NADONA/LTC 2013 Annual Conference

June 8-12, 2013; Las Vegas, NV

Preventing Antimicrobial Resistance in Long-Term Care

The World Health Organization defines antimicrobial resistance (AMR) as resistance of a microorganism to an antimicrobial medicine to which it was previously sensitive, thereby rendering standard treatments ineffective and enabling infections to persist and spread. Resistant organisms can include bacteria, fungi, viruses, and some parasites. During a presentation at the NADONA/LTC 2013 annual meeting, William R. Jarvis, MD, Jason and Jarvis Associates, discussed several important steps that can be implemented to reduce the risk of AMR in the long-term care (LTC) setting. These steps focus on preventing AMR from developing and curbing transmission when an infection occurs.

Jarvis noted that prevention is the essential first step, which can be achieved by proper inoculation of healthcare providers and patients. He recommended administering influenza and pneumococcal vaccines to institutionalized adults prior to discharge, whether they are in a hospital setting or an LTC facility. He also recommended that healthcare providers be vaccinated for influenza.

Jarvis stated that another key preventive strategy is to use catheters only when absolutely necessary and to remove them promptly when they are no longer needed. He emphasized that catheters are the primary exogenous cause of hospital-onset infections.

When infection occurs, it is essential to focus on preventing transmission. This can be achieved by containing infectious body fluids; using standard infection control practices, such as practicing good hand hygiene; and consulting infection control experts when needed, said Jarvis. In addition, staff should be encouraged to stay home when sick.

Another essential step is to educate healthcare providers about pathogens and their survival rate so that proper precautions can be taken. For example, pathogens like vancomycin-resistant enterococci are able to survive for days and weeks on environmental surfaces. As a result, healthcare providers can inadvertently transmit these diseases to other patients if they touch contaminated environmental surfaces with their hands or gloves and fail to wash their hands or remove their gloves before seeing other patients.

Finally, it is essential to clean hospital environmental surfaces with liquid chemical disinfectants and to make use of the newer environmental decontamination technologies (eg, ultraviolet light disinfection). Jarvis concluded that although these steps may seem tedious, they are absolutely essential to prevent AMR, a disconcerting phenomenon that is becoming more prevalent worldwide.—Morgan Marsicano

Improving Pain Management in the LTC Facility

The identification, assessment, and management of pain and chronic pain remains a difficult and important aspect of long-term care (LTC). Estimates of chronic pain in the LTC setting ranges from 45% to 80%, and pain in the older population specifically range from 49% to 83%. Pain in this population can sometimes be underrecognized and undertreated, thus resulting in the wide percentage gap. Untreated pain can lead to agitation, depression, decreased socialization, and sleep disturbances.

The implementation of Minimum Data Set 3.0 and Care Area Assessments has improved the management of pain in this specific setting. Albert Riddle, MD, CMD, presented a session titled A Renewed Focus on Pain Management in the LTC Setting during the NADONA’s 2013 conference, discussing current measures and focuses on pain in the older adult LTC population.

The Centers for Medicare & Medicaid Services’ F-Tag 309 focuses on quality of care, specifically to help a resident attain or maintain the highest practicable level of well-being and to prevent and manage pain to the highest extent possible. This includes recognizing when a resident has pain, identifying circumstances where pain can be anticipated, evaluating the existing pain and its causes, and managing or preventing the pain consistent with the comprehensive plan of care, current clinical standards of practice, and the resident’s goals or preferences.

According to Dr. Riddle, there are 4 predictors for the development of chronic pain in a patient: demographic variables, characteristics of the pain, psychological factors, and context of the injury. Demographic factors include age, gender, education, employment, and health status. Pain characteristics include high pain intensity, long pain duration, radiation of pain, prior episodes of pain, multiple sites of pain, and multiple somatic symptoms. Psychological factors include negative emotion, depression, anxiety, anger, fear, stress, distress, catastrophizing, hypervigilence, self-efficacy, neuroticism, pain sensitivity, and somatization. Context of injury factors include work-related injury, litigation, reward for remaining injured or disabled, and social support from family or others.

In the LTC setting there are a number of barriers in managing pain; these include the expectation that pain is a consequence of older age, residents are unable or do not report their pain, polypharmacy can decrease the effects of analgesics, and there are altered pharmacokinetics and pharmacodynamics for patients taking a number of medications.

Depression and opioids are also commonly linked with chronic pain. Dr. Riddle posed the following question during his presentation: “Which comes first: depression or pain?” According to research, those with baseline depressive disorders have twice the risk for new onset back pain up to 13 years into the future. Most data supports the idea that depression is a consequence of chronic pain and that treatment of depression can improve pain and disability. Another question was posed during the presentation: “Do opioids cause chronic pain?” Again, research indicates a powerful positive reinforcement for individuals on opioids to continue to use, thus setting an unreasonable standard for pain control. Addiction is a common concern for patients on opioids, which could result in primary addiction, pseudo-addiction, and/or dependence on the drug.

Dr. Riddle concluded the presentation by discuss- ing long-acting opioids and how they are underutilized for pain in this patient population. Opioids can be used for acute pain, traumatic pain, cancer pain, chronic nonmalignant pain, neuropathic pain when used with adjuvents, and breakthrough pain. When increasing a dose of opioids for pain, the total daily dose should increase in 25% to 50% increments.—Kerri Fitzgerald

Reducing Avoidable Hospital Readmissions Is a Top Priority

One in 5 Medicare-age patients are rehospitalized within 30 days of discharge, and 50% occur within the first week following release. A presentation by Kathleen Glendening, MPH, BSN, NHA, RAC-CT, and Aysha Kuhlor, RN, BA, CDONA, at NADONA’s 2013 conference shared this information and gave suggestions as to how care transition can reduce hospital readmissions by 40% to 50%.

The presenters introduced the “Never” Event programs, which can be integrated to reduce rehospitalizations and emergency department visits. The following are 4 “Never” Events: (1) Medication errors resulting in ongoing monitoring and/or harm; (2) Infections resulting in a facility outbreak; (3) Falls resulting in major injury; and (4) Pressure ulcers, which are high risk and facility acquired.

Awareness of the “Never” events could help to decrease preventable hospital-acquired conditions by 40% by the end of 2013 compared to 2010. Preventing complications during a transition from one care setting to another could also be decreased so that hospital readmissions would reduce by 12% by the end of 2013 compared to 2010.

Because of the changes that are being implemented by the Patient Prevention and Affordable Care Act and Medicare programs, hospitals could be penalized if the rate of readmissions from nursing homes does not improve. In addition, payers will not pay for additional costs of care, and the patients and families will become increasingly aware of providers’ rate of readmission in relation to other facilities of care.

Another program, INTERACT, which stands for Interventions to Reduce Acute Care Transfers, is a quality improvement program designed to identify situations that commonly result in transfers of patients to the hospital. INTERACT also encourages healthcare providers to work together to manage patients in the nursing home safely and effectively rather than transferring to hospital care, when possible.

INTERACT can help to reduce hospital transfers in a number of ways. The program can help to prevent conditions from becoming too severe to treat in the nursing home setting and instead manage these conditions effectively. Advanced care planning is also encouraged, especially the use of palliative care plans when appropriate as an alternative to hospitalization.

Complex medical conditions, such as chronic obstructive pulmonary disease and pneumonia, can often lead to rehospitalizations in the geriatric population, so certain strategies can be adopted by nursing home facilities to decrease these readmissions. Identifying and targeting the specific demographics susceptible to these complex conditions, as well as reviewing readmission and emergency visit primary causes and trends can help. Reviewing strategies employed by hospitals can also reduce the performance gap.

Changing internal educational practices in the nursing home facilities can have a big impact as well. Competency tests, protocol assessments, and partnerships with hospitals for learning purposes can lead to better care in nursing homes. Acquiring necessary emergency equipment, such as crash carts, cardiac chairs, bariatric equipment, and electrocardiogram machines, was also noted during the presentation.—Kerri Fitzgerald