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Long-term Care

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Infections are a serious problem in nursing homes

Acute infections account for 27 percent of transfers of nursing home residents to hospitals. In turn, complications of infections and their treatment can contribute to functional decline among the residents. Three studies supported by the Agency for Healthcare Research and Quality (HS08551) and led by David Mehr, M.D., M.S., of the University of Missouri-Columbia School of Medicine, examined acute infections in nursing homes.

In the first study, researchers concluded that inadequate communication between nursing staff and physicians is a major barrier to rapid identification and treatment of acute infections among nursing home residents. The second study revealed that many nursing home residents who survive to 30 days following a lower respiratory infection develop new functional limitations and are more likely to decline in daily functioning within 3 months. According to the third study, most of the variation in the cost of treating pneumonia in nursing home residents is not explained by severity of illness. All three studies are summarized here.

Longo, D.R., Young, J., Mehr, D., and others (2002, November). "Barriers to timely care of acute infections in nursing homes: A preliminary qualitative study." Journal of the American Medical Directors Association 3, pp. 360-365.

Communication problems between nursing staff and physicians, who are usually offsite, constitute a major barrier to rapid identification and treatment of acute infections among nursing home residents, according to these researchers. They used focus groups and interviews with four residents, seven nurses, and six physicians to identify factors promoting or acting as barriers to prompt identification and treatment of six episodes of acute illness among residents from four nursing homes participating in a longitudinal study of lower respiratory infection.

The researchers identified four distinct stages in the process of managing acute infections in nursing home residents: sign and symptom recognition, illness identification, physician notification, and treatment. Content analysis of interview transcripts revealed 22 factors that influenced the timeliness of effective care. Six communication-related barriers to timely effective care stood out: failure of the physician to receive the message; evening or weekend illness onset that hampered contact with the on-call physician; reliance on an intermediary (for example, an office nurse) to convey orders from the physician; the communication of inappropriate or inaccurate information; inadequate information transfer at shift changes; and a nurse's reluctance to talk with a physician who was perceived as "difficult."

As evidenced by nurses' notes and interviews with staff, nurses or nurses aides promptly recognized symptoms of infection in the six cases considered. However, timely intervention (diagnostic or treatment orders received from the notified clinician within the same working day or within 8 hours outside usual office hours) occurred in only three instances. For one resident, 4 days elapsed between symptom recognition by the nursing staff and initiation of treatment, including more than 24 hours after the first physician contact. Three of the six residents, including this one, were ultimately hospitalized. The researchers recommend staff training in better communication both within facilities and with off-site clinicians to improve care of acute infections and avoid unnecessary transfer of residents to the hospital for treatment.

Binder, E.F., Kruse, R.L., Sherman, A.K., and others (2003). "Predictors of short-term functional decline in survivors of nursing home-acquired lower respiratory tract infection." Journal of Gerontology: Medical Sciences 58A(1), pp. 60-67.

Among nursing home residents who developed new functional dependencies 1 month after an episode of acute lower respiratory infection (LRI), two-thirds had not regained their pre-infection ability to carry out activities of daily living (ADLs, for example, dressing, feeding, or bathing oneself) at 3 months, according to this study. Initial hospitalization for acute treatment of LRI was associated with nearly twice the decline in the patient's ability to perform ADLs. Either initial hospitalization may indicate greater illness severity, or the more restricted mobility of hospitalized individuals, with associated muscle atrophy and loss of strength, could directly contribute to ADL impairments, suggest the investigators.

They prospectively studied 781 episodes of LRI in 1,044 residents in 36 nursing homes to examine what clinical factors predicted short- and long-term ADL decline following an acute episode of LRI. They defined functional decline as a 3-point worsening on the Minimum Data Set (MDS) activities of daily living long form scale (0 to 28, where 28 indicates complete dependence). Of the 781 LRI patients who survived to 30 days, nearly 29 percent had a decline in ADLs. After adjustment for other factors, chronic feeding tube use more than quadrupled the likelihood of ADL decline. Also increasing the likelihood of ADL decline were decubitus ulcers, shortness of breath, short-term memory problems, decline in self-toileting in the 24 hours prior to evaluation, age, and baseline ADL score.

Addition of treatment variables to the model showed that initial hospitalization was associated with nearly twice the ADL decline. Residents with ADL decline at 30 days were less likely to recover to their baseline ADL status at 90 days. The results of this study suggest that measures of chronic illness severity or related disability may have a greater role in predicting short-term ADL decline than clinical measures of acute LRI illness severity at the time of symptom onset. Similar to studies performed in the hospital setting, the nursing home residents in this study with moderate baseline ADL impairments, cognitive impairment, and poor nutritional status were at high risk for functional decline.

Kruse, R.L., Boles, K.E., Mehr, D.R., and others (2003, March). "The cost of treating pneumonia in the nursing home setting." Journal of the American Medical Directors Association 4, pp. 81-89.

The cost of treating pneumonia and treatment of residents with similar clinical presentations varies substantially among nursing homes, according to this study. As part of a larger study of lower respiratory infection (LRI) in nursing home residents, these investigators examined the costs of caring for 502 residents with pneumonia who were not hospitalized, including residents who were evaluated in the emergency department (ED) and returned to the nursing home without hospital admission. The researchers abstracted from the medical records the examination findings, diagnostic testing, and treatment information for 30 days following evaluation by study nurses, and they obtained copies of bills for individuals evaluated in the ED.

Most of the residents who suffered pneumonia were fairly old and frail, and many had coexisting conditions such as congestive heart failure. About one-fifth were dependent on others for help with grooming, walking, toileting, and eating. The average cost for treating an episode of pneumonia in the nursing home, over and above usual care, was $458. For residents who received some ED treatment, the average cost of care was $1,486 compared with $425 for residents with no ED treatment.

Most residents received both x-ray and other diagnostic testing in the nursing home. X-rays accounted for nearly half (47 percent) of the total nursing home costs, followed by provider visits (20 percent) and medications (20 percent), with a mean cost per resident ranging from $0 to $739. The mean antibiotic cost was not significantly related to illness severity. Pneumonia episode costs were higher for residents seen in a hospital ED, residents with decubitus ulcers, black residents, and those in larger facilities. Although total episode costs were related to illness severity, most of the variation in cost was not explained by resident or illness characteristics.

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