Browsing by Author "Unroe, Kathleen T."
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Item Age-specific rates of hospital transfers in long-stay nursing home residents(Oxford Academic, 2022-01) Tu, Wanzhu; Li, Ruohong; Stump, Timothy E.; Fowler, Nicole R.; Carnahan, Jennifer L.; Blackburn, Justin; Sachs, Greg A.; Hickman, Susan E.; Unroe, Kathleen T.; Biostatistics, School of Public HealthIntroduction hospital transfers and admissions are critical events in the care of nursing home residents. We sought to determine hospital transfer rates at different ages. Methods a cohort of 1,187 long-stay nursing home residents who had participated in a Centers for Medicare and Medicaid demonstration project. We analysed the number of hospital transfers of the study participants recorded by the Minimum Data Set. Using a modern regression technique, we depicted the annual rate of hospital transfers as a smooth function of age. Results transfer rates declined with age in a nonlinear fashion. Rates were the highest among residents younger than 60 years of age (1.30-2.15 transfers per year), relatively stable between 60 and 80 (1.17-1.30 transfers per year) and lower in those older than 80 (0.77-1.17 transfers per year). Factors associated with increased risk of transfers included prior diagnoses of hip fracture (annual incidence rate ratio or IRR: 2.057, 95% confidence interval (CI): [1.240, 3.412]), dialysis (IRR: 1.717, 95% CI: [1.313, 2.246]), urinary tract infection (IRR: 1.755, 95% CI: [1.361, 2.264]), pneumonia (IRR: 1.501, 95% CI: [1.072, 2.104]), daily pain (IRR: 1.297, 95% CI: [1.055,1.594]), anaemia (IRR: 1.229, 95% CI [1.068, 1.414]) and chronic obstructive pulmonary disease (IRR: 1.168, 95% CI: [1.010,1.352]). Transfer rates were lower in residents who had orders reflecting preferences for comfort care (IRR: 0.79, 95% CI: [0.665, 0.936]). Discussion younger nursing home residents may require specialised interventions to reduce hospital transfers; declining transfer rates with the oldest age groups may reflect preferences for comfort-focused care.Item Attitudes and Experiences of Frontline Nursing Home Staff Towards Coronavirus Testing(Elsevier, 2020-11-05) Hofschulte-Beck, Spencer L.; Hickman, Susan E.; Blackburn, Justin L.; Mack, Laramie M.; Unroe, Kathleen T.; Medicine, School of MedicineThe Indiana State Department of Health tested nursing home staff for COVID-19 in June 2020. A survey of staff found many felt physical discomfort, some questioned testing the asymptomatic, but a majority agreed testing is important.Item The Avoidable Transfer Scale: A New Tool for Identifying Potentially Avoidable Hospital Transfers of Nursing Home Residents(Oxford University Press, 2022-05-11) Carnahan, Jennifer L.; Unroe, Kathleen T.; Evans, Russell; Klepfer, Sarah; Stump, Timothy E.; Monahan, Patrick O.; Torke, Alexia M.; Medicine, School of MedicineBackground and objectives: Prior approaches to identifying potentially avoidable hospital transfers (PAHs) of nursing home residents have involved detailed root cause analyses that are difficult to implement and sustain due to time and resource constraints. They relied on the presence of certain conditions but did not identify the specific issues that contributed to avoidability. We developed and tested an instrument that can be implemented using review of the electronic medical record. Research design and methods: The OPTIMISTIC project was a Centers for Medicare and Medicaid Services demonstration to reduce avoidable hospital transfers of nursing home residents. The OPTIMISTIC team conducted a series of root cause analyses of transfer events, leading to development of a 27-item instrument to identify common characteristics of PAHs (Stage 1). To refine the instrument, project nurses used the electronic medical record (EMR) to score the avoidability of transfers to the hospital for 154 nursing home residents from 7 nursing homes from May 2019 through January 2020, including their overall impression of whether the transfer was avoidable (Stage 2). Each transfer was rated independently by 2 nurses and assessed for interrater reliability with a kappa statistic. Results: Kappa scores ranged from -0.045 to 0.556. After removing items based on our criteria, 12 final items constituted the Avoidable Transfer Scale. To assess validity, we compared the 12-item scale to nurses' overall judgment of avoidability of the transfer. The 12-item scale scores were significantly higher for submissions rated as avoidable than those rated unavoidable by the nurses (mean 5.3 vs 2.6, p < .001). Discussion and implications: The 12-item Avoidable Transfer Scale provides an efficient approach to identify and characterize PAHs using available data from the EMR. Increased ability to quantitatively assess the avoidability of resident transfers can aid nursing homes in quality improvement initiatives to treat more acute changes in a resident's condition in place.Item Care Consistency With Documented Care Preferences: Methodologic Considerations for Implementing the “Measuring What Matters” Quality Indicator(Elsevier, 2016-11) Unroe, Kathleen T.; Hickman, Susan E.; Torke, Alexia M.; Department of Medicine, School of MedicineA basic tenet of palliative care is discerning patient treatment preferences and then honoring these preferences, reflected by the inclusion of “Care Consistency With Documented Care Preferences” as one of 10 “Measuring What Matters quality” indicators. Measuring What Matters indicators are intended to serve as a foundation for quality measurement in health care settings. However, there are a number of logistic and practical issues to be considered in the application of this quality indicator to clinical practice. In this brief methodologic report, we describe how care consistency with documented care preferences has been measured in research on patients near the end of life. Furthermore, we outline methodologic challenges in using this indicator in both research and practice, such as documentation, specificity and relevance, preference stability, and measuring nonevents. Recommendations to strengthen the accuracy of measurement of this important quality marker in health care settings include consistent recording of preferences in the medical record, considerations for selection of treatment preferences for tracking, establishing a protocol for review of preferences, and adoption of a consistent measurement approach.Item Comfort Measures Orders and Hospital Transfers: Insights From the OPTIMISTIC Demonstration Project(Elsevier, 2019) Unroe, Kathleen T.; O'Kelly Phillips, Erin; Effler, Shannon; Ersek, Mary; Hickman, Susan E.; Medicine, School of MedicineContext Nursing facility residents and their families may identify “comfort measures” as their overall goal of care, yet some hospital transfers still occur. Objectives Describe nursing facility residents with comfort measures and their hospital transfers. Methods Mixed methods, including root cause analyses of transfers by registered nurses and interviews with a subset of health care providers and family members involved in transfers. Participants were residents in 19 central Indiana facilities with comfort measures orders who experienced unplanned transfers to the hospital between January 1, 2015 and June 30, 2016. Project demographic and clinical characteristics of the residents were obtained from the Minimum Data Set 3.0. Interviews were conducted with stakeholders involved in transfer decisions. Participants were prompted to reflect on reasons for the transfer and outcomes. Interviews were transcribed and coded using qualitative descriptive methods. Results Residents with comfort measures orders (n = 177) experienced 204 transfers. Most events were assessed as unavoidable (77%). Communication among staff, or between staff and the resident/family, primary care provider, or hospital was the most frequently noted area needing improvement (59.5%). In interviews, participants (n = 11) highlighted multiple issues, including judgments about whether decisions were “good” or “bad,” and factors that were important to decision-making, including communication, nursing facility capabilities, clinical situation, and goals of care. Conclusion Most transfers of residents with comfort measures orders were considered unavoidable. Nonetheless, we identified several opportunities for improving care processes, including communication and addressing acute changes in status.Item Community COVID-19 activity level and nursing home staff testing for active SARS-CoV-2 infection in Indiana(Elsevier, 2020) Blackburn, Justin; Weaver, Lindsay; Cohen, Liza; Menachemi, Nir; Rusyniak, Dan; Unroe, Kathleen T.; Health Policy and Management, School of Public HealthObjectives: To assess whether using coronavirus disease 2019 (COVID-19) community activity level can accurately inform strategies for routine testing of facility staff for active severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Design: Cross-sectional study. Setting and Participants: In total, 59,930 nursing home staff tested for active SARS-CoV-2 infection in Indiana. Measures: Receiver operator characteristic curves and the area under the curve to compare the sensitivity and specificity of identifying positive cases of staff within facilities based on community COVID-19 activity level including county positivity rate and county cases per 10,000. Results: The detection of any infected staff within a facility using county cases per 10,000 population or county positivity rate resulted in an area under the curve of 0.648 (95% confidence interval 0.601‒0.696) and 0.649 (95% confidence interval 0.601‒0.696), respectively. Of staff tested, 28.0% were certified nursing assistants, yet accounted for 36.9% of all staff testing positive. Similarly, licensed practical nurses were 1.4% of staff, but 4.7% of positive cases. Conclusions and Implications: We failed to observe a meaningful threshold of community COVID-19 activity for the purpose of predicting nursing homes with any positive staff. Guidance issued by the Centers for Medicare and Medicaid Services in August 2020 sets the minimum frequency of routine testing for nursing home staff based on county positivity rates. Using the recommended 5% county positivity rate to require weekly testing may miss asymptomatic infections among nursing home staff. Further data on results of all-staff testing efforts, particularly with the implementation of new widespread strategies such as point-of-care testing, is needed to guide policy to protect high-risk nursing home residents and staff. If the goal is to identify all asymptomatic SARS-Cov-2 infected nursing home staff, comprehensive repeat testing may be needed regardless of community level activity.Item The Complexity of Determining Whether a Nursing Home Transfer Is Avoidable at Time of Transfer(Wiley, 2018-05) Unroe, Kathleen T.; Carnahan, Jennifer L.; Hickman, Susan E.; Sachs, Greg A.; Hass, Zachary; Arling, Greg; Medicine, School of MedicineObjectives To describe the relationship between nursing facility resident risk conditions and signs and symptoms at time of acute transfer and diagnosis of conditions associated with potentially avoidable acute transfers (pneumonia, urinary tract infection, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) or asthma, dehydration, pressure sores). Design As part of a demonstration project to reduce potentially avoidable hospital transfers, Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project clinical staff collected data on residents who transferred to the emergency department (ED) or hospital. Cross‐tabulations were used to identify associations between risk conditions or symptoms and hospital diagnoses or death. Mixed‐effects logistic regression models were used to describe the significance of risk conditions, signs, or symptoms as predictors of potentially avoidable hospital diagnoses or death. Setting Indiana nursing facilities (N=19). Participants Long‐stay nursing facility residents (N=1,174), who experienced 1,931 acute transfers from November 2014 to July 2016. Measurements Participant symptoms, transfers, risk factors, and hospital diagnoses. Results We found that 44% of acute transfers were associated with 1 of 6 potentially avoidable diagnoses. Symptoms before transfer did not discriminate well among hospital diagnoses. Symptoms mapped into multiple diagnoses and most hospital diagnoses had multiple associated symptoms. For example, more than two‐thirds of acute transfers of residents with a history of CHF and COPD were for reasons other than exacerbations of those two conditions. Conclusion Although it is widely recognized that many transfers of nursing facility residents are potentially avoidable, determining “avoidability” at time of transfer is complex. Symptoms and risk conditions were only weakly predictive of hospital diagnoses.Item COVID-19 in Older Adults: Transfers Between Nursing Homes and Hospitals(ACEP, 2020) Levine, Stacie; Bonner, Alice; Perry, Adam; Melady, Donald; Unroe, Kathleen T.; Medicine, School of MedicineItem COVID‐19 disease trajectories among nursing home residents(Wiley, 2021-09) Carnahan, Jennifer L.; Lieb, Kristi M.; Albert, Lauren; Wagle, Kamal; Kaehr, Ellen; Unroe, Kathleen T.; Medicine, School of MedicineIntroduction Older adults are at greater risk of both infection with and mortality from COVID‐19. Many U.S. nursing homes have been devastated by the COVID‐19 pandemic, yet little has been described regarding the typical disease course in this population. The objective of this study is to describe and identify patterns in the disease course of nursing home residents infected with COVID‐19. Setting and Methods This is a case series of 74 residents with COVID‐19 infection in a nursing home in central Indiana between March 28 and June 17, 2020. Data were extracted from the electronic medical record and from nursing home medical director tracking notes from the time of the index infection through August 31, 2020. The clinical authorship team reviewed the data to identify patterns in the disease course of the residents. Results The most common symptoms were fever, hypoxia, anorexia, and fatigue/malaise. The duration of symptoms was extended, with an average of over 3 weeks. Of those infected 25 died; 23 of the deaths were considered related to COVID‐19 infection. A subset of residents with COVID‐19 infection experienced a rapidly progressive, fatal course. Discussion/Conclusions Nursing home residents infected with COVID‐19 from the facility we studied experienced a prolonged disease course regardless of the severity of their symptoms, with implications for the resources needed to care for and support of these residents during active infection and post‐disease. Future studies should combine data from nursing home residents across the country to identify the risk factors for disease trajectories identified in this case series.Item Describing Transfers Originating Out-of-Facility for Nursing Home Residents(Elsevier, 2022) Webb, Hanna T.; Lieb, Kristi M.; Stump, Timothy E.; Unroe, Kathleen T.; Carnahan, Jennifer L.; Medicine, School of MedicineObjectives: Potentially avoidable hospitalizations are harmful to nursing home residents. Despite extensive care transitions research, no studies have described transfers originating outside the nursing home (eg, visiting family members or at a dialysis center). This article describes 82 out-of-facility (community) transfers and compares them to transfers originating within the nursing home (direct transfers). Design: Secondary data analysis with multivariable model for community transfer risk factors. Setting and participants: Eighty-two community transfers and 1362 transfers originating in the nursing home, involving 870 residents enrolled in the OPTIMISTIC demonstration project between January 1, 2015, and June 30, 2016. Methods: Transfers were compared using data from the Minimum Data Set and root cause analyses performed at time of transfer. Multivariable associations were assessed at the transfer level to define risk factors for community transfers. Project nurses collected data on community transfers to inform a root cause analysis. Results: Residents with community transfers were younger (74.4 years vs 78.2 years), with lower prevalence of cognitive impairment (44.8% vs 70.3%) and higher rates of heart failure (38.7% vs 23.3%) than residents with direct transfers. Community transfers were more likely due to cardiovascular illness (31.2% vs 8.7%), whereas less likely to be for cognitive, behavioral, and psychiatric concerns (11.7% vs 22.7%). Nearly half (46%) of community transfers originated at dialysis centers. Residents transferred outside the nursing home were less likely to have documented limitations to care such as a do not resuscitate code status. Communication during community transfers was identified on root cause analyses as a potential area for improvement. Conclusions and implications: Community transfers were more likely to occur in younger residents with higher rates of cardiovascular disease and lower rates of cognitive impairment. Improved communication between nursing home staff and outside providers as well as more extensive advance care planning for residents with cardiovascular disease may reduce community transfers.