The effect of mobilizing large numbers of CD34 + cells (super-mobilizers) on the engraftment and survival in patients undergoing autologous stem cell transplantation.

With the use of plerixafor in addition to growth factor for peripheral blood stem cell mobilization, the yield of autologous stem cell harvest has been higher while the length of apheresis days has become shorter. There is still debate whether higher cell collection efficacy in autologous stem cell transplant (ASCT) affect outcomes. In this retrospective study, we defined two groups of patients, group 1, super-mobilizers, with more than double the target cell dose collected (n = 15), while group 2 included all other patients (n = 75). Multiple myeloma (MM) and lymphoma patients were combined. Patients with chemo-mobilization, those needed more than one day apheresis, or with less than 100 days after ASCT were excluded. Correlations were performed between cell collection efficacy and post thaw CD34 cell viability (by 7AAD flow cytometry method), product HCT, and engraftment of neutrophils and platelets. We performed multiple linear regression using the above variables in addition to age, sex and disease type. We used Kaplan Meier's curves to show effect of cell collection efficacy on 1-year overall survival (OS). Our results show that all super-mobilizers received plerixafor in addition to G-CSF, while 83% did in group 2. Correlations between cell collection efficacy and neutrophil and platelet engraftment in group 1 and 2 was modest and better in group 1 (R=0.449 Vs 0.233 for neutrophils; R=0.464 Vs 0.110 for platelets, respectively). However, multiple linear regression showed statistically significant association between cell collection, as a continuous variable, with disease type (P < 0.001), product HCT (P < 0.001), post thaw viability (P = 0.003), and age (P = 0.013). MM patients were more likely to be super-mobilizers, while the product HCT was higher in the super-mobilizers. No significant effect of cell collection efficacy was found on engraftment of neutrophils or platelets. With relatively short post ASCT follow up, 6 patients in group 2 died of any cause while no deaths were recorded in the super-mobilizers group (P = 0.1892 by log-rank test). In conclusion, stem cell collection efficacy in ASCT is more frequent in MM than lymphoma patients, but is not predictive of faster engraftment. On the other hand, 1-year OS was 100% in the super-mobilizers group versus 93% in the other group.

Impact of state mandates on electronic prescribing of acute opioid prescriptions for the treatment of pain in Kansas and Colorado.

BACKGROUND: Government and health care entities are seeking solutions to optimize safe opioid prescribing practices. Electronic prescribing of controlled substance (EPCS) state mandates are becoming common, but lack thorough evaluation. OBJECTIVE: This study aimed to evaluate whether EPCS state mandates affect opioid prescribing patterns for acute pain treatment. METHODS: This retrospective study was designed to assess prescribing patterns via percent change for quantity, day supply, and prevalence of prescribing method utilized for opioid prescriptions 3 months pre- and post-EPCS mandate. Prescription data are extracted from two regional divisions of a large community-based pharmacy chain between April 1, 2021 to October 1, 2021. Relationships of patient geographical locations and prescribing methods were assessed. Likewise, the relationship of opioids prescribed between insurance types were evaluated. Data was evaluated utilizing Chi-Square and Mann-Whitney U tests, with an a-priori alpha of 0.05. RESULTS: There was an increase before to after state mandate of quantity and day supply (0.8% and 1.3% [P = 0.02; P < 0.001], respectively). There were significant decreases in total daily dose and daily morphine milligram equivalent (2.0% and 1.9% [P < 001; P = 0.254], respectively). A 16.3% increase was seen in electronic prescribing before to after state mandate for prevalence of electronic prescribing versus other prescribing methods. CONCLUSION: There is a correlation between EPCS and prescribing patterns for acute pain treatment with opioids. The use of electronic prescribing increased after state mandate. By promoting the use of electronic prescribing, the benefit of awareness and caution of opioid use draws attention to prescribers.

Implementation effectiveness of psychosocial and environmental care practices in assisted living.

Psychosocial and environmental care practices are recommended to address behavioral expressions in persons with dementia, but their use has been limited partly because guidance is lacking regarding implementation. In response, we developed a simple "how-to" guide of evidence-based protocols for aromatherapy, natural light, familiar music, and robotic pets; trained staff in four assisted living (AL) communities to use the practices; provided materials; met with them regularly; and evaluated fidelity, facilitators and barriers to implementation, and staff knowledge, attitudes, and self-efficacy. After two months, staff reported more familiarity, confidence, and use; barriers such as difficulty locating supplies and task-focused staff with limited time; and staff "champion" facilitators. Notable differences were identified across communities, suggesting that just as care to individuals must be person-centered, practices embraced by communities must fit that community. Through strategic adoption, successful implementation is possible. The "how-to" guide is appropriate for AL, nursing homes, and persons' own homes.

Family perceptions of mouth care for assisted living residents with dementia: Implications for care.

Mouth care is an important component of care for persons with dementia in assisted living (AL). However, there is little information about family member knowledge, beliefs, and experiences with resident oral health. Family perceptions and involvement in care may impact oral and systemic health for AL residents. Therefore, semi-structured interviews to assess these domains were conducted with 23 adult family members of AL residents with dementia, from 9 AL communities. Thematic analysis found that families identified (1) the centrality of oral health to well-being; (2) organizational influences on mouth care; (3) mouth care in the context of dementia; and (4) collaboration to facilitate mouth care. Family perspectives can provide useful guidance for collaborative interventions that support oral health and mouth care in AL.

Impact of an Individually Tailored Light Mask on Sleep Parameters in Older Adults With Advanced Phase Sleep Disorder.

Objective: This study investigated whether light delivered through the eyelids of sleeping persons might create phase delay in older adults who are adversely affected by advanced sleep phase disorder. Participants: Thirty-two cognitively intact, community-dwelling participants aged ≥ 50 years (20 females, 12 males) with Pittsburgh Sleep Quality Index scores ≥ 5 (poor sleep) completed the study. Methods: This within-subjects, randomized, two-treatment crossover design study exposed participants to an active "blue" (λmax  =  480 nm) lighting intervention or a placebo "red" (λmax = 640 nm) control through closed eyelids during sleep for 8 weeks. Conditions were administered 1 hr after bedtime using custom-built light masks delivering a train of 2-s duration light pulses presented every 30 s for ≤ 2 hr (approximately 240 pulses/night). Dependent variables were subjective measures of sleep and depression (questionnaires) and objective measures of sleep (wrist actigraphy), analyzed using linear mixed models with treatment, period, and carryover as fixed effects. Results: The actigraphy analysis found no effect of the intervention or the control condition on sleep start time, total sleep time, number of sleep bouts, or sleep efficiency, either compared to baseline or to one another. Subjective responses of study participants, however, indicated statistically significant (p < 0.05) improvement in seven of eight reported measures of sleep quality with both the intervention and the control condition, but no difference between the two conditions. Conclusions: The participants reported improvement in sleep quality, but the intervention did not confer additional advantages after adjusting for period and carryover effects.

Fidelity and sustainability of Mouth Care Without a Battle and lessons for other innovations in care.

There are countless efficacious interventions that improve outcomes when conducted in controlled situations. Many fewer are effective when implemented in real-world situations, largely because they are not implemented with fidelity. Still fewer are sustained over time, for reasons including lack of institutional support and fit with existing values, among others. It is especially important to examine fidelity and sustainability when efficacious interventions are being implemented, because these interventions are the ones that hold the most promise. This project examined the fidelity and sustainability of Mouth Care Without a Battle (MCWB), an evidence-based program conducted in a two-year cluster randomized trial in 14 nursing homes. Results that triangulated two sources of data indicated that fidelity decreased after the first year; they provide guidance to promote fidelity and sustainability of this and other new care practices in nursing homes, including ongoing education, coaching, evaluation, feedback, and sufficient resources.

Bergamot Aromatherapy for Medical Office-Induced Anxiety Among Children With an Autism Spectrum Disorder: A Randomized, Controlled, Blinded Clinical Trial.

This randomized, blinded clinical trial evaluated the effects of aromatherapy on medical office-induced anxiety in children with an autism spectrum disorder. Patients awaiting office visits were randomized into an aromatherapy group and a control group. After adjusting for baseline scores, there was no significant difference between the 2 groups.

Nursing home nurses' and community-dwelling older adults' reported knowledge, attitudes, and behavior toward antibiotic use.

BACKGROUND: Antibiotic overuse causes antibiotic resistance, one of the most important threats to human health. Older adults, particularly those in nursing homes, often receive antibiotics when they are not indicated. METHODS: To understand knowledge, attitudes, and behaviors of nursing home (NH) nurses and community-dwelling older adults towards antibiotic use, especially in clinical situations consistent with antibiotic overuse, we conducted a mixed-method survey in two NHs and one Family Medicine clinic in North Carolina, among English-speaking nurses and community-dwelling, cognitively intact adults aged 65 years or older. Based on the Knowledge-Attitude-Practice model, the survey assessed knowledge, attitudes, and behavior towards antibiotic use, including three vignettes designed to elicit possible antibiotic overuse: asymptomatic bacteriuria (ASB), a viral upper respiratory illness (URI), and a wound from a fall. RESULTS: Of 31 NH nurses and 66 community-dwelling older adults, 70% reported knowledge of the dangers of taking antibiotics. Nurses more often reported evidence-based attitudes towards antibiotics than older adults, except 39% agreed with the statement "by the time I am sick enough to go to the doctor with a cold, I expect an antibiotic", while only 28% of older adults agreed with it. A majority of nurses did not see the need for antibiotics in any of the three vignettes: 77% for the ASB vignette, 87% for the URI vignette, and 97% for the wound vignette. Among older adults, 50% did not perceive a need for antibiotics in the ASB vignette, 58% in the URI vignette, and 74% in the wound vignette. CONCLUSIONS: While a substantial minority had no knowledge of the dangers of antibiotic use, non-evidence-based attitudes towards antibiotics, and behaviors indicating inappropriate management of suspected infections, most NH nurses and community-dwelling older adults know the harms of antibiotic use and demonstrate evidence-based attitudes and behaviors. However, more work is needed to improve the knowledge, attitudes and behaviors that may contribute to antibiotic overuse.

Costs and benefits of transforming primary care practices: a qualitative study of North Carolina's Improving Performance in Practice.

Primary care organizations must transform care delivery to realize the Institute for Healthcare Improvement's Triple Aim of better healthcare, better health, and lower healthcare costs. However, few studies have considered the financial implications for primary care practices engaged in transformation. In this qualitative, comparative case study, we examine the practice-level personnel and nonpersonnel costs and the benefits involved in transformational change among 12 primary care practices participating in North Carolina's Improving Performance in Practice (IPIP) program. We found average annual opportunity costs of $21,550 ($6,659 per full-time equivalent provider) for maintaining core IPIP activities (e.g., data management, form development and maintenance, meeting attendance). This average represents the cost of a 50% full-time equivalent registered nurse or licensed practical nurse. Practices were able to limit transformation costs by scheduling meetings during relatively slow patient care periods and by leveraging resources such as the assistance of IPIP practice coaches. Still, the costs of practice transformation were not trivial and would have been much higher in the absence of these efforts. Benefits of transformation included opportunities for enhanced revenue through reimbursement incentives and practice growth, improved efficiency and care quality, and maintenance of certification. Given the potentially high costs for some practices, policy makers may need to consider reimbursement and other strategies to help primary care practices manage the costs of practice redesign.

Design and Rationale of the Outcomes Database to Prospectively Assess the Changing Therapy Landscape in Renal Cell Carcinoma Registry: A Multi-institutional, Prospective Study of Patients with Metastatic Renal Cell Carcinoma.

Introduction and hypotheses: The Outcomes Database to prospectivelY aSSEss the changing TherapY landscape in Renal Cell Carcinoma (ODYSSEY RCC) Registry is a large, nationally representative prospective registry of patients with metastatic renal cell carcinoma (mRCC) that aims to provide a real-world picture of longitudinal clinical management and patient experiences that impact clinical outcomes. The primary goal of this study is to understand the cancer management and health-related quality of life in patients with mRCC in routine real-world clinical practice in the USA. Design: This is an observational, phase 4 study with planned enrollment of up to 800 patients aged ≥19 yr with mRCC in the USA. Patients will be identified through electronic health record (EHR) data from the PCORnet network of sites for care received at collaborating sites. A unique aspect of the study is the multiple data sources that will be linked to the EHR data. These include: (1) Medicare claims data, (2) laboratory results, (3) tissue specimens, (4) radiographic images, and (5) patient-reported outcomes, physicians' treatment selection, and discontinuation surveys. Protocol overview: We created a novel data resource that can inform patient care. Investigators have the opportunity to use these to study novel research questions after submitting an ancillary proposal and upon approval of the executive committee. Limitations include the potential for selection bias, residual confounding, and missing information. Summary: The ODYSSEY Registry will provide an advanced data resource that can examine numerous clinical questions related to patient and physician choice, and support methodological research related to omics and artificial intelligence. Patient summary: Cancer medications and treatments are changing rapidly. Collecting data on real-world clinical practice and patient-answered questionnaires will help us better understand cancer management and health-related quality of life while receiving metastatic renal cell carcinoma-specific treatment.

Facilitators of transforming primary care: a look under the hood at practice leadership.

PURPOSE: This study examined how characteristics of practice leadership affect the change process in a statewide initiative to improve the quality of diabetes and asthma care. METHODS: We used a mixed methods approach, involving analyses of existing quality improvement data on 76 practices with at least 1 year of participation and focus groups with clinicians and staff in a 12-practice subsample. Existing data included monthly diabetes or asthma measures (clinical measures) and monthly practice implementation, leadership, and practice engagement scores rated by an external practice coach. RESULTS: Of the 76 practices, 51 focused on diabetes and 25 on asthma. In aggregate, 50% to 78% made improvements within in each clinical measure in the first year. The odds of making practice changes were greater for practices with higher leadership scores (odds ratios = 2.41-4.20). Among practices focused on diabetes, those with higher leadership scores had higher odds of performing nephropathy screening (odds ratio = 1.37, 95% CI, 1.08-1.74); no significant associations were seen for the intermediate outcome measures of hemoglobin A1c, blood pressure, and cholesterol. Focus groups revealed the importance of a leader, typically a physician, who believed in the transformation work (ie, a visionary leader) and promoted practice engagement through education and cross-training. Practices with greater change implementation also mentioned the importance of a midlevel operational leader who helped to create and sustain practice changes. This person communicated and interacted well with, and was respected by both clinicians and staff. CONCLUSIONS: In the presence of a vision for transformation, operational leaders within practices can facilitate practice changes that are associated with clinical improvement.

Identifying Opportunities for Impact of Community-Based Pharmacist-Led Biometric Health Screenings on ASCVD Risk.

Introduction: Community-based pharmacists are positioned uniquely to assist in the early detection of underlying cardiovascular disease (CVD) which affects approximately 50% of adults in the United States. Organizations utilize community-based pharmacists to conduct annual biometric health screenings to help employees identify health risks previously undetected. The goal of this study was to evaluate how community-based pharmacists could impact lifetime atherosclerotic cardiovascular disease (ASCVD) risk for a large population. Methods: This study was a retrospective analysis of annual pharmacist-led 15-minute biometric health screening data from a large regional community-based pharmacy chain. Employees between the ages of 20 and 79 who had completed at least three biometric health screenings between July 1, 2015 and June 30, 2020 were included. Incomplete biometric health screening records were excluded. To calculate lifetime ASCVD risk and identify perceived gaps in care, prescription fill history of study participants was used. The pharmacists did not make clinical interventions; however, education was provided with the information found. Results: A total of 10,001 patients were included. Median baseline ASCVD risk was 1.5% and increased to 1.8% (p < 0.001). Additionally, 1,187 patients with an elevated ASCVD risk ≥ 7.5%, showed statistically significant improvements in blood pressure, body mass index, and cholesterol. Conclusions: Improvements for high-risk patients were seen in several biometric health screening parameters including blood pressure, body mass index, and cholesterol. Community-based pharmacists were well positioned to intervene clinically to support reduction of ASCVD life-time risk.

Improving Advance Care Planning Documentation Using Reminders to Patients and Physicians: A Longitudinal Study in Primary Care.

OBJECTIVE: Documenting advance care planning (ACP) in primary care requires multiple triggers. New Medicare codes make it easier for providers to bill for these encounters. This study examines the use of patient and provider reminders to trigger advance care planning discussions in a primary care practice. Secondary outcome was billing of new ACP billing codes. METHODS: Patients 75 years and older scheduled for a primary care appointment were screened for recent ACP documentation in their chart. If none was found, an electronic or mail message was sent to the patient, and an electronic message to their provider, about the need to have discussion at the upcoming visit. Chart review was performed 3 months after the visit to determine if new ACP discussion was documented in the chart. RESULTS: In the 3 months after the reminder had been sent to patients and providers, new ACP documentation or billing was found in 28.8% of the patients. Most new documentation was health care decision maker (75.6% of new documentation) with new DNR orders placed for 32.3% of these patients. The new Medicare billing code was filled 10 times (7.8%). CONCLUSION: Reminders sent to both patients and providers can increase documentation of ACP during primary care visits, but rarely triggers a full ACP conversation.

Impact of COVID-19 on Structure and Function of Program of All-Inclusive Care for the Elderly (PACE) Sites in North Carolina.

OBJECTIVES: The novel coronavirus disease 2019 (COVID-19) deeply affected all forms of long-term care for older adults, highlighting infection control issues, provider and staff shortages, and other challenges. As a comparatively new, community-based long-term care option, the Program of All-Inclusive Care for the Elderly (PACE) faced unique challenges. This project investigated the impact of COVID-19 on operations in all PACE programs in one US state. DESIGN: Qualitative study. SETTING AND PARTICIPANTS: Structured interviews with administrators of all 12 PACE programs in North Carolina. METHODS: Interviews were conducted December 2020 to January 2021 by trained interviewers over Zoom; they were transcribed, coded, and qualitatively analyzed using thematic analysis. RESULTS: Reported COVID-19 infection rates among PACE participants for 2020 averaged 12.3 cases, 4.6 hospitalizations, and 1.9 deaths per 100 enrollees. Six themes emerged from analyses: new, unprecedented administrative challenges; insufficient access to and integration with other health care providers; reevaluation of the core PACE model, resulting in a transition to home-based care; reorientation to be more family-focused in care provision; implementation of new, creative strategies to address participant and family psychological and social well-being in the home; and major reconfiguration of staffing, including transitions to new and different roles and a concomitant effort to provide support and relief to staff. CONCLUSIONS AND IMPLICATIONS: While facing many challenges that required major changes in care provision, PACE was successful in mounting a COVID-19 response that upheld safety, promoted the physical and mental well-being of participants, and responded to the needs of family caregivers. Administrators felt that, after the pandemic, the PACE service model is likely to remain more home-based and less reliant on the day center than in the past. As a result, PACE may have changed for the better and be well-positioned to play an expanded role in our evolving long-term care system.

Overdiagnosis of urinary tract infections by nursing home clinicians versus a clinical guideline.

PURPOSE: To inform overprescribing and antibiotic stewardship in nursing homes (NHs), we examined the concordance between clinicians' (NH primary care providers and registered nurses) diagnosis of suspected UTI with a clinical guideline treated as the gold standard, and whether clinician characteristics were associated with diagnostic classification. METHODS: We conducted a cross-sectional web-based survey of a U.S. national convenience sample of NH clinicians. The survey included a discrete choice experiment with 19 randomly selected clinical scenarios of NH residents with possible UTIs. For each scenario, participants were asked if they thought a UTI was likely. Responses were compared to the guideline to determine the sensitivity and specificity of clinician judgment and performance indicators. Multivariable logistic mixed effects regression analysis of demographic, work, personality, and UTI knowledge/attitudes characteristics was conducted. RESULTS: One thousand seven hundred forty-eight NH clinicians responded to 33,212 discrete choice scenarios; 867 (50%) were NH primary care providers and 881 (50%) were NH registered nurses, 39% were male, and the mean age was 45 years. Participants were uncertain about diagnosis in 30% of scenarios. Correct classification occurred for 66% of all scenarios (providers: 70%; nurses: 62%). Respondent judgment had a sensitivity of 78% (providers: 81%; nurses: 74%) and specificity of 54% (providers: 59%; nurses: 49%) compared to the clinical guideline. Adjusting for covariates in multivariable models, being a nurse and having higher closemindedness were associated higher odds of false positive UTI (odds ratio [OR] 1.61, p < 0.001; and OR 1.09, p = 0.039, respectively), although higher UTI knowledge and conscientiousness were associated with lower odds of false positive UTI ratings (OR 0.80, p < 0.001; OR 0.90, p = 0.005, respectively). CONCLUSIONS: Clinicians tend to over-diagnose urinary tract infections, necessitating systems-based interventions to augment clinical decision-making. Clinician type, UTI knowledge, and personality traits may also influence behavior and deserve further study.

The Imperative to Reimagine Assisted Living.

Assisted living (AL) has existed in the United States for decades, evolving in response to older adults' need for supportive care and distaste for nursing homes and older models of congregate care. AL is state-regulated, provides at least 2 meals a day, around-the-clock supervision, and help with personal care, but is not licensed as a nursing home. The key constructs of AL as originally conceived were to provide person-centered care and promote quality of life through supportive and responsive services to meet scheduled and unscheduled needs for assistance, an operating philosophy emphasizing resident choice, and a residential environment with homelike features. As AL has expanded to constitute half of all long-term care beds, the increasing involvement of the real estate, hospitality, and health care sectors has raised concerns about the variability of AL, the quality of AL, and standards for AL. Although the intent to promote person-centered care and quality of life has remained, those key constructs have become mired under tensions related to models of AL, regulation, financing, resident acuity, and the workforce. These tensions have resulted in a model of care that is not as intended, and which must be reimagined if it is to be an affordable care option truly providing quality, person-centered care in a suitable environment. Toward that end, 25 stakeholders representing diverse perspectives conferred during 2 half-day retreats to identify the key tensions in AL and discuss potential solutions. This article presents the background regarding those tensions, as well as potential solutions that have been borne out, paving the path to a better future of assisted living.

Mouth Care in Assisted Living: Potential Areas for Improvement.

BACKGROUND: Poor oral care may lead to systemic disease, and there is evidence that assisted living (AL) residents lack quality oral care; in AL, poor care may be due to staff knowledge and attitudes, as well as organizational barriers to providing care. OBJECTIVES: Determine AL staff knowledge and attitudes regarding mouth care and barriers to changing care. DESIGN: Self-administered repeated-measures questionnaires completed before and after oral care training. SETTING AND PARTICIPANTS: A total of 2012 direct care staff and administrators from 180 AL communities. METHODS: Nine knowledge questions and 8 attitude and practice intention questions, and open-ended questions regarding training and obstacles to providing oral care. RESULTS: Overall, 2012 participants completed pretraining questionnaires, and 1977 completed posttraining questionnaires. Baseline knowledge was high, but staff were not uniformly aware of the systemic-oral link whereby mouth care affects pneumonia and diabetes. Almost all staff reported learning a new technique (96%), including for residents who resist care (95%). Suggested areas to improve mouth care included having more hands-on experience. The primary perceived obstacles to care centered around residents who resist care and a lack of time. CONCLUSIONS AND IMPLICATIONS: Based on reports of having benefitted from training, AL staff overwhelmingly noted that new knowledge was helpful, suggesting the benefit of skills-based training, especially in dementia care. Mouth care in AL has been sorely understudied, and merits additional attention.

Nurse Decision-making for Suspected Urinary Tract Infections in Nursing Homes: Potential Targets to Reduce Antibiotic Overuse.

OBJECTIVES: To determine what information is most important to registered nurses' (RNs) decisions to call clinicians about suspected urinary tract infections (UTIs) in nursing home residents. DESIGN: Web-based discrete choice experiment with 19 clinical scenarios. SETTING AND PARTICIPANTS: Online survey with a convenience sample of RNs (N = 881) recruited from a health care research panel. METHODS: Clinical scenarios used information from 10 categories of resident characteristics: UTI risk, resident type, functional status, mental status, lower urinary tract status, body temperature, physical examination, urinalysis, antibiotic request, and goals of care. Participants were randomized into 2 deliberation conditions (self-paced, n = 437 and forced deliberation, n = 444). The degree to which evidence- and non-evidence-based information was important to decision-making was estimated using unconditional multinomial logistic regression. RESULTS: For all nurses (22.8%) and the self-paced group (24.1%), lower urinary tract status had the highest importance scores for the decision to call a clinician about a suspected UTI. For the forced-deliberation group, body temperature was most important (23.7%), and lower urinary tract status was less important (21%, P = .001). The information associated with the highest odds of an RN calling about a suspected UTI was painful or difficult urination [odds ratio (OR) 4.85, 95% confidence interval (CI) 4.16-5.65], obvious blood in urine (OR 4.66, 95% CI 3.99-5.44), and temperature at 101.5° (OR 3.80, 95% CI 3.28-4.42). For the self-paced group, painful or difficult urination (OR 5.65, 95% CI 4.53-7.04) had the highest odds, whereas obvious blood in urine (OR 4.39, 95% CI 3.53-5.47) had highest odds for the forced-deliberation group. CONCLUSIONS AND IMPLICATIONS: This study highlighted the importance of specific resident characteristics in nurse decision-making about suspected UTIs. Future antimicrobial stewardship efforts should aim to not only improve the previously studied overprescribing practices of clinicians, but to improve nurses' assessment of signs and symptoms of potential infections and how they weigh resident information.

Measuring Self-Efficacy and Attitudes for Providing Mouth Care in Nursing Homes.

OBJECTIVES: Mouth care is increasingly recognized as an important component of care in nursing homes (NHs), yet is known to be deficient. To promote quality improvement and inform research efforts, it is necessary to have valid measures of staff self-efficacy and attitudes to provide mouth care. DESIGN: A self-administered questionnaire completed by NH staff, information about the NH obtained from the administrator, and oral hygiene assessments of NH residents. SETTING AND PARTICIPANTS: A total of 434 staff in 14 NHs in North Carolina who were participating in a cluster randomized pragmatic trial of Mouth Care Without a Battle (MCWB). METHODS: Staff in MCWB homes completed the questionnaire at baseline; staff in control homes completed it at 2-year follow-up. The 35-item questionnaire used new items and those from previous measures, many of which were modified for the NH setting. Factorial, construct, and criterion validity were assessed. RESULTS: Exploratory factor analysis identified a 3-factor 11-item self-efficacy scale (promoting oral hygiene, providing mouth care, obtaining cooperation) named "Self-Efficacy for Providing Mouth Care" (SE-PMC), and a 2-factor 11-item attitudes scale (care of residents' teeth, care of own teeth), named Attitudes for Providing Mouth Care (A-PMC). Scores varied significantly across NHs and differentiated them based on profit status, age, and, for the A-PMC, NH size. Scores also differentiated among staff based on age and, for the SE-PMC, years of experience. In NHs where staff scored more highly, residents featured better oral hygiene (P < .001). CONCLUSIONS AND IMPLICATIONS: The SE-PMC and A-PMC are valid, parsimonious, and useful measures for quality improvement and research to improve mouth care in NHs that can be used jointly or individually. Preliminary evidence suggests that these scales may be associated with resident-level plaque and gingival hygiene, making them useful tools to assess promotion of mouth care.

Which Nursing Home Residents With Pneumonia Are Managed On-Site and Which Are Hospitalized? Results from 2 Years' Surveillance in 14 US Homes.

OBJECTIVES: Pneumonia is a frequent cause of hospitalization among nursing home (NH) residents, but little information is available as to how clinical presentation and other characteristics relate to hospitalization, and the differential use of antimicrobials based on hospitalization status. This study examined how hospitalized and nonhospitalized NH residents with pneumonia differ. DESIGN: Data from a 2-year prospective study of residents who participated in a randomized controlled trial. SETTING AND PARTICIPANTS: All residents from 14 NHs in North Carolina followed for pneumonia over a 2-year period. METHODS: Clinical features, antimicrobial treatment, hospitalization, and demographic data on residents with a pneumonia diagnosis were abstracted from charts; NH information was obtained from NH administrators. RESULTS: A total of 509 pneumonia episodes were reported for 395 unique residents; the incidence was not higher in the winter months, and 28% were hospitalized. The likelihood of hospitalization did not differ by clinical characteristics except that residents with a respiratory rate >25 breaths per minute were more likely to be hospitalized. Being on hospice [odds ratio (OR) 3.3, 95% confidence interval (CI) 1.5-7.4] and not having dementia (OR 1.9, 95% CI 1.1-3.2) also related to increased likelihood of hospitalization. Fluoroquinolone (usually levofloxacin) monotherapy was the most common treatment (54%) in both settings, and ceftriaxone monotherapy varied by hospitalization status (7% of hospitalized vs 16% treated on-site). Approximately 36% of nonhospitalized residents received antimicrobials for more than 7 days. CONCLUSIONS/IMPLICATIONS: Respiratory rate is associated with hospitalization but was not documented for more than a quarter of residents, suggesting the clinical benefit of more consistently conducting this assessment. Differential hospitalization rates for persons with dementia and on hospice suggest that care is being tailored to individuals' wishes, but this assumption merits study, as does use of fluoroquinolones (due to side effects) and treatment duration (due to potential contribution to antibiotic resistance).