Interventions In Long-term Care Facilities Research Articles

Person-focused interventions for fall risk assessment, fall prevention and fall injury prevention in long-term care facilities: a scoping review

ObjectiveFalls are a significant concern in long-term care facilities (LTCFs) as fall-related injuries can result in functional impairment, disability and death. Older adults living in LTCFs are at greater risk...

Sarcopenia interventions in long-term care facilities targeting sedentary behaviour and physical inactivity: A systematic review.

Sedentary behaviour and physical inactivity are independent risk factors for sarcopenia for long-term care facility residents. Understanding the components, mechanisms and context of interventions that target change in these risk factors can help optimize sarcopenia management approaches. This study aimed to identify, appraise and synthesize the interventions targeting sedentary behaviour and physical inactivity, construct a Theory of Change logic model, inform complex sarcopenia intervention development and identify areas for improvement. Eight electronic databases, including Embase and Web of Science, were searched for eligible interventional studies from inception until February 2024. Narrative synthesis was used. The Theory of Change was applied to develop a logic model presenting the synthesized results. A Cochrane risk of bias assessment tool was used for quality appraisal. The study included 21 articles involving 1014 participants, with mean ages ranging from 72.5 to 90.4years. The proportion of female participants ranged from 8.0% to 100.0%. The applied sarcopenia diagnosis criteria varied, including those of the Asian Working Group for Sarcopenia and the European Working Group on Sarcopenia in Older People. The overall risk of bias in the included studies was moderate. Interventions primarily targeted physical inactivity, with resistance training being the most common intervention type. The reporting of intervention adherence was insufficient (only 11 out of 21 included studies provided adherence reports), and adherence overall and by intervention type was not possible to discern due to inconsistent criteria for high adherence across these studies. Four categories of intervention input were identified: educational resources; exercise equipment and accessories; monitoring and tailoring tools; and motivational strategies. Intervention activities fell into five categories: determining the intervention plan; educating; tailoring; organizing, supervising, assisting and motivating; and monitoring. While sarcopenia-related indicators were commonly used as desired outcomes, intermediate outcomes (i.e., sedentary time and physical activity level) and other long-term outcomes (i.e., economic outcomes) were less considered. Contextual factors affecting intervention use included participant characteristics (i.e., medical condition and education level) and intervention provider characteristics (i.e., trustworthiness). The findings led to the development of a novel logic model detailing essential components for interventions aimed at managing sarcopenia in long-term care facilities, with a focus on addressing sedentary behaviour and physical inactivity. Future sarcopenia interventions in long-term care facilities should fully attend to sedentary behaviour, enhance adherence to interventions through improved education, monitoring, tailoring and motivation and establish an agreed standard set of outcome measures.

The Effectiveness of Palliative Care Interventions in Long-Term Care Facilities: A Systematic Review.

The increasing elderly population is driving higher utilization rates of long-term care facilities, where residents often have multiple chronic diseases, making them potential candidates for palliative care. Timely palliative care interventions can improve their quality of life and medical autonomy. This study systematically reviews the effectiveness of palliative care programs in long-term care facilities. Databases such as PubMed, EMBASE, Cochrane Library, and Airiti Library were searched up to 31 December 2023, using PICO criteria and the following keywords: 'care home', 'nursing home', 'residential aged care facility', and 'long-term care facility' for patients; and 'Gold Standard Framework in Care Homes', 'integrated care pathway', 'care home project', and 'palliative care program' for interventions. Seven articles were included. The results indicate that the Program of All-Inclusive Care for the Elderly (PACE) intervention did not significantly influence overall quality of life but did improve the quality of death. There were no statistical differences in comfort or quality of death between the dementia and non-dementia groups. However, PACE significantly reduced healthcare costs. The implementation of the Liverpool Care Pathway (LCP) notably enhanced the control of terminal symptoms, while the Gold Standard Framework in Care Homes (GSFCH) effectively improved end-of-life care rates, do-not-resuscitate (DNR) signing rates, advance care planning (ACP) completion rates, and reduced inappropriate readmission rates. While palliative care interventions are shown to improve the quality of end-of-life care, their practical application should be adapted to fit the implementation conditions and capabilities of domestic long-term care facilities.

A SCOPING REVIEW FOR PERSON-FOCUSED FALL PREVENTIVE INTERVENTIONS IN LONG-TERM CARE FACILITIES

Abstract Falls are a significant concern in long-term care facilities (LTCFs) as fall-related injuries (FRI) can result in functional impairment, disability, and death. Older adults living in LTCFs are at greater risk for falls than those in the community. Using scoping review methodology, we aimed to synthesize evidence examining intervention effects of person-focused interventions for risk assessment and prevention in LTCFs to identify evidence-based practices. Databases searched included Medline, CINAHL, and EMBASE to identify original research from 2017 to April 2022 in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guideline. Following the removal of duplicates, 888 articles were identified for possible review, following title and abstract screening 84 studies underwent full-text review against inclusion/exclusion criteria, with 30 studies remaining for analysis. We conducted a narrative synthesis to summarize the included studies. Evidence-based interventions for fall prevention identified include (1) exercise programs (e.g., high-intensity functional exercise, aerobic exercise, short stick exercises, etc.); (2) balance training programs (e.g., Wii Fit); (3) multifaceted, nurse-led education; and (4) others (e.g., whole body vibration, and lavender olfactory stimulation). Outcomes of included studies included the number of falls, fall rate, risk of falls, and fear of falls before and after interventions. Overall, most studies reported significant effects of person-focused interventions in LTCFs. Available evidence supports that well-designed person-focused interventions can reduce falls and fear of falls for individuals in LTCFs.

The Effect of Virtual Reality Application on Pain, Functional Independence, and Depression in the Older Adults: A Pilot Study

Abstract Purpose: The aim of the study is to determine the effects of virtual reality (Kinect game called Dance Central) experience on pain, depression and functional ability in elderly adults living in nursing homes. Design and Methods: This study was carried out for a total of 3 weeks, by applying it twice a day, 15 minutes in the morning and 15 minutes in the evening, 3 days a week. Findings: A statistically significant difference (χ2=13.455;p=0.001) was found between the depression scales of the elderly in the experimental group. In the pain scale, it was determined that there was a significant difference (t=2.317; p=0.039) between the experimental group and the control group at the 1st month. Practice Implications: Nurses creating appropriate interventions in long-term care facilities can have an impact on the pain and depression of older adults.

Barriers and facilitators for the successful implementation of antimicrobial stewardship interventions in long-term care facilities: a scoping review

Barriers and facilitators for the successful implementation of antimicrobial stewardship interventions in long-term care facilities: a scoping review

Implementation strategies to support fall prevention interventions in long-term care facilities for older persons: a systematic review

BackgroundFalls are common among older people in long-term care facilities (LTCFs). Falls cause considerable morbidity, mortality and reduced quality of life. Of numerous interventional studies of fall prevention interventions in LTCFs, some reduced falls. However, there are challenges to implementing these interventions in real-world (non-trial) clinical practice, and the implementation techniques may be crucial to successful translation. This systematic review thus aimed to synthesise the evidence on implementation strategies, implementation outcomes and clinical outcomes included in fall prevention intervention studies.MethodsA systematic search of six electronic databases (PubMed, CINAHL, EMBASE, PsycINFO, SCOPUS, Web of Science) and eight grey literature databases was conducted, involving papers published during 2001–2021, in English or Arabic, targeting original empirical studies of fall prevention interventions (experimental and quasi-experimental). Two seminal implementation frameworks guided the categorisation of implementation strategies and outcomes: the Expert Recommendations for Implementing Change (ERIC) Taxonomy and the Implementation Outcomes Framework. Four ERIC sub-categories and three additional implementation strategies were created to clarify overlapping definitions and reflect the implementation approach. Two independent researchers completed title/abstract and full-text screening, quality appraisal assessment, data abstraction and coding of the implementation strategies and outcomes. A narrative synthesis was performed to analyse results.ResultsFour thousand three hundred ninety-seven potential papers were identified; 31 papers were included, describing 27 different fall prevention studies. These studies used 39 implementation strategies (3–17 per study). Educational and training strategies were used in almost all (n = 26), followed by evaluative strategies (n = 20) and developing stakeholders’ interrelationships (n = 20). Within educational and training strategies, education outreach/meetings (n = 17), distributing educational materials (n = 17) and developing educational materials (n = 13) were the most common, with 36 strategies coded to the ERIC taxonomy. Three strategies were added to allow coding of once-off training, dynamic education and ongoing medical consultation. Among the 15 studies reporting implementation outcomes, fidelity was the most common (n = 8).ConclusionThis is the first study to comprehensively identify the implementation strategies used in falls prevention interventions in LTCFs. Education is the most common implementation strategy used in this setting. This review highlighted that there was poor reporting of the implementation strategies, limited assessment of implementation outcomes, and there was no discernible pattern of implementation strategies used in effective interventions, which should be improved and clearly defined.Trial registrationThis systematic review was registered on the PROSPERO database; registration number: CRD42021239604.

Economic evaluation of healthcare-associated infection prevention and control in long-term care: a systematic review protocol

BackgroundGiven the high risk of contracting a healthcare-associated infection in long-term care facilities, infection prevention and control are essential for the quality of care and safety of residents and staff. To develop more effective infection prevention and control interventions in long-term care facilities, it is important to assess the cost-effectiveness and cost-benefit of existing interventions. There are only a few reviews on this subject, but these are not recent and most do not perform an economic evaluation. Moreover, none uses a discounting approach which limits inter-study comparison. To address these gaps, we will conduct a systematic review of economic evaluations related to healthcare-associated infection prevention and control in long-term care facilities using a discounting approach.MethodsWe will query MEDLINE, Embase, Web of Science, Cochrane, CINAHL, EconLit, JSTOR, and Scopus, as well as the gray literature databases CORDIS and ProQuest. We will include quantitative studies that evaluate four clinical best practices associated with infection prevention and control (hand hygiene, hygiene and sanitation, screening, basic, and additional precautions) and use at least one of five economic analyses (cost-effectiveness, cost-benefit, cost-minimization, cost-utility, cost-consequences). Primary outcomes will include net cost savings, incremental cost-effectiveness ratio, incremental cost per quality-adjusted life year, and incremental cost per disability-adjusted life year. Two co-authors will independently screen and select articles, extract data, and assess the quality of selected articles using the Scottish Intercollegiate Guidelines Network criteria, the Economic Evaluation criteria, and the Cochrane criteria for economic evaluation. Extracted data will be synthesized, and values will be adjusted to 2022 Canadian dollars using the discount rates of 3%, 5%, and 8%.DiscussionInformation obtained through this systematic review may help researchers and policy makers make more efficient use of limited healthcare resources to ensure the safety and quality of long-term care.Systematic review registrationResearch registry ID: reviewregistry1210.

Behavioral and Psychological Symptoms of Dementia in Different Dementia Disorders: A Large-Scale Study of 10,000 Individuals.

Background:The majority of individuals with dementia will suffer from behavioral and psychological symptoms of dementia (BPSD). These symptoms contribute to functional impairment and caregiver burden.Objective:To characterize BPSD in Alzheimer’s disease (AD), vascular dementia (VaD), mixed (Mixed) dementia, Parkinson’s disease dementia (PDD), dementia with Lewy bodies (DLB), frontotemporal dementia (FTD), and unspecified dementia in individuals residing in long-term care facilities.Methods:We included 10,405 individuals with dementia living in long-term care facilities from the Swedish registry for cognitive/dementia disorders (SveDem) and the Swedish BPSD registry. BPSD was assessed with the Neuropsychiatric Inventory - Nursing Home Version (NPI-NH). Multivariate logistic regression models were used to evaluate the associations between dementia diagnoses and different BPSDs.Results:The most common symptoms were aberrant motor behavior, agitation, and irritability. Compared to AD, we found a lower risk of delusions (in FTD, unspecified dementia), hallucinations (FTD), agitation (VaD, PDD, unspecified dementia), elation/euphoria (DLB), anxiety (Mixed, VaD, unspecified dementia), disinhibition (in PDD), irritability (in DLB, FTD, unspecified dementia), aberrant motor behavior (Mixed, VaD, unspecified dementia), and sleep and night-time behavior changes (unspecified dementia). Higher risk of delusions (DLB), hallucinations (DLB, PDD), apathy (VaD, FTD), disinhibition (FTD), and appetite and eating abnormalities (FTD) were also found in comparison to AD.Conclusion:Although individuals in our sample were diagnosed with different dementia disorders, they all exhibited aberrant motor behavior, agitation, and irritability. This suggests common underlying psychosocial or biological mechanisms. We recommend prioritizing these symptoms while planning interventions in long-term care facilities.

Implementation strategies supporting fall prevention interventions in a long-term care facility for older persons: a systematic review protocol

IntroductionFalls are common among older people in long-term care facilities (LCFs). Falls lead to significant morbidity, mortality and reduced quality of life among residents. Fall prevention interventions have been shown...

Behavioral Interventions in Long-Term Care Facilities during the COVID-19 Pandemic: A Case Study

During the COVID-19 pandemic, long-term care (LTC) centers have adopted a series of measures that have affected the physical and cognitive health of patients. The routines of the patients, as well as the interventions of professionals, have been altered. In the case presented here, our aim was to explain the effect that the strong confinement due to the spread of the first COVID-19 wave in Spain had on a 75-year-old resident in an LTC center, with cognitive and behavioral symptomatology compatible with a diagnosis of mixed dementia, as well as the measures that the center adopted to manage the lockdown situation in the best possible way, including personalized attention protocols and a video call program. Different nosological hypotheses are also raised using a semiological analysis, including the analysis of the initial and continuation diagnostic protocols, as well as the therapeutic options.

Palliative care integration indicators: an European regional analysis

ObjectiveTo estimate the capacity of European countries to integrate palliative care (PC) into their health systems through PC service provision for patients of all ages, with different care needs and...

Infection prevention and control and antimicrobial stewardship in European long-term care, 2016-2017

Abstract Background Europe's population is ageing. Long-term care facilities (LTCFs) for this vulnerable population are often relatively homelike with low staff-to-resident ratios. In 2016-2017, ECDC coordinated its third point prevalence survey (PPS) of healthcare-associated infections (HAIs) and antimicrobial use in European long-term care facilities (LTCFs). It included collection of data on structure and process indicators (SPIs) of infection prevention and control (IPC) and antimicrobial stewardship, to support countries' identification of national and local interventions in LTCFs. Methods In each country, national contacts recruited a convenience sample of LTCFs. National/LTCF PPS teams used a standard protocol that included case definition algorithms (adapted US CDC/SHEA definitions) applied to each resident with signs/symptoms of infection on the PPS day, and questions for LTCF staff on SPIs of IPC and antimicrobial stewardship activities. Denominators indicate the number of responses available for analysis. Results 3,052 LTCFs in 24 EU/EEA countries were recruited, with 102,301 residents included. The prevalence of HAIs (residents with ≥1 HAI) was 3.7%. Although 1,524/1,623 (94%) LTFS had a hand hygiene (HH) protocol, only 1,046/1,585 (66%) LTCFs had organised ≥1 HH training session for care professionals during the previous year. 1,185/1,561 (76%) LTCFs reported IPC training of nursing and paramedical staff. Only 340/1,639 (21%) of LTCFs reported training on appropriate prescribing and 493/1,623 (30%) LTCFs had provided feedback to GPs on antimicrobial consumption. On the PPS day, annual antimicrobial consumption data were available to only 530/1,623 (32%) LTCFs. Conclusions Even in LTCFs with the capacity to perform this PPS, IPC training was non-ubiquitous and antimicrobial stewardship activities, including training, were rarely reported. ECDC encourages EU/EEA countries to recruit LTCFs to participate in future PPSs, to allow them to benchmark HAI rates and practices. Key messages The prevalence of healthcare-associated infections in European long-term care facilities (LTCFs) highlights their requirement for infection prevention and control (IPC) and antimicrobial stewardship. This multi-national point prevalence survey (PPS) indicates that European countries can consider reinforcing IPC, antimicrobial stewardship practices and participation in PPSs in LTCFs.

Interventions to improve appropriate antibiotic prescribing in long-term care facilities: a systematic review

BackgroundOveruse of antibiotics has contributed to antimicrobial resistance; a growing public health threat. In long-term care facilities, levels of inappropriate prescribing are as high as 75%. Numerous interventions targeting long-term care facilities’ antimicrobial stewardship have been reported with varying, and largely unexplained, effects. Therefore, this review aimed to apply behavioural science frameworks to specify the component behaviour change techniques of stewardship interventions in long-term care facilities and identify those components associated with improved outcomes.MethodA systematic review (CRD42018103803) was conducted through electronic database searches. Two behavioural science frameworks, the Behaviour Change Wheel and Behaviour Change Technique Taxonomy were used to classify intervention descriptions into intervention types and component behaviour change techniques used. Study design and outcome heterogeneity prevented meta-analysis and meta-regression. Interventions were categorised as ‘very promising’ (all outcomes statistically significant), ‘quite promising’ (some outcomes statistically significant), or ‘not promising’ (no outcomes statistically significant). ‘Promise ratios’ (PR) were calculated for identified intervention types and behaviour change techniques by dividing the number of (very or quite) promising interventions featuring the intervention type or behaviour change technique by the number of interventions featuring the intervention type or behaviour change technique that were not promising. Promising intervention types and behaviour change techniques were defined as those with a PR ≥ 2.ResultsTwenty studies (of19 interventions) were included. Seven interventions (37%) were ‘very promising’, eight ‘quite promising’ (42%) and four ‘not promising’ (21%). Most promising intervention types were ‘persuasion’ (n = 12; promise ratio (PR) = 5.0), ‘enablement’ (n = 16; PR = 4.33) and ‘education’ (n = 19; PR = 3.75). Most promising behaviour change techniques were ‘feedback on behaviour’ (n = 9; PR = 8.0) and ‘restructuring the social environment’ (e.g. staff role changes; n = 8; PR = 7.0).ConclusionSystematic identification of the active ingredients of antimicrobial stewardship in long-term care facilities was facilitated through the application of behavioural science frameworks. Incorporating environmental restructuring and performance feedback may be promising intervention strategies for antimicrobial stewardship interventions within long-term care facilities.

Palliative Care Implementation in Long-Term Care Facilities: European Association for Palliative Care White Paper

ObjectivesThe number of older people dying in long-term care facilities (LTCFs) is increasing globally, but care quality may be variable. A framework was developed drawing on empirical research findings from the Palliative Care for Older People (PACE) study and a scoping review of literature on the implementation of palliative care interventions in LTCFs. The PACE study mapped palliative care in LTCFs in Europe, evaluated quality of end-of-life care and quality of dying in a cross-sectional study of deceased residents of LTCFs in 6 countries, and undertook a cluster-randomized control trial that evaluated the impact of the PACE Steps to Success intervention in 7 countries. Working with the European Association for Palliative Care, a white paper was written that outlined recommendations for the implementation of interventions to improve palliative and end-of-life care for all older adults with serious illness, regardless of diagnosis, living in LTCFs. The goal of the article is to present these key domains and recommendations. DesignTransparent expert consultation. SettingInternational experts in LTCFs. ParticipantsEighteen (of 20 invited) international experts from 15 countries participated in a 1-day face-to-face Transparent Expert Consultation (TEC) workshop in Bern, Switzerland, and 21 (of 28 invited) completed a follow-up online survey. MethodsThe TEC study used (1) a face-to-face workshop to discuss a scoping review and initial recommendations and (2) an online survey. ResultsThirty recommendations about implementing palliative care for older people in LTCFs were refined during the TEC workshop and, of these, 20 were selected following the survey. These 20 recommendations cover domains at micro (within organizations), meso (across organizations), and macro (at national or regional) levels addressed in 3 phases: establishing conditions for action, embedding in everyday practice, and sustaining ongoing change. Conclusions and implicationsWe developed a framework of 20 recommendations to guide implementation of improvements in palliative care in LTCFs.

Reinforcement of an infection control bundle targeting prevention practices for Clostridioides difficile in Veterans Health Administration nursing homes

Clostridioides difficile infection (CDI) causes significant morbidity in nursing home residents. Our aim was to describe adherence to a bundled CDI prevention initiative, which had previously been deployed nationwide in Veterans Health Administration (VA) long-term care facilities (LTCFs), and to improve compliance with reinforcement. A multicenter pre- and post-reinforcement of the VA bundle consisting of environmental management, hand hygiene, and contact precautions was conducted in 6 VA LTCFs. A campaign to reinforce VA bundle components, as well as to promote select antimicrobial stewardship recommendations and contact precautions for 30 days, was employed. Hand hygiene, antimicrobial usage, and environmental contamination, before and after bundle reinforcement, were assessed. All LTCFs reported following the guidelines for cleaning and contact precautions until diarrhea resolution pre-reinforcement. Environmental specimens rarely yielded C difficile pre- or post-reinforcement. Proper hand hygiene across all facilities did not change with reinforcement (pre 52.51%, post 52.18%), nor did antimicrobial use (pre 87-197 vs. post 84-245 antibiotic days per 1,000 resident-days). LTCFs found it challenging to maintain prolonged contact precautions. Variation in infection prevention and antimicrobial prescribing practices across LTCFs were identified and lessons learned. Introducing bundled interventions in LTCFs is challenging, given the available resources, and may be more successful with fewer components and more intensive execution with feedback.

Workplace Interventions and Vaccination-Related Attitudes Associated With Influenza Vaccination Coverage Among Healthcare Personnel Working in Long-Term Care Facilities, 2015‒2016 Influenza Season

ObjectivesInfluenza vaccination of healthcare personnel working in long-term care (LTC) facilities can reduce influenza-related morbidity and mortality among healthcare personnel and among resident populations who are at increased risk for complications from influenza and who may respond poorly to vaccination. The objective of this study was to investigate workplace interventions and healthcare personnel vaccination-related attitudes associated with higher influenza vaccination coverage among healthcare personnel working in LTC facilities. Setting and participantsData were obtained from an online survey of healthcare personnel conducted in April 2016 among a nonprobability sample of 2258 healthcare personnel recruited from 2 preexisting national opt-in Internet panels. Respondents were asked about influenza vaccination status, workplace vaccination policies and interventions, and their attitudes toward vaccination. Analyses were restricted to the 332 healthcare personnel who worked in nursing homes, assisted living facilities, or other LTC facilities. MeasuresLogistic regression models were used to assess the independent associations between each workplace intervention and higher influenza vaccination coverage compared with referent levels, controlling for occupation, age, and race/ethnicity. Prevalence ratios were calculated under the assumption of simple random sampling. ResultsApproximately 77% of healthcare personnel working in LTC facilities reported receiving influenza vaccination in the 2015‒2016 influenza season. Influenza vaccination was independently associated with an employer vaccination requirement (prevalence ratio (PR) [95% confidence interval] = 1.28 [1.11, 1.47]), being offered free onsite vaccination (PR = 1.20 [1.04, 1.39]), and employers publicizing vaccination coverage level to employees (PR = 1.24 [1.09, 1.41]). Vaccination was most highly associated with a combination of 3 or more workplace interventions. Most healthcare personnel working in LTC facilities reported positive attitudes toward the safety and effectiveness of influenza vaccination. Conclusions/ImplicationsImplementing employer vaccination interventions in LTC facilities, including employer vaccination requirements and free on-site influenza vaccination that is actively promoted, could increase influenza vaccination among healthcare personnel.

Antimicrobial Stewardship Programs in Long-Term Care Settings: A Meta-Analysis and Systematic Review.

BACKGROUNDAntimicrobial stewardship programs have been established in hospitals, but less studied in long‐term care facilities (LTCFs), a setting with unique challenges related to patient populations and available resources. This systematic review sought to provide a comprehensive assessment of antimicrobial stewardship interventions implemented in LTCFs, using meta‐analysis to examine their impact on overall antimicrobial use.METHODSElectronic searches of MEDLINE, Embase, and CINAHL (1990 to July 2018) identified any antimicrobial stewardship interventions in LTCFs, with no restriction on patient population, study design, or outcomes. Intervention components were categorized using the Cochrane Effective Practice and Organization of Care taxonomy on implementation strategies. Random‐effects meta‐analysis used ratio of means to facilitate pooling of different metrics of antimicrobial use.RESULTSEighteen studies (one randomized controlled trial [RCT], four cluster RCTs, four controlled pre/post studies, and nine uncontrolled pre/post studies) met inclusion, using 13 different antimicrobial stewardship intervention strategies; 15 studies used multifaceted (maximum, seven; median, four) interventions. The three most commonly implemented strategies were educational materials, educational meetings, and guideline implementation. Intervention labor intensity and resource requirements varied considerably among interventions. Meta‐analysis of 11 studies demonstrated that antimicrobial stewardship strategies were associated with a 14% reduction in overall antimicrobial use (95% confidence interval = −8% to −20%; P < .0001), with similar results by study design but high heterogeneity (I2 = 86%) for the uncontrolled pre/post study subgroup and no heterogeneity (I2 = 0%) for the cluster RCT and controlled pre/post study subgroups. Funnel plot analysis suggested publication bias, with a lack of publication of smaller studies showing increased antibiotic use.CONCLUSIONAntimicrobial stewardship strategies implemented in long‐term care vary considerably in design and resource intensity, but collectively suggest potential to reduce antimicrobial use in this challenging setting. J Am Geriatr Soc 67:392–399, 2019.

Approaches of psychoanalysis in the care of the elderly: an integrative review

Abstract Objective: to map publications about the clinical psychoanalytical care of the elderly and describe their characteristics. Method: an integrative review was carried out, considering the period 2008 to 2017 using the following databases: Index-Psychology, LILACS, MedLine, PubMED, SciELO and RedALyC, irrespective of language. The terms Elderly (Idoso), Aging (Envelhecimento) and Psychoanalysis (Psicanálise) were used. The guiding question was: what scientific literature exists about the elderly and psychoanalytical clinical care? A total of 33 articles were considered. Results: five categories were constructed: "Elderly clinical care with a psychoanalytical approach" (15), "Psychoanalytical Approaches in old age” (9), "Psychoanalytical Interventions in long-term care facilities" (6), "Representations of old age for health professionals in the light of psychoanalysis" (2) and "Generationality and psyche" (1). The concern of psychoanalysis for the elderly is incipient and precedes epistemological issues, meaning that production regarding clinical practice is greater; in turn, there are fewer research studies, as most of the articles are reflective in nature. Conclusion: the published studies indicate the possibility of employing psychoanalysis with the elderly, as the unconscious does not age and symptoms are continuously updated. The timidity of psychoanalysis in contrast to the increase in the numbers of elderly persons may be criticized. It is also emphasized that the losses, the effects on the body and the reduction of social ties require adjustments in clinical care, such as the inclusion of group activities and activities beyond the analytical setting, especially hospitals, homes and LTCFs.

1833. Impact of Antibiotic Stewardship on Antimicrobial Use for Urinary Tract Infection at a Veteran’s Affairs Long-Term Care Facility

BackgroundUrinary tract infections (UTI) are common infections in long-term care facilities (LTCF) and can lead to increased antibiotic use and resistance. The impact of antimicrobial stewardship programs (ASP) interventions in the appropriate selection of antimicrobials for the treatment of UTIs is unclear.MethodsA prospective review was conducted at a 60-bed LTCF from an urban Veteran’s Affairs Medical Center. The review followed analysis of antimicrobial selection and resistance patterns from this ward with implementation of an electronic medical record-based clinical decision support tool (EMR-CDS) for the treatment of UTI. Antibiotics were divided into two groups: guideline recommended and discouraged. Antibiotic use data (days of therapy (DOT)/1,000 patient-days (PD)) was compared between the two groups in the pre-intervention and the post-intervention periods (January 2014 to December 2015 and August 2016 to March 2018, respectively) to determine the impact of the ASP intervention. Antimicrobial susceptibilities were also compared.ResultsA reduction in total antimicrobial use from 48.61 to 25.62 DOT/1,000 PD (P < 0.001) was seen. Overall, guideline discouraged antibiotic use decreased 59% from 30 to 12.3 DOT/1,000 PD (P < 0.001) compared with guideline recommended antibiotic, which decreased by 29% from 18.65 to 13.3 DOT/PD (P < 0.001). Guideline recommended antibiotics with increased usage during the study period included cephalexin (2.34 to 6.35 DOT/1,000 PD; P < 0.001) (Figure 1). The percentage of appropriately prescribed antibiotics increased from 38.4% to 51.9% (P < 0.001) between the pre- and postintervention periods. The greatest reduction in guideline-discouraged antibiotics use was cefuroxime from 17 to 1.58 DOT/1,000 PD (P < 0.001). Antimicrobial susceptibility increased in both antibiotic recommended and discouraged groups (25.8% and 26.8%) (Figure 2). ConclusionTargeted ASP interventions in LTCFs leveraging antimicrobial resistance patterns, high-risk antimicrobials, and EMR-CDS support systems are successful methods for reducing total antimicrobial use, increasing appropriate antimicrobial prescribing, and decrease resistance.Disclosures All authors: No reported disclosures.