Long-term Care Facilities Patients Research Articles

Impact of nursing home admission on in-hospital mortality and morbidity and length of stay: A case-control analysis

MethodsWe examined a quality measurement database containing de-identified cases from across Switzerland. All patients with a complete dataset treated between 2015 and 2021 were included. A case-control matching method (same age, comorbidity, sex, diagnosis, admission type, and insurance coverage) was used to evaluate the impact of pre-admission residence. The outcomes measured included complications during hospitalization, in-hospital mortality, and length of stay. Statistical significance was set at a p-value of <0.001 due to our large size of analyzed cases. ResultsWe noted a higher prevalence of comorbidities and higher ASA scores among the 2130 (1.9 %) patients admitted from long-term care facilities (LTCFs). Complication rates in the LTCF group were higher than those in the home group (15 % vs. 6.9 %, p = <0.001). Pneumonia was the most frequent complication in both groups. The in-hospital mortality rate was also significantly higher in the LTCF group than the home group (5.8 % vs. 1.1 %, p = <0.001). However, matched-pair analysis showed no significant difference in complication rates and overall mortality between the two groups. Patients admitted from LTCFs even had a shorter hospital stay (7.5 ± 8.7 days vs. 8.9 ± 7.9 days, p = <0.004). ConclusionsDespite higher complication and mortality rates among LTCF patients, the matched-pair analysis showed no significant differences in these rates between the two groups. However, patients from LTCFs were discharged earlier, indicating the effectiveness of Switzerland's care system for older adults living in nursing homes.

Colonization with drug-resistant pathogens among patients in long-term care facilities and under home hospice care - a cross-sectional study.

The spread of drug-resistant bacteria is deemed a worldwide threat. Patients in long-term care, including those under palliative care, are exposed to a high risk of colonization and infection with drug-resistant pathogens. This refers primarily to long-term care facilities as opposed to home care. A cross-sectional study was carried out between 1January 2018 - 30 June 2019. The study was approved by the Bioethics Committee at the Medical University of Warsaw (KB/222/2017). The aim of the study was to assess the frequency and type of colonization with drug-resistant pathogens among patients in long-term care facilities and those under home hospice care. An additional aim was evaluation the risk of pathogen transmission according to the type of provided long-term care. The study included 129 participants: 68 patients under the care of 3 long-term care facilities in Warsaw, Poland, 42 patients under home hospice care, and 19 household members of hospice patients. All included participants provided written informed consent. Oropharyngeal and rectal swabs were obtained from all participants for microbiological assessment. Colonization with pathogens was more common in long-term care facilities residents (82.4%)than in at-home hospice patients (42.9%). Risk of colonization was significantly lower in patients staying at home than in long-term care facilities patients (OR 0.16; 95% CI 0.06-0.38). Conclusions. Risk of colonization with drug-resistant pathogens depends on the type of care and is significantly higher in patients staying at long-term care facilities. Systemic measures, such as microbiological screening, are necessary to provide optimal patient care and to ensure epidemiological safety, both to patients and their caregivers.

88. Increasing Bioburden of Candida auris Body Site Colonization is Associated with Environmental Contamination

Abstract Background Environmental contamination is suspected to play a key role in transmission of Candida auris in healthcare facilities. We recently showed that environmental surfaces near C. auris-colonized patients are commonly recontaminated within hours after disinfection. Clinical factors contributing to environmental contamination are not well characterized. Methods We conducted a multi-regional (Chicago, IL; Irvine, CA) prospective study of environmental contamination associated with C. auris colonization at six long-term care facilities (LTCF) and 1 acute-care hospital (ACH). On day of sampling, 5 participant body sites were cultured once, followed by routine daily room cleaning by facility staff, then targeted disinfection of high-touch surfaces with hydrogen peroxide wipes by research staff. Surfaces were cultured for C. auris using pre-moistened sponge-sticks and neutralizer immediately pre- and post-disinfection, and 4, 8, and 12 hours post-disinfection. We calculated the odds of surface recontamination after disinfection as a function of body site colonization with C. auris using generalized estimating equations to account for clustering among multiple surfaces within timepoints, patients, and facilities. Models included an interaction between facility type and colonization. Results C. auris was cultured from ≥1 body site in 41 participants (12 ACH and 29 LTCF patients, 205 body sites) on day of sampling. Proportion of body sites colonized did not vary by facility type (Table). Although environmental contamination rates were similar prior to disinfection [ACH 38% (n=60 samples) vs LTCF 29%, (n=145 samples), p=0.209)], the proportion of surfaces recontaminated between 4–12 hours after disinfection was higher in ACH vs LTCF (n=574 samples) (Figure). Number of body sites colonized with C. auris was associated with higher odds of environmental recontamination [ACH: OR 2.16 (95% CI 1.63–2.88), p&amp;lt; 0.001; LTCF: OR 1.40 (95% CI 1.07–1.84), p=0.015; Interaction ACH vs LTCF p&amp;lt; 0.001]. Conclusion The number of body sites colonized was associated with odds of C. auris environmental contamination. Differences in environmental recontamination by facility type may be related to greater provider-patient interactions in ACH as a driving factor. Disclosures Gabrielle M. Gussin, MS, Medline: Conducted studies in which hospitals and nursing homes received contributed antiseptic and/or environmental cleaning products|Stryker: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products|Xttrium Laboratories: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products Raveena D. Singh, MA, Medline: Conducted studies in which hospitals and nursing homes received contributed antiseptic and/or environmental cleaning products|Stryker: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products|Xttrium Laboratories: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products Raheeb Saavedra, AS, Medline: Conducted studies in which hospitals and nursing homes received contributed antiseptic and/or environmental cleaning products|Stryker: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products|Xttrium Laboratories: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products Nicholas M. Moore, PhD, D(ABMM), Abbott Molecular: Grant/Research Support|Cepheid: Grant/Research Support Susan S. Huang, MD, MPH, Medline: Conducted studies in which hospitals and nursing homes received contributed antiseptic and/or environmental cleaning products|Molnlyke: Conducted clinical studies in which hospitals received contributed antiseptic product|Stryker: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products|Xttrium Laboratories: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic product Mary K. Hayden, MD, Sanofi: Member, clinical adjudication panel for an investigational SARS-CoV-2 vaccine.

Modified reporting of positive urine cultures to reduce treatment of asymptomatic bacteriuria in long-term care facilities: a randomized controlled trial.

ObjectivesWe conducted a prospective, randomized, unblinded superiority trial of the safety and efficacy of modified reporting of positive urine cultures to improve the appropriateness of treatment for asymptomatic bacteriuria (ASB) and urinary tract infection (UTI) in long-term care facilities (LTCFs).MethodsConsecutive positive urine cultures collected from LTCF patients were randomized between standard (identification and susceptibility) or modified (without identification and susceptibility) laboratory reports. Exclusion criteria were current antibiotic treatment, neutropenia, or transfer to acute care. The diagnosis of UTI or ASB was made prospectively.ResultsOne hundred and sixty-nine urine cultures were considered, 100 were randomized and included in ITT analysis, and 96 were included in PP analysis. Sixty-two out of 100 (62%) patients had ASB [41/62 (66%) treated] and 38/100 (38%) had UTI [35/38 (92%) treated]. The lab was called to report the identification and susceptibility in 31/51 (61%) modified reports. The rate of appropriate treatment was higher in the modified report arm: 31/51 (61%) versus 25/49 (51%) (+10%, P = 0.33). Untreated ASB was higher in the modified report arm: 13/32 (41%) versus 8/30 (27%) (+14%, P = 0.25). There were two deaths (one treated ASB, one untreated ASB) and 15 adverse events in the modified arm. There were no deaths (P = 0.16) and 11 adverse events (P = 0.43) in the standard arm. Three patients with untreated UTI survived.ConclusionsModified reporting of urine culture improved the appropriateness of treatment by reducing treatment of ASB, but not significantly. Many LTCF prescribers requested standard urine culture reports. Modified reporting may not be suitable for LTCF implementation.

Clinical Impact of the Early Use of Monoclonal Antibody LY-CoV555 (Bamlanivimab) on Mortality and Hospitalization Among Elderly Nursing Home Patients: A Multicenter Retrospective Study.

ImportanceCoronavirus disease 2019 (COVID-19) outbreaks are frequent occurrences in nursing homes and long-term care facilities (LTCFs), resulting in subsequent hospitalization and death.RationaleVirus-neutralizing monoclonal antibodies demonstrate a significant decrease in both viral load and hospital transfer rate among patients with mild-to-moderate COVID-19 infection.ObjectiveTo assess the clinical outcomes of COVID-19 patients with mild-to-moderate symptoms in LTCFs who received LY-CoV555 as compared to those who did not receive this treatment.DesignRetrospective case-control study and logistic regression analysis.SettingLTCFs in New York.ParticipantsTwo-hundred forty-six (246) LTCF patients diagnosed with mild-to-moderate COVID-19 infection with positive COVID-19 polymerase chain reaction (PCR) from November 15, 2020, to January 31, 2021.MethodsTwo-hundred forty-six (246) COVID-19 patients were identified from electronic medical records, out of which 160 cases were exposed to LY-CoV555 treatment (700 mg single dose, intravenous infusion). Eighty-six (86) patients were unexposed controls who did not receive monoclonal antibodies, LY-CoV555.OutcomeWe assessed the odds of death and hospitalization of exposed cases as compared to unexposed controls. Using logistic regression analysis, we also assessed the risk factors associated with these outcomes in the entire sample population.ResultsThe mean age of the entire sample was 82.4 years. Fifty-two percent (52%) of patients (n = 129) were female and 48% (n = 117) were male. The mean ages of the exposed group and the unexposed group were 81 years and 84 years, respectively. At the end of the study, 92% (148/160) of the exposed group were alive or not transferred to the hospital as compared to 79% (68/86) patients of the unexposed group (OR 3.23, 95% CI: (1.48, 7.31), p-value = 0.0032). Three percent (3%; 5/160) of patients died in the exposed group compared to 10% (9/86) of patients who died in the unexposed group (OR = 0.25, 95% CI: (0.1, 0.85), p-value = 0.0257). Four point thirty-seven percent (4.37%; 7/160) of patients in the exposed group and 10.46% (9/86) of patients in the unexposed group were transferred to the hospital (OR = 0.35, 95% CI: (0.15, 1.08), p-value = 0.0793).ConclusionEarly treatment with monoclonal antibody LY-CoV555 is associated with decreased mortality among high-risk patients with mild-to-moderate COVID-19 infection in LTCFs. Although not statistically significant, there was a trend towards a lower risk of hospitalization in patients treated with LY-CoV555.

1006. Demographic, Clinical, Microbiological Characteristics and Outcome of Patients Admitted to the Emek Medical Center with Blood Stream Infection Acquired in LTCF: A 5-Year Surveillance

BackgroundResidents from long-term care facilities (LTCF) hospitalized with an acute infectious disease are challenging in terms of diagnosis and treatment, considering atypical clinical presentation are high rate of resistant bacteria,.This study aimed to Characterize patients with LTCF acquired bacteremia (LTCF-B), epidemiology of blood cultures (BC) and potential risk for mortality.MethodsA retrospective study of LTCF residents hospitalized with LTCF-B. Demographic, clinical and laboratory data were collected and analyzed using SPSS 22 and SAS.ResultsOne hundred seventy-seven LTCF residents hospitalized in internal wards were included, mean age 81.6 years, mostly completely dependent, 54.8% were males. Most frequent diagnoses was urinary tract infection (UTI), second by respiratory tract infections. Half were hospitalized during prior 6 months, one-third had a permanent indwelling urinary catheter. On admission, 70% had WBC blood count >10,000 cells/mL. The following pathogens were isolated from BC: Gram-negative enterobacteriaceae (70%): E. coli were 40% and Gram-positive cocci (21%): S. aureus 5.08% (55.5% of them MRSA). Extended-spectrum-β-lactamase (ESBL) producing enterobacteriaceae were in 47.1% BC, clearly document increase during the years, 26% (2010)–63% (2014). Absolute majority of enterobacteriaceae were sensitive to carbapenems and amikacin, half were resistant to gentamycin, second- and third-generation cephalosporins and quinolones. Inappropriate empiric antimicrobial therapy was given to 46.8% of patients with ESBL-producing enterobacteriaceae (P < 0.001). Mortality rates were 21.5% in-hospital and 46.3% day-90 post discharge. Variables associated with mortality: initial diagnosis of skin and soft-tissue infections (SSTI) (OR = 14.44), inappropriate empiric antibiotic (OR = 5.038), high level of urea (OR = 1.017), and nasogastric tube (OR = 4.966). UTI (OR = 0.316) was a protective factor.ConclusionDiagnosis of SSTI, high urea levels, nasogastric tube, and inappropriate empiric antibiotic were associated with in-hospital mortality. The notable increased rate of ESBL-producing enterobacteriaceae should alert physicians to be aware of local microbial resistance profile, especially among LTCFs patients.Disclosures All authors: No reported disclosures.

491. Clinical Manifestations and Outcomes of Clostridium difficile Infection in Long-Term Care Patients: An 8-Year Retrospective Cohort Study

BackgroundResidents of long-term care facilities (LTCF) have high risk of Clostridium difficile infection (CDI) and its associated adverse outcomes. We describe the clinical characteristics and outcomes of CDI in LTCF patients admitted to an acute care (AC) hospital.MethodsThis is a descriptive retrospective study of CDI patients admitted to Detroit Medical Center (DMC) from LTCF from January 2009 to December 2017. Patients identified through chart review as having CDI on admission or within 48 hours of admission and without recent AC hospitalization in the prior 4 weeks were included. CDI and CDI severity were defined based on 2017 clinical consensus guidelines. Definitions: CDI-Either presence of diarrhea or evidence of ileus or megacolon and either presence of C. difficile toxin in stool or evidence of pseudomembranous colitis. Severe CDI-Presence of white blood counts ≥15,000 and serum creatinine >1.5 mg/dL. Complicated CDI-Presence of either toxic megacolon, sepsis, systemic inflammatory response syndrome, colonic perforation, or requiring ICU admission. Demographics, medical conditions, laboratory results, prior 60-day antibiotic use, CDI treatment, and outcomes were collected. Patients’ follow-up extended 90 days; however, data were limited to hospital charts from index admission or readmission to the same hospital.ResultsAmong the 85 patients who met the inclusion criteria, 45 (53%) were female, the mean age was 76 (SD: 16), and the median Charlson index score was 6 (range: 4–8). The common source of prior 60-day antimicrobial exposure was β-lactam/β-lactamase inhibitors (39%), Flagyl (15%), vancomycin (18%). The majority of patients were treated with flagyl (71%), 41% with vancomycin and 17% with concurrent or sequential flagyl and vancomycin. Majority of CDI patients (56%) experienced severe CDI with 25% experiencing complicated CDI. During the 90-day follow-up period, 32% of patients required readmission (within 30 days of discharge) for recurrent CDI and 15% of patients died in the hospital.ConclusionCDI patients admitted to DMC from LTCF experience considerable clinical burden. Further research is warranted toward understanding the burden of CDI among LTCF patients admitted to AC facilities.Disclosures S. Chandramohan, Pfizer Inc.: Collaborator, Research grant. P. Zhang, Pfizer Inc.: Employee, Salary. K. Heinrich, Pfizer Inc.: Employee, Salary. E. Gonzalez, Pfizer Inc.: Employee, Salary. T. Chopra, Pfizer Inc.: Collaborator, Research grant.

Examining the epidemiology and microbiology of Clostridium difficile carriage in elderly patients and residents of a healthcare facility in southern Ontario, Canada

Whereas Clostridium difficile has been extensively studied in acute care facilities (ACFs), there is limited information about long-term care facilities (LTCFs), despite the high occurrence of putative risk factors (e.g. age, antimicrobial use, healthcare system contact). To evaluate C.difficile colonization in elderly patients and residents from one ACF and its associated LTCF. Stool swabs were collected from 884 LTCF and elderly (>65 years) hospital patients. Selective culture, polymerase chain reaction ribotyping and toxin gene characterization were performed. C.difficile was isolated from 92/410 (22.4%) ACF and 89/474 (18.8%) LTCF samples. Ribotypes 027 (35%) and 020 (10.4%) predominated in the LTCF whereas ribotypes AI-82/1 (20.7%) and ribotype O (14.1%) predominated at the ACF (P=0.031). In the LTCF, C.difficile colonization was associated with a history of proton pump inhibitor (PPI) use, and the interaction terms of male residents with prior medical leave of absence, and a prior history of C.difficile infection (CDI) combined with fluoroquinolone use. In the ACF, C.difficile colonization was associated with length of stay, feeding through a tube, antibiotic use, immunosuppressive therapy and VRE colonization, as well as the interaction terms for cephalosporin and fluoroquinolone use, prior CDI and cephalosporin use, and prior CDI and fluoroquinolone use. C.difficile colonization by ACF and LTCF residents was common, despite a low apparent incidence of CDI. The association with PPI provides further evidence of the potential importance of this widely used drug class in C.difficile colonization. Wide genetic diversity was present, highlighting the likelihood of multiple unidentified routes of C.difficile acquisition.

Epidemiology of Clostridium difficile-Associated Disease (CDAD): A Shift from Hospital-Acquired Infection to Long-Term Care Facility-Based Infection

Previous epidemiological studies on Clostridium-difficile-Associated Diarrhea (CDAD) have focused on hospitalized patients with nosocomial transmission. However, increasing numbers of patients with CDAD are being admitted to acute-care hospitals from long-term care facilities (LTCFs) and the local community. The purpose of our study was to study the changing epidemiological trends of CDAD patients admitted to an acute-care hospital and examine factors contributing to this shift in epidemiology. This IRB-approved retrospective study included 400 randomly selected patients with a diagnosis of CDAD, admitted to an acute-care hospital between January, 2005 and December, 2010. CDAD was defined as ≥3 episodes of loose stools in <24 h with a positive Clostridium difficile stool toxin assay. The patients were divided into three groups: hospital-acquired CDAD, long-term care facility (LTCF)-acquired CDAD, and community-acquired CDAD. The groups were compared in terms of demographics, ICU admissions, hospital length of stay, co-morbidities, presenting complaint, and medication use. Patients who were hospitalized in the preceding 12 weeks or who had history of antibiotic use in the prior 8 weeks were excluded. Final analysis included 258 toxin-positive CDAD patients. Only 53 (20.6%) patients had hospital-acquired CDAD. Patients from LTCFs (n=119, 46.1%) and the community (86 patients, 33.3%) comprised 79.4% of patients. The mean age for LTCF population was significantly higher than the hospital-acquired and community-acquired CDAD groups (p<0.0001). The presenting complaint was categorized as diarrhea or non-diarrheal symptom. Other non-diarrheal symptoms included fever, abdominal pain and altered mental status. Only 15.2% of LTCF patients had diarrhea as their presenting complaint (n=18) as compared to 29.1% of patients from the community (n=25; p<0.05). Most LTCF patients (n=101, 84.8%) had non-diarrheal symptoms as their presenting complaint as compared to only 61 patients from the community (70.9%) (p<0.05). Use of proton pump inhibitor (PPI) was more frequent in LTCF patients (73%) and patients with hospital-acquired CDAD (69.8%) as compared to patients with community-acquired CDAD (43%) (p<0.05). No valid indication was found for PPI use in 24.13% of LTCF patients and 32.1% of patients with community-acquired CDAD as compared to only 12.9% of patients with hospital-acquired CDAD. These observations suggest that CDAD originated predominantly in patients from LTCFs (46.1%) and community (33.3%) rather than from hospitalized patients (20.6%). Diarrhea was the presenting complaint in LTCF patients in only 15.2% of cases. Hence, CDAD should be suspected if LTCF patients present with symptoms such as abdominal pain, fever, or altered mental status along with loose stools. Majority of the LTCF patients were found to be on PPIs, a risk factor for CDAD, with as many as 24% of these patients with no valid indication for their use.

Epidemiology and genetic characteristics of extended-spectrum -lactamase-producing Gram-negative bacteria causing urinary tract infections in long-term care facilities

To assess risk factors for acquiring extended-spectrum β-lactamase-producing Gram-negative bacteria (ESBL+ GN) causing urinary tract infections (UTIs) in long-term care facilities (LTCFs). A prospective case-case-control study was carried out. In the first study, cases were defined as patients harbouring ESBL+ GN, while, in the second study, cases were defined as patients harbouring ESBL-negative (ESBL-) GN. Controls were selected by simple random sampling from patients without GN infection. ESBL determinants were characterized by hybridization, and confirmed by PCR and sequencing. The study involved 297 LTCF patients (99 with ESBL+ GN UTI, 99 with ESBL- GN UTI and 99 without GN infection). ESBL+ GN UTIs were due to Escherichia coli (64%), Proteus mirabilis (25%) and Klebsiella pneumoniae (11%). The CTX-M-type enzymes were the most prevalent (73% of isolates), whereas TEM- and SHV-type ESBLs and AmpC-type enzymes were less prevalent (10%, 2% and 15% of isolates, respectively). Patients with ESBL+ GN UTI were more likely to have a permanent urinary catheter (OR 15, 95% CI 6.9-30.5) and to have received antimicrobial therapy in the previous 30 days (OR 4, 95% CI 1.2-10.9). After adjusting for type, dosage and duration of antibiotic, exposure to ≥7 days of quinolones and third-generation cephalosporins was associated with the highest risk of ESBL+ GN UTI development (OR 7, 95% CI 1.2-40). Independent risk factors for acquiring ESBL- GN UTIs were previous surgical procedures (OR 2, 95% CI 1.1-4) and the presence of a urinary catheter (OR 8, 95% CI 4-16). No specific antibiotics remained a significant risk for ESBL- GN UTI after adjusting for demographic and clinical risk factors. Exposure to ≥7 days of quinolones and third-generation cephalosporins significantly increases the risk of ESBL+ GN UTI. Interventions aimed at improving compliance with antimicrobial stewardship principles should be further developed and implemented in LTCFs.

Antimicrobial Resistance in Long-Term Care Facilities

During the last quarter century, numerous reports have indicated that antimicrobial resistance commonly is encountered in long-term–care facilities (LTCFs). Gramnegative uropathogens resistant to penicillin, cephalosporin, aminoglycoside, or fluoroquinolone antibiotics and methicillin-resistant Staphylococcus aureus have received the greatest attention, but other reports have described the occurrence of multiply-resistant strains of Haemophilus influenzae and vancomycin-resistant enterococci (VRE) in this setting. Antimicrobial-resistant bacteria may enter LTCFs with colonized patients transferred from the hospital, or they may arise in the facility as a result of mutation or gene transfer. Once present, resistant strains tend to persist and become endemic. Rapid dissemination also has been documented in some facilities. Person-to-person transmission via the hands of healthcare workers appears to be the most important means of spread. The LTCF patients most commonly affected are those with serious underlying disease, poor functional status, wounds such as pressure sores, invasive devices such as urinary catheters, and prior antimicrobial therapy. The presence of antimicrobial-resistant pathogens in LTCFs has serious consequences not only for residents but also for LTCFs and hospitals. Experience with control strategies for antimicrobial-resistant pathogens in LTCFs is limited; however, strategies used in hospitals often are inapplicable. Six recommendations for controlling antimicrobial resistance in LTCFs are offered, and four priorities for future research are identified (Infect Control Hosp Epidemiol 1996;17:129-140).

Variability in Glycosylated Hemoglobin Values in Diabetic Patients Living in Long-Term Care Facilities

The objectives of this study were to determine the prevalence of diabetes and mean A1C of patients in long-term care facilities (LTCFs); to determine differences in A1C values based on patient characteristics; and to examine the self-reported practices of providers regarding diabetes management goals. Twelve-month retrospective review of patient charts; survey of physicians and nurse practitioners providing care to these patients. Nursing facility practice of an urban teaching hospital. Participants included 168 diabetic patients living in 20 nursing facilities and 18 physician and nurse practitioners in one practice providing care to these patients. The prevalence of diabetes was 21.6% (168 of 778 patients). Mean A1C was 7.1% +/- 1.2%for 135 patients who had AIC values measured during the study interval. A1C varied by age, with patients younger than 65 having higher A1C values than patients older than 65. Higher A1C values were associated with insulin use, frequent glucose monitoring, and attending a diabetes clinic. Although a survey of providers identified modifying A1C target ranges for LTCF compared with ambulatory patients, they did not reach consensus on the actual target A1C. No association between provider perception of either patient health status or patient life expectancy and A1C values was found. Relatively low A1C values were obtainable in LTCF patients without diabetes specialty clinic use. Providers identified modifying target A1C values for LTCF patients, but achieved relatively low A1C values and did not agree on a target A1C value for LTCF patients.

Outcome in Ambulatory Status Immediately Following Hip Fracture Surgery in the Acute Setting: A Comparison of Nursing Home Residents and Community Older Adults

To compare the ambulatory status following hip fracture surgery in the acute setting between older adults from long-term care facilities (LTCF) and the community. A 650-bed, urban, inner city, university-affiliated teaching hospital. One hundred forty hip fracture patients (60-97 years) from long-term care facilities and the community were examined. Ambulatory status before and after surgery was categorized four ways based on the degree of independence in ambulation: A1 = independent ambulation (with or without an assisting device), A2 = assistance of another person required, A3 = predominant use of a wheelchair, and A4 = bed-bound. Change in ambulatory status was designated as "moderate" if the deterioration was one status level only (A1 to A2, A2 to A3, and A3 to A4) or "major" if the deterioration was more than one status level (A1 to A3/A4 or A2 to A4). Additional variables such as age, sex, risk factors, length of stay, history of drug use, and laboratory results also were examined. Hip fracture patients from LTCF were older (P = 0.0160) and had more overall risk factors for hip fracture (P = 0.0039) than community patients. They also had higher rates of dementia (P < 0.000), arrhythmia (P = 0.025), delirium (P = 0.0016) and anxiolytics use (P = 0.019) than patients from the community. On admission, LTCF patients had lower serum calcium (P = 0.0003), phosphorus (P = 0.0210), and albumin (P = 0.0004) than community patients. Before hospitalization they also were less ambulatory (P = 0.002) than community patients. Post surgery, ambulatory status declined in both groups. However, a "major" change (decline) in ambulatory status occurred more often in LTCF patients (P = 0.001). A greater decline in ambulatory status is seen in patients from LTCF than in community patients, immediately following hip fracture surgery. Compared with community patients, LTCF patients are also older, sicker (higher total risk score) and have an increased risk for a decline in functional status.

Antimicrobial use in long-term-care facilities. SHEA Long-Term-Care Committee.

There is intense antimicrobial use in long-term-care facilities (LTCFs), and studies repeatedly document that much of this use is inappropriate. The current crisis in antimicrobial resistance, which encompasses the LTCF, heightens concerns of antimicrobial use. Attempts to improve antimicrobial use in the LTCF are complicated by characteristics of the patient population, limited availability of diagnostic tests, and the virtual absence of relevant clinical trials. This position paper recommends approaches to management of common infections in LTCF patients and proposes minimal standards for an antimicrobial review program. In developing these recommendations, the position paper acknowledges the unique aspects of provision of care in the LTCF.

Antimicrobial resistance in long-term-care facilities.

During the last quarter century, numerous reports have indicated that antimicrobial resistance commonly is encountered in long-term-care facilities (LTCFs). Gram-negative uropathogens resistant to penicillin, cephalosporin, aminoglycoside, or fluoroquinolone antibiotics and methicillin-resistant Staphylococcus aureus have received the greatest attention, but other reports have described the occurrence of multiply-resistant strains of Haemophilus influenzae and vancomycin-resistant enterococci (VRE) in this setting. Antimicrobial-resistant bacteria may enter LTCFs with colonized patients transferred from the hospital, or they may arise in the facility as a result of mutation or gene transfer. Once present, resistant strains tend to persist and become endemic. Rapid dissemination also has been documented in some facilities. Person-to-person transmission via the hands of healthcare workers appears to be the most important means of spread. The LTCF patients most commonly affected are those with serious underlying disease, poor functional status, wounds such as pressure sores, invasive devices such as urinary catheters, and prior antimicrobial therapy. The presence of antimicrobial-resistant pathogens in LTCFs has serious consequences not only for residents but also for LTCFs and hospitals. Experience with control strategies for antimicrobial-resistant pathogens in LTCFs is limited; however, strategies used in hospitals often are inapplicable. Six recommendations for controlling antimicrobial resistance in LTCFs are offered, and four priorities for future research are identified.

Effect of the prospective-pricing system on drug use in Pennsylvania long-term-care facilities

Health status, nondrug treatment, and drug use were compared for patients discharged from hospitals to seven long-term-care facilities (LTCFs) in Pennsylvania before and after implementation of the prospective-pricing system (PPS) for hospitalized Medicare patients. Data were collected from medical records of LTCF patients for August 1982 through July 1983 (pre-PPS) and August 1985 through July 1986 (post-PPS). Patients in the post-PPS group (n = 297) had greater numbers of illnesses and more serious illnesses on admission to the LTCFs and were more likely to be readmitted to hospitals than pre-PPS patients (n = 312). Patients in the post-PPS group required more nondrug treatments such as urinary catheters, nutritional supplements, and oxygen and received significantly more drug therapy. The cost of drugs was 50% higher in the PPS group. The post-PPS patients admitted to the LTCFs apparently required more posthospital drug and non-drug therapy than the pre-PPS patients. Any system for prospective pricing in LTCFs should take into account the increases in costs for providing long-term care, including drug therapy, that have occurred since prospective pricing for hospitalized patients began.