Preventing pressure ulcers is extremely difficult. Some facilities are able to consistently deliver high quality pressure ulcer preventive care despite these difficulties. Relatively little is known, though, as to how they achieve this. This pre-implementation project addresses this gap by identifying the characteristics of effective teams, focusing on the three separate but overlapping "pressure ulcer teams" that are key to providing effective pressure ulcer care within the Community Living Center (CLC) setting. It also updates data on pressure ulcer rates in VHA CLCs nationwide. This study used mixed methods to purposively select CLCs with higher and lower pressure ulcer development rates. Staff interviews were conducted to illuminate barriers to and facilitators of successful pressure ulcer prevention.
The study set out to accomplish the following specific aims: (1) To investigate the association between the functioning of pressure ulcer teams and pressure ulcer rates in CLCs, hypothesizing that CLCs with high-functioning pressure ulcer teams are more likely to have low pressure ulcer rates. (2) To examine organizational factors associated with the presence of high-functioning pressure ulcer teams, hypothesizing that (a) CLCs with high-functioning pressure ulcer teams are more likely to have a strong resident safety culture, and (b) CLCs with high-functioning pressure ulcer teams are more likely to have organizational contexts with elements associated with positive organizational changes, such as strong leadership support and alignment of activities and resources with organizational goals. A sub-study examined pressure ulcer rates throughout VHA nursing homes over time.
A retrospective longitudinal examination of 109 VHA nursing homes' pressure ulcer rates was conducted as a sub-study, using Minimum Data Set (MDS) data from FY 08-11. Pressure ulcer development was defined as a stage 2 or larger pressure ulcer on an MDS assessment with no pressure ulcer on the previous assessment. A risk adjustment model was developed using 105,274 MDS observations to predict the likelihood of pressure ulcer (c statistic = 0.72). A Bayesian hierarchical model, which adjusted for differences in the reliability of pressure ulcer rates from facilities of different sizes, was used to calculate smoothed risk-adjusted (sra) rates of pressure ulcers for each facility.
This model was used to identify three higher and three lower performing facilities. Data were collected using semi-structured telephone interviews with CLC pressure ulcer team members. The CLC Employee Survey of Attitudes about Resident Safety (CESARS) was also administered at each of the six sites to gather data on resident safety culture. A structured analytic tool was used to analyze data from the interviews. This enabled investigation of the function, implementation, and impact of pressure ulcer teams in the CLCs, in addition to other organizational factors. CESARS data analysis explored resident safety culture differences between the high and low performing facilities.
Median sra CLC pressure ulcer development rates for the 4 study years were fairly consistent: 4.1%, 4.3%, 4.1%, and 4.4%. 12 CLCs had significantly increasing and 12 had significantly decreasing sra rates across the years. Of these, 7 sites had significantly improving (p<.001) rates below the median. The proportion of new pressure ulcers that were deep increased (p<.001) over the study period.
A total of 23 staff members from 3 higher performing (n=14) and 3 lower performing (n=9) CLCs participated in the semi-structured interviews. The qualitative analysis identified support for 6 key concepts that (1) differentiated higher and lower performing sites and (2) identified facilitators of and barriers to successful pressure ulcer prevention. The 6 concepts were Leadership of the pressure ulcer prevention efforts; Organizational prioritization, alignment, and support for pressure ulcer prevention; Existence of an Improvement culture; Clarity of roles and responsibilities regarding pressure ulcer prevention; Communication strategies regarding pressure ulcer prevention; and Factors affecting progress in pressure ulcer prevention. Analysis revealed evidence across all sites that pointed to the implementation of "basic" pressure ulcer care. That is, participants from all sites were aware of the importance of pressure ulcer prevention, used a number of methods to educate staff about prevention, and implemented various pressure ulcer prevention techniques. But beyond these similarities, discernable differences between the higher and lower performing sites emerged. The additional impact of leadership's visible prioritization of and support for pressure ulcer prevention was the most striking component represented at higher performing sites but not lower performing ones. Higher performing sites were more likely to align front line staff and leadership goals for pressure ulcer prevention.
The analysis of the CESARS survey results revealed only 1 item that had significantly different responses between higher and lower performing sites. That item matched the qualitative analyses findings related to leadership. The item was the following: In the past 3 months, how often have you seen someone from CLC leadership ON THE UNIT? (CLC leadership is the service line director, the associate chief nurse, etc.) (p<.01, t-test).
This study examined differences between facilities that did well and those that did less well on pressure ulcer care. Findings showed that there is substantial variation in CLCs on pressure ulcer care and that the severity of new pressure ulcers increased in the study period. Qualitative findings highlighted the potentially important role of leadership in fostering strong pressure teams and improving care. These results provide valuable information about how CLCs can improve pressure ulcer care. This information may be used to help design interventions for improving pressure ulcer care.
- Hartmann CW, Solomon J, Palmer JA, Lukas CV. Contextual Facilitators of and Barriers to Nursing Home Pressure Ulcer Prevention. Advances in Skin and Wound Care. 2016 May 1; 29(5):226-38; quiz E1.
- Hartmann CW, Shwartz M, Zhao S, Palmer JA, Berlowitz DR. Longitudinal Pressure Ulcer Rates After Adoption of Culture Change in Veterans Health Administration Nursing Homes. Journal of the American Geriatrics Society. 2016 Jan 1; 64(1):151-5.