Jacob Dimant

From Quality Assurance to Quality Management in Long Term Care

This article describes the continuing evolution of the quality assurance program at Crown Nursing Home, a privately owned, skilled long-term care facility in Brooklyn, New York, into quality management. Activities are intended to improve the systems and processes of resident care, develop and implement practice guidelines, integrate suppliers and vendors into the facility processes, use information systems for indicator monitoring, encourage residents and family participation, provide care through a team approach, and promote human resource management and staff enhancement.

Avoiding Physical Restraints in Long-Term Care Facilities

Despite evidence that physical restraints and full-length bed rails do not prevent falls and injuries in nursing home residents, their use is still widespread in many facilities. Although physical restraints use in nursing homes has significantly decreased since the implementation of the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87) in 1990, the Centers for Medicare and Medicaid Services (CMS, formerly HCFA) Online Survey Certification and Reporting (OSCAR) data show that as of March 1999, 12.7% of nursing home residents were physically restrained (physical restraints as defined by CMS) ranging as high as 23.1% in Louisiana and as low as 2.5% in Iowa. Prevention of falls and related injuries in nursing homes remains a significant clinical challenge to the nursing home care team. There is evidence that alternatives to physical restraints and full-length bed rails can be applied safely, without increasing, and probably decreasing, negative outcomes such as falls and injuries. To consistently apply care principles rooted in evidence, the care team must adhere to a care process, which includes symptom identification, assessment and cause finding, care planning (with ethical considerations, considerations of risks and benefits, principles of risk prevention and evidence-based interventions), application of interventions, monitoring (for efficacy and complications), and revisions of the care plan based on the monitoring. This must be done while maintaining regulatory compliance but without compromising the appropriate individualized care for each resident. Because federal regulations define physical restraints and essentially require adherence to the care process in a detailed fashion, regulatory requirements can be integrated into the care process without compromising appropriate care. The wide geographical variation in the rate of restraint use suggests the presence of a pervasive system problem in the care process related to the use or avoidance of restraints. This problem is in part related to societal attitudes toward the care of the elderly, in which protection and safety receive undue emphasis at the expense of individual choices, freedom, control, and individuality. Confusion as to the definition of physical restraints adds to the problem. But to achieve and enhance the quality of care, standards defining the performance expectations, structures, or processes must be substantially in place in the facility. Organizing the process of care efficiently is an important determinant of quality of care. When processes of care and teamwork related to restraints are efficient and well organized, the use of physical restraints can be avoided. To successfully avoid the use of physical restraints, a facility must educate caregivers to consider resident preferences first in any care planning process and must have in place a care process that would assure the avoidance of unnecessary restraints. However, in some instances, the continuous recording of use or physical restraints in a facility is related not to outdated or inappropriate practice, but to the way the CMS defines physical restraints (as discussed below). Many interventions (which were first used as alternatives to physical restraints) must be considered as physical restraints based on CMS functional definition. Many of these interventions are indeed appropriate and necessary as part of the individualized care planning of specific residents. These treatments may include certain special seating devices, orthotic devices, devices such as Velcro belts or lap trays on chairs, and even the use of constraint therapy for poststroke rehabilitation. Frequently, such treatments or interventions are not intended to be used as restraints but rather as functional enablers for various purposes such as positioning or comfort. But because they have the effect of restricting movement, they must be defined as restraints. This is not necessarily negative because defining such devices as restraints assures that the team provides risk assessment and preventive interventions for potentially negative outcomes related to restricting mobility. The desire to create a “restraint free” environment, or remain in regulatory compliance, should not prevent the care team from providing appropriate interventions for specific residents who need them The purpose of this article is to describe the principles of a process of care that would help providers avoid use of restraints and institute other appropriate treatments and intervention to address resident risks or symptoms. It is likely that following the appropriate process of care in assessment, care planning, intervention, and monitoring of patients’ symptoms would cause the care team to plan for appropriate treatments Lutheran Augustana Center for Extended Care and Rehabilitation and Lutheran Medical Center, Brooklyn, New York.

Delivery of Nutrition and Hydration Care in Nursing Homes: Assessment and Interventions to Prevent and Treat Dehydration, Malnutrition, and Weight Loss

Last year’s Institute of Medicine report To Err Is Human: Building a Safer Health System has focused national attention on quality of care. Prevention of medical errors is becoming even more important in long-term care facilities with the publication of recent HCFA guidelines to surveyors for determining immediate jeopardy. These guidelines define triggers for findings of abuse and neglect that may constitute immediate jeopardy including, among others, failure to prevent or address malnutrition and dehydration. If an immediate jeopardy situation is found, surveyors are instructed to determine if the facility created the situation, allowed it to continue, or had an opportunity but did not implement corrective or preventive measures; in other words, surveyors will look to see if the facility has in place appropriate systems and processes for detection and prevention of, and intervention for, malnutrition and dehydration. Most errors and negative outcomes can be prevented by adherence to care delivery systems and processes which include the detection and assessment of conditions and risks, the care planning process, execution of the care plan, and continual monitoring. This article presents a framework for establishing interdisciplinary care processes for the delivery of nutrition and hydration care in nursing homes. The goals of nutrition and hydration care are to improve nutritional status, prevent and/or treat weight loss, malnutrition, and dehydration, and improve quality of life related to eating and drinking. To achieve these goals, a facility must have in place interdisciplinary processes to appropriately detect and assess presence and risk of malnutrition and dehydration, develop care plans, and deliver and monitor the care. In addition, systems for food delivery, dining, and assisted feeding must be in place. The process should include the use of specific risk-assessment tools complementary and compatible with the Minimum Data Set (MDS) and Resident Assessment Protocols (RAPs) as well as care planning based on the assessment. The care planning must always include measurable and realistic goals. The assessment, care planning, and intervention systems and processes should focus on the following key areas:

Expanding the knowledge base of resident and facility outcomes of care delivered by advanced practice nurses in long-term care: expert panel recommendations.

In 2003, a panel of nationally recognized experts in geriatric practice, education, research, public policy, and long-term care convened to examine and make recommendations about care quality and safety issues related to advanced practice nurses (APNs) in nursing home practice. This article reports on the panel recommendation that addressed expanding the evidence base of resident and facility outcomes of APN nursing home practice. A review of the small but important body of research related to nursing home APN practice suggests a positive impact on resident care and facility outcomes. Recommendations are made for critically needed research in four key areas: (a) APN nursing home practice, (b) relative value unit coding, (c) outcomes related to geropsychiatric and mental health nursing services, and (d) outcomes related to geriatric specialization. The APN role could be significantly enhanced and executed if its specific contribution to resident and facility outcomes was more clearly delineated through the recommended rigorous research.

Serum Digoxin Levels in Elderly Nursing Home Patients: Appraisal of Routine Periodic Measurements

ABSTRACT: An assessment was made of the clinical value of routine periodic measurement of serum digoxin levels in 51 elderly nursing home patients with cardiac disease. The findings showed that the serum digoxin level was not correlated with the dosage of digoxin nor the patients clinical state of digitalization. All patients were effectively digitalized, as judged clinically, and no digitalis toxicity occurred despite a wide range of serum digoxin levels. When adequate medical supervision, electrocardiograms, roentgenograms, serum electrolyte determinations and renal function tests are available, the routine periodic measurement of serum digoxin concentration does not offer any additional benefit in the management of nursing home patients with cardiac disease.

Implementing Pressure Ulcer Prevention and Treatment Programs: Using AMDA Clinical Practice Guidelines

The American Medical Directors Association (AMDA) Clinical Practice Guidelines (CPG) project was undertaken to develop tools that long-term care (LTC) practitioners can use to improve the delivery of quality care. Each guideline was developed by an interdisciplinary work group of LTC professionals using a process that combined evidence-based and consensus-based thinking. The CPG is a tool to guide the care delivery in a specific area and can help the care team in developing programs and care processes. A CPG detailing the implementation of other CPGs was developed as well. The Pressure Ulcers CPG was one of the initial CPGs developed by AMDA in 1996, and it was followed by a Pressure Ulcer Therapy Companion CPG in 1999. In developing both Pressure Ulcers CPGs, the workgroups were assisted by the previously developed Agency for Health Care Policy and Research (AHCPR) CPGs on the prevention and treatment of pressure ulcers. The workgroup attempted to apply the AHCPR recommendations to the specific practice environment in LTC facilities. This article reviews key points of AMDA’s Pressure Ulcer Therapy Companion CPG supplemented by information from the AHCPR. To assist facilities in implementation, important points in the AMDA Guideline Implementation CPG are discussed as they relate to implementation of the Pressure Ulcer CPG. The goal of this review is to assist medical directors, physicians and all other members of the care team in LTC facilities to understand, develop and implement pressure ulcer prevention and treatment programs.

Nutritional Assessment and Care of Nursing Facility Residents: A Practical Approach

Comprehensive care of the nursing facility resident requires attention to nutritional status and its interactions with disease states, morbidity, functional ability, and mortality. Proteinenergy malnutrition and weight loss is present in 30 to 60% of nursing facility residents. Protein-energy malnutrition is a syndrome characterized by too little lean body mass, secondary to inadequate caloric or protein intake. This syndrome can be quantified as less than 80% of one’s ideal body weight (IBW) or a loss of more than 10% of usual weight in 6 months, with muscle wasting. When not attended to on a timely basis, malnutrition often leads to other negative outcomes, including pressure ulcers and infections. Early recognition of weight loss can trigger beneficial nutritional assessment, intervention, and monitoring, which may prevent excess morbidity and mortality. This article will suggest a primary care approach to nutritional care among nursing facility residents at risk for nutritional deficiencies.