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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    • "These are typically self-study modules or classroom sessions designed to deliver content to individual staff members about geriatric syndromes such as falls, pressure ulcers, and behavior management in dementia (Jones et al., 2004; Kuske et al., 2007; Stein et al., 2001). This individual staff training is intended for use in conjunction with NH-level Quality Improvement processes (Baier et al., 2003). "
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    ABSTRACT: Purpose of the study: The CONNECT intervention is designed to improve staff connections, communication, and use of multiple perspectives for problem solving. This analysis compared staff descriptions of the learning climate, use of social constructivist learning processes, and outcomes in nursing facilities receiving CONNECT with facilities receiving a falls education program alone. Design and methods: Qualitative evaluation of a randomized controlled trial was done using a focus group design. Facilities (n = 8) were randomized to a falls education program alone (control) or CONNECT followed by FALLS (intervention). A total of 77 staff participated in 16 focus groups using a structured interview protocol. Transcripts were analyzed using framework analysis, and summaries for each domain were compared between intervention and control facilities. Results: Notable differences in descriptions of the learning climate included greater learner empowerment, appreciation of the role of all disciplines, and seeking diverse viewpoints in the intervention group. Greater use of social constructivist learning processes was evidenced by the intervention group as they described greater identification of communication weaknesses, improvement in communication frequency and quality, and use of sense-making by seeking out multiple perspectives to better understand and act on information. Intervention group participants reported outcomes including more creative fall prevention plans, a more respectful work environment, and improved relationships with coworkers. No substantial difference between groups was identified in safety culture, shared responsibility, and self-reported knowledge about falls. Implications: CONNECT appears to enhance the use of social constructivist learning processes among nursing home staff. The impact of CONNECT on clinical outcomes requires further study.
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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.
    Full-text · Article · Jun 2010 · Cost Effectiveness and Resource Allocation
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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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