Abstract
Pressure ulcer prevalence remains a major health concern in long-term care facilities. The treatment of these pressure ulcers causes a financial drain on health care resources and adds potential costs for the family of the institutionalized elderly, according to the Agency for Healthcare Research and Quality. The prevention of pressure ulcer development continues to be an essential objective of caregivers for elderly people. This study demonstrated a correlation between the permanent assignment of nursing assistants and the prevention of pressure ulcers among the elderly in a nursing home.
Keywords: Elderly, Facility-acquired pressure ulcer, Incidence rate of pressure ulcers, Long-term care setting, Nursing assistants, Permanent assignment
Incidence of pressure ulcers remains a major health concern in long-term care facilities. The increased mortality and morbidity caused by pressure ulcers in the elderly patient population is a challenge for nursing home caregivers (Agency for Healthcare Research and Quality, 2009).1
A study was conducted in our 100-bed skilled nursing unit in the hope of promoting a statistically significant decline in the incidence rate of facility-acquired pressure ulcers in 4 years after a permanent certified nursing assistants’ schedule was implemented.
Certified nursing assistants are essential personnel in the care provided to elderly patients. A permanent assignment means that the same nursing assistant cares for the same group of patients for at least 85% of the assistant’s shift. Skilled nursing units normally use a rotation system of certified nursing assistant assignments.
Innovation Consistent with Evidenced-Based Practice
Matthew Wayne, MD, (2004)2 the chief medical officer of the Eliza Jennings Senior Care Center in Ohio, conducted a study that confirmed that permanent staff assignments resulted in a happier and empowered staff and had a significant impact on the prevention of pressure ulcers in that facility.
Bowers, Edmond, and Jacobson (2000)3 conducted a qualitative study that provided evidence of a correlation of permanent staff assignment with higher ratings for residents’ personal appearance, hygiene, and skin integrity.
Feasibility of the Study in Our Facility
Our facility practice is committed to achieving excellence in patient care and promoting evidence-based quality care; therefore, the change described in this article was consistent with the philosophy pertaining to the prevention of facility-acquired pressure ulcers.
The director of nursing services approved the implementation of the intervention within the facility, and the unit manager was likewise in full support of the innovative strategy to enhance evidence-based clinical practice on her unit of responsibility. There was no need for the hospital’s internal review board approval because of the noninvasive nature of the intervention.
Project Implementation
The study design was a correlational cross-sectional project for a period of 4 years. The study used a sampling of nursing assistants (N = 30) who met all inclusion criteria and voluntarily consented to participate.
This project manager implemented the permanent assignments on the premise that the nursing assistants were previously educated about the philosophy of pressure ulcer development, prevention strategies, and the definition of permanent assignment.
The following implementation steps were taken:
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Informed consents were obtained from the nursing assistants who volunteered to participate.
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The assignments of the nursing assistants were changed to permanent schedule for the group of patients for whom they provided daily care.
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A detailed process timeline and activity log guideline were developed to monitor the implementation of the proposed intervention.
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Staff compliance with the intervention was monitored by the clinical supervisors.
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Baseline facility-acquired pressure ulcer incident rate data were obtained from previous quality improvement projects.
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Succeeding-quarter data were collected, collated, presented in graph format, and benchmarked from national and state statistics.
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The results were reported to the facility’s quality council and during in-service classes and meetings.
The project manager worked on the premise that if the trends in facility-acquired pressure ulcer incidence rates did not demonstrate improvement, the intervention would be discontinued.
Postimplementation Plans
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Identification of potential barriers to the success of the study, such as resistance from staff, family members, or patients, and appropriate attention to any barriers through reeducation and explanation
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Staff interviews to determine compliance and support
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Documentation and reporting of the progress or nonprogress of the project
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Award of certificates of appreciation for staff participation and recognition of efforts at end of the study period
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Monitoring of trends and computation of the data:
Number of facility-acquired pressure ulcers per quarter × (1,000 / number of patient days in the quarter)
The Table and Figure provide the data showing the continued decline in the incidence of facility-acquired pressure ulcers.
Table.
Annual Incidence Rates of Facility Acquired Pressure Ulcer for FY 2007-2010
| Fiscal Year | FY 2007 | FY 2008 | FY 2009 | FY 2010 |
|---|---|---|---|---|
| Number of facility-acquired pressure ulcers | 87 | 38 | 32 | 14 |
| Facility-acquired pressure ulcer incidence rate/patient days | 2.48 | ↓1.31 | ↓0.95 | ↓0.41 |
Figure.
Monitoring of trends and computation of data: Number of facility acquired pressure ulcers per quarter × 1000/number of patient days. Data collated annually. The graph should be color coded to reflect one color for number of pressure ulcers and another color for the annual incidence rates.
Conclusions
Implementation of consistent assignment of the nursing assistants produced a statistically significant sustained decline in facility-acquired pressure ulcer incidence rates for the past 4 years.
Strategies to maintain the intervention and outcome included the consistent education of new staff. The success of the study demonstrated compliance with regulatory standards on pressure ulcer prevention and with evidence-based practice.
By permanently assigning nursing assistants to specific residents, we infused the assistants with an increased sense of commitment to and accountability for the care of their elderly patients, which produced a significant effect on the prevention of pressure ulcers in our facility.
Footnotes
Conflict of interest: The author reports no conflicts of interest.
References
- 1.Agency for Healthcare Research and Quality. (2009). Pressure ulcer guidelines. Available at: http://www.ahrq.gov. Accessed May 2, 2009.
- 2.Wayne M. (2004). Application of the preventative healthcare model to wound care: Novel clinical methods. Available at: www.centeredcare.org/elizajennings senior care network/html. Accessed May 8, 2009.
- 3.Bowers B., Esmond S., Jacobson N. The relationship between staffing and quality in long-term care facilities. Journal of Nursing Care Quality. 2000;14:55–64. doi: 10.1097/00001786-200007000-00009. [DOI] [PubMed] [Google Scholar]