Dep-ent  of  Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
EARLY  EXPERIENCES  WITH

CLINICAL  l?RACTICE  GUIDELWS 
SPONSO~D  BY 
THE	 AGENCY  FOR  HEAL~  C
POLICY  AND  RESEARCH 
CASE STUDIES

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OEI-01-94-00251
 OFFICE  OF  INSPECTOR  GENEIWL 
The mission of the Office of Inspector  General  (OIG), as mandated  by Public Law 95-452, as 
amended, is to protect the integrity of the Department  of Health  and Human Services (HHS) 
programs as well as the health and welfare of beneficiaries semxi  by those programs.  This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by three OIG operating components:  the Office of Audit Senfices, the 
OflIce of Investigations, and the Office of Evaluation and Inspections.  The OIG also informs 
the Secretary of HHS of program and management problems and recommends courses to 
correct them. 
OFFICE  OF AUDIT  SERVICES 
The OIGS Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors in 
carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations  in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout  the Department. 
OFFICE  OF INVESTIGATIONS 
The OIGS Office of Investigations (01) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HIM programs or to HHS beneficiaries and of 
unjust enrichment by providers.  The investigative efforts of 01 lead to criminal convictions, 
administrative sanctions, or civd money penalties.  The 01 also oversees State Medicaid fraud 
control units which investigate and prosecute fraud and patient  abuse in the Medicaid program. 
OFFICE  OF EVALUATION  AND  INSPEC130NS 
The OIGS Office of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the Department, 
the Congress, and the public.  The findings and recommendations contained in these inspection 
reports generate  rapid, accurate, and up-to-date  information on the efficiency, vulnerability, 
and effectiveness of departmental  programs. 
This report was prepared  under the direction of Mark R. Yessian, Ph.D., Regional Inspector 
General, and Martha B. Kvaal, Deputy Regional Inspector General, Boston Region, Office of 
Evaluation and Inspections.  Participating in this project were the following people: 
Boston  Headquarters 
Dana L. Miller, fioject  Leader  Ann OConnor, ProgramSpecialist 
Russell W. Hereford, Ph.D.  Dep-ent  of  Health  and Human  Services
OFFICE  OF 
INSPECTOR  GENERAL 
EARLY  EXPERIENCES  WITH

CL~CAL  PRAC~CE  GUIDEL~S 
SPONSORED  BY 
THE	 AGENCY  FOR  HEALTH  C
POLICY  AND  RESEARCH 
CASE STUDIES

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OEI-01-94-002S1
 TABLE  OF  CONTENTS

PAGE 
INTRODUCllON  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..1

CAsES~~  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..2

HosPrrALs 
1:	 ARural,  County-Owned  Hospitals  Use

of the  Pressure  U1cer Prevention  Guideline  . . . . . . . . . . . . . . . . . . . . . . . ...2

2  ARural,  Non-Profit  Hospitals  Use

of the  Pressure  Ulcer  Prevention  Guideline  . . . . . . . . . . . . . . . . . . . . . . . ...4

.

3:	 ARural,  County-Omed  Hospitals  Use

of the  Pressure  Ulcer  Prevention  Guideline  . . . . . . . . . . . . . . . . . . . . . . . ...6

4	 A Rural,  Private,  Non-Profit  Hospitals  Use

of the  Pressure  Ulcer  Prevention  and  Pain  Management  Guidelines  . . . . . . .  9

5:  A Rural  Hospitals  Use  of the  Pain  Management  Guideline  . . . . . . . . . . . . .  11

6  A Mid-Sized  Town  Hospitals  Use  of the  Pain  Management  Guideline  . . . .  13

7  A Rural,  County-Owned  Hospitals  Use  of the  Incontinence  Guideline  . . . .  15

NURSING HOMES 
8:	 A Rural,  Proprietary  Nursing  Homes  Use

of the  Pressure  LTlcerPrevention  Guideline  . . . . . . . . . . . . . . . . . . . . . . . . .  18

9	 A Large  Nursing  Homes  Use

of the  Pressure  Ulcer  Prevention  Guideline  . . . . . . . , . . . . . . . . . . . . . . . . .  20

10	 A Skilled-Nursing  Homes  Use

of the  Pressure  Ulcer  Prevention  and  Incontinence  Guidelines  . . . . . . . . . . .  22

11:	 A Small-Tom,  Proprietary  Nursing  Homes  Use 
of the  Incontinence  Guideline  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..24 
12:	 A Large  Health  Maintenance  Organizations  Use

of the  Cataract  Guideline  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...26

13:  A Consortiums  Use  of the  Pressure  Ulcer  Prevention  Guideline  . . . . . . . . .  28
 INTRODUCTION 
We have  conducted  an inspection  that  focuses  on the  early  experiences  of healthcare

organizations  that  have  used  the  clinical  practice  guidelines  sponsored  by the  Agency

for Health  Care  Policy and  Research  (AHCPR).  In that  inspection,  we examined  the

extent  to which  healthcare  organizations  have  used  AHCPR  guidelines,  the  ways in

which they  have  used  them,  and  any obstacles  they have  encountered  in the  process.

To  collect  information  for that  inspection,  we sent  a mail  survey  to 380 healthcare

organizations:  150 randomly  selected  nursing  homes,  150 randomly  selected  non-

teaching  hospitals  with no more  than  100 patient  beds,  and  all 80 of the  health

maintenance  organizations  with  staff-model  components.  We  received  responses  horn

64 percent  of the  organizations  surveyed.

We  present  our  findings  in a companion  report  entitled  Clinical  Practice  Guidelines

Sponsored  by the  Agency  for  Heaith  Care  Policy and  Research:  Eariy  Experiences  in

Clinical  Settings,  (OE1-01-94-00250).

In this report,  we offer  supplementary  case descriptions  of the  ways in which

healthcare  organizations  have  used  the  AHCPR  guidelines.  These  descriptions  were

developed  from  interviews  that  we conducted  with clinician-managers  in organizations

that  responded  to  our  survey.

These  descriptions  are  more  detailed  than  those  provided  in our  companion  report.

We report  the  information  as organizations  reported  it to us, without  further  review  or

confirmation  on our  part.  We  present  the  case  descriptions,  without  additional

analysis,  as background  information  for the  Agency  to  use as it chooses.
 I I 
c%SEl:  A RUR&  COUNTY-OWNED  HOSPITALS 
USE  OF  THE  PRESSURE  ULCER  PREVENTION  GUIDELINE 
ORGANTZAfYONPROHLE 
This  is the  oniy hospital  within  a 35-mile  radius.  It is located  in a county  with a 
population  of just  under  10,000.  Seventy  percent  of its patient  population  is geriatric. 
The  hospital,  which  has  an elected  governing  board,  is a 49-bed,  acute-care  facility 
with  39 in-service  beds  and  a few swing beds.  It has  6 family-practice  physicians, 
1 general  surgeon,  1 physician  assistant,  and  1 family-nurse  practitioner.  The  hospital 
offers  6 specialty  clinics several  times  each  month. 
MOTIVATION FOR USINGTHE GUIDELINE 
Shortly  after  the  hospital  received  its copy of the  pressure  ulcer  guideline  from 
AHCPR,  a patient  with stage-4  pressure  ulcers  came  into  the  hospital  from  a long
terrn  care  facility.  The  plight  of this  patient,  who subsequently  died,  raised  staff 
interest  in better  understanding  effective  means  of treating  pressure  uicers.  At that 
point.  the  hospital  did not  systematically  assess  patient  risk for  pressure  ulcers.  The 
nursing  quality-assurance  committee  identified  the  need  for  an  effective  assessment 
tool  and  protocol,  and  its members  set  out  in search  of information. 
WAYS OF USING THE GUIDELINE 
New  policy and  procedures.  In the  fall of 1993, hospital  staff  attended  meetings  on 
pressure  ulcers  at different  sites around  the  State.  The  staff  also  formed  a task  force 
to review  relevant  information  that  it gathered  from  professional  journals.  It rewrote 
its protocol  for nursing  assessment  of pressure  ulcers  and  incorporated  the  A.HCPR
recommended  Norton  assessment  scale  into  its protocol.  The  hospital  also  established 
an  algorithm  for  care  of patients  at increased  risk of pressure  uicers;  this algorithm 
was derived  from  the  AHCPR  guideline. 
Use  with clinicians.  The  hospital  distributed  the  pressure  ulcer  guideline  to all clinical 
staff.  .+dditional  copies  are  kept  at the  nursing  station  and  in the  hospital  library.  A 
skin-care  product  company  provided  additional  information  and  training  for  staff.  The 
company  held  all-day  training  sessions  for nurses  on prevention  and  treatment  of 
pressure  ulcers  and  it held  luncheon  lectures  for physicians.  It demonstrated  care 
techniques  on the  floor.  Physicians  and  nurses  trained  one  another  to perform  the 
recommended  procedures.  In addition,  pressure  ulcer  prevention  and  care  have  been 
addressed  in monthly  staff meetings. 
Use  with patienis.  The  hospital  has not  used  the  AHCPR  patient  guides,  but  intends 
to do so as part  of patient  teaching  with  those  of its at-risk  patients  who  are  able  to 
understand  the  materiai. 
2
 ~h4PIJANCE  AND EVALUATION 
The  hospital  quality-assurance  reviews  address  pressure  ulcers;  patient  care  in the 
swing-bed  unit  is reviewed  each  week.  Originally,  feedback  was provided  to staff  as a 
group.  Now, when  failure  to comply  with the  new hospital  policies  and  procedures  is 
identified,  clinicians  are  addressed  on an individual  basis. 
The  hospital  has  not  yet conducted  an evaluation  of the  effects  of guideline  use.  The 
smail patient  population  has limited  the  hospitals  capacity  to perform  a statistically 
sound  assessment.  A representative  noted,  however,  that  hospital  patients  seem  to 
have  been  faring  better  with regard  to pressure  ulcers.  He  added  that  the  guidelines 
have  been  helpful  in terms  of both  achieving  better  patient  outcomes  and 
standardizing  clinicai  practice. 
Clay County  Hospital 
617 Liberty  Street 
Clay Center,  Kansas  67432 
Telephone:  9136322144 
J  I
CXE  2:.  A RUIU&  NON-PROFIT  HOSPITALS  USE  OF 
TEE  PRESSURE  ULCER  PREVENTION  GUIDELINE 
ORGANIZATIONPROFILE

This rural,  non-profit  hospital  has  74 beds  and  approximately  225 admissions  each

month.  It also  has  two long-term  care  skilled-nursing  facilities  with a total  of  170 beds

and  a residential-care  facility with  45 beds.  The  hospital  also  has a large  home-health

program  and  a hospice.  The  hospital  manages  a health  maintenance  organization

(HMO)  as one  of its departments.  In addition,  the  hospital  owns and  manages  14

physician  clinics, inciuding  6 rural  health  clinics.  The  hospital  employs  approximately

700 staff, including  111 registered  nurses  and  28 licensed  practical  nurses.  The

hospital  empioys  27 physicians  and  has  about  50 consulting  physicians.

The  HMO  serves  approximately  1900 members.  About  60 percent  of the  hospital

patients  are  Medicare  beneficiaries;  25 percent  are  covered  by Medicaid;  1S percent

are  seif-pay,  and  a few are  covered  by private  insurance.

MOTIVATIONFOR USINGTHE GUIDELINE

The  hospitals  director  of quality  improvement  leamed  about  the  pressure  ulcer

guideline  from  the  hospitals  chief  executive  officer  and  from  a meeting  she attended

in 1993.  The  hospital  reviewed  the  guideline  when  it standardized  the  assessment  and

treatment  of pressure  ulcers  across  all components  of the  organization.

WAYS OF USING THE GUIDELINE

New poiicy and  procedures.  The  hospital  used  information  relevant  for its practices  to

revise  its policy  and  procedures  in the  winter  of 1993/94.

Use  by clinicians.  The  director  of quality  improvement  explained  the  AHCPR

guideline  and  the  new policy and  procedures  at regularly  scheduled  staff  meetings.

She gave copies  of the  guideline  to  physicians,  directors  of nursing,  and  nurse

managers.  She  also  sent  out  a hospital-wide  notice  announcing  the  availability  of all of

the  AHCPR  guidelines  that  had  been  published  to date.  In response  to this memo,

the  social services  department  requested  a copy of the  guideline  on depression.  The

hospital  education  department  has  held  in-service  educational  sessions  about  the

pressure  ulcer  guideline  for nurses  and  nursing  assistants.

The  hospital  used  the  guideline--and  specifically  the  Norton  and  Braden  scales  it

references--to  develop  a new  pressure  ulcer  risk-assessment  tool  for the  nurses.  The

hospital  instituted  a new risk-assessment  form  for use in its acute-care  unit.  The  risk

assessment  was also  incorporated  into  the  form  used  to assess  all patients  for

admission  and  on a daily basis  thereafter.

4
 Usewith  patients.  ~eorgantiation  hasnotdistfibuted  thepressure  ulcer  guideline  as 
a regular  part  of patient  education.  The  director  of quality  improvement  believes  that 
hospitalized  patients  who develop  pressure  ulcers  are  too  ill to understand  them. 
Nonetheless,  the  pressure  ulcer  guideline  is used  to educate  patients  and  their  families 
in the  hospitals  home-health  sefice. 
OBSTACLESK) USE 
The  hospital  interpreted  the  pressure  ulcer  guideline  as recommending  that  patients 
be turned  evew  hour,  and  the  staff  have  found  that  this goal  is difficult  to  achieve  in a 
long-term  care-facility  such as theirs.  The  hospital  policy  is that  patients  be  turned 
every  two hours. 
The  hospital  considers  the  AHCPR  guideline  to be general  and  adaptable  to local 
conditions.  Adaptation,  however,  has  been  an expensive  and  time-consuming  process. 
The  hospital  had  planned  to use  the  acute  pain  management  guideline  as well as the 
pressure  ulcer  guideline.  Facility-wide  use  of the  pain  management  guideline  was put 
on hold when  it became  apparent  that  each  of the  organizations  many  components 
had  developed  its own pain  assessment  and  treatment  procedures  and  did not  want  to 
change  systems. 
COMPLIANCEAND EVALUATION 
Recently,  the  hospital  assigned  a nurse  on the  medical/surgical  floor  to spend  one  shift 
each  week  evaluating  pressure  ulcers  to ensure  that  care  plans  are  appropriate  and 
are  being  implemented.  In the  long-term  care  unit,  assessment  of pressure  ulcers  is 
conducted  on a monthly  basis. 
The  hospital  has  not  measured  clinicians  compliance  with  the  guideline,  but  it has 
measured  their  compliance  with  the  new policy and  procedures.  The  hospital  has 
measured  incidence  of pressure  uicers  as one  of its quality-improvement  indicators, 
and  it has  developed  a quarterly  report  on pressure  uicer  incidence.  The  director  of 
quality  improvement  has also  used  the  report  to identify  patient  characteristics  that 
correlate  with  pressure  ulcers.  The  hospital  expects  the  report  will show a downward 
trend  in the  incidence  of pressure  ulcers,  especially  in the  long-term  care  unit. 
Citizens  Memorial  Hospital 
1500 North  Oakland 
Bolivar,  Missouri  65613 
Telephone:  4173260553 
5
 I
CASE  3:  A RUR&  COUNTY-OWNED  HOSPITALS 
USE  OFTHE  PRESSURE  ULCER  PREVENTION  GUIDELINE  1 
ORGANIZATION PROFILE

This  county-owned  hospital  in a rural,  farming  community  is licensed  for 42 beds

(including  8 swing beds);  34 of these  are  now occupied.  The  hospitaI  provides

generai-medicai,  surgical,  pediatric,  and  obstetric  services,  and  it has an intensive-care

unit.

The  hospital  is staffed  by 25 registered  nurses  and  6 general-practice  physicians,  3 of

whom  have  been  with the  hospital  for over  thirty  years  and  3 of whom  have joined

during  the  past  5 years.  In addition,  a radiologist  visits  the  hospital  4 days a wee&  and

a pathologist  and  a general  surgeon  each  visit the  hospital  1 day a week.  The

hospitals  home  health  program  is staffed  by 55 nurses  and  nursing  aides,  who conduct

about  2500 home  visits a month.

Approximately  60 percent  of the  patients  are  Medicare  beneficiaries.

MOTIVATIONFOR USINGTHE GUIDELINE

The  hospital  has  used  three  of the  AHCPR  clinical  practice  guidelines:  acute  pain

management,  pressure  ulcer  prevention,  and  urinary  incontinence.  This discussion

addresses  the  hospitals  use of the  pressure  ulcer  guideline.

One  hospital  physician  has been  the  medical  director  at  a nearby  nursing  home  that

was cited  by State  sumeyors  for unsatisfactory  care  of pressure  ulcers.  The  State

asked  the  hospital  to help  the  nursing  home  improve  its performance.  In so doing,

both  the  hospital  and  the  nursing  home  began  to use  the  pressure  ulcer  guideline.

Even  though  the  hospital  had  launched  a skin-integrity  quality-improvement  initiative

several  years  earlier,  the  hospital  had  made  little  progress.  The  biggest  problem  was

that  its pressure  uicer  indicators  were  calibrated  such  that  they failed  to register

improvement.  In addition,  each  physician  had  his own way of managing  pressure

ulcers;  the  hospital  lacked  a consistent  approach  to the  problem.

Recognizing  these  problems,  the  nursing  director  wanted  to develop  new poiicy and

procedures  for  the  hospitals  treatment  of pressure  ulcers.  Her  goals were  to decrease

the  incidence,  severity,  and  duration  of pressure  ulcers  and  to increase  consistency

among  staff  in treating  the  condition.  Reducing  the  costs  of treating  pressure  ulcers

was not a specified  goal,  although  the  director  suspects  that  costs have gone  down  due

to less variation  in the  supplies  purchased.

6
 In seeking  information  from  which  to  build new policy and  procedures,  the  director

reviewed  materials  from  neighboring  hospitals  and  looked  for  a public  standard  for

measuring  skin  integrity.

WAYS OF USING THE GUIDELINE

Use with clinicians.  The  nursing  director  distributed  handouts  describing  the  new

policy and  procedures  and  explaining  pressure  ulcer  assessment  and  treatment.  The

hospital  held  informal  skills-training  sessions  for staff  about  pressure  ulcer  care.  This

skills training  addressed,  among  other  things,  the  use  of a camera  in documenting

pressure  ulcers.  To keep  staff  from  failing back  into  their  old routines,  the  director

has held  review  sessions  at staff meetings.

The  hospital  changed  its clinician-patient  encounter  forms,  which are  now used  on a

daily basis.  The  hospital  also  expanded  the  options  listed  on  its laboratory  culture-

order  form  for  pressure  ulcers,  but  these  changes  were  not  made  in response  to the

AHCPR  guideline.

Use  with patients.  For  the  past  year,  the  hospital  has  used  the  pressure  ulcer

guideline  in its home-health  classes  to educate  patients  and  their  families  about  ways

to avoid  and  heal  pressure  ulcers.  It has not  distributed  the  pressure  ulcer  guideline

to hospital  patients  because  those  most  at risk for pressure  ulcers  lack  the  capacity  to

understand  the  material  and/or  to act  on it.

OBSTACLESTO USE

The  hospitals  physicians  anticipated  that  a clinical  path  for  pressure  ulcers  could  be

developed  in one  week,  but  it took  longer.  Implementing  the  guideline  throughout  the

hospital  took  about  six months.

Staff have  been  unclear  about  how to score  the  Braden  scale  for assessing  risk factors.

The  hospital  found  that  the  guideline  does  not  explain  how  to calculate  a total  score

by combining  the  score  on the  Braden  scale with the  24-hour  assessment.  The

hospital  has  sought  guidance  from  AHCPR  on this subject.

COMPLIANCEAND EVALUATION

The  hospital  has  conducted  quarterly  skin-integrity  quality-improvement  studies  to

determine  improvement  in preventing  and  caring  for pressure  ulcers.  These  studies

have  examined  the  extent  to which  patients  pressure  ulcers  have  been  assessed  at

both  admission  and  discharge  and  have  reviewed  treatment,  including  photographs  and

measurements  of the  ulcers,  and  documentation  of improvement  or deterioration  in

the  patients  condition.

The  nursing  director  has reviewed  indicators  of patient  care  and  status  and.  in

instances  in which  the  indicators  demonstrate  a negative  trend,  she has  reviewed  more
 extensive  information.  When  clinicians  care  of pressure  ulcers  has  not  met  the  new 
standards,  the  nursing  director  has provided  feedback  on  a one-to-one  basis.  She has 
also provided  feedback  to the  staff  as a group  in staff  meetings. 
The  nursing  director  noted  that  the  incidence  and  severity  of pressure  ulcers  have 
decreased  in the  hospital.  Patients  who  have  entered  the  hospital  with stage  one  or 
two ulcers  now leave  with none.  She also  noted  the  benefit  to patients  of having  both 
the  hospital  and  nursing  home  staffs  adhering  to the  same  standards  of care. 
Craig  General  Hospital 
Post  Office  BOX326 
Vinita,  Oklahoma  74301 
Telephone:  9182567551  CASE 4  A RUR&  PRIVATQ  NON-PROFIT  HOSPJ1ALS 
USE  OF THE  PRESSURE  ULCER  PREVENTION 
AND  PAIN  MANAGEMENT  GUIDELINES 
ORGANIZATIONPROFILE 
This  rural  facility, which is run  by an  independent,  private,  non-profit  organization,  has 
fewer  than  50 beds  and  an average  of  14 patients.  The  hospital  is staffed  by 3 
uhvsicians.  a nurse  Practitioner,  and  other  nursing  staff.  The  acute-care  unit  has 
? r~gister~d  nurses,11  licensed practical  nurses,  ~nd 20 nurse  aides.  The  emergency 
room  has  about  220 visits a month. 
In the  past  two years,  the  hospital  has  established  two health  clinics from  the  three 
physician  practices  that  it acquired  and  has opened  a home-health  agency. 
Approximately  80 percent  of the  hospitals  patients  are  either  Medicare  or Medicaid 
beneficiaries. 
MOTIVATIONFOR USINGTHE GUIDELINES 
The  hospital  administrator  introduced  the  staff  to the  acute  pain  management  and 
pressure  ulcer  guidelines  after  he  become  aware  of important  inconsistencies  in the 
treatment  of pressure  ulcers  and  potential  abuses  in the  treatment  of pain.  For 
pressure  ulcers,  physicians  had  used  their  own, sometimes  home-spun  and  untested, 
remedies.  For  pain  management,  physicians  had  sometimes  inappropriately  prescribed 
Schedule-2  narcotics  for headaches.  At  the  same  time,  the  hospitals  insurance 
company  requested  that  the  hospital  begin  to grade  its physicians  clinical  performance 
at the  time  of their  annual  recredentiaiing. 
WAYS OF USING THE GUIDELINES 
New hospital  guidelines.  The  administrator  obtained  copies  of the  two AHCPR 
guidelines  and  drafted  brief  summaries  (each  less than  two  pages)  for the  hospitals 
use.  The  physicians  and  the  hospitals  governing  board  approved  them. 
Use with clinicians.  The  administrator  presented  the  new  guidelines  at a few staff 
meetings.  The  hospital  bought  a taped  series  on pressure  ulcer  care  for the  hospital 
staff and  home-health  agency  employees.  In addition,  the  physical  therapist  conducted 
in-service  training  on pressure  ulcers  for  the  nurses  and  nurse  assistants.  Skills 
training  on pressure  ulcers  has  been  conducted  as part  of the  regular  orientation  for 
new staff. 
The  hospitals  guidelines  called  for a new patient-turning  chart.  This  chart  lists the 
times that  each  patients  position  must  be changed,  and  it requires  a sign-off by the 
nurses  to indicate  that  the  turning  has  been  accomplished.  Patient-turning  is also 
9
 noted  in the  patients  charts.  The  physical  therapist  must  assess  pressure  ulcer

patients  three  times  a week.

To implement  the  new pain  management  guideline,  a new  emergency  room  encounter

form was developed  specifically  for pain  patients.  This  form  informs  patients  of the

hospitals  policy  with regard  to pain  medication.  Thus  far,  the  form  has prompted  no

comments  and  has  resulted  in a less frequent  use  of narcotics.  The  administrator

noted  that  patients  hoping  to receive  narcotics  often  walk  out  of the  emergency  room

after  reviewing  the  form;  they  no longer  even  try to get  the  medicine.

OBSTACLESTO USE

The  administrator  noted  initial  difficulties  in getting  all the  staff to  adhere  to  the  new

policies  on  a consistent  basis.  For  instance,  the  emergency  room  staff  sometimes

forgot  to use  the  new pain  form  with patients.  The  administrator  responded  to these

difficulties  by reinforcing  the  importance  of the  forms  in staff  meetings  and  in personai

meetings  with  staff  members.  He  indicated  that  tact  has  been  an important

component  of his strategy  to achieve  successful  implementation  of the  new poiicies.

COMPLIANCEAND EVALUATION

As part  of the  recredentiaIing  process,  the  hospital  now reviews  physicians  pain-

management  and  pressure  ulcer  management  practices  against  the  new guidelines.  In

addition,  deviations  from  the  new guidelines  are  discussed  in monthly  staff meetings.

A  a result  of the  new pressure  ulcer  guidelines,  physicians  have  relinquished  care  of

pressure  ulcers  to the  physical  therapist.

Sayre  Memorial  Hospital

Post  Office  Box 680

Sayre,  Oklahoma  73662

Telephone:  4059285541

10
 CASE  5:  A RURAL  HOSPITALS 
USE  OF  THE  PAIN  WAGEMENT  GUIDELINE 
ORGANIZATIONPROFILE 
This rural  hospital  has  74 intermediate-care  beds  and  53 acute-care  beds.  Some  of the 
acute-care  beds  are  swung beds.  An independent-living  unit  that  houses  33 seniors  is 
also part  of the  hospital. 
The  hospital  is staffed  by 5 general  practitioners,  2 internists,  and  2 general  surgeons, 
35 acute-care  nurses,  10 intermediate-care  nurses,  and  12 home  health/public-health 
nurses. 
MOTIVATIONFOR USING H  GUIDELINE 
The  facility has  used  three  AHCPR  guidelines--pain  management,  depression,  and 
pressure  ulcer  prevention.  This  description  focuses  on the  use  of the  pain 
management  guideline. 
The  hospitals  nursing  research  committee  first began  to  consider  practice  guidelines  a 
few years  ago  as a way of improving  quality  of care.  A literature  review  uncovered 
the AHCPR  guideline,  which was suited  to the  hospitals  needs. 
WAYS OF USING THE GUIDELINE 
Use with clinicians.  The  hospital  has placed  primary  emphasis  on  treating  pain  after 
surgery,  and,  to  a lesser  extent,  on managing  pain  in cancer  patients.  The  hospital  has 
fully implemented  a patients  self-assessment  pain  scale. 
OBSTACLESTO USE 
The  hospital  has  been  educating  its physicians  to make  them  more  comfortable  with 
PCA (patient-controlled  analgesic)  pumps.  A young,  newly-trained  surgeon  who is 
familiar  with the  pumps  has been  working  with other  physicians.  Several  physicians 
have  continued  to use Demerol,  even  though  the  guideline  encourages  use of 
morphine  for  better  pain  control. 
The  physicians  have  been  receptive  to writing  patient  orders  that  allow different 
approaches  to pain  control.  The  director  of nursing  beiieves  that  they would  be even 
more  receptive  to options  if the  nurses  would  ask for them.  She  noted,  as an  exarnpk 
that  the  guideline  presents  a range  of dose  ieveis and  a range  of lengths  of time  for 
medication.  Many  nurses,  however,  are  used  to administering  injections  every  4 hours 
and  have  not  considered  other  ways of controlling  pain.  Staff nurses  initially  found  the  guideline  ovenvhelming;  they  did  not  have  time  to read 
it all.  Each  nurse  manager,  however,  has been  involved  in in-service  training. 
COMPLIANCEAND EVALUATION 
The  hospital  has assessed  the  effects  of its change  in pain-management  practice  in tsvo 
ways.  First,  the  hospital  has  conducted  audits  of patient  charts  to determine  how 
often  pain  assessments  are  conducted,  pain  is reported,  medication  is administered; 
and  the  length  of time  between  the  administrations  of pain  medications.  The  hospital 
aims  to prevent  pain  from  exceeding  5 on the  l-to-10  scale.  Second,  the  hospital  has 
added  a question,  Was your  pain  adequately  controlled,  to the  hospitals  patient 
satisfaction  questionnaire. 
Greene  County  Medic-d  Center 
1000 West  Lincoinway 
Jefferson,  Iowa  50129 
Telephone:  5153862114 
12
 CASE  6,  A MID-SIZED  TOWN  HOSPJT.ALS 
USE  OF  THE  PAIN  MANAGEMENT  GUIDELINE 
ORGANIZATION PROFILE 
This hospital  is located  in a town  of about  30,000 people.  The  hospital  has  a capacity 
of 70 beds,  but  operates  only 34 beds.  Overall,  the  hospital  has about  200 employees, 
including  80 nurses  and  15 physicians  on the  active  medical  staff. 
MOTIVATIONFOR USINGTHE GUIDELINE 
The  nursing  staff  conducted  an overall  review  of their  protocols  for treating  different 
conditions,  including  acute  pain.  During  that  time,  the  nursing  director  attended  a 
seminar,  at which  she received  information  about  the  guideline.  She presented  this 
material  to the  nursing  staff during  an in-service  training  session.  Then,  the  hospital 
incorporated  the  guideline  into  its new policies. 
The  hospital  has  been  using the  pain  management  guideline  for  15 months. 
WAYS OF USING IWE GUIDELINE 
Use  with clinicians.  The  nursing  staff  developed  their  own  5-point  pain-assessment 
scale,  based  on  the  AHCPR  guidelines  l-to-10  point  scale.  They  also  developed  a 
second,  modified  scale  by assigning  colors  to the  different  pain  levels:  these  colors 
range  from  red,  which connotes  the  most  severe  pain,  to white,  which  indicates  no 
pain.  The  coior  scale has  been  especially  useful  with pediatric  patients. 
A new flow-charting  system  helps  staff  determine  when  to offer  different  medication  to 
patients.  One  benefit  of this system  has  been  getting  physicians  to increase  use  of 
patient-controlled  analgesic  (PCA)  pumps.  Originally,  the  PCA  pumps  were  ordy used 
post-operatively.  They are  now routinely  used  with cesarean-sections,  kidney  stones 
and  severe  back  pain. 
Use with patients.  Recently,  the  hospital  began  to distribute  information  routinely  to 
patients  on  admission.  This information  is tailored  to each  patients  needs.  When 
appropriate,  materials  include  the  consumer  pamphlets  on the  pain  guideline. 
OBSTA- TO USE 
The  director  of nursing  suggested  that  physicians  have  been  somewhat  resistant  to 
changing  established  practice.  Despite  this resistance,  however,  physicians  have 
followed  the  modifications  in clinical  procedures.  She  noted  that,  while  there  has  been 
no formal  approval  of the  modifications  by the  medical  staff,  there  have  been  subtle 
changes  in practices. 
13
 COMPLIANCEAN13EVALUA170N

The  hospital  has  not  undertaken  a formal  evaluation  of the  effects  of its guideline  use.

Informally,  staff  nurses  have  told  the  nursing  director  that  patients  have  been  more

comfortable,  have  been  less likely to complain  about  a lack  of medication,  and  have

been  more  ambulatory.  They  have  reported  no added  cost  as a result  of

implementing  the  guideline.

Fostoria  Cmmmmity  Hospital

501 Van  Buren  Street

Fostoria,  Ohio  44830

Telephone:  4194357734
 I
CASE .1  A RURAIj  COUNTT-OWNED  HWPITAL~ 
USEOF  THE  IIVCOBITJIWWCE  GUIDEI-IIW 
ORGANIZAmON PROFILE 
This county-owned,  frontier  hospital  is located  in a town  of 9,000, about  120 miles 
away from  the  next  hospital.  The  hospital  has  35 acute-care  beds  (medical/surgical 
and  pediatric),  5 intensive-care  beds,  and  10 Iong-terrn  care  beds.  The  staff consists  of 
54 registered  nurses,  12 licensed  practical  nurses,  and  7 nurse  assistants.  In addition, 
the  hospital  has  12 physicians  on staff,  including  5 for  the  emergency  room.  The 
hospital  performs  100 surgeries  per  week  and  sees about  1,000 patients  in its 
emergency  room  each  month. 
Forty  percent  of the  hospital  patients  are  Medicare  beneficiaries;  nearly  8 percent  are 
Medicaid  beneficiaries;  and  3 percent  receive  workmans  compensation. 
MOTIVATIONFOR USINGTT+JZGUDELINE 
In  1994, the  hospitals  chief  executive  officer  of 12 years  resigned,  along  with the 
senior  financial  staff.  The  new  administrative  team  has  begun  to change  hospital 
operations,  and  has added  new  home-health  and  cardiac-rehabilitation  services.  As 
part  of these  changes,  the  hospital  has  adopted  the AHCPR  guidelines  on acute  pain 
management,  urinary  incontinence,  pressure  ulcers,  cataracts,  and  sicide cell disease. 
This  discussion  addresses  the  hospitals  use of the  urinary  incontinence  guideline. 
WAYS OF USKNGTHE GUIDELINE 
I4ewpolicy and  procedures.  The  director  of nursing  first  learned  about  the 
incontinence  guideline  at a seminar  in 1993.  At that  time,  the  hospital  had  no 
standards  of care  for  stress  incontinence.  The  director  got additional  copies  of the 
guideline  and  brought  them  to the  clinical  practice  committee,  which was composed  of 
nurse  managers  and  a few staff  nurses.  This committee  used  the  guideline  to create 
its first standards  of care  for  stress  incontinence  and  quickly  rewrote  the  hospitals 
policy and  procedures  to make  them  consistent  with the  guideline. 
Use with patients.  The  hospital  does  not  routinely  provide  the  guideline  to patients  or 
teach  them  about  the  recommended  care.  Physicians  must  order  guideline  education 
for their  patients.  When  incontinent  patients  are  discharged  from  the  hospital, 
however,  the  discharge  planner  gives them  a copy of the  guideline. 
The  hospital  has  held  educational  sessions  about  urinary  incontinence  at senior  centers 
and  at health  fairs.  It distributes  copies  of the  guideline  at these  sessions  and  may 
present  a video  it has  developed. 
15
 Use  wth clinicians.  After  the  clinical  practice  committee  adopted  its new policy  and 
procedure  on incontinence,  each  nursing  unit  received  ten  copies  of the  clinical 
practice  guideline.  In addition,  each  nurse  manager  took  information  onthe  new 
policy and  procedures  back  from  the  committee  meetings  to  discuss with staff. 
No training  was provided  for the  nursing  staff when  the  new  policy and  procedures 
were  introduced.  Consequently,  many  nurses  failedto  comply  with  them.  The  nursing 
director  found  that  she had todoa  lot ofeducatingof  the  nursing  staff about  stress 
incontinence  and  bladder  training.  . . . I had  to go back  to  basic  anatomy  and 
physiology  to educate  the  nurses.  To  determine  the  focus  for this training,  she 
solicited  from  each  nurse  an assessment  of her  training  needs. 
Ultimately,  the  hospitals  education  department  coordinated  five in-sexvice sessions  on 
incontinence  that  were  mandatoxy  for nursing  staff.  Some  additional  lectures  and 
demonstrations  were  incorporated  into  regular  staff  meetings.  Some  staff, inciuding 
members  of the  skin care  committee,  attended  seminars  off-site  to learn  about 
incontinence. 
The  hospitals  physicians  received  information  about  the  new  policy and  procedures  on 
incontinence  only once--at  a monthly  staff meeting.  The  nursing  director  explained:  r 
dont want  to bug the  doctors. 
The  hospital  has  completely  computerized  its patient  records,  including  all nursing 
notes,  physician  notes,  and  care  plans.  The  guideline  recommendations  have  also 
been  built  into  the  system as reminders  to clinicians.  When  a nurse  brings  up  a 
patients  chart  on the  computer,  for  example,  the  system  W-ll display  recommended 
~reatment.  If the  nurse  chooses  not  to fofiow it, she  must  explain  her  decision  in the 
chart. 
In response  to the  AHCPR  guideline,  the  hospital  has  expanded  its medical-profile 
data-collection  for  newly admitted  patients.  Previously,  patients  were  asked  only one 
question  related  to incontinence:  Are you incontinent?  Now, more  detailed 
information  is gathered  with a  12-question  admitting  and  monitoring  instrument.  In 
addition,  the  hospital  has developed  a new bladder-training  form  for  educating 
patients  and  has  changed  the  instructions  given to patients  at discharge. 
OBSTAm  To  usE 
Uncertainty  about  how to implement  the  guideline  was an  obstacle.  Initially,  the 
nursing  director  sought  information  from  other  hospitals  about  their  plans  for 
implementing  the  guideline.  She found  that  many hospitals  havent  heard  of the 
AHCPR  guidelines.  The  hospital  had  to figure  out  how to  use the  guideline  by itself. 
16
 COMPLIAN=  AND EVALUATION

The  computer  system  has provided  easy  access  to patients  files for quality-assurance

reviews.  The  system  has a quality-improvement  component  that  provides  patient-care

and  outcome  data  to nurse  managers.  This  component  allowed  the  hospital  to identify

the  initial  failure  of some  of the  nursing  staff to comply  with  the  new policy and

procedures  on stress  incontinence.  After  the  intensive  training  effort,  further  review

reveaied  that  staff were  in compliance  in 93 percent  of the  cases.  The  hospital  is

planning  another  compliance  review  in 1995.

The  hospital  has  not  monitored  individual  clinicians  compliance  with the  guideline.  It

may do so, however,  because  the  hospitals  human  resources  department  has been

urging  hospital  Leadership  to develop  criteria  for evaluating  clinician  performance.  To

date,  feedback  has  been  provided  oniy to  groups  of clinicians,  not  to individuals.

The  hospital  has  used  a satisfaction  questionnaire  to assess  patients  perceptions  of

their  care.  In addition,  staff  have  telephoned  stress-incontinence  patients  after  their

discharge  to make  sure  that  they  understand  how to manage  their  incontinence  and  to

make  sure  that  their  home  care  is going well.  The  questionnaires  have  reveaIed  that

patients  have  been  satisfied  with  the  new  care,  especially  with  the  follow-up  calIs.

Memorial  Hospital  of Carbon  County

Post  Office  Box 460

Rawlins,  Wyoming  82301

Telephone:  3073242221
 I
CASE  &  AR%  PROPRIETY  NURSING  HOMES 
USE  OF  THE  PRESSURE  ULCER  PREVENTION  GUIDELINE 
ORGANZZAflON PROFiLE 
This facility  has  70 beds,  6 of which  are  skilled-nursing  beds.  The  facility was acquired 
a few years  ago  by a national,  proprietary  firm  that  owns  many  nursing  homes  across 
the  country. 
Since  the  acquisition,  a new administrator  and  a new director  of nursing  have  been 
hired.  The  day staff  includes  two registered  nurses,  seven  certified  nursing  aides,  and 
one  restorative  aide.  The  facility has  two primary  care  physicians,  each  of whom  visits 
one  day a week. 
 
About  one-half  of the  facilitys patients  are  Medicaid  beneficiaries;  the  other  half  are 
private  pay. 
MOTIVATION FOR USING THE GUIDELINE 
The  facility has  used  A.HCPR  guidelines  for  acute  pain  management,  urinary 
incontinence,  pressure  ulcer  prevention,  and  depression.  Most  of its experience  has 
been  with the  pressure  ulcer  guideline. 
A State  survey  recently  found  deficiencies  in the  homess  management  of pressure 
ulcers.  State  law requires  nursing  homes  to turn  patients  at  least  once  eve~  two hours 
and  to take  other  steps  to prevent  and  treat  pressure  ulcers.  Medicare  also imposes 
requirements. 
When  the  national  firm  took  over  the  nursing  home,  it found  that  many  patients  had 
severe  skin problems.  Its own skin-care  policies,  which  reflect  the  AHCPR  guideline 
on pressure  ulcers,  are  at least  as strict  as those  of the  State  and  Medicare.  The 
national  firm  has  been  working  with  the  local  home  to correct the  problems. 
WAYS OF USING THE GUIDELINE 
Use with clinicians.  The  home  has  posted  turning  schedules  for patients  on their 
headboards  as reminders  to nurses  and  aides.  The  home  has  also  begun  to use the 
Briggs patient-encounter  forms,  which  are  more  detailed  than  the  forms  used 
previously. 
Feedback  on  pressure  ulcer  care  has been  provided  during  monthly  nurse  and  nursing 
aide  meetings.  In addition,  the  director  of nursing  has  made  rounds  of the  units  and 
has provided  individual  feedback  in that  context. 
18
 Usewith  patients.  The  facdityconductsi  ittlepatient  teaching  about  pressure  ulcers. 
The  director  of nursing  explained  that  most  residents  are  unable  to  understand 
information  about  pressure  ulcers  and  that  most  are  unable  to control  their 
movements--so  they  cannot  act  on the  information.  The  home  does  do a little  patient 
teaching  with  those  residents  who  can  both  understand  the  information  and  act  on it. 
The  home  also  does  teaching  with  family members. 
OBSTACLES?0  USE 
Before  the  home  was acquired,  relationships  among  physician,  nursing,  and 
administrative  staff were  strained.  After  the  acquisition,  the  new director  of nursing 
held  a reception  for physicians  and  has made  a concerted  effort  to win their 
cooperation.  This  effort  seems  to have  been  successful. 
When  the  new firm  took  over,  the  facility was way over  budget,  and  budget 
constraints  remain  problematic.  The  nursing  director  has  submitted  a budget  that  will 
enable  the  home  to address  the  pressure  ulcer  problem  in the  facility. 
COMPLIANCEAND EVALUATION 
The  homes  quality-assurance  program  has  involved  seven  annual,  in-depth  internal 
surveys of each  department.  These  reviews,  intended  to simulate  the  State  suxvey, 
address  all aspects  of care,  including  skin care. 
&  part  of these  reviews,  reports  on pressure  ulcers  are  prepared  for  every pressure 
ulcer  resident  every  night by the  night  nurse.  These  reports  are  rewewed by 
consultant  nurses.  Because  the  homes  medical  records  are  mostly  computerized, 
these  reviews  (and  others  on weekly,  monthly,  and  quarterly  bases)  can  be conducted 
very easily. 
The  review  reports  are  sent  to the  regional  administrator  and  the  corporate  specialist 
on a monthly  basis.  In addition  to the  seven  annual  reviews  managed  by the  facility 
itself, the  parent  firm  conducts  its own annual  suxvey. 
The  nursing  home  requested  that  its name  not  be released  in this report. 
19
 I C~E  9:  A LARGE  NURSING  HOMES 
USE  OF  THE  PRESSURE  ULCER  PREVENTION  GUIDELINE
I~ 
ORGANIZATIONPROFILE

This nursing  home  has  about  150 skilled  and  240 intermediate  beds.  Ninety-six

percent  of its patients  are  covered  by Medicaid.  Most  are  elderly,  and  some  are

mentally  handicapped.  Most  patients  are  moderately  to severely  limited  in their  ability

to petiorm  the  activities  of daily living.

MOTIVATIONFOR USINGTHE GUIDELINE

In June  1993, State  nursing  home  surveyors  cited  the  home  for shortcomings  in its

care  of pressure  ulcers.  The  home  then  conducted  its own 3-month  study  of pressure

ulcers  care  and  found  the  incidence,  although  having  remained  stable  for 5 years,  was

higher  than  anticipated.  The  nursing  director  established  goals  to reduce  both  the

incidence  of pressure  ulcers  and  the  variation  in treatment  approaches.  The  director

also hoped  to reduce  costs by reducing  the  amount  of nursing  time  needed  to treat

pressure  ulcers  and  by eliminating  the  costs  associated  with  ineffective  treatments.

WAYS OF USING THE GUIDELINE

New policy and  procedures.  A staff  nurse  brought  the  AHCPR  pressure  ulcer

guideline  to the  attention  of the  nursing  director.  To develop  the  revised  policy and

procedures,  he  researched  books,  articles,  and  product  information.  He  discussed

pressure  ulcer  prevention  and  treatment  with nursing  and  administrative  staff  in

regularly  scheduled  meetings.  In addition,  he consulted  with  the  assistant  director  of

nursing,  the  nursing  supemisors,  the  infection  control  nurse,  the  quality  assurance

nurse,  the  dietitian,  the  social  services  department  and  the  activities  department.

The  new policy  uses a modified  Norton  Scale  with  additional  nutritional  risk factors.

It was introduced  to the  home  on a pilot  test  basis and  has  been  in full use since  early

1994.

Use with clinicians.  The  nursing  director  placed  a copy of the  complete  guideline  and

the  quick  reference  guide  in each  nursing  unit.  He  then  held  a series  of three  in

sexvice training  sessions  for nurses.  Administrative  staff  attended  off-site  seminars  on

pressure  uicer  treatment.  Gaining  acceptance  of the  guideline  interventions  was

relatively  easy once  staff were  able  to agree  about  causes  of pressure  ulcers.

The  home  created  new patient-encounter  forms  to reflect  the  guideline;  modified  its

dietary-reporting  forms;  and  designed  new  activity  forms  to indicate  the  times  for

repositioning  each  patient.  In addition,  it has conducted  more  nutritional  lab-tests

related  to pressure  ulcers.

20
 To  track  progress  in the  care  of pressure  ulcers,  the  home  developed  a new  reporting

system.  An incident  report  is completed  whenever  a pressure  ulcer  is identified.  This

report  triggers  the  computer  to order  an  assessment  of the  pressure  ulcer.  Within  five

days of the  incident  report,  the  shift supervisor  must  conduct  a Norton  assessment  of

risk factors  for  pressure  ulcers,  review  any plan  that  was in place  for care  of the

pressure  ulcer,  and  determine  if that  plan  was appropriate  and  if it was followed.  The

supervisor  must  correct  any deficiencies  in the  pian  or its implementation.  One  week

later,  the  supervisor  must  review  the  revised  plan  to  assure  that  it is appropriate  and  is

being  implemented.

OBSTACLESTO USE

Despite  education  for  the  homes  residents  about  the  new  procedures,  some  have

refused  to adhere  to the  interventions.  In particular,  some  younger  residents

(35-45 years  old)  have  viewed  the  repositioning  plan  (which  entails  moving  the  patients

in their  chairs .eve~  fifteen  minutes  and  mowng them  in their  beds  every  two hours,

even  when  sleeping)  as an encroachment  on their  personal  freedom.  For  these

residents,  the  staff  have  developed  care  plans  that  address  the  residents

noncompliance,  and  they  have  tried  to educate  the  patients  about  the  importance  of

the  repositioning.  In addition,  the  staff  are  required  to  document  the  provision  of

information  to  the  patient  about  the  need  for  the  intervention  and  the  consequences

of nonintervention,  and  the  patients  refusal  of the  intervention.

COMPLIANCEAND EVALUATION  

The  homes  assessments  have  focused  on patient  outcomes  more  than  nursing

practices.  The  home  has produced  a pressure  ulcer  report  that  lists residents  names,

status,  and  trends  in health  status.  Initially,  these  reports  were  prepared  weekly  they

are  now produced  on a monthly  basis.

After  the  first year  of guideline  use,  the  incidence  of, and  the  time  required  to treat,

pressure  ulcers  decreased:  the  initial  incidence  included  27 areas  (of which  17 were

stage-one  areas);  after  1 year,  the  home  reported  an  incidence  of  14 pressure  ulcers,  2

of which were  not  acquired  in the  home.  Anecdotal  reports  have  indicated  that  stage-

1 ulcers  now require  very little  treatment  and  that  all treatments  now require  less care

time  than  before.

In addition  to  outcome  measures,  the  home  has conducted  annual  evaluations  of

nurses performance  during  an  episode  of patient  care.  Other  observations  and

assessments  of nursing  practice  take  place  throughout  the  year.

Cumberkmd  County  Nursing  Home

375 Claremont  Road

CarlisJe, PA  17013

Telephone:  7172432031

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 CASE  10  A SKILLED-NURSING  HOMES 
USE  OF  THE  PRESSURE  ULCER  PREVENTION 
AND  INCONTINENCE  GUTDELINES 
ORGANIZATIONPROFILE 
This non-profit  facility is affiliated  with a denominational  social-service  organization 
and  is located  in a medium-sized  urban  area.  The  home  has  140 beds,  including  a 
58-bed  Alzheimers  unit.  The  home  is staffed  by nearly  100 nurses  and  nursing  aides, 
and  2 medical  directors.  Eight  physicians  visit patients  at  the  facility.  In recent 
months,  the  home  has had  a significant  staff  turnover. 
MOTIVATIONFOR USINGTHE GUIDELINES 
State  law stipulates  that  patients  entering  nursing  homes  should  not  develop  pressure 
ulcers  in the  homes.  In the  homes  recent  State  survey,  ten  patients  were  found  to 
have  pressure  ulcers;  six of them  had  developed  the  ulcers  after  entering  the  facility. 
As a result,  the  facility received  a citation. 
State  law also  requires  that  the  homes  maintain  patients  continence.  IrI the  State 
survey, the  home  also received  a citation  for failure  to properly  monitor  incontinence 
and  for failure  to fully implement  a bowel  and  bladder  program.  In response  to both 
citations,  the  home  was required  to  develop  corrective  action  plans. 
The  director  of nursing  had  used  the  pressure  ulcer  and  incontinence  guidelines  at the 
nursing  facility  where  he was previously  employed.  He  regarded  the  guidelines  as 
useful  tools  for  quality  assurance  and  thought  that  they  would  provide  a sound 
foundation  for  revising  this facilitys policies  and  procedures  in these  two areas.  He 
has found  that  adhering  to the  incontinence  guideline  has  resulted  in reduced  use  of 
incontinence  products  and  reduced  laundry  costs,  and  that  treatments  for pressure 
ulcers  have  been  far more  expensive  than  prevention. 
WAYS OF USING THE GUIDELINES 
Revised  policy  and  prowdures.  The  nursing  director  worked  with two staff members 
to develop  new  policies  and  procedures  that  reflect  the  guidelines.  This  rewrite  took 
two months  and  drew  on information  from  sales  representatives  and  professional 
journals.  in addition  to the  AHCPR  guidelines.  The  nursing  director  indicated  that, 
while the  new policy and  procedures  are  in place,  the  homes  implementation  of the 
guidelines  is at  an  early  stage. 
Use with clinicians.  The  nursing  director  distributed  copies  of the  guidelines  to each 
nurse  manager,  charge  nurse,  unit  manager,  and  support-staff  nurse.  Copies  were 
made  available  to all others.  He  discussed  the  guidelines  with  his staff  almost  page 
for page, and  talked  about  how best  to adapt  the  guidelines  for use in the  facility. 
The  staff decided  that  some  aspects  of the  guidelines  were  impractical  for use in either  the 
Alzheimers  unit  or the  entire  facility. 
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 Use with patients.  The  nursing  director  felt  that  the  patients  wouidnt understand  or care

about  the  guidelines.  Nonetheless,  he maintains  an  open-door  policy for

residents  and  their  families.  In addition,  the  staff explain  the  care  of pressure  ulcers  and

incontinence  to  all residents  and  the  families  of the  residents  that  express  interest.

The  home  already  conducted  annual  pressure  ulcer  in-service  training  (one  session  is

required  by the  State).  In addition,  two nurse  managers  were  trained  in guideline-

recommended  care  for pressure  ulcers  and  incontinence.  These  wo  nurse  managers  then

taught  the  other  nurses.

The  facility has  instituted  the  use  of a new  skin-care  form  that  reflects  the  pressure  ulcer

guideline;  this is used  on a weekly  basis  to  assess the  status  of patients  pressure  ulcers.

OBSTACLES70  USE

The  nursing  director  had  anticipated  some  resistance  to the  guideline  by clinical  staff.  The

homes  internal  review  process  had  indicated  that  physicians  were  in the  habit  of ordering

antibiotics  for their  patients  without  examining  the  wounds  and  without  consulting  with  the

nurses.  The  nursing  director  wrote  to the  physicians  about  the  guideline  and  asked  that  they

not  be upset  if nursing  staff  questioned  the  use of antibiotics  or other  specific  treatments

when  these  were  inconsistent  with  the  new  policy and  procedures.  The  physicians  have

realized  that  they  have  had  to depend  on the  nursing  staff  to  provide  the  bulk  of patient

care  and  have  accepted  the  wound  care  protocol,  which is now  part  of the  routine  standing

orders.

Nurses  initially were  resistant  to  the  new policy and  procedures  because  they  thought  too

much  work was involved.  Some  nurses  still refuse  to comply,  but  most  have  come  to

appreciate  that  the  new rules  can  mean  less work  and  better  patient  outcomes.

COMPLIANCEAND EVALUA170N

The  unit  managers  have  assessed  the  appropriateness  of care  plans  and  the  extent  to which

clinicians  have  implemented  care  plans.  As a resuit  of the  recent  State  citations  for pressure

ulcers  and  incontinence,  the  unit  managers  have  focussed  their  reviews  on these  two topics.

In addition,  the  home  has  had  nurse  consultants  review  records  on pressure  ulcer  and

incontinence  care  on a monthly  basis.

The  home  is planning  to have  a nurse  consultant  perform  a formal  review  of the  homes

progress  in using the  new policy and  procedures.  Weekly  record  reviews  have  already

demonstrated  a decrease  in the  incidence  of pressure  ulcers  among  the  residents.

Hillside  Lutheran  Manor

1430 Alamo  Avenue

Kalamazoo.  Michigan  49006

Telephone:  6163492661 
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 CASE  11:.  A SMAILTOWN,  PROPRIETARY  NURSING  HOMES 
USE  OF THE  INCONITNEN CE. GUIDELINE  I 
ORGANIZATION PROFILE 
This  facility has  about  100 Medicaid-certified  beds.  Recently,  it was purchased  by a firm 
that  owns other  nursing  homes  in the  State  and  in a neighboring  State. 
It has  a staff  of about  90 and has  8 physicians  treating  residents  at  the  facility. 
MOTIVATION FOR USING THE GUID~ 
The  faciIity has  been  using the AHCPR  guidelines  on acute  pain  management,  urinary 
incontinence,  depression,  and  cataracts,  but  has  the  most  expedience  with the  urinary 
incontinence  guideline. 
State  law requires  quarterly  and  annual  reports  on the  residents  bowel  and  bladder 
conditions  and  on the  homes  ability  to  address  bowel and  bladder  problems  among  the 
residents. 
A pharmacy  that  provides  training  for  the  home  provided  a copy  of the  incontinence 
guideline  and  suggested  that  the  home  implement  it.  A speaker  at  one  of the  training 
sessions  warned  that  State  surveyors  would  look  for the  guideline  as part  of their  annual 
survey.  In fact,  the  surveyors  did make  a written  note  documenting  the  presence  of the 
guideline  materials. 
The  parent  firm,  which  provided  the  home  whh  its quality-assurance  system,  also 
recommended  use  of the  guideline. 
WAYS OF USING THE GUIDELINE 
Use  with clinicians.  The  nursing  director  discussed  the  guideline  wth the  nursing  staff 
during  a regularly  scheduled  staff  meeting.  The  guidelines  and  the  patient  guides  have  been 
kept  in a central  office and  have  been  available  for the  staff  to review.  Handouts  were 
made  available  to the  staff.  There  has  been  no in-service  training  on urinary  incontinence, 
although  there  has been  in-service  training  on pain  management. 
The  home  has  been  modifying  its policy  and  procedures  to  reflect  the  urinary  incontinence 
guideline  recommendations.  The  home  has incorporated  the  AHCPR  guidelines  ten-point 
pain  scale  into  its policy and  procedures.  The  director  of nursing  is not yet  completely 
satisfied.  however,  that  all the necessary  changes  have  been  incorporated. 
The  home  has  been  changing  its incontinence  treatments  to reflect  guideline 
recommendations.  It has instituted  measures  to increase  awareness  of patients  fluid  intake 
and  of the  patients  activity schedules.  It has also  tried  to make  its incontinence  programs 
better  suited  to  individual needs.  The  nursing  director  reported,  however,  that  it is ~ifficult 
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 to get staff to follow-up  on care  with  measurements  and  documentation  of the  residents 
conditions. 
The  home  has started  using a new incontinence  assessment  form  for new patients  and,  on a 
quarterly  basis, for  those  patients  who  stay at  the  home. 
Use with patients.  The  facility does  not  distribute  guides  to the  patients.  It conducts  all 
patient  teaching  when  patients  are  discharged  from  the  facility. 
OBSTACLESK) USE 
The  nursing  director  noted  that  the  physicians  have  tended  to  be highly suspicious  of 
mandates  coming  from  State  government.  They  have  responded  more  favorably  to the 
guidelines  when  the  association  with  State  mandates  is not  made. 
Another  obstacle  noted  by the  director  was insufficient  time  for  her  staff to read  and 
implement  all of the  guideline  recommendations.  She  suggested  that  a pocket  guideline 
would be  more  even  useful  than  the  quick  reference  guide. 
COMPLIANCEAND EVALUATION 
Quality  assurance  retiews  have  been, conducted  on a monthly  basis.  Nurses  are  provided 
with feedback  on  their  care  of incontinence  at  least  quarterly,  during  care  plan  conferences 
for incontinent  patients. 
The  nursing  home  requested  that  its name  not  be released  in this report. 
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 CASE  12  A LARGE  H?MILTH MAINTENANCE  ORGA.NIZAfiOWS 
USE  OF  ~CIATARACZ  GUIDELINE  1 
ORGANIZATIONPROFILE 
This health  maintenance  organization  (HMO)  is part  of a nationai,  proprietary  chain  with a 
presence  in many  States.  It seines  8 counties  in a large  metropolitan  area.  It has  more  than 
150,000 members  belonging  to its HMO  and  preferred  provider  organization  (PPO) 
programs.  About  40 percent  of its members  are  Medicare  beneficiaries.  Its staff  model 
HMO  component  has  2 physicians  and  serves  about  2,000 members.  The  rest  of the 
organizations  physicians  are  under  contract;  they practice  either  solo,  in small groups,  or in 
physician  organizations. 
MOTIVATIONFOR USINGTHE GUIDELINE 
Because  of its large  Medicare  membership,  the  HMO  has  had  a lot of interaction  with  the 
Medicare  Peer  Review  Organization  (PRO).  In one  recent  instance,  a patient  complained  to 
the  PRO  that  he  was unfairly  denied  cataract  surgery.  The  PRO  found  some  merit  in the 
patients  complaint  and  recommended  that  the  HMO  adhere  to the  AHCPR  guideline  on 
cataracts  as a means  of settling  the  dispute.  The  HMO  had  its own committee  review  the 
guideline.  Ultimately,  this committee  ;Iso  recommended  adherence  to the  guideline,  and  the 
company  has adopted  it as a new  policy.  The  guideline  represents  a slight change  in the 
protocol  previously  used  by the  HMO. 
WAYS OF USING THE GUIDIZLINIZ 
Use with clinicians.  The  HMO  sent  notification  of its change  in policy and  the  new  criteria 
for determining  the  need  for  cataract  surgery  to all of the  primaxy  care  physicians  and 
ophthalmologists  contracted  and  credentialed  with the  company.  The  organization  did not 
distribute  the  AHCPR  guideline  per  se because  it uses a standardized  format  for 
communicating  standards  of care  to its providers. 
Clinicians  received  no education  or skills training  on the  guideline.  A physician  ~th  the 
HMO  explained  that,  because  the  change  in policy was slight--and  not  a matter  of new 
diagnosis  or treatment  techniques--no  education  or skills training  was necessary.  He  feels 
that  the  HMOs  physicians  have  accepted  the  new standard. 
Use with patients.  As part  of the  HMOs  agreement  with  the  PRO,  the  HMO  plans  to 
publish  an article  for patients  about  cataract  treatment  and  its use  of the  AHCPR  guideline. 
The  article  will also  invite  patients  to call the  HMO  for additional  information. 
COMPLIANCEAND EVALUATION. The  HMO  is pIanning  a follow-up  audit  of clinician 
compliance  with  the  guidelines  standards  of care:  The  ~opulation  for this study will be alI 
patients  aged  65 or older  who underwent  cataract  surgery  during  a 6-month  period.  In 
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 addition,  the  HMO  is considering  a cooperative  project  with  the  PRO  in which  records

would  be  chosen  at random  for  a detailed  review  of compliance  with the  new cataract

surgery  standard.  This  proposed  project  would  use encounter  or claims  data  as a basis for

the  assessment  of clinician  performance.

Humana  Medical  Pl~  Inc.

5401 West  Kennedy  Boulevard,  Suite  1031

Tampa,  Florida  33609

Telephone:  8132876260

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