Long-term Health Care Facility Research Articles

Device-related infections in long-term healthcare facilities: the challenge of prevention.

The world is aging and the number of elderly multimorbid patients is steadily increasing. The limited numbers of acute care beds in hospitals, in addition to the need to reduce costs, has led to the introduction of efficient discharge policies, which in turn have increased demand for beds in nursing homes and long-term care facilities (LTCFs). As a consequence, the number of postacute LTCF residents is rising, as is the number of residents requiring complex medical care delivered by use of indwelling medical devices. These devices place patients at a heightened risk for infection. Furthermore, infection control resources in LTCFs are often limited. This article reviews the preventive measures that should be taken in LTCFs to reduce the risk of device-related infections.

Clinical impact of Gram-negative nonfermenters on adults with community-onset bacteremia in the emergency department

To determine clinical predictors and impact of Gram-negative nonfermenters (GNNFs) infections among adults with community-onset bacteremia in the emergency department (ED). Adults with bacteremia visiting the ED from January 2007 to June 2008 were identified retrospectively. Demographic characteristics, underlying illnesses, clinical conditions, bacteremic pathogens, antimicrobial agents, and outcome, were retrieved from chart records. After the exclusion of 261 patients with contamination of blood cultures and 24 patients referred from other hospitals, 518 adults with community-onset bacteremia were eligible; their mean age was 65.1 years, with slight predominance of female (262 patients, 50.6%). Of a total of 565 bacteremic isolates, Escherichia coli (228 isolates, 40.4%) and Klebsiella pneumoniae (100, 17.7%) were the major microorganisms. GNNFs caused bacteremia in 31 (6.0%) patients. A higher proportion of inappropriate antibiotic therapy in the ED (87.1% vs. 26.5%, p < 0.001) and higher 28-day crude mortality rate (19.4% vs. 8.4%, p = 0.05) were observed in bacteremic patients caused by GNNFs than those not caused by GNNFs. In further analysis of Kaplan-Meier survival curve, patients with GNNF bacteremia had a worse outcome than those due to other pathogens (p = 0.04). Multivariate analysis revealed that the independent predictors related to GNNF bacteremia included surgery during previous 4 weeks prior to ED arrival [odds ratio (OR), 10.79; 95% confidence interval (CI), 1.84-63.24; p = 0.01], residents in long-term healthcare facilities (OR, 4.62; 95% CI, 2.08-10.29; p < 0.001), and malignancy (OR, 2.24; 95% CI, 1.10-5.40; p = 0.02). For adults with bacteremia visiting the ED, GNNF is associated with a higher mortality rate and more inappropriate empirical antibiotic therapy in the ED. To allow early administration of empirical antibiotics, several clinical predictors of GNNF infections were identified.

Dental Implant Status of Patients Receiving Long‐Term Nursing Care in Japan

The increase in implant patients is expected to give rise to a new problem: the changing general health status of those who have had implants placed. The aim of this present study was to find out the needs of and proper measures for elderly implant patients in long-term care facilities. A questionnaire was sent by mail to 1,591 long-term care health facilities, daycare services for people with dementia, and private nursing homes for the elderly in the Osaka area, which is in the middle area of Japan, in order to extract patients with cerebrovascular disease or dementia who were possibly at risk of inadequate oral self-care, as well as patients with implants. Approximately half of all facilities responded that they cannot recognize implants, and many facilities did not know anything about oral care for implant patients. Residents with implants were reported at 19% of all facilities. Also, the facilities pointed out problems with implants relating to the difference in oral care between implants and natural teeth. There are people with implants in some 20% of caregiving facilities, and there is a low level of understanding regarding implants and their care among nurses and care providers who are providing daily oral care.

The Effect of Laughter Intervention on Swallowing Frequency in the Elderly

 Abstract The purpose of this study was to assess the effect of laughter intervention on swallowing frequency in the elderly. Our results showed that swallowing frequency decreased after the start of laughter intervention and increased after the laughing intervention. I. Introduction Laughter in humans promotes balance in the autonomic nervous system and activates NK cells. It also activates the stomatognathic system through the contraction of mimetic and other types of muscles related to speech production. Some research has shown that swallowing function decreases with age due to the progressive loss of strength of muscles in the stomatognathic system. Therefore, caregivers in health care facilities are conducting swallowing exercises to improve swallowing function in the elderly. The aim of this study was to assess the effect of laughter intervention on swallowing frequency in elderly residents at a long-term health care facility.

The assessment and management of falls in residential care settings

Care of the older person has become more specialised in Ireland particularly since the introduction of national and international healthcare standards. In this regard, older people are receiving more evidence-based quality care when living in long-term healthcare facilities in Ireland. Assessment and management of falls is currently high on the quality agenda in terms of measuring quality outcomes. Clinical practice is being standardised using evidence-based practice and research. Residential care nurses caring for older people in Ireland are required to demonstrate clinical competence when assessing and managing falls in the residential care setting. Healthcare legislation, policy and in-service education, occurring in both the public and private sector, require a multidisciplinary-team approach. This article addresses the nursing priorities regarding falls assessment and management strategies that residential nurses should consider when caring for the older person at risk of falling.

Adverse event reporting in Czech long-term care facilities

To describe adverse event reporting processes in long-term care facilities in the Czech Republic. Prospective cohort study involving a written questionnaire followed by in-person structured interviews with selected respondents. Long-term care facilities located in the Czech Republic. Staff of 111 long-term care facilities (87% of long-term care facilities in the Czech Republic). None. Sixty-three percent of long-term health-care facilities in the Czech Republic have adverse event-reporting processes already established, but these were frequently very immature programs sometimes consisting only of paper recording of incidents. Compared to questionnaire responses, in-person interview responses only partially tended to confirm the results of the written survey. Twenty-one facilities (33%) had at most 1 unconfirmed response, 31 facilities (49%) had 2 or 3 unconfirmed responses and the remaining 11 facilities (17%) had 4 or more unconfirmed responses. In-person interviews suggest that use of a written questionnaire to assess the adverse event-reporting process may have limited validity. Staff of the facilities we studied expressed an understanding of the importance of adverse event reporting and prevention, but interviews also suggested a lack of knowledge necessary for establishing a good institutional reporting system in long-term care.

Hybrid metaheuristic method for determining locations for long-term health care facilities

Long-term health care facilities have gained an important role in today’s health care environments, due to the global trend of aging of human population. This paper considers the problem of network design in health-care systems, named the Long-Term Care Facility Location Problem (LTCFLP), which deals with determining locations for long-term care facilities among given potential sites. The objective is to minimize the maximal number of patients assigned to established facilities. We have developed an efficient hybrid method, based on combining the Evolutionary Approach (EA) with modified Variable Neighborhood Search method (VNS). The EA method is used in order to obtain a better initial solution that will enable the VNS to solve the LTCFLP more efficiently. The proposed hybrid algorithm is additionally enhanced by an exchange local search procedure. The algorithm is benchmarked on a data set from the literature with up to 80 potential candidate sites and on large-scale instances with up to 400 nodes. Presented computational results show that the proposed hybrid method quickly reaches all optimal solutions from the literature and in most cases outperforms existing heuristic methods for solving this problem.

給食施設における「日本人の食事摂取基準」の活用の現状 (第1報)

給食施設における「日本人の食事摂取基準」の活用の現状 (第1報)

Implementation of Computerized Physician Order Entry for Critical Patients in an Academic Emergency Department is Not Associated with a Change in Mortality Rate.

Introduction:There is limited literature on the effect of computerized physician order entry (CPOE) on mortality. The objective of our study was to determine if there was a change in mortality among critically ill patients presenting to the emergency department (ED) after the implementation of a CPOE system.Methods:This was a retrospective study of all critically ill patients in the ED during the year before and the year after CPOE implementation. The primary outcome measures were mortality in the ED, after admission, and overall. Secondary outcome measures included length of stay in the resuscitation area of the ED, length of hospital stay, and disposition following hospitalization. Patient disposition was used as a marker for neurologic function, and patients were grouped as either being discharged to home vs. nursing home, rehabilitation center, or a long-term healthcare facility. We analyzed data using descriptive statistics, chi- square, and Wilcoxon rank sum tests.Results:There were 2,974 critically ill patients in the year preceding CPOE and 2,969 patients in the year following CPOE implementation. There were no differences in mortality between the two groups in the ED, after admission, or overall. The pre- and post-CPOE mortality rate for the ED, hospital, or overall was 2.52% vs. 2.02% (P = 0.19, 95% confidence interval [CI] −0.3 to 1.3), 7.8% versus 8.29% (P = 0.61, 95% CI −1.9 to 0.9), and 10.32% vs. 10.31% (P = .60, 95% CI −1.5 to 1.6), respectively. There was no difference in hospital length of stay between pre- and post-CPOE patients (3 days versus 3 days), a difference of 0.05 days (95% CI −0.47 to 0.57). Length of stay in the ED resuscitation area was longer in the post-CPOE group (31 versus 32 minutes), a difference of −1.96 minutes (95% CI −3.4 to −0.53). More patients were discharged to home in the pre-CPOE group (66.8% versus 64.3%), a difference of 2.54% (95% CI 0.13% to 4.96%).Conclusion:The implementation of CPOE was not associated with a change in mortality of critically ill ED patients, but was associated with a decrease in proportion of patients discharged to home after hospitalization.

高齢者介護施設の管理職に求められる能力や資質

高齢者介護施設の管理職に求められる能力や資質

Defining characteristics of communication quality in culture-changed long-term healthcare facilities

Inter-staff communication plays a significant role on the efficiency of healthcare delivery and on patients’ health outcomes; however, previous studies focused on communication and its associated effects at facilities, such as resident-centered long-term care settings, are extremely limited. The current survey study investigates inter-staff communication characteristics and patterns based on staff's roles and responsibilities in a culture-changed nursing home. ‘Timeliness’, ‘accuracy’, ‘understanding’, ‘effectiveness’, and ‘openness’, five dimensions of communication quality, are used to evaluate staff's preferred communication modalities and behaviors. Results found that 28.3% of respondents have more than one role or responsibility. Therefore, strategies for communication modalities and qualities vary accordingly. Among different modalities, synchronous communication modalities were most preferred to achieve the five communication quality dimensions in all groups, but there were significant differences between roles when using the asynchronous modalities to achieve understandable and effective communication. In conclusion, management should serve as a mediator in setting up a series of communication policies that not only achieve communication quality within a facility and satisfy staff's communication preferences, but also maintain efficient operational workflow and residents’ quality of life in the resident-centered long-term care facility.

A norovirus outbreak in a nursing home: Norovirus shedding time associated with age

BackgroundNorovirus (NoV) GII.4 has been identified as predominant in outbreaks in the long-term health-care facilities. ObjectivesNoV excretion during an outbreak of gastroenteritis affecting 19/42 residents and 12/33 employees was investigated in a Taiwan nursing home. Study designReal-time reverse transcription polymerase chain reaction (RT-PCR) was used to quantify viral RNA from stool samples up to the point of negative detection. ResultsInitial fecal viral loads in affected residents were higher than in affected employees (p=0.024). Viral reduced rate was measured as 0.66/day, with a viral half-life of 1.7 days. A mixed model indicated that time (days post-illness onset), initial virus load and resident status (as opposed to employee status) were the most important determining factors of fecal NoV concentration. According to a univariable accelerated failure time (AFT) model, strong associations existed between virus excretion duration and both age (p=0.005) and resident status (p=0.004). No associations were noted between viral excretion duration and either initial viral load or diarrhea duration. According to a multivariable AFT model, age was the only factor affecting virus excretion duration. ConclusionIn conclusion, outbreaks in nursing homes may have resulted from environmental contamination, the existence of asymptomatic residents and prolonged virus shedding time in the elderly and care providers. This outbreak finished quickly because frequent cleaning of the surface was done and contact precautions were taken for prolonged viral shedding residents.

Conditions associated with wandering in people with dementia from the viewpoint of self-awareness: five case reports.

The conditions associated with wandering in people with dementia include purposeless activity, purposeful actions, irritation, and symptoms of depression. The words and actions of 5 people admitted to long-term health care facilities who often exhibited wandering behavior were observed, and the above conditions were studied based on our self-awareness model (consisting of "theory of mind," "self-evaluation," and "self-consciousness"). One person who had not passed the theory of mind task but had passed the self-evaluation task was aware of her wandering. However, she could not understand where she wanted to go or for what purpose. Four persons who had not passed the self-evaluation tasks were not aware of their wandering and had no purpose for their wandering.

The Decision Making Unit In The Choice Of A Long-Term Health Care Facility

&lt;span&gt;As the size of the elderly market increases, so does the need to understand the decision making process for selecting long-term health care (LTHC) facilities. This study describes the membership and relative degree of influence of specific participants in the decision making unit (DMU) as well as the situational effects of time, prompt and stage of decision making on the size, composition and influence of CMU participants.&lt;/span&gt;

Impact of Shift Work on Physical and Postural Demands Among Nursing Aides in Long-Term Health Care Facilities

Nursing aides is one profession that is dominated by shift work as care needs to be provided 24 hour a day and 7 days a week. To date, there is limited information about how the physical and postural demands vary across different shifts—different lengths and times. Fifty-four nursing aides from local long-term health care facilities were observed for an entire shift to document the whole body postural response and physical activities. The results indicate a very active demand for nursing aides on the 8-hr day shift and a more sedentary demand on 8-hr and 12-hr night shifts. The discomfort felt by the nursing aides appeared to be more related to the job demands rather than the length of exposure (e.g. not that much difference between 8-hr and 12-hr shifts).

Clostridium difficileOutbreak Strain BI Is Highly Endemic in Chicago Area Hospitals

Describe the clinical and molecular epidemiology of incident Clostridium difficile infection (CDI) cases in Chicago area acute healthcare facilities (HCFs). Laboratory, clinical, and epidemiologic information was collected for patients with incident CDI who were admitted to acute HCFs in February 2009. Stool cultures and restriction endonuclease analysis typing of the recovered C. difficile isolates was performed. Two hundred sixty-three patients from 25 acute HCFs. Acute HCF rates ranged from 2 to 7 patients with CDI per 10,000 patient-days. The crude mortality rate was 8%, with 20 deaths occurring in patients with CDI. Forty-two (16%) patients had complications from CDI, including 4 patients who required partial, subtotal, or total colectomy, 3 of whom died. C. difficile was isolated and typed from 129 of 178 available stool specimens. The BI strain was identified in 79 (61%) isolates. Of patients discharged to long-term care who had their isolate typed, 36 (67%) had BI-associated CDI. Severe disease was common and crude mortality was substantial among patients with CDI in Chicago area acute HCFs in February 2009. The outbreak-associated BI strain was the predominant endemic strain identified, accounting for nearly two-thirds of cases. Focal HCF outbreaks were not reported, despite the presence of the BI strain. Transfer of patients between acute and long-term HCFs may have contributed to the high incidence of BI cases in this investigation.

Emergence and Rapid Regional Spread of Klebsiella pneumoniae Carbapenemase-Producing Enterobacteriaceae

Exposure network analysis and molecular epidemiologic methods were used to analyze the emergence and regional spread of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae over a 1-year period. Although 40 patients and 26 health care facilities were affected, 1 long-term acute care hospital played a critical role in the convergence of patients at high risk, amplification by cross-infection, and dissemination of these multidrug-resistant bacteria. Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae are an emerging antibiotic resistance threat with demonstrated epidemic potential. We conducted an outbreak investigation of KPC-producing Enterobacteriaceae among patients of acute and long-term acute care hospitals (LTACHs) in 4 adjacent counties in Indiana and Illinois from 1 January 2008 through 31 December 2008 (cases). The study used traditional and molecular epidemiologic methods and an adaptation of social network analysis ("exposure network analysis"). Clinical records for 40 (95%) of 42 patients were available. Patients were mostly older with multiple comorbid conditions. Eleven patients (27.5%) died during the index hospitalization or were discharged to hospice; 23 (57.5%) were discharged to a nursing home, and 4 (10.0%) were discharged to home. One LTACH (LTACH-A) was central to the regional outbreak: 24 (60%) of 40 cases were linked to LTACH-A, and at least 10 patients (25%) acquired KPC there. Of 16 cases not linked to LTACH-A, 12 (75%) were linked to 3 nursing homes. Only 4 patients (10%) definitely acquired KPC during an acute care hospital stay. Molecular typing revealed the 31 available KPC-positive K. pneumoniae isolates to be similar and to cluster with epidemic multilocus sequence type 258; 2 KPC-positive Escherichia coli isolates were unique. We observed extensive transfer of KPC-positive patients throughout the exposure network of 14 acute care hospitals, 2 LTACHs, and 10 nursing homes. Although few cases were identified at most institutions, many facilities were affected. Successful control of KPC-producing Enterobacteriaceae will require a coordinated, regional effort among acute and long-term health care facilities and public health departments.

State University of New York Upstate Medical University College of Medicine

State University of New York Upstate Medical University College of Medicine

高齢者の貧血有病率の検討

Although anemia is common among the elderly, available data for anemia among them are limited in Japan. The aim of the present study was to compare the prevalence of anemia among elderly groups, and evaluate factors attributable to anemia. We enrolled 284 elderly residents in 2 long-term health care facilities, and 1,019 people aged 65 and over who visited outpatient clinics for medical checkups in 1 hospital all located in urban areas in Hiroshima. Hematological data from the 2004 National Nutrition Survey in Japan were cited for comparison. Based on the WHO criteria for anemia, more than half of the residents in both health care facilities were anemic, regardless of gender. However, the prevalence of anemia among elderly people visiting outpatient clinics at hospital was only about 6% for both genders. Analysis of underlying diseases among residents of the health care facility did not reveal any association between a particular disease and anemia. Total serum protein values were significantly lower in the elderly in health care facilities than in those of the elderly of the outpatient clinics, and they showed weak statistical correlations with anemic state in the former group. Finally, the elderly in outpatient clinics showed significantly lower prevalence of anemia compared to the elderly in the National Nutrition Survey in Japan, partly due to selection bias. The prevalence of anemia in the elderly covered a broad spectrum depending on the group examined. Anemia in the elderly was an indicator of comorbidity.

The influence of organizational respect on emotional exhaustion in the human services

The influence of organizational respect on emotional exhaustion was examined in a longitudinal field study in the human services industry. Of a sample of 108 Certified Nursing Assistants (CNAs) working in a long-term health care facility for the elderly, those CNAs who reported greater organizational respect at Time 1 experienced less emotional exhaustion 16 months later (Time 2). Through a longitudinal field experiment, we also examined the outcomes of an organizational change intended to increase organizational respect for the facility's employees. As predicted, CNAs on units undergoing organizational change experienced a decrease in emotional exhaustion from Time 1 to Time 2 compared to CNAs on the control units, and this effect was partially mediated by the degree of organizational respect reported by the employees. CNA's satisfaction with the change was also related to a decrease in emotional exhaustion, and this effect was completely mediated by the degree of reported organizational respect.