Reducing Fluoroquinolone Use and Clostridioides difficile Infections in Community Nursing Homes Through Hospital-Nursing Home Collaboration.

OBJECTIVE: Nursing homes (NHs) are an important target for antibiotic stewardship (AS). We describe a collaborative model to reduce Clostridioides difficile infections (CDIs) in NHs through optimization of antibiotic use including a reduction in high-risk antibiotics such as fluoroquinolones. DESIGN: Quasi-experimental, pre- and post-intervention study. SETTING AND PARTICIPANTS: Six NHs in Monroe County, NY. METHODS: A hospital-based AS expert team assisted NHs in identifying targets for improving antibiotic use. Interventions included (1) collaboration with a medical director advisory group to develop NH consensus guidelines for testing and treatment of 2 syndromes (urinary tract infections and pneumonia) for which fluoroquinolone use is common, (2) provision of multifaceted NH staff education on these guidelines and education of residents and family members on the judicious use of antibiotics, and (3) sharing facility-specific and comparative antibiotic and CDI data. We used Poisson regression to estimate antibiotic use per 1000 resident days (RD) and CDIs per 10,000 RD, pre- and post-intervention. Segmented regression analysis was used to estimate changes in fluoroquinolone and total antibiotic rates over time. RESULTS: Postintervention, the monthly rate of fluoroquinolone days of therapy (DOT) per 1000 RD significantly decreased by 39% [rate ratio (RR) 0.61, 95% confidence interval (CI) 0.59-0.62, P < .001] across all NHs and the total antibiotic DOT decreased by 9% (RR 0.91, 95% CI 0.90-0.92, P < .001). Interrupted time series analysis of fluoroquinolone and total DOT rates confirmed these changes. The quarterly CDI rate decreased by 18% (RR 0.82, 95% CI 0.68-0.99, P = .042). CONCLUSIONS AND IMPLICATIONS: A hospital-NH partnership with a medical director advisory group achieved a significant reduction in total antibiotic and fluoroquinolone use and contributed to a reduction in CDI incidence. This approach offers one way for NHs to gain access to AS expertise and resources and to standardize practices within the local community.

An Evidence-Based Review of Elevated Blood Pressure for the Inpatient.

Elevated blood pressure is common in patients who are hospitalized. There are no guidelines and few recommendations to help inpatient providers manage patients with elevated blood pressure. There are no normal reported values for blood pressure in the inpatient and recording circumstances often widely vary. Many factors may influence blood pressure such as pain, anxiety, malaise, nicotine withdrawal, or withholding home medications. This review of available literature suggests potential harm and little to no potential benefit in treating asymptomatic patients with elevated blood pressure. This review also found no evidence that asymptomatic elevated blood pressure progresses to lead to end-organ damage. However, there are clear instances of hypertensive emergency where treatment is indicated. Conscientious adjustment of an anti-hypertensive regimen should be undertaken during episode of elevated blood pressure associated with end-organ damage.

Frailty and Short-Term Outcomes in Patients With Hip Fracture.

OBJECTIVES: To assess the prevalence of frailty and its ability to predict short-term outcomes in older patients with hip fracture. DESIGN: Prospective cohort study. SETTING: University-affiliated community hospital. PARTICIPANTS: Thirty-five patients aged ≥65 treated with hip fracture. MEASUREMENTS: Frailty was assessed using the 5 criteria of the Fried Frailty Index, modified for a post-fracture population. Cognitive impairment was assessed with the Montreal Cognitive Assessment (MoCA). The primary outcome was overall hospital complication rate. Secondary outcomes were length of stay (LOS) and specific complications. Differences between the frail and the non-frail were identified using chi-square analysis and analysis of variance (ANOVA) for categorical and continuous variables, respectively. RESULTS: Eighteen (51%) participants were frail. Seventeen (49%) had ≥1 hospital complication. Twelve (67%) frail patients versus 5 (29%) non-frail patients had a complication (P = .028). Mean LOS was longer in patients with frailty (7.3 ± 5.9 vs 4.1 ± 1.2 days, P = .038). Most were frail for the weakness criterion (94%), and few were frail for the physical activity criterion (9%). Excluding these criteria, we developed a 3-criteria frailty index (shrinking, exhaustion, and slowness) that identified an increased risk of complications (64.7% vs 33.3%, P = .061) and LOS (7.4 ± 6.1 vs 4.2 ± 1.3 days, P = .040) in participants with frailty. Among non-frail participants with a high MoCA score of ≥20 (n = 12), 2 (17%) had complications compared to 10 (71%) frail participants with a low MoCA score (n = 14). CONCLUSION: Frailty is common in older patients with hip fracture and associated with increased LOS and postoperative complications. A low MoCA score, a hypothesized marker of more advanced cognitive frailty, may further increase risk. Frailty assessment has a role in prognostic discussion and care planning. The 3-criteria frailty index is an easily used tool with potential application in clinical practice.

Preoperative optimization and risk assessment.

Because most older adults with hip fractures require urgent surgical intervention, the preoperative medical evaluation focuses on the exclusion of the small number of contraindications to surgery, and rapid optimization of patients for operative repair. Although many geriatric fracture patients have significant chronic medical comorbidities, most patients can be safely stabilized for surgery with medical and orthopedic comanagement by anticipating a small number of common physiologic responses and perioperative complications. In addition to estimating perioperative risk, the team should focus on intravascular volume restoration, pain control, and avoidance of perioperative hypotension.

Management of postoperative complications: cardiovascular disease and volume management.

Postoperative cardiovascular complications are common, predictable, and typically treatable in geriatric patients who have sustained fractures. Although intervention-specific data are sparse, observational evidence from high-performing geriatric fracture centers coupled with an understanding of geriatric principles can serve as a basis for treatment guidelines. Many patients can be safely and effectively managed with close attention to intravascular volume status, heart rate control, and minimization of other physiologic stresses, including pain and delirium. Many chronic cardiovascular therapies may be harmful in the immediate postoperative period, and can usually be safely omitted or attenuated until hemodynamic stability and mobility have been restored.

Case discussion: hip fracture in a patient on hospice with dementia and anemia.

This case presents a discussion of a frail 98-year-old woman in hospice care, with a history of dementia, previous hip fracture, and anemia, who is admitted with a left intertrochanteric fracture. Care is coordinated and expedited by an interdisciplinary team to optimize her outcome, in the context of her goals of care.

Screening and preventive services for older adults.

Federal, professional, and academic efforts are converging to address the preventive care needs of older Americans. Medicare is placing an increased emphasis on preventive care services for older adults. With the passage of the Patient Protection and Affordable Care Act, access to preventive services has been enhanced by reducing out-of-pocket costs for older adults and increasing reimbursement to healthcare providers. In 2010-11, newly revised guidelines for screening and preventive services have been issued by the US Preventive Services Task Force and the Centers for Disease Control and Prevention. In addition to these guidelines and the landmark changes in Medicare coverage, there are significant new attempts to modify national screening recommendations based on age and expected risk/benefit for older adults. These population-specific guidelines with new emphasis on functional status and multiple risk factor reduction are of increasing importance to an aging population, where more conventional disease-focused guidelines are less suitable for maintaining physical function and quality of life. Evidence-based measures of physical performance appropriate for primary-care office use are being developed and piloted. As a result of these policies, guidelines, and tools, we have the ability to offer older adults more comprehensive, cost-effective screening and preventive measures than in any other previous time. Mt Sinai J Med 78:498-508, 2011. © 2011 Mount Sinai School of Medicine.