Carol L. Joseph

Infectious Disease Outbreaks in Nursing Homes: An Unappreciated Hazard for Frail Elderly Persons

The common occurrence and dire consequences of infectious disease outbreaks in nursing homes often go unrecognized and unappreciated. Nevertheless, these facilities provide an ideal environment for acquisition and spread of infection: susceptible residents who share sources of air, food, water, and health care in a crowded institutional setting. Moreover, visitors, staff, and residents constantly come and go, bringing in pathogens from both the hospital and the community. Outbreaks of respiratory and gastrointestinal infection predominate in this setting, but outbreaks of skin and soft-tissue infection and infections caused by antimicrobial-resistant bacteria also occur with some frequency.

Screening for Alcohol Use Disorders in the Nursing Home

OBJECTIVES: To determine the prevalence of Alcohol Use Disorders (AUDs) among residents of a Veterans Affairs (VA) nursing home (NH) using DSM‐III‐R criteria for alcohol abuse and dependence, and to examine the demographic variables associated with AUDs among NH residents. A third objective was to assess the sensitivity, compared with DSM‐III‐R criteria, of three screening tests for AUDs in the NH: the CAGE, the MAST‐G, and the two‐question instrument developed by Cyr and Wartman.

Uncovering frustrations. A qualitative needs assessment of academic general internists as geriatric care providers and teachers.

BACKGROUND: General internists commonly provide medical care for older adults and geriatric education to trainees, but lack the necessary knowledge and skills to fulfill these tasks.OBJECTIVE: Assess the geriatric training needs of academic general internists in 3 hospital systems in Portland, OR.DESIGN: Ten focus groups and 1 semi-structured interview. Interview transcripts were analyzed using thematic analysis, a well-recognized qualitative technique.PARTICIPANTS: A convenience sample of 22 academic general internists and 8 geriatricians from 3 different teaching hospitals.MEASUREMENTS: We elicited stories of frustration and success in caring for elderly patients and in teaching about their care. We asked geriatricians to recount their experiences as consultants to general internists and to comment on the training of Internists in geriatrics.RESULTS: In addition to deficits in their medical knowledge and skills, our Internists reported frustration with the process of delivering care to older adults. In particular, they felt ill prepared to guide care transitions for patients, use multidisciplinary teams effectively, and were frustrated with health care system issues. Additionally, general internists’ approach to medical care, which largely relies on the medical model, is different from that of geriatricians, which focuses more on social and functional issues.CONCLUSIONS: Although our findings may not be broadly representative, improving our general internists’ abilities to care for the elderly and to teach learners how to do the same should address deficits in medical knowledge and skills, barriers to the processes of delivering care, and philosophical approaches to care. Prioritizing and quantifying these needs and measuring the effectiveness of curricula to address them are areas for future research.

Program at home: a Veterans Affairs Healthcare Program to deliver hospital care in the home.

The Portland Veterans Affairs Medical Center (PVAMC) participated in a research‐based National Demonstration and Evaluation Study of Hospital at Home Care for Elderly Patients. PVAMC continued hospital at home care in a modified form based on the results of that research phase and feedback from patients, families, and staff. The modified clinical program (referred to as Program @ Home) provided care for the same diagnoses (exacerbation of congestive heart failure, exacerbation of chronic obstructive pulmonary disease, community‐acquired pneumonia, cellulitis) but differed from the research‐based demonstration project in that it accepted patients of all ages, accepted early‐discharge patients from the hospital, and provided a less‐intensive physician and nursing model. In the first 42 months, 290 patients were admitted; 23% came from the emergency room, 54% were early hospital discharge, and the remainder came from an outpatient clinic or home care. Average length of stay was 3.2 days, and 37% were younger than 65. The results describe how a home hospital program has been integrated into the clinical care offerings of a managed care health system and how it supports inpatient, primary, emergency, and home care programs.

Aiming to improve care of older adults: an innovative faculty development workshop.

Introduction/ AimsInternists care for older adults and teach geriatrics to trainees, but they often feel ill-prepared for these tasks. The aims of our 1-day Continuing Medical Education workshop were to improve the knowledge and self-perceived competence of general internists in their care of older adults and to increase their geriatrics teaching for learners.SettingTwo internal medicine training programs encompassing University, Veterans Affairs, and a community-based hospital in Portland, OR, USA.Program DescriptionCourse faculty identified gaps in assessment of cognition, function, and decisional capacity; managing care transitions; and treatment of behavioral symptoms. To address these gaps, our workshop provided geriatric content discussions followed by small group role plays to apply newly learned content. Forty teaching faculty participated.Program EvaluationParticipants completed 13-item multiple-choice pre- and post-workshop geriatric knowledge tests, pre- and post-workshop surveys of self-perceived competence to care for older adults, and completed an open-ended ‘commitment to change’ prompt after the intervention. Knowledge scores improved following the intervention (61% to 72%, p < .0001), as did self-perceived competence (11 of 14 items significant). Seventy-one percent of participants reported success in meeting their commitment to change goals.DiscussionA 1-day intervention improved teaching faculty knowledge and self-perceived competence to care for older patients and led to self-perceived changes in teaching behaviors.

Routine laboratory assessment of nursing home patients

Little is known about protocols for routine laboratory testing in nursing homes. To determine what laboratory protocols are employed by community nursing homes, directors of nursing service in the 73 long‐term‐care facilities in Portland, Oregon were surveyed. One‐hundred percent responded, and 56% reported having laboratory testing protocols. Ninety percent of protocols employed screening tests, and 88% employed monitoring tests, but content varied widely.

Sterile vs Clean Urinary Catheterization

To the Editor-Intermittent urethral catheterization (IC) has been recommended for nursing home patients who require bladder drainage to reduce chronic indwelling catheter use and its attendant complications.’ However, nursing homes rarely use IC, citing lack of acceptance by nursing staff, concerns about urinary infection, and cost of sterile supplies as barriers to its implementation.’ Self-catheterization using clean technique substantially lowers costs but frequently cannot be performed by nursing home patient^.^ There are no studies of such catheterization of the elderly by nursing staff in an institutional setting. Accordingly, we conducted a pilot study of intermittent urinary catheterization in elderly nursing home patients utilizing a new modification of clean technique and conventional sterile technique. Between August 1987 and September 1989, 14 male patients over 50 years of age in the Nursing Home Care Unit (NHCU) were randomized to receive 16 weeks of either standard sterile or modified clean IC performed by nursing staff. Patient characteristics and details of study participation are listed in Table 1. Patients gave informed consent prior to starting the study which was approved by the Subcommittee for Human Studies and the Research and Development Committee of the Portland Veterans Affairs Medical Center. Patients were catheterized three to four times a day as directed by their physicians. Sterile catheterizations were performed by nursing staff using a disposable sterile kit and standard sterile technique^.^ Patients in the modified clean group were catheterized by nursing staff wearing clean latex gloves and using a lubricated single use sterile red rubber catheter. No drapes were used. The meatus was cleaned with a Castile soap pledget, and urine was drained into the patient’s urinal. A new catheter was used for each catheterization. The standard clean self-catheterization protocol employs a reuseable catheter with a soap and water washing between each use. However, using a disposable catheter increased acceptability for the nursing staff, and the additional nursing time required for catheter care offset the small savings in supply cost by reusing the catheter. Urinalysis and culture were obtained weekly, and patients were followed clinically for infection. Bacteriuria was defined by a urine culture with greater than 100,000 bacteria per mL. Physicians caring for the patients were blinded to the method of catheterization used. Patients were followed for an average of 10.9 weeks in the clean group and 11.5 weeks in the sterile group. One patient in each group had a major urinary tract infection, characterized by temperature >38OC, bacteriuria, and transfer to acute care (Table 2). Neither patient was bacteremic. In addition, there were three minor infections diagnosed on the basis of dysuria or frequency without elevation of temperature. Two of these infections were in the sterile group and one in the clean group. Both episodes were treated with oral antibiotics in the NHCU. Hence, there was a total of three symptomatic infections in the sterile group (all in the same patient) and two in the clean group (in two different patients). The procedure was generally well tolerated and there were no local complications. Patients in both groups had asymptomatic bacteriuria the majority of the time (87%), often with multiple organisms. In both groups, the most frequent urinary isolates were Gramnegative organisms. The cost of supplies was

Use of Estrogen Therapy in a Patient with Gastrointestinal Bleeding Secondary to arteriovenous malformations

2.03 for each sterile catheterization and

Editors note: The above letter was referred to the authors of the original article and Dr. Joseph's reply follows

.48 for each clean Catheterization. In this study, the catheterization costs for the sterile group were

Healthy aging demonstration project: Nurse coaching for behavior change in older adults†

3,404. If the clean technique had been used, the cost would have been