Community Living Centers Research Articles

QUALITY IMPROVEMENT IN DEMENTIA CARE: EFFECTIVENESS OF IMPLEMENTING STAR-VA IN A VA COMMUNITY LIVING CENTER

Staff Training in Assisted Living Residences adapted for Veterans Affairs (STAR-VA) is an evidence-based, interdisciplinary behavioral intervention to manage challenging Behavioral Symptoms of Dementia (BSD) at VA Community Living Centers (CLCs). Components of STAR-VA included creating realistic expectations for individuals with dementia, effective communication, using a behavioral problem-solving approach, and increasing resident-centered pleasant events. STAR-VA was implemented at VA Western New York CLC to help staff manage Veteran BSD. The purpose of the study was to examine the effectiveness of STAR-VA implementation in 17 CLC Veterans with Dementia who demonstrated BSD distressing to themselves, other Veterans and/or staff and documented in 2017-2018. STAR-VA was facilitated by the behavioral coordinator and nurse champion in partnership with the CLC behavior team during weekly rounds and as needed modeling and debriefing. The team included the medical provider, recreation therapist, social worker, and all levels of nursing. On average, the intervention involved four assessments over 75 days. Outcome measures at baseline and post-intervention included assessments of target behavior frequency and severity, direct care tracking of behaviors, and the Minimum Data Set distress behavior indicator. Compared to baseline scores, clinically meaningful reduction was documented using team assessment and direct care ratings of BSD frequency and severity, and overall inappropriate utilization of antipsychotic medication. CLC clinical staff tailored implementation of STAR-VA to be feasible and effective. Ongoing evaluation of STAR-VA implementation using routine measures promotes measurement based care, providing feedback to the team to improve care quality.

QUALITY IMPROVEMENT IN LTC: EFFECTIVENESS OF MONTESSORI-BASED ACTIVITY PROGRAMMING IN VA COMMUNITY LIVING CENTER

Montessori-based Activity Programming (MAP) was adapted for Veterans Affairs (VA) Community Living Centers (CLCs) and aims to increase independence and meaningful engagement in residents with cognitive impairment. The Montessori model prioritizes offering choice, knowing and harnessing a resident’s abilities, and enabling them to carry out purposeful roles and activities. Any perceived deficit in cognitive functioning is “circumvented” by preparing the environment to support maximum independence. The implementation of MAP-VA in VA Western NY CLC involved 3 lodges, 52 staff, 16 champions, and 65 CLC residents. Standardized implementation measures demonstrated improvements over six months in five domains assessing development of a resident-directed community. Hypothesized outcomes included improved national percentile quality improvement (QI) rankings related to psychological symptoms and medications (e.g., depressive symptoms and use of antipsychotic/antianxiety medications) and physical functioning (e.g., less falls and ability to move independently). Scores six months prior to the implementation of MAP-VA (April, 2018 to September, 2018) were compared with scores during six months of implementation post training (November, 2018 to March, 2019). Compared to pre-intervention QI measures related to psychological symptoms, a clinically meaningful trajectory of symptom decrease was observed with rankings during implementation (e.g., depressive symptoms, amount of antipsychotic medications). Likewise, compared to pre-intervention QI rankings regarding physical functioning, post-training rankings showed a trajectory of improvement (e.g., help with ADLs, ability to move independently). Implementation of the MAP-VA intervention demonstrates preliminary evidence for improvement in QI measures related to psychological symptoms and physical functioning. Implications for QI efforts in VA CLCs will be presented.

AN MDS 3.0 BEHAVIORAL INDICATOR: RELIABILITY AND VALIDITY WHEN MEASURING BEHAVIOR SYMPTOMS OF DEMENTIA IN CLCS

Persons with dementia frequently demonstrate behavior symptoms of dementia (BSD), associated with poorer outcomes. A measure of BSD was created for routine use in VA Community Living Centers (CLCs). Reliability and validity of Minimum Data Set (MDS 3.0) behavior items was established using exploratory factor analysis and a multitrait, multimethod correlation matrix. 385 CLC residents with BSD were assessed using validated measures of BSD, depression, and anxiety, and team ratings of the frequency and severity of target behaviors identified for intervention. Factor analysis on MDS items closest to baseline resulted in two stable factors. MDS behavior factors related to validated clinical measures in predicted ways at baseline and post-intervention. MDS distress behavior factor sensitivity to change was evaluated by using change score correlations with validated clinical measures. The MDS distress behavior factor can be used routinely, evaluate the impact of intervention effectiveness, and provide quality improvement feedback.

CHALLENGES AND STRATEGIES FOR SUSTAINING A NEW DEMENTIA BEHAVIORAL CARE APPROACH IN NURSING HOMES

The STAR-VA training program in Veterans Health Administration Community Living Centers (CLCs) has been helping interdisciplinary care teams understand and manage dementia-related behaviors in the nursing home setting, with promising clinical outcomes. However, sustaining a new care approach in a health care system poses multiple challenges. This presentation will discuss facilitators and barriers to STAR-VA sustainability based on CLC team and nurse leader feedback. Findings are informing development of a new site coaching program and a sustainability toolkit. Feedback to date suggests that critical STAR-VA implementation and sustainability strategies include: regularly scheduled team meetings to discuss behavioral assessment and care plans; ongoing staff training (e.g., new staff orientation); communicating care plans across shifts and in the health record; multiple nurse/shift champions; impromptu huddles; acknowledging staff successes; leadership engagement. The coaching program engages teams in setting and tracking site sustainability goals. Lessons learned will be discussed.

PARTNERED EVALUATION OF LONGITUDINAL IMPACT OF STAR-VA: IMPLICATIONS FOR PROGRAM SUSTAINABILITY

Between 2013 and 2018, 86 Community Living Center (CLC) teams received STAR-VA training and consultation and implemented the intervention. Program evaluation has consistently demonstrated that STAR-VA Veteran training cases experience significantly decreased frequency and severity of target behaviors, symptoms of depression, anxiety, and agitation. VA Central Office leaders responsible for ongoing STAR-VA implementation and evaluation sought to understand the program’s systemic impact on important outcomes, if outcomes are maintained, and factors influencing variation in sustained adherence to STAR-VA. This presentation will describe the rationale for and methods used to develop a valid quality improvement metric to assess behavioral symptoms of dementia, to compare Veteran- and site-level outcomes at trained and untrained CLCs, and to identify factors associated with sustained STAR-VA implementation. This partnered evaluation, combining quantitative and qualitative methodologies, is critical for informing operational strategies for promoting STAR-VA and supporting its sustained implementation in VA CLCs.

A QUALITATIVE STUDY OF NURSING HOME STAFF CONCEPTUALIZATION OF EVERYDAY DECISION-MAKING CAPACITY

Because nursing homes are both a residence and a treatment setting, care providers are faced with the challenge of balancing resident autonomy and safety on a daily basis. While there are standardized approaches for determining a capacity to make larger decisions such as providing consent for medical procedures, there are virtually no methods for assessing capacity to make everyday decisions (e.g., food choices, smoking, navigating outside the nursing home). While it is easier for staff to prevent residents from making decisions they deem risky, to truly offer person-centered care, it is important to support a resident’s right to make decisions if they have the capacity to do so. Currently, little is known about how nursing home staff conceptualize and determine everyday decision-making capacity and how that information is used in care planning. To understand the current processes and language nursing home staff use when considering a resident’s decision-making capacity, we conducted interviews with 37 staff at two Veterans Affairs (VA) Community Living Centers (VA-operated nursing homes; CLCs). Using qualitative content analysis, we coded the transcribed interviews and identified several overarching themes: autonomy vs. safety, communication (e.g., pathways, with caregivers, with residents), determining capacity (e.g., information gathering, assessment, assumptions, indicators, interdisciplinary team member roles, referrals), interventions (e.g., legal and staff-led), and terminology used. We will describe how the findings from this study can be used to tailor development and adaptation of tools to help nursing home staff assess resident everyday decision-making capacity and to incorporate the results into person-centered care approaches.

ORGANIZATIONAL READINESS TO CHANGE AND NURSING HOME SAFETY: RESULTS FROM A NATIONAL SURVEY

In nursing homes, safety climate (employee attitudes and beliefs about safety) is a key contributing factor to safety and a potential leverage point for improvement. Yet relatively little is known about how contextual factors such as organizational readiness to change affect safety climate. We sampled employees from 56 Department of Veterans Affairs (VA) Community Living Centers (CLCs—nursing homes) and conducted an anonymous, cross-sectional web-based survey using the previously validated CLC Employee Survey of Attitudes about Resident Safety (CESARS) and the Organizational Readiness to Change Assessment instrument. From hierarchical mixed random effects regression models, we calculated intraclass correlation coefficients (ICC) as the proportion of CLC-level variance over the sum of CLC-level plus residual variance. Each of the CESARS’ 7 safety climate domains was a dependent variable in separate models; employee- and CLC-level factors were independent variables. The survey had a 26% response rate; 1,397 respondents. Mean ORCA scores (1-5 scale, higher better) was 3.3. We began with models containing only employee-level variables. ICC values ranged from 2.34% to 9.85%, suggesting substantial variation in CESARS outcomes. As we dropped insignificant variables and added CLC-level variables to the models, the ICC decreased over 2% in six models, suggesting organizational-level variables accounted for substantial variability. The only independent variable with a significant effect in all 7 models was organizational-level: organizational readiness to change. Unlike many other organizational-level variables, organizational readiness to change is potentially amenable to low-cost interventions such as communication and teamwork interventions, providing viable opportunities to efficiently improve nursing home care.

TRANSITIONAL CARE OUTCOMES IN VETERANS RECEIVING POST-ACUTE CARE IN A SKILLED NURSING FACILITY

More than 200,000 Veterans transition between hospital and skilled nursing facility (SNF) annually. Capturing outcomes of these transitions has been challenging because older adult Veterans receive care at VA and non-VA hospitals, and four different kinds of SNFs: VA-owned and -operated Community Living Centers (CLCs), VA-contracted community nursing homes (CNHs), State Veterans Homes (SVHs), and non-VA community SNFs. We used a novel data source which concatenates VA, Medicare, and Medicaid data into longitudinal episodes of care for Veterans, to calculate the rate of adverse outcomes associated with the transition from hospital to SNF in all enrolled Veterans age 65 and older undergoing this transition 2012-2014. The composite primary outcome included Emergency Department (ED) visits, rehospitalizations, and mortality (not in the context of hospice) within 7 days of hospital discharge to SNF. We used multivariable logistic regression to adjust for Veteran and hospital characteristics and hospital random effects. In the 388,339 Veterans discharged from 1502 hospitals in our sample, we found more than 4 in 5 Veteran transitions (81.7%) occurred entirely outside the VA system. The overall 7-day outcome rate was 10.7%. After adjustment, VA hospitals had lower adverse outcome rates than non-VA hospitals (OR 0.80, 95% CI 0.74-0.86). VA hospital-CLC transitions had the lowest adverse outcome rates; in comparison, non-VA hospital-CNH (OR 2.51, 95% CI 2.09-3.02) and non-VA hospital-CLC (OR 2.25, 95% CI 1.81-2.79) had the highest rates. These findings raise important questions about the VA’s role as a major provider and payer of post-acute care in SNF.

2012. Trends in Microbiological Culture Collection Across Veterans Affairs Medical Centers and Community Living Centers, 2010 to 2017

BackgroundMicrobiological cultures are critical in the diagnosis of infection, identification of pathogenic organisms, and tailoring antibiotic use. However, unnecessary collection of cultures, particularly from the urine, may lead to overuse of antibiotics. There have been no national studies to evaluate trends in the collection of cultures in acute and long-term care settings. Here we describe changes in the collection of cultures nationally across Veterans Affairs medical centers (VAMCs) and Community Living Centers (CLCs).MethodsAll positive and negative cultures collected from 2010 to 2017 among Veterans admitted to VAMCs or CLCs were included. Cultures were categorized by specimen source (urine, blood, skin and soft tissue, or lung). Joinpoint software was used for regression analyses of trends over time and to estimate annual average percent changes with 95% confidence intervals (CI).ResultsA total of 5,089,640 cultures from 158 VAMCS and 342,850 cultures from 146 CLCs were identified. The number of cultures collected for all culture types in VAMCs and CLCs decreased significantly. The number of cultures collected per admission decreased significantly by 5.5% annually among VAMCs (95% CI −7.0 to −4.0%) and by 8.4% annually among CLCs (95% CI −10.1 to −6.6%). The proportion of positive cultures decreased 1.6% annually among VAMCs (95% CI −2.3 to −0.9%) and remained stable among CLCs (-0.4% annually, 95% CI, −1.1 to 0.4%). The most common culture source among VAMCs was blood (36.2%), followed by urine (31.8%), and among CLCs was urine (56.9%), followed by blood (16.0%). Urine cultures decreased by 4.5% annually among VAMCs (95% CI −5.4 to −3.6%) and 7.0% annually among CLCs (95% CI −7.6 to −6.4%).ConclusionOur study demonstrates a significant reduction in the number of cultures collected over time. Positive cultures decreased significantly in VAMCs, possibly indicating fewer culture-positive infections.In both VAMCs and CLCs, decreases in cultures taken may represent an important reduction in the collection of unnecessary cultures nationally driven by increased awareness about over-testing and over-treatment of presumed infection, particularly urinary tract infections.Disclosures All authors: No reported disclosures.

2049. Trends in Antibiotic Use and Antibiotic Resistance among Veterans Affairs Community Living Centers from 2011 to 2017

BackgroundAntibiotic resistance is a global public health crisis, with antibiotic overuse contributing to selection pressure, and thus driving antibiotic resistance. Strategies to reduce antibiotic overuse may slow the development of resistance, but large-scale studies assessing trends in antibiotic use and resistance among nursing homes at the national level are limited. We describe trends in antibiotic use and resistance nationally among Veterans Affairs (VA) Community Living Centers (CLCs).MethodsWe assessed antibiotic use and microbiological cultures among VA CLC residents from 2011 to 2017. Antibiotics were grouped into eight drug classes and annual days of antibiotic therapy per 1,000 bed-days were calculated. Facility-weighted annual antibiotic resistance rates were calculated. Joinpoint Software was used for regression analyses of trends over time and to estimate annual average percent changes (AAPC) with 95% confidence intervals (CI).ResultsOver 7 years and among 146 CLCs, several significant trends in decreasing antibiotic use and corresponding reductions in resistance were identified. Fluoroquinolone use decreased by 9.9% annually (95% CI −11.6 to −8.2%) and fluoroquinolone resistance decreased by 2.3% per year for Escherichia coli, 5.1% for Klebsiella spp., 1.8% for Proteus mirabilis, 4.9% for Pseudomonas aeruginosa, 12.6% for Enterobacter spp., and 3.2% for Enterococcus spp. Anti-pseudomonal penicillin use decreased by 6.6% annually (95% CI −10.6 to −2.4%) and anti-pseudomonal penicillin resistance rates decreased each year by 7.9% for Escherichia coli, 8.9% for Klebsiella spp., 15.2% for Proteus mirabilis and 4.2% for Pseudomonas aeruginosa. Anti-staphylococcal penicillin use decreased by 5.4% annually (95% CI −10.0 to −0.5%) and resistance in Staphylococcus aureus decreased 1.7% per year.ConclusionNationally among VA CLCs, we observed significant reductions in the use of several classes of antibiotics with corresponding reductions in antibiotic resistance, including an impressive decline in fluoroquinolone use and corresponding decreases in fluoroquinolone resistance among six organisms. Future research should assess whether reductions in antibiotic use predict later reductions in antibiotic resistance and improvements in resident outcomes.Disclosures All authors: No reported disclosures.

516. Social Network Analysis to Study MDRO Transmission in VA Community Living Centers and Spinal Cord Injury Units

BackgroundResidents of VA Community Living Centers (CLC) and Spinal Cord Injury units (SCI) are commonly colonized or infected with multidrug-resistant organisms (MDROs). The mechanisms by which MDROs are spread between residents in CLC/SCI settings remain poorly understood. Our objective was to develop methods to better understand how MDROs are spread in VA CLCs/SCIs.MethodsPreliminary data from two of the four VA medical centers participating in an ongoing study are included in these analyses. A structured sociometric survey was employed to collect data on interactions between residents, staff and environmental surfaces in study units. UCINET was used to construct a sociogram and calculate network characteristics (density, centrality) using responses to the surveys administered in one of the participating facilities.ResultsA total of 136 surveys were completed by 49 staff and 45 residents at the two VA sites. Staff reported more interactions with residents than with other staff. Residents reported more interactions with staff than with other residents, the latter tending to only occur during group activities. Sociograms generated from preliminary surveys collected at one site suggest a four-core-person social network pattern connecting two staff with two specific residents and showed that the dining room was the group setting most frequently visited by residents. Mobile computers, blood pressure cuffs/thermometers and glucometers were the equipment used most heavily during resident care activities (figure). Challenges in identifying contact patterns include recall bias and inability of some residents to identify names of individuals with whom they interacted. Residents were still able to reliably identify staff roles.ConclusionThis preliminary work shows heterogeneous contact patterns between persons and surfaces in VA CLCs/SCIs. Characterizing this heterogeneity and its influence on MDRO spread via this type of social network analysis is feasible in the VA CLC/SCI setting, albeit with some limitations. Next steps in our studies include adding data from two additional sites and using observation techniques supplemented with microbiological sampling of targeted environmental surfaces to further understand potential transmission patterns. Disclosures All authors: No reported disclosures.

An Art Intervention to Promote Comfort with Veterans in Long Term Care: From Not Significant (Ns) To Significance

Objectives: The study objective was to promote hospitalized veterans’ comfort through an art intervention (AI). Kolcaba’s comfort theory guided the study. Sample and setting: Researchers recruited residents from a Community Living Center (CLC) at Miami Veterans Administration Healthcare System (MVAHS). Nurse researchers and recreational therapists collaborated to deliver the AI. Methods and variables: A quasi-experimental pre-post-test design tested the AI on veteran comfort, depression, and social connectedness. Results: Over six-months, staff identified 81 residents as appropriate to recruit for the study. Fifty-one males and 10 females (ages 26-95) agreed (75% response rate). Due to data collection challenges, residents’ cognition, time constraints, disabilities, and respondent burden, only 18 sets of usable pre-post data were available for analysis (ns results). Implications for nursing: The AI was “significant” to many other participants (n = 160) who were unable or unwilling to complete the research instruments. The most popular AI activity, the monoprint, has been “adopted” by recreational therapists and suggested to enhance communication with oncology patients. Kolcaba’s comfort theory will continue to be promoted during art activities on CLC I and II with extension of art activities to the bedside of CLC III Hospice residents. Keywords: Veterans, Art, Intervention, Comfort, Long Term Care

SAVE-CLC: An Intervention to Reduce Suicide Risk in Older Veterans following Discharge from VA Nursing Facilities

ABSTRACTObjective: We describe the development and implementation of a telephonic intervention (SAVE-CLC) piloted at three VA sites for Veterans returning to the community from VA nursing facilities (Community Living Centers or “CLCs”). Care transitions present a known period of medical risk for older adults and may pose increased risk for suicide. Veterans discharging from CLCs are at elevated risk compared to age and gender matched controls.Methods: Using a quality improvement approach, input was gathered from key stakeholders to aid in the development of the intervention. Veterans were screened for depressive symptoms and need for additional support by phone.Results: Of the Veterans who received the SAVE-CLC intervention, 87.9% had at least one prior mental health diagnosis, though only 19.7% had an outpatient mental health appointment arranged at CLC discharge. Results suggest that the intervention is feasible across multiple outpatient settings and is generally well-received by Veterans and caregivers, with 97% of those contacted reporting that the telephone calls were helpful.Conclusion: This flexible, telephone-based intervention addresses the unmet need of integrating mental health care into discharge planning during care transitions.Clinical Implications: SAVE-CLC offers a feasible and acceptable solution to suicide risk in older Veterans exiting a CLC.

Trends in Collection of Microbiological Cultures Across Veterans Affairs Community Living Centers in the United States Over 8 Years

ObjectivesTo describe and evaluate changes in the collection of microbiological cultures across Veterans Affairs (VA) Community Living Centers (CLCs) nationally. DesignDescriptive study. Setting146 VA CLCs. ParticipantsWe identified both positive and negative microbiological cultures collected during VA CLC admissions from January 2010 through December 2017. MeasuresWe measured the average annual percentage change (AAPC) in the rate of cultures collected per 1000 bed days and per admission, overall and stratified by culture type (ie, urine, blood, skin and soft tissue, and respiratory tract). AAPCs were also calculated for the proportion and rate of positive cultures collected, overall and stratified by culture type and organism (ie, Escherichia coli, Proteus mirabilis, Staphylococcus aureus, Enterococcus spp, Pseudomonas aeruginosa, Klebsiella spp, Enterobacter spp, Morganella morganii, Citrobacter spp, Serratia marcescens, and Streptococcus pneumoniae). Joinpoint regression software was used to assess trends and estimate AAPCs and 95% confidence intervals (CIs). ResultsOver 8 years, 355,329 cultures were collected. The rate of cultures collected per 1000 bed days of care decreased significantly by 6.0% per year (95% CI –8.7%, −3.2%). The proportion of positive cultures decreased by 0.9% (95% CI –1.4%, −0.4%). The most common culture types were urine (48.4%), followed by blood (27.7%). The rate of cultures collected per 1000 bed days of care decreased per year by 6.3% for urine, 5.0% for blood, 4.4% for skin and soft tissue, and 4.9% for respiratory tract. In 2010, S aureus was the most common organism identified, and in all subsequent years E coli was the most common. Conclusion and implicationsWe identified a significant reduction in the number of cultures collected over time among VA CLCs. Our findings may be explained by decreases in the collection of unnecessary cultures in VA CLCs nationally due to increased antibiotic stewardship efforts targeting unnecessary culturing and antibiotic treatment.

Effects of Mental Health Disorders on Nursing Home Residents' Nine-Month Pain Trajectories.

To determine the key classes of nursing home residents' nine-month pain trajectories, the influence of residents' mental health disorders on membership in these classes, and nine-month health-related outcomes associated with pain trajectory class membership. Four times over a nine-month period, the MDS 3.0 resident assessment instrument was used to record the demographic characteristics, mental health disorder diagnoses, pain characteristics, and health and functioning outcomes of 2,539 Department of Veterans Affairs Community Living Center (VA CLC) residents. Growth mixture modeling was used to estimate the key classes of residents' nine-month pain trajectories, the influence of residents' mental health disorders on their pain trajectory class membership, and the associations of class membership with residents' health and functioning outcomes at nine-month follow-up. Four-class solutions best described nursing home residents' nine-month trajectories of pain frequency, severity, and interference. Residents with dementia and severe mental illness diagnoses were less likely, and those with depressive disorder, PTSD, and substance use disorder diagnoses more likely, to belong to adverse nine-month pain trajectory classes. Membership in adverse pain frequency and pain severity trajectory classes, and in trajectory classes characterized by initially high but steeply declining pain interference, portended more depressive symptoms but better cognitive and physical functioning at nine-month follow-up. Nursing home residents' mental health disorder diagnoses help predict their subsequent pain frequency, severity, and interference trajectories. This may be clinically useful information for improving pain assessment and treatment approaches for nursing home residents.

Our Town, the MacDowell Colony, and the Art of Civic Mediation

Abstract Thornton Wilder’s Our Town (1938) has found unusual currency of late. In 2011, the play lent its name to a major funding program launched by the National Endowment for the Arts; in 2017, it appeared in the center of a popular podcast and was revived by a British theater company in the wake of a terrorist attack. These productions recognize what terms like middlebrow obscure: Our Town is a civic mediator, a performance that installs art at the center of community life and community at the center of art. Taking inspiration from Antoine Hennion’s sociology of music, this essay ventures into the archive to trace an unfamiliar origin story for Our Town, involving a turn-of-the-century writers’ colony, a Progressive-Era historical pageant, and Wilder’s self-understanding as both confirmed bachelor and “community man.” Through the trajectory of a single play, civic mediation emerges as a pervasive strategy and ethos of American cultural practice, connecting diverse media through time and space.

National trends in the treatment of urinary tract infections among Veterans’ Affairs Community Living Center residents

To describe urinary tract infection (UTI) treatment among Veterans' Affairs (VA) Community Living Centers (CLCs) nationally and to assess related trends in antibiotic use. Descriptive study. All UTI episodes treated from 2013 through 2017 among residents in 110 VA CLCs. UTI episodes required collection of a urine culture, antibiotic treatment, and a UTI diagnosis code. UTI episodes were stratified into culture-positive and culture-negative episodes. Frequency and rate of antibiotic use were assessed for all UTI episodes overall and were stratified by culture-positive and culture-negative episodes. Joinpoint software was used for regression analyses of trends over time. We identified 28,247 UTI episodes in 14,983 Veterans. The average age of Veterans was 75.7 years, and 95.9% were male. Approximately half of UTI episodes (45.7%) were culture positive and 25.7% were culture negative. Escherichia coli was recovered in 34.1% of culture-positive UTI episodes, followed by Proteus mirabilis and Klebsiella spp, which were recovered in 24.5% and 17.4% of culture-positive UTI episodes, respectively. The rate of total antibiotic use in days of therapy (DOT) per 1,000 bed days decreased by 10.1% per year (95% CI, -13.6% to -6.5%) and fluoroquinolone use (ciprofloxacin or levofloxacin) decreased by 14.5% per year (95% CI, -20.6% to -7.8%) among UTI episodes overall. Similar reductions in rates of total antibiotic use and fluoroquinolone use were observed among culture-positive UTI episodes and among culture-negative UTI episodes. Over a 5-year period, antibiotic use for UTIs significantly decreased among VA CLCs, as did use of fluoroquinolones. Antibiotic stewardship efforts across VA CLCs should be applauded, and these efforts should continue.

Influence of Cognition on Length of Stay and Rehospitalization in Older Veterans Admitted for Post-Acute Care.

Evaluate the relative contribution of cognitive test performance to post-acute care (PAC) length of stay (LOS) and rehospitalization while controlling for key demographic, medical, and functional outcomes. Retrospective medical record review of 160 older Veterans, including cognitive test performance (Addenbrooke's Cognitive Examination-Revised [ACE-R]), on admission to a Veterans Administration Hospital Community Living Center (CLC) PAC. Individuals with impaired scores on the ACE-R had a longer LOS (10 median days longer; U = 2,547.00, p = .028). Of those rehospitalized, 71.4% (n = 20) screened positive for cognitive impairment. Key medical factors explained the largest amount of variance in CLC-PAC LOS (29.8%), followed by admission ADL (activities of daily living) dependency (4.6%) and ACE-R total score (3.30%). Cognitive screening should be considered on PAC admission, with impairment on ACE-R predicting geriatric rehabilitation outcomes such as risk of increased LOS and rehospitalization.

Collaborative capacity and patient-centered care in the Veterans' Health Administration Community Living Centers.

Previous research in acute care settings has shown that collaborative capacity, defined as the way providers collaborate as equal team members, can be improved by the ways in which an organization supports its staff and teams. This observational cross-sectional study examines the association between collaborative capacity and supportive organizational context, supervisory support, and person-centered care in nursing homes to determine if similar relationships exist. We adapted the Care Coordination Survey for nursing homes and administered it to clinical staff in 20 VA Community Living Centers. We used random effects models to examine the associations between supportive organizational context, supervisory support, and person-centered care with collaborative capacity outcomes including quality of staff interactions, task independence, and collaborative influence. A total of 723 Community Living Center clinical staff participated in the Care Coordination Survey resulting in a response rate of 29%. We found that teamwork and collaboration-measured as task interdependence, quality of interactions and collaborative influence-did not differ significantly between Community Living Centers but did differ significantly across occupational groups. Moreover, staff members' experiences of teamwork and collaboration were positively associated with supportive organizational context and person-centered care. Our findings suggest that elements of organizational context are important to facilitating collaborative capacity. Additionally, investing in staffing, rewards, and person-centered care may improve teamwork.

Parainfluenza III Outbreak in a Veterans’ Affairs affiliated Nursing Home

BACKGROUND Parainfluenza III is one of the four serotypes of the parainfluenza virus (PIV) that causes upper respiratory tract infections (URI) in adults. Clinical presentation can range from mild URI to pneumonia, to death. We report a cluster of respiratory illness due to PIV III in a Community Living Center, (CLC) Nursing Unit. METHODS An outbreak of PIV III URI occurred at a VAMC CLC - 30 bed unit in June 2018. Cases were confirmed via nasopharyngeal respiratory viral real-time PCR panel. Case definition included a resident with new onset respiratory complaints and positive PCR test. Clinical presentation, laboratory data and outcome were reviewed in each case. RESULTS Ten residents tested positive for PIV III from 6/2 to 6/26, 2018. All residents were men with ages ranging from 59 to 84?years. The index case occurred on 6/2 with temperature of 102.30F. Thereafter, a health care provider presented with symptoms of URI but continued to work. The Infection control team was notified on five cases detected on 6/12; 4 cases were detected 6/18 to 6/26. One patient required hospitalization due to post-viral bacterial pneumonia. No deaths occurred. Five healthcare providers presented with symptoms of URI during this outbreak. Aggressive infection control measures were implemented: temporally halting admissions; high index of suspicion for symptomatic patients with obtaining viral panel; encouraging them to remain in their room; and teaching respiratory etiquette; enforcing hand hygiene and symptomatic patients leaving the nursing unit had to wear a mask; terminal cleaning of virus-contaminated surfaces/objects; discouraging floating of staff, directing ill employees to stay home. CONCLUSIONS PIV III can cause a serious outbreak in nursing homes. Therefore, Infection Control Preventionists can have an instrumental role in rapid recognition of an outbreak and strategically implementing targeted measures to halt the outbreak.