Quality Improvement for Pressure Ulcer Care in the Nursing Home Setting: The Northeast Pressure Ulcer Project

Department of Community Health, Brown University School of Medicine, Providence, Rhode Island, USA.
Journal of the American Medical Directors Association (Impact Factor: 4.94). 11/2003; 4(6):291-301. DOI: 10.1097/01.JAM.0000094064.06058.74
Source: PubMed


The objectives of this study were to evaluate the impact of a collaborative model of quality improvement in nursing homes on processes of care for the prevention and treatment of pressure ulcers.
The study design was experimental.
We studied 29 nursing homes in New Jersey, Pennsylvania, and Rhode Island.
Participants consisted of pressure ulcer quality improvement teams in 29 nursing homes.
Quality improvement teams attended a series of workshops to review clinical guidelines and quality improvement principles and to share best practices, and worked one-on-one with mentors to implement quality improvement techniques and to collect data independently.
We calculated process measures based on the Agency for Healthcare Research and Quality (AHRQ) guidelines. Process measures addressed each facility's processes of care for the prevention and treatment of pressure ulcers at baseline and after 12 months of intervention. Prevention measures focused on recent admissions and high-risk residents; treatment measures focused on patients newly diagnosed with pressure ulcers and all patients with pressure ulcers.
Overall, 6 of 8 prevention process measures improved significantly, with percent difference between baseline and follow up ranging from 11.6% to 24.5%. Three of 4 treatment process measures improved significantly, with 5.0%, 8.9%, and 25.9% difference between baseline and follow up. For each process measure, between 5 and 12 facilities demonstrated significant improvement between baseline and follow up, and only 2 or fewer declined for each process measure.
Improvement in processes of care after the use of a structured collaborative quality improvement approach is possible in the nursing home setting.

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Available from: Rosa R Baier, Sep 28, 2015
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    • "A QIC program team includes experts in both the health condition and methods of quality improvement. According to a recent systematic review, QICs have shown moderate effectiveness in terms of patient outcomes [10] and several studies suggest effectiveness of QICs for PUs in particular [13,14]. Despite the popularity of QIC's, the cost-effectiveness of QICs is rarely considered [10], in fact only a study by Huang addressed this aspect [15]. "
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    ABSTRACT: A quality improvement collaborative (QIC) in the Dutch long-term care sector (nursing homes, assisted living facilities, home care) used evidence-based prevention methods to reduce the incidence and prevalence of pressure ulcers (PUs). The collaborative consisted of a core team of experts and 25 organizational project teams. Our aim was to determine its cost-effectiveness from a healthcare perspective. We used a non-controlled pre-post design to establish the change in incidence and prevalence of PUs in 88 patients over the course of a year. Staff indexed data and prevention methods (activities, materials). Quality of life (Qol) weights were assigned to the PU states. We assessed the costs of activities and materials in the project. A Markov model was built based on effectiveness and cost data, complemented with a probabilistic sensitivity analysis. To illustrate the results of longer term, three scenarios were created in which change in incidence and prevalence measures were (1) not sustained, (2) partially sustained, and (3) completely sustained. Incidence of PUs decreased from 15% to 4.5% for the 88 patients. Prevalence decreased from 38.6% to 22.7%. Average Quality of Life (Qol) of patients increased by 0.02 Quality Adjusted Life Years (QALY)s in two years; healthcare costs increased by euro2000 per patient; the Incremental Cost-effectiveness Ratio (ICER) was between 78,500 and 131,000 depending on whether the changes in incidence and prevalence of PU were sustained. During the QIC PU incidence and prevalence significantly declined. When compared to standard PU care, the QIC was probably more costly and more effective in the short run, but its long-term cost-effectiveness is questionable. The QIC can only be cost-effective if the changes in incidence and prevalence of PU are sustained.
    Cost Effectiveness and Resource Allocation 06/2010; 8(1):11. DOI:10.1186/1478-7547-8-11 · 0.87 Impact Factor
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    • "Frequently, the healthcare workers did not receive a formal introduction to the protocol. Process oriented studies about quality of care for nursing home residents revealed that measures for pressure ulcer prevention were rarely concordant with evidence-based guidelines and that there were numerous opportunities to improve care related to pressure ulcer prevention (Baier et al. 2003, Bates-Jensen et al. 2003, Saliba et al. 2003, Wipke-Tevis et al. 2004). In home health care, similar suboptimal pressure ulcer prevention practices were reported. "
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    ABSTRACT: 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. 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. 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. 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. 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.
    Journal of Clinical Nursing 04/2008; 17(5):627-36. DOI:10.1111/j.1365-2702.2007.02109.x · 1.26 Impact Factor
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    • "They found no significant improvement, which resulted in their efforts to strengthen the intervention and to identify predictors of successful implementation (Rantz et al. 2001). While several studies have documented improvement following the introduction of specific QI interventions, these studies have generally used highly selective facilities (Baier et al. 2003, 2004). Given the difficulty of implementing and sustaining improvement, some have concluded that the success of the quality improvement movement in nursing homes is predicated on leadership that is ill prepared to implement these innovations (Schnelle, Ouslander, and Cruise 1997). "
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    ABSTRACT: 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.
    Milbank Quarterly 02/2005; 83(3):333-64. DOI:10.1111/j.1468-0009.2005.00405.x · 3.38 Impact Factor
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