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Table 2, Chapter 21. Multi-component pressure ulcer prevention initiatives conducted in long-term care settings in the United StatesAuthor/YearDescriptionof PSPStudy DesignTheory or Logic ModelDescription of OrganizationContextsImplementation DetailsOutcomes: BenefitsInfluence of Contexts on OutcomesHorn et al. 2010 ADDIN REFMGR.CITE <Refman><Cite><Author>Horn</Author><Year>2010</Year><RecNum>571503</RecNum><IDText>Pressure ulcer prevention in long-term-care facilities: a pilot study implementing standardized nurse aide documentation and feedback reports</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>571503</Ref_ID><Title_Primary>Pressure ulcer prevention in long-term-care facilities: a pilot study implementing standardized nurse aide documentation and feedback reports</Title_Primary><Authors_Primary>Horn,S.D.</Authors_Primary><Authors_Primary>Sharkey,S.S.</Authors_Primary><Authors_Primary>Hudak,S.</Authors_Primary><Authors_Primary>Gassaway,J.</Authors_Primary><Authors_Primary>James,R.</Authors_Primary><Authors_Primary>Spector,W.</Authors_Primary><Date_Primary>2010/3</Date_Primary><Keywords>Aged,80 and over</Keywords><Keywords>Clinical Protocols</Keywords><Keywords>st [Standards]</Keywords><Keywords>Female</Keywords><Keywords>*Frail Elderly</Keywords><Keywords>Humans</Keywords><Keywords>Interdisciplinary Communication</Keywords><Keywords>*Long-Term Care</Keywords><Keywords>og [Organization &amp; Administration]</Keywords><Keywords>Male</Keywords><Keywords>*Medical Order Entry Systems</Keywords><Keywords>st [Standards]</Keywords><Keywords>*Nurses&apos; Aides</Keywords><Keywords>og [Organization &amp; Administ</Keywords><Reprint>Not in File</Reprint><Start_Page>120</Start_Page><End_Page>131</End_Page><Periodical>Adv Skin Wound Care</Periodical><Volume>23</Volume><Issue>3</Issue><User_Def_2>EMBASE (OVID) 8/18/2011, EMBASE (OVID) 8/18/2011, MEDLINE - Ovid 8/17/2011, MEDLINE - Ovid 7/12/2011, MEDLINE - Ovid 6/27/2011, MEDLINE - Ovid 6/24/2011, MEDLINE - Ovid 6/14/2011, MEDLINE - Ovid 6/13/2011</User_Def_2><User_Def_3>Given to Nancy Sullivan on 6/17/2011 for EPC0015</User_Def_3><ISSN_ISBN>20177165</ISSN_ISBN><Availability>NGC0010 , Sharepoint , EPC0015 , NGC0001 , SRPMEPC15_060911 , HD_EPC15open , SRMLEPC15_0623-2411 , SRMLEPC15_081611 , SREMEPC15_081611 , EPC15_Final_11-28-11</Availability><Address>International Severity Information Systems, Inc, Institute for Clinical Outcomes Research, Salt Lake City, Utah, USA</Address><ZZ_JournalStdAbbrev><f name="System">Adv Skin Wound Care</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>17Real-Time Program (renamed OnTime Quality Improvement for Long Term Care [On-Time])Target safety problem: PUKey elements: CNA assist in redesigning documentation to include core data elements to help identify high-risk patients; facilitators provide feedback on weekly clinical decision-making reports; staff educated on QI methods and smooth integration of these CNA documentation and clinical reports into day-to-day flowTime series Based on best practices from AHRQ and AMDA guidelines, and findings from the National Pressure Ulcer Long-term Care Study (NPULS)11 not-for-profit facilities in 7 statesBed size:44–432 beds1–3 highest-risk units per facility participatedExternal: AHRQ fundedOrganizational Characteristics: NSTeamwork, Leadership,Culture: NSImplementation tools: CNA documentation processes and timely reports to identify patients at riskA project leader (e.g., DON) and ongoing team identified Educate staff on QI methods and use of documentation forms and reportsLength: 9 monthsProcess:Facilitators work with a multidisciplinary team from each facility. Redesigned CNA documentation incorporating “core data elements” including nutrition and incontinence variables. CNA’s coached to improve documentation. Sites fax scannable forms to project office. Clinical reports returned within 24?hours and displayed. Feedback includes inconsistencies and completeness of CNA documentation per unit/unit over time/shift. After reviewing with CNAs, need for additional education noted.Conference calls (bi-weekly), all-facility meetings (every 6 months) and on-site meetings were scheduled with facilitators, project leaders and frontline staff. Successes:CNA’s widely accept revised forms and increase productivity.Documentation completeness rates increase from80%–90% to mid90%. Barriers: EMR system used by 1 facility could only export data elements and create 1 report Issues raised with preparing the CNA documentation forms needing the resident’s study ID number and faxing forms for report generationStaff turnover especially by DON slowed project momentum.Addressing Barriers:Add new CNA documentation process into orientation programs Phase in use of documentation.Develop a strong multidisciplinary team to lead improvement efforts and not rely on one project leader.Sustainability:“HIT needed to capture CNA documentation and generate reports.”“Managing the manual data collection, faxing forms to the project office and creating clinical reports for distribution back to the facilities on a weekly basis could not be maintained over the long term for many facilities.”Program expanded throughout the U.S.CMS HRPrU QM prior to implementation(k = 7): 13.0%CMS HRPrU QM 12 months after implementation(k = 7): 8.7%HRPrU QM % change(5 facilities using≥2 reports)-25% to -82.4%High Risk PrU QM% change(2 facilities using 1 report)+8.3%, +14.3%Average number of in-house acquired PU (all stages) per facility pre-implementationvs post-implementation:12.1 to 4.6(62% reduction) Average number of CNA documentation forms reduced by 53.2%.Facility “B” which had the highest reduction in PU(-82.4%) was the only facility that:had 100% participation of residents(n = 75) Facility “B” was 1 of 3 facilities who incorporated all 4 clinical reports for care planning.Two facilities with the lowest reduction in PUs did not involve a multidisciplinary team.Rantz et al. 2010 ADDIN REFMGR.CITE <Refman><Cite><Author>Rantz</Author><Year>2010</Year><RecNum>577262</RecNum><IDText>Cost, staffing and quality impact of bedside electronic medical record (EMR) in nursing homes</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>577262</Ref_ID><Title_Primary>Cost, staffing and quality impact of bedside electronic medical record (EMR) in nursing homes</Title_Primary><Authors_Primary>Rantz,M.J.</Authors_Primary><Authors_Primary>Hicks,L.</Authors_Primary><Authors_Primary>Petroski,G.F.</Authors_Primary><Authors_Primary>Madsen,R.W.</Authors_Primary><Authors_Primary>Alexander,G.</Authors_Primary><Authors_Primary>Galambos,C.</Authors_Primary><Authors_Primary>Conn,V.</Authors_Primary><Authors_Primary>Scott-Cawiezell,J.</Authors_Primary><Authors_Primary>Zwygart-Stauffacher,M.</Authors_Primary><Authors_Primary>Greenwald,L.</Authors_Primary><Date_Primary>2010/9</Date_Primary><Keywords>Advanced Practice Nursing</Keywords><Keywords>og [Organization &amp; Administration]</Keywords><Keywords>Costs and Cost Analysis</Keywords><Keywords>*Electronic Health Records</Keywords><Keywords>ec [Economics]</Keywords><Keywords>Humans</Keywords><Keywords>Missouri</Keywords><Keywords>*Nursing Homes</Keywords><Keywords>*Personnel Staffing and Scheduling</Keywords><Keywords>Point-of-Care Systems</Keywords><Keywords>Quality Indicators,Health Care</Keywords><Keywords>*Quality</Keywords><Reprint>Not in File</Reprint><Start_Page>485</Start_Page><End_Page>493</End_Page><Periodical>J Am Med Dir Assoc</Periodical><Volume>11</Volume><Issue>7</Issue><User_Def_2>EMBASE (OVID) 8/18/2011, EMBASE (OVID) 8/18/2011, MEDLINE - Ovid 8/17/2011</User_Def_2><User_Def_3>Given to Nancy Sullivan on 8/23/2011 for EPC0015</User_Def_3><ISSN_ISBN>20816336</ISSN_ISBN><Availability>Sharepoint , EPC0015 , SRMLEPC15_081611new , SRMLEPC15_081611 , SREMEPC15_081611 , EPC15_Final_11-28-11</Availability><Address>Sinclair School of Nursing and Family and Community Medicine, School of Medicine, University of Missouri, Columbia, MO, USA. rantzm@missouri.edu</Address><ZZ_JournalStdAbbrev><f name="System">J Am Med Dir Assoc</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>18Bedside EMR (OEMR, Irvine, CA) and statewide on-site clinical consultation services(QIPMO – Quality Improvement Program for Missouri)Target safety problem: ComprehensiveKey elements:Mandatory OEMR training, QIPMO nurses RCT 4-group comparisonGroup 1:EMR plus consultGroup 2: EMRGroup 3:ConsultGroup 4: ControlNS18 facilities in 3 U.S. statesGroup 1: 4 facilitiesBed size range,98–240,total 668Group 2:4 facilitiesBed size range, 105–218, total 635Group 3:5 facilitiesBed size range,90–123,total 543Group 4:5 facilitiesBed size range, 120–310,total 890Group 1, 3, 4 from MissouriGroup 2: Other StatesExternal: CMS funds OEMR hardware, software and ongoing tech supportOrganizational Characteristics:Mix of for-profit,not-for-profit, and governmental facilitiesTeamwork, Leadership, Culture:NSImplementation tools:Project coordinator assigned at intervention facilityQIPMO nurses Length: 2 yearsProcess:Project coordinator works with OEMR staffStaff works with QIPMO nurses at least monthlyQIPMO nurses encourage staff to focus on clinical care and improving care systems to be enabled by OEMRSuccesses:Group 1, 2 and 3 showed improvements at12 months;Group 1 and 2 sustained at 24?months Barriers: NSAddressing Barriers: NSSustainability:Improvement sustained during Year 2 for Group 1 and 2Relative improvement in high risk pressure sores (negative scores indicate improvement)12 monthsGroup 1: -53%Group 2: -12%Group 3: -5%Group 4: +435%24 months Group 1: -3%Group 2: -8%Group 3: +59%Group 4: +105%“Total costs for the 3-year evaluation for the groups of facilities implementing technology increased $15.11 (12.5%) for Group 1 and $16.89 (9.6%) for Group 2, while those for the comparison groups did not.”“Cost increases were most likely attributable to the cost of technology, maintaining and supporting the technology, and on-going staff training to use the EMR and not increase direct care staffing or turnover.” Milne et al. 2009 ADDIN REFMGR.CITE <Refman><Cite><Author>Milne</Author><Year>2009</Year><RecNum>572565</RecNum><IDText>Reducing pressure ulcer prevalence rates in the long-term acute care setting</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>572565</Ref_ID><Title_Primary>Reducing pressure ulcer prevalence rates in the long-term acute care setting</Title_Primary><Authors_Primary>Milne,C.T.</Authors_Primary><Authors_Primary>Trigilia,D.</Authors_Primary><Authors_Primary>Houle,T.L.</Authors_Primary><Authors_Primary>Delong,S.</Authors_Primary><Authors_Primary>Rosenblum,D.</Authors_Primary><Date_Primary>2009/4</Date_Primary><Keywords>Connecticut</Keywords><Keywords>ep [Epidemiology]</Keywords><Keywords>Evidence-Based Practice</Keywords><Keywords>Humans</Keywords><Keywords>*Long-Term Care</Keywords><Keywords>og [Organization &amp; Administration]</Keywords><Keywords>Needs Assessment</Keywords><Keywords>og [Organization &amp; Administration]</Keywords><Keywords>Nurse Clinicians</Keywords><Keywords>og [Organization &amp; Administration]</Keywords><Keywords>Nursing Evaluation Research</Keywords><Keywords>*Outcome an</Keywords><Reprint>Not in File</Reprint><Start_Page>50</Start_Page><End_Page>59</End_Page><Periodical>Ostomy Wound Manage</Periodical><Volume>55</Volume><Issue>4</Issue><User_Def_2>MEDLINE - Ovid 8/17/2011, MEDLINE - Ovid 8/17/2011, MEDLINE - Ovid 6/27/2011</User_Def_2><User_Def_3>Given to Nancy Sullivan on 8/23/2011 for EPC0015</User_Def_3><ISSN_ISBN>19387096</ISSN_ISBN><Availability>NGC0010 , Sharepoint , EPC0015 , NGC0001 , SRPMEPC15_081611 , SRPMEPC15_081611new , SRMLEPC15_081611 , EPC15_Final_11-28-11</Availability><Address>Connecticut Clinical Nursing Associates, LLC, Bristol, Connecticut, USA. ccna2@</Address><ZZ_JournalStdAbbrev><f name="System">Ostomy Wound Manage</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>19LTACH care process improvementTarget safety problem: PUKey elements:Nursing association consults; team training; improve assessment and documentation methods; EMR revised; formal and informal staff education; wound care product reviews Time seriesFailure mode and effects analysis*Long-term acute care facility in CTBed size, 108External: NSOrganizational Characteristics:Above average PU prevalenceTeamwork, Leadership, Culture:Faulty EMRInconsistent use of EMR by cliniciansDeficient risk assessment documentationImplementation tools:Training by nursing associationAPN appointed inhouse leaderAPN and nursing supervisor become WCCTeam clinicians trained in prevalence data collectionEMR revised; PUSH tool added Staff educated via formal clinical rounds, interactive sessions and one-on-one bedside sessionsImmediate feedback given on trainingLength: 13 months facility wideProcess:Roles for new skin team members definedTeam meets weekly to review “failure modes” and develop new care processesRevamping of policies and procedures after review of CPGs Wound care product reviewsSuccesses:PU reduced to <3% on two units due to increased monitoring of modified nasal cannula (pulmonary unit) and increased attentiveness to heel offloading, support surfaces and proper positioning (SCI/trauma unit); of the 396 charts reviewed, <1% had missing data; staging and wound etiology were consistently determined by wound team in greater than 90% of cases (based on a review of 45 patient charts)Barriers:Rates climbed once strict monitoring was leveled offAddressing Barriers:Increase in unit presence, chart monitoring, feedback to staff, and biweekly prevalence rounds Sustainability:CWCN certification of 2 team members provide in-house expertise Monthly review of documentation and PU prevention interventionsEarly intervention Mean facility-acquired PU prevalence:Pre: 41%Post: 4.2%Pulmonary-focused unit:Pre: 25%Post: <3%SCI/trauma unit:Pre: 33.8%Post: 2.9%Data on PU prevention implementation in a LTACH is spare. Two LTACH units however were able to reduce PUs to <3% due to “increased diligence” by the team. The authors noted an “increased collaboration among disciplines with regard to wound prevention and treatment as well as a tendency for early intervention when wounds are newly discovered.” Tippet A. 2009 ADDIN REFMGR.CITE <Refman><Cite><Author>Tippet</Author><Year>2009</Year><RecNum>572671</RecNum><IDText>Reducing the incidence of pressure ulcers in nursing home residents: a prospective 6-year evaluation</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>572671</Ref_ID><Title_Primary>Reducing the incidence of pressure ulcers in nursing home residents: a prospective 6-year evaluation</Title_Primary><Authors_Primary>Tippet,A.W.</Authors_Primary><Date_Primary>2009/11/1</Date_Primary><Keywords>Humans</Keywords><Keywords>Incidence</Keywords><Keywords>*Inpatients</Keywords><Keywords>*Nursing Homes</Keywords><Keywords>*Pressure Ulcer</Keywords><Keywords>ep [Epidemiology]</Keywords><Keywords>Prospective Studies</Keywords><Keywords>United States</Keywords><Keywords>ep [Epidemiology]</Keywords><Reprint>Not in File</Reprint><Start_Page>52</Start_Page><End_Page>58</End_Page><Periodical>Ostomy Wound Manage</Periodical><Volume>55</Volume><Issue>11</Issue><User_Def_2>MEDLINE - Ovid 8/17/2011, MEDLINE - Ovid 6/28/2011</User_Def_2><User_Def_3>Given to Nancy Sullivan on 8/23/2011 for EPC0015</User_Def_3><ISSN_ISBN>19934464</ISSN_ISBN><Availability>NGC0010 , Sharepoint , EPC0015 , NGC0001 , SRMLEPC15_081611new , SRMLEPC15_081611 , EPC15_Final_11-28-11</Availability><Address>Advanced Wound Team, Cincinnati, Ohio 45242, USA. tippettaw@</Address><ZZ_JournalStdAbbrev><f name="System">Ostomy Wound Manage</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>20Physician consultant leads deficient nursing home to zero facility-acquired PUs Target safety problem: PUKey elements:Physician wound consultant, multidisciplinary team, education, weekly informal feedback, wound care protocols based on AHRQ CPG, wound coordinator sustains programTime seriesBased on AHRQ CPGMidwest skilled facilityBed size: 151External: G-level citation (actual harm deficiency) and state survey deficienciesOrganizational Characteristics: NSTeamwork, Leadership, Culture: NSImplementation tools:Physician consultantMulti-disciplinary team Braden Scale, AHRQ CPG Incentive programsInformal feedbackSimplified wound care formularyEquipment evaluation (Delphi process used to evaluate products)Length: 6 yearsProcess:Physician consultant educates staff and conducts yearly follow-up training (all mandatory)Team forms goals and meets weeklySelect members conduct wound roundsFollow-up training through in services, and yearly follow-up Nursing supervisors conduct one-on-one with staff and weekly informal feedbackPreventive care plans created Protocols discussed in classes, become part of routine shift reporting and charting All nursing staff made accountable for care and reportingSuccesses:Goal of zero facility acquired ulcers reached after 6?monthsFacility citation free“Accolades from surveyors for wound program”Judged competitions between floors promote teamwork and buy-inBarriers: NSAddressing Barriers: NSSustainability:Wound care coordinator position established to supervise, train, provide clinical support and track wounds.Permanent decline after 6 months through study endAverage pre-initiative incidence: 5.19%Average post-initiative incidence: 0.73% (p<0.0001)4 year post-initiative incidence: 0.06%(p<0.0001)Estimated cost savings per PU/per month:$1,617Monthly savings: $10,187Yearly savings:>$122,000Rosen et al. 2006 ADDIN REFMGR.CITE <Refman><Cite><Author>Rosen</Author><Year>2006</Year><RecNum>446128</RecNum><IDText>Ability, incentives, and management feedback: organizational change to reduce pressure ulcers in a nursing home</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>446128</Ref_ID><Title_Primary>Ability, incentives, and management feedback: organizational change to reduce pressure ulcers in a nursing home</Title_Primary><Authors_Primary>Rosen,J.</Authors_Primary><Authors_Primary>Mittal,V.</Authors_Primary><Authors_Primary>Degenholtz,H.</Authors_Primary><Authors_Primary>Castle,N.</Authors_Primary><Authors_Primary>Mulsant,B.H.</Authors_Primary><Authors_Primary>Hulland,S.</Authors_Primary><Authors_Primary>Nace,D.</Authors_Primary><Authors_Primary>Rubin,F.</Authors_Primary><Date_Primary>2006/3</Date_Primary><Keywords>Aged</Keywords><Keywords>Aptitude</Keywords><Keywords>Attitude of Health Personnel</Keywords><Keywords>Clinical Competence</Keywords><Keywords>Employee Discipline</Keywords><Keywords>Feedback,Psychological</Keywords><Keywords>*Health Personnel</Keywords><Keywords>education</Keywords><Keywords>organization &amp; administration</Keywords><Keywords>psychology</Keywords><Keywords>Humans</Keywords><Keywords>Incidence</Keywords><Keywords>Inservice Training</Keywords><Keywords>*organization &amp; administration</Keywords><Keywords>Longitudinal</Keywords><Reprint>Not in File</Reprint><Start_Page>141</Start_Page><End_Page>146</End_Page><Periodical>J Am Med Dir Assoc</Periodical><Volume>7</Volume><Issue>3</Issue><User_Def_2>EMBASE (OVID) 8/18/2011, EMBASE (OVID) 8/18/2011, MEDLINE - Ovid 6/27/2011, MEDLINE - Ovid 6/14/2011, MEDLINE - Ovid 6/13/2011, EMBASE (OVID) 9/8/2008, MEDLINE 6/29/2006</User_Def_2><User_Def_3>Given to Nancy Sullivan on 6/16/2011 for EPC0015 ; Given to TrialStat on 10/20/2008 for PPC0002</User_Def_3><ISSN_ISBN>16503306</ISSN_ISBN><Availability>Sharepoint , RFP0051 , SRMLRFP0051_062906 , TrialStat , PPC0002 , PPC2_TSupload0908 , SREMPPC2_090808 , PPC2_EE , EPC0015 , SRPMEPC15_060911 , HD_EPC15open , SRMLEPC15_0623-2411 , SREMEPC15_081611 , EPC15_Final_11-28-11</Availability><Address>Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15241, USA. rosenji@upmc.edu</Address><ZZ_JournalStdAbbrev><f name="System">J Am Med Dir Assoc</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>21Ability, Incentives, and Management feedback (AIM system)Target safety problem: PUKey elements:Staff ability enhancement (skin care training, use of penlights and TAP card), realtime management feedback, financial incentivesLongitudinal time series study; four 12-week periods (baseline assessment, intervention, and two post-intervention periods)NSNot-for-profit nursing home in U.S.Bed size, 136External: AHRQ fundedOrganizational Characteristics:Received multiple Department of Health citations due to persistently high PU ratesTeamwork, Leadership, Culture:Lack of management to oversee earlier processesImplementation tools: Research team contacts administrators responsible for overseeing implementation. Mandatory “skin?care” training (a 40minute computer-based, interactive-video education program).Penlights Caregivers wear plastic TAP (turn and position card) to remind all hospital personnel the direction residents should be facing every 2 hours. Administrators receive a weekly report of staff that had completed training. A graphic “thermometer” of PU incidence was also updated weekly and displayed in the staff lounge. Each staff member received $75 if?the PU incidence was below target goal (incidence <3%) set by administration. Staff reprimanded for non-completion. Staff terminated for not completing training during extension period. Length: 48 weeksProcess:One skin care nurse assessed patients upon admission or notification by staff of any skin changes.During the post-intervention periods, no weekly reports were provided to the administrators, no established targets or goals were established, and there were no financial incentives offered to staff. Only 3 of 29 new hires completed training.Sustainability:The intervention was not sustained over the two post-intervention periods however Rosen et al. indicated that a highly motivated administrator could have maintained the 3 program components. Significant reduction in emergence of stage 1–4 PUs Pre-intervention: 28.3%Intervention:9.3% (z[I] = 2.64,p<0.001)Total ulcersStage 1 and beyondPre-intervention(n = 134): 38% (28.3)Intervention(n = 107): 10% (9.3)Post-Intervention I:19% (17.7)Post-Intervention II:19% (17.7)Total ulcersStage 2 and beyondPre-intervention:31% (23.1)Intervention: 10% (9.3)Post-Intervention I:15% (14.0)Post-Intervention II:17% (15.9)With a mean cost of $2700 of treating a single stage II PU, [26] reducing the incidence of these ulcers by approximately 15 over 12 weeks yields a potential savings of more than $40,000 while distributing less than $10,000 as incentives. This does not take into consideration the added savings in fewer personal injury lawsuits. The primary management feedback tool was adherence to the mandated training (not emergence of a new PU). Additional real-time feedback was provided to staff in the form of a visual “thermometer” of PU occurrences each week. All a nonfinancial incentive, it served as a supplementary motivating factor as the incidence of PUs was visually perceived as declining. Abel et al. 2005 ADDIN REFMGR.CITE <Refman><Cite><Author>Abel</Author><Year>2005</Year><RecNum>496894</RecNum><IDText>Quality improvement in nursing homes in Texas: results from a pressure ulcer prevention project</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>496894</Ref_ID><Title_Primary>Quality improvement in nursing homes in Texas: results from a pressure ulcer prevention project</Title_Primary><Authors_Primary>Abel,R.L.</Authors_Primary><Authors_Primary>Warren,K.</Authors_Primary><Authors_Primary>Bean,G.</Authors_Primary><Authors_Primary>Gabbard,B.</Authors_Primary><Authors_Primary>Lyder,C.H.</Authors_Primary><Authors_Primary>Bing,M.</Authors_Primary><Authors_Primary>McCauley,C.</Authors_Primary><Date_Primary>2005/5</Date_Primary><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Cross-Sectional Studies</Keywords><Keywords>Female</Keywords><Keywords>Follow-Up Studies</Keywords><Keywords>Health Care Surveys</Keywords><Keywords>*Homes for the Aged</Keywords><Keywords>st [Standards]</Keywords><Keywords>Homes for the Aged</Keywords><Keywords>td [Trends]</Keywords><Keywords>Humans</Keywords><Keywords>Incidence</Keywords><Keywords>Male</Keywords><Keywords>*Nursing Homes</Keywords><Keywords>st [Standards]</Keywords><Keywords>Nursing Homes</Keywords><Keywords>td [Trends]</Keywords><Keywords>*Pressure Ulcer</Keywords><Keywords>ep</Keywords><Reprint>Not in File</Reprint><Start_Page>181</Start_Page><End_Page>188</End_Page><Periodical>J Am Med Dir Assoc</Periodical><Volume>6</Volume><Issue>3</Issue><User_Def_2>EMBASE (OVID) 8/18/2011, EMBASE (OVID) 8/18/2011, MEDLINE - Ovid 6/27/2011, MEDLINE - Ovid 9/8/2008</User_Def_2><User_Def_3>Given to Nancy Sullivan on 7/6/2011 for EPC0015 ; Given to TrialStat on 10/20/2008 for PPC0002</User_Def_3><ISSN_ISBN>15894247</ISSN_ISBN><Availability>Sharepoint , TrialStat , PPC0002 , SRMLPPC2_090808 , PPC2_TSupload0908 , PPC2_EE , EPC0015 , SRMLEPC15_0623-2411 , SREMEPC15_081611 , EPC15_Final_11-28-11</Availability><Address>Texas Medical Foundation, Austin, TX 78746, USA. babel@txqio.</Address><ZZ_JournalStdAbbrev><f name="System">J Am Med Dir Assoc</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>22Process of care system changes in collaboration with a state QIOTarget safety problem: PUsKey elements: Collaborative with a state QIO, intervention tool kit, nurses aid and licensed staff training Pre-post NS20 facilities in TexasAverage residents: 100Average Medicare beds: 15External: Identified from 143 Medicare-certified skilled nursing facilities as having high rates of PUs and a high volume of residents receiving preventive careOrganizational Characteristics: Selected due to accessibility to state QIO (Texas Medical Foundation [TMF])Teamwork, Leadership, Culture: NSImplementation tools:TMF provides toolsNurses Station Reference CardsPocket Assessment CardMobility Program Fax Communication FormCare Planning ToolResidentPatient and Family Education BrochureTool kit components based on information from the AHRQ CPGs, Rhode Island Quality Partners, and regulatory requirements (federal and state) Nursing staff internally responsible TMF externally responsibleQA committeeLength: 2 yearsProcess:Monthly onsite visits by TMFTools modified Periodic progress assessmentSuccesses:Performance significantly improved on 8 of 12 QIs Management maintains autonomy which promoted “continued commitment and a sense of ownership”Barriers:Staff resistance“Staff turnover and variation in new staff orientation often contributed to clinical or operational practices that were inconsistent with their protocol requirements.”Incomplete risk assessmentsMonitoring systems not appropriately usedDocumented risk factors not acted uponAddressing Barriers: Monthly visits by TMF and improving performance Sustainability: NSIncidence rate: Pre: 13.6%Post: 10.0%Significant improvements in 8?QIs (baseline vs. re-measurement):Proportion of residents with appropriate risk assessment completed within 2 days of admission(2.2% vs. 15.3%;p<0.0001)Proportion of high-risk residents with appropriate care plan for ALL selected triggers for high-risk residents(10.1% vs. 21.8%;p<0.0001)Proportion of high-risk residents whose care reflects the triggered care plan interventions (2.0% vs. 9.8%; p<0.0001)Proportion of residents with PUs that receive weekly skin assessments (12.6% vs. 32.8%; p<0.0001)Proportion of facility-acquired and community-acquired PUs with appropriate ulcer description within 24 hours of ulcer recognition (53.5% vs. 68.9%; p?=?0.035)Proportion of residents with PUs and mobility issues using a pressure relief mattress/overlay (50.7 vs. 76.7; p<0.0001)Proportion of residents identified as high?risk (as per MDS) using a pressure relief mattress/overlay (33.0% vs. 53.4%; p?=?0.003)Proportion of residents whose treatment orders and care plan interventions for PUs reflect facility wound care protocol (1.3% vs. 4.9%; p = 0.0505)“Although there are areas for improvement, the implementation of process of care system changes by NHs in a collaborative relationship with a QIO may yield improvements in measures of patient outcomes (e.g., PU incidence).” Abel et al. also indicated that the 10?facilities with the highest [QI] scores at re-measurement showed a trend toward a lower [PU] incidence rates than the 10 facilities with the lowest [QI] indicator scores at re-measurement(S = 125.5,p = 0.07).Facilities with the highest QI scores versus facilities with the lowest QI scores (baseline vs. re-measurement; PU incidence rate, %):High scoring group:12.3% vs. 7.7% Low scoring group:14.8% vs. 12.2% Facilities with the greatest improvement versus facilities with the least improvement in QI scores (baseline vs. re-measurement; PU incidence rate, %):High scoring group:13.1% vs. 7.1%Low scoring group:14.0% vs. 12.8%Rantz et al. 2001 ADDIN REFMGR.CITE <Refman><Cite><Author>Rantz</Author><Year>2001</Year><RecNum>577172</RecNum><IDText>Randomized clinical trial of a quality improvement intervention in nursing homes</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>577172</Ref_ID><Title_Primary>Randomized clinical trial of a quality improvement intervention in nursing homes</Title_Primary><Authors_Primary>Rantz,M.J.</Authors_Primary><Authors_Primary>Popejoy,L.</Authors_Primary><Authors_Primary>Petroski,G.F.</Authors_Primary><Authors_Primary>Madsen,R.W.</Authors_Primary><Authors_Primary>Mehr,D.R.</Authors_Primary><Authors_Primary>Zwygart-Stauffacher,M.</Authors_Primary><Authors_Primary>Hicks,L.L.</Authors_Primary><Authors_Primary>Grando,V.</Authors_Primary><Authors_Primary>Wipke-Tevis,D.D.</Authors_Primary><Authors_Primary>Bostick,J.</Authors_Primary><Authors_Primary>Porter,R.</Authors_Primary><Authors_Primary>Conn,V.S.</Authors_Primary><Authors_Primary>Maas,M.</Authors_Primary><Date_Primary>2001/8</Date_Primary><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Consultants</Keywords><Keywords>Education</Keywords><Keywords>Feedback</Keywords><Keywords>*Homes for the Aged</Keywords><Keywords>Humans</Keywords><Keywords>*Nursing Homes</Keywords><Keywords>Outcome and Process Assessment (Health Care)</Keywords><Keywords>*Quality Assurance,Health Care</Keywords><Keywords>*Quality Indicators,Health Care</Keywords><Keywords>Total Quality Management</Keywords><Reprint>Not in File</Reprint><Start_Page>525</Start_Page><End_Page>538</End_Page><Periodical>Gerontologist</Periodical><Volume>41</Volume><Issue>4</Issue><User_Def_2>MEDLINE - Ovid 8/17/2011, MEDLINE - Ovid 8/17/2011</User_Def_2><User_Def_3>Given to Nancy Sullivan on 8/19/2011 for EPC0015</User_Def_3><ISSN_ISBN>11490051</ISSN_ISBN><Availability>Sharepoint , EPC0015 , EPC15_Final_11-28-11</Availability><Address>Sinclair School of Nursing, University of Missouri-Columbia, Columbia, MO 65211, USA. RantzM@health.missouri.edu</Address><ZZ_JournalStdAbbrev><f name="System">Gerontologist</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>23Statewide implementation of Show-Me QI reportTarget safety problem: ComprehensiveKey elements:Workshops, Minimum Data Set (MDS) Quality Indicator (QI) feedback reports, clinical consultationRCTGroup 1:Workshop plus feedback reportsGroup 2:Workshop, feedback reports and clinical consultGroup 3:ControlNS87 nursing homes in MissouriBed size:1–60:1061–120:52120+:25External: NSOrganizational Characteristics:Adequate experience with transmitting MDS data electronicallyTeamwork, Leadership, Culture: NSImplementation tools:Educational workshopRAI manualRAPsCPG (AHRQs)Comparative feedback Show-Me QI report (quarterly)GCNS consult Length: 1 year Process:“Core group” receives Show-Me QI report in workshop; subsequent quarterly reports sent to administrator and DONGCNS help interpret report, assess resident problems, and document care15 facilities (Group 2) had ≥1?on-site visits and GCNS calls18 facilities (Group 2) had only 1 call and limited GCNS calls13 quality indicator outcome measures were evaluated Successes:Reduction in pressure ulcers (overall and low-risk) for residents in facilities using GCNS Barriers:Short staffStaff turnover especially nurse RAI coordinator“Taking care themselves”Cancelled site visit at last minuteAdditional time needed to correct inaccurate MDS assessmentsTeams “mired in the MDS assessment process and coding issues”Difficulty convincing staff to use continuous QI principlesAddressing Barriers:Stronger incentives to use GCNSGCNS more local More flexible site visit timesExtend time to implement changeUse teams to address problemsPost accomplishmentsMultiple nurses responsible for RAI processUse of quality manager on staff to support care delivery improvementsLeadership buy in to QI Sustainability: NSSecondary regression analysis:MDS QI 29Pressure Ulcers (overall):Case mix: 0.156Time Pre-Post: 0.240Intervention: 0.026Group X Time: 0.085 (p≤0.10)MDS QI 29lrPressure ulcers low risk: Case mix: 0.417Time Pre-Post: 0.037Intervention: 0.064Group X Time: 0.057 (p≤0.10)A subset of Group 2 nursing homes that were intensely involved with the intervention showed improvement in MDS QI scores for five outcome measures including MDS QI 29 (pressure ulcers). “Nursing homes that did have continuous quality improvement systems in place were often part of larger health care systems that have ongoing support from a quality improvement expert.”Ryden et al. 2000 ADDIN REFMGR.CITE <Refman><Cite><Author>Ryden</Author><Year>2000</Year><RecNum>572506</RecNum><IDText>Value-added outcomes: the use of advanced practice nurses in long-term care facilities</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>572506</Ref_ID><Title_Primary>Value-added outcomes: the use of advanced practice nurses in long-term care facilities</Title_Primary><Authors_Primary>Ryden,M.B.</Authors_Primary><Authors_Primary>Snyder,M.</Authors_Primary><Authors_Primary>Gross,C.R.</Authors_Primary><Authors_Primary>Savik,K.</Authors_Primary><Authors_Primary>Pearson,V.</Authors_Primary><Authors_Primary>Krichbaum,K.</Authors_Primary><Authors_Primary>Mueller,C.</Authors_Primary><Date_Primary>2000/12</Date_Primary><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Aggression</Keywords><Keywords>Depression</Keywords><Keywords>nu [Nursing]</Keywords><Keywords>Female</Keywords><Keywords>Follow-Up Studies</Keywords><Keywords>Geriatric Assessment</Keywords><Keywords>*Geriatric Nursing</Keywords><Keywords>st [Standards]</Keywords><Keywords>Health Services Research</Keywords><Keywords>Humans</Keywords><Keywords>Job Description</Keywords><Keywords>*Long-Term Care</Keywords><Keywords>ma [Manpower]</Keywords><Keywords>Long-Term Care</Keywords><Keywords>st [Standards]</Keywords><Keywords>Male</Keywords><Keywords>Minn</Keywords><Reprint>Not in File</Reprint><Start_Page>654</Start_Page><End_Page>662</End_Page><Periodical>Gerontologist</Periodical><Volume>40</Volume><Issue>6</Issue><User_Def_2>MEDLINE - Ovid 6/27/2011</User_Def_2><User_Def_3>Given to Nancy Sullivan on 7/8/2011 for EPC0015</User_Def_3><ISSN_ISBN>11131082</ISSN_ISBN><Availability>Sharepoint , EPC0015 , SRMLEPC15_0623-2411 , EPC15_Final_11-28-11</Availability><Address>University of Minnesota School of Nursing, Minneapolis, MN 55455, USA</Address><ZZ_JournalStdAbbrev><f name="System">Gerontologist</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>24Protocol implementation by APNs Target safety problem: ComprehensiveKey elements:APNs assist staff to implement care plan; APNs?provide direct care to residentsControlled before-and-afterAPN treatment (2?facilities) vs. usual care (1 facility)Havelock’s (1974) model of effective research utilization3 privately-owned facilities located in suburban Minneapolis-St.?Paul area; certified for Medicare External: NSOrganizational Characteristics:APNs work with head nurse who works with physician or GNPTeamwork, Leadership, Culture: NSImplementation tools:AHRQ CPG Staff educationWork with nursing assistants APNs participate in conferences and wound care roundsLength: 6 monthsProcess:RAs assess risk/collect data2 APNs reassess risk, analyze data (10 hrs/week per facility)APNs meet with residents 1530?min/wkSuccesses:6 months of APN treatment significantly improved 3 of 4clinical problems compare to usual careBarriers:High turnover of unlicensed staffAddressing Barriers: NSSustainability: A wound care committee was established at 1?facility.APN Treatment(n = 86)Pre: 19.8Post: 3.5x2 = 3.01(1), p = 0.04, one-tailedUsual Care(n = 111)Pre: 17.3Post: 10.0“The relatively short?time (10 hr per week in each nursing home) and the high turnover rates of unlicensed staff (range of 11%45%) reduced opportunities for each APN to establish relationships with staff.”APNs:Advanced practice gerontological nursesCMS:Centers for Medicare and MedicaidCPG:Clinical practice guidelinesDON:Director of NursingEMR:Electronic medical recordGCNS:Gerontological clinical nurse specialistGNP:General nurse practitionerGP:General PractitionerHRPrU:High-risk PU quality measureInt:InterventionLPN:Licensed practical nursesLTACH:Long-term acute care hospitalNS:Not statedPT:Physical therapistPU:Pressure ulcerQI:Quality indicatorQM:Quality measureRA:Resident assistantsRAI:Resident assessment instrumentRAP RAI:Resident assessment protocolsRCT:Randomized controlled trialSCI:Spinal cord injuryWCC:Wound Care CertifiedReferences1. Lynch S, Vickery P. Steps to reducing hospital-acquired pressure ulcers. Nursing 2010 Nov;40(11):61-2. PMID: 209754362. Young J, Ernsting M, Kehoe A, et al. Results of a clinician-led evidence-based task force initiative relating to pressure ulcer risk assessment and prevention. J Wound Ostomy Continence Nurs 2010 Sep-Oct;37(5):495-503. PMID: 207368583. Bales I, Padwojski A. Reaching for the moon: achieving zero pressure ulcer prevalence. J Wound Care 2009 Apr;18(4):137-144. PMID:?193499334. Chicano SG, Drolshagen C. Reducing hospital-acquired pressure ulcers. J Wound Ostomy Continence Nurs 2009 Jan-Feb;36(1):45-50. PMID: 191558235. Walsh NS, Blanck AW, Barrett KL. Pressure ulcer management in the acute care setting: a?response to regulatory mandates. J Wound Ostomy Continence Nurs 2009 Jul-Aug;36(4):385-8. PMID: 196091586. Dibsie LG. Implementing evidence-based practice to prevent skin breakdown. Crit Care Nurs Q 2008 Apr-Jun;31(2):140-9. PMID:?183601447. McInerney JA. Reducing hospital-acquired pressure ulcer prevalence through a focused prevention program. Adv Skin Wound Care 2008 Feb;21(2):75-8. PMID: 183497348. Ballard N, McCombs A, Deboor S, et al. How?our ICU decreased the rate of hospital-acquired pressure ulcers. J Nurs Care Qual 2008 Jan-Mar;23(1):92-6. PMID: 182818829. Catania K, Huang C, James P, et al. Wound wise: PUPPI: the Pressure Ulcer Prevention Protocol Interventions. Am J Nurs 2007 Apr;107(4):44-52; quiz 53. PMID: 1741373210. LeMaster KM. Reducing incidence and prevalence of hospital-acquired pressure ulcers at Genesis Medical Center. Jt Comm J Qual Patient Saf 2007 Oct;33(10):611-6, 585. PMID: 1803086311. Courtney BA, Ruppman JB, Cooper HM. Save?our skin: initiative cuts pressure ulcer incidence in half. Nurs Manage 2006 Apr;37(4):36, 38, 40 passim. PMID: 1660394612. Gibbons W, Shanks HT, Kleinhelter P, et al. Eliminating facility-acquired pressure ulcers at Ascension Health. Jt Comm J Qual Patient Saf 2006 Sep;32(9):488-96. PMID: 1798787213. Hiser B, Rochette J, Philbin S, et al. Implementing a pressure ulcer prevention program and enhancing the role of the CWOCN: impact on outcomes. Ostomy Wound Manage 2006 Feb;52(2):48-59. PMID:?1646499414. Lyder CH, Grady J, Mathur D, et al. Preventing pressure ulcers in Connecticut hospitals by using the plan-do-study-act model of quality improvement. Jt Comm J Qual Saf 2004 Apr;30(4):205-14. Also available: . PMID: 1508578615. Stier L, Dlugacz YD, O’Connor LJ, et al. Reinforcing organizationwide pressure ulcer reduction on high-risk geriatric inpatient units. Outcomes Manag 2004 Jan-Mar;8(1):28-32. PMID: 1474058116. Soban LM, Hempel S, Munjas BA, et al. Preventing pressure ulcers in hospitals: a systematic review of nurse-focused quality improvement interventions. Jt Comm J Qual Patient Saf 2011 Jun;37(6):245-52. PMID:?2170698417. Horn SD, Sharkey SS, Hudak S, et al. Pressure ulcer prevention in long-term-care facilities: a pilot study implementing standardized nurse aide documentation and feedback reports. Adv?Skin Wound Care 2010 Mar;23(3):120-31. PMID: 2017716518. Rantz MJ, Hicks L, Petroski GF, et al. Cost,?staffing and quality impact of bedside electronic medical record (EMR) in nursing homes. J Am Med Dir Assoc 2010 Sep;11(7):485-93. PMID: 2081633619. Milne CT, Trigilia D, Houle TL, et al. Reducing pressure ulcer prevalence rates in the long-term acute care setting. Ostomy Wound Manage 2009 Apr;55(4):50-9. PMID:?1938709620. Tippet AW. Reducing the incidence of pressure ulcers in nursing home residents: a?prospective 6-year evaluation. Ostomy Wound Manage 2009 Nov 1;55(11):52-8. PMID:?1993446421. Rosen J, Mittal V, Degenholtz H, et al. Ability, incentives, and management feedback: organizational change to reduce pressure ulcers in a nursing home. J Am Med Dir Assoc 2006 Mar;7(3):141-6. PMID: 1650330622. Abel RL, Warren K, Bean G, et al. Quality improvement in nursing homes in Texas: results from a pressure ulcer prevention project. J Am Med Dir Assoc 2005 May-Jun;6(3):181-8. PMID: 1589424723. Rantz MJ, Popejoy L, Petroski GF, et al. Randomized clinical trial of a quality improvement intervention in nursing homes. Gerontologist 2001 Aug;41(4):525-38. PMID:?1149005124. Ryden MB, Snyder M, Gross CR, et al. Value-added outcomes: the use of advanced practice nurses in long-term care facilities. Gerontologist 2000 Dec;40(6):654-62. PMID:?11131082 ................
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