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A 6-month clinical trial was conducted to evaluate two models of restorative nursing care designed to improve mobility in nursing home residents. The models were compared on number of residents enrolled, documentation of nursing assistant (NA) compliance, and nursing staff satisfaction. The designated model, which relied on one specially trained NA to perform restorative activities on the unit, resulted in higher rates of enrollment, compliance, and staff satisfaction compared with the integrated model, which relied on regular staff NAs who were trained to incorporate restorative activities into their daily routines.

Objectives: To determine the accuracy of patient care staff estimates and documentation of food intake of residents in nursing homes., Design: Prospective, observed, unblinded cohort study., Setting: Three urban nursing home facilities., Subjects: Staff estimation and documentation of 27 nursing home residents' meal intake., Measurements: Actual amount consumed by 27 nursing home residents was ascertained by weighing food and caloric fluids on resident trays before and after one lunch time meal. Staff estimates and documentation of percent of meal consumed was compared with actual intake., Results: Patient care staff estimates differed from actual intake by approximately 20%, and in most instances intake was overestimated. Almost one-third of the residents at risk for nutritional problems were not identified correctly by staff. Chart documentation of meal intake frequently did not reflect either actual amount of meal consumed or the staff's estimation of what was eaten., Conclusion: Study findings indicate that the present system used to document nursing home residents' intake is inadequate and that a more accurate mechanism or an entirely different process for identifying residents at risk for nutritional problems should be developed and implemented.

Diarrhea is a common problem among residents of long-term care facilities. Although the etiology of many cases of diarrhea will be noninfectious, the approach to managing all patients with diarrhea must include assuring the adequacy of hydration and controlling the spread of infection. The latter issue is especially critical in nursing homes where a large proportion of patients can became ill over a several-day period during an outbreak. Although most outbreaks of diarrhea are viral in origin, bacterial outbreaks can lead to hospitalization and even death. Increasing awareness among physicians and infection control practitioners of the correct approaches to investigating and managing cases of diarrhea among nursing home patients is necessary because the magnitude of this problem will grow as the number of individuals being cared for in long-term care facilities increases.

Stool specimens obtained from 77 residents of a nursing home were analysed to determine the relationship between colonisation with digoxin-reducing strains of Eubacterium lentum and infection with Clostridium difficile. Patients were categorised according to previous antibiotic treatment, prescription of enteral feedings, and pattern of bowel habits. Colonisation with digoxin-reducing E. lentum was less common in subjects infected with C. difficile, in those treated with antibiotics previously, and in those prescribed enteral feedings. Normal bowel habits were more common in those without C. difficile. The lowest incidence of diarrhoea was seen in patients without C. difficile who were colonised with digoxin-reducing species. This study establishes an inverse relationship between the presence of C. difficile and E. lentum that reduce digoxin which is related to previous treatment with antibiotics and prescription of enteral feedings. Bacterial markers may prove to be a useful tool for predicting clinical disturbances in bowel function.

Clostridium difficile causes pseudomembranous colitis and is responsible for 20% to 25% of cases of postantibiotic diarrhea. In an earlier study, nursing-home patients with C. difficile infection were noted to have a high mortality rate. Because most of these infected patients had been treated with antibiotics, it was not clear whether this high mortality rate was associated with C. difficile infection or simply with antibiotic treatment. A prospective study was carried out to determine the rate of postantibiotic C. difficile colonization and risk factors for infection in patients in a 233-bed long-term care facility, as well as to determine whether C. difficile infection is associated with increased mortality. During a six-month period 150 courses of antibiotics were prescribed for 108 patients. Stool specimens were collected from 36 (33%) patients following the first course of antibiotic treatment, and 12 (33%) were infected with C. difficile. Risk factors for infection included ward location and stool incontinence. Age, body-mass index less than or equal to 18 kg/m2, and diagnoses of dementia and pressure scores tended to be associated with infection, but not significantly. Early mortality rates did not differ, but 12-month mortality for the infected patients was higher (83% vs 50%, P = .05). Therefore, we conclude that postantibiotic C. difficile infection serves as a marker of death in nursing-home patients, one that can be differentiated from the risk of antibiotic treatment alone. This increased death rate may be related in part to clinically unrecognized pseudomembranous colitis or, alternatively, to absorption of C. difficile toxins or even endotoxin from the gut lumen into the systemic circulation.

There are no large studies on long-term treatment of nursing home patients with pressure sores. A 4-year experience of treating 95 nursing home patients on air-fluidized beds was reviewed. Treated patients were elderly (median age 73 years) and neurologically impaired (79% with dementia, cerebral vascular accident, or anoxic encephalopathy). The index pressure sores (deepest truncal sore for each patient) were large (median surface area 35.3 cm2) and commonly located on the sacrum (41%) and trochanters (38%). Only 13 of 95 (14%) index sores healed completely, and only two small sores healed in less than 30 days. No others treated less than 30 days had greater than or equal to 50% reduction in sore surface area. Patients were grouped according to whether or not treatment was less than 30 days, and for those treated greater than or equal to 30 days, according to whether or not greater than or equal to 50% reduction in sore surface area occurred. None of the easily measured patient characteristics examined were associated with longer or more successful treatment. These results indicate that although air-fluidized beds can be used to treat pressure sores successfully, even in severely debilitated nursing home patients, no simple criteria can be used to predict which patients will benefit from this treatment. Because long periods of time are necessary for treatment [median trial length 79 days and 17 of 95 (18%) trials greater than 180 days], substantial patient-care expenditures result.(ABSTRACT TRUNCATED AT 250 WORDS)