Design/Methodology: Case Report- 78 year old male with past medical history of Hypertension, Hyperlipedemia, who is a long term resident in extended care facility was sent to ER for evaluation of his multiple somatic complaints. He described his mood as terrible, sad at times with suicidal thoughts. He had an existing diagnosis of Major Depressive disorder for which he was started with SSRI for 1 year with no improvement. The patient repeatedly says ‘‘I am feeling awful.’’ Social history revealed that he is a widower, had university level education and recently retired as a teacher. On examination he was alert and oriented, but appears apathetic. Mood appeared alternating between labile and constricted as patient was tearful at one moment and started laughing within minutes. MMSE revealed 20/30 with 3/3 recall with abnormal Clock drawing test and verbal Fluency of 7. Advanced neurocognitive evaluation showed that patient lacked initiation and perseverence. He was not able to do Trail B test. The patient hospital stay was remarkable for multiple episodes of disinhibited behavior, being sexually preoccupied, grabbing nursing staff and making inappropriate gestures. Rest of the physical examination, laboratory data was unremarkable. CT scan of head was suggestive of diffuse cortical atrophy with mild microvascular ischemic changes. Results: Patient was started on Depakote 125 mg bid for his behavior abnormality. Ritalin 2.5mg bid was added to pre-existing dose of celexa 40 mg. His mood variability improved significantly but sexual impulsivity is still persisting. Conclusion/Discussion: FTD can often be misdiagnosed and treated as a psychiatric disorder. In this case FTD was not picked up at its early stage and patient was been treated for sole major depression. FTD is a chronic and progressive disorder which becomes resistant to treatment if it is not recognized early. This case illustrates the difficulty faced by the clinician in recognizing a relatively common condition like Fronto temporal dementia if it is complicated or superimposed by Major depressive syndrome. Early recognition and diagnosis offers improved quality of life and as our case demonstrates may decrease burden on nursing staff and caregiver. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
Hartmans’ Pouch Mucocele Misdiagnosed as an Ovarian Tumor in an 86 Year Old Nursing Home Resident Presenting Author: S. L. Oakes, MD, University of Texas Health Science Center Family and Community Medicine Author(s): S. L. Oakes, MD, S. Kanjee, MD; and D. V. Espino, MD Introduction/Objective: An end sigmoid colostomy resulting in a Hartmann’s pouch is the procedure of choice when permanent fecal diversion is required. The distal portion of the rectosigmoid colon is exteriorized resulting in a mucinous fistula. This procedure can lead to the development of a mucocele which may be misdiagnosed unless a complete evaluation is done. Design/Methodology: Case report. Results: An 86-year old female with past medical history of atrial fibrillation, stroke with left hemiparesis, moderate Alzheimer’s who underwent hemicolectomy for ischemic bowel disease was admitted to the nursing home. On admission, the nursing home staff noted that she was draining a large amount of mucus from her rectum associated with intermittent, moderate abdominal pain. An abdominal CT scan revealed a cystic pelvic lesion which was highly suggestive of a primary ovarian cancer. The senior interventional radiologist differed with the initial interpretation and instead inserted a rectal tube which drained 200 cc of gelatinous material. A follow-up CT scan revealed resolution of the lesion. Further history taken from the family indicated that the patient had required daily rectal ‘‘drainage’’ of mucous material by abdominal pressure done by her in-home care provider prior to her nursing home admission. Finally, a post drainage sigmoidoscopy revealed old unexcreted pills in the Hartmann’s pouch that most likely contributed to the increased mucous production. Conclusion/Discussion: It has been noted that following colon resection using the Hartmann’s procedure the rectal mucosa continues to secrete mucus. This is rarely a clinical problem as the mucus passes through the rectum. However, on occasion, a mucocele can occur. This is a rare event as only four English language case reports have been published. Of note was the initial diagnosis of ovarian cancer, which may have been erroneously discussed
with her family had the workup been stopped there. As with all patients, this case demonstrates the need to attempt a tissue diagnosis and and/or endoscopic evaluation for all but the most obvious suspected tumors. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
Identifying Hospice Eligible Nursing Home Residents: The Hospice Eligibility Prediction (HELP) Tool Presenting Author: Cari R. Levy, MD, PhD, CMD, Denver VA Medical Center Medicine Author(s): Cari R. Levy, MD, PhD, CMD, Lauren Pointer; and Evelyn Hutt Introduction/Objective: Nursing homes are the site of death for 25% of Americans. Research indicates that end-of-life care in nursing homes is suboptimal but improves if hospice is involved. Precision in estimating life expectancy is necessary if hospices are to enroll patients with a life expectancy of 6months or less. Tools are needed to aid in accurate estimation of prognosis among nursing home residents who often have multiple co-morbid conditions contributing to mortality risk rather than a single disease entity. Design/Methodology: A series of logistic regressions were applied to a cohort of VA nursing home residents (N528,865) in FY 2003-2005 to identify Minimum Data Set variables predictive of 6-month mortality. Results: Fifteen resident-level variables were selected for the final predictive model with a c-index of 0.845. This model was then tested on a validation cohort (N58660) with a c-index of 0.851. The c-index was 0.845 when the model was applied to the entire VA CLC cohort (developmental + validation cohort). After assigning a HELP tool probability for hospice eligibility to all residents in the cohort, 62.6% were not in hospice and not eligible, 15.9% were in hospice and eligible, 14.7% were not in hospice but eligible and 6.8% were in hospice but not eligible. Conclusion/Discussion: Hospice eligibility was incorrectly assessed for 1 in 5 residents. The HELP tool may improve accuracy in assessing hospice eligibility for nursing home residents. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
Identifying Patterns of Skilled Nursing Facility Readmission Presenting Author: Yanping Ye, MD, UTHSC at San Antonio Author(s): Yanping Ye, MD, Ughanmwan Efeovbokhan; and Robert W. Parker, MD Introduction/Objective: One-fourth of the Medicare beneficiaries who are discharged from an acute hospital to a Skilled Nursing Facility (SNF) are readmitted within 30 days. Re-hospitalization of SNF patients can be costly, disruptive to patients and families, and interrupt their plan of care. In addition, hospitalization of frail elders can lead to a variety of complications including delirium, iatrogenic illness, de-conditioning, poly-pharmacy, and pressure ulcers. Identifying and decreasing readmissions decreases patient mortality and lowers health care costs. In this study, we sought to conduct a preliminary review of re-hospitalization events within 30 days after discharge to one of our 5 community based Skilled Nursing Facilities, and identify indicators that could be targeted to reduce re-admissions. Design/Methodology: SNF data were obtained from EMR between January 2010 and September 2010, and the readmission events were recorded if patients were re-hospitalized within 30 days after they were discharged to the SNF. Data included date of readmission, SNF Length of Stay (LOS), SNF admission diagnosis, reason for re-admission, and number of visits by either physician or GNP prior to readmission. Hospital discharge summaries were reviewed for verifying readmission diagnosis. Results: There were total 79 readmissions recorded during this period. Fifteen patients (22%) expired after re-hospitalization. Among those patients, ten (67%) were on hospice prior to their death. The most common reasons to be on hospice are pulmonary disease, mental status change and cardiac conditions. Among the surviving patients, forty four patients were discharged to home, four patients are staying in SNF; two patients were at assisted living
facilities, nine patients were in long term care. Overall, patients spent average 11 days in the SNF, and received two E&M visits before being readmitted to hospitals. Wednesday and Thursday were the most common days of readmission (18% each). The most common reasons for readmission were cardiac related diseases (16.46%); pulmonary related diseases (15.19%); mental status change (13.92%); gastrointestinal (11.39%) problems and abnormal labs (8.89%). In addition, comparing the admission and re-admission diagnosis, we found that patients with mental status change, pulmonary disease, GI problem, cardiac condition and infection were at high risk of re-hospitalized with the same diagnosis. Conclusion/Discussion: Patients with cardiac diseases, pulmonary diseases and mental status change are most likely to be readmitted, and they are at higher risk to die or be placed on hospice thereafter. Patients with underlying atrial fibrillation, CHF are at increased risk for readmission due to cardiac condition even after surgical procedures. This indicates that standardized protocols for managing post surgical care patients and monitoring of chronic diseases is necessary. Currently, CNAs are trained to use early warning signs to recognize patients’ change of conditions, and RNs are trained to use SBAR (Surrounding, Background, Assessment and Request) form for improving communication with on-call providers. The INTERACT (Intervention to Reduce Acute Care Transfer) care pathway tools are being implemented in the SNF. These quality improvement programs emphasizing communication and standardized protocols may reduce the 30-day readmission rate and thus improve the patient care. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
ments in pain management. Pain recognition did not change in persons with severe cognitive impairments with the F-Tag 309 implementation suggesting that different pain assessment tools may be required for these residents. Disclosures: Kate Lapane, PhD, MS and Brian Quilliam, PhD, RPh received funds for project consulting from Ortho-McNeil Janssen Scientific Affairs Wing Chow, PharmD, MPH and Myoung Kim, PhD, MS, MBA are employees of Ortho-McNeil Janssen Scientific Affairs.
Impact of F-Tag 309 Survey Interpretive Guidelines on Persistent Pain Management Among Nursing Home Residents
Table 1. Interdisciplinary Team Approach to Noro Gastroenteritis Outbreak
Presenting Author: Kate Lapane, PhD, MS, Virginia Commonwealth University Author(s): Kate Lapane, PhD, MS, Brian Quilliam, PhD, RPh, Wing Chow, PharmD, MPH; and Myoung Kim, PhD, MS, MBA Introduction/Objective: Introduction: In March 2009, the Centers for Medicare & Medicaid Services implemented new guidelines which direct surveyors to investigate whether facilities are following proper pain management practices. Objective: To estimate the extent to which implementation of F-Tag 309 improved recognition and management of pain among nursing home residents Design/Methodology: Design: Quasi-experimental. Setting: One hundred seventy-four for profit nursing homes in nineteen U.S. states. Participants: Residents with at least two Minimum Data Set (MDS) assessments living in one of the included nursing homes in operation during January 2007 through March 30, 2009 (before F-Tag implementation; n58,449) and between March 31, 2009 and December 2009 (after F-Tag implementation; n51,400). Intervention: Implementation of F-Tag 309 into the surveyors’ interpretative guidelines Measurements: MDS assessments provided information on pain, analgesics, cognitive, functional, and emotional status. Separate logistic regression models adjusting for clustering effects of residents residing in nursing homes provided estimates of the relationship between the implementation of F-Tag 309 and prevalence of pain as well as use of analgesics and adjuvant medications for pain. Results: Pain was more likely to be documented post-F-Tag (persistent: 25.6%, Intermittent: 30.0%) relative to pre-F-tag (persistent: 25.2%, Intermittent: 25.7%, p50.0009). Residents were more likely to have persistent or intermittent pain recognized after the implementation of F-Tag 309 (Adjusted odds ratio (AOR): 1.15; 95% Confidence Interval (CI): 1.011.31). Among all residents, increases in use of any analgesic was observed in the post-F-Tag 309 era (AOR: 1.43; 95% CI: 1.26-1.62) with greater improvements in use of analgesics for residents experiencing intermittent pain (AOR: 1.51; 95% CI: 1.18-1.92). Increases in opioid use (Post F-Tag 309: 43.3% vs. Post: 34.5%; p\0.0001) and use of medications potentially used as adjuvants for pain (Post: 72.7% vs. Pre: 64.6%; p\0.0001) increased with F-Tag 309 implementation. Conclusion/Discussion: Use of directed language as part of the surveyor’s interpretive guidelines may be a viable approach to stimulating improveB14
Improving Noroviral Gastroenteritis Attack Rate and Clinical Outcomes in a Skilled Nursing Facility Presenting Author: Louis M. Mudannayake, MD, CMD, Cobble Hill Health Center Author(s): Louis M. Mudannayake, MD, CMD Introduction/Objective: Noroviral Gastroenteritis is the leading cause of infective gastroenteritis in the US and worldwide. Nursing home patients can have significant MORBIDITY and MORTALITY secondary to infective norogastroenteritis. My objective was to limit attack rates and improve clinical outcomes in a noroviral gastroenteritis outbreak in a Skilled Nursing Facility in Brooklyn, New York. Design/Methodology: This is a retrospective study of a norovirus gastroenteritis outbreak in a 360 bed Long Term Care Facility from December 26, 2008 – February 5, 2009. Using an INTERDISCIPLINARY Team there was a proactive approach to prevention of spread and treatment of patients during a norogastroenteritis outbreak in Brooklyn, New York
Early recognition of potentially infected patients. Immediate isolation and administration of oral rehydration salts (ORS) Early cleaning of fomites. Containment of infected material Educating families of involved patient or prevention on prevention of spread measure Early recognition of potentially infected patients. Assist nursing with administration of ORS Ensuring adequate stocked ORS in house and delivery to affected units Coordination of efforts in conjunction with Infection Control Nurse Education of all Departments
Housekeeping Social Service
Dietary Medical Director
Prevention of Spread Measures
There should be high suspicion index for any patient in-house having diarrhea, or other symptoms such as abdominal pain and vomiting in conjunction with fever. Any patient suspected of infection should be placed on report and staff from Infection Control and the Medical Director or Attending Physician of the unit informed All such patients should be confined to their rooms and placed on contact isolation until further notice. All staff and visitors entering the rooms of these residents must wash their hands before entering and again upon leaving the room. Housekeeping should clean all fomites, (e.g. door handles, toilet seats, walls) with a 10% bleach solution as soon as possible. Roommates should be asked to pay attention to hand washing and remain on the units as far as is possible
JAMDA – March 2011