CHOOSING WISELY TO IMPROVE CARE FOR GERIATRIC PATIENTS

Transcription

1 CHOOSING WISELY TO IMPROVE CARE FOR GERIATRIC PATIENTS

2 About Choosing Wisely First conceived by the National Physicians Alliance and Funded by an ABIM Foundation grant As much as 30% of care delivered in the US may be duplicative or unnecessary according to a 2008 Congressional Budget Office Report Promotes conversations between physicians and patients to focus on care that is: Supported by evidence Not duplicative of other tests or procedures already received Free from harm Truly necessary

3 The Choosing Wisely Campaign Leading specialty societies were asked to create a list of Things Physicians and Patients Should Question To date, 56 societies have released lists, some of them releasing a second or third list Consumer Reports has worked with the ABIM Foundation to maximize reach and impact of the Choosing Wisely campaign Engaged coalition of consumer organizations to disseminate content and messages about appropriate use to the communities they serve

4 AGS-Ten Things Clinicians and Patients Should Question 1 Don t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer assisted oral feeding Don t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia. Avoid using medications to achieve hemoglobin A1c <7.5% in most adults age 65 and older; moderate control is generally better. Don t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium. 5 Don t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.

5 AGS-Ten Things Clinicians and Patients Should Question 6 7 Don t prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects. Don t recommend screening for breast or colorectal cancer, nor prostate cancer (with the PSA test) without considering life expectancy and the risks of testing, overdiagnosis and overtreatment. 8 Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, provide feeding assistance, and clarify patient goals and expectations. 9 Don t prescribe a medication without conducting a drug regimen review. 10 Avoid physical restraints to manage behavioral symptoms of hospitalized older adults with delirium.

6 Choosing Wisely : Antimicrobials to Treat Bacteriuria in Older Adults Don t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present. Don t obtain a urine culture unless there are clear signs and symptoms that localize to the urinary tract Don t place an indwelling urinary catheter to manage urinary incontinence

7 Asymptomatic bacteriuria (ASB) Asymptomatic bacteriuria, or asymptomatic urinary infection, is isolation of a specified quantitative count of bacteria in an appropriately collected urine specimen obtained from a person without symptoms or signs referable to urinary infection. Nicolle LE, et al. Clin Infect Dis. 2005;40(5):

8 ASB is common in older adults Population ASB Rates Community women >70 11% 16% Community men >70 4% 19% Long-term care overall 15% 50% LTC men 15% 40% LTC women 25% 50% Chronic indwelling catheter 100%

9 ASB in older adults is benign Increased risk of infection, but not related to bacteriuria No long-term increased risk of hypertension No long-term increased risk of renal failure Survival differences are similar when controlling for other functional and clinical factors Nordenstram GR, et. al. N Engl J Med. 1986;314:

10 Treating ASB with antimicrobials does not improve outcomes Author Subjects Intervention Outcome Nicolle et al, NEJM men >80 yr NH residents Randomized to abx vs none Duration 2 years No Δ in: Mortality Infectious morbidity Nicolle et al, Am J Med women 83 yr NH residents Randomized to abx vs none Duration 1 year No Δ in: Mortality, GU morbidity. ADR and resistance in treated group. Juthani-Mehta M. Clin Geriatr Med. 2007;23:

11 Treating ASB with antimicrobials does not improve outcomes Author Subjects Intervention Outcome Abrutyn et al, Ann Intern Med women, 82 yr Apartment and NH Randomized to abx vs none Duration 8 years No survival benefit in treatment group Ouslander et al, Ann Intern Med women and men 85 yr NH Randomized to abx vs placebo 4 weeks No Δ in chronic urinary incontinence symptoms

12 Treating ASB with antimicrobials has potentially harmful effects Increased adverse drug reactions Rash Candidiasis Diarrhea Swollen mouth Dizziness NNH: 2 3 Increased antibiotic resistance Nicolle et al. Am J Med

13 Educational information for primary care clinicians -Modified McGeer Criteria Symptomatic urinary tract infection must have a positive urine culture (10 5 cfu/ml of no more than 2 species in voided sample), and Fever or leukocytosis and one symptom localizing to the urinary tract: acute costovertebral angle or suprapubic pain or tenderness, hematuria, new or marked increase in incontinence, urgency, or Two symptoms localizing to the urinary tract. Symptomatic urinary tract infection with an indwelling catheter requires fever, rigors, leukocytosis, new onset hypotension, acute costovertebral angle or suprapubic pain or tenderness, and no alternate site of infection. Note that hematuria, catheter obstruction, and cloudy urine are not sufficient. Stone ND, et al. Infect Control Hosp Epidemiol Oct; 33(10):

14 Do treat ASB prior to invasive urologic procedures in older adults Bacteremia occurs in 60% of bacteriuric patients undergoing TURP Clinical evidence of sepsis in 6% 10% NNT to prevent septicemia: Urologic interventions with a high probability of mucosal bleeding should be considered at risk, and treated. Nicolle LE, et al. Clin Infect Dis. 2005;40(5):

15 Patients with indwelling urethral catheters Short term Catheter Approximately, 80% of acute care facility patients with short term (<30 days) indwelling urethral catheters receive active microbial therapy, usually for an indication other than urinary infection. Long term Catheter A study of consecutive courses of anti microbial treatment to eradicate bacteriuria in elderly patients revealed: no decrease in the number of episodes of fever with treatment immediate recurrence of bacteriuria after therapy Increased risk of bacterial antibiotic resistance

16 Sustained Reduction of Inappropriate Treatment of ASB Educational interventions requiring minimal resources can result in sustained reductions in inappropriate treatment of ASB in long term care and decreased total antimicrobial use. Education of the nursing staff regarding appropriate criteria for requesting urine cultures should be a component of such interventions.

17 Sample Educational Information for Nursing Staff Criteria for sending a urine culture: Fever or rigors New urinary urgency or frequency New Dysuria or urinary incontinence Hematuria Acute urinary retention Flank pain Significant change in mental status, with no other explanation Do NOT send a urine routinely for: Foul-smelling or cloudy urine After every urethral catheter change Upon admission After treatment to document cure

18 Catheter associated urinary tract infection Catheter associated bacteriuria is the most common healthcare associated infection worldwide and is result of widespread use of urinary catheterization much of which is inappropriate in LTC.

19 Reduction of Inappropriate Urinary Catheter Insertion Not used for the management of urinary incontinence for staff or patient convenience Institutions should develop a list of appropriate indications for inserting indwelling urinary catheters, educate staff about such indications, and periodically assess adherence to the institution-specific guidelines. Institutions should consider the use of bladder scans to document retention before inserting a catheter.

20 Catheter related complications Bacteremia. Febrile episodes Bladder stones Fistula formation Erosion of the urethra Epididymitis Pyelonephritis Blockage Poor urine flow Persistent leakage around catheter

21 Sources Nordenstam GR, Brandberg CA, Odén AS, Svanborg Edén CM, Svanborg A. Bacteriuria and mortality in an elderly population. N Engl J Med May 1;314(18): Nicolle LE, Mayhew WJ, Bryan L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women. Am J Med. 1987Jul;83(1): Juthani-Mehta M. Asymptomatic bacteriuria and urinary tract infection in older adults. Clin Geriatr Med [Internet] Aug;23(3): Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM; Infectious Diseases Society of America; American Society of Nephrology; American Geriatric Society. Infectious Diseases Society of America Guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. [Internet] Mar 1;40(5): Stone ND, Ashraf MS, Calder J, Crnich CJ, Crossley K, Drinka PJ, Gould CV, Juthani-Mehta M, Lautenbach E, Loeb M, MacCannell T, Malani TN, Mody L, Mylotte JM, Nicolle LE, Roghmann MC, Schweon SJ, Simor AE, Smith PW, Stevenson KB, Bradley SF. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer Criteria. Infec Control Hosp Epidemiol. 2012; 33(10): Drinka P. Treatment of bacteriuria without urinary signs, symptoms, or systemic infectious illness (S/S/S). J Am Med Dir Assoc Oct;10(8): Arinzon Z, Peisakh A, Shuval I, Shabat S, Berner YN. Detection of urinary tract infection (UTI) in long-term care setting: is the multireagent strip an adequate diagnostic tool? Arch Gerontol Geriatr Mar-Apr;48(2): High KP, Bradley SF, Gravenstein S, Mehr DR, Quagliarello VJ, Richards C, Yoshikawa TT. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. J Am Geriatr Soc Mar;57(3): Zabarsky TF, Sethi AK, Donskey CJ. Sustained reduction in inappropriate treatment of asymptomatic bacteriuria in a long-term care facility through an educational intervention. Am J Infect Control Sep;36(7): Richards CL Jr. Infection control in long-term care facilities. J Am Med Dir Assoc Mar;8(3 Suppl):S18-25.

22 Sources Ducharme J, Neilson S, Ginn JL. Can urine cultures and reagent test strips be used to diagnose urinary tract infection in elderly emergency department patients without focal urinary symptoms? CJEM Mar;9(2): Loeb M, Brazil K, Lohfeld L, McGeer A, Simor A, Stevenson K, Zoutman D, Smith S, Liu X, Walter SD. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomized controlled trial. BMJ Sep 24;331(7518):669. Loeb M, Brazil K, Lohfeld L, McGeer A, Simor A, Stevenson K, Walter S, Zoutman D. Optimizing antibiotics in residents of nursing homes: protocol of a randomized trial. BMC Health Serv Res Sep 3;2(1):17. Nicolle LE. Urinary tract infection in geriatric and institutionalized patients. Curr Opin Urol Jan;12(1):51-5. Boscia JA, Kobasa WD, Abrutyn E, Levison ME, Kaplan AM, Kaye D. Lack of association between bacteriuria and symptoms in the elderly. Am J Med Dec;81(6): Nicolle LE, Bentley D, Garibaldi R, Neuhaus E, Smith P. SHEA Long-Term-Care Committee. Antimicrobial use in long-term-care facilities. Infect Control Hosp Epidemiol. 1996;17: High KP, Bradley SF, Gravenstein S, Mehr DR, Quagliarello VJ, Richards C, Yoshikawa TT. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term CMS Manual System Pub State Operations Provider Certification. Transmittal 8. Revision of Appendix PP Section (d) Urinary Incontinence, Tags F315 and F316. Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services; 2005 Jun 28 [cited 2014 Dec 31]. Available from: Guidance/Guidance/Transmittals/downloads/r8som.pdf. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated urinary tract infections Infect Control Hosp Epidemiol Apr;31(4): Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, Saint S, Schaeffer AJ, Tambayh PA, Tenke P, Nicolle LE; Infectious Diseases Society of America. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis Mar;50(5):