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In it for the Long Haul


Annals of Long-Term Care: Clinical Care and Aging. 2014;22(9):11.


Gregg Warshaw, MD; Medical Editor

Improving quality of care and quality of life in nursing homes requires tremendous effort. While working toward these goals, seemingly insurmountable barriers arise—limitations on time and resources; the limitations of treatments, such as antibiotic resistance; the complexity of managing multiple chronic conditions; and the inevitable progression of Alzheimer’s disease, to name a few. But as Chinese philosopher Lao Tzu said, “A journey of a thousand miles begins with a single step.” The articles in this month’s issue of Annals of Long-Term Care: Clinical Care and Aging (ALTC) speak to these words of wisdom by inspiring long-term solutions rather than quick fixes.

In our first article, “Improving the Management of Urinary Tract Infections in Nursing Homes: It’s Time to Stop the Tail From Wagging the Dog,” authors Christopher Crnich, MD, PhD, and Paul Drinka, MD, address the widespread problem of inappropriate antibiotic prescribing for residents with suspected urinary tract infections (UTIs). The authors attribute this problem, in large part, to institutional attitudes toward delayed or withheld prescribing—specifically, a hastiness to give antibiotics when urine test results are abnormal, regardless of clinical circumstances. To change this practice, the authors propose a new standardized process for evaluating change in a resident’s status that is both condition-based and criterion-based. The authors believe that integration of their unified algorithm will enhance antibiotic decision-making for UTIs across long-term care settings, but it will require a significant shift in institutional attitudes toward immediate versus delayed consequences. 

In our second article, “Improving Outcomes Through a Coordinated Diabetes Disease Management Model,” Cristi Day, DNP, RN, and colleagues describe their evidence-based quality improvement project to combat the inappropriate prescription of sulfonylureas and sliding scale insulin orders to manage diabetes, as these have both been associated with increased risk of hypoglycemia in long-term care residents. A key strategy to their project’s success was hiring a nurse practitioner (NP) with specialized diabetes training as part of the facility’s interdisciplinary team.

The results of their study revealed significant improvements in patient outcomes, including reductions in the incidence of hypoglycemia. Although this approach may be challenging for some facilities due to the cost associated with hiring a specialized NP, the authors suggest that initial costs are likely to be offset by substantial long-term savings through improved health outcomes.

In this issue, you will also find the next article in our Ask the Expert series, focusing on the complex decision of whether to place a feeding tube in elderly persons with advanced dementia. Although the evidence strongly shows that feeding tubes do not improve outcomes or prolong life in this population, many patients and their family caregivers ultimately decide upon this course of action for the patient’s final days of life. ALTC spoke with Ramona Rhodes, MD, about the American Geriatrics Society’s (AGS) updated evidence-based recommendations for feeding tube use in older adults with advanced dementia. She emphasizes the importance of informed decision-making that is inclusive of and respectful to the patient’s and family’s preferences. This Ask the Expert report is complemented by a tip sheet from the AGS’ series of geriatrics evaluation and management tools. This resource assists providers with identifying and managing dementia-related behavioral problems.

We also encourage you to visit us online at for daily news and exclusive content you won’t find in our print issue. Our website has been recently designed for optimal navigation and easier reading on your tablet and smartphone. You can also stay connected with ALTC on-the-go by signing up for our free e-newsletters at

As always, we greatly appreciate your feedback on this month’s issue of ALTC. Please e-mail your comments and questions to our interim managing editor, Allison Musante, at

Thank you for reading!

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