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CASE STUDIES FOR HALT-2

LECTURE 5. CASE STUDIES FOR HALT-2. LECTURE OBJECTIVES. To use case scenarios to aid completion of HALT resident questionnaire and understanding of HALT definitions. RESIDENT: H. Horatio. H. Horatio, a 55-year old male living in the LTCF for the last 25 days.

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CASE STUDIES FOR HALT-2

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  1. LECTURE 5 CASE STUDIES FOR HALT-2

  2. LECTURE OBJECTIVES • To use case scenarios to aid completion of HALT resident questionnaire and understanding of HALT definitions.

  3. RESIDENT: H. Horatio • H. Horatio, a 55-year old male living in the LTCF for the last 25 days. • He was transferred to the LTCF from an acute hospital following surgery as a result of a road traffic accident. • Due to a spinal injury he currently requires a wheelchair and has a suprapubic catheter. • He underwent surgery two months previously and he has a pressure sore at the base of his spine.

  4. RESIDENT: H. Horatio • On the survey day (8th May 2012), he is present at 8am and is complaining of a dry cough, stuffy nose and sore throat. He tells you that he has had these symptoms for the last two days. • He has no vascular catheters in situ. • His temperature is normal and he is fully orientated and continent.

  5. RESIDENT: H. Horatio • Complete a resident questionnaire for H. Horatio.

  6. RESIDENT: H. Horatio

  7. RESIDENT: H. Horatio

  8. RESIDENT: H. Horatio

  9. TEACHING POINTS Q: For the purposes of the HALT questionnaire is a suprapubic catheter the same as a urinary catheter? A: Yes. According to the HALT-2 protocol a urinary catheter is defined as “any tube system placed in the body to drain and collect urine from the bladder, e.g. an indwelling urinary catheter, suprapubic or abdominal wall catheter, a cystostomy”

  10. TEACHING POINTS A suprapubic catheter is also classified as an “other wound” as per HALT protocol. The definition of “Other wounds” is: All wounds other than a pressure, including leg ulcers, traumatic or surgical wounds and insertion sites for PEG, gastrostomy, tracheostomy, urostomy, colostomy or suprapubic and peritoneal catheters.

  11. RESIDENT: P. Polonius • P. Polonius, 88-year old male living in the LTCF for past three years. • He is bedridden but continent. • He was admitted to hospital two weeks previously for cholecystectomy, from which he has recovered well. • He has no history of heart or breathing problems. • He has a urinary catheter. • His surgical wound is healing well. • He does not have a vascular catheter or pressure sores and is fully orientated.

  12. RESIDENT: P. Polonius • On the day of the survey (8th May 2012) P. Polonius is in the LTCF at 8am. • He has cough that was not present the day before and an O2 saturation of 92%. • His temperature on the day is 38.3oC. • He is not on any antimicrobials – the GP is due to review him later that day.

  13. RESIDENT: P. Polonius • Complete a resident questionnaire for P. Polonius.

  14. RESIDENT: P. Polonius

  15. RESIDENT: P. Polonius

  16. RESIDENT: P. Polonius

  17. TEACHING POINT Q: What are constitutional signs and symptoms? A: They include: - Fever - Leucocytosis - Acute change in mental status from baseline - Acute functional decline The definitions of constitutional signs/ symptoms can be found in page 3 of the resident questionnaire.

  18. RESIDENT: B. Bianca • B. Bianca, 69-year old female living full time in the LTCF for past five years. • She suffers with dementia and has recently lost the ability to swallow food. As a result she had a PEG tube inserted two weeks previously, following an outpatient procedure in a local hospital endoscopy department. • She is disorientated and incontinent and uses a walking aid. • She is present at 8am on the day of the survey (8th May 2012).

  19. RESIDENT: B. Bianca • On the day of the survey a yellow exudate has been noted at the PEG tube site and B. Bianca has a temperature of 37.9oC. • She has been spiking temperatures of up to 37.9oC for the last 24 hours though is otherwise very well – her blood pressure is within normal limits. • The laboratory results on a pus sample sent from the PEG site for culture and sensitivities are not yet available but a Gram stain shows Gram-positive cocci.

  20. RESIDENT: B. Bianca • The ward staff received a phone call earlier on the day of the survey from the microbiologists - A blood culture sample taken on 7th May 2012, has “flagged” positive and Gram-positive cocci found on Gram stain but no culture results are available. The microbiologists advised starting oral antibiotics and to repeat the blood cultures – however the staff are waiting for the medical officer to prescribe them. • B. Bianca has no urinary catheter/no vascular catheter/ no pressure sores.

  21. RESIDENT: B. Bianca • Complete a resident questionnaire for B. Bianca.

  22. RESIDENT: B. Bianca

  23. RESIDENT: B. Bianca

  24. TEACHING POINT Q: Why did the microbiologist advise starting B. Bianca on antimicrobials? A: It is possible that she has a bloodstream infection but this cannot be confirmed until the blood cultures results are obtained. If the resident is well a decision may be made to hold off on starting treatment until results are back but if she is unwell treatment may be started. A “blood culture” is two or more blood culture bottles taken together, sometimes referred to as a “set of blood cultures”

  25. RESIDENT: M. Macbeth • M. Macbeth, an 80-year old male living in the LTCF for the last two years. • He uses a wheelchair and requires oxygen at night for emphysema for which he also regularly uses an albuterol inhaler. • He had returned to the LTCF on May 8th 2012 following a week-long home visit with family. • During this visit he had a suspected respiratory tract infection and has been on amoxicillin for four days.

  26. RESIDENT: M. Macbeth • On the day of the survey (May 8th 2012) he has: - No pressure sores or wounds. - No vascular or urinary catheters and is fully continent. - Had no recent admissions to hospital. - A normal temperature, is fully orientated and on his last day of antimicrobial treatment.

  27. RESIDENT: M. Macbeth • Complete a resident questionnaire for M. Macbeth.

  28. TEACHING POINTS Q: M. Macbeth is not an eligible resident – Why?  A: This resident was not present in the LTCF for the 24 hours prior to PPS survey day.

  29. TEACHING POINTS Q:If he had been present for 24 hours prior to the survey day would he be an eligible resident? A: Yes, once he had been in the facility 24hrs prior to PPS date and present at 8am that day, a resident questionnaire would be completed for this resident because he is receiving antimicrobial therapy. The details of the signs and symptoms of his “chest infection” would also be obtained from his medical notes/chart and entered into the respiratory tract infections section of the resident questionnaire.

  30. RESIDENT: S. Shylock • S. Shylock, a 72-year old male was discharged from hospital, following knee surgery the previous week, and admitted directly to LTCF on the evening of May 6th 2012. • He is currently using a walking aid but is otherwise in general good health.

  31. RESIDENT: S. Shylock • On the day of the survey (May 8th 2012) he has had several episodes of diarrhea and vomiting which had started the evening before. He has - No pressure sores or wounds. - No vascular or urinary catheters. - A normal temperature, is fully orientated and is fully continent.

  32. RESIDENT: S. Shylock • Complete a resident questionnaire for S. Shylock.

  33. TEACHING POINT Q: How would you fill out a resident questionnaire for this resident? A: A resident questionnaire would NOT be filled out for this resident because, given the time frame of the emergence of the signs and symptoms described, it is likely the resident’s infection was in incubation at time of admission to the LTCF and was most likely acquired whilst in hospital. Therefore, he does not fulfill the criteria necessary for infection data analysis as per HALT2 protocol (see infection data section of HALT protocol).

  34. COMPLETING WARD LIST- Example

  35. RESIDENT: D. Desdemona • D. Desdemona, an 82-year old female diabetic living in LTCF for seven years with no recent history of hospital admissions. • She is bedridden. • She has a pressure sore on her hip and no wounds. • She has a long-term urinary catheter and no vascular catheters. • She has a normal temperature, is fully orientated and continent.

  36. RESIDENT: D. Desdemona • On the day of the survey (May 8th 2012) she is feeling well and her appetite is good. • Laboratory results on two consecutive urine samples show the presence of >105 cfu/ ml glycopeptide susceptible Enterococcus faecalis. • Her GP has commenced her on oral co-amoxiclav for five days. • Her medical notes contain no recent history of fever, suprapubic pain or costovertebral angle pain or tenderness and on inspection the catheter is not blocked or leaking.

  37. RESIDENT: D. Desdemona • Complete a resident questionnaire for D. Desdemona.

  38. RESIDENT: D. Desdemona

  39. RESIDENT: D. Desdemona

  40. RESIDENT: D. Desdemona From HALT Microorganism Code List

  41. RESIDENT: D. Desdemona

  42. TEACHING POINTS Q: Does this resident fulfill the criteria for a urinary tract infection? A: No, because she has no signs and symptoms of infection, it is more likely she has asymptomatic bacteruria.

  43. TEACHING POINTS Q: Is the treatment prescribed sufficient? A: Treatment of asymptomatic bacteruria is not recommended in elderly LTCF residents as, while it may lead to the temporary elimination of bacteria, there is a high recurrence rate of bacteruria after antimicrobial use. More importantly, inappropriate antimicrobial use can contribute to the emergence of antimicrobial resistant microorganisms.

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