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Background: Post-acute sequelae of SARS-CoV-2 (PASC) describes a syndrome of physical and cognitive decline that persists after acute symptoms of infection resolve. Few studies have explored PASC among nursing home (NH) residents., Methods: A retrospective cohort study was conducted at two NHs in Michigan. COVID-positive patients were identified from March 21, 2020 to October 26, 2021. The comparison group were patients who lived at the same NH but who were never infected during the study period. Minimum Data Set was used to examine trajectories of functional dependence (Activity of Daily Living [ADL] composite score) and cognitive function (Brief Interview for Mental Status [BIMS]). Linear mixed-effects models were constructed to estimate short-term change in function and cognition immediately following diagnosis and over time for an additional 12 months, compared to pre-COVID and non-COVID trajectories and adjusting for sex, age, and dementia status., Results: We identified 171 residents (90 COVID-19 positive, 81 non-COVID) with 719 observations for our analyses. Cohort characteristics included: 108 (63%) ≥ 80 yrs.; 121 (71%) female; 160 (94%) non-Hispanic white; median of 3 comorbidities (IQR 2-4), with no significant differences in characteristics between groups. COVID-19 infection affected the trajectory of ADL recovery for the first 9 months following infection, characterized by an immediate post-infection decrease in functional status post-infection (-0.60 points, p = 0.002) followed by improvement toward the expected functional trajectory sans infection (0.04 points per month following infection, p = 0.271)., Conclusions: NH residents experienced a significant functional decline that persisted for 9 months following acute infection. Further research is needed to determine whether increased rehabilitation services after COVID-19 may help mitigate this decline., (© 2023 The American Geriatrics Society.)

Antibiotics are among the leading causes of adverse drug events in older adults. Short-course antibiotic therapy has been shown to work as well as the traditional longer durations for many types of infections. Antibiotic stewardship interventions including deprescribing strategies have shown a reduction in patient readmissions and mortality among older adults. We identified practice-changing clinical trials focusing on three major domains of overprescribing antibiotics in older adults - community-acquired pneumonia, urinary tract infections, and gram-negative bacteremia. The selected articles underscore the safety and effectiveness of shorter durations of antibiotic treatment for infections in older adults, thus highlighting an opportunity for deprescribing in the aging population. By optimizing antibiotic use, we stand to reduce adverse events and enhance overall health outcomes in older adults., (© 2022 The American Geriatrics Society.)

An effective clinical research effort in nursing homes to address prevention and treatment of COVID-19 faced overwhelming challenges. Under the Health Care Systems Research Network-Older Americans Independence Centers AGING Initiative, a multidisciplinary Stakeholder Advisory Panel was convened to develop recommendations to improve the capability of the clinical research enterprise in US nursing homes. The Panel considered the nursing home as a setting for clinical trials, reviewed the current state of clinical trials in nursing homes, and ultimately developed recommendations for the establishment of a nursing home clinical trials research network that would be centrally supported and administered. This report summarizes the Panel's recommendations, which were developed in alignment with the following core principles: build on available research infrastructure where appropriate; leverage existing productive partnerships of researchers with groups of nursing homes and nursing home corporations; encompass both efficacy and effectiveness clinical trials; be responsive to a broad range of stakeholders including nursing home residents and their care partners; be relevant to an expansive range of clinical and health care delivery research questions; be able to pivot as necessary to changing research priorities and circumstances; create a pathway for industry-sponsored research as appropriate; invest in strategies to increase diversity in study populations and the research workforce; and foster the development of the next generation of nursing home researchers., (© 2022 The American Geriatrics Society.)

As a method of research, pragmatic trials are recommended so as to generate results that are applicable to real-world care. This intent is especially important for the millions of older adults who receive long-term care in thousands of nursing homes and assisted living communities across the country-and many millions more around the globe. This article presents key points raised by experts participating in a conference funded by the National Institute of Aging held at the 2021 conference of the Society for Post-Acute and Long-term Care Medicine. The purpose of the conference was to convene leading clinicians, researchers, and industry partners to address special considerations of pragmatic trials in long-term care. Cross-cutting and unique challenges and solutions to conducting pragmatic trials were discussed focusing on 3 areas of clinical relevance to long-term care: (1) functional care and outcomes, (2) psychosocial care and quality of life, and (3) medical care and outcomes, with a special focus on persons with dementia. Challenges and innovative solutions were organized across the 9 domains of the revised Pragmatic-Explanatory Continuum Indicator Summary (PRECIS) Tool, and future research recommendations for pragmatic trials in long-term care were identified., (© 2022 The American Geriatrics Society.)

Background: SARS-CoV-2 outbreaks in nursing homes (NHs) have been devastating and have led to the creation of coronavirus disease 2019 (COVID-19) units within NHs to care for affected patients. Frequency and persistence of SARS-CoV-2 environmental contamination in these units have not been studied., Methods: A prospective cohort study was conducted between October 2020 and January 2021 in four Michigan NHs. Swabs from high-touch surfaces in COVID-19-infected patient rooms were obtained at enrollment and follow-up. Demographic and clinical data were collected from clinical records. Primary outcome of interest was the probability of SARS-CoV-2 RNA detection from specific environmental surfaces in COVID-19 patient rooms. We used multivariable logistic regression to assess patient risk factors for SARS-CoV-2 contamination. Pairwise Phi coefficients were calculated to measure correlation of site-specific environmental detection upon enrollment and during follow-up., Results: One hundred and four patients with COVID-19 were enrolled (61.5% >80 years; 67.3% female; 89.4% non-Hispanic White; 51% short stay) and followed up for 241 visits. The study population had significant disabilities in activities of daily living (ADL; 81.7% dependent in four or more ADLs) and comorbidities, including dementia (55.8%), diabetes (40.4%), and heart failure (32.7%). Over the 3-month study period, 2087 swab specimens were collected (1896 COVID-19 patient rooms, 191 common areas). SARS-CoV-2 positivity was 28.4% (538/1896 swabs) on patient room surfaces and 3.7% (7/191 swabs) on common area surfaces. Nearly 90% (93/104) of patients had SARS-CoV-2 contamination in their room at least once. Environmental contamination upon enrollment correlated with contamination of the same site during follow-up. Functional independence increased the odds of proximate contamination., Conclusions: Environmental detection of viral RNA from surfaces in the rooms of COVID-19 patients is nearly universal and persistent; more investigation is needed to determine the implications of this for infectiousness. Patients with greater independence are more likely than fully dependent patients to contaminate their immediate environment., (© 2021 The American Geriatrics Society. This article has been contributed to by US Government employees and their work is in the public domain in the USA.)

Background/objectives: Almost half of deaths related to COVID-19 in the United States are linked to nursing homes (NHs). We describe among short-term and long-term residents at three NHs in Michigan the outbreak identification process, universal testing, point prevalence of COVID-19, and subsequent containment efforts, outcomes, and challenges., Design: Outbreak investigation., Setting: Three NHs in southeast Michigan., Participants: All residents (N = 215) at three NHs (total beds = 356) affiliated with a large academic healthcare system., Methods: Upon detection of confirmed cases within the facility, each NH in collaboration and consultation with local hospital, public health officials, and parent corporation implemented immediate facility-wide testing and the following intervention measures: cohorting of COVID-19 positive residents; communication regarding testing and results with residents, healthcare professionals, and families; personal protective equipment reeducation and use throughout facilities; and dedicated staffing for infected patients cohorted in a dedicated COVID-19 wing. We collected patient data regarding demographics, symptoms, comorbidities, hospitalization, and 14-day outcomes., Results: A total of 29 cases of COVID-19 were identified at three participating NHs. Nineteen cases of COVID-19 were identified through symptom-triggered testing from March 23 to April 23, 2020; 10 (4.7%) additional cases were identified through universal testing of 215 residents conducted from April 7 to 15, 2020. The hospitalization rate was 37.9%. The case fatality rate was 20.7% (6/29); these patients had multiple comorbidities. No residents who tested positive through the point-prevalence survey required hospitalization, and five were discharged home within 14 days., Conclusion: Proactive and coordinated steps between NH medical directors and administrators, referral hospitals including their laboratories, and local public health officials are necessary to rapidly respond to an outbreak and limit the transmission of COVID-19. This coordinated public health approach may save lives, minimize the burden to the healthcare system, and reduce healthcare costs., (© 2020 The American Geriatrics Society.)

Objectives: To quantify the multidrug-resistant organism (MDRO) burden of high-touch common area and rehabilitation gym surfaces, and to assess microorganism transfer potential during rehabilitation sessions., Design: Prospective study of environmental contamination., Setting: Nursing home (NH)., Participants: Six Michigan NHs., Measurements: Monthly samples from common area surfaces (eg, living room), rehabilitation equipment, and rehabilitation personnel hands were screened for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and resistant gram-negative bacilli (R-GNB). To assess microorganism transfer potential, we conducted an in-depth assessment of microorganism transfer during 10 rehabilitation sessions. Microorganism transfer was defined as the identification of a microorganism on a destination surface that was uncontaminated before the rehabilitation session. Patient frequency of common area usage was also assessed qualitatively., Results: We obtained 1338 common area specimens from 180 monthly facility visits, of which 13.4% (179/1338) were MDRO positive: MRSA, 3.8%; VRE, 5.8%; and R-GNB, 5.1%. A total of 64% (116/180) of sampling visits had at least one MDRO-positive common area specimen. Within rehabilitation gyms, we obtained 521 equipment and 190 personnel hand specimens during 60 monthly visits. Of the equipment specimens collected, 7.7% (40/521) were MDRO positive: MRSA, 2.5%; VRE, 4.0%; and R-GNB, 1.9%. Of the 190 rehabilitation personnel hand specimens collected, 3.7% (7/190) were MDRO positive. Overall, 55% (33/60) of rehabilitation gym visits had at least one MDRO-positive specimen. Microorganism transfer assessment during 10 rehabilitation sessions revealed 35 opportunities for transfer during which microorganism transfer occurred in 17.1% (6/35) of opportunities., Conclusion: NH common areas and rehabilitation gyms are MDRO reservoirs that may contribute to the transmission of healthcare-associated pathogens. Because NHs accommodate the increasing short-stay patient population, developing effective interventions that reduce MDRO transmission in the common area and rehabilitation gym environment should be considered an infection prevention priority. J Am Geriatr Soc 68:478-485, 2020., (© 2019 The American Geriatrics Society.)

Objectives: Although preventable, healthcare-associated infections (HAIs) are commonly observed in post-acute care settings for at-risk older adults and are a leading cause of hospital readmissions. However, whether HAIs resulting in avoidable readmissions for preexisting HAIs (the same HAI as at the index admission) are more common for patients discharged to post-acute care as opposed to home is unknown. We examined the risk of preexisting HAI readmissions according to patient discharge disposition and comorbidity level., Design: We used 2013-2014 national hospital discharge data to estimate the likelihood of readmissions for preexisting HAIs according to patients' discharge disposition and whether the likelihood varies according to patient comorbidity level, across four common types of HAIs (not including respiratory infections)., Participants: A total of 702 304 hospital discharges for Medicare beneficiaries 65 years or older., Measurements: Our outcome was a 30-day preexisting, or "linked," HAI readmission (readmission involving the same HAI diagnosis as at the index admission). Patient discharge disposition was skilled nursing facility (SNF), home health care, and home care without home health care ("home")., Results: Of 702 304 index admissions involving HAI treatment, 353 073 (50%) were discharged to a SNF, 179 490 (26%) to home health care, and 169 872 (24%) to home. Overall, 17 523 (2.5%) of preexisting HAIs resulted in linked HAI readmissions, which were more common for Clostridioides difficile infections (4.0%) and urinary tract infections (2.4%) than surgical site infections (1.1%; P < .001). Being discharged to a SNF compared to home or to home health care was associated with a 1.15 percentage point (95% confidence interval = -1.29 to -1.00), or 38%, lower risk of a linked HAI readmission. This risk difference was observed to increase with greater patient comorbidity., Conclusions: SNF discharges were associated with fewer avoidable readmissions for preexisting HAIs compared with home discharges. Further research to identify modifiable mechanisms that improve posthospital infection care at home is needed. J Am Geriatr Soc 68:370-378, 2020., (© 2019 The American Geriatrics Society.)

Through the National Institute on Aging's (NIA's) "Grants for Early Medical/Surgical Specialists" Transition to Aging Research (GEMSSTAR) U13 grant, the NIA and the American Geriatrics Society (AGS) developed three transdisciplinary research conferences with a focus on mentoring and leadership skills development. The NIA's GEMSSTAR program evolved from two earlier programs, the AGS' Dennis W. Jahnigen and the Association of Specialty Professors' T. Franklin Williams Career Development Scholars Awards. It supports the continued cultivation of the next generation of medical and surgical specialty researchers with an interest in aging research. The award requires both geriatrics and specialty mentoring and currently provides up to $150,000 a year in direct support to scholars. Additionally, the award requires that scholars have a professional development plan that is complementary to the GEMSSTAR award. The U13 conferences, focused on frailty, models of aging, and cognition, brought together GEMSSTAR scholars, former scholars, innovators, mentors, and leaders in aging research, the specialties, and geriatric medicine. This article describes the themes of each of the GEMSSTAR U13 conferences and highlights the lessons learned on mentoring, team science, aging research networks, and work-life balance. We plan to use these lessons to guide the support we provide to the growing group of emerging leaders who are poised to lead the transdisciplinary research network of the future. J Am Geriatr Soc 67:650-656, 2019., (© 2019 The American Geriatrics Society.)

Objective: To assess the economic effect and cost effectiveness of a targeted catheter-associated urinary tract infection (CAUTI) prevention intervention in the nursing home (NH) setting., Design: Randomized clinical trial., Setting: Community-based NHs (N=12)., Participants: NH residents with indwelling urinary catheters (N=418)., Intervention: Standard care versus infection prevention program involving barrier precautions, active surveillance, and NH staff education., Measurements: Costs of the intervention, costs of disease, and health outcomes were used to calculate an incremental cost-effectiveness ratio for the intervention. Data came from intervention results and the literature and outcomes were analyzed over one year., Results: A 120-bed NH would have program costs of $20,279/year. The cost of disease treatment would be reduced by $54,316 per year, resulting in a $34,037 net cost savings. Most of this savings would come from fewer CAUTI hospitalizations ($39,180), with $15,136 in savings from CAUTI care within the NH. The intervention also yielded a gain of 0.197 quality-adjusted life-years (QALYs). Taking into account uncertainty in all parameters suggests there is an 85% chance that the intervention is cost-saving., Conclusions: The CAUTI prevention program is expected to benefit payers by reducing costs and improving health outcomes. Because the savings accrue to payers and not to NHs, payers such as Medicare and private insurers may want to provide incentives for NHs to implement such programs., Trial Registration: clinicaltrials.gov Identifier: NCT01062841., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

The diagnosis, treatment, and prevention of infectious diseases in older adults in long-term care facilities (LTCFs), particularly nursing facilities, remains a challenge for all health providers who care for this population. This review provides updated information on the currently most important challenges of infectious diseases in LTCFs. With the increasing prescribing of antibiotics in older adults, particularly in LTCFs, the topic of antibiotic stewardship is presented in this review. Following this discussion, salient points on clinical relevance, clinical presentation, diagnostic approach, therapy, and prevention are discussed for skin and soft tissue infections, infectious diarrhea (Clostridium difficile and norovirus infections), bacterial pneumonia, and urinary tract infection, as well as some of the newer approaches to preventive interventions in the LTCF setting., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Objectives: To identify facility- and individual-level predictors of nursing home safety culture., Design: Cross-sectional survey of individuals within facilities., Setting: Nursing homes participating in the national Agency for Healthcare Research and Quality Safety Program for Long-Term Care: Healthcare-Associated Infections/Catheter-Associated Urinary Tract Infections Project., Participants: Responding nursing home staff (N = 14,177) from 170 (81%) of 210 participating facilities., Measurements: Staff responses to the Nursing Home Survey on Patient Safety Culture (NHSOPS), focused on five domains (teamwork, training and skills, communication openness, supervisor expectations, organizational learning) and individual respondent characteristics (occupation, tenure, hours worked), were merged with data on facility characteristics (from the Certification and Survey Provider Enhanced Reporting): ownership, chain membership, percentage residents on Medicare, bed size. Data were analyzed using multivariate hierarchical models., Results: Nursing assistants rated all domains worse than administrators did (P < .001), with the largest differences for communication openness (24.3 points), teamwork (17.4 points), and supervisor expectations (16.1 points). Clinical staff rated all domains worse than administrators. Nonprofit ownership was associated with worse training and skills (by 6.0 points, P =.04) and communication openness (7.3 points, P =.004), and nonprofit and chain ownership were associated with worse supervisor expectations (5.2 points, P =.001 and 3.2 points, P =.03, respectively) and organizational learning (5.6 points, P =.009 and 4.2 points, P = .03). The percentage of variation in safety culture attributable to facility characteristics was less than 22%, with ownership having the strongest effect., Conclusion: Perceptions of safety culture vary widely among nursing home staff, with administrators consistently perceiving better safety culture than clinical staff who spend more time with residents. Reporting safety culture scores according to occupation may be more important than facility-level scores alone to describe and assess barriers, facilitators, and changes in safety culture., (© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.)

Historically, the medical subspecialties have not focused on the needs of older adults. This has changed with the implementation of initiatives to integrate geriatrics and aging research into the medical and surgical subspecialties and with the establishment of a home for internal medicine specialists within the annual American Geriatrics Society (AGS) meeting. With the support of AGS, other professional societies, philanthropies, and federal agencies, efforts to integrate geriatrics into the medical and surgical subspecialties have focused largely on training the next generation of physicians and researchers. They have engaged several subspecialties, which have followed parallel paths in integrating geriatrics and aging research. As a result of these combined efforts, there has been enormous progress in the integration of geriatrics and aging research into the medical and surgical subspecialties, and topics once considered to be geriatric concerns are becoming mainstream in medicine, but this integration remains a work in progress and will need to adapt to changes associated with healthcare reform., (© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.)

Objectives: To determine the relationship between clinically diagnosed catheter-associated urinary tract infection (CAUTI) and standardized criteria and to assess microorganism-level differences in symptom burden in a cohort of catheterized nursing home (NH) residents., Design: Post hoc analysis of a prospective longitudinal study., Setting: Twelve NHs in southeast Michigan., Participants: NH residents with indwelling urinary catheters (n = 233; 90% white, 52% male, mean age 73.7)., Measurements: Clinical and demographic data, including CAUTI epidemiology and symptoms, were obtained at study enrollment, 14 days, and monthly thereafter for up to 1 year., Results: One hundred twenty participants with an indwelling catheter (51%) were prescribed systemic antibiotics for 182 clinically diagnosed CAUTIs. Common signs and symptoms were acute change in mental status (28%), fever (21%), and leukocytosis (13%). Forty percent of clinically diagnosed CAUTIs met Loeb's minimum criteria, 32% met National Health Safety Network (NHSN) criteria, and 50% met Loeb's minimum or NHSN criteria. CAUTIs involving Staphylococcus aureus and Enterococcus spp. were least likely to meet criteria. CAUTIs involving Klebsiella pneumoniae were most likely to meet Loeb's minimum criteria (odds ratio (OR) = 9.7, 95% confidence interval (CI) = 2.3-40.3), possibly because of an association with acute change in mental status (OR = 5.9, 95% CI = 1.8-19.4)., Conclusion: Fifty percent of clinically diagnosed CAUTIs met standardized criteria, which represents an improvement in antibiotic prescribing practices. At the microorganism level, exploratory data indicate that symptom burden may differ between microorganisms. Exploration of CAUTI signs and symptoms associated with specific microorganisms may yield beneficial information to refine existing tools to guide appropriate antibiotic treatment., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Objectives: To evaluate the use of diagnostic testing before treating an infection in nursing home (NH) residents suspected of having a urinary tract infection (UTI) or pneumonia., Design: Prospective longitudinal study nested within a randomized trial, using data from control sites., Setting: Six NHs in southeast Michigan., Participants: NH residents with an indwelling urinary catheter, enteral feeding tube, or both (N = 162) with 695 follow-up visits (189 (28%) visits with an infection)., Measurements: Clinical and demographic data-including information on incident infections, antibiotic use, and results of diagnostic tests-were obtained at study enrollment, after 14 days, and monthly thereafter for up to 1 year., Results: One hundred (62%) NH residents had an incident infection requiring antibiotics, with substantial variations between NHs. In addition to presence of infection-specific symptoms, change in function was a significant predictor of ordering a chest X-ray to detect pneumonia (odds ratio (OR) = 1.7, P = .01). Similarly, change in mentation was a significant predictor of ordering a urinalysis (OR = 1.9, P = .02), chest X-ray (OR = 3.3, P < .001), and blood culture (OR = 2.3, P = .02). Antibiotics were used empirically, before laboratory results were available, in 50 of 233 suspected cases of UTI (21.5%) and 16 of 53 (30.2%) suspected cases of pneumonia. Antibiotics were used in 17% of visits without documented clinical or laboratory evidence of infection., Conclusion: Constitutional symptoms such as change in function and mentation commonly lead to diagnostic testing and subsequent antibiotic prescribing. Antibiotic use often continues despite negative test results and should be a target for future interventions., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Objectives: To understand the perceived preparedness of frontline nurses (registered nurses (RNs), licensed practical nurses (LPNs)), unit nurse managers, and skilled nursing facility (SNF) administrators in providing care for residents with peripherally inserted central catheters (PICCs) in SNFs., Design: Exploratory, qualitative pilot study., Setting: Two community based SNFs., Participants: Residents with PICCs, frontline nurses (RNs, LPNs), unit nurse managers, and SNF administrators., Methods: Over 36 weeks, 56 residents with PICCs and their nurses were observed and informally interviewed, focusing on PICC care practices and documentation. In addition, baseline PICC data were collected on placement indication (e.g., antimicrobial administration), placement setting (hospital vs SNF), and dwell time. Focus groups were then conducted with frontline nurses and unit nurse managers, and semistructured interviews were conducted with SNF administrators to evaluate perceived preparedness for PICC care. Data were analyzed using a descriptive analysis approach., Results: Variations in documentation were observed during weekly informal interviews and observations. Differences were noted between resident self-reported PICC concerns (quality of life) and those described by frontline nurses. Deficiencies in communication between hospitals and SNFs with respect to device care, date of last dressing change, and PICC removal time were also noted. During focus group sessions, perceived inadequacy of information at the time of care transitions, limited availability of resources to care for PICCs, and gaps in training and education were highlighted as barriers to improving practice and safety., Conclusion: Practices for PICC care in SNFs can be improved. Multimodal strategies that enhance staff education, improve information exchange during care transitions, and increase resource availability in SNFs appear necessary to enhance PICC care and safety., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Objectives: To describe patterns of use, care practices, and outcomes related to peripherally inserted central catheter (PICC) use in skilled nursing facilities (SNFs)., Design: Prospective cohort study., Setting: Two community SNFs., Participants: Adult SNF residents with PICCs (N = 56)., Measurements: Information on indication for PICC use, device characteristics (e.g., lumens, gauge), and participant data (comorbidities, medications) were obtained from medical records. Care practices (e.g., frequency of flushing, dressing care) and problems related to PICCs were recorded. Major (central line-associated bloodstream infection, venous thromboembolism, catheter dislodgement) and minor (migration, dressing disruption, lumen occlusion, exit site infection) complications and process measures (flushing of PICC, assessment of necessity) were recorded. Bivariate analyses with t-tests, chi-square tests, or Fischer exact tests were used for continuous and categorical data., Results: Participants were enrolled from two SNFs. The most common indication for PICC use was intravenous antibiotic delivery. The average PICC dwell time was 43 days, and most devices were single-lumen PICCs. Major and minor complications were common and occurred in 11 (20%) and 18 (32%) participants, respectively. Occlusion (23%, n = 13), accidental dislodgement (12%, n = 7), and dressing disruption (11%, n = 6) were the commonest complications observed. Documentation regarding catheter care practices occurred in 41% of cases., Conclusion: Quality improvement efforts that seek to benchmark practice, identify gaps, and institute efforts to improve PICC care and practice in SNFs appear necessary., (© 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.)

Objectives: To use a simple measure of activities of daily living, wounds, and indwelling devices (urinary catheter, feeding tube) to predict prevalent, new, and intermittent multidrug-resistant organism (MDRO) acquisition in nursing home (NH) residents., Design: Secondary analysis, prospective cohort study., Setting: Southeast Michigan NHs (n = 15)., Participants: NH residents (N = 111, mean age 81) with two or more monthly visits (729 total)., Measurements: Monthly microbiological surveillance for MDROs from multiple anatomic sites from enrollment until discharge or 1 year. The Arling scale, previously developed as a measure of NH residents' need (time-intensity) for nursing resources, was used to predict prevalent and time to new or intermittent acquisition (months) of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and antibiotic-resistant gram-negative bacteria (R-GNB) colonization using multiple-failure accelerated time-factor survival analysis, controlling for comorbidity, hospitalization, and antibiotic use in the prior month., Results: One-fifth of participants had a wound, and one-third had a device. There were 60 acquisitions of MRSA, 56 of R-GNB, and 15 of VRE. Expected time to acquisition was less than 1 year for MRSA (median 6.7 months) and R-GNB (median 4.5 months) and more than 1 year for VRE (median 40 months). Arling score was associated with earlier new MRSA and VRE acquisition. A resident with only mild functional impairment and no device or wound would be expected to acquire MRSA in 20 months, versus 5 months for someone needing the most-intense nursing contact., Conclusion: MDRO acquisition is common in community NHs. Need for nursing care predicts new MDRO acquisition in NHs, suggesting potential mechanisms for MDRO acquisition and strategies for future interventions for high-risk individuals (e.g., enhanced barrier precautions)., (Published 2015. This article is a U.S. Government work and is in the public domain in the USA.)

Objectives: To identify characteristics of residential care facilities (RCFs) associated with having a pandemic influenza plan., Design: Nationally representative, cross-sectional survey., Setting: RCFs in the United States., Participants: Participating facilities in the 2010 National Survey of RCFs (N = 2,294), representing 31,030 assisted living facilities and personal care homes., Measurements: Facility-level characteristics associated with a pandemic influenza plan, including general organization descriptors, staffing, resident services, and immunization practices., Results: Forty-five percent (95% confidence interval (CI) = 43-47%) had a pandemic plan, 14% (95% CI = 13-16%) had a plan in preparation, and 41% (95% CI = 38-43%) had no plan. In the multivariable model, organization characteristics, staffing, and immunization practices were independently associated with the presence of a pandemic preparedness plan. Organization characteristics were larger size (extra large, OR = 3.27, 95% CI = 1.96-5.46; large, OR = 2.60, 95% CI = 1.81-3.75; medium, OR = 1.66, 95% CI = 1.21-2.27 vs small), not-for-profit status (OR = 1.65, 95% CI = 1.31-2.09 vs for profit), and chain affiliation (OR = 1.65, 95% CI = 1.31-2.09 vs nonaffiliated). Staffing characteristics included number of registered nurse hours (<15 minutes, OR = 1.36, 95% CI = 1.07-1.74 vs no hours), any licensed practical nurse hours (OR = 1.47, 95% CI = 1.08-1.99 vs no hours), and at least 75 hours of required training for aides (OR = 1.34, 95% CI = 1.05-1.71 vs <75 hours). RCFs with high staff influenza vaccination rates (81-100%, OR = 2.12, 95% CI = 1.27-3.53 vs 0% vaccinated) were also more likely to have a pandemic plan., Conclusion: A majority of RCFs lacked a pandemic influenza plan. These facilities were smaller, for-profit, non-chain-affiliated RCFs and had lower staff vaccination rates. These characteristics may help target facilities that need to develop plans to handle a pandemic, or other disasters., (© 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.)

Objectives: To assess the knowledge of recommended urinary catheter care practices among nursing home (NH) healthcare workers (HCWs) in southeast Michigan., Design: Self-administered survey., Setting: Seven NHs in southeast Michigan., Participants: HCWs., Measurements: The survey included questions about respondent characteristics and knowledge about indications, care, and personal hygiene pertaining to urinary catheters. The association between knowledge measures and occupation (nurses vs aides) was assessed using generalized estimating equations., Results: Three hundred fifty-six of 440 HCWs (81%) responded. More than 90% of HCWs were aware of measures such as cleaning around the catheter daily, glove use, and hand hygiene with catheter manipulation. They were less aware of research-proven recommendations of not disconnecting the catheter from its bag (59% nurses, 30% aides, P<.001), not routinely irrigating the catheter (48% nurses, 8% aides, P<.001), and hand hygiene after casual contact (60% nurses, 69% aides, P=.07). HCWs were also unaware of recommendations regarding alcohol-based hand rub (27% nurses and 32% aides with correct responses, P=.38). HCWs reported informal (e.g., nurse supervisors) and formal (in-services) sources of knowledge about catheter care., Conclusion: Significant discrepancies remain between research-proven recommendations pertaining to urinary catheter care and HCWs' knowledge. Nurses and aides differ in their knowledge of recommendations against harmful practices, such as disconnecting the catheter from the bag and routinely irrigating catheters. Further research should focus on strategies to enhance dissemination of proven infection control practices in NHs., (© 2010, Copyright the Authors. Journal compilation © 2010, The American Geriatrics Society.)

Older adults continue to be underrepresented in clinical research despite their burgeoning population in the United States and worldwide. Physicians often propose treatment plans for older adults based on data from studies involving primarily younger, more-functional, healthier participants. Major barriers to recruitment of older adults in aging research relate to their substantial health problems, social and cultural barriers, and potentially impaired capacity to provide informed consent. Institutionalized older adults offer another layer of complexity that requires cooperation from the institutions to participate in research activities. This paper provides study recruitment and retention techniques and strategies to address concerns and overcome barriers to older adult participation in clinical research. Key approaches include early in-depth planning; minimizing exclusion criteria; securing cooperation from all interested parties; using advisory boards, timely screening, identification, and approach of eligible patients; carefully reviewing the benefit:risk ratio to be sure it is appropriate; and employing strategies to ensure successful retention across the continuum of care. Targeting specific strategies to the condition, site, and population of interest and anticipating potential problems and promptly employing predeveloped contingency plans are keys to effective recruitment and retention.

Objectives: To assess use of urinary collection devices (external, intermittent, and indwelling catheters; pads or briefs) and examine predictors of indwelling catheters in skilled nursing facilities (SNFs)., Design: Retrospective cohort study., Setting: SNFs in California, Florida, Michigan, New York, and Texas., Participants: All patients admitted to SNFs in 2003 who remained there for 1 year (N=57,302)., Measurements: Characteristics of patients who used different collection strategies (indwelling, intermittent, and external catheterization; pads or briefs) and predictors of indwelling urinary catheterization from the Nursing Home Minimum Data Set using multinomial logistic regression., Results: The prevalence of indwelling catheterization was 12.6% at admission and 4.5% at the annual assessment (P<.001). Intermittent and external catheterization were infrequently used (<1% at admission and annual assessment). Paraplegia, quadriplegia, multiple sclerosis, and comatose state were strongly associated with indwelling catheterization. Male residents were more likely to use an indwelling catheter at every assessment, as were obese patients; individuals with diabetes mellitus, renal failure, skin conditions, deep vein thrombosis, aphasia, or end-stage disease; and those who were taking more medications., Conclusion: Coinciding with federal regulations, urinary catheterization was lower than has been reported previously and declined over time. Further reduction should be targeted at the evaluation of skin problems, appropriateness of multiple medications, and alternative measures in patients with diabetes mellitus, obesity, deep vein thrombosis, and communication problems.

Objectives: To quantify the relationship between indwelling devices (urinary catheters, feeding tubes, and peripherally inserted central catheters) and carriage of antimicrobial-resistant pathogens in nursing home residents., Design: Cross-sectional., Setting: Community nursing home in Southeast Michigan., Participants: Residents with indwelling devices (n=100) and randomly selected control residents (n=100) in 14 nursing homes., Measurements: Data on age, functional status, and Charlson comorbidity score were collected. Samples were obtained from nares, oropharynx, groin, wounds, perianal area, and enteral feeding tube site. Standard microbiological methods were used to identify methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and ceftazidime-resistant (CTZ-R) gram-negative bacteria (GNB)., Results: Use of indwelling devices was associated with colonization with MRSA at any site (odds ratio (OR)=2.0, P=.04), groin (OR=4.8, P=.006), and perianal area (OR=3.6, P=.01) and CTZ-R GNB at any site (OR=5.6, P=.003). Use of enteral feeding tubes was associated with MRSA colonization in the oropharynx (OR=3.3, P=.02)., Conclusion: Use of indwelling devices is associated with greater colonization with antimicrobial-resistant pathogens. This study serves as an initial step in defining a high-risk group that merits intensive infection control efforts.

Avian influenza or Influenza A (H5N1) is caused by a viral strain that occurs naturally in wild birds, but to which humans are immunologically naïve. If an influenza pandemic occurs, it is expected to have dire consequences, including millions of deaths, social disruption, and enormous economic consequences. The Department of Health and Human Resources plan, released in November 2005, clearly affirms the threat of a pandemic. Anticipating a disruption in many factions of society, every segment of the healthcare industry, including nursing homes, will be affected and will need to be self-sufficient. Disruption of vaccine distribution during the seasonal influenza vaccine shortage during the 2004/05 influenza season is but one example of erratic emergency planning. Nursing homes will have to make vital decisions and provide care to older adults who will not be on the initial priority list for vaccine. At the same time, nursing homes will face an anticipated shortage of antiviral medications and be expected to provide surge capacity for overwhelmed hospitals. This article provides an overview of current recommendations for pandemic preparedness and the potential effect of a pandemic on the nursing home industry. It highlights the need for collaborative planning and dialogue between nursing homes and various stakeholders already heavily invested in pandemic preparedness.

Objectives: Evaluate the effect of preadmission functional status on severity of pneumonia, length of hospital stay (LOS), and all-cause 30-day and 1-year mortality of adults aged 60 and older and to understand the effect of pneumonia on short-term functional impairment., Design: Prospective cohort study., Setting: University hospital., Participants: One hundred twelve patients with radiograph-proven pneumonia (mean age 74.6) were enrolled., Measurements: Functional status and comorbidities were assessed using the Functional Autonomy Measurement System (SMAF) and Charlson Comorbidity Index. Clinical information was used to calculate the Pneumonia Prognostic Index (PPI)., Results: Eighty-four (75%) patients were functionally independent (FI) before admission, with a SMAF score of 40 or lower. Dementia and aspiration history were higher in the group that was functionally dependent (FD) before admission (P<.001). The FI group had less-severe pneumonia per the PPI and shorter mean LOS+/-standard deviation (5.62+/-0.51 days) than the FD group (11.42+/-2.58, P<.004). The FI group had lower 1-year mortality (19/65, 23%) than the FD group (14/28, 50%), and the difference remained significant after adjusting for Charlson Index and severity of illness (P=.009). All patients lost function after admission, with loss being more pronounced in the FI group (mean change 19.24+/-12.9 vs 4.72+/-6.55, P<.001)., Conclusion: Older adults who were FI before admission were more likely to present with less-severe pneumonia and have a shorter LOS. In addition, further loss of function was common in these patients. Assessment of function before and during hospitalization should be an integral part of clinical evaluation in all older adults with pneumonia.

Objectives: Mortality rates from pneumonia increase steadily with age. Recently, a disease severity model (the Pneumonia Prognosis Index (PPI)) has been developed to predict mortality from community-acquired pneumonia (CAP). PPI ranks severity of pneumonia from 1 to 5, with 5 being most severe. This retrospective study utilizes the PPI to address the prognosis of CAP in older adults., Design: Retrospective review of medical charts., Setting: Department of Veterans Affairs Medical Center., Participants: All adults aged 60 and older admitted to a Veterans Affairs Medical Center with CAP between January 1 and December 31, 1998., Measurements: PPI was calculated using subjects' demographics, comorbidities, presenting symptoms, and laboratory measurements., Results: Eighty-two patients aged 60 and older were admitted with 101 episodes of CAP. The mean age +/- standard deviation was 72 +/- 9. Seventy-four episodes were admitted from the emergency room, 20 from another hospital, seven from nursing homes, and five from outpatient clinics. Mean length of stay was 7.1 +/- 6 days. Comorbid conditions included coronary artery disease, diabetes mellitus, congestive heart failure, neoplasm, stroke, and renal failure. Most episodes fell into higher PPI classes, with 20% in Class 3, 46% in Class 4, and 32% in Class 5. PPI score was significantly related to length of stay (P < .001), intensity of care (P < .0001), and presence of complications (P <.001). Mortality was 14% at 30 days: 0.5% in Class 3,10.8% in Class 4, and 25% in Class 5., Conclusion: The PPI was effective in identifying older adults with CAP who were at risk of a poor outcome, but the practical utility of this index remains to be determined.Further prospective studies are required to elucidate the importance of comorbidities, severity at presentation, and premorbid functional status on clinical and functional outcomes of CAP in older adults.