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~ CPOLICY 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 O’Connor, 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 CPOLICY AND RESEARCH 

CASE STUDIES


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*W JUNE GIBBS BROWN k 

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‘%’d~~ September 1995 

> OEI-01-94-002S1

TABLE OF CONTENTS


PAGE 

INTRODUCllON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..1


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


HosPrrALs 

1:	 ARural, County-Owned Hospital’s Use


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


2 ARural, Non-Profit Hospital’s Use


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


3:	 ARural, County-Omed Hospital’s Use


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


4	 A Rural, Private, Non-Profit Hospital’s Use


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


5: A Rural Hospital’s Use of the Pain Management Guideline . . . . . . . . . . . . . 11


6 A Mid-Sized Town Hospital’s Use of the Pain Management Guideline . . . . 13


7 A Rural, County-Owned Hospital’s Use of the Incontinence Guideline . . . . 15


NURSING HOMES 

8:	 A Rural, Proprietary Nursing Home’s Use


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


9	 A Large Nursing Home’s Use


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


10	 A Skilled-Nursing Home’s Use


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


11:	 A Small-Tom, Proprietary Nursing Home’s Use 

of the Incontinence Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..”24 

12:	 A Large Health Maintenance Organization’s Use


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


13: A Consortium’s 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

c%SE”l: A RUR& COUNTY-OWNED HOSPITAL’S 

USE OF THE PRESSURE ULCER PREVENTION GUIDELINE I 

ORGANTZA’fYONPROHLE 

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 longterrn 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.HCPRrecommended 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 hospital’s 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 HOSPITAL’S USE OF 

TEE PRESSURE ULCER PREVENTION GUIDELINE 

ORGANIZATION PROFILE


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 hospital’s director of quality improvement leamed about the pressure ulcer


guideline from the hospital’s 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 hospital’s home-health sefice. 

OBSTACLES‘K) 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 organization’s 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 HOSPITAL’S 

USE OF’THE 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


hospital’s 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.


MOTIVATION FOR 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 hospital’s 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 hospital’s 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 hospital’s 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 HOSPJ1’AL’S 

USE OF THE PRESSURE ULCER PREVENTION 

AND PAIN MANAGEMENT GUIDELINES 

ORGANIZATION PROFILE 

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 hospital’s 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 hospital’s 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 hospital’s 

use. The physicians and the hospital’s 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 hospital’s guidelines called for a new patient-turning chart. This chart lists the 

times that each patient’s 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


hospital’s 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 HOSPITAL’S 

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 hospital’s 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 hospital’s 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 hospital’s patient 

satisfaction questionnaire. 

Greene County Medic-d Center 

1000 West Lincoinway 

Jefferson, Iowa 50129 

Telephone: 5153862114 

12

CASE 6, A MID-SIZED TOWN HOSPJT.AL’S 

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. 

MOTIVATION FOR 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 guideline’s 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 patient’s 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

COMPLIANCEAN13EVALUA’170N


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’~ 

USE’OF 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 workman’s compensation. 

MOTIVATIONFOR USINGTT+JZGUDELINE 

In 1994, the hospital’s 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 hospital’s use of the urinary incontinence guideline. 

WAYS OF USKNGTHE GUIDELINE 

I’4ewpolicy 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 hospital’s 

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 w“th 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 hospital’s 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 hospital’s physicians received information about the new policy and procedures on 

incontinence only once--at a monthly staff meeting. The nursing director explained: “r 

don’t 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 

patient’s 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 haven’t 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 hospital’s 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 HOME’S 

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 facility’s 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 homes’s 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 c’orrect 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 home’s 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 rew”ewed by 

consultant nurses. Because the home’s 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 HOME’S 

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 home’s 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 mow”ng 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 home’s 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


21

CASE 10 A SKILLED-NURSING HOME’S 

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 home’s 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 facility’s 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 home’s 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. 

22

Use with patients. The nursing director felt that the patients “wouidn’t 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


home’s 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 EVALUA’170N


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 home’s


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 

23

CASE 11:. A SMAILTOWN, PROPRIETARY NURSING HOME’S 

USE OF THE INCON’ITNEN 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 home’s 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 w“th 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 guideline’s 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 

24

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. 

OBSTACLES‘K) 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. 

25

CASE 12 A LARGE H?MILT’H 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 

organization’s physicians are under contract; they practice either solo, in small groups, or in 

physician organizations. 

MOTIVATIONFOR USING THE 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 

patient’s 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 HMO’s physicians have accepted the new standard. 

Use with patients. As part of the HMO’s 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 guideline’s 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 

26

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


27