The National Pressure Ulcer Long-Term Care Study: pressure ulcer development in long-term care residents

OBJECTIVES: To identify resident, treatment, and facility characteristics associated with pressure ulcer (PU) development in long-term care residents. DESIGN: Retrospective cohort study with convenience sampling. SETTING: Ninety-five long-term care facilities participating in the National Pressure Ulcer Long-Term Care Study throughout the United States. PARTICIPANTS: A total of 1,524 residents aged 18 and older, with length of stay of 14 days or longer, who did not have an existing PU but were at risk of developing a PU, as defined by a Braden Scale for Predicting Pressure Sore Risk score of 17 or less, on study entry. MEASUREMENTS: Data collected for each resident over a 12-week period included resident characteristics (e.g., demographics, medical history, severity of illness using the Comprehensive Severity Index, Braden Scale scores, nutritional factors), treatment characteristics (nutritional interventions, pressure management strategies, incontinence treatments, medications), staffing ratios and other facility characteristics, and outcome (PU development during study period). Data were obtained from medical records, Minimum Data Set, and other written records (e.g., physician orders, medication logs). RESULTS: Seventy-one percent of subjects (n=1,081) did not develop a PU during the 12-week study period; the remaining 29% of residents (n=443) developed a new PU. Resident, treatment, and facility characteristics associated with greater likelihood of developing a Stage I to IV PU included higher initial severity of illness, history of recent PU, significant weight loss, oral eating problems, use of catheters, and use of positioning devices. Characteristics associated with decreased likelihood of developing a Stage I to IV PU included new resident, nutritional intervention (e.g., use of oral medical nutritional supplements and tube feeding for >21 days), antidepressant use, use of disposable briefs for more than 14 days, registered nurse hours of 0.25 hours per resident per day or more, nurses' aide hours of 2 hours per resident per day or more, and licensed practical nurse turnover rate of less than 25%. When Stage I PUs were excluded from the analyses, the same variables were significant, with the addition of fluid orders associated with decreased likelihood of developing a PU. CONCLUSION: A broad range of factors, including nutritional interventions, fluid orders, medications, and staffing patterns, are associated with prevention of PUs in long-term care residents. Research-based PU prevention protocols need to be developed that include these factors and target interventions for reducing risk factors.     

Stage 2 pressure ulcer healing in nursing homes

OBJECTIVES: To identify resident and wound characteristics associated with Stage 2 pressure ulcer (PrU) healing time in nursing home residents. DESIGN: Retrospective cohort study with convenience sampling. SETTING: One hundred two nursing homes participating in the National Pressure Ulcer Long‐Term Care Study (NPULS) in the United States. PARTICIPANTS: Seven hundred seventy‐four residents aged 21 and older with length of stay of 14 days or longer who had at least one initial Stage 2 (hereafter Stage 2) PrU. MEASUREMENTS: Data collected for each resident over a 12‐week period included resident characteristics and PrU characteristics, including area when first reached Stage 2. Data were obtained from medical records and logbooks. RESULTS: There were 1,241 initial Stage 2 PrUs on 774 residents; 563 (45.4%) healed. Median time to heal was 46 days. Initial area was significantly associated with days to heal. Using Kaplan‐Meier survival analyses, median days to heal was 33 for small (≤1 cm²), 53 days for medium (>1 to ≤4 cm²), and 73 days for large (>4 cm²) ulcers. Using Cox proportional hazard regression models to examine effects of multiple variables simultaneously, small and medium ulcers and ulcers on residents with agitation and those who had oral eating problem healed more quickly, whereas ulcers on residents who required extensive assistance with seven to eight activities of daily living (ADLs), who temporarily left the facility for the emergency department (ED) or hospital, or whose PrU was on an extremity healed more slowly. CONCLUSION: PrUs on residents with agitation or with oral eating problems were associated with faster healing time. PrUs located on extremities, on residents who went temporarily to the ED or hospital, and on residents with high ADL disabilities were associated with slower healing time. Interaction between PrU size and place of onset was also associated with healing time. For PrU onset before or after admission to the facility, smaller size was associated with faster healing time.     

Long-term care liability for pressure ulcers

More than 20% of residents who have been in long-term care (LTC) facilities for 2 or more years will develop at least one pressure ulcer (PU). Residents suffer pain, disfigurement, and decreased quality of life, and their risk of illness and death increases. LTC facilities face censure from residents, their families, and surveyors and the threat of expensive lawsuits. Lawsuits are typically based on contentions of residents with a PU--or their advocates--that the LTC facility was negligent and failed to provide the care that, by industry standards, it must provide to prevent or manage such wounds (managing pressure, incontinence, and nutrition). In this article, data from 1999 and 2002 are presented, showing that lawsuits related to PUs are increasingly common and costly for LTC owners and care providers. Residents realized some type of recovery against the facility in 87% of the cases (verdicts for the resident plus settlements) and were awarded amounts as high as $312 million in damages. Even LTC administrators who believe that care in their facility equals or exceeds industry standards often settle lawsuits out of court to avoid jury verdicts. The data also show that jury awards were highest for PUs caused by multiple factors and that the highest awards for PUs caused by a single factor were seen when that factor was inadequate nutrition. LTC providers can help improve the health and quality of life of their residents, improve survey results, and minimize their risk of expensive lawsuits by developing, implementing, and documenting a plan of basic measures to prevent PUs.     

Black/White differences in pressure ulcer incidence in nursing home residents

OBJECTIVES: To compare black and white nursing home residents with respect to the incidence of nursing home (NH)-acquired pressure ulcers (PUs) and to examine the role of resident characteristics and facility characteristics in explaining differences between the racial groups. DESIGN: Prospective cohort study conducted between 1992 and 1995. SETTING: Fifty-nine Maryland NHs. PARTICIPANTS: A total of 1,938 residents (301 black, 1,637 white) aged 65 and older newly admitted to participating NHs. MEASUREMENTS: The outcome variable was the first occurrence of a Stage 2, 3, or 4 PU as determined based on medical record review. The predictor variable was race (black, white). Eight resident characteristics (age, sex, number of activity of daily living dependencies, bedfast, PU on admission to facility, incontinence, dementia, and whether the resident was on Medicaid) and three facility characteristics (number of beds, for-profit ownership status, and urban/nonurban location) were considered as possible confounding variables. RESULTS: The incidence of PUs was 0.38 per person-year in the NH. The rate for blacks was significantly higher than for whites (0.56 vs 0.35 per person-year) (P<.001). In multivariate analysis, controlling for eight resident characteristics and three facility characteristics, race was significantly associated with PU incidence (hazard ratio comparing blacks with whites=1.31, 95% confidence interval=1.02-1.66). CONCLUSION: Blacks have a higher incidence of NH-acquired PUs than whites; resident characteristics appear to mediate the higher risk. Future research should aim to identify modifiable factors that explain differences between racial groups in PU risk and to develop solutions to prevent the suffering and cost associated with PUs.     

The occurrence of pressure ulcers in three nursing homes

Background: In the 27 nursing homes located within the Veterans Affairs (VA) Central Region, the proportion of residents with pressure ulcers in 1986 varied from 2% to 16%. Three of these nursing homes were selected for study: nursing home A from the highest prevalence quintile, B from close to the median, and C from the lowest quintile. Methods: Two indicators of pressure ulcer occurrence were calculated: the point-in-time prevalence of bedsores and the percentage of residents who were free of pressure ulcers at the beginning of a six-month study period but who had bedsores six months later. Data were also collected in each nursing home to determine the bedsore status at the time of admission and the resident’s location if and when a bedsore began. Results: The three institutions were generally similar in available measures of casemix and severity of illness. The ratio of nursing and medical personnel to residents was 29%–76% lower in nursing home A than in B or C. In nursing home A, the turnover of nursing personnel was about twice as rapid as that in B or C. In each institution the pressure ulcer statistics showed little variation from one six-month period to another. The average rates in nursing home A were 15.3% for prevalence and 10.3% for the six-month conversion from bedsore-negative to bedsore-positive status. The average rates in facilities B and C were, respectively, 6.9% and 3.5% for prevalence and 4.7% and 4.2% for the six-month conversion from negative to positive status. Furthermore, the number of new bedsores that developed during uninterrupted nursing home residence, per 100,000 resident days, was 36.5 in A, 10.8 in B, and 2.1 in C. Conclusions: The pressure ulcer statistics in nursing homes B and C were consistently superior to those in A. The interinstitutional differences could not be explained by the comparisons of scoring methodologies and of casemixes that were made. It is hypothesized that more favorable staffing patterns in B and C than in A contributed to more effective prevention of bedsores in the former two institutions. Received from the Geriatric Medicine Sections, Veterans Affairs Medical Centers, Milwaukee, Wisconsin, Tomah, Wisconsin, and Togus, Maine. Supported by the Department of Veterans Affairs Medical Research Service.     

Pressure ulcer prevalence in long-term nursing home residents since the implementation of OBRA '87. Omnibus Budget Reconciliation Act

OBJECTIVES: To evaluate change in pressure ulcer prevalence in long-term nursing home residents since the implementation of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87). DESIGN: Cross-sectional comparison of two time periods. SETTING: Ninety-two nursing homes scheduled for a quality-of-care survey randomly selected from 22 representative states. PARTICIPANTS: Four thousand six hundred seventy-nine residents who had resided in the facility for at least 100 days were evaluated: 2,336 during 1992-1994 and 2,343 during 1997-1998. MEASUREMENTS: Trained registered nurses collected data on pressure ulcer prevalence, stage, and risk factors from medical record review during on-site evaluations. Risk-adjusted differences were estimated using logistic regression. RESULTS: Unadjusted prevalence rates for all stages of pressure ulcers (8.52% vs 8.54%, P =.983) and those rated stage 2 or greater (5.31% vs 5.63%, P =.624) did not differ between the two time periods. After adjustment for urinary incontinence, immobility, poor nutrition, and history of previous pressure ulcers, the relative odds of having a pressure ulcer in 1992/4 versus 1997/8 was 1.06 (95% confidence interval (CI) = 0.84-1.34) for all stages and 1.21 (95% CI = 0.92-1.60) for stages 2 and greater. CONCLUSIONS: No change in pressure ulcer prevalence was demonstrated since implementation of OBRA '87 in this nationally derived sample of long-term nursing home residents.     

Group Therapy in Long Term Care Sites

ABSTRACT

Group therapy is an intervention that is particularly suited for residents in long term care settings, because it can reduce social isolation and efficiently address the common issue of adjustment to institutional living. This article first specifies the types of groups that should be offered in long term care settings as a function of therapeutic aims and resident composition. It then enumerates Yalom's common curative factors and how they are reflected in the group process with frail nursing home residents. The unique elements in doing group therapy within long term care sites are then discussed. Next, the meager research on group psychotherapy in long term care sites is summarized, and a plea is made for more empirical studies to be conducted in this exciting but neglected area. Finally, reimbursement issues for group therapy in nursing homes are briefly considered.     

Impact of pain on outcomes in long-term care residents with and without multiple sclerosis

OBJECTIVES: To compare long-term care (LTC) residents with and without multiple sclerosis (MS); to compare admission status of pain, physical disability, pressure ulcers, depression, and cognitive performance in LTC residents with and without MS; and to examine the impact of MS and pain on outcomes 90 and 180 days after LTC admission. DESIGN: Retrospective analysis of a large data set. SETTING: LTC facilities in Missouri. PARTICIPANTS: Residents admitted to non-hospital-based LTC facilities. MEASUREMENTS: Minimum Data Set/Resident Assessment Instrument, Version 2.0; Activities of Daily Living Scale; Cognitive Performance Scale. RESULTS: Residents with and without MS had similar pain prevalence and intensity after admission, with daily pain more frequent in residents with MS (P=.03). On admission, residents with MS had more physical disability (P<.001) and a greater prevalence of pressure ulcers (P=.004) and depression (P<.001) than residents without MS. In all LTC residents, initial pain status was associated with physical disability (P<.001), pressure ulcers (P<.001), depression (P<.001), and cognitive performance (P<.001) 90 and 180 days after admission. A diagnosis of MS was associated with physical disability (P<.001) 90 and 180 days after admission and pressure ulcer development 180 days after admission (P=.02). CONCLUSION: Residents with MS were more physically disabled and had more frequent pain and a higher prevalence of pressure ulcers and depression on admission than residents without MS. Pain, or lack thereof, in residents with and without MS on admission may warn of problems that could occur within 6 months after admission to a LTC facility.     

The Influence of Long-Term Care Insurance on the Likelihood of Nursing Home Admission

OBJECTIVES: To determine the effect of long-term care (LTC) insurance on nursing home use.
DESIGN: Longitudinal analysis, 1998 to 2006 waves of the Health Retirement Study.
SETTING: Community-dwelling nationally representative sample.
PARTICIPANTS: Nineteen thousand one hundred seventy adults aged 50 and older, 1998 wave.
METHODS: Two groups of respondents were created at baseline: those with and without an LTC insurance policy. Respondents admitted to the nursing home from 1998 to 2006 were identified. Propensity scores were used to control for known predictors of LTC insurance possession. A Cox proportional hazards model was used to compare the probability of nursing home admission over 8 years of follow-up for respondents possessing LTC insurance and those without a policy.
RESULTS: Of the 19,170 respondents aged 50 and older in 1998, 1,767 (9.2%) possessed LTC insurance. A total of 1,778 (8.5%) were admitted to a nursing home during the 8-year period: 149 (8.7%) of those with LTC insurance and 1,629 (8.4%) of those without LTC insurance. The hazard ratio, adjusted for propensity score, for those with LTC insurance entering a nursing home compared with those without was 1.07 (95% confidence interval=0.83–1.38). Likelihood of nursing home admission was relatively low because the low-risk population included in the study, limiting the power to detect small differences in risk of nursing home utilization between groups.
CONCLUSION: There was no difference in nursing home utilization between low-risk older adults who did and did not possess an LTC insurance policy.     

Similarities and differences in attitudes toward long-term care between Japanese Americans and Caucasian Americans

The purpose of this study was to compare attitudes toward the use of long-term care between older Japanese Americans (n = 1,244) and older Caucasian Americans (n = 1,354). When presented with a hypothetical situation in which they have dementia, 39% of older Japanese Americans and 42% of older Caucasians intended to be cared for at home, whereas 53% versus 38%, respectively, intended to use nursing home care (P <.001). If the hypothetical situation was hip fracture, 81% of older Japanese Americans and 72% of older Caucasians intended to be cared for at home, with 13% of both groups intending to use nursing home care (P = NS). The subjects' perceptions of what their families, friends, ministers, and communities would want them to choose differed, with more uncertainty among Caucasians (P <.001). For provision of home care, Japanese Americans were more likely to rely on loved ones than Caucasians, who were more likely to rely on paid providers. Multivariate logistic regression showed ethnicity to be independently related to intention to use nursing home care in the dementia scenario, controlling for demographic variables. Being married lowered the odds of intending to use nursing homes in any situation. We conclude that Caucasian Americans intend to use paid home health care at higher rates than Japanese Americans if they become disabled by dementia. Japanese Americans demonstrated more certainty about the influences of others on their opinions, suggesting a more stable cultural norm in this population, and intended to use more nursing home care in the event of permanent debility (dementia).     

Conservative Care for ESRD in the United Kingdom: A National Survey

Background and objectives

Conservative kidney management (CKM) has been developed in the United Kingdom (UK) as an alternative to dialysis for older patients with stage 5 CKD (CKD5) and multiple comorbidities. This national survey sought to describe the current scale and pattern of delivery of conservative care in UK renal units and identify their priorities for its future development.

Design, setting, participants, & measurements

A survey on practice patterns of CKM for patients age 75 and older with CKD5 was sent to clinical directors of all 71 adult renal units in the UK in March 2013.

Results

Sixty-seven units (94%) responded. All but one unit reported providing CKM for some patients. Terminology varied, although "conservative management" was the most frequently used term (46%). Lack of an agreed-upon definition of when a patient is receiving CKM made it difficult to obtain meaningful data on the numbers of such patients. Fifty-two percent provided the number of CKM patients age ≥75 years in 2012; the median was 45 per unit (interquartile range [IQR], 20–83). The median number of symptomatic CKM patients who would otherwise have started dialysis was eight (IQR, 4.5–22). CKM practice patterns varied: 35% had a written guideline, 23% had dedicated CKM clinics, 45% had dedicated staff, and 50% provided staff training on CKM. Most units (88%) provided primary care clinicians with information/advice regarding CKM. Eighty percent identified a need for better evidence comparing outcomes on CKM versus dialysis, and 65% considered it appropriate to enter patients into a randomized trial.

Conclusions

CKM is provided in almost all UK renal units, but scale and organization vary widely. Lack of common terminology and definitions hinders the development and assessment of CKM. Many survey respondents expressed support for further research comparing outcomes with conservative care versus dialysis.     

A training program to enhance recognition of depression in nursing homes,assisted living,and other long-term care settings: Description and evaluation

ABSTRACT

Low levels of symptom recognition by staff have been “gateway” barriers to the management of depression in long-term care. The study aims were to refine a depression training program for front-line staff in long-term care and provide evaluative knowledge outcome data. Three primary training modules provide an overview of depression symptoms; a review of causes and situational and environmental contributing factors; and communication strategies, medications, and clinical treatment strategies. McNemar’s chi-square tests and paired t-tests were used to examine change in knowledge. Data were analyzed for up to 143 staff members, the majority from nursing. Significant changes (p < .001) in knowledge were observed for all modules, with an average change of between 2 and 3 points. Evidence was provided that participants acquired desired information in the recognition, detection, and differential diagnosis and treatment strategies for those persons at significant risk for a depressive disorder.     

The management of depression in older nursing home residents

OBJECTIVES: Depression remains underrecognized and undertreated in older people. We estimated the prevalence of depression in older nursing home (NH) residents and described its pharmacological management. DESIGN: Cross-sectional study. SETTING: Residents in 1,492 NHs in five states (Kansas, Maine, Mississippi, New York, South Dakota). PARTICIPANTS: Forty-two thousand nine hundred one residents aged 65 and older with depression documented as an active clinical condition on the Minimum Data Set (MDS) assessment. MEASUREMENTS: Data were from the Systematic Assessment of Geriatric drug use via Epidemiology database. We grouped antidepressant medications by class: tricyclic antidepressants (TCAs), tetracyclics, selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors, and others. Logistic regression models revealed predictors of receipt of any antidepressant and, among those treated, predictors of receipt of an SSRI. RESULTS: Eleven percent of the residents were identified as depressed on the MDS. Of these, 55% received antidepressant therapy. Of depressed residents receiving antidepressant therapy, 32% received doses less than the manufacturers' recommended minimum effective dose for treating depression, with residents on TCAs more likely to receive less than the recommended dose for treating depression. The oldest-old (> or = 85 years) (odds ratio (OR) = 0.93, 95% confidence interval (CI) = 0.88-0.98), black residents (OR = 0.83, 95% CI = 0.75-0.92), and those with severe cognitive impairment (OR = 0.69, 95% CI = 0.64-0.75) were the least likely to receive an antidepressant. In those treated, cardiovascular diseases were associated with an increased likelihood of SSRI use. Despite control for comorbid conditions, women were less likely than men to receive an SSRI (OR = 0.77, 95% CI = 0.72-0.82). CONCLUSIONS: Although depression is a treatable illness, the majority of NH residents may be inadequately treated.     

Measuring the quality of dying in long-term care

OBJECTIVES: To describe two versions of a new measure, The Quality of Dying in Long-Term Care, for postdeath administration to surrogate respondents (staff and family caregivers) of all decedents (QOD-LTC) and of cognitively intact decedents (QOD-LTC-C) who die in nursing homes (NHs) and residential care or assisted living (RC/AL) facilities. DESIGN: Using two levels of exploratory factor analysis, 15 candidate items for the QOD-LTC and 36 candidate items for the QOD-LTC-C were tested using multiple criteria to determine factor structure and interpretability of the quality of dying in long-term care (LTC). SETTING: One hundred seventeen RC/AL facilities and 31 NHs in FL, MD, NC, and NJ. PARTICIPANTS: Family (n=439) and staff (n=332) caregivers of 633 decedents from a stratified random sample from RC/AL facilities and NHs in four states. MEASUREMENTS: Trained interviewers asked respondents to rate statements describing potentially important aspects of the quality of dying using a 5-point Likert scale. The scale items were analyzed using exploratory factor analysis with communalities set to unity using a Promax rotation. RESULTS: The 11-item QOD-LTC (alpha=0.66), appropriate for surrogate respondents for all decedents, consists of three domains (personhood, closure, preparatory tasks). The 23-item instrument for surrogate respondents of cognitively intact decedents, the QOD-LTC-C (alpha=0.85), consists of five domains (sense of purpose, closure, control, social connection, preparatory tasks). CONCLUSION: The QOD-LTC and QOD-LTC-C are psychometrically acceptable measures of the quality of the dying experience, developed for and tested in LTC settings. Use of these measures can increase understanding of the dying experience in LTC.     

National estimates of medication use in nursing homes: findings from the 1997 medicare current beneficiary survey and the 1996 medical expenditure survey

OBJECTIVES: To provide the first nationwide estimates of medication use in nursing homes (NHs) and to introduce a new data set for examining drug use in long-term care facilities. DESIGN: Cross-sectional comparison. SETTING: NH medication files from two nationally representative data sets, the 1997 Medicare Current Beneficiary Survey (MCBS) and the 1996 Medical Expenditure Panel Survey-Nursing Home Component (MEPS-NHC). PARTICIPANTS: NH residents in the MCBS (n=929, weighted n=2.0 million) and MEPS-NHC (n=5,899, weighted n=3.1 million). MEASUREMENTS: Estimates include characteristics of facilities and residents, average number of drugs used per person per month, and the prevalence and duration of use by select therapeutic drug classes. RESULTS: NH residents received, on average, seven to eight medications each month (7.6 MCBS, 7.2 MEPS-NHC). About one-third of residents had monthly drug regimens of nine or more medications (31.8% MCBS, 32.4% MEPS-NHC). The most commonly used medications in NHs, in descending order, were analgesics and antipyretics, gastrointestinal agents, electrolytic and caloric preparations, central nervous system agents, anti-infective agents, and cardiovascular agents. CONCLUSION: These estimates serve as examples of the first national benchmarks of prescribing patterns in NHs. This study highlights the usefulness of the MCBS as an important new resource for examining medication use in NHs.     

Home care services in Israel-implications of the expansion of home care following implementation of the Community Long-Term Care Insurance Law

In 1986 the Israeli Parliament enacted the Community Long-Term Care Insurance (CLTCI) Law, in response to concern over the growing need for long-term care. The principal aims of this study were to examine the extent to which the law has improved the appropriateness of care, reduced unmet needs, and lessened the burden on families of disabled elderly living in the community; and to assess the degree to which the expansion of formal services has supplemented, or substituted for, informal assistance. The findings show that expansion of formal services under the law has significantly increased the number of elderly receiving care, as well as the quantity of care they receive. This study also indicates that the formal services added under the law supplement, but do not substitute for, informal care: This has had a positive effect both on the elderly and on their families.     

Nursing Time Devoted to Medication Administration in Long-Term Care: Clinical, Safety, and Resource Implications

OBJECTIVES: To quantify the time required for nurses to complete the medication administration process in long-term care (LTC).
DESIGN: Time-motion methods were used to time all steps in the medication administration process.
SETTING: LTC units that differed according to case mix (physical support, behavioral care, dementia care, and continuing care) in a single facility in Ontario, Canada.
PARTICIPANTS: Regular and temporary nurses who agreed to be observed.
MEASUREMENTS: Seven predefined steps, interruptions, and total time required for the medication administration process were timed using a personal digital assistant.
RESULTS: One hundred forty-one medication rounds were observed. Total time estimates were standardized to 20 beds to facilitate comparisons. For a single medication administration process, the average total time was 62.0±4.9 minutes per 20 residents on physical support units, 84.0±4.5 minutes per 20 residents on behavioral care units, and 70.0±4.9 minutes per 20 residents on dementia care units. Regular nurses took an average of 68.0±4.9 minutes per 20 residents to complete the medication administration process, and temporary nurses took an average of 90.0±5.4 minutes per 20 residents. On continuing care units, which are organized differently because of the greater severity of residents' needs, the medication administration process took 9.6±3.2 minutes per resident. Interruptions occurred in 79% of observations and accounted for 11.5% of the medication administration process.
CONCLUSION: Time requirements for the medication administration process are substantial in LTC and are compounded when nurses are unfamiliar with residents. Interruptions are a major problem, potentially affecting the efficiency, quality, and safety of this process.