# Presentation: 026002

## Clinical Practice Improvement

**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   **
**www.isisicor.com**

## AHRQ Transforming Healthcare Quality through Information Technology 

**NURSING HOME IT:  OPTIMAL MEDICATION and CARE DELIVERY**

## Build on ICOR experience
NPULS study
AHRQ Partnership for Quality: ‘Real-time Optimal Care Plans for Nursing Home QI’

Implement HIT solutions in long term care:
Electronic CNA documentation 
Clinical decision support focused on incontinence care, nutrition management, skin assessment, behavior management, and restorative care best practices
Electronic medication documentation and administration. 

Identify HIT implementation best practices:
Collaborative, multi-disciplinary partnerships
Workflow analysis and clinical process redesign efforts throughout each stage of implementation
Ongoing assessment of implementation processes and refinement based on evaluation results

**NPULS study**
**AHRQ Partnership for Quality: ‘Real-time Optimal Care Plans for Nursing Home QI’**
**Implement HIT solutions in long term care:**
**Electronic CNA documentation **
**Clinical decision support focused on incontinence care, nutrition management, skin assessment, behavior management, and restorative care best practices**
**Electronic medication documentation and administration. **
**Identify HIT implementation best practices:**
**Collaborative, multi-disciplinary partnerships**
**Workflow analysis and clinical process redesign efforts throughout each stage of implementation**
**Ongoing assessment of implementation processes and refinement based on evaluation results**

**Objectives**

**NURSING HOME IT: OPTIMAL MEDICATION and CARE DELIVERY**

##  ICOR Experience: Research

**National Pressure Ulcer Long-term care Study (NPULS)**
**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, 1996-97**

## NPULS Results: General Care

**Outcome: Develop Pressure Ulcer**

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

**Incontinence**
**Interventions**

**Pressure Relief**
**Interventions**

**Staffing**
**Interventions**

** ****+ Age ******** 85**
** ****+ Male**
** ****+ Severity of Illness**
** ****+ History of PU**
** ****+ Dependency in ******** 7  **
**   ****ADLs**
** ****+ Diabetes**
** ****+ History of tobacco use**
**    **

** ****+ Mechanical devices for the containment of urine (catheters) (treatment time ******** 14 days) **
** ****- Disposable briefs****	**** (treatment time ******** 14 days) **
** ****- Toileting Program (treatment time ******** 21days****)**

** ****+ Static pressure reduction: protective device (treatment time ******** 14 days) **
** ****+ Positioning: protective device (treatment time ****** **14 days) (p=.07)**

** ****- RN hours per resident  per day ****** **0 .25**
** ****- CNA hours per resident per day ****** **2**
** ****- LPN hours per resident per day ****** **0.75**

**Medications**

** ****- ****Antidepressant**

## NPULS Results: Nutritional Care

** ****Assessment**

**Nutritional**
**Interventions**

** ****+ Dehydration signs and symptoms:  ****low systolic blood pressure, high temperature, dysphagia, high BUN, diarrhea, dehydration **
** ****+ Weight Loss: ****** **5% in last 30 days or ****** **10% in last 180 days**

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

**NPULS Results: Nutritional Care**
**Outcome: Develop Pressure Ulcer**

## NPULS Psychiatric Medications 

**Dementia & Agitation n = 803**
**	****	****No Psych Meds****	****	****	****	****32.5%**
**	****	****Anti-psychotics****	****	****	****	****31.5%**
**	****	****Anti-depressants****	****	****	****	****34.6%**
**	****	****Anti-anxiety****	****	****	****	****34.9%**
**Combinations in 42% of treated residents**

## Long-Term Care Residents with Agitation in DementiaRecommended Practice

**Use fewest number of medications possible (Omnibus Reconciliation Act 1987)**
**Minimize use of benzodiazepines**
**Use atypical over typical antipsychotics**
**Use SSRIs over tertiary amine antidepressants**
**Avoid combination therapy**

## NPULS Results:  Medication Use with Dementia with AgitationOutcome:  Develop Pressure Ulcer

**Monotherapy includes antipsychotic only, antidepressant only, or antianxiety only **
**SSRI + includes SSRI and antipsychotic or antianxiety medications concurrently **
**  *****p**_**<**_**.05****   ******p**_**<**_**.01**

## Integrate sustainable quality improvement into daily operations
Incorporate evidence-based practices for pressure ulcer prevention  
Integrate into daily work versus ‘add-on’ project

Focus on critical data elements and information flow
Eliminate redundant documentation
Reduce paperwork and streamline documentation
Improve accuracy of information
Improve communication among multi-disciplinary care teams

Translate documentation into data & data into multi-disciplinary clinical reports

Establish pre-IT foundation

- Incorporate evidence-based practices for pressure ulcer prevention
- Integrate into daily work versus ‘add-on’ project
- Focus on critical data elements and information flow
- Eliminate redundant documentation
- Reduce paperwork and streamline documentation
- Improve accuracy of information
- Improve communication among multi-disciplinary care teams
- Translate documentation into data & data into multi-disciplinary clinical reports
- Establish pre-IT foundation

**AHRQ Partnership for Quality**
**Real-time Optimal Care Plans for Nursing Home QI**

## Workflow Redesign Target Areas

**CNA Daily Workflow**
**Documentation flow sheets**
**Communication with clinical team**
**Nursing Daily Workflow**
**Wound Nurse documentation and reporting**
**Care Plan documentation and communication**
**Care Planning Processes**
**Identify residents at risk for pressure ulcer development**
**Reports used in clinical decision-making**
**Response between identification of resident need and intervention**
**Monitoring of resident outcomes**

## Results to Date

**Workflow inefficiencies reduced:**
**# 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**
**Communication among care team improved**
**Pressure ulcer development reduced**
**Decreased approximately 25% in one year**
**Average of $1,885 per pressure ulcer event in FY 04 **
**Front-line satisfaction improved**

## Medication Findings Replicated in Practice

**Benefits of Combination Psychiatric Medication Therapy**
**23 residents in one facility with weight loss **
**    ****(5-10% in <=30 days, >10% in <=180 days)**
**3 (13%)residents treated with combination therapy**
**12 (52%) residents treated with mono-therapy**
**8 (35%) residents received no psych meds**

## Impact Workflow Efficiency: CNA Documentation

**Impact Workflow Efficiency: ****CNA Documentation**

**Standardization of CNA documentation streamlined documentation processes for staff and resulted in consolidation of forms.**

## Impact On Pressure Ulcer QMs 

**Impact On Pressure Ulcer QMs **

**Source:  CMS Nursing Home Compare; Facility QM data reports**

**The combined facilities’ average (includes 7 facilities that implemented in Apr ’04) shows an overall reduction in the QM % of high risk residents with pressure ulcer from pre-implementation to initial post-implementation time periods. **
**Note that 4 of the 11 participating facilities are not reported: 2 implemented in Q1 05, 1 does not report QM data, 1 was not reported in Nursing Home Compare database.**

**Q4 03 – Q3 04**_** **_**% Change =  -26.4% **
**Q4 03 – Q4 04: % Change = - 56.9%**

**Combined Facilities**

**National Norm**

**CMS data through Q3 04**

**3 Sites provided data Q4 04**

## AHRQ Transforming Healthcare Quality through Information TechnologyNURSING HOME IT: OPTIMAL MEDICATION and CARE DELIVERY

**Implement HIT solutions in long term care:**
**Electronic CNA documentation **
**Clinical decision support **
**Electronic medication documentation and administration**
**Identify HIT implementation best practices:**
**Collaborative, multi-disciplinary partnerships**
**Workflow analysis and clinical process redesign **
**Ongoing assessment and refinement of implementation processes**

## Workflow Redesign Target Areas: Clinical Documentation 

**Clinical documentation and reporting: **
**CNA - daily flow sheets **
**Care team documentation**
**Resident care plan**
**Diet orders**
**Restorative care**
**Skin assessments**
**Pressure ulcer documentation **
**Feedback reporting to improve resident care**
**MDS information**
**Federal and State survey information**
**Care plan information**

## Workflow Redesign Target Areas: Medication Administration Process

**Entering MD orders**
**RN enters into MD order module**** **
**Communicating with pharmacy**
**Order verification **
**MedPass**
**Eliminate time wasters: new medication look-up**
**Bar code scanning of medications**
**Verify that the “five rights” have been met – right patient, medication, dose, time, route.**

## Factors for Successful HIT

**Effective Project Management Team Approach**
**Facility Implementation Team**
**representatives of all clinical staff**
**	**
**Regular conference calls **
**Forum for sharing perspectives and learning across facilities**
**Identify next steps**
**Written minutes**
**Staged Approach with Clear Incremental Objectives**
**Each phase has defined scope**
**Facilities make investments incrementally **
**Identify incremental milestones**

## Factors for Successful HIT

**Focus on Workflow Redesign as Initial Step**
**Redesign daily workflow versus add-on project work**
**Emphasize CNA involvement and feedback****  **
**Streamline Documentation and Information Flow**
**Focus on critical data elements**
**Reduce redundant documentation **
**Improve accuracy of documentation**
**Improve communication among multi-disciplinary care teams**

## Factors for Successful HIT

**Translate Documentation into Data**
**Migrate from paper environment toward a data culture environment**
**Translate Data into Multi-disciplinary Reports**
**Migrate from a culture of using quarterly reports for retrospective analysis**
**          ****TO**
**Culture that uses weekly reports for timely resident care planning  **

## Unanticipated Changes to Project Plans in Year 1

**Additional HIT vendors **
**eMAR offerings for long term care are new and untested   **
**HIT vendor product development schedule is not predictable**
**Time associated with evaluating and selecting HIT**
**Vendors reluctant to acknowledge product limitations  **
**Product demonstrations do not always reflect system  capabilities**
**Vendors reluctant to interface with other systems**
**Expanded number of participating facilities **

## Learning

**Long term care facilities are eager to proceed with HIT implementation**
**Assistance is needed to:**
**Standardize data elements that incorporate requirements for best practices and quality **
**Share information and learning across facilities **
**Redesign daily processes **
**Educate staff to use timely feedback reports  **

## Opportunities to Improve Medication Delivery

**Accuracy of MAR**
**Transcription of initial medication order to MAR**
**Monthly ‘change over’ process:  transcribing medications for all residents each month **
**Efficiency**
**Time to enter new orders**
**Time to complete monthly ‘change over’**
**Time from MD order to RN verification to pharmacy **
**MedPass**
**Time to complete**
**# delays due to searching for information**

## Impact On Outcomes & Safety

**Decrease Pressure Ulcer Development**
**Optimize nutrition and incontinence treatments**
**Decrease Medication Errors**
**Wrong resident, wrong drug, wrong dose, wrong timing, or omission**
**Increase Adherence to Best Practices**
**Right interventions for Right resident at Right time**
**Increase Staff Accountability and Satisfaction**
**Inclusion of front-line workers in QI efforts**
**Comprehensive documentation at point of care**