Spotlight Case

1. Spotlight Case The Safety and Quality of Long Term Care

2. Source and Credits • This presentation is based on the September 2011AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Amy A. Vogelsmeier, PhD, RN, GCNS-BC, University of Missouri-Columbia, Sinclair School of Nursing • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Bradley A. Sharpe, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Identify commonly reported adverse events in long-term care • Identify two to three challenges of nursing home care that may contribute to adverse events • Describe patient safety monitoring systems used in nursing homes • Describe what is being done or can be done to make nursing homes safer

4. Case: Safety of Long Term Care A 64-year-old woman with a past medical history of morbid obesity, type II diabetes mellitus, recurrent urinary tract infections, and depression was a resident of a long-term care facility (a skilled nursing facility) due to multiple chronic illnesses. At baseline, she used a wheelchair for mobility and required some assistance with activities of daily living (ADLs).

5. Case: Safety of Long Term Care (2) During an unassisted transfer from her wheelchair to her bed she slipped and fell. She immediately complained of hip pain and was transferred to an acute care hospital. She was found to have a left hip fracture as a result of the fall and underwent an uncomplicated surgical repair. She was ultimately readmitted to the original skilled nursing facility with severely limited mobility secondary to the surgery. At the time of readmission, she was essentially bedbound, unable to transfer to a chair or her wheelchair.

6. Case: Safety of Long Term Care (3) A few weeks later, she continued to remain bedbound with little progress in her functional status. One morning when the nurse was delivering her morning medications, the patient was found to be confused and combative where previously she had been alert, oriented, and always very pleasant. She was febrile to 102oF and had a blood pressure of 110/70 mm Hg, which was lower than her usual. Because of concerns for an acute infection, she was transferred to an acute care hospital.

7. Case: Safety of Long-Term Care (4) At the hospital, a full examination revealed a very deep pressure ulcer in her sacrum (stage IV full thickness ulcer), which had developed at the long-term care facility after her hip fracture. Unfortunately, likely secondary to an infection of the pressure ulcer, she developed septic shock and died 3 days later despite maximal efforts.

8. Background: Adverse Events • Adverse events are common in nursing homes • Prior research has focused on pressure ulcers, adverse drug events (ADEs), and falls • Data regarding incidence of adverse events in nursing homes is heterogeneous • Rate of pressure ulcers ranges from 2.2% to 23.9% • Adverse event rates in nursing homes may be higher than acute care • In a recent report, ADEs were nearly twice as common See Notes for references.

9. Challenges of Nursing Home Care • Nursing home residents are often frail • Predominantly elderly, have multiple chronic medical conditions, take multiple medications, etc. • A large percentage have dementia or cognitive impairments • The care needs of nursing home residents are complex • By federal regulation, any change in condition requires a formal assessment and a new plan of care See Notes for references.

10. Challenges of Nursing Home Care (2) • Many nursing homes do not have adequate resources to manage these complex needs • Such care may best be provided by RNs • However, presence of RNs in nursing homes is declining • Nursing home residents frequently transition between settings • Transfers from nursing homes to acute care are nearly 10% of all Medicare admissions • Transitions may be fragmented and may involve poor communication See Notes for references.

11. Issues in this Case • The events in this case highlight the challenges of nursing home care • Unclear if initial fall was avoidable • After initial hospitalization, resident’s condition had changed significantly, but it is unclear if a new detailed assessment was performed • The resident was transferred twice between acute and long term care; with each transfer, her condition worsened • Better communication across settings might have reduced the risk for harm

12. Systems to Improve Safety • The Joint Commission Patient Safety Goals for Long Term Care are a framework for improvement • Specific goals are: • Accurate resident identification • Safe medication use • Reconciled medications • Reduced harm from falls • Reduced health care−associated pressure ulcers See Notes for reference.

13. Monitoring Systems • Monitoring systems must be in place to identify risk for adverse events • Multidisciplinary team meetings can help identify and aggressively manage individuals’ risks for falls, pressure ulcers, health care–associated infections, etc. • Organizations can monitor their rates of falls, pressure ulcers, infections, unplanned hospitalizations, and emergency room visits to identify problematic trends and determine where changes need to occur

14. Technology and Nursing Home Safety • Technology systems can identify high-risk patients (e.g., pressure ulcer risk, fall risk, etc.) or high-risk processes (e.g., anticoagulant use)to assure appropriate management • May also generate alerts when safety systems have failed (e.g., medication error) • In this case, such a report might have alerted staff about an increased pressure ulcer risk

15. Role of the Providers • Providers including administrators, physicians, nurses, and frontline caregivers play the greatest role in resident safety through ongoing communicating and feedback about resident- or organization-specific risks • Nursing homes may consider daily safety briefings to share concerns about resident safety • Multi-disciplinary teams can work together to assess and modify care for high-risk patients

16. Path to Better Safety • Improving safety requires two key steps: • Nursing home leaders and staff must be willing to access and respond to information about safety risks • Staff must be willing to report and leaders must act when safety concerns arise • These steps require a culture where leaders and staff share values and beliefs that resident safety is a priority See Notes for reference.

17. Take-Home Points • Many challenges exist in nursing homes that may contribute to the occurrence of adverse events • Monitoring systems designed to identify both resident level and organizational level risk for adverse events are critical to improve the quality and safety of nursing home care • To ensure resident quality and safety in nursing homes, it is essential that a culture exists where administrators, physicians, nurses, and frontline caregivers access and respond to information alerting them to safety risks