Clinical Practice Guidelines in the Long Term Care SettingAMDA has published the following Clinical Practice Guidelines specifically for use in long term care settings. The subjects are noted below (year of publication is indicated in parentheses). Click on a CPG title for a description.
Each guideline is presented in a user-friendly format, and contains an introduction explaining the purpose, development process, and terminology; a step-by-step narrative text that covers definition, recognition, diagnosis, treatment, and monitoring of the condition discussed; and an algorithm that summarizes the steps involved in addressing the condition. These guidelines were developed by interdisciplinary workgroups using a process combining evidence- and consensus-based thinking, and reviewed by several national organizations and individual experts. As a result, these guidelines are applicable to members of the long-term care interdisciplinary team including physicians, nurses, consultant pharmacists, and others. Guidelines may be ordered individually or as a full set; multiple copies of each individual guideline are also available. For more information on AMDA's continuing program of clinical practice guideline development, please call or write AMDA, or send e-mail to AMDA Clinical Affairs. For a complete listing of AMDA resources, follow this link.
Clinical Practice Guideline: Complete Set of CPGs*Includes 22 guidelines (One copy of each current CPG) Order Information:
Clinical Practice Guideline: Acute Change of ConditionIn the long-term care setting a primary goal of identifying acute change of conditions (ACOCs) is to enable staff to evaluate and manage a patient at the facility and avoid transfer to a hospital or emergency room (ER). To achieve this goal, the facility's staff and practitioners must recognize an ACOC and identify its nature, severity, and cause(s). The approach to recognition, assessment, treatment, and monitoring of ACOCs that is proposed in this guideline should result in better management of these events in the long-term care facility and fewer transfers to hospitals and other acute-care settings. Order Information: Note: To earn AMA PRA category 1 credit, see the CME insert included with this CPG or go to www.amdacmedirect.com/acoc. For additional information, visit the Clinical Corner on Acute Change of Condition.
Clinical Practice Guideline: Altered Nutritional Status in the Long Term Care Setting (Revised)Weight has emerged as a principal screening and monitoring indicator in LTC because it is easy to measure and the measurement is reasonably accurate and reproducible, noninvasive, acceptable to most patients, and relatively inexpensive to obtain. Change in weight is common among patients of LTC facilities. Among patients who remain in LTC for at least 2 years, 50% to 60% experience weight change; equal numbers of patients gain and lose weight. Any unplanned weight change that occurs quickly or continues to occur over an identified period of time may have negative clinical implications; the degree of concern warranted usually is proportional to the rate and degree of change. Weight may change in either direction, but the implications of weight loss are markedly different from those of weight gain. Among LTC patients, significant unintended weight may be a significant clinical indicator of worsening health status, but not necessarily remediable. This CPG has been developed to help interdisciplinary teams evaluate and manage nursing home patients who are at risk for or who have experienced a significant change in weight. The guideline offers a structured approach to the recognition, assessment, treatment, and monitoring of ANS that acknowledges the ethical implications of this condition for patients, their families, and the staff of LTC facilities. It is hoped that this guideline will also be helpful to those who develop and determine institutional policies and procedures and the survey processes at the federal and the state levels. This guideline recognizes that failure to identify or to correct a remediable cause of weight loss can have profound implications for the patient’s prognosis and the facility’s regulatory and legal liability. Therefore, it is essential to clearly define unavoidable clinical decline and include palliative and end of life care as part of the facility’s spectrum of clinical responsibilities. Order Information:
Clinical Practice Guideline: AnemiaAnemia is common in the long-term care setting, with a prevalence ranging from 34 to 60%, increasing with each decade of life over age 70. Anemia often goes unevaluated or is inadequately evaluated in the frail elderly. Studies suggest the importance of treating anemia to improve patients’ overall health and prevent certain comorbid conditions.This CPG focuses on the recognition and management of anemia that may improve patient function, outcomes, and overall quality of life, as well as reduce healthcare costs. Outcomes that may be expected:
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Clinical Practice Guideline: Certified Nursing Assistants (CD-Rom)The Clinical Practice Guidelines for Nursing Assistants slide set is an educational resource that provides the nursing assistant with the information they need for a better understanding of specific conditions and care of the resident with dementia, depression, diabetes, falls/osteoporosis, pain, pressure ulcers and urinary incontinence. The CD-Rom includes sign-in sheets, Power Point presentations with speaker notes, and post-inservice activities for each topic. The slides can be used to assist in teaching nursing assistants the signs and symptoms that a resident who has or is at risk for having those conditions might display while providing the nursing assistant with a framework for observation and communication regarding the status of their residents. The nursing assistant will learn the skills needed to become a dynamic member of the interdisciplinary team by providing pertinent information regarding the resident and assisting the team to identify the resident's functional abilities, goals and concerns.Order Information:
Clinical Practice Guideline: Common InfectionsInfections are a significant source of illness and death in the long-term care setting (LTC). It is estimated that between 1.6 million and 3.8 million infections occur annually among patients in LTC facilities. Infections account for up to half of all transfers from LTC facilities to hospitals and result in an estimated 150,000 to 300,000 hospital admissions annually. Numerous studies indicate that pneumonia, urinary tract infections, and skin and soft-tissue infections account for nearly 75 percent of all infections acquired in the LTC setting. This guideline focuses on management of the four most common types of infections occurring in long-term care--urinary tract, respiratory, gastrointestinal, and skin infections. The guideline also discusses infection control, colonization versus true infection, and antibiotic resistance in long-term care facilities. Order Information: Note: To earn AMA PRA category 1 credit, see the CME insert included with this CPG or go to www.amdacmedirect.com/infections. For additional information, visit the Clinical Corner on Infection Control.
Clinical Practice Guideline: COPD Management (Revised)Chronic obstructive pulmonary disease (COPD) causes more than 80,000 deaths annually and is the fourth leading cause of death in the United States after heart disease, cancer, and stroke. In contrast to other major chronic diseases, prevalence of and mortality from COPD are increasing. Recognition, assessment, treatment, and monitoring of COPD in the long-term care setting can be challenging. Order Information: Note: To earn AMA PRA category 1 credit, see the CME insert included with this CPG or go to www.amdacmedirect.com/copd. For additional information, visit the Clinical Corner on Chronic Obstructive Pulmonary Disease (COPD).
Clinical Practice Guideline: Dehydration and Fluid MaintenanceThis CPG offers a structured approach to the recognition, assessment, treatment and monitoring of dehydration and fluid and electrolyte imbalances and acknowledges the ethical implications of this condition for patients, their families, and the staff of long term care facilities. This guideline provides helpful and educational components such as how to differentiate between dehydration and fluid and electrolyte imbalance, how to document related to varieties of fluid and electrolyte imbalance and how to manage hydration issues in those with end-stage and terminal illnesses. It also provides a step-by-step approach to address the condition with a corresponding treatment algorithm. Order Information: For additional information, visit the Clinical Corner on Nutrition & Hydration.
Clinical Practice Guideline: Delirium and Acute Problematic BehaviorProblematic behavior and delirium are common in both the short-stay and long-term residential facility populations. Although disease or organ dysfunction may cause or affect behavior, disruptive or problematic behavior itself is not an illness or disease and it should not be viewed or managed as such. Instead, problematic behavior and altered mental function are symptoms or syndromes (collections of signs and symptoms) needing careful evaluation and thoughtful management. These are complex issues with diverse potential causes. A systematic approach allows them to be handled effectively most of the time and serves the best interests of both patients and facilities. Following the steps in this guideline should permit facilities and their staff and practitioners to optimize their approach to these issues. Order Information: For additional information, visit the Clinical Corner on Delirium and Acute Problematic Behavior
Clinical Practice Guideline: DementiaDementia—a disorder characterized by progressive decline in multiple areas of cognitive function—causes a range of cognitive, mood, behavioral, and functional impairments. Optimal management of dementia in the LTC setting involves the entire interdisciplinary team, with practitioners playing an important leadership role. This guideline offers a systematic approach to the recognition, assessment, treatment, and monitoring of patients with dementia in the LTC setting. Implementing this guideline should help LTC facilities to improve their ability to:
Product Code: CPG8R Member Price: $15 Non-member Price: $35 Follow this link to order
For additional information, visit the Clinical Corner on Dementia & Altered Mental States.
Clinical Practice Guideline: DepressionDepressive symptoms are common among older adults and can have a major effect on their quality of life. It has been estimated that between 12 percent and 16 percent of older adults living in long-term care facilities have major depression, 50 percent may have a minor depressive disorder, and up to 70 percent may at one time experience depressed, sad, or blue mood. Order Information: Note: To earn AMA PRA category 1 credit, see the CME insert included with this CPG or go to www.amdacmedirect.com/depression. For additional information, visit the Clinical Corner on Depression.
Clinical Practice Guideline: Diabetes ManagementDiabetes is an independent predictor of long term care (LTC) facility placement in the elderly. Residents of LTC facilities who have diabetes are a vulnerable group who often take multiple medications and who experience frequent infections, high rates of cardiovascular complications, dehydration, hospitalizations, hyperosmolar states, and physical and cognitive disability. Diabetes causes serious morbidity and mortality from macrovascular and microvascular complications. Evidence is mounting that insulin resistance and diabetes increase the risk of cognitive impairment and dementia. People with diabetes are more likely to experience depression, which has been shown to be a major factor in hospital admissions and death. The prevalence of functional disability and multiple comorbid conditions in the LTC population increases the complexity of diabetes management. Hyperglycemia impairs cognition and, when untreated, may contribute to further functional decline in patients with dementia. Additionally, hyperglycemia decreases pain thresholds, impairs vision, impedes wound healing, and may increase the risk for falls. A comprehensive approach to diabetes management may improve glycemic control and reduce the progression of existing complications that result in morbidity and premature mortality. This guideline recommends processes that, if implemented, should help LTC facilities to systematically manage and improve the care of residents with diabetes. Potential benefits associated with the implementation of this guideline include the following:
Order Information: For additional information, visit the Clinical Corner on Diabetes.
Clinical Practice Guideline: Falls and Fall RiskThe Falls and Fall Risk Clinical Practice Guideline is a tool to guide physicians, other practitioners, and staff in assessing and managing individuals who have a recent history of falls or who are at risk of falling. Falling is a significant cause of injury and death in older individuals, especially the frail elderly. Nursing facility patients fall for various reasons and there are many age-related factors that contribute to a greater risk of falling. This guideline will help identify ways to modify some of the risk factors for falls, as well as identifying ways to adjust the patient's environment to minimize the risk of injury due to falls.The revised guideline has an expanded discussion on restraint reduction as it relates to falls, and discusses products that have been introduced (low beds, split rails, certain alarm systems, hip protectors etc.), that reduce risk of consequence with falls since it’s original publication. There are also new and more accurate fall predictors, an expand the discussion related to medications and their relation to falls and much more. Order Information: Note: To earn AMA PRA category 1 credit, see the CME insert included with this CPG or go to www.amdacmedirect.com/falls. For additional information, visit the Clinical Corner on Falls & Fall Risk.
Clinical Practice Guideline: Gastrointestinal DisordersAlthough aging has relatively minimal effects on GI function, age-related changes can cause or contribute to several GI disorders. For example, oral changes (e.g., decreased taste sensation, decreased saliva production) can cause poor appetite, with associated weight loss. Aging can result in impaired function of the gastric mucosal barrier and increased risk of peptic ulcer disease. Patients residing in long-term care facilities typically have numerous concurrent conditions and use numerous medications that may complicate the assessment and treatment of GI disorders. GI disorders may also be caused or exacerbated by a variety of medical conditions that are more prevalent with age. Fecal impaction and dehydration are sentinel events that may indicate a patient has or is at high risk for a GI disorder. In addition, the presentation of many GI disorders in older people is atypical. For example, GERD may present as dysphagia, asthma, recurrent aspiration pneumonia, or even cough. It is important for members of the interdisciplinary team in the long-term care setting to realize the impact that GI disorders can have on patients’ quality of life. These conditions can prevent patients from participating in activities, hinder their mobility, disrupt their sleep, and cause them to become socially isolated. The G.I disorders guideline focuses on the gastrointestinal (GI) disorders most commonly seen in the long-term care population. The following outcomes may be expected from implementation of this clinical practice guideline; reduced incidence of some acute GI disorders and greater stability of chronic GI disorders; appropriate use of medications to treat GI disorder; appropriate use of acute care facilities to assess and treat GI disorders if indicated ; appropriate use of specialist referrals and invasive testing in the management of GI disorders; reduced morbidity, mortality, and incidence of complications (e.g., fecal impaction, dehydration) of GI conditions and improved palliative care outcomes in residents with poor prognosis. Published 2006Order Information:
Clinical Practice Guideline: Health MaintenanceHealth maintenance in long-term care settings incorporates systemic, proactive approaches that promote patients’ physical, emotional, psychological, cognitive, and functional integrity. Early detection and prevention of illness may reduce morbidity and mortality in the elderly. Standard published guidelines for preventive care may be inappropriate when applied to populations such as the frail institutionalized elderly. Implementation of appropriate, individualized preventive care measures may represent an opportunity to improve longevity or quality of life for frail elders. This clinical practice guideline focuses on primary prevention, to the extent that it is feasible and beneficial in the frail elderly long-term care population. Outcomes that may be expected:
Clinical Practice Guideline: Heart FailureHeart failure is a common condition among patients in nursing facilities and is one of the most common reasons for new or recurrent hospitalizations among persons over 65 years of age. Considerable progress has been made during the past decade in providing symptomatic relief for such patients. By implementing the processes and practices outlined in this guideline and by keeping up with new recommendations for managing heart failure as they emerge, the interdisciplinary care team can improve the quality of life of patients with heart failure in the nursing facility. Order Information: For additional information, visit the Clinical Corner on Heart Failure.
Clinical Practice Guideline: Osteoporosis and Fracture PreventionThe aging process, the postmenopausal state, low calcium intake, lack of physical activity, and other risk factors predispose to low bone mass. Most elderly nursing facility patients have age-related changes in bones, resulting in a lower than normal bone mass. The Osteoporosis and Fracture Prevention Clinical Practice Guideline will guide the physician in the recognition, diagnosis, and management of patients with osteoporosis or patients who are at risk for osteoporosis. Order Information: For additional information, visit the Clinical Corner on Osteoporosis.
Clinical Practice Guideline: Pain ManagementThis guideline outlines many of the myths and misperceptions about pain caused by nonmalignant conditions and the barriers to effective pain management and offers steps for overcoming these barriers. Order Information:
Clinical Practice Guideline: Parkinson's Disease (Revised)Parkinson’s Disease (PD) is a progressive, degenerative neurologic disorder that commonly presents late in life. Although there is no known cure for PD, treatment can often prolong the patient’s life, improve mobility and function, and enhance dignity and quality of life. Early detection of PD is essential to its effective treatment. Understanding all the manifestations of the disease; the importance of basic, competent primary nursing and medical care; the roles of various disciplines, therapies, and specialties; and the concept of realistic goal setting for the individual patient are essential to effective treatment of PD. Effective treatment should be multifaceted, taking into consideration not only the individual patient’s physical needs, but also his or her spiritual, social, and emotional needs and concerns as well as those of the family. Expected Outcomes from Implementation of This Clinical Practice GuidelineThis guideline recommends processes that, if implemented, should help long-term care facilities to improve the care of patients with PD. Potential benefits associated with the implementation of this guideline include the following:
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Clinical Practice Guideline: Pharmacotherapy Companion to DepressionPharmacotherapy is one component of a multifaceted approach to the management of depression in the long-term care setting. This companion to the depression clinical practice guideline focuses on the pharmacotherapy of depression. The goals of this companion are to promote effective treatment of depression in the long-term care facility. It provides information for all members of the team about the rationale for and choice of antidepressant drugs and discusses the concept of pharmacoeconomics. Order Information: For additional information, visit the Clinical Corner on Depression.
Clinical Practice Guideline: Pressure UlcersThe updated guideline is evidence based and incorporates the revised federal guidance to surveyors on pressure ulcers (Tag F314) including:
The guideline also includes the updates for staging according to the 2007 National Pressure Ulcer Advisory Panel (NPUAP). This guideline removes practices that were experientially based (that is, have no evidence to support that practice) and moves to true evidence-based medicine. Additionally, the CPG discusses such controversial areas as photographic documentation, nutritional interventions, reverse staging, risk assessment tools, debriding of wounds, selection of ulcer care products and support surface options, treatments such as negative pressure wound therapy, incontinence as a causative factor, and much more. This updated CPG combines AMDA’s previous two CPGs--Pressure Ulcers and Pressure Ulcer Therapy Companion. Order Information:
Clinical Practice Guideline: Sleep DisordersSleep problems are extremely common among residents of long-term care facilities. Sleep disturbance and its behavioral consequences in patients with dementia are a common reason for admission to long-term care. Data suggests that age-related sleep changes, medical conditions common among older people, medications that affect sleep, substance use, and factors related to the long-term care facility environment all contribute to the prevalence of sleep difficulties in the long-term care population. Most patients with sleep disorders in the long-term care setting can be appropriately assessed and treated without specialist referral using a stepwise approach that emphasizes nonpharmacologic techniques and that uses a combination of pharmacologic and nonpharmacologic therapies if the latter alone are unsuccessful. The sleep disorders clinical practice guideline focuses on the evaluation and management of sleep disorders that are secondary to chronic medical conditions or environmental issues. Most sleep disorders in the long-term care setting fall into this category. Outcomes that may be expected from the implementation of this guideline include better awareness and understanding of sleep disorders among patients and caregivers, proper utilization of pharmacologic sleep agents, greater acceptance of individualized scheduling (i.e., enabling patients to get up, go to bed, and eat meals at times of their choosing rather than at institutionally established times), reduction in the frequency of daytime drowsiness, increased levels of participation in activities, enhanced quality of life, improved physical and cognitive function and fewer falls, reduction in nighttime disruptive behavior caused by sleep problems, reduction in distressed daytime behavior in patients with dementia, decline in geriatric psychiatry referrals for evaluation of behavioral problems related to sleep disorders, increased participation in rehabilitation programs and better rehabilitation outcomes and increased job satisfaction among caregivers. Published 2006 Order Information:
Clinical Practice Guideline: Stroke Management and PreventionThere are many challenges to treating and preventing stroke. Survivors of an acute stroke who are transferred to a long term care facility need a multidisciplinary assessment and treatment plan that lowers risk for post-stroke complications, helps to optimize physical and cognitive function, and reduces the risk of stroke recurrence. This new guideline will help the facility care team individualize its approach to stroke evaluation, treatment, and prevention; reach shared decisions about care that consider the patient's physical and cognitive status, prognosis, goals of therapy; and includes an assessment of the benefits, burdens, and alternatives to evaluations, tests, and treatments. Nursing assistants, nurses, and other caregiving staff will learn how to respond and with whom to communicate when they recognize the signs and symptoms that may signal an acute stroke or stroke complications. Order Information:
Clinical Practice Guideline: Urinary IncontinenceThe Urinary Incontinence Clinical Practice Guideline is a tool to guide care decisions. This guideline is a starting place that will guide the care team through a process of addressing urinary incontinence in the long term care facility resident. The document includes a narrative portion that covers definition, recognition, diagnosis, treatment, and monitoring of urinary incontinence. The algorithm summarizes the steps involved in addressing the condition. Tables include information on signs and symptoms of urinary incontinence, risk factors, contributing factors, assessment, treatment options, and indications for chronic indwelling catheters.Order Information: For additional information, visit the Clinical Corner on Urinary Incontinence.
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