Prevalence and characteristics of nursing home-acquired infections in the aged

Prevalence of indwelling urinary catheters in nursing home residents: Systematic review

BACKGROUND

This systematic review examines the prevalence of indwelling urinary catheters in nursing home residents.

METHODS

MEDLINE via PubMed, CINAHL, and EMBASE were searched from inception to 9 August 2022. Cross-sectional studies and longitudinal studies with cross-sectional analyses reporting catheter prevalence in nursing home residents were identified and summarized descriptively. Study quality was assessed using the Joanna Briggs Institute's tool.

RESULTS

Sixty-seven studies (92.5 % cross-sectional) were included. The reported number of included residents ranged from 73 to 110,656. The median catheter prevalence was 7.3 % (interquartile range 4.3-10.1 %; n = 65 studies). It was higher in Germany (10.2 % [9.7-12.8 %]; n = 15) than in the United States of America (9.3 % [6.3-11.9 %]; n = 9), United Kingdom (6.9 % [4.8-8.5 %]; n = 7), and Sweden (7.3 % [6.4-7.9 %]; n = 6). Furthermore, it was higher among men (17.0 % [16.0-26.0 %]) than among women (5.3 % [4.0-9.5 %]) (n = 9). Only one study investigated differences by age. The prevalence was higher for transurethral (5.7 % [5.6-7.2 %]; n = 12) than for suprapubic (1.2 % [0.6-2.5 %]; n = 13) catheters. Most catheterized residents were long-term catheterized (n = 6) and had their catheter changed within 3 months (n = 2). Symptomatic urinary tract infections were more common among catheterized than among non-catheterized residents (n = 4).

DISCUSSION

Catheter prevalence in nursing home residents varies between studies and countries. Prevalence differences by sex, age, and catheter type as well as duration of catheterization, catheter change intervals, and catheter-associated urinary tract infections are rarely reported because most studies do not primarily focus on catheters. Future studies should focus on the circumstances of urinary catheter use and care in nursing home residents.

REGISTRATION AND FUNDING

PROSPERO (29 August 2022; CRD42022354358); no funding.

Not as simple as it seems: extensive facility and training gaps in nursing home bathing

Standardized observation of bed baths and showers for 100 residents in 8 nursing homes revealed inadequate cleansing of body sites (88%-100% failure) and >90% process failure involving lather, firm massage, changing dirty wipes or cloths, and following clean-to-dirty sequence. Insufficient water warmth affected 86% of bathing opportunities. Bathing training and adequate resources are needed.

The COVID-19 Pandemic and the Incidence of the Non-COVID-19 Pneumonia in Adults

Introduction: The coronavirus disease 2019 (COVID-19) lockdown strategies were associated with a significant decrease in the common respiratory viral diseases and decreased the need for hospitalization among children in the COVID-19 outbreak. However, the trend of non-COVID-19 pneumonia in adult people remains uncertain. Our aim is to assess the impact of the COVID-19 pandemic on the incidence of the non-COVID-19 pneumonia in adult people and understand whether the substantial decrease in pneumonia cases is the same as the decline in the incidence of respiratory viral disease activity.

Methods: We conducted a retrospective analysis of adult patients presenting with pneumonia from January 2019 to December 2020. Details on all the demographics of the patient of pneumonia, hospital course details, prior admission history within 3 months, respiratory culture, and antibiotics sensitivity test were also obtained.

Results: The number of adult patients with community-acquired pneumonia in 2020 was lower than that in 2019, which decreased by 74 patients in 2020. The decreasing number of patients with community-acquired pneumonia between 2019 and 2020 was from −13.9% in January to March 2020 to −39.7% in October to December 2020. The decreasing number of patients with community-acquired pneumonia between 2019 and 2020 was from −14.8% in the youngest cohort to −28.7% in those aged ≥85 years. The number of reduced patients with community-acquired pneumonia is greater in late seasons and older age, respectively. The number of adult patients with hospital-acquired pneumonia in 2020 was lower than that in 2019, which decreased by 23 patients in 2020. The decreasing number of patients with hospital-acquired pneumonia between 2019 and 2020 was from −20.0% in January to March 2020 to −52.4% in October to December 2020. The decreasing number of patients with hospital-acquired pneumonia between 2019 and 2020 was from 0% in the youngest cohort to −45.6% in those aged ≥ 85 years. The number of reduced patients with hospital-acquired pneumonia is greater in late seasons and older age, respectively.

Conclusion: Interventions applied to control the COVID-19 pandemic were effective not only in substantial changes in the seasonal influenza activity, but also in decreasing adult pneumonia cases.

Risk adjustment for benchmarking nursing home infection surveillance data: A narrative review

Until recently, there was no national surveillance system for monitoring infection occurrence in long-term care facilities (LTCF) in the United States. As a result, there are no national benchmarks for LTCF infection rates that can be utilized for quality improvement at the facility level. One of the major challenges in the reporting of health care-related infection data is accounting for nonmodifiable facility and patient characteristics that influence benchmarks for infection. The objectives of this paper are to review: (a) published infection rates in LTCF in the United States to assess the level of variability; (b) studies describing facility- and resident-level risk factors for infection that can be used in risk adjustment models; (c) published attempts to risk-adjust LTCF infection rates; and (d) efforts to develop models specifically for risk adjustment of infection rates in LTCF for benchmarking. It is anticipated that this review will stimulate further study of methods to risk-adjust LTCF infection rates for benchmarking that will facilitate research and public reporting.

The Use of Inappropriate Antibiotics in Patients Admitted to Intensive Care Units with Nursing Home-Acquired Pneumonia at a Korean Teaching Hospital

Background

Use of appropriate antibiotics for the treatment of pneumonia is integral in patients admitted to intensive care units (ICUs). Although it is recommended that empirical treatment regimens should be based on the local distribution of pathogens in patients with suspected hospital-acquired pneumonia, few studies observe patients admitted to ICUs with nursing home–acquired pneumonia (NHAP). We found factors associated with the use of inappropriate antibiotics in patients with pneumonia admitted to the ICU via the emergency room (ER).

Methods

We performed a retrospective cohort study of 83 pneumonia patients with confirmed causative bacteria admitted to ICUs via ER March 2015–May 2017. We compared clinical parameters, between patients who received appropriate or inappropriate antibiotics using the Mann-Whitney U, Pearson's chi-square, and Fisher's exact tests. We investigated independent factors associated with inappropriate antibiotic use in patients using multivariate logistic regression.

Results

Among 83 patients, 30 patients (36.1%) received inappropriate antibiotics. NHAP patients were more frequently treated with inappropriate antibiotics than with appropriate antibiotics (47.2% vs. 96.7%, p<0.001). Methicillin-resistant Staphylococcus aureus was more frequently isolated from individuals in the inappropriate antibiotics–treated group than in the appropriate antibiotics–treated group (7.5% vs. 70.0%, p<0.001). In multivariate analysis, NHAP was independently associated with the use of inappropriate antibiotics in patients with pneumonia admitted to the ICU via ER.

Conclusion

NHAP is a risk factor associated with the use of inappropriate antibiotics in patients with pneumonia admitted to the ICU via the ER.

Limited evidence for diagnosing bacterial skin infections in older adults in primary care: systematic review

Background

Older adults with bacterial skin infections may present with atypical symptoms, making diagnosis difficult. There is limited authoritative guidance on how older adults in the community present with bacterial skin infections. To date there have been no systematic reviews assessing the diagnostic value of symptoms and signs in identifying bacterial skin infections in older adults in the community.

Methods

We searched Medline and Medline in process, Embase and Web of Science, from inception to September 2017. We included cohort and cross-sectional studies assessing the diagnostic accuracy of symptoms and signs in predicting bacterial skin infections in adults in primary care aged over 65 years. The QUADAS-2 tool was used to assess study quality.

Results

We identified two observational studies of low-moderate quality, with a total of 7991 participants, providing data to calculate the diagnostic accuracy of 5 unique symptoms in predicting bacterial skin infections. The presence of wounds [LR+: 7.93 (CI 4.81–13.1)], pressure sores [LR+: 4.85 (CI 2.18–10.8)] and skin ulcers [LR+: 6.26 (CI 5.49–7.13)] help to diagnose bacterial skin infections. The presence of urinary incontinence does not help to predict bacterial skin infections (LR + ‘s of 0.99 and 1.04; LR-‘s of 0.96 and 1.04).

Conclusions

Currently, there is insufficient evidence to inform the diagnosis of bacterial skin infections in older adults in the community; clinicians should therefore rely upon their clinical judgement and experience. Evidence from high quality primary care studies in older adults, including studies assessing symptoms traditionally associated with bacterial skin infections (e.g. erythema and warmth), is urgently needed to guide practice.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1061-y) contains supplementary material, which is available to authorized users.

Diagnostic value of symptoms and signs for identifying urinary tract infection in older adult outpatients: Systematic review and meta-analysis

OBJECTIVES

To critically appraise and evaluate the diagnostic value of symptoms and signs in identifying UTI in older adult outpatients, using evidence from observational studies.

METHODS

We searched Medline and Medline in process, Embase and Web of Science, from inception up to September 2017. We included studies assessing the diagnostic accuracy of symptoms and/or signs in predicting UTI in outpatients aged 65 years and above. Study quality was assessed using the QUADAS-2 tool.

RESULTS

We identified 15 eligible studies of variable quality, with a total of 12,039 participants (range 65-4259), and assessed the diagnostic accuracy of 66 different symptoms and signs in predicting UTI. A number of symptoms and signs typically associated with UTI, such as nocturia, urgency and abnormal vital signs, were of limited use in older adult outpatients. Inability to perform a number of acts of daily living were predictors of UTI: For example, disability in feeding oneself, + ve LR: 11.8 (95% CI 5.51-25.2) and disability in washing one's hands and face, + ve LR: 6.84 (95% CI 4.08-11.5).

CONCLUSIONS

The limited evidence of varying quality shows that a number of symptoms and signs traditionally associated with UTI may have limited diagnostic value in older adult outpatients.

The Nursing Home Pneumonia Risk Index: A Simple, Valid MDS-Based Method of Identifying 6-Month Risk for Pneumonia and Mortality

BACKGROUND

Pneumonia is the leading infectious cause of hospitalization and death for nursing home (NH) residents; however, diagnosis is often delayed because classic signs of infection are not present. We sought to identify NH residents at high risk for pneumonia, to identify persons to target for more intensive surveillance and preventive measures.

METHODS

Based on a literature review, we identified key risk factors for pneumonia and compiled them for use as prediction tool, limiting risk factors to those available on the Minimum Data Set (MDS). Next, we tested the tool's ability to predict 6-month pneumonia incidence and mortality rates in a sample of 674 residents from 7 NHs, evaluating it both as a continuous and a dichotomous variable, and applying both logistic regression and survival analysis to calculate estimates.

RESULTS

NH Pneumonia Risk Index scores ranged from -1 to 6, with a mean of 2.1, a median of 2, and a mode of 2. For the outcome of pneumonia, a 1-point increase in the index was associated with a risk odds ratio of 1.26 (P = .038) or a hazard ratio of 1.24 (P = .037); using it as a dichotomous variable (≤2 vs ≥3), the corresponding figures were a risk odds ratio of 1.78 (P = .045) and a hazard ratio of 1.82 (P = .025). For the outcome of mortality, a 1-point increase in the NH Pneumonia Risk Index was associated with a risk odds ratio of 1.58 (P = .002) and a hazard ratio of 1.45 (P = .013); using the index as a dichotomous variable, the corresponding figures were a risk odds ratio of 3.71 (P < .001) and a hazard ratio of 3.29 (P = .001).

CONCLUSIONS

The NH Pneumonia Risk Index can be used by NH staff to identify residents for whom to apply especially intensive preventive measures and surveillance. Because of its strong association with mortality, the index may also be valuable in care planning and discussion of advance directives.

Adequacy of initial evaluation of fever in long-term care facilities

AIM

Febrile residents in long-term care facilities (LTCF) might be inadequately evaluated by caregivers. The present study aimed to examine the factors associated with inadequacy of initial fever evaluations by caregivers at night in LTCF.

METHODS

We carried out a cross-sectional study among a convenience sample of caregivers employed at 11 LTCF in Japan using a vignette-based questionnaire. The respondents were randomly assigned to one of two scenarios describing a mild or severe febrile episode in an LTCF resident at night. The respondents' thinking patterns were classified based on influential factors in their fever evaluation. Associations between adequacy of evaluation and respondents' characteristics were evaluated using generalized linear mixed models.

RESULTS

A total of 34% of fever evaluations among caregivers were considered to be inadequate regarding the necessity for examination by a physician, due in most cases to underestimating the severity of the fever. Respondents' thinking patterns in fever evaluation were significantly associated with the adequacy of the evaluation. Caregivers who placed particular importance on the preferences of residents and families versus other factors including the resident's febrile condition, were more likely to make an inadequate evaluation than those who did not.

CONCLUSIONS

Our findings here suggest that eagerness to comply with residents' preference in fever evaluation could prompt caregivers not to call for an appropriate diagnostic procedure. Geriatr Gerontol Int 2017; 17: 1294-1299.

Anthropometric measurements may be informative for nursing home-acquired pneumonia

Objective:

To evaluate the relationship between anthropometric measurements and Nursing Home-Acquired Pneumonia (NHAP) risk.

Methods:

Consecutive patients of 65 years or elderly who were living in the Balikli Rum Hospital Nursing Homes were included in this prospective study. At the beginning of this study, the patients’ anthropometrics values were measured. The patients were followed for one year, and any incidences of pneumonia attacks were recorded. The relationship between the anthropometric measurements and pneumonia occurrences was analyzed.

Results:

There were 133 inmates at the initial assessments. Of 108 patients who were eligible for the study, 77 (72.2%) were female and 37 (27.8%) were male. The mean age of the group was 79.8±10.5. Patients were assigned to a group according to the presence of pneumonia during the one -year follow-up. There were 74 (55.6%) patients who had suffered from at least one attack of pneumonia during the follow-up period. The mean triceps skinfold was significantly thinner in the pneumonia group, and the mean handgrip measurements in both the dominant and non-dominant hands were significantly weaker in the pneumonia group. Furthermore, the frequency of Chronic Obstructive Pulmonary Diseases (COPD) was significantly higher in this group (p < 0.001).

Conclusions:

The risk of pneumonia was high in the elderly population who live in nursing homes. Simple anthropometric values may be predictive of the potential for Nursing Home-Acquired Pneumonia.

Bladder Management and Urinary Tract Infections in Danish Hospitals, Nursing Homes, and Home Care: A National Prevalence Study

Objective:

To establish the prevalence of urinary tract infection in patients undergoing various forms of bladder management.

Design:

A nationwide descriptive point-prevalence survey with logistic regression analysis of the data relating infection to bladder management.

Setting:

Fifteen hospitals, 21 nursing homes, and 13 home care districts throughout Denmark.

Patients:

Information was collected on 3,665 patients. On the day of the study, 349 patients had indwelling catheters and 1,150 were using external urine drainage systems (condoms or diapers) for bladder management.

Results:

The prevalence of urinary tract infections in catheterized patients and those using external drainage systems was 13.2% and 8.1%, respectively. The prevalence of hospital-acquired urinary tract infection (4.2%) had not changed from that reported in 1978. The proportion of these infections related to the indwelling catheter, however, had reduced from 66% to 30%. Logistic regression analysis confirmed that, when corrected for the patient-related confounders (female gender, age >60 years, incontinence, immobility, and stay in hospital for longer than 15 days), condoms (odds ratio [OR], 5.94; 95% confidence interval [CI95], 2.8 to 12.5), indwelling catheters (OR, 3.3; CI95, 2.3 to 4.8), and diapers (OR, 1.5; CI95, 1.1 to 2.1) were significantly (P<.001, P<.001, and P=.008, respectively) related to infection.

Conclusions:

Prevalence surveys have revealed that over the period 1978 to 1991, during which efforts have been made to restrict the use of indwelling catheters and to encourage the care of catheterized patients according to guidelines recommended by the Danish National Centre for Hospital Hygiene, the percentage of hospital-acquired urinary tract infections associated with indwelling catheters has been halved. External urine drainage systems, however, have emerged as significant risk factors for urinary tract infection.

Infection Prevention and Control in the Long-Term-Care Facility

More than 1.5 million residents reside in US nursing homes. In recent years, the acuity of illness of nursing home residents has increased. Long-term-care facility residents have a risk of developing nosocomial infection that is similar to acute-care hospital patients. A great deal of information has been published concerning infections in the long-term-care facility, and infection control programs are nearly universal.

This position paper reviews the literature on infections and infection control programs in the long-term-care facility, covering such topics as tuberculosis, bloodborne pathogens, epidemics, isolation systems, immunization, and antibiotic-resistant bacteria. Recommendations are developed for long-term-care infection control programs based on interpretation of currently available evidence. The recommendations cover the structure and function of the infection control program, including surveillance, isolation, outbreak control, resident care, and employee health. Infection control resources also are presented.

Changing the culture of mouth care: mouth care without a battle

PURPOSE OF THE STUDY

Culture change aims to fundamentally improve care provision in a manner consistent with individual preferences. However, few studies of culture change have focused on the quality of daily care, despite the fact that system-wide efforts are important to assure the effectiveness, adoption, and sustainability of person-centered care to meet daily needs. This paper describes a new culture change practice, Mouth Care Without a Battle. The focus on mouth care is predicated on the important association between person-centered support for oral hygiene and quality of life.

DESIGN AND METHODS

Mouth Care Without a Battle is a person-centered approach to quality mouth care for persons with cognitive and physical impairment. It was developed by an interdisciplinary team of clinician researchers based on literature review, consultation with experts, environmental scan of existing programs, and testing in nursing homes. Building from the success of Bathing Without a Battle, Mouth Care Without a Battle was evaluated in terms of changed care practices and outcomes, developed into a training program, and packaged for dissemination as a digital video disk (DVD) and website.

RESULTS

The development and evaluation of Mouth Care Without a Battle demonstrate attention to the areas necessary to establish the evidence-base for culture change, to ultimately empower and support staff to provide care to achieve quality outcomes.

IMPLICATIONS

As illustrated in this paper, it is beneficial to build the evidence base for culture change by attending to care processes and outcomes benefiting all residents, ability to implement culture change, and costs of implementation.

Interaction between cognitive impairment and discharge destination and its effect on rehospitalization

OBJECTIVES

To evaluate the effect of cognitive impairment on rehospitalization in older adults.

DESIGN

One-year longitudinal study.

SETTING

Medical service of an urban, 340-bed public hospital in Indianapolis between July 2006 and March 2008.

PARTICIPANTS

Individuals aged 65 and older admitted to the medical service (N = 976).

MEASUREMENTS

Rehospitalization was defined as any hospital admission after the index admission. Participant demographics, discharge destination, Charlson Comorbidity Index, Acute Physiology Score, and prior hospitalizations were measured as the confounders. Participants were considered to have cognitive impairment if they had two or more errors on the Short Portable Mental Status Questionnaire.

RESULTS

After adjusting for confounders, a significant interaction between cognitive impairment and discharge location was found to predict rehospitalization rate (P = .008) and time to 1-year rehospitalization (P = .03). Participants with cognitive impairment discharged to a facility had a longer time to rehospitalization (median 142 days) than participants with no cognitive impairment (median 98 days) (hazard ratio (HR) = 0.77, 95% confidence interval (CI) = 0.58-1.02, P = .07), whereas participants with cognitive impairment discharged to home had a slightly shorter time to rehospitalization (median 182 days) than those without cognitive impairment (median 224 days) (HR = 1.15, 95% CI = 0.92-1.43, P = .23). These two nonsignificant HRs in opposite directions were significantly different from each other (P = .03).

CONCLUSION

Discharge destination modifies the association between cognitive impairment and rehospitalization. Of participants discharged to a facility, those without cognitive impairment had higher rehospitalization rates, whereas the rates were similar between cognitively impaired and intact participants discharged to the community.

Comparison of the bacterial isolates and antibiotic resistance patterns of elderly nursing home and general community patients

BACKGROUND

Nursing home-acquired infections may differ from general community-acquired infections in bacteriology and antibiotic resistance. However, there are currently limited data on this topic in the Australian setting.

AIMS

To compare bacterial isolates and antibiotic resistance patterns, from pathology specimens of nursing home and community patients, and to comment on the suitability of empiric antibiotic guidelines for nursing home-acquired infection.

METHODS

This was a retrospective cohort study of patients, aged ≥ 65 years, who resided in either nursing homes or the general community. Patients with a hospital admission in the previous 28 days were excluded. Positive specimen cultures, collected between July 2003 and June 2008 in the Emergency Department and Outpatient Clinics of the Austin Hospital (Melbourne), were examined. The main outcome measures were the bacterial isolates, and their antibiotic resistance patterns, of patients from nursing homes and the general community.

RESULTS

Specimens of blood (638), sputum (425), urine (4044) and wound cultures (785) were examined. The bacteriology of blood culture isolates did not differ between the two groups (P= 0.3). However, the bacteriology of sputum, urine and wound cultures differed significantly between the groups (P= 0.025, P < 0.001, P= 0.004 respectively). There were also higher proportions of antibiotic resistance among some bacteria in nursing home patients, especially methicillin resistance among Staphylococcus aureus isolates across all specimen types, and resistance to several empiric antibiotics among Enterobacteriaceae isolates in urine cultures.

CONCLUSION

Empiric antibiotic guidelines appear adequate to treat nursing home-acquired septicaemia and pneumonia. However, guidelines for urinary tract infections and wound infections may need to be refined.

Pneumonia in the long-term resident

Pneumonia in the long-term resident is common. It is associated with high morbidity and mortality. However, diagnosis and management of pneumonia in long-term care residents is challenging. This article provides an overview of the epidemiology, pathophysiology, diagnostic challenges, and management recommendations for pneumonia in this setting.

Nursing home-acquired pneumonia: a review of risk factors and therapeutic approaches

OBJECTIVE

To review the risk factors, etiologic profile, treatment approaches, and guidelines for the management of nursing home-acquired pneumonia (NHAP).

RESEARCH DESIGN AND METHODS

A search of the current literature was conducted using the MEDLINE and Embase databases. This search, limited to studies performed in humans and published in English between January 1, 1990 and October 31, 2009, included the terms 'acquired pneumonia', 'associated pneumonia', 'nursing home', 'long-term care', 'institution', and 'healthcare'.

RESULTS

Older age, male gender, swallowing difficulty, and inability to take oral medications are all significant risk factors for pneumonia. Medications such as antipsychotics and anticholinergics, histamine receptor blockers and proton pump inhibitors have also been linked to higher risk of pneumonia. The etiology of NHAP overlaps with that of community-acquired pneumonia (CAP), with Streptococcus pneumoniae and Haemophilus influenzae as predominant pathogens in long-term care facilities. In patients who require hospitalization, Chlamydophila pneumoniae, Staphylococcus aureus, and influenza virus have also been identified. In contrast, the etiology of severe NHAP overlaps with that of hospital-acquired pneumonia (HAP), with S. aureus, including methicillin-resistant S. aureus (MRSA), Pseudomonas aeruginosa, and enteric Gram-negative bacilli as important causative pathogens. Therapy is dependent on disease severity and, on the treatment setting. Respiratory fluoroquinolones or β-lactams plus a macrolide are recommended in patients with NHAP. Patients hospitalized with severe NHAP may require triple combination therapy that covers both MRSA and P. aeruginosa. However, there is little evidence of the clinical superiority of one regimen over another, making it challenging to establish guidelines for the treatment of NHAP in the nursing home setting.

CONCLUSION

There is a pressing need for clinical trials of antibiotic therapy in nursing home patients that would help establish uniform guidelines to standardize therapy in the nursing home setting.

Nursing home-associated infections in Department of Veterans Affairs community living centers

BACKGROUND

Little is known about factors contributing to nursing home-associated infections (NHAIs). We conducted a survey of residents in 133 Department of Veterans Affairs community living centers to determine the roles of indwelling device use, bed locations, and treatment codes on NHAIs.

METHODS

A Web-based point prevalence survey of NHAIs using modified Centers for Disease Control and Prevention definitions for health care-associated infections was conducted on November 14, 2007.

RESULTS

Among 10,939 residents, 575 had at least one NHAI, for a point prevalence rate of 5.3%. Urinary tract infection, skin infection, asymptomatic bacteriuria, and pneumonia were the most prevalent NHAIs. A total of 2687 residents had one or more indwelling devices; 290 of these also had an NHAI, for a prevalence of 10.8%. In contrast, the prevalence of NHAIs in residents without indwelling devices was 3.5% (P < .0001). Indwelling urinary catheters, percutaneous gastrostomy tubes, peripherally inserted central catheters, and suprapubic urinary catheters were the most commonly used devices. There were 4027 residents in designated units and 6912 residents in dispersed units. The rate of device use was 21.4% in the designated units and 26.4% in the dispersed units (P < .0001). The prevalence of NHAIs was 4.5% in the designated units and 5.7% in the dispersed units (P < .001). Rates of NHAIs and device use varied greatly among the various treatment codes; however, there was a positive correlation between the rates of NHAIs and device use. Stepwise logistic regression analysis of data from long-stay and short-stay skilled nursing care residents revealed that only the presence of an indwelling device, not length of stay or bed location, affected the rate of NHAIs.

CONCLUSION

Indwelling device use, but not bed location or treatment code, was found to be associated with increased rate of NHAIs.

Survey of healthcare-associated infection rates in a nursing home resident population

In this study we assessed the incidence and types of healthcare-associated infection (HCAI) in a nursing home resident population. The influences of home size, resident category, gender and age were also examined. Fifteen homes were recruited and infection rates recorded from 1 October 2006 to 2 December 2006. A rate of 6.04 infections/1000 bed days was recorded for the complete study. Infection rates for the four main categories of infection (number of infections/ 1000 bed days) were respiratory (2.52), urinary (1.87), skin and soft tissue (1.57) and gastrointestinal (0.41). Infection rates for small, medium and large homes were 4.64 (range 1.95—6.51), 5.9 (range 0.49—10.76) and 7.79 (range 5.79—9.39), respectively; however, statistical significance was not achieved ( p = 0.335). Results indicate that respiratory infection rates are higher in larger homes (4.08) than in small (1.88) or medium size homes (2.22). Urinary infection rates were similar in small (1.89), medium (1.88) and large (1.82) homes and skin and soft tissue infections were lower in small homes (0.87) but similar in medium (1.69) and large (1.90) homes. We found a statistically significant relationship between the type of infection acquired and both resident category ( p = 0.017) and gender ( p = 0.005); the relationship between type of infection and age did not reach statistical significance ( p = 0.346).

Urinary Tract Infections in Extended Care Facilities: Preventive Management Strategies

OBJECTIVE

To provide health care professionals with an overview of interventions that may be done to reduce the incidence of urinary tract infections (UTIs) in elderly patients, especially those residing in extended care facilities.

DATA SOURCES

A Medline search of the English literature was performed from 1980 to January 2006 to find literature relevant to urinary tract prophylaxis. Further references were hand-searched from relevant sources.

STUDY SELECTION

When assessing the effectiveness of various clinical interventions for reducing the incidence of UTIs in the elderly, preference was given to more recent, double-blind, placebo-controlled randomized studies, but studies of less robust design also were included in the discussions when the former were lacking.

DATA EXTRACTION

Where possible, recent publications were favored over older studies. References were all reviewed by the authors and chosen to present key citations.

DATA SYNTHESIS

Data selection was prioritized to address specific subtopics.

CONCLUSION

Though still frequent in occurrence and quite costly in terms of morbidity, mortality, and cost to the health care system, numerous measures may be taken to ameliorate the incidence of UTIs in elderly, institutionalized residents. First and foremost, establishing and adhering to good infection-control practices by health care givers and minimizing the use of indwelling catheters are essential. Adequate staffing and training are germane to this effort. Reasonably well-designed clinical studies also give credence to the use of topical estrogens and lactobacillus "probiotics" for female subgroups and cranberry juice for a wider array of patients. Vitamin C is of no proven benefit. With regard to antibiotics, with the relative paucity of data available for this patient population, concerns for resistance proliferation must be balanced against perceived gains in UTI reduction.

Pilot testing of intervention protocols to prevent pneumonia in nursing home residents

OBJECTIVES

To test intervention protocols for feasibility, staff adherence, and effectiveness in reducing pneumonia risk factors (impaired oral hygiene, swallowing difficulty) in nursing home residents.

DESIGN

Prospective study.

SETTING

Two nursing homes.

PARTICIPANTS

Fifty-two nursing home residents.

INTERVENTION

Thirty residents with impaired oral hygiene were randomly assigned to manual oral brushing plus 0.12% chlorhexidine oral rinse at different frequencies daily. Twenty-two residents with swallowing difficulty were randomly assigned to upright feeding positioning, teaching swallowing techniques, or manual oral brushing. All protocols were administered over 3 months.

MEASUREMENTS

Feasibility was assessed monthly and defined as high if the protocol took less than 10 minutes to administer. Adherence was assessed weekly and defined as high if full staff adherence was demonstrated in more than 75% of assessments. Effectiveness for improved oral hygiene (reduction in oral plaque score) and swallowing (reduction in cough during swallowing) was compared at baseline and 3 months.

RESULTS

Daily manual oral brushing plus 0.12% chlorhexidine rinse demonstrated high feasibility, high staff adherence, and effectiveness in improving oral hygiene (P<.001 vs baseline); this combination administered twice per day showed the highest plaque score reduction. Daily manual oral brushing and upright feeding positioning demonstrated high feasibility, high staff adherence, and effectiveness in improving swallowing.

CONCLUSION

Manual oral brushing, 0.12% chlorhexidine oral rinse, and upright feeding positioning demonstrated high feasibility, high staff adherence, and effectiveness in pneumonia risk factor reduction. A protocol combining these components warrants testing for its ability to reduce pneumonia in nursing home residents.

Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America

Residents of long‐term care facilities (LTCFs) are at great risk for infection. Most residents are older and have multiple comorbidities that complicate recognition of infection; for example, typically defined fever is absent in more than one‐half of LTCF residents with serious infection. Furthermore, LTCFs often do not have the on‐site equipment or personnel to evaluate suspected infection in the fashion typically performed in acute care hospitals. In recognition of the differences between LTCFs and hospitals with regard to hosts and resources present, the Infectious Diseases Society of America first provided guidelines for evaluation of fever and infection in LTCF residents in 2000. The guideline presented here represents the second edition, updated by data generated over the intervening 8 years. It focuses on the typical elderly person institutionalized with multiple chronic comorbidities and functional disabilities (e.g., a nursing home resident). Specific topic reviews and recommendations are provided with regard to what resources are typically available to evaluate suspected infection, what symptoms and signs suggest infection in a resident of an LTCF, who should initially evaluate the resident with suspected infection, what clinical evaluation should be performed, how LTCF staff can effectively communicate about possible infection with clinicians, and what laboratory tests should be ordered. Finally, a general outline of how a suspected outbreak of a specific infectious disease should be investigated in an LTCF is provided.

Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America

Residents of long-term care facilities (LTCFs) are at great risk for infection. Most residents are older and have multiple comorbidities that complicate recognition of infection; for example, typically defined fever is absent in more than one-half of LTCF residents with serious infection. Furthermore, LTCFs often do not have the on-site equipment or personnel to evaluate suspected infection in the fashion typically performed in acute care hospitals. In recognition of the differences between LTCFs and hospitals with regard to hosts and resources present, the Infectious Diseases Society of America first provided guidelines for evaluation of fever and infection in LTCF residents in 2000. The guideline presented here represents the second edition, updated by data generated over the intervening 8 years. It focuses on the typical elderly person institutionalized with multiple chronic comorbidities and functional disabilities (e.g., a nursing home resident). Specific topic reviews and recommendations are provided with regard to what resources are typically available to evaluate suspected infection, what symptoms and signs suggest infection in a resident of an LTCF, who should initially evaluate the resident with suspected infection, what clinical evaluation should be performed, how LTCF staff can effectively communicate about possible infection with clinicians, and what laboratory tests should be ordered. Finally, a general outline of how a suspected outbreak of a specific infectious disease should be investigated in an LTCF is provided.

Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America

Residents of long-term care facilities (LTCFs) are at great risk for infection. Most residents are older and have multiple comorbidities that complicate recognition of infection; for example, typically defined fever is absent in more than one-half of LTCF residents with serious infection. Furthermore, LTCFs often do not have the on-site equipment or personnel to evaluate suspected infection in the fashion typically performed in acute care hospitals. In recognition of the differences between LTCFs and hospitals with regard to hosts and resources present, the Infectious Diseases Society of America first provided guidelines for evaluation of fever and infection in LTCF residents in 2000. The guideline presented here represents the second edition, updated by data generated over the intervening 8 years. It focuses on the typical elderly person institutionalized with multiple chronic comorbidities and functional disabilities (e.g., a nursing home resident). Specific topic reviews and recommendations are provided with regard to what resources are typically available to evaluate suspected infection, what symptoms and signs suggest infection in a resident of an LTCF, who should initially evaluate the resident with suspected infection, what clinical evaluation should be performed, how LTCF staff can effectively communicate about possible infection with clinicians, and what laboratory tests should be ordered. Finally, a general outline of how a suspected outbreak of a specific infectious disease should be investigated in an LTCF is provided.

Prevalence of nursing home-associated infections in the Department of Veterans Affairs nursing home care units

BACKGROUND

The Department of Veterans Affairs (VA) is the largest single provider of long-term care in the United States. The prevalence of nursing home-associated infections (NHAIs) among residents of VA nursing home care units (NHCUs) is not known.

METHODS

A Web-based point prevalence survey of NHAIs using modified Centers for Disease Control and Prevention definitions for health care-associated infections was conducted in the VA's 133 NHCUs on November 9, 2005.

RESULTS

From a total population of 11,475 NHCU residents, 591 had at least 1 NHAI for a point prevalence rate of 5.2%. Urinary tract infection, asymptomatic bacteriuria, pneumonia, skin infection, gastroenteritis, and soft tissue infection were most prevalent, constituting 72% of all NHAIs. A total of 2817 residents (24.5%) had 1 or more indwelling device. Of these 2817 residents with an indwelling device(s), 309 (11.0%) had 1 or more NHAI. In contrast, the prevalence of NHAIs in residents without an indwelling device was 3.3%. Indwelling urinary catheter, percutaneous gastrostomy tube, intravenous peripheral line, peripherally inserted central catheter, and suprapubic urinary catheter were most common, accounting for 79.3% of all devices used.

CONCLUSION

There are effective infection surveillance and control programs in VA NHCUs with a point prevalence of NHAIs of 5.2%.

Prevalence of long-term care acquired infections in nursing and residential homes in the Emilia-Romagna Region

BACKGROUND

Hardly any data on the occurrence of infection in Italian nursing homes have been published; yet Italy has the second oldest population in the world. The objective of the study was to assess the frequency of infections in a sample of Italian nursing homes.

MATERIALS AND METHODS

A 1-day prevalence survey was conducted in three local health authorities (LHAs) of the Emilia-Romagna region in Italy, aimed at describing the prevalence of patients with long-term care facilityassociated infections and their associated factors among residents of nursing and residential facilities. All nursing homes (NHs) and a stratified random sample of residential homes (RHs) in the three LHAs were included in the study, for a total of 1,926 elderly people in 49 facilities. The following data were recorded: infections, medical condition, activities of daily living (ADL), use of antibiotics. The main outcome of the study was infection prevalence.

RESULTS

The prevalence of patients with long-term care facility-associated infection was 8.4/100 residents overall (CI 95% 7.9-9.0), 14.6/100 in NHs and 7.5/100 in RHs (CI 95% 6.8-8.1). The prevalence of infection significantly varied with LHA and facility. It was associated with level of dependency and exposure to invasive procedures, such as urinary catheterization and parenteral procedures. Six percent of residents received a systemic antimicrobial on the day of the study, and in 22% of cases there was no evidence of suspected or diagnosed infections.

CONCLUSION

The prevalence study identified a high prevalence of infected patients in nursing homes in Italy, consistent with observation in other geographic areas.

Healthcare-associated infection among residents of long-term care facilities: a cohort and nested case-control study

Knowledge of infection control measures in nursing homes is limited. This study aimed to assess the incidence of, and potential risk factors for, healthcare-associated infection in long-term care facilities in Norway. Incidence of healthcare-associated infection was recorded prospectively in six long-term care facilities located in two major cities in Norway between 1 October 2004 and 31 March 2005. For each resident with an infection we aimed for two controls in a nested case-control study to identify potential risk factors. Incidence of infection was 5.2 per 1000 resident-days. Urinary and lower respiratory tract infections were the most common. Patients confined to their beds [odds ratio (OR=2.7)], who stayed <28 days (OR=1.5), had chronic heart disease (OR=1.3), urinary incontinence (OR=1.5), an indwelling urinary catheter (OR=2.0) or skin ulcers (OR=1.8) were shown to have a greater risk for infection. Age, sex and accommodated in a two- versus single-bed room were not significant factors. Incidence of infection in nursing homes in Norway is within the range reported from other countries. This study identified several important risk factors for healthcare-associated infection. There is a need to prevent infection by implementing infection control programmes including surveillance in long-term care facilities.

Mortality and Adverse Health Events in Newly Admitted Nursing Home Residents with and without Dementia

OBJECTIVES

To evaluate the association between dementia and mortality, adverse health events, and discharge disposition of newly admitted nursing home residents. It was hypothesized that residents with dementia would die at a higher rate and develop more adverse health events (e.g., infections, fevers, pressure ulcers, falls) than residents without dementia because of communication and self-care difficulties.

DESIGN

An expert clinician panel diagnosed an admission cohort from a stratified random sample of 59 Maryland nursing homes, between 1992 and 1995. The cohort was followed for up to 2 years or until discharge.

SETTING

Fifty-nine Maryland nursing homes.

PARTICIPANTS

Two thousand one hundred fifty-three newly admitted residents aged 65 and older not having resided in a nursing home for 8 or more days in the previous year.

MEASUREMENTS

Mortality, infection, fever, pressure ulcers, fractures, and discharge home.

RESULTS

Residents with dementia had significantly lower overall rates of infection (relative risk (RR)=0.77, 95% confidence interval (CI)=0.70-0.85) and mortality (RR=0.61, 95% CI=0.53-0.71) than those without dementia, whereas rates of fever, pressure ulcers, and fractures were similar for the two groups. These results persisted when rates were adjusted for demographic characteristics, comorbid conditions, and functional status. During the first 90 days of the nursing home stay, residents with dementia had significantly lower rates of mortality if not admitted for rehabilitative care under a Medicare qualifying stay (RR=0.25, 95% CI=0.14-0.45), were less often discharged home (RR=0.33, 95% CI=0.28-0.38), and tended to have lower fever rates (RR=0.78, 95% CI=0.63-0.96) than residents without dementia.

CONCLUSION

Newly admitted nursing home residents with dementia have a profile of health events that is distinct from that of residents without dementia, indicating that the two groups have different long-term care needs. Results suggest that further investigation of whether residents with dementia can be well managed in alternative residential settings would be valuable.

Medicare cost differences between nursing home patients admitted with and without dementia

PURPOSE

Our objective in this study was to compare Medicare costs of treating older adults with and without dementia in nursing home settings.

DESIGN AND METHODS

An expert panel established the dementia status of a stratified random sample of newly admitted residents in 59 Maryland nursing homes between 1992 and 1995. Medicare expenditures per-person month (PPM) were compared for 640 residents diagnosed with dementia and 636 with no dementia for 1 year preadmission and 2 years postadmission. Multivariate analysis with generalized estimating equations was used to identify the source of Medicare cost differentials between the two groups.

RESULTS

Medicare expenditures peaked in the month immediately preceding admission and dropped to preadmission levels by the third month in a nursing home. Adjusted PPM costs postadmission for the dementia group as a whole were 79% (p < .001) of the Medicare costs of treating residents without dementia. For the subgroup of residents admitted without a Medicare qualified stay (MQS), those with dementia had Medicare costs of just 63% (p < .001) of those without dementia. Overall Medicare costs PPM were insignificantly different between the two groups admitted with a MQS.

IMPLICATIONS

Whether nursing home residents are admitted with a MQS is the single most important factor in assessing treatment cost differentials between residents admitted with and without dementia. Failure to consider this factor may lead researchers and policy makers to misdirect their attention from the true source of the differential-dementia patients admitted without a qualifying stay.

Water and sodium disturbances predict prognosis of acute disease in long term cared frail elderly

Elderly patients are at increased risk for developing infections and fever. We aimed to investigate the incidence, causes and outcome of hypernatemia and hyponatremia among elderly long-term care patients with febrile illness. This is a prospective study conducted in a 110 beds, nursing department for dependent elderly in geriatric long-term care facility during 20 months period. Changes in plasma sodium concentrations were found in 48% (132/270) of the febrile illness: during the acute illness in 38% (102/270) of the events and during the follow-up period after acute febrile event, in 30% (59/198) of the events. Upper respiratory tract, bronchial, lung, and urinary tract infections were the most common causes for the fever. Hypernatremia was more prevalent on acute febrile illness (63%). Hyponatremia was more common before the febrile illness (10%) and during the follow-up period (69%). The most common causes of hypernatremia were inadequate hydration or correction (57%) and continuous diuretic treatment (38%). The most common causes of hyponatremia were: Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) (38%), incorrect hydration (19%), and continuous diuretic treatment (30%). During the study, 60% (28/47) of the patients died, and hypernatremia was detected in 82% (20/28). Disturbances in sodium concentrations were predictors of bad outcomes, related to the underlying diseases burden, and were not related to the magnitude of the changes in plasma sodium, time of its development, advanced age, gender and coexisting changes in plasma potassium level.

Modifiable risk factors for nursing home-acquired pneumonia

BACKGROUND

This study sought to identify modifiable risk factors for pneumonia in elderly nursing home residents.

METHODS

A cohort of 613 elderly residents (age, >65 years) of 5 nursing homes in the New Haven, Connecticut, area was followed-up prospectively from February 2001 through March 2003. The primary outcome was radiographically documented pneumonia within a 12-month surveillance period. Baseline modifiable risk factors were evaluated for their independent association with pneumonia.

RESULTS

Of 613 elderly nursing home residents, 131 (21%) died, and an additional 112 (18%) developed a radiographically documented case of pneumonia during the 12-month surveillance period. Among the 9 candidate modifiable risk factors that were evaluated individually in Cox proportional hazards models adjusting for covariates (i.e., nursing home facility, age, race, coexisting conditions, and immobility), inadequate oral care (hazard ratio [HR], 1.60; 95% confidence interval [CI], 1.06-2.35; P=.024) and swallowing difficulty (HR, 1.65; 95% CI, 1.04-2.62; P=.033) were associated with pneumonia. When modifiable risk factors were evaluated simultaneously in the same Cox proportional hazards model, inadequate oral care (HR, 1.55; 95% CI, 1.04-2.30; P=.030) and swallowing difficulty (HR, 1.61; 95% CI, 1.02-2.55; P=.043) remained independently associated with pneumonia, adjusting for the same covariates. Calculation of population-based attributable fractions showed that 21% of all cases of pneumonia in our cohort could have been avoided if inadequate oral care and swallowing difficulty were not present.

CONCLUSIONS

Two biologically plausible and modifiable risk factors increased the risk of pneumonia in elderly nursing home residents. These results provide a framework for the development and testing of a targeted pneumonia prevention strategy.

A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia

OBJECTIVES

To compare usual care with a proactive case-finding approach for critically ill patients with terminal dementia using an inpatient palliative care service.

DESIGN

Prospective comparison to historical control.

SETTING

Urban, university-affiliated hospital.

PATIENTS

Total of 52 men and women with end-stage dementia, 26 subjects in each control and intervention group.

INTERVENTIONS

Proactive case-finding by the palliative care service was done to offer early assistance to the intensive care unit staff about the treatment of patients with terminal dementia. Results were compared with data obtained retrospectively.

MEASUREMENTS AND MAIN RESULTS

Measurements included age, gender, Acute Physiology and Chronic Health Evaluation Score, Therapeutic Intervention Scoring System, mortality, intensive care unit and hospital lengths of stay, frequency, timing, and goals of do-not-resuscitate orders. The proactive, case-finding approach decreased hospital and medical intensive care unit length of stay. More important, a proactive palliative intervention decreased the time between identification of the poor prognosis and the establishment of do-not-resuscitate goals, decreased the time terminal demented patients remained in the intensive care unit, and reduced the use of nonbeneficial resources, thus reducing patient burden and the cost of care while having the potential to afford the patient and family increased comfort and psychoemotional support.

CONCLUSIONS

Proactive interventions from a palliative care consultant within this subset of patients improved end-of-life care and decreased use of superfluous resources.

The Minimum Data Set Bedfast Quality Indicator

BACKGROUND

Excessive time in bed has negative effects on both physical conditioning and functioning. There are no data or practice guidelines relevant to how nurses should manage the in-bed times of nursing home residents, although all nursing homes receive a bedfast prevalence quality indicator report generated from the Minimum Data Set.

OBJECTIVES

To compare nursing homes that score in the upper and lower quartiles on the Minimum Data Set bedfast prevalence quality indicator for proportion of bedfast residents, activity and mobility nursing care, and amount of time all residents spend in bed, and to evaluate whether residents who spend more time in bed are different from those who spend less time in bed according to functional measures.

METHODS

A cohort design used medical records, resident interviews, and direct observation data to compare 15 nursing homes (n = 451 residents) on the proportion of bedfast residents, the amount of time residents spent in bed, the frequency of activity, and the scores on six activity and mobility care process indicators.

RESULTS

Significant differences were found between upper (i.e., higher prevalence of bedfast residents) and lower quartile nursing homes in the proportion of time residents were observed in bed (43% vs. 34%, respectively; p =.007), and in the proportion of residents who spent more than 22 hours in bed per day (18% vs. 8%, respectively; p =.002). All nursing homes underestimated the number of bedfast residents. The residents of upper quartile homes showed more activity episodes and reported receiving more walking assistance than the residents of lower quartile homes.

DISCUSSION

Minimum Data Set bedfast quality indicator identified nursing homes in which residents spent more time in bed, but did not reflect differences in activity and mobility care. In fact, upper quartile homes provided more activity and mobility care than lower quartile homes. Across all the nursing homes, most of the residents spent at least 17 hours a day in bed. Further study of activity and mobility care and bedfast outcomes in nursing homes is needed, and nurses need to note the amount of time nursing home residents spend in bed.

Validity of the minimum data set in identifying urinary tract infections in residents of long-term care facilities

OBJECTIVES

To determine the validity of the Minimum Data Set (MDS) to detect cases of urinary tract infection (UTI) that meet specific evidence-based criteria.

DESIGN

Prospective surveillance.

SETTING

Sixteen long-term care facilities (LTCFs) in Idaho.

PARTICIPANTS

Residents of participating LTCFs for whom an MDS form was completed.

MEASUREMENTS

Prospective surveillance of all types of infection, including UTI, and data collection on clinical manifestation, microbiology, and treatment; MDS data on identification of UTI.

RESULTS

A stratified analysis demonstrated that the validity of MDS was 14% when using the evidence-based criteria for UTIs as the criterion standard. The estimated sensitivity and specificity of MDS entries were 57.9% and 86.5%, respectively. The estimated positive and negative predictive values for the study population were 13.9% and 98.2%, respectively.

CONCLUSION

MDS has the potential to be an important measure of quality in the long-term care setting. When used to detect residents with UTIs, it appears to greatly overestimate the number of cases while adequately screening out residents without UTIs. These problems may be overcome by providing more-explicit definitions for UTIs to be used by providers when completing MDS information on individual residents.

The Effects of Staffing on In-Bed Times of Nursing Home Residents

OBJECTIVES

To examine the effect of staffing level on time observed in bed during the daytime in nursing home (NH) residents.

DESIGN

Descriptive, cross-sectional study.

SETTING

Thirty-four southern California NHs.

PARTICIPANTS

A total of 882 NH residents: 837 had hourly observation data, 777 had mealtime observations, 837 completed interviews, and 817 completed a physical performance test.

MEASUREMENTS

Cross-sectional data collected from participants at each NH site included direct observations (hourly and mealtime), resident interviews, medical record review, and physical performance tests.

RESULTS

In multivariate analyses, staffing level remained the strongest predictor of time observed in bed after controlling for resident functional measures (odds ratio=4.89; P=.042). Residents observed in bed during the daytime in more than 50% of hourly observations were observed also to experience increased daytime sleeping (P<.001) and less social engagement (P=.026) and consumed less food and fluids during mealtimes than those observed in bed in less than 50% of observations, after adjusting for resident function (P<.001).

CONCLUSION

In this sample of NHs, resident functional measures and NH staffing level predicted observed time in bed according to hourly observations, with staffing level the most powerful predictor. Neither of these predictors justifies the excessive in-bed times observed in this study. Staff care practices relevant to encouraging residents to be out of bed and resident preferences for being in bed should be examined and improved. Practice recommendations regarding in-bed time should be considered, and further research should seek to inform the development of such recommendations.

Performance improvement in the long-term-care setting: building on the foundation of infection control

Infection control programs were among the first organized efforts to improve the quality of healthcare delivered to patients and are an excellent model for the development of other healthcare performance improvement activities. Whether labeled as infection control, quality improvement, or patient safety, performance improvement initiatives share similar methods and principles. The quality of care in long-term-care facilities (LTCFs) has been scrutinized for years and has received renewed attention with the recent initiation of public reporting of quality measures by Medicare. This article reviews the principles of performance improvement, discusses the importance of employing evidence-based interventions, and emphasizes the value of local performance improvement in LTCFs. Residents of LTCFs remain at high risk for the development of nosocomial infections, and among performance improvement initiatives, infection control is recommended as a high priority for all LTCFs. Fortunately, infection control contains the essential elements for performance improvement, and a successful infection control program can provide the foundation for expanding performance improvement throughout the LTCF. There is still much that needs to be done to determine the best clinical practices for LTCFs, and this should remain a priority for future research. Furthermore, efforts should continue to apply these principles at the local level to ensure that all residents of LTCFs receive the best care possible.

Immunologic and inflammatory mediators and cognitive decline in Alzheimer's disease

Local up-regulation of immune mediators is implicated in the development of AD; however, the systemic cell-mediated immune response in patients with AD may be impaired. Progression of AD from moderate to severe stages is accompanied by a progressive decline in cognitive function, independence, and behavioral and motor impairments and by the occurrence of recurrent infections, such as bronchitis and pneumonia. Several factors, including malnutrition, may be implicated in the reduced ability to mount an adequate immune response against invading pathogens in advanced stages of AD. The immune system has an important role in the development, progression, and potential treatment of AD and is involved in determining the subsequent sequelae and morbidity outcomes in patients with advanced-stage AD. A better understanding of the immune mediators that are involved in the local and systemic immune response in AD may assist in mediating the development of AD, halting its progression, and treating patients with anti-inflammatory drugs and immunization strategies.

Infectious disease risk in the elderly

Older persons suffer excessively from infectious diseases such as pneumonia and urinary tract infections. This article discusses some of the reasons for this additional morbidity and mortality, including the anatomical and physiological changes with aging, impairment of immune function, presence of co-morbid diseases, and delays in diagnosis and initiation of therapy.

Nursing home-acquired pneumonia

Pneumonia is the most serious of the common infections that occur in nursing homes, with a high case-fatality rate and considerable mortality among survivors. Risk factors for nursing home-acquired pneumonia (NHAP) have been defined, and prediction models for death due to NHAP have been developed. The bacterial etiology of NHAP has been debated, but "typical" bacterial pathogens (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis) are most important. Clinical presentation of NHAP is said to be "atypical," but this may be confounded by dementia in the nursing home resident. A recent guideline has made recommendations regarding the minimal diagnostic workup when a resident has a suspected case of pneumonia. Until recently, most guidelines for the treatment of pneumonia did not specifically address NHAP; there is some evidence that use of a quinolone alone may be an acceptable first choice of therapy for most cases. Pneumococcal and influenza vaccination have been the primary prevention measures. However, additional methods to prevent NHAP should be evaluated, including improving the oral hygiene of residents and instituting pharmacological interventions.

Utility of pulse oximetry in diagnosing pneumonia in nursing home residents

BACKGROUND

The differential diagnosis of acute infection in elderly nursing home patients is often difficult. This study evaluated pulse oximetry in pneumonia in this population.

METHODS

A case-control study was performed in a veteran's nursing home involving 2 analyses: (1) pneumonia patients (case subjects) were compared with patients with nonpulmonary infections (control subjects) at time of acute infection; (2) differences in paired values measured at time of infection versus a noninfected baseline were compared for pneumonia patients and control subjects. Vital signs including pulse oximetry were obtained routinely (at least monthly) and with acute illness.

RESULTS

Oxygen saturations were lower in 45 pneumonia patients than in 22 patients with acute nonpulmonary infections (P < 0.001). An oxygen saturation < 94 gave a sensitivity for pneumonia of 80%, specificity of 91%, and positive predictive value of 95%. The drop in oxygen saturation from the last baseline value was greater in pneumonia patients than in control subjects (P < 0.001). The sensitivity of an oxygen saturation drop >3% from baseline for pneumonia was 73% with specificity and positive predictive values of 100%.

CONCLUSIONS

Pulse oximetry may be very helpful in evaluating acutely infected nursing home residents. The present study suggests that in acutely infected nursing home patients, a decrease in oxygen saturation of >3% from baseline, as well as a single oxygen saturation of <94, should suggest pneumonia. A decrease from baseline of <4% or a single oxygen saturation of 94 or higher suggests that pneumonia is unlikely.

Dementia

Alzheimer's disease is the most common cause of dementia, but often several other conditions causing dementia are present on brain autopsies. Palliative care medical issues are similar in all late stage progressive degenerative dementias and include; cardiopulmonary resuscitation, transfer to acute care setting, antibiotic therapy, and tube feeding. Behavioral symptoms of dementia include agitation and resistiveness to care. Quality of life of individuals suffering from dementia is enhanced by availability of meaningful activities and by avoidance of restraints. Family support and involvement are crucial for optimal care. Formulation of advanced directives or an advance proxy plan is important for assuring the patient's previous wishes or best interests are considered when decisions about treatment strategies are made.