The utilization of intravenous therapy programs in community long-term care nursing facilities.

OBJECTIVE: To determine if non-federal Boston-area long-term care nursing facilities are actively using intravenous (IV) therapy as a form of treatment, the specific design of such programs and to assess the availability of central line IVs, percutaneous endoscopic gastrostomy (PEG) tubes and hypodermoclysis for hydration in this setting. DESIGN/SETTINGS: A prospective telephone survey of 100 Boston-area skilled nursing facilities, each with a minimum of 50 beds and representing a total of 12,763 beds, certified to provide both Medicaid (Title-19) and Medicare services, to ascertain their ability to provide IV and other modes of hydration for their residents. METHODS: A series of questions were asked of a member of the staff knowledgeable in the operations of the nursing facility. Questions included whether an IV program was in existence, duration of the program, provider of IV training for nurses, presence of a subacute unit, whether IVs were administered in non-subacute areas, frequency of IV usage, the ability to manage central lines and the use of PEG tubes or hypodermoclysis for hydration. RESULTS: A total of 100 nursing facilities were surveyed between September and October of 1996. A total of 79 nursing facilities had active IV programs (79%) and 54 of those (68%) also managed central lines. However, in those facilities with active IV programs, 73% (N = 58) reported administering a total of less than five IVs per month. Training for 82% of the nursing facilities (N = 65) was by an outside vendor pharmacy and initial training ranged from one to three days in duration. Of the 19 nursing facilities with IV programs available only in subacute or equivalent units, only 26% (N = 5) did not allow direct transfer of residents from other wards into these units. Of the 79 nursing facilities having IV capability, a total of 91% (N = 72) have also used PEG tubes for hydration and nutritional needs although only 6% (N = 5) have ever used hypodermoclysis for hydration. CONCLUSIONS: The majority of nursing facilities in the Boston area provide IV programs for their residents, although in limited numbers on a monthly basis. Residents with central lines are admitted in the majority of these nursing facilities although total staff training time is only one to three days. The use of PEG tubes for hydration is quite frequent, although the use of hypodermoclysis was extremely low. Further work is necessary to fully elucidate the clinical implications of whether these programs decrease the need for acute hospitalization or are used mainly in the post-hospitalization (Medicare A-covered) period.

Clinical triggers for detection of fever and dehydration. Implications for long-term care nursing.

1. Fever is a common problem among long-term care residents, and the clinical manifestations of fever and infections may be vague or nonspecific. 2. The majority of fevers in this study were staff-detected versus resident-initiated; this implies that staff vigilance is important in the detection of fever. 3. Staff documentation of impaired oral intake during febrile episodes was associated highly with either elevated serum sodium or blood urea nitrogen/creatinine ratios. Therefore, nursing assessment and interventions to hydrate residents at the first indication of impaired oral intake may prevent dehydration. 4. Routine mandated vital signs were found to be of little or no value in detecting fevers.

Indices of dehydration among frail nursing home patients: highly variable but stable over time.

OBJECTIVE: To determine changes in standard laboratory measures of dehydration among residents of a nursing home care unit (NHCU) over a 6-month period. DESIGN: A prospective cohort analytic study. SETTING: A 130-bed NHCU in a Department of Veterans Affairs Hospital. PATIENTS: Fifteen infirm but stable male residents (mean age 77 years; range (R) 62-93) on one ward of the NHCU. MAIN OUTCOME MEASURES: We studied prospectively for 6 months the serum osmolality (osm), serum sodium (Na), blood urea nitrogen/creatinine (BUN/Cr) ratios and weight (wt) for 15 patients of the NHCU. None of the patients was acutely ill during the study period or exhibited clinical signs of dehydration. RESULTS: Mean serum osm at baseline: 291.6 mOsm/kg (R 278 to 300); 3 months: 291.5 mOsm/kg (R 276 to 301); 6 months: 291.3 mOsm/kg (R 283-300) were all similar. Forty percent (6/15) of patients had at least one high normal/elevated reading (> or = 295 mOsm/kg) during the study. Three patients (20%) had readings of > or = 300 mOsm/kg, but none of these patients had either concurrent increased serum Na (> or = 146 mmole/L) or BUN/Cr ratios (> or = 25). Mean serum Na at baseline: 143.0 mmole/L (R 139-148); 3 months: 142.1 mmole/L (R 138-149); 6 months: 142.9 mmole/L (R 137-150) were all similar. Sixty percent (9/15) of the patients maintained normal (nl) serum Na levels throughout the study. The relationship between the change in serum Na and serum osm levels from baseline to 6 months was not significant (r = 0.242). BUN/Cr ratios ranged from 12-34 over the study period with 3 of 15 patients (20%) demonstrating elevated ratios consistently throughout the study without clinical evidence of dehydration. Only two patients had both high nl/elevated serum osm and elevated serum Na, although both had nl BUN/Cr ratios. Neither of these patients was thought by staff to be clinically dehydrated. Analysis of variance (ANOVA) indicated none of the laboratory measures changed significantly over time (serum osm: F(2,28) < 1; Na: F(2,28) < 1; BUN/Cr: F(2,28) < 1). There was no significant change in weight between the baseline and six month readings. CONCLUSIONS: These data suggest that in the presence of clinical stability, long-term care residents may have a serum osm in the high normal/elevated range without overt clinical evidence of dehydration, an accompanying elevated Na, or BUN/Cr ratio. This may indicate a different central osm setting for these residents as the serum osm appeared to be stable for each resident over time. These data also suggest that measures of serum osm, Na, and BUN/Cr in the long-term care setting may accurately predict future laboratory values in an individual patient if baseline values are drawn when the patient is not acutely ill.

Dehydration and death during febrile episodes in the nursing home.

OBJECTIVE: To determine the incidence of early hypernatremic dehydration among residents of a nursing home care unit (NHCU) presenting with significant febrile episodes (FE). DESIGN: Prospective cohort analytic study. FE were defined as temperature (T) > 100 degrees F oral (o) or 101 degrees F rectal (r) for > or = 24 hours. SETTING: NHCU in a Veterans Administration hospital. PATIENTS: A total of 130 residents of the NHCU were monitored for FE during a 4-month study period. MAIN OUTCOME MEASURES: Blood urea nitrogen (BUN)/creatinine (Cr) (abnormal > or = 25) and serum sodium (Na)(abnormal > or = 146 mmol/L) were drawn within 24-48 hours of the onset of all FE; documentation of impaired oral intake (OI) by staff; necessity of transfer to acute medical wards and mortality were recorded. RESULTS: There were 48 FE among 42 residents (39 M, 3 F; mean age 75 +/- 11.3). Maximum recorded T during the FE ranged from 100.1 degrees F-102.2 degrees F o and 101.2 degrees F-105.3 degrees F r. Laboratory values were available for 40/48 FE. Twenty-three percent (9/40) had elevated BUN/Cr ratios, 25% (10/40) had elevated serum Na, and 12.5% (5/40) had both. In patients noted to have impaired OI (n = 11) as documented by staff, increased serum Na or BUN/Cr ratio was observed in 82% (9/11). A random control group of 37 nonacutely ill, nonfebrile NHCU residents (33 M, 4 F; mean age 75 +/- 10.1) having routine annual laboratory tests revealed only 1 resident (age 95) with an elevated Na of 146 and BUN/Cr ratio of 26 and 1 resident with an increased BUN/Cr ratio of 28. None of the controls had any staff documentation of impaired OI. Of the 5 deaths in the febrile group with laboratory data (total deaths = 6; 14%), 100% had either elevated serum Na and/or elevated BUN/Cr ratios, and 80% (4/5) had both. Comparing the febrile group with controls, BUN/Cr ratios were found to be significantly elevated in the febrile group (P < 0.05). Serum sodium values were also significantly elevated in the febrile group (P < 0.01). CONCLUSIONS: Staff documentation of impaired OI was highly associated with either elevated serum Na or increased BUN/Cr ratios. These data show that many older NHCU patients with significant fevers often have early impaired OI and laboratory evidence of dehydration. These data indicate that staff should institute appropriate monitoring for dehydration at the time of earliest detection of fever in this population.