Pressure ulcer prevention in long-term-care facilities: a pilot study implementing standardized nurse aide documentation and feedback reports

Abstract

Objective: To design and facilitate implementation of practice-based evidence changes associated with decreases in pressure ulcer (PrU) development in long-term-care (LTC) facilities and promote these practices as part of routine care.

Design: Pre/post observational study.

Settings and participants: Frail older adult residents in 11 US LTC facilities.

Intervention: Project facilitators assisted frontline multidisciplinary teams (certified nurse aides [CNAs], nurses, and dietitians/dietary aides) to develop streamlined standardized CNA documentation and weekly reports to identify high-risk residents and to integrate clinical reports into day-to-day practice and clinical decision making. The program was called "Real-Time Optimal Care Plans for Nursing Home QI" (Real-Time).

Main outcome measures: Prevalence of PrUs using Centers for Medicare & Medicaid Services (CMS) quality measures (QMs), number of in-house-acquired PrUs, and number and completeness of CNA documentation forms.

Main results: Seven study LTC facilities that reported data to CMS experienced a combined 33% (SD, 36.1%) reduction in the CMS high-risk PrU QM in 18 months and reduction in newly occurring PrUs (number of ulcers in the fourth quarter of 2003: range, 2-19; and in the third quarter of 2005: range, 1-6). Five of these LTC facilities that fully implemented Real-Time experienced a combined 48.1% (SD, 23.4%) reduction in the CMS high-risk PrU QM. Ten facilities reduced by an average of 2 to 5 their number of CNA documentation forms; CNA weekly documentation completeness reached a consistent level of 90% to 95%, and 8 facilities integrated the use of 2 to 4 weekly project reports in routine clinical decision making.

Conclusions: Quality improvement efforts that provide access to focused and timely clinical information, facilitate change, and promote staff working together in multidisciplinary teams impacted clinical outcomes. Prevention of PrUs showed a trend of improvement in facilities that fully integrated tools to identify high-risk residents into day-to-day practice. CNA documentation facilitated better information for clinical decision making. More than 70 additional LTC facilities across the United States are implementing this QI program.