Improving Nursing Home Disaster Readiness Through Implementation Science

As large-scale disasters continue to become increasingly common worldwide, nursing homes, whose residents are more vulnerable to disaster-related health and psychosocial shocks, and their staff, are carrying progressively more responsibility for health care readiness practices. Implementation science is a research discipline that seeks to improve uptake of evidence-based practices, such as health care readiness planning, and thus has potential to improve nursing home care delivery during and after disasters. We describe the limited field of existing evidence-based strategies in the peer-reviewed literature that seek to advance health care readiness in the nursing home setting and illustrate how implementation science can better support health care readiness planning for nursing homes. We rest on 3 main themes: (1) implementation science frameworks can strengthen nursing home staff engagement around health care readiness; (2) implementation science can support tailoring of emergency preparedness plans to individual nursing homes' unique needs; and (3) implementation science can advance the integration of nursing homes into local, state, and federal health care readiness planning initiatives. Finally, research is urgently needed to both generate and disseminate implementation strategies that increase uptake of evidence-based health care readiness practices in the nursing home setting.

Establishing Medicaid incentives for liberating nursing home patients from ventilators

BACKGROUND

Chronic ventilator use in Tennessee nursing homes surged following 2010 increases in respiratory care payment rates. Tennessee's Medicaid program implemented multiple policies between 2014 and 2017 to promote ventilator liberation in 11 nursing homes, including quality reporting, on-site monitoring, and pay-for-performance incentives.

METHODS

Using repeated cross-sectional analysis of Medicare and Medicaid nursing home claims (2011-2017), hospital discharge records (2010-2017), and nursing home quality reports (2015-2017), we examined how service use changed as Tennessee implemented policies designed to promote ventilator liberation in nursing homes. We measured the annual number of nursing home patients with ventilator-related service use; discharge destination of ventilated inpatients and percent of nursing home patients liberated from ventilators.

RESULTS

Between 2011 and 2014, the number of Medicare SNF and Medicaid nursing home patients with ventilator use increased more than sixfold. Among inpatients with prolonged mechanical ventilation, discharges to home decreased as discharges to nursing homes increased. As Tennessee implemented policy changes, ventilator-related service use moderately declined in nursing homes from a peak of 198 ventilated Medicare SNF patients in 2014 to 125 in 2017 and from 182 Medicaid patients with chronic ventilator use in 2014 to 145 patients in 2017. Nursing home weaning rates peaked at 49%-52% in 2015 and 2016, but declined to 26% by late 2017. Median number of days from admission to wean declined from 81 to 37 days.

CONCLUSIONS

This value-based approach demonstrates the importance of designing payment models that target key patient outcomes like ventilator liberation.

Ultrasonography: New Insights in its Applicability to Explore Muscle Mass and Musculoskeletal Inflammation in Critically ill Patients

Objective: The main aim of the study was to explore muscle mass changes and to investigate musculoskeletal inflammation in critically ill patients.

Methods: A pure observational study that comprised two musculoskeletal analyses was conducted. Ultrasonography was used to determine the inflammatory process and muscle mass modifications. We assessed the presence of musculoskeletal inflammation and muscles area reduction. We recruited 26 patients and we performed both imaging investigations (shoulder and hip joints, biceps brachii and rectus femoris areas) and anthropometric measurements (mid-upper arm circumference).

Results: More than 70% of patients were classified with low muscle mass, over one half of sarcopenic patients being over-weight and 17% being obese. The relationship between the length of stay in intensive care unit, mechanical ventilation and presence of low mid-upper arm circumference, highlighted a significant difference when comparing sarcopenic and non-sarcopenic groups. Musculoskeletal inflammation expressed by step-down lesions, calcifications and osteophytes, is common in these patients. Statistically significant results were obtained when comparing the dimensions of the investigated muscles. Good inter-observer variability in day 3 of assessment for biceps brachii and rectus femoris was noticed.

Conclusions: More than 1/3 of critically ill patients included in the present study was classified with low muscle mass. The length of stay in intensive care unit and the length of mechanical ventilation had an important impact on sarcopenic patients. Musculoskeletal impairment was frequent, reflected by presence of enthesitis lesions in joints and by dynamic reduction of muscle area.

Efficacy of Acupuncture Treatment for Improving the Respiratory Status in Patients Receiving Prolonged Mechanical Ventilation in Intensive Care Units: A Retrospective Observational Study

BACKGROUND AND OBJECTIVE

Patients in critical care settings often require prolonged mechanical ventilation (MV) therapy and, occasionally, they cannot be weaned from MV. The authors evaluated the efficacy of acupuncture treatment for improving the respiratory status and promoting successful weaning from prolonged MV in patients at intensive care units (ICUs).

DESIGN

Retrospective observational study.

SETTING

Gifu University Hospital, Gifu, Japan.

SUBJECTS

The authors included 16 tracheostomized patients receiving MV for >21 days at the ICU of Gifu University Hospital, who underwent acupuncture therapy for improving their respiratory status.

INTERVENTION

Acupuncture treatment was conducted in four sessions per week.

OUTCOME MEASURES

The data of tidal volume (VT), respiratory rate (RR), heart rate (HR), oxygen saturation as measured by pulse oximetry (SpO₂), dynamic lung compliance (Cdyn), rapid shallow breath index (RSBI; RR/VT) values before and immediately after acupuncture were extracted from the medical records.

RESULTS

The median number of days on MV before acupuncture initiation was 31 days. VT and Cdyn were significantly increased immediately after acupuncture (all p < 0.001), whereas RR, HR, and RSBI were significantly decreased (all p < 0.05). Eleven patients were successfully weaned from MV after acupuncture initiation. In the weaning success group, VT and Cdyn were significantly increased (all p < 0.01), whereas RR, HR, and RSBI were significantly decreased (all p < 0.05) after acupuncture. Conversely, in the weaning failure group, these values were not changed significantly. The increase in Cdyn after acupuncture was larger in the weaning success group than in the weaning failure group (p < 0.05).

CONCLUSION

Acupuncture treatment might have beneficial effects on the respiratory status of ICU patients receiving MV and may help in weaning from prolonged MV. Further large prospective cohort studies are warranted.

Long-Term Mechanical Ventilation

Although precise numbers are difficult to obtain, the population of patients receiving long-term ventilation has increased over the last 20 years, and includes patients with chronic lung diseases, neuromuscular diseases, spinal cord injury, and children with complex disorders. This article reviews the equipment and logistics involved with ventilation outside of the hospital. Discussed are common locations for long-term ventilation, airway and secretion management, and many of the potential challenges faced by individuals on long-term ventilation.

Acquisition of Mycobacterium abscessus among ventilator-dependent patients in Taiwan chronic respiratory care facilities

AIM

To investigate the acquisition of Mycobacterium abscessus among ventilator-dependent patients.

MATERIALS & METHODS

We prospectively recruited ventilator-dependent patients in five respiratory care wards (RCWs). Respiratory specimens were cultured for mycobacteria on day 1 (D1), 3 months (M3) and 6 months (M6) after enrollment.

RESULTS

72 patients had cultures taken at all three time points. The proportion of patients with a culture positive for M. abscessus increased from 15.3% (11/72) on D1 to 30.6% (22/72) at M3 and 38.9% (28/72) at M6. Two M. abscessus subspecies abscessus isolates obtained from different patients had identical randomly amplified polymorphic DNA patterns. Being in RCW D and advanced age were significantly associated with initial cultures positivity.

CONCLUSION

Our study reveals that acquisition of M. abscessus was common among ventilator-dependent patients.

Clinical application of the ProVent score in Korean patients requiring prolonged mechanical ventilation: A 10-year experience in a university-affiliated tertiary hospital

PURPOSE

We evaluated the clinical usefulness of a prognostic scoring system ("the ProVent score") in Korean patients requiring prolonged mechanical ventilation.

MATERIAL AND METHODS

We retrospectively analyzed the data of 184 patients in a medical intensive care unit of a tertiary care hospital between January 2004 and December 2013.

RESULTS

The patients' median age was 65 years, and 66.8% were male. One-year mortality was 67.4%. On day 21 of mechanical ventilation, the ProVent score was 0 in 13 patients (7.1%), 1 in 39 patients (21.2%), 2 in 73 patients (39.7%), 3 in 42 patients (22.8%), and greater than or equal to 4 in 17 patients (9.2%). For patients with a ProVent score ranging from 0 to greater than or equal to 4, 1-year mortality was 46.2%, 53.8%, 68.5%, 76.2%, and 88.2%, respectively. The Kaplan-Meier curves of 1-year survival for each ProVent score showed statistically significant differences (log-rank test: P = .001). Logistic regression analysis showed that only thrombocytopenia was independently associated with 1-year mortality in our cohort (odds ratio = 4.786, P < .001).

CONCLUSIONS

In our study, the ProVent score could be applied to predict 1-year mortality for patients requiring prolonged mechanical ventilation in Korea. Among variables contributing to this score, only thrombocytopenia was an independent prognostic factor for 1-year mortality.

The influence of music during mechanical ventilation and weaning from mechanical ventilation: A review

Mechanical ventilation (MV) causes many distressing symptoms. Weaning, the gradual decrease in ventilator assistance leading to termination of MV, increases respiratory effort, which may exacerbate symptoms and prolong MV. Music, a non-pharmacological intervention without side effects may benefit patients during weaning from mechanical ventilatory support. A narrative review of OVID Medline, PsychINFO, and CINAHL databases was conducted to examine the evidence for the use of music intervention in MV and MV weaning. Music intervention had a positive impact on ventilated patients; 16 quantitative and 2 qualitative studies were identified. Quantitative studies included randomized clinical trials (10), case controls (3), pilot studies (2) and a feasibility study. Evidence supports music as an effective intervention that can lesson symptoms related to MV and promote effective weaning. It has potential to reduce costs and increase patient satisfaction. However, more studies are needed to establish its use during MV weaning.

Acute and chronic respiratory failure

Respiratory failure (RF) can be attributed to a plethora of neuromuscular diseases (NMDs) and manifests clinically in a multitude of overt or more subtle ways. The basic principles of pathophysiology, diagnosis and treatment of neurologic diseases and of RF apply concomitantly to this subset of patients. Various entities should be approached according to the latest evidence-based recommendations. Treatment follows the natural disease progression, from minimal respiratory assistance to mechanical ventilation (MV). A comprehensive treatment plan has to be formulated that takes into consideration the patient's wishes.

Unplanned transfers following admission to a long-term acute care hospital: a quality issue

The unplanned transfer of patients from long-term acute care hospitals (LTACHs) back to acute facilities disrupts the continuity of care, delays recovery and increases the cost of care. This study was performed to better understand the unplanned transfer of patients with pulmonary disease. A retrospective analysis of data obtained for quality management in a cohort of patients admitted to an LTACH system over a 3-year period. Of the 3506 patients admitted with a pulmonary diagnosis studied, 414 (12%) underwent 526 unplanned transfers back to an acute facility after a median LTACH length of stay (LOS) of 45 days. Mechanical ventilation via tracheostomy was used in 259 (63%) patients admitted to the LTACH with a pulmonary diagnosis. The commonest reasons for unplanned transfers included acute respiratory failure, cardiac decompensation, gastrointestinal bleed and possible sepsis. Over 50% of patients had LOS at the LTACH between 4 and 30 days prior to the unplanned transfer. Patients with an LOS <3 days prior to transfer were more likely to be transferred around the weekend. In all, 32% of patients died within a median of 7 days of transfer back to the acute facility. Thirty-day mortality following unplanned transfer appeared independent of organ system involved, attending physician specialty/coverage status, nursing shift or transferring LTACH unit. Unplanned transfers disrupting continuity of care remain a significant problem in patients admitted to an LTACH with a pulmonary diagnosis and are associated with significant mortality. Strategies designed to reduce cardiopulmonary decompensation, gastrointestinal bleeding and possible sepsis in the LTACH along with additional strategies implemented throughout the health care continuum will be needed to reduce this problem.

Caregivers of the chronically critically ill after discharge from the intensive care unit: six months' experience

BACKGROUND

Chronically critically ill patients typically undergo an extended recovery after discharge from the intensive care unit, making involvement of family caregivers essential. Prior studies provide limited detail about specific ways this experience affects caregivers.

OBJECTIVES

To (1) describe lifestyle restrictions and distress among caregivers of chronically critically ill patients 1 and 6 months after discharge and (2) explore how caregivers' lifestyle restrictions and distress differ according to patients' and caregivers' characteristics.

METHODS

Sixty-nine chronically critically ill patients and their family caregivers completed follow-up at 1 and 6 months after discharge from the intensive care unit. Data were collected from medical records and survey via telephone or mail.

RESULTS

Caregivers' perceived lifestyle restrictions (Changes in Role Function) decreased from 1 month (mean [SD], 23.0 [8.3]) to 6 months (19.4 [8.6]) after discharge (P = .003), although patients' problem behaviors and caregivers' distress (8.9 [9.3] vs 7.9 [9.6], respectively; P = .32) did not change. Change in caregivers' lifestyle restrictions differed by patients' disposition (P = .02) and functional status (Health Assessment Questionnaire; P = .007). Caregiver's lifestyle restrictions remained high when patients never returned home or never recovered their preadmission functional status. Caregivers reported the most restrictions in social life and personal recreation. Patients' negative emotions and pain caused the most caregiver distress.

CONCLUSIONS

Caregivers of chronically critically ill patients perceived fewer lifestyle restrictions over time but reported no change in patients' problem behaviors or distress. Lifestyle restrictions and distress remained high when patients never returned home or regained their preadmission functional status.

Variation in duration of respiratory support among Australian and New Zealand pediatric intensive care units

OBJECTIVE

To test if there was significant variation of mean adjusted duration of respiratory support (RS) at the site level among Australian and New Zealand pediatric intensive care units (PICUs) and to determine whether the pattern of variation differed from the site-level pattern of variation in length of stay (LoS).

DESIGN

Separate outcome prediction models for estimating PICU LoS and duration of RS were constructed, using patient data collected between 2002 and 2007. Gamma regression was used to model LoS for all admissions included in the study population, and log normal regression was used to model duration of RS for the subset of patients receiving RS. For both models, case-mix adjustment was achieved by entering patient risk factors as fixed effects, and the PICU or site of care was entered as a random effect.

SETTING

Data for 31,358 admissions were collected from nine specialist PICUs in Australia and New Zealand.

MEASUREMENTS AND MAIN RESULTS

Average risk-adjusted duration of RS and LoS for each PICU. There was significant unit-level variation in the adjusted mean LoS and duration of RS among PICUs in Australia and New Zealand. One site had a mean duration of RS that was significantly longer than expected, whereas two sites had a mean duration of RS that was significantly shorter than expected at the 95% level. Unit-level variation in duration of RS is consistent with unit-level variation in LoS for six PICUs and significantly different in two units.

CONCLUSION

There is unit-level variation in LoS and duration of RS, not accounted for by case-mix. Concurrent analysis of unit-level variation in LoS and duration of RS can help to identify differences in discharge practice and provide direction for improvements in clinical or administrative efficiency.

Antimicrobial resistance of bacterial isolates from respiratory care wards in Taiwan: a horizontal surveillance study comparison of the characteristics of nosocomial infection and antimicrobial-resistant bacteria in adult Intensive Care Units and two respiratory care facilities for mechanically ventilated patients at a tertiary care centre in Taiwan

The objectives of this study were to compare the incidence of nosocomial infections (NIs) and the distribution of resistant nosocomial pathogens in adult Intensive Care Units (ICUs) and two respiratory care facilities for prolonged mechanically ventilated patients [i.e. the respiratory care centre (RCC) and the respiratory care ward (RCW)] in a 1100-bed tertiary care hospital in Taiwan from 2003 to 2006. The overall incidences of NI for adult ICUs, the RCC and the RCW were 14.0, 10.3 and 5.0 per 1000 patient-days, respectively. Urinary tract infections, bloodstream infections and pneumonias occurred most frequently. The most common reported microorganisms in adult ICUs were non-fermentative Gram-negative bacilli (NFGNB) (33.0%), Enterobacteriaceae (26.5%), Candida spp. (18.2%), Staphylococcus aureus (8.9%), coagulase-negative staphylococci (CoNS) (4.9%) and enterococci (4.5%). In comparison, RCW patients had a higher proportion of NIs caused by S. aureus [odds ratio (OR)=1.9], enterococci (OR=2.2) and Enterobacteriaceae (OR=2.2), but a lower proportion of CoNS (OR=0.3), NFGNB (OR=0.5) and Candida spp. (OR=0.2). RCW patients had higher incidence rates of methicillin-resistant S. aureus (OR=4.91) and extended-spectrum β-lactamase-producing Enterobacteriaceae (OR=4.06) than ICU patients. Further study is needed to delineate the mechanisms responsible for the differences in resistance profile amongst pathogens associated with nosocomial infection in ICUs, RCCs and RCWs.