Emergency hospitalizations for adverse drug events in older Americans.

BACKGROUND: Adverse drug events are important preventable causes of hospitalization in older adults. However, nationally representative data on adverse drug events that result in hospitalization in this population have been limited. METHODS: We used adverse-event data from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project (2007 through 2009) to estimate the frequency and rates of hospitalization after emergency department visits for adverse drug events in older adults and to assess the contribution of specific medications, including those identified as high-risk or potentially inappropriate by national quality measures. RESULTS: On the basis of 5077 cases identified in our sample, there were an estimated 99,628 emergency hospitalizations (95% confidence interval [CI], 55,531 to 143,724) for adverse drug events in U.S. adults 65 years of age or older each year from 2007 through 2009. Nearly half of these hospitalizations were among adults 80 years of age or older (48.1%; 95% CI, 44.6 to 51.6). Nearly two thirds of hospitalizations were due to unintentional overdoses (65.7%; 95% CI, 60.1 to 71.3). Four medications or medication classes were implicated alone or in combination in 67.0% (95% CI, 60.0 to 74.1) of hospitalizations: warfarin (33.3%), insulins (13.9%), oral antiplatelet agents (13.3%), and oral hypoglycemic agents (10.7%). High-risk medications were implicated in only 1.2% (95% CI, 0.7 to 1.7) of hospitalizations. CONCLUSIONS: Most emergency hospitalizations for recognized adverse drug events in older adults resulted from a few commonly used medications, and relatively few resulted from medications typically designated as high-risk or inappropriate. Improved management of antithrombotic and antidiabetic drugs has the potential to reduce hospitalizations for adverse drug events in older adults.

Clinical preventive services for older adults: the interface between personal health care and public health services.

Healthy aging must become a priority objective for both population and personal health services, and will require innovative prevention programming to span those systems. Uptake of essential clinical preventive services is currently suboptimal among adults, owing to a number of system- and office-based care barriers. To achieve maximum health results, prevention must be integrated across community and clinical settings. Many preventive services are portable, deliverable in either clinical or community settings. Capitalizing on that flexibility can improve uptake and health outcomes. Significant reductions in health disparities, mortality, and morbidity, along with decreases in health spending, are achievable through improved collaboration and synergy between population health and personal health systems.

Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future).

ABSTRACT: The explicit declaration in the landmark 1999 Institute of Medicine report "To Err Is Human" that, in the United States, 44,000 to 98,000 patients die each year as a consequence of "medical errors" gave widespread validation to the magnitude of the patient safety problem and catalyzed a number of U.S. federal government programs to measure and improve the safety of the national healthcare system. After more than 10 years, one of those federal programs, the Medicare Patient Safety Monitoring System (MPSMS), has reached a level of maturity and stability that has made it useful for the consistent measurement of the safety of inpatient care. The MPSMS is a chart review-based national patient safety surveillance system that provides rates of 21 specific hospital inpatient adverse event measures, which have been divided into 4 clinical domains (general, hospital-acquired infections, postprocedure adverse events, and adverse drug events) for analysis. The 2014 MPSMS national sample was drawn from 1109 hospitals and includes approximately 20,000 medical records of patients admitted to the hospital (all payors) for at least 1 of the 4 conditions of congestive heart failure, acute myocardial infarction, pneumonia, and major surgical procedures as defined by the Centers for Medicare and Medicaid Services Surgical Care Improvement Project. The MPSMS is now going through a major transformation to capture additional types of adverse events and is being redeveloped as the Quality and Safety Review System (QSRS). As an example of this transformation, QSRS will electronically import electronic data, which are standardized according to the Centers for Medicare and Medicaid Services billing definitions and will be updated and evolve over time to incorporate expanded standardized data available from electronic health records. This article reviews the development of MPSMS, the strengths and limitations of MPSMS, and expected future directions in patient safety measurement, focusing on those issues that are informing the development and implementation of QSRS.

Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America.

Residents of long-term care facilities (LTCFs) are at great risk for infection. Most residents are older and have multiple comorbidities that complicate recognition of infection; for example, typically defined fever is absent in more than one-half of LTCF residents with serious infection. Furthermore, LTCFs often do not have the on-site equipment or personnel to evaluate suspected infection in the fashion typically performed in acute care hospitals. In recognition of the differences between LTCFs and hospitals with regard to hosts and resources present, the Infectious Diseases Society of America first provided guidelines for evaluation of fever and infection in LTCF residents in 2000. The guideline presented here represents the second edition, updated by data generated over the intervening 8 years. It focuses on the typical elderly person institutionalized with multiple chronic comorbidities and functional disabilities (e.g., a nursing home resident). Specific topic reviews and recommendations are provided with regard to what resources are typically available to evaluate suspected infection, what symptoms and signs suggest infection in a resident of an LTCF, who should initially evaluate the resident with suspected infection, what clinical evaluation should be performed, how LTCF staff can effectively communicate about possible infection with clinicians, and what laboratory tests should be ordered. Finally, a general outline of how a suspected outbreak of a specific infectious disease should be investigated in an LTCF is provided.

Identification of hospital-acquired catheter-associated urinary tract infections from Medicare claims: sensitivity and positive predictive value.

BACKGROUND AND OBJECTIVE: Hospital-acquired catheter-associated urinary tract infection (CAUTI) is one of the first 6 conditions Medicare is targeting to reduce payment associated with hospital-acquired conditions under Congressional mandate. This study was to determine the positive predictive value (PPV) and sensitivity in identifying patients in Medicare claims who had urinary catheterization and who had hospital-acquired CAUTIs. RESEARCH DESIGN: CAUTIs identified by ICD-9-CM codes in Medicare claims were compared with those revealed by medical record abstraction in random samples of Medicare discharges in 2005 to 2006. Hospital discharge abstracts (2005) from the states of New York and California were used to estimate the potential impact of a present-on-admission (POA) indicator on PPV. RESULTS: ICD-9-CM procedure codes for urinary catheterization appeared in only 1.4% of Medicare claims for patients who had urinary catheters. As a proxy, claims with major surgery had a PPV of 75% and sensitivity of 48%, and claims with any surgical procedure had a PPV of 53% and sensitivity of 79% in identifying urinary catheterization. The PPV and sensitivity for identifying hospital-acquired CAUTIs varied, with the PPV at 30% and sensitivity at 65% in claims with major surgery. About 80% of the secondary diagnosis codes indicating UTIs were flagged as POA, suggesting that the addition of POA indicators in Medicare claims would increase PPV up to 86% and sensitivity up to 79% in identifying hospital-acquired CAUTIs. CONCLUSIONS: The validity in identifying urinary catheter use and CAUTIs from Medicare claims is limited, but will be increased substantially upon addition of a POA indicator.

Importance of bacterial burden among methicillin-resistant Staphylococcus aureus carriers in a long-term care facility.

OBJECTIVE: To evaluate the prevalence and transmission of methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization, as well as risk factors associated with MRSA carriage, among residents of a long-term care facility (LTCF). DESIGN: Prospective, longitudinal cohort study. SETTING: A 100-bed Veterans Administration LTCF. PARTICIPANTS: All current and newly admitted residents of the LTCF during an 8-week study period. METHODS: Nasal swab samples were obtained weekly and cultured on MRSA-selective media, and the cultures were graded for growth on a semiquantitative scale from 0 (no growth) to 6 (heavy growth). Epidemiologic data for the periods before and during the study were collected to assess risk factors for MRSA carriage. RESULTS: Of 83 LTCF residents, 49 (59%) had 1 or more nasal swab cultures that were positive for MRSA; 34 (41%) were consistently culture-negative (designated "noncarriers"). Of the 49 culture-positive residents, 30 (36% of the total of 83 residents) had all cultures positive for MRSA (designated "persistent carriers"), and 19 (23% of the 83 residents) had at least 1 culture, but not all cultures, positive for MRSA (designated "intermittent carriers"). Multivariate analysis showed that participants with at least 1 nasal swab culture positive for MRSA were likely to have had previous hospitalization (odds ratio, 3.9) or wounds (odds ratio, 8.2). Persistent carriers and intermittent carriers did not differ in epidemiologic characteristics but did differ in mean MRSA growth score (3.7 vs 0.7; P<.001). CONCLUSIONS: Epidemiologic characteristics differed between noncarriers and subjects with at least 1 nasal swab culture positive for MRSA. However, in this LTCF population, only the degree of bacterial colonization (as reflected by mean MRSA growth score) distinguished persistent carriers from intermittent carriers. Understanding the burden of colonization may be important when determining future surveillance and control strategies.

Medication use leading to emergency department visits for adverse drug events in older adults.

BACKGROUND: The Beers criteria identify inappropriate use of medications in older adults. The number of and risk for adverse events from these medications are unknown. OBJECTIVE: To estimate the number of and risk for emergency department visits for adverse events involving Beers criteria medications compared with other medications. DESIGN: Nationally representative, public health surveillance of adverse drug events and a cross-sectional survey of outpatient medical visits. SETTING: National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance System, 2004-2005; National Ambulatory Medical Care Survey, 2004; and National Hospital Ambulatory Medical Care Survey, 2004. PARTICIPANTS: Persons 65 years of age or older seeking emergency department and outpatient care. MEASUREMENTS: Estimated number of and risks for emergency department visits for adverse drug events involving Beers criteria medications and other medications. RESULTS: Among U.S. patients 65 years of age or older, an estimated 177,504 emergency department visits (95% CI, 100,155 to 254,854 visits) for adverse drug events occurred both years. An estimated 3.6% (CI, 2.8% to 4.5%) of these visits were for adverse events medications considered to be always potentially inappropriate, according to the Beers criteria, and 33.3% (CI, 27.8% to 38.7%) of visits were for adverse events from 3 other medications (warfarin [17.3%], insulin [13.0%], and digoxin [3.2%]). Accounting for outpatient prescription frequency, the risk for emergency department visits for adverse events due to these 3 medications was 35 times (CI, 9.6 to 61) greater than that for medications considered to be always potentially inappropriate. LIMITATION: Adverse events were identified only in emergency departments. CONCLUSION: Compared with other medications, Beers criteria medications caused low numbers of and few risks for emergency department visits for adverse events. Performance measures and interventions targeting warfarin, insulin, and digoxin use could prevent more emergency department visits for adverse events.

Collection of Data on Race, Ethnicity, Language, and Nativity by US Public Health Surveillance and Monitoring Systems: Gaps and Opportunities.

OBJECTIVE: Despite increasing diversity in the US population, substantial gaps in collecting data on race, ethnicity, primary language, and nativity indicators persist in public health surveillance and monitoring systems. In addition, few systems provide questionnaires in foreign languages for inclusion of non-English speakers. We assessed (1) the extent of data collected on race, ethnicity, primary language, and nativity indicators (ie, place of birth, immigration status, and years in the United States) and (2) the use of data-collection instruments in non-English languages among Centers for Disease Control and Prevention (CDC)-supported public health surveillance and monitoring systems in the United States. METHODS: We identified CDC-supported surveillance and health monitoring systems in place from 2010 through 2013 by searching CDC websites and other federal websites. For each system, we assessed its website, documentation, and publications for evidence of the variables of interest and use of data-collection instruments in non-English languages. We requested missing information from CDC program officials, as needed. RESULTS: Of 125 data systems, 100 (80%) collected data on race and ethnicity, 2 more collected data on ethnicity but not race, 26 (21%) collected data on racial/ethnic subcategories, 40 (32%) collected data on place of birth, 21 (17%) collected data on years in the United States, 14 (11%) collected data on immigration status, 13 (10%) collected data on primary language, and 29 (23%) used non-English data-collection instruments. Population-based surveys and disease registries more often collected data on detailed variables than did case-based, administrative, and multiple-source systems. CONCLUSIONS: More complete and accurate data on race, ethnicity, primary language, and nativity can improve the quality, representativeness, and usefulness of public health surveillance and monitoring systems to plan and evaluate targeted public health interventions to eliminate health disparities.

Group a streptococcal disease in long-term care facilities: descriptive epidemiology and potential control measures.

Group A streptococci (GAS) are an important cause of severe, life-threatening illness among the elderly population, particularly those individuals residing in long-term care facilities (LTCFs). Outbreaks of GAS infection are potentially devastating in this vulnerable population and often require large-scale control efforts involving LTCF staff, public health officials, and infectious diseases practitioners. Although multiple outbreaks of GAS infection in LTCFs have been described in the medical literature, this topic has not been reviewed for 15 years, and there is a need for updated guidance on how to approach GAS infection outbreak control. We reviewed published documents on GAS infection in LTCFs to describe the current understanding of the disease's epidemiology in this setting, identify techniques for outbreak investigation and prevention, and expose areas where additional research is needed. We highlight well-accepted prevention and control strategies that can be employed during investigation and control of GAS infection outbreaks in LTCFs.

Estimating health care-associated infections and deaths in U.S. hospitals, 2002.

OBJECTIVE: The purpose of this study was to provide a national estimate of the number of healthcare-associated infections (HAI) and deaths in United States hospitals. METHODS: No single source of nationally representative data on HAIs is currently available. The authors used a multi-step approach and three data sources. The main source of data was the National Nosocomial Infections Surveillance (NNIS) system, data from 1990-2002, conducted by the Centers for Disease Control and Prevention. Data from the National Hospital Discharge Survey (for 2002) and the American Hospital Association Survey (for 2000) were used to supplement NNIS data. The percentage of patients with an HAI whose death was determined to be caused or associated with the HAI from NNIS data was used to estimate the number of deaths. RESULTS: In 2002, the estimated number of HAIs in U.S. hospitals, adjusted to include federal facilities, was approximately 1.7 million: 33,269 HAIs among newborns in high-risk nurseries, 19,059 among newborns in well-baby nurseries, 417,946 among adults and children in ICUs, and 1,266,851 among adults and children outside of ICUs. The estimated deaths associated with HAIs in U.S. hospitals were 98,987: of these, 35,967 were for pneumonia, 30,665 for bloodstream infections, 13,088 for urinary tract infections, 8,205 for surgical site infections, and 11,062 for infections of other sites. CONCLUSION: HAIs in hospitals are a significant cause of morbidity and mortality in the United States. The method described for estimating the number of HAIs makes the best use of existing data at the national level.

Infection surveillance and control programs in the Department of Veterans Affairs nursing home care units: a preliminary assessment.

A survey was conducted to assess the capacity and current practices of the infection surveillance and control programs at the Department of Veterans Affairs' 130 nursing home care units (VA NHCUs) covering a total of 15,006 beds in 2003. All 130 VA NHCUs responded to the survey, although not all NHCUs answered every question. The majority of the VA NHCUs provided specialized services that might pose increased risks of infection. For every 8 to 10 VA NHCU beds, there was 1 regular-pressure or negative-pressure infection control room available. Each VA NHCU had an active ongoing infection surveillance and control program managed by highly educated infection control personnel (ICP), of which 96% had a minimum of a bachelor degree. A median of 12 hours per week of these ICP efforts was devoted to the infection surveillance and control activities. The most frequently used surveillance methods were targeted surveillance for specific infections and for specific organisms. Most VA NHCUs conducted surveillance for antibiotic-resistant organisms. However, VA NHCUs did not use a uniform set of definitions for nosocomial infections for their infection surveillance and control purposes. We conclude that VA NHCUs have a considerable infrastructure and capacity for infection surveillance and control. This information can be used to develop a nationwide VA NHCU nosocomial infection surveillance system.

Preventing antimicrobial-resistant bacterial infections among older adults in long-term care facilities.

For older adults in long-term care facilities (LTCFs), the rate of infections caused by antimicrobial resistant strains of bacteria has increased and is prompting renewed interest in investing health care resources for prevention and control of these pathogens. This document offers a simple framework to combat infections due to antimicrobial resistant bacteria in LTCF residents by providing a multi-step approach consisting of four major strategies: prevent infection, diagnose and treat infection effectively, use antimicrobials wisely, and prevent transmission. Recommendations from this multi-step approach are directed at LTCF medical directors and practicing clinicians involved with the medical care of older adult LTCF residents.

Monitoring health care workers after smallpox vaccination: findings from the Hospital Smallpox Vaccination-Monitoring System.

BACKGROUND: The Advisory Committee on Immunization Practices and the Healthcare Infection Control Practices Advisory Committee recommended that hospitals establish on-site, daily assessments of health care workers vaccinated with smallpox vaccine. The Hospital Smallpox Vaccination Monitoring System (HSVMS) was 1 component of the smallpox vaccination plan to monitor adverse events on-site in hospitals. This report presents findings from February to August 2003. METHODS: All US institutions participating in the smallpox vaccination program were eligible to enroll in and use HSVMS through the Internet-based Centers for Disease Control Secure Data Network. RESULTS: Of the 730 enrolled vaccinees, 341 (47%) were nurses; 122 (17%) physicians; 75 (10%) laboratory, patient care, radiology, or other technicians; 39 (5%) administrators; 22 (3%) housekeepers; 21 (3%) physical or respiratory therapists; 20 (3%) infection control professionals; 19 (3%) safety or security staff; and 17 (2%) epidemiologists; and 54 (7%) were workers in other job categories. Most (86%) vaccinees had been previously vaccinated. Postvaccination signs and symptoms were frequent: itching (75.2%), pain at the vaccination site (31.6%), swollen or tender lymph nodes (26.4%), fatigue (26.2%), and headache (20.8%). Symptoms were highest during the first week after vaccination; symptoms were more frequently reported among vaccinees without previous vaccination. Adherence to recommended vaccination site care was reported in 2732 of 3091 (88.4%) follow-up visits among workers with patient contact. Of the 4379 days workers planned to work, during 31 (0.7 per 100) days, workers performed restricted activities, and, in 60 (1.4 per 100) days, workers were absent. CONCLUSIONS: Findings from HSVMS indicate that adherence to post-smallpox vaccination site care was high and that the number of days of work affected was low.

Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project.

HYPOTHESIS: Surgical site infections (SSIs) are a major contributor to patient injury, mortality, and health care costs. Despite evidence of effectiveness of antimicrobials to prevent SSIs, previous studies have demonstrated inappropriate timing, selection, and excess duration of administration of antimicrobial prophylaxis. We herein describe the use of antimicrobial prophylaxis for Medicare patients undergoing major surgery. DESIGN: National retrospective cohort study with medical record review. SETTING: Two thousand nine hundred sixty-five acute-care US hospitals. PATIENTS: A systematic random sample of 34,133 Medicare inpatients undergoing coronary artery bypass grafting; other open-chest cardiac surgery (excluding transplantation); vascular surgery, including aneurysm repair, thromboendarterectomy, and vein bypass operations; general abdominal colorectal surgery; hip and knee total joint arthroplasty (excluding revision surgery); and abdominal and vaginal hysterectomy from January 1 through November 30, 2001. MAIN OUTCOME MEASURES: The proportion of patients who had parenteral antimicrobial prophylaxis initiated within 1 hour before the surgical incision; the proportion of patients who were given a prophylactic antimicrobial agent that was consistent with currently published guidelines; and the proportion of patients whose antimicrobial prophylaxis was discontinued within 24 hours after surgery. RESULTS: An antimicrobial dose was administered to 55.7% (95% confidence interval [CI], 54.8%-56.6%) of patients within 1 hour before incision. Antimicrobial agents consistent with published guidelines were administered to 92.6% (95% CI, 92.3%-92.8%) of the patients. Antimicrobial prophylaxis was discontinued within 24 hours of surgery end time for only 40.7% (95% CI, 40.2%-41.2%) of patients. CONCLUSION: Substantial opportunities exist to improve the use of prophylactic antimicrobials for patients undergoing major surgery.

Preventing antimicrobial-resistant bacterial infections among older adults in long-term care facilities.

For older adults in long-term care facilities (LTCFs), the rate of infections caused by antimicrobial resistant strains of bacteria has increased and is prompting renewed interest in investing health care resources for prevention and control of these pathogens. This document offers a simple framework to combat infections due to antimicrobial resistant bacteria in LTCF residents by providing a multi-step approach consisting of four major strategies: prevent infection, diagnose and treat infection effectively, use antimicrobials wisely, and prevent transmission. Recommendations from this multi-step approach are directed at LTCF medical directors and practicing clinicians involved with the medical care of older adult LTCF residents.

Antimicrobial use in post-acute care: a retrospective descriptive analysis in seven long-term care facilities in Georgia.

BACKGROUND: Antimicrobial use in long-term care facilities (LTCF) is an important public health issue, especially regarding its potential role in antimicrobial resistance. Up to two thirds of long-stay LTCF residents receive antimicrobial therapy each year. However, little is known specifically about antimicrobial use in short-stay LTCF residents receiving post-acute care. METHODS: The authors conducted a retrospective chart review of a random sample of residents admitted for post-acute care in seven LTCFs in Georgia from September 1, 1999 to August 31, 2000 to determine the rates and characteristics of antimicrobial prescribing in this population. RESULTS: Of 221 post-acute care residents, 105 (48%) received 152 courses of antimicrobial therapy during their post-acute stay. At least one antimicrobial was prescribed on 796 of 5220 resident-days (15%). Antimicrobial therapy was split evenly between hospital-initiated antimicrobial therapy (n = 53, 50%) and antimicrobial therapy initiated in the LTCF during post-acute care (n = 52, 50%). Levofloxacin was the most commonly prescribed antimicrobial. Where documentation on the suspected infection was present, the most common infections were urinary tract infections (UTIs) and pneumonias. For residents with post-acute care-initiated therapy, documentation regarding the presumed source of infection was absent for 44% of antimicrobial prescriptions. Most antimicrobial courses initiated for presumed infections in post-acute care were by telephone orders (66%). CONCLUSIONS: Utilization of antimicrobial therapy in LTCF residents in post-acute care is relatively high and may be greater than for long-stay LTCF residents. For hospital-initiated therapy, improved communication between hospital and LTCF staff may improve documentation and antimicrobial therapy in LTC. For antimicrobial therapy initiated by telephone orders in post-acute care, improving documentation of suspected source of infection is needed.

The changing face of surveillance for health care-associated infections.

Surveillance of health care-associated infections and antimicrobial resistance is an important aspect of prevention. In 2004, the Centers for Disease Control and Prevention had 3 national health care surveillance systems. During 2004-2005, these will be combined into a single Internet-based system, the National Healthcare Safety Network (NHSN). The NHSN will feature a number of enhancements, and ultimately, all US hospitals and other health care facilities will be encouraged to participate. Health care surveillance using standard methods has been very useful and is cited as a model for prevention. However, alternative approaches may improve health care surveillance by reducing complexity, decreasing the burden of data collection, and improving accuracy. These alternative approaches include adopting simpler methods and more-objective definitions, using sampling and estimation, substituting information in computer databases for manually collected data, and increasing surveillance for process measures with known prevention efficacy. Maintaining successful features of standard systems, adopting alternate surveillance approaches, and exploiting new technologies, such as the Internet, will make health care surveillance an even better tool for prevention.

Infections in residents of long-term care facilities: an agenda for research. Report of an expert panel.

The number of frail, older residents of long-term care facilities (LTCFs) will increase dramatically over the next 30 years. Improving the quality of health care provided in LTCFs is an important national and international priority. Improving the prevention and management of infections in LTCFs is a critical component of efforts to improve quality of care and poses unique challenges. This report summarizes the presentations and discussions of participants in an invitational conference to propose a research agenda for prevention and management of infections in LTCFs. The conference was held in March 2001 in Atlanta, Georgia. The discussants identified key research questions to better understand general issues involving the overall burden of infections in LTCFs, prevention and control interventions, and antimicrobial use and resistance. The participants also discussed research questions involving specific infections, including pneumonia and urinary tract, skin, and soft tissue infections. Recommendations for research were discussed and are presented in summary form in this report. Improving the prevention and management of infections in LTCF residents should be a priority if quality of care in these facilities is to be improved. Many unanswered questions remain in this field, and the research agenda outlined in this report will require resources and focus. The benefit of such efforts to LTCF residents and their caregivers is likely to be substantial.