Healthcare Infection Prevention-Long-term care too quick on the transfer trigger

Fever does not warrant hazardous hospitalization

Drawing the sometimes fine line between fever and infection in long-term care, a multidisciplinary panel warns that residents are too often transferred to acute care based solely on febrile episodes.

The practice guidelines for evaluation of fever and infection in long-term care were created with the participation of the Society for Healthcare Epidemiology of America and the Infectious Disease Society of America.¹

"This guideline was written with a balance with what is known from an academic research perspective and what can really be done as day-to-day, practical feasible things," says Thomas T. Yoshikawa, MD, chairman of the IDSA practice guidelines committee.

A febrile episode is a frequent reason for transfer to an emergency department and admission to an acute-care facility, the guidelines state. However, there is concern transfer may be overused and may not always be in the best interest of the patient. Hospitalization is associated with an increased risk of colonization with highly virulent or drug-resistant bacteria, and translocation trauma.

Patient, societal cost

Several studies have shown that long-term care residents with severe functional dependence experience a very high risk of mortality, regardless of setting of care, and they question the benefit of hospitalization on clinical outcome. In addition, the expenses incurred through transfer and admission add to the societal costs of long-term care and often are unnecessary.

"If you look at data on what is the common reason for long-term care [residents] to be transferred to an acute-care facility for some event, infectious usually is No. 1 or 2," Yoshikawa says. "But fever in itself is not a necessary reason to transfer somebody. But one has to determine the severity of illness and what you suspect is causing the fever, if possible."

Of course, evaluation capabilities and transfer decisions will boil down to facility resources in many cases, he notes. "If you are in a VA facility, you can treat a lot of these in the nursing home because a lot VA nursing homes are hospital based. If you are in a small community place, that same patient may require transfer. The message is that we don't feel that everybody needs to be transferred. Many of these cases could be treated in the long-term care facility."

Indeed, the ability to provide parenteral therapies in long-term care is becoming quite common. Moreover, some drugs may be administered intramuscularly (e.g., select third-generation cephalosporins) and demonstrate similar efficacy to the intravenous route of injection. In addition, several antibiotics (e.g., quinolones) have been developed that achieve systemic concentrations by oral administration that are comparable to concentrations achieved with administration via a parenteral route, the practice guidelines emphasize. In addition to fever, such advances could mitigate the necessity for transfers to an acute-care facility for mild or uncomplicated infections.

Performance measures for JCAHO

Regardless of the transfer situation, the reason for the decision should be documented in the medical record, Yoshikawa says. Such documentation is one of the "performance measures" listed at the conclusion of the guideline. "Performance measures are standard now for [the Joint Commission on the Accreditation of Healthcare Organizations]," he says. "It's easy to make policy; [the question] is whether to adhere to it."

The performance measures were not assigned any target values or benchmark rates to determine compliance with the measure. Rather, the panel determined that those targets should be established at each institution according to its own unique circumstances and available resources. "We don't have a performance measure for every recommendation, obviously, but we tried to include four or five of them that indicate you are doing in general the major things [that] we asked to be done," Yoshikawa says.

In addition to documenting transfer reasons, the performance measures for long-term care facilities (LTCF) include:

• A licensed nurse (licensed practical nurse or registered nurse) should document any change of clinical status of an LTCF resident.

• A licensed nurse should communicate directly to a physician, advance-practice nurse, or physician assistant any change in the clinical status of LTCF residents in a timely manner, as defined by the LTCF.

• Vital signs, including temperature, pulse, respiration rate, and blood pressure, should be measured and recorded in the medical record of LTCF residents suspected of an infection.

• There should be an appropriate assessment by a licensed health care provider (i.e., physician, advance-practice nurse, or physician assistant) of the clinical status of LTCF residents suspected of having an infection.

Reference

1. Bentley, DW, Bradley S, High K, et al. Practice guideline for evaluation of fever and infection in long-term care facilities. Clin Infect Dis 2000; 31:640-645.