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Pressure Ulcer Prevention in Long-Term-Care Facilities: A Pilot Study Implementing Standardized Nurse Aide Documentation and Feedback Reports

Horn, Susan D. PhD; Sharkey, Siobhan S. MBA; Hudak, Sandra MS, RN; Gassaway, Julie MS, RN; James, Roberta MStat; Spector, William PhD

Advances in Skin & Wound Care: March 2010 - Volume 23 - Issue 3 - p 120-131
doi: 10.1097/01.ASW.0000363516.47512.67
FEATURES: ORIGINAL INVESTIGATION
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OBJECTIVE: To design and facilitate implementation of practice-based evidence changes associated with decreases in pressure ulcer (PrU) development in long-term-care (LTC) facilities and promote these practices as part of routine care.

DESIGN: Pre/post observational study.

SETTINGS AND PARTICIPANTS: Frail older adult residents in 11 US LTC facilities.

INTERVENTION: Project facilitators assisted frontline multidisciplinary teams (certified nurse aides [CNAs], nurses, and dietitians/dietary aides) to develop streamlined standardized CNA documentation and weekly reports to identify high-risk residents and to integrate clinical reports into day-to-day practice and clinical decision making. The program was called "Real-Time Optimal Care Plans for Nursing Home QI" (Real-Time).

MAIN OUTCOME MEASURES: Prevalence of PrUs using Centers for Medicare & Medicaid Services (CMS) quality measures (QMs), number of in-house-acquired PrUs, and number and completeness of CNA documentation forms.

MAIN RESULTS: Seven study LTC facilities that reported data to CMS experienced a combined 33% (SD, 36.1%) reduction in the CMS high-risk PrU QM in 18 months and reduction in newly occurring PrUs (number of ulcers in the fourth quarter of 2003: range, 2-19; and in the third quarter of 2005: range, 1-6). Five of these LTC facilities that fully implemented Real-Time experienced a combined 48.1% (SD, 23.4%) reduction in the CMS high-risk PrU QM. Ten facilities reduced by an average of 2 to 5 their number of CNA documentation forms; CNA weekly documentation completeness reached a consistent level of 90% to 95%, and 8 facilities integrated the use of 2 to 4 weekly project reports in routine clinical decision making.

CONCLUSIONS: Quality improvement efforts that provide access to focused and timely clinical information, facilitate change, and promote staff working together in multidisciplinary teams impacted clinical outcomes. Prevention of PrUs showed a trend of improvement in facilities that fully integrated tools to identify high-risk residents into day-to-day practice. CNA documentation facilitated better information for clinical decision making. More than 70 additional LTC facilities across the United States are implementing this QI program.

The objective of this study was to design and facilitate implementation of practice-based evidence changes associated with decreases in pressure ulcer development in long-term-care facilities and promote these practices as part of routine care.

Susan D. Horn, PhD, is Senior Scientist, International Severity Information Systems, Inc, Institute for Clinical Outcomes Research, Salt Lake City, Utah. Siobhan S. Sharkey, MBA, and Sandra Hudak, MS, RN, are Principal, Health Management Strategies, Austin, Texas. Julie Gassaway, MS, RN, is Director of Projects/Product Development, and Roberta James, MStat, is Data Systems Specialist, International Severity Information Systems, Inc, Institute for Clinical Outcomes Research, Salt Lake City, Utah. William Spector, PhD, is Senior Social Scientist, Center for Delivery, Organizations and Markets, Agency for Healthcare Research and Quality, Rockville, Maryland.

© 2010 Lippincott Williams & Wilkins, Inc.