Nursing Home Quality and Pressure Ulcer Prevention and Management Practices

Interventions to promote the implementation of pressure injuries prevention measures in nursing homes: a scoping review protocol

INTRODUCTION

Currently, various guidelines and documents on the prevention of pressure injuries have been published, but there are many serious lags in the actual practice in nursing homes. So some interventions are required to promote the implementation of normative practices. There was a review of preventive interventions for pressure injuries in long-term care facilities, but there is no systematic review of how to promote the implementation of preventive measures. This review aims to summarise interventions that promote the implementation of pressure injuries prevention measures in nursing homes, explore the research scope and gaps in this field and provide evidence and striving direction for global nursing homes to improve existing preventive behaviours.

METHODS AND ANALYSIS

This scoping review will combine the Arksey and O'Malley framework with further clarification and advice of the scoping review by Levac et al as methodological guidance. Systematic retrieval of relevant literature databases, grey literature and references included studies will be conducted. Two reviewers will screen titles and abstracts independently, and then screen the full text of potentially relevant articles to determine final inclusion. After that, two reviewers will extract data based on a predesigned data extraction table independently. Inductive analysis and narrative analysis will be used to collate, summarise and report the results. Finally, managers of nursing homes in China will be consulted for additional information and their viewpoints on the research findings.

ETHICS AND DISSEMINATION

Since the scoping review is a secondary analysis of the literature, there is no need to apply for ethical approval. Our goal is to share the results with key stakeholders to help them find the direction of effort and improve clinical practice. Therefore, dissemination plans include publication in international journals and sharing it at conferences to inform more healthcare workers about the scope and gaps of the studies.

Evidence-Based Prevention and Management of Pressure Injuries in Home Care: A Scoping Review

OBJECTIVE

To determine the presence of evidence-based practice protocols for the prevention and management of pressure injuries (PIs) in home care settings, whether the contents of existing protocols were based on current evidence, and adherence to these protocols.

DATA SOURCES

Comprehensive and structured literature searches were conducted using PubMed, Cochrane Library, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycINFO, Ovid, Scopus, Web of Science, and Joanna Briggs Institute Evidence-Based Practice Database.

STUDY SELECTION

A literature search retrieved 2,929 articles. Investigators evaluated the titles, abstracts, and full texts of the articles retrieved from the literature search in accordance with the review questions and eligibility criteria. The authors included four studies in this scoping review.

DATA EXTRACTION

The researchers extracted details of the full-text articles, including author(s)/year of publication/country, aim(s), study population and sample size, study design, intervention type, outcomes, and key findings.

DATA SYNTHESIS

The four articles included in this scoping review are descriptive cross-sectional studies published between 2005 and 2010. Although the articles provided significant data on the quality of practices for the prevention and management of PIs in home care, no studies reported on the achievement of objective results.

CONCLUSIONS

The use of protocols for the prevention and management of PIs, including evidence-based interventions in home care, and adherence to existing protocols were low. Comprehensive observational and randomized controlled studies are necessary to improve evidence-based prevention and management of PIs in home care settings.

Bridging the Knowledge Gap for Pressure Injury Management in Nursing Homes

BACKGROUND

Pressure injuries in nursing homes remain a consistent problem. Unfortunately, despite the variety of pressure injury education offered in nursing homes, the knowledge learned cannot be applied in practice, and as a result, the prevalence and incidence of such injuries are consistently high. This study aimed to address those gaps by analyzing the nursing competency for pressure injury management and implementing pressure injury education programs in nursing homes.

METHODS

Two phases were conducted based on the action cycle in the knowledge to action model. During the first phase, a framework was constructed by analyzing nursing experience. The second phase consisted of the implementation and monitoring of the program to evaluate the effects of the framework.

RESULTS

The main results for nursing competencies for pressure injury management in nursing homes are integrated thinking, understanding in an environmental context, interpersonal relationships for efficient decision making, and meeting any challenges to professional development. The results concerning the program's effects showed significant differences in the participants' knowledge, attitude, stage discrimination ability, and clinical management judgment ability.

CONCLUSION

The educational framework and program derived from this study are expected to improve nurses' pressure injury management competency in nursing homes and to contribute to effective pressure injury management and quality of life for residents in nursing homes.

Improving practice and informing policy development: The impact of gerontological nursing research

Nurses have always approached the clinical care challenges they encounter with a combination of critical observation and a profound concern for human suffering. Beginning in earnest in the early 1980s, nurse researchers have pursued the answers to questions about the wellbeing of older adults, particularly those suffering from serious, chronic conditions. This paper offers three exemplars of nursing research domains that illustrate the creativity and commitment of nurse researchers seeking to understand and improve pervasive clinical problems experienced by older adults and to demonstrate the profound influence these activities have had on the evolution of the science and the quality of care for older adults. The impact of this work is reflected in practice protocols, institutional policies, government oversight, and improved outcomes for patients.

Support surfaces for treating pressure ulcers

BACKGROUND

Pressure ulcers are treated by reducing pressure on the areas of damaged skin. Special support surfaces (including beds, mattresses and cushions) designed to redistribute pressure, are widely used as treatments. The relative effects of different support surfaces are unclear. This is an update of an existing review.

OBJECTIVES

To assess the effects of pressure-relieving support surfaces in the treatment of pressure ulcers.

SEARCH METHODS

In September 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included published or unpublished randomised controlled trials (RCTs), that assessed the effects of support surfaces for treating pressure ulcers, in any participant group or setting.

DATA COLLECTION AND ANALYSIS

Data extraction, assessment of 'Risk of bias' and GRADE assessments were performed independently by two review authors. Trials with similar participants, comparisons and outcomes were considered for meta-analysis. Where meta-analysis was inappropriate, we reported the results of the trials narratively. Where possible, we planned to report data as either risk ratio or mean difference as appropriate.

MAIN RESULTS

For this update we identified one new trial of support surfaces for pressure ulcer treatment, bringing the total to 19 trials involving 3241 participants. Most trials were small, with sample sizes ranging from 20 to 1971, and were generally at high or unclear risk of bias.

PRIMARY OUTCOME

healing of existing pressure ulcersLow-tech constant pressure support surfacesIt is uncertain whether profiling beds increase the proportion of pressure ulcer which heal compared with standard hospital beds as the evidence is of very low certainty: (RR 3.96, 95% CI 1.28 to 12.24), downgraded for serious risk of bias, serious imprecision and indirectness (1 study; 70 participants).There is currently no clear difference in ulcer healing between water-filled support surfaces and foam replacement mattresses: (RR 0.93, 95% CI 0.63 to 1.37); low-certainty evidence downgraded for serious risk of bias and serious imprecision (1 study; 120 participants).Further analysis could not be performed for polyester overlays versus gel overlays (1 study; 72 participants), non-powered mattresses versus low-air-loss mattresses (1 study; 20 participants) or standard hospital mattresses with sheepskin overlays versus standard hospital mattresses (1 study; 36 participants).High-tech pressure support surfacesIt is currently unclear whether high-tech pressure support surfaces (such as low-air-loss beds, air suspension beds, and alternating pressure surfaces) improve the healing of pressure ulcers (14 studies; 2923 participants) or which intervention may be more effective. The certainty of the evidence is generally low, downgraded mostly for risk of bias, indirectness and imprecision.Secondary outcomesNo analyses were undertaken with respect to secondary outcomes including participant comfort and surface reliability and acceptability as reporting of these within the included trials was very limited.Overall, the evidence is of low to very low certainty and was primarily downgraded due to risk of bias and imprecision with some indirectness.

AUTHORS' CONCLUSIONS

Based on the current evidence, it is unclear whether any particular type of low- or high-tech support surface is more effective at healing pressure ulcers than standard support surfaces.

Nursing records, prevention measures and incidence of pressure ulcers in an Intensive Care Unit

OBJECTIVES

The aim of this paper is to determine the incidence and most incident pressure ulcers (PU) category. Establish the main clinical characteristics of these PU. Determine whether there is adequate documentation of PU and of the measures used to prevent them.

METHOD

Observational descriptive and retrospective study during 2014 at Intensive Care Unit (ICU)-University Hospital of Araba. Study sample, all patients suffering from PU at the time of the study by accidental sampling. Computerised records regarding risk assessment, clinical assessment and pressure sore treatment, provided by the 'Metavision' computer programme and descriptive statistics using SPSS version 22.0. Approval from the Ethics Committee for Clinical Research of the University Hospital of Araba was obtained.

RESULTS

The incidence of patients suffering from PU during 2014 was 6.78%. The most common locations for PU were the sacral region and the heels: the most incident pressure ulcers category was grade II, followed by grade I. Out of the 98 PU treated in our patients, 43 occurred outside the ICU and 55 in the unit itself. The lack of records, in all the variables described about PU, was 19.10%.

CONCLUSIONS

The incidence of pressure ulcers was lower than in the current literature. The most frequent category, location and clinical characteristics are comparable to previous studies. There is a high rate of failing to record the characteristics of the PU declared. Good PU prevention measures and recording were carried out.

Improvement of pressure ulcer prevention care in private for-profit residential care homes: an action research study

Background

A need exits to develop a protocol for preventing pressure ulcers (PUs) in private for-profit nursing homes in Hong Kong, where the incidence of PUs is relatively high and which have high proportion of non-professional care staff. The implementation of such protocol would involve changes in the practice of care, likely evoking feelings of fear and uncertainty that may become a barrier to staff adherence. We thus adopted the Systems Model of Action Research in this study to manage the process of change for improving PU prevention care and to develop a pressure ulcer prevention protocol for private for-profit nursing homes.

Methods

A total of 474 residents and care staff who were health workers, personal care workers, and/or nurses from four private, for-profit nursing homes in Hong Kong participated in this study. Three cyclic stages and steps, namely, unfreezing (planning), changing (action), and refreezing (results) were carried out. During each cycle, focus group interviews, field observations of the care staff’s practices and inspections of the skin of the residents for pressure ulcers were conducted to evaluate the implementation of the protocol. Qualitative content analysis was adopted to analyse the data. The data and methodological triangulation used in this study increased the credibility and validity of the results.

Results

The following nine themes emerged from this study: prevention practices after the occurrence of PUs, the improper use of pressure ulcer prevention materials, non-compliance with several prevention practices, improper prevention practices, the perception that the preventive care was being performed correctly, inadequate readiness to use the risk assessment tool, an undesirable environment, the supplying of unfavorable resources, and various management styles in the homes with or without nurses. At the end of the third cycle, the changes that were identified included improved compliance with the revised risk assessment method, the timely and appropriate use of PU prevention materials, the empowering of staff to improve the quality of PU care, and improved home management.

Conclusion

Through the action research approach, the care staff were empowered and their PU prevention care practices had improved, which contributed to the decreased incidence of pressure ulcers. A PU prevention protocol that was accepted by the staff was finally developed as the standard of care for such homes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0361-8) contains supplementary material, which is available to authorized users.

Are there racial-ethnic disparities in time to pressure ulcer development and pressure ulcer treatment in older adults after nursing home admission?

OBJECTIVE

The objective of this study was to assess whether there are racial and ethnic disparities in the time to development of a pressure ulcer and number of pressure ulcer treatments in individuals aged 65 and older after nursing home admission.

METHOD

Multi-level predictors of time to a pressure ulcer from three national surveys were analyzed using Cox proportional hazards regression for White Non-Hispanic residents. Using the Peters-Belson method to assess for disparities, estimates from the regression models were applied to American Indians/Alaskan Natives, Asians/Pacific Islanders, Blacks, and Hispanics separately resulting in estimates of expected outcomes as if they were White Non-Hispanic, and were then compared with their observed outcomes.

RESULTS

More Blacks developed pressure ulcers sooner than expected. No disparities in time to a pressure ulcer disadvantaging other racial/ethnic groups were found. There were no disparities in pressure ulcer treatment for any group.

DISCUSSION

Reducing disparities in pressure ulcer development offers a strategy to improve the quality of nursing home care.

Evidence based practice in long term care settings

PURPOSE

The purpose of this manuscript is to discuss the need for use of evidence based practice (EBP) in LTC, the current use of evidence in long term care facilities and what we know about adoption of the use of EBP in LTC.

METHODS

Literature review and reporting of findings from the M-TRAIN study that was a quasi-experimental design to test the effectiveness of an intervention to increase the use of EBPs for urinary incontinence and pain in 48 LTC facilities.

RESULTS

Barriers to adopting EBPs include lack of available time, lack of access to current research literature, limited critical appraisal skills, excessive literature to review, non-receptive organizational culture, limited resources, and limited decision-making authority of staff to implement change. Strategies to promote adoption of EBP include the commitment of management; the culture of the home; leadership; staff knowledge, time, and reward; and facility size, complexity, the extent that members are involved outside the facility, NH chain membership, and high level of private pay residents. Findings from the M-TRAIN add, stability of nurse leader and congruency between the leaders perception of their leadership and the staff's perception of the leadership.

CONCLUSION

There is clear evidence of the need and the benefits to residents of LTC and to the health care system yet adoption of EBP continues to be slow and sporadic. There is also evidence for the process of establishing best evidence and many resources to find the available EBPs. The urgent need now is finding ways to best get the EBPs implemented in LTC. There is growing evidence about best methods to do this but continued research is needed. Clearly, residents in LTC deserve the best care possible and EBPs represent an important vehicle by which to do this.

Head-of-Bed Elevation in Critically Ill Patients: A Review

Clinicians are confused by conflicting guidelines about the use of head-of-bed elevation to prevent aspiration and pressure ulcers in critically ill patients. Research-based information in support of guidelines for head-of-bed elevation to prevent either condition is limited. However, positioning of the head of the bed has been studied more extensively for the prevention of aspiration than for the prevention of pressure ulcers, especially in critically ill patients. More research on pressure ulcers has been conducted in healthy persons or residents of nursing homes than in critically ill patients. Thus, the optimal elevation for the head of the bed to balance the risks for aspiration and pressure ulcers in critically ill patients who are receiving mechanical ventilation and tube feedings is unknown. Currently available information provides some indications of how to position patients; however, randomized controlled trials where both outcomes are evaluated simultaneously at various head-of-bed positions are needed.

Translating research into practice in nursing homes: can we close the gap?

PURPOSE

A gap between research and practice in many nursing home (NH) care areas persists despite efforts by researchers, policy makers, advocacy groups, and NHs themselves to close it. The reasons are many, but two factors that have received scant attention are the dissemination process itself and the work of the disseminators or change agents. This review article examines these two elements through the conceptual lens of Roger's innovation dissemination model.

DESIGN AND METHODS

The application of general principles of innovation dissemination suggests that NHs are characteristically slow to innovate and thus may need more time as well as more contact with outside change agents to adopt improved practices.

RESULTS

A review of the translation strategies used by NH change agents to promote adoption of evidence-based practice in NHs suggests that their strategies inconsistently reflect lessons learned from the broader dissemination literature.

IMPLICATIONS

NH-related research, policy, and practice recommendations for improving dissemination strategies are presented. If we can make better use of the resources currently devoted to disseminating best practices to NHs, we may be able to speed NHs' adoption of these practices.

Comparison of the effectiveness of two protocols for treating nursing home residents with advanced dementia

The Serial Trial Intervention (STI) is a decision support tool to address the problem of underassessment and undertreatment of pain and other unmet needs of people with dementia. This study compared the effectiveness of the 5-step and 9-step versions of the STI using a two-group repeated measures quasi-experimental design with randomization of 12 matched nursing homes. The sample consisted of 125 residents with moderate to severe dementia. Both the 5- and 9-step STIs significantly decreased discomfort and agitation from pre- to posttest (effect sizes = 0.45 to 0.90). The 9-step version was more effective for comorbid burden and increased cortisol slope (effect sizes = 0.50 and 0.49). Process variables were all statistically significantly improved using the 9-step STI. Nurse time was not different between the two groups. The clinical decision support rules embedded in the STI, particularly the 9-step version, helped nurses change practice and improved resident outcomes.

An evaluation of the usability of a computerized decision support system for nursing homes

BACKGROUND

Computerized decision support systems (CDSSs) have the potential to significantly improve the quality of nursing care of older people by enhancing the decision making of nursing personnel. Despite this potential, health care organizations have been slow to incorporate CDSSs into nursing home practices.

OBJECTIVE

This study describes facilitators and barriers that impact the ability of nursing personnel to effectively use a clinical CDSS for planning and treating pressure ulcers (PUs) and malnutrition and for following the suggested risk assessment guidelines for the care of nursing home residents.

METHODS

We employed a qualitative descriptive design using varied methods, including structured group interviews, cognitive walkthrough observations and a graphical user interface (GUI) usability evaluation. Group interviews were conducted with 25 nursing personnel from four nursing homes in southern Norway. Five nursing personnel participated in cognitive walkthrough observations and the GUI usability evaluation. Text transcripts were analyzed using qualitative content analysis.

RESULTS

Group interview participants reported that ease of use, usefulness and a supportive work environment were key facilitators of CDSS use. The barriers identified were lack of training, resistance to using computers and limited integration of the CDSS with the facility's electronic health record (EHR) system. Key findings from the usability evaluation also identified the difficulty of using the CDSS within the EHR and the poorly designed GUI integration as barriers.

CONCLUSION

Overall, we found disconnect between two types of nursing personnel. Those who were comfortable with computer technology reported positive feedback about the CDSS, while others expressed resistance to using the CDSS for various reasons. This study revealed that organizations must invest more resources in educating nursing personnel on the seriousness of PUs and poor nutrition in the elderly, providing specialized CDSS training and ensuring that nursing personnel have time in the workday to use the CDSS.

Predictors of nonpharmacological and pharmacological treatments stopped and started among nursing home residents with dementia

The purpose of this study was to describe the nonpharmacological and pharmacological treatments stopped and started over 6 weeks among a sample of nursing home residents with moderate to severe dementia and to identify nurse and resident factors associated with starting new and stopping ineffective/unnecessary nonpharmacological and pharmacological treatments. One hundred thirty-four nursing home residents with dementia and 39 nurses from 12 nursing homes in the Midwest participated in this study. Resident and nursing process data were collected on daily tracking forms completed by the primary nurse over a 6-week period. Both assessment-driven intervention and evaluation-driven follow through significantly predicted treatments stopped and new treatments started. The findings demonstrate that nurses serve an essential role in maintaining resident physiological and psychological homeostasis by vigilantly responding to residents' physical problems and behaviors with assessment-driven intervention and evaluation-driven follow through.

Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly

BACKGROUND

Computerized decision support systems (CDSSs) have been shown to help health care professionals to avoid errors and improve clinical practice and efficiency in health care. Little is known about its influence on nursing practice and outcomes for residents in nursing homes.

AIM

The aim of this study was to evaluate the effects on the risk for and prevalence of pressure ulcers (PUs) and malnutrition of implementing a CDSS to improve prevention and care of PUs and also to improve nutrition in the elderly in nursing homes.

DESIGN SETTING AND PARTICIPANTS

The study used a quasi-experimental design with two intervention groups and one control group. A convenience sample of residents from 46 units in 15 nursing homes in rural areas in Norway was included. A total of 491 residents participated at baseline in 2007 and 480 residents at follow-up in 2009.

METHODS

The intervention included educational sessions in prevention of PUs and malnutrition for registered nurses (RNs) and nursing aides (NAs) in the two intervention groups. In addition, one intervention group (intervention group 1) had a CDSS integrated into the electronic healthcare record (EHR) based on two research-based risk assessment instruments: the Risk Assessment Pressure Scale (RAPS) for PU risk screening and the Mini Nutritional Assessment (MNA(®)) scale for screening nutritional status. In each participating nursing home trained RNs and NAs examined all residents who consented to participate on the RAPS and the MNA(®) scale. This examination included a skin assessment and details about PUs were collected.

RESULTS

The proportion of malnourished residents decreased significantly in intervention group 1 between the two data collection periods (2007 and 2009). No other significant effects of the CDSS on resident outcomes based on the RAPS and MNA(®) scores were found.

CONCLUSION

CDSSs used by RNs and NAs in nursing homes are still largely unexplored. A CDSS can be incorporated into the EHR to increase the meaningful use of these computerized systems in nursing home care. The effects of CDSS on healthcare provider workflow, clinical decision making and communication about preventive measures in nursing home practice still need further exploration. Based on results from our study, recommendations would be to increase both sample size and the number of RNs and NAs who participate in CDSS education programs.

Prevention and treatment of pressure ulcers in a university hospital centre: a correlational study examining nurses' knowledge and best practice

This descriptive correlational study had the goal of exploring if relationships existed between the level of knowledge of nurses concerning pressure ulcers, certain nurses' characteristics and the preventive care they applied. A multi-method approach was taken using a questionnaire to measure the level of knowledge of nurses (n = 256) and chart audits (n = 235) to identify the preventive care applied. The results show that the level of knowledge of the nurses is insufficient. They also show a correlation between a higher level of knowledge and (i) the sector of activities in which the nurses are working, (ii) the training periods provided by the university hospital centre, and a (iii) good perception by the nurses of their level of knowledge. However, training on its own cannot guarantee the provision of quality health care, as there is a wide discrepancy between what nurses know and what they put into practice.

Practices and outcomes: pressure ulcer management in nursing facilities

INTRODUCTION

The objective of this study was to compare reported pressure ulcer prevention and treatment practices in nursing facilities with high prevalence of pressure ulcers versus nursing facilities with low prevalence of pressure ulcers.

METHODS

A 26-item survey on implementation of nationally accepted standards for pressure ulcer prevention and treatment was mailed to directors of nursing in all 68 nursing facilities in an urban county.

RESULTS

There were no statistically significant differences on reported pressure ulcer prevention interventions based on pressure ulcer prevalence. When treating pressure ulcers, respondents of facilities with high prevalence of pressure ulcers reported more frequent pain assessments, more frequent use of low air-loss beds, and daily wound assessments.

DISCUSSION

The study failed to support the hypothesis that nursing facilities with low prevalence of pressure ulcers report using more guideline-recommended pressure ulcer prevention and treatment interventions than facilities with high prevalence of pressure ulcers. Reported adherence to recommended interventions for repositioning and pressure relief measures, moisture management, and attention to nutrition exceeded 60% in all facilities.

CONCLUSION

The disparity between reported interventions and pressure ulcer prevalence rates offers an opportunity for future collaborative quality improvement projects, research, and the need for leadership to develop systems of care to ensure the use of pressure ulcer prevention guidelines.

Factors associated with time to identify physical problems of nursing home residents with dementia

This study describes new problems emerging over 6 weeks for nursing home residents with advanced dementia and factors associated with time to identify the problems. The sample of 65 developed 149 new acute problems or exacerbations of existing conditions over the 6 weeks of data collection. The majority of these problems involved uncontrolled pain, new infections, and severe psychoses. Nurse assessment skill was associated with a shorter time to identify the new problem and more time spent on the problem. A higher ratio of new to existing interventions was also associated with a shorter time to identify the problem. Other patient characteristics associated with time to identify problems included nonspecific vocalizations, physical signs, cognitive status, and length of stay. While future research is warranted, findings from this study highlight the frequency of problems requiring treatment and suggest that improved assessment of residents may decrease the time to identify new problems.

Explaining the national differences in pressure ulcer prevalence between the Netherlands and Germany--adjusted for personal risk factors and institutional quality indicators

BACKGROUND

Pressure ulcers have a known impact on quality of life as well as on morbidity and mortality of the persons affected. Remarkable differences in pressure ulcer prevalence between the Netherlands and Germany have been found during the last 6 years. This study explores to what extent the individual risk of the population and quality indicators of the institutions can explain the variation in national prevalence.

METHODS

Data of a binational multi-centred cross-sectional study in 103 hospitals (n = 21,378 patients) and 129 nursing homes (n = 15,579 residents) were analysed using random effects regression models to calculate the differences in national prevalences within the nursing homes and hospitals, adjusted for personal risk for pressure ulcer and quality indicators.

RESULTS

The prevalence of pressure ulcers among the at-risk group (Bradenscore <or=20) in nursing homes was 30.8% in the Netherlands and 8.3% in Germany [OR: 4.9 (CI 95%: 4.2-5.7)]. In hospitals, the prevalence among the at-risk group was 26.1% in the Netherlands and 21.2% in Germany [OR: 1.3 (CI 95%: 1.2-1.5)]. After adjusting for individual risk factors (age, gender, Bradenscore) as well as for quality structures (use of prevention and treatment protocols, experts groups, information leaflets, nurses training, central pressure ulcer statistics and regular updating of protocols), the chance of developing a pressure ulcer was 6.05 times higher (CI 95%: 4.0-9.2) in a Dutch nursing home than in a German nursing home. Within the hospitals, the OR for Dutch patients was 2.03 (CI 95%: 1.4-3.0).

CONCLUSION

A remarkable national variation exists in pressure ulcer prevalence and nursing practice. Neither the populations vulnerability for pressure ulcers nor pressure ulcer management as measured in this study could explain this national variation. Therefore, other risk factors should be taken into consideration. Additionally, it is possible that quality indicators are implemented in differing ways with varying levels of effectiveness. Therefore, further research is needed to examine prospectively and in more detail the reality of care within facilities in both countries.

Nursing sensitive quality indicators for nursing home care: international review of literature, policy and practice

OBJECTIVES

To review nursing sensitive indicators used for nursing home care across seven nations with similar elder care (USA, Australia, Norway, New Zealand, England, Sweden and Denmark), and to evaluate their validity.

DESIGN

Systematic search in the literature and other sources to find descriptions of development and validity testing of national quality indicators.

DATA SOURCES

Papers from scientific databases, relevant websites, additional papers and reports, and personal communication with experts in the field. The material was included if it contributed to the description of each country's processes in defining nursing sensitive quality indicators for nursing home care, and the main focus was use, developing and/or testing of quality.

REVIEW METHODS

An overview of each country's utilization of nursing sensitive quality indicators was obtained. The evidence for the validity in development and testing procedures was analyzed using a set of evaluation criteria.

RESULTS

All countries, except Sweden, have nationally standardized assessment of the patient before admission to the nursing home. There is large variation in the way these data collection tools were developed and how the data is used. Only the USA has systematically developed quality indicators on the basis of resident assessments. Twenty-three indicators used nationally in USA, thirteen in Australia, four in Norway, three in New Zealand and three in England were selected for review, and were evaluated for their validity as described in the literature. All selected indicators had satisfactory face validity, and for the twenty-three indicators used in the USA there was evidence for reliability testing. None of the quality indicators met all the criteria for validity. Evidence that the quality indicators can demonstrate meaningful differences in care and that the information can be extracted with minimal extra efforts was not found. Thresholds for high or low quality were determined only for the US quality indicators.

CONCLUSIONS

There are concerns about the validity and reliability of nursing sensitive quality indicators for nursing home care. The indicator development is sparsely documented. It is recommended that the development of quality indicators follows a sound process and that extensive empirical testing of the indicators is done.

Adherence to pressure ulcer prevention guidelines in home care: a survey of current practice

AIMS AND OBJECTIVES

To investigate the pressure ulcer prevalence in home nursing patients and to evaluate guideline adherence of measures for the prevention of pressure ulcers and the participation of informal carers in pressure ulcer prevention.

BACKGROUND

Since 2002, the Belgian Guideline for the Prevention of Pressure Ulcers was published on the Internet, but no information was available on guideline adherence in home care.

METHODS

A cross-sectional survey of pressure ulcer prevalence and guideline adherence was performed in a cluster randomized sample of 2779 clients of nine regional nursing departments in Flanders, Belgium. The Belgian Guideline for the Prevention of Pressure Ulcers was the reference standard for the evaluation of the guideline adherence.

RESULTS

There were 744 subjects at risk for developing pressure ulcers. The overall prevalence of pressure ulcers for the total sample population was 6.8%. The age-, sex- and risk-standardized prevalence per regional department varied between 4.9% and 9.1%. Of the 744 subjects at risk, 33 (4.4%) received preventive measures, which were in adherence to the Belgian Guideline for Prevention of Pressure Ulcers, 482 persons (64.8%) were administered measures, which did not adhere to the Belgian Guideline for Prevention of Pressure Ulcers and in 229 subjects (30.8%) at risk for developing pressure ulcers, prevention was lacking. For subjects with at least one pressure ulcer, the proportions were: 4.8% adherence, 76.6% no adherence and 18.6% no prevention. A proportion of 22.2% of the patients at risk and their informal carers were informed and motivated by the home care nurse to participate in the pressure ulcer prevention and their actual participation in the prevention was 21.4% of all risk cases.

CONCLUSIONS

The adherence of nurses and clients to the guideline for pressure ulcer prevention was low. RELEVANCE TO THE CLINICAL PRACTICE: The study demonstrates a detailed evaluation of guideline adherence to pressure ulcer prevention in an individual patient situation, with special attention for materials and measures, which are not adequate and not recommended by the Belgian Guideline for the Prevention of Pressure Ulcers.

Collaborative Clinical Quality Improvement for Pressure Ulcers in Nursing Homes

The National Nursing Home Improvement Collaborative aimed to reduce pressure ulcer (PU) incidence and prevalence. Guided by subject matter and process experts, 29 quality improvement organizations and six multistate long-term care corporations recruited 52 nursing homes in 39 states to implement recommended practices using quality improvement methods. Facilities monitored monthly PU incidence and prevalence, healing, and adoption of key care processes. In residents at 35 regularly reporting facilities, the total number of new nosocomial Stage III to IV PUs declined 69%. The facility median incidence of Stage III to IV lesions declined from 0.3 per 100 occupied beds per month to 0.0 (P<.001) and the incidence of Stage II to IV lesions declined from 3.2 to 2.3 per 100 occupied beds per month (P=.03). Prevalence of Stage III to IV lesions trended down (from 1.3 to 1.1 residents affected per 100 occupied beds (P=.12). The incidence and prevalence of Stage II lesions and the healing time of Stage II to IV lesions remained unchanged. Improvement teams reported that Stage II lesions usually healed quickly and that new PUs corresponded with hospital transfer, admission, scars, obesity, and immobility and with noncompliant, younger, or newly declining residents. The publicly reported quality measure, prevalence of Stage I to IV lesions, did not improve. Participants documented disseminating methods and tools to more than 5,359 contacts in other facilities. Results suggest that facilities can reduce incidence of Stage III to IV lesions, that the incidence of Stage II lesions may not correlate with the incidence of Stage III to IV lesions, and that the publicly reported quality measure is insensitive to substantial improvement. The project demonstrated multiple opportunities in collaborative quality improvement, including improving the measurement of quality and identifying research priorities, as well as improving care.

Nurses’ reasoning process during care planning taking pressure ulcer prevention as an example. A think-aloud study

BACKGROUND

Nurses' clinical reasoning is of great importance for the delivery of safe and efficient care. Pressure ulcer prevention allows a variety of aspects within nursing to be viewed.

OBJECTIVE

The aim of this study was to describe both the process and the content of nurses' reasoning during care planning at different nursing homes, using pressure ulcer prevention as an example.

DESIGN

A qualitative research design was chosen.

SETTINGS

Seven different nursing homes within one community were included.

PARTICIPANTS

Eleven registered nurses were interviewed.

METHOD

The methods used were think-aloud technique, protocol analysis and qualitative content analysis. Client simulation illustrating transition was used. The case used for care planning was in three parts covering the transition from hospital until 3 weeks in the nursing home.

RESULT

Most nurses in this study conducted direct and indirect reasoning in a wide range of areas in connection with pressure ulcer prevention. The reasoning focused different parts of the nursing process depending on part of the case. Complex assertations as well as strategies aiming to reduce cognitive strain were rare. Nurses involved in direct nursing care held a broader reasoning than consultant nurses. Both explanations and actions based on older ideas and traditions occurred.

CONCLUSIONS

Reasoning concerning pressure ulcer prevention while care planning was dominated by routine thinking. Knowing the person over a period of time made a more complex reasoning possible. The nurses' experience, knowledge together with how close to the elderly the nurses work seem to be important factors that affect the content of reasoning.

Barriers to and facilitators of clinical practice guideline use in nursing homes

OBJECTIVES

To identify barriers to and facilitators of the diffusion of clinical practice guidelines (CPGs) and clinical protocols in nursing homes (NHs).

DESIGN

Qualitative analysis.

SETTING

Four randomly selected community nursing homes.

PARTICIPANTS

NH staff, including physicians, nurse practitioners, administrative staff, nurses, and certified nursing assistants (CNAs).

MEASUREMENTS

Interviews (n=35) probed the use of CPGs and clinical protocols. Qualitative analysis using Rogers' Diffusion of Innovation stages-of-change model was conducted to produce a conceptual and thematic description.

RESULTS

None of the NHs systematically adopted CPGs, and only three of 35 providers were familiar with CPGs. Confusion with other documents and regulations was common. The most frequently cited barriers were provider concerns that CPGs were "checklists" to replace clinical judgment, perceived conflict with resident and family goals, limited facility resources, lack of communication between providers and across shifts, facility policies that overwhelm or conflict with CPGs, and Health Insurance Portability and Accountability Act regulations interpreted to limit CNA access to clinical information. Facilitators included incorporating CPG recommendations into training materials, standing orders, customizable data collection forms, and regulatory reporting activities.

CONCLUSION

Clinicians and researchers wishing to increase CPG use in NHs should consider these barriers and facilitators in their quality improvement and intervention development processes.

Simply the Best: Teaching Gerontological Nursing Students to Teach Evidence-Based Practice

This article describes a teaching strategy used in an undergraduate gerontological nursing clinical course to familiarize students with evidence-based practice. Students are required to read and summarize an assigned evidence-based practice guideline published by The University of Iowa Gerontological Nursing Interventions Research Center. They then develop a "tip sheet," based on the assigned guideline, to disseminate to health care staff at their practicum sites, which is either a long-term care facility or a hospital-based skilled nursing facility. Nursing students' reactions to the assignment and nursing staff's responses to the tip sheets are discussed.

Organizational change and quality improvement in nursing homes: approaching success

Nursing home residents' quality of life (QoL) is directly related to the quality improvement (QI) processes mandated by federal law. This article describes a 3-year longitudinal study of QI process innovations in two nursing homes and highlights details of a successful 6-month initiative. The initial QI initiatives were based on the principles of staff empowerment, enhanced ability through training, and financial incentives. After 18 months without measurable success, the QI process was modified to include real-time feedback. Two not-for-profit nursing homes participated in this study to explore the effect of organizational change in nursing homes on residents' quality of care and QoL and staff members' job satisfaction. At 6-month intervals, residents and staff participated in structured assessments of residents' QoL and quality of care and staff members' job satisfaction. When the QI process was modified to include real-time feedback, there was a significant reduction in the rate of new pressure ulcers, stage 2 or greater (p < .05), in one of the facilities that had struggled with this problem for more than 18 months. By examining QI processes in nursing homes, the researchers were able to identify some of the obstacles to improving quality of care and QoL. Only when the element of real-time feedback was introduced, in combination with enhanced staff abilities and financial incentives, were substantial improvements seen in key clinical outcomes.

Entrepreneurial program of research and service to improve nursing home care

This is a methodological article intended to demonstrate the integration of multiple goals, multiple projects with diverse foci, and multiple funding sources to develop an entrepreneurial program of research and service to directly affect and improve the quality of care of older adults, particularly nursing home residents. Examples that illustrate how clinical ideas build on one another and how the research ideas and results build on one another are provided. Results from one study are applied to the next and are also applied to the development of service delivery initiatives to test results in the real world. Descriptions of the Quality Improvement Program for Missouri and the Aging in Place Project are detailed to illustrate real-world application of research to practice.

Pressure Ulcer Prevention in Black and White Nursing Home Residents:

OBJECTIVE

To determine if educating nursing home staff about pressure ulcer prevention reduces the differential risk of pressure ulcer development in black and white nursing home residents.

DESIGN

Subanalysis of a study designed to monitor the emergence of all pressure ulcers in nursing home residents during 12-week baseline and intervention periods.

PARTICIPANTS

All residents and staff of a not-for-profit, 136-bed nursing home in urban western Pennsylvania.

MAIN OUTCOME MEASURE

The quality improvement intervention, featuring a computer-based interactive video education program on pressure ulcer prevention and early detection, consisted of 3 components: (1) staff ability enhancement, (2) staff financial incentives, and (3) real-time management feedback. Three specific outcome measures were monitored for differential risk of pressure ulcer development in black and white nursing home residents: (1) the rate of emergent Stage I-IV pressure ulcers identified, (2) the rate of emergent Stage II-IV pressure ulcers identified, and (3) the rate of individual residents developing at least 1 pressure ulcer (Stages II-IV).

RESULTS

At baseline, black residents demonstrated a higher rate of Stage II-IV pressure ulcer emergence. Black residents with any pressure ulcer were also more likely to have multiple Stage II pressure ulcers compared with white residents. During the baseline period, 31.8% of the pressure ulcers detected in white residents were Stage I, whereas no Stage I pressure ulcers were detected in black residents. During the intervention period, the rate of emergence of all pressure ulcers declined for both groups in similar trends.

CONCLUSION

Black residents were more likely to have multiple Stage II-IV pressure ulcers and were less likely to have Stage I pressure ulcers identified at baseline compared with white residents. The education intervention effectively reduced the rate of pressure ulcers for all residents and eliminated the racial disparity noted during the baseline period.

Pressure Ulcer Prevention in Homecare

OBJECTIVE

The purpose of this study was to gain insight into the availability and quality of protocols for pressure ulcer prevention in homecare agencies in the Netherlands.

DESIGN

A descriptive study was completed.

SETTING AND SUBJECTS

Forty-one homecare agencies in the Netherlands that provide nursing care were queried.

INSTRUMENTS

Three instruments were used to collect data: (1) a structured questionnaire containing 46 closed and open-ended questions, (2) a checklist used by experts to analyze the protocols for conformity to guidelines, and (3) a tool used to generate a numerical score for each protocol based on the experts' reviews.

METHODS

A questionnaire was mailed to all homecare agencies in the Netherlands that provided nursing care. The quality of each protocol was judged and scored by 3 pressure ulcer prevention experts. The scores were analyzed using descriptive statistics.

RESULTS

A pressure ulcer protocol was available in 78% of the agencies. Seventy-five percent had at least 1 wound care nurse who spent an average of 10 hours per week on pressure ulcer prevention. In 20% of the agencies, no introduction or instruction was given to the nurses when the protocol was implemented. In 25% of the agencies, nurses did not participate in the revision of the protocol. At the end of 2003, only 13% of the agencies had executed 1 or more revisions of their protocol since 2002, when the last Dutch pressure ulcer guideline was introduced. The 26 pressure ulcer prevention protocols had a mean score of 47 points out of a maximum of 100 points (range 9 to 82; SD, 18).

CONCLUSIONS

Although the use of protocols is considered an important adjunct in the prevention of pressure ulcers, 22% of the participating agencies did not have a pressure ulcer prevention protocol and 25% did not have wound care nurses, indicating a need for further promotion of standardized pressure ulcer prevention strategies. In addition, the available protocols were frequently of low quality or outdated, reflecting a need for increased attention to current and accurate tools to guide nursing practice.

Ability, Incentives, and Management Feedback: Organizational Change to Reduce Pressure Ulcers in a Nursing Home

OBJECTIVE

Quality improvement (QI) processes in nursing homes are highly variable and often ineffective. This study evaluated an innovative QI process to reduce pressure ulcers (PUs) in a nursing home with a high rate of PUs.

DESIGN

This was a 48-week, longitudinal study comparing the incidence of PUs during 12-week baseline and intervention and post-intervention periods.

SETTING

Not-for-profit, 136-bed nursing home in urban Western Pennsylvania.

PATIENTS OR OTHER PARTICIPANTS

All residents and all staff at the nursing home participated in this study.

INTERVENTIONS

The intervention consisted of 3 components: Ability enhancement, incentivization, and management feedback. To enhance ability, all staff members completed a computer-based interactive video education program on PU prevention and were mandated to use penlights to promote early detection. Incentivization included $75 for each staff member if the desired reduction in PU incidence was achieved. Management feedback provided real-time information of staff"s adherence to the mandated training.

MAIN OUTCOME MEASURES

Outcome measures consisted of staff's adherence to mandated training and the incidence of new PUs during the baseline period compared to the intervention and post-intervention periods.

RESULTS

Management responded to noncompliance with training with both rewards and stepped discipline. Adherence to protocol, as measured by training compliance, was 100%. There was a significant reduction (P < .05) in the incidence of stage 2 or worse PUs during the intervention period. During the post-intervention periods, the effect was lost.

CONCLUSION

An innovative QI initiative resulted in a significant decrease in PUs in 1 facility. This intervention was not sustainable when the 3 components of the QI intervention were no longer actively maintained.

The National Pressure Ulcer Long-Term Care Study: outcomes of pressure ulcer treatments in long-term care

OBJECTIVES

To identify resident, wound, and treatment characteristics associated with pressure ulcer (PrU) healing in long-term care residents.

DESIGN

Retrospective cohort study with convenience sampling.

SETTING

Ninety-five long-term care facilities participating in the National Pressure Ulcer Long-Term Care Study throughout the United States.

PARTICIPANTS

Eight hundred eighty-two residents, aged 18 and older, with length of stay of 14 days or longer, who had at least one Stage II to IV PrU.

MEASUREMENTS

Data collected for each resident over a 12-week period included resident characteristics, treatment characteristics, and change in PrU area. Data were obtained from medical records, Minimum Data Set, and other records.

RESULTS

Two multiple regression models, one for each stage grouping (Stage II, Stage III and IV), were completed. The area of Stage II PrU was reduced more with moist (F=21.91, P<.001) than with dry (F=13.41, P<.001) dressings. PrUs cleaned with saline or soap showed less decrease in area (F=12.34, P<.001) than PrUs cleaned with other cleansers such as antiseptic, antibiotic, or commercial cleansers. Change in area of Stage III and IV PrUs was related to sufficient enteral feeding (F=5.23, P=.02), enteral feeding without higher acuity levels (F=3.94, P=.048), size of PrU (very large (F=120.89, P=.001) and large (F=27.82, P=.001)), and type of dressing (moist (F=14.70, P<.001) and dry (F=5.88, P=.02)). Stage III and IV PrUs increased in area when debrided (F=5.97, P=.02). The overall models were significant (Stage III and IV, F=20.30, coefficient of determination (R2)=0.06, P<.001; Stage II, F=40.28, R2=0.13, P<.001) but explained little of the variation in change in PrU area.

CONCLUSION

In this sample of nursing facility residents, use of moist dressings (Stage II, Stage III and IV) and adequate nutritional support (Stage III and IV) are strong predictors of PrU healing.

Improving the quality of long-term care with better information

Publicly reporting information stimulates providers' efforts to improve the quality of health care. The availability of mandated, uniform clinical data in all nursing homes and home health agencies has facilitated the public reporting of comparative quality data. This article reviews the conceptual and technical challenges of applying information about the quality of long-term care providers and the evidence for the impact of information-based quality improvement. Quality "tools" have been used despite questions about the validity of the measures and their use in selecting providers or offering them bonus payments. Although the industry now realizes the importance of quality, research still is needed on how consumers use this information to select providers and monitor their performance and whether these efforts actually improve the outcomes of care.

Impact of Pain on Outcomes in Long-Term Care Residents with and without Multiple Sclerosis

OBJECTIVES

To compare long-term care (LTC) residents with and without multiple sclerosis (MS); to compare admission status of pain, physical disability, pressure ulcers, depression, and cognitive performance in LTC residents with and without MS; and to examine the impact of MS and pain on outcomes 90 and 180 days after LTC admission.

DESIGN

Retrospective analysis of a large data set.

SETTING

LTC facilities in Missouri.

PARTICIPANTS

Residents admitted to non-hospital-based LTC facilities.

MEASUREMENTS

Minimum Data Set/Resident Assessment Instrument, Version 2.0; Activities of Daily Living Scale; Cognitive Performance Scale.

RESULTS

Residents with and without MS had similar pain prevalence and intensity after admission, with daily pain more frequent in residents with MS (P=.03). On admission, residents with MS had more physical disability (P<.001) and a greater prevalence of pressure ulcers (P=.004) and depression (P<.001) than residents without MS. In all LTC residents, initial pain status was associated with physical disability (P<.001), pressure ulcers (P<.001), depression (P<.001), and cognitive performance (P<.001) 90 and 180 days after admission. A diagnosis of MS was associated with physical disability (P<.001) 90 and 180 days after admission and pressure ulcer development 180 days after admission (P=.02).

CONCLUSION

Residents with MS were more physically disabled and had more frequent pain and a higher prevalence of pressure ulcers and depression on admission than residents without MS. Pain, or lack thereof, in residents with and without MS on admission may warn of problems that could occur within 6 months after admission to a LTC facility.

Quality management systems and clinical outcomes in Dutch nursing homes

The objective of the article is to explore the impact quality management systems and quality assurance activities in nursing homes have on clinical outcomes. The results are based on a cross-sectional study in 65 Dutch nursing homes. The management of the nursing homes as well as the residents (N = 12,377) participated in the study. Primary survey-data about the implementation of quality management systems and quality assurance activities were collected in 1994/1995 and in 1998, and were combined with information on resident characteristics and the prevalence of undesirable clinical outcomes. The results demonstrate that there are differences between nursing homes in the prevalence of undesirable clinical outcomes. In the nursing homes with the lowest scores, undesirable outcomes occur approximately 10 times less often than in nursing homes with the highest scores. The multi-level analysis has demonstrated that the differences in outcomes are mainly caused by differences between residents and, to some extent, also by differences between nursing homes. Resident characteristics explain 48% of the differences between residents and 72% of the differences between nursing homes. The size of the nursing home, the involvement of a client council and the implementation of a quality management system could explain a small part of the remaining variation in the number of undesirable outcomes. It seems that the implementation of a quality management system and the involvement of a client council had significant influence on the number of undesirable outcomes. Approximately 50% of the undesirable outcomes cannot be explained by the selected resident characteristics, the size of the nursing home and the implementation of quality management systems or quality assurance activities.