Fernandez Helen M, Callahan Kathryn E, Likourezos Antonios, Leipzig Rosanne M
Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, NY 10009, USA.
Arch Intern Med. 2008 Feb 25;168(4):390-6. doi: 10.1001/archinternmed.2007.87.
Many hospitalized older adults develop iatrogenic complications unrelated to their presenting diagnoses that can result in longer hospitalizations, functional impairment, or unanticipated medical or surgical interventions. These complications are often referred to as "hazards of hospitalization" and include delirium, malnutrition, urinary incontinence, pressure ulcers, depression, falls, restraint use, infection, functional decline, adverse drug effects, and death. The aims of this study were to assess house staff member awareness of older patients' risk factors for developing hazards of hospitalization and to determine areas in which interventions may help improve recognition.
A cross-sectional study was performed, from December 1, 1999, through August 31, 2002, of internal medicine and medicine or pediatric house staff members and their patients from 4 medical units at Mount Sinai Medical Center. Each house staff member completed a 23-item survey on 3 of their recently admitted patients. These patients and, if appropriate, their surrogates were interviewed by the study investigator within 2 hours of the completion of the house staff survey. House staff member responses are compared with those obtained by the study investigator. The completed house staff surveys were compared with the reference standard, and areas of agreement and disagreement were noted.
Eighty-six house staff teams, consisting of 1 intern and 1 resident (in either the second or third postgraduate year), and 105 patients were enrolled in the study. The house staff members were in frank disagreement or poor agreement with the reference standard in knowing the following: how well their patients were oriented to place or how long they had been hospitalized; patients' quality of sleep, presence of pain, history of falls, mood, quantity of food intake, and use of hearing aids, glasses, or an ambulation assistive device when at home; and the name of their patients' primary care physicians.
This study showed that internal medicine house staff members are not aware of many of their patients' risk factors for developing the hazards of hospitalization. Some of these deficits are glaring, particularly the lack of awareness of patients' orientation to place and time (duration of hospitalization), presence of pain, and the identity of their primary care physician. It will likely take education and cultural change to improve this performance. Such improvement could be accomplished as part of 3 of the Accreditation Council for Graduate Medical Education competencies: interpersonal communication, patient care, and systems-based practice. Such a process might improve not only house staff member awareness but also patient outcomes, since interdisciplinary communication and interventions are key to preventing the hazards of hospitalization.
许多住院的老年人会出现与他们当前诊断无关的医源性并发症，这些并发症可能导致住院时间延长、功能受损，或需要进行意外的医疗或外科干预。这些并发症通常被称为“住院风险”，包括谵妄、营养不良、尿失禁、压疮、抑郁、跌倒、使用约束措施、感染、功能衰退、药物不良反应和死亡。本研究的目的是评估住院医师对老年患者发生住院风险的危险因素的认知，并确定哪些领域的干预措施可能有助于提高识别能力。
1999年12月1日至2002年8月31日，在西奈山医疗中心的4个内科和内科或儿科住院医师及其患者中进行了一项横断面研究。每位住院医师对他们最近收治的3名患者完成了一项包含23个项目的调查。在住院医师完成调查后的2小时内，研究调查员对这些患者及其代理人（如适用）进行了访谈。将住院医师的回答与研究调查员获得的回答进行比较。将完成的住院医师调查问卷与参考标准进行比较，并记录一致和不一致的领域。
86个住院医师团队参与了该研究，每个团队由1名实习医生和1名住院医生（研究生二年级或三年级）组成，共涉及105名患者。住院医师在了解以下方面与参考标准存在明显分歧或一致性较差：患者对地点的定向程度或住院时间；患者的睡眠质量、疼痛情况、跌倒史、情绪、食物摄入量，以及在家时使用助听器、眼镜或步行辅助设备的情况；患者初级保健医生的姓名。
本研究表明，内科住院医师并不了解他们许多患者发生住院风险的危险因素。其中一些缺陷很明显，特别是对患者对地点和时间（住院时长）的定向、疼痛情况以及初级保健医生身份的认知不足。可能需要通过教育和文化变革来改善这种情况。这种改善可以作为研究生医学教育认证委员会三项能力要求的一部分来实现：人际沟通、患者护理和基于系统的实践。这样一个过程不仅可能提高住院医师的认知，还可能改善患者的治疗结果，因为跨学科沟通和干预是预防住院风险的关键。
