Study of Infection Management and Palliative Care at End-of-Life (SIMP-EL)

在为许多老年人提供护理的养老院(NH)环境中，卓越的姑息护理是一个优先事项 患有晚期疾病的居民在生命的末期。不幸的是，不理想的姑息治疗很常见。 感染是经常发生的，由于许多原因，管理具有挑战性。在我们的成功中 家长研究我们关注了全国NHS的感染控制和管理项目，并发现 每年有40%的经过联邦医疗保险认证的国民健康保险制度因感染控制不力和 不到一半的NHS(46%)制定了抗生素起始指南。抗生素大约占到 英国国家医疗服务体系所有药物的40%。不幸的是，大部分使用都是不适当的，就像抗生素一样。 通常在没有细菌感染的临床证据的情况下开始，这种误用是一个主要的危险因素。 适用于耐多药生物和艰难梭菌感染。疑似感染是常见的原因 对于老年居民转院，这是繁重的，而且往往对临床没有好处。对于 大多数NH居民，与抗生素使用和医院转院相关的风险和痛苦 感染可能大于收益。此外，感染的控制和管理以及姑息治疗 随着各种区域和州一级倡议的实施，NHS的护理环境正在发生变化。它是 对于一些NHS来说，这些举措可能会促进以居民为中心的医疗服务，将感染纳入其中 管理和姑息治疗，而在其他情况下，NH人员将被要求遵守有利于负担的标准 根治疗法。在我们的竞争续订中，我们将使用纵向最小数据集数据和联邦医疗保险 文件(即2011至2017年约100万居民)，以识别NH老年居民和 重要的住院医生水平协变量(例如，晚期疾病)，跟踪抗生素和临终关怀的使用，并跟踪医院 与感染有关的转移。我们将补充这些二级数据集，并将其与环境 对国家和地区活动的扫描，以及对新的NHS和我们的“核心”的全国调查数据 作为我们母公司研究的一部分，NHS在2014年进行了调查(我们估计将有1500名NHS做出回应)。这项调查将 描述当前建议的结构和流程的实施情况，这些结构和流程涉及：1)感染控制 和管理，2)姑息治疗，以及3)感染管理和姑息治疗的整合。我们的 具体目标是：1)描述NHS感染管理和姑息治疗的整合情况 相关设施、州和地区特征；2)检查与抗生素使用相关的因素 老年医院居民；以及3)检查与老年人因感染而转院的相关因素 NH居民。了解如何最好地改进感染管理和姑息治疗的整合 提高居民生活质量是一个有待深入研究的领域。因此，这一创新 这项研究有可能通过促进以居民为中心的终末期治疗做出临床和政策相关的贡献。 为数百万生活在NHS的美国人提供生命关怀。

Excellence in palliative care is a priority in the nursing home (NH) setting, which provides care to many older residents with advanced illness at the end of life. Unfortunately, suboptimal palliative care is common. Infections are a frequent occurrence and management is challenging for many reasons. In our successful parent study we focused on infection control and management programs in NHs across the nation and found that annually 40% of all Medicare-certified NHs receive deficiency citations for inadequate infection control and less than half of NHs (46%) had written guidelines for antibiotic initiation. Antibiotics account for approximately 40% of all medications administered in NHs. Unfortunately, much of the use is inappropriate as antibiotics are often initiated in the absence of clinical evidence of a bacterial infection, and this misuse is a major risk factor for multidrug-resistant organisms and Clostridium difficile infections. Suspected infections are common reasons for elderly resident transfers to hospitals, and these are burdensome and often not clinically beneficial. For the majority of NH residents, the risks and suffering associated with antibiotic use and hospital transfer due to infection may outweigh the benefit. In addition, the infection control and management as well as the palliative care landscapes are changing in NHs with various regional and state level initiatives being implemented. It is likely that for some NHs these initiatives will promote resident-centered care that integrates infection management and palliative care while in others, NH personnel will be held to standards that favor burdensome curative treatments. In our competing renewal, we will use longitudinal Minimum Data Set data and Medicare files (i.e., approximately 1 million residents over years 2011 to 2017) to identify elderly NH residents and important resident level covariates (e.g., advanced illness), track antibiotic and hospice use, and track hospital transfers related to infections. We will complement and link these secondary datasets with environmental scans of state and regional activities as well as with data from a national survey of new NHs and our “core” NHs surveyed in 2014 as part of our parent study (we estimate that 1,500 NHs will respond). The survey will characterize implementation of current recommended structures and processes related to: 1) infection control and management, 2) palliative care, and 3) the integration of infection management and palliative care. Our specific aims are to: 1) Describe the integration of infection management and palliative care in NHs and the associated facility, state, and regional characteristics; 2) Examine factors associated with antibiotic use in elderly NH residents; and 3) Examine factors associated with hospital transfer due to infections among elderly NH residents. Understanding how best to improve the integration of infection management and palliative care to improve residents' quality of life is an under-studied area in need of rigorous research. Thus, this innovative study has the potential to make clinical and policy-relevant contributions by promoting resident-centered end- of-life care for millions of Americans living in NHs.