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P OSTER
A BSTRACTS
complex elders should consider extra clinic visits and resources (e.g.,
pharmacy to review additional medication burden).
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Defining Fever in Nursing Home Patients.
P. D. Sloane, 1,2 C. Kistler, 2 C. Mitchell, 1 A. S. Beeber, 4 R. Bertrand, 5
S. Zimmerman. 1,3 1. Sheps Ctr for Health Services Research, Univ. of
North Carolina at Chapel Hill, Chapel Hill, NC; 2. Department of
Family Medicine, Univ. of North Carolina at Chapel Hill, Chapel Hill,
NC; 3. School of Social Work, Univ. of North Carolina at Chapel Hill,
Chapel Hill, NC; 4. School of Nursing, Univ. of North Carolina at
Chapel Hill, Chapel Hill, NC; 5. Abt Associates, Inc., Cambridge, MA.
Supported By: Agency for Healthcare Research and Quality
Background: Existence of fever is often identified as a criterion
for determining the “appropriate” use of systemic antibiotics; however,
several different criteria exist for determining what temperature
in a nursing home patient constitutes a fever.Among the more popular
fever guidelines are those of Loeb et al., who defined fever as either
37.9°C [100°F] or 1.5°C [2.4°F] above average routine temperature.
Methods: To develop a more empirical basis for definition of
fever, we evaluated 257 residents of six North Carolina nursing
homes who had been treated with antibiotics for a presumed infection
during a two month observation period. Data collected included
the temperature recorded on the day the treatment was started, and
three prior routine temperatures recorded when the residents were
not ill. We then proposed to redefine fever based on the temperature
distribution in the sample, and used that standard to evaluate
whether or not fever was present at the time of a suspected infection
for each of the 257 residents using both the standard Loeb fever criteria
and this new definition.
Results: The mean routine temperature was 97.8°F, with a standard
deviation of 0.59°F. Based on these routine temperatures, we derived
two empirical definitions of fever in nursing home patients: (1)
a temperature of 99.0° F or higher (i.e., above the 95th percentile for
the sample); or (2) 1.2° F (i.e., two standard deviations) above the average
temperature for an individual patient. Applying these criteria
to the 257 episodes of antibiotic prescribing, we found that 21% of
urinary tract infections, 22% of respiratory infections, and 15% of
skin infections treated with systemic antibiotics were accompanied by
a fever. In contrast, 13% of urinary infections, 14% of respiratory infections,
and 6% of skin infections met the Loeb fever criteria.
Conclusions: The presence or absence of fever should be assessed
using different criteria in nursing home patients from that used
with the general adult populations. Whether, when, and how often a
fever should be present for antibiotic prescribing to be considered
“appropriate” remains debatable.
B114
Reducing Potentially Inappropriate Antibiotic Prescribing in
Nursing Homes.
S. Zimmerman, 2,4 P. D. Sloane, 1,2 A. S. Beeber, 3 C. Kistler, 1
R. Bertrand, 5 L. Haddon, 5 C. Mitchell. 2 1. Dept. of Family Medicine,
Univ. of North Carolina, Chapel Hill, NC; 2. Sheps Ctr for Health
Services Research, Univ. of North Carolina, Chapel Hill, NC; 3.
School of Nursing, Univ. of North Carolina, Chapel Hill, NC; 4.
School of Social Work, Univ. of North Carolina, Chapel Hill, NC; 5.
Abt Associates Inc., Cambridge, MA.
Supported By: Agency for Healthcare Research and Quality
Background: As concern regarding antibiotic-resistant organisms
has reached global proportions, attention has become focused
on populations in which prescribing is high and may be inappropriate.
Nursing home residents are one such population.
Methods: To examine the extent of potentially inappropriate antibiotic
prescribing and the ability of educational efforts to reduce
such prescribing, we conducted and evaluated a quality improvement
program in six North Carolina nursing homes. The program had four
components: 1) training physicians in antibiotic prescribing criteria,
especially criteria prescribed by Loeb and colleagues; 2) training
nursing home (NH) nurses in the use of a Medical Care Referral
Form (MCRF) to report the signs and symptoms of the Loeb criteria
to physicians; 3) providing information to residents, their family
members, and other NH staff about antibiotic prescribing; and 4)
maintaining contact with physicians and NH staff during a six-month
quality improvement program, providing information about prescribing
rates, concurrence with the Loeb criteria, and use of the MCRF.
Results: At baseline, the number of monthly antibiotic prescriptions
(unadjusted) ranged from 26-52 across the six NHs. Within three
months of initiating the program, five of the six settings evidenced reduced
prescribing ranging from 19-41%. Adherence to the Loeb criteria
for prescribing increased for urinary tract infections (8% at
baseline to 12% at follow-up), respiratory infections (2% at baseline
to 8% at follow-up) and especially for skin infections (41% at baseline
to 82% at follow-up). The MCRF was used to report information
for only a minority of treated infections (from 0 to 17%).
Conclusions: Antibiotic prescribing may be reduced in nursing
homes through concerted efforts including prescriber training, more
detailed and focused staff-prescriber communication, and patient and
family education. While not all treated infections should meet published
criteria for appropriateness, some further reduction in prescribing
that does not meet criteria would likely constitute optimal care.
The MCRF may be a mechanism to improve prescribing practices.
B115
Where Heroes Meet Angels:the Medical Foster Home.
T. Edes, 3 C. Levy, 4 D. Goedken, 3 B. kinosian. 2,1 1. Univ of PA,
Philadelphia, PA; 2. CHERP, Philadelphia VAMC, Philadelphia, PA;
3. Dept. Veterans Affairs, Washington DC, DC; 4. Denver VAMC,
Denver, CO.
Background: Medical Foster Home (MFH) merges care in a personal
home with an interdisciplinary home care team (IDT), such as
VA Home Based Primary Care (HBPC). MFH is for veterans who
cannot live independently because of complex chronic medical, psychological
and functional impairments and lack of adequate family
support. The Department of Veterans Affairs (VA) has rapidly expanded
the availability of MFHs, growing from 3 programs in 2008 to
over 56, with 358 foster homes caring for 484 veterans. Over 1,245 veterans
have been served since program inception. All Veterans in
MFH meet nursing home level of care. MFH is intended to be the Veteran’s
home often until the end of life. HBPC provides comprehensive
care in the home, as well as caregiver training and support.Veterans
pay the MFH caregiver, approximately $1800 to $2500 per month.
Methods: All 56 MFH programs for FY 2011 were analyzed in
terms of their expenses (administration, coordination, HBPC-IDT
management of complex care needs) and their revenue, creating an
internal, virtual firm. We operationalized revenue as the lowest-cost
nursing facility care VA could provide to veterans who were eligible
to have VA covered nursing home care (veterans in Priority Group
1A), crediting monthly NH payments each month a P1A veteran was
in MFH. In FY2011, the community NH rate VA paid was
$7076/month, while HBPC and MFH administration cost
$1520/month. We also examined savings if VA were to cover the
MFH housing cost of $2400/mo for P1A veterans.
Results: During FY 2011, census grew from 297 total and80 P1A
to 454 total and 132 P1As at year end. Discharges averaged
6%/month (240 for FY2011), with 13% to an assisted living facility,
9% to a nursing home, 18% to their own or family’s home, and 49%
due to death. With a total of 4459 MFH months/1217 months for
P1As, expenses would be $6.372M with revenues of $8.61 M, or a net
margin of $2.24M (35% ROI). Serving 27% P1A veterans, the program
would still be slightly in the black ($6.4M in net revenue, or a
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AGS 2012 ANNUAL MEETING