Ulcer study tries to unify paperwork, speed alerts

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Wound care nurse Perry Tackett said he was elated when he found out his facility, Sugarcreek Rest in Worthington, PA, was picked out of a hundred to take part in a study aimed at speeding up nursing interventions to reduce pressure ulcers.

"We don't have a real high rate of occurrence as it is, but any is too many," says Tackett.
At Sugarcreek, there are two 30-bed skilled nursing wings where 99% of pressure ulcers occur. The nursing staff on the wings currently record information in four separate logbooks: bladder sheet, meal and fluid intake, skin lesions, and activities of daily living. These four will be consolidated into one to save nursing staff time and allow registered nurses to react quickly to subtle warning signs.
"If I want to know how much fluid this person is taking, I don't have to go down to the diner to look it up, it's right there," Tackett says.
Sugarcreek is one of 14 participants nationwide in the five-year study conducted by the Institute for Clinical Outcomes Research, the research arm of the International Severity Information Systems, Salt Lake City, UT.
The Agency for Healthcare Research and Quality has given the institute a grant to work with the facilities and consolidate their records systems onto a single, scannable form. ICOR started the project, Real Time Optimal Care Plans for Nursing Home Quality Improvement, in October 2002.
The ICOR team first helped the facilities create their own tailored form with questions for certified nursing assistants to answer in various areas -- nutrition, staffing, medication and incontinence. Queries include "Did the person eat breakfast? Lunch? Dinner?" or "Is he or she tube-feeding?" Ultimately, the nursing staff will fax or e-mail their daily records (each resident is assigned a code number) to ICOR's staff. ICOR will scan the information, find danger areas to alert the nurses and send back a real-time report to the nursing home.
This study is a spin-off of a 1996 to 1997 study of 2,490 residents at 109 facilities nationwide. ICOR discovered through the National Pressure Ulcer Long-Term Care Study that 11% of nursing home residents on average develop two pressure ulcers. Not only does this cause residents severe pain, but it also costs facilities between $1,284 and $4,647 per ulcer per resident, the group determined. That would be $300,000 annually for a 100-bed facility with 500 residents revolving through it in a year.
The clinicians learned that in order to decrease pressure ulcers by half in long-term care settings, there needs to be staff intervention protocols in other areas of care as well -- nutrition, staffing, medication and incontinence -- because they are all intertwined.
During the NPULS study, leaders found that the nursing aides' documentation on each resident is scattered in logbooks, on clip books, and on loose sheets of paper throughout nursing homes. And this is all separate from the Minimum Data Set information.
"It's hard to see a whole picture of who this person is," says Dr. Susan Horn, senior scientist at ICOR. "Now we're getting the day, evening, and night shifts for seven days on one form, where there's not only a consolidation, but we can also see what the resident looks like across shifts. Frankly, it's so much easier to do the right assessments."


Lights out on paper use


Only one of the participating facilities, Traditions at Stygler Road in Gahanna, OH, uses an electronic CareTracker system. The nurses still document some areas of care on paper, as well. The administrator is changing this. The 100-bed facility has four wall-mounted kiosks, two at the nursing stations and at least six computers where nurses can enter information. Ultimately, the computer screen will be divided into eight touch-screen boxes highlighting each subject: ADLs, restorative care, bathing. When a nurse inputs information about a resident, the entire square will be lit up until each question is answered for the day. Then it will turn off.
If a resident needs more hydration, for example, an alert will automatically be sent back through the CareTracker. Director of Nursing Terri Martin said she hoped the lighting phase of the project would be implemented by the end of February. She said her facility is moving rapidly because it'