RESUMO
BACKGROUND: Experience in trials of implementing quality improvement (QI) programs in nursing homes (NHs) has been variable. Understanding the characteristics of NHs that demonstrate improvements during these trials is critical to improving NH care. DESIGN: Secondary analysis of a randomized controlled trial of implementation of a QI program to reduce hospital transfers. PARTICIPANTS: Seventy-one NHs that completed the 12-month trial INTERVENTION: Implementation included distance-learning strategies, involvement of a champion, regular submission of data on hospitalizations and root cause analyses of transfers, and training, feedback and support. MEASUREMENTS: Primary outcomes included all-cause and potentially avoidable hospitalizations and emergency department (ED) visits per 1000 NH resident days, and the percentage of residents readmitted in 30-days. We compared multiple other variables that could influence effective program implementation in NHs in the highest versus lowest quartile of changes in the primary outcomes. RESULTS: The 18 high-performing NHs had significant reductions in hospitalization and ED visits, whereas the 18 NHs in the low-performing group had increases. The difference in changes in each outcome varied between a reduction of 0.75 and 2.30 events relative to a NH with a census of 100; the absolute difference in 30-day readmissions was 19%. None of the variables we examined reached significance after adjustment for multiple comparisons between the groups. There was no consistent pattern of differences in nonprofit status, nursing staffing, and quality ratings. CONCLUSION: Our experience and reviews of other NH trials suggest that key factors contributing to successful implementation QI programs in NHs remain unclear. To improve NH care, implementation trials should account for intervention fidelity and factors that have not been examined in detail, such as degree and nature of leadership support, financial and regulatory incentives, quality measures, resident and family perspectives, and the availability of onsite high-quality medical care and support of the medical director.
Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Melhoria de Qualidade/normas , Instituições de Cuidados Especializados de Enfermagem/normas , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Recursos Humanos de Enfermagem/estatística & dados numéricos , Análise de Causa Fundamental , Instituições de Cuidados Especializados de Enfermagem/classificaçãoAssuntos
Tamanho das Instituições de Saúde/classificação , Instituições de Cuidados Especializados de Enfermagem/classificação , Tamanho das Instituições de Saúde/economia , Tamanho das Instituições de Saúde/estatística & dados numéricos , Instituições de Cuidados Especializados de Enfermagem/economia , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Estados UnidosAssuntos
Moradias Assistidas/economia , Hospitais para Doentes Terminais/economia , Renda/classificação , Centros de Reabilitação/economia , Instituições de Cuidados Especializados de Enfermagem/economia , Moradias Assistidas/classificação , Hospitais para Doentes Terminais/classificação , Renda/estatística & dados numéricos , Propriedade , Centros de Reabilitação/classificação , Instituições de Cuidados Especializados de Enfermagem/classificação , Estados UnidosRESUMO
OBJECTIVE: To determine whether transfer from a long-term care facility (LTCF) is a risk factor for colonization with Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae upon acute care hospital admission. DESIGN: Microbiologic survey and nested case-control study. SETTING: Four hospitals in a metropolitan area (Chicago) with an early KPC epidemic. PATIENTS: Hospitalized adults. METHODS: Patients transferred from LTCFs were matched 1â¶1 to patients admitted from the community by age (± 10 years), admitting clinical service, and admission date (± 2 weeks). Rectal swab specimens were collected within 3 days after admission and tested for KPC-producing Enterobacteriaceae. Demographic and clinical information was extracted from medical records. RESULTS: One hundred eighty patients from LTCFs were matched to 180 community patients. KPC-producing Enterobacteriaceae colonization was detected in 15 (8.3%) of the LTCF patients and 0 (0%) of the community patients ([Formula: see text]). Prevalence of carriage differed by LTCF subtype: 2 of 135 (1.5%) patients from skilled nursing facilities without ventilator care (SNFs) were colonized upon admission, compared to 9 of 33 (27.3%) patients from skilled nursing facilities with ventilator care (VSNFs) and 4 of 12 (33.3%) patients from long-term acute care hospitals (LTACHs; [Formula: see text]). In a multivariable logistic regression model adjusted for a propensity score that predicted LTCF subtype, patients admitted from VSNFs or LTACHs had 7.0-fold greater odds of colonization (ie, odds ratio; 95% confidence interval, 1.3-42; [Formula: see text]) with KPC-producing Enterobacteriaceae than patients from an SNF. CONCLUSIONS: Patients admitted to acute care hospitals from high-acuity LTCFs (ie, VSNFs and LTACHs) were more likely to be colonized with KPC-producing Enterobacteriaceae than were patients admitted from the community. Identification of healthcare facilities with a high prevalence of colonized patients presents an opportunity for focused interventions that may aid regional control efforts.