Improving Quality of Care in Nursing
Homes
Quality
Improvement Organizations (QIOs) have played a key role in the federal
Nursing Home Quality Initiative (NHQI) launched by the Centers for
Medicare & Medicaid Services ( CMS ) in
November 2002. The quality initiative combines public reporting on
quality of care by all Medicare and Medicaid certified nursing homes
with assistance to nursing homes from QIOs working under contract to
CMS . QIOs have offered guidance on improving care to all of the nation’s
nursing homes, and provided intensive hands-on assistance to a percentage
of homes in each state.
Data recently released by CMS show nationwide improvement by nursing
homes in the treatment of pain, and in reduction in the use of physical
restraints. CMS data also shows that nursing homes working closely with
QIOs achieved significantly greater improvement in key clinical areas.
Here are a few examples of what nursing homes have accomplished during
the pilot (2001-2002) and full implementation (2002-2004) of the initiative:
Pain Management
Multi-facility national companies improve pain management
As part
of the Nursing Home Quality Initiative, some of the nation’s
largest nursing home companies participated in a two-year QIO study that
resulted in greater than 45% improvement in pain management. Led by Quality
Partners of Rhode Island and the Colorado Foundation for Medical Care,
the QIOs for Rhode Island and Colorado , respectively, the study involved
163 nursing homes across the country with total potential resident population
of more than 19,000. Companies participating included Beverly Health
Care, Genesis Health Care, HCR Manor Care, Kindred Healthcare, Mariner
Health Care, Sovereign Health Care, SunBridge Healthcare, Inc., and Trans
Healthcare, Inc. The companies are developing a plan for spreading information
and strategies from the study to their non-participating facilities.
Ongoing awareness of the pain collaborative continues within the companies
through company wide newsletters and as a standing agenda item for meetings
of all levels within the companies. They continue to share ideas and
materials through learning sessions, monthly conference calls, and by
an email list serve. For more information: Erich Kirshner, 303-306-4514
or ekirshner@coqio.sdps.org.
In Minnesota , 68 nursing homes improve 45% in chronic pain measure
A group
of 68 nursing homes in Minnesota demonstrated more than 45% relative
improvement in chronic pain management and almost 20% relative improvement
in post-acute care pain management after working with Stratis Health,
the Minnesota QIO. Early in the Nursing Home Quality Initiative, Stratis
Health selected homes to work with intensively, a group that reflected
a balance of profit and non-profit, urban and rural, independent and
affiliated, varying bed sizes, and experience with quality improvement.
These homes were then divided regionally to foster networks of support
and invited to a series of quarterly Stratis Health learning workshops
offered at four locations across the state. The workshops covered quality
improvement basics, leadership, and evidence-based strategies for pain
management. By the last collaborative session, the nursing homes were
offering advice and support to one another, and had added the topic
of pressure ulcers to their work. Stratis Health provided customized
facility support between sessions and facility-specific data from the
Centers for Medicare & Medicaid
Services ( CMS ) for the collaborative participants to assess their
performance on the quality measures. For more info, Kate Johnston,
952-853-8539, kjohnston@mnqio.sdps.org.
In South Carolina , nursing homes improve pain, pressure ulcer measures
The Carolinas Center for Medical Excellence, the South Carolina QIO, led projects in 2003 and early
2004 that resulted in a nearly 20% relative change in post acute pain
management and 17% relative change in chronic pain as well as a reduction
in self-reported data for pressure ulcers. Forty-three nursing homes
took part in the effort to reduce pain and 70 nursing homes participated
in the project to reduce pressure ulcers. CMR held three learning sessions
for each collaborative. These sessions, which included working through
multi-disciplinary teams and employing an expert panel, built trust
and encouraged participants by showing visible improvements. Participating
facilities submitted senior leader reports and shared data with CMR
on a consistent basis. Conway Nursing Center , for example, dramatically
cut the number of “breakthrough” episodes for
chronic pain residents: residents experienced 30.1 episodes during the
baseline month—which were reduced to 6.8 episodes eight months
later. AtMyrtle Beach Manor home,staffcut
the number of “breakthrough” episodes for chronic pain from17
episodes during the baseline month to 6.2 episodes at re-measurement
five months later. Chesterfield Convalescent Center dramatically increased
the percent of post acute pain residents that experienced a decrease
in peak pain intensity during the first 14 days of admission. Over five
months, Chesterfield increased from a baseline measure of 50% of residents
experiencing a decrease in pain intensity to 100% showing a decrease
at re-measurement. For more info, Diana M. Zona, 803-731-8225 or dzona@scqio.sdps.org.
Reducing
pain among Idaho nursing
home residents
To help Idaho nursing homes improve pain evaluation and management,
Qualis Health, the QIO for Idaho , held educational workshops and provided
evidence-based tools for improving care. Among 59 nursing homes across
the state, the percentage of long-term residents reporting moderate to
severe pain fell from 18% in spring 2002 to 8% in spring 2004. For more
info, John Ballenot, 208-389-5024 or johnb@qualishealth.org.
West Virginia homes make gains against chronic pain
The West
Virginia Medical Institute (WVMI), the state QIO, has provided technical
assistance to help homes successfully reduce resident pain. For more
info, Marc McCombs, 304-346-9864, ext. 2267 or mmccombs@wvmi.org. Some
examples:
- Good Shepherd Nursing Home L.C ., a 192-bed
facility in Wheeling, reduced the percentage of residents who suffer
from chronic pain to less than 2%--compared to the state
average of 8% and the national average of 7%--by implementing procedures
to assess and track residents’ pain throughout their stay.
The approach looked at pain as the fifth vital sign, along with blood
pressure, pulse, respiration and temperature. Staff now checks daily
for pain when vital signs are taken and also perform a weekly assessment
of residents on a pain management program. A more comprehensive care-planning
assessment is performed at least quarterly.
- Elkins
Regional Convalescent Centerreduced the percentage of residents
who have chronic pain to 2%. Through
in-services and consultation with WVMI, Elkins Regional developed
a pain-management committee that put new assessment and documentation
tools into place. The new tools helped to decrease the percentage
of residents experiencing chronic pain from 10% to 2%. At Elkins
Regional, the percentage of residents who have moderate to severe
pain is 1%, compared to the state and national average of 6%.
- Cameron Continuous Care Center , a 60-bed
rural facility, reduced the percentage of residents who have chronic
pain from 14% in the third quarter of 2003 to 8% mid-2004. With
WVMI providing resources and guidance, the center’s interdisciplinary
team took a fresh look at how it assesses residents’ pain:
reviewing patient charts to make sure the appropriate pain-management
medications were being used; exploring approaches other than medication
to relieve pain, such as repositioning the patient; working with
residents to determine if behaviors, such as combativeness, were
the result of pain; and learning to identify the signs and symptoms
of pain such as restlessness, grimacing and crying. Staff learned
to accept residents’ perception of pain and to treat it appropriately.
The facility’s physician helped to improve treatment of breakthrough
pain, pain experienced despite taking around-the-clock medication
to alleviate it. In addition, Cameron Continuous Care began using
a patient-controlled analgesic pump with morphine to improve comfort
at the end of life after trying other options, such as alternative
pain medications and approaches other than medication.
Washington state home reduces chronic, acute pain
Pinewood Terrace Nursing Center in Colville , WA , substantially improved
pain management, reducing chronic pain by 87% and post-acute pain 88%
while participating in an intensive 18-month collaboration with Seattle-based
QIO Qualis Health. The collaborative developed educational materials
on attitudes toward pain, which were used for staff training; implemented
a tool and a protocol to allow the staff to accurately assess pain in
cognitively impaired residents; developed and implemented a new protocol
to promote faster relief for residents in chronic pain. For more info,
Robert Miskimon, 206-366-3371, robertm@qualishealth.org.
Providence Mother Joseph facility reduces the number of residents having
constant or intermittent pain:
This 152-bed long term care facility in Olympia , WA worked with Qualis
Health, the Seattle-based QIO, over a three-month period to reduce the
number of residents having constant or intermittent pain by changing
medications from a transdermal patch to an oral form of medication. None
of the residents have required breakthrough pain medication after implementation
of the change. The staff also reports that the residents are more alert
and their appetites have improved. For more info, Robert Miskimon, 206-368-2401,
robertm@qualishealth.org.
Kansas nursing home system dramatically lowers pain
The percentage
of residents suffering chronic pain at The Cedars’ home
dropped from 19.96% to 2.39% after participating in a year-long quality
improvement project with the Kansas Foundation for Medical Care, the
Kansas QIO. KFMC trained nursing staff on pain identification and management,
which reinforced the need for staff to question and regularly observe
residents for pain. The Cedars created a new system that calls for pain
assessments to be conducted at routine times. Certified nursing assistants
( CNA ) now carry pocket tools for screening residents, which they monitor
on flow sheets. If the resident reports a high level of pain, the CNA
notifies the nurse, who conducts a comprehensive pain assessment. The
Cedars has also established tools that allow nurses to assess pain experienced
by residents with dementia. After updating its pain-screening system,
The Cedars cut the number of residents suffering from chronic pain dramatically,
with only 3 out of 95 residents experiencing chronic pain. For more info,
Lisa Williams, 785-273-2552, lwilliams@ksqio.sdps.org.
In New York nursing home, post acute pain dropped from 26% to 4%
By making
pain management tools more user-friendly and pain assessment more timely,
Providence Rest Nursing Home in the Bronx cut post-acute pain among
residents from 26% to 4% and reduced chronic pain to just 1% of its
residents. IPRO, the New York QIO, worked with staff at Providence
from June 2002 to December 2003. An interdisciplinary quality improvement
team reviewed the facility’s systems and processes related to
pain quality measures—including assessment tools, flow sheets
and car plans—for both the chronic and the post-acute care populations.
The team then developed a one-page pain assessment form for all residents
that reduced unnecessary work for nursing home staff and increased the
timeliness of pain assessments. The team also identified interventions
for managing pain and implemented data tracking tools for concurrent
review of resident records at weekly care meetings. For more info, Spencer
Vibbert, 516-326-7767, svibbert@nyqio.sdps.org.
Timely
pain treatment at central California nursing
home jumps to 100%
Horizon
Health and Subacute Center , located in Fresno CA , worked intensively
with California ’s QIO, Lumetra, on improving treatment
for pain in 2003. Starting with a pilot population, the year-long collaboration
offered Horizon Health training, expert assistance and clinical best
practice methods on improving care, with the goal of increasing the number
of residents being screened, assessed and treated for pain. In the course
of the project, the facility discovered that meeting these goals significantly
increased residents' satisfaction with the care provided in the facility.
Now, 100% of the home’s new residents receive consistent pain screening,
up from 16% of residents in the pilot population. Where 62.5 % of residents
received timely treatment for moderate or severe pain before the collaborative,
more than 95% are now consistently treated for pain in a timely manner.
Increase in resident satisfaction scores rose from 13% in the beginning
of the collaborative to 100% at the end of project. For more info, Danielle
Simmons, 415-677-2122, dsimmons@caqio.sdps.org.
Nebraska
home makes major gains in pain control
Working with the Nebraska QIO, CIMRO of Nebraska, Highland Park Care
Center in Alliance , NE reduced the percentage of patients experiencing
chronic pain from 22% down to 14% and reduced the percentage of residents
with ADL decline from 25% to 9% in 2003-2004. Linda Schneider, Director
of Nursing, stated these improvements can be attributed primarily to
listening to residents, reviewing and revising policies and procedures,
generating the participation and buy-in of all staff, structured analysis
and monitoring of data. For more info, Keri McDermott, 402-476-1399 or
kmcdermott@neqio.sdps.org
Colorado nursing homes make dramatic cuts in chronic pain
Working with the Colorado Foundation for Medical Care (CFMC), the state
QIO, a number of homes are being recognized as models of improvement
in pain management. For more info, contact Erich Kirshner, 303-306-4514,
ekirshner@coqio.sdps.org. Some examples:
- Mount
St. Francis cuts number of residents reporting chronic pain by
63%. This facility began an intensive evaluation
of its existing pain program—organizing a pain team and utilizing
educational materials, including self-assessment checklists provided
by CFMC, to identify areas for improvement. The facility provided
pain education to resident and family councils to encourage involvement
and to assist residents and families in understanding their important
role in the pain management process. The staff members also participated
in educational training sessions and have increased their awareness
of pain management.
- Garden
of the Godscare center cuts percentage
of patients experiencing chronic pain to 7%. This facility
organized a pain management committee to address the needs of residents
in chronic pain. CFMC provided educational materials and resources
including pain management checklists and self-audit tools. Through
the use of improved screening and assessment tools, increased use
of round the clock medication verses as needed medication, and use
of alternative treatment including aroma therapy this facility has
improved pain management awareness and thus the quality of care for
the residents.
- Doak Walker Care Center, in Steamboat Springs, Colorado,
cuts the number of patients reporting pain from 36% to 7%. Doak
Walker Care Center worked in partnership with the adjacent hospital’s
pain team to provide innovative pain treatment not routinely seen
in nursing homes. They have used the following interventions to help
those residents with chronic pain: epidural steroid injections, diagnostic
nerve blocks, trigger point injections, botox A and B injections,
cervical and lumbar sympathetic blocks, implantable pain pumps, and
percutaneous disc decompression. Additionally, this facility has
been working with the Colorado QIO on quality improvement of pain
management since participation in the Nursing Home Quality Initiative
Pilot Project.
- Clear
Creek Care Center in Westminster , Colorado , cuts by 50% the number
of patients experiencing moderate to severe daily pain. Clear
Creek developed a pain management committee with a clearly defined
mission: make every resident as comfortable as possible. CFMC provided
Clear Creek with pain management material and a checklist for care
that was shared with supervisors, nurses, CNAs, dietitians, and
social workers.
Virginia
nursing home decreases post-acute pain by more than 36%
The Health
Care Center at Lucy Corr Village in Chesterfield, VA implemented an
aggressive pain management program called “STOP the Pain” that
has decreased its post-acute pain measure by more than 36% since it began
working with the Virginia Health Quality Center, the state’s QIO.
The facility’s chronic care pain measure has also decreased significantly
by almost 23%, from 25.89% in November 2002 to 2.93% in March of 2004.
STOP notes were started which include Severity, Type, Onset and Place
and STOP Signs were posted throughout the facility with numeric and facial
pain scales, the drug regimen was reviewed and educational activities
on pain management were sponsored by the facility pain team. For more
info, Beth Simos, VHQC, 804-289-5320, bsimos@vhqc.org.
Green
Valley Pavilion Nursing Home in Delaware cuts the
percentage of patients reporting serious pain from 39% to 3%:
Quality Insights, the Delaware QIO, worked with the staff of Green
Valley Pavilion by providing resources in the areas of pain assessment
and pain management, such as tracking pain via flow sheets, and conducting
sharing sessions and workshops. These practices have practically eliminated
pain for long-term residents at Green Valley Pavilion. For more info,
Paula C. Savini, Director of Communications, Quality Insights of Delaware
at 302-478-3600, ext. 105 or psavini@deqio.sdps.org.
Santa Rita Care Center, an Arizona nursing home, reduces pain
for residents:
Working
with the Arizona QIO, Health Services Advisory Group (HSAG), Santa
Rita Care Center adopted a quality improvement model for sustained
change that relies on small, rapid-cycle improvement. This 115 bed,
urban, for-profit, nursing home cut the percentage of patients experiencing
chronic pain from 12% down to 2% in 2002-2003. The home’s administrator
provides support within the nursing home, attends and encourages nursing
leadership to participate in statewide learning sessions, and has assisted
in coordinating improvement activities in conjunction with the nursing
home trade association. For more info, Debra Nixon, 602-665-6168 at dnixon@azqio.sdps.org.
Hilton
Convalescent Home near Detroit cuts
chronic pain among residents:
Hilton
Convalescent Home volunteered to partner with MPRO, the Michigan QIO,
in a pain management project that raised not only the pain awareness
of Hilton staff but resulted in reduced chronic pain scores. Hilton’s
score on the Chronic Pain Measure for November 2002 was 10%. In August
2003, that same score dropped to 0%. Hilton’s “Pain Team” focused
on increasing the involvement of the nursing home staff in quality improvement
efforts and boosted staff commitment through active participation in
the creation of a project slogan that spearheaded the Miles of Smiles campaign.
For more info, Tom Leyden, 248-465-7388 or tleyden@mpro.org.
In Ohio , QIO pain management seminars pay off:
Seminars conducted by Ohio KePRO, the state QIO, led staff in homes
across the state to make changes resulting in less pain for residents.
For more info, contact Suzana Iveljic, sveljic@ohqio.sdps.org, 216-447-9604.
Some examples:
- Maria-Joseph
Living Care Center reduced percentage of short-stay residents with
pain from 45% to 1%. Maria-Joseph,
a 350-bed nursing facility in Dayton , Ohio , began a pain control
program following their medical director’s attendance at the
Ohio QIO-sponsored pain seminar. Maria-Joseph did a chart audit after
attendance that determined they were only assessing 80% of their
short stay residents for pain at time of admission. This assessment
is now at 99%. Maria-Joseph also worked with discharging hospitals
and physicians to change pain medication protocol to routine vs.
PRN both prior to hospital discharge/transfer and at time of admission
to Maria-Joseph. Progress in these areas was charted for facility
staff so that they could be recognized for successful efforts.
- Bradley
Bay improves post acute pain scores by 26% . Through attendance at training
seminars, on-site support and use of educational materials provided
by the QIO, Bradley Bay updated their pain management policy and
developed both a Pain Assessment Tool and a separate tool for the
cognitively impaired. A 126-bed facility in Bay Village , Ohio ,
Bradley Bay implemented a new protocol for appropriate medication
orders to significantly reduce the use of PRN medication and increase
resident comfort within the first 14 days of stay. Their efforts
have spread to three sister homes that have begun implementing this
new policy and its tools.
- Bellbrook
Rehab and Health Care Center reduces
the percentage of residents reporting serious pain from 17% to 1%. This
78-bed facility in Dayton , reduced the percentage of residents complaining
of serious pain from a baseline of 17% in the second quarter of 2002
to 1% in the 2 nd quarter of 2003. Bellbrook attributes this to QIO
technical assistance in the form of pain resource manuals and educational
seminars. Bellbrook instituted new pain screening policies and provided
education to their clinical staff on appropriate treatment regimes
and MDS coding, and to all staff members on the recognition of pain.
Bellbrook has also utilized their medical director and local hospice
as additional resources for ongoing pain management programs for
staff.
- Royal
Oaks Nursing and Rehab Center improves
care for pain in chronic and post acute population. This
99-bed facility in Middleburg Heights , OH , improved quality measure
scores for pain in the chronic care population from 13% to 5%, and
in the post acute population from 20% to 5%. Following attendance
at QIO pain management seminars, Royal Oak looked held facility-wide
pain awareness meetings and information-gathering sessions, and developed
of a new pain assessment policy that has spread for implementation
to its nine sister facilities.
Riverview
Healthcare Community in Coventry, Rhode Island, cuts pain by 46%
for short-stay residents; reduces pain for long-term care patients
by more than a third:
Riverview
joined with Quality Partners of Rhode Island, the local QIO, in a pain
management project that nursing services director Karen Morin says
produced “dramatic results.” “Our staff is screening
for pain more. So, they are thinking about it more and they are using
medications more effectively to break through pain,” says Morin,
who notes that RIQP helped Riverview re-evaluate and improve pain assessment
procedures in a way that involves the entire staff. These changes are
affecting not just patient outcomes, but also staff satisfaction. For
more info, Cyndi S. Forcier, 401-528-3200, cforcier@riqio.sdps.org.
Massachusetts
nursing facility reduces pain rate by 57%
Working
in consultation with MassPRO, the QIO for Massachusetts , the pain
management committee at Woodbriar of Wilmington Rehabilitation and
Skilled Nursing Center in Wilmington , MA , developed a multi-phased
intervention directed at improving pain management in long-term stay
residents. The committee reviewed current policies, revised assessment
tools, and conducted a facility-wide education program that included
working with the Medical Director to send a letter and questionnaire
on pain management to all attending physicians, and developing a series
of storyboards to inform residents, families and staff about the pain
management program. The goal was to increase awareness of the importance
of managing patients’ pain, and to demonstrate the Center’s
commitment to continuously improving this outcome measure. Data indicates
the pain rate for long stay residents has been reduced by 57%. For more
info, Sue Kelman at 781-890-0011 or skelman@maqio.sdps.org.
Lutheran
Home-Albemarle nursing facility of North
Carolina perfects pain assessment
Lutheran
Home-Albemarle, a skilled nursing facility with 76 certified beds,
has participated in a Nursing Home Quality Improvement Collaborative
with Carolinas Center for Medical Excellence, the state’s Quality Improvement
Organization. The 18-month collaborative focuses on the clinical topics
of pain and restraints. Lutheran Home-Albemarle used a phased-in approach
to quality improvement by first establishing a process rooted in continuous
quality improvement principles and then institutionalizing treatment
approaches. Since May 2003, Lutheran Home-Albemarle, has consistently
implemented processes advocated by the QIO to improve pain management,
ensuring that all residents who trigger for pain are assessed and treated.
Early in the collaborative, Lutheran Home-Albemarle scored 100% on all
of the process measures, indicating that all residents that screen for
pain are fully evaluated, care planned, and receive both medication and
non-medication interventions to treat pain. For more info, Sue Hunter,
800-682-2650 or shunter@ncqio.sdps.org.
Pain
rates fall at many Louisiana homes
A number of nursing homes showed significant gains against resident
pain after working with the state QIO, Louisiana Health Care Review (LHCR).
For more info, Cathy Lewis, 225-926-6353 or clewis@lhcr.org,. Some examples:
- Maison Hospitaliere Pain Rate Declines from 20.49% to 7.61%. Maison
Hospitaliere approached pain management from a comprehensive perspective,
by using a restorative program, social services, and treatment of associated
conditions, such as pain and anxiety. A major area of emphasis is pain
assessment for all cognitively impaired residents and any residents
who are unable to verbalize pain. In these residents, staff watch for
any changes that might signify the presence of pain and use non-sedating
analgesics to the extent possible. Inspired by their success with pain
management, the facility is now using materials supplied by LHCR for
other areas of quality improvement.
- The
Oaks Care Center Reduces Pain Rate from a high of 32 % to 7%. Working
with LHCR, staff members of The Oaks Care Center were educated
on the importance of screening and recognizing pain. Particular
emphasis for the training was given to Certified Nursing Assistants
( CNA ). Screening tools for both the cognitively intact and impaired
were put in place, and the effectiveness of each resident’s
pain management program is tracked.
- Riverview
Care Center Reduces Pain Rate from 13% to 3%. Working with LHCR, Riverview
Care Center did an in-depth education of the CNA staff to recognize
pain in residents who are cognitively impaired. The assistant director
of nursing developed the Learn to Recognize Pain Card Game for
the staff to play in order to raise awareness and recognition of
residents in pain. To play the game, one person must demonstrate
without using words one of the emotions or needs listed in the card
guidelines. Another player must attempt to guess what the first player
is attempting to convey. This game uses an ordinary set of playing
cards and is simple to implement but has been very effective in helping
Riverview reduce its pain rate.
- Claiborne
Healthcare Center Reduces Pain Rate From 9.5% to 3% and Restraint
Rate from 15% to 3%. This
facility reduced its pain rate by changing its care plan to include
pain assessments for both cognitively intact and impaired residents.
CNAs were educated on how to recognize pain in the cognitively impaired
and asked to screen residents for pain on a weekly basis. The effectiveness
of the pain regime is also tracked. They reduced the restraint rate
by leadership endorsement of the project. Leadership encouraged staff
members, who were then empowered to seek out restraint alternatives.
The staff and family were educated on the hazards of restraint use.
Preventing/Treating Pressure Ulcers
66% Reduction in pressure ulcers at Missouri nursing home
Westwood Hills Nursing Home in Poplar Bluff , MO cut the number of
pressure ulcers by 66% in just three months after working with Primaris,
the Missouri QIO. In March of 2003, Westwood Hills detected pressure
ulcers in 12 of its 132 residents, and set a goal to cut that number
in half. The staff purchased pressure-relieving mattresses and cushions,
conducted weekly skin reporting, implemented report-tracking systems,
and assigned a dedicated wound care nurse to oversee the program. By
the end of June, Westwood Hills reduced its pressure ulcer rate by two-thirds
to four residents. In addition, attending to nutrition and hydration
needs of all residents to prevent pressure ulcers, helped staff reduce
the number of residents with significant weight loss. For more info,
Deborah K. Finley, 573-817-8300 ext. 133 or dfinley@moqio.sdps.org.
Iowa home cuts pressure ulcer rates down to 1.4%
In a year-long
improvement process, the Fleur Heights Care Center in Des Moines, IA,
cut its pressure ulcer rate from 14.8% to just 1.4% with the help of
the Iowa QIO, the Iowa Foundation for Medical Care. The nursing home
developed incentive programs for the staff to adopt QIO interventions,
including using a clinically validated assessment tool that allows
nurses and other health care providers to reliably score a patient's
level of risk for developing pressure ulcers; i mplementing a quick,
reliable tool to monitor the change in pressure ulcer status over time;
adopting t urning schedules; purchasing pressure relief products such
as mattress overlays and chair cushions; i nstituting a protocol for
treatment; and giving one nurse responsibility for measuring pressure
ulcers. The success of the interventions demonstrated the importance
of data tracking as well as increasing awareness and involvement in
the process. As a result of the nursing home’s work with IFMC,
Fleurs Heights not only experienced a significant reduction in the
percentage of pressure ulcers among its residents, it also went 101
days without experiencing a new nosocomial pressure ulcer. For more
info, Deb Innis at 515-440-8224 and dinnis@iaqio.sdps.org.
California
nursing home takes ‘No New Pressure Ulcers’ challenge
An acute
unit of a California nursing home accepted the “No New
Pressure Ulcers” challenge and agreed to work with Lumetra, the
California QIO, to improve the home’s 8% incidence rate. This challenge
was especially difficult because residents in this unit were high-risk
for pressure ulcers and the nursing home unit also faced difficulties
with staff turnover. Working with Lumetra, the California QIO, the nursing
home began to use certified nursing assistant for skin checks and assigned
one nurse to provide all wound care. Addressing workplace relations,
the nursing home also focused more on staff helping each other and providing
ongoing education and direction on goals for the unit. The home used
data to show staff the outcomes of improvements in prevention strategies
and as a result this nursing home sub-unit went 85 days without any new
pressure ulcers. For more info, Danielle Simmons, 415-677-2122, dsimmons@caqio.sdps.org.
Virginia
home eliminates acquired p ressure
ulcers in its pilot unit
Woodbine
Rehabilitation and Healthcare Center in Alexandria , VA has been “waging
a war on wounds.” Woodbine kicked off its battle
plan in October 2003 with an innovative multidisciplinary wound round
process that involved weekly meetings to discuss wound progress, treatment
changes, nutritional interventions, care plans and resident education.
Woodbine also involved frontline staff in the decision making process,
increasing their willingness to adopt new procedures. For example, a “Turning
and Repositioning Compliance Report” was developed that showcased
those certified nursing assistants who properly turned and repositioned
residents, thus helping to decrease the occurrence and severity of pressure
ulcers. Woodbine reported that the number of acquired stage II-IV pressure
ulcers in its pilot unit had reached zero residents. For more: Beth Simos,
VHQC, 804-289-5320, bsimos@vhqc.org.
Jacksonville , Florida , home uses new techniques to avoid pressure
ulcers
All Saints
Catholic Nursing Home & Rehabilitation Center, worked
with FMQAI, the state QIO, to practically
eliminate the incidence of new, avoidable, facility acquired pressure
ulcers during 2004. The facility adopted a Monitoring Turn Clock procedure
by attaching a laminated turn clock to each employee’s name tag.
The staff was taught to how to use the clock and which directions people
should face when repositioned. Random checks indicated a baseline compliance
of 54%. A subsequent goal of 90% compliance rate in the turning schedule
has been met, 50% of the ulcers prior to the onset of the project have
been healed and new pressure ulcers have been prevented. For more info,
contact: David Ruscitti, 813-354-9111or druscitti@flqio.sdps.org.
Wyoming home cuts pressure ulcer rate below state, national averages
Working
during 2004 with Mountain-Pacific Quality Health Foundation, the state
QIO, the staff at the Pioneer Manor Nursing Home in Gillette , WY ,
cut incidence of high-risk residents with pressure sores to 8% from
21%. The Skin Integrity Tissue Strategy (SITS) Committee , comprised
of the director of nursing, nursing managers, dietary managers, a registered
dietician, a wound specialist nurse, a physical therapist and pharmacist,
meets on a monthly basis to review QI statistics, evaluate anyone identified
as high risk, review lab results and the outcomes of the skin & nutritional
assessments. Prevention begins before the patient develops a pressure
ulcer. If positioning is a problem, physical therapy is instituted. High
protein supplements and a multivitamin are also part of the regime. Pictures
of wounds are taken upon admission or when identified and additional
pictures are taken to document healing at intervals. Staff has standardized
dressing supplies and protocols and will begin using an Easy Wound Graph
to document wounds on a weekly basis. For more info: Peg Donahue, 406-443-4020,
or pdonahue@mtqio.sdps.org.
Assistance
on pressure ulcers boosts care in Louisiana
While national rates for reducing pressure ulcers have not fallen greatly
over the past year, there are some bright spots. The QIO in Louisiana
for example, Louisiana Health Care Review, has seen a number of outstanding
results. For more info, Cathy Lewis, 225-926-6353 or clewis@lhcr.org.
- Natchitoches
Parish Hospital Long Term Care Unit Reduces Pressure Ulcers by
50% Challenged
by the Louisiana QIO to employ innovative, simple interventions,
the facility initiated a “Got Water” campaign that ensures
residents are well hydrated. Each resident is given his own water
sports bottle. Pitchers of water are added to the table, and staff
members wear “Got Water” buttons to increase awareness.
The staff also educated the CNAs to turn residents on schedule, and
to recognize skin changes, and perform a daily skin check. When Natchitoches
featured its success at the Louisiana QIO’s Quality Forum,
this quickly became the most popular take-home idea.
- Chateau
D’Arbonne Reduces Pressure Ulcer Rate by 62%
and Restraint Rate by 40% This facility incorporated its
quality projects into its electronic medical record ( EMR ) system.
A beta-test showed that the EMR was a great tool to remind staff
to follow the designed care plan and increase awareness of skin status
and risk. Minimal documentation changes helped the facility to drastically
improve care and LHCR Quality Improvement Specialists seized the
moment by urging the vendor to include best practices for pressure
ulcer prevention in the next software enhancement.
- Pilgrim Manor Guest Care Center Reduces Pressure Ulcers
From 15% to 7% and Restraints From 20.5% to 9% O ne of
the first homes to begin work with Louisiana Health Care Review,
Inc. on quality measures, this facility used its multi-disciplinary
pressure ulcer team to teach CNAs how to recognize skin changes and
to turn residents regularly. Its next step was to address restraints
using the team approach. The multi-disciplinary team reviews all
restraints, advising alternatives, and makes suggestions as to which
restraint can be reduced or eliminated.
Chestnut Hill Convalescent Center in Passaic , New Jersey , reduces
pressure ulcers by almost 50%.
Since November
2002, Chestnut Hill has been working with Healthcare Quality Strategies, Inc., the New Jersey QIO,
to decrease the number of residents who have pressure ulcers. The nursing
home formed an interdisciplinary team to direct a facility wide effort,
examine tools being used throughout the facility and encourage the
involvement of staff at all levels. Chestnut Hill purchased special
mattresses for residents and has created a quality improvement program
that enhances aides’ commitment to the reduction of pressure
ulcers. The project is run by the aides themselves and includes the completion
of daily flow sheets that record the functioning of adaptive equipment
and the availability of skin integrity products. Chestnut Hill also stresses
weekly monitoring of plan of action activities and monitoring of residents
by staff on all shifts. Staff uses a pressure ulcer and wound tracking
tool that records information, such as areas of the body affected, origin,
stage, pressure-reducing devices, and progress. The team also has a skin
assessment check sheet that is completed by Certified Nursing Assistants
( CNA ) and reviewed by nursing staff. For more info, Cari Miller at
Healthcare Quality Strategies, Inc. at 732-238-5570, ext. 2043; e-mail: cmiller@njqio.sdps.org.
Windsor
Place in Dangerfield, Texas, reduces the prevalence rate of facility-acquired
pressure ulcers from 9% to 3.2% in
six months:
Working
with the TMF Health Quality Institute, the Texas QIO, Windsor Place implemented
new care guidelines that required staff to screen all new patients
for the risk of pressure ulcers and monitor those patients carefully
to help prevent ulcers from occurring. The facility created pressure
ulcer prevention care plans for patients at risk and increased the use
of equipment and techniques designed to reduce pressure on patients’ skin.
Windsor Place integrated a reminder system into its procedures to ensure
that weekly skin monitoring occurred for patients with ulcers or at risk
for ulcers. TMF assisted with evidence-based guidelines, interim data
reports to help staff monitor their progress and clinical materials (such
as the assessment and reminder tools). During the last six months of
the project, no new pressure ulcers were acquired in the facility. For
more info, Karen Leach, Communications Ma nager TMF Health Quality Institute
512-334-1650 or kleach@txqio.sdps.org.
Cedar Crest Sub-Acute and Rehabilitation Centre in Cranston,
Rhode Island, reduces pressure ulcer rates in its 145-bed facility
over nine months from 11.81% to 5.0%:
Working
with Quality Partners of Rhode Island, the Rhode Island QIO, Cedar
Crest developed better ways to target at-risk residents by paying closer
attention to them. Staff worked to ensure that at-risk patients had
mattresses and wheelchairs with special pressure-relieving cushions.
Staff also designed posters hung throughout the unit that used phrases
like, "Don't be a frump, get off your rump," to encouraged
residents to increase mobility. Cedar Crest is expanding its quality
improvement efforts to other units of the nursing home. For more info,
Cyndi S. Forcier, Director of Marketing & Communications, Quality
Partners of Rhode Island , 401-528-3200 or cforcier@riqio.sdps.org.
St.
Mary’s
Nursing Center in Leonardtown, Maryland, reduces facility-acquired
pressure ulcers in a test group by 69%:
Working
with the Delmarva Foundation, the Maryland QIO, St. Mary’s
tested whether effectively managing pain could reduce the incidence of
pressure ulcers. “If patients are in pain, they are not going to
get up. As they become increasingly immobile, they get pressure ulcers,” says
Monica Hayden, Director of Nursing at St. Mary’s. “We wanted
to see if quickly addressing pain reduced pressure ulcers and it did.” Delmarva
provided staff training, assessment protocols, and guidelines for revising
policies. “Before working with Delmarva, we were doing pain assessment
on admission and every three days. There was a lot of trial and error,” Hayden
says. “Delmarva had us look at ourselves. They really put our feet
to the fire to make this a priority. Reducing pressure ulcers was a direct
result of this project.” For more info, Robin Wolfgang at Delmarva,
410-822-0697 or wolfgangr@dfmc.org.
Community
Nursing Services increases the percentage of patients who show improvement
on ‘Pain Interfering with Activity’ by 10%
Community Nursing Services ( CNS ) developed an action plan that focused
on pain assessment and intervention consistency among disciplines. Their
intervention actions included: re-designing nurse's notes to match physical
therapy notes (same pain scale), in-services on pain and pain scale interpretation,
and discussions on pain at each multi-disciplinary team meeting (bi-monthly
for six months). Michelle Dunn, Director of Total Quality Management,
attributes much of their improvement success to the in-services and multi-disciplinary
discussions on pain. HealthInsight and CNS have worked together
since September 2002. CNS staff members have consistently attended HealthInsight’s Collaborative
Learning Sessions, and are using the concepts and principles they have
learned in order to enhance their quality improvement activities. For
more info, Cher Edmonds, 801-892-0155.
Reducing Use of Restraints
West Virginia NH reduces use of physical restraints by 44%
Working with the West Virginia Medical Institute (WVMI), the state
QIO, a 105-bed skilled nursing home reduced by almost half the percentage
of residents who were physically restrained. Worthington Manor in Parkersburg
, WV , attended educational seminars sponsored by WVMI, which addressed
how the use of physical restraints can lead to problems such as pressure
ulcers, emotional distress and loss of ability to walk. Worthington Manor
subsequently developed a restraint committee to discuss the use of physical
restraints and to check newly admitted residents to make sure the least
restrictive devices, such as alarms, are being used. As a result, Worthington
Manor is exploring alternative methods to keep patients safe. Since December
2003, Worthington Manor has reduced the percent of residents who were
physically restrained by 44 % and is 90% free of restraints. For more
info, Marc McCombs, 304.346.9864, ext. 2267 or mmccombs@wvmi.org.
Louisiana
homes show strong results reducing restraints
Louisiana Health Care Review, the state QIO reports its technical assistance
projects have helped a number of homes in the state take major steps
towards ensuring resident safety without the use of restraints. For more
information: Cathy Lewis, 225-926-6353 or clewis@lhcr.org . Some examples:
- Village Health Care at the Glen Reduces Restraint Rate From
18% to 8%. Village Health Care at the Glen now reviews
all restraints from a team approach. A restraint is only approved
after all restraint alternatives are considered, or found ineffective.
- N
orthshore Living Center Reduces Restraints by 72%. This
facility has embraced fall prevention to reduce restraints. The
facility utilized the Falling Star program to alert staff of “at
risk” residents and the Fall Buster
program to key in on “high risk” residents who experienced
a recent fall. In addition, Northshore used fall prevention contests
that challenged shifts to compete against each other for the lowest
fall rates. Falls are fully investigated to identify the cause, as
well as interventions likely to prevent recurrence. As a result of
staff education, staff members are very attuned to early identification
and intervention when changes in mental status occur.
- Lafon Nursing Facility of the Holy Family Reduces Restraints
from 56.57% to 18.75%. Lafon Nursing Facility set out to
reduce physical restraints pursuing a multi-faceted plan. Two of
the simpler tasks were scrutiny of MDS restraint coding and the education
of families. The plan also made use of resident conditioning through
activity programs, physical and occupational therapy, monthly reviews
of restraint use and identification of ways to reduce or eliminate
restraints. Lafon added a weekly fall review, with a fall-screening
process that includes having occupational therapy assess for gait
disturbances. The use of low beds and mattresses on the floor were
also instituted.
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