Prevalence and predictors of influenza vaccination among residents of long-term care facilities

Influenza is a respiratory illness which results in significant morbidity and mortality, especially in the older population. Older people living in Long-Term Care Facilities (LTCFs) have a significantly higher risk of infection and complications from influenza. Influenza vaccine is considered the best strategy to prevent infection in high-risk populations. In Australia, the Communicable Diseases Network Australia (CNDA) suggests a vaccination coverage rate of 95% in both staff and residents¹. This study aims to measure the vaccination coverage rates for residents in LTCFs and identify predictors of vaccination uptake for these individuals.This study was conducted in nine LTCFs in four sites from March to September 2018. This was done via medical record reviews for residents over 65 years old in these LTCFs, collecting information such as vaccination status, age, gender, ethnicity and occupation. Simple and multivariable logistic regression was used to calculate the Odds Ratio (OR) to determine significant predictors of influenza vaccination uptake.The overall vaccination rate among LTCF residents was 83.6%. Significant predictors of vaccination were LTCF location, ethnicity and previous year vaccination status. Residents in LTCF Site D were less likely to be vaccinated compared to Site A (OR 0.11, 95% CI 0.02–0.61), non-Caucasians were less likely to get vaccinated (OR 0.09, 95% CI 0.01–0.67), and residents who refused the 2017 vaccine were less likely to be vaccinated (OR 0.04, 95% CI 0.01–0.15).Compared with previous Australian studies on LTCF vaccination rates, the overall vaccination rate was high in these LTCFs (83.6% versus 66–84%), but it varied across different sites. Reasons for varying vaccination rates should be explored further – for example, lower rates in non-Caucasians with diverse cultural backgrounds. Better understanding the causes of under-vaccination can help improve vaccination programs in LTCFs.     

Healthcare-associated infection among residents of long-term care facilities: a cohort and nested case-control study

Knowledge of infection control measures in nursing homes is limited. This study aimed to assess the incidence of, and potential risk factors for, healthcare-associated infection in long-term care facilities in Norway. Incidence of healthcare-associated infection was recorded prospectively in six long-term care facilities located in two major cities in Norway between 1 October 2004 and 31 March 2005. For each resident with an infection we aimed for two controls in a nested case-control study to identify potential risk factors. Incidence of infection was 5.2 per 1000 resident-days. Urinary and lower respiratory tract infections were the most common. Patients confined to their beds [odds ratio (OR=2.7)], who stayed <28 days (OR=1.5), had chronic heart disease (OR=1.3), urinary incontinence (OR=1.5), an indwelling urinary catheter (OR=2.0) or skin ulcers (OR=1.8) were shown to have a greater risk for infection. Age, sex and accommodated in a two- versus single-bed room were not significant factors. Incidence of infection in nursing homes in Norway is within the range reported from other countries. This study identified several important risk factors for healthcare-associated infection. There is a need to prevent infection by implementing infection control programmes including surveillance in long-term care facilities.     

Methods of pain assessment in residents of long-term care facilities: a pilot study

OBJECTIVES: Structured programs for routine pain assessment and treatment are necessary to optimize care for residents of long-term care facilities (LTCFs). A pilot study was designed to develop, implement, and evaluate a system for pain assessment and monitoring in a LTCF. Additional goals were to determine whether a verbal and/or non-verbal tool adequately assess pain in residents of LTCFs and whether the pharmacologic therapy for pain changes with the implementation of a pain assessment and monitoring system. DESIGN: Quantitative, nonexperimental design using two pain assessment tools. SETTING: The study was conducted at a LTCF in a rural midwestern setting. PARTICIPANTS: The study population for phase I included residents on any pain medication (regularly scheduled or as needed) on the secure dementia unit. The target population for phase II consisted of residents on any pain medication on an open unit. INTERVENTION: Training was provided to the nursing staff on how to use two pain assessment tools, one verbal (colored visual analog scale) and one nonverbal (observed pain target behaviors), and documentation. In addition, a continuing education program on pain assessment and management in elderly residents and barriers to pain management in LTCFs was offered to medical providers. MEASUREMENTS: Evaluation with the colored visual analog scale (CVAS) occurred twice daily. Pain target behaviors were monitored throughout the day and recorded by nursing staff at the end of each shift. All residents in the study population were monitored daily for six months. RESULTS: Most of the residents on both units were unable to use the verbal tool; however, the nonverbal tool was used successfully for all residents studied. On the dementia unit, the use of pain medications increased, and pain target behaviors decreased during the study period; on the open unit, the use of pain medications remained stable, and pain target behaviors decreased. CONCLUSION: These data suggest that an increase in awareness of pain may facilitate an improvement in the assessment and management of pain in residents of LTCFs. The feasibility of the nonverbal pain monitoring method shown in this study has positive implications on quality of care issues if generalizable to a larger population.     

Dying in long-term care facilities: support needs of other residents, relatives, and staff

This paper explores the support needs of residents, relatives, and care staff when someone dies in a facility for older people. The authors draw on the qualitative findings from an English study, which investigated the case for applying the principles and practices of palliative care to people dying in these settings. Relatives need practical as well as emotional support, which is often not met adequately by nursing home staff. Managers varied in the extent to which they recognized other residents' emotional needs or supported relatives. Care staff members acknowledged needing practical and emotional support, but management was often unable to deliver it. Lack of training in recognizing and addressing needs in addition to financial and staffing constraints were factors that prevented managers from providing support for staff, residents, and relatives.     

Cytomegalovirus infection and responsiveness to influenza vaccination in elderly residents of long-term care facilities

Ample evidence suggests that infection with cytomegalovirus (CMV) leads to accelerated aging of the immune system and may contribute to poor responsiveness to influenza vaccination in older persons. The objective of this study was to investigate whether CMV infection, acquired earlier in life, affects the response to influenza vaccination in a randomized controlled trial among older persons in long-term care facilities. During the 1997-1998 influenza season, 731 residents (median age 83 [interquartile range 78-88], 75.4% female) in 14 long-term care facilities in the Netherlands were randomly assigned to receive 15 or 30 μg of inactivated influenza vaccine, followed by a 15 μg booster vaccine or a placebo vaccine at day 84. Blood samples were collected at day 0, day 25, day 84 and day 109. Seroresponses to influenza vaccination were measured by hemagglutination-inhibition tests to the A/H3N2 strain at all time points. Subsequently, baseline levels of IgG anti-CMV antibodies were measured using an automated chemiluminescent microparticle immunoassay. Participants with CMV antibody level≥6 AU/mL were considered to harbor CMV infection. At baseline, no differences in pre-vaccination geometric mean antibody titers (GMT) were observed between participants with (n=571, 78.1%) or without CMV infection (n=160, 21.9%). During follow-up, participants with and without CMV infection had similar responses to influenza vaccination as measured with changes in GMT (linear mixed model, adjusted for gender, age, pre-vaccination GMT and vaccination strategy, p=0.46). Analogously, no association was found between CMV infection and a more than 4-fold increase in antibody titer (Generalized Estimating Equations, adjusted OR 1.14 [95%CI 0.80;1.64]) or an antibody titer≥40 (adjusted OR 1.24 [95%CI 0.86;1.80]). In conclusion, CMV infection did not explain poor responsiveness to influenza vaccination in residents of long-term care facilities.     

Increasing influenza and pneumococcal vaccination and tuberculosis screening among residents of Colorado long-term care facilities

Persons residing in long-term care facilities are especially vulnerable to potentially preventable morbidity and mortality caused by influenza, S. pneumoniae, and tuberculosis. This project's objective was to increase the rates of pneumococcal vaccination, tuberculosis screening, and annual influenza vaccination. Intervention consisted of staff training videos, sample policies, and educational materials for residents and their families. At baseline during the 1995-1996 flu season, 84% of Colorado long-term care residents were vaccinated for influenza; 16% of residents had ever received pneumococcal vaccination; and 59% had been screened for tuberculosis. At remeasurement during 1997 to 1998, influenza vaccination rates were up to 89%, p = 0.006. The percentage of residents who had ever received pneumococcal vaccination increased to 48% at remeasurement, p < 0.001. Tuberculosis screening rates increased to 83%, p < 0.001. Following an educational intervention targeting both residents and staff, residents were significantly more likely to receive all three preventive services.     

Improving communication among attending physicians, long-term care facilities, residents, and residents' families

Effective bidirectional communication between attending physicians and long-term care facilities is of critical importance to ensure timely, appropriate, and high-quality care that is responsive to residents' needs, values, and preferences. Ongoing communication with residents and residents' families is essential to the establishment of mutual trust and respect. This earned trust and respect in turn promotes frank discussions among long-term care practitioners and the facility staff who can then better guide residents and families through difficult care decisions.     

A questionnaire to examine food service satisfaction of elderly residents in long-term care facilities

The purpose of this study was to develop a survey tool for assessing the satisfaction of elderly long-term care (LTC) residents with the meals and food services they receive, as well as to assess quality of life issues related to eating. Food service delivery should be provided in an environment that fosters autonomy, interpersonal relations, and security. The questionnaire was administered as face-to-face interviews with 205 residents (> or = 65 years of age) of 13 LTC facilities in Saskatoon, Saskatchewan, Canada (participation rate = 67%). Residents expressed some concern with food variety, quality, taste, and appearance, and with the posting of menus. Quality of life issues were mostly positive; however, residents were less satisfied with areas related to their autonomy such as food choice and snack availability.     

Vitamin D deficiency in residents of academic long-term care facilities despite having been prescribed vitamin D

OBJECTIVES: Vitamin D is vitally important in maintaining skeletal health. A low plasma vitamin D concentration is associated with increased parathyroid hormone secretion, increased bone turnover, osteomalacia, and osteoporosis. As a result, vitamin D deficiency is associated with a higher incidence of hip and other fractures. Although Vitamin D deficiency has been reported in long-term care facilities, optimal methods of replenishment have not been defined. The objective of the present study was to identify the pattern of calcium and vitamin D supplementation in nursing home residents and to identify vitamin D deficiency in residents already on supplement therapy. DESIGN: Retrospective chart review. SETTING: Five academic nursing homes staffed by faculty from the University of Arkansas for Medical Sciences. PARTICIPANTS: Elderly residents aged 65 and older receiving calcium and vitamin D supplements. MEASUREMENTS: Data on dose, frequency, and levels of calcium and vitamin D were collected. The medication list and creatinine levels were also recorded. RESULTS: Forty-four (40%) residents were receiving 1000 mg, 48 (44%) were receiving 1200 mg, and 9 (8.2%) were receiving 1500 mg of calcium carbonate. Similarly, 79 (72%) residents were on 400 IU, 13 (12%) were on 600 IU, and only 8 (7%) were on 800 IU of vitamin D3 (cholecalciferol). Low levels of Vitamin D 25 (OH) D (values <30 ng/mL) were identified in 49.4% of residents; 16% were found to have deficiency (<20 ng/mL). CONCLUSION: Despite clear benefit, nursing home residents were not supplemented adequately with calcium and vitamin D.     

Supplementation with vitamin D and calcium in long-term care residents

Vitamin D deficiency is a common finding in institutionalized older persons. Vitamin D-deficient elderly persons are at higher risk of falls and fractures. Long-term care residents should be considered at high risk of vitamin D deficiency and therefore vitamin D supplementation is highly recommended in this population. The minimal effective dose is 800 IU per day. It is recommended that vitamin D supplementation should be implemented in all patients in residential aged care facilities. In addition to vitamin D, calcium supplementation has shown to enhance the effect of vitamin D on bone. Calcium intake should be optimized (1200-1500 mg per day recommended) and supplementation offered to those with inadequate intake. The addition of calcium depends on tolerance, history of kidney stones, and emerging data regarding its cardiovascular safety.     

Characteristics of long-term care facilities associated with standing order programs to deliver influenza and pneumococcal vaccinations to residents in 13 states

BACKGROUND: Standing order programs (SOPs) are effective evidence-based interventions in which nurses or pharmacists are authorized to vaccinate according to an approved protocol without a physician order or examination. National rates for influenza and pneumococcal vaccination in long-term care facilities (LTCF) are far below HP2010 goals of 90%. OBJECTIVES: The aim of this study was to describe the prevalence of SOPs and other types of immunization programs in LTCFs and determine characteristics of LTCFs implementing SOPs. DESIGN: Mailed survey. SETTING: All Medicare- or Medicaid-licensed LTCFs in 13 states. PARTICIPANTS: Directors of Nursing (DONs). MEASUREMENTS: Survey collecting information on SOPs and barriers to their use in respondents' LTCF. Data from this survey were linked to the On-line Survey and Certification Administrative Record (OSCAR), a federal administrative database containing structural, staffing and other information on LTCFs. RESULTS: A total of 3,451 of 4,366 (79%) LTCFs completed surveys. Few facilities used SOPs for influenza (9%) or pneumococcal vaccination (7%). The greatest use of influenza SOPs compared with other immunization program types were seen in facilities that were government owned or owned by nonprofit entities compared with for-profit entities (15% and 10% vs. 7%; odds ratio [OR] = 2.3, 95% confidence interval [CI] = 1.5 to 3.4 and OR = 1.4, CI = 1.1 to 1.8, respectively); dually-certified (both Medicare- and Medicaid-certified) nursing facilities compared with distinct part skilled nursing facilities in which beds are set aside for residents with a specific payment source (11% vs. 7%; OR = 1.6, CI = 1.3 to 2.1); independent facility compared with one that is part of a multi-facility chain (10% vs. 7%; OR = 1.3, CI = 1.1 to 1.7); and lower acuity index (resident resource needs) compared with higher (10% vs. 7%; OR = 1.4, CI = 1.1 to 1.7). Findings were similar for pneumococcal vaccination SOPs. SOP use varied substantially by state (range = 0% to 23% influenza; range = 3% to 15% pneumococcal). The most frequently reported barriers to SOP use were legal concerns: liability for the facility (53%) and staff lacking legal authority (39%) to vaccinate by standing orders. CONCLUSIONS: Although LTCFs with certain characteristics used SOPs more often, overall few facilities (<10%) used SOPs to improve vaccination rates. SOP use varied by state indicating that state policies or other factors may promote or inhibit SOP use. More studies are needed to examine the causes of state-level variations in vaccination interventions and their relationships to health outcomes of residents in LTCFs. The federal government's resources to promote SOPs should focus on all LTCFs, but with a particular focus on those that are less likely to be using SOPs and that represent a large proportion of homes nationally (i.e., for-profit and chain facilities).     

HIV/AIDS and long-term care: A state perspective

Long-term care services for people with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) were fostered in New York State by passage of HIV-specific regulations that set program standards and authorized reimbursement rates sufficient to support these standards. A rapid expansion of HIV-specific capacity has occurred. Demographic and selected clinical characteristics of the populations in AIDS residential health care facilities and AIDS adult day health care programs in New York State are presented. Aspects of the service models for these two program types that have changed to meet new needs are discussed. Ms. Chorost is from the Chronic Care Section, Division of HIV Health Care, AIDS Institute; Dr. Chesnut is from the Information Systems Office of the AIDS Institute.