge summary, fewer PIMs and optimised pharmacotherapy

Delirium, neurofilament light chain, and progressive cognitive impairment: analysis of a prospective Norwegian population-based cohort

Background: Previous population-based, longitudinal studies have shown that delirium is associated with an increased risk of dementia and cognitive decline. However, the underlying biological mechanisms are largely unknown. We aimed to assess the effects of delirium on both cognitive trajectories and any neuronal injury, measured via neurofilament light chain (NfL). // Methods: In this analysis of a prospective, 2-year follow-up, cohort study of participants aged 65 years or older living in Sandefjord municipality, Norway, we included cohort participants who were receiving domiciliary care services at least once per week between May 12, 2015, and July 8, 2016. Individuals with a life expectancy of less than 1 week, with Lewy body dementia, with psychiatric illness (except dementia), or for whom substance misuse was the principal indication for domiciliary services were excluded. Participants had a comprehensive assessment at 6-month intervals for 2 years, which included the Montreal Cognitive Assessment (MoCA) and a blood sample for NfL to measure neuronal injury. All information on clinical diagnoses and medications were cross-referenced with medical records. During any acute change in mental status or hospitalisation (ie, admission to hospital), participants were assessed once per day for delirium with Diagnostic and Statistical Manual of Mental Disorders, fifth edition criteria. We also measured NfL from blood samples taken from participants who were acutely hospitalised. // Findings: Between May 12, 2015, and July 8, 2016, 210 participants were eligible for inclusion and assessed at baseline (138 [66%] of whom were female and 72 [34%] of whom were male), 203 completed cognitive assessment, and 141 were followed up for 2 years. 160 (76%) of 210 had moderate or severe frailty and 112 (53%) were living with dementia. During the 2-year follow-up, 89 (42%) of 210 participants were diagnosed with one or more episodes of delirium. Incident delirium was independently associated with a decrease in MoCA score at the next 6-month follow-up, even after adjustment for age, sex, education, previous MoCA score, and frailty (adjusted mean difference –1·5, 95% CI –2·9 to –0·1). We found an interaction between previous MoCA score and delirium (β –0·254, 95% CI –0·441 to –0·066, p=0·010), with the largest decline being observed in people with better baseline cognition. Participants with delirium and good previous cognitive function and participants with a high peak concentration of NfL during any hospitalisation had increased NfL at the next 6-month follow-up. Mediation analyses showed independent pathways from previous MoCA score to follow-up MoCA score with contributions from incident delirium (–1·7, 95% CI –2·8 to –0·6) and from previous NfL to follow-up MoCA score with contributions from acute NfL concentrations (–1·8, –2·5 to –1·1). Delirium was directly linked with a predicted value of 1·2 pg/mL (95% CI 1·02 to 1·40, p=0·029) increase in NfL. // Interpretation: In people aged 65 years or older, an episode of delirium was associated with a decline in MoCA score. Greater neuronal injury during acute illness and delirium, measured by NfL, was associated with greater cognitive decline. For clinicians, our finding of delirium associated with both signs of acute neuronal injury, measured via NfL, and cognitive decline is important regarding the risk of long-term cognitive deterioration and to acknowledge that delirium is harmful for the brain

Persistent delirium is associated with cerebrospinal fluid markers of neuronal injury

Delirium is associated with the risk of future long-term cognitive impairment, but the degree to which markers of neuronal injury may be distinct or shared with dementia has yet to be comprehensively described. We investigated CSF biomarkers of dementia, astrocytosis and neuronal damage in a clinical cohort with persistent delirium, comparing them with an outpatient memory clinic sample. Our aim was to determine if different patterns of biomarker changes could implicate specific mechanisms for delirium-related neuronal injury over and above that attributable to comorbid dementia. We recruited 35 participants from the Prince of Wales Hospital, Sydney, Australia. We included inpatients with delirium persisting for at least 5 days (n = 15, 10 with underlying dementia) and participants from outpatient memory clinics (n = 20, 17 with dementia). CSF assays were as follows: amyloid-β42, amyloid-β40, phosphorylated tau181, neurofilament light chain and glial fibrillary acidic protein. We used propensity score matching to estimate effect sizes for each standardized CSF biomarker separately for persistent delirium (irrespective of underlying dementia) and dementia (irrespective of superimposed delirium). Compared with individuals without delirium, persistent delirium was associated with elevated glial fibrillary acidic protein (normalized coefficient per transformed standard deviation, β = 0.85; 95% confidence interval: 0.03-1.68) and neurofilament light chain (β = 1.1; 95% confidence interval: 0.5-1.6), but not phosphorylated tau181. Compared with individuals without dementia, glial fibrillary acidic protein, neurofilament light chain and phosphorylated tau181 were all increased to expected levels in dementia cases, with the former two biomarkers at levels comparable to those seen in persistent delirium [glial fibrillary acidic protein (β = 1.54; 95% confidence interval: 1.05-2.0) and neurofilament light chain (β = 0.65; 95% confidence interval: 0.24-1.1)]. Persistent delirium was linked with changes in CSF biomarkers not necessarily attributable to dementia. These findings support the potential that delirium is associated with direct neuronal injury independent of dementia pathophysiology. Whether this neuronal injury involves astrocyte dysfunction or direct axonal damage are both possibilities. Future work examining acute brain injury in delirium is needed.</p

Skrøpelighet blant eldre pasienter med hjemmesykepleie

BAKGRUNN Det er et politisk ønske at eldre personer med hjelpebehov skal kunne bo hjemme så lenge som mulig og motta helsetjenester utenfor institusjon. Denne gruppens grad av skrøpelighet samt risiko for akuttinnleggelser og død, er lite studert. Hensikten med prosjektet var å studere dette gjennom to år i en middelsstor norsk kommune. MATERIALE OG METODE Et utvalg pasienter i Sandefjord kommune, 65 år eller eldre, med ukentlig offentlig hjemmesykepleie ble inkludert. Pasientene gjennomgikk en geriatrisk vurdering i eget hjem hvert halvår i to år. Grad av skrøpelighet ble beregnet ved hjelp av Skrøpelighetsindeks (Frailty Index). Forekomst av dødsfall og akutte sykehusinnleggelser ble registrert i to år. RESULTATER Av 271 forespurte pasienter ble 210 inkludert. 160 pasienter (76 %) ble klassifisert som moderat eller alvorlig skrøpelige. I løpet av observasjonsperioden ble det registrert 307 akuttinnleggelser med til sammen 1 235 liggedøgn i sykehus. Sammenliknet med pasienter med alvorlig skrøpelighet var pasienter med mild skrøpelighet sjeldnere innlagt på sykehus (hasardratio (HR) 0,33; 95 % konfidensintervall (KI) 0,19–0,60). 63 (30 %) av deltakerne døde i løpet av to års observasjonstid. Dødeligheten var høyest blant pasienter med alvorlig skrøpelighet. Ved justert Cox-regresjon var økende alder assosiert med økt risiko for død, men ikke med akuttinnleggelser. FORTOLKNING Eldre pasienter som mottar hjemmesykepleie, har høy grad av skrøpelighet, og grad av skrøpelighet er assosiert med risiko for sykehusinnleggelser og død

Skrøpelighet blant eldre pasienter med hjemmesykepleie

BAKGRUNN: Det er et politisk ønske at eldre personer med hjelpebehov skal kunne bo hjemme så lenge som mulig og motta helsetjenester utenfor institusjon. Denne gruppens grad av skrøpelighet samt risiko for akuttinnleggelser og død, er lite studert. Hensikten med prosjektet var å studere dette gjennom to år i en middelsstor norsk kommune. MATERIALE OG METODE: Et utvalg pasienter i Sandefjord kommune, 65 år eller eldre, med ukentlig offentlig hjemmesykepleie ble inkludert. Pasientene gjennomgikk en geriatrisk vurdering i eget hjem hvert halvår i to år. Grad av skrøpelighet ble beregnet ved hjelp av Skrøpelighetsindeks (Frailty Index). Forekomst av dødsfall og akutte sykehusinnleggelser ble registrert i to år. RESULTATER: Av 271 forespurte pasienter ble 210 inkludert. 160 pasienter (76 %) ble klassifisert som moderat eller alvorlig skrøpelige. I løpet av observasjonsperioden ble det registrert 307 akuttinnleggelser med til sammen 1 235 liggedøgn i sykehus. Sammenliknet med pasienter med alvorlig skrøpelighet var pasienter med mild skrøpelighet sjeldnere innlagt på sykehus (hasardratio (HR) 0,33; 95 % konfidensintervall (KI) 0,19–0,60). 63 (30 %) av deltakerne døde i løpet av to års observasjonstid. Dødeligheten var høyest blant pasienter med alvorlig skrøpelighet. Ved justert Cox-regresjon var økende alder assosiert med økt risiko for død, men ikke med akuttinnleggelser. FORTOLKNING: Eldre pasienter som mottar hjemmesykepleie, har høy grad av skrøpelighet, og grad av skrøpelighet er assosiert med risiko for sykehusinnleggelser og død

Development and initial validation of MedHipPro-Q: a questionnaire assessing medication management of hip fracture patients in different care settings

Background A validated questionnaire to assess medication management of hip fracture patients within and outside the hospital setting was lacking. The study aims were to describe the hip fracture patient pathway, and develop a valid and feasible questionnaire to assess clinicians’ experience with medication management of hip fracture patients in different care settings throughout the patient pathway. Methods This qualitative, descriptive methodological study used strategic and snowball sampling. The questionnaire was developed, and face and content validity explored through interviews with stakeholders. Phase I described the hip fracture patient pathway, and identified questionnaire dimensions in semi-structured interviews with management and clinicians (n = 37). The patient pathway was also discussed in six meetings (n = 70). Phase II refined a first draft of the questionnaire through cognitive interviews with future respondents (n = 23). The draft was modified after each interview. Post hoc, cognitive interview data were analysed using matrix analysis to condense problems and solutions into themes and subthemes. Phase III, converted the final version to a digital format, and tested its feasibility with a subset of the cognitive interview participants (n = 21) who completed the questionnaire and provided feedback. Results Phase I: Hip fracture patients were cared for in at least three different care settings, and went through at least four handovers between and within primary and secondary care. Three questionnaire dimensions were identified: 1) Medication reconciliation and review, 2) Communication of key information, and 3) Profession and setting. Phase II: The MedHipPro-Q was representative of how the different professions experienced medication management in all settings, and hence showed face and content validity. Post hoc analysis: Problem themes (with sub-themes) were Representativeness (-of patient pathway and -of respondent reality) and Presentation (Language and Appearance). Solution themes (with sub-themes) were: Content (added or deleted) and Presentation (modified appearance or corrected language). Phase III: Participants did not identify technical, linguistic or content flaws in the questionnaire, and the digital version was considered feasible for use. Conclusion The novel MedHipPro-Q showed good face and content validity, and was feasible for use throughout the hip fracture patient pathway. The rigorous development process supports its construct validity and reliability

Perioperative hemodynamics and risk for delirium and new onset dementia in hip fracture patients; A prospective follow-up study

Background Delirium is common in hip fracture patients and many risk factors have been identified. Controversy exists regarding the possible impact of intraoperative control of blood pressure upon acute (delirium) and long term (dementia) cognitive decline. We explored possible associations between perioperative hemodynamic changes, use of vasopressor drugs, risk of delirium and risk of new-onset dementia. Methods Prospective follow-up study of 696 hip fracture patients, assessed for delirium pre- and postoperatively, using the Confusion Assessment Method. Pre-fracture cognitive function was assessed using the Informant Questionnaire of Cognitive Decline in the Elderly and by consensus diagnosis. The presence of new-onset dementia was determined at follow-up evaluation at six or twelve months after surgery. Blood pressure was recorded at admission, perioperatively and postoperatively. Results Preoperative delirium was present in 149 of 536 (28%) assessable patients, and 124 of 387 (32%) developed delirium postoperatively (incident delirium). The following risk factors for incident delirium in patients without pre-fracture cognitive impairment were identified: low body mass index, low level of functioning, severity of physical illness, and receipt of ≥ 2 blood transfusions. New-onset dementia was diagnosed at follow-up in 26 of 213 (12%) patients, associated with severity of physical illness, delirium, receipt of vasopressor drugs perioperatively and high mean arterial pressure postoperatively. Conclusion Risk factors for incident delirium seem to differ according to pre-fracture cognitive status. The use of vasopressors during surgery and/or postoperative hypertension is associated with new-onset dementia after hip fracture