Against all odds

A health department shutdown was averted and compliance achieved in 90 days.

Against All Odds

AMIE M O D I G H SANDRA L. VENEGONI In January 1982, the nursing home administrator of a 250-bed proprietary intermediate care facility in St. Louis, with about an 85 percent Medicaid population, contacted St. Louis University Medical Center to propose a mutually beneficial relationship. The Medical Center would provide pharmaceutical, laboratory, and acute care services for the residents when needed. In turn, physicians from the medical center could admit patients who needed long-term care. The four physicians who made up the primary care department at the medical center were to provide medical care to the nursing home residents, with plans to appoint a geriatric nurse practitioner (GNP) as soon as obtainable. One of the four physicians who had a great deal of interest and expertise in geriatric medicine was appointed medical director. Amie Modigh, RN, MSN, GNP, is associate chief for geriatric services at Hunter-Holmes McGuire VA Medical Center and is clinical professor at the Schools of Medicine and Nursing at the Medical College of Virginia, Richmond, VA. Sandra L. Venegoni, RN, MN, ANP, is a doctoral student in nursing administration at the Medical College of Virginia, Richmond, VA.

Each physician was to spend part of one afternoon a week seeing patients in the nursing home clinic. The medical director was to participate in department head meetings at the home. At the time, there were approximately 60 residents. About a year later following a federal inspection, the nursing home received a letter stating essentially that if there was not a "substantial" improvement in 90 days, it would be closed by the federal agency. Changes would have to be made and structures reorganized. Low staff morale and union problems complicated the issue. On February 1, 1983, a master's prepared RN with extensive background in clinical geriatrics was appointed director of nursing (DON). She had six years of clinical and administrative experience in a combination nursing-retirement home and six years of teaching experience in bachelor's and master's programs. She was to be paid by the medical center (salary and benefits) and had a clinical appointment with the School of Nursing. After accepting the position, the DON was almost overwhelmed by the initial shock of learning about the multiple federal and state deficiencies. In fact, the DON was informally

told by a sympathetic inspector that the task was virtually impossible and that she was wasting her time. Concurrently, the medical center employed a GNP with a master's in nursing. She had a joint appointment with the Schools of Medicine and Nursing and would work clinically with the primary care physicians. She had experience in teaching, administration, and clinical geriatrics and gerontology. Both she and the D O N had worked together on the same faculty and at the same nursing-retirement home. Because of their prior success in creating an outstanding facility for the elderly, they saw this as another opportunity to improve health care for the elderly in a different setting. Administrative nursing supervisory staff comprised two assistant DONs, one supervisor for each shift, and a day and evening charge nurse on the heaviest care floor. Staffing for the rest of the facility conformed to the minimal level of long-term-care standards for nursing care for the state of Missouri. The DON, ADONs, administrator, GNP, and physicians at the outset met to plan strategies. Then, the DON met with the nursing staffand spelled out her expectations of them and invited the same from them. She made herself visible to all shifts, and she or the ADON made rounds daily on all floors. In addition, all staff knew they had access to the DON by appointment. Weekly meetings were held with

Geriatric Nursing Selatember/October. 1988 289

the support staff to monitor problems and progress. Weekly rounds on all shifts by all department heads were held to encourage teamwork and to develop a milieu therapy for the residents. Whenever an undesirable activity was reported, it was dealt with immediately and objectively with proper disciplinary action. Similarly, if a goal was accomplished or praise was given by the patients or family, personal congratulations and usually a memo posted on the employees' bulletin board immediately followed. Staff were informed by memos to each floor regarding the results of any inspections or policy and other changes. Prior to the arrival of the GNP, all medical problems were handled by the physicians. Staff would call for any change in condition, diet, or physical therapy, need for medications, or results of lab work or other tests. Gradually, the GNP was introduced by memos, at staff meetings, and by making afternoon rounds to talk with staff and residents. Only one staffmember had any concept of a nurse practitioner; consequently the need for good explanations and demonstrations was evident. The GNP carded out all admission assessments, taking complete histories, doing physical exams, and ordering lab work. These were discussed with and signed by one of the physicians. She then helped the staff with the nursing care plans. It was interesting and rewarding to observe the staffs changing reaction over a rather short period. During the first week, staff politely listened to what the role o f a GNP was and how she could help them. By the second and third week, some of the staff, motivated by curiosity, followed the GNP into some of the residents' rooms and asked if they could observe her examinations and interactions. The GNP quickly used those times for teaching and also took advantage of appropriate opportunities to compliment the nurses on their patient care. The DON asked that charge nurses send to the nursing office a daily list of residents they wanted checked by the GNP on her rounds. Few names

appeared the first couple of weeks. As the list grew, it became a useful tool for planning time, conference topics, and teaching. Less than 6 weeks after the inception, the GNP was used freely by all staff. Staff knew what the GNP could and couldn't do, understood her liaison role with the physicians, and appeared to be truly interested in learning all they could. Any questions regarding patients were first directed to the GNP. She would assess the patients, discuss results with the staff, phone physicians as appropriate, write telephone orders, and be available to staff for any needed explanations and/or demonstrations of care to be implemented.

In-service education was provided by the GNP on a variety of topics, including physical, physiological, and emotional needs of patients. The GNP's presence stimulated staffs independent learning on all levels. Nursing assistants sometimes brought in articles they had read regarding some aspect of health, and many useful informal teaching sessions resulted from these. One LPN suggested using a treatment plan for decubitus ulcers that she found successful in another setting. A comparison was conducted using her method for one resident and the GNP's for another. The decubiti compared in this study were approximately the same size, and the patient's conditions were similar. The patient treated with the LPN's

290 GeriatricNursing September/October 1988

remedy healed faster. This led to further collaborative efforts (and a lot of fun and pride), all resulting in improved patient care. The DON and A D e N worked with members of other departments to devise an assessment tool that would enable them to provide appropriate patient care. In order to comply with state regulations, a daily patient-care conference was held. At this time, the DON and A D e N met with the charge nurse, chaplain, speech therapist, GNP, physician (on occasion), and a representative from the dietary, physical therapy, social work, and activities departments and instituted or revised the health care plans for two or three patients presented by the charge nurse. These patients were either present with the group or were informed of the plan by a representative from the team at a later time. The assessment tool used allowed for a quick overall picture of areas in which patients had improved or regressed. Thus, a O in the category of continence on admission and a 2 three months later indicated some degree of incontinence. An assessment and plan to improve this would follow. These daily meetings proved to be productive for continuity of care of the residents and further led to improved morale among the staff as they became interested in devising ways to improve patient care and quality of life. The 90-day deadline approached rapidly. Although everyone realized that there was improvement, all were anxious when the federal team appeared for their week-long inspection. Finally, the exit evaluation was held. The main speaker for the inspection team stated, "Before we go over changes in individual deficiencies from last inspection, I would like to make an announcement on behalf of the entire team. None of us in all our years of experience have ever seen an improvement like this in 90 days." The administrative staff, medical director, GNP, and charge nurses from all floors were proud, relieved, excited, and motivated to continue striving toward their goals. The enthusiasm quickly spread to the rest of

the staff, all of whom were congratulated and praised for their invaluable contributions to making the evaluation successful. Measurement of quality in longterm care is accomplished through either structure, process, or outcome components(l). In this program, both physical and functional changes (outcome components) were measured at the time of each resident's 30day assessment. Specific changes such as increase or decrease in functional status and complications (for example, decibutus ulcer or hospital admission) were tabulated at the end of each month. These outcome components were then incorporated into the disciplinary team conferences and nursing care plans. In November 1983, a written summary was prepared of successes, failures, goals met, and areas in need of further improvement. The number of resident falls decreased by 28 percent in nine months. Undoubtedly, several factors were involved. The GNP at, d physicians had decreased or stopped countless orders of psychotropic and tranquilizing drugs, which patients were receiving at the time of admission from orders by previous health care providers. In many instances, antihypertensive drugs had been decreased or discontinued. General alertness by nursing and housekeeping staff to objects and liquids on the floors and special attention to footwear helped in decreasing the number of falls. Bowel and bladder training programs were quite successful. In January 1983, 18 percent of the residents were using Foley catheters; only 2.4 percent still used them in November. Over one-half of the residents who had their catheters removed became fully continent by November 1. One of the most dramatic improvements was the decrease in decubitus ulcers. In February 1983,just over 30 percent of the residents had some degree of decubitus ulcer. On November 1, these ulcers were present in 10 percent of the residents and 6 percent of those patients were still improving (4 percent were the same, worse, or deceased). It is strongly felt that good nursing care with vigorous treatment and detection of early

signs and symptoms were vital in decreasing this ever present problem. In the area of hospital admissions, the number of patients admitted to the hospital during a 6-month period in 1982 was almost the same as during the 6-month period in 1983 after the program began. Yet the patient population at the nursing home had increased by over 85 percent (110 residents). Since this is not a formal research project, one can only speculate that improved nursing care, close collaboration in patient-care planning, and the daily presence of the GNP all contributed to the proportionate decrease in hospital admissions. Prior to the GNP's amval, when Mrs. S vomited, was slightly confused, and had a liquid stool, she more than likely would have been sent to the hospital. Now however, the GNP was consulted first. She assessed the patient and discovered a fecal impaction. This was removed, and the patient was relieved and resumed taking fluids. A few hours later, Mrs. S was eating dinner in the dining room. So too with Mr. J who was experiencing some increased shortness of breath and swollen ankles. On assessment, the G N P heard a gallop on the cardiac exam and found his lungs clear and pitting edema of the lower extremities. A call to the physician led to orders for digitalization, a diuretic, potassium chloride, laboratory work, and an x-ray. However, Mr. J was managed in the nursing home. The GNP rechecked him at the end of the day, and on the following day the physician examined Mr. J during his regularly scheduled visit. The patient had already improved. Prior to this program, both patients most likely would have been needlessly admitted to the hospital. However, when any patients needed hospitalization it was quickly and expeditiously carried out by the GNP/ MD team. Many terminally ill patients who in the past had been rushed to the hospital at the first sign of impending death were now first assessed by the GNP. Thus, many patients were spared the agony of being rushed by ambulance to an emergency room

where tubes and needles were attached and one or two days later they died. Instead, they were allowed to die with dignity in their "home" where they had supportive care with loved ones at their sides. It took time, classes, and informal discussions before most staff members accepted death in the nursing home. However, as they did they also became quite skilled in supportive care of both patients and families. Another informal observation worth mentioning was that the need for the physician at the nursing home decreased considerably when the GNP was present on a daily basis. In fact, in the first four months phone calls to the physicians decreased by 90 percent. Because the GNP's educational background included advanced studies and practice in interviewing skills and clinical assessment of the elderly, the physician's medical expertise was not needed for the admission history and physical exam. In addition, monthly assessment of each resident was done by the GNP and confirmed with the physician. These facts would undoubtedly prove to be cost effective. Of course, when abnormalities of any complicated nature were discovered, the expertise of the physician was needed and always available. No doubt there were many factors that contributed to this nursing home's success. That the medical director was a geriatrician when there are so few and that the DON and GNP were educated and experienced in geriatrics and gerontology greatly helped in improving the care(2). More stable and knowledgeable staff, availability of medical expertise, and improved nursing care were all vital factors that contributed to the improved quality of life and death for the residents at this nursing home. References I. Kurowski, B. D., and Shaughnessy, P. W. The measurement and assurance of quality. IN LongTerm Care: Perspectivesfrom Research and Demonstrations, ed. by R. J. Vogel and Hans Palmers. Rockville, MD, Aspen Publications, 1984, pp. 105. 2. LI.S. National Institute on Aging. Report on Education and Training in Geriatrics and Gerontology. Washington, D.C., U.S. Government Printing Ofrice, 1984, p. 14.

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