- Email: [email protected]
Rapid Cycles (Continuous Quality Improvement), an Essential Part of the Medical Director's Role
EDITORIALS
Rapid Cycles (Continuous Quality Improvement), an Essential Part of the Medical Director’s Role John E. Morley, MB, BCh Despite the emphasis on quality improvement in long-term care, there is a paucity of studies examining its effectiveness.1,2 Available studies tend to show that quality improvement projects improve staff satisfaction, but have not been clearly shown to improve overall outcomes.3 Report cards developed by the Centers for Medicare and Medicaid Services have limited values as they fail to adjust for differences in risk in different long-term care facilities.4 Clearly there is a need to use multilevel modeling to make Nursing Home Compare useful to the public.5 Inappropriate approaches to quality reporting and improvement by government agencies and facilities represents a major inhibition to improving care.6 Chart documentation as used for the development of the Minimum Data Set has been shown not to relate to the level of care received.7–9 The latest popular approach to improving quality of care in nursing homes is rapid cycles. This is the “plan-do-study-act” approach and is a component of continuous quality improvement.10 Based on articles in the Journal over the past few years, we have developed the top 10 areas in which the medical director can develop rapid cycles to improve quality of care (Table 1). An area of major problems for most physicians and nurses is out-of-hours telephone conversations.11,12 A simple education program for nurses on the evening and night shifts coupled with a reporting form that is completed before phoning the physician will greatly improve communication (Table 2). In addition, physicians should keep a log of calls received and action taken.13 The program is studied by comparing monthly the number of nursing forms completed, the physician logs, and outcomes. A similar simple approach can be used for a communication sheet for when the resident is
Saint Louis University School of Medicine and GRECC, VA Medical Center, St. Louis, MO. Address correspondence to John E. Morley, MB, BCh, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Blvd., M238, St. Louis, MO 63104. E-mail: [email protected]
Published by Elsevier, Inc. on behalf of the American Medical Directors Association DOI: 10.1016/j.jamda.2008.08.001 EDITORIAL
sent to the emergency department or for a visit to an outside physician.14 –16 Falls are inevitable and the focus needs to be on reducing injurious falls.17,18 Recent studies have clearly demonstrated a key role for low vitamin D levels in injurious falls.19 –24 Thus, a simple rapid cycle is to determine if all residents have had vitamin D levels measured and to create a standing order for this to be done in all residents on admission and thereafter in January of subsequent years. The appropriate use of vitamin D should then be measured. The prevalence of bisphosphonate use in the facility can be another rapid cycle.25–27 In all persons who fall, orthostasis should be measured.28 This should be the focus of another rapid cycle. Two quality improvement programs for falls have recently been reported in the Journal.29,30 Warfarin use can be a major problem in long-term care.31–34 A rapid cycle introducing the use of the Internet site www.warfarindosing.org for developing appropriate doses of warfarin with a copy placed in the chart by the pharmacist will improve outcomes. Another rapid cycle could train dispensing pharmacists to contact the physician when a drug that will interact with warfarin is prescribed. The number of pressure ulcers acquired in the facility should be reported monthly to the medical director.35–37 Any increase in pressure ulcers should lead to a rapid cycle to determine the cause of the variation. The pharmacist and the medical director should provide a printout of the number of scheduled and nonscheduled med-
Table 1. The Top Ten Areas for The Medical Director to Improve Quality of Care 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Telephone Conversations Transitional Care Falls and Hip Fracture Coumadin Use Pressure Ulcers Inappropriate Medications Pain Control Urinary Incontinence Weight Loss Exercise
Morley 535
Table 2. Simple Communication Tool for Nurse-Physician Interaction Problem: Does the resident have a change in behavior? Has the resident had a recent fall? Is the resident complaining of pain? Vital Signs: BP____/____ Pulse____ RR____ Temp____ % Oxygen Saturation____ If the resident had a fall, blood pressure should be measured standing and lying: Is the patient on coumadin? Does the patient have any allergies? (HAVE MEDICATION LIST AVAILABLE) Physician Instructions:
Medications (eg, digoxin, theophylline, cimetidine) Emotional (depression) Alcoholism, anorexia tardive, abuse (elder) Late life paranoia Swallowing problems Oral problems Nosocomial infections Wandering/dementia Hyperthyroidism, hypercalcemia, hypoadrenalism, hyperglycemia Enteral problems (malabsorption) Eating problems (eg, tremor) Low-salt, low-cholesterol diet Stones (cholecystitis)
icines and the use of antipsychotics and anxiolytics to each physician in the facility (Table 3). The list should allow the physician to compare his or her performance to other physicians in the facility. The medical director, pharmacist, and director of nursing should meet monthly to review the charts of residents who are on more than 12 medicines or on inappropriate medications.38 – 42 Suggested changes should be provided to the resident’s physician. Four to 5 charts should be reviewed each month. Education on the recognition and approach to pain management should be given to aides and all nurses.43–50 Pain scales should be instituted.51 Buttons proclaiming “ask me about your pain” should be worn by all staff.52 Comfort kits for pain management should be available. The utility of scheduled pain medicines should be stressed. The importance of believing the resident’s perception of his or her pain should be understood. Each section of the nursing home and each shift should have a nurse champion. Zarowitz and Ouslander53,54 have reviewed the application of evidence-based principles of care for urinary incontinence. Other articles in the Journal have provided possible approaches to enhancing care for urinary incontinence.55–57 Weight loss is an important monitor for the development of problems in nursing home residents.58,59 Depression is the number 1 cause of weight loss in nursing home residents.60 – 65 All residents with weight loss should have the geriatric de-
Table 3. Quality Assurance Table to Allow Physicians to Compare Their Medication Use Physician
A
Medicines/Patient As Needed Medications (PRN)/Patient % Antipsychotics % Anxiolytics % Sedatives
12.2 5.1
536 Morley
38 25 45
B 6.8 2.2 16 8 4
C 15.4 3.8 33 7 6
D 7.6 2.7 12 15 8
Table 4. MEALS-ON-WHEELS Mnemonic: Causes of Weight Loss67
E 8.2 3.1 24 32 0
pression scale or the Cornell depression index measured.57,60 Monthly review of residents with weight loss with the dietitian, pharmacist, director of nursing, and medical director should be undertaken. Using the “MEALS-ON-WHEELS” mnemonic to identify treatable causes of weight loss can be helpful (Table 4).66,67 Use of a hydration and nutrition cart between meals and the delivery of caloric supplements 2 hours before meals will improve intake.68 Rapid cycles to investigate the behaviors of the residents, nurses, and aides can resolve feeding problems.69 –72 Finally, the emerging evidence of the importance of exercise in decreasing agitation, cognitive decline, depression, falling, and fear of falling requires that all medical directors push the need for exercise programs at the monthly quality assurance meetings.73–76 Obviously there are many other continuous quality improvement programs and rapid cycles that can be developed.77– 83 We request that our readers send us letters or brief clinical reports explaining their favorite program. REFERENCES 1. Morley JE, Flaherty JH, Thomas DR. Geriatricians, continuous quality improvement, and improved care for older persons. J Gerontol A Biol Sci Med Sci 2003;58:M809 –M812. 2. Schnelle JF. Continuous quality improvement in nursing homes: Public relations or a reality? J Am Med Dir Assoc 2007;8:S2–S5. 3. Berlowitz DR, Young GJ, Hickey EC, et al. Quality improvement implementation in the nursing home. Health Serv Res 2003;38:65– 83. 4. Mukamel DB, Glance LG, Li Y, et al. Does risk adjustment of the CMS quality measures for nursing homes matter? Med Care 2008;46:532–541. 5. Arling G, Lewis T, Kane RL, et al. Improving quality assessment through multilevel modeling: The case of nursing home compare. Health Serv Res 2007;42:1177–1199. 6. Taunton RL, Piamjariyakul U, Gajewski B, et al. Care planning integrity in nursing facilities. Nurs Res 2008;57:271–282. 7. Schnelle JF, Cadogan MP, Yoshii J, et al. The minimum data set urinary incontinence quality indicators: Do they reflect differences in care processes related to incontinence? Med Care 2003;41:909 –922. 8. Bates-Jensen BM, Simmons SF, Schnelle JF, Alessi C. Evaluating the accuracy of minimum data set bed-mobility ratings against independent performance assessments: Systematic error and directions for improvement. Gerontologist 2005;45:731–738. 9. Del Rio RA, Goldman M, Kapella BK, et al. The accuracy of Minimum Data Set diagnoses in describing recent hospitalization at acute care facilities. J Am Med Dir Assoc 2006;7:212–218. JAMDA – October 2008
10. Monteleoni C, Clark E. Using rapid-cycle quality improvement methodology to reduce feeding tubes in patients with advanced dementia: Before and after study. BMJ 2004;329:491– 494. 11. Hastings SN, Whitson HE, White HK, et al. After-hours calls from long-term care facilities in a geriatric medicine training program. J Am Geriatr Soc 2007;55:1989 –1994. 12. Whitson HE, Hastings SSN, Lekan DA, et al. A quality improvement program to enhance after-hours telephone communication between nurses and physicians in a long-term care facility. J Am Geriatr Soc 2008;56:1080 –1086. 13. Hastings SN, Whitson HE, White HK, et al. Development and implementation of the TrAC (Tracking After-hours Calls) database: A tool to collect longitudinal data on after-hours telephone calls in long-term care. J Am Med Dir Assoc 2007;8:178 –182. 14. Terrell KM, Miller DK. Challenges in transitional care between nursing homes and emergency departments. J Am Med Dir Assoc 2006;7:499 –505. 15. McFetridge B, Gillespie M, Goode D, Melby V. An exploration of the handover process of critically ill patients between nursing staff from the emergency department and the intensive care unit. Nurs Crit Care 2007;12:261–269. 16. Jones JS, Swyer PR, White LJ, Firman R. Patient transfer from nursing home to emergency department: Outcomes and policy implications. Acad Emerg Med 1997;4:908 –915. 17. Morley JE. Falls and fractures. J Am Med Dir Assoc 2007;8:276 –278. 18. Dharmarajan TS. Falls and fractures linked to anemia, delirium, osteomalacia, medications, and more: The path to success is strewn with obstacles! J Am Med Dir Assoc 2007;8:549 –550. 19. Zarowitz BJ, Stefanacci R, Hollenack K, O’Shea T. The application of evidence-based principles of care in older persons (issue I): Management of osteoporosis. J Am Med Dir Assoc 2007;8:e51– e57. 20. Munir J, Wright RJ, Carr DB. A quality improvement study on calcium and vitamin D supplementation in long-term care. J Am Med Dir Assoc 2007;8:e19 – e23. 21. Drinka PJ, Krause PF, Nest LJ, Goodman BM. Determinants of vitamin D levels in nursing home residents. J Am Med Dir Assoc 2007;8:76 –79. 22. Hamid Z, Riggs A, Spencer T, et al. Vitamin D deficiency in residents of academic long-term care facilities despite having been prescribed vitamin D. J Am Med Dir Assoc 2007;8:71–75. 23. Morley JE. Should all long-term care residents receive vitamin D? J Am Med Dir Assoc 2007;8:69 –70. 24. Drinka PJ. The importance of parathyroid hormone and vitamin D status in the treatment of osteoporosis and renal insufficiency. J Am Med Dir Assoc 2006;7:S5–S9. 25. Wright RM. Use of osteoporosis medications in older nursing facility residents. J Am Med Dir Assoc 2007;8:453– 457. 26. Kamel HK. Update of osteoporosis management in long-term care: Focus on bisphosphonates. J Am Med Dir Assoc 2007;8:434 – 440. 27. Duque G, Mallet L, Roberts A, et al. To treat or not to treat, that is the question: Proceedings of the Quebec symposium for the treatment of Osteoporosis in long-term care institutions.Saint-Hyacinthe, Quebec, November 5, 2004. J Am Med Dir Assoc 2007;8:e67– e73. 28. Iwanczyk L, Weintraub NT, Rubenstein LZ. Orthostatic hypotension in the nursing home setting. J Am Med Dir Assoc 2006;7:163–167. 29. Taylor JA, Parmelee P, Brown H, et al. A model quality improvement program for the management of falls in nursing homes. J Am Med Dir Assoc 2007;8:S26 –S36. 30. Montero-Odasso M, Levinson P, Gore B, et al. A flowchart system to improve fall data documentation in a long-term care institution: A pilot study. J Am Med Dir Assoc 2007;8:300 –306. 31. Weinberg AD, Altman JS, Pals JK. Quality improvement case study: Warfarin sodium interactions. J Am Med Dir Assoc 2006;7:315–318. 32. Chafin CC, Ritter BA, James A, Self TH. Hospital admission due to warfarin potentiation by TMP-SMX. Nurse Pract 2000;25:73–75. 33. Gheno G, Cinetto L. Levofloxacin-warfarin interaction. Eur J Clin Pharmacol 2001;57:427. EDITORIAL
34. Dharmarajan TS, Varma S, Akkaladevi S, et al. To anticoagulate or not to anticoagulate? A common dilemma for the provider: Physicians’ opinion poll based on a case study of an older long-term care facility resident with dementia and atrial fibrillation. J Am Med Dir Assoc 2006;7:23–28. 35. Thomas DR. Managing pressure ulcers: Learning to give up cherished dogma. J Am Med Dir Assoc 2007;8:347–348. 36. Jones KR, Fennie K. Factors influencing pressure ulcer healing in adults over 50: An exploratory study. J Am Med Dir Assoc 2007;8:378 –387. 37. Berlowitz DR, Frantz RA. Implementing best practices in pressure ulcer care: The role of continuous quality improvement. J Am Med Dir Assoc 2007;8:S37–S41. 38. Zuckerman IH, Langenberg P, Baumgarten M, et al. Inappropriate drug use and risk of transition to nursing homes among community-dwelling older adults. Med Care 2006;44:722–730. 39. Glew CM, Rentler RJ. Use of proton pump inhibitors and other acid suppressive medications in newly admitted nursing facility patients. J Am Med Dir Assoc 2007;8:607– 609. 40. Takahashi PY, North F. Pilot study of inappropriate medications and balance: A study in a continuous care center. J Am Med Dir Assoc 2007;8:545. 41. Jervis LL, Shore J, Hutt E, Manson SM. Suboptimal pharmacotherapy in a tribal nursing home. J Am Med Dir Assoc 2007;8:1–7. 42. Swagerty D, Brickley R; American Medical Directors Association, American Society of Consultant Pharmacists. American Medical Directors Association and American Society of Consultant Pharmacists joint position statement on the Beers List of Potentially Inappropriate Medications in Older Adults. J Am Med Dir Assoc 2005;6:80 – 86. 43. Teno JM, Kabumoto G, Wetle T, et al. Daily pain that was excruciating at some time in the previous week: Prevalence, characteristics, and outcomes in nursing home residents. J Am Geriatr Soc 2004;52:762–767. 44. Tait RC, Chibnall JT. Under-treatment of pain in dementia: Assessment is key. J Am Med Dir Assoc 2008;9:372–374. 45. Keeney CE, Scharfenberger JA, O’Brien JG, et al. Initiating and sustaining a standardized pain management program in long-term care facilities. J Am Med Dir Assoc 2008;9:347–353. 46. Sawyer P, Lillis JP, Bodner EV, Allman RM. Substantial daily pain among nursing home residents. J Am Med Dir Assoc 2007;8:158 –165. 47. Hollenack KA, Cranmer KW, Zarowitz JB, O’Shea T. The application of evidence-based principles of care in older persons (issue 4): Pain management. J Am Med Dir Assoc 2006;7:514 –522. 48. Gallagher R, Drance E, Higginbotham S. Finding the person behind the pain: Chronic pain management in a patient with traumatic brain injury. J Am Med Dir Assoc 2006;7:432– 434. 49. Cipher DJ, Clifford PA, Roper KD. Behavioral manifestations of pain in the demented elderly. J Am Med Dir Assoc 2006;7:355–365. 50. Buhr GT, White HK. Quality improvement initiative for chronic pain assessment and management in the nursing home: A pilot study. J Am Med Dir Assoc 2006;7:246 –253. 51. Schuler MS, Becker S, Kaspar R, et al. Psychometric properties of the German “Pain Assessment in Advanced Dementia Scale” (PAINAD-G) in nursing home residents. J Am Med Dir Assoc 2007;8:388 –395. 52. Baier RR, Gifford DR, Patry G, et al. Ameliorating pain in nursing homes: A collaborative quality-improvement project. J Am Geriatr Soc 2004;52:1988 –1995. 53. Zarowitz BJ, Ouslander JG. The application of evidence-based principles of care in older persons (issue 6): Urinary incontinence. J Am Med Dir Assoc 2007;8:35– 45. 54. Ouslander JG. Quality improvement initiatives for urinary incontinence in nursing homes. J Am Med Dir Assoc 2007;8:S6 –S11. 55. Schnelle JF, Ousland JG. CMS guidelines and improving continence care in nursing homes: The role of the medical director. J Am Med Dir Assoc 2006;7:131–132. 56. Lawhorne LW, Ouslander JG, Parmelee PA, et al. Urinary incontinence: A neglected geriatric syndrome in nursing facilities. J Am Med Dir Assoc 2008;9:29 –35. 57. Etheridge F, Tannenbaum C, Couturier Y. A systemwide formula for continence care: Overcoming barriers, clarifying solutions, and defining team members’ roles. J Am Med Dir Assoc 2008;9:178 –189. Morley 537
58. Morley JE. Weight loss in the nursing home. J Am Med Dir Assoc 2007;8:201–204. 59. Morley JE. Weight loss in older persons: New therapeutic approaches. Curr Pharm Des 2007;13:3637–3647. 60. Thakur M, Blazer DG. Depression in long-term care. J Am Med Dir Assoc 2008;9:82– 87. 61. Harris Y. Depression as a risk factor for nursing home admission among older individuals. J Am Med Dir Assoc 2007;8:14 –20. 62. Cabrera MA, Mesas AE, Garcia AR, de Andrade SM. Malnutrition and depression among community-dwelling elderly people. J Am Med Dir Assoc 2007;8:582–584. 63. Morley JE, Kraenzle D. Causes of weight loss in a community nursing home. J Am Geriatr Soc 1994;42:583–585. 64. Morley JE, Thomas DR. Cachexia: New advances in the management of wasting diseases. J Am Med Dir Assoc 2008;9:205–210. 65. Yeh SS, Lovitt S, Schuster MW. Pharmacological treatment of geriatric cachexia: Evidence and safety in perspective. J Am Med Dir Assoc 2007;8:363–377. 66. Morley JE. Decreased food intake with aging. J Gerontol A Biol Sci Med Sci 2001;56:81– 88. 67. Morley JE, Silver AJ. Nutritional issues in nursing home care. Ann Intern Med 1995;123:850 – 859. 68. Wilson MM, Purushothaman R, Morley JE. Effect of liquid dietary supplements on energy intake in the elderly. Am J Clin Nutr 2002;75: 944 –947. 69. Simmons SF. Quality improvement for feeding assistance care in nursing homes. J Am Med Dir Assoc 2007;8:S12–S17. 70. Chang JC, Finucane TE, Christmas C, et al. Nutrition and involuntary weight loss: A pilot study of an educational intervention for nursing home surveyors. J Am Med Dir Assoc 2007;8:110 –114. 71. Aoyama L, Weintraub N, Reuben DB. Is weight loss in the nursing home a reversible problem? J Am Med Dir Assoc 2006;7:S66 –S72.
538 Morley
72. Keller HH, Gibbs-Ward A, Randall-Simpson J, et al. Meal rounds: An essential aspect of quality nutrition services in long-term care. J Am Med Dir Assoc 2006;7:40 – 45. 73. Morley JE. The magic of exercise. J Am Med Dir Assoc 2008;9:375–377. 74. Colberg SR, Somma CT, Sechrist SR. Physical activity participation may offset some of the negative impact of diabetes on cognitive function. J Am Med Dir Assoc 2008;9:434 – 438. 75. Hui EK, Rubenstein LZ. Promoting physical activity and exercise in older adults. J Am Med Dir Assoc 2006;7:310 –314. 76. Volicer L, Simard J, Pupa JH, et al. Effects of continuous activity programming on behavioral symptoms of dementia. J Am Med Dir Assoc 2006;7:426 – 431. 77. Handler SM, Perera S, Olshansky EF, et al. Identifying modifiable barriers to medication error reporting in the nursing home setting. J Am Med Dir Assoc 2007;8:568 –574. 78. Morley JE. Caring for the vulnerable elderly: Are available quality indicators appropriate? J Am Med Dir Assoc 2008;9:1–3. 79. Chang JC, Finucane TE, Christmas C, et al. Nutrition and involuntary weight loss: A pilot study of an educational intervention for nursing home surveyors. J Am Med Dir Assoc 2007;8:110 –114. 80. Mor V. Defining and measuring quality outcomes in long-term care. J Am Med Dir Assoc 2007;8:e129 – e137. 81. Schnelle JF, Ouslander JG, Simmons SF. Direct observations of nursing home care quality: Does care change when observed? J Am Med Dir Assoc 2006;7:541–544. 82. Shah MN, Fairbanks RJ, Lerner EB. Cardiac arrests in skilled nursing facilities: Continuing room for improvement? J Am Med Dir Assoc 2006;7:350 –354. 83. Morley JE, Flaherty JH, Thomas DR. Geriatricians, continuous quality improvement, and improved care for older persons. J Gerontol A Biol Sci Med Sci 2003;58:M809 –M812.
JAMDA – October 2008
Rapid Cycles (Continuous Quality Improvement), an Essential Part of the Medical Director’s Role John E. Morley, MB, BCh Despite the emphasis on quality improvement in long-term care, there is a paucity of studies examining its effectiveness.1,2 Available studies tend to show that quality improvement projects improve staff satisfaction, but have not been clearly shown to improve overall outcomes.3 Report cards developed by the Centers for Medicare and Medicaid Services have limited values as they fail to adjust for differences in risk in different long-term care facilities.4 Clearly there is a need to use multilevel modeling to make Nursing Home Compare useful to the public.5 Inappropriate approaches to quality reporting and improvement by government agencies and facilities represents a major inhibition to improving care.6 Chart documentation as used for the development of the Minimum Data Set has been shown not to relate to the level of care received.7–9 The latest popular approach to improving quality of care in nursing homes is rapid cycles. This is the “plan-do-study-act” approach and is a component of continuous quality improvement.10 Based on articles in the Journal over the past few years, we have developed the top 10 areas in which the medical director can develop rapid cycles to improve quality of care (Table 1). An area of major problems for most physicians and nurses is out-of-hours telephone conversations.11,12 A simple education program for nurses on the evening and night shifts coupled with a reporting form that is completed before phoning the physician will greatly improve communication (Table 2). In addition, physicians should keep a log of calls received and action taken.13 The program is studied by comparing monthly the number of nursing forms completed, the physician logs, and outcomes. A similar simple approach can be used for a communication sheet for when the resident is
Saint Louis University School of Medicine and GRECC, VA Medical Center, St. Louis, MO. Address correspondence to John E. Morley, MB, BCh, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Blvd., M238, St. Louis, MO 63104. E-mail: [email protected]
Published by Elsevier, Inc. on behalf of the American Medical Directors Association DOI: 10.1016/j.jamda.2008.08.001 EDITORIAL
sent to the emergency department or for a visit to an outside physician.14 –16 Falls are inevitable and the focus needs to be on reducing injurious falls.17,18 Recent studies have clearly demonstrated a key role for low vitamin D levels in injurious falls.19 –24 Thus, a simple rapid cycle is to determine if all residents have had vitamin D levels measured and to create a standing order for this to be done in all residents on admission and thereafter in January of subsequent years. The appropriate use of vitamin D should then be measured. The prevalence of bisphosphonate use in the facility can be another rapid cycle.25–27 In all persons who fall, orthostasis should be measured.28 This should be the focus of another rapid cycle. Two quality improvement programs for falls have recently been reported in the Journal.29,30 Warfarin use can be a major problem in long-term care.31–34 A rapid cycle introducing the use of the Internet site www.warfarindosing.org for developing appropriate doses of warfarin with a copy placed in the chart by the pharmacist will improve outcomes. Another rapid cycle could train dispensing pharmacists to contact the physician when a drug that will interact with warfarin is prescribed. The number of pressure ulcers acquired in the facility should be reported monthly to the medical director.35–37 Any increase in pressure ulcers should lead to a rapid cycle to determine the cause of the variation. The pharmacist and the medical director should provide a printout of the number of scheduled and nonscheduled med-
Table 1. The Top Ten Areas for The Medical Director to Improve Quality of Care 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Telephone Conversations Transitional Care Falls and Hip Fracture Coumadin Use Pressure Ulcers Inappropriate Medications Pain Control Urinary Incontinence Weight Loss Exercise
Morley 535
Table 2. Simple Communication Tool for Nurse-Physician Interaction Problem: Does the resident have a change in behavior? Has the resident had a recent fall? Is the resident complaining of pain? Vital Signs: BP____/____ Pulse____ RR____ Temp____ % Oxygen Saturation____ If the resident had a fall, blood pressure should be measured standing and lying: Is the patient on coumadin? Does the patient have any allergies? (HAVE MEDICATION LIST AVAILABLE) Physician Instructions:
Medications (eg, digoxin, theophylline, cimetidine) Emotional (depression) Alcoholism, anorexia tardive, abuse (elder) Late life paranoia Swallowing problems Oral problems Nosocomial infections Wandering/dementia Hyperthyroidism, hypercalcemia, hypoadrenalism, hyperglycemia Enteral problems (malabsorption) Eating problems (eg, tremor) Low-salt, low-cholesterol diet Stones (cholecystitis)
icines and the use of antipsychotics and anxiolytics to each physician in the facility (Table 3). The list should allow the physician to compare his or her performance to other physicians in the facility. The medical director, pharmacist, and director of nursing should meet monthly to review the charts of residents who are on more than 12 medicines or on inappropriate medications.38 – 42 Suggested changes should be provided to the resident’s physician. Four to 5 charts should be reviewed each month. Education on the recognition and approach to pain management should be given to aides and all nurses.43–50 Pain scales should be instituted.51 Buttons proclaiming “ask me about your pain” should be worn by all staff.52 Comfort kits for pain management should be available. The utility of scheduled pain medicines should be stressed. The importance of believing the resident’s perception of his or her pain should be understood. Each section of the nursing home and each shift should have a nurse champion. Zarowitz and Ouslander53,54 have reviewed the application of evidence-based principles of care for urinary incontinence. Other articles in the Journal have provided possible approaches to enhancing care for urinary incontinence.55–57 Weight loss is an important monitor for the development of problems in nursing home residents.58,59 Depression is the number 1 cause of weight loss in nursing home residents.60 – 65 All residents with weight loss should have the geriatric de-
Table 3. Quality Assurance Table to Allow Physicians to Compare Their Medication Use Physician
A
Medicines/Patient As Needed Medications (PRN)/Patient % Antipsychotics % Anxiolytics % Sedatives
12.2 5.1
536 Morley
38 25 45
B 6.8 2.2 16 8 4
C 15.4 3.8 33 7 6
D 7.6 2.7 12 15 8
Table 4. MEALS-ON-WHEELS Mnemonic: Causes of Weight Loss67
E 8.2 3.1 24 32 0
pression scale or the Cornell depression index measured.57,60 Monthly review of residents with weight loss with the dietitian, pharmacist, director of nursing, and medical director should be undertaken. Using the “MEALS-ON-WHEELS” mnemonic to identify treatable causes of weight loss can be helpful (Table 4).66,67 Use of a hydration and nutrition cart between meals and the delivery of caloric supplements 2 hours before meals will improve intake.68 Rapid cycles to investigate the behaviors of the residents, nurses, and aides can resolve feeding problems.69 –72 Finally, the emerging evidence of the importance of exercise in decreasing agitation, cognitive decline, depression, falling, and fear of falling requires that all medical directors push the need for exercise programs at the monthly quality assurance meetings.73–76 Obviously there are many other continuous quality improvement programs and rapid cycles that can be developed.77– 83 We request that our readers send us letters or brief clinical reports explaining their favorite program. REFERENCES 1. Morley JE, Flaherty JH, Thomas DR. Geriatricians, continuous quality improvement, and improved care for older persons. J Gerontol A Biol Sci Med Sci 2003;58:M809 –M812. 2. Schnelle JF. Continuous quality improvement in nursing homes: Public relations or a reality? J Am Med Dir Assoc 2007;8:S2–S5. 3. Berlowitz DR, Young GJ, Hickey EC, et al. Quality improvement implementation in the nursing home. Health Serv Res 2003;38:65– 83. 4. Mukamel DB, Glance LG, Li Y, et al. Does risk adjustment of the CMS quality measures for nursing homes matter? Med Care 2008;46:532–541. 5. Arling G, Lewis T, Kane RL, et al. Improving quality assessment through multilevel modeling: The case of nursing home compare. Health Serv Res 2007;42:1177–1199. 6. Taunton RL, Piamjariyakul U, Gajewski B, et al. Care planning integrity in nursing facilities. Nurs Res 2008;57:271–282. 7. Schnelle JF, Cadogan MP, Yoshii J, et al. The minimum data set urinary incontinence quality indicators: Do they reflect differences in care processes related to incontinence? Med Care 2003;41:909 –922. 8. Bates-Jensen BM, Simmons SF, Schnelle JF, Alessi C. Evaluating the accuracy of minimum data set bed-mobility ratings against independent performance assessments: Systematic error and directions for improvement. Gerontologist 2005;45:731–738. 9. Del Rio RA, Goldman M, Kapella BK, et al. The accuracy of Minimum Data Set diagnoses in describing recent hospitalization at acute care facilities. J Am Med Dir Assoc 2006;7:212–218. JAMDA – October 2008
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72. Keller HH, Gibbs-Ward A, Randall-Simpson J, et al. Meal rounds: An essential aspect of quality nutrition services in long-term care. J Am Med Dir Assoc 2006;7:40 – 45. 73. Morley JE. The magic of exercise. J Am Med Dir Assoc 2008;9:375–377. 74. Colberg SR, Somma CT, Sechrist SR. Physical activity participation may offset some of the negative impact of diabetes on cognitive function. J Am Med Dir Assoc 2008;9:434 – 438. 75. Hui EK, Rubenstein LZ. Promoting physical activity and exercise in older adults. J Am Med Dir Assoc 2006;7:310 –314. 76. Volicer L, Simard J, Pupa JH, et al. Effects of continuous activity programming on behavioral symptoms of dementia. J Am Med Dir Assoc 2006;7:426 – 431. 77. Handler SM, Perera S, Olshansky EF, et al. Identifying modifiable barriers to medication error reporting in the nursing home setting. J Am Med Dir Assoc 2007;8:568 –574. 78. Morley JE. Caring for the vulnerable elderly: Are available quality indicators appropriate? J Am Med Dir Assoc 2008;9:1–3. 79. Chang JC, Finucane TE, Christmas C, et al. Nutrition and involuntary weight loss: A pilot study of an educational intervention for nursing home surveyors. J Am Med Dir Assoc 2007;8:110 –114. 80. Mor V. Defining and measuring quality outcomes in long-term care. J Am Med Dir Assoc 2007;8:e129 – e137. 81. Schnelle JF, Ouslander JG, Simmons SF. Direct observations of nursing home care quality: Does care change when observed? J Am Med Dir Assoc 2006;7:541–544. 82. Shah MN, Fairbanks RJ, Lerner EB. Cardiac arrests in skilled nursing facilities: Continuing room for improvement? J Am Med Dir Assoc 2006;7:350 –354. 83. Morley JE, Flaherty JH, Thomas DR. Geriatricians, continuous quality improvement, and improved care for older persons. J Gerontol A Biol Sci Med Sci 2003;58:M809 –M812.
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