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A Tour of AHRQ Prevention Tools A Tour of AHRQ Prevention Tools for Clinicians for Clinicians

On-Time Prevention of Pressure Ulcers in On-Time Prevention of Pressure Ulcers in

Nursing HomesNursing Homes

Thursday, September 27, 2007; 3:30 – 5pmThursday, September 27, 2007; 3:30 – 5pm

Susan D. Horn, PhDSusan D. Horn, PhDInstitute for Clinical Outcomes ResearchInstitute for Clinical Outcomes Research

699 E. South Temple, Suite 100 699 E. South Temple, Suite 100 Salt Lake City, Utah 84102-1282Salt Lake City, Utah 84102-1282801-466-5595 (T) 801-466-6685 (F)801-466-5595 (T) 801-466-6685 (F)

shorn@isisicor.comshorn@isisicor.com

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• Build partnerships / Develop interdisciplinary Build partnerships / Develop interdisciplinary team capacityteam capacity to promote faster QI in LTC to promote faster QI in LTC

• Integrate evidence-based researchIntegrate evidence-based research on pressure on pressure ulcer prevention into long term care daily ulcer prevention into long term care daily workflowworkflow

• Redesign clinical care planningRedesign clinical care planning processes using processes using standardized documentation and timely standardized documentation and timely feedback reportsfeedback reports

ObjectivesObjectives

ON-TIME PREVENTION OF ON-TIME PREVENTION OF PRESSURE ULCERS IN NURSING HOMESPRESSURE ULCERS IN NURSING HOMES

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Research Research Based Best Practices Based Best Practices Nursing Home Study (NPULS) 1996-1997Nursing Home Study (NPULS) 1996-1997

• 6 long-term care provider organizations6 long-term care provider organizations

• 109 facilities109 facilities

• 2,490 residents studied2,490 residents studied

• 1,343 residents with pressure ulcer; 1,147 at risk1,343 residents with pressure ulcer; 1,147 at risk

• 70% female, 30% male70% female, 30% male

• Average age = 79.8 yearsAverage age = 79.8 yearsFunded by Ross Products Division, Abbott LaboratoriesFunded by Ross Products Division, Abbott Laboratories

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Long Term Care CPI ResultsLong Term Care CPI ResultsOutcome: Develop Pressure UlcerOutcome: Develop Pressure Ulcer

GeneralGeneral AssessmentAssessment

IncontinenceIncontinenceInterventionsInterventions

NutritionNutritionInterventionsInterventions

StaffingStaffingInterventionsInterventions

+ Age + Age 85 85

+ Male+ Male

+ Severity of Illness+ Severity of Illness

+ History of PU+ History of PU

+ Dependency in + Dependency in >= 7 ADLs>= 7 ADLs

+ Diabetes+ Diabetes

+ History of tobacco use+ History of tobacco use

+ Dehydration+ Dehydration

+ Weight loss+ Weight loss

+ Mechanical devices + Mechanical devices for the containment of for the containment of urine (catheters) urine (catheters)

- Disposable briefs- Disposable briefs

- Toileting Program- Toileting Program

- RN hours per - RN hours per resident day >=0 .5resident day >=0 .5

- CNA hours per - CNA hours per resident day >= 2.25resident day >= 2.25

MedicationsMedications

- SSRI + Antipsychotic

Horn et al, Horn et al, J. Amer Geriatr SocJ. Amer Geriatr Soc March 2004; 52(3):359-367 March 2004; 52(3):359-367

- Fluid Order- Fluid Order

- Nutritional Supplements- Nutritional Supplements

• standard medicalstandard medical

- Enteral Supplements- Enteral Supplements

• disease-specificdisease-specific• high calorie/high high calorie/high proteinprotein

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Common Challenges Across FacilitiesCommon Challenges Across Facilities

1.1. Inefficient ProcessesInefficient Processes

2.2. Incomplete DocumentationIncomplete Documentation

3.3. CNAs: untapped resourceCNAs: untapped resource

4.4. Communication Breakdowns / Lack Communication Breakdowns / Lack Standard ProcessesStandard Processes

5.5. Clinical Decision Support NeedsClinical Decision Support Needs

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Step 1: Build PartnershipsStep 1: Build Partnerships

• Empower all members of a facility teamEmpower all members of a facility team

• Front-line workers actively participate Front-line workers actively participate in QI activities, including CNAs: in QI activities, including CNAs: bottom-up approachbottom-up approach

• Share across facilitiesShare across facilities

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Step 2: Standardize DocumentationStep 2: Standardize Documentation

• Comprehensive documentation for front-Comprehensive documentation for front-line workersline workers

• Redesign work flow – consolidate Redesign work flow – consolidate documentation documentation

• Allow individual facility customizationAllow individual facility customization

• Encourage inter-facility sharingEncourage inter-facility sharing

• Observe facilities come to consensus over Observe facilities come to consensus over timetime

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Comprehensive Standardized Comprehensive Standardized DocumentationDocumentation

CNACNA

• Daily flow sheet Daily flow sheet

• Single form replaced Single form replaced multiple logs, multiple logs, clipboards, bedside clipboards, bedside chartscharts

• Reduced redundant Reduced redundant documentation documentation “document one time, “document one time, in one place”in one place”

PrU Tracking SheetPrU Tracking Sheet

• Wound RN Wound RN standardized PrU standardized PrU documentation: tracks documentation: tracks resident risk and resident risk and pressure ulcer status pressure ulcer status

• Information used to Information used to compile summary compile summary reportsreports

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10

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Step 3: Timely Feedback ReportsStep 3: Timely Feedback Reports

• Use comprehensive standardized documentation dataUse comprehensive standardized documentation data

• First reports provide feedback on documentation First reports provide feedback on documentation completenesscompleteness

• Other reports target alerts for specific components of Other reports target alerts for specific components of carecare

• Summarize clinical information in variety of formats Summarize clinical information in variety of formats for use by RNs, MDS coordinators, dieticians, CNAs, for use by RNs, MDS coordinators, dieticians, CNAs, wound RN, etc.wound RN, etc.

• Reports contribute to individualized care planning Reports contribute to individualized care planning processesprocesses

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Timely Reports focus on Timely Reports focus on Pressure Ulcer PreventionPressure Ulcer Prevention

Weekly ReportsWeekly Reports Nutrition Report / Weight SummaryNutrition Report / Weight Summary

Behavior ReportBehavior Report

Pressure Ulcer ReportPressure Ulcer Report

Priority ReportPriority Report

Monthly ReportsMonthly Reports Health Status Summary ReportHealth Status Summary Report

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• Nutrition SummaryNutrition Summary» Meal intake for 4 weeksMeal intake for 4 weeks» Fluid intake for 4 weeksFluid intake for 4 weeks» Diet orderDiet order» Supplement product Supplement product » Weight change since last weekWeight change since last week» Existing pressure ulcerExisting pressure ulcer» History of resolved ulcerHistory of resolved ulcer

• Weight SummaryWeight Summary» Weight 180 days priorWeight 180 days prior» Weight 30 days priorWeight 30 days prior» Weight for each of past 4 weeksWeight for each of past 4 weeks» Weight change since last week Weight change since last week » 5-10% weight loss past 30 days5-10% weight loss past 30 days» >10% weight loss past 180 days>10% weight loss past 180 days

Example: Nutrition ReportExample: Nutrition Report

Stratified by RiskStratified by Risk

Provide ‘BIG picture’ over time, not just snapshot of one shift or one dayProvide ‘BIG picture’ over time, not just snapshot of one shift or one day

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Nutrition ReportNutrition Report

What are uses of the Nutrition Report?What are uses of the Nutrition Report?

• Identify which meals are not being eatenIdentify which meals are not being eaten

• Promote use of nutritional supplementsPromote use of nutritional supplements

• Identify need for consistent weightsIdentify need for consistent weights

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• Decreased meal intake Decreased meal intake • Weight lossWeight loss• Increased incontinence episodesIncreased incontinence episodes• Increased behavior problemsIncreased behavior problems• Existing red areas on skinExisting red areas on skin• History of pressure ulcer in last 90 History of pressure ulcer in last 90

daysdays•

Example: Priority ReportExample: Priority Report

Identifies residents at riskIdentifies residents at risk

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Benefits of Benefits of Timely Feedback ReportsTimely Feedback Reports

• Access to summarized information for Access to summarized information for clinical decision-makingclinical decision-making

• Improve response time between Improve response time between identification of resident need and identification of resident need and interventionintervention– Identify residents at risk for pressure ulcer Identify residents at risk for pressure ulcer

developmentdevelopment

• Transform from paper to data cultureTransform from paper to data culture– Link reports to documentation elementsLink reports to documentation elements

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Step 4Step 4: Integrate into Daily Workflow: Integrate into Daily Workflow

• Comprehensive forms replace (Comprehensive forms replace (not not supplementsupplement) previous forms) previous forms

• Importance of front-line CNA Importance of front-line CNA observations stressedobservations stressed

• Feedback is based on documentationFeedback is based on documentation

• Feedback contributes to care plan Feedback contributes to care plan updatesupdates

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ResultsResults Decrease Pressure Ulcer DevelopmentDecrease Pressure Ulcer Development

Increase Adherence to Best PracticesIncrease Adherence to Best Practices

Increase Staff Accountability and SatisfactionIncrease Staff Accountability and Satisfaction– Inclusion of front-line workers in QI effortsInclusion of front-line workers in QI efforts– Comprehensive documentation at point of careComprehensive documentation at point of care– Communication among care team improvedCommunication among care team improved

Reduce InefficienciesReduce Inefficiencies– # documentation forms for CNAs# documentation forms for CNAs– CNA time looking for documentation bookCNA time looking for documentation book– Time to compile reports for State Regulators and MDS Time to compile reports for State Regulators and MDS – Time for Wound RN to summarize and report dataTime for Wound RN to summarize and report data

Improve State Survey ProcessImprove State Survey Process

Establish a foundation for EHREstablish a foundation for EHR

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Q4 03 (Pre-Implementation) to Q3 05 (Post-Intervention Review) Combined Facilities Average

0.0

5.0

10.0

15.0

20.0

% H

igh

Ris

k R

esid

ents

Facilities Average 14.0 13.0 12.9 10.6 9.6 9.4 12.0 9.1 8.7

National Norm 14.0 14.0 14.0 13.0 13.0 13.0 14.0 14.0 13.0

Q3 03 Q4 03 Q1 04 Q2 04 Q3 04 Q4 04 Q1 05 Q2 05 Q3 05

Impact On Pressure Ulcer QMsImpact On Pressure Ulcer QMs

Source: CMS Nursing Home Compare; Facility QM data reports

The combined facilities’ average shows an overall reduction of 33% in the QM % of high risk residents with pressure ulcer from pre-implementation to initial post-implementation time periods

Combined Facilities

National Norm

Q4 03 – Q3 05% Change = - 33%

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Summary of Key Program BenefitsSummary of Key Program Benefits

Improve QualityImprove Quality Improve clinical decision making: integrate reports Improve clinical decision making: integrate reports

into day-to-day workflowinto day-to-day workflow Identify residents at high risk early Identify residents at high risk early Timely communication among multi-disciplinary Timely communication among multi-disciplinary

team membersteam members

QI CollaborationQI Collaboration Receive technical assistance from QI expertsReceive technical assistance from QI experts Collaborate with peers to share experiences and best Collaborate with peers to share experiences and best

practicespractices

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Summary of Key Program Benefits Summary of Key Program Benefits (cont)(cont)

Improve CNA DocumentationImprove CNA Documentation Consolidate current documentationConsolidate current documentation Standardize data elements and eliminate redundancyStandardize data elements and eliminate redundancy Audit and train for accuracyAudit and train for accuracy

Gain EfficiencyGain Efficiency Reduce time spent searching for multiple sources of Reduce time spent searching for multiple sources of

informationinformation Automated reports replace manual compilation of Automated reports replace manual compilation of

resident informationresident information

Increase MoraleIncrease Morale Empower multidisciplinary teams with CNAs as important Empower multidisciplinary teams with CNAs as important

membersmembers CNAs see importance of their workCNAs see importance of their work

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Available On-Time ToolsAvailable On-Time Tools

CNA documentationCNA documentation http://ahrq.gov/research/ltc/pucnaform.pdfhttp://ahrq.gov/research/ltc/pucnaform.pdf

On-Time ReportsOn-Time Reports http://ahrq.gov/research/ltc/pusamplerep.pdfhttp://ahrq.gov/research/ltc/pusamplerep.pdf

Video and other resourcesVideo and other resources http://ahrq.gov/research/puwebcast.htmhttp://ahrq.gov/research/puwebcast.htm