scholarly journals Inappropriate Testing for Clostridioides difficile in Long-Term Care: Implications Highlight the Need for an Algorithm

2019 ◽  
pp. 52-57
Author(s):  
Katie Vivian ◽  
Rebecca Jones
Keyword(s):  
Laboratory Test ◽  
Long Term Care ◽  
Cost Savings ◽  
Negative Consequences ◽  
Term Care ◽  
Repeat Testing ◽  
Clostridioides Difficile ◽  
Increased Risk ◽  
Test Result

This article provides clear guidance related to appropriate testing for Clostridioides difficile (C. diff) and identifies the negative implications of inappropriate testing, repeat testing, and testing for cure. Residents of long-term care (LTC) facilities are at increased risk for developing C. diff. Complications can arise if a resident does not have an active C. diff infection (colonization) and has a positive C. diff laboratory test result. The authors share a fictional bedside story illustrating the negative consequences that can result from inappropriate C. diff testing, and present a decision tree that promotes mindful application of testing, which may result in cost savings and prevent adverse resident outcomes. Keywords: C. diff, long-term care, test, diarrhea, stool, algorithm, treatment, diagnosis

scholarly journals Risk of Hospital-Onset C. difficile Infection Increases With Prior Inpatient and Outpatient Visits

2020 ◽  
Vol 41 (S1) ◽  
pp. s78-s79
Author(s):  
Aaron Miller ◽  
Alberto Segre ◽  
Daniel Sewell ◽  
Sriram Pemmaraju ◽  
Philip Polgreen
Keyword(s):  
Substance Abuse ◽  
Nursing Home ◽  
Long Term Care ◽  
Prior Exposure ◽  
Term Care ◽  
Healthcare Settings ◽  
Clostridioides Difficile ◽  
Increased Risk ◽  
Healthcare Associated

Background:Clostridioides difficile is a leading cause of healthcare-associated infections, and greater healthcare exposure is a primary risk factor for Clostridioides difficile infection (CDI). Longer hospital stays and greater CDI pressure, both at the hospital level and the level, have been linked to greater risk. In addition, symptoms associated with healthcare-associated CDI often do not present until a patient has been discharged. Our study objective was to estimate the extent to which exposure to different types of healthcare settings (eg, prior hospitalization, emergency department [ED], outpatient or long-term care) increase risk for hospital-onset CDI. Methods: We conducted a case-control study using the Truven Marketscan Commerical Claims and Medicare Supplemental databases from 2001 to 2017. Case patients were selected as all inpatient visits with a secondary diagnosis of CDI and no previous CDI diagnosis in the prior 90 days. Controls were selected from all inpatient admissions without any CDI diagnosis during the current admission or prior 90 days. A logistic regression model was used to estimate risk associated with prior healthcare exposure. Indicators were created for prior exposure to different healthcare settings: separate indicators were used to indicate transfer, exposure to that setting in the prior 1–30 days, 31–60 days and 61–90 days. Separate indicators were created for prior hospitalization, ED, outpatient clinic, nursing home or long-term care facilities (LTCFs), psychiatric or substance-abuse facility or other outpatient facility. We also included an indicator for prior exposure to a family member with CDI and prior outpatient antibiotics. Results: Estimates for selected variables (odds ratios) are presented in Table 1. Prior hospitalization, ED visits, outpatient clinics, nursing home and LTCFs were all associated with increased risk of secondary diagnosed CDI. Prior hospitalization and nursing home/LTCF conveyed the greatest risk. In addition, a ‘dose-–response’ relationship occurred for each of these exposure settings, with exposure nearest the admission date having the largest risk. Prior exposure to psychiatric , substance abuse, or other outpatient facilities were not risk factors for CDI. Having a family member with prior CDI and both low-risk and high-risk outpatient antibiotics were associated with increased risk. These factors also exhibited a ‘dose–response’ pattern. Conclusions: Exposure to various healthcare settings significantly increased risk for secondary CDI. Prior healthcare exposures occurring nearest to the point of admission conveyed the greatest risk. These results suggest that many hospital-associated CDI cases attributed to a current hospital stay may actually be acquired from prior healthcare settings.Funding: CDC Modeling Infectious Diseases (MInD) in Healthcare NetworkDisclosures: None

scholarly journals Online Opioid Stewardship Training for Long-Term Care Staff

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 533-533
Author(s):  
Linda Edelman ◽  
Troy Andersen ◽  
Cherie Brunker ◽  
Nicholas Cox ◽  
Jorie Butler ◽  
...  
Keyword(s):  
Staff Training ◽  
Long Term Care ◽  
Treatment Strategies ◽  
Care Staff ◽  
Video Content ◽  
Opioid Use ◽  
Term Care ◽  
Increased Risk ◽  
Pain Management Strategy

Abstract Opioids are often the first-line chronic pain management strategy for long-term care (LTC) residents who are also at increased risk for opioid-related adverse events. Therefore, there is a need to train LTC providers and staff about appropriate opioid use and alternative treatment strategies. Our interdisciplinary team worked with LTC partners to identify staff educational needs around opioid stewardship. Based on this need’s assessment, we developed eight modules about opioid use and risks for older adults, including those with dementia, recommendations for de-prescribing including other pharmacological and non-pharmacological alternatives, SBIRT, and motivational interviewing to determine “what matters”. Each 20-minute module contains didactic and video content that is appropriate for group staff training or individuals and provides rural LTC facilities access to needed training in their home communities. Within the first month of launching online, the program received over 1100 hits and LTC partners are incorporating modules into clinical staff training schedules.

scholarly journals #MoreThanAVisitor: Families as “Essential” Care Partners During COVID-19

2020 ◽  
Author(s):  
Candace L Kemp
Keyword(s):  
Family Involvement ◽  
Long Term Care ◽  
Research Policy ◽  
Well Being ◽  
Direct Care ◽  
Negative Consequences ◽  
Public Health Response ◽  
Term Care ◽  
Care Partners

Abstract The public health response to the current Coronavirus pandemic in long-term care communities, including assisted living, encompasses prohibiting visitors. This ban, which includes family members, has been criticized for being unfair, unhealthy, and unsafe. Against this backdrop, I examine the roles family play in residents’ daily lives and care routines. I argue that classifying family as “visitors” rather than essential care partners overlooks their critical contributions and stems from taken-for-granted assumption about gender, families, and care work, and I demonstrate why families are more than visitors. Policies that ban family visits also reflect a narrow understanding of health that focuses on mitigating infection risk, but neglects overall health and well-being. This policy further stems from a limited comprehension of care relations. Research shows that banning family visits has negative consequences for residents, but also families themselves, and direct care workers. I argue that identifying ways to better understand and support family involvement is essential and demonstrate the utility of the Convoys of Care model for guiding the reconceptualization of family in long-term care research, policy, and practice during and beyond the pandemic.

Association of Dementia-Related Psychosis With Long-term Care Use and Death

Neurology ◽  
2021 ◽  
Vol 96 (12) ◽  
pp. e1620-e1631
Author(s):  
James B. Wetmore ◽  
Yi Peng ◽  
Heng Yan ◽  
Suying Li ◽  
Muna Irfan ◽  
...  
Keyword(s):  
Long Term Care ◽  
Fold Increase ◽  
Proportional Hazard ◽  
Comorbid Conditions ◽  
Term Care ◽  
Risk Of Death ◽  
Cox Proportional Hazard ◽  
Increased Risk ◽  
Cox Proportional Hazard Regression

ObjectiveTo determine the association of dementia-related psychosis (DRP) with death and use of long-term care (LTC); we hypothesized that DRP would be associated with increased risk of death and use of LTC in patients with dementia.MethodsA retrospective cohort study was performed. Medicare claims from 2008 to 2016 were used to define cohorts of patients with dementia and DRP. Outcomes were LTC, defined as nursing home stays of >100 consecutive days, and death. Patients with DRP were directly matched to patients with dementia without psychosis by age, sex, race, number of comorbid conditions, and dementia index year. Association of DRP with outcomes was evaluated using a Cox proportional hazard regression model.ResultsWe identified 256,408 patients with dementia. Within 2 years after the dementia index date, 13.9% of patients developed DRP and 31.9% had died. Corresponding estimates at 5 years were 25.5% and 64.0%. Mean age differed little between those who developed DRP (83.8 ± 7.9 years) and those who did not (83.1 ± 8.7 years). Patients with DRP were slightly more likely to be female (71.0% vs 68.3%) and white (85.7% vs 82.0%). Within 2 years of developing DRP, 16.1% entered LTC and 52.0% died; corresponding percentages for patients without DRP were 8.4% and 30.0%, respectively. In the matched cohort, DRP was associated with greater risk of LTC (hazard ratio [HR] 2.36, 2.29–2.44) and death (HR 2.06, 2.02–2.10).ConclusionsDRP was associated with a more than doubling in the risk of death and a nearly 2.5-fold increase in risk of the need for LTC.

scholarly journals 2044. An Assessment and Feedback Model Bringing Antimicrobial Stewardship Program Expertise to Long-Term Care Facilities

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S687-S687
Author(s):  
Philip Chung ◽  
Kate Tyner ◽  
Scott Bergman ◽  
Teresa Micheels ◽  
Mark E Rupp ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Long Term Care ◽  
Rank Test ◽  
Post Intervention ◽  
Term Care ◽  
Clostridioides Difficile ◽  
Stewardship Program ◽  
Days Of Therapy ◽  
Care Facilities

Abstract Background Long-term care facilities (LTCF) often struggle with implementation of antimicrobial stewardship programs (ASP) that meet all CDC core elements (CE). The CDC recommends partnership with infectious diseases (ID)/ASP experts to guide ASP implementation. The Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP) is an initiative funded by NE DHHS via a CDC grant to assist healthcare facilities with ASP implementation. Methods ASAP performed on-site baseline evaluation of ASP in 5 LTCF (42–293 beds) in the spring of 2017 using a 64-item questionnaire based on CDC CE. After interviewing ASP members, ASAP provided prioritized facility-specific recommendations for ASP implementation. LTCF were periodically contacted in the next 12 months to provide implementation support and evaluate progress. The number of CE met, recommendations implemented, antibiotic starts (AS) and days of therapy (DOT)/1000 resident-days (RD), and incidence of facility-onset Clostridioides difficile infections (FO-CDI) were compared 6 to 12 months before and after on-site visits. Paired t-test and Wilcoxon signed rank test were used for statistical analyses. Results Multidisciplinary ASP existed in all 5 facilities at baseline with medical directors (n = 2) or directors of nursing (n = 3) designated as team leads. Median CE implemented increased from 3 at baseline to 6 at the end of follow-up (P = 0.06). No LTCF had all 7 CE at baseline. By the end of one year, 2 facilities implemented all 7 CE with the remaining implementing 6 CE. LTCF not meeting all CE were only deficient in reporting ASP metrics to providers and staff. Among the 38 recommendations provided by ASAP, 82% were partially or fully implemented. Mean AS/1000 RD reduced by 19% from 10.1 at baseline to 8.2 post-intervention (P = 0.37) and DOT/1000 RD decreased by 21% from 91.7 to 72.5 (P = 0.20). The average incidence of FO-CDI decreased by 75% from 0.53 to 0.13 cases/10,000 RD (P = 0.25). Conclusion Assessment of LTCF ASP along with feedback for improvement by ID/ASP experts resulted in more programs meeting all 7 CE. Favorable reductions in antimicrobial use and CDI rates were also observed. Moving forward, the availability of these services should be expanded to all LTCFs struggling with ASP implementation. Disclosures All authors: No reported disclosures.

scholarly journals Case–control study to estimate odds of death within 28 days of positive test for SARS-CoV-2 prior to vaccination for residents of long-term care facilities in England, 2020–2021

2021 ◽  
pp. jech-2021-218135
Author(s):  
Karthik Paranthaman ◽  
Hester Allen ◽  
Dimple Chudasama ◽  
Neville Q Verlander ◽  
James Sedgwick
Keyword(s):  
Long Term Care ◽  
Multivariable Analysis ◽  
Adverse Outcomes ◽  
Positive Test ◽  
Mortality Data ◽  
Multivariable Logistic Regression Analysis ◽  
Term Care ◽  
Increased Risk ◽  
Care Facilities

BackgroundPersons living in long-term care facilities (LTCFs) are presumed to be at higher risk of adverse outcomes from SARS-CoV-2 infection due to increasing age and frailty, but the magnitude of increased risk is not well quantified.MethodsAfter linking demographic and mortality data for cases with confirmed SARS-CoV-2 infection between March 2020 and January 2021 in England, a random sample of 6000 persons who died and 36 000 who did not die within 28 days of a positive test was obtained from the dataset of 3 020 800 patients. Based on an address-matching process, the residence type of each case was categorised into one of private home and residential or nursing LTCF. Univariable and multivariable logistic regression analysis was conducted.ResultsMultivariable analysis showed that an interaction effect between age and residence type determined the outcome. Compared with a 60-year-old person not living in LTCF, the adjusted OR (aOR) for same-aged persons living in residential and nursing LTCFs was 1.77 (95% CI 1.21 to 2.6, p=0.0017) and 3.95 (95% CI 2.77 to 5.64, p<0.0001), respectively. At 90 years of age, aORs were 0.87 (95% CI 0.72 to 1.06, p=0.21) and 0.74 (95% CI 0.61 to 0.9, p=0.001), respectively. The model had an overall accuracy of 94.2% (94.2%) when applied to the full dataset of 2 978 800 patients.ConclusionThis study found that residents of LTCFs in England had higher odds of death up to 80 years of age. Beyond 80 years, there was no difference in the odds of death for LTCF residents compared with those in the wider community.

scholarly journals 2055. Action: A Year in the Lives of Consultant Pharmacists Working on Antimicrobial Stewardship in Long-Term Care Facilities

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S692-S693
Author(s):  
Philip Chung ◽  
Alex Neukirch ◽  
Rebecca J Ortmeier ◽  
Scott Bergman ◽  
Mark E Rupp ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
First Generation ◽  
Long Term Care ◽  
Diagnostic Testing ◽  
Drug Regimen ◽  
Term Care ◽  
Clostridioides Difficile ◽  
Care Facilities ◽  
Tract Infections

Abstract Background The CDC recommends consultant pharmacists (CP) support antimicrobial stewardship (AS) activities in long-term care facilities (LTCF) by reviewing antimicrobial appropriateness. We initiated a project training CP from a regional long-term care pharmacy to support AS implementation in LTCF. Methods CP were trained to evaluate the appropriateness of all systemic antimicrobial therapy (AT) and provide prescriber feedback during their monthly drug regimen review (DRR). An electronic database was developed to facilitate data reporting. Antimicrobial use (AU) and adverse events (AE) from 32 LTCF were analyzed for 2018 using descriptive statistics. Results A total of 5327 courses of AT with a median duration of 7 days (IQR 5–10) were reviewed. The majority of AT was started in the LTCF (55%) but was also initiated in hospitals (24%), clinics (11%) and emergency departments (2%). Of 2926 AT started in LTCF, 36% were based on nurse evaluation (NE) while 33% began after prescriber evaluation (PE). Fluoroquinolones (FQ) and first-generation cephalosporins were the most commonly prescribed agents (Table 1). Treatment or prophylaxis of urinary tract infections accounted for 40% of AU (Figure 1). Diagnostic testing was associated with 37% of AT courses. Urine cultures were the most frequent test performed (81%). Overall, 41% of AT was determined to be inappropriate resulting in > 800 feedback letters sent to prescribers. Unnecessary antibiotic starts (based on revised Mc Geer or Loeb’s criteria) were identified as the most common reason (Figure 2). AT appropriateness varied depending on the setting in which it was initiated. A majority (87%) of AT initiated in hospitals was found to be appropriate with 56% and 46% appropriate for ED and clinic starts. Appropriateness of LTCF initiated AT was 49% (59% after PE and 42% after NE). AE were associated with 3% of AT with allergic reactions and Clostridioides difficile infections occurring with 0.4% and 0.7% of AT, respectively. AE were most frequently associated with folate antagonists (5%) and FQ (3%). Conclusion This study demonstrates many AU improvement opportunities exist in LTCF and CP can play an important role in identifying them if trained in AS principles. CP should review all AU for appropriateness and provide data to inform AS efforts in LTCF. Disclosures All authors: No reported disclosures.

Palliative Management of Parkinson Disease: Focus on Nonmotor, Distressing Symptoms

2008 ◽  
Vol 21 (4) ◽  
pp. 262-272 ◽  
Author(s):  
Jack J. Chen ◽  
Dominick P. Trombetta ◽  
Hubert H. Fernandez
Keyword(s):  
Parkinson Disease ◽  
Long Term Care ◽  
Functional Dependence ◽  
Care Facility ◽  
The United States ◽  
Elderly Persons ◽  
Motor Complications ◽  
Term Care ◽  
Increased Risk

Parkinson disease is a progressive neurodegenerative disease that commonly affects elderly persons. In the absence of neuroprotective or curative therapies, currently available therapies only provide symptomatic benefit. Progression to advanced Parkinson disease is often accompanied by functional dependence with increased risk of admission to a long-term care facility. The prevalence of Parkinson disease in long-term care facilities, within the United States, has been estimated to be between 5.2% and 10%. Patients with advanced Parkinson disease also experience other distressing motor and nonmotor conditions, such as motor complications, dementia, depression, gastrointestinal distress, orthostatic hypotension, pain, and psychosis, which can be a challenge for clinicians to manage. The presence of distressing symptoms along with the fact that Parkinson disease remains incurable necessitate discussion on a palliative care approach to this disorder. This article discusses the symptomatic management of distressing symptoms encountered in the long-term care resident with Parkinson disease, including motor complications and nonmotor features.

Mobile Technology to Assess Balance During Sit to Stand Manuever Among Older Adults at Risk for Falling

2018 ◽  
Vol 7 (1) ◽  
pp. 248-248
Author(s):  
Deanna Gray-Miceli ◽  
William Craelius ◽  
Kang Li
Keyword(s):  
Blood Pressure ◽  
Older Adults ◽  
Long Term Care ◽  
Measurement Unit ◽  
Term Care ◽  
Sit To Stand ◽  
Arterial Blood ◽  
Increased Risk ◽  
Loss Of Balance

Older adults over age 65 are susceptible to loss of balance for a variety of reasons including drops in blood pressure with standing (orthostatic hypotension [OH]; Gray-Miceli, Ratcliffe, Thomasson, Quigley, Li & Craelius, 2016). OH is a treatable condition, and cause of falls if detected. Nearly 50% of the 1.43 million older adults in long-term care experience falls (National Center for Injury Prevention and Control, 2017). Falls often occur among older adults in long term care during periods of transitioning, where older adults are susceptible to loss of balance and increased risk to fall. As found in our prior work, older adults with OH may not always experience classic dizziness symptoms that may accompany OH (Gray-Miceli, Ratcliffe, Liu, Wantland & Johnson, 2012; Gray). To better understand this phenomenon, our project adapted a cellphone as an inertial measurement unit attached to the person’s center of mass to determine body sway. The objective of this pilot study was to determine if a relationship was observable during the sit to stand maneuver (StS) while older adults wore a Smartphone measuring three dimensions of motion among older adults who had evidenced of symptoms or OH. A sample of four older adults from a rehabilitation facility who were 65 years of age, receiving physical therapy at the time of testing, were cognitively intact, able to perform the StS maneuver and had no active cancer, fractures or serious injuries were recruited and enrolled. Oh determinations, pulse rate and symptoms of dizziness were elicited during a 30 second StS maneuver. In Patient A and Patient B we present the Z-axis and X-axis of front acceleration and patterns of motion side by side for case comparison while highlighting clinical findings. In Patient B, a greater degree of sway at the start of the StS maneuver is noted. Patient B’s blood pressure also dropped 33 mmHg and there were symptoms of dizziness. Drops in mean arterial blood pressure were greater among those with symptomatic OH. Limitations of this pilot include noise, selection of filters and time stamping of the data. Project aims are to help clinicians prevent falls by further assessing symptoms among elders who suffer from LOB and OH.

scholarly journals COST SAVINGS FOR CAPABLE PROGRAM DRIVEN BY DECREASES IN HOSPITAL AND LONG-TERM CARE FOR PARTICIPANTS

2017 ◽  
Vol 1 (suppl_1) ◽  
pp. 1392-1392
Author(s):  
S.L. Szanton ◽  
N.H. Alfonso ◽  
L. Roberts ◽  
D.H. Bishai
Keyword(s):  
Long Term Care ◽  
Cost Savings ◽  
Term Care
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