This survey of a 33 per cent random sample (1,139) of 3,456 patients in 42 skilled nursing facilities (SNFs) in upstate New York yielded 64.2 per cent with significant behavioral problems. Of these, 257 (22.6 per cent) of the total sample had what were defined as "serious" problems (i.e., excluding those with only impaired judgment and/or physical restraint orders). Details of the problem behaviors of this group, their previous history, current management, frequency of psychiatric consultation, and adequacy of documentation were analyzed. Median age was the same as the general SNF population, a slightly lower proportion was female, and, while 66.5 per cent had diagnoses indicating organic brain syndrome, very few had specific psychiatric diagnoses, and only 4.7 per cent had been admitted from a psychiatric facility. The attending physician had noted the behavioral problem in the record in only 9.7 per cent and had requested psychiatric consultation in 14.8 per cent of these "serious" cases. The need for more staff training in mental health care, and more physician and psychiatric consultative assistance are discussed. (Am J
In this evaluation of the prevalence and quality of systemic antibiotic use in nursing homes, 42 skilled nursing facilities (SNFs) and their 11 attached intermediate care facilities (ICFs) were surveyed. A random sample of 2238 patients (51%) from the total of 4378 beds was selected and of these, 7.7% of the total (8.6% of the SNF and 4.5% of the ICF) patients were on systemic antibiotics on the day of the survey. The most common suspected sites of infection were urinary tract (58.4%), lower respiratory tract (19.1%), and skin or subcutaneous tissue (4.6%). Criteria for appropriateness of initiating systemic antibiotics, for adequacy of initial diagnostic workup, and for appropriate specific antibiotics were developed by the authors, with input from a group of medical directors of nursing homes, based on Centers for Disease Control and Federal Drug Administration guidelines. Evidence to start an antibiotic was judged adequate in 62.4% of cases. Workups were considered inadequate in a high proportion of cases. For example, urinalysis was ordered in only 23.8% and urine culture in 57.4% of suspected urinary tract infections; chest x-ray was ordered in 24.2% and sputum culture in 3.0% of suspected lower respiratory infections. Recommendations are made as to minimum adequate workup for suspected infections and appropriate evidence to justify start of a systemic antibiotic, recognizing the limitations in diagnostic modalities in the nursing home setting and the special problems of their resident populations.
The purpose of this study was to describe the actual daily oral care provided by certified nursing assistants (CNAs) for dentate elderly nursing home (NH) residents who required assistance with oral care. The study was conducted in five nonrandomly selected NHs in upstate New York using real-time observations of CNAs providing morning care to residents, retrospective chart review, and CNA screening interviews. Oral care standards developed and validated by a panel of 10 experts (dentists, dental hygienists, registered nurses) to be appropriate for dentate NH residents were used to evaluate the oral care provided by 47 primary dayshift CNAs to a convenience sample of 67 residents. CNAs were blinded to the study's specific focus on oral care. Adherence to individual standards was low, ranging from a high of 16% to a low of 0%. Teeth were brushed and mouths rinsed with water in 16% of resident observations. One resident had her tongue brushed. Standards never met were brushing teeth at least 2 minutes, flossing, oral assessment, rinsing with mouthwash, and wearing clean gloves during oral care. Most residents (63%) who received oral care assistance were resistive to CNA approaches. For most observations, oral care supplies were not evident. Actual oral care provided to residents contrasts sharply with CNAs' self-reported practices in the literature and suggests that NH residents who need assistance receive inadequate oral health care.
The objective of this study was to assess the use of the Agency for Health Care Policy and Research (now called the Agency for Healthcare Research and Quality) Urinary Incontinence (UI) Guideline (1996) in nursing homes (NHs) using retrospective chart review and nursing assistant screening interviews. The study was conducted in a nonrandom sample of 52 NHs in upstate New York. Two hundred residents developing new UI or newly admitted with UI on the dayshift and who met criteria for evaluation and treatment/management were evaluated in the 12 weeks after onset of or admission with UI. Fifteen percent of newly admitted residents needed evaluation. Of residents already in NHs, 2.3 per 100 beds developed new UI over the 12 weeks. Aspects of UI evaluation rarely done were rectal examination (15%), digital examination of prostate (15%), and pelvic examination (2%). Sixty-eight percent had a culture/sensitivity, 56% a urinalysis, and 6% a postvoid residual. Eighty-one percent had a reversible cause at the time of onset, but only 34% had all addressed. Few (2%) needed urologist evaluation. Treatment was rare (3%), but management using toileting and absorbent products were common. Only 6% achieved resolution of UI. These results suggest that assessment and treatment of UI is manageable (a total of 4.2 new cases per 100 beds per 12 weeks) but quality is not adequate. On average, only 20% of the standards applicable were met, due primarily to lack of awareness of new UI and lack of familiarity with the guideline. Thus, improvements are needed. Recommendations for guideline revision are made.
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