Long-Term Care Survey Alert

Best practices can translate into better resident and survey outcomes ... and help lawsuit-proof your facility.

Beware: Surveyors are handing out more F281 tags, which means facilities need to jump on the evidence-based bandwagon for residents' sake - and their own.

Ranked number three on the list of top 10 deficiencies nationwide, F281 requires facilities to provide services that meet accepted standards of clinical practice. "Surveyors are looking to see if facilities have care processes based on established practice guidelines," says Jacqueline Vance, RN,C, CDONA/LTC, director of clinical affairs for the American Medical Directors Association (AMDA).

Facilities that use accepted best practices can also head off lawsuits by showing they did everything by the book to prevent a resident's adverse outcome; ergo, the outcome must have been unavoidable.

Target These 4 Clinical Hot Spots

Surveyors and plaintiff's attorneys may look to see if you're using evidence-based practices to target these issues:

1. Pressure ulcers. The upcoming revised F314 tags incorporate the latest standards of care for pressure ulcers, including risk assessment, prevention and treatment.

Heads up: The Centers for Medicare & Medicaid Services doesn't say facilities have to use a standardized skin risk assessment, such as the Braden or Norton. But if your facility uses a home brew or composite form, surveyors may ask how you know it's valid and reliable, cautioned Courtney Lyder, ND, RN, professor of nursing at the University of Virginia Medical Center in comments at the September 2004 National Association of Subacute and Postacute Care conference in Washington, D.C.

Also, nursing facilities that use wet to dry dressings for anything other than wound debridement are out of synch with the current standard of practice, Lyder said.

2. Anticoagulation therapy. "Facilities need to look at how they are titrating and monitoring anticoagulation therapy to ensure patient safety," says Beth Klitch, president of Survey Solutions Inc. in Columbus, OH. "Over or under coagulation can be catastrophic."

Physicians also need to individualize anticoagulation therapy based on the resident's medical condition. "For example, someone who has had chronic atrial fibrillation may require a different level of anticoagulation than one who has had an acute event such as a pulmonary embolism treated in the immediate hospitalization prior to SNF admission," Klitch adds. (For expert tips on monitoring patients on Coumadin and other anticoagulants, see the May 2004 Long-Term Care Survey Alert.)

3. Detecting hyperglycemia caused by atypical antipsychotic drugs. Screen and monitor patients taking atypical or second generation antipsychotic drugs (SGAs) for rapid weight gain and signs of diabetes, advises a consensus statement by a panel of professional organizations, including the American Psychiatric Association and American Diabetes Association (ADA). Some SGAs, such as clozapine and olanzapine, while effective treatment options, raise a greater risk of weight gain, diabetes and lipid disorders than others, warns the panel.

Watch out: In some cases, people taking SGAs have developed diabetic ketoacidosis, which can be life-threatening, according to the panel.

Check a patient's fasting blood glucose before he starts an SGA medication. "The facility can obtain a blood glucose reading early in the morning before the patient eats breakfast if he hasn't eaten since dinner," says Adam Rosenblatt, MD, a psychiatrist with Johns Hopkins Medical Center in Baltimore. "But the resident should not have a blood glucose over 200, period, whether it's a fasting blood glucose or not."

"Monitor the resident's blood glucose levels at least monthly (if the readings are stable), as the problems with blood glucose tend to occur over time," advises Angela Lobreto, RN, C, C, CRRN, PhD, a consultant in Benbrook, TX.

Pay close attention to patients taking SGAs who begin to gain quite a bit of weight - greater than 7 percent of their baseline weight - within one to two months, if the weight gain puts them over their ideal body weight, advises Lori Daiello, PharmD, a consultant in Orlando. 

Tip: Data show that people who have schizophrenia or bipolar disorder have a greater risk of developing SGA-induced hyperglycemia than other patients, including those with dementia-related psychosis.

4. Diagnosing and treating infection. Providers should decide whether to treat a patient with antibiotics based on his symptoms and the results of culture and sensitivity studies, according to guidelines from the Centers for Disease Control and Prevention and professional groups, such as the Association for Professionals in Infection Control and Epidemiology. (For more on infection control, see Article 6.)

"The clinical driver for antibiotic use should be the patient's signs and symptoms, because colonization and infection both produce positive cultures," emphasized Alexander Makris, MD, CMD, an infectious disease expert speaking on antibiotic-resistant infection at the June 2004 National Association of Directors of Nursing Administration in Long-Term Care conference in Orlando.

"Yet if the nurse calls the doctor about a positive urine culture, you can bet the physician will prescribe an antibiotic even if the patient has no signs and symptoms of UTI."

Clinical tip: "If the urine looks cloudy and dark, the resident more likely has dehydration" than an infection, said Makris.

Pick and Fit Your Guidelines

The good news: You don't have to reinvent the wheel in selecting and implementing practice guidelines suited to frail elderly nursing home residents. For example, AMDA guidelines provide a systematic approach for assessing and managing numerous diseases or conditions in long-term care, says Vance.

Check out the list of 18 AMDA guidelines at www.amda.com.

Use this resource: Nursing facilities can tailor other practice guidelines to their patient population. For example, you can adapt "Hyperglycemic Crises in Patients with Diabetes Mellitus," an evidence-based protocol developed by the ADA, to long-term care, says a new CMS Web site (see Article 3).

Looking for geriatric nursing best practices? Visit GeronurseOnline.org, which offers information on the causes and treatments of common geriatric health problems, such as incontinence, dementia and pressure sores. The Web site is funded by The Atlantic Philanthropies (USA) Inc., which includes the American Nurses Association, the American Nurses Credentialing Center and New York University's John A. Hartford Foundation Institute for Geriatric Nursing.