# Presentation: 007662

## A Tour of AHRQ Prevention Tools for Clinicians  

**On-Time Prevention of Pressure Ulcers   in Nursing Homes**
**Thursday, September 27, 2007; 3:30 – 5pm**
**Susan D. Horn, PhD**
**Institute for Clinical Outcomes Research**
**699 E. South Temple, Suite 100 **
**       ****Salt Lake City, Utah  84102-1282**
**801-466-5595 (T)     801-466-6685 (F)**
**shorn@isisicor.com**

## Build partnerships / Develop interdisciplinary team capacity to promote faster QI in LTC
Integrate evidence-based research on pressure ulcer prevention into long term care daily workflow
Redesign clinical care planning processes using standardized documentation and timely feedback reports

_**Integrate evidence-based research**_** on pressure ulcer prevention into long term care daily workflow**
_**Redesign clinical care planning**_** processes using standardized documentation and timely feedback reports**

**Objectives**

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

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

**6 long-term care provider organizations**
**109 facilities**
**2,490 residents studied**
**1,343 residents with pressure ulcer; 1,147 at risk**
**70% female, 30% male**
**Average age = 79.8 years**
**Funded by Ross Products Division, Abbott Laboratories**

## Long Term Care CPI ResultsOutcome: Develop Pressure Ulcer

**General**
** ****Assessment**

**Incontinence**
**Interventions**

**  ****Nutrition**
**Interventions**

**Staffing**
**Interventions**

**+ Age ******** 85**
**+ Male**
**+ Severity of Illness**
**+ History of PU**
**+ Dependency in **
**   ****>= 7 ADLs**
**+ Diabetes**
**+ History of tobacco use**
**+ Dehydration**
**+ Weight loss**
**    **

**+ Mechanical devices for the containment of urine (catheters) **
**- Disposable briefs**
**- Toileting Program**

**- RN hours per resident day >=0 .5**
**- CNA hours per resident day >= 2.25**

**Medications**

**- SSRI + Antipsychotic**

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

**- Fluid Order**
**- Nutritional Supplements**
** ****standard medical**
**- Enteral Supplements**
** ****disease-specific**
** ****high calorie/high **
**  ****protein****   **

## Common Challenges Across Facilities

**Inefficient Processes**
**Incomplete Documentation**
**CNAs: untapped resource**
**Communication Breakdowns / Lack Standard Processes**
**Clinical Decision Support Needs**

## Step 1: Build Partnerships

**Empower all members of a facility team**
**Front-line workers actively participate in QI activities, including CNAs: bottom-up approach**
**Share across facilities**

## Step 2: Standardize Documentation

**Comprehensive  documentation for front-line workers**
**Redesign work flow – consolidate documentation **
**Allow individual facility customization**
**Encourage inter-facility sharing**
**Observe facilities come to consensus over time**

## Comprehensive Standardized Documentation

_**CNA**_
**Daily flow sheet **
**Single form replaced multiple logs, clipboards, bedside charts**
**Reduced redundant documentation “document one time, in one place”**** **

_**PrU Tracking Sheet**_
**Wound RN standardized PrU documentation: tracks resident risk and pressure ulcer status **
**Information used to compile summary reports**

## Slide 9

## Slide 10

## Step 3: Timely Feedback Reports

**Use comprehensive standardized documentation data**
**First reports provide feedback on documentation completeness**
**Other reports target alerts for specific components of care**
**Summarize clinical information in variety of formats for use by RNs, MDS coordinators, dieticians, CNAs, wound RN, etc.**
**Reports contribute to individualized care planning processes**

## Timely Reports focus on   Pressure Ulcer Prevention

_**Weekly Reports**_
***  *****  ****Nutrition Report / Weight Summary**
**	****Behavior Report**
**	****Pressure Ulcer Report**
**   ****Priority Report**
_**Monthly Reports**_
***  *****  ****Health Status Summary Report**

_**Nutrition Summary**_
**Meal intake for 4 weeks**
**Fluid intake for 4 weeks**
**Diet order**
**Supplement product **
**Weight change since last week**
**Existing pressure ulcer**
**History of resolved ulcer**

_**Weight Summary**_
**Weight 180 days prior**
**Weight 30 days prior**
**Weight for each of past 4 weeks**
**Weight change since last week **
**5-10% weight loss past 30 days**
**>10% weight loss past 180 days**

**Example: Nutrition Report**

**Stratified by Risk**
**Provide ‘BIG picture’ over time, not just snapshot of one shift or one day**

## Nutrition Report

**What are uses of the Nutrition Report?**
**Identify which meals are not being eaten**
**Promote use of nutritional supplements**
**Identify need for consistent weights**

**Decreased meal intake **
**Weight loss**
**Increased incontinence episodes**
**Increased behavior problems**
**Existing red areas on skin**
**History of pressure ulcer in last 90 days**

**Example: Priority Report**

**Identifies residents at risk**

## Benefits of Timely Feedback Reports

**Access to summarized information for clinical decision-making**
**Improve response time between identification of resident need and intervention**
**Identify residents at risk for pressure ulcer development**
**Transform from paper to data culture**
**Link reports to documentation elements**

## Step 4: Integrate into Daily Workflow

**Comprehensive forms replace (**_**not supplement**_**) previous forms**
**Importance of front-line CNA observations stressed**
**Feedback is based on documentation**
**Feedback contributes to care plan updates**

## Results

**Decrease Pressure Ulcer Development**
**Increase Adherence to Best Practices**
**Increase Staff Accountability and Satisfaction**
**Inclusion of front-line workers in QI efforts**
**Comprehensive documentation at point of care**
**Communication among care team improved**
**Reduce Inefficiencies**
**# documentation forms for CNAs**
**CNA time looking for documentation book**
**Time to compile reports for State Regulators and MDS **
**Time for Wound RN to summarize and report data**
**Improve State Survey Process**
**Establish a foundation for EHR**

## Impact On Pressure Ulcer QMs

**Impact 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%**** **

## Summary of Key Program Benefits

_**Improve Quality**_
**Improve clinical decision making:  integrate reports into day-to-day workflow**
**Identify residents at high risk early **
**Timely communication among multi-disciplinary team members**
_**QI Collaboration**_
**Receive technical assistance from QI experts**
**Collaborate with peers to share experiences and best practices**** **

## Summary of Key Program Benefits (cont)

_**Improve CNA Documentation**_
**Consolidate current documentation**
**Standardize data elements and eliminate redundancy**
**Audit and train for accuracy**
_**Gain Efficiency**_
**Reduce time spent searching for multiple sources of information**
**Automated reports replace manual compilation of resident information**
_**Increase Morale**_
**Empower multidisciplinary teams with CNAs as important members**
**CNAs see importance of their work**

## Available On-Time Tools

**CNA documentation**
**http://ahrq.gov/research/ltc/pucnaform.pdf**
**On-Time Reports**
**http://ahrq.gov/research/ltc/pusamplerep.pdf**
**Video and other resources**
**http://ahrq.gov/research/puwebcast.htm**