Study of Infection Management and Palliative Care at End-of-Life (SIMP-EL)

In this study, we will identify elderly nursing home residents and important resident level covariates (e.g., advanced illness), as well as track antibiotic use, hospice use, and hospital transfers related to infections.

This study is conducted by the Columbia University School of Nursing in partnership with the RAND Corporation and the Hebrew Senior Life Institute for Aging Research. It is funded by NIH’s National Institute of Nursing Research (R01NR13687).


Excellence in palliative care is a priority in the nursing home (NH) setting, which provides care to many older residents with advanced illness at the end of life. For 90% of these residents, the main goal of care is palliation as residents and their families value dignity and quality of life, not life-prolongation.1,2Unfortunately, suboptimal palliative care in the NH setting is common.3,4 Infections are a frequent occurrence in NHs and suboptimal infection control and management is also occurring.5-7

In our successful parent study “Prevention of Nosocomial Infections and Cost-Effectiveness in Nursing Homes” (PNICE-NH), we found that annually 40% of Medicare-certified NHs receive deficiency citations for inadequate infection control and less than half (46%) have written guidelines for antibiotic initiation.8,9Antibiotics account for approximately 40% of all medications administered in NHs.10 Unfortunately, much of the use is inappropriate as antibiotics are often initiated in the absence of clinical evidence to support a bacterial infection, and this misuse is a major risk factor for multidrug-resistant organisms and Clostridium difficile infections.10-14 Furthermore, suspected infections are common reasons for transfers to hospitals and these can be burdensome for the resident and not clinically beneficial.15,16 Taken together, for the majority of NH residents whose goals of care are primarily to promote comfort rather than life prolongation, the risks and burdens of antibiotic use and hospital transfers outweigh the potential benefit.5

The infection control and management, as well as the palliative care landscapes, are changing in NHs with various regional and state-level initiatives being implemented.17-20 It is likely that for some NHs these initiatives will promote resident-centered care that improves quality of life and reduces resident suffering by integrating infection management and palliative care; in others, NH personnel may be held to standards that favor burdensome curative treatments (e.g., aggressive antibiotic use).10,21-23 Evidence establishing the effectiveness of these interventions is needed to determine how best to:

  1. Integrate infection management and palliative care in NH settings
  2. Meet resident and family goals of care
  3. Decrease burdensome treatments

Study Goals

We will use longitudinal elderly resident Minimum Data Set (MDS) data and Medicare files (i.e., approximately one million unique individual residents for years 2011 to 2017) to identify elderly NH residents and important resident level covariates (e.g., advanced illness), as well as track antibiotic use, hospice use, and hospital transfers related to infections.

We will complement and link these secondary datasets with environmental scans of state and regional activities as well as with data from a national survey of new NHs and our “core” NHs surveyed in 2014. The survey will characterize implementation of current recommended structures and processes related to:

  1. Infection control and management
  2. Palliative care
  3. The integration of infection management and palliative care

Study Aims

  1. Describe the integration of infection management and palliative care in NHs and the associated facility, state, and regional characteristics.
  2. Examine factors associated with antibiotic use in elderly NH residents.
  3. Examine factors associated with hospital transfer due to infections among elderly NH residents.

Focus on Alzheimer’s Disease

Advanced illness due to Alzheimer’s disease and its related dementias (AD/ADRD) is a common and growing problem. Unless another fatal illness intervenes, all patients with AD/ADRD will reach the advanced stages of this disease. While recent initiatives have highlighted the need to improve end-of-life care, there is evidence that the experience for Americans dying with AD/ADRD is suboptimal. Suspected infectious episodes are hallmarks of advanced illness in AD/ADRD. Limited research has demonstrated extensive antibiotic use and transfers to hospitals among patients dying with advanced AD/ADRD, both of which are often burdensome, result in limited to no symptom relief and/or survival benefit, incur high costs, and are not consistent with palliative care goals. A supplement grant will evaluate how best to define advanced illness and examine best practices for infection management, antibiotic use, and transfers to hospitals in patients dying with AD/ADRD.

Supplement Aims

  1. Develop alternative algorithms to identify advanced illness in elderly AD/ADRD NH residents.
  2. Identify trends over time and resident and facility characteristics associated with antibiotic use and hospital transfers in elderly NH residents
    with advanced AD/ADRD.
  3. Identify how region, state, NH infection management, antibiotic stewardship, and palliative care policies impact antibiotic use, hospital transfers, and survival of elderly NH residents with advanced AD/ADRD.


  1. Harris-Kojetin LD, Sengupta M, Park-Lee E, Valverde R. Long-term care services in the United States: 2013 overview. National Center for Health Statistics. Vital Health Stat. 2013;3(37).
  2. Miller SC, Lima J, Gozalo PL, Mor V. The growth of hospice care in U.S. nursing homes. J Am Geriatr Soc. 2010;58(8):1481-8. PMCID: PMC2955193.
  3. Hickman SE, Nelson CA, Moss AH, Tolle SW, Perrin NA, Hammes BJ. The consistency between treatments provided to nursing facility residents and orders on the physician orders for life-sustaining treatment form. J Am Geriatr Soc. 2011;59(11):2091-9. PMCID: PMC3228414.
  4. Hickman SE, Tolle SW, Brummel-Smith K, Carley MM. Use of the Physician Orders for Life-Sustaining Treatment program in Oregon nursing facilities: beyond resuscitation status. J Am Geriatr Soc. 2004;52(9):1424-9.
  5. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, D.C.: The National Academies Press, 2015.
  6. Mody L, Bradley SF, Huang SS. Keeping the "home" in nursing home: implications for infection prevention. JAMA Intern Med. 2013;173(10):853-4. PMCID: PMC3716459.
  7. Richards CL, Jr. Infection control in long-term care facilities. J Am Med Dir Assoc. 2007;8(3 Suppl):S18-25.
  8. Herzig CT, Stone PW, Castle N, Pogorzelska-Maziarz M, Larson EL, Dick AW. Infection Prevention and Control Programs in US Nursing Homes: Results of a National Survey. J Am Med Dir Assoc. 2016;17(1):85-8. PMCID: PMC4696513.
  9. Pogorzelska-Maziarz M, Herzig CT, Cohen CC, Larson E, Stone PW. Infection Control Practices Related to Multi-drug Resistant Organisms and C. difficile in a National Sample of Nursing Homes. IDWeek, San Diego, CA; 2015.
  10. Albrecht JS, McGregor JC, Fromme EK, Bearden DT, Furuno JP. A nationwide analysis of antibiotic use in hospice care in the final week of life. J Pain Symptom Manage. 2013;46(4):483-90. PMCID: PMC3723720.
  11. Pogorzelska-Maziarz M, Alvarez KJ, Larson E. Burden of multi-drug resistant healthcare-associated infections in the long-term care setting. IDWeek, San Francisco, CA; 2013.
  12. Pogorzelska-Maziarz M, Alvarez KJ, Smaldone A, Larson E. Prevalence of MRSA colonization in elderly residents of long-term care facilities: A systematic review and meta-analysis. Gerontological Society of America Annual Scientific Meeting, Washington, DC; 2014.
  13. van Buul LW, van der Steen JT, Veenhuizen RB, Achterberg WP, Schellevis FG, Essink RT, et al. Antibiotic use and resistance in long term care facilities. J Am Med Dir Assoc. 2012;13(6):568 e1-13.
  14. Nicolle LE, Bentley DW, Garibaldi R, Neuhaus EG, Smith PW. Antimicrobial use in long-term-care facilities. SHEA Long-Term-Care Committee. Infect Control Hosp Epidemiol. 2000;21(8):537-45.
  15. Gozalo P, Teno JM, Mitchell SL, Skinner J, Bynum J, Tyler D, et al. End-of-life transitions among nursing home residents with cognitive issues. N Engl J Med. 2011;365(13):1212-21. PMCID:PMC3236369.
  16. U.S. Department of Health and Human Services, Office of Inspector General. Medicare Nursing Home Resident Hospitalization Rates Merit Additional Monitoring (OEI-06-11-00040) 2013 [Accessed February 2, 2016].
  17. Physician Orders for Life-Sustaining Treatment Paradigm [Accessed June 17, 2016].
  18. Centers for Disease Control and Prevention. NHSN e-News 2015 [Accessed December 30, 2015].
  19. Centers for Medicare & Medicaid Services. Reform of Requirements for Long-Term Care Facilities: Proposed Rules (CMS-3260-P) 2015 [Accessed August 13, 2015].
  20. Jennings LA, Zingmond D, Louie R, Tseng CH, Thomas J, O'Malley K, et al. Use of the Physician Orders for Life-Sustaining Treatment among California Nursing Home Residents. J Gen Intern Med. 2016.
  21. Dwyer LL, Harris-Kojetin LD, Valverde RH, Frazier JM, Simon AE, Stone ND, et al. Infections in long-term care populations in the United States. J Am Geriatr Soc. 2013;61(3):342-9.
  22. Juthani-Mehta M, Malani PN, Mitchell SL. Antimicrobials at the End of Life: An Opportunity to Improve Palliative Care and Infection Management. JAMA. 2015;314(19):2017-8. PMCID: PMC4675049.
  23. U.S. Department of Health and Human Services. National action plan to prevent healthcare-associated infections: Roadmap to elimination 2013.