Novel care bundle of established basic and practical approaches greatly reduces urinary tract infections in nursing facility residents without indwelling catheters.

BACKGROUND: Residents in nursing facilities (NFs) are at greater risk of developing urinary tract infections (UTIs) with higher hospitalizations and costs than people living in communities. These residents also have increased likelihood of uroseptic shock and death. The objective of the study was to prevent UTIs and to reduce UTI-associated costs among NF residents. METHODS: Quality assurance performance improvement initiative conducted between April 1, 2018 and March 31, 2022 at a large skilled NF. Participants were 262 residents newly diagnosed with UTIs without indwelling catheters. The initiative consisted of (1) a 12-month baseline; (2) a 12-month intervention; and (3) a 24-month follow-up. A novel care bundle which included staff's hand hygiene monitoring, residents' hydration status, effective incontinence and perineal care, and in-house UTI treatment was implemented during the intervention. The plan-do-study-act cycle was used to gauge its effectiveness. RESULTS: Quarterly UTI rates decreased from 4.2% at baseline to 0.9% at follow-up, a 79% reduction (P < .001). All 262 residents were treated in-house with no UTI-related hospitalizations. Antibiotic prescriptions fell from 373 at baseline down to 143 at follow-up, a 62% reduction. Facility costs decreased from $42,188 at baseline to $8,281 at follow-up (P < 0.001). CONCLUSION: This bundle was very effective in preventing UTIs and reducing UTI-associated costs. Its use in other NFs is encouraged to determine suitability elsewhere.

An Interdisciplinary Ethics Panel Approach to End-of-Life Decision Making for Unbefriended Nursing Home Residents.

For those with advanced life-limiting illness, the optimization of quality of life and avoidance of nonbeneficial treatments at the end of life are key ethical concerns. This article evaluates the efficacy of an Interdisciplinary Ethics Panel (IEP) approach to decision making at the end of life for unbefriended nursing home residents who lack decisional capacity and have advanced life-limiting illness, through the use of a nine-step algorithm developed for this purpose. We reviewed the outcomes of three quality-of-care phased initiatives conducted in our facility, a large public nursing home in New York City, between June 2016 and February 2020, which indicated that this IEP approach promoted advance-care planning, as palliative measures were endorsed to optimize quality of life for this vulnerable population at the end of life. We also examined another quality-of-care initiative when this IEP approach was applied to end-of-life decision making for nursing home residents who had a surrogate during the COVID-19 pandemic. This application appeared to be beneficial in adding more residents to our Palliative Care Program while it improved rates of advance-care planning. When all of the above findings are considered, we believe this novel IEP approach and algorithm have the potential to be applied elsewhere after appropriate assessment.

Newly Developed COVID-19 Bundle Greatly Reduces the Infection Fatality Rate for a Highly Vulnerable Nursing Home Population.

This performance improvement initiative used a bundle designed to reduce the COVID-19 infection fatality rate (IFR) by ≥33% and the new infection rate (IR) to <1% among nursing home (NH) residents over a 3-month period at a large public NH in New York City. Participants were all NH residents, newly testing COVID-19 PCR positive between March 1, 2020 and June 30, 2020. Key bundle components involved close observation of all residents with vital signs taken once/shift, including O2 saturation, frequent clinical team follow-up visits for those symptomatic, and ramped-up COVID-19 PCR testing. From April to June, average IFR was 12.3%, a 49.6% reduction from the March baseline (P < 0.05), and average new IR was 5.4%, a 29.9% reduction from baseline (P < 0.05). In the 2 follow-up months, no deaths occurred with a new IR < 1%, indicating sustained improvement. Because of its simplicity, this bundle or components of it could be readily applied elsewhere after appropriate assessment.

Chronic Comorbid Illnesses Predict the Clinical Course of 866 Patients Requiring Prolonged Mechanical Ventilation in a Long-Term, Acute-Care Hospital.

OBJECTIVE: To determine whether burdens of chronic comorbid illnesses can predict the clinical course of prolonged mechanical ventilation (PMV)patients in a long-term, acute-care hospital (LTACH). METHODS: Retrospective study of 866 consecutive PMV patients whose burdens of chronic comorbid illnesses were quantified using the Cumulative Illness Rating Scale (CIRS). Based on increasing CIRS scores, 6 groups were formed and compared: group A (≤25; n = 97), group B (26-28; n = 105), group C (29-31; n = 181), group D (32-34; n = 208), group E (35-37; n = 173), and group F (>37; n = 102). RESULTS: As CIRS scores increased from group A to group F, rates of weaning success, home discharges, and LTACH survival declined progressively from 74% to 17%, 48% to 0%, and 79% to 21%, respectively (all P < .001). Negative correlations between the mean score of each CIRS group and correspondent outcomes also supported patients' group allocation and an accurate prediction of their clinical course (all P < .01). Long-term survival progressively declined from a median survival time of 38.9 months in group A to 3.2 months in group F (P < .001). Compared to group A, risk of death was 75% greater in group F (P = .03). Noteworthy, PMV patients with CIRS score <25 showed greater ability to recover and a low likelihood of becoming chronically critically ill. Diagnostic accuracy of CIRS to predict likelihood of weaning success, home discharges, both LTACH and long-term survival was good (area under the curves ≥0.71; all P <.001). CONCLUSIONS: The burden of chronic comorbid illnesses was a strong prognostic indicator of the clinical course of PMV patients. Patients with lower CIRS values showed greater ability to recover and were less likely to become chronically critically ill. Thus, CIRS can be used to help guide clinicians caring for PMV patients in transfer decisions to and from postacute care setting.

Effects of Reinstitution of Prolonged Mechanical Ventilation on the Outcomes of 370 Patients in a Long-Term Acute Care Hospital.

OBJECTIVE: To investigate the effects of the reinstitution of continuous mechanical ventilator support of >21 days in 370 prolonged mechanical ventilation (PMV) patients, all free from ventilator support for ≥5 days. METHODS: Four groups were formed based on the time and number of PMV reinstitutions and compared (group A: reinstitutions within 28 days, n = 51; group B: a single reinstitution after 28 days, n = 53; group C: multiple reinstitutions after 28 days, n = 52; and group D: no known reinstitutions, n = 214). RESULTS: Of the 370 patients, 156 (42%) required PMV reinstitutions. Most reinstitutions occurred within 7 months: 51 (33%) of the 156 patients within 28 days and 49 (31%) within the next 6 months. Group comparisons revealed a progression of outcomes from group A, the worst, to group D, the best, with groups B and C having intermediate but significantly different values. Decannulation was associated with an 88% decreased risk of PMV reinstitution and a 43% lower risk of death (all P < .001). CONCLUSION: Prolonged mechanical ventilation reinstitution rates were high, with most occurring within 7 months of freedom from MV. In general, the longer the period of ventilator freedom, the less the likelihood of a PMV reinstitution. The identification of 4 distinct PMV groups of patients by time and number of reinstitutions added useful prognostic information. Since PMV reinstitutions within 28 days lead to permanent MV support, >28 days of ventilator freedom provided an optimal cut point for assessing the likelihood of again requiring PMV.

Relationship of the Duration of Ventilator Support to Successful Weaning and Other Clinical Outcomes in 437 Prolonged Mechanical Ventilation Patients.

OBJECTIVE: To investigate the relationships between durations of ventilator support and weaning outcomes of prolonged mechanical ventilation (PMV) patients. METHODS: Cohort study of 957 PMV patients sequentially admitted to a long-term acute care hospital (LTACH). The study population was 437 PMV patients who underwent weaning, having achieved ≥4 hours of sustained spontaneous breathing. They were divided into tertiles of mechanical ventilation (MV) durations and compared for differences (tertile A: 21-58 days, n = 146; tertile B: 59-103 days, n = 147; and tertile C: ≥104 days, n = 144). RESULTS: Tertiles showed comparable weaning success rates and survival. As MV durations increased, LTACH postweaning days became progressively greater, whereas decannulations and discharge physical function diminished, and home discharges decreased while nursing facility discharges increased (all P < .001). Patients with lower physical function before critical illness or greater burdens of comorbidities were least likely to be weaned (all P < .001). Younger ages, lower comorbidity burdens, neurological diagnoses, higher admission prealbumin levels, and successful weaning, each independently reduced the risk of death (all P < .01). CONCLUSION: Durations of MV did not affect weaning success or survival, although deleterious effects were found in discharges, decannulations, LTACH postweaning days, and discharge physical function. Durations of MV alone should not guide transfer decisions for subsequent continuing care.

Prolonged mechanical ventilation in 540 seriously ill older adults: effects of increasing age on clinical outcomes and survival.

OBJECTIVES: To investigate effects of older age, comorbidities, and physiological measures on outcomes of elderly adults requiring prolonged mechanical ventilation (PMV). DESIGN: Retrospective cohort study. SETTING: Public long-term acute care hospital (LTACH) with an active program for ventilator weaning from PMV. PARTICIPANTS: Chronically seriously ill individuals with PMV aged 65 and older divided into six cohorts (65-69, 70-74, 75-79, 80-84, 85-89, ≥ 90) for comparative purposes (n = 540). MEASUREMENTS: Main outcomes were weaning criteria met, weaning success, discharge dispositions, and long-term survival. Other outcomes included weaning duration, LTACH days, discharge physical function, tracheostomy decannulation, and relapses to ventilator support. Weaning success was defined as 4 weeks or longer entirely free from mechanical ventilator support. RESULTS: The main finding from age cohort comparisons was that the likelihood of meeting weaning criteria (P = .001) and subsequent successful weaning (P = .002) decreased with age. Best predictors for weaning success in multivariable analysis were lower comorbidity burden (P < .001) and less-severe illness (P = .001). Other clinically important predictors were more-normal values in the respiratory physiology measures of rapid shallow breathing (P = .001) and static compliance (P = .003). Successful weaning was also associated with a 62% lower risk of death (P < .001). CONCLUSION: Although meeting weaning criteria and being successfully weaned decreased with increasing age, age was not the dominant factor in predicting outcomes. More importantly, individuals with PMV with better respiratory physiology and lower comorbidity burdens were more likely to be weaned and have longer survival, no matter their age.

A comparison of seriously ill patients with or without AIDS requiring prolonged mechanical ventilation.

PURPOSE: The aim of this study was to compare differences in underlying diagnoses, weaning outcomes, discharge disposition, and survival in prolonged mechanical ventilator (PMV)-dependent patients with and without AIDS. METHODS: Ninety consecutive AIDS patients requiring PMV were retrospectively matched with 90 clinically similar non-AIDS patients to form matched cohorts to determine differences in their outcomes. RESULTS: AIDS patients had more acute diagnoses requiring PMV, whereas non-AIDS patients had more chronic diagnoses (P < .001). Weaning outcomes were alike with 31 (35%) AIDS and 37 (41%) non-AIDS patients successfully weaned. More AIDS patients went home, and fewer, to nursing facilities (P = .04). In each cohort, successfully weaned patients had significantly longer survival than their unweaned counterparts (all P < .001). Successful weaning reduced the risk of death in AIDS and non-AIDS patients (hazard ratios, 0.29 and 0.20; 95% confidence intervals, 0.17-0.50 and 0.11-0.36, respectively; all P < .001). CONCLUSIONS: AIDS had little effect on weaning success or survival. Successful weaning increased survival regardless of a diagnosis of AIDS. The AIDS patients had more home discharges and fewer to nursing facilities, which likely resulted from the AIDS patients having more acute illnesses leading to PMV than the non-AIDS patients.

Influence of age on rehabilitation outcomes and survival in post-acute inpatient cardiac rehabilitation.

PURPOSE: To investigate the relationship of increasing age to clinical characteristics, rehabilitation outcomes, and long-term survival in a post-acute inpatient cardiac rehabilitation program. METHODS: The study population consisted of all 364 consecutive cardiac rehabilitation patients admitted over a 4-year period to an inpatient cardiac rehabilitation program in a long-term acute care hospital.Admission and discharge comparisons were made between 3 age cohorts: 65 years (n = 117), 65 to 74 years (n = 127), and ≥ 75 years (n = 120). Patients were followed through January, 2010 for survival. RESULTS: The 3 cohorts on admission differed significantly in Functional Independence Measure, estimated Glomerular Filtration Rate, smoking and hypertension histories, body mass index, and cardiac diagnoses (all P < .05) but not in Simplified Acute Physiology Score II, Cumulative Illness Rating Scale for Geriatrics, or left ventricular ejection fraction. There were no cohort differences in rehabilitation outcomes of physical function, inpatient days, and discharge disposition. Survival was longest in the youngest cohort whereas the 2 older cohorts had similar survivals (P < .01; log-rank test). All 3 cohorts had at least 40% survival at 8 years. Cox regression analyses showed that the comorbidity burden as quantified by the Cumulative Illness Rating Scale for Geriatrics was the only predictor of death in all cohorts (all P ≤ .002). CONCLUSIONS: This study provided evidence that post-acute inpatient cardiac rehabilitation programs equally benefited both elderly patients and younger patients. These programs are valuable in the continuum of care for elderly patients who are not yet ready for discharge to home following a serious cardiac event.

Vaginocervical stimulation releases oxytocin within the spinal cord in rats.

Vaginocervical stimulation (VS) significantly elevated the concentration of oxytocin (OT) in spinal cord superfusates of 8 intact urethane-anesthetized rats measured 10-15 min after VS (median [interquartile range]: 1.7 [1.00-3.37] pg/ml) compared to that measured 10-15 min before VS (1.1 [1.01-1.40] pg/ml). When VS was administered once (n = 8), it produced a 55% increase over baseline values; when administered a second time 45 min later (n = 6), it produced only a 22% increase over pre-VS values. The effects of estrogen on the VS-induced release of OT were then investigated using ovariectomized rats that were treated either with estradiol benzoate (EB; 10 microg/100 g bw) (n = 6) or with an oil vehicle (n = 6) subcutaneously for 3 days. The EB treatment significantly elevated the basal levels of OT released into spinal cord superfusates above vehicle control levels. Within 5-10 min after the onset of VS, OT concentrations in the superfusates were significantly higher in EB-treated than in vehicle-treated rats. The vehicle-treated rats did not show a significant elevation in OT concentration following VS. To rule out the possibility that the posterior pituitary gland was the source of this OT, the effect of hypophysectomy (HYPOX) was assessed on the VS-induced release of OT into spinal cord superfusates and plasma. The concentration of OT in spinal cord superfusates of both the HYPOX (n = 5) and intact rats (n = 6) increased significantly from 5.8 [4.4-6.5] pg/ml pre-VS to 7.9 [6.7-10.3] pg/ml immediately after VS, and from 4.4 [3.8-5] pg/ml pre-VS to 5.1 [4.6-5.7] pg/ml immediately after VS, respectively. There was no significant difference in baseline levels of OT in cerebrospinal fluid between the two groups. By contrast, plasma OT levels, while significantly elevated in response to VS from 3.42 [2.9-5.34] pg/ml baseline to 7.25 [5.33-15.77] pg/ml in the intact group, failed to respond significantly to VS in the HYPOX group (n = 5). The present findings provide evidence of a direct estrogen-dependent release of OT within the spinal cord in response to VS, presumably via descending oxytocinergic neurons.

Analysis of FIM instrument scores for patients admitted to an inpatient cardiac rehabilitation program.

OBJECTIVE: To evaluate in an inpatient cardiac rehabilitation program (a phase IB) whether length of stay (LOS), discharge to home, and improvement in physical function differed between patients with lower and higher degrees of functional independence on admission. DESIGN: A retrospective study. SETTING: A public acute long-term care hospital. PATIENTS: All cardiac rehabilitation patients (N = 143) admitted to the hospital from January 1998 through June 1999. Patients were divided into a higher- and a lower-functioning group by using the admission FIM instrument scores above and below the midpoint of 72. Comparisons in LOS, discharge disposition, and functional gains between these 2 groups were then performed. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM scores, FIM change, FIM gains per week, LOS, and discharge disposition. RESULTS: Total FIM scores at discharge were significantly higher than those on admission (25%, P <.0001). The median value of total FIM gains per week was 7.78 with a stay of 17 days and a home discharge rate of 76%. The higher-functioning group (n = 106) differed from the lower group (n = 37) with shorter stay (15 vs 23d, P <.0001), greater FIM gains per week (8.6 vs 4.8, P =.002), and greater likelihood of discharge to home or community (84% vs 54%, P <.001). The average incremental FIM change in each group was the same. In multivariate analysis, both admission (P =.001) and discharge (P <.001) FIM scores were the best predictors of patients' discharge disposition to home. CONCLUSIONS: Admission FIM scores are important predictors for the clinical course and discharge outcomes of cardiac rehabilitation patients, with those with higher admission FIM scores having a shorter LOS and greater likelihood of discharge to home. The admission FIM scores can help to establish realistic goals.