Development of definitions for acute illness in nursing home residents based on chart-recorded physical exam findings

OBJECTIVES

To develop and test simple, chart-based criteria for acute illness in nursing home residents for clinical and epidemiological study.

DESIGN

Observational study.

SETTING

A 409-bed not-for-profit nursing home.

PARTICIPANTS

102 custodial care residents.

MEASUREMENTS

Physical exam findings commonly performed in nursing home residents were used to define 10 acute conditions. Residents were observed prospectively to test the clinical relevance of these definitions. Episodes of acute illness satisfying definition criteria were identified, as well as treatment changes, hospitalizations, and deaths.

RESULTS

During a median follow-up of 60 days, 43 acute illnesses occurred, affecting 30 (29%) residents. Of these episodes, 77% were associated with treatment changes, hospitalization, or death. The new definitions captured 79% of all episodes of acute illness. The most common diagnoses were urinary tract infection, lower respiratory infection, and gastroenteritis/gastrointestinal upset. Independent risk factors for acute illness were gastrostomy feeding, depression, and history of fracture.

CONCLUSIONS

Acute illness in the nursing home is common and frequently associated with treatment changes, hospitalization and death. It can be identified using a small number of chart-recorded physical exam-based findings as criteria.

Nursing assistants detect behavior changes in nursing home residents that precede acute illness: development and validation of an illness warning instrument

BACKGROUND

Acute illness causes considerable morbidity and mortality in nursing home residents but is often difficult to recognize early. Nursing assistants often notice early signs of acute illness but do not methodically document or communicate their observations with medical staff.

OBJECTIVE

To enhance nursing assistants' observation and documentation of signs of acute illness by developing a validated, standardized instrument for communication with medical staff.

DESIGN

Observational cohort study.

SETTING

Urban not-for-profit nursing home.

SUBJECTS AND METHODS

Candidate instrument items were generated in focus group interviews with nursing home staff. Twenty-three nursing assistants completed the instrument on 74 nursing home residents over 4 weeks. Acute illness, the primary outcome, was identified by nurse report and chart review and determined according to preset criteria.

MEASUREMENTS

Predictive validity was assessed by determining the relationship between instrument responses and development of acute illness within 7 days. Interobserver agreement was calculated between morning and afternoon nursing assistants' responses. Convergent validity was assessed by comparing instrument responses with three standard status indicators.

RESULTS

The instrument consisted of 12 items that assessed behavioral and functional status changes. Residents with an instrument-recorded change were more likely to develop an acute illness within 7 days than those with no change (risk ratio 4.1, 95% confidence interval 2.6, 6.3). A final five-item instrument had a sensitivity of 53% and a specificity of 93% for acute illness. Nursing assistants' documentation of signs of illness preceded chart documentation by an average of 5 days. Interobserver agreement between morning and afternoon nursing assistants was 76%. Correlation of responses with standard indicators of functional, mental, and global status was high.

CONCLUSIONS

A new instrument developed for nursing assistants to document behavioral and functional status changes in nursing home residents demonstrates fair sensitivity and high specificity for acute illness. Close monitoring of patients with a positive instrument might avert morbidity and mortality from acute illness by allowing earlier treatment.