Adherence to Pressure Ulcer Prevention Guidelines: Implications for Nursing Home Quality

Authors

  • Debra Saliba MD, MPH,

    1. Center for the Study of Healthcare Provider Behavior and
    2. Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Sepulveda, California;
    3. Department of Medicine, University of California at Los Angeles, Los Angeles, California;
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  • Lisa V. Rubenstein MD, MSPH,

    1. Center for the Study of Healthcare Provider Behavior and
    2. Department of Medicine, Veterans Affairs Medical Center, Greater Los Angeles System, Los Angeles, California;
    3. Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Sepulveda, California;
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  • Barbara Simon MA,

    1. Center for the Study of Healthcare Provider Behavior and
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  • Elaine Hickey RN, MS,

    1. Center for Health Quality, Outcomes and Economic Research, Bedford Veterans Affairs Medical Center, Bedford, Massachusetts; and
    2. Boston University School of Public Health, Boston, Massachusetts.
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  • Bruce Ferrell MD,

    1. Center for the Study of Healthcare Provider Behavior and
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  • Elaine Czarnowski,

    1. Center for Health Quality, Outcomes and Economic Research, Bedford Veterans Affairs Medical Center, Bedford, Massachusetts; and
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  • Dan Berlowitz MD, MPH

    1. Center for Health Quality, Outcomes and Economic Research, Bedford Veterans Affairs Medical Center, Bedford, Massachusetts; and
    2. Boston University School of Public Health, Boston, Massachusetts.
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  • Dr. Saliba is a Research Associate of the Veterans Affairs Health Services Research and Development Services and a 2000 Pfizer/American Geriatrics Society Foundation for Health in Aging Junior Faculty Scholar for Health Outcomes in Geriatrics.

Address correspondence to Debra Saliba, MD, MPH, RAND Corporation, 1700 Main Street, Santa Monica, CA 90401. E-mail: saliba@rand.org

Abstract

OBJECTIVES: This study aims to assess overall nursing home (NH) implementation of pressure ulcer (PU) prevention guidelines and variation in implementation rates among a geographically diverse sample of NHs.

DESIGN: Review of NH medical records.

SETTING: A geographically diverse sample of 35 Veterans Health Administration NHs.

PARTICIPANTS: A nested random sample of 834 residents free of PU on admission.

MEASUREMENTS: Adherence to explicit quality review criteria based on the Agency for Healthcare Research and Quality Practice Guidelines for PU prevention was measured. Medical record review was used to determine overall and facility-specific adherence rates for 15 PU guideline recommendations and for a subset of six key recommendations judged as most critical.

RESULTS: Six thousand two hundred eighty-three instances were identified in which one of the 15 guideline recommendations was applicable to a study patient based on a specific indication or resident characteristic in the medical record. NH clinicians adhered to the appropriate recommendation in 41% of these instances. For the six key recommendations, clinicians adhered in 50% of instances. NHs varied significantly in adherence to indicated guideline recommendations, ranging from 29% to 51% overall adherence across all 15 recommendations (P < .001) and from 24% to 75% across the six key recommendations (P < .001). Adherence rates for specific indications also varied, ranging from 94% (skin inspection) to 1% (education of residents or families). Standardized assessment of PU risk was identified as one of the most important and measurable recommendations. Clinicians performed this assessment in only 61% of patients for whom it was indicated.

CONCLUSIONS: NHs' overall adherence to PU prevention guidelines is relatively low and is characterized by large variations between homes in adherence to many recommendations. The low level of adherence and high level of variation to many best-care practices for PU prevention indicate a continued need for quality improvement, particularly for some guidelines.

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