Beyond risk assessment: elements for pressure ulcer prevention.

Considerable emphasis has been placed on identifying individuals who are at risk for developing pressure ulcers. However, the generality of diagnostic discriminations and consequent intervention strategies may have resulted in less effective outcomes than otherwise would be possible. When such processes are carried out in a system devoid of the fundamental elements required for increased diagnostic/prescriptive precision and systematic improvement, practitioners are, at best, relegated to relying on external trial-based research to yield new "best practices." At worst, ineffective and costly practices continue without systematic evaluation and alteration. Several necessary elements of any empirically-based prevention system are addressed, and an attempt to integrate the elements into a system for field utilization is illustrated. If successful, the system will result in incremental improvements in the outcomes of prevention efforts over time.

Managing for quality in a nursing home: a resident-directed approach.

As the population ages, the need for nursing care services will increase. Consumer focus on quality of life as well as reduction of expenditures poses a major challenge to the traditional nursing home, which often reinforces dependent resident behavior. The authors propose various strategies for improving life satisfaction and functional status of residents as well as efficiency and productivity of staff.

Computerized decision support systems: implications for practice.

The informatics literature variously defines Computerized Decision Support (CDS) systems. These definitions are sometimes narrow and sometime broad, leading to occasional confusion in terminology. For purposes of this paper, a broad definition that enjoys some professional consensus has been adapted from Langston and colleagues: CDS systems encompass any computer software employing a knowledge base (facts and/or rules) designed for use by a clinician involved in patient care, as a direct aid to clinical decision-making.

The Wound Intelligence System: early issues and findings from multi-site tests.

The purpose of this manuscript is to address a gap in our efforts to incrementally improve wound care practice through evidence-based practice. The Pressure Sore Status Tool (PSST) provides data to extend evidence-based practice beyond clinical trials and into the clinical area itself. The computerized PSST was evaluated over one year through over 70 beta sites. Two studies which were part of that evaluation period are described which give a comparative analysis of wound stage and PSST scores, and similarities and differences in wound characteristics of four types of wounds: arterial/ischemic ulcers, neuropathic ulcers, pressure ulcers, and venous ulcers. In the first study, a relationship between PSST scores and staging scores for the presenting wound was present, indicating promise for the utilization of the PSST as an alternative to staging scores for describing changes in wound status. However, in the second study, clear difference was not noticeable between the four wound types, suggesting that discriminations regarding wound type may not be able to be made from PSST assessments. The goal of these studies was to provide feedback on the use of the computerized PSST, thereby providing feedback based on objective outcomes of the practice of clinicians themselves.

The use of a computer-based model to implement an incontinence management program.

A computerized total quality management model was used to implement an incontinence system in eight nursing homes. Research staff measured resident wetness for one month, provided training in the implementation of the program in less than five days, and measured resident wetness for six months after implementation. Seven of the eight nursing homes significantly improved resident dryness for a six-month period. However, extensive monitoring of the nursing home computers by modem and telephone feedback from the research staff was necessary to produce successful maintenance.

Toward an intelligent wound assessment system.

There is general agreement regarding the need for pressure ulcer assessment methodology which more discretely reflects relevant aspects of wound status than does the commonly used staging system. The Pressure Sore Status Tool (PSST) is one such instrument which was developed with consensual expert input. While the psychometric properties of the PSST have been reported in the literature, the instrument was validated using ET nurses, highly trained wound care specialists, and existed only in manual form. This paper reports results from attempts to establish reliability estimates for healthcare practitioners without extraordinary wound care training or experience. The paper further describes the automation of the PSST and provides examples of pressure ulcer profiles tracked over time. Results indicate that inter-rater reliability with general healthcare practitioners was .78 and intra-rater reliability was .89. The practitioners were able to use the PSST for over six months and the automated system allowed analysis of wound healing profiles that would have been difficult using a manual system. These results imply that movement toward an automated system which makes discriminations regarding the effects of various treatment and intervention strategies is possible and practical.