Anti-infection agents in Long Term Care

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Anti-toxins in Long Term Care David Gary Smith, MD, FACP Abington Memorial Hospital

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Audience Response System Keypads-must return them Real time surveying of group of onlookers Anonymity

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Do you truly need to hear a discussion about anti-infection agents and LTC? Yes-furthermore drive nails into my fingers No-I would rather listen to lift music

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What is your calling? Nurture MD/DO Social Work Administrator Other clinical

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Goals Outline of the anti-toxin "issue" Guidelines for anti-microbial utilize address over use Antibiotics and the "Objectives of Care" difficulty Existential model for patient centeredness at the bedside

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Patterns of Antimicrobial Use in NH Residents with Advanced Dementia Approximately 1 year of f/u 66% (n=142) got no less than one course of antimicrobial treatment 540 endorsed courses 42% (n=42) of decedents got anti-toxins inside two weeks of their demise and 41courses were regulated parenterally D'Agata E, Mithcell S, Arch Int Med 2008;168:357-361

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Antibiotic Therapy in the Demented Elderly Population: R edefining the Ethical Dilemma Low probability of advantage Emerging resistance Avoidance of "objectives of treatment" talk Easier to treat than to raise the "D" word Costs Schaber M, Cormelli Y, Arch Int Med 2008;168:349-350

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2 Studies on Benefit of Educational Program on Antibiotic Use in LTCF Reported recurrence of imperfect anti-microbial utilize 25-75% Educational mediations diminished blunders by roughly 20% Post intercession adherence to convention rates-40-77% Scwartz D , JAGS, 2007;.55:1236-1242 Monette J, JAGS, 2007; 55:1231-1235

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Case 88 y.o. with indwelling foley and dementia. The clinical chaperon calls on the grounds that the pee is dull and the way of life uncovered >100,000 states E. Coli. She needs to comprehend what anti-toxin would you like to utilize. No hypersensitivities. No fever.

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What is your supposition? TMP/Sulfa Amoxacillin Levafloxacin Transfer for IV anti-infection agents No treatment

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Minnesota Guidelines No indwelling catheter Acute dysuria or Fever >38.9 (102 F) and no less than one of the accompanying: Urgency Frequency Suprapubic torment Hematuria CVA delicacy New onset urinary incontinence

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Minnesota Guidelines Indwelling Foley Need no less than one of the accompanying: Fever >38.9 (102) New CVA delicacy Rigors New onset of wooziness

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Another call from same NH 78 yo persistent with COPD and has new hack with yellow sputum. Temp is typical. Heartbeat is 80. Respiratory rate is 15. No daze, rigors.

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What is your feeling? PO Levofloxacin PO Azithromycin Other PO anti-microbial Transfer to healing facility for IV anti-toxins No anti-infection agents required

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Minnesota Guidelines Fever > 38.9 (102 F) and one of the accompanying: Respiratory Rate>25 Productive hack Or Fever > 37.9 (100 F) and hack and no less than one of the accompanying: Pulse >100 Delirium Rigors Respiratory Rate >25

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Minnesota Guidelines Or COPD history and purulent hack * Or New penetrate on mid-section xray and no less than one of the accompanying: Respiratory rate > 25 Productive hack Fever > 37.9 (100 F)

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Same attendant calls you about another case 83 yo with dementia has a fever of 37.9 (100 F) and a few parts of a ridiculousness. You are available to come back to work for this patient who is trailed by your accomplice. She has no other central manifestations or signs. Would you like to begin anti-infection agents?

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What is your conclusion? Attentive holding up Send her to the healing center PO Levafloxacin Call her essential care doctor in AM

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Minnesota Guidelines Fever with obscure center of contamination Fever > 37.9 (100 F) and no less than one of the accompanying: New Delirium Rigors

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Do you believe that anti-toxins are over-used? Yes No

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Do you have conventions set up to guide administration? Yes No

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Contributors to pointless anti-infection utilize Antibiotics are abused in LTCFs? (% concur) MD 82 Nurse Practitioner 91 Director of Nursing 66 Infection Control 80 Established conventions Facilities 31 Providers 16 Gahr P J Amer Ger Soc 2007;55:471-474

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What do you think the most imperative calculate is this abuse? Family weight Nurse weight Cognitive disability Lack of clear rules Other

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Contributors to superfluous anti-infection utilize Factors which add to pointless utilization of anti-infection agents Pressure from medical caretaker 54-56% Pressure from family- 21-28% Resident subjective impede.- 57-58% Need for: Education for attendants 62-73% Education for MDs/NPs- 35-57% Nursing rules 60-70% Gahr P J Amer Ger Soc 2007;55:471-474

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Lessons in this way… We suck (my young people order) at settling on choices about anti-microbials Part of the reason we suck is the absence of clear rules, conventions, updates, frameworks of responsibility… . We as a whole have a tendency to maintain a strategic distance from or butcher the "objectives of treatment" dialog Overestimate advantage of Abs and so forth. Evade the "D" word

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Good News We can make a move", "in the event that we want to make a move. Anti-infection Protocol champion that has stature and power!!!!

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"If you need reality to stand clear before you, never be for or against. The battle amongst "for" and against" is the mind's most exceedingly awful malady. - Sent-Ts'an (otherwise known as Seng Tsan) c. 700 C.E.1

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Existential Issues Talk about a patient who tested us as of late on administration. The subtle elements of the case have been changed to secure the personality of all members with the exception of me. Objectives of case Talk about hindrances to certified patient focused care Discuss a method for defeating those obstructions

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Case 39 y.o. Constant Vegetative State patient is conceded for her 5 th presentation for a presumed pneumonia. She has been at home with her family in this state for 8 months. The family noticed an adjustment in her breathing and slight increment in her discharges. Subintern (fourth year medicinal understudy) on administration is sent into see tolerant yet she is obviously startled by the task. Why?

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View from subintern and going to How would I approach a patient in a PVS? The family? My sentiments of sadness? My powerlessness to frame an association with the patient? How would I decide the objectives of care? Can I even observe the patient? Adapting style-imagine that there is no patient as individual however only a natural readiness (a petri dish) with microscopic organisms that need anti-infection agents.

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View from subintern and going to Additional sentiments manage the asset usage; diverting the clinicians from somebody who truly needs our consideration; the preposterousness of the entire circumstance. These sentiments underlie a considerable measure of the morals counsels concerning tolerant vanity got by morals boards of trustees. Strain between a family that requests mind and the clinicians who see no reason in giving that care

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How would you feel about administering to such a patient? Extremely Sad Angry about the misuse of assets No inclination at all Other

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What might you prescribe to the family? IV anti-microbials Withhold anti-toxins Palliative care counsel Other

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Feeling and Impact on Care Elkman-"Your face is the reflect of everything inside" The family could detect a clinical despise by the healing facility staff in the past toward them for needing to proceed with care

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Do you want to "fake" that you give it a second thought? Completely Definitely not Never pondered it Other

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. The therapeutic understudy and I strolled through the ER window ornament and viewed a scene of awesome dedication by the spouse and the little girl for the patient that was transformative for us.

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This case Any earlier thought, originations, emotions were completely washed away. We just remained there and viewed a scene of scriptural extent. Our course was given us from inside the scene at the bedside.

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An Approach Suspension of Values Interiorization Letting go and the understanding will develop Senge P, Nearness: An Exploration of Profound Change in People, Organizations and Society. 2004

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Generalizability Can everybody do this? Does it require much investment? In what capacity will it at last influence me?

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Downside None

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Patient Centered There is no better model out there for a genuinely persistent focused experience!

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Summary We can positively make a superior showing with regards to endorsing anti-toxins or whatever other kind of medications for our patients We need to hold onto this entire territory as basically vital particularly given the various critical activities that we ought to grasp We need to abstain from respecting the powers inside pharmaceutical that crushes the majority of our humanities