Risk factors associated with COVID-19 infection and mortality in nursing homes

OBJECTIVE

The aim of this paper was to analyse the association of demographic, clinical and pharmacological risk factors with the presence of SARS-COV-2 virus infection, as well as to know the variables related to mortality from COVID-19 in nursing home (NH) residents.

DESIGN

Retrospective case-control study. The study variables of those residents who acquired the infection (case) were compared with those of the residents who did not acquire it (control). A subgroup analysis was carried out to study those variables related to mortality. SITE: Nursing homes in the region of Guipúzcoa (Spain).

PARTICIPANTS AND INTERVENTIONS

4 NHs with outbreaks of SARS-CoV-2 between March and December 2020 participated in the study. The infectivity and, secondary, mortality was studied, as well as demographic, clinical and pharmacological variables associated with them. Data were collected from the computerised clinical records.

MAIN MEASUREMENTS

Infection and mortality rate. Risk factors associated with infection and mortality.

RESULTS

436 residents were studied (median age 87 years (IQR 11)), 173 acquired SARS-CoV-2 (39.7%). People with dementia and Global Deterioration Scale ≥6 were less likely to be infected by SARS-CoV-2 virus [OR=0.65 (95% CI 0.43-0.97; p<.05)]. Overall case fatality rate was 10.3% (a mortality of 26% among those who acquired the infection). COVID-19 mortality was significantly associated with a Global Deterioration Scale ≥6 (OR=4.9 (95% CI 1.5-16.1)), COPD diagnosis (OR=7.8 (95% CI 1.9-31.3)) and antipsychotic use (OR=3.1 (95% CI 1.0-9.0)).

CONCLUSIONS

Advanced dementia has been associated with less risk of SARS-CoV-2 infection but higher risk of COVID-19 mortality. COPD and chronic use of antipsychotics have also been associated with mortality. These results highlight the importance of determining the stage of diseases such as dementia as well as maintaining some caution in the use of some drugs such as antipsychotics.

The impact of automation on the safety of drug dispensing in nursing homes

OBJECTIVE

To compare the frequency and seriousness of notified dispensing errors in nursing homes when medication is dispensed manually versus automatically using a specifically selected automatic dispensing system.

METHOD

A pre-post retrospective observational study in 7 nursing homes. We  compare voluntarily notified dispensing errors in a manually dispensed weekly  system on the one hand (year 2013), with an Automated Tablet Dispensing and  Packaging System Xana4001U2 Tosho® for oral solid drugs used in combination  with a manual system for other drug forms (year 2015), on the other. We  analyze patient function, cognition and pharmacological data in two time  periods.

RESULTS

Residents' mean age (83.9 vs 83.6 years; p &gt; 0.05) and physical functioning (Barthel index 41.8 vs 44.2; p &gt; 0.05) were similar, but not  cognitive functioning (MMSE 20.3 vs 21.7; p &lt; 0.0,5). During the year previous to the automated dispensing, 408 errors were detected with the manual system, whereas only 36 were detected in the following yearwith the automated system. This represents a reduction of 91% in dispensing errors. 43 errors reached the patient during the manually dispensing year, versus 6 during the automated year. And 5 errors versus 1 required monitoring.

CONCLUSIONS

The introduction of an automatic tablet dispensing and packaging  system has shown to be an important improvement in safety in the dispensing  and administration of solid drugs in nursing homes. The voluntary notification of  errors has permitted the comparison of safety during two time periods with  different dispensing systems.

[Infection epidemiology in gerontology centres]

INTRODUCTION

Infection processes in gerontology centres (GC) are one of the main causes of mortality and aggravation of concomitant chronic diseases. An epidemiological surveillance system was set up to find out their magnitude and distribution.

MATERIAL AND METHODS

A prevalence study was conducted during the years 2006-2009 in 4 GCs of the Matia Foundation. Prevalence was measured by making an annual cut-off, recording: infection type, demographic data, risk factors and antibiotic use. The incidence was measured for two years in one GC as a pilot centre, recording: infection type and antibiotic use.

RESULTS

The prevalence in the GCs varied between 4.8% and 6.44%. The infection incidence density in the pilot study was between 3.45-5.77 infections per 1,000 resident days. The most common infection location and in this order were, respiratory, urinary and cutaneous. The incidence of respiratory infection is more statistically significant in the presence of dysphagia, malnutrition and COPD. However, no significant relationship was seen in the incidence of urinary infection with the different risk factors analysed.

CONCLUSIONS

The frequency and repercussions of nosocomial infections in GCs demonstrate the need for intervention plans and the development of adequate prevention measures.

[Prevalence of prescription of anticholinergic/sedative burden drugs among older people with dementia living in nursing homes]

BACKGROUND AND OBJECTIVE

Dementia is one of the most frequent diseases in the elderly, being its prevalence of up to 64% in institutionalized people. In this population, in addition to antidementia drugs, it is common to prescribe drugs with anticholinergic/sedative burden that, due to their adverse effects, could worsen their functionality and cognitive status. The objective is to estimate the prevalence of the use of drugs with anticholinergic/ sedative burden in institutionalized older adults with dementia and to assess the associated factors.

MATERIALS AND METHODS

A cross-sectional study developed in older with dementia living in nursing homes. The prevalence of prescription of anticholinergic/sedative drugs was estimated according to the Drug Burden Index (DBI). A comparative analysis of the DBI score was performed between different types of dementia as well as among various factors and according to the anticholinergic/sedative risk, establishing as a cut-off point of DBI≥1 (high anticholinergic/sedative risk).

RESULTS

178 residents were included. 83.7% had some drug with anticholinergic/sedative burden according to DBI. 50% had a DBI≥1 score. Residents with vascular dementia had a mean DBI of 1.34 (SD 0.84), a significantly higher score than residents with Alzheimer's disease (0.41, 95% CI 0.04-0.78).). Likewise, a higher DBI was associated with more polypharmacy (3.36; 95% CI 2.64-4.08), more falls, hospital admissions and emergency room visits (P<.05).

CONCLUSIONS

Polypharmacy and prescription of anticholinergic/sedative drugs is frequent among institutionalized older adults with dementia, finding an association between DBI, falls and hospital admissions or emergency department visits. Therefore, it is necessary to propose interdisciplinary pharmacotherapeutic optimization strategies.

EPERCAS study (Strategies for Preventing Medication Administration Errors in Nursing Homes). Preparation of a list of strategies to prevent the most frequent medication administration errors in the residential care environment

Medication administration errors are one of the most frequent types of errors. There are different safety guides and recommendations to prevent medication errors generally directed to the hospital environment. However, specific recommendations for the management process in the residential care environment are lacking. The main objective of this study was to develop a list of recommendations to aid in preventing the most important medication errors that occur during the administration process in nursing homes (NHs), such as not administering doses or administering medication to the wrong patient. The effectiveness and feasibility of the strategies proposed were evaluated by a panel of experts. The conventional Delphi method was applied. The first round in our study was a face-to-face questionnaire; the second round included an online questionnaire based on the results of the first round. Finally, eight strategies were included in the EPERCAS List: one professional in charge per shift; one professional commissioned by the residential unit; avoid interruptions; avoid medication outside of meal times; personalized medication drawer for each resident including oral medication from a bag and laxatives, inhalers, syrups, eye drops, etc.; identification of the resident and their medication; visual check that everything has been administered; and signature to verify medication administration. The great continual challenge for NH is to define safe and affordable procedures. Minimum safety recommendations for administering the medications, such as those included in this study, should be employed. Our next stage is to implement these strategies in one of our NH and subsequently, evaluate its effectiveness and consider expanding it to the rest of the NH.

Determination of the cross-contamination and validation of the cleaning process for an automated personalised dosing system

OBJECTIVE

To determine the degree of cross-contamination and to validate a cleaning process for an Automated Personalised Dosing System (APDS), respecting the permitted residue transfer limits.

METHOD

An analytical determination by high pressure liquid chromatography with mass spectrometry was performed for 11 drugs considered critical for their potential for contamination, toxicity (National Institute for Occupational Safety and Health (NIOSH) List 2016) and/or narrow therapeutic index. The test was carried out for three consecutive weeks, seven repetitions per week, in a state of maximum contamination and maximum cleanliness. The main validation criterion of the cleaning protocol was to quantify that the active ingredients measured were below the Permitted Daily Exposure index or fraction 1/1000 of the minimum daily dose, both in a state of maximum contamination and when the APDS is in a clean condition, for an average number of tablets consumed per person per day.

RESULTS

In all the samples analysed, some compound could always be quantified below 2% of the permitted transfer limits, highlighting the presence of paracetamol and carbamazepine. In the state of maximum contamination, the mean±SD values of paracetamol and carbamazepine were 5.83±1.56 µg and 0.22±0.07 µg, respectively, without significant differences in mean values over the 3 weeks of the study. After the cleaning protocol was executed, only paracetamol and carbamazepine were detected, with the average values being 4.67 µg (95% CI 3.92 to 5.43, p<0.05) and 0.07 µg (95% CI 0.03 to 0.10, p<0.05) lower than the state of maximum contamination, respectively.

CONCLUSIONS

In all cases the level of cross-contamination for an APDS was below the pre-established limits. The cleaning protocol has been validated, confirming APDS decontamination of the most critical medicines.