An outbreak of influenza A (H3N2) in a well immunized nursing home population.

OBJECTIVE: To describe the epidemiologic features of an outbreak of influenza A that occurred in a skilled nursing home although over 90 percent of the resident population had previously received influenza vaccine. DESIGN: Retrospective cohort study. SETTING: Skilled nursing home facility in western New York State. PATIENTS: Nursing home residents and patient-care staff. MAIN OUTCOME MEASURE: Incidence of influenza-like illness among vaccinated versus unvaccinated nursing home residents and staff. RESULTS: Thirty-seven of 124 residents (attack rate = 30%) and 18 of 146 staff (attack rate = 12%) had an influenza-like illness. Staff illness began 16 days prior to onset among residents. Six cases of pneumonia and three influenza-related deaths occurred, all among the vaccinated residents. Ninety percent of the nursing home residents and 10% of the staff received the influenza vaccine prior to the outbreak. The calculated vaccine efficacies were minus 21% and plus 45% for residents and staff, respectively. CONCLUSION: While antigenic drift of the circulating influenza virus was the major factor in the apparent vaccine failure, the observed poor staff immunization rate (10%) and absence of surveillance which precluded the use of amantadine chemoprophylaxis suggest that the use of these strategies may be of importance in controlling influenza outbreaks in nursing homes.     

Influenza outbreak detection and control measures in nursing homes in the United States

OBJECTIVE: To evaluate the use of influenza vaccine, rapid influenza testing, and influenza antiviral medication in nursing homes in the US to prevent and control outbreaks. METHODS: Survey questionnaires were sent to 1017 randomly selected nursing homes in nine states. Information was collected on influenza prevention, detection and control practices, and on outbreaks during three influenza seasons (1995-1998). RESULTS: The survey response rate was 78%. Influenza vaccine was offered to residents and staff by 99% and 86%, respectively, of nursing homes. Among nursing homes offering the influenza vaccine, the average vaccination rate was 83% for residents and 46% for staff. Sixty-seven percent of the nursing homes reported having access to laboratories with rapid antigen testing capabilities, and 19% reported having a written policy for the use of influenza antiviral medications for outbreak control. Nursing homes from New York, where organized education programs on influenza detection and control have been conducted for many years, were more likely to have reported a suspected or laboratory-confirmed influenza outbreak (51% vs 10%, P = .01), to have access to rapid antigen testing for influenza (92% vs 63%, P = .01), and to use antivirals for prophylaxis and treatment of influenza A for their nursing home residents (94% vs 55%, P = .01) compared with nursing homes from the other eight states. CONCLUSIONS: Influenza outbreaks among nursing home residents can lead to substantial morbidity and mortality when prevention measures are not rapidly instituted. However, many nursing homes in this survey were neither prepared to detect nor to control influenza A outbreaks. Targeted, sustained educational efforts can improve the detection and control of outbreaks in nursing homes.     

The management of adverse clinical events in nursing homes: a 1-year survey study

OBJECTIVE: In Italian nursing homes (NHs), care delivery at night and during holidays is not regulated by regional laws; some facilities employ staff physicians, others employ physicians engaged from year to year (temporary physicians), and others employ publicly funded National Health System (NHS) physicians. This study was designed to determine whether the use of different kinds of physicians leads to different outcomes with regard to the rate of hospitalization and appropriateness of the management of adverse clinical events. DESIGN: Prospective, nonrandomized-survey data collection. SETTING: Ten nonprofit nursing facilities in Italy. PARTICIPANTS: Three hundred and fifty-two NH residents, staff physicians, temporary physicians, and NHS physicians. MEASUREMENTS: Medical intervention during adverse clinical events occurring at night and during holidays. RESULTS: Three hundred and fifty-two residents experienced 551 adverse clinical events; 78 were hospitalized. The hospitalization rate of NHS physicians was about two times that of the temporary physicians and six times that of the staff physicians. Staff physicians' diagnoses and management were appropriate in the majority of cases; NHS diagnosis and management were doubtful or incorrect in about one-third of all cases. CONCLUSIONS: NH residents frequently experience adverse clinical events; physician characteristics influence the rate of hospitalization and the quality of medical interventions.     

Effect of Influenza Vaccination of Nursing Home Staff on Mortality of Residents: A Cluster-Randomized Trial

OBJECTIVES: To evaluate the effect of staff influenza vaccination on all-cause mortality in nursing home residents.
DESIGN: Pair-matched cluster-randomized trial.
SETTING: Forty nursing homes matched for size, staff vaccination coverage during the previous season, and resident disability index.
PARTICIPANTS: All persons aged 60 and older residing in the nursing homes.
INTERVENTION: Influenza vaccine was administered to volunteer staff after a face-to-face interview. No intervention took place in control nursing homes.
MEASUREMENTS: The primary endpoint was total mortality rate in residents from 2 weeks before to 2 weeks after the influenza epidemic in the community. Secondary endpoints were rates of hospitalization and influenza-like illness (ILI) in residents and sick leave from work in staff.
RESULTS: Staff influenza vaccination rates were 69.9% in the vaccination arm versus 31.8% in the control arm. Primary unadjusted analysis did not show significantly lower mortality in residents in the vaccination arm (odds ratio=0.86, P =.08), although multivariate-adjusted analysis showed 20% lower mortality ( P =.02), and a strong correlation was observed between staff vaccination coverage and all-cause mortality in residents (correlation coefficient=−0.42, P =.007). In the vaccination arm, significantly lower resident hospitalization rates were not observed, but ILI in residents was 31% lower ( P =.007), and sick leave from work in staff was 42% lower ( P =.03).
CONCLUSION: These results support influenza vaccination of staff caring for institutionalized elderly people.     

Experience with oseltamivir in the control of nursing home influenza A outbreak

OBJECTIVE: Influenza outbreaks have revealed that elderly persons are a great risk of death and serious complications after infection. The administration of oseltamivir, a neuramidase inhibitor, is effective for prophylaxis of influenza and to reduce disease duration and severity in healthy adults with naturally acquired febrile influenza. To clarify the usefulness of oseltamivir in the elderly we administered oseltamivir to all residents when an influenza A outbreak occurred in a nursing home. PATIENTS: Sixty-eight residents in the nursing home were investigated in which the influenza A outbreak occurred; 32 residents had fever and 28 residents were positive for influenza A with direct enzyme immunoassay. METHODS: Oseltamivir was administered at 75 mg twice daily for 5 days to all residents. RESULTS: Oseltamivir almost inhibited symptom onset in the influenza A-positive afebrile group. Initiation at 0 hour (22 cases), 1-12 hours (4 cases), 13-24 hours (5 cases) or 72 hours (1 case) from onset of symptoms was associated with mean fever durations of 26+/-18 hours, 38+/-21 hours, 54+/-12 hours and 120 hours, respectively, indicating that earlier initiation of therapy was associated with faster resolution of fever in elderly patients. Oseltamivir may be effective for household prophylaxis in the elderly persons. Oseltamivir administration was well tolerated in elderly persons. CONCLUSION: Oseltamivir is effective for the reduction or prophylaxis of influenza A infection in elderly persons.     

End-of-life care in assisted living and related residential care settings: comparison with nursing homes

OBJECTIVES: To define the current state of end-of-life care in residential care/assisted living (RC/AL) facilities and nursing homes (NHs) and to compare these two types of care settings. DESIGN: Interviews of staff and family informants about deaths that occurred during a longitudinal study. SETTING: Fifty-five RC/AL facilities and 26 NHs in Florida, Maryland, New Jersey, and North Carolina. PARTICIPANTS: Two hundred twenty-four staff and family informants that best knew the 73 RC/AL residents and 72 NH residents who died in or within 3 days after discharge from a study facility. MEASUREMENTS: Telephone interviews conducted with the facility staff member who knew the decedent best and the family member who was most involved in care during the last month of life of the decedent. Data were collected on circumstances of death, perceptions of dying process, cause of death, care during the last month of life, mood, discomfort, and family satisfaction. RESULTS: Most decedents died in the facility where they had resided, and more than half of the subjects were alone when they died. Greater proportions of staff and family in the NHs knew that the resident's death was only days or weeks away. Both RC/AL and NH residents experienced few highly negative moods, and even on their most uncomfortable day, the overall discomfort was low for residents in both facility types. Summary ratings of family satisfaction were significantly higher for the RC/AL (32.1) than the NH (41.2) group (P=.016). CONCLUSION: These data suggest that end-of-life care in RC/AL settings appears similar in process and outcomes to that provided in NHs. Thus, aging and dying-in-place can effectively occur in RC/AL.     

Efficacy of Influenza Vaccine in Elderly Persons in Welfare Nursing Homes: Reduction in Risks of Mortality and Morbidity During an Influenza A (H3N2) Epidemic

BACKGROUND: The effect of influenza vaccination on the occurrence and severity of influenza virus infection in a population residing in nursing homes was studied through a program by the Osaka Prefectural Government, which is the first and official support for influenza vaccination of the elderly population during an influenza A (H3N2) epidemic in JAPAN: METHODS: A cohort study located in the Osaka Prefecture, Japan, followed the outcomes of elderly nursing home residents who received influenza vaccinations (n = 10,739) in comparison with control subjects who did not receive influenza vaccinations (n = 11,723) and monitored clinically the onset of serious morbidity and mortality of influenza illness. Subjects were 22,462 persons older than 65 years who resided in 301 welfare nursing homes in the Osaka Prefecture, Japan during an influenza A (H3N2) epidemic in 1998 to 1999. RESULTS: Of 22,462 individuals living in 301 nursing homes, 10,739 received either one dose (2027 subjects) or two doses (8712 subjects) of inactivated, subunit trivalent influenza vaccine. Through the period from November 1998 to March 1999, there were 950 cases of influenza infection diagnosed clinically with cases by virus isolation and/or serology. There were statistically significantly fewer clinical cases of influenza, hospital admissions due to severe infection, and deaths due to influenza in the vaccinated cohort (256 cases, 32 hospital admissions, and one death) compared with the unvaccinated controls (694 cases, 150 hospital admissions, and five deaths). Vaccination was equally effective in those who received one dose of vaccine as in those who received two doses. No serious adverse reactions to vaccination were recorded. Thus, influenza vaccination is safe and effective in this population and should be an integral part of the routine care of persons aged 65 years and older residing in nursing homes. CONCLUSIONS: This study provides an analysis of the clinical efficacy of influenza vaccination in a large cohort of nursing home residents in JAPAN: Annual influenza vaccine administration requires the attention of all nursing home attendants, physicians, and public health organizations.     

Effects of a Restraint Minimization Program on Staff Knowledge, Attitudes, and Practice: A Cluster Randomized Trial

OBJECTIVES: To evaluate the effects of a restraint minimization education program on staff knowledge and attitudes and use of physical restraints.
DESIGN: Cluster-randomized controlled trial with nursing units as the basis for randomization.
SETTING: Forty group dwelling units for people with dementia.
PARTICIPANTS: At baseline, there were 184 staff and 191 residents in the intervention group and 162 staff and 162 residents in the control group. At the 6-month follow-up, there were 156 staff and 185 residents (36 newly admitted) in the intervention group and 133 staff and 165 residents (26 newly admitted) in the control group.
INTERVENTION: A 6-month education program for all nursing staff.
MEASUREMENTS: Staff knowledge and attitudes and physical restraint use were measured before and after the education program.
RESULTS: In the intervention group, staff knowledge about and attitudes toward restraint use changed, and the overall use of physical restraints decreased. A comparison including only residents present during the whole study period showed that the level of use was similar between the groups at baseline, whereas it was significantly lower in the intervention group at follow-up. Adjusted analyses showed that the odds of being restrained at follow-up were lower in the intervention group than in the control group. There was no significant change in the number of falls or use of psychoactive medication.
CONCLUSION: The results indicate that staff education can increase knowledge, change attitudes, and reduce the use of physical restraints without any change in the incidence of falls or use of psychoactive drugs.     

Do Vaccination Strategies Implemented by Nursing Homes Narrow the Racial Gap in Receipt of Influenza Vaccination in the United States?

OBJECTIVES: To determine whether the racial inequity between African Americans and Caucasians in receipt of influenza vaccine is narrower in residents of nursing homes with facility‐wide vaccination strategies than in residents of facilities without vaccination strategies. DESIGN: Secondary data analysis using the National Nursing Home Survey 2004, a nationally representative survey. SETTING: One thousand one hundred seventy‐four participating nursing homes sampled systematically with probability proportional to bed size. PARTICIPANTS: Thirteen thousand five hundred seven randomly sampled residents of nursing homes between August and December 2004. MEASUREMENTS: Receipt of influenza vaccine within the last year. Logistic regression was used to examine the relationship between facility‐level influenza immunization strategy and racial inequity in receipt of vaccination, adjusted for characteristics at the resident, facility, state, and regional levels. RESULTS: Overall in the Untied States, vaccination coverage was higher for Caucasian and African‐American residents; the racial vaccination gaps were smaller (<6 percentage points) and nonsignificant in residents of homes with standing orders for influenza vaccinations (P=.14), verbal consent allowed for vaccinations(P=.39), and routine review of facility‐wide vaccination rates (P=.61) than for residents of homes without these strategies. The racial vaccination gap in residents of homes without these strategies were two to three times as high (P=.009, P=.002, and P=.002, respectively). CONCLUSION: The presence of several immunization strategies in nursing homes is associated with higher vaccination coverage for Caucasian and African‐American residents, narrowing the national vaccination racial gap.     

The potential of wash-and-dry toilets to improve the toileting experience for nursing home residents

PURPOSE: We investigated the feasibility of using a "wash-and-dry" toilet in the nursing home. DESIGN AND METHODS: We used a controlled comparison baseline-versus-treatment design with 22 female nursing home residents aged 75 and older living in a 562-bed, not-for-profit nursing home facility in Maryland. The Luscence Luxury Lavage wash-and-dry toilet-bidet system was installed in the bathrooms of the experimental group. Measurements included staff and resident toilet experiences and toilet reaction questionnaires, utilization logs, Minimum Data Set information, Mini-Mental State Examination scores, and urine cultures. RESULTS: About half of the residents and staff members reported the toilet to have a positive effect on toileting. We saw a positive trend in resident affect for the experimental group that was not apparent for the comparison group. Nursing staff reported that the toilet functions did clean the residents, but that cleaning was not complete. Bacterial content of urine decreased in the experimental group and increased in the comparison group during the trial. Toilet installation was more complex than anticipated. IMPLICATIONS: These results show that a wash-and-dry toilet shows promise for improved resident comfort in toileting and cleanliness, although further research is needed to verify the findings. Improved toilet design, design of nursing homes, and design of care activities would all improve the utility of these toilets in the nursing home population.     

Emergence and transmission of amantadine-resistant influenza A in a nursing home

OBJECTIVES: To prospectively detect amantadine-resistant influenza when amantadine was used for influenza A outbreak control. DESIGN: Prospective clinical surveillance and viral culture of all new respiratory illnesses during the course of amantadine prophylaxis. SETTING: A 721-bed, 14-ward nursing home for veterans and spouses during an influenza A outbreak (1993-94). PARTICIPANTS: Residents of a veterans hospital and their spouses. MEASUREMENTS: Nasopharyngeal and throat viral culture. All residents with positive cultures who developed new respiratory symptoms while receiving or residing on a unit receiving amantadine prophylaxis had antiviral-resistance testing and polymerase chain reaction restriction analyses performed. RESULTS: Amantadine prophylaxis was administered sequentially on nine of 14 wards to all well residents for 14 to 31 days/ward to control influenza outbreaks between December 9, 1993, and January 28, 1994. Amantadine treatment was simultaneously provided to 29 ill residents. Between December 3, 1993, and January 22, 1994, 68 culture-positive cases of influenza A were detected. Twenty subjects were receiving or residing on units receiving amantadine prophylaxis. Amantadine sensitivity testing could be performed on 16 residents; 12 residents had amantadine resistant strains. Four of the 12 had not received any antiviral treatment. Illness onset ranged from 1 to 22 days after amantadine prophylaxis was begun on the individual's unit. Two ribonucleic acid (RNA) mutations in the gene coding the M2 protein transmembrane region were observed that were clustered in time and space. Isolates from two roommates, one receiving amantadine for 18 days and one on no antiviral, had identical RNA sequences. CONCLUSION: Antiviral resistance may be responsible for failure of prophylaxis in nursing home outbreaks. Strategies that use different classes of antivirals for prophylaxis and treatment may limit emergence and transmission of resistant virus.     

Protective efficacy of combined live intranasal and inactivated influenza A virus vaccines in the elderly.

OBJECTIVE: To evaluate the efficacy of adding intranasal live attenuated cold-adapted influenza A vaccine to inactivated influenza vaccine to prevent influenza A in elderly residents of long-term-care institutions. DESIGN: Randomized, double-blind, placebo-controlled study conducted over 3 years. SETTING: Three large nursing homes. PARTICIPANTS: A total of 523 residents of nursing homes (mean age, 84.2 years). INTERVENTIONS: All participants received trivalent inactivated influenza vaccine parenterally and were randomly assigned to receive either live attenuated influenza A (H3N2) virus vaccine or placebo intranasally. MEASUREMENTS: Laboratory-documented influenza A was defined as a respiratory illness plus isolation of influenza A virus from nasal secretions, significant serologic response, or both. Participants were considered to have been exposed to influenza A if they resided in an institution in which cases of influenza A were documented. Outbreak-associated illnesses were defined as those occurring between the first and last isolation of influenza virus from within the institution, +/- 3 days. RESULTS: Participants who received intranasal vaccine and were subsequently exposed to influenza A had significantly lower rates of laboratory-documented influenza A (9 of 162 vaccine recipients compared with 24 of 169 placebo recipients; vaccine protective efficacy, 60.6%; 95% CI, 18% to 82%), outbreak-associated respiratory illnesses (13 of 162 vaccine recipients compared with 34 of 169 placebo recipients; vaccine protective efficacy, 56.8%; CI 23% to 76%), and outbreak-associated influenza-like illnesses (6 of 162 vaccine recipients compared with 18 of 169 placebo recipients; vaccine protective efficacy, 65.0%; CI 17% to 86%). CONCLUSIONS: Intranasal immunization with live attenuated influenza A virus vaccine provided additional protection against influenza A when added to parenteral trivalent inactivated influenza vaccine among elderly nursing home residents.     

Patterns of utilization for the Minnesota senior health options program

OBJECTIVES: To compare the use of medical services provided under the Minnesota Senior Health Options (MSHO) (a special program designed to serve dually eligible older persons) with that provided to controls who received fee-for-service Medicare and Medicaid managed care. DESIGN: Quasi-experimental design using two control groups; separate matched cohort and rolling cross-sectional analyses; regression models used to adjust for case-mix differences. SETTING: Urban Minnesota community and nursing home long-term care. PARTICIPANTS: Dually eligible elderly MSHO enrollees in the community and in nursing homes were compared with two sets of controls; one was drawn from nonenrollees living in the same area (control-in) and another from comparable persons living in another urban area where the program was not available (control-out). Cohorts living in the community and in nursing homes were included. MEASUREMENTS: Use of hospitals and emergency rooms, physician visits. RESULTS: In the community cohort, there were no significant differences in hospital admission rates or in hospital days. MSHO enrollees had significantly fewer preventable hospital admissions and significantly fewer preventable emergency services than the control-in group. MSHO nursing home enrollees had significantly fewer hospital admissions than either control group with or without adjustment at 12 and 18 months. MSHO enrollees had significantly fewer hospital days and preventable hospitalizations than the control-in group. MSHO enrollees had significantly fewer emergency room visits and preventable emergency room visits than either control group. CONCLUSION: In general, the results of this evaluation are mixed but favor MSHO. The effect of MSHO was stronger for nursing home enrollees than community enrollees. The lower rate of preventable hospitalizations and emergency room visits of MSHO enrollees suggests that MSHO affected the process of care by providing more of some types of preventive and community-care services for community residents.     

Improving food intake in nursing home residents with feeding assistance: a staffing analysis.

BACKGROUND: Recommendations have been made to increase the number of nursing home (NH) staff available to provide feeding assistance during mealtime. There are, however, no specific data related to two critical variables necessary to estimate mealtime staffing needs: (1) How many residents are responsive to feeding assistance? (2) How much staff time is required to provide feeding assistance to these residents? The purpose of this study was to collect preliminary data relevant to these two issues. METHODS: Seventy-four residents in three NHs received a 2-day, or six-meal, trial of one-on-one feeding assistance. Total percentage (0% to 100%) of food and fluid consumed during mealtime was estimated across 3 days during usual NH care and 2 days during the intervention. The amount of time that staff spent providing assistance and type of assistance (i.e., frequency of verbal and physical prompts) was measured under each condition. RESULTS: One half (50%) of the participants significantly increased their oral food and fluid intake during mealtime. The intervention required significantly more staff time to implement (average of 38 minutes per resident/meal vs 9 minutes rendered by NH staff). CONCLUSIONS: The time required to implement the feeding assistance intervention greatly exceeded the time the nursing staff spent assisting residents in usual mealtime care conditions. These data suggest that it will almost certainly be necessary to both increase staffing levels and to organize staff better to produce higher quality feeding assistance during mealtimes.     

Predictors of advance directive restrictiveness and compliance with institutional policy in a long-term-care facility.

OBJECTIVE: To ascertain factors influencing the level of advance directives selected by nursing home residents or surrogates and the time delay to documentation of these choices in the medical record after implementation of a facility-wide policy. DESIGN: Longitudinal cohort study of nursing home residents followed from date of advance directive policy initiation or time of admission for a maximum of 21 months from study commencement. SETTING: A 315-bed multilevel nursing home. PARTICIPANTS: Four hundred twenty-four nursing home residents (mean age 85, 74.9% female, 96.1% white). OUTCOME MEASURES: Level of advance directive status chosen--full code, do not resuscitate (DNR) or palliative care only--and date documented in the medical record. RESULTS: Factors predictive of restricted advance directives (DNR or palliative care) included age greater than 85 years (P = 0.025), documented use of a surrogate decision maker (P = 0.001), low physical function (P less than 0.001), low cognitive function (P less than 0.001), and having a nursing home-employed physician (P = 0.001). These results were confirmed using logistic regression models. Median time to directive documentation decreased from 54 days for residents admitted in the first quarter to 1 day for residents admitted in the fourth quarter of the year following initiation of an advance directive policy. CONCLUSION: In logistic models, nursing home-employed physicians were more likely to write restricted advance directive orders than community-based physicians even after controlling for resident age, cognitive status, and physical function. In addition, implementation of a formal nursing home advance directive policy can shorten time to physician documentation of resident advance directive status.     

Occurrence of adverse effects and high amantadine concentrations with influenza prophylaxis in the nursing home

Amantadine, in a dose of 100 mg/day, is recommended for influenza prevention in older nursing home residents. We studied an influenza prevention protocol in a 98-bed community nursing home (96% female; mean age = 87.4 years). Fifty-five residents received amantadine when influenza A was confirmed. Although no further influenza cases were diagnosed, 22% experienced adverse events. Dose in mg/kg/day was significantly higher in the group experiencing adverse events (2.24 +/- 0.98 vs 1.76 +/- 0.35; P less than .01). Amantadine concentrations in 32 residents ranged from 128-5,810 ng/mL. Six residents had amantadine concentrations greater than 1,000 ng/mL. Seventy-eight percent would have qualified for further dose reduction on the basis of estimated creatinine clearance. The results suggest that adverse events may be an important problem with the 100 mg/day dose, and this dose may be excessive for influenza prophylaxis in many nursing home residents.     

Upper respiratory tract infection and serum antibody responses in nursing home patients

Residents of a Veterans Administration nursing home care unit (NHCU) were observed for the development of upper respiratory tract infection (URI) during 12 consecutive months to determine the frequency of sporadic cases or outbreaks of URI and to characterize them clinically and by laboratory means. Fifty-nine episodes of URI occurred in 56 residents during the study period. Serologic testing or virus isolation proved or suggested an etiologic agent on 22 occasions. URI was more common in late Fall and Winter and was caused by various agents, including influenza, Mycoplasma pneumoniae, respiratory syncytial virus, and parainfluenza viruses. A minor outbreak of influenza B in February 1986 contrasted with previous cases of URI in that the patients had a higher mean temperature and abnormal breath sounds, and they were clinically sicker. This suggests that clinical and epidemiologic surveillance during the influenza season may allow the early recognition of influenza in elderly nursing home residents. Over a 4-year period 147 serum antibody responses after influenza infection or influenza vaccination were compiled. Antibody responses to individual influenza vaccine components were measured 75 to 90 days after vaccination. The geometric mean titer (GMT) and the percentage of samples with antibody levels greater than 1:40 were determined for each of the three antigenic subtypes on 3 consecutive years. The GMT to individual vaccine components was consistently greater than 1:40, except to influenza B/Singapore in 1984 and A/Chile and B/U.S.S.R. in 1985, when these subtypes were first included in the vaccine, suggesting the NHCU residents responded less vigorously to unfamiliar vaccine subtypes.(ABSTRACT TRUNCATED AT 250 WORDS)     

Management of adverse clinical events by duty physicians in a nursing home

BACKGROUND AND AIMS: The nature of adverse clinical events (ACE) during duty hours (16:00-08:00 and holidays), as well as the way they are addressed by duty physicians (DP) in a nursing home (NH) are the subject of this study. METHODS: Data, including medical details concerning ACEs and the resultant referrals to hospital, were collected prospectively during 183 consecutive days in a 90-bed NH. RESULTS: Ninety-six residents experienced 370 ACEs, representing an average of one for every 44.5 patient days. The highest rate of events was during evening hours (18:00-21:00). The most prevalent ACE was fever (32%). Most cases (53%) were treated by the DPs on site. No intervention was needed in 19% of cases, whereas 28% of ACEs (104 cases) were referred to the Emergency Room (ER) of a general hospital. Sixty-six percent of these were actually admitted. The rate of ER referral of residents was one for every 158 patient days. About 40% of the referred patients had been discharged from hospital the previous week. High fever was the commonest cause for referral: 47%. During the working hours of the study period, the rate of referral by the staff physician was only 1 for every 915 patient days. Only 17% of these had high fever. CONCLUSIONS: Evening rounds by staff physicians, strengthening of working relations with hospital physicians, as well as fostering intravenous treatment in NHs, are suggested as means for reducing hospital transfers. A standardized method for the reporting of ACEs and referrals to hospitals should be adopted in order to facilitate comparisons between NHs and to evaluate its use as a quality indicator.