Large Long-term Care Facility Research Articles

415. A Whole Genome Sequencing Analysis of a Multi-unit Long-term Care Facility COVID-19 Outbreak

BackgroundThe coronavirus disease (COVID-19) pandemic has affected residents in long-term care facilities (LTCF) significantly. Understanding transmission dynamics in this setting is crucial to control the spread of COVID-19 in this population. Using whole genome sequencing (WGS) of SARS-CoV-2, we aimed to delineate the points of introduction and transmission pathways in a large LTCF in Quebec, Canada.MethodsBetween 2020-10-28 and 2021-01-09, COVID-19 cases occurred in 102 residents and 111 HCW at a 387-bed LTCF; cases were distributed in 11 units on 6 floors. As part of outbreak analysis, SARS-CoV-2 isolates underwent WGS using the Oxford Nanopore Minion and the Artic V3 protocol. Lineage attribution and sequence types (ST, within 3 mutations) were assigned based on Pangolin classification and variant analysis. Epidemiologic data including date of positive PCR test, resident room number and HCW work location were collected. Self-reported high-risk exposures were collected by HCW questionnaire via phone interview after consent. Cases and their ST, geo-temporal relations and HCW-reported exposures were examined via network plots and geography-based epidemic curves to infer points of introduction and paths of transmission. ResultsOf 170 isolates available from 100/102 residents and 70/111 HCW, 130 (76.4%) were successfully sequenced. Phylogenetic analysis revealed 7 separate introductions to the LTCF. Grouping of ST by units was observed, with temporal appearance of ST supporting HCW introduction in 7/11 units. Proportion of phone interview completion was low at 35% (26/70). Few HCW recalled specific high-risk exposures. Recalled exposures supported by genetic linkage revealed potential between-unit introductions from HCW-to-HCW transmission at work and outside the workplace (e.g. carpooling). On one unit, a wandering resident was identified as a likely source of transmission to other residents (Figure 1). Network plot of cases clustered by geographic unit, colour-coded by sequence type. Circles represent residents; addition signs represent healthcare workers. Blue lines represent identified high-risk exposures. Node labels represent floor and unit identifiers; 2 units per floor.ConclusionWe demonstrate the complex genomic epidemiology of a multi-unit LTCF outbreak, putting into evidence the importance of a multi-faceted approach to limit transmission. This analysis highlights the utility of using WGS to uncover unsuspected transmission routes, such as HCW contact outside work, which can prompt new infection control measures. Disclosures All Authors: No reported disclosures

Positive Behaviors and Strengths of People With Dementia

Assessment of and care for people with dementia is shifting away from a purely medical disease model toward a more holistic, biopsychosocial approach. Within this movement is growing interest in balancing the negative, symptom-based view of people with dementia with better understanding of strengths and positive behaviors exhibited by people with dementia. The aim of this qualitative study was to gather perspectives of professional caregivers regarding positive behaviors and strengths observed in people with dementia. Data were obtained from three focus groups conducted at a memory care unit within a large long-term care facility. Focus group participants (N=14) worked in nursing and the activities department. Inductive methods were used to code and analyze focus group transcripts and recordings. Five major themes were identified: enduring abilities and values, enduring traits and strengths, sense of purpose and meaning, desire to be helpful, and prosocial behavior. These themes illustrate many domains in which professional caregivers have observed positive behaviors and strengths in people with dementia living in a long-term care facility. The results of this study contribute to the growing literature pertaining to the intersection of positive psychology and dementia research and practice. Future directions include development of an assessment tool to measure positive behavior and strengths in people living with dementia.

Compulsory notification at skilled nursing facilities.

Notifiable diseases (NDs) encompass conditions of high clinical severity and/or contagious. Being closed communities, long-term care facilities (LTCF) are places that deserve attention on their own, but one might be left wondering: what is the reality of NDs at Brazilian LTCFs? To determine the prevalence and type of NDs at large LTCF. Active search for NDs conducted by the Hospital Infection Control Committee (HICC) in 459 beds. Due to the low turnover of patients, the monthly list kept by the HICC on NDs was analyzed. Data were grouped into males and females, and into elderly (age ≥ 60 years) and non-elderly (age ≤ 59 years). 31 diseases in 29 patients (6.9% of all inpatients - 19 males and 10 females): 23 cases of hepatitis C, five of hepatitis B, two of human immunodeficiency virus (HIV), and one case of renal tuberculosis. One patient with hepatitis B and another HIV-positive also had hepatitis C. There was no statistical significance in the comparison of the two groups with the total number of other institutionalized patients - by age and gender - for total number of NDs and cases of hepatitis C (p>0.05). Chronic NDs and those requiring chronic treatment observed in this study suggest that Brazil needs more studies to define the dynamics of these diseases at LTCFs.

Intention to receive the seasonal influenza vaccine among nurses working in a long-term care facility.

The factors affecting influenza vaccine uptake among nurses might vary between different medical facilities. The purpose of the present study was to explore factors that affect the intention of nurses at a long-term care facility to receive the influenza vaccine and whether the health belief model predicts this intention. In this cross-sectional quantitative correlational study, a convenience sample of 150 nurses employed at a large long-term care facility in central Israel completed a questionnaire based on the health belief model. Data collection took place between January and February of 2016. Forty-two percent of the respondents reported having been vaccinated against influenza in the current year. The health belief model explained 53% of the variance (p<.01), with perceived (personal) benefits of the vaccine being the most significant factor. The number of times of receiving the influenza vaccine in the past was strongly correlated with the intention to receive the vaccine (p<.01). To improve nurses' compliance with influenza vaccination at long-term care facilities, we find that it is necessary to emphasize the benefits of vaccination and, particularly, the personal benefits. Annual vaccination behavior should be promoted to make it become a routine.

Implementation of a Diabetes Management Flow Sheet in a Long-Term Care Setting.

Physicians lack clear guidance about adaptation of clinical practice guidelines for elderly institutionalized patients with diabetes. In a large long-term care facility, a diabetes management flow sheet was trialed to determine which clinical parameters were found useful by clinicians in the management of diabetes in that setting. Clinical practice guidelines for diabetes management were reviewed with attending physicians. Diabetes management flow sheets were distributed for all patients coded as having diabetes on their most recent minimum data sets. After a period of 14 months, flow sheet completion rates were ascertained and physicians were surveyed regarding the utility of the flow sheet. Initial flow sheet data were completed in full or in part for only 57% of the 121 study subjects; 39% of the subjects died within 14 months. Quarterly follow-up data were completed for 58% of the flow sheets. The diabetes management flow sheet was not found to be useful by attending physicians as a chronic-disease management tool.

Nurses' experiences of the seasonal influenza vaccine in residential care.

The experience of nurses who work in the residential elderly care setting regarding the seasonal influenza vaccine is often overlooked, with a paucity of published qualitative studies. The aim of this study is to present an insight into the issues concerning nurses with regard to the seasonal influenza vaccine. The study purposively sampled registered nurses (n=11) working in a large long-term care facility for older people (n=142) in Ireland. Using a broad qualitative research approach, data were collected through interviews, transcribed, analysed and grouped into the following themes: knowing: the seasonal influenza vaccine; mandatory vaccination: balancing autonomy and control; and meaningful education. This study reveals the complexity of issues and concerns for nurses when it comes to the seasonal influenza vaccine. These issues and concerns include influences such as family, friends, peers, the media and how nurses inform themselves. The position of nurses within the organisation and recommendations for meaningful nurse education are also discussed. The findings of this study provide an insight that could inform future influenza policy and education, which should be explored before the introduction of any mandatory influenza campaigns.

Immediate financial impact of computerized clinical decision support for long-term care residents with renal insufficiency: a case study

In a randomized trial of a clinical decision support system for drug prescribing for residents with renal insufficiency in a large long-term care facility, analyses were conducted to estimate the system's immediate, direct financial impact. We determined the costs that would have been incurred if drug orders that triggered the alert system had actually been completed compared to the costs of the final submitted orders and then compared intervention units to control units. The costs incurred by additional laboratory testing that resulted from alerts were also estimated. Drug orders were conservatively assigned a duration of 30 days of use for a chronic drug and 10 days for antibiotics. It was determined that there were modest reductions in drug costs, partially offset by an increase in laboratory-related costs. Overall, there was a reduction in direct costs (US$1391.43, net 7.6% reduction). However, sensitivity analyses based on alternative estimates of duration of drug use suggested a reduction as high as US$7998.33 if orders for non-antibiotic drugs were assumed to be continued for 180 days. The authors conclude that the immediate and direct financial impact of a clinical decision support system for medication ordering for residents with renal insufficiency is modest and that the primary motivation for such efforts must be to improve the quality and safety of medication ordering.

Physically restraining elder residents of long‐term care facilities from a nurses' perspective

The purpose of the current study was to identify and analyse major variables affecting intended decisions of nursing staff to physically restrain elder residents of long-term care facilities. The study explored whether a research model constructed of staff characteristics and resident characteristics would prove useful for predicting behavioural intentions. A total of 120 reliable and validated questionnaires, based on the research model, were administered to nurses working in a large long-term care facility for older adults in central Israel; 104 questionnaires were returned for a response rate of 86%. The research findings indicate that most of the nurses who responded (67.2%) reported that they had physically restrained elder residents more than 10 times over the past year; however, the nurses had a low intention of restraining residents during the coming year. The research results indicate that the intended decision of nursing staff to restrain elderly residents is a derivative of their behavioural beliefs and attitudes, normative beliefs and subjective norms, as well as of residents' dementia, physical state and stress.

C-A4-01: Computerized Clinical Decision Support During Drug Ordering for Long-term Care Residents With Renal Insufficiency

Terry S Field, DSc, Paula Rochon, MD, Monica Lee, PharmD, Linda Gavendo, RPh, Joann L Baril, BS and Jerry H Gurwitz, MD Terry S Field, DSc, Meyers Primary Care Institute; Paula Rochon, MD, Kunin-Lunenfeld Applied Research Unit; Monica Lee, PharmD, Kunin- Lunenfeld Applied Research Unit; Linda Gavendo, RPh, Kunin-Lunenfeld Applied Research Unit; Joann L Baril, BS, Meyers Primary Care Institute; Jerry H Gurwitz, MD, Meyers Primary Care Institute

Computerized Clinical Decision Support During Medication Ordering for Long-term Care Residents with Renal Insufficiency

ObjectiveTo determine whether a computerized clinical decision support system providing patient-specific recommendations in real-time improves the quality of prescribing for long-term care residents with renal insufficiency. DesignRandomized trial within the long-stay units of a large long-term care facility. Randomization was within blocks by unit type. Alerts related to medication prescribing for residents with renal insufficiency were displayed to prescribers in the intervention units and hidden but tracked in control units. MeasurementThe proportions of final drug orders that were appropriate were compared between intervention and control units within alert categories: (1) recommended medication doses; (2) recommended administration frequencies; (3) recommendations to avoid the drug; (4) warnings of missing information. ResultsThe rates of alerts were nearly equal in the intervention and control units: 2.5 per 1,000 resident days in the intervention units and 2.4 in the control units. The proportions of dose alerts for which the final drug orders were appropriate were similar between the intervention and control units (relative risk 0.95, 95% confidence interval 0.83, 1.1) for the remaining alert categories significantly higher proportions of final drug orders were appropriate in the intervention units: relative risk 2.4 for maximum frequency (1.4, 4.4); 2.6 for drugs that should be avoided (1.4, 5.0); and 1.8 for alerts to acquire missing information (1.1, 3.4). Overall, final drug orders were appropriate significantly more often in the intervention units—relative risk 1.2 (1.0, 1.4). ConclusionsClinical decision support for physicians prescribing medications for long-term care residents with renal insufficiency can improve the quality of prescribing decisions.Trial Registration: http://clinicaltrials.gov Identifier: NCT00599209

Effect of Computerized Provider Order Entry with Clinical Decision Support on Adverse Drug Events in the Long‐Term Care Setting

To evaluate the efficacy of computerized provider order entry with clinical decision support for preventing adverse drug events in long-term care. Cluster-randomized controlled trial. Two large long-term care facilities. One thousand one hundred eighteen long-term care residents of 29 resident care units. The 29 resident care units, each with computerized provider order entry, were randomized to having a clinical decision support system (intervention units) or not (control units). The number of adverse drug events, severity of events, and whether the events were preventable. Within intervention units, 411 adverse drug events occurred over 3,803 resident-months of observation time; 152 (37.0%) were deemed preventable. Within control units, there were 340 adverse drug events over 3,257 resident-months of observation time; 126 (37.1%) were characterized as preventable. There were 10.8 adverse drug events per 100 resident-months and 4.0 preventable events per 100 resident-months on intervention units. There were 10.4 adverse drug events per 100 resident-months and 3.9 preventable events per 100 resident-months on control units. Comparing intervention and control units, the adjusted rate ratios were 1.06 (95% confidence interval (CI)=0.92-1.23) for all adverse drug events and 1.02 (95% CI=0.81-1.30) for preventable adverse drug events. Computerized provider order entry with decision support did not reduce the adverse drug event rate or preventable adverse drug event rate in the long-term care setting. Alert burden, limited scope of the alerts, and a need to more fully integrate clinical and laboratory information may have affected efficacy.

Both Sleepless AD Patients, Caregivers Benefit From Nondrug Interventions

Both Sleepless AD Patients, Caregivers Benefit From Nondrug Interventions

Development of a Comprehensive Falls Prevention Model in a Long-Term Care Facility

This article discusses the development of a comprehensive falls prevention and injury reduction model in a large long-term care facility. The model, appropriately named the S.A.F.E. program, was adopted from another Veterans Administration medical center and significantly revised to meet the specific needs of our patient population. The importance of carefully selecting a fall risk screening tool to identify those residents that have a high probability of falling is discussed. Intrinsic and extrinsic risk factors are briefly reviewed based on the current literature. High-risk residents should be referred to the appropriate discipline for in-depth assessment. Evidenced-based interventions that address these risk factors are discussed. Interventions are preventative or reactive in nature and specifically designed to prevent falls or to reduce the degree of injury respectively. The value of continuous quality improvement measures is reviewed. A clinical falls algorithm is discussed along with the S.A.F.E. model that outlines the steps staff should follow to improve resident safety as it relates to falls.

Asymptomatic Bacteriuria in Institutionalized Elders in Israel

<h3>Objectives</h3> To document the prevalence of asymptomatic bacteriuria in patients in one large long-term care facility, and describe clinical outcomes in initially bacteriuric and nonbacteriuric residents during prospective observation encompassing one year. <h3>Methods</h3> Patients enrolled in the study were residents of the Haim-Shoham Geriatric Center, a long-term care institute with 800 inhabitants. Twenty patients were related randomly for study enrollment on each of the ten wards. A urine culture was obtained from the enrolled patients. A second culture was obtained within one week if the initial culture grew ≥ 10⁵ colony-forming units per milliliter (cfu/ml) of at least one uropathogen. Demographic data and comorbidities, as well as most recent laboratory results, were recorded for all patients enrolled. Subjects were followed prospectively for one year or until death. Clinical events and usage of antibiotics were recorded. In patients with asymptomatic bacteriuria, repeated urine cultures were obtained every two months. <h3>Results</h3> Eighty-five (43.3%) of a total of 196 elder residents screened presented asymptomatic bacteriuria. There were no differences between patients with and without asymptomatic bacteriuria in age, gender, and underlying diseases. Patients with asymptomatic bacteriuria were significantly more bed-ridden (91.7% vs. 82.1%, <i>P</i> = 0.05); demented (78.8% vs. 59.8%, <i>P</i> = 0.03); and incontinent of urine (93% vs. 71.4%, <i>P</i> < 0.0001) and bowel (85.8% vs. 59.3%). During one year of prospective observation, bacteriuric patients had a mortality rate of 25.9%, compared to 7.1% for nonbacteriuric (<i>P</i> < 0.0001). Mortality in the group with bacteriuria was higher due to both urinary infection and other causes. <h3>Conclusions</h3> In our population, asymptomatic bacteriuria was associated with increased functional impairment and increased mortality over 12 months. The increased mortality, however, was not fully attributable to urinary infection.

Asymptomatic Bacteriuria in Institutionalized Elders in Israel

To document the prevalence of asymptomatic bacteriuria in patients in one large long-term care facility, and describe clinical outcomes in initially bacteriuric and nonbacteriuric residents during prospective observation encompassing one year. Patients enrolled in the study were residents of the Haim-Shoham Geriatric Center, a long-term care institute with 800 inhabitants. Twenty patients were related randomly for study enrollment on each of the ten wards. A urine culture was obtained from the enrolled patients. A second culture was obtained within one week if the initial culture grew >or= 10(5) colony-forming units per milliliter (cfu/ml) of at least one uropathogen. Demographic data and comorbidities, as well as most recent laboratory results, were recorded for all patients enrolled. Subjects were followed prospectively for one year or until death. Clinical events and usage of antibiotics were recorded. In patients with asymptomatic bacteriuria, repeated urine cultures were obtained every two months. Eighty-five (43.3%) of a total of 196 elder residents screened presented asymptomatic bacteriuria. There were no differences between patients with and without asymptomatic bacteriuria in age, gender, and underlying diseases. Patients with asymptomatic bacteriuria were significantly more bed-ridden (91.7% vs. 82.1%, P = 0.05); demented (78.8% vs. 59.8%, P = 0.03); and incontinent of urine (93% vs. 71.4%, P < 0.0001) and bowel (85.8% vs. 59.3%). During one year of prospective observation, bacteriuric patients had a mortality rate of 25.9%, compared to 7.1% for nonbacteriuric (P < 0.0001). Mortality in the group with bacteriuria was higher due to both urinary infection and other causes. In our population, asymptomatic bacteriuria was associated with increased functional impairment and increased mortality over 12 months. The increased mortality, however, was not fully attributable to urinary infection.

Development and psychometric evaluation of the Environment-Behavior Interaction Code (EBIC).

Although the behavioral changes with progressive dementia are seen to increasingly depend on the environmental context until late stage disease, measurement has not reflected this interaction in real time to allow examination of antecedents to disruptive behavior. To develop and evaluate the psychometric properties of the Environment-Behavior Interaction Code (EBIC) for use in dementia care research with either sequential or nonsequential analyses of behavioral data. Development of the computer-based (sequential event format) EBIC provided an observational coding system to classify all behavior and environmental context in real time, so that the probability of social environmental antecedents to resident disruptive behavior could be estimated. A checklist (interval format) EBIC, based on the same behavioral taxonomy, was developed for clinical outcome research. A total of 158 elderly residents of dementia care units were purposively selected from three large long-term care facilities for the psychometric study components. Psychometric results indicated significant (p < 0.01) known-groups validity for the disruptive behavior construct, which was defined as a composite of aversive, harmful, and high intensity neutral behavior. Interrater agreement for the event format of the EBIC was estimated by average kappa (0.65) and percentage agreement (78%). For the interval format, the mean interrater kappa was 0.80 with 96% agreement. Stability of the event format using a 2-week retest interval ranged from r= .50 (positive behavior) to r = 0.73 (negative behavior, defined as aversive + harmful). On replication with a new sample, stability was higher for positive (r = 0.92) and negative (r = 0.95) components, and for composite scores of nondisruptive (positive + low intensity neutral; r = 0.65) and disruptive (r= 0.85) behavior. This research provided support for the reliability and validity of both event and interval EBIC formats. Measurement using the EBIC taxonomy has applicability to dementia care research questions that call for either sequential analysis of social interactions or nonsequential analysis of behavioral outcomes in intervention studies.

Some Methodologic Considerations in Nursing Diagnosis Research

The validation of nursing diagnostic concepts, interventions, and desired outcomes is necessary for the development of nursing science. The purpose of this article is to contribute to the development of more rigorous methods for research of nursing diagnoses. Methodologic problems and issues are discussed and illustrated in the context of a descriptive study of the nursing diagnoses of patients at a large long-term care facility. Issues surrounding the selection of setting and samples, the source and presentation of data collected, and methods used for data analysis and interpretation are described. The need for consistency among research questions, setting and sample, data collection methods, and data analysis and interpretation are emphasized. Researchers are encouraged to explicate the issues and decisions in nursing diagnosis research to encourage scholarly criticism and refinement by clinicians and scientists.