| A Fresh Look at Infection Prevention | https://www.providermagazine.com/Articles/Pages/A-Fresh-Look-at-Infection-Prevention.aspx | A Fresh Look at Infection Prevention | <p>Infection prevention and control has been a top priority in long term and post-acute care centers this past year and a half. However, much of it has understandably focused on COVID-19. Moving into flu season and the holidays, there is much to learn from COVID to help prevent and manage other common infections.</p><h2>While Focused on COVID . . .</h2><p>While everyone was busy managing the pandemic, a few developments regarding other infections have been made. <br></p><p>For instance, earlier this summer, the Infectious Disease Society of America and the Society for Healthcare Epidemiology of America released new evidence-based guidelines on the management of Clostridioides difficile infection (CDI) in adults.<br></p><p>The guidelines include three recommendations on suggested treatments for patients with initial and recurring CDI episodes, based on new data for fidaxomicin and for bezlotoxumab, a monoclonal antibody targeting toxin B produced by C. difficile. Specifically, the revised guidelines say that patients with an initial C. diff infection should receive fidaxomicin instead of a standard course of vancomycin, though they say that implementing it depends on available resources. <br></p><p><img src="/Issues/2021/September/PublishingImages/GhinwaDumyati.jpg" alt="Ghinwa Dumyati, MD" class="ms-rtePosition-1" style="margin:5px;width:160px;height:204px;" />Elsewhere, Ghinwa Dumyati, MD, professor of medicine, infectious diseases, at the University of Rochester Medical Center, says, “In recent years there have been more studies showing that reducing inappropriate urine culture testing reduces the use of antibiotics, which is a positive step forward. At least one <a href="https://www.reliasmedia.com/articles/144326-avoid-antibiotics-by-reducing-unnecessary-urine-tests" target="_blank">study</a> found that inappropriate treatment of urinary tract infections with antibiotics raises the risk of C. diff.” <br></p><p>Influenza took a back seat during the pandemic. According to the Centers for Disease Control and Prevention (CDC), indicators of influenza began to decline by mid- to late-February 2020. In the 2020-2021 season, the United States saw approximately 700 deaths from influenza, compared with 22,000 in the previous season. These numbers are likely due to several contributing factors, including lockdowns and quarantines, mask-wearing, and hand hygiene.<br></p><p>“Our flu rates were fantastic this last year because everyone was taking precautions,” says Morgan Katz, MD, MHS, assistant professor of medicine at the Johns Hopkins University School of Medicine. “We did learn some things from COVID that will likely help us with flu prevention moving forward.”</p><h2>Putting Stewardship on the Front Burner</h2><p>Katz says that in recent years, clinicians have made advances on issues such as antibiotic stewardship. “That’s been put on the back burner [for now], but we need to get back on track with that,” she says.<br>Katz says that when COVID hit, staff were incredibly taxed, overwhelmed, and overworked, and they didn’t have time to prioritize stewardship.<br></p><p><img src="/Issues/2021/September/PublishingImages/MorganKatz.jpg" alt="Morgan Katz, MD" class="ms-rtePosition-2" style="margin:5px;width:160px;height:200px;" />At the same time, she says, “Prior to the pandemic, CDC had just come out with guidelines for enhanced barrier precaution for nursing homes, which prioritizes the use of PPE [personal protective equipment] for specific high-risk residents during high-risk activities to reduce the transmission of multi-drug-resistant organisms. Unfortunately, with the pandemic, we had to dedicate our PPE and our time and effort to caring for COVID patients.”</p><h2>IPs Need Attention ASAP</h2><p>“For nursing homes, I think one positive development is that everyone realizes we need more robust infection prevention programs,” Dumyati says. The federally mandated infection preventionist position may need to be expanded moving forward, she says. <br></p><p>“Being able to support someone working full-time on infection prevention and control is something we learned we need. We must figure out how to support this position and enable someone to have adequate time and resources to do the job well,” she says. “People are paying attention to [the issue], and that’s very positive. Looking ahead, we will need to look at the layout and design of facilities.” <br></p><p>One study showed that smaller units with fewer people such as the Green House model fared much better during the pandemic than facilities with multiple people sharing a room and a bathroom, Dumyati says. However, she adds, “Funding needs to be available.” In the meantime, she suggests, “We can look at things like updating ventilation and HVAC systems and replacing carpeting.”</p><h2>Lessons Learned</h2><p>Getting staff and others vaccinated for influenza and pneumococcal illnesses has always been a challenge. It’s too early to tell if the pandemic and the situation with the COVID vaccine will change how people view vaccinations in general, experts note.<br></p><p>“We mandated influenza vaccines for staff in the hospital and improved our numbers. In the nursing home, we never went above about 60 percent,” Dumyati says. “There is always distrust by some groups, and it’s clear from the response to the COVID vaccine that this hasn’t changed.<br></p><p>“But we need to be able to address these things. I have spent hours talking with people who didn’t want to get vaccinated. Some ultimately agreed to get vaccinated, and others didn’t.”<br></p><p>The recent groundswell for COVID vaccine mandates for staff may extend to influenza as well. “In general, based on the discussions I’ve had, facilities are considering mandating flu vaccines moving forward,” Katz says. “My hope is that this will happen, as it has proven to be the most effective way to increase staff vaccination rates.”<br></p><p>With flu season approaching, Dumyati says providers need to address all the issues and objections now. A blanket approach won’t work, she says. Instead, leaders need to talk to people one-on-one and have multiple conversations.<br></p><p>“We have learned that you can’t wait until the last minute to make decisions,” Katz says. “We need to have discussions about goals of care early. We found out during the pandemic how important that is.”</p><h2>Promising Future?</h2><p>COVID brought to light the continued need to improve infection prevention in long term care settings, Katz says. “We need to evaluate processes and regulations in this setting and dedicate the resources and research to improving practices. I do think things are going to change because of what has happened.”<br></p><p>Nonetheless, there may be some bumpy roads ahead. “I am prepared for fall to be a challenging time,” Katz says. “The flu is going to come back, as will other viruses. And the onset of the Delta variation of COVID makes it clear we’re not done with this virus either.” <br><br><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em></p> | Moving into flu season and the holidays, there is much to learn from COVID to help prevent and manage other common infections. | 2021-09-01T04:00:00Z | <img alt="" src="/Issues/2021/September/PublishingImages/0921_CF1.jpg" style="BORDER:0px solid;" /> | COVID-19;Infection Control | Cover Feature | Joanne Kaldy | 48 | 9 |
| Long COVID: An Emerging Threat | https://www.providermagazine.com/Articles/Pages/Long-COVID-An-Emerging-Threat.aspx | Long COVID: An Emerging Threat | <p><img src="/Issues/2021/September/PublishingImages/WilliamHaseltine.jpg" class="ms-rtePosition-1" alt="William Haseltine, PhD" style="margin:5px;width:160px;height:200px;" />Long COVID—symptoms that drag on long after someone gets ill with the coronavirus—has many in long term and post-acute care experiencing déjà vu. Diagnostic challenges, questions about treatments, and a limited body of research—these are the same issues they faced at the start of the pandemic over a year ago.<br></p><p>However, while there are still questions, providers have learned much from the pandemic that will help centers navigate the challenges of long COVID and implement and sustain standards, processes, protocols, and interventions that maximize outcomes and quality of life for residents with this condition.</p><h2>What is Known</h2><p>Long COVID is real. Nonetheless, there are still many unknowns, and research is ongoing. “Particularly if someone has been intubated, it takes a long time to recover. It may take many months,” says William Haseltine, PhD, president of ACCESS Health International. “We’ve come to realize that about one in five people infected by COVID suffers consequences well beyond a six-week period.”<br></p><p>Long COVID symptoms are also known as PASC, or post-acute sequelae of SARS-COV-2. However, they are collectively more commonly referred to as long COVID, and people living with this condition are often called “long haulers.” These individuals no longer have live COVID in their bodies, and, if tested, they would test negative for the coronavirus. Yet they are still suffering as a result of their COVID infection. <br></p><p>It’s encouraging to know that health providers are not starting at square one with long COVID. Several common signs and symptoms of the condition have been identified. These include fatigue, shortness of breath or breathing difficulties, cough, joint or chest pain, memory or concentration problems, trouble sleeping, and muscle pain or headache.<br></p><p>Other signs include fast or pounding heartbeat, loss of smell or taste, depression or anxiety, fever, and dizziness on standing.<br></p><p><img src="/Issues/2021/September/PublishingImages/LisaEber.jpg" alt="Leslie Eber, MD, CMD" class="ms-rtePosition-1" style="margin:5px;width:160px;height:200px;" />Leslie Eber, MD, CMD, medical director of Orchard Park Health Care Center and attending physician with Rocky Mountain Senior Care in Colorado, says, “My experience is that our geriatric patients may present with different long COVID symptoms. The most prevalent symptoms I’ve seen are weight loss and anorexia.” </p><p>However, she points out, “We don’t have a clear algorithm of symptoms now or a clear test to determine if someone definitively has long COVID.”</p><h2>Respiratory Underpinnings</h2><p>COVID-19 is thought of as primarily a respiratory illness, and long COVID can affect the lungs long term. For instance, the kind of pneumonia often experienced by COVID patients can cause long-term damage to tiny air sacs in the lungs, resulting in scar tissue that can contribute to long-term breathing difficulties.<br></p><p>However, COVID-19 also can cause long-term damage to other organs. Haseltine explains, “Subacute inflammation from a viral infection can cause changes to the vascular system that affect the brain.”<br></p><p>“We have seen cognitive decline get worse in some COVID survivors,” says David Nace, MD, MPH, clinical chief of geriatric medicine and director of long term care in the Division of Geriatric Medicine at the University of Pittsburgh. “Organizational skills and executive function also can be affected.”<br></p><p>This inflammation also can lead to central nervous system damage through inflammation factors that affect neurofunction, Nace says. Even in young people, COVID can cause strokes, seizures, and Guillain-Barre syndrome (which causes temporary paralysis). It also may increase some people’s risk of developing Parkinson’s or Alzheimer’s disease, physicians report.<br></p><p><img src="/Issues/2021/September/PublishingImages/DavidNace.jpg" alt="David Nace, MD, MPH" class="ms-rtePosition-2" style="margin:5px;width:160px;height:200px;" />Cardiac complications also are possible, and some COVID survivors have been seen to have lasting damage to the heart muscle, which may increase the future risk of heart failure or other cardiac issues.<br></p><p>“We have come to realize that this virus gets in, suppresses the immune system for enough time, and gets out,” Haseltine says. “Only then does the immune system realize something is wrong and everything goes haywire.” <br></p><p>As with COVID-19, there are misconceptions about long COVID. “The most common of these is that it only affects older patients and those who were hospitalized for COVID. In fact, it can happen to younger and asymptomatic patients as well,” says Haseltine. </p><h2>Is it Long COVID or Something Else?</h2><p>While it may not be hard to recognize the signs and symptoms of long COVID in a resident, “it’s difficult to determine if those signs actually are related to long COVID,” Haseltine says. This is particularly true in older patients, who often have multiple illnesses and conditions, some with symptoms that are similar to long COVID. As a result, he says, “We don’t have well-defined treatment for things like chronic fatigue. That is what we’re working out right now.”<br></p><p>“It’s hard to know for sure if an issue or symptom is due to long COVID or something else,” Nace says. “We don’t have a metric we can point to. We are still learning what long COVID looks like, for instance, what aspects of cognition are affected.” He adds that clinicians need to be mindful that some declines have occurred because of social isolation. <br></p><p>“We can’t just chalk these up as advancing dementia,” he says. “Additionally, we need more studies to help determine what cognitive issues are associated with COVID.”<br></p><p>Nonetheless, the symptoms must be managed, whether they stem from long COVID or some other issue. <br></p><p>“We don’t have enough studies to know how to treat signs of long COVID. But the first step is to make sure there’s nothing else that can be accounting for these types of problems,” Nace says. “You need to determine if you’re dealing with other infections, medication changes or adverse reactions, or any cardiac conditions.”<br></p><p>For cognitive issues and psychological symptoms such as anxiety, he says, “We can take the usual steps to diagnose, manage, and monitor these issues.”<br></p><p>Once a resident is displaying signs of long COVID, a COVID test may or may not be helpful. <br></p><p>“Testing is probably still worthwhile, especially if the resident is in a county with a higher prevalence of infections. We don’t yet know how long vaccine protection will last,” Nace says. Nonetheless, “If someone’s test comes back positive and they’ve never had COVID, we would isolate them and monitor for symptoms.”</p><h2>Plan For The Future </h2><p>It’s important to plan ahead. As Nace says, “We already know some states are having upticks in COVID cases, and we may see more activity in the fall. We need to be proactive and prepared to respond if we start seeing more infections.”<br></p><p>All of these recommendations align with guidance coming out of the National Institutes of Health and the Centers for Disease Control and Prevention. “When patients have symptoms, we want to do an appropriate workup, then we want to work with them to manage these symptoms according to their wishes, all with an understanding that long COVID is a possibility,” Eber says. “We need to work within the parameters of their priorities to give them the highest quality of life.”<br></p><p>Eber says clinicians also need to work with families to let them know that long COVID is a possibility but also what other issues could be causing the symptoms. “We need to be honest with them and address their questions and concerns,” she says.</p><h2>Keep Community Informed</h2><p>It is important to avoid the miscommunications and gaps in knowledge that were so problematic during the earlier phases of the pandemic. “The key is to be transparent and honest, saying, ‘This is what we know and don’t know, and this may change over time,’” says Nace. “Mistrust comes in when people put out statements with no evidence to support them. And, unfortunately, there are actors out there doing everything they can to sow distrust, discord, and confusion.” <br></p><p>“If we’ve learned nothing else from COVID, we know we have to respect the scientific process,” Eber stresses. “At the same time, we need to be honest and admit that we don’t have all the answers and that diagnosing long COVID can be challenging.”<br></p><p>As there currently is little published research about long COVID in the geriatric and nursing home population, she suggests, “We need to follow the science and keep up with new studies and innovations. But in the meantime, we can fall back on what we know to be true, what works, and what will help our patients.”<br></p><p>At least for the immediate future, vigilance will be necessary. “We’re already seeing patients with long COVID. If we ignore the possibilities and don’t pay attention, that is where we’ll have problems,” says Nace. “We have to study individuals who we suspect of having long COVID and report what we find.” <br></p> | Long COVID—symptoms that drag on long after someone gets ill with the coronavirus—has many in long term and post-acute care experiencing déjà vu. | 2021-09-01T04:00:00Z | <img alt="" src="/Issues/2021/September/PublishingImages/0921_CF2.jpg" style="BORDER:0px solid;" /> | COVID-19;Chronic Illness | Cover Feature | Joanne Kaldy | 48 | 9 |
| Pandemic Takes its Toll on Sleep | https://www.providermagazine.com/Articles/Pages/Pandemic-Takes-its-Toll-on-Sleep.aspx | Pandemic Takes its Toll on Sleep | <p>During the pandemic, sleep was in short order for many people. In one survey, 56 percent of U.S. adults said they have experienced more sleep disturbances—ranging from problems falling or staying asleep to having disturbing dreams or nightmares—in the past year and a half. In fact, this has been so common, the phenomenon has been given a name—COVID-somnia. <br></p><p>Pandemic-related sleep issues haven’t discriminated. Young and old people alike report some sleep-related problem. Long term and post-acute care centers not only need to identify and address sleep disturbances in their residents but in their staff as well. </p><h2>Wide Awake, Not Dreaming</h2><p>Numerous factors have contributed to the widespread sleep disruptions. “Stress, anxiety, changes in schedules, and increased caffeine or alcohol consumption can all contribute to sleep problems,” says Steven Buslovich, MD, MS, CMD, a New York-based geriatrician and president of Patient Pattern. At the same time, chronic pain, thyroid disease, dementia, and other medical issues can cause sleep disruptions. <br></p><p><img src="/Issues/2021/September/PublishingImages/Buslovich.jpg" alt="Steven Buslovich, MD, MS, CMD" class="ms-rtePosition-1" style="margin:5px;width:160px;height:200px;" />Numerous prescription medications can cause insomnia, says Robin Fine, RPH, a consultant with Forum Extended Care Services. These include selective serotonin reuptake inhibitors (antidepressants), dopamine agonists, psychostimulants and amphetamines, anticonvulsants, steroids, beta agonists, and theophylline. <br></p><p>It is important not to make assumptions about what is causing someone’s sleep issues or that they are normal or not worth addressing. “We have to determine what is causing the problem,” Fine stresses. “Once we identify the root cause, we can begin to address it with targeted interventions.”<br></p><p>Getting to the bottom of a resident’s sleep disturbances or even getting the person to admit or realize he has a problem can be a challenge. “We need to make asking about sleep a regular part of our interactions with residents,” suggests Buslovich. This doesn’t just means asking how he is sleeping. Instead, it calls for a deeper dive and inquiring if he is falling asleep quickly, if he wakes up in the middle of the night, if he experiences early morning wakening with the ability to return back to sleep, or if he is sleeping later than usual. <br></p><p>By identifying and addressing sleep problems early, it is possible to prevent falls, behavioral issues, and other problems that can result due to lack of sleep.<br></p><p>“We don’t generally focus on sleep as a quality measure, but looking at sleep patterns and sleep disturbances can give you insights into other things that are going on, such as depression or untreated pain. All of these tend to manifest at night. Inquiring about sleep is a gateway question to discovering other issues,” Buslovich notes. <br></p><p>Lea Watson, MD, a Colorado-based geriatric psychiatrist, says, “[Certified nurse assistants] can walk down the hall at night and peek into residents’ rooms to see if they are asleep. However, we need other, more accurate means to assess sleep, such as the use of wearable devices.”</p><h2>Treating COVID-somnia</h2><p>Instead of starting with medications, says Watson, it is important to consider nonpharmacologic solutions. For instance, environment interventions such as reducing noise, light, and room temperature can help. Aromatherapy and white noise or sound machines are other options.<br></p><p><img src="/Issues/2021/September/PublishingImages/LeaWatson.jpg" alt="Lea Watson, MD" class="ms-rtePosition-2" style="margin:5px;width:160px;height:200px;" />Good sleep hygiene—getting up and going to bed on a regular schedule, limiting caffeine intake to the morning hours, and getting some exercise during the day—also can make a difference. “When I get calls about patients having problems sleeping, they often aren’t doing these things,” Watson says. “It’s important not to assume that people know about sleep hygiene.”<br></p><p>For instance, some people may think that wine or other alcoholic beverage before bed will help them relax and go to sleep when, in fact, it may result in disrupted sleep.<br></p><p>Don’t underestimate the power of sunshine and light on sleep. “Natural sunlight in the morning can help reset your circadian rhythm, the body’s 24-hour clock that coordinates lots of processes, including sleep,” Watson says.</p><h2>Positive Actions</h2><p>Exercise is key to good sleep, and this has been challenging during lockdowns and quarantines. “Re-entry phenomenon is a huge issue. Our residents are so used to having their activity restricted. We need to rebuild their trust and confidence to get out do things they want to do,” Watson says. “We’ve seen a drop in enthusiasm about activities, and we have to find ways to build this back up.”<br></p><p>Patients or families may be tempted to use over-the-counter sleep aids, but no decision should be made without consulting a physician, pharmacist, or other clinician. “These products aren’t without side effects and actually may not be as effective as changing behaviors and employing nonpharmacologic interventions,” says Watson.<br></p><p>As more family come in for visits, Fine says, “They will want to bring in foods and take residents out for meals and social events. It is important to remind them about the impact of caffeine, alcohol, sugar, eating heavy meals before bedtime, and other things on sleep.”<br></p><p>At the same time, she suggests, remind family to reach out to the physician, pharmacist, or other practitioner if their loved one isn’t sleeping well, instead of bringing in over-the-counter products, herbals, or other prescriptives.<br></p><p>Prescription drugs should be a last result and not a first-line treatment, Watson says. “Many approved hypnotics on the market have a limited evidence base for outcomes. And there is a huge myth that sleeping pills are robustly helpful, but this too is based on limited data, and they have serious side effects.”<br></p><p>When prescription drugs are necessary, she says, “I don’t put anyone on long-term use of sleep medicines. They always should be scheduled and not be given PRN. This reinforces the positive loop of having to demonstrate the need for the meds regularly over time.”<br></p><p>Fine agrees: “You can’t just throw medication at the problem. You have to do a root-cause analysis. If you find that a resident is on a medication, such as a beta-blocker for cardiac issues that can’t be changed, you have to look at other ways to improve sleep quality.” </p><h2>When Sleeplessness Slams Staff</h2><p>Team members may feel tired or have trouble sleeping, but they also may just shrug it off or be hesitant to admit it. “Despite increased attention to this issue, there is still a lack of awareness,” says Buslovich. At the same time, he says, “Sleep deprivation is common in this field, but that doesn’t mean it’s okay or that we can’t help people get better sleep.” <br></p><p>Watson concurs and says, “This is absolutely a real problem. People are homeschooling their children and going to work. They’re overburdened and overworked, and they’re not doing normal self-care.” However, people aren’t likely to report their lack of sleep. <br></p><p>“There is a misplaced idea that lack of sleep says you’re working hard. Frontline staff are sleep-deprived but don’t think to report it,” she says, which is because they often don’t identify insomnia as a chief complaint.<br>When people aren’t sleeping well, particularly because of stress or anxiety, it can be tempting to self-medicate with over-the-counter medications, illicit substances, and/or alcohol. It is important to encourage staff to take positive, safe, and healthy approaches to better sleep.<br></p><p>“We may not be able to improve quantity of sleep, but we can help people get better quality of sleep,” says Buslovich. It is important to encourage staff to pursue exercise, healthy eating, and mental and physical rejuvenation and give them opportunities via efforts such as a lunchtime walking group and onsite yoga classes, easy access to healthy snacks, and mindfulness meditation training. </p><h2>Willing Watchfulness </h2><p>Jea Theis, MSW, LCSW, LIMHP, of Omaha Therapy and Arts Collaborative, stresses, “Anything we consume can contribute to our distress, which can impact our sleep. For instance, feeding ourselves a steady diet of TV news or other media increases stress and anxiety. We call it secondary trauma exposure, and we need to limit our consumption of these things.”<br></p><p>Providing staff with links to free downloads of music, movies, and books may encourage them to turn off the news and pursue more positive, uplifting diversions. <br></p><p>It can be challenging, but promoting a work-life balance is important, Theis says. Sending and receiving after-hours work-related emails or texts can increase stress and make it harder for people to relax and clear their minds. It may help to encourage managers and team leaders to think twice before sending a late-night message to a colleague or employee and consider: Is this urgent or can it wait until morning?<br></p><p>Moving forward, says Theis, “Be alert. Any time you see a shift in behavior or mood—such as irritability, anger, increased confusion, or lack of focus—in a resident or staff member, that is telling you something. And it may be saying that sleep quality isn’t good. It is important to check in with people, particularly when you see these signs.”<br></p><p>At the same time, she suggests, have integrative therapies readily available, everything from pet therapy and yoga to aromatherapy and mindfulness. “People need things that help them feel good and that bring their bodies to a safer, calmer place,” she says. <br></p><p>On a broader level, it’s about connections, Theis says. “If we just ask people about sleep, we are missing the bigger picture. We need to talk about healthy ways to live, improve their quality of life, and ultimately get quality sleep.” <br></p> | In one survey, 56 percent of U.S. adults said they have experienced more sleep disturbances—ranging from problems falling or staying asleep to having disturbing dreams or nightmares—in the past year and a half. | 2021-09-01T04:00:00Z | <img alt="" src="/Issues/2021/September/PublishingImages/0921_CF3.jpg" style="BORDER:0px solid;" /> | COVID-19;Clinical | Cover Feature | Joanne Kaldy | 48 | 9 |