Emerging issues in antibiotic resistant infections in long-term care facilities.

Managing patients infected with antibiotic resistant bacteria is becoming one of the major clinical obstacles facing physicians who treat patients in long-term care facilities (LTCFs). Penicillin-resistant pneumococci (PRP), vancomycin-resistant enterococci (VRE), gram-negative bacteria that produce extended-spectrum and ampC-type beta-lactamase enzymes, and quinolone-resistant gram-positive and gram-negative bacteria are the major resistant pathogens that are emerging in these settings. The mechanisms responsible for the evolution of these antibiotic resistant organisms (molecular rearrangement of penicillin binding protein genes, acquisition of a mobile genetic element, and point mutation that alter the active site) are reviewed. Vancomycin intermediate Staphylococcus aureus (VISA) and multidrug efflux pumps in gram-negative bacteria are also threatening our most potent antimicrobials. Aggressive screening, education, antibiotic-control measures, and immunization are advocated as important preventive measures. The combined efforts of the medical directors, infection-control personnel, and administrators are needed to stem this problem.     

Tetanus immunity in long-term care facilities

OBJECTIVES: To investigate the correlates of tetanus immunity in the elderly residing in a long-term care facility in Hawaii. DESIGN: Cross-sectional. SETTING: A nursing home in Honolulu, Hawaii. PARTICIPANTS: Sixty subjects aged 65 and older: 30 men and 30 women. MEASUREMENTS: The interview included demographic information, immunization history, military service information, and other potential risk factors for tetanus. Serum tetanus antibody titers were measured. RESULTS: The data showed that 76.7% (46/60) had adequate tetanus titers. This is in stark contrast to previous studies, which have reported immunity rates of 27% to 46% in similar populations. There were significant associations between immunity and prior history of military service. There were no significant associations between immunity and past history of immunization, education, socioeconomic status, or sex. CONCLUSION: History of immunization from patients, families, or medical charts may be unreliable indicators of tetanus immunity. Recognizing patterns of and barriers to immunization could have important consequences for public health policy in long-term care institutions.     

Limited-treatment policies in long-term care facilities

Two-thirds of the long-term care facilities in Minnesota accept do-not-resuscitate (DNR) orders and 73% accept care plans to limit medical treatment. The major objectives for limited-treatment plans cited by the 16.3% of facilities with administrative protocols for such plans was to provide for the resident's physical and emotional comfort and dignity. Nearly half of the protocols said limited treatment plans were intended to limit emergency care or hospitalization or to allow death to occur. Protocols advocated the alleviation of physical discomfort, anxiety, and social isolation. Tube feedings were not recommended when oral feeding became impossible. Airway suctioning, oxygen, or antibiotic treatment was suggested only as needed to alleviate suffering. Only a fourth of the protocols described a primary role for the resident in these decisions. This study demonstrates that nursing homes are developing administrative protocols for the formulation of limited-treatment plans and suggests that model policy statements describing key decision-making principles, issues, and procedural safeguards could play a constructive role in this process.     

Infection control in long-term care facilities.

Infections are common in long-term care facilities. The most frequent endemic infections are urinary infection, respiratory infection, and skin and soft tissue infections. Outbreaks also occur frequently, and some facilities have a high prevalence of colonization of residents with antimicrobial-resistant organisms. Our understanding of infections and the development of infection-control programs for long-term care facilities have progressed greatly over the past 15 years. Whereas the occurrence of infections has been described and specific guidelines for infection-control programs in long-term care facilities have been developed, there is still limited evaluation of the effectiveness of programs or specific interventions to support prioritization of infection-control resources. In addition, the spectrum of patients and care delivered in long-term care facilities continues to evolve. Increasingly, chronic care patients, including those requiring chronic respirator therapy, dialysis, or percutaneous feeding tubes, are cared for in these facilities. Our understanding of prevention of infection in these patients remains limited. Important questions include what interventions may prevent endemic infections, what are the most effective means to identify outbreaks early, and what interventions may minimize the prevalence of antimicrobial-resistant organisms. Programs to optimize antimicrobial use need to be developed. Thus, although progress in understanding and practice has been made, important questions remain.     

Medical care evaluation studies in long-term care facilities.

This report describes the selection, design, conduct, analysis, and application of medical care evaluation studies in long-term care facilities (skilled nursing homes) in a regional program in the Rochester region of upstate New York. Eight examples are presented to highlight methodologic approaches and problems. They are classified under four general headings: Administration Audits, Diagnosis-specific Studies, Care Modality-specific Studies, and General Outcome Indicators. The implementation of results and recommendations from the studies is discussed and an application of "tracer" methodology for assessing the components of care activities in long-term facilities is described. Problems and challenges in long-term quality care are outlined.     

Recruitment of long-term care facilities for research

We report the successful recruitment of a stratified random sample of nursing homes in the state of Maryland into three research studies funded by the National Institute on Aging. These studies examine the prevalence of infections and urinary tract instrumentation and the incidence of antimicrobial use in nursing home residents. Following selection of a facility, the administrator was telephoned and a meeting at the home was requested. At this meeting, the project was explained in detail using a packet of promotional information which included a project summary, a listing of project staff and their qualifications, and letters of support from influential organizations. A total of 61 eligible facilities were contacted in order to achieve a group of 53 participating homes with approximately 5000 beds. One hundred percent cooperation was achieved from all strata except small (less than or equal to 50 beds) proprietary comprehensive care facilities, and homes with both comprehensive and domiciliary beds. A direct, personal approach, backed by a carefully prepared study information and the support of medical and nursing home organizations resulted in successful recruitment of 53 (87%) of 61 homes sampled.     

Impacts associated with special care units in long-term care facilities

This study is a comprehensive, longitudinal assessment of the characteristics of special care patients. Demented patients in special care units (SCUs) within four nursing homes were compared with their demented counterparts in the same facilities who were not placed in SCUs. Results of this preliminary study suggest that the two groups differ in level of cognitive impairment, in behavior, and in functional and physical status. No deleterious or beneficial effects were associated with SCU residence during a 6-month period.     

The effects of animal-assisted therapy on loneliness in an elderly population in long-term care facilities

BACKGROUND: Animal-assisted therapy (AAT) is claimed to have a variety of benefits, but almost all published results are anecdotal. We characterized the resident population in long-term care facilities desiring AAT and determined whether AAT can objectively improve loneliness. METHODS: Of 62 residents, 45 met inclusion criteria for the study. These 45 residents were administered the Demographic and Pet History Questionnaire (DPHQ) and Version 3 of the UCLA Loneliness Scale (UCLA-LS). They were then randomized into three groups (no AAT; AAT once/week; AAT three times/week; n = 15/group) and retested with the UCLA-LS near the end of the 6-week study. RESULTS: Use of the DPHQ showed residents volunteering for the study had a strong life-history of emotional intimacy with pets and wished that they currently had a pet. AAT was shown by analysis of covariance followed by pairwise comparison to have significantly reduced loneliness scores in comparison with the no AAT group. CONCLUSIONS: The desire for AAT strongly correlates with previous pet ownership. AAT reduces loneliness in residents of long-term care facilities.     

Pneumonia in nursing homes and long-term care facilities

This article reviews the epidemiology of pneumonia in residents of nursing homes and other long-term care facilities (LTCFs). Streptococcus pneumoniae is the most important cause of pneumonia in residents of nursing homes and LTCFs. Factors suggestive of aspiration are the most important risk factors for pneumonia in this population. The clinical presentation of pneumonia among long-term care facility residents is challenging; residents tend to be older and more debilitated than their elderly community-dwelling counterparts. Data on optimal antimicrobial therapy in this setting is sparse. Functional status is an important predictor of outcome in this population. There are key management issues, such as site of care, which remain unresolved. Immunization with influenza and pneumococcal vaccines remains the mainstay of prevention.     

Hand hygiene practices of health care workers in long-term care facilities

Little is known about hand hygiene practice in the long-term care setting. In this study, we observed 459 hand hygiene opportunities in 2 long-term care facilities in Hamilton, Ontario. Overall hand hygiene adherence was 14.7%, with a mean handwashing time of 15.9 seconds. Adherence varied by activity performed and the presence or absence of a sink.     

Current admission policies of long-term care facilities in Japan

Background:   The rapidly aging society in Japan is putting demands on long-term care facilities for the elderly who require care. In Europe and the USA, there is ongoing reform of elderly care services, but the establishment of system based on social insurance is still being explored in Japan.
Methods:   Two studies were conducted, the first in 2000 and the second in 2001, involving 91 long-term care facilities located in or around the city of Nagoya. Questionnaires were sent to facility directors, chief administrators or head nurses to inquire about their admission policies for six major patient categories. Two educational lectures on methicillin-resistant Staphylococcus aureus (MRSA) and urinary incontinence were given between the distribution of the questionnaires.
Results:   For all six categories featured on the questionnaire, the acceptance rate in both studies was the highest in geriatric hospitals, and an improvement in acceptance rates was seen in the second study in all three types of care facilities. When the effect the lectures had on changes in admission policies at these facilities was examined, no correlation was found.
Conclusions:   Lectures should be given to facility management and personnel to raise their awareness of key issues and improve their efficiency.