Diabetes care in rest homes in Christchurch, New Zealand.

AIM: To determine the prevalence and describe the management of known diabetes in a group of New Zealand rest homes. METHODS: A random sample of 54 rest homes in Christchurch were studied. Residents with known diabetes were identified by rest home staff and interviewed. Selected staff members of all rest homes were also interviewed using structured questionnaires. The medical and nursing records and laboratory results of all residents with known diabetes were reviewed and all information pertaining to diabetes management recorded. RESULTS: The prevalence of known diabetes in Christchurch rest homes was 11.7%. Residents with known diabetes had a mean of five other comorbidities and were prescribed a mean of 7.5 medications. Of residents with diabetes, 45% were taking oral glucose-lowering agents, 28% were on a diet alone and 27% on insulin treatment. The mean blood pressure was 134/73 mmHg. The mean HbA(1c) was 7.3%. Routine blood glucose monitoring was performed often but residents with possible hypoglycaemic episodes frequently did not have their blood glucose level checked. CONCLUSIONS: The prevalence of known diabetes in Christchurch rest homes is similar to that found in British studies but less than that found in studies from the USA. Indicators of quality of care in residents with diabetes in this study appeared to be satisfactory, in contrast to other studies. There was poor recognition by staff of the necessity of checking acutely blood glucose levels in residents with diabetes who became unwell.     

Impact of visitation and cohorting policies to shield residents from covid-19 spread in care homes: an agent-based model

BackgroundThis study examines the impact of visitation and cohorting policies as well as the care home population size upon the spread of COVID-19 and the risk of outbreak occurrence in this setting.MethodsAgent-based modellingResultsThe likelihood of the presence of an outbreak in a care home is associated with the care home population size. Cohorting of residents and staff into smaller, self-contained units reduces the spread of COVID-19. Restricting the number of visitors to the care home to shield its residents does not significantly impact the cumulative number of infected residents and risk of outbreak occurrence in most scenarios. Only when the community prevalence where staff live is considerably lower than the prevalence where visitors live (the former prevalence is less than or equal to 30% of the latter), relaxing visitation increases predicted infections much more significantly than it does in other scenarios. Maintaining a low infection probability per resident-visitor contact helps reduce the effect of allowing more visitors into care homes.ConclusionsOur model predictions suggest that cohorting is effective in controlling the spread of COVID-19 in care homes. However, according to predictions shielding residents in care homes is not as effective as predicted in a number of studies that have modelled shielding of vulnerable population in the wider communities.     

Failing to meet the needs of generations of care home residents with diabetes: a review of the literature and a call for action

In residential care homes and aged‐care facilities globally, between one in three and one in four residents may have diabetes, an often complex highly co‐morbid illness that leads to frailty, dependency, disability and reduced life expectancy. Residents with diabetes also have a high risk of hypoglycaemia, avoidable hospital admissions, and represent one of the most difficult challenges to health professionals and care staff in optimizing their diabetes and medical care. This detailed review examines the literature relating to care home diabetes over the last 25 years to assess what has been achieved in characterizing residents with diabetes, and what we know about the various but limited intervention studies that have been carried out internationally. The guidance and guidelines that have been published to assist clinicians in planning effective and safe care for this rather vulnerable group of people with diabetes are also reviewed. The review presents the first diagrammatic representation of a likely physiological cascade depicting the mainly irreversible functional decline a resident with diabetes might experience, provides modern principles of care for each resident with diabetes, and identifies what priority recommendations are required to be implemented if diabetes care is to improve. The review concludes that action is required since diabetes care still remains fragmented, sub‐optimal, and in need of investment, otherwise care home residents with diabetes will continue to have their needs unfulfilled.     

Guidelines for the management of diabetes services and patients during the COVID-19 pandemic

The UK National Diabetes Inpatient COVID Response Group was formed at the end of March 2020 to support the provision of diabetes inpatient care during the COVID pandemic. It was formed in response to two emerging needs. First to ensure that basic diabetes services are secured and maintained at a time when there was a call for re-deployment to support the need for general medical expertise across secondary care services. The second was to provide simple safe diabetes guidelines for use by specialists and non-specialists treating inpatients with or suspected of COVID-19 infection. To date the group, comprising UK-based specialists in diabetes, pharmacy and psychology, have produced two sets of guidelines which will be continually revised as new evidence emerges. It is supported by Diabetes UK, the Association of British Clinical Diabetologists and NHS England.     

A qualitative interview study comparing and contrasting resident and staff perspectives of engaging in meaningful activity in a UK care home

The provision of meaningful activities in care homes is essential for maintaining residents' mental and physical health, yet many do not get adequate opportunities to participate. This qualitative study explored resident and staff perceptions of engaging in meaningful activities in a residential care home for older people (aged over 65 years) in South London, UK. Nine residents and eleven staff members were recruited and their experiences explored through semi-structured interviews. Data were analysed thematically, and three themes emerged. (1) Appreciation of activity: both staff and residents were aware of the benefits of activity to physical and mental health, yet there was a lack of provision within the home. (2) Residents' desire for engagement: residents perceived themselves as active individuals who had previously enjoyed activities, and had goals that they wanted to achieve. This was in contrast to views of care staff, who perceived residents as inactive, lacking in motivation and sedentary due to intrinsic factors such as their age. (3) Impact of care home culture and physical space: staff and residents perceived different barriers to activity; staff reported they were often expected to take on multiple roles within the home leading to a lack of time to engage residents in activities, whilst residents perceived that the layout and design of the home hindered provision. It was concluded that comparing and contrasting views of residents and staff could assist residential homes to reach greater levels of shared understanding of activity provision and highlight particular areas to target for increasing activity engagement.     

Care home medicine in the UK--in from the cold

The quality of care within care homes comes under frequent media scrutiny, and is underpinned by the medical support to the staff. In the UK, medical care to care homes is provided by general practitioners. A GP is likely to have patients in many homes, and each home relates to many GPs. The growing complexity of patients in care requires proactive models of care delivered by those with an understanding of care home medicine. A range of innovative models of medical care are emerging across the UK which have the potential to improve the standard of care in homes, and reduce inappropriate use of secondary care admissions. These models are described, and the need for them to be subjected to evaluation.     

Undiagnosed diabetes mellitus and metabolic control assessed by HbA(1c) among residents of nursing homes.

AIMS/HYPOTHESIS: Diabetes prevalence and diabetes care in residents of nursing homes is a neglected area of research although the growing number of elderly people with diabetes represents a growing challenge for health care in most countries. In this study, we used HbA(1c) measurement to estimate the percentage of residents with undiagnosed diabetes and the quality of metabolic control of subjects with known diabetes in nursing homes. METHODS: All 41 nursing homes in the county of Heinsberg in Northrhine-Westfalia were asked to complete a structured questionnaire on the prevalence of known diabetes among all residents. In addition, all residents were offered measurement of glycated haemoglobin A1c (HbA(1c)) from a capillary blood sample. Undiagnosed diabetes was defined by a HbA(1c) level greater than 6.0%. RESULTS: 39 nursing homes participated in the study comprising 99.6% of all residents. Among the 1936 residents 507 (26.2%) were known to suffer from diabetes. Among the latter 37.0% were under insulin treatment. Blood samples for the determination of HbA(1c) were obtained from 979 subjects from 20 nursing homes. Among those 60 years old or above (n = 843) the mean level of HbA(1c) in those with known diabetes was 7.3 +/- 1.5% and in those without 6.1 +/- 0.9%. Only 16.7% of the subjects with known diabetes had a HbA(1c) greater than 8.5% indicating poor metabolic control. Among the residents previously not known to have diabetes 47.2% had a HbA(1c) equal to or greater than 6.1%, but among those only 8.5% had a HbA(1c) greater than 7.0%. CONCLUSIONS/INTERPRETATION: Although the prevalence of undiagnosed diabetes mellitus defined by HbA(1c) above the normal range in elderly nursing home residents is high, only few may require treatment. The quality of metabolic control among those with known diabetes mellitus is better than expected.     

Knowledge and attitudes of nursing home staff and surveyors about the revised federal guidance for incontinence care

PURPOSE: We assessed nursing home staff and state nursing home surveyors regarding their knowledge and attitudes about urinary incontinence, its management, and the revised federal Tag F315 guidance for urinary incontinence. DESIGN AND METHODS: We conducted a questionnaire survey of a convenience sample of nursing home staff and state nursing home surveyors from a midwestern state attending two statewide workshops on the revised guidance. RESULTS: Of 558 attendees, 500 (85%) responded, including 39% of the state's directors of nursing and 57% of state nursing home surveyors. There were striking deficiencies in knowledge regarding urinary incontinence and catheter care, with significant discrepancies by type of respondent, particularly between state surveyors and nursing home staff. Staff cited documentation and staffing levels as the most frequent concerns about implementation. Open-ended responses reflected the divergence of concerns and antagonism among the stakeholders, and staff nurses' feeling that F315 violated residents' rights. IMPLICATIONS: The revised Tag F315 guidance will be unlikely to improve the quality of urinary incontinence care in nursing homes because of significant knowledge and attitudinal discrepancies between nursing home staff and state surveyors, facility staff's focus on documentation and staffing, and reliance on implementation strategies known to be ineffective. Federal, state, and other urinary incontinence guideline efforts should focus on managerial structures and methods to improve quality nursing home care. Research is needed to address how nursing home residents and families define and value "quality" urinary incontinence management and to incorporate these in quality-improvement strategies and measures.     

Prevalence of Methicillin-Resistant Staphylococcus aureus Colonization in Residents and Staff in Nursing Homes in Northern Ireland

OBJECTIVES: To determine the prevalence of, and factors associated with, methicillin-resistant Staphylococcus aureus (MRSA) colonization in residents and staff in nursing homes in one geographically defined health administration area of Northern Ireland.
DESIGN: Point prevalence study.
SETTING: Nursing homes.
PARTICIPANTS: Residents and staff in nursing homes.
MEASUREMENTS: Nasal swabs were taken from all consenting residents and staff. If relevant, residents also provided urine samples, and swabs were taken from wounds and indwelling devices.
RESULTS: A total of 1,111 residents (66% of all residents) and 553 staff (86% of available staff) in 45 nursing homes participated. The combined prevalence rate of MRSA in the resident population was 23.3% (95% confidence interval (CI)=18.8–27.7%) and 7.5% in staff (95% CI=5.1–9.9%). Residents who lived in nursing homes that were part of a chain were more likely to be colonized with MRSA (odds ratio (OR)=1.91, 95% CI=1.21–3.02) than those living in independently owned facilities. Residents were also more likely to be colonized if they lived in homes in which more than 12.5% of all screened healthcare staff (care assistants and nurses) were colonized with MRSA (OR=2.46, 95% CI=1.41–4.29) or if they lived in homes in which more than 15% of care assistants were colonized with MRSA (OR=2.64, 95% CI=1.58–4.42).
CONCLUSION: The findings suggest that there is substantial colonization of MRSA in nursing home residents and staff in this one administrative health area. Implementation of infection control strategies should be given high priority in nursing homes.     

Covid-19 and the next outbreak: decreasing frailty by using mild stress?

The coronavirus disease 2019 (Covid-19) has resulted in many deaths, particularly of very old or obese people. These people are at risk to die in the event of an outbreak, like under one-year old babies were at risk to die one century ago from various diseases. It is argued that mild stress could help people to resist new outbreaks. The people who are obese because of bad feeding habits (snacking, junk food, overfeeding) and inactivity should adopt more healthy behaviours. Because an inactive way of life at old age can increase frailty, physical and mental activities should be kept at the highest possible level in elderly people, particularly if they live in retirement homes. In the event of an outbreak, management staff of these homes should not confine residents in their room for weeks or months, as it can increase inactivity, under-nutrition, sarcopenia, and depressive symptoms. People with or without co-morbidities should be active and one could wonder whether other mild stresses such as sauna bathing could help to better resist infection.

     

Care of the nursing-home resident with diabetes.

Diabetes is a common and costly illness among elderly nursing-home residents. People with diabetes more often require skilled care, experience more frequent health problems and hospitalizations, and have longer nursing-home stays. This article provides information about recommendations for diabetes care in nursing homes, the current level of care, and strategies to improve the quality of care for residents with diabetes.     

“It just happens”. Care home residents’ experiences and expectations of accessing GP care

BackgroundCare homes provide personal care and support for older people who can no longer be supported in the community. As part of a larger study of integrated working between the NHS and care homes we asked older people how they accessed health care services. Our aim was to understand how older people resident in care homes access health services using the Andersen model of health care access.MethodsCase studies were conducted in six care homes with different socio-economic characteristics, size and ownership in three study sites. Residents in all care homes with capacity to participate were eligible for the study. Interviews explored how residents accessed NHS professionals. The Andersen model of health seeking behaviour was our analytic framework.FindingsThirty-five participants were interviewed with an average of 4 different conditions. Expectations of their health and the effectiveness of services to mitigate their problems were low. Enabling factors were the use of intermediaries (usually staff, but also relatives) to seek access. Residents expected that care home staff would monitor changes in their health and seek appropriate help unprompted.ConclusionsCare home residents may normalise their health care needs and frame services as unable to remediate these which may combine to disincline older care home residents to seek care. Care access was enabled using intermediaries -either staff or relatives-and the expectation that staff would proactively seek care when they observed new/changed needs. Residents may over-estimate the health-related knowledge of care home staff and their ability to initiate referrals to NHS professionals.     

COVID-19 in Nursing Homes: Calming the Perfect Storm

The pandemic of viral infection with the severe acute respiratory syndrome coronavirus-2 that causes COVID-19 disease has put the nursing home industry in crisis. The combination of a vulnerable population that manifests nonspecific and atypical presentations of COVID-19, staffing shortages due to viral infection, inadequate resources for and availability of rapid, accurate testing and personal protective equipment, and lack of effective treatments for COVID-19 among nursing home residents have created a “perfect storm” in our countryʼs nursing homes. This perfect storm will continue as society begins to reopen, resulting in more infections among nursing home staff and clinicians who acquire the virus outside of work, remain asymptomatic, and unknowingly perpetuate the spread of the virus in their workplaces. Because of the elements of the perfect storm, nursing homes are like a tinderbox, and it only takes one person to start a fire that could cause many deaths in a single facility. Several public health interventions and health policy strategies, adequate resources, and focused clinical quality improvement initiatives can help calm the storm. The saddest part of this perfect storm is that many years of inaction on the part of policy makers contributed to its impact. We now have an opportunity to improve nursing homes to protect residents and their caregivers ahead of the next storm. It is time to reimagine how we pay for and regulate nursing home care to achieve this goal. J Am Geriatr Soc 68:2153–2162, 2020.     

Building community and resilience in Massachusetts nursing homes during the COVID-19 pandemic

During the COVID-19 pandemic, frontline nursing home staff faced extraordinary stressors including high infection and mortality rates and ever-changing and sometimes conflicting federal and state regulations. To support nursing homes in evidence-based infection control practices, the Massachusetts Senior Care Association and Hebrew SeniorLife partnered with the Agency for Healthcare Research and Quality AHRQ ECHO National Nursing Home COVID-19 Action Network (the network). This educational program provided 16 weeks of free weekly virtual sessions to 295 eligible nursing homes, grouped into nine cohorts of 30–33 nursing homes. Eighty-three percent of eligible nursing homes in Massachusetts participated in the Network, and Hebrew SeniorLife's Training Center served the vast majority. Each cohort was led by geriatrics clinicians and nursing home leaders, and coaches trained in quality improvement. The interactive sessions provided timely updates on COVID-19 infection control best practices to improve care and also created a peer-to-peer learning community to share ongoing challenges and potential solutions. The weekly Network meetings were a source of connection, emotional support, and validation and may be a valuable mechanism to support resilience and well-being for nursing home staff.     

Risk factors for outbreaks of COVID‐19 in care homes following hospital discharge: A national cohort analysis

BackgroundThe population of adult residential care homes has been shown to have high morbidity and mortality in relation to COVID‐19.MethodsWe examined 3115 hospital discharges to a national cohort of 1068 adult care homes and subsequent outbreaks of COVID‐19 occurring between 22 February and 27 June 2020. A Cox proportional hazards regression model was used to assess the impact of time‐dependent exposure to hospital discharge on incidence of the first known outbreak, over a window of 7‐21 days after discharge, and adjusted for care home characteristics, including size and type of provision.ResultsA total of 330 homes experienced an outbreak, and 544 homes received a discharge over the study period. Exposure to hospital discharge was not associated with a significant increase in the risk of a new outbreak (hazard ratio 1.15, 95% CI 0.89, 1.47, P = .29) after adjusting for care home characteristics. Care home size was the most significant predictor. Hazard ratios (95% CI) in comparison with homes of <10 residents were as follows: 3.40 (1.99, 5.80) for 10‐24 residents; 8.25 (4.93, 13.81) for 25‐49 residents; and 17.35 (9.65, 31.19) for 50+ residents. When stratified for care home size, the outbreak rates were similar for periods when homes were exposed to a hospital discharge, in comparison with periods when homes were unexposed.ConclusionOur analyses showed that large homes were at considerably greater risk of outbreaks throughout the epidemic, and after adjusting for care home size, a discharge from hospital was not associated with a significant increase in risk.     

Outbreak of invasive group A streptococcal infections in a nursing home. Lessons on prevention and control.

OBJECTIVE--Nine outbreaks of group A streptococcal (GAS) infections in nursing homes were reported to the Centers for Disease Control (Atlanta, Ga) during the past two winters. We conducted an intensive epidemiologic and laboratory investigation of one of these outbreaks to determine clinical characteristics, risk factors for transmission and infection, and methods of control and prevention. METHODS--Cases were detected using cultures and serologic tests. Matched case-control and retrospective cohort studies were performed to determine risk factors for infection. RESULTS--Between December 13, 1989, and January 31, 1990, 16 (20%) of 80 residents, and three (7%) of 45 staff, were infected with GAS. Eleven of the residents had invasive disease and four died. Isolates were available from four persons; all were serotype M-1, T-1. There was strong spatial clustering of cases within the nursing home; having a roommate with prior infection was the most important risk factor. Residents with preexisting decubiti had a reduced risk of infection, perhaps because of stricter infection control practices in their care. No evidence was found for common-source transmission of infection. No further cases occurred after improvement of infection control practices and administration of prophylactic antimicrobials to all residents and staff. CONCLUSIONS--Invasive GAS disease is increasing nationwide, and is a potentially serious problem in the growing and high-risk setting of nursing homes. These data suggest that, in this outbreak, a virulent GAS strain was introduced, with subsequent person-to-person transmission. Adherence to infection control practices can prevent or control GAS outbreaks. Prophylactic antimicrobials may be an effective adjunct to control severe or ongoing outbreaks.     

Challenges of diabetes care management in developing countries with a high incidence of COVID-19: A brief report

Background and aimsDiabetes mellitus (DM) is one of the most critical risk factors for complications and death in COVID-19 patients. The present study aims to highlight challenges in the management of diabetic patients during the COVID-19 outbreak in developing countries.MethodsWe reviewed the literature to obtain information about diabetic care during the Covid-19 crisis. We also seek opinions of clinicians working in undeveloped countries.ResultsCurrent challenges faced by clinicians in the management of diabetic patients in developing countries are as follows: lack of preventive measures, inadequate number of visits, loss of the traditional method of communication with the patient, shortage of medications, impaired routine diabetic care, and absence of telehealth services.ConclusionsDeveloping countries are faced with many challenges in diabetes management due to a lack of resources.