Academic Long-term Care Facility Research Articles

Risk Factors, Presentation, and Course of Coronavirus Disease 2019 in a Large, Academic Long-Term Care Facility

ObjectiveTo describe clinical characteristics and risk factors associated with coronavirus disease 2019 (COVID-19) in long-stay nursing home residents. Design and ParticipantsRetrospective cohort study (March 16, 2020 to May 8, 2020). SettingAcademic long-term chronic care facility (Boston, MA). ParticipantsLong-term care residents. MethodsPatient characteristics and clinical symptoms were obtained via electronic medical records and Minimum Data Set. Staff residence was inferred by zip codes. COVID-19 infection was confirmed by polymerase chain reaction testing using nasopharyngeal swabs. Residents were followed until discharge from facility, death, or up to 21 days. Risks of COVID-19 infection were modeled by generalized estimating equation to estimate the relative risk (RR) and 95% confidence intervals (CI) of patient characteristics and staff community of residence. ResultsOverall 146 of 389 (37.5%) long-stay residents tested positive for COVID-19. At the time of positive test, 66 of 146 (45.5%) residents were asymptomatic. In the subsequent illness course, the most common symptom was anorexia (70.8%), followed by delirium (57.6%). During follow-up, 44 (30.1%) of residents with COVID-19 died. Mortality increased with frailty (16.7% in pre-frail, 22.2% in moderately frail, and 50.0% in frail; P < .001). The proportion of residents infected with COVID-19 varied across the long-term care units (range: 0%‒90.5%). In adjusted models, male sex (RR 1.80, 95% CI 1.07, 3.05), bowel incontinence (RR 1.97, 95% CI 1.10, 3.52), and staff residence remained significant predictors of COVID-19. For every 10% increase in the proportion of staff living in a high prevalence community, the risk of testing positive increased by 6% (95% CI 1.04, 1.08). Conclusions and ImplicationsAmong long-term care residents diagnosed with COVID-19, nearly one-half were asymptomatic at the time of diagnosis. Predictors of COVID-19 infection included male sex, bowel incontinence, and staff residence in a community with a high burden of COVID-19. Universal testing of patients and staff in communities with high COVID-19 rates is essential to mitigate outbreaks.

Quality Improvement in Long Term Care: The Psychotropic Assessment Tool (PAT)

There are already a substantial number of individuals with dementia in long-term care. Many nursing home patients have difficult behaviors and are currently managed with psychotropic medications. Medications for behavior need to be titrated and monitored over time for efficacy and safety, and subsequently tapered if ineffective. Some of these medications are not without risk, and that risk-benefit ratio should be discussed and documented with the family. Currently, we are not aware of any quality improvement process that has been developed in long-term care to address these issues. To describe the process of a novel quality improvement intervention that was designed to improve documentation in the medical record and interdisciplinary communication of the usefulness and possible side effects of psychotropic agents used in the management of difficult behaviors for dementia. Retrospective review of the chart and quality improvement records in a long-term care facility. An academic long-term care facility that specializes in dementia care in St. Louis, MO. The quality improvement team created a process and a form named the Psychotropic Assessment Tool (PAT) to document current behavioral symptoms of the residents; determine whether the resident was on psychotropic agents; identify whether agents had been initiated, titrated, and/or tapered if appropriate; and whether there were any side effects related to the behavioral medications. A letter was created and provided to the surrogate decision maker that described the risk-benefit ratio of the use of antipsychotic agents when these drugs were prescribed. Recommendations from the quality improvement team were provided to the primary care physician. After 1 year of this process, we reviewed the medical charts and quality improvement PAT forms of all residents. We documented the use of psychotropic agents before and after initiating the PAT process, the presence of current behavioral symptoms, the presence of possible side effects, and the recommendations of the interdisciplinary team that met after the monthly quality improvement meetings. A total of 110 patients were included in this study, which reviewed psychotropic drug use between July 2005 and July 2006. The mean age of the residents was 83.8 +/- 7.5 years. All residents had a diagnosis of dementia. Mean MMSE score was 13.5 +/- 7.3. The prevalence of potential problems that could have been associated with psychotropic drug use was not insignificant and included falls (45%), weight loss (16%), weight gain (7%), dizziness (9%), and sedation (5%). However, behaviors that might warrant psychotropic drug use were not uncommon and included active depression (12%), anxiety (24%), hallucinations (11%), disruptive behavior (21%) and delusions (21%). The percentage of residents on antipsychotics changed from 26.5% pre-PAT process to 25.2% post-PAT process; those on anxiolytics changed from 6.0% to 4.0%. There was a change in hypnotics from 2.6% to 3.4%. Antidepressant usage remained the same at 55%. The PAT CHAT discussion resulted in recommendation of medication changes in 25% of residents. The initiation of this quality improvement process using the PAT led to improved chart documentation and interdisciplinary communication between the team, primary care physicians, and families. Further studies are needed to determine whether this process can impact use of psychotropic agents, improve quality of life, decrease adverse drug events, and/or reduce medical-legal risk.

A Quality Improvement Study on Calcium and Vitamin D Supplementation in Long-term Care

The objectives of this study were to evaluate the impact of a quality improvement (QI) study on improving calcium and vitamin D supplementation in a long-term care setting. Retrospective chart review. An academic long-term care facility that specializes in dementia care in St Louis, MO. Participants consisted of 83 long-term care residents. The quality improvement team created an educational letter that was signed by the medical director and sent to the facilities' primary care physicians. This letter provided clinicians with the rationale and method to achieve adequate calcium supplementation, assess vitamin D status, and provide adequate vitamin D supplementation in our long-term care setting. Following the letter, the facility pharmacist reviewed the orders during monthly medication reviews and faxed requests to the primary care physicians for appropriate supplements or laboratory tests when necessary. We reviewed the charts for the presence of calcium supplementation orders, vitamin D levels, and vitamin D supplementation before and after our QI intervention. Of the 83 resident charts that were reviewed, only 37 (44.6%) had calcium supplementation, 19 (22.8%) had assessment of their vitamin D status, and 29 (34.9%) had ongoing vitamin D supplementation prior to implementation of the study. After the QI intervention, calcium supplementation was present in 66 residents (79.5%), vitamin D status had been assessed in 61 residents (73.4%), and vitamin D supplementation had been initiated in 65 residents (78.3%). These changes were statistically significant (P < .05). A quality improvement project that used an educational letter from the medical director combined with a medication and laboratory review by the pharmacist was able to increase the number of residents in our long-term care setting with calcium supplementation, increase the number of residents who had vitamin D status assessed, identify many residents with low vitamin D levels, and increase supplementation of vitamin D when indicated.

A Quality Improvement Study on Calcium and Vitamin D Supplementation in Long-term Care

The objectives of this study were to evaluate the impact of a quality improvement (QI) study on improving calcium and vitamin D supplementation in a long-term care setting. Retrospective chart review. An academic long-term care facility that specializes in dementia care in St Louis, MO. Participants consisted of 83 long-term care residents. The quality improvement team created an educational letter that was signed by the medical director and sent to the facilities' primary care physicians. This letter provided clinicians with the rationale and method to achieve adequate calcium supplementation, assess vitamin D status, and provide adequate vitamin D supplementation in our long-term care setting. Following the letter, the facility pharmacist reviewed the orders during monthly medication reviews and faxed requests to the primary care physicians for appropriate supplements or laboratory tests when necessary. We reviewed the charts for the presence of calcium supplementation orders, vitamin D levels, and vitamin D supplementation before and after our QI intervention. Of the 83 resident charts that were reviewed, only 37 (44.6%) had calcium supplementation, 19 (22.8%) had assessment of their vitamin D status, and 29 (34.9%) had ongoing vitamin D supplementation prior to implementation of the study. After the QI intervention, calcium supplementation was present in 66 residents (79.5%), vitamin D status had been assessed in 61 residents (73.4%), and vitamin D supplementation had been initiated in 65 residents (78.3%). These changes were statistically significant (P < .05). A quality improvement project that used an educational letter from the medical director combined with a medication and laboratory review by the pharmacist was able to increase the number of residents in our long-term care setting with calcium supplementation, increase the number of residents who had vitamin D status assessed, identify many residents with low vitamin D levels, and increase supplementation of vitamin D when indicated.

Quality Improvement in Nursing Homes in Texas

Quality Improvement in Nursing Homes in Texas

Predictors of Do Not Resuscitate Orders in the Nursing Home

Background The outcome of cardiopulmonary resuscitation of residents of long-term care facilities is poor. However, only about one half of residents of long term care facilities have a do not resuscitate (DNR) order. The remainder usually have resuscitation by order or by default policy. Understanding predictors of DNR may help clinicians address end-of-life issues with the older long-term care population. Objectives To determine (1) the prevalence of DNR orders, and (2) predictors of DNR orders in older institutionalized individuals in a large community teaching nursing home. Methods A cross-sectional chart review study of 177 consecutively located older patients from an 899-bed academic long-term care facility. Results The prevalence of a DNR order was 40%. The frequency of ordering DNR was greater in subjects who were 85 years or older compared with subjects who were younger than 85 years (57% vs. 30%, P < .05). Ordering DNR was associated significantly with race (49% of whites compared with 13% African Americans, P < .05) but not with sex. Subjects with a DNR order were more likely to have been diagnosed with depression (52% vs. 35%, P < .05) but not dementia, and overall had greater number of medical conditions (5.9 ± 2 vs. 5.1 ± 2, P < .05) compared with subjects without DNR orders. The frequency of DNR orders did not significantly differ between subjects who were able to ambulate (with or without assistance) compared with subjects who were wheelchair or bed bound. Using logistic regression analysis, only age (with a B of −1.04 and P of .017) and race (with a B of 1.4 and a P of .01) were independent predictors of DNR status. Conclusion Fewer than half of this sample of long-term care residents had a DNR order. Among seven factors studied, only age and race were independent predictors of DNR status in the nursing home. The outcome of cardiopulmonary resuscitation of residents of long-term care facilities is poor. However, only about one half of residents of long term care facilities have a do not resuscitate (DNR) order. The remainder usually have resuscitation by order or by default policy. Understanding predictors of DNR may help clinicians address end-of-life issues with the older long-term care population. To determine (1) the prevalence of DNR orders, and (2) predictors of DNR orders in older institutionalized individuals in a large community teaching nursing home. A cross-sectional chart review study of 177 consecutively located older patients from an 899-bed academic long-term care facility. The prevalence of a DNR order was 40%. The frequency of ordering DNR was greater in subjects who were 85 years or older compared with subjects who were younger than 85 years (57% vs. 30%, P < .05). Ordering DNR was associated significantly with race (49% of whites compared with 13% African Americans, P < .05) but not with sex. Subjects with a DNR order were more likely to have been diagnosed with depression (52% vs. 35%, P < .05) but not dementia, and overall had greater number of medical conditions (5.9 ± 2 vs. 5.1 ± 2, P < .05) compared with subjects without DNR orders. The frequency of DNR orders did not significantly differ between subjects who were able to ambulate (with or without assistance) compared with subjects who were wheelchair or bed bound. Using logistic regression analysis, only age (with a B of −1.04 and P of .017) and race (with a B of 1.4 and a P of .01) were independent predictors of DNR status. Fewer than half of this sample of long-term care residents had a DNR order. Among seven factors studied, only age and race were independent predictors of DNR status in the nursing home.

Underutilization of Calcium and Vitamin D Supplements in an Academic Long-Term Care Facility

<h3>Background</h3> Good scientific evidence indicates that calcium and vitamin D supplementation decrease the incidence of osteoporosis-related fractures among institutionalized elderly. <h3>Objective</h3> The objective was to study the frequency of prescribing calcium and vitamin D supplements in elderly institutionalized individuals in a large community teaching nursing home. <h3>Methods</h3> A cross-sectional chart review study of 177 consecutively located elderly residents from an 899-bed academic long-term care facility. <h3>Results</h3> Calcium and vitamin D supplements were prescribed in only 12% and 9% of subjects, respectively. Among subjects with the diagnosis of osteoporosis (n = 12), 66% were prescribed calcium and 58% were prescribed vitamin D supplements. Among subjects with hip fractures (n = 8), only 25% were prescribed calcium with a similar percentage prescribed vitamin D supplements. Female residents were more likely than male residents to receive calcium (<i>P</i> <0.05) and vitamin D supplements (<i>P</i> = 0.08). <h3>Conclusion</h3> There is a major need to increase the utilization of calcium and vitamin D supplementation among institutionalized elderly to decrease the risk of osteoporotic fractures, including hip fractures.

Underutilization of Calcium and Vitamin D Supplements in an Academic Long-Term Care Facility

Good scientific evidence indicates that calcium and vitamin D supplementation decrease the incidence of osteoporosis-related fractures among institutionalized elderly. The objective was to study the frequency of prescribing calcium and vitamin D supplements in elderly institutionalized individuals in a large community teaching nursing home. A cross-sectional chart review study of 177 consecutively located elderly residents from an 899-bed academic long-term care facility. Calcium and vitamin D supplements were prescribed in only 12% and 9% of subjects, respectively. Among subjects with the diagnosis of osteoporosis (n = 12), 66% were prescribed calcium and 58% were prescribed vitamin D supplements. Among subjects with hip fractures (n = 8), only 25% were prescribed calcium with a similar percentage prescribed vitamin D supplements. Female residents were more likely than male residents to receive calcium (P <0.05) and vitamin D supplements (P = 0.08). There is a major need to increase the utilization of calcium and vitamin D supplementation among institutionalized elderly to decrease the risk of osteoporotic fractures, including hip fractures.

Validity of the minimum data set for assessing nutritional status in nursing home residents

The Minimum Data Set (MDS), a Health Care Financing Administration (HCFA)-mandated resident assessment system used in community nursing homes, is potentially useful for assessing nutritional status. We compared anthropometric measures of nutritional status available in the MDS [weight and body mass index (BMI)] with other anthropometric and bioelectrical measures of nutritional status, not available on the MDS. We also studied associations of MDS-measured clinical characteristics of nursing home residents with anthropometric and bioelectrical measures of lower and higher nutritional status, defined as measures in the 25th percentile and below, and 75th percentile and above, respectively. Data were from a sample of residents of an academic long-term care facility (n = 186, 75% female, mean age 89.9 +/- 5.6 y). Results were as follows: 1) MDS measures of weight and BMI were significantly correlated with all the anthropometric and bioelectrical measures of nutritional status in women, and most measures in men; 2) some MDS variables, including poor oral intake and advanced cognitive decline, were significantly associated with two or more anthropometric and bioelectrical measures of low nutritional status; and 3) complaints of hunger were significantly associated with two or more anthropometric and bioelectrical measures of high nutritional status. Results suggest that 1) weight and BMI, available in the MDS, are correlated with other measures of nutritional status not available, and 2) MDS clinical variables are associated with measures of low and high nutritional status, and may be useful in identifying patients at nutritional risk.

Short-term functional outcomes of long-term care residents with pneumonia treated with and without hospital transfer.

To determine 2-month mortality and functional status outcomes after resolution of pneumonia in older long-term care facility (LTCF) patients treated with and without hospital transfer. Retrospective cohort study. Hebrew Rehabilitation Center for Aged, a 725-bed LTCF affiliated with an academic medical center, whose residents are cared for by staff physicians and geriatric fellows. LTCF residents with an acute episode of pneumonia, defined as a new respiratory sign or symptom and a new infiltrate on chest radiograph. Functional decline or death in the 2 months after the resolution of pneumonia. Of 312 cases of pneumonia, 246 (79%) were treated in the LTCF and 66 (21%) were treated in the hospital. Equal proportions of patients died of their pneumonia (13% vs 12%), but a larger proportion of those hospitalized had either worsening in their functional status or had died at 2 months (P = .005, Mantel-Haenszel trend test). In a logistic regression model controlling for differences between patients treated at the two sites, hospital treatment remained associated with poorer 2-month outcome (AOR 3.02, 95% CI 1.32, 7.22), with a significant interaction between respiratory rate and treatment site. LTCF treatment was associated with better 2-month outcomes only among patients with a lower respiratory rate. For these patients, the difference in outcome between LTCF treatment and hospital treatment was greatest for patients who were independent or mildly dependent at baseline. In this academic LTCF, treatment for pneumonia without hospital transfer resulted in better 2-month outcomes compared with hospital treatment. Although the difference in outcome may be explained in part by differences between patients treated with and without hospital transfer, it persisted after correcting for these differences. The benefits of LTCF treatment appear to be greatest for those with less severe pneumonia and more independent functional status.