Long-term Skilled Nursing Facility Research Articles

CHANTER Syndrome: A Rare Cause of Encephalopathy and Ischemic Lesions (P2-5.017)

<h3>Objective:</h3> To present a rare case of Cerebellar Hippocampal and Basal Nuclei Transient Edema with Restricted Diffusion (CHANTER) Syndrome. <h3>Background:</h3> CHANTER syndrome is a recently recognized constellation of clinical and radiologic findings. The clinical features include acutely depressed consciousness with obstructive hydrocephalus secondary to cerebellar edema. MRI findings are restricted diffusion in the cerebellar cortex, hippocampi, and basal nuclei. CHANTER is distinguished from ischemic stroke by lack of distribution in a specific vascular territory or vascular occlusion present on angiographic imaging. Etiology may be a primary metabolic or mitochondrial failure of the gray matter with anoxic injury precipitated by opiates or other drugs of abuse. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> A 70-year-old right-handed hypertensive woman with HIV, end-stage renal failure, and lymphoma in remission was in respiratory distress. Seizures of unclear duration were noted on ambulance arrival and midazolam was administered. She was intubated and loaded with levetiracetam for status epilepticus. Norepinephrine was given during a hypotensive episode. Neurological examination was remarkable for lack of motor response to noxious stimuli and present brainstem reflexes consistent with coma. Opiates were detected in urine. MRI brain showed multiple small foci of restricted diffusion involving bilateral cerebellar hemispheres, hippocampi, basal ganglia, and in the right parietal cortex. MR angiography of the head and neck was normal. Video EEGs showed severe diffuse slowing, generalized periodic discharges that became blunted with triphasic morphology after lorazepam and levetiracetam administration. Cardiac monitoring and echocardiogram were unremarkable. Her alertness improved and withdrew minimally all extremities to painful stimuli. She was discharged to a long-term skilled nursing facility. <h3>Conclusions:</h3> This case highlights a rare clinical manifestation suggestive of CHANTER syndrome. Unlike other cases previously described, the cerebellar lesions were not sufficiently large to cause hydrocephalus. However, the clinical recovery was very limited. Status epilepticus and transient hypotension may have played a role in the poor recovery. <b>Disclosure:</b> Dr. Hiana has nothing to disclose. Dr. Soh has nothing to disclose. Dr. Marchidann has stock in Eli Lilly. Dr. Marchidann has stock in Pfizer. Dr. Marchidann has stock in Merck. Dr. Marchidann has stock in Illumina. Dr. Marchidann has stock in Aeterna Zentaris. Dr. Marchidann has stock in Abbot. Dr. Marchidann has received publishing royalties from a publication relating to health care. Dr. Marchidann has received publishing royalties from a publication relating to health care.

Efficacy of COVID-19 outbreak management in a skilled nursing facility based on serial testing for early detection and control

SARS-CoV-2 has a high risk of outbreak in long-term skilled nursing facilities (SNF). Coronavirus disease (COVID-19) has high mortality rates among the elderly with chronic health conditions. Following identification of COVID-19 index case in a SNF, serial point-prevalence was implemented with reverse transcription–polymerase chain reaction (RT-PCR) and immunochromatographic assays. Active surveillance and early isolation of infected patients were implemented. Out of 23 SNF residents and 26 healthcare workers (HCW), 18 (78%) and 12 (46%) tested positive for SARS-CoV-2, respectively. High proportion (38%) of positive patients were asymptomatic and RT-PCR was positive up to six days before symptoms. Five (21.74%) residents were hospitalized with COVID-19, and 2 (9%) died; only 1 (4%) HCW needed to be hospitalized and no staff members died. Active surveillance helped COVID-19 control and management in a SNF. Testing symptomatic individuals only may fail to identify and isolate all persons contributing to transmission. In high-risk elderly, only symptoms screening may not be enough for outbreak control.

Acute kidney injury in ventilated patients with coronavirus disease-2019 pneumonia: A single-center retrospective study.

Background:Acute kidney injury (AKI) is repeatedly observed in ventilated critically ill patients with coronavirus disease-2019 (COVID-19) pneumonia. This study aimed to determine the incidence, risk factors, and consequences of AKI in the ventilated critically ill adult patients with COVID-19 pneumonia.Methods:This retrospective study included all the ventilated critically ill adult patients with COVID-19 pneumonia from March 1, 2020, to June 1, 2020. Data were collected from the electronic medical system. AKI was diagnosed using the Kidney Disease: Improving Global Outcomes 2012 Clinical Practice definition. Patients were followed 90 days from the intensive care unit (ICU) admission time or to the date when they were discharged from the hospital.Results:AKI occurred in 65.1% of patients, with 26.6% of these started on continuous renal replacement therapy (CRRT). Patients with AKI had higher comorbidity and illness severity scores (P < 0.001). Age and the vasopressor requirements were predictors of AKI (P= 0.016 and P = 0.041) and hypertension predicted AKI (P = 0.099) and its progression (P = 0.05). The renal recovery rate was 86.7% and was associated with the mean arterial pressure on ICU admission in the no-CRRT group (P = 0.014) and the hypoxic index in the CRRT group (P = 0.019). AKI was associated with higher mortality (P = 0.017) and significantly longer ICU length-of-stay (P = 0.001). Additionally, AKI patients were more often discharged to a long-term skilled nursing facility (P = 0.005).Conclusion:COVID-19-associated AKI was common and associated with poor outcome, with the specific mechanisms being the main driving factors.

Analysis of Possible Sexual Assault or Abuse in a 67-Year-Old Female With Early Dementia Post–Brain Attack

The case analysis explores an emergency department visit by a 67-year-old female with early dementia post-brain attack, with complaints of possible sexual assault or abuse. This patient resides in a long-term skilled nursing facility. The case outlines the forensic care provided by the Advanced Practice Forensic Nurse (APFN) once medically cleared by the emergency department Advanced Practice Nurse (APN). The case discussion includes issues related to sexuality in aging populations, consent, sexual abuse or assault in institutions, and forensic care of older persons. Expected genital injuries in older women that result from sexual assault and abuse are also explored. The case discussion will analyze the key elements for critical thinking and clinical reasoning and demonstrate standards of care for the APFN and APN practice.

Effects of a dynamic progressive orthotic intervention for chronic hemiplegia: A case series

Study designCase series design on a single subgroup of participants. IntroductionManagement of hypertonicity and resistance to passive movement (RTPM) in the upper extremity is an intractable problem for persons with stroke and the therapists who provide their care. Therapists have limited options for assessment and treatment of this condition which can profoundly limit functional performance and quality of life. Purpose of the studyTo evaluate the effect of a 12-week dynamic progressive orthotic intervention in persons with chronic stroke exhibiting wrist flexion contracture who are residents of a long-term skilled nursing facility. MethodsA custom-fitted dynamic progressive wrist extension orthotic was applied to 6 residents with chronic stroke. The orthotic was worn for 4 h daily, 4×/week for 12 weeks. Wrist passive range of motion (PROM) and RTPM were measured weekly and after discontinuation of the orthotics using the Modified Ashworth Scale and the Tardieu Scale of Spasticity. Signal analysis of electromyographical (EMG) flexor response to extensor stretching was also measured before and after orthotic intervention using maximal root mean square (RMS) values and EMG burst onset time. ResultsA moderate effect was found for changes in PROM with the orthotic intervention. Progress made diminished following discontinuation. Moderate effects were also seen in EMG measures which indicated increases in amount of resistive-free movement following intervention. ConclusionA dynamic progressive orthotic intervention can be an effective option for increasing wrist PROM and reducing RTPM in persons with chronic stroke. Level of evidence4.

Improving Safety and Operational Efficiency in Residential Care Settings With WiFi-Based Localization

To assess the effectiveness of a wireless network (WiFi-based) localization system (devices mounted on resident wheelchairs) in decreasing caretaker time spent searching for residents and providing alerts of residents going outdoors in a skilled nursing facility. A controlled study over two 2-month periods approved by the institutional review board. A long-term skilled nursing facility in Massachusetts specializing in multiple sclerosis previously instrumented with wireless network infrastructure. Nineteen residents and 9 staff members at the facility for the first 2-month period; 9 residents and 3 staff members at the facility for the second 2-month period. Software was installed on 4 staff computers to display the locations of residents enrolled in the study. This software was made available to enrolled staff for the second half of the first 2-month period and the entirety of the second 2-month study. In the second 2-month study, the software was modified to provide alerts if any 1 of 9 participating "high-risk"' residents went outdoors, and the accuracy of the alert system was evaluated. In the first 2-month study, 9 staff members recorded the amount of time it took them to locate participating residents (as and when needed during the course of their daily activities). In the second 2-month study, 3 staff members recorded whether outdoor-alerts correctly identified a resident leaving the building or if it was a false alarm. In both phases, participating staff members made frequent use of the system (44 searches and 215 outdoor alerts). Overall, the localization information decreased the average time needed to find residents by about two-thirds (from 311.1 seconds to 110.9 seconds). For outdoor alerts, the system had a false-alarm rate of 9.1% (under normal facility operations); systematic tests of the outdoor-alert system carried out by the authors had a false-negative, or missed-alarm, rate of 1.7%. Using timely resident location information can provide significant gains for both operational efficiency (finding residents) and enhanced resident safety (outdoor alerts). This approach may provide an inexpensive alternative for facilities that have sufficient wireless infrastructure; future work should assess its effectiveness in additional settings.

Aggressive Management of Necrotizing Fasciitis Through a Multidisciplinary Approach Using Minimal Surgical Procedures: A Case Report

Necrotizing fasciitis is an aggressive, destructive infection of the soft tissue and fascia and is a life-threatening surgical emergency. A case study is presented of necrotizing fasciitis in the right lower extremity of a 53-year-old male resident of a long-term skilled nursing facility. Limb salvage was achieved through a multidisciplinary approach with early surgical management and aggressive postoperative management. Through 3 surgical procedures, the combined efforts of podiatric surgery, orthopaedic surgery, general/trauma surgery, and infectious disease provided early wound closure and limb salvage. An aggressive multidisciplinary approach to the management of necrotizing fasciitis in the lower extremity is necessary for limb salvage. Use of this multidisciplinary approach will minimize the number of surgical procedures and decrease the potential morbidity and mortality seen in patients with this infection.

Silence Is Not Golden

Silence Is Not Golden

A protocol for assessment of risk in wheelchair driving within a healthcare facility

Purpose: The purpose of this article is to describe how a skilled nursing facility with significant wheelchair traffic developed a protocol for the multidisciplinary assessment and intervention management of patients whose wheelchair use represents a risk to self and others. This article describes the procedure and two case studies illustrating the utility of the protocol. Method: Staff of the facility developed a protocol for responding to sentinel events related to patients hurting themselves and others while using a wheelchair or observed using the wheelchair in an unsafe manner. The goal of the protocol is to determine the cause of the event, identify the necessary multidisciplinary interventions, and the evaluation of the effectiveness of the interventions. Results: Case study analysis of the interventions indicated that a multidisciplinary evaluation and treatment plan leads to treatment interventions that suit the patient's medical condition while affording the patient the greatest amount of independence. Conclusion: Many patients who live in a long-term skilled nursing facility must use either a manual or a power wheelchair for mobility. For these patients, the wheelchair may represent one of the last forms of independence they enjoy. The implementation of the protocol helped staff respond to important changes to the patient's condition and prepare a coordinated intervention. The patients found the protocol to be a helpful component of their treatment.

Nursing unit meal management maintenance program. Continuation of safe-swallowing and feeding beyond skilled therapeutic intervention.

Feeding, deglutition, and swallowing are the most natural means of alimentation. These means provide nutrition and hydration to the body. Management of dysphagia has become a widespread clinical practice in acute care, rehabilitation, and long-term skilled nursing facilities from rehabilitation and nursing perspectives. Caring for chronic dysphagic and feeding-impaired patients on nursing units is a central concern of this article. The purpose of this descriptive article is to report on a practical meal supervision program that may be used on nursing units to facilitate the continuum of dysphagia care after skilled therapeutic intervention. This program stresses the importance of: (a) identifying patient help level and corresponding nursing care; (b) centralized, supervised dining; (c) organized seating assignments; and (d) an effective, integrated communication system. This article addresses staff training and continuous quality improvement monitoring, and discusses potential investigations concerning compliance.

Diabetic Neuropathy and Possible Treatment

To the Editor:—Insulin-dependent diabetes mellitus is commonly associated with increasing incidence of neurovascular complications with age.1-3 Age-associated vascular changes include a slowly continuous and symmetrical thickening of vessel walls, due in part to deposition of connective tissue and smooth muscle cells and to an increased percentage of lipid substitution into vascular layers.4, 5 The diabetic contribution affects vessel stiffening, flow dynamics, shear forces, and loss of sympathetic vasoconstrictor tone,2, 5 resulting in impaired venous return and perfusion of tissues.5, 6 The involvement of vascular abnormalities in the pathogenesis of diabetic neuropathy is suggested by animal studies indicating faulty regulation of the microcirculation and oxygen delivery systems.5, 7 Diabetic neuropathic processes are now regarded as the most common cause of peripheral neuropathies,1, 2 ultimately affecting up to 50% of patients with long-term diabetes.1, 5 The most common type is a distal-symmetrical sensory pattern1-3, 5 accompanied by dysesthesias and paresthesias.1, 2 Evolution of sensory-pain tract involvement is in a centripetal pattern,3 which may lead to a distribution of paralysis,5 particularly to distal affected areas.3 Persistent pain to the lower legs and feet can become severe and functionally disruptive despite regulated maintenance of serum glucose levels.2, 3 The most difficult aspect of diabetic neuropathic management is treatment of pain.8 Analgesics, antidepressants, anticonvulsants, and vitamin supplements have all been advocated, with little evidence of efficacy.8 We are interested to learn if nitroglycerine 2% in ointment form, (Nitro-Bid), a compound with local vasodilating properties, might affect impaired peripheral circulation and reduce pain associated with neurovascular changes and neuropathy in insulin-dependent diabetes mellitus. We present two brief cases of diabetic peripheral neuropathy treated empirically with nitroglycerine 2% ointment. We are not aware of the previous use of nitroglycerine 2% ointment for neurovascular disease. Ms. S was an 81-year-old female with end-stage arthritis and insulin-dependent diabetes mellitus who resided in a long-term skilled nursing facility. She suffered severe nocturnal peripheral neuropathy that left her insomniac. Because of impaired renal function, analgesics were not well tolerated. A trial of nitroglycerin 2% ointment was applied to the pedal areas and covered by socks at bedtime. Subjectively, and by nurse report, Ms. S was able to obtain some symptomatic relief, and sleep improved after the third evening of application. Mr. B is a 57-year-old man, with diabetic peripheral neuropathy. The discomfort, exacerbated by weight bearing, was blamed for his insomnia. A trial of lorazepam (Ativan) and trazodone (Desyrel), for his complaints of insomnia failed to offer sustained relief. A bedtime application of nitroglycerin 2% ointment was begun. After 5 days of treatment, Mr. B reported that he was able to stand at the race track and, further, that his sleep was improved. His pain persisted, but at a more tolerable level. There is no follow up on the above patients as Ms. S died shortly after initial contact, and Mr. B became non-compliant for his out-patient follow-up appointments. The accumulative vascular changes of aging and diabetes affect vessel plasticity, hemodynamic tolerance, nutrient transport capacity, and hemorrheologic threshold.5 The theorized benefits of nitroglycerine 2% ointment treatments for neurovascular abnormalities rest in its principal pharmacological action as a locally acting vasodilator of veins more than arteries and vascular smooth muscle;9 conceivably these properties could lead to a favorable redistribution of blood flow to deprived tissue.6 Nitroglycerine 2% ointment is a relatively inexpensive medication and has been a safe and well tolerated therapy. Common side effects include hypotension and headaches, which are associated with thoracic application. It is our hope that controlled studies will be designed to evaluate the efficacy of nitroglycerine 2% ointment therapy for peripheral neuropathy since diabetic-neuropathic deterioration is a widespread and, as yet, treatment-refractory condition.