Evaluation of AHRQ's on-time pressure ulcer prevention program: a facilitator-assisted clinical decision support intervention for nursing homes.

BACKGROUND: Pressure ulcers present serious health and economic consequences for nursing home residents. The Agency for Healthcare Research & Quality, in partnership with the New York State Department of Health, implemented the pressure ulcer module of On-Time Quality Improvement for Long Term Care (On-Time), a clinical decision support intervention to reduce pressure ulcer incidence rates. OBJECTIVE: To evaluate the effectiveness of the On-Time program in reducing the rate of in-house-acquired pressure ulcers among nursing home residents. RESEARCH DESIGN AND SUBJECTS: We employed an interrupted time-series design to identify impacts of 4 core On-Time program components on resident pressure ulcer incidence in 12 New York State nursing homes implementing the intervention (n=3463 residents). The sample was purposively selected to include nursing homes with high baseline prevalence and incidence of pressure ulcers and high motivation to reduce pressure ulcers. Differential timing and sequencing of 4 core On-Time components across intervention nursing homes and units enabled estimation of separate impacts for each component. Inclusion of a nonequivalent comparison group of 13 nursing homes not implementing On-Time (n=2698 residents) accounts for potential mean-reversion bias. Impacts were estimated via a random-effects Poisson model including resident-level and facility-level covariates. RESULTS: We find a large and statistically significant reduction in pressure ulcer incidence associated with the joint implementation of 4 core On-Time components (incidence rate ratio=0.409; P=0.035). Impacts vary with implementation of specific component combinations. CONCLUSIONS: On-Time implementation is associated with sizable reductions in pressure ulcer incidence.

Potentially avoidable hospitalizations for elderly long-stay residents in nursing homes.

BACKGROUND: Hospitalizations of long-stay nursing home (NH) residents are common. The high estimates of potentially avoidable hospitalizations in NHs suggest that efforts to reduce avoidable hospitalizations may be effective in lowering health care expenditures as well as improving the quality of care for NH residents. OBJECTIVE: To determine the relationship between clinical risk factors, facility characteristics and State policy variables, and both avoidable and unavoidable hospitalizations. METHOD: Hospitalization risk is estimated using competing risks proportional hazards regressions. Three hospitalization measures were constructed: (1) ambulatory care-sensitive conditions (ACSCs); (2) additional NH-sensitive avoidable conditions (ANHACs); and (3) nursing home "unavoidable" conditions (NHUCs). In all models, we include clinical risk factors, facility characteristics, and State policy variables that may influence the decision to hospitalize. SUBJECTS: The population of interest is a cohort of long-stay NH residents. Data are from the Nursing Home Stay file, a sample of residents in 10% of certified NHs in the United States (2006-2008). RESULTS: Three fifths of hospitalizations were potentially avoidable and the majority was for infections, injuries, and congestive heart failure. Clinical risk factors include renal disease, diabetes, and a high number of medications among others. Staffing, quality, and reimbursement affect avoidable, but not unavoidable hospitalizations. CONCLUSIONS: A NH-sensitive measure of avoidable hospitalizations identifies both clinical facility and policy risk factors, emphasizing the potential for both reimbursement and clinical strategies to reduce hospitalizations from NHs.

Evaluation of a seven state criminal history screening pilot program for long-term care workers.

This article summarizes results from an evaluation of a federally sponsored criminal history screening (CHS) pilot program to improve screening for workers in long-term care settings. The evaluation addressed eight key issues specified through enabling legislation, including efficiency, costs, and outcomes of screening procedures. Of the 204,339 completed screenings, 3.7% were disqualified due to criminal history, and 18.8% were withdrawn prior to completion for reasons that may include relevant criminal history. Lessons learned from the pilot program experiences may inform a new national background check demonstration program.

The nursing home dining assistant program: a demonstration project.

The purpose of this study was to extend earlier research on the dining assistant (DA) federal regulation allowing trained non-nursing staff to provide feeding assistance care in nursing homes. Observations were conducted pre- and post-implementation, with periodic observations during implementation. To assess sustainability, data were analyzed at 12 months post-implementation. Results replicated previous findings: DAs spent more time assisting residents, and the quality of care was comparable to that of nurse aides. Results confirmed continuation of the program at 12 months post-implementation. DA programs that augment nursing home staffing levels offer a feasible way to improve feeding assistance care within the constraints of existing resources.

Use of "shuttered" hospitals to expand surge capacity.

INTRODUCTION: With limited available hospital beds in most urban areas, there are very few options when trying to relocate patients already within the hospital to make room for incoming patients from a mass-casualty incident (MCI) or epidemic (a patient surge). This study investigates the possibility and process for utilizing shuttered (closed or former) hospitals to accept medically stable, ambulatory patients transferred from a tertiary medical facility. METHODS: Two recently closed, acute care hospitals were evaluated critically to determine if they could be made ready to accept inpatients within 3-7 days of a MCI. This surge facility ideally would be able to support 200-300 patients/beds. Two generic scenarios were used for planning: (1) a patient surge (including one caused by conventional war or terrorism, weapons of mass destruction, or a disaster caused by natural hazards) requiring transfer of ambulatory, medically-stable inpatients to another facility in an effort to increase capacity at existing hospitals; and (2) a bio-event or epidemic where a shuttered hospital could be used as an isolation facility. RESULTS: Both recently closed hospitals had significant, but different challenges to reopening, although with careful planning and resource allocation it would be possible to reopen them within 3-7 days. Planning was the most conclusive recommendation. It does not appear possible to reopen shuttered hospitals with major structural deterioration or a complete lack of current mission (i.e., no current utilities). Staffing would represent the most challenging issue as a surge facility would represent an incremental additional need for existing and scarce human resources. CONCLUSIONS: With careful planning, a shuttered hospital could be reopened and ready to accept patients within 3-7 days of a MCI or epidemic.

A preliminary evaluation of the paid feeding assistant regulation: impact on feeding assistance care process quality in nursing homes.

PURPOSE: The Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality sponsored a nationwide study to evaluate the federal paid feeding assistant (PFA) regulation that allows nursing homes to hire single-task workers to provide feeding assistance to nursing home residents. Organizers designed the PFA regulation to increase the number of staff available to provide assistance with eating and improve nutritional care process quality. DESIGN AND METHODS: Trained research staff used standardized protocols to conduct direct observations during meals and face-to-face staff interviews in a convenience sample of seven facilities with PFA programs to evaluate care process quality. RESULTS: Most (84%) of the trained PFAs in the seven site visit facilities were non-nursing staff within the facility; the quality of feeding assistance care provided by these workers was comparable to that provided by indigenous nurse aides. There were no reported changes in existing staffing levels (nurse aide or licensed nurses) following PFA program implementation, and the majority (> 90%) of indigenous staff at all levels reported positive benefits of the PFA program for both staff and residents. IMPLICATIONS: Findings from this preliminary study indicate that the PFA regulation may serve to increase the utilization of existing non-nursing staff to improve feeding assistance care during meals without having a negative impact on existing nurse aide and licensed nurse staffing levels.

Does adherence to the Loeb minimum criteria reduce antibiotic prescribing rates in nursing homes?

OBJECTIVES: The Loeb minimum criteria (LMC), developed by a 2001 consensus conference, are minimum standards for initiation of antibiotics in long term care settings, intended to reduce inappropriate prescribing. This study examined the relationship between nursing home prescriber adherence to the LMC and antibiotic prescribing rates, overall and for each of three specific conditions (urinary tract infections, respiratory infections, and skin and soft tissue infections). DESIGN: We performed a cross-sectional analysis at the resident-day level. We estimated multivariate models adjusting for nursing home characteristics via multilevel Poisson regression, with robust standard errors to account for clustering of prescriptions within residents within nursing homes. SETTING: Data were collected through medical record abstraction in 12 North Carolina nursing homes between March and May 2011. PARTICIPANTS: In total, we identified 3381 antibiotic prescriptions across the 3-month observation period, representing 110,810 nursing home resident-days. In addition, we performed chart audits for a random sample of 653 prescriptions for urinary tract, respiratory, and skin and soft tissue infections to create measures of LMC adherence. MEASUREMENTS: The primary outcome was a count of prescriptions per resident per day, and the key explanatory variable was a nursing home-level estimate of the proportion of antibiotic prescriptions that adhered to the LMC. RESULTS: Only 12.7% of prescriptions were classified as LMC adherent, although there was substantial variation across study nursing homes (range: 4.8% to 22.0%) and by infection type (1.9% adherence for respiratory infections, 10.2% for urinary tract infections, and 42.7% for skin and soft tissue infections). We found no statistically significant relationship between adherence to the LMC and total prescribing rates (IRR 1.00, 95% CI 0.98-1.03; P = .84). Similarly, there was no significant relationship between LMC adherence and prescribing rates for treating urinary tract infections (IRR 0.99, 95% CI 0.96-1.02; P = .49), respiratory infections (IRR 0.91, 95% CI 0.76-1.08; P = .28), or skin and soft tissue infections (IRR 0.99, 95% CI 0.98-1.01; P = .39) considered alone. CONCLUSION: We found little evidence that prescribers in study nursing homes considered the LMC when making prescribing decisions. Further, we found no evidence that greater adherence to the LMC was associated with lower rates of antibiotic prescribing. Evidence-based guidelines for antibiotic initiation must be adopted more widely before any substantial gains from adherence are likely to be recognized.

Resident choice and the survey process: the need for standardized observation and transparency.

PURPOSE: To describe a standardized observation protocol to determine if nursing home (NH) staff offer choice to residents during 3 morning activities of daily living (ADL) and compare the observational data with deficiency statements cited by state survey staff. DESIGN AND METHODS: Morning ADL care was observed in 20 NHs in 5 states by research staff using a standardized observation protocol. The number of observations in which choice was not offered was documented for 3 morning ADL care activities and compared with deficiency statements made by surveyors. RESULTS: Staff failed to offer choice during morning ADL care delivery for at least 1 of 3 ADL care activities in all 20 NHs. Observational data showed residents were not offered choice about when to get out of bed (11%), what to wear (25%), and breakfast dining location (39%). In comparison, survey staff issued only 2 deficiencies in all 20 NHs relevant to choice in the targeted ADL care activities, and neither deficiency was based on observational data. IMPLICATIONS: Survey interpretative guidelines instruct surveyors to observe if residents are offered choice during daily care provision, but standardized observation protocols are not provided to surveyors to make this determination. The use of a standardized observation protocol in the survey process similar to that used by research staff in this study would improve the accuracy and transparency of the survey process.

The importance of standardized observations to evaluate nutritional care quality in the survey process.

OBJECTIVE: Guidelines written for government surveyors who assess nursing home (NH) compliance with federal standards contain instructions to observe the quality of mealtime assistance. However, these instructions are vague and no protocol is provided for surveyors to record observational data. This study compared government survey staff observations of mealtime assistance quality to observations by research staff using a standardized protocol that met basic standards for accurate behavioral measurement. Survey staff used either the observation instructions in the standard survey process or those written for the revised Quality Improvement Survey (QIS). METHODS: Trained research staff observed mealtime care in 20 NHs in 5 states during the same time period that survey staff evaluated care in the same facilities, although it could not be determined if survey and research staff observed the same residents during the same meals. Ten NHs were evaluated by government surveyors using the QIS survey instructions and 10 NHs were evaluated by surveyors using the standard survey instructions. RESULTS: Research staff observations using a standardized observation protocol identified a higher proportion of residents receiving inadequate feeding assistance during meals relative to survey staff using either the standard or QIS survey instructions. For example, more than 50% of the residents who ate less than half of their meals based on research staff observation were not offered an alternative to the served meal, and the lack of alternatives, or meal substitutions, was common in all 20 NHs. In comparison, the QIS survey teams documented only 2 instances when meal substitutes were not offered in 10 NHs and the standard survey teams documented no instances in 10 NHs. CONCLUSIONS: Standardized mealtime observations by research staff revealed feeding assistance care quality issues in all 20 study NHs. Surveyors following the instructions in either the standard or revised QIS surveys did not detect most of these care quality issues. Survey staff instructions for observation of nutritional care are not clearly written; thus, these instructions do not permit accurate behavioral measurement. These instructions should be revised in consideration of basic principles that guide accurate behavioral measurement and shared with NH providers to enable them to effectively implement quality improvement programs.