‘Possible’ acute change in mental status finds additional HAIs in nursing homes
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Using a “possible” acute change in mental status criterion identified an additional 21 health care-associated infections among nursing home residents in 161 facilities, according to findings in Infection Control and Hospital Epidemiology.
“During our analysis of surveillance data collected on more than 15,000 nursing home residents, we were surprised to discover that none met the definition for confirmed acute change in mental status (ACMS),” Austin R. Penna, MPH, of the CDC’s Division of Healthcare Quality Promotion, told Healio. “Because several health care-associated infection (HAI) surveillance definitions include ACMS as a criterion, we wanted to learn if using a more sensitive definition of ‘possible’ ACMS would improve HAI detection.”
In 2017, the CDC’s Emerging Infections Program (EIP) performed a nursing home prevalence survey of HAIs in 10 states: California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon and Tennessee. Trained EIP staff examined the resident medical records for any signs or symptoms of infection on the survey date or the day before; if present, these findings led to a more thorough review to identify all infection criteria present, including for any ACMS that were new or different from baseline, on the survey date or in the 6 days before.
Penna and colleagues then determined the incidence of each Confusion Assessment Method (CAM) element or combinations of elements, as well as confirmed ACMS. They defined possible ACMS as the documentation of any of the four CAM elements. They then calculated and compared the number of residents meeting catheter-associated urinary tract infection, lower respiratory tract infection, pneumonia and cellulitis and/or soft tissue infection definitions using the confirmed and possible ACMS constitutional criteria.
According to Penna, using possible ACMS as a criterion led to the detection of 21 additional HAIs among nursing home residents, most of which were respiratory infections such as pneumonia (n = 8; 29.6%) and lower respiratory tract infections (n = 9; 37.5%), bringing the infection prevalence from 0 to 1.9%.
Data from the study showed that among 15,276 residents from 161 nursing homes, no resident had the required documentation to meet the confirmed ACMS criterion. The most frequently documented CAM element was disorganized thinking (n = 164; 1.1%), followed by altered level of consciousness (n = 117; 0.8%), fluctuating behavior (n = 59; 0.4%) and inattention (n = 9; 0.1%). Altogether, 296 residents (1.9%) had at least one CAM element documented, meeting the possible ACMS criterion. The most common elements in combination were disorganized thinking and altered level of consciousness.
Residents who met the possible ACMS criterion were older than those with no CAM elements documented (median age, 82 years vs. 80 years; P < .009) and had shorter nursing home stays than those with no CAM elements documented (median days from nursing home admission date to survey date, 132 days vs. 334 days; P < .0001).
Penna says these findings suggest there are likely barriers to assessing or documenting ACMS in nursing homes.
“Our proposed definition of ‘possible’ ACMS may be better suited as a criterion for retrospective infection surveillance in nursing homes,” he said. “CDC’s National Healthcare Safety Network is piloting a module for respiratory tract infection surveillance in nursing homes and will use the possible ACMS criterion. Additional research to assess barriers associated with assessment and documentation practices for ACMS in nursing homes is needed when evaluating residents for infections.”
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