Submitted by Richard Frank, RN, BA
Abstract
Nurses confront safety issues in nursing homes every day. These can be divided into two categories: resident and staff safety issues. This paper discusses resident safety, outlined into four general classifications: skin care, falls, infections, and medication errors. Skin care is one of the costliest, yet one of the most solvable issues. It’s reported that 60% of residents fall annually, yet simple, frontline, interventions have been shown to be the most effective in addressing this problem. Infections in geriatric patients are difficult to diagnose due to lack of training and information flow. Medication errors occur primarily at the prescribing and laboratory monitoring levels. This analysis discusses these factors and what the literature suggests can be done to begin solving these problems that affects over 1.7 million residents.
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Safety Issues in Nursing Homes
Nursing home safety can be divided into two categories: patient safety and staff safety. Patient safety will be the focus of this discussion. Future writing will integrate staff safety into this issue, and will discuss the relationship between these two cohorts.
Patient safety in the nursing home has become a concern among professionals, administrators, industry observers, and regulatory agencies over the past 20 years, since enactment of the Omnibus Budget Reconciliation Act (OBRA) in 1987. Nursing home beds in the U.S. outnumber hospital beds almost two to one. Length of stay for hospitals averages six days, compared with more than 850 days for nursing homes. The average cost of a hospital stay is about $8,500 while it exceeds $100,000 for the nursing home (U.S. Dept. of Health and Human Services, 2008). However, given the difference in money spent on nursing home care comparatively little attention has been given to how safety issues threaten the quality of care, quality of life, lives of residents, and financial health of residents, their families and the facilities charged with their care (Scott-Cawiezell and Vogelsmeier, 2006). The following categories comprise the scope of patient safety in nursing homes: skin care, falls, infections, and medication errors.
Pressure ulcers are “localized injury to skin and/or underlying tissue that result from sustained physical pressure, shear or friction” (Grunier and Mor, 2008, p. 372). Pressure ulcer grading is typically done using a four level staging system: stage one typically presents as non-blanchable skin redness, and stage four is represented by full thickness tissue loss exposing bone, tendon, or muscle (National Pressure Ulcer Advisory Panel, 2007). A study done to investigate and compare interventions has shown encouraging results in reducing the prevalence of pressure ulcers (Horn, Smout, Bergstrom, Bender, Ferguson, Taler, et al. 2005). It suggested that variables contributing to a reduction in pressure ulcers included nutritional interventions, use of antidepressants and disposable briefs. The use of well known skin assessment tools like the Braden Scale, exercise, specialty dressings, and sitting devices have shown no significant reduction of pressure ulcer occurrence. However, a reduction in pressure ulcer incidence was realized due to implementation of skin care programs, and scheduled skin cleansing activity (Scott-Caiwezell & Vogelsmeir, 2006). The presence of a registered nurse (RN) as a member of direct care staff also contributed to reduction in pressure ulcer development (Grunier and Mor, 2008; Handler et. al., 2006). Thus, skin care along with scheduled and as needed washing, drying and moisturizing of skin, often performed by nursing assistant staff, remains a front line intervention to maintain lower incidence of pressure ulcer. This, as well as nutritional interventions, such as feeding programs or supplements [i.e. Carnation Instant Breakfast], and use of disposable briefs suggest that reinforcement of basic nursing care principles related to skin care are effective in ameliorating the incidence of pressure ulcers.
Falls, witnessed and un-witnessed, are the most commonly reported adverse incidents in nursing homes. It is estimated that the average 100 bed nursing home experiences between 100-200 falls annually. Falls account for more than 80% of fractures in nursing homes, and falls result in fracture almost 25% of the time (Grunier and Mor, 2008). Factors that contribute to falls include incontinence, dehydration, dementia, and environmental hazards [i.e. furniture, floor coverings, and lighting]. Although most falls do not result in injury, and do not require medical intervention they do require assessment, and if the fall is un-witnessed most facilities have policies requiring neural vital sign monitoring for 48-72 hours. This is due to the possibility that the resident struck his or her head during the fall, and such monitoring is a safety precaution. A recent study has demonstrated a reduction in fall rates by almost 40% (Bonner, MacCulloch, Gardner and Chase, 2007). The study involved a design that was used with nursing assistants and implemented falls knowledge pre-testing, a training program, and post-testing of the sample at 30 and 60 days. The fall rate before training was 16.1%, at 30 days it was 12.3%, and at 60 days it was 9.9%. This is encouraging and it also highlights the importance of nursing assistants’ training as well as their importance as primary caregivers in the nursing home.
Because infections manifest differently many times in the geriatric population it is not surprising that studies have reported that only 52% of residents are assessed for infection in the presence of an acute change in their condition. Contributing factors include lack of direct patient care by a nurse, poor communication, or information flow, between shifts or the nursing staff and physician, and evening or weekend illness (Scott-Caiwezell and Vogelsmeir, 2006). It is difficult to pinpoint the direct effects on the quality of care of undetected infections, but it would suffice to say that there would be less morbidity, fewer required hospital transfers, and lower labor costs if nurses were better trained to identify infection in the geriatric population in addition to having better communication tools in order to communicate with physicians.
Abstract
Nurses confront safety issues in nursing homes every day. These can be divided into two categories: resident and staff safety issues. This paper discusses resident safety, outlined into four general classifications: skin care, falls, infections, and medication errors. Skin care is one of the costliest, yet one of the most solvable issues. It’s reported that 60% of residents fall annually, yet simple, frontline, interventions have been shown to be the most effective in addressing this problem. Infections in geriatric patients are difficult to diagnose due to lack of training and information flow. Medication errors occur primarily at the prescribing and laboratory monitoring levels. This analysis discusses these factors and what the literature suggests can be done to begin solving these problems that affects over 1.7 million residents.
___________________________________________________
Safety Issues in Nursing Homes
Nursing home safety can be divided into two categories: patient safety and staff safety. Patient safety will be the focus of this discussion. Future writing will integrate staff safety into this issue, and will discuss the relationship between these two cohorts.
Patient safety in the nursing home has become a concern among professionals, administrators, industry observers, and regulatory agencies over the past 20 years, since enactment of the Omnibus Budget Reconciliation Act (OBRA) in 1987. Nursing home beds in the U.S. outnumber hospital beds almost two to one. Length of stay for hospitals averages six days, compared with more than 850 days for nursing homes. The average cost of a hospital stay is about $8,500 while it exceeds $100,000 for the nursing home (U.S. Dept. of Health and Human Services, 2008). However, given the difference in money spent on nursing home care comparatively little attention has been given to how safety issues threaten the quality of care, quality of life, lives of residents, and financial health of residents, their families and the facilities charged with their care (Scott-Cawiezell and Vogelsmeier, 2006). The following categories comprise the scope of patient safety in nursing homes: skin care, falls, infections, and medication errors.
Pressure ulcers are “localized injury to skin and/or underlying tissue that result from sustained physical pressure, shear or friction” (Grunier and Mor, 2008, p. 372). Pressure ulcer grading is typically done using a four level staging system: stage one typically presents as non-blanchable skin redness, and stage four is represented by full thickness tissue loss exposing bone, tendon, or muscle (National Pressure Ulcer Advisory Panel, 2007). A study done to investigate and compare interventions has shown encouraging results in reducing the prevalence of pressure ulcers (Horn, Smout, Bergstrom, Bender, Ferguson, Taler, et al. 2005). It suggested that variables contributing to a reduction in pressure ulcers included nutritional interventions, use of antidepressants and disposable briefs. The use of well known skin assessment tools like the Braden Scale, exercise, specialty dressings, and sitting devices have shown no significant reduction of pressure ulcer occurrence. However, a reduction in pressure ulcer incidence was realized due to implementation of skin care programs, and scheduled skin cleansing activity (Scott-Caiwezell & Vogelsmeir, 2006). The presence of a registered nurse (RN) as a member of direct care staff also contributed to reduction in pressure ulcer development (Grunier and Mor, 2008; Handler et. al., 2006). Thus, skin care along with scheduled and as needed washing, drying and moisturizing of skin, often performed by nursing assistant staff, remains a front line intervention to maintain lower incidence of pressure ulcer. This, as well as nutritional interventions, such as feeding programs or supplements [i.e. Carnation Instant Breakfast], and use of disposable briefs suggest that reinforcement of basic nursing care principles related to skin care are effective in ameliorating the incidence of pressure ulcers.
Falls, witnessed and un-witnessed, are the most commonly reported adverse incidents in nursing homes. It is estimated that the average 100 bed nursing home experiences between 100-200 falls annually. Falls account for more than 80% of fractures in nursing homes, and falls result in fracture almost 25% of the time (Grunier and Mor, 2008). Factors that contribute to falls include incontinence, dehydration, dementia, and environmental hazards [i.e. furniture, floor coverings, and lighting]. Although most falls do not result in injury, and do not require medical intervention they do require assessment, and if the fall is un-witnessed most facilities have policies requiring neural vital sign monitoring for 48-72 hours. This is due to the possibility that the resident struck his or her head during the fall, and such monitoring is a safety precaution. A recent study has demonstrated a reduction in fall rates by almost 40% (Bonner, MacCulloch, Gardner and Chase, 2007). The study involved a design that was used with nursing assistants and implemented falls knowledge pre-testing, a training program, and post-testing of the sample at 30 and 60 days. The fall rate before training was 16.1%, at 30 days it was 12.3%, and at 60 days it was 9.9%. This is encouraging and it also highlights the importance of nursing assistants’ training as well as their importance as primary caregivers in the nursing home.
Because infections manifest differently many times in the geriatric population it is not surprising that studies have reported that only 52% of residents are assessed for infection in the presence of an acute change in their condition. Contributing factors include lack of direct patient care by a nurse, poor communication, or information flow, between shifts or the nursing staff and physician, and evening or weekend illness (Scott-Caiwezell and Vogelsmeir, 2006). It is difficult to pinpoint the direct effects on the quality of care of undetected infections, but it would suffice to say that there would be less morbidity, fewer required hospital transfers, and lower labor costs if nurses were better trained to identify infection in the geriatric population in addition to having better communication tools in order to communicate with physicians.
Because nurses are often the responsible party that administer medications to nursing home residents this is a critical issue of concern for the profession. The total number of medications, and not the medical condition of the resident, contribute most to the likelihood of a medication error occurring in the nursing home (Scott-Caiwezell and Vogelsmeir, 2006). It has been pointed out that the majority of medication errors, especially concerning warfarin therapy, occur at the prescribing and monitoring stages (Gurwitz, Field, Radford, Harrold, Becker, Reed et al., 2007). For example, a nurse calls the physician only to be told the primary care physician is being covered by a different physician. This creates a gap in patient knowledge which contributes to a medication error. Without a better system of information flow, and monitoring, this population will continue to experience what is estimated to be approximately 34,000 fatal, life-threatening or otherwise serious medication errors attributed just to warfarin therapy (Gurwitz et al, 2007).
Patient safety issues in nursing homes are varied, and result in injury, even death to residents across the country every year. Fortunately studies are being published to show the outcomes of various interventions. In addition studies are highlighting specific areas where improvement will have the biggest impact on patient safety. Armed with such information nurses can practice with evidence based outcome support, and they can advocate for their patients in a manner that management will understand. Hopefully this will lead to a safer culture of practice in the nursing home.
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References
- Bonner, A., MacCulluch, P., Gardner, T. and Chase, C. (2007). A student-led demonstration project on fall prevention in a long-term care facility, Geriatric Nursing, 28, 312-318. Retrieved electronically September 26, 2008.
- Department of Health and Human Services, Center for Medicare and Medicaid Services [CMS-1390-N]. Medicare Program; Hospital inpatient prospective payment systems and
FY2009 rates. Retrieved electronically October 1, 2008. - Gruneir, A., and Mor, V. (2008). Nursing home safety: current issues and barriers to improvement. Annual Review of Public Health,29, 369-382. Publication first published online 1/3/08. http://publhealth.annualreviews.org/. Retrieved electronically September 26, 2008.
- Gurwitz, J.H., Field, T.S., Radford, M.J., Harrold, L.R., Becker, R., Reed, G. et al. (2007). The safety of warfarin therapy in the nursing home setting, The American Journal of Medicine, 120, 539-544. Retrieved electronically September 27, 2008.
- Handler, S., Castle, N., Studenski, S., Perera, S., Fridsma, D., Nace, D. and Hanlon, J. (2006). Patient safety culture assessment in the nursing home, Quality and Safety in Health Care, 15, 400-404. Retrieved electronically September 26, 2008.
- National Center for Health Statistics, United States (2007), Center for Disease Control
Hyattsville, MD: 2007. Retrieved electronically October 1, 2008. - National Pressure Ulcer Advisory Panel (2007). Updated Pressure Ulcer Stages. http://www.npuap.org/pr2.htm. Retrieved electronically October, 1, 2008.
- Horn, S.D., Smout, R.J., Bergstrom, N., Bender, S.A., Ferguson, M.L., Taler, et al. (2005). The national pressure ulcer long-term care study: pressure ulcer development in long-term care residents, Journal of the American Geriatrics Society, 52(3), 359-367.
- Scott-Cawiezell, J. and Vogelsmeier, A. (2006). Nursing home safety: a review of the literature. In J.J. Fitzpatrick (Ed.), Annual Review of Nursing Research, 24, 179-218. New York: Springer Publishing. Retrieved electronically September 26, 2008.
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