Use In Long-term Care Facilities Research Articles

A New Care Model Reduces Polypharmacy and Potentially Inappropriate Medications in Long-Term Care

ObjectivesAssess the impact of a new pharmaceutical care model on (1) polypharmacy and (2) potentially inappropriate medication (PIM) use in long-term care facilities (LTCFs). DesignPragmatic quasi-experimental study with a control group. This multifaceted model enables pharmacists and nurses to increase their professional autonomy by enforcing laws designed to expand their scope of practice. It also involves a strategic reorganization of care, interdisciplinary training, and systematic medication reviews. Setting and ParticipantsTwo LTCFs exposed to the model (409 residents) were compared to 2 control LTCFs (282 residents) in Quebec, Canada. All individuals were aged 65 years or older and residing in included LTCFs. MeasuresPolypharmacy (≥10 medications) and PIM (2015 Beers criteria) were analyzed throughout 12 months between March 2017 and June 2018. Groups were compared before and after implementation using repeated measures mixed Poisson or logistic regression models, adjusting for potential confounding variables. ResultsOver 12 months, for regular medications, polypharmacy decreased from 42% to 20% (exposed group) and from 50% to 41% (control group) [difference in differences (DID): 13%, P < .001]. Mean number of PIMs also decreased from 0.79 to 0.56 (exposed group) and from 1.08 to 0.90 (control group) (DID: 0.05, P = .002). Conclusions and ImplicationsCompared with usual care, this multifaceted model reduced the probability of receiving ≥10 medications and the mean number of PIMs. Greater professional autonomy, reorganization of care, training, and medication review can optimize pharmaceutical care. As the role of pharmacists is expanding in many countries, this model shows what could be achieved with increased professional autonomy of pharmacists and nurses in LTCFs.

Impact of Training Consultant Pharmacists on Antimicrobial Stewardship Programs in Long-Term Care Facilities

Background: The CDC recommends that consultant pharmacists support antimicrobial stewardship programs (ASPs) in long-term care facilities (LTCFs). We studied CDC-recommended ASP core elements implementation and antibiotic use in LTCFs before and after training consultant pharmacists. Methods: Between August 2017 and October 2017, consultant pharmacists from a regional long-term care pharmacy attended 5 didactic sessions preparing them to assist LTCFs in implementation of CDC-recommended ASP core elements. Training also included creating a process for evaluating appropriateness of all systemic antibiotics and providing prescriber feedback during their monthly mandatory drug-regimen reviews. Once monthly “meet-the-expert” sessions were held with consultant pharmacists throughout the project (November 2017 to December 2018). LTCF enrollment began in November 2017 and &gt;90% of facilities joined by January 2018. After enrollment, consultant pharmacists initiated ASP interventions including antibiotic reviews and feedback using standard templates. They also held regular meetings with infection preventionists to discuss Core Elements implementation and provided various ASP resources to LTCFs (eg, antibiotic policy template, guidance documents and standard assessment and communication tools). Data collection included ASP Core Elements, antibiotic starts, days of therapy (DOT), and resident days (RD). The McNemar test, the Wilcoxon signed-rank test, generalized estimating equation model, and the classic repeated measures approach were used to compare the presence of all 7 core elements and antibiotic use during the baseline (2017) and intervention (2018) year.Results: In total, 9 trained consultant pharmacists assisted 32 LTCFs with ASP implementation. When evaluating 27 LTCFs that provided complete data, a significant increase in presence of all 7 Core Elements after the intervention was noted compared to baseline (67% vs 0; median Core Elements, 7 vs 2; range, 6–7 vs 1–6; P &lt; .001). Median monthly antibiotic starts per 1,000 RD and DOT per 1,000 RD decreased in 2018 compared to 2017: 8.93 versus 9.91 (P &lt; .01) and 106.47 versus 141.59 (P &lt; .001), respectively. However, variations in antibiotic use were detected among facilities (Table 1). When comparing trends, antibiotic starts and DOT were already trending downward during 2017 (Fig. 1A and 1B). On average, antibiotic starts decreased by 0.27 per 1,000 RD (P &lt; .001) and DOT by 1.92 per 1,000 RD (P &lt; .001) each month during 2017. Although antibiotic starts remained mostly stable in 2018, DOT continued to decline further (average monthly decline, 2.60 per 1,000 RD; P &lt; .001). When analyzing aggregated mean, antibiotic use across all sites per month by year, DOT were consistently lower throughout 2018 and antibiotic starts were lower for the first 9 months (Fig. 1C and 1D). Conclusions: Consultant pharmacists can play an important role in strengthening ASPs and in decreasing antibiotic use in LTCFs. Educational programs should be developed nationally to train long-term care consultant pharmacists in ASP implementation.Funding: Merck &amp; Co., Inc, provided funding for this study.Disclosures: Muhammad Salman Ashraf and Scott Bergman report receipt of a research grant from Merck.

Assessing Policies Versus Practices Utilizing the CDC Infection Control Assessment and Response Tool

Background: The Infection Control Assessment and Response (ICAR) tool was developed by the CDC following the 2014 Ebola outbreak. Over a 3-year period, the CDC dispensed Funding: to all public health divisions in all 50 states to implement and promote the ICAR. The ICAR was developed as a self-assessment tool to evaluate policies, competencies, and practices across healthcare settings. The primary aim of the tool and associated Funding: was to guide quality improvement activities by addressing the identified gaps in infection prevention (IP). Independent of state funding, we sought to use the ICAR to evaluate whether there were differences in reported policies from observed practices related to hand hygiene (HH) and personal protective equipment (PPE) use in long-term care facilities (LTCFs), ambulatory surgical centers (ASCs), and outpatient pain clinics (OPCs). Methods: From November 2018 to August 2019, we conducted in-person ICAR assessments in 7 LTCFs in 3 states (Arizona, Utah, and Idaho), 2 ASCs in 2 states (Arizona, Indiana), and 5 OPCs in 1 state (Arizona). All on-site assessments were conducted with the ICAR tool by a board-certified infection preventionist. The paper form was converted to a mobile compatible digital audit tool utilizing Microsoft Forms on the Microsoft 365 platform. Once a survey was completed, it was sent to an Excel database and analyzed utilizing SPSS software. Results: All facilities (14 of 14, 100%) had a designated person responsible for coordinating and/or directing the IP program. Moreover, 4 of 7 LTCFs (57%), 2 of 2 ASCs (100%), and 5 of 5 OPCs (100%) reported having written IP policies that met evidence-based guidelines, regulations, or standards (eg, CDC/HICPAC). None of the 7 LTCFs (0%), 2 of 2 ASCs (100%), and none of the 5 OPCs (0%) reported active surveillance to monitor and document adherence to proper PPE selection and use. During direct observation of hand hygiene opportunities, compliance was 23% for LTCFs (7 of 31 opportunities), 37% for ASCs (7 of 19 opportunities), and (11 of 28 opportunities) 39% in OPCs. Conclusions: Our results indicate that the ICAR tool remains a useful resource for distinguishing between the reporting of IP polices from the actual implementation of evidence-based practices. Although all facilities had a designated role for IP and most had written evidence-based IP polices, this did not translate to the observation of recommended HH and PPE practices. By utilizing this tool, healthcare facilities can support their evidence-based IP polices and further promote patient safety by identifying and mitigating gaps in practices.Funding: NoneDisclosures: None

Determining Antibiotic Use in Long-Term Care Facilities Across Tennessee

Background: Antibiotic stewardship is an area of great concern in long-term care facilities nationwide. The CDC promotes 7 core elements of antimicrobial stewardship. Based on information obtained from the Infection Control Assessment and Response (ICAR) Program, the 2 core elements most infrequently achieved by LTCFs are tracking and reporting. Currently, minimal data are available on antibiotic use (AU) in LTCFs in Tennessee. To address both issues, the Tennessee Department of Health (TDH) developed a monthly antibiotic use (AU) point-prevalence (PP) survey to provide LTCFs with a free tool to both track and report their AU and to gather data on how LTCFs are using antibiotics. Methods: We used REDCap to create a questionnaire to collect information on selected antibiotics administered in Tennessee LTCFs. This self-administered survey was promoted through the TDH monthly antimicrobial stewardship and infection control (ASIC) call as well as at various conferences and speaking engagements across the state. Antimicrobial stewardship leads for each facility were targeted. Antibiotics were grouped into 4 classes according to their indications: C. difficile infections, urinary tract infections, skin and soft-tissue infections (SSTIs) and respiratory infections. We determined AU percentage by dividing the number of days of therapy for a drug by a facility’s average census. Individualized reports are provided to each participating facility on a quarterly basis. Results: Currently, 16 facilities have participated in the survey. Overall, 40.7% of antibiotics prescribed were in the common for SSTI category and 39.3% were common for respiratory infections. The top 33 most commonly prescribed antibiotics were amoxicillin (156 days of therapy [DOT]), nitrofurantoin (92 DOT), and levofloxacin (88 DOT). The average percentage of residents on antimicrobials on the day of survey was 12.3%; within this group, 57% of antibiotics were initiated in the LTCF, whereas 43% were present upon admission. Conclusions: Early results from the TDH AU PP survey revealed that drugs commonly used for SSTIs and respiratory infection were the most common antibiotic prescriptions and a potential area of focus for TDH’s antimicrobial stewardship efforts. None of the 3 most frequently prescribed antibiotics, however, fall under the SSTI indication, despite SSTI being the most commonly prescribed indication based on the survey’s evaluation metrics. This finding could be related to the larger number of antibiotics that fall under the SSTI indication. Preliminary data are being used to guide the direction of TDH’s future ASIC calls to better suit disease states, which have room for improvement.Funding: NoneDisclosures: None

Pharmacy-led Medication Management Services in Long-term Care Facilities: Lessons from other Countries for Korea

The elderly usually have a high risk of drug-related problems by polypharmacy, therefore they are in need of drug management in long-term care facilities. This study aims to obtain the implications for developing a drug management system in long-term care facilities by pharmacists suitable for Korea by reviewing the drug management programs in long-term care facilities in countries that experienced population aging first. The United States, Canada, Australia, and Japan have enacted laws to optimize drug management in long-term care facilities according to the social demands of the aging population and operate specific programs based on those laws. Drug management programs in longterm care facilities operate in a variety of forms to suit the circumstances of each country. In long-term care facilities, pharmacists participate in the medication regimen review, in setting up drug related service frames and in developing relevant policies of the facilities. The results of the pharmacist s medication regimen review are not only provided to the doctor but also included in the medical record and kept for a while. Pharmacists emphasize cooperation with physicians and other health practitioners for proper drug management in long-term care facilities. In Korea, where the number of long-term care facilities is increasing along with the surge in the elderly population, it is necessary to develop a drug management system by pharmacists for safe drug use in long-term care facilities.

Hospice Utilization Among Residents in Long-Term Care Facilities.

Hospice care can improve quality of life for persons nearing end of life, yet little is known about utilization of hospice care among persons residing in long-term care facilities (LTCFs). Given the increasing number of deaths that occur in LTCFs, it is important to examine hospice care practices in LTCFs. The aim of the cross-sectional study was to describe residents who received hospice care in LTCFs and explore factors that can predict hospice use in LTCFs across Canada. This study included 185 715 residents aged 19 years or older in LTCFs in Canada in 2015. Of all residents, 2.7% (n = 4973) received hospice care and 6.8% (n = 12 684) were profiled as having an end-stage disease. Among those who received hospice care, most were noted as end stage (89.5%) and had severe physical impairment (Activities of Daily Living Hierarchy Scale ≥ 5, 74.3%), mild-to-severe pain (Pain Scale ≥ 1, 76.0%), and moderate-to-severe health instability (Changes in Health, End-Stage Disease, Signs, and Symptoms Scale ≥3, 82.9%). Residents who received hospice care were in more severe and complex clinical conditions than those who did not receive hospice care. Only a small proportion of residents in LTCFs received hospice care. Further investigation of standardized assessment of terminal status is needed as accuracy of end-stage diagnosis continues to be challenging and criteria for hospice eligibility are narrow. Special attention should be paid to improve access to hospice care among residents with dementia or other progressive chronic diseases with severe and complex clinical needs.

Effectiveness of interventions targeting antibiotic use in long-term aged care facilities: a systematic review and meta-analysis

ObjectivesThere are high levels of inappropriate antibiotic use in long-term care facilities (LTCFs). Our objective was to examine evidence of the effectiveness of interventions designed to reduce antibiotic use and/or...

PRN Medicines Management for Psychotropic Medicines in Long-Term Care Settings: A Systematic Review.

Many medications are prescribed and administered PRN (pro re nata, as needed). However, there are few integrative reviews to inform PRN psychotropic medication use in long-term care facilities and nursing or care homes. Accordingly, this integrative systematic review aimed to improve our understanding of PRN medicines management with a focus on psychotropic medications (antipsychotics, sedatives, anxiolytics, and hypnotics) in long-term care settings. Keywords relating to PRN in English, Norwegian, and Spanish were used, and articles published between 2009 and 2019 were retrieved. Based on the inclusion criteria, eight articles were used for data analysis and synthesis. This review offers a description of PRN prescription and administration of psychotropic medications in long-term care. Variations were observed in the management of PRN psychotropic medications based on residents’ underlying health conditions and needs, duration of use, and changes between medications and doses. Neither the reasons for PRN prescription and administration nor the steps taken to identify and manage any associated adverse reactions or adverse drug events were reported. Further initiatives are needed to improve PRN medicines management to explore factors that affect PRN prescription and administration and to develop appropriate PRN guidelines to prevent harm and improve the safety of people living in long-term care facilities.

The Importance of a Complete Allergy Assessment in Clinical Stewardship

National agencies have championed stewardship initiatives to enhance antimicrobial and opioid use in long-term care facilities. Health care providers for these residents have been given the task to ensure "the right drug is used for the right indication at the right time and duration." One potential challenge to this is incorrect or incomplete documentation of allergies. Many long-term care facilities have traditionally, and currently, used a "list format" of allergies in, or on, the resident's chart. This approach is incomplete as it rarely provides detailed information about the reaction to a particular drug. Senior care pharmacists and their students can play a role within long-term care facilities by helping ensure the optimal selection of drugs by providing a detailed allergy assessment that documents detailed reaction information, whenever possible.

Decrease in Antibacterial Use and Facility-Level Variability After the Introduction of Guidelines and Implementation of Physician-Pharmacist-Nurse Quality Circles in Swiss Long-term Care Facilities

ObjectivesThe objective of this study is to describe antibacterial use in long-term care facilities and to investigate the determinants of use. DesignThis study is a quality improvement study conducted from January 2011 to December 2016. SettingLong-term care facilities in the canton of Vaud, Western Switzerland, were investigated. ParticipantsTwenty-three long-term care facilities were included in this study. InterventionThe intervention included the publication of local guidelines on empirical antibacterial therapy and the implementation of physician-pharmacist-nurse quality circles. MeasuresThe main outcome was antibacterial use, expressed as defined daily doses (DDD) per 1000 beds per day. Statistical analyses were performed through a 1-level mixed model for repeated measurements. ResultsAntibacterial use decreased from 45.6 to 35.5 DDD per 1000 beds per day (−22%, P < .01) over the 6-year study period, which was mostly explained by reduced fluoroquinolone use (−59%, P < .001). A decrease in range of use among LTCFs was observed during the study period, and 27% of antibacterial use was related to the WATCH group (antibiotics with higher toxicity concerns and/or resistance potential) according to the AWaRe categorization of the WHO, decreasing from 17.3 DDD per 1000 beds per day to 9.5 (−45%) over the study period. The use of antibacterials from the RESERVE group (“last-resort” treatment options) was very low. Conclusion and implicationsA reduction in facility-level antibacterial use and in variability across LTCFs was observed over the study period. The dissemination of empirical antibacterial prescription guidelines and the implementation of physician-pharmacist-nurse quality circles in all LTCFs of the canton of Vaud likely contributed to this reduction. Antibacterials from the WATCH group still represented 27% of the total use, providing targets for future antibiotic stewardship activities.

Healthcare-associated infections and antimicrobial use in long-term care facilities (HALT3): an overview of the Italian situation

Awareness of healthcare-associated infections (HAIs) and antimicrobial use in long-term care facilities (LTCFs) is increasing. In 2017, the third national point prevalence survey (PPS) was conducted in Italy as part of the third 'Healthcare-Associated Infections in European Long-Term Care Facilities' (HALT3) study. To report the results of HALT3 and analyse the resident population of LTCFs, implementation of good practices, prevalence of infections and antimicrobial use. The survey was designed as a PPS, carried out from April to June 2017. All residents who lived full-time in the institution were included. All facilities were asked to complete an institutional questionnaire, a ward list for all residents, and a resident questionnaire for those residents presenting with signs/symptoms of active infection and/or receiving an antimicrobial agent. In total, 418 facilities took part in the study; 24,132 residents were eligible, and most were aged >85 years, disoriented and incontinent. The prevalence of HAIs was 3.9%, and 50% of the institutions reported that they had a professional trained in infection control on their staff. Only 26.4% of infections were confirmed by a microbiological sample, and 26.9% of the isolated micro-organisms were resistant to at least one antimicrobial class. In total, 1022 residents received at least one antimicrobial agent, and cephalosporins were prescribed most commonly. The number of infection control and antimicrobial stewardship measures implemented was found to be considerably higher in this study compared with previous studies. This could lead to a reduction in the prevalence of HAIs, antimicrobial use and antimicrobial resistance. Further studies are needed to monitor these aspects.

Improving Antimicrobial Prescribing: A Multinomial Model Identifying Factors Associated With First- and Second-Line Prescribing

Background/objectivesBroad-spectrum, second-line antimicrobials may be prescribed when initial first-line options prove ineffective. This study compares prescribing practices and identifies potential influencing factors for first- and second-line antimicrobials in long-term care facilities. DesignPoint prevalence survey of health care–associated infections and antimicrobial use in long-term care facilities (HALT), expanded by additional data collection. SettingLong-term care facilities in Ireland. ParticipantsOf long-term care facilities that participated in the HALT study 2016, additional data provided by 77 facilities with a record of 3677 residents. MeasurementOn the survey date, an institutional questionnaire was completed by each participating long-term care facility, and resident questionnaires were completed only for those residents who met a health care–associated infection surveillance definition and/or were prescribed a systemic antimicrobial. All participating long-term care facilities were contacted at a later time point to provide limited anonymized data (age, sex, urinary catheterization, and disorientation) on all current residents. These additional data were matched to the original data set, facilitating multilevel multinominal logistic regression (first-line/second-line/no antimicrobial). ResultsOf 3677 residents in 77 long-term care facilities, 381 (10%) were prescribed systemic antimicrobials on the survey day. Of those, 46% were categorized as second-line choices, with substantial interfacility variation observed with regard to prescription of first- versus second-line antimicrobials. The odds of a second-line antimicrobial prescription for a resident doubled when comparing the highest with the lowest prescribing long-term care facilities (median odds ratio = 2.0, credibility interval = 1.5-2.9). Male residents were less often prescribed first-line antimicrobials [odds ratio (OR) = 0.6, 95% confidence interval (CI) = 0.4-0.9, P = .02]. Long-term care facilities that reported the provision of education on antimicrobial prescribing use significantly less second-line antimicrobials (OR = 0.2, 95% CI = 0.1-0.7, P = .02). Females and residents with a urinary catheter were more likely to receive first-line antimicrobials. Conclusion/ImplicationsThe use of second-line antimicrobials is common practice in long-term care facilities, but education and training on appropriate antimicrobial use has the potential to reduce second-line antimicrobial prescribing, improve patients' outcomes, and reduce antimicrobial resistance.

1837. Comparison of Antibiotic Use in Post-Acute and Long-Term Care Facilities Based on Proportion of Short Stay Residents Using a Long-Term Care Pharmacy Database

BackgroundCMS requires participating long-term care facilities (LTCF) to have an antibiotic stewardship program (ASP). Common barriers encountered by LTCF include lack of antibiotic use (AU) data and inability to benchmark use. We initiated a project that utilized a long-term care pharmacy (LTCPh) database to obtain and compare AU data across enrolled LTCF.MethodsWe partnered with a regional LTCPh that dispenses and reviews medications for 40 LTCF, of which 32 agreed to participate. Prescriptions filled by the pharmacy were used to calculate antibiotic (AB) starts and days of therapy (DOT). Start and end dates were used to calculate DOT, if available. For those without an end date (<10%), duration was obtained by manual review of administration records. Bed-size and proportion of short-stay (Medicare-A) beds were estimated for each LTCF based on a cross-sectional evaluation of billing records at the LTCPh. Baseline resident-days (RD) during 2017 were obtained from each LTCF. The influence of short-stay residents on AB start rates and DOT was evaluated by grouping LTCF in three cohorts based on estimated proportion of short-stay residents.ResultsData from 29 (90.6%) LTCF were included in the final analysis; 3 were excluded due to lack of RD data. Median bed-size was 57 (range 17–253). Overall, 13.9% of LTCF residents were in the short-stay category. Fifteen LTCF were estimated to have 5% to 20% of RD attributable to short-stay residents, six had <5% while eight had >20%. Antibiotic starts/1000 RD varied from 3.84 to 19.38 and DOT/1000 RD from 34.86 to 252.09, and showed strong correlation (Figure 1). The proportion of short-stay beds correlates better with AB starts/1,000 RD than DOT/1,000 RD (Figure 2). LTCF cohort with >20% short-stay residents had higher mean AB starts/1000 RD compared with LTCF with 5%-20% and <5% short-stay residents (13.08, 9.78, 7.45, respectively; P < 0.05 by one-way ANOVA). However, a similar trend was not noted for DOT/1000 RD (179.30, 128.29, 128.12, respectively; P = 0.12). ConclusionLTCPh can play an important role in supporting ASP in LTCF by providing AU data for benchmarking. Antibiotic use in LTCF is highly variable and may be influenced by the proportion of beds dedicated to short-stay residents amongst other factors.Disclosures S. Bergman, Merck: Grant Investigator, Grant recipient. T. Vanschooneveld, Merck: Grant Investigator, Grant recipient. M. S. Ashraf, Merck & Co. Inc.: Grant Investigator, Research grant.

Antimicrobial use in European long-term care facilities: results from the third point prevalence survey of healthcare-associated infections and antimicrobial use, 2016 to 2017.

Antimicrobials are commonly prescribed and contribute to the development of antimicrobial resistance in long-term care facilities (LTCFs). In 2010, the European Centre for Disease Prevention and Control initiated point prevalence surveys (PPS) of healthcare-associated infections and antimicrobial use in European LTCFs, performed by external contractors as the Healthcare-Associated infections in Long-Term care facilities (HALT) projects. Here, we investigated prevalence and characteristics of antimicrobial use and antimicrobial stewardship indicators in European LTCFs in 2016–17. Twenty-four European Union/European Economic Area (EU/EEA) countries, the former Yugoslav Republic of Macedonia and Serbia participated in the third PPS in European LTCFs. Overall, 4.9% (95% confidence interval: 4.8–5.1) of LTCF residents in the EU/EEA participating countries received at least one antimicrobial. The most commonly reported Anatomical Therapeutic Chemical (ATC) groups were beta-lactam antibacterials/penicillins (J01C), other antibacterials (J01X) (e.g. glycopeptide antibacterials, polymyxins), quinolones (J01M), sulfonamides and trimethoprim (J01E), and other beta-lactams (J01D). Urinary tract infections and respiratory tract infections were the main indications for antimicrobial prescription. This PPS provides updated and detailed information on antimicrobial use in LTCFs across the EU/EEA that can be used to identify targets for future interventions, follow-up of these interventions and promote prudent use of antimicrobials in European LTCFs.

Factors related to physical restraint use in long-term care facilities and a comparison of physical restraint prevalence among prefectures in Japan

Factors related to physical restraint use in long-term care facilities and a comparison of physical restraint prevalence among prefectures in Japan

Utilization of Antibiotics in Long-Term Care Facilities in British Columbia, Canada

BackgroundAntibiotic use is highly prevalent in long-term care facilities (LTCFs); a resident's annual exposure to at least 1 course of antibiotic is approximately 50% to 80%. The objective of this study was to understand the extent of antibiotic use in the population of residents in British Columbia's (BC) LTCFs from 2007 to 2014. MethodsAntibiotic prescription data for LTCF residents was extracted from the central prescription database and linked to the physician billing plan to obtain antibiotic indication. Total defined daily dose (DDD) per 1000 residents per day was calculated. ResultsOur database had 381 LTCFs with an average of nearly 24,694 residents annually and 419,036 antibiotic prescriptions. Antibiotic utilization did not change dramatically between 2007 and 2014, ranging from 39.2 in 2007 to 35.2 DDD per 1000 residents per day in 2014. Although usage of most antibiotics declined, use of moxifloxacin, amoxicillin-clavulanate, doxycycline, and amoxicillin increased significantly. The indication most frequently linked to prescription was urinary tract infection (6.58 DDD per 1000 residents per day), with nitrofurantoin, ciprofloxacin, and trimethoprim/sulfamethoxazole being the most commonly prescribed agents. This was followed closely by prescriptions for respiratory infections (5.34 DDD per 1000 residents per day), with moxifloxacin being the most commonly prescribed antibiotic, primarily for upper respiratory tract infection (URTI), whereas doxycycline is used commonly for lower respiratory tract infection. Duration of antibiotic therapy in LTCF residents has decreased significantly from 9.29 days to 7.3 days per prescription in 2014. ConclusionAntibiotic use in LTCFs is high relative to the general population. Our study underscores that stewardship in LTCFs should continue to focus on length of treatment, appropriate detection of urinary tract infections, and avoidance of treating URTIs with antibiotics.

Factors Associated With the Trend of Physical and Chemical Restraint Use Among Long-Term Care Facility Residents in Hong Kong: Data From an 11-Year Observational Study

BackgroundNegative effects of restraint use have been well-documented. However, the prevalence of restraints use has been high in long-term care facilities in Hong Kong compared with other countries and this goes against the basic principles of ethical and compassionate care for older people. The present study aimed to review the change in the prevalence of physical and chemical restraint use in long-term care facilities (LTCFs) over a period of 11 years in Hong Kong and to identify the major factors associated with their use. MethodsThis is an observational study with data obtained from the Hong Kong Longitudinal Study on LTCF Residents between 2005 and 2015. Trained assessors (nurses, social workers, and therapists) used the Minimum Data Set Resident Assessment Instrument to collect the data from 10 residential LTCFs. Physical restraint was defined as the use of any of the following: full bedside rails on all open sides of bed, other types of bedside rails used, trunk restraint, limb restraint, or the use of chair to prevent rising during the past 7 days. Chemical restraint was defined as the use of any of the following medications: antipsychotic, antianxiety, or hypnotic agents during past 7 days, excluding elder residents with a diagnosis of psychiatric illness. OutcomesAnnual prevalence of restraint use over 11 years and factors that were associated with the use of physical and chemical restraints. ResultsWe analyzed the data for 2896 older people (978 male individuals, mean age = 83.3 years). Between 2005 and 2015, the prevalence of restraint use was as follows: physical restraint use increased from 52.7% to 70.2%; chemical restraint use increased from 15.9% to 21.78%; and either physical or chemical restraint use increased from 57.9% to 75.7%. Physical restraint use was independently associated with older age, impaired activities of daily living or cognitive function, bowel and bladder incontinence, dementia, and negative mood. Chemical restraint use was independently associated with older age, falls, bladder incontinence, use of feeding tube, dementia, poor cognitive function, delirium, behavioral problems, and negative mood. The increasing time-trend of physical but not chemical restraint use remained significant after adjusting for other factors as mentioned above (coefficient = 0.092, P < .001). ConclusionsUse of physical and chemical restraint was highly prevalent among LTCF residents in Hong Kong, with an increasing trend over a period of 11 years, especially targeting the most physically and cognitively frail older people. Appropriate healthcare staff education and policy change are urgently needed to ensure personal care that is characterized by respect, dignity, empathy, and compassion for the older generation.

Emergency Department Utilization in Patients With Neurogenic Bladder: Contemporary Burden and National Trends in Prevalence, Inpatient Admission, and Associated Charges, 2006-2011

To quantify the national burden of neurogenic bladder disease, a chronic debilitating condition associated with frequent hospital visits, in the contemporary emergency care setting. Relying on the Nationwide Emergency Department Sample, 2006-2011, we abstracted patients presenting to the emergency department (ED) with neurogenic bladder utilizing International Classification of Diseases, Ninth Revision (ICD-9) codes. National trends in ED presentation, subsequent inpatient admission vs discharge, and associated charges were examined using the estimated annual percent change methodology. Over the study period, a total of 875,066 patients with neurogenic bladder were seen in the ED, of which 538,532 (61.5%) were admitted. Total and median ED charges increased at an annual rate of 36.66% (P <.001) and 13.24% (P <.001), respectively, with total ED charges amounting to 87.48 million USD in the year 2011. Annual ED utilization also increased, although at a slower rate, 1.89% (P = .017). Inpatient admissions decreased at an annual rate of 3.67% (P <.001), whereas the use of long-term care facilities increased at 11.82% (P = .005). Total ED charges are increasing at a dramatic rate, driven by the increasing utilization of the ED as an entry point to health care as well as the increasing per-visit charges. Encouragingly, the rates of inpatient admission are decreasing, likely secondary to improved triaging in the ED and increased utilization of long-term care facilities. It remains to be seen, however, whether the increased spending in the ED for better triaging and investment in long-term care facilities will translate into an overall economic benefit by reducing inpatient charges or not.

Educational intervention on physical restraint use in long-term care facilities – Systematic review and meta-analysis

“Physical restraint” formerly used as a measure of protection for psychiatric patients is now widely used. However, existing studies showed that physical restraint not only has inadequate effect of protection but also has negative effects on residents. To analyzes the impact of educational program on the physical restraint use in long-term care facilities. Design: A systematic review with meta-analysis and meta-regression. Eight databases, including Cochrane Library, ProQuest, PubMed, EMBASE, EBSCO, Web of Science, Ovid Medline and Physiotherapy Evidence Database (PEDro), were searched up to January 2017. Eligible studies were classified by intervention and accessed for quality using the Quality Assessment Tool for quantitative studies. Sixteen research articles were eligible in the final review; 10 randomize control trail studies were included in the analysis. The meta-analysis revealed that the use of physical restraint was significantly less often in the experimental (education) group (OR = 0.55, 95% CI: 0.39 to 0.78, p < 0.001) compared to the control group. Meta-regression revealed the period of post education would have decreased the effect of the restraint educational program (β: 0.08, p = 0.002); instead, the longer education period and more times of education would have a stronger effect of reducing the use of physical restraint (β: −0.07, p < 0.001; β: −0.04, p = 0.056). The educational program had an effect on the reduced use of physical restraint. The results of meta-regression suggest that long-term care facilities should provide a continuous education program of physical restraint for caregivers.

Influences on the start, selection and duration of treatment with antibiotics in long-term care facilities.

Understanding the extent to which current antibiotic prescribing behaviour is influenced by clinicians' historical patterns of practice will help target interventions to optimize antibiotic use in long-term care. Our objective was to evaluate whether clinicians' historical prescribing behaviours influence the start, prolongation and class selection for treatment with antibiotics in residents of long-term care facilities. We conducted a retrospective cohort study of all physicians who prescribed to residents in long-term care facilities in Ontario between Jan. 1 and Dec. 31, 2014. We examined variability in antibiotic prescribing among physicians for 3 measures: start of treatment with antibiotics, use of prolonged durations exceeding 7 days and selection of fluoroquinolones. Funnel plots with control limits were used to determine the extent of variation and characterize physicians as extreme low, low, average, high and extreme high prescribers for each tendency. Multivariable logistic regression was used to assess whether a clinician's prescribing tendency in the previous year predicted current prescribing patterns, after accounting for residents' demographics, comorbidity, functional status and indwelling devices. Among 1695 long-term care physicians, who prescribed for 93 132 residents, there was wide variability in the start of antibiotic treatment (median 45% of patients, interquartile range [IQR] 32%-55%), use of prolonged treatment durations (median 30% of antibiotic prescriptions, IQR 19%-46%) and selection of fluoroquinolones (median 27% of antibiotic prescriptions, IQR 18%-37%). Prescribing tendencies for antibiotics by physicians in 2014 correlated strongly with tendencies in the previous year. After controlling for individual resident characteristics, prior prescribing tendency was a significant predictor of current practice. Physicians prescribing antibiotics exhibited individual, measurable and historical tendencies toward start of antibiotic treatment, use of prolonged treatment duration and class selection. Prescriber audit and feedback may be a promising tool to optimize antibiotic use in long-term care facilities.