Pressure ulcer prevalence in Ohio nursing homes: clinical and facility correlates

Risk factors associated with dehydration in older people living in nursing homes: Scoping review

BACKGROUND

Dehydration in the older people is a prevalent problem that is often associated with physiological changes, physical limitations and environmental conditions.

OBJECTIVES

The scoping review was carried out to identify risk factors associated with dehydration in older people living in nursing homes.

DESIGN

The revised scoping methodology framework of Arksey and O'Malley (2005) was applied. Study selection was carried out in accordance with Davis et al. (2009) and focused on the inclusion criteria (people over 65 years old and living in nursing homes). Risk factors were classified using the geriatric assessment.

DATA SOURCES

An electronic database search was performed in PubMed, Scopus and CINAHL. The literature search was carried out between October 2016 and January 2017.

REVIEW METHODS

Thematic reporting was performed and study findings were validated through interdisciplinary meetings of experts. The quality of the papers consulted was also evaluated using the Newcastle-Ottawa Scale adapted for cross-sectional, cohort and case-control studies.

RESULTS

In all, 16 papers were analysed, all of which were observational studies. The risk of bias ranged from very low (n = 1), to medium (n = 13) and high (n = 2). The risk factors were classified in line with the different components of the geriatric assessment. In the socio-demographic characteristics age and gender were identified. In the clinical component, infections, renal and cardiovascular diseases and end-of-life situations were the most common factors highlighted in the papers analysed. With reference to the functional component, its limitation was associated with dehydration, while for factors of mental origin, it was related to dementia and behavioural disorders. Finally, the factors relating to the social component were institutionalisation, requiring a skilled level of care and it being winter.

CONCLUSIONS

The most commonly repeated factors highlighted in the review were age, gender, infections, end of life and dementia, with it being important to highlight the large number of factors in the clinical component. Even so, the great majority of the factors were unmodifiable conditions associated typically associated with the physiology of ageing.

Pressure Ulcers Among Newly Admitted Nursing Home Residents: Measuring the Impact of Transferring From Hospital

OBJECTIVES

Pressure ulcers (PUs) are reported more often among newly admitted nursing home (NH) residents who transfer from hospital versus community. We examine for whom this increased risk is greatest, further defining hospitalized patients most in need of better PU preventive care.

RESEARCH DESIGN

Retrospective observational cohort study.

SUBJECTS

All NH residents (N=5617) newly admitted between April 1, 2008 and March 31, 2012 in Winnipeg, MB, Canada.

MEASURES

RAI-MDS 2.0 data were linked to administrative health care use files capturing each person's NH admission date, their presence of a PU at this time, whether they transferred into NH from hospital or community, and their PU susceptibility (eg, amount of help needed to maneuver in bed or to transfer from one surface to another, frequency of incontinence, presence of diabetes, amount of food consistently left uneaten). Log-binomial regression with interaction terms was used to analyze data.

RESULTS

67.6% of our cohort transferred into a NH directly from hospital; 9.2% of these residents were reported to have a stage 1+ PU on NH admission versus 2.6% of those who transferred from community. From regression models, transferring from hospital versus community was associated with increased PU risk equally across various subgroups of less and more susceptible residents.

CONCLUSIONS

Transferring from hospital versus community places both more and less susceptible newly admitted NH residents at increased PU risk. Using evidence-based preventive care practices is thus needed for all subgroups of hospital patients before NH use, to help reduce PU risk.

Evaluation of AHRQ's on-time pressure ulcer prevention program: a facilitator-assisted clinical decision support intervention for nursing homes

BACKGROUND

Pressure ulcers present serious health and economic consequences for nursing home residents. The Agency for Healthcare Research & Quality, in partnership with the New York State Department of Health, implemented the pressure ulcer module of On-Time Quality Improvement for Long Term Care (On-Time), a clinical decision support intervention to reduce pressure ulcer incidence rates.

OBJECTIVE

To evaluate the effectiveness of the On-Time program in reducing the rate of in-house-acquired pressure ulcers among nursing home residents.

RESEARCH DESIGN AND SUBJECTS

We employed an interrupted time-series design to identify impacts of 4 core On-Time program components on resident pressure ulcer incidence in 12 New York State nursing homes implementing the intervention (n=3463 residents). The sample was purposively selected to include nursing homes with high baseline prevalence and incidence of pressure ulcers and high motivation to reduce pressure ulcers. Differential timing and sequencing of 4 core On-Time components across intervention nursing homes and units enabled estimation of separate impacts for each component. Inclusion of a nonequivalent comparison group of 13 nursing homes not implementing On-Time (n=2698 residents) accounts for potential mean-reversion bias. Impacts were estimated via a random-effects Poisson model including resident-level and facility-level covariates.

RESULTS

We find a large and statistically significant reduction in pressure ulcer incidence associated with the joint implementation of 4 core On-Time components (incidence rate ratio=0.409; P=0.035). Impacts vary with implementation of specific component combinations.

CONCLUSIONS

On-Time implementation is associated with sizable reductions in pressure ulcer incidence.

MDS-based state Medicaid reimbursement and the ADL-decline quality indicator

PURPOSE

We examined the relationship between the quality indicator for decline in activities of daily living (ADL) and the use of the Minimum Data Set (MDS) for determining Medicaid skilled nursing facility reimbursement.

DESIGN AND METHODS

We conducted a cross-sectional analysis using the 2004 National MDS Facility Quality Indicator reports as the dependent variable in a multilevel regression model. Our primary explanatory variable was a state-level binary variable distinguishing whether or not the state used an MDS-based Medicaid-reimbursement system in 2004. We obtained control variables through the Online Survey, Certification, and Reporting System.

RESULTS

Skilled nursing facilities located in states that used the MDS for Medicaid reimbursement reported more ADL decline than did facilities in states that did not use the MDS for reimbursement.

IMPLICATIONS

The finding suggests that the ADL-decline quality indicator captures more than just quality, including state-level policy differences. Therefore, the ADL-decline quality indicator should be investigated and refined prior to being relied on for pay-for-performance initiatives.

Nursing Homes' Response to the Nursing Home Compare Report Card

OBJECTIVE

The Centers for Medicare and Medicaid Services have recently begun publishing the Nursing Home Compare report card. The objective of this study was to examine the initial reactions of nursing homes to publication of the report card and to evaluate the impact of the report card on quality-improvement activities.

METHODS

We conducted a survey of a random national sample of 1,502 nursing home administrators; 724 responded. We analyzed frequency of responses to questions regarding views of the quality measures and actions taken.

RESULT

A model of nursing homes' behavior predicted that the report card would provide an incentive for facilities to improve quality. A majority of facilities (69%) reported reviewing their quality scores regularly, and many have taken specific actions to improve quality. Homes with poor quality scores were more likely to take actions following the publication of the report card.

DISCUSSION

These findings suggest that the Nursing Home Compare report card has the potential to positively affect nursing home quality.

A comparison of pressure ulcer prevalence rates in nursing homes in the Netherlands and Germany, adjusted for population characteristics

Annual pressure ulcer surveys in the Netherlands and Germany have shown remarkable differences in prevalence rates. We explored the differences between the two populations, and the degree to which these differences were associated with differences in prevalence. To this end, data from 48 Dutch and 45 German facilities (n = 9772) from 2003 were analyzed. The prevalence of pressure ulcers (excluding grade 1) was 12.5% in the Netherlands and 4.3% in Germany. After adjusting for age, sex, and other risk factors, the probability of developing a pressure ulcer of stage 2 or higher in Dutch nursing homes was three times greater than in German homes.

Effects of absorbent incontinence pads on pressure management mattresses

AIM

The aim of this paper is to report a study to determine the effects of absorbent pads on the pressure-relieving properties of 'standard' and pressure management mattresses.

BACKGROUND

Pressure ulcers and incontinence often co-exist. There is a strong association between poor mobility and continence problems and patients using pressure management products are therefore also likely to be using absorbent pads.

METHODS

An instrumented articulated anthropometric phantom with simulated soft body 'tissues' in the gluteal and sacral areas was used as the 'subject'. The phantom was raised and lowered on to three mattresses (standard foam, visco-elastic foam and surface-cut foam) in three states: naked, wearing a dry pad (Tena Super, SCA Hygiene AB) and wearing a wet pad. The pressure mapping device Xsensor was used to record the distribution of pressure over the sacral and ischial areas of the phantom. Peak pressure was used as the primary outcome variable and 10 repeats were made on each mattress under each condition.

RESULTS

There were substantial and significant differences for all three mattresses in recorded peak pressures between the naked buttocks and the buttocks wearing a dry pad. There were no significant differences between measurements made using the dry vs. wet pad. Peak pressures frequently occurred over areas of pad folds. Additional testing showed that pads that were 'smoothed' by hand had significantly lower peak pressures than 'unsmoothed' pads.

CONCLUSIONS

Absorbent pads have a substantial adverse effect on the pressure redistribution properties of mattresses. Pad folds appear to contribute to this effect, which can be ameliorated slightly by smoothing. Absorbent pad manufacturers should consider engineering pads that minimize disruption to pressure management. Further examination of continence and pressure management products is necessary to establish optimum combinations for nursing care.

Quality report cards and nursing home quality

PURPOSE

This study examined the potential role that publicly disseminated quality report cards can play in improving quality of care in nursing homes.

DESIGN AND METHODS

We review the literature and the experience gained over the last two decades with report cards for hospitals, physicians, and health plans, and consider the issues that are of particular importance in the context of nursing home care.

RESULTS

Experience with report cards in other areas of the health care system suggests that nursing home quality reports may have a role to play in informing consumers' choices and providing incentives for quality improvement. Their impact may, however, not be large. Methodological issues that may limit the accuracy of quality indicators and issues related to the design and comprehension of the information by consumers are discussed.

IMPLICATIONS

Quality report cards should be viewed as one of several options to ensure higher quality nursing home care.

Diabetes in the elderly: problems of care and service provision

Diabetes is common in the elderly and old UK citizens, affecting between 10% and 25%. There is considerable associated morbidity and mortality, with dementia being a common problem. The diabetic elder is also at risk of drug side-effects. Most of the evidence base for treatment is based on trials performed in younger diabetic subjects or older nondiabetic subjects; however, we can practice evidence-biased medicine whilst awaiting the results of ongoing trials. The older persons national service framework (NSF) may share some similarities with the diabetes NSF; it was 1 year late, and had no clear funding, amongst several other worries. Residential care, which is more likely to be required by diabetic elders, is also under-funded with major concerns about the quality of care for the diabetic resident. The little evidence that we have regarding care of the older diabetic person also suggests inadequacies. Given the likelihood that we will have to manage with present resources, managed clinical networks may be one way to cope.

Pressure ulcer prevalence in long-term nursing home residents since the implementation of OBRA '87. Omnibus Budget Reconciliation Act

OBJECTIVES

To evaluate change in pressure ulcer prevalence in long-term nursing home residents since the implementation of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87).

DESIGN

Cross-sectional comparison of two time periods.

SETTING

Ninety-two nursing homes scheduled for a quality-of-care survey randomly selected from 22 representative states.

PARTICIPANTS

Four thousand six hundred seventy-nine residents who had resided in the facility for at least 100 days were evaluated: 2,336 during 1992-1994 and 2,343 during 1997-1998.

MEASUREMENTS

Trained registered nurses collected data on pressure ulcer prevalence, stage, and risk factors from medical record review during on-site evaluations. Risk-adjusted differences were estimated using logistic regression.

RESULTS

Unadjusted prevalence rates for all stages of pressure ulcers (8.52% vs 8.54%, P =.983) and those rated stage 2 or greater (5.31% vs 5.63%, P =.624) did not differ between the two time periods. After adjustment for urinary incontinence, immobility, poor nutrition, and history of previous pressure ulcers, the relative odds of having a pressure ulcer in 1992/4 versus 1997/8 was 1.06 (95% confidence interval (CI) = 0.84-1.34) for all stages and 1.21 (95% CI = 0.92-1.60) for stages 2 and greater.

CONCLUSIONS

No change in pressure ulcer prevalence was demonstrated since implementation of OBRA '87 in this nationally derived sample of long-term nursing home residents.

How can we improve prevalence and incidence monitoring?

Many studies have attempted to calculate pressure ulcer occurrence rates, but their results cannot be compared due to variations in the methodologies used. How can this problem be overcome?

Are we improving the quality of nursing home care: the case of pressure ulcers

BACKGROUND

There are widespread concerns regarding the quality of nursing home care and whether care is improving. We evaluated a large provider of nursing home care to determine whether risk-adjusted rates of pressure ulcer development have changed.

METHODS

We used the Minimum Data Set to study National HealthCare Corporation nursing homes from 1991 through 1995. Rates of pressure ulcer development were calculated for successive 6-month periods by determining the proportion of residents initially ulcer-free having a stage 2 or larger pressure ulcer on subsequent assessments. Rates were risk-adjusted for patient characteristics. The proportion of new ulcers that were deep (stages 3 or 4) were also calculated.

RESULTS

We examined risk-adjusted rates of pressure ulcer development based on 144,379 observations of 30,510 residents at 107 nursing homes. The number of observations per 6-month period ranged from 11,041 to 15,805. Between 1991 and 1995, there was a significant (P<.05) rate decline of more than 25%. Additionally, the proportion of new ulcers that were stages 3 or 4 declined from 30 to 22% (P<.01).

CONCLUSIONS

Nursing homes showed significant improvement in the quality of pressure ulcer preventive care from 1991 to 1995.

Pressure ulcer development in the VA: characteristics of nursing homes providing best care

This study identifies structural characteristics of VA nursing homes that are associated with the best patient outcomes. We evaluated risk-adjusted rates of pressure ulcer development in VA nursing homes and related these rates to facility size, staffing patterns, teaching nursing home status, and rural versus urban locale. Higher rates of pressure ulcer development were seen among urban teaching nursing homes and among nursing homes associated with both larger and smaller VA hospitals. Staffing patterns had a complex association with pressure ulcer development, and smaller nursing home staffs were not clearly associated with higher rates. For multivariate modeling, only hospital size and staffing remained significant independent predictors of pressure ulcer development. These results emphasize that while structural characteristics of VA nursing homes can provide insights about care, improving the quality of care in this setting will require a much greater understanding of how nursing homes are organized to meet patient needs.

Using outcomes to make inferences about nursing home quality

Recent concerns about containing the growth of public expenditures on nursing home care and the development of prospective and casemix reimbursement systems with incentives for cost containment have increased the importance of monitoring quality in nursing homes. The current view is that quality assurance systems should include more outcome measures to improve quality. This article discusses why it is difficult to develop facility-level outcome measures that can be used to evaluate and compare the quality of care of nursing homes. The article places the current interest in outcomes measures in its historical policy context and reviews important conceptual and methodological issues associated with outcome-based quality assessment. The authors discuss the difficulty in isolating the facility effect when studying nursing home outcomes and implications of using different estimation approaches. In conclusion, they discuss the need to integrate research with outcome-based quality assurance systems to allow ongoing evaluation and quality improvement.